Kremena K. Nikolova

Lyubomir A. Dourmishev

Malena J. Gergovska

Maria B. Balabanova

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264Acta Dermatovenerol Croat 2010;18(4):264-266 CASE REPORTErythema Annulare Centrifugum in a Patient Operated on for Breast Carcinoma Lyubomir A. Dourmishev, Malena J. Gergovska, Kremena K. Nikolova,  Maria B. BalabanovaDepartment of Dermatology and Venereology, Medical University, Sofia, BulgariaCorresponding author: Lyubomir Dourmishev MD, PhDDepartment of Dermatology and VenereologySofia Medical University 1431 SofiaBulgariaL_Dourmishev@yahoo.comReceived: March 31, 2010Accepted: October 12, 2010SUMMARY A 73-year-old Caucasian female patient presented for three annular erythematous lesions on the left leg and buttock, per-sisting for two months, clinically interpreted as erythema annulare centrifugum. Routine laboratory findings were within the normal ranges, Borrelia serology and wet mount microscopy for mycosis were negative. Histologic examination confirmed the diagnosis of superficial erythema annulare centrifugum. Since no association of erythema annulare centrifugum with concomitant bacterial or viral infections, or active systemic disease was found in our patient, we considered the possible activation of her previous breast cancer operated on in October 2000. KeY woRdS: erythema annulare centrifugum, breast cancer, paraneoplastic associationIntRodUCtIonErythema annulare centrifugum (EAC), first described by Darier in 1916 (1), belongs to the group of figurate erythematous dermatoses with uncertain multifactor etiology and chronic course. Clinically, the lesions are annular or figurate with raised borders and spread peripherally with a ten-dency of central clearing. EAC is a rare syndrome estimated to affect one case per 100,000 popula-tion per year (2), and according to our literature search, our case might be the second one with proposed association with breast carcinoma.  CASe RepoRtA 73-year-old Caucasian female patient pre-sented to our Department of Dermatology and Venereology for the presence of three erythema-tous, annular lesions, which appeared two months before and involved the left leg (Fig. 1) and but-tock (Fig. 2). The cutaneous lesions were clinically diagnosed as EAC. Routine laboratory findings were within the normal ranges, Borrelia serology and wet mount microscopy for mycosis were neg-ative. Histologic examination revealed edema of the papillary dermis and perivascular infiltrate of lymphocytes and histiocytes around the superfi-cial vessels, confirming the diagnosis of superficial EAC (Fig. 3). We did not find any association of EAC with concomitant bacterial or viral infections, or active systemic disease in our patient, and she denied taking systemic medication for any reason. In her past history, the patient underwent mam-mectomy with regional lymph node dissection for breast cancer in October 2000. No clinical sign of an active underlying neoplastic process was 265ACTA DERMATOVENEROLOGICA CROATICAdiagnosed at the time of hospitalization at our de-partment. We referred our patient for neoplastic screening, which found no data of neoplastic ac-tivity so far. The cutaneous lesions moderately im-proved after treatment with potent local steroids. dISCUSSIonErythema annulare centrifugum is classi-fied into superficial (as in our patient) and deep (non-scaling) types (3), and is often idiopathic or provoked by benign factors, in contrast to ery-thema gyratum repens, which is believed to be exclusively paraneoplastic expression. The patho-genesis of EAC remains unclear, proposing the role of Th1 mediated reaction to a variety of infec-tive agents (bacterial, mycobacterial, viral, fungal (4), and parasitic), medications, systemic diseases (Graves disease, liver disease, hypereosinophilic syndrome, sarcoidosis), food substances (blue cheese), and malignancy. Among paraneoplastic diseases, EAC is mainly associated with Hodgkin (5) and non-Hodgkin lymphomas (6), acute leu-kemia (7,8), gastric (9), lung (10) and prostatic carcinomas (11), and carcinoid tumors (12). The association of EAC and breast cancer, however, is an extremely rare observation. Recently, Panasiti et al. (13) have reported on an interesting case of a 74-year-old woman, which they claim to be the first case of superficial type EAC associated with breast cancer. Since no association of EAC with concomitant infec-tions or internal diseases was found in our patient, except for the history of breast cancer operated on nine years before, we considered the possible activation of the previous neoplastic condition. Moreover, both patients are almost of the same age and share some similarities in the course of disease. In contrast to the case presented by Pa-nasiti et al. (13), in our patient it was difficult to prove definite relationship between the previous, currently clinically inactive neoplastic disease, i.e. breast cancer, and the superficial form of EAC. Nevertheless, we share the observation of Drake et al. (14) that physical examination and imaging techniques may fail to detect early stages of can-cer activation in patients with paraneoplastic syn-dromes. Therefore, neoplastic screening may not exclude an early relapse of the neoplasm and we will continue to monitor our patient in the future.In conclusion, the above mentioned clinical cases strongly support the possible pathogenetic role of breast carcinoma in provoking EAC lesions in some patients.   Figure 3. Papillary dermis edema and perivascular lym-phocytic and histiocytic infiltrates compatible with su-perficial erythema annulare centrifugum HE x 40.Figure 1. Annular erythematous macular lesion on the left leg of our patientFigure 2. Two annular lesions involving the left leg and buttock.Dourmishev et al.     Acta Dermatovenerol CroatErythema annulare centrifugum 2010;18(4):264-266266 ACTA DERMATOVENEROLOGICA CROATICAReferences1.   Darier J. De l’érythème annulaire centrifuge et de quelques éruptions analogues. Ann Der-matol et Syphilograph 1916,5:57-8.2.   Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special reference to its association with underlying disease. Clin Exp Dermatol 1983;8:383-7. 3.   Weyers W, Diaz-Cascajo C, Weyers I. Erythe-ma annulare centrifugum: results of a clinico-pathologic study of 73 patients. Am J Derma-topathol 2003;25:451-62.4.   Alex MP, Mohan L, Singh KK, Mukhija RD. Er-ythema annulare centrifugum due to candida infection. Indian J Dermatol Venereol Leprol 1999;65:283-4.5.   Yaniv R, Shpielberg O, Shpiro D, Feinstein A, Ben-Bassat I. Erythema annulare centrifugum as the presenting sign of Hodgkin’s disease. Int J Dermatol 1993;32:59-61.6.   Carlesimo M, Fidanza L, Mari E, Pranteda G, Cacchi C, Veggia B, et al. Erythema annula-re centrifugum associated with mantle B-cell non-Hodgkin’s lymphoma. Acta Derm Vene-reol 2009;89:319-20.7.   Gündeşlioğlu AO, Ertaş NM, Celebioğlu S, Hücümenoglu S. Erythema annulare centrifu-gum: an unusual presentation for acute leuke-mia. Plast Reconstr Surg 2004;113:798-9.8.   Miljković J, Bartenjev I. Hypereosinophilic der-matitis-like erythema annulare centrifugum in a patient with chronic lymphocytic leukaemia. J Eur Acad Dermatol Venereol 2005;19:228-31.9.   Lee HJ, Chang SE, Lee MW, Choi JH, Moon KC, Koh JK. Metastatic gastric carcinoma pre-senting as an erythema annulare centrifugum-like lesion. J Dermatol 2008;35:186-7.10. Monsieur I, Meysman M, Noppen M, de Greve J, Delhove O, Velckeniers B, et al. Non-small-cell lung cancer with multiple paraneoplastic syndromes. Eur Respir J 1995;8:1231-4.11. Dupré A, Carrère A, Bonafé JL, Viraben R, Christol B, Lassère J. Erythema annulare centrifugum of the legs symptomatic of pro-state adenocarcinoma; a specific paraneo-plastic syndrome? Ann Dermatol Venereol 1979;106:789-92.12. Everall JD, Dowd PM, Ardalan B. Unusual cutaneous associations of a malignant carci-noid tumour of the bronchus-erythema annu-lare centrifugum and white banding of the toe nails. Br J Dermatol 1975;93:341-5.13. Panasiti V, Devirgiliis V, Curzio M, Rossi M, Roberti V, Bottoni U, et al. Erythema annulare centrifugum as the presenting sign of breast carcinoma. J Eur Acad Dermatol Venereol 2009;23:318-20.14. Davis MD, Ahmed I. Ovarian malignancy in patients with dermatomyositis and polymyosi-tis: a retrospective analysis of fourteen cases. J Am Acad Dermatol 1997;37:730-3.Dourmishev et al.     Acta Dermatovenerol CroatErythema annulare centrifugum 2010;18(4):264-266

Erythema Annulare Centrifugum in a Patient Operated on for Breast Carcinoma

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