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Case Reports

Abstract

A six-year-old male was referred to rheumatology-dermatology clinic with suspected eosinophilic cellulitis on the lower extremities for 3 years. A new lesion developed every 2 months with spontaneous resolution. Treatment with mometasone 0.1% had improved healing time, however new lesions still developed. Biopsy of the lesion at an outside institution showed eosinophils and flame figures, leading to suspicion for eosinophilic cellulitis (Wells’ Syndrome). “Flame figures” are composed of eosinophilic major basic protein and collagen. Repeat biopsy showed superficial and deep perivascular and interstitial infiltrate of lymphocytes, histiocytes, and numerous eosinophils with prominent flame figures. Our patient had a negative workup to look for underlying diseases such as thyroid disease, connective tissue disease, and Lyme disease. With the clinicopathologic picture, our dermatopathologist and clinician favored Eosinophilic Annular Erythema (EAE) as the diagnosis. Although flame figures are present in eosinophilic cellulitis, they are not pathognomonic: they are seen in arthropod bites, atopic dermatitis, and bullous pemphigoid. Histologically, EAE has perivascular inflammatory infiltrate composed of eosinophils and lymphocytes. Eosinophilic cellulitis has diffuse inflammatory infiltrate in the dermis primarily composed of eosinophils with degranulation. Clinically, EAE has an earlier age of onset, annular/figurate pattern and often spontaneous resolution as in our patient. There is debate over whether these conditions are truly distinct or if they exist on a spectrum. There are blurred lines between the true distinguishing features: flame figures as well as peripheral eosinophilia can be present in both conditions. EAE should be considered in the differential even when flame figures are present.