Erythema Sweetobullosum a Rare Presentation of Coccidioidomycosis

BACKGROUND: Erythema nodosum (EN) and erythema multiforme (EM) are known reactive cutaneous manifestations of acute infection with coccidioidomycosis. In endemic area, these findings could be diagnostic in the presence of proper clinical presentation. In our experience at Kern Medical similar to our colleagues in Arizona we have observed unique form of cutaneous manifestation of acute coccidioidiomycosis with blisters. This form of skin eruption was given different names such as toxic erythema in 1940 and recently sweet syndrome in 2005. The term erythema sweetobullosum (ESB) was suggested first by David J. Elbaum in 1998 in San Joaquin Valley California in a nine case series. This study showed in contrast to sweet syndrome in ESB histology appears to change based on when the patient is seen. Early on ESB shows lymphocytic dominance, later will be neutrophil rich and eventually histiocytic phase and even granulomatous. METHODS: Retrospective chart review. RESULTS: Six cases are identified. Upon presentation they were between 27 and 47 years old half male and other half female. In all cases, ESB lesions were present as multiple tense erythematous plaques base with central crusting and surrounding cluster of vesicular formation. ESB lesions were located on bilateral upper and lower arms in all cases (Figures 1–3). IgM immunodiffusion serology was positive in all cases. Chest X-ray was positive for infiltration or nodule or cavity in five cases. Eosinophilia was present in four cases (800–1600). All cases had EM and two cases had EN present. Histopathology in one case described as subepidermal vesicular dermatitis with lymphocytes and histocytes. No evidence of dissemination was found in all six cases. One case lost follow-up but rest had significant clinical, radiological and serological response to fluconazole therapy with complete resolution of all skin manifestations. CONCLUSION: We are describing six cases of acute pulmonary coccidioidomycosis with unique reactive skin manifestation described as erythema sweetobullosum. The acknowledgment of skin findings assists in prompt clinical suspicious to make diagnosis and initiate treatment. DISCLOSURES: All authors: No reported disclosures.