D3.293 - Acrodermatitis chronica atrophicans in the field of scleroderma

Seventy-one-year-old woman was referred to our clinic for an immunological examination for complaints characterized by tingling and trembling of the right lower limb. She was also followed for osteoporosis, polyarthrosis and hypercholesterolemia. Subjectively, she reported muscle and joint pain on exertion. The predominant finding on the right lower limb was intense purple discoloration of the skin on the thigh, and stiff skin with calcifications on the tibia.  Laboratory investigations were performed and revealed mild leukopenia, rheumatoid factor positivity in IgG and IgM subclasses, anti-nuclear antibody ANAb 1:320, anti-NOR90 IgG and anti-Mi-2β IgG antibody positivity. The patient was indicated for skin sampling laterally on the upper right tibia and from the right thigh for histological examination. The histologic findings from the right tibia were consistent with the inflammatory phase of scleroderma, but histology performed from the medial aspect of the right thigh showed findings consistent with pseudoscleroderma in Lyme disease, with a significant finding of a large proportion of plasmocytes. Histology was complemented by serology for Lyme disease (Borrelia ELISA IgG 6.924 positive - range 0.9-1.101; Borrelia ELISA IgM 1.756 positive, range 0.9-1.101) including WB, which was positive in both IgG and IgM classes. Based on these findings, the patient was treated with i.v. Ceftriaxone 2 g for 14 days and doxycycline for 28 days with a good clinical response for both skin and neurological symptoms.

Patient with localized scleroderma and concomitant acrodermatitis, which poses a potential problem in differential diagnosis and delays the initiation of antibiotic therapy. They are two distinct diseases, the coexistence of which cannot be excluded.