ARTICLE
The possibility of inflammation conduction from deeper structures to
the skin has been known for over two centuries. In 1768, Sir Percivall
Pott described a case of frontal sinusitis infection causing an indolent,
puffy, circumscribed swelling of the forehead. Surgery revealed a subperiosteal
abscess and osteomyelitis of the frontal bone [1, 2]. Pott's puffy tumour
has become a historical vignette and it still attracts dermatologists'
and other specialists' attention today [3, 4]. Similar clinical signs
may also occur in other inflammatory processes at different locations
[5-8]. Nevertheless, this type of cutaneous inflammatio per continuitatem
in the disguise of conventional inflammatory dermatosis is not mentioned
in any of the standard British, American, French or German dermatological
textbooks.
Case reports
Case 1
An 82-year-old male patient with a chronic history of rosacea presented
with an oedematous livid erythema of the nasal bridge accompanied by sebaceous
gland hyperplasia (Fig. 1).
The condition had developed slowly over two months to a painful and slightly
hyperthermic process. Laboratory tests were normal except for an erythrocyte
sedimentation rate (ESR) of 23/61 mm.
Computerized tomography revealed an ethmoidal process. Exploratory ethmoidectomy
and histology disclosed a destructive metatypical carcinoma of the ethmoidal
labyrinth with secondary superinfection due to Haemophilus influenzae.
Tumour resection was followed by recovery from the dermatological symptoms
within one week.
Case 2
A 61-year-old man presented with a sternal erythema. It had started
two weeks after a thoracotomy (aortocoronary bypass operation) and progressed
within two weeks to form an oval-shaped lesion 14 cm in diameter. Treatment
with cefotiam (Spizef®, Takeda Pharma, Aachen) did not
have any effect. It became asymmetric, painful, hyperthermic and indurative
(Fig. 2). The general
condition was poor. Histology revealed abundant deposits of acid mucin
throughout the dermis with accumulation around the eccrine gland lobules.
Inflammatory cells were rarely encountered. Laboratory testing showed
an increased ESR of 40/80 mm, a leukocytosis of 12.0 GPt/l and a gamma
globulin level of 20.6 g/l. A radiography of the sternum did not show
abnormalities, but computerized tomography demonstrated a fluid-like retrosternal
tumour. Thoracotomy revealed an abscess, which confirmed the sonographical
findings. Bacteria were not found.
The sternal erythema disappeared within 7 days in conjunction with the
healing of the underlying abscess.
Case 3
A 42-year-old woman with a chronic history of acne nodulocystica showed
an erythema studded with pustules at the left nasolabial fold (Fig.
3). The condition had been developing for four weeks without any
other general symptoms. Laboratory parameters (ESR, blood count) were
within normal ranges. Histology showed fibrinous epidermal crusts with
cell detritus, diffuse lymphocytic and neutrophilic perifollicular and
periadnexal infiltrates with sparse mucinosis. Dental examination and
X-rays led to the diagnosis of CIS due to an odontogenic abscess caused
by Staphylococcus aureus. Dental surgery and systemic administration
of flucloxacillin completely cleared the lesion within ten days.
Case 4
A 49-year-old man presented with a centrofacial oedematous erythema
which had been progressing for three weeks, accompanied by fever attacks.
On admission the patient's general condition was poor. On clinical examination,
the patient exhibited extensive and painful erythema and oedema of the
nose, cheeks, eyelids and middle forehead with haemorrhagic and purulent
crusts (Fig. 4). Abnormal
laboratory parameters were ESR 127/140, leukocytes 17.7 GPt/l, fibrinogen
10.1 g/l, gamma globulin level 35.4 g/l, albumin 21.0 g/l and partial
thromboplastin time of 15 s. Microbiological investigation of a skin smear
showed Pseudomonas aeruginosa and Enterobacter cloacae.
A bilateral purulent sinusitis maxillaris and ethmoidalis was diagnosed
by computerized tomography. An initial treatment with antibiotics (a combination
of cefotiam and flucloxacillin) was followed by an endonasal ethmoidectomy
which led to slow recovery.
Discussion
Contiguous inflammation of the skin is characterized by the invasion
of an inflammatory process from subcutaneous or deeper anatomical structures
into the superficial cutaneous tissues.
A summary of the cases presented shows several clear features in common:
1. An inflammation of adjacent deep-seated anatomical structures was
revealed as the underlying primary cause of the skin affection in all
patients.
2. In every case, the skin symptoms were neither a metastatic condition
nor a common symptom of the causal process.
3. Bacterial inflammatory processes (in case 1 secondary to a tumour)
were found as the causative agent in 3 patients. In case 2, causative
pathogens could not be proved, possibly because of antibiotic pre-treatment.
4. The cutaneous symptoms showed subacute development and followed a
protracted course.
5. Clinical symptoms comprised strictly localized erythema, edema, moderate
to severe pain and local hyperthermia. Reduced general condition and laboratory
signs of inflammation did not occur in all cases.
6. In two patients, a pre-existent chronic facial skin disorder (case
1: rosacea, case 3: nodulocystic acne) apparently worsened.
With regard to the formal pathogenesis of CIS, it is possible that the
spread of inflammation might be due to the transport or migration of inflammatory
cells (neutrophils, lymphocytes) and/or the effect of diffusing mediators
with a low local tissue attachment. Thus, it seems possible that even
aseptic foci may exert a contiguous inflammation as has been indicated
recently by solitary bony plasmocytomas [8]. However, direct tissue destruction
by neutrophils [9] seems unlikely in CIS areas as histological examination
revealed no neutrophilic tissue destruction in the dermis and no abscesses
or necrosis of subcutaneous fatty tissue. This evidently distinguishes
CIS from phlegmon or metastatic abscesses, which are characterized by
a more acute and destructive course rather than a protracted course.
In both cases in which histological examinations were carried out (cases
2 and 3), dermal mucinosis, which was considerably accentuated in the
periacinary stroma of eccrine sweat glands, was to be found. This is remarkable
but not specific to CIS and may be found in association with various inflammatory
or neoplastic diseases, particularly if the lesion is ulcerated.
CIS therapy has to be surgical in most cases. If an underlying abscess
is found, open or percutaneous [10] abscess drainage should be performed
and additional antibiotic therapy is necessary.
CIS is a rare complication of a primary inflammatory focus of deeper
components. Especially in cases of pre-existent skin diseases, the protracted
course of the condition may cause primary misdiagnoses by non-dermatologists,
as observed by our and other authors' experiences [6, 8]. The presented
cases mimicked a solid facial edema (case 1), a morphea-like condition
(case 2), a gram-negative pyoderma (case 3). Thus, the well-informed dermatologist
plays a key role in the rapid and correct diagnosis, unmasking the underlying,
sometimes life-threatening inflammatory process which gives rise to the
visible cutaneous affection.
REFERENCES
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to which the head is liable from external violence. London: L. Hawes,
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1992; 76: 319-26.
3. Babu RP, Todor R, Kasoff SS. Pott's puffy tumor: the forgotten entity.
J Neurosurg 1996; 84: 110-2.
4. Bellaney GJ. Pott's puffy tumor. Presentation on the meeting of the
Royal Society of Medicine, Section of Dermatology. London, 18/4/1996.
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as a pleural-based mass. Chest 1993; 103: 1912-3.
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carcinoma mimicking infection or inflammation. Cutis 1988; 42:
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7. Goldberg RA, Weisman JS, McFarland JE, Krauss HR, Hepler RS, Shorr
N. Orbital inflammation and optic neuropathies associated with chronic
sinusitis of intranasal cocaine abuse. Possible role of contiguous inflammation.
Arch Ophthalmol 1989; 107: 831-5.
8. Schoenlaub P, Lipsker D, Massard G, Christmann D, Grosshans E. Syndrome
adéno-cutané associé au plasmocytome osseux. Ann
Dermatol Vénéréol 1997; 124: 228-32.
9. Weiss SJ. Tissue destruction by neutrophils. New Engl J Med
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10. Van Sonnenberg E, D'Agostino HB, Casola G, Halasz NA, Sanchez RB,
Goodacre BW. Percutaneous abscess drainage: current concepts. Radiology
1991; 181: 617-26.
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