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Dermatologic Manifestations of Eosinophilia-Myalgia Syndrome Differential Diagnoses

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
 
Updated: Jun 09, 2016
 
 

Diagnostic Considerations

Also consider toxic oil syndrome,[30, 31, 32]  polymyositis, and polyarteritis nodosa.

Eosinophilic fasciitis should be differentiated from eosinophilia-myalgia syndrome (EMS).[33, 34, 35] Eosinophilic fasciitis is typically evident as painful swelling with progressive cutaneous and subcutaneous induration of the limbs.[36] The criterion standard for diagnosis of eosinophilic fasciitis is a deep skin-to-muscle biopsy. Some believe eosinophilic fasciitis to be linked to L-tryptophan ingestion, statins, and, possibly, iron infusions.[37]

Probiotics, live microorganisms that when administered confer a health benefit, are often used for rheumatic diseases to enhance the immune system despite adverse events including bacteremia and fungemia in immunocompromised patients. Two patients developed a severe eosinophilic syndrome with vasculitis and mononeuritis multiplex, temporally associated with use of a new brand of probiotics.[38] However, neither had the eosinophilia myalgia syndrome since there was no cutaneous edema, no fibrosis, and no history of L-tryptophan ingestion.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, David Arbesfeld, MD, Vinay Arya, MD, and Nicole Quartarolo, MD, to the development and writing of this article.

References
  1. Martínez-Cabot A, Messeguer A. Generation of quinoneimine intermediates in the bioactivation of 3-(N-phenylamino)alanine (PAA) by human liver microsomes: a potential link between eosinophilia-myalgia syndrome and toxic oil syndrome. Chem Res Toxicol. 2007 Oct. 20(10):1556-62. [Medline].

  2. Allen JA, Peterson A, Sufit R, Hinchcliff ME, Mahoney JM, Wood TA, et al. Post-epidemic eosinophilia-myalgia syndrome associated with L-tryptophan. Arthritis Rheum. 2011 Nov. 63(11):3633-9. [Medline].

  3. Fernstrom JD. Effects and side effects associated with the non-nutritional use of tryptophan by humans. J Nutr. 2012 Dec. 142(12):2236S-2244S. [Medline].

  4. Smith MJ, Garrett RH. A heretofore undisclosed crux of eosinophilia-myalgia syndrome: compromised histamine degradation. Inflamm Res. 2005 Nov. 54(11):435-50. [Medline].

  5. Smith MJ, Garrett RH. Part II. Eosinophilia-Myalgia Syndrome: further correlations between compromised histamine degradation, eosinophilias and myopathies. Inflamm Res. 2007 Mar 14. [Medline].

  6. Rieber N, Belohradsky BH. AHR activation by tryptophan--pathogenic hallmark of Th17-mediated inflammation in eosinophilic fasciitis, eosinophilia-myalgia-syndrome and toxic oil syndrome?. Immunol Lett. 2010 Feb 16. 128(2):154-5. [Medline].

  7. Zhang H, Yu P, Xiang ML, Li XB, Kong WB, Ma JY, et al. Prediction of drug-induced eosinophilia adverse effect by using SVM and naïve Bayesian approaches. Med Biol Eng Comput. 2015 Jun 5. [Medline].

  8. Clara RO, Assmann N, Ramos Moreno AC, Coimbra JB, Nurenberger N, Dettmer-Wilde K, et al. Melanocytes are more responsive to IFN-γ and produce higher amounts of kynurenine than melanoma cells. Biol Chem. 2016 Jan. 397 (1):85-90. [Medline].

  9. Yorucu C, Lau K, Mittar S, Green NH, Raza A, Rehman IU, et al. Raman spectroscopy detects melanoma and the tissue surrounding melanoma using tissue-engineered melanoma models. Appl Spectrosc Rev. 2016 Apr 20. 51 (4):243-257. [Medline].

  10. Swygert LA, Back EE, Auerbach SB, Sewell LE, Falk H. Eosinophilia-myalgia syndrome: mortality data from the US national surveillance system. J Rheumatol. 1993 Oct. 20(10):1711-7. [Medline].

  11. Campagna AC, Blanc PD, Criswell LA, Clarke D, Sack KE, Gold WM, et al. Pulmonary manifestations of the eosinophilia-myalgia syndrome associated with tryptophan ingestion. Chest. 1992 May. 101(5):1274-81. [Medline].

  12. Tazelaar HD, Myers JL, Drage CW, King TE Jr, Aguayo S, Colby TV. Pulmonary disease associated with L-tryptophan-induced eosinophilic myalgia syndrome. Clinical and pathologic features. Chest. 1990 May. 97(5):1032-6. [Medline].

  13. De Schryver-Kecskemeti K, Bennert KW, Cooper GS, Yang P. Gastrointestinal involvement in L-tryptophan (L-Trp) associated eosinophilia-myalgia syndrome (EMS). Dig Dis Sci. 1992 May. 37(5):697-701. [Medline].

  14. Hepburn A, Coady A, Livingstone J, Pandit N. Eosinophilic cholecystitis as a possible late manifestation of the eosinophilia-myalgia syndrome. Clin Rheumatol. 2000. 19(6):470-2. [Medline].

  15. Greenberg AS, Takagi H, Hill RH, Hasan A, Murata H, Falanga V. Delayed onset of skin fibrosis after the ingestion of eosinophilia- myalgia syndrome-associated L-tryptophan. J Am Acad Dermatol. 1996 Aug. 35(2 Pt 1):264-6. [Medline].

  16. Kaufman LD, Seidman RJ, Phillips ME, Gruber BL. Cutaneous manifestations of the L-tryptophan-associated eosinophilia-myalgia syndrome: a spectrum of sclerodermatous skin disease. J Am Acad Dermatol. 1990 Dec. 23(6 Pt 1):1063-9. [Medline].

  17. Ostezan LB, Callen JP. Cutaneous manifestations of selected rheumatologic diseases. Am Fam Physician. 1996 Apr. 53(5):1625-36. [Medline].

  18. Freimer ML, Glass JD, Chaudhry V, Tyor WR, Cornblath DR, Griffin JW, et al. Chronic demyelinating polyneuropathy associated with eosinophilia- myalgia syndrome. J Neurol Neurosurg Psychiatry. 1992 May. 55(5):352-8. [Medline].

  19. Ronen N, Livne E, Gross B. Oxidative damage in rat tissue following excessive L-tryptophan and atherogenic diets. Adv Exp Med Biol. 1999. 467:497-505. [Medline].

  20. Silver RM, McKinley K, Smith EA, Quearry B, Harati Y, Sternberg EM, et al. Tryptophan metabolism via the kynurenine pathway in patients with the eosinophilia-myalgia syndrome. Arthritis Rheum. 1992 Sep. 35(9):1097-105. [Medline].

  21. Stahl JL, Cook EB, Pariza MA, Cook ME, Graziano FM. Effect of L-tryptophan supplementation on eosinophils and eotaxin in guinea pigs. Exp Biol Med (Maywood). 2001 Mar. 226(3):177-84. [Medline].

  22. Arnouts PJ, Colemont LJ, Van Outryve MJ, Van Moer EM. L-tryptophan-induced eosinophilia-myalgia syndrome. J Intern Med. 1991 Jul. 230(1):83-6. [Medline].

  23. Back EE, Henning KJ, Kallenbach LR, Brix KA, Gunn RA, Melius JM. Risk factors for developing eosinophilia myalgia syndrome among L-tryptophan users in New York. J Rheumatol. 1993 Apr. 20(4):666-72. [Medline].

  24. Henning KJ, Jean-Baptiste E, Singh T, Hill RH, Friedman SM. Eosinophilia-myalgia syndrome in patients ingesting a single source of L-tryptophan. J Rheumatol. 1993 Feb. 20(2):273-8. [Medline].

  25. Johnson KL, Klarskov K, Benson LM, Williamson BL, Gleich GJ, Naylor S. Presence of peak X and related compounds: the reported contaminant in case related 5-hydroxy-L-tryptophan associated with eosinophilia-myalgia syndrome. J Rheumatol. 1999 Dec. 26(12):2714-7. [Medline].

  26. Kamb ML, Murphy JJ, Jones JL, Caston JC, Nederlof K, Horney LF, et al. Eosinophilia-myalgia syndrome in L-tryptophan-exposed patients. JAMA. 1992 Jan 1. 267(1):77-82. [Medline].

  27. Klarskov K, Johnson KL, Benson LM, Gleich GJ, Naylor S. Eosinophilia-myalgia syndrome case-associated contaminants in commercially available 5-hydroxytryptophan. Adv Exp Med Biol. 1999. 467:461-8. [Medline].

  28. Naylor S, Johnson KL, Williamson BL, Klarskov K, Gleich GJ. Structural characterization of contaminants in commercial preparations of melatonin by on-line HPLC-electrospray ionization-tandem mass spectrometry. Adv Exp Med Biol. 1999. 467:769-77. [Medline].

  29. Kilbourne EM, Philen RM, Kamb ML, Falk H. Tryptophan produced by Showa Denko and epidemic eosinophilia-myalgia syndrome. J Rheumatol Suppl. 1996 Oct. 46:81-8; discussion 89-91. [Medline].

  30. Diggle GE. The toxic oil syndrome: 20 years on. Int J Clin Pract. 2001 Jul-Aug. 55(6):371-5. [Medline].

  31. Philen RM, Posada M. Toxic oil syndrome and eosinophilia-myalgia syndrome: May 8-10, 1991, World Health Organization meeting report. Semin Arthritis Rheum. 1993 Oct. 23(2):104-24. [Medline].

  32. Vanhooren HM, Vanoirbeek JA, Xu H, Verbeken E, Nemery B. Strain-dependent acute lung injury after intra-tracheal administration of a 'refined' aniline-denatured rapeseed oil: a murine model of the toxic oil syndrome?. Food Chem Toxicol. 2007 Dec. 45(12):2563-73. [Medline].

  33. Akanay-Diesel S, Richter J, Schneider M, Schulte KW, Reifenberger J, Hanneken S. [Shulman's syndrome (eosinophilic fasciitis)]. Hautarzt. 2009 Apr. 60(4):278-81. [Medline].

  34. Naoui A, Bouslama K, Abdallah M, et al. [Eosinophilic fasciitis (Shulman's disease): a case series of 11 patients]. Rev Med Interne. 2010 Aug. 31(8):535-9. [Medline].

  35. Varga J, Kahari VM. Eosinophilia-myalgia syndrome, eosinophilic fasciitis, and related fibrosing disorders. Curr Opin Rheumatol. 1997 Nov. 9(6):562-70. [Medline].

  36. Pinal-Fernandez I, Selva-O' Callaghan A, Grau JM. Diagnosis and classification of eosinophilic fasciitis. Autoimmun Rev. 2014 Apr-May. 13(4-5):379-82. [Medline].

  37. Firoz BF, Goldberg LH, Landau J, Kaye V, Berman L. Eosinophilic fasciitis secondary to intravenous iron infusions. Dermatol Online J. 2010 May 15. 16(5):5. [Medline].

  38. Mendoza FA, Purohit S, Kenyon L, Jimenez SA. Severe eosinophilic syndrome associated with the use of probiotic supplements: a new entity?. Case Rep Rheumatol. 2012. 2012:934324. [Medline]. [Full Text].

  39. Hatch DL, Goldman LR. Reduced severity of eosinophilia-myalgia syndrome associated with the consumption of vitamin-containing supplements before illness. Arch Intern Med. 1993 Oct 25. 153(20):2368-73. [Medline].

 
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