eMedicine Specialties > Rheumatology > Systemic Rheumatic Disease

Eosinophilic Fasciitis: Differential Diagnoses & Workup

Author: Peter M Henning, DO, MAJ, MC, Fellow, Department of Rheumatology, Walter Reed Army Medical Center, Washington, DC
Coauthor(s): George R Mount, MD, MAJ USA MC, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Attending Physician, Department of Rheumatology, Walter Reed Army Medical Center, Washington, DC; Nicholas David Kortan, DO, CPT, MC,, Resident Physician, Department of Internal Medicine, Walter Reed Army Medical Center, Washington, DC; Sherif Nasef, MD, Consulting Staff, Department of Internal Medicine, Division of Rheumatology, Lake Havasu Regional Medical Center; Kristine M Lohr, MD, MS, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology and Women's Health, University of Kentucky School of Medicine
Contributor Information and Disclosures

Updated: Oct 2, 2009

Differential Diagnoses

Eosinophilia
Eosinophilia-Myalgia Syndrome
Localized Fibrosing Disorders - Linear Scleroderma, Morphea, and Regional Fibrosis
Scleroderma
Systemic Sclerosis
Toxic Oil Syndrome

Other Problems to Be Considered

Differential considerations include the following:

  • The localized forms of scleroderma, morphea, and linear forms of scleroderma
  • Limited and diffuse cutaneous systemic sclerosis
  • Other localized cutaneous fibrosing disorders, eg, nephrogenic systemic fibrosis, scleromyxedema, and scleredema

In general, these alternative etiologies can be excluded by the absence of peripheral eosinophilia. Additionally, the absences of Raynaud phenomenon, abnormal capillaroscopy findings, and visceral involvement are key findings that differentiate eosinophilic fasciitis (EF) from systemic sclerosis.

Eosinophilia-myalgia syndrome and toxic oil syndrome are two disorders that share common clinical and histopathological features with eosinophilic fasciitis, including peripheral eosinophilia. In contrast to eosinophilic fasciitis, these two conditions present in epidemic form and, after epidemiological analysis, appear to be almost universally toxin-associated.32,33

In 1989, an epidemic of a connective-tissue disease with peripheral eosinophilia and prominent myalgias was recognized in the United States and was therefore termed eosinophilic myalgia syndrome. Subsequent epidemiologic studies indicated that most individuals who developed eosinophilic myalgia syndrome had consumed l-tryptophan from a single source. Diffuse induration of the integument affecting the extremities and occasionally the torso, but sparing the face, hands, and feet, developed in a large number of patients with eosinophilic myalgia syndrome. In contrast to eosinophilic fasciitis, patients with eosinophilic myalgia syndrome typically presented with prominent systemic symptoms, including fever, myalgia, and rash.

Similarly, in 1980 in Spain, an epidemic of connective-tissue disease with peripheral eosinophilia was recognized. The epidemic was eventually traced to rapeseed oil that had been denatured with aniline and sold in bulk as olive oil for cooking. As many as 20,000 Spaniards were affected. Acute symptoms were similar to those of eosinophilic myalgia syndrome, with prominent systemic symptoms in addition to cutaneous changes. In contrast to eosinophilic myalgia syndrome, acute symptoms included more prominent pulmonary manifestations. In chronic disease, patients with toxic oil syndrome were more likely to demonstrate systemic (pulmonary, neurologic) symptoms.8,34,35

Workup

Laboratory Studies

Characteristic laboratory findings of eosinophilic fasciitis (EF) include the following:

  • Peripheral blood eosinophilia is present in 61%-83% of patients. The degree of eosinophilia is variable over time, even in the absence of specific therapy.15,36,37
  • Hypergammaglobulinemia is characteristic, although this finding varies widely by case series, occurring in 18%-67% of patients. It is most often due to a polyclonal increase in immunoglobulin G.16,17,36
  • An increase in the erythrocyte sedimentation rate (ESR) is found in 29%-70% of cases.16

Additional laboratory findings of eosinophilic fasciitis include the following:15,17,36

  • Serum creatine kinase and aldolase levels are generally normal.
  • Rheumatoid factor (RF) and antinuclear antibodies are occasionally positive.
  • Hematologic abnormalities and disease are associated with eosinophilic fasciitis. Aplastic anemia, although rare, is the most frequent common associated hematological complication, but cases have been described with thrombocytopenia, hemolytic anemia, pernicious anemia, lymphoma, and leukemia.38,39
  • Borrelia serology or polymerase chain reaction (PCR) findings are occasionally positive and may suggest a treatable etiology. However, as discussed above, the exact correlation between eosinophilic fasciitis and Borrelia remains unclear.23,24
  • Metalloproteinase 1 (TIMP-1) may be a new serological marker of disease activity.9

Imaging Studies

  • MRI is the imaging modality of choice. MRI of the involved areas shows characteristic findings of fascial thickening, abnormal signal intensity, and contrast enhancement. Additionally, MRI aids in making the diagnosis, locating the biopsy site, and monitoring the response to treatment.40,41,42,43
  • Although it has not been used frequently or studied extensively in eosinophilic fasciitis, one case report has shown that ultrasonography can aid in early diagnosis.44

Other Tests

  • While eosinophilic fasciitis is generally not associated with myositis or myopathy, electromyography has occasionally been performed, and findings may be abnormal in the presence of normal serum muscle enzymes.17
  • Pulmonary function testing may show a restrictive pattern in patients with severe truncal involvement.17

Procedures

  • Definitive diagnosis relies on a full-thickness incisional skin biopsy. The specimen should include the skin, fat, fascia, and superficial muscle in continuity. Biopsy is especially important in an atypical presentation.45,46,47

Histologic Findings

Inflammation, edema, thickening, and sclerosis of the fascia are hallmarks of eosinophilic fasciitis. Acute findings include infiltration of deep fascia and an adjacent subcutis layer with lymphocytes, plasma cells, histiocytes, and eosinophils. Distribution of the eosinophils in the fascia may be focal, and a close relationship appears to exist between blood and tissue eosinophilia. In the deeper portions of the panniculus, a similar infiltrate is found in the fibrous septa and at the periphery of the fat lobules. Deep in the fascia, the inflammatory infiltrate can extend into the epimysium, perimysium, and endomysium. In addition, vascular cuffing with lymphocytes and plasma cells is often seen.7,11,48

As the disease progresses, inflammatory changes are replaced by generalized sclerosis and thickening of the fascia and adjacent tissue layers. The sclerosis can be dense with hyalinized collagen bands running parallel to the fascia and small foci of fat cells trapped between them.36,49

Eosinophilic fasciitis. Top: In this gross specim...

Eosinophilic fasciitis. Top: In this gross specimen, the dermis (A), subcutaneous adipose tissue (B), and skeletal muscle do not appear unusual. However, the fascia (D) is markedly thickened. Bottom left: The gross findings are recapitulated in this low-power photomicrograph. The epidermis, dermis (A), and subcutaneous adipose tissue are not remarkable in this case. The fascia (D) is markedly thickened and focally infiltrated by inflammatory cells (E). The small amount of skeletal muscle (C) appears normal (hematoxylin and eosin stain at low power). Bottom right: A close-up photograph of a portion of the fascia showing mostly edematous cellular connective tissue (F). It is focally infiltrated by inflammatory cells, including lymphocytes, plasma cells, and histiocytes. The more intensely stained hypocellular pink bands across the top of the field (G) are part of an interstitial exudate of fibrin (hematoxylin and eosin stain at medium power).

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Eosinophilic fasciitis. Top: In this gross specim...

Eosinophilic fasciitis. Top: In this gross specimen, the dermis (A), subcutaneous adipose tissue (B), and skeletal muscle do not appear unusual. However, the fascia (D) is markedly thickened. Bottom left: The gross findings are recapitulated in this low-power photomicrograph. The epidermis, dermis (A), and subcutaneous adipose tissue are not remarkable in this case. The fascia (D) is markedly thickened and focally infiltrated by inflammatory cells (E). The small amount of skeletal muscle (C) appears normal (hematoxylin and eosin stain at low power). Bottom right: A close-up photograph of a portion of the fascia showing mostly edematous cellular connective tissue (F). It is focally infiltrated by inflammatory cells, including lymphocytes, plasma cells, and histiocytes. The more intensely stained hypocellular pink bands across the top of the field (G) are part of an interstitial exudate of fibrin (hematoxylin and eosin stain at medium power).


More on Eosinophilic Fasciitis

Overview: Eosinophilic Fasciitis
Differential Diagnoses & Workup: Eosinophilic Fasciitis
Treatment & Medication: Eosinophilic Fasciitis
Follow-up: Eosinophilic Fasciitis
Multimedia: Eosinophilic Fasciitis
References
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References

  1. Shulman LE. Diffuse fasciitis with eosinophilia: a new syndrome?. Trans Assoc Am Physicians. 1975;88:70-86. [Medline].

  2. Endo Y, Tamura A, Matsushima Y, Iwasaki T, Hasegawa M, Nagai Y. Eosinophilic fasciitis: report of two cases and a systematic review of the literature dealing with clinical variables that predict outcome. Clin Rheumatol. Sep 2007;26(9):1445-51. [Medline].

  3. Viallard JF, Taupin JL, Ranchin V, Leng B, Pellegrin JL, Moreau JF. Analysis of leukemia inhibitory factor, type 1 and type 2 cytokine production in patients with eosinophilic fasciitis. J Rheumatol. Jan 2001;28(1):75-80. [Medline].

  4. Dziadzio L, Kelly EA, Panzer SE, Jarjour N, Huttenlocher A. Cytokine abnormalities in a patient with eosinophilic fasciitis. Ann Allergy Asthma Immunol. Apr 2003;90(4):452-5. [Medline].

  5. Toquet C, Hamidou MA, Renaudin K, Jarry A, Foulc P, Barbarot S. In situ immunophenotype of the inflammatory infiltrate in eosinophilic fasciitis. J Rheumatol. Aug 2003;30(8):1811-5. [Medline].

  6. Kahari VM, Heino J, Niskanen L, et al. Eosinophilic fasciitis. Increased collagen production and type I procollagen messenger RNA levels in fibroblasts cultured from involved skin. Arch Dermatol. May 1990;126(5):613-7. [Medline].

  7. Peltonen J, Kahari L, Jaakkola S, et al. Evaluation of transforming growth factor beta and type I procollagen gene expression in fibrotic skin diseases by in situ hybridization. J Invest Dermatol. Mar 1990;94(3):365-71. [Medline].

  8. Mori Y, Kahari VM, Varga J. Scleroderma-like cutaneous syndromes. Curr Rheumatol Rep. Apr 2002;4(2):113-22. [Medline].

  9. Jinnin M, Ihn H, Yamane K, Asano Y, Yazawa N, Tamaki K. Serum levels of tissue inhibitor of metalloproteinase-1 and 2 in patients with eosinophilic fasciitis. Br J Dermatol. Aug 2004;151(2):407-12. [Medline].

  10. Moutsopoulos HM, Webber BL, Pavlidis NA, Fostiropoulos G, Goules D, Shulman LE. Diffuse fasciitis with eosinophilia. A clinicopathologic study. Am J Med. May 1980;68(5):701-9. [Medline].

  11. Barnes L, Rodnan GP, Medsger TA, Short D. Eosinophilic fasciitis. A pathologic study of twenty cases. Am J Pathol. Aug 1979;96(2):493-518. [Medline].

  12. Brent LH, Abruzzo JL. Localized eosinophilic fasciitis in a patient with rheumatoid arthritis. J Rheumatol. Oct 1985;12(5):987-9. [Medline].

  13. Allen SC. Eosinophilic fasciitis in an African--possible benefit of chloroquine treatment. Postgrad Med J. Oct 1984;60(708):685-6. [Medline].

  14. Nawata Y, Sueishi M, Koike T, Tomioka H. Eosinophilic fasciitis with autoimmune features. Arthritis Rheum. May 1983;26(5):688. [Medline].

  15. Lakhanpal S, Ginsburg WW, Michet CJ, et al. Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases. Semin Arthritis Rheum. May 1988;17(4):221-31. [Medline].

  16. Antic M, Lautenschlager S, Itin PH. Eosinophilic fasciitis 30 years after - what do we really know? Report of 11 patients and review of the literature. Dermatology. 2006;213(2):93-101. [Medline].

  17. Bischoff L, Derk CT. Eosinophilic fasciitis: demographics, disease pattern and response to treatment: report of 12 cases and review of the literature. Int J Dermatol. Jan 2008;47(1):29-35. [Medline].

  18. Wollheim FA, Lindstrom CG, Eiken O. Eosinophilic fasciitis complicated by carpal tunnel syndrome. J Rheumatol. Sep-Oct 1981;8(5):856-60. [Medline].

  19. Caspi D, Fishel R, Varon M, et al. Multisystem presentation of eosinophilic fasciitis. Rheumatol Rehabil. Nov 1982;21(4):218-21. [Medline].

  20. Choquet-Kastylevsky G, Kanitakis J, Dumas V, Descotes J, Faure M, Claudy A. Eosinophilic fasciitis and simvastatin. Arch Intern Med. Jun 11 2001;161(11):1456-7. [Medline].

  21. DeGiovanni C, Chard M, Woollons A. Eosinophilic fasciitis secondary to treatment with atorvastatin. Clin Exp Dermatol. Jan 2006;31(1):131-2. [Medline].

  22. Buchanan RR, Gordon DA, Muckle TJ, McKenna F, Kraag G. The eosinophilic fasciitis syndrome after phenytoin (dilantin) therapy. J Rheumatol. Sep-Oct 1980;7(5):733-6. [Medline].

  23. Granter SR, Barnhill RL, Duray PH. Borrelial fasciitis: diffuse fasciitis and peripheral eosinophilia associated with Borrelia infection. Am J Dermatopathol. Oct 1996;18(5):465-73. [Medline].

  24. Antón E. Failure to demonstrate Borrelia burgdorferi-specific DNA in lesions of eosinophilic fasciitis. Histopathology. Jul 2006;49(1):88-90. [Medline].

  25. Blauvelt A, Falanga V. Idiopathic and L-tryptophan-associated eosinophilic fasciitis before and after L-tryptophan contamination. Arch Dermatol. Aug 1991;127(8):1159-66. [Medline].

  26. Hibbs JR, Mittleman B, Hill P, Medsger TA Jr. L-tryptophan-associated eosinophilic fasciitis prior to the 1989 eosinophilia-myalgia syndrome outbreak. Arthritis Rheum. Mar 1992;35(3):299-303. [Medline].

  27. Lee P. Eosinophilic fasciitis: new associations and current perspectives [editorial]. J Rheumatol. Jan-Feb 1981;8(1):6-8. [Medline].

  28. Doyle JA, Connolly SM, Hoagland HC. Hematologic disease in scleroderma syndromes. Acta Derm Venereol. 1985;65(6):521-5. [Medline].

  29. Masuoka H, Kikuchi K, Takahashi S, Kakinuma T, Hayashi N, Furue M. Eosinophilic fasciitis associated with low-grade T-cell lymphoma. Br J Dermatol. Nov 1998;139(5):928-30. [Medline].

  30. Garcia VP, de Quiros JF, Caminal L. Autoimmune hemolytic anemia associated with eosinophilic fasciitis. J Rheumatol. Sep 1998;25(9):1864-5. [Medline].

  31. Hur JW, Lee HS, Uhm WS, et al. Eosinophilic fasciitis associated with autoimmune thyroiditis. Korean J Intern Med. Jun 2005;20(2):180-2. [Medline].

  32. Katz JD, Wakem CJ, Parke AL. L-tryptophan associated eosinophilia-myalgia syndrome. J Rheumatol. Nov 1990;17(11):1559-61. [Medline].

  33. Shulman LE. The eosinophilia-myalgia syndrome associated with ingestion of L- tryptophan. Arthritis Rheum. Jul 1990;33(7):913-7. [Medline].

  34. Kaufman LD, Krupp LB. Eosinophilia-myalgia syndrome, toxic-oil syndrome, and diffuse fasciitis with eosinophilia. Curr Opin Rheumatol. Nov 1995;7(6):560-7. [Medline].

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

  36. Abeles M, Belin DC, Zurier RB. Eosinophilic fasciitis: a clinicopathologic study. Arch Intern Med. May 1979;139(5):586-8. [Medline].

  37. Falanga V, Medsger TA Jr. Frequency, levels, and significance of blood eosinophilia in systemic sclerosis, localized scleroderma, and eosinophilic fasciitis. J Am Acad Dermatol. Oct 1987;17(4):648-56. [Medline].

  38. Kim SW, Rice L, Champlin R, Udden MM. Aplastic anemia in eosinophilic fasciitis: responses to immunosuppression and marrow transplantation. Haematologia (Budap). 1997;28(3):131-7. [Medline].

  39. Naschitz JE, Yeshurun D, Zuckerman E, Rosenbaum M, Misselevitch I, Shajrawi I. Cancer-associated fasciitis panniculitis. Cancer. Jan 1 1994;73(1):231-5. [Medline].

  40. Sugimoto T, Nitta N, Kashiwagi A. Usefulness of magnetic resonance imaging in eosinophilic fasciitis. Rheumatol Int. Jun 2007;27(8):791-2. [Medline].

  41. Moulton SJ, Kransdorf MJ, Ginsburg WW, Abril A, Persellin S. Eosinophilic fasciitis: spectrum of MRI findings. AJR Am J Roentgenol. Mar 2005;184(3):975-8. [Medline].

  42. Agnew KL, Blunt D, Francis ND, Bunker CB. Magnetic resonance imaging in eosinophilic fasciitis. Clin Exp Dermatol. Jul 2005;30(4):435-6. [Medline].

  43. Baumann F, Bruhlmann P, Andreisek G, et al. MRI for diagnosis and monitoring of patients with eosinophilic fasciitis. AJR Am J Roentgenol. Jan 2005;184(1):169-74. [Medline].

  44. Dybowski F, Neuen-Jacob E, Braun J. Eosinophilic fasciitis and myositis: use of imaging modalities for diagnosis and monitoring. Ann Rheum Dis. Apr 2008;67(4):572-4. [Medline].

  45. Bertken R, Shaller D. Chronic progressive eosinophilic fasciitis: report of a 20-year failure to attain remission. Ann Rheum Dis. Feb 1983;42(1):103-5. [Medline].

  46. Carneiro S, Brotas A, Lamy F, et al. Eosinophilic fasciitis (Shulman syndrome). Cutis. Apr 2005;75(4):228-32. [Medline].

  47. Daniel RS, Brown AN. Case report of unilateral eosinophilic fasciitis in a Vietnamese woman. Am J Med Sci. Feb 2009;337(2):153-4. [Medline].

  48. Cramer SF, Kent L, Abramowsky C, Moskowitz RW. Eosinophilic fasciitis. Immunopathology, ultrastructure, literature review,a nd consideration of its pathogenesis and relation to scleroderma. Arch Pathol Lab Med. Feb 1982;106(2):85-91. [Medline].

  49. Kähäri VM, Heino J, Niskanen L, Fräki J, Uitto J. Eosinophilic fasciitis. Increased collagen production and type I procollagen messenger RNA levels in fibroblasts cultured from involved skin. Arch Dermatol. May 1990;126(5):613-7. [Medline].

  50. Chan MK, Lages W. Eosinophilic fasciitis: visceral involvement. Arch Intern Med. Nov 1982;142(12):2201-2. [Medline].

  51. Tzaribachev N, Holzer U, Schedel J, Maier V, Klein R, Kuemmerle-Deschner J. Infliximab effective in steroid-dependent juvenile eosinophilic fasciitis. Rheumatology (Oxford). Jun 2008;47(6):930-2. [Medline].

  52. Tahara K, Yukawa S, Shoji A, Hayashi H, Tsuboi N. Long-term remission by cyclosporine in a patient with eosinophilic fasciitis associated with primary biliary cirrhosis. Clin Rheumatol. Sep 2008;27(9):1199-201. [Medline].

  53. Herson S, Brechignac S, Godeau P. Cimetidine in eosinophilic fasciitis. Ann Intern Med. Sep 1 1990;113(5):412-3. [Medline].

  54. Bukiej A, Dropinski J, Dyduch G, Szczeklik A. Eosinophilic fasciitis successfully treated with cyclosporine. Clin Rheumatol. Nov 2005;24(6):634-6. [Medline].

  55. Suzuki G, Itoh Y, Horiuchi Y. Surgical management of eosinophilic fasciitis of the upper extremity. J Hand Surg Br. Jun 1997;22(3):405-7. [Medline].

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Further Reading

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Keywords

eosinophilic fasciitis, EF, eosinophilia, scleroderma, systemic sclerosis, elevated sedimentation rate, elevated ESR, hypergammaglobulinemia, fascial thickening, hematologic disease, Shulman syndrome, Shulman's syndrome, peripheral eosinophilia, fasciitis, fibrosing disorders, diffuse fasciitis with eosinophilia

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Contributor Information and Disclosures

Author

Peter M Henning, DO, MAJ, MC, Fellow, Department of Rheumatology, Walter Reed Army Medical Center, Washington, DC
Peter M Henning, DO, MAJ, MC is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

George R Mount, MD, MAJ USA MC, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Attending Physician, Department of Rheumatology, Walter Reed Army Medical Center, Washington, DC
George R Mount, MD, MAJ USA MC is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Nicholas David Kortan, DO, CPT, MC,, Resident Physician, Department of Internal Medicine, Walter Reed Army Medical Center, Washington, DC
Nicholas David Kortan, DO, CPT, MC, is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Sherif Nasef, MD, Consulting Staff, Department of Internal Medicine, Division of Rheumatology, Lake Havasu Regional Medical Center
Sherif Nasef, MD is a member of the following medical societies: American College of Physicians, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, and American Medical Association
Disclosure: Nothing to disclose.

Kristine M Lohr, MD, MS, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology and Women's Health, University of Kentucky School of Medicine
Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Medical Women's Association
Disclosure: Nothing to disclose.

Medical Editor

John Varga, MD, Professor, Department of Internal Medicine, Division of Rheumatology, Northwestern University
John Varga, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Central Society for Clinical Research, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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