WELLS SYNDROME-RELATED TO TETANUS VACCINE

A 69-year-old woman was admitted to the Surgery Department of our hosp ital in November 1993 because of persistent erythematous skin lesions suspected clinically to be infectious cellulitis. Two months before ad mission she had noticed a red itchy pruriginous plaque, measuring 10 x 5 cm, on her left buttock that had become larger in spite of treatmen t with oral antimicrobials. One month before entry, two more lesions f lared up on her right buttock and left groin that soon became infiltra ted. She did not notice any systemic symptoms, Past history of urticar ia, atopy, tinea infection, or insect bites was not recalled. Two mont hs before the first skin lesion erupted, the second dose of a tetanus vaccine had been given to the patient. The patient's temperature was 3 6.5 degrees C on admission. On physical examination the patient appear ed well and there were no systemic abnormalities. Examination of the s kin revealed a red indurated plaque covering her left buttock and anot her one measuring 4 x 5 cm on the right buttock. A red nodular lesion, 3 x 2 cm in size, on her left groin was also noticed (Fig. 1). Labora tory investigation revealed a total white count of 9.7 x 10(3)/mm(3), with 68% neutrophils and 22% lymphocytes. Erythrocyte sedimentation ra te was 110/h. Her erythrocyte count was 3.33 x 10(6)/mm(3). Blood gluc ose, kidney and liver function tests, and complement were all normal, and a polyclonal hypergammaglobulinemia of 23 g/L was seen on immunoel ectrophoresis. Antinuclear antibodies (ANA) and alpha-1-antitrypsin an tibodies were negative. Parenteral antibiotic therapy with penicillin and clindamycin was started with no improvement. After surgical debrid ement, no purulent exudate was found. A skin biopsy specimen of an inf iltrated plaque was taken, showing an inflammatory infiltrate of lymph ocytes and eosinophils, mostly perivascular, in the superficial and de ep dermis, but especially in the deep subcutaneous tissue, with histio cytes and clusters of eosinophilic granules on the collagen fibers. Eo sinophilic cellulitis (Wells' syndrome) was diagnosed and therapy with 20 mg/day of prednisone was started immediately. The skin lesions imp roved in a few days and the dose was tapered 3 weeks after starting th erapy with oral steroids, She has not experienced any recurrence.