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Rom J Morphol Embryol
Rom J Morphol Embryol
RJME
Romanian Journal of Morphology and Embryology
1220-0522
2066-8279
Academy of Medical Sciences, Romanian Academy Publishing House, Bucharest

39020550
650224341347
10.47162/RJME.65.2.22
Case Report
Eosinophilic fasciitis: unraveling the clinical tapestry of a rare case and review of literature
Cherim Aifer 1
Bastian Alexandra Eugenia 2
Popp Cristiana Gabriela 2
Mihon Maia Ioana 3
Efrem Ion Cristian 45
Vreju Ananu Florentin 6
Ionescu Răzvan Adrian 1
1 Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
2 Department of Pathology, Colentina Clinical Hospital, Bucharest, Romania
3 Department of Rheumatology, Emergency County Clinical Hospital, Cluj, Romania
4 Department of Internal Medicine – Medical Semiology, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, Romania
5 Department of Internal Medicine, Philanthropy Clinical Hospital, Craiova, Romania
6 Department of Rheumatology, Emergency County Hospital, Craiova, Romania
Corresponding Author: Ion Cristian Efrem, Associate Professor, MD, PhD Department of Internal Medicine – Medical Semiology,Faculty of Dentistry University of Medicine and Pharmacy of Craiova 2 Petru Rareş Street 200349 Craiova Romania + 40785–216 697 cristian.efrem@umfcv.ro
Apr-Jun 2024
30 6 2024
65 2 341347
08 4 2024
11 7 2024
Copyright © 2024, Academy of Medical Sciences, Romanian Academy Publishing House, Bucharest
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open-access article distributed under the terms of a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Public License, which permits unrestricted use, adaptation, distribution and reproduction in any medium, non-commercially, provided the new creations are licensed under identical terms as the original work and the original work is properly cited.
Eosinophilic fasciitis (EF) remains a diagnostic challenge due to its rarity and resemblance to scleroderma. This case report aims to provide a cohesive exploration of EF’s clinical nuances, emphasizing the importance of accurate diagnosis and effective management. A 52-year-old male developed bilateral forearm and calf hardening, along with erythema, pruritus, and pain four months prior to the presentation in our Clinic. The symptoms initially debuted bilaterally in the forearms and progressed to involve the calves, distal arms, and thighs. Clinical examination revealed symmetrical plaques on forearms and calves, featuring erythematous, hyper, and hypopigmented elements extending proximally, a positive “groove sign” and a moderate difficulty in knee joint flexion. Despite these findings, the patient was generally in good condition, without any other notable clinical signs. Initial laboratory findings showed slightly increased percentual eosinophil levels, elevated C-reactive protein (CRP), normal erythrocyte sedimentation rate (ESR), and negative antinuclear and scleroderma specific antibodies. Magnetic resonance imaging (MRI) demonstrated enhanced fascial signal and thickening while the fascia-muscle biopsy revealed marked edema and inflammatory lymphoplasmacytic infiltrate, consistent with the diagnosis of EF. The patient showed a favorable response to systemic corticosteroids. EF predominantly affects males aged 30 to 60 and is characterized by a sudden onset and unclear etiological factors. Differential diagnosis requires careful exclusion of scleroderma and other mimicking conditions. Diagnostic modalities such as skin-muscle biopsy and MRI reveal characteristic findings like inflammatory infiltrate and fascial thickening. Accurate diagnosis and differentiation from scleroderma are crucial, with early intervention involving glucocorticoids and immunosuppressive agents improving long-term outcomes.

Shulman’s disease
eosinophilic fasciitis
fibrosis
corticosteroids
biopsy
magnetic resonance imaging
==== Body
pmcIntroduction

First described in 1974 by Shulman [1], and by Rodnan et al. in 1975 [2], eosinophilic fasciitis (EF) is considered a rare disease, and many cases go unreported, resulting in a lack of clarity regarding its prevalence. Some authors suggest a higher prevalence in male patients, others in female patients, while others argue that there is no sex difference [3, 4, 5, 6, 7, 8]. The disease is affecting usually middle-aged patients [9] with few cases described with childhood debut [10, 11, 12, 13, 14, 15, 16]. The onset of the disease is sudden in approximately half of the patients. The underlying factors and processes leading to EF are currently ill-defined. The cause of this condition is unclear, although an autoimmune mechanism is presumed. Strenuous activity has been described as a trigger factor [14, 15, 16, 17]. Symptoms include bilateral and symmetrical hardening of the skin in the extremities, resembling scleroderma, associated with erythema, tenderness of the skin and deep fascia leading to joint contractures as it advances. However, unlike scleroderma, patients are not affected by internal organ damage; additionally, the hands and face are not interested, and the Raynaud phenomenon is not characteristic. In 29–40% of patients, morphea can also be associated. Diagnostic procedures commonly employed include full-thickness skin to muscle biopsy which shows inflammatory infiltrate and fascial thickening and magnetic resonance imaging (MRI) which demonstrates increased T2 signal and increased enhancement of the structures observed on fat-suppressed T1 images after gadolinium administration. The main treatment includes oral glucocorticoids and depending on the treatment response or as a corticosteroid-sparing option for patients needing prolonged corticosteroid use, Methotrexate or other immunosuppressive drugs may be incorporated into the regimen.

Case presentation

A 52-year-old male presented with symmetric, bilateral hardening and erythema of the forearms and calves with sparing of the hand and legs, which debuted four months prior to the presentation in our Clinic. The lesions extended centripetally to the distal arms and thighs, on the inferior abdominal wall and on the upper back and were associated with pruritus and pain, the latter demonstrating amelioration subsequent to self-administration of analgesics. Additionally, the patient complained of difficult swallowing which appeared three years ago with no progression, and a 5 kg weight loss in the last four months with preserved appetite.

The symptoms initially manifested four months ago in the forearm region, subsequently appearing bilaterally on the calves, and later progressing to the distal arms, distal thighs, inferior abdominal wall, and upper back.

Two months prior to the presentation in our Clinic, the patient consulted the local hospital for erythema, swelling and stiffness of the forearms and calves without improvement. Later on, he was consulted in a dermatology clinic where he underwent a skin biopsy that demonstrated collagen deposition and lymphoplasmacytic infiltrate. The dermatologist proposed two diagnostic considerations: Buschke’s scleredema and scleroderma. Despite the initiation of antifibrotics, Pentoxifylline, Piascledine, Penicillin infusions, and topical corticosteroids, the patient showed no signs of improvement. No systemic corticosteroids were initiated.

The patient reported no myalgia, muscular weakness, arthritis, fatigue, dyspnea, swelling of the fingers, or Raynaud phenomenon.

There was no indication of strenuous physical activity in the patient’s history before the onset of the disease. Nonetheless, the patient acknowledged using an herbicide containing Florasulam (6.25 g/L) and 2,4-D 2-Ethylhexyl ester (300 g/L), in the weeks leading up to the manifestation of symptoms.

The patient’s past medical records indicate a five-year history of treated hypertension, an appendicectomy in his twenties, and a diagnosis of Helicobacter pylori-positive gastritis 15 years ago. Family history revealed cardiovascular disease in both parents, with no other documented significant health conditions noted.

Upon clinical examination, the patient presented hardened, erythematous, hyper and hypopigmented plaques distributed symmetrically on the forearms (Figure 1) and legs (Figure 2), with a moderate difficulty in knee joint flexion but no mobility restriction in the upper arms. The hands remained unaffected, while the legs exhibited hyperpigmented plaques (Figure 2) with no other notable findings. The calves also exhibited a distinct lack of normal hair in certain areas and the skin displayed a shiny appearance (Figure 2). Bilateral positivity of the “groove sign” was observed on the forearms when the upper arms were abducted (Figure 3). On the inferior abdominal region, the patient exhibited a hardened horizontal plaque restricting inspirations. Additionally, the patient presented hyperpigmented plaques on the upper back which resembled morphea (Figure 4).

No fever, gastrointestinal (GI), or urinary symptoms were noted, the cardiorespiratory examination normal, and no lymph node enlargement was identified.

Blood tests showed increased percentual levels of eosinophils and monocytes, accompanied by a reduction in lymphocytes; however, there were no changes in the absolute values.

Figure 1 Hyperpigmented and hypopigmented lesions associated with induration located symmetrically on the forearms

Figure 2 Hyperpigmented and hypopigmented lesions associated with induration located symmetrically on the calves. Loss of hair. Hyperpigmented plaques on the dorsal aspect of the foot

Figure 3 Positive “groove sign”

Figure 4 Hyperpigmented plaques on the upper back

C-reactive protein (CRP) was moderately increased (16.46 mg/dL, normal values: <5 mg/dL), while the erythrocyte sedimentation rate (ESR) was normal (17 mm/h, normal values: <20 mm/h). Beta-2 microglobulin levels were slightly increased (2.89 mg/L, normal values: 0.80–2.20 mg/L). To our surprise, anti-Borrelia immunoglobulin M (IgM) antibodies were present, while immunoglobulin G (IgG) was absent. A Western blot immunoassay was conducted subsequently that concluded it was a false positive result. Creatine phosphokinase (CPK), serum aldolase, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase, blood urea nitrogen (BUN), creatinine, sodium, potassium and the urine sediment were all within normal limits. Autoantibodies to histidyl-transfer ribonucleic acid (tRNA) synthetase (anti-Jo-1), and anticentromere, anti-U1 ribonucleoprotein (RNP), anti-topoisomerase I (anti-Scl-70) antibodies, as well as quantitative anti-nuclear antibody (ANA) were within normal limits. The immunoelectrophoresis with immunofixation and the peripheral blood smear showed no abnormal findings.

It is noteworthy that in the previous consults, the patient did present a moderate hypergammaglobulinemia [gamma globulin: 19.8% (normal values: 11.1–18.8%)] and the absolute eosinophil count was slightly increased [eosinophils: 0.58×103/μL (normal values: 0.00–0.50×103/μL)] in one of the two previous hospital presentations, and the CRP was also slightly increased while the ESR was normal. Other specific investigations from the previous presentation that were within normal limits included: nasal and pharyngeal exudate cultures, anti-streptolysin O, complement C3, C4, rheumatoid factor, thyroid stimulating hormone (TSH), free thyroxine (T4) levels, prostate specific antigen (PSA), carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), IgM, total serum proteins, serum immunoelectrophoresis, Treponema pallidum hemagglutination assay and venereal disease research laboratory test.

During the hospitalization in our Clinic, we conducted a biopsy from the triceps muscle and fascia, which showed fascial marked edema, hyperemia, moderate fibrosis and marked diffuse inflammatory infiltrate with lymphocytes, plasma cells, histiocytes and very rare eosinophils, distributed diffusely and perivascularly, with extension in the adipose tissue, isolating groups of adipocytes, findings that are compatible with EF diagnosis (Figure 5A, 5B).

Figure 5 (A and B) Enlarged, edematous, thickened and fibrosed fascia with diffuse and perivascular lymphoplasmacytic infiltrate, with numerous macrophages and rare eosinophilic granulocytes, spreading to the adjacent muscle fibers, identified on paraffin-embedded muscle tissue sections and cryosections. Hematoxylin–Eosin (HE) staining: (A) ×100; (B) ×200.

Figure 6 Symmetrical hypersignal short tau inversion recovery (STIR), T2 and proton density (PD) is visible at the level of the muscular fascia of the gastrocnemius muscles bilaterally and symmetrically, with the appearance of fascial edema and diffuse contrast uptake at this level, circumferentially affecting the muscle surface (likely, sign of fascial inflammation)

We also performed a contrast enhanced full body computed tomography (CT) scan that identified a significant thickening of the gastric wall, with no other significant findings. Consequently, the patient underwent an upper GI endoscopy that showed no alarming mucosal findings. Biopsies were taken, and the results concluded chronic gastritis (Figure 7) associated with H. pylori infection (Figure 8).

Figure 7 Gastric oxyntic mucosa with mild chronic infiltrate in lamina propria. HE staining, ×100

Figure 8 Helicobacter pylori is easily identifiable in gastric foveola. Giemsa staining, ×400

Based on clinical and paraclinical findings, and after ruling out scleroderma, a diagnosis of EF was established.

We then started a 3-day course of intravenous Methylprednisolone at 500 mg/day, followed by oral Methylprednisolone starting at 72 mg/day (0.8 mg per kg per day) gradually decreasing the dose, over several months, associated with Esomeprazole and Sucralfate.

The patient’s symptoms improved after the intravenous treatment, and the CRP normalized.

Discussions

EF is classified as a rare disorder, with no reliable data regarding its true prevalence, and no treatment guidelines. Certain authors suggest a greater occurrence among male patients, whereas some argue for a higher prevalence among female patients, and yet others contend that there is no discernible difference between sexes [3, 4, 5, 6, 7, 8]. Typically, this condition manifests in middle-aged individuals [9, 19], although there have been a few documented cases with an onset during childhood [10, 11, 12, 13, 14, 15, 16]. The precise etiological factors and pathogenic mechanisms remain unknown. On average, it takes approximately 11 months to diagnose EF [6]. Strenuous physical activity or trauma has been identified as a potential trigger factor [3, 5, 6, 14, 15, 16, 17, 20, 21]. Other potential trigger factors are autoimmune diseases [3, 22, 23], exposure to certain medications such as statins [24, 25, 26], heparin [27, 28, 29], Ramipril [30], Nivolumab [31] or toxins [28, 29, 32, 33], hematological disorders [34], solid organ cancers [34], infection with Borrelia burgdorferi [35], [36] and others [37, 38, 39, 40, 41, 42]. In our particular case, we discovered positive anti-Borrelia IgM antibodies (which we later demonstrated were false positive) and a history of exposure to toxins as a potential cause.

While eosinophilia is classically described in this disease, not all patients exhibit elevated eosinophils in the blood or eosinophilic infiltrates on biopsy [1, 3, 7, 8, 22], as was our case. It is suggested that eosinophilia typically manifests in the early stages of the disease and may diminish in the later stages [43]. Our patient illustrated this pattern, displaying a slight increase in the absolute eosinophil count approximately 1–2 months after the disease onset. However, two months later, there was only an elevated percentual eosinophil count.

The typical biopsy shows edema and inflammatory infiltrate with plasmocytes, lymphocytes, eosinophils and histiocytes in the deep fascia and subcutaneous tissue and the fascia is thickened. In later phases, the fascia becomes sclerotic, and the inflammatory infiltrate can disappear [3, 5, 7]. The histological findings can also be seen at the level of muscle, interesting all layers (epi, peri, endomysium and muscle fibers) [44]. Noteworthy, the absence of eosinophils in the biopsy does not exclude the EF diagnosis [45]. In both previous biopsies (skin and muscle-fascia), our patient did not display elevated levels of eosinophils.

Clinical manifestations evolve through several stages and encompass bilateral and symmetrical cutaneous redness, edema and pain involving the extremities [1, 3, 4, 7, 19], trunk [8] and neck. The hands and face are spared. Following this, induration and fibrosis progress, resulting in the occurrence of joint contractures, as observed in our patient. In this stage, the skin texture can resemble the texture of an “orange peel” also known as “peau d’orange” [18]. Certain patients may also concurrently display morphea plaques [46], as was observed in our case. In addition, the “groove sign” can also be positive: linear depression following the path of blood vessels [1, 47]. It is better observed when the patient abducts the arms.

EF may also present with accompanying symptoms such as fever, fatigue, weight loss, arthralgias, arthritis, myalgias, and carpal tunnel syndrome [48, 49]. Notably, in our patient, these manifestations were limited, with only a slight weight loss observed. Internal organ involvement is notably absent in most cases [18], however, some cases associated with restrictive lung disease, pleural effusion, pericardial and renal involvement have been described [50, 51, 52]. Raynaud’s phenomenon is not usually reported [18].

Patients may present eosinophilia, increased acute phase reactants (ESR, CRP), polyclonal hypergammaglobulinemia, normal CPK and increased aldolase, which can correlate with the activity of the disease [18, 19, 43, 53, 54, 55]. One explanation for the disparity in CPK and aldolase levels is attributed to the capability of superficial muscle fibers to secrete aldolase but not CPK [56]. In our case, aldolase and CPK levels were within normal limits.

Although specific antibodies are generally absent in patients with EF, they are usually screened for excluding scleroderma. It is noteworthy that 15–20% of individuals with EF may exhibit positive anticentromere, anti-topoisomerase I, and anti-RNA polymerase III autoantibodies; however, this was not observed in our patient.

Differential diagnosis includes systemic sclerosis, scleromyxedema, nephrogenic systemic fibrosis, toxic oil syndrome, eosinophilia–myalgia syndrome and graft versus host disease.

Standard diagnostic modalities encompass full-thickness skin-to-muscle biopsy and MRI [57, 58, 59, 60]. Fascial inflammation is confirmed by increased T2 signal in the subcutaneous and deep fascia and the enhancement of the structures on fat-suppressed T1 images after gadolinium administration [18, 61].

Ultrasound is predominantly utilized as a supplementary tool for MRI and biopsy procedures [61, 62].

Several diagnostic criteria have been proposed, all-encompassing considerations of clinical manifestations, biopsy, and MRI imaging. Our patient fulfilled both diagnostic criteria sets (Tables 1, 2) [18, 53].

Table 1 Diagnostic criteria for eosinophilic fasciitis [53]

Major criterion

	Symmetrical plate-like sclerotic lesions are present on the four limbs.

	
Minor criteria

	1. The histology of a skin biopsy that incorporates fascia shows fibrosis of the subcutaneous connective tissue, with thickening of the fascia and cellular infiltration of eosinophils and monocytes.

2. Thickening of the fascia on magnetic resonance imaging (MRI).

	
A definitive diagnosis is made when a patient has the major criterion and one of the minor criteria, or the major criterion and two of the minor criteria [53].

Table 2 Proposed criteria for the diagnosis of patients with eosinophilic fasciitis [18]

Major criteria

	1. Swelling, induration, and thickening of the skin and subcutaneous tissue that is symmetrical or non-symmetrical, diffuse (extremities, trunk and abdomen) or localized (extremities).

2. Fascial thickening with accumulation of lymphocytes and macrophages with or without eosinophilic infiltration (determined by full-thickness wedge biopsy of clinically affected skin).

	
Minor criteria

	1. Eosinophilia (normal: 0.5×10 9 /L).

2. Hypergammaglobulinemia (normal: 1.5 g/L).

3. Muscle weakness and/or elevated aldolase levels.

4. “Groove sign” and/or “peau d’orange”.

5. Hyperintense fascia on magnetic resonance imaging (MRI) T2-weighted images.

	
Exclusion criterion: diagnosis of systemic sclerosis. Presence of both major criteria, or one major criterion plus two minor criteria, establishes the diagnosis of eosinophilic fasciitis [18]

Primary therapeutic interventions in EF include glucocorticoids [3, 4, 7], starting with equivalent doses of 1 mg/kg/day of Prednisone and a corticosteroid-sparing agent for patients necessitating prolonged corticosteroid use, such as Methotrexate [7, 63, 64], Cyclosporine [65, 66], Cyclophosphamide, Tocilizumab [67, 68], Rituximab [69]. The utilization of Psoralen and ultraviolet A (PUVA) therapy has also been proven to be effective in treating EF [70, 71]. Our patient demonstrated substantial improvement with the administration of glucocorticoids, and this positive response persisted even with gradual dose reduction. Early treatment of the disease with glucocorticoids and an additional immunosuppressive agent has been suggested to improve the remission rate and help in the reduction of steroid intake.

Conclusions

EF is a rare disease whose diagnosis is based on clinical awareness of some nonspecific signs. It can easily be misdiagnosed as scleroderma or Buschke’s scleredema. We emphasize a thorough clinical examination and diagnostic work-up in order to avoid underdiagnosis. Early treatment intervention is of paramount importance for improving the prognosis and quality of life for individuals suffering from EF. Within our case, we have identified a potential trigger factor that has not been previously described in the literature: an herbicide containing Florasulam (6.25 g/L) and 2,4-D 2-Ethylhexyl ester (300g/L).

Conflict of interests

The authors declare that they have no conflict of interests.
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References

1 Shulman LE Diffuse fasciitis with eosinophilia: a new syndrome Trans Assoc Am Physicians 1975 88 70 86 1224441
2 Rodnan GP DiBartolomeo A Medsger TA Proceedings: Eosinophilic fasciitis. Report of six cases of a newly recognized scleroderma-like syndrome Arthritis Rheum 1975 18 5 525 525
3 Lakhanpal S Ginsburg WW Michet CJ Doyle JA Moore SB Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases Semin Arthritis Rheum 1988 17 4 221 31 3232080
4 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 2008 47 1 29 35
5 Mertens JS Seyger MMB Thurlings RM Radstake TRDJ de Jong Morphea and eosinophilic fasciitis: an update Am J Clin Dermatol 2017 18 4 491 512 28303481
6 Wright NA Mazori DR Patel M Merola JF Femia AN Vleugels RA Epidemiology and treatment of eosinophilic fasciitis: an analysis of 63 patients from 3 tertiary care centers JAMA Dermatol 2016 152 1 97 99 26559760
7 Lebeaux D Francès C Barete S Wechsler B Dubourg O Renoux J Maisonobe T Benveniste O Gatfossé M Bourgeois P Amoura Z Cacoub P Piette JC Sène D Eosinophilic fasciitis (Shulman disease): new insights into the therapeutic management from a series of 34 patients Rheumatology (Oxford) 2012 51 3 557 561 22120602
8 Endo Y Tamura A Matsushima Y Iwasaki T Hasegawa M Nagai Y Ishikawa O Eosinophilic fasciitis: report of two cases and a systematic review of the literature dealing with clinical variables that predict outcome Clin Rheumatol 2007 26 9 1445 1451 17345001
9 Mazori DR Femia AN Vleugels RA Eosinophilic fasciitis: an updated review on diagnosis and treatment Curr Rheumatol Rep 2017 19 12 74 74 29101481
10 Uçkun A Sipahi T Akgün D Oksal A Eosinophilic fasciitis successfully treated with oral Hydroxyzine: a new therapeutic use of an old drug Eur J Pediatr 2002 161 2 118 119 11954748
11 Rodríguez Bandera Sebaratnam DF de Lucas Diagnostic ultrasonography in a child with eosinophilic fasciitis Clin Exp Dermatol 2019 44 1 85 86 30168166
12 Wu TT Goodarzi H Wang J Novoa R Teng JMC Imatinib as a potentially effective therapeutic alternative in corticosteroid-resistant eosinophilic fasciitis Pediatr Dermatol 2020 37 6 1171 1172 32970342
13 Ergun T Seckin D Salman A Ocak ES Yucelten AD Direskeneli H Ekinci G Bayik M Atypical presentations of eosinophilic fasciitis Indian J Dermatol Venereol Leprol 2016 82 1 47 52 26728810
14 Alexanian C Cheng M Kiuru M Wang JZ Le ST Tartar DM Eosinophilic fasciitis presenting as a unilateral, solitary plaque Dermatol Online J 2019 25 8 13030 13030
15 Namita U Rajesh S Vidya C A rarer association of eosinophilic fasciitis J Family Med Prim Care 2019 8 6 2158 2160 31334201
16 Ortega-Loayza AG Merritt BG Groben PA Morrell DS Eosinophilic fasciitis in a female child J Am Acad Dermatol 2008 58 5 Suppl 1 S72 S74 18489052
17 Watanabe S Kondo M Ichishi M Hayashi A Matsushima Y Hirokawa Y Habe K Yamanaka K Eosinophilic fasciitis induced by a game of drumming probably via type 2 innate immunity Int J Rheum Dis 2022 25 3 364 366 35023307
18 Pinal-Fernandez I Selva-O’Callaghan A Grau JM Diagnosis and classification of eosinophilic fasciitis Autoimmun Rev 2014 13 4-5 379 382 24424187
19 Ihn H Eosinophilic fasciitis: from pathophysiology to treatment Allergol Int 2019 68 4 437 439 30910631
20 Aun JA Knox RS Roberts JE The enigmatic fascia: eosinophilic fasciitis J Osteopath Med 2021 121 6 555 559 33783170
21 Lamback EB Resende FSS Lenzi TCR Eosinophilic fasciitis An Bras Dermatol 2016 91 5 Suppl 1 57 59 28300895
22 Lebeaux D Sène D Eosinophilic fasciitis (Shulman disease) Best Pract Res Clin Rheumatol 2012 26 4 449 458 23040360
23 de Masson Bouaziz JD de Latour Benhamou Y Moluçon-Chabrot C Bay JO Laquerrière A Picquenot JM Michonneau D Leguy-Seguin V Rybojad M Bonnotte B Jardin F Lévesque H Bagot M Socié G Severe aplastic anemia associated with eosinophilic fasciitis: report of 4 cases and review of the literature Medicine (Baltimore) 2013 92 2 69 81 23429351
24 Serrano-Grau P Mascaró-Galy JM Iranzo P Desarrollo de fascitis eosinofílica tras la ingesta de Simvastatina [Eosinophilic fasciitis after taking Simvastatin] Actas Dermosifiliogr 2008 99 5 420 421 18501180
25 DeGiovanni C Chard M Woollons A Eosinophilic fasciitis secondary to treatment with Atorvastatin Clin Exp Dermatol 2006 31 1 131 132 16309506
26 Choquet-Kastylevsky G Kanitakis J Dumas V Descotes J Faure M Claudy A Eosinophilic fasciitis and Simvastatin Arch Intern Med 2001 161 11 1456 1457 11386897
27 Cantini F Salvarani C Olivieri I Padula A Senesi C Bellandi F Truglia MC Niccoli L Palchetti R Possible association between eosinophilic fasciitis and subcutaneous heparin use J Rheumatol 1998 25 2 383 385 9489839
28 Treichel AM Zheng DX Ranasinghe GC Zeft AS Bergfeld WF Bayart CB Eosinophilic fasciitis in a young male auto mechanic exposed to organic solvents Reumatismo 2023 75 3
29 Chan WH Lewis DJ Kim EJ Aung PP Duvic M Generalized morphea/eosinophilic fasciitis overlap after epoxy exposure JAAD Case Rep 2018 4 2 175 178 29892660
30 Serratrice J Pellissier JF Champsaur P Weiller PJ Fasciitis with eosinophilia: a possible causal role of angiotensin converting enzyme inhibitor] Rev Neurol (Paris) 2007 163 2 241 243 17351545
31 Le Tallec Lescoat A Ballerie A Cador B Lena H Ricordel C Damien S Lebbe C Jego P Belhomme N Eosinophilic fasciitis triggered by Nivolumab: a remarkable efficacy of the mTOR inhibitor Sirolimus J Thorac Oncol 2020 15 2 e29 e30 32127188
32 Hayashi N Igarashi A Matsuyama T Harada S Eosinophilic fasciitis following exposure to Trichloroethylene: successful treatment with Cyclosporin Br J Dermatol 2000 142 4 830 832 10792252
33 Posada de Alonso Gordo Castro García Díaz de Abaitua Borda Tabuenca Oliver Toxic oil syndrome, scleroderma, and eosinophilic fasciitis Arthritis Rheum 1984 27 10 1200 1200 6487400
34 Joly-Chevrier M Gélinas A Ghazal S Moussa S McCuaig CC Piram M Mereniuk A Litvinov IV Osman M Pehr K Netchiporouk E Morphea, eosinophilic fasciitis and cancer: a scoping review Cancers (Basel) 2023 15 18 4450 4450 37760419
35 Granter SR Barnhill RL Duray PH Borrelial fasciitis: diffuse fasciitis and peripheral eosinophilia associated with Borrelia infection Am J Dermatopathol 1996 18 5 465 473 8902092
36 Hashimoto Y Takahashi H Matsuo S Hirai K Takemori N Nakao M Miyamoto K Iizuka H Polymerase chain reaction of Borrelia burgdorferi flagellin gene in Shulman syndrome Dermatology 1996 192 2 136 139 8829496
37 Silló P Pintér D Ostorházi E Mazán M Wikonkál N Pónyai K Volokhov DV Chizhikov VE Szathmary S Stipkovits L Kárpáti S Eosinophilic fasciitis associated with Mycoplasma arginini infection J Clin Microbiol 2012 50 3 1113 1117 22189109
38 Buchanan RR Gordon DA Muckle TJ McKenna F Kraag G The eosinophilic fasciitis syndrome after Phenytoin (Dilantin) therapy J Rheumatol 1980 7 5 733 736 7441663
39 Florell SR Egan CA Gregory MC Zone JJ Petersen MJ Eosinophilic fasciitis occurring four weeks after the onset of dialysis in a renal failure patient J Cutan Med Surg 2001 5 1 33 36 11281432
40 Sherber NS Wigley FM Paget SA Diffuse fasciitis with eosinophilia developing after local irradiation for breast cancer Clin Rheumatol 2009 28 6 729 732 19224125
41 Minciullo PL Morabito F Mandaglio R Iacopino P Gangemi S Eosinophilic fasciitis associated with autoimmune phenomena after bone marrow transplantation: report of two cases Clin Rheumatol 2006 25 1 80 82 15988557
42 Hamilton ME Eosinophilic fasciitis associated with L-tryptophan ingestion Ann Rheum Dis 1991 50 1 55 56 1994870
43 Nashel J Steen V The use of an elevated aldolase in diagnosing and managing eosinophilic fasciitis Clin Rheumatol 2015 34 8 1481 1484 25245261
44 Huang KW Chen XH Pathology of eosinophilic fasciitis and its relation to polymyositis Can J Neurol Sci 1987 14 4 632 637 3690437
45 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 16902285
46 Moulin C Cavailhes A Balme B Skowron F Morphoea-like plaques revealing an eosinophilic (Shulman) fasciitis Clin Exp Dermatol 2009 34 8 e851 e853 19843081
47 Ferreli C Gasparini G Parodi A Cozzani E Rongioletti F Atzori L Cutaneous manifestations of scleroderma and scleroderma-like disorders: a comprehensive review Clin Rev Allergy Immunol 2017 53 3 306 336 28712039
48 Trallero Araguas Selva O’Callaghan Simeón Aznar Sanjurjo Golpe García-Patos V Vilardell Tarrés Fascitis eosinofílica: estudio de 10 pacientes [Eosinophilic fasciitis: analysis of a series of 10 patients] Med Clin (Barc) 2005 125 4 145 148 15989857
49 Serratrice G Pellissier JF Roux H Quilichini P Fasciitis, perimyositis, myositis, polymyositis, and eosinophilia Muscle Nerve 1990 13 5 385 395 2189069
50 Killen JW Swift GL White RJ Eosinophilic fasciitis with pulmonary and pleural involvement Postgrad Med J 2000 76 891 36 37 10622780
51 Rizzo S Eosinophilic pleuropericarditis and fasciitis. A new case Monaldi Arch Chest Dis 2002 57 5-6 311 313 12814048
52 Kirschstein M Helmchen U Jensen R Küster RM Lehmann H Kidney involvement in a 17-year-old boy with eosinophilic fasciitis Clin Nephrol 1999 52 3 183 187 10499315
53 Jinnin M Yamamoto T Asano Y Ishikawa O Sato S Takehara K Hasegawa M Fujimoto M Ihn H Diagnostic criteria, severity classification and guidelines of eosinophilic fasciitis J Dermatol 2018 45 8 881 890 29235676
54 Yamamoto T Ito T Asano Y Sato S Motegi SI Ishikawa O Matsushita T Takehara K Makino T Okiyama N Fujimoto M Jinnin M Ihn H Characteristics of Japanese patients with eosinophilic fasciitis: a brief multicenter study J Dermatol 2020 47 12 1391 1394 32860239
55 Fujimoto M Sato S Ihn H Kikuchi K Yamada N Takehara K Serum aldolase level is a useful indicator of disease activity in eosinophilic fasciitis J Rheumatol 1995 22 3 563 565 7783084
56 Nakajima H Fujiwara S Shinoda K Ohsawa N Magnetic resonance imaging and serum aldolase concentration in eosinophilic fasciitis Intern Med 1997 36 9 654 656 9313113
57 Kirchgesner T Dallaudière B Omoumi P Malghem J Vande Berg Lecouvet F Houssiau F Galant C Larbi A Eosinophilic fasciitis: typical abnormalities, variants and differential diagnosis of fasciae abnormalities using MR imaging Diagn Interv Imaging 2015 96 4 341 348 25746223
58 Moulton SJ Kransdorf MJ Ginsburg WW Abril A Persellin S Eosinophilic fasciitis: spectrum of MRI findings AJR Am J Roentgenol 2005 184 3 975 978 15728627
59 Baumann F Brühlmann P Andreisek G Michel BA Marincek B Weishaupt D MRI for diagnosis and monitoring of patients with eosinophilic fasciitis AJR Am J Roentgenol 2005 184 1 169 174 15615969
60 Barnes L Rodnan GP Medsger TA Short D Eosinophilic fasciitis. A pathologic study of twenty cases Am J Pathol 1979 96 2 493 518 474708
61 Chohan S Wong N Hanson J Darwish M Osto M Daveluy S Diagnostic imaging for eosinophilic fasciitis: a systematic review JAAD Int 2023 13 10 12 37575513
62 Mondal S Goswami RP Sinha D Ghosh A Ultrasound is a useful adjunct in diagnosis of eosinophilic fasciitis Rheumatology (Oxford) 2015 54 11 2041 2041 26316576
63 Berianu F Cohen MD Abril A Ginsburg WW Eosinophilic fasciitis: clinical characteristics and response to Methotrexate Int J Rheum Dis 2015 18 1 91 98 25530187
64 Janzen L Jeffery JR Gough J Chalmers IM Response to Methotrexate in a patient with idiopathic eosinophilic fasciitis, morphea, IgM hypergammaglobulinemia, and renal involvement J Rheumatol 1995 22 10 1967 1970 8992001
65 Debusscher L Bitar N De Maubeuge De Conninck Stryckmans P Eosinophilic fasciitis and severe aplastic anemia: favorable response to either antithymocyte globulin or Cyclosporine A in blood and skin disorders Transplant Proc 1988 20 3 Suppl 4 310 313 3381290
66 Kato T Nakajima A Soejima M Nagai R Yago T Tanohara K Ichida H Masuda I Yamada T Taniguchi A Akiyama Y Mimura T Tsuchida T Kamatani N Hara M Therapeutic efficacy of intravenous Cyclophosphamide concomitant with moderate- to high-dose Prednisolone in two patients with fasciitis panniculitis syndrome Mod Rheumatol 2008 18 2 193 199 18286355
67 Brandy-García AM Fernández S Pampín-Sánchez R Tocilizumab in the treatment of eosinophilic fasciitis: case report and literature review Rev Clin Esp (Barc) 2022 222 7 440 442 35305958
68 El Iskandarani Khasho M Merashli M Tocilizumab in the treatment of eosinophilic fasciitis: a case study and review of literature Mediterr J Rheumatol 2023 34 1 78 85 37223590
69 Kougkas N Bertsias G Papalopoulos I Repa A Sidiropoulos P Avgoustidis N Rituximab for refractory eosinophilic fasciitis: a case series with long-term follow-up and literature review Rheumatol Int 2021 41 10 1833 1837 34009397
70 Schiener R Behrens-Williams SC Gottlöber P Pillekamp H Peter RU Kerscher M Eosinophilic fasciitis treated with Psoralen-ultraviolet A bath photochemotherapy Br J Dermatol 2000 142 4 804 807 10792237
71 Weber HO Schaller M Metzler G Röcken M Berneburg M Eosinophilic fasciitis and combined UVA1-retinoid-corticosteroid treatment: two case reports Acta Derm Venereol 2008 88 3 304 306 18480946
