A rare case of papular‐purpuric “gloves and socks” syndrome associated with influenza

Abstract

Papular‐purpuric “gloves and socks” syndrome (PPGSS) is a unique, self‐limited dermatosis characterized by edema, erythema, and pruritic petechiae and papules in a distinct “gloves and socks” distribution. This is often accompanied by systemic symptoms, including fever, lymphadenopathy, asthenia, myalgia, and arthralgias. PPGSS has also been described as a manifestation of an underlying immunological mechanism that can be triggered by viral or drug‐related antigens. A 32‐year‐old male developed a painful eruption on the bilateral hands and feet after being diagnosed with influenza B. On examination, scattered papular purpura with occasional overlying scale was noted on the bilateral hands, fingers, feet, toes, volar wrists, and ankles. Histopathologic sections showed a mixed pattern of inflammation with interface and spongiotic changes. A parakeratotic scale with overlying basket‐weave orthokeratosis was also seen. Within the epidermis, there was intraepidermal vesicles and Langerhans cell microabscess formation with scattered apoptotic keratinocytes. The underlying dermis showed a superficial perivascular lymphocytic infiltrate with mild edematous changes, and extravasation of red blood cells. Clinicopathologic correlation strongly supported a diagnosis of popular‐purpuric gloves and socks syndrome. The influenza virus has never been reported in association with PPGSS; thus, this case outlines an important new variant that clinicians should be familiar with.

Arising Concerns of Atypical Manifestations in Patients with Hand, Foot, and Mouth Disease

“…The histopathology of HFMD showed: spongiosis, neutrophilic exocytosis, massive keratinocyte necrosis, shadow cells in the upper epidermis, the vacuolization of basal cells, necrotic cells in follicles and sweat glands, dense superficial dermal infiltrates of CD3 lymphocytes, and strong granulysin expression [ 30 ]. Although pathological examination is not routinely used in clinical practice, leukocytoclastic vasculitis and glove and stocking purpura can also be distinguished by histopathology, as they are caused by other viral infections, subepidermal immunodeficiency or nutritional deficiencies [ 31 , 32 ]. Table 3 shows the main differential diagnoses of petechial/purpuric eruptions and some similar diseases.…”

“…The underlying dermis showed a superficial perivascular lymphocytic infiltrate with mild edematous changes and extravasation of red blood cells [ 32 ].…”

Papular purpuric gloves and socks syndrome bei Parvovirus‐B19‐Primärinfektion

“…Neben dem Parvovirus B19 konnte eine Vielzahl anderer Viren als Auslöser identifiziert werden. So zum Beispiel Masern‐, Hepatitis B‐, Coxsackie B6‐, Epstein‐Barr‐ und Cytomegalieviren sowie in jüngster Zeit je ein Fall nach SARS‐CoV‐19‐ und Influenza‐Infektion 8–10 …”

Papular‐purpuric gloves and socks syndrome caused by parvovirus B‐19 primary infection

“…In addition to parvovirus B‐19, a number of other viruses have been identified as triggers, including measles, hepatitis B, coxsackie B6 virus, Epstein‐Barr virus and cytomegalovirus 8 . Recently, PPGSS has been reported in a patient with SARS‐CoV‐2 and in a patient with influenza infection 9,10 …”

“…8 Recently, PPGSS has been reported in a patient with SARS-CoV-2 and in a patient with influenza infection. 9,10 Differential diagnosis include mainly handfoot syndrome after mRNA COVID-19 vaccine, hand-foot-and-mouth disease and erythema multiforme. 11 The diagnosis of PPGSS is made clinically and should be supported by blood tests, especially viral serologies, as possible complications may be caused by the underlying viral infection.…”