Gianotti-Crosti Syndrome, Pityriasis Rosea, Asymmetrical Periflexural Exanthem, Unilateral Mediothoracic Exanthem, Eruptive Pseudoangiomatosis and Papular-Purpuric Gloves and Socks Syndrome: A Brief Review and Arguments for Diagnostic Criteria

Abstract

Several exanthems including Gianotti-Crosti syndrome, pityriasis rosea, asymmetrical periflexural exanthem, eruptive pseudoangiomatosis, and papular-purpuric gloves and socks syndrome are suspected to be caused by viruses. These viruses are potentially dangerous. Gianotti-Crosti syndrome is related to hepatitis B virus infection which is the commonest cause of hepatocellular carcinoma, and Epstein-Barr virus infection which is related to nasopharyngeal carcinoma. Pityriasis rosea has been suspected to be related to human herpesvirus 7 and 8 infections, with the significance of the former still largely unknown, and the latter being a known cause of Kaposi's sarcoma. Papular-purpuric gloves and socks syndrome is significantly associated with human B19 erythrovirus infection which can lead to aplastic anemia in individuals with congenital hemoglobinopathies, and when transmitted to pregnant women, can cause spontaneous abortions and congenital anomalies. With viral DNA sequence detection technologies, false positive results are common. We can no longer apply Koch's postulates to establish cause-effect relationships. Biological properties of some viruses including lifelong latent infection, asymptomatic shedding, and endogenous reactivation render virological results on various body tissues difficult to interpret. We might not be able to confirm or refute viral causes for these rashes in the near future. Owing to the relatively small number of patients, virological and epidemiology studies, and treatment trials usually recruit few study and control subjects. This leads to low statistical powers and thus results have little clinical significance. Moreover, studies with few patients are less likely to be accepted by mainstream dermatology journals, leading to publication bias. Aggregation of data by meta-analyses on many studies each with a small number of patients can theoretically elevate the power of the results. Techniques are also in place to compensate for publication bias. However, these are not currently feasible owing to different inclusion and exclusion criteria in clinical studies and treatment trials. The diagnoses of these rashes are based on clinical assessment. Investigations only serve to exclude important differential diagnoses. A wide spectrum of clinical features is seen, and clinical features can vary across different populations. The terminologies used to define these rashes are confusing, and even more so are the atypical forms and variants. Previously reported virological and epidemiological results for these rashes are conflicting in many aspects. The cause of such incongruence is unknown, but low homogeneity during diagnosis and subject recruitment might be one of the factors leading to these incongruent results. The establishment and proper validation of diagnostic criteria will facilitate clinical diagnosis, hasten recruitment into clinical studies, and allow results of different studies to be directly compared with each another. Meta-analyses and systematic reviews would be more valid. Diagn...

The diagnostic criteria of pityriasis rosea and Gianotti-Crosti syndrome – a protocol to establish diagnostic criteria of skin diseases

“…The next step would be to evaluate whether diagnostic criteria are already in place, otherwise the existence of multiple diagnostic criteria for one disease would make combining results from multiple clinical studies difficult. 6 It has been proposed that diagnostic criteria exist on a continuum with classification criteria. This is indeed the case for PR, as the diagnostic criteria 2,3 are fully compatible with our proposed clinical classification.…”

“…The power of findings from these studies would then be substantially greater. 6 Moreover, primary care physicians have been reported to significantly underdiagnose PR. Validated diagnostic criteria might assist these medical practitioners as well as specialist trainees in dermatology when they confront patients with marginal clinical manifestations of PR, GCS, and their differential diagnoses.…”

“…The pros and cons of the diagnostic criteria have been assessed in detail 6 and are summarised in Table 3. In brief, most clinical studies, including clinical trials on these exanthems, adopted different inclusion criteria, and the results cannot be readily meta-analysed.…”

The first reported patient with non-Hodgkin lymphoma presenting as pityriasis rosea

“…The aetiology of pityriasis rosea (PR) is largely unknown (1)(2)(3)(4)(5)(6)(7)(8). It might be related to primary infections and endogenous reactivations of human herpesviruses (2,3).…”

comment: Does pityriasis rosea Koebnerise?

“…At the current state of knowledge, we believe that PR might be associated with questionable IR only. Should there be further reports, such association might be occasional IR if the pathogen is yet unidentified, or pseudo IR if we finally identify the true culprit(s) in PR, with the latter scenario being highly unlikely at this moment, considering uncertain microbiological aetiology of PR [7].…”