JMIR Publications

ABSTRACT

Introduction: Giant cellulitis-like Sweet syndrome (GCLSS) is a rare variant of Sweet syndrome (acute febrile neutrophilic dermatosis) characterized by painful erythematous plaques that can mimic severe bacterial skin and soft tissues infections like cellulitis and necrotizing fasciitis. Recognition of the condition is challenging as the patient develops rapidly progressive erythema, pain, leukocytosis, and skin necrosis, prompting equally rapid treatment despite being an inflammatory process instead of an infectious one. Case Presentation: A 76-year-old woman with a history of heart failure, Type 2 diabetes mellitus, B-cell lymphoproliferative disorder, and morbid obesity, presented with an extensive, poorly demarcated erythematous rash across her gluteal region and rapidly progressing to involve the bilateral posterolateral thighs. The patient was originally treated for bilateral cellulitis with broad-spectrum; however, the eruption continued to progress with increasing pain, violaceous purpura, bullae, skin induration and areas of necrosis. Necrotizing fasciitis became the primary concern and resulted in surgical exploration which demonstrated viable tissue without fascial necrosis or the typical dishwater fluid. Blood and tissue cultures remained negative while a skin biopsy taken during the surgery demonstrated papillary edema and mixed dermal inflammation with neutrophils without definitive vasculitis or necrosis. Given the bilateral distribution, lack of response to antibiotics, negative cultures, elevated inflammatory markers, leukocytosis, and histopathologic findings, GCLSS was considered in the setting of an underlying malignancy. Antibiotics were then discontinued and intravenous methylprednisolone was initiated, resulting in marked improvement in pain and erythema within 48 hours, thus confirming the diagnosis of GCLSSS. The patient was subsequently transitioned to oral prednisone with a planned taper and outpatient oncological follow-up. Conclusion: GCLSS should be considered in patients with obesity and an underlying malignancy presenting with rapidly progressive rash mimicking cellulitis or necrotizing fasciitis, particularly when lesions are bilateral, cultures remain negative, and there is inadequate response to antibiotic therapies. Recognition of this condition is important to prevent unnecessary surgical intervention and delay of corticosteroid therapy.