Zebra Card SK-003: postexertional skin thickening

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	Stiff joints and thickened skin after an episode of unusual physical exertion
	Differential Diagnosis	[Top] [Nav]
	eosinophilic fasciitis (Shulman disease)
	Discussion -- not available online	[Top] [Nav]

Notes

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Unusual thickening of the skin is no longer a zebra, or at least it wasn't in the late 1980s and early 1990s. In 1989 a new syndrome was discovered: eosinophilia-myalgia linked with ingestion of L-tryptophan. One of the characteristic findings in this syndrome is progressive thickening of the skin, sometimes occurring after physical exertion. The Varga paper and the Troy editorial nicely discuss the eosinophilia-myalgia syndrome's relationship to eosiniphilic fasciitis, the toxic oil syndrome, scleroderma (systemic and morphea), and even carcinoid. [Some patients with the carcinoid syndrome develop skin thickening, thought due to high levels of serotonin. Tyrptophan is metabolized to serotonin.]

	Update Comments	[Top] [Nav]
	Half of the Mayo Clinic's patients with eosinophilic fasciitis had been exposed to tryptophan. [101] The pathologist diagnosed eosinophilic fasciitis, but this was later revised (see letter below). [104] The patient in CPC 4-1990 had long used tryptophan as a sleeping aid, until mid-1987. Her first visit to the arthritis clinic was in August 1988. She was found dead at home in January 1990. [105] Lyme disease can express a syndrome of diffuse fasciitis and peripheral eosinophilia. [106] Old letter reporting prompt improvement in eosinophilic fasciitis in response to cimetidine treatment. [107] Studied the patients in one psychiatrist's practice in South Carolina. Opines that the CDC diagnostic criteria for eosinophilia-myalgia syndrome do not identify all affected patients. [110] First report of the syndrome. [113] Reminds that other toxic agents and diseases may be associated with scleroderma-like skin thickening: polyvinylchloride, chlorinated hydrocarbons, silicone implants, porphyria cutanea tarda, phenylketonuria, and some of the glycogenoses. [114] Implicates the tryptophan manufactured by one company in Japan. [116] Scleroderma-like skin thickening is part of this syndrome. [117]

Footnotes in Print Edition

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	(1)	Clinical conferences at The Johns Hopkins Hospital. Johns Hopkins Med J 1981 Feb;148(2):81-6. Pubmed Similars
	(2)	Diffuse fasciitis with eosinophilia in childhood. Sills EM. Johns Hopkins Med J 1982 Nov;151(5):203-7. Pubmed+Abstract Similars
	(3)	Textbook of Rheumatology. 2nd ed. Kelley WN, et al. Philadelphia: Saunders, 1985: 1195-1196.

New References

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	Eosinophilic fasciitis
	101.	The eosinophilia-myalgia syndrome: the Los Alamos Conference. Hertzman PA, Falk H, et al. J Rheumatol 1991 Jun;18(6):867-73. Pubmed+Abstract Similars
	102.	Eosinophilic fasciitis associated with use of L-tryptophan: a case- control study and comparison of clinical and histopathologic features. Martin RW, Duffy J, et al. Mayo Clin Proc 1991 Sep;66(9):892-8. Pubmed+Abstract Similars
	103.	L-tryptophan ingestion associated with eosinophilic fasciitis but not progressive systemic sclerosis. Freundlich B, Werth VP, et al. Ann Intern Med 1990 May 15;112(10):758-62. Pubmed+Abstract Similars
	104.	Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 4-1990. A 53-year-old woman with cutaneous thickening and eosinophilia. N Engl J Med 1990 Jan 25;322(4):252-61. Pubmed Similars
	105.	Case 4-1990: eosinophilic fasciitis [letter]. Gorn A. N Engl J Med 1990 Mar 29;322(13):931. Pubmed Similars
	106.	Identification of Borrelia burgdorferi in diffuse fasciitis with peripheral eosinophilia: borrelial fasciitis. Granter SR, Barnhill RL, et al. JAMA 1994 Oct 26;272(16):1283-5. Pubmed+Abstract Similars
	107.	Cimetidine and eosinophilic fasciitis [letter]. Garcia-Morteo O, Maldonado-Cocco JA, et al. Ann Intern Med 1984 Feb;100(2):318-9. Pubmed Similars
	Eosinophilia-myalgia
	108.	The natural history of eosinophilia-myalgia syndrome in a tryptophan- exposed cohort in South Carolina. Sullivan EA, Kamb ML, et al. Arch Intern Med 1996 May 13;156(9):973-9. Pubmed+Abstract Similars
	109.	Repeated coronary artery spasm in a young woman with the eosinophilia- myalgia syndrome. Hertzman PA, Maddoux GL, et al. JAMA 1992 Jun 3;267(21):2932-4. Pubmed+Abstract Similars
	110.	Eosinophilia-myalgia syndrome in L-tryptophan-exposed patients [see comments]. Kamb ML, Murphy JJ, et al. JAMA 1992 Jan 1;267(1):77-82. Pubmed+Abstract Similars
	111.	The cause and pathogenesis of the eosinophilia-myalgia syndrome [see comments]. Varga J, Uitto J, et al. Ann Intern Med 1992 Jan 15;116(2):140-7. Pubmed+Abstract Similars
	112.	Natural history of the eosinophilia-myalgia syndrome. Culpepper RC, Williams RG, et al. Ann Intern Med 1991 Sep 15;115(6):437-42. Pubmed+Abstract Similars
	113.	Eosinophilia-myalgia syndrome--New Mexico. MMWR Morb Mortal Wkly Rep 1989 Nov 17;38(45):765-7. Pubmed Similars
	114.	Eosinophilia-myalgia syndrome [editorial; comment]. Troy JL. Mayo Clin Proc 1991 May;66(5):535-8. Pubmed Similars
	115.	Eosinophilia-myalgia syndrome. A clinical case series of 21 patients. New Mexico Eosinophilia-Myalgia Syndrome Study Group. Philen RM, Eidson M, et al. Arch Intern Med 1991 Mar;151(3):533-7. Pubmed+Abstract Similars
	116.	An investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use [see comments]. Belongia EA, Hedberg CW, et al. N Engl J Med 1990 Aug 9;323(6):357-65. Pubmed+Abstract Similars
	Toxic oil syndrome
	117.	Clinical epidemiology of toxic-oil syndrome. Manifestations of a New Illness. Kilbourne EM, Rigau-Perez JG, et al. N Engl J Med 1983 Dec 8;309(23):1408-14. Pubmed+Abstract Similars
	118.	3-(Phenylamino)alanine, a novel aniline-derived amino acid associated with the eosinophilia-myalgia syndrome: a link to the toxic oil syndrome? [see comments]. Mayeno AN, Belongia EA, et al. Mayo Clin Proc 1992 Dec;67(12):1134-9. Pubmed+Abstract Similars

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