Sweet's syndrome mimicking alkali burn: A clinical conundrum

Introduction: Sweet's syndrome or acute febrile neutrophilic dermatosis presents most commonly on the hands, upper extremities and face. The disease is of clinical relevance to surgeons as it could mimic an infective aetiology but debridement negates such wounds. Case: A 34-year-old man was referred from a peripheral hospital with suspected infected alkali burn to the hands. A builder by profession, he had been working outdoors with possible exposure to cement-concrete mix, 5 days previously. At presentation, the dorsal aspect of the thenar eminence appeared erythematous and oedematous, with pustules and blisters with central ulcerations. Haematological investigation revealed a neutrophilic leucocytosis and raised CRP. On the second day of admission the patient became febrile. He was treated with analgesia, IV Tazocin (Pipperacillin and Tazobactam) and the wounds were surgically debrided and covered using autologous cell therapy via the Recell kit. Two days following surgery, microbiology of wound swabs, tissue samples and blood cultures yielded no growth. The wound was noted to be extending beyond the zone of injury and a new area of erythema was evident on the neck. A diagnosis of idiopathic acral Sweet's syndrome was confirmed when histopathological investigation showed a moderate inflammatory cell infiltrate in the dermis. A rapid response to oral corticosteroids was clinically evident after 48 h and the lesions were completely healed at 4 weeks follow-up. Conclusion: We recommend thorough clinical history and examination, systematic wound review, tissue biopsy and culture in conjunction with dermatology opinion in cases of suspected Sweet's syndrome. Surgical debridement should be avoided as it has the potential to negate such wounds secondary to pathergy phenomenon. © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.