Eosinophilic fasciitis (EF), also known as Schulman syndrome, is a rare fibrosing disorder characterized by the abrupt fibrosis of the fascia overlying the musculature of the body.
Classically, EF presents with symmetrical edema and woody induration of the affected extremities sparing the hands, feet, and face, which progresses rapidly to fibrosis, induration, and a peau d'orange appearance. EF is usually accompanied by pain and joint contractures resulting in a decreased range of motion and paresthesias. The skin in EF is often bound down, accentuating the natural planes between muscles and vasculature, and revealing linear depressions along superficial veins causing the groove sign.
The cause of the disease is currently unknown. EF affects both sexes, with women more commonly affected than men. White individuals have been most commonly reported to suffer from EF. The disease has occurred in patients of all ages, from childhood to older adults, but most patients are between ages 30 and 50. A history of strenuous physical activity preceding the clinical findings of EF occurs in approximately 30% of patients. Some researchers have hypothesized that certain environmental exposures, including drugs, toxins, and infections (Borrelia burgdorferi), may be potential causes. In addition, thrombocytopenia, aplastic anemia, myelodysplastic syndromes, and other myeloproliferative disorders are associated with EF. The presence of monoclonal gammopathy has been detected in 16%-33% of patients with EF.
Trunk involvement and the presence of peau d'orange have been reported to be associated with a poorer prognosis. While some authorities believe that EF overlaps with deep morphea and scleroderma, features that distinguish EF are a peripheral eosinophilia (in 60%-80% of patients), hypergammaglobulinemia (in 20%-70% of patients), and an absence of Raynaud phenomenon that is common to systemic sclerosis. In a retrospective study, 21 of 60 patients (35%) had concurrent plaque morphea. Antinuclear antibody (ANA) titers are normal. Erythrocyte sedimentation rate (ESR) is usually elevated.
Eosinophilic fasciitis in Adult
Alerts and Notices
Synopsis
Codes
ICD10CM:
M35.4 – Diffuse (eosinophilic) fasciitis
SNOMEDCT:
24129002 – Fasciitis with eosinophilia syndrome
M35.4 – Diffuse (eosinophilic) fasciitis
SNOMEDCT:
24129002 – Fasciitis with eosinophilia syndrome
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Scleroderma – A more superficial fibrotic connective tissue disease that is associated with Raynaud phenomenon and internal visceral involvement.
- Morphea – A form of cutaneously limited scleroderma characterized by isolated plaques of the skin; it is usually not as symmetrical, extensive, or abrupt as EF.
- Scleromyxedema – Presents with papules coalescing into indurated plaques on the extremities and is associated with paraproteinemia as well, but biopsy shows a hypercellular and myxedematous superficial fibrosis rather than a deep fibrosis of the fascia.
- Nephrogenic systemic fibrosis – Occurs in the setting of significant kidney disease and is highly associated with the administration of gadolinium-based contrast agents during periods of renal insufficiency.
- Eosinophilia-myalgia syndrome / toxic oil syndrome – In the 1980s and early 1990s, contaminated rapeseed oil and contaminated tryptophan supplements resulted in a disease presentation similar to EF that caused erythema, edema, fibrosis, and joint contractures, but the illnesses disappeared with identification of the contaminated ingestants.
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
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References
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Last Reviewed:05/24/2022
Last Updated:01/08/2023
Last Updated:01/08/2023
Eosinophilic fasciitis in Adult