864 - Sweet Syndrome: A Rare Case of Pain's Impact on Activities of Daily Living

Case Diagnosis: Drug-induced Sweet Syndrome

Case Description: A 53 year-old with recurrent leiomyosarcoma presented with intractable pain and diffuse circumferential edema in the left upper extremity (LUE) for five days following pegfilgrastim granulocyte-colony stimulating factor (G-CSF) injection. LUE MRI showed diffuse muscular edema and enhancement patterns suggestive of myositis. She was treated with prednisone taper in the setting of drug-induced Sweet syndrome (DISS). Despite aggressive pain management involving opiates and intravenous steroids, the patient remained in achy, burning pain that affected her sleep and LUE range of motion (ROM). She subsequently required assistance with activities of daily living (ADLs) such as upper body dressing, grooming, and bathing due to worsening fatigue, weakness, and pain. Physical medicine and rehabilitation was consulted, and her pain improved drastically after addition of methocarbamol and pregabalin. With occupational therapy, the patient’s strength and LUE ROM further improved, reaching supervision levels with upper body ADL’s at time of discharge.

Discussions: Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is characterized by sudden, painful skin changes that manifest from infection, visceral malignancy, and injection therapy, among others. G-CSF is the most widely reported contributing medication to DISS. Pathogenesis is poorly understood, although its excellent response to first-line systemic glucocorticoids support the current theory of hypersensitivity reaction. In this case, it is uncertain if our patient benefited adequately from steroids alone, as the addition of muscle relaxant and neuropathic agent expedited her recovery significantly.

Conclusions: Sweet syndrome is a rare neutrophilic dermatosis that can cause severe pain and hinder functional goals. This patient with DISS responded significantly to a multimodal treatment approach including various analgesics, steroids and rehabilitation to her pain, weakness and ADL’s. It is important for physiatrists to specify the nature of a patient’s pain and treat accordingly, regardless of the rarity of a condition, to promote functional gains.