Derm Cases · Dermatology / Haematology / Internal medicine
OSCE — fever and tender red plaques: diagnose Sweet syndrome and screen for malignancy
An 8-minute OSCE station on acute febrile neutrophilic dermatosis criteria, classic vs malignancy-associated Sweet syndrome, histopathology without vasculitis, and corticosteroid first-line therapy with malignancy screening.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on acute febrile neutrophilic dermatosis criteria, classic vs malignancy-associated Sweet syndrome, histopathology without vasculitis, and corticosteroid first-line therapy with malignancy screening.
Brief (to candidate)
A 55-year-old man develops abrupt fever and painful red-violet plaques on the face, neck and arms. Bloods show neutrophilia; biopsy is reported as dense dermal neutrophils without vasculitis. You have 8 minutes to diagnose Sweet syndrome, classify classical vs paraneoplastic disease, and start treatment with appropriate screens.
[3]Candidate instructions
- Define Sweet syndrome (acute febrile neutrophilic dermatosis).
- List major and minor diagnostic criteria conceptually.
- Separate classical, malignancy-associated, and drug-induced forms.
- State first-line therapy and expected response.
- Plan haematologic malignancy screening and mention VEXAS in recurrent older-male disease.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Definition | Abrupt tender red-violet papules/plaques/nodules + fever + neutrophilia + dense dermal neutrophilic infiltrate without vasculitis[1][6] |
| Key histology | Neutrophilic dermatosis without fibrinoid vasculitis — distinguish from cutaneous small-vessel vasculitis[4] |
| Subtypes | Classical (post-infection, IBD, pregnancy, idiopathic); malignancy-associated (AML/MDS especially); drug-induced (e.g. G-CSF and others)[3] |
| Work-up | FBC + film, inflammatory markers, drug history, infection screen as indicated; age-appropriate malignancy evaluation when no clear trigger or recurrent disease; bone marrow if cytopenias/suspicious film |
| Therapy | Systemic corticosteroids first-line with typically rapid response; steroid-sparing options (colchicine, dapsone, potassium iodide, etc.) for refractory/relapsing disease; stop culprit drug if drug-induced[1][3] |
| Special entities | Consider VEXAS (UBA1) in older man with recurrent neutrophilic dermatosis, fever, cytopenias, chondritis/vasculitis features[2] |
| Safety-net | Do not miss AML/MDS; counsel that skin improvement on steroids does not exclude underlying malignancy |
Model key actions
- Diagnose Sweet syndrome from fever + tender plaques + neutrophilia + non-vasculitic neutrophilic histology.[1][6]
- Screen for haematologic malignancy, especially AML/MDS, when triggers are absent or disease recurs.[3]
- Start systemic corticosteroids as first-line therapy.[4]
Common errors
- Labelling Sweet as cellulitis and giving prolonged antibiotics alone.
- Assuming vasculitis because of red tender plaques.
- Missing drug (G-CSF) and malignancy work-up.
- Stopping evaluation once steroids clear the rash.
- Ignoring cytopenias that should trigger haematology referral.
References5ShowHide
- [1]Villarreal-Villarreal CD, Ocampo-Candiani J, Villarreal-Martínez A. Sweet Syndrome: A Review and Update. Actas dermo-sifiliograficas, 2016.PMID 26826881
- [2]Loeza-Uribe MP, Hinojosa-Azaola A, Sánchez-Hernández BE, et al. VEXAS syndrome: Clinical manifestations, diagnosis, and treatment. Reumatologia clinica, 2024.PMID 38160120
- [3]Calabrese L, Satoh TK, Aoki R, et al. Sweet syndrome: an update on clinical aspects, pathophysiology, and treatment. Italian journal of dermatology and venereology, 2024.PMID 39560338
- [4]Nelson CA, Stephen S, Ashchyan HJ, et al. Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease. Journal of the American Academy of Dermatology, 2018.PMID 29653210
- [6]Cohen PR. Sweet's syndrome – a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet Journal of Rare Diseases, 2007.PMID 17655751