Irritant contact dermatitis

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

A 27-year-old female is self-referred to our clinic for evaluation of skin rash, maculopapular and pruritic which affects both hands, forearms, and the lower portion of her neck. She has had the rash for four months.

She works as a manual laborer at a parcel courier service, moving boxes. Apart from the rash, she does not report any other symptoms. The skin rash started 4 months ago. She is not on any medications and does not have any significant past medical history.

She wants to have "skin prick testing done for allergies."

Physical examination

The physical examination is positive for maculopapular rash and xerosis affecting both hands, forearms, and the lower portion of the neck.

What is the most likely diagnosis?

This is a patient with contact dermatitis which is most likely of irritant etiology. It is likely that her hands are in contact with the irritant substance and then she gets lesions wherever she scratches her skin with the contaminated hands, mostly on the forearms and lower portion of the neck.

What treatment would you suggest?

We prescribed prednisone 40 mg po daily for 5 days and hydrocortisone 1% ointment daily for 7 days and also we advised her to use skin moisturizers twice a day.

What did we learn from this case?

The occurrence of a rash on the neck and forearms does not mean that the rash originated there. Often, in the case of irritant allergic dermatitis, the irritant substance on the person's fingers and nails can cause a rash wherever they touch their skin or scratch.

One example is a patient who complains of rash affecting the eyelids which is actually caused by the nail polish applied to the fingernails. Many of these patients have lengthy evaluations for periorbital rashs while the correct diagnosis is irritant contacts dermatitis of the hands with a secondary spread to the periorbital area.

Published: 02/23/2010
Updated: 02/23/2010

Suspected progesterone allergy

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 21-year-old female is here for evaluation of chronic urticaria for the last 7 weeks with daily symptoms. She did not have any systemic or life threatening symptoms, specifically she had no angioedema or respiratory symptoms. She was treated initially with prednisone a month ago which helped her symptoms somewhat, but did not resolve the hives. She took one dose of Benadryl (diphenhydramine) three days ago, which relieved some of her urticaria symptoms. She is referred by her primary care physician for skin prick testing.

Past medical history

She became pregnant last year and had a delivery of a healthy baby 3 months ago. Soon after that, she received progesterone depot injection for contraception in and her first symptoms of urticaria appeared 3-4 weeks later. She is due to receive another injection in 2 weeks.

Medications

Progesterone depot injection.

Physical examination

Normal vital signs and singular urticarial lesions in multiple locations in both upper and lower extremities. The scratch test was negative for dermatographic reaction. The rest of the physical examination was unremarkable.

What is the most likely diagnosis?

This is a patient with chronic urticaria which started after receiving a progesterone depot injection for contraception. She is due to receive another injection and the therapeutic level is probably lower by now, but the half life of the medication is obviously much longer. Therefore we advised her to avoid any hormonal contraceptives including injections, oral medications and intrauterine contraceptive devices. She can use barrier methods of contraception.

We also prescribed antihistamine, loratadine 10 mg po bid for her and we will see her in six weeks.

If this therapy and discontinuation of the progesterone injections does not resolve her chronic urticaria, then we will consider further laboratory work up. Skin prick testing is probably not indicated at this moment and it could not be done because the patient took an antihistamine three days prior to the day of the visit.

Related reading

A Case of Progesterone-Induced Anaphylaxis, Cyclic Urticaria/Angioedema, and Autoimmune Dermatitis. J Womens Health 2011.

Published: 02/23/2010
Updated: 02/23/2011

Chronic Urticaria Due to Thyroid Antibodies

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 45 year-old Caucasian male is here for evaluation of urticaria for 6 weeks. He was prescribed two courses of oral prednisone which led to resolution of his symptoms, but the urticaria lesions reappeared when he decreased the dose to 5 mg a day. He reports 4 episodes of angioedema symptoms affecting his upper lip during the last 6 weeks, often occurring during exacerbations of his urticaria. The urticarial lesions occur daily and are worse in the afternoon.

Past medical history

His past medical history is positive for hypertension, hyperlipidemia, erectile dysfunction, and allergic rhinitis.

Medications

His medications include Levitra (vardenafil), lisinopril, simvastatin, levothyroxine, amlodipine, hydrocodone prn, triamterene/hydrochlorothiazide and two courses of prednisone.

He was advised to stop lisinopril and simvastatin and he did discontinue those two weeks ago.

The review of systems is negative apart from the history of present illness as above. He reports no shortness of breath, wheezing, chest tightness, chest pain or abdominal symptoms.

Physical examination

The physical examination is remarkable for 4-5 small urticarial lesions on both flanks in the abdominal area.

What is the most likely diagnosis?

This is a patient with chronic urticaria and angioedema for six weeks. He has been on ACE inhibitor (lisinopril) and simvastatin. Both medications were stopped 2 weeks ago.

What laboratory workup would you suggest?

We suggested laboratory work up in attempt to clarify the etiology of his condition and this includes CMP, CBC with differential and smear review, ANA, sedimentation rate, rheumatoid factor, TSH, T4, C1Q, C4 and C2 levels, CH50 level, C1 esterase inhibitor (qualitative and quantitative), H. pylori IgG antibody, thyroid autoantibodies (antimicrosomal and antithyroglobulin antibodies).

What treatment would you suggest?

We prescribed loratadine 10 mg po bid and strongly recommended he should stay off any ACE inhibitors and follow with his primary care physician for blood pressure control.

What happened next?

Thyroid autoantibodies were reported positive with "extremely high" titer. TSH level was normal.

Anti-TPO - Greater than 1000.0

(reference range 0-3.9 IU/mL)

Thyroglobulin antibody 219

(reference range 0-14 IU/mL)

TSH 2.8

(reference range 0.34-5.6 IU/mL)

The patient was referred to see an endocrinologist specialist again.

What did we learn from this case?

A workup including C1Q, C4 and C2 levels, CH50 level, C1 esterase inhibitor (qualitative and quantitative) is indicated in chronic urticaria patients who have concurrent angioedema symptoms.

Thyroid function tests and thyroid antibodies are indicated in selected patients with chronic urticaria.


Diagnosis of Chronic Urticaria (click to enlarge the image).

References

Anti-FceR1 Autoantibodies in Chronic Urticaria

Published: 02/23/2010
Updated: 09/24/2010

How to Treat an Exacerbation of Allergic Bronchopulmonary Aspergillosis (ABPA)?

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

A 60-year-old male with a long history of Allergic Bronchopulmonary Aspergillosis (ABPA) is her for a a follow-up. He has been followed by our clinic for the last 7 years. He has been on omalizumab (Xolair) for 3 years. He had one interruption of therapy for approximately a year when he was off Xolair because of health insurance issues and then Xolair was resumed 8 months ago. Since then, his condition has been stable, but he continues to have symptoms of shortness of breath, wheezing, and episodic ABPA exacerbations.

He developed another ABPA exacerbation 5 days ago with worsening shortness of breath, wheezing, and cough productive of yellow sputum, which turned green recently. He reports no fever, abdominal pain, nausea, vomiting, diarrhea or constipation. His symptoms are worsening despite taking prednisone 40 mg po daily for the last 4 days.

Past medical history

Allergic Bronchopulmonary Aspergillosis (ABPA), allergic rhinitis.

Medications

His maintenance dose of prednisone is 15 mg po every other day. He is also on Advair 500/50 mcg one inhalation bid, Flonase, albuterol, and theophylline 300 mg po bid. Hhe reports symptomatic improvement when he was on itraconazole for 3 months approximately 3 years ago.

Physical examination

Physical examination is positive for mild tachypnea in the range of 16-20 breaths per minute. He also has evidence of bilateral expiratory wheezing and pale boggy turbinates on both sides. The rest of the physical examination is unremarkable.

What is the most likely diagnosis?

This is a patient with ABPA exacerbation with good effect with itraconazole in the past and current evidence of intercurrent respiratory infection.

What would you do?

We decided to start Augmentin 875 mg po bid for 10 days. He reports no significant effect with levofloxacin (Levaquin) taken in the past, and repeatedly good symptomatic effect with Augmentin, and therefore we decided to prescribe the same antibiotic.

We also started itraconazole at a dose of 200 mg po bid for 16 weeks and we will perform liver function testing today and on monthly intervals while he is on itraconazole. At this point, we decided to continue Xolair and to re-evaluate him in near future.

What did we learn from this case?

Antifungals, and intraconazole in particular can have a steroid-sparing effect in some patients with ABPA. A monitoring of the liver enzymes is necessary.

References

Allergic Bronchopulmonary Aspergillosis. Merck Manual.
http://www.merck.com/mmhe/sec04/ch051/ch051d.html

Allergic Bronchopulmonary Aspergillosis. NEJM.
http://content.nejm.org/cgi/content/full/359/6/e7

Published: 02/23/2010

Updated: 02/23/2010

Hereditary angioedema type III

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D.

A 32-year-old Caucasian female was seen in the clinic for evaluation of an episode of uvular and peritonsillar edema which resolved within 12 hours of taking 40 mg of prednisone previously prescribed by her primary care physician. She has a long history of angioedema since the age of 11 with temporary improvement during pregnancy, but without full resolution of her symptoms. Her mother and her uncle also have symptoms of angiodema history.

Past medical history

Angioedema.

Medications

Prednisone 20 mg po daily and Zyrtec 10 mg po bid.

The physical examination is unremarkable.

The previous laboratory tests included CBC with differential, CMP, sedimentation rate, ANA, rheumatoid factor, TSH, and thyroid antibodies, as well as previous evaluation of the complement components, and there were no significant abnormalities.

What is the most likely diagnosis?

Hereditary angioedema is suspected since similar symptoms have occurred in other members of her family. We suspect that the patient might have type 3 hereditary angioedema.

What would you recommend as next step?

She was advised to taper the prednisone dose to 15 mg po daily for 2 weeks and then to continue prednisone 10 mg po daily for another 2 weeks.

While staying on the maintenance dose of prednisone 10 mg po daily, she was advised to start Celebrex 200 mg po daily and to make a follow up appointment in 4 weeks. Celebrex controlled symptoms in a family member (uncle) who also has angioedema.

If at the 8 week follow up, the patient had no improvement with Celebrex, then we will consider starting progesterone to control her symptoms.

Diagnosis

Hereditary angioedema type III. There is unfortunately no test for "type III" angioedema (source: AAAAI Ask the Expert).

What did we learn from this case?

Hereditary angioedema type III is typically described in women but can occur in men as well. Certain patients have symptomatic improvement during pregnancy and for them a trial of progesterone therapy may be worth a consideration. Please have in mind that progesterone will stop the menstruation in the such female patients.

Factor XII (Hageman factor)

Hereditary angioedema type III occurs in people with normal C1 inhibitor activity. In some families, mutations in the coagulation factor XII (Hageman factor) gene were detected in the affected persons. Factor XII is encoded by the F12 gene located on the tip of the long arm of the fifth chromosome. Two missense mutations have been identified in F12, the gene encoding human coagulation factor XII. These mutations are thought to be the cause of HAE type III.

Hageman factor was first discovered in 1955 when a routine preoperative blood sample of the 37-year-old railroad brakeman John Hageman was found to have prolonged clotting time in test tubes, even though he had no hemorrhagic symptoms. Hageman was then examined by Dr. Oscar Ratnoff who found that Mr. Hageman lacked a previously unidentified clotting factor. Dr. Ratnoff later found that the Hageman factor deficiency is an autosomal recessive disorder. Paradoxically, pulmonary embolism contributed to Hageman's death after an occupational accident. Since then, case series clinical studies have identified an association of thrombosis and Factor XII deficiency, though the pathophysiology of the relationship is unclear.


The coagulation cascade. Image source: Wikipedia, GNU Free Documentation License.

A 29 year old female has had 5 episodes of lip and tongue swelling and abdominal pain. C4 level, C1-INH level and C1-INH functional level are all normal. Which one of the following should be checked next?

(A) CBC

(B) Factor III

(C) Factor X

(D) Factor VII

(E) Factor XII

(F) Factor II

Answer: E, Factor XII

References

Angioedema, Hereditary. eMedicine Specialties > Dermatology > Allergy & Immunology.
http://emedicine.medscape.com/article/1048994-overview

Angioedema. eMedicine Specialties > Allergy and Immunology > Urticaria and Angioedema.
http://emedicine.medscape.com/article/135208-overview

Hereditary angioedema with normal C1 inhibition. Current Allergy and Asthma Reports, Volume 9, Number 4 / July, 2009.

Ratnoff OD, Margolius A (1955). Hageman trait: an asymptomatic disorder of blood coagulation. Trans. Assoc. Am. Physicians 68: 149–54. PMID 13299324.

Published: 02/23/2010
Updated: 04/23/2011