Param
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50 year old Asian woman moved from San Francisco to Los Angeles, 2 years ago. Soon after 2 months of moving, started developing generalized pruritis and rashes over abdomen, trunk & limbs. 2 dermatologists saw her - the first one said "eczema" and started her on Pred 30mg daily for 10 days( no tapering), Cetaphil as a moisturizer and Atarax 5mg hs; the 2nd doctor told her it was not eczema, but "lichen planus" and wanted her to try Griseofulvin which she did not agree to as he himself was not sure how effective the treatment would be. He too gave her Pred, triamcinolone cream & another moisturizer. She was well for the time period that she was on the steroids, but the itching never really subsided. Her Hb was 9.2 & she was started on slow release Fe.
The question is what do you think is her problem? How would you manage this case? (She has not had a biopsy done - no insurance - so both the doctors did not insist!) Both the doctors told her that the climate & water seems to make her skin burn & itch. She also told them that her skin burned & itched whenever she went in the sun or had a shower.
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| no more a loser
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well dont know the answer. it can not be polycythemia cuz her Hb is low. so maybe its some kind of porphyria.
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| alice8
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Maybe a paraneoplastic presentation of any kind of GIS malignancy that causes the Hb decrease with bleeding :?:
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| guest
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generalised rash and pruritus....i will consider the porphyrias and possilbly hyperbilirubinaemia and investigate her for any of those. I wiould also consider bathe pruritus which is something you get when your skin gets wet from bathing or sweating in the hot sun. A biopsy will be useful if unresolved but i think there are less invasive procedures they coiuld do first....like a full blood investigation.
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| Param
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Thank you - you wonderful people out there. I'm now enclosing the investigations done for this pt. Sorry I could not do it last night as I was really tired! Still sad to say - no diagnosis as yet!
Glucose 91
Na 145
K 4.2
Cl 111
CO2 22
BUN/CREATININE RATIO
BUN 21
Creatinine 1.0
BUN/Creatinine 21.0(ratio)
Calcium 9.9
Total protein 7.0
Albumin 4.4
Globulin 2.6
A/G Ratio 1.7
Bilirubin Total 0.4
Alk phos. total 37
AST(SGOT) 13
ALT (SGPT) 15
T4, Thyroxine 8.7
T3 Uptake 33.1
FTI Calculation 8.9
TSH, Serum 1.37
Hemogram (w/o platelets)
WBC 12.2 (HIGH)
RBC 4.09
Hemoglobin 10.2 (LOW) remember she was started
release Fe??
Hematocrit 35.2 (LOW)
MCV 75 (LOW)
MCH 21.8 (LOW)
MCHC 29.1(LOW)
ESR - Westergren 5
ANA (EIA) 0.3
FSH, Serum 4.0 (1)
LH, Serum 16.4 (2)
Urine - nothing abnormal to note.
OK folks, there you have all the results. She thinks her low Hb is due to the fact that even at 50 she is still menstruating & her days are up to 10-15 each time.
So guys & girls - what do you think? See her abnormal hemogram panel. I hope you don't want me to write the normal values as well next to the test results.
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| veronica
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she abviously has some sort of photosensitivity. as rash is exacerbated by sunlight. this could be nutritional from niacin deficiency(pellagra). this may fit with poor nutrition overall resulting in Fe deficiency anaemia.
the other causes of photosensitivity such as porphyria (prev mentioned), SLE (if ANA is increased but would need to dsDNA to confirm), drug reaction should be looked into. Particularly, if the photosensitive rash improves with steroids would definitely suggest autoimmune disease mechanism. Autoimmune screen needed.
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| alice8
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a disorder with mast cells :?: maybe mastocytosis or mastocytosis with an associated hematologic disorder (like mast cell leukemia) can maybe the cause of symptoms of this patient...it can explain the increase in wbc count and decrease in rbc associated parameters..am i thinking too complicated :?:
peripheric smear could be useful to see what it is :?:
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| alice8
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i think i also would like to see the skin biopsy
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| Yulia
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mastoid cell disorder also can't be excluded without skin biopsy... she would have some systemic symptoms and typical lesions, which Param haven't mentioned though...
any chance her symptoms are due to fe-deficient anemia???
as far as i know these pts sometimes itch miserably.
and skin lesions are secondarily produced by scratching.
what's the right answer, Param? 
or if you could explain why we're wrong here, that would be even better
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| zaki
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hi, i am late to this question but plz do u give the results of stool analysis report and stool for ova and parasite as many of the parasites can give rashes and pruritis.and as well causing blood loss from the gut if not do the stool test and if positive deworm . my dear collegue have all mention the other causes so no need for me to mention them all again and also to remember that these other causes are rare too.
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Maverick
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| guest
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i don't know any worm that causes eczematous rashes in united states........
it may be a common cause in your palistan....but here.......less common
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| filiz
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Numerous drugs affect BUN by competing with it for excretion by the kidneys, including many taken by people with AIDS & HIV, so watch for higher than normal levels on these tests. A BUN/creatinine ratio greater than 20 can indicate kidney disease or failure. :roll:
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| carla
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My inclination will be to run a stool analysis and check for parasites. Kidney failure? yeah maybe, but with no other systemic symptoms associated :?: Any particular herbal product (tea of any kind?) that she maybe using?
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Carla
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| carla
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regarding the parasite in USA remember that the patient is ASIAN and they have a different diet than standard Americans and the buy imported products in Asian Markets. Do you know if her high whites is due to eosinophiles?
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Carla
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| Param
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carla:
I don't understand the question. When you say any particular herbal product that the pt was using, what are you referring to? Oral or on her body?
I'm so glad to see that we are all still struggling with this case. I think I did mention before that she was so disgusted with the 2 Derms that she saw, that she has given up on all of us! She said to my colleague that all that they were interested was their consultation fees up front the moment they came to know she does not have insurance!
The last time I spoke to my colleague, he said that she is still miserable. I keep reading different web sites to reach a diagnosis. She refuses to go & see anyone else now.
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| Param
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carla:
I will try & find out about the eosinophil count.
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| holistic medicine
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I was thinking in what Chineses use as holistic medicine, teas made of different plants that can produce an allergic reaction and she is not saying for she does not think it is the cause...... The puzzling thing is that she got all her symptoms almost upon moving to her new place. What is she is in contact with??? Is this a real case??? Although the nuclear antibodies where negative in your first report I will keep an open mind for an autoimmune disease.....I wander what is the pattern of differentiation of her TH1 T cells......levels of IFN-gamma??? Very interesting case. I keep thinking. :?
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| Param
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carla/holistic medicine:
I hope you are one & the same person since you seem to be talking about the herbal teas etc.
This is a real case & she has never experienced anything like this before.
Thank you for all your input - I too am really interested in this case & do try to read up on it whenever I get a chance.
She told my colleague that as long as she lived in San Francisco she was absolutely in good health, everything changed when she moved to LA. Within 2 months she developed these pruritic macular - papular rashes over the abdomen, trunk, upper & lower limbs. She later noticed them in the intertriginous areas. Her main complaint - they are extremely itchy.
If I get any more information I will post it here.
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| carla
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Yes, please keep us posted
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Carla
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