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AN UNUSUAL INFECTIOUS CAUSE OF ACUTE URTICARIA
S90
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
Family history was significant for lip and eyelid swelling in multiple family members. Although not known to have been prescribed ACE inhibitors, a bottle of lisinopril was discovered in the patient’s belongings. Physical examination found bilateral periorbital edema and edema of the neck without erythema or warmth. Subcutaneous crepitus was not appreciated. Initial CT imaging demonstrated pneumothorax. Angioedema from antibiotic drug allergy, ACE-inhibitors and hereditary or acquired C1 inhibitor deficiency angioedema were considered. Treatment was initiated with H1 and H2 antihistamines, epinephrine, systemic corticosteroids, fresh frozen plasma, and plasmaderived C1 esterase inhibitor without improvement. C4 level was normal. Repeat CT imaging revealed the development of extensive subcutaneous emphysema of the face and eyelids. He recovered with supportive care. Discussion: This patient’s case highlights the importance of considering a broad differential when evaluating for suspected angioedema of the neck and face including subcutaneous emphysema, contact dermatitis, cellulitis, and superior vena cava syndrome.
patch on his back consistent with erythema migrans, and transient, migratory raised plaques on his arms and legs consistent with urticaria. He had a WBC of 12 k with 80.7% neutrophils, and an otherwise normal complete blood count, basic metabolic panel, and liver panel. Lyme IgM was positive, confirmed by Western Blot. CSF revealed 13 nucleated cells with a lymphocytic predominance. He was treated for Lyme meningitis with ceftriaxone 2 g daily. His urticarial rash was controlled with fexofenadine. Upon completion of Lyme treatment, he had no recurrence of urticaria despite discontinuation of fexofenadine. Discussion: Infections are a commonly identified cause of acute urticaria with viruses and parasites being the most cited pathogens, and less frequently bacteria. Notably, Lyme disease is not commonly listed as a cause of acute urticaria, although Borrelia burgdorferi has been shown to induce mast cell activation in vitro. This case provides a potential in vivo correlate to these in vitro findings in a patient with concurrent acute urticaria and Lyme borrelliosis.
M171
M172
AN UNUSUAL INFECTIOUS CAUSE OF ACUTE URTICARIA J. Gereige*, K. Hysell, K. Reynolds, M. Guenechea-Sola, Boston, MA Introduction: Although many cases of acute urticaria are caused by infectious illnesses, certain pathogens are not frequently reported in association with urticaria. Urticaria
DELAYED URTICARIA AND ANGIOEDEMA FOLLOWING YELLOW FEVER VACCINE IMMUNIZATION M. Beronilla*, M. Karagic, G. Hudes, Bronx, NY Introduction: Few cases of acute allergic reaction to Yellow Fever Vaccine (YFV) are reported. We present a case of delayed urticaria and angioedema (U&A) following YFV immunization. Case Description: A 51-year-old female with multiple medical problems including history of malignancy presented for evaluation of U&A for over a month. Two days after YFV immunization she developed progressive neurological symptoms over a period of time and eventually was admitted to the hospital. She found to have hypertension, but extensive laboratory and radiology evaluations were not contributory. The patient was treated symptomatically and discharged. Neurological symptoms gradually improved but three weeks after YFV immunization she developed episodic U&A responsive to steroids. Our evaluation revealed normal complement studies, normal functional C1 esterase, no specific IgE to egg or gelatin, negative rheumatological work up and no gross immunodeficiency, although she had elevated CRP and ESR. We advised the patient to stop new medications and treated the U&A. At two month follow up U&A symptoms completely resolved. Reintroduction of medications did not cause U&A. Discussion: We suspect that our patient developed delayed non IgE mediated reaction to YFV. Health care providers should take caution administering YFV to patients with an underlying malignancy. A complete medical history is needed to determine risk benefit ratio of YFV immunization. Asthma and Other Lower Airway Disorders
M200 ROCK, PAPER, SCISSORS, ASTHMA, BRONCH: ROCK BEATS ASTHMA H. Ahmad1, A. Gonzalez-Estrada2, 1. Johnson City, TN; 2. Jacksonville, FL
Case Description: A 28-year-old man presented with 1 week of fevers, neck stiffness and a migratory pruritic rash. His past medical history included asthma and metastatic melanoma that is now in remission. He had received 3 years of pembrolizumab, with the last dose being 1 year prior to presentation. He was non-toxic appearing and had mild nuchal rigidity, a 5 £ 7cm well-defined erythematous
Introduction: Broncholithiasis occurs due to calcified substance found in the bronchial tree. Patients present with wheezing, cough, shortness of breath, and less commonly lithoptysis. Broncholiths can result in recurrent post obstructive pneumonia and bronchiectasis. In symptomatic patients, rigid or flexible bronchoscopy is often needed. We present a case of broncholithiasis and treatment with bronchoscope removal. Case Description: A 52-year-old female non-smoker was evaluated for a three-year history of non-productive cough, globus sensation, shortness of breath, wheezing, fatigue, halitosis, and weight loss. She had a history of two episodes of chest x-ray proven pneumonia. Physical examination revealed expiratory wheezing. A sinus CT scan was
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
Family history was significant for lip and eyelid swelling in multiple family members. Although not known to have been prescribed ACE inhibitors, a bottle of lisinopril was discovered in the patient’s belongings. Physical examination found bilateral periorbital edema and edema of the neck without erythema or warmth. Subcutaneous crepitus was not appreciated. Initial CT imaging demonstrated pneumothorax. Angioedema from antibiotic drug allergy, ACE-inhibitors and hereditary or acquired C1 inhibitor deficiency angioedema were considered. Treatment was initiated with H1 and H2 antihistamines, epinephrine, systemic corticosteroids, fresh frozen plasma, and plasmaderived C1 esterase inhibitor without improvement. C4 level was normal. Repeat CT imaging revealed the development of extensive subcutaneous emphysema of the face and eyelids. He recovered with supportive care. Discussion: This patient’s case highlights the importance of considering a broad differential when evaluating for suspected angioedema of the neck and face including subcutaneous emphysema, contact dermatitis, cellulitis, and superior vena cava syndrome.
patch on his back consistent with erythema migrans, and transient, migratory raised plaques on his arms and legs consistent with urticaria. He had a WBC of 12 k with 80.7% neutrophils, and an otherwise normal complete blood count, basic metabolic panel, and liver panel. Lyme IgM was positive, confirmed by Western Blot. CSF revealed 13 nucleated cells with a lymphocytic predominance. He was treated for Lyme meningitis with ceftriaxone 2 g daily. His urticarial rash was controlled with fexofenadine. Upon completion of Lyme treatment, he had no recurrence of urticaria despite discontinuation of fexofenadine. Discussion: Infections are a commonly identified cause of acute urticaria with viruses and parasites being the most cited pathogens, and less frequently bacteria. Notably, Lyme disease is not commonly listed as a cause of acute urticaria, although Borrelia burgdorferi has been shown to induce mast cell activation in vitro. This case provides a potential in vivo correlate to these in vitro findings in a patient with concurrent acute urticaria and Lyme borrelliosis.
M171
M172
AN UNUSUAL INFECTIOUS CAUSE OF ACUTE URTICARIA J. Gereige*, K. Hysell, K. Reynolds, M. Guenechea-Sola, Boston, MA Introduction: Although many cases of acute urticaria are caused by infectious illnesses, certain pathogens are not frequently reported in association with urticaria. Urticaria
DELAYED URTICARIA AND ANGIOEDEMA FOLLOWING YELLOW FEVER VACCINE IMMUNIZATION M. Beronilla*, M. Karagic, G. Hudes, Bronx, NY Introduction: Few cases of acute allergic reaction to Yellow Fever Vaccine (YFV) are reported. We present a case of delayed urticaria and angioedema (U&A) following YFV immunization. Case Description: A 51-year-old female with multiple medical problems including history of malignancy presented for evaluation of U&A for over a month. Two days after YFV immunization she developed progressive neurological symptoms over a period of time and eventually was admitted to the hospital. She found to have hypertension, but extensive laboratory and radiology evaluations were not contributory. The patient was treated symptomatically and discharged. Neurological symptoms gradually improved but three weeks after YFV immunization she developed episodic U&A responsive to steroids. Our evaluation revealed normal complement studies, normal functional C1 esterase, no specific IgE to egg or gelatin, negative rheumatological work up and no gross immunodeficiency, although she had elevated CRP and ESR. We advised the patient to stop new medications and treated the U&A. At two month follow up U&A symptoms completely resolved. Reintroduction of medications did not cause U&A. Discussion: We suspect that our patient developed delayed non IgE mediated reaction to YFV. Health care providers should take caution administering YFV to patients with an underlying malignancy. A complete medical history is needed to determine risk benefit ratio of YFV immunization. Asthma and Other Lower Airway Disorders
M200 ROCK, PAPER, SCISSORS, ASTHMA, BRONCH: ROCK BEATS ASTHMA H. Ahmad1, A. Gonzalez-Estrada2, 1. Johnson City, TN; 2. Jacksonville, FL
Case Description: A 28-year-old man presented with 1 week of fevers, neck stiffness and a migratory pruritic rash. His past medical history included asthma and metastatic melanoma that is now in remission. He had received 3 years of pembrolizumab, with the last dose being 1 year prior to presentation. He was non-toxic appearing and had mild nuchal rigidity, a 5 £ 7cm well-defined erythematous
Introduction: Broncholithiasis occurs due to calcified substance found in the bronchial tree. Patients present with wheezing, cough, shortness of breath, and less commonly lithoptysis. Broncholiths can result in recurrent post obstructive pneumonia and bronchiectasis. In symptomatic patients, rigid or flexible bronchoscopy is often needed. We present a case of broncholithiasis and treatment with bronchoscope removal. Case Description: A 52-year-old female non-smoker was evaluated for a three-year history of non-productive cough, globus sensation, shortness of breath, wheezing, fatigue, halitosis, and weight loss. She had a history of two episodes of chest x-ray proven pneumonia. Physical examination revealed expiratory wheezing. A sinus CT scan was