Massoud Mahmoudi - Challenging Cases in Allergic and Immunologic Diseases of the Skin

Department of Dermatology, A.T. Still University/Northeast Regional Medical Center, 700 W. Jefferson Street, Kirksville, MO 63501, USA

Lloyd J. Cleaver

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The patient is a 68-year-old white female who was referred for a new evolving rash for 1 week. The patient initially developed red, dime to nickel sized itchy bumps on her back. This rash continued to progress over the next week and eventually involved her bilateral arms, legs, back, abdomen, and face. She complained of an intense itch as well as some associated pain at the lesions that was keeping her awake at night. She had received intramuscular injections of triamcinolone. She stated that this has slowed the formation of new lesions, relieved the tightness in her throat and chest, but there was still an intense itch present. The patient denied any other systemic symptoms present since the start of her rash. The patient was on multiple medicines, including pramipexole, medroxyprogesterone, propranolol, atorvastatin, gabapentin, fenofibrate, aspirin, amlodipine, vitamin B1, vitamin B12, and a multivitamin. The patient had recently been switched from omeprazole to ranitidine approximately 34 days before the first lesion appeared. She has a significant past medical history of squamous cell carcinoma with metastasis to the neck with the treatment of chemotherapy and radiation, chronic bronchitis, hypertension, myocardial infarction, chronic kidney disease, and frequent bladder infections.

Upon physical examination, the patient demonstrated multiple erythematous, wheal-based, annular to serpiginous, targetoid lesions. The lesions were present on the bilateral legs, arms, back, abdomen, and minimal involvement of the face (Figs. ). No involvement was noted of the mucosal membranes and the patient had no adenopathy present of the cervical, axillary, inguinal, or supraclavicular nodes.

The clinical presentation of extremely pruritic targetoid urticaria-like lesions that respond to previously given IM steroids most likely suggests some type of urticaria. The tenderness of some of the lesions, the systemic involvement, and the tightness in the throat and chest suggest possibly a vasculitic component. Urticarial vasculitis was favored.

Acute urticaria, erythema multiforme, urticaria vasculitis, drug eruption, Sweets syndrome, neutrophilic vasculitis.

The diagnosis is urticarial vasculitis secondary to the use of ranitidine. The acute onset of her urticarial breakout after the new use of ranitidine is a large clue to the diagnosis. The punch biopsy is fairly specific for a leukocytoclastic vasculitis consistent with urticarial vasculitis. Urticarial vasculitis has a propensity for eosinophils over other types of vasculitis. Sweetssyndrome demonstrates a more intense dermal infiltrate with marked upper dermal edema. The syndrome typically possesses karyorrhexis and lacks vessel wall necrosis, fibrin, and vasocentric neutrophils, which are features of urticarial vasculitis. The punch biopsy along with clinical features is the standard for diagnosing urticarial vasculitis, but it does not help determine the etiology. Acute urticaria does not demonstrate vasculitic changes.

The patient was instructed to stop the ranitidine immediately. She was prescribed fexofenadine 180 mg to take daily, hydroxyzine 25 mg at night, and fluocinonide 0.05% cream to apply to the red itchy areas twice a day. The patient was also given pramoxine hydrochloride 1% to apply throughout the day. The lesions completely cleared within 1 week and the proteinuria cleared within 4 weeks. The patient was later rechallenged with the ranitidine and had an acute urticarial dermatitis. Since avoiding ranitidine, the patient has been symptom free.