Q:

A 39 year old male university administrator 15 year history (more frequent for a year) of intermittent nasolabial folds pruritis without a rash, 2-6 times yearly lasting 15 minutes. The only consistent trigger is drinking robust beer. In November, 2010 he flew to Austrailia (took his usual Tums before the flight and ate on the flight). 3-4 hours later (not sure if after or before dinner) his had pruritis of his neck then back and posterior thighs (where in contact with the seat). He saw diffuse urticaria and facial flushing and anal pruritis. He needed Benadryl every 4-6 hours to get some relief. He took Phenergan in Australia; all symptoms gone in morning. On the return flight he premedicated with Phenergan and had less, (? urticaria). He has flown many times before and since (not Unitied) without reactions. He has had an episode of pruritis of his face, forearms and chest with "throat swelling" (he was scared) after drinking a strong Belgian ale (and another similar episode without obvious trigger). If he is in the kitchen when his wife chops fresh basil (he can eat it in the meal), eating Altoids, dark chocolate, balsamic vinegar, fresh fruit salad, some cookies and smelling some perfumes causes facial pruritis. Recently he notices trouble swallowing food (never impaction) and choking on liquids. When he is stressed, he gets itchy skin. He had heartburn in grad school (endoscopy showed reflux), now only once a month. He wheezes when exercising and occasionally when laughing. He had palatal pruritis as a child. He has not had poison oak, latex sensitivity or adverse reactions to medications. He takes probiotics occasionally. Two sibs have metal contact dermatitis. He has no dermatographism. His lower tarsal conjunctivae are moderately injected. Pulse is 104 (he has always had a rapid pulse). What do you think? Systemic contact dermatitis, Balsam of Peru? Auriculotemporal syndrome?

 

I gave him Epi. What to do?

A:

Thank you for your recent inquiry.

Unfortunately, the history that you describe does not "ring any particular bell." There are multiple symptoms, none of which have been objectively confirmed, and it is unclear whether these manifestations are in any way related to one another. I don't think a single diagnosis could explain all the manifestations you mentioned. The "good news" is that he feels that there are certain triggers which can precipitate these symptoms.

With these observations in mind, I think there are at least two strategies that one can pursue to try and delineate the nature of his problems, and hopefully be able to offer your patient some help.

First of all, I do not think we should "lump" these manifestations. I would approach them separately.

Secondly, I believe that the most important strategy would be to try and objectively confirm these symptoms under observation by challenging with the triggers noted.

From what you describe, there may be some psychological element involved in his interpretation of these symptoms, and to better clarify this you need objective confirmation. Therefore I would suggest the following:

He states that he has wheezing with exercise and with laughing, implying that he may have mild intermittent asthma. You could certainly objectively pursue this diagnosis in a standard fashion. This can be done through several modalities as follows:

You could ask him to do a free run, measuring pulmonary functions before and after the run.

You could consider a mannitol or methacholine challenge. If the challenge was negative, it would rule out asthma. A positive challenge, of course, would not establish the diagnosis.

If none of these were acceptable to the patient, you could at least give him a peak flow meter and an albuterol inhaler to see if there was a drop in peak flow with exercise. It would also discern if he improved his symptoms by pretreatment with albuterol. If it does, then you would at least have a mechanism to prevent one of his complaints.

I do not think that his heartburn has anything to do with the other complaints, but if you are considering the fact that these may be related to atopy, and he has eosinophilic esophagitis, you could certainly request a repeat endoscopy with biopsies done to look for this diagnosis.

The dysphagia can be tested by esophageal swallowing studies. This, of course, like a potential endoscopy, would probably be best done via a consult with a gastroenterologist.

He states that if he is in the kitchen when his wife chops fresh basil or when he eats dark chocolate, Balsamic vinegar, et cetera, he develops facial pruritus. You could certainly bring him into your office, expose him in a manner similar to that via "home exposures" to see if any objective confirmation of his symptoms appear. You could also do the same thing by having him, perhaps on a separate occasion, drink "robust" beer while under your observation. I would also ask him to bring into the office the "Belgian ale" for an oral challenge.

I do not think that the family history in his case or his physical findings are of any particular significance.

Finally, you could certainly consider standard patch tests and a standard battery of allergy skin tests.

As far as the issue of Balsam of Peru is concerned, you could obtain Balsam of Peru and do a patch test. If he did have systemic contact dermatitis to Balsam of Peru, you would be able to pick it up by patch testing.

These are just suggestions as to how you might approach this patient. On the basis, however, of the description, I would not be surprised if you failed to objectively confirm symptoms through these exposures, but nonetheless I believe that they are certainly worth a try if the patient would be willing to go through this.

Just based on personal experiences, in the vast majority of instances, workup of patients who present with this type of history is quite often nonrevealing, and one simply is unable to make any definitive diagnosis. In those instances, empiric treatment as he has used himself (e.g., an H1 antagonist for his cutaneous symptoms and an H2 antagonist for his reflux symptoms) is all that one can offer.

Nonetheless, I do think that objective confirmation, although quite tedious in his case, would be worth a try if the patient would be agreeable to the above mentioned procedures.

In closing auriculotemporal syndrome would not explain the majority of his symptoms and would only produce gustatory sweating and flushing usually located around the parotid.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology