Q:

6/3/2013
A 49 year-old caucasian male with no significant past history presented with an initial evaluation of of GI symptoms consisting of abdominal fullness or discomfort (no n/v) and a few hours later a low-grade fever and generally feeling unwell for 1-2 days followed by improvement with an upper torso red rash which is blotchy non pruritic, non urticarial but symmetric that would last for 2-3 days before fading away. During that period his appetite is poor and he does not eat and drinks liquids sparingly. He then gradually increases his diet until it normalizes into his regular schedule. These episodes first started in Thailand where he was living about 6 years ago and he had 1-2 attacks per year not related to any specific foods. This year he has had two episodes in two months. This time he ate a bran muffin, chicken pot pie. He sometimes feels high fatty foods can trigger these symptoms. His physical exam was unremarkable.

I am not sure how to proceed. His initial lab work including CBC with diff, ESR, LFTS were normal. No stool workup was done. I was thinking of getting a baseline tryptase level as well as a 24 hr urine histamine and PGD2 levels. Any suggestions would be greatly appreciated. Thank you.

A:

Thank you for your inquiry.

Unfortunately, the illness that you described does not “ring any diagnostic bells.” In my experience, this is a very unusual symptom complex to be evaluated by an allergist-immunologist. From the description, I do not think that you will find the cause of your patient’s episodes in any area that we, as allergists-immunologists, normally pursue.

Although there is no harm in ordering the workup you have suggested, it would be, in my opinion, very unlikely to offer any useful information. I would be very reluctant to order an extensive workup in this patient without further objective confirmation of the nature of these events. What I would try and do in this situation is to see the patient in the throes of an episode, document the appearance of the rash, and perhaps obtain a biopsy as well as document the fever. I would also make sure to obtain a CBC, sed rate and CRP, during the event, and if abdominal symptoms are severe consider getting a CT of the abdomen at the same time. A visit during one of these events would be most helpful in making sure that the patient’s description adequately fits the manifestations of his illness.

In addition, if he has not been seen by a gastroenterologist, I think that a consultation in this regard is indicated. Since fever and a rash occur during these episodes, and they started in Thailand, if he has not seen Infectious Disease, a consultation in this area would also be indicated.

In summary, based on your description of his events, I cannot think of any specific test that an allergist-immunologist would normally utilize to pursue the etiology of his episodes. I think it would be very important to see him during an episode as mentioned above, and if the above consultations have not been obtained, would also suggest looking into these as well. If the episodes continue at the same pace, it should therefore not be too long before you would be able to “catch him” during an event, and doing so may save ordering tests which would be of little help, while allowing you to be more specific in your approach. Since he has had this condition for six years, I do not think that a delay before pursuing a workup would be of any threat to him.

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