Hyperpigmentation and eosinophilia
Question:
4/12/2016
In April 2015, 55 year-old male developed a bleeding ulcer with severe blood loss subsequently followed by renal shutdown. Patient reports he currently has 20% renal function and renal dialysis was started in November 2015. The patient subsequently developed an erythematous pruritic rash on his lower extremities which gradually moved up, now encompassing his entire body. His skin has turned dark essentially black on most areas of his body and is still extremely pruritic. Dermatology workup including biopsy did not reveal a definitive diagnosis. A CBC however did reveal 20% eosinophilia with WBC: 7.1). Of note is that patient was in Japan from July 2013 to December 2015 and spent time in other areas of Asia as well.
Not sure how to tie all this together. I haven't seen parasitosis or hypereosinophilia present with this type of hyperpigmentation, but maybe still a possibility. I read somewhere that eosinophilia can be associated with dialysis. Maybe the hyperpigmentation and eosinophilia are separate issues. No current GI Sx. Patient on antihypersensives and PPI therapy.
Answer:
I agree this is a perplexing presentation. The pruritus with hyperpigmentation suggests that perhaps the color change is an inflammatory effect secondary to scratching. Renal insufficiency is associated with pruritus. I would question whether he may have a coagulopathy that may increase the dermatologic bleeding from scratching and result in pigmentation from the hemosiderin. Trauma to the skin may also result in melanocyte stimulation from inflammatory cytokines, mediators and nitric oxide. Other explanations for pigmentation include adrenal insufficiency (which also could cause eosinophilia), drug induced pigmentation (methotrexate, 5 fluorouracil, hydroxyurea, amiodarone, clofazamine, minocycline, tricyclics, thorazine, hydroxychloroquine and zidovudine), erythema dischromium perstans which can be associated with whipworm infestation and eosinophilia, primary cutaneous amyloidosis and lichen planus pigmentosus. Eosinophilia could be associated with parasite infestation including whipworm, adrenal insufficiency, drug reaction, primary eosinophil disease, T cell abnormality, autoimmune disease or infection.
My suggestion would be to have the skin biopsy reviewed to specifically look for evidence of lichen planus, melanocyte increase versus other causes of pigmentation (such as hemosiderin) and amyloid. Sezary syndrome might also be a consideration so would ask pathologist to review with this in mind. Alternatively, you could discuss with your dermatology consultant. You might consider screening for hepatitis in light of the blood transfusions and even consider HIV or HTLV screening. If he is not having diarrhea, I do not think you will gain information with stool studies but you may want to obtain serology for parasites associated with eosinophilic response such as ascaris, whip worm and strongyloides. I would also obtain a total IgE as often this will be increased with systemic parasite response. I would look carefully for adrenal function with cortisol levels or referral to endocrinologist. I would review all medications to be certain not associated with pigmentation. Finally, the original reason for the GI bleed should be reviewed to be certain no malignancy.
I hope this information is of help to you and your patient.
All my best.
Dennis K. Ledford, MD, FAAAAI