Clinical History

Informant: Patient July 18, 2009

Reliability: 95%

General Data

V.M., 43 year old female, single, nanny, Roman Catholic from Tumaga Porcentro,
consulted for the first time at Doctors Hospital last July 18, 2009.

Chief complaint: Itching of both upper extremities

History of Present Illness

About 6 years prior to consultation (PTC), the patient developed rashes on both feet upon
wearing a rubber slipper. The rashes were described to be pruritic, painless, symmetrical, and
multiple erythematous patches that appear underneath the straps of the slippers. No other
asscociated signs and symptoms. Bioderm soap was used to cleanse the rashes and an unrecalled
sulfur product was applied to relieve the itching. No consultation was done.
Five (5) years PTC, patient began to developed skin lesions that first appear in the upper
extremities and eventually involved the lower extremities, the trunk, and some part of the face.
The lesions appeared as multiple, discrete scattered papules, pruritic, erythematous, painless, and
associated with burning sensation on the skin. No fever and no vomiting. The course of the
lesions last for about 4 to 6 hours and subsequently disappear. The patient experienced multiple
episodes of same condition which were triggered by the following as identified by the patient:
sea foods, shrimp paste, dried fish, lotion, earrings, and chicken. Still no consulation was done
and no medications.
Few hours prior to admission, the patient had severe pruritus on both upper extremities
upon application of lotion, which prompt the consultation.

Past Medical History

The patient is allergic to foods, such as shrimp paste, dried fish, chicken, sea foods, and
others things like rubber slippers, certain lotion products, earrings. No maintenance medication.
No history of previous hospitalization and surgical operations. Last meal was chicken products.
The patient applied lotion on both upper extremities before the appearance of the condition.

Family History

The patient’s 1st cousin and nephew have similar condition but associated with fever and
vomiting (hay fever). Her nephew has asthma. Patient’s mother died of liver problem and her
father died of stroke.

Personal and Social History

No vices. No history of travel. Taking a bath once a day. Watches over her nephew.

1
Review of Systems
General: (-) weight loss,
Skin: (-) dryness, (-) skin peelings, (-) jaundice
Head: (-) dizziness, (-) headache
Eyes: (-) use of eye glasses
Ears: (-) discharge, (-) pain
Nose: (-) discharge, (-) nosebleed
Mouth and Throat: (-) difficulty of breathing
Neck: (-) lumps, (-) tenderness, (-) pain on movement
Chest: (-) pain, (-) cough
Cardiac: (-) palpitations
GIT: (-) abdominal pain, (-) nausea, (-) vomiting
Urinary: (-) anorexia, (-) dysuria, (-) hematuria
Extremities: (-) numbness, (-)myalgia

Physical Examination

General Survey
Conscious, coherent, cooperative, not in cardio-respiratory distress.

Vital Signs
BP- 130/86 mmHg (left arm)
PR- 68 beats/minute
RR- 23 breaths/minute
T – 36.3 oC (axillary)

Skin: Multiple, scattered discrete, erythematous papules on both upper extremities.

Hypopigmented and scaling lesions on the 1 st inter-digital space extending about 5cm to the
dorsum region, 3 cm in diameter, symmetrical on both feet. There are secondary lesions
(lichenification) on both feet appearing like straps of rubber slippers.

anterior posterior

Head:
Symmetrical, no deformities, no abnormal movements, no tenderness, no
lymphadenopathy.

2
Eyes:
Eyebrows: black, equally distributed, no scaliness.
Eyelids: brown, no lesions
Eyelashes: black, evenly distributed, outward direction
Lacrimal Apparatus: no inflammation
Conjunctiva: transparent bulbar, pink palpebral, no inflammation
Sclera: white, no ulcers, no protrusions
Cornea: convex, transparent
Iris: brown, markings are prominent
Pupils: round, equal in symmetry and size of 3mm of both eyes

Ear and Mastoid:

Auricles: symmetrical, no rashes, lumps or deformities
Ear canals: no discharges, no swelling
Mastoid: no tenderness, no swelling

Nose:
Appearance: symmetrical, brown in color, no lesions, no alar flaring
Mucosa: pinkish, no discharges, no swelling, no inflammation
Nasal septum: no perforation, no deviation

Mouth and throat:

Lips: symmetrical, no ulceration, pale in color
Buccal Mucosa: pinkish in color, no ulcers
Hard Palate: no lesions, pinkish
Soft palate: no lesions, no swelling, no redness
Uvula: midline, no inflammation
Tonsils: symmetrical, no inflammation

Neck:
Symmetrical, trachea at midline, no pulsations observed, no venous distension, thyroid
not visible, carotid pulsation with equal intensity on both sides, no palpable thyroid gland
and lymph nodes, no bruits

Chest and Lungs:

Symmetrical, no lesions, no masses, no discoloration, equal chest expansion, no
supraclavicular and subcostal retractions, no masses upon palpation, equal tactile
fremitus, no chest lagging, equal breath sounds on both lung fields, equal vocal fremitus,
no rales, resonant on both lung fields

Abdomen:
Globular, no mass, no discoloration, 4 cm scar midline and inferior to the umbilicus, no
pulsations, normoactive bowel sounds on all quadrants of the abdomen, no bruit, tympanitic on
all quadrants, no palpable mass, no tenderness, no organomegaly

3
Extremities: Good capillary refill time (<2 seconds), pulses are strong and equal, warm, no
edema, no clubbing, no pallor

Clinical Impression: Atopic dermatitis to consider contact dermatitis

Basis: Pruritic rashes. Recurrent episodes of allergic reactions upon exposures. History of
allergies: sea foods, shrimp paste, dried fish, rubber slippers, certain lotion products,
earrings, and chicken foods. History hay fever and asthma in the family.

Differential diagnosis:

Diseases Rule In Rule Out

Allergic Urticaria Sudden onset of erythematous (-) swelling
papules, itching,
Erythema Multiforme Erythematous papules, Itching (-) target/iris lesion, (-)
(minor) fever, (-) malaise, (-)
athralgia,

Paraclinicals:

Patch testing – to be able to identify the specific allergen causing the hypersensitivity
reactions

CASE DISCUSSION:
Pathophysiology:

Initial exposure: Re-exposure:

Antigens Antigens

Epidermal dendritic Langerhans cells Migration of memory T cells

Lymph nodes Release of cytokines and

chemokines
CD4 + T cells
Recruits inflammatory cells

Effector and
memory T cells. Erythema Pruritus

4
 In order to understand what is happening to our patient, let us first review and understand
what Atopic dermatitis and contact dermatitis are and discuss a little on their pathogenesis.
Atopic dermatitis is a chronic, pruritic, superficial inflammation of the skin, frequently
associated with a personal history or family history of allergic disorders (Hay fever and asthma).
Susceptibility is genetic, but the disorder is triggered by various environmental agents and
factors.
Contact dermatitis is an acute or chronic inflammation, often asymptomatic, produced by
substance contacting the skin and causing toxic (irritant) or allergic reactions. The above diagram
shows the common pathogenesis of Contact dermatitis. On the initial exposure, the antigens are
taken up by the dendritic Langerhans cells located at the epidermal layer of the skin. These
Langerhans cells then migrate to the lymph nodes by way of dermal lymphatics. Here, the
antigens that are processed by the Langerhans cells are presented to the CD4+T cells. This event
would lead to the activation of CD4+T cells and develop into effector and memory T cells. Re-
exposure of the antigens would cause the migration of these memory T cells to the affected skin
site, where they adhere to the post-capillary venules, extravasate into tissues, and release
cytokines and chemokines. Recruitment of inflammatory cells takes place that result in
erythematous and pruritic lesion of the affected skin.
Our patient V.M, a 43 year female, probably has been exposed to unknown substances,
irritants or allergens in the past and was re-exposed 5 years ago to similar antigens that initiate
the condition. Recurrent exposures lead to recurrent of symptoms of the patient. These
recurrences may be attributed to the following factors: 1. Lack of knowledge and awareness of
the patient regarding her condition, no consultation was done for the past 5 years. 2. Strong
family history of the patient (Hay fever and Asthma) which made her genetically susceptible to
allergic reactions.
As the identified by the patient, foods like shrimp paste, dried fish, chicken, sea foods,
and other things like rubber slippers, certain lotion products, and earrings cause hypersensitivity
reactions upon contact with the patient. It is a good thing for the patient to be able to identify the
things that she/he is allergic from; after all, the mainstay of treatment is to avoid those things that
cause the condition.
On the day of consultation, the patient reported that she ate chicken meal in the morning
and she also applied lotion on both her upper extremities. The patient is both allergic to both
chicken meal and lotion, but what might be the cause of her recent attack? Upon physical
examinations, we noted the location and distribution of her lesions were only limited to both her
upper extremities. This finding is a major clue in identifying what cause the allergic reactions.
Therefore, we can say that most probably the recent allergic reaction of the patient was due to
application of lotion, if it were because of chicken she ate, the lesion, most likely would be
generalized.

Management:

The cause of contact dermatitis must be identified; otherwise, the patient is at increased
risk for chronic or recurrent dermatitis. It is important to advice the patient to avoid the identified
allergens.

Marah, Dendrazier K.
Level III, Medical Student