case

1. Case 1

2. History
A 14-year-old female middle school student seen initially in the allergy
clinic on October 2009. She described frequent attacks of itchy hives,
swelling of lips, and eyelids. They were followed by dyspnea, wheezing,
and dizziness spills. She gave history of four attacks over the last year.
In all the attacks, her symptoms appeared during physical exertion
immediately following the ingestion of her dinner that usually contains
wheat bread, cheese, and eggs. Surprisingly, she could tolerate these
foods if it was not followed by exercise. Moreover, her symptoms never
occurred if a meal did not precede performing the exercise activity.

3. Cont.
Her last attack was severe and occurred while jogging and running at
the backyard immediately after having a slice of vegetarian pizza for
which she attended the emergency room.
She gave history of not taking any medication specifically nonsteroidal
anti-inflammatory drugs (NSAIDs) before having exercise. Also, the
attacks were not related to her menstruation. Review of her past
medical history and family history were noncontributory.

4. Examination
• Dermographism test – negative
• The serum tryptase is not checked in the ED during the attacks.
• The allergy skin prick testing for common food showed a positive
reaction to only wheat.
• A supervised graded oral challenge with wheat at rest was performed
and was tolerated without any consequences.

5. Questions
• What is the diagnosis?
• What is the management?

6. Case 2

7. History
A 26-year-old woman attends the dermatology clinic complaining of a 4-month history of
an itchy eruption. She describes the eruption as ‘cloud-like’. She previously suffered from
eczema as a child but this rash is different. The eruption waxes and wanes, with
individual lesions lasting 8 to 12 hours, she is rarely clear of lesions for more than half a
day. Sometimes she goes to bed with the eruption and wakes clear, but the opposite can
also occur. She has never experienced angioedema. It is often worse perimenstrually. The
eruption is worse with exercise or a hot bath, but does not appear to be aggravated by
pressure or cold. The eruption is partially attenuated by cetirizine 10 mg daily, which she
is taking for her hay fever. Her only other medication is occasional ibuprofen for
dysmenorrhoea.
There is no family history of skin lesions. Both of her parents are well, although her
mother has a diagnosis of osteoporosis and is on thyroxine replacement. On close
questioning she admits that although circumstances at work are stable and have not
changed for a longtime she is experiencing difficulty coping and frequently cries at work.

8. Examination
On examination there are several scattered lesions over her trunk, limbs
and face. They are composed of well-defined erythematous oedematous
plaques surrounded by a pale ‘flare’. The lesions vary in size and shape but
not in morphology. Unable to elicit dermographism. The lesion ringed
initially had disappeared by the time she presented to photography 2
hours later, with new lesions developing over adjacent skin. Following
their resolution the lesions leave no persistent skin change. Although the
eruption is pruritic there is no evidence of lichenification or excoriations.
Blood pressure is 105/68 mmHg and pulse rate 102 beats/min.
Cardiorespiratory system is otherwise normal. Her abdomen is soft and
non-tender. You notice a degree of bilateral upper eyelid lag. She has a
smoothly enlarged goitre and stretching her hands out she has a fine
tremor.

9. Cont.
Neurological system is normal. Urinalysis was negative for blood, white
cells and glucose.
The patient to put on her coat and walk briskly up and down the
corridor outside. After five minutes she returns with a marked
aggravation of her eruption, which is now widespread and generalized
over her trunk and proximal limbs.
Investigations
Full blood count – Normal
Urea and electrolytes – Normal
Liver function tests – Normal

10. Questions
• How would you investigate this patient?
• What is the management?