Case and Research Letters
Dyshidrotic Eczema Secondary to Intravenous Immunoglobulin Infusion: A Report of 2 Cases
Eccema dishidrótico secundario a la infusión de inmunoglobulinas intravenosas: presentación de 2 casos
A.A. Garrido-Ríos
, C. Martínez-Morán, J. Borbujo
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Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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Garrido-Ríos, C. Martínez-Morán, J. Borbujo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A.A." "apellidos" => "Garrido-Ríos" "email" => array:1 [ 0 => "natachagarrido@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Martínez-Morán" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Borbujo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eccema dishidrótico secundario a la infusión de inmunoglobulinas intravenosas: presentación de 2 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 657 "Ancho" => 986 "Tamanyo" => 91376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Vesicular lesions on an erythematous base on the palm of the second patient.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present 2 cases of dyshidrotic eczema secondary to intravenous immunoglobulin infusion. The first patient was a 58-year-old man who had been diagnosed with Guillain-Barré syndrome after presenting with sock-like paresthesia, unstable gait, and diminished tendon reflexes. The patient was treated with intravenous immunoglobulin, and his symptoms gradually improved. Ten days after admission, he began to develop asymptomatic lesions on his palms and soles.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed punctate vesicular lesions filled with clear fluid on an erythematous base located bilaterally on the palms and soles (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Some of the vesicular lesions were purpuric in appearance and filled with blood, especially in dependent parts of the body (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No mucosal involvement or lesions at other sites were observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology revealed an epidermis with psoriasiform hyperplasia, lymphocytic and erythrocytic exocytosis, and extensive spongiosis with formation of large subcorneal vesicles. The underlying dermis showed a moderate superficial perivascular lymphohistiocytic inflammatory infiltrate accompanied by blood extravasation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The second patient was a 67-year-old man whose personal history included removal of pleomorphous sarcoma on the right pectoral muscle and treatment with radiotherapy and chemotherapy. He was admitted 8 months after surgery for assessment of ataxia. During admission, and given the gradual worsening of his condition, he received intravenous immunoglobulin, and his symptoms partially resolved. A dermatological evaluation was ordered for the asymptomatic skin lesions, which were very similar to those of the first patient: vesicular lesions filled with clear fluid on an erythematous base located on the palms and soles. Histopathology findings were very similar to those of the first patient (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We diagnosed both patients with dyshidrotic eczema secondary to treatment with intravenous immunoglobulin.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lesions resolved in both cases with topical corticosteroids, although they reappeared in the first patient during the second cycle of treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Intravenous immunoglobulins are isolated from plasma obtained from between 1000 and 100 000 persons. They are subsequently purified to eliminate or inactivate infectious agents and prevent the formation of aggregates.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> They have been approved by the European Medicines Agency for the following indications: primary immunodeficiency syndromes with impaired antibody production; hypogammaglobulinemia and recurrent bacterial infections in patients with chronic lymphocytic leukemia in which antibiotic prophylaxis has not been successful; hypogammaglobulinemia and recurrent bacterial infection in patients with plateau-phase multiple myeloma who did not respond to pneumococcal vaccination; hypogammaglobulinemia in patients who undergo allogenic stem cell transplantation; congenital AIDS with recurrent bacterial infection; primary immune thrombocytopenia; patients at high risk of bleeding; patients undergoing surgery to correct their platelet count; Guillain-Barré syndrome; and Kawasaki disease.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> They are used off-label in numerous hematologic, neurologic, rheumatologic, infectious, and dermatologic conditions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Intravenous immunoglobulin has a good safety profile, and most adverse effects are associated with administration. The adverse effects, which are immediate, mild, and transient, consist of flulike symptoms that include headache, flushing, general malaise, chest tightness, fever, chills, myalgia, fatigue, dyspnea, back pain, nausea and vomiting, diarrhea, changes in blood pressure, and tachycardia. The most severe adverse effects are usually late in onset and manifest as thromboembolic events and renal, neurologic, and/or hematologic toxicity. Cutaneous adverse effects appear in 0.4%-6% of patients in the form of transient urticaria or maculopapular rash, palmar pruritus, hair loss, erythema multiforme, erythematous purpuric rash, petechiae on the limbs, ulceration of the oral mucosa, transient epidermolysis bullosa, lichenoid eruptions, and Baboon syndrome.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Eczema is rarely associated with administration of intravenous immunoglobulin. In their review of the literature, Gerstenblith et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> found 64 patients with eczematous reactions associated with intravenous immunoglobulin. The most common findings were the presence of multiple punctate erythematous vesicles grouped together on the palms and soles. Histopathology revealed the spongiotic loculated vesicles that are typical of dyshidrosis and a perivascular infiltrate composed of lymphocytes and eosinophils, as well as lymphocytic exocytosis in the epidermis. Overall, 62.5% of patients had lesions of dyshidrotic eczema on the palms and soles or on the palms and soles and at least 1 other affected site. Most patients received intravenous immunoglobulin for neurologic diseases. Almost all patients responded well to topical corticosteroids or did not require treatment, although treatment with oral corticosteroids was occasionally necessary. The eczematous reaction improved in all the cases reported, although in 1 case, itching persisted for months after suspending intravenous immunoglobulins. Despite these findings, therapy was suspended because of the eczematous reactions. No clear mechanism has been identified that might explain the association with eczema,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> although some authors suggest a hypersensitivity reaction to the drug or vehicle that has not been demonstrated with patch testing or prick testing.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the first patient, we thought that the skin lesions were gloves and socks syndrome, given that the histopathology findings were consistent with this syndrome and that this and Guillain-Barré syndrome can be triggered by common infectious agents such as parvovirus, <span class="elsevierStyleItalic">Mycoplasma</span>, Epstein-Barr virus, and cytomegalovirus<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a>; however, the results of serology testing to various pathogens were repeatedly negative.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Other diseases that can be taken into consideration with this type of lesion include palmoplantar pustular psoriasis, allergic contact dermatitis, dyshidrosiform tinea, scabies, id reaction, herpes simplex, and other bullous diseases such as pemphigus, pemphigoid, and epidermolysis bullosa.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">As this was a first episode of asymptomatic lesions associated in time with infusion of intravenous immunoglobulin (8 and 5 days, respectively) and reappearance of the lesions during the second treatment cycle in the first patient, we were able to confirm the diagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Garrido-Ríos AA, Martínez-Morán C, Borbujo J. Eccema dishidrótico secundario a la infusión de inmunoglobulinas intravenosas: presentación de 2 casos. Actas Dermosifiliogr. 2016;107:431–433.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 788 "Ancho" => 950 "Tamanyo" => 174941 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vesicular lesions on an erythematous base on the palm of the first patient.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 657 "Ancho" => 986 "Tamanyo" => 95410 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Vesicular blood-filled lesions on the sole of the first patient.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 657 "Ancho" => 986 "Tamanyo" => 91376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Vesicular lesions on an erythematous base on the palm of the second patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of intravenous immunoglobulin G (IVIG)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 4 | 10 |
| 2024 Octubre | 113 | 63 | 176 |
| 2024 Septiembre | 125 | 46 | 171 |
| 2024 Agosto | 159 | 74 | 233 |
| 2024 Julio | 174 | 55 | 229 |
| 2024 Junio | 150 | 65 | 215 |
| 2024 Mayo | 119 | 49 | 168 |
| 2024 Abril | 95 | 37 | 132 |
| 2024 Marzo | 106 | 47 | 153 |
| 2024 Febrero | 122 | 46 | 168 |
| 2024 Enero | 105 | 48 | 153 |
| 2023 Diciembre | 125 | 32 | 157 |
| 2023 Noviembre | 146 | 41 | 187 |
| 2023 Octubre | 200 | 38 | 238 |
| 2023 Septiembre | 143 | 45 | 188 |
| 2023 Agosto | 97 | 32 | 129 |
| 2023 Julio | 179 | 79 | 258 |
| 2023 Junio | 106 | 37 | 143 |
| 2023 Mayo | 134 | 44 | 178 |
| 2023 Abril | 115 | 40 | 155 |
| 2023 Marzo | 135 | 36 | 171 |
| 2023 Febrero | 144 | 40 | 184 |
| 2023 Enero | 116 | 41 | 157 |
| 2022 Diciembre | 132 | 44 | 176 |
| 2022 Noviembre | 101 | 56 | 157 |
| 2022 Octubre | 85 | 40 | 125 |
| 2022 Septiembre | 105 | 56 | 161 |
| 2022 Agosto | 46 | 50 | 96 |
| 2022 Julio | 69 | 43 | 112 |
| 2022 Junio | 60 | 34 | 94 |
| 2022 Mayo | 210 | 49 | 259 |
| 2022 Abril | 205 | 67 | 272 |
| 2022 Marzo | 228 | 59 | 287 |
| 2022 Febrero | 241 | 41 | 282 |
| 2022 Enero | 233 | 48 | 281 |
| 2021 Diciembre | 178 | 63 | 241 |
| 2021 Noviembre | 179 | 50 | 229 |
| 2021 Octubre | 156 | 58 | 214 |
| 2021 Septiembre | 136 | 60 | 196 |
| 2021 Agosto | 122 | 33 | 155 |
| 2021 Julio | 116 | 32 | 148 |
| 2021 Junio | 139 | 26 | 165 |
| 2021 Mayo | 149 | 32 | 181 |
| 2021 Abril | 373 | 43 | 416 |
| 2021 Marzo | 214 | 23 | 237 |
| 2021 Febrero | 162 | 32 | 194 |
| 2021 Enero | 108 | 26 | 134 |
| 2020 Diciembre | 119 | 18 | 137 |
| 2020 Noviembre | 111 | 25 | 136 |
| 2020 Octubre | 72 | 9 | 81 |
| 2020 Septiembre | 98 | 19 | 117 |
| 2020 Agosto | 48 | 16 | 64 |
| 2020 Julio | 59 | 21 | 80 |
| 2020 Junio | 44 | 35 | 79 |
| 2020 Mayo | 32 | 27 | 59 |
| 2020 Abril | 27 | 22 | 49 |
| 2020 Marzo | 38 | 18 | 56 |
| 2020 Febrero | 1 | 2 | 3 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Mayo | 5 | 1 | 6 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 2 | 3 | 5 |
| 2019 Febrero | 3 | 0 | 3 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 3 | 0 | 3 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Febrero | 35 | 5 | 40 |
| 2018 Enero | 56 | 8 | 64 |
| 2017 Diciembre | 68 | 8 | 76 |
| 2017 Noviembre | 53 | 5 | 58 |
| 2017 Octubre | 33 | 8 | 41 |
| 2017 Septiembre | 22 | 6 | 28 |
| 2017 Agosto | 31 | 3 | 34 |
| 2017 Julio | 25 | 10 | 35 |
| 2017 Junio | 31 | 11 | 42 |
| 2017 Mayo | 50 | 2 | 52 |
| 2017 Abril | 22 | 5 | 27 |
| 2017 Marzo | 31 | 3 | 34 |
| 2017 Febrero | 22 | 10 | 32 |
| 2017 Enero | 22 | 7 | 29 |
| 2016 Diciembre | 31 | 16 | 47 |
| 2016 Noviembre | 32 | 28 | 60 |
| 2016 Octubre | 23 | 27 | 50 |
| 2016 Junio | 0 | 5 | 5 |
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