AN UNUSUAL RASH IN A PATIENT WITH PULMONARY EMBOLISM

Abstract

Introduction Rashes are common and mostly benign but some may reflect serious disease. Case Description A 54-year-old male presented 2 months after developing a pruritic, erythematous, generalized papular rash. It did not improve on amoxicillin, antihistamines, and topical corticosteroids. He developed acute SOB and chest CT revealed pulmonary embolism treated with anticoagulant (apixaban). However, the rash worsened and the patient was transferred to our hospital. On PE, the right arm was swollen, erythematous, warm, and tender, with few vesicles on the forearm (Fig). There were also multiple small vesicles on the back, upper chest, and face. There was no lymphadenopathy. Patient was started on clindamycin. Apixaban was switched to enoxaparin for possible drug reaction. CBC was normal except for eosinophilia 4090/mL. He had negative blood culture and normal CMP, troponin, and EKG. Ultrasound on right arm showed no DVT. Chest CT showed multiple hypodense fillings scattered throughout both lungs. Serology for HIV, Toxocara, Strongyloides, Coccidiodes, and Histoplasmosis were negative. The rash worsened with involvement of the left arm and face. Biopsy showed intracorneal/subcorneal bullae with marked eosinophilic infiltrate, but negative immunofluorescence studies, HSV, VZ, and acid fast bacilli. He developed dysphagia and esophageal biopsies revealed 20-30 eosinophils/HPF. Methylprednisolone 60 mg BID resulted in rapid improvement within 2 days in the skin and eosinophilia (20/mL). Laboratory tests were negative for eosinophilic granulomatosis with polyangiitis, mastocytosis, and myeloproliferative or lymphocytic hypereosinophilic disease. Discussion The rash was considered eosinophilic cellulitis likely secondary to idiopathic hypereosinophilic syndrome.