Journal of the Scientific Society

CASE REPORT
Year
: 2022  |  Volume : 49  |  Issue : 2  |  Page : 201--203

Severe eczematous dermatitis with hyperimmunoglobulin E syndrome


Raavi Ramapure, Nidhi Pugalia, Samyak Ganjre, Adarshlata Singh, Bhushan Madke 
 Department of Dermatology, Venereology and Leprosy, Datta Meghe Institute of Medical Sciences, Jawaharlal Nehru Medical College, Sawangi Meghe, Wardha, Maharashtra, India

Correspondence Address:
Raavi Ramapure
Department of Dermatology, Jawaharlal Nehru Medical College, Sawangi, Belgaum, Karnataka
India

Abstract

Primary immunodeficiency syndrome represents a heterogeneous group of inherited disorders caused by mutations in genes encoding functional proteins of the immune cells and characterized by an increased risk of infections, autoimmunity, autoinflammation, malignancy, and allergic disorders. Hereby, we report an 8-year-old-male child with complaints of severe itchy lesions over the body since infancy. Thorough investigations showed he had primary immunodeficiency with underlying hyperimmunoglobulin E syndrome.



How to cite this article:
Ramapure R, Pugalia N, Ganjre S, Singh A, Madke B. Severe eczematous dermatitis with hyperimmunoglobulin E syndrome.J Sci Soc 2022;49:201-203


How to cite this URL:
Ramapure R, Pugalia N, Ganjre S, Singh A, Madke B. Severe eczematous dermatitis with hyperimmunoglobulin E syndrome. J Sci Soc [serial online] 2022 [cited 2022 Dec 5 ];49:201-203
Available from: https://www.jscisociety.com/text.asp?2022/49/2/201/354278


Full Text



 Introduction



Primary immunodeficiency syndrome (PIS) represents a heterogeneous group of inherited disorders caused by mutations in genes encoding functional proteins of the immune cells and characterized by an increased risk of infections, autoimmunity, autoinflammation, malignancy, and allergic disorders.[1]

A recent systematic review observed both infectious and noninfectious skin disorders being common in PIS and may be among the presenting clinical manifestations. Staphylococcus aureus-induced skin infections are the most common infectious skin disorders in many primary immunodeficiencies. On the other hand, dermatitis is one of the most prominent noninfectious skin manifestations and may be part of the atopic diathesis. Patients with an atopic constitution show atopic dermatitis (AD) tendency toward the development of food allergies, asthma, and rhinoconjunctivitis.[2]

In a prospective study on 290 Tunisian children with PIS, 32% of cases were found to have bacterial skin infections whereas eczematous dermatitis was found in 21.38%.[3]

Al Herz and Nanda found that 100% of patients with hyper-immunoglobin E (IgE) syndromes (HIES) and Wiskott–Aldrich syndrome (WAS) had eczematous skin rashes. Netherton syndrome, severe combined immunodeficiency, Omenn syndrome, immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome, hyper-IgM syndrome, selective IgA deficiency, common variable immunodeficiency (CVID), and ataxia–telangiectasia commonly presents as eczematous dermatitis in the infancy period. Eczema with underlying immunodeficiency syndrome tends to be more severe, extensive, and often recalcitrant to conventional treatment.[4]

 Case Report



An 8-year-old male child presented extensive itchy lesions over most of his body. Parents reported that the skin lesions started from the 1st year of life and there were frequent episodes of remission and relapses. Parents revealed that the child had frequent episodes of upper respiratory tract infections which were resolved with a course of oral antibiotics and symptomatic treatment. There were few episodes of ear infection and seropurulent discharge from the ear in the past. The child had to be admitted on two occasions in the past for severe pneumonia.

Cutaneous examination showed multiple small to large eczematous patches and plaques on trunk extremities. The lesions had linear erosions due to severe scratching [Figure 1] and [Figure 2]. The erosion in the groin was secondarily infected which made walking difficult. A complete hemogram showed increased white blood cell count (19,700cells/cu.mm) with raised eosinophil count. IgE level was markedly raised (>2500IU/ml).{Figure 1}{Figure 2}

We made a diagnosis of primary immunodeficiency disease with HIES according to the criteria defined by the International Union of Immunological Societies Expert Committee for Primary Immunodeficiency. The diagnosis of eczematous dermatitis was made based on the UK Working Party criteria and the severity was assessed using (Eczema Area and Severity Index).

The patient was admitted in dermatology and was started on oral steroid (1 mg/kg), parenteral antibiotic, local emollients, and topical steroid antibiotic. After a week, the child showed significant improvement in the severity of eczema.

 Discussion



Eczematous dermatitis is associated with several immunodeficiencies including selective IgA deficiency, CVID, WAS, X-linked agammaglobulinemia, HIES, and Omenn syndrome.[2]

In our case, the diagnosis of primary immunodeficiency with underlying HIES was made based on the investigations.

HIES can be diagnosed by the clinical laboratory triad of recurrent staphylococcal skin infections, recurrent sinopulmonary tract infections, and high serum level of IgE (>2000 IU/mL).[5],[6] Most of the patients with HIES patients present with papulopustular skin rashes in their neonatal period beginning on the face/scalp. There are several reports that showed the copresence of HIES and AD manifestations.[7],[8] Differentiation between the HIES and AD is critical since delay in the diagnosis of underlying primary immunodeficiency may delay in initiation of an appropriate treatment and portend a poor prognosis.[9],[10],[11]

Our patient was managed with parenteral antibiotics, oral steroids, and local emollients which controlled the flare of severe eczema. We are currently exploring the option of using JAK inhibitor (tofacitinib/baracitinib) in our patient since long-term steroids are not indicated to maintain remission of eczema. Long-term bland emollients are the mainstay of treatment with need-based topical steroids to achieve remission (e.g., weekend therapy).

Our case highlights that severe and recalcitrant cases of eczema with a history of frequent upper respiratory tract infection should be investigated for underlying primary immunodeficiency disorders.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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