A 15-year-old Korean male patient visited the Department of Allergy and Clinical Immunology, Cheju Halla General Hospital, due to having allergic rhinitis for several years and the presence of round and scaly skin eruptions on the whole body for 2 months. He had no specific family history or past medical history. The patient felt slight itching on the skin lesion sites.
Basic allergic tests (blood tests and a skin prick test) were conducted. He underwent blood tests for a complete blood count (CBC) with differential serum eosinophil cationic protein and serum total IgE. Specific IgE levels for allergens were found using a multiple allergosorbent test (MAST, Green Cross PD, Korea). In the MAST, the specific IgEs for 41 allergens were evaluated, including Dermatophagoides pteronyssinus (Dp), Dermatophagoides farina (Df), cat, dog, egg white, milk, soybean, crab, shrimp, peach, mackerel, rye pollen, house dust mites, cockroach, Clasporium herbarum, Aspergillus fumigatus, Alternaria alternata, birch-alder mix, white oak, short ragweed, mugwort, Japanese hop, hazelnut, sweet vernal grass, Bermuda grass, orchard grass, timothy grass, reed, Penicillium notatum, sycamore, sallow willow, poplar mix, ash mix, pine, Japanese cedar, acacia, oxeye daisy, dandelion, Russian thistle, goldenrod and pigweed. The test results showed the level of specific IgE for each allergen, and a normal negative range was 0.000-0.349 IU/mL.
A skin prick test was also performed for 53 allergens. The allergens tested by the skin prick test were Alternaria alternaria, Aspergillus fumigatus, Aspergillus nigre, Candida albicans, Cladosporium, Penicillium chrysogenum, German cockroach, Dp, Df, dog, cat, grey elder/silver birch, grass mix, mugwort, short ragweed, black willow pollen, orchard grass, Bermuda grass, timothy, English plantain, English rye grass, Holm oak, Japanese cedar, cotton flock, milk mix, egg mix, chicken, beef, pork, cod, oyster, salmon, prawn, mackerel, tuna, almond, peanut, bean, carrot, cabbage, walnut, maize, peach, tomato, black pepper, spinach, wheat flour, rabbit, kapok, hop, F acacia, pine and poplar. Skin prick tests were performed on the upper back between the scapular and L1 spinal levels. The area to be tested was cleaned with alcohol and coded with a skin marker pen corresponding to the number of allergens being tested. The marks were 2 cm apart. A drop of allergen solution was placed beside each mark. A small prick is made in the skin through the drop using a Morrow Brown Needle→ (Morrow BrownⓇ Allergy Diagnostics, USA) by holding the needle perpendicular to the test site and punching firmly through the test extract and into the epidermis. The drop was removed immediately after the skin was pricked, and the needle was discarded immediately. Histamine hydrochloride 1 mg/ml was used as a positive control, and physiological saline was used as a negative control. The results were measured as the wheal size. Reactions were read after 15 min and described as negative (0, no reaction), 1+ (reaction greater than a control reaction but smaller than half the size of histamine), 2+ (equal to or more than half the size of histamine), 3+ (equal to or more than the size of histamine) and 4+ (equal to or more than twice the size of histamine). The minimum size of a positive reaction was 3 mm.
The severity score was evaluated using the Psoriasis Area and Severity Index (PASI) . Over 4 body regions (head [h], trunk [t], upper [u] and lower [l] extremities) were assessed according to erythema (E), infiltration (I), desquamation (D), and body surface area involvement (A). The degree of severity (per body region) value was given as 0 for no symptoms, 1 for slight symptoms, 2 for moderate symptoms, 3 for marked symptoms, and 4 for very marked symptoms. The surface involvement (per body region) value was given as 1 for 10%>, 2 for 10%-29%, 3 for 30%-49%, 4 for 50%-69%, 5 for 70%-89% and 6 for 90%-100%. Because the head, upper extremities, trunk, and lower extremities corresponded to approximately 10%, 20%, 30%, and 40% of body surface area, respectively, the PASI score was calculated by the formula PASI = 0.1(Eh + Ih + Dh)Ah + 0.2(Eu + Iu + Du)Au + 0.3(Et + It + Dt) At + 0.4(El + Il + Dl)Al. Skin biopsy was performed to confirm the diagnosis of psoriasis.
The patient underwent laboratory tests, skin prick tests and PASI scoring before and after treatment. White blood cell (WBC) counts were normal at 5.57 before treatment and 7.99 after treatment (normal range: 3.9–11.0 1000/µl). In the differential counts of WBCs, neutrophil, lymphocyte, eosinophil and basophil fractions were within the normal range. Blood eosinophil cationic protein levels were as high as 37.9 before treatment and decreased to 35.5 after treatment (normal range: 0–24 (ng/ml)). After Histobulin™ therapy, the serum IgA level was evaluated for selective IgA deficiency and was normal at 95.7 (normal range 70–400 mg/dL). The total IgE level was normal at 203 before and 297 after treatment (normal range: less than or equal to 350 IU/ml).
In the MAST, specific IgEs for Dp, Df, cat, shrimp and timothy grass were positive before treatment and decreased after treatment in all items (Table 1). In the skin test, the changes in reactions according to the allergens were variable and insignificant .
Skin biopsy was performed at the lesion site and a normal site on the back. The specimens were 0.4x0.3x0.5 cm. H&E stain was performed. The pathologic finding of the lesion site was suggestive subacute spongiotic dermatitis. The results showed acanthosis, a microscopic focus of spongiosis with overlying microscopic parakeratosis and the absence of keratohyalin granules. Acanthosis with elongated epidermal ridges was observed (HE X100). Club-shaped epidermal ridges (HE X 200) and elongated dermal papillae containing dilated capillaries (HE X 400), which is typical of psoriasis, were observed. The pathologic diagnosis was psoriasis (Fig. 1).
The final diagnosis was allergic rhinitis and psoriasis. Histobulin™ therapy for allergic rhinitis was initiated, and the clinical severity of psoriasis was evaluated simultaneously. Psoriasis progressed, and the PASI score increased from 14.5 to 18 points over 2 weeks, during which skin biopsy was performed and the pathologic diagnosis was made.
The clinical response was rapid, and the patient improved after just the first injection of Histobulin™ (Fig. 2). Although the patient temporarily showed some aggravation after the third injection, the clinical manifestations, including skin lesions, improved continually and completely disappeared after the eighth injection. The patient showed no symptoms or signs of psoriasis for 4 weeks during which time 4 subsequent injections were administered. Medication ceased, and the patient did not experience recurrence for more than 6 months.