A 23-year-old, female with acute redness of the left eye, pain and swelling in the left foot followed by joint pain and swelling of the elbow in next 8 days

Discussion of case

The 23-year-old female had allergic conjunctivitis associated with pain and swelling of the left foot and elbow. She had a history of fever, maculopapular rashes, and evening sweats. She was on oral bronchodilators for asthma. Examination revealed tenderness over the swelling and joint mobility was normal. Investigations revealed normal ESR, ANA, RF, C3, C4, ACE, elevated IgE, and CRP.

The diagnostic possibilities include infections especially due to viruses or mycoplasma, acute onset connective tissue diseases, erythema nodosum-related diseases like sarcoidosis, tuberculosis, and allergic angioedema secondary to trigger factors.

The presentation of acute onset fever, conjunctival inflammation, swelling around joints with pain, papulosquamous rashes and oral ulcer suggests a possibility of viral exanthematous fever or erythema nodosum (unilateral). However, some features, like the presentation of conjunctiva inflammation as an allergic reaction and minimal oral ulcers were not consistent with exanthema. The rashes, arthritis-like presentation, oral ulcers, and young age suggest a possibility of connective tissue disease, especially lupus. However, negative ANA, normal C3 and C4, and shorter duration of disease were against the possibility of lupus. The Viral infection though a possibility and often the angioedema is described, they are unusual. The conjunctivitis of viral origin is usually not accompanied by lid edema. However, elevated white cell count does not favor Viral infection.

The patient had a history of allergic diathesis and asthma. The swelling in the foot and ankle could be due to painful angioedema. The ophthalmologist opined the eye finding was allergic conjunctivitis.

The painful angioedema, especially around the joints, may often get confused with inflammatory joint or skin disease. The absence of painful movement of both the joints and tenderness in the joint line suggests that the swelling could be due to angioedema.¹ The history of allergy and the presence of papulosquamous rashes indicate an allergic or autoimmune etiology. The latest position statement by Cicardi et al. has described the diagnostic approach for this kind of special clinical circumstances.² A history of allergy and the first episode of angioedema in the present patient suggests the possibility of histamine-driven angioedema, while elevated IgE indicates the possibility of allergic diathesis. As per the recommendation of the World allergy association (WAO), to establish the allergy etiology, the patient should be subjected to antigen specificity tests namely in vivo skin prick test, and radioallergosorbent test (RAST), western blot, and other methods.

In the current case, the patient was sensitive to sunflower and parthenium pollen when screened by western blot. The patient did respond to both short-term steroids and the use of antihistamine. She was treated with sublingual immune therapy and in her follow-up, after 6 months both wheezing episodes and the skin allergy had significantly reduced

Final diagnosis

Allergic diathesis with angioedema

Follow-up

The present patient was found to be sensitive to sunflower and parthenium pollen using western blot. The patient responded well to both short-term steroids and antihistamines. She was treated with sublingual immunotherapy, and follow-up after 6 months showed a significant reduction in the wheezing episode and skin allergy.

Learning points

• The presentation of allergic and non-allergic angioedema along with periarthritis or painful swelling around joints may rarely mimic arthritis.
• A careful clinical examination will help in differentiating the conditions.
• In a suspected case of angioedema; C3, C4, and serum IgE will assist in differential diagnosis, and further work-up is required to characterize the etiology.

References

1. Nonallergic Angioedema: Role of Bradykinin [Internet]. PubMed Journals. [cited 2016 Nov 12]. Available from: https://ncbi.nlnih.gov/labs/articles/17620062/
2. Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, et al. Classification, diagnosis, and approach to treatment for angioedema: a consensus report from the Hereditary Angioedema International Working Group. Allergy. 2014; 69(5): 602–616.