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A Man with Abdominal Pain and Obscure Gastrointestinal Bleeding

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. Several areas of excoriation were noted. He had recently run through a field of tall grass but denied any other exposure history.

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. He had recently run through a field of tall grass but denied any other exposure history. Your Dx?

Clinical Topics

What Cause of This Itchy Rash?

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Rash Around the Mouth of a 5-year-old Child

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Hard Purple Nodules: Your Dx?

The mother of a 10-year-old boy brings him in for evaluation of his moles (which are all benign). During the visit, the mother asks about the lesions on the first 2 knuckles of his right hand; she initially noticed them several months earlier. The boy is otherwise healthy.

White Knuckles

A 42-year-old man presents with a pruritic rash characterized by pink, scaly plaques with a few crusted erosions on the elbows

knees, lower back, and buttocks. Review of systems was negative, although there was a strong positive family history of celiac disease. He took no medications and was otherwise healthy.

A pruritic, scaly rash appeared on this 42-year-old man's elbows, knees, lower back, and buttocks. Can you ID? 

Elbow Erosions 

A panelist discusses how the current anaphylaxis grading system classifies reactions from zero (no reaction) to four (death), with grade two representing moderate but significantly uncomfortable symptoms affecting multiple body systems.

Oral Food Challenge (OFC) Study with Epinephrine Nasal Spray 

Video content above is prompted by the following: 

The availability of specific data on oral food challenges using epinephrine products has historically been limited, with most published research consisting of case series and retrospective studies. However, a significant advancement came with the launch of Nephi (epinephrine nasal spray), which included a dedicated study conducted in Japan examining its effectiveness during oral food challenge procedures. This Japanese study provided valuable clinical evidence by observing 15 pediatric patients who underwent oral food challenges and experienced grade two allergic reactions or worse, though the majority of participants specifically presented with grade two symptoms.

The study's significance becomes clearer when viewed through the updated allergic reaction grading system introduced by professional allergy, asthma, and immunology societies two years prior. This revised classification system ranges from grade zero (no reaction) to grade four (death), with grade three representing severe reactions. Grade two reactions, which comprised the majority of cases in the Nephi study, represent moderate but clinically significant allergic responses that cause considerable patient distress and require immediate medical intervention.

Patients experiencing grade two allergic reactions during oral food challenges face substantial symptoms including abdominal pain, recurrent vomiting and diarrhea, persistent coughing, chest tightness, and audible wheezing detectable through auscultation. Additional manifestations may include mild hypotension and tachycardia, creating a genuinely distressing and potentially dangerous clinical scenario. The Japanese study's focus on these grade two reactions demonstrates the real-world effectiveness of epinephrine nasal spray in managing moderate allergic reactions during controlled oral food challenge procedures, providing crucial evidence for clinical practice and patient safety protocols.

A panelist discusses how a study of Neffy (epinephrine nasal spray) in Japan demonstrated effectiveness in treating 15 pediatric patients who experienced grade 2 allergic reactions during oral food challenges, with these moderate reactions including symptoms like abdominal pain, vomiting, wheezing, and mild cardiovascular effects according to the updated grading system from professional allergy societies.

Video Series

Oral Food Challenge (OFC) Study with Epinephrine Nasal Spray

Reena Julka, MD

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