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Abstract: An 82-year-old patient with chronic eczema for 8 years presented to the hospital with sudden onset of blistering macules on the trunk and extremities and increased pruritus. Pathological examination of the excised tissue suggested that it was not eczema, but herpetiform aspergillosis. Herpes pemphigoid is an autoimmune herpetic disease, the exact cause of which is not known, and is common in the elderly. The patient’s condition is usually stabilized after anti-inflammatory and anti-allergic treatment.
[Basic information] Male, 82 years old
Disease Type】Herpetiform aspergillosis
Hospital】Guangdong Provincial People’s Hospital
Date of Consultation】August 2021
Treatment plan】Medication (methylprednisolone tablets + minocycline hydrochloride capsules + epinephrine tablets + halometasone/triclosan cream)
Treatment period】2 weeks of inpatient treatment, 2 weeks and 1 month of outpatient follow-up
Treatment effect】Blister blisters dry up and crust over, erythema turns darker, skin itching is reduced
I. Initial consultation
The 82-year-old man came to the clinic with a rash. After taking off his clothes, he saw large bright red edematous spots on his trunk and limbs, as well as disseminated blisters of soybean to broad bean size, some of which had even ruptured and flowed clear liquid. The patient kept pressing for prescription of medication, and it was difficult to calm down before starting the consultation. The family informed the patient that he had been diagnosed with eczema at the local community hospital for 8 years, and had been taking anti-itch medication and using compound menthol ointment, but none of the blisters appeared until the previous medication failed to control them. Upon continued understanding, it was found that the patient not only had skin problems, but also had hypertension for more than 30 years, but his blood pressure was relatively well controlled because he insisted on taking levamlodipine benzoate tablets orally, and only occasionally rose with poor sleep. In addition, because the patient was in the countryside, he had not had a systematic physical examination for a long time, and it was difficult to say whether there were problems with other organs. After understanding the general situation, we informed the patient and his family that it was not eczema, and that we now suspected herpetiform aspergillosis, which could not be treated directly with medication and required hospitalization for examination to clarify the diagnosis before starting systemic treatment, after which the patient was hospitalized. After the general examination, the forearm blisters were also removed for histopathological examination and immunofluorescence, and the results showed a large subepidermal blister with a few eosinophils scattered in the blister; immunofluorescence: IgG (+) and C3 (+) were seen in the basement membrane zone and were deposited in a linear pattern, which basically confirmed the diagnosis of herpetiform aspergillosis.
II. Treatment history
Since it takes up to 5 working days to wait for pathological results and to avoid delaying treatment to continue aggravating the disease, the patient was started on medication before the basic test results were available. In addition, although the patient had hypertension as the underlying disease, no other abnormal liver or kidney function results were found. After informing the family, treatment was started according to herpes pemphigoid while waiting for the results: anti-inflammatory treatment with glucocorticoid methylprednisolone tablets and minocycline hydrochloride capsules, and symptomatic anti-itch treatment with epinastine tablets, as well as topical application of halometasone/triclosan cream to the blisters and erythema for anti-inflammation and prevention of infection.
III. Treatment effect
The effect was seen after 3 days of medication, when the patient no longer had new blisters and erythema, and the pathology and fluorescence results came out, confirming my diagnosis.
At the time of discharge, the patient could no longer see blisters and blisters, only scattered erythema and old scratches all over the body, the pruritus had basically disappeared, and the blood pressure level was controlled at a normal level during the admission, and no other uncomfortable symptoms were expressed. When the patient was discharged from the hospital, he was discharged with medication to continue treatment. 2 weeks later, he returned to the outpatient clinic for a follow-up visit, and the erythema had all turned darker, the blisters were no longer occurring for more than 2 weeks, and there were basically no pruritic symptoms. After the condition was controlled and stabilized, the glucocorticoid dosage was reduced again and the patient was instructed to return to the clinic in 1 month to adjust the treatment.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but patients with this disease still need to pay attention to some matters: 1.
1. Herpetiform aspergillosis is a type of autoimmune related disease, the onset of which is related to a variety of factors. It is best to avoid spicy and stimulating foods, sun exposure, long-term hot and humid environments, exertion and upper respiratory tract infections.
2, some patients with herpetiform aspergillosis are triggered by drugs or tumors, such as sulfonamide antibiotics, etc., except when the disease recurs or worsens, attention should be paid to screening for these triggers at the same time.
Although glucocorticoids have side effects, do not stop or change the medication on your own to avoid aggravation of the disease.
V. Personal insight
The symptoms of herpetiform aspergillosis are atypical in the early stage, and the blisters and large blisters with thick walls may not be visible, so it is easy to be misdiagnosed as eczema or other diseases.
Clinical treatment for herpetiform aspergillosis can take a long time, about 2-3 years, and requires regular follow-up and gradual adjustment of medication doses. In addition, it is important to emphasize to the patient the importance of follow-up visits and medication compliance, as well as the need for the physician to be patient and reassure the patient’s psychological state during the follow-up visit.