Eosinophilic Dermatitis and Elevated IgE in a Patient with Hepatitis B

N. E. Kirsch, University of Nevada, Las Vegas
H. A. Feng, University of Nevada, Las Vegas
H. Bhamidi, University of Nevada, Las Vegas
J. Yoo, University of Nevada, Las Vegas


Idiopathic Hypereosinophilic Syndrome (IHES) is an uncommon diagnosis that has been rarely associated in the literature with chronic infectious hepatitis. In patients with chronic infectious hepatitis, IHES is thought to occur secondary to hepatic immune ysregulation due to longstanding inflammation 1 . Typically, patients present with a diffuse rash and cardiac 2, pulmonary 3, or rheumatologic 4 symptoms. Here, we report a case of IHES presenting with diffuse dermatitis and angioedema in a patient with a history of chronic hepatitis B.A 66-year-old male with a past medical history of chronic hepatitis B presented to our emergency department complaining of a several-year history of a ruddy complexion and a two-day history of angioedema. The patient endorsed traveling to American Samoa and Texas six-months prior, where he was hospitalized for cellulitis and community acquired pneumonia, respectively. Review of systems was positive for weakness and fatigue. The patient denied any recent changes in topical cleansers, fragrances, detergents, or medications. Physical examination revealed pitting edema of all extremities and diffusely erythematous, lichenified, skin, with extensive excoriations and dehisced areas. Laboratory studies were remarkable for a white blood cell count of 13.1 x 10 3, with an absolute eosinophil count of 6.75 x 10 3, positive hepatitis B serologies, and an IgE of 3661 IU/mL.Given the patient’s history of recent travel and laboratory studies, work up for causes of hypereosinophilia 5,6 was begun. Parasitosis was ruled out via stool microscopy. Autoimmune serologies were unremarkable. Full body computed tomography was unremarkable for solid organ malignancy. Peripheral blood smear was unremarkable for primary blood malignancy. Skin biopsy, examined under both light microscopy and immunofluorescence, only revealed evidence of hypereosinophilia. Due to the patient’s nondiagnostic work up, a diagnosis of IHES was made. The patient was aggressively intravascularly rehydrated and begun on glucocorticoids, with improvement of his hypereosinophilia and symptoms. Upon discharge, the patient’s symptoms were resolving, and his eosinophil count had returned to within the reference range.To the best of our knowledge, IHES secondary to an infectious hepatitis presenting as a rash without systemic symptoms has yet to be published in the literature. We suspect that our patient’s IHES, and the resultant diffuse dermatitis, was the result of chronic infectious hepatitis as evinced by his non-diagnostic work up and significant improvement with glucocorticoids. It is important for clinicians to recognize the rare features of immune dysregulation in patients with chronic infections, as they may manifest as critical illness, like in our patient.