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Our patient was a 55-year-old man with a history of asthma who presented with acute onset of numbness and tingling in his extremities. A neurologic examination was notable for hyporeflexia. The patient had a purpuric rash on both lower extremities. A pulmonary examination was unremarkable. The white-cell count was 23.1x103 per microliter with 47% eosinophils. Skin biopsy revealed a leukocytoclastic vasculitis with an eosinophilic infiltrate (Figure 1). The patient was treated with intravenous methylprednisolone. His symptoms improved, treatment was changed to oral prednisone, and he was discharged several days later. Cyclophosphamide was added to outpatient therapy.
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David E. Winchester, M.D.
Ashok Jacob, M.D.
Tom Murphy, M.D.
University of Virginia Health System
Charlottesville, VA 22908-0696
References
2 agonist. With omalizumab (300 mg every 2 weeks), his asthma was brought under control (regimen at 6 months: 500 µg of fluticasone per day and 100 µg of salmeterol per day), but the patient reported a recurrence of obstructive nasal polyposis. The second patient had uncontrolled severe allergic asthma treated with 2000 µg of fluticasone per day and 200 µg of salmeterol per day. She received eight short courses of systemic corticosteroids per year. Omalizumab (250 mg every 2 weeks) was initiated in January 2006. After 3 months, her asthma was controlled. Six weeks later, she was found to have subacute adrenal insufficiency. Exhaustive questioning revealed that the patient had received two intramuscular injections of 80 mg of triamcinolone acetonide, the last one in November 2005.
The possibility of paradoxical complications of successful treatment with omalizumab, induced by the rapid reduction of glucocorticoids, must be considered.
André-Bernard Tonnel, M.D.
Isabelle Tillie-Leblond, M.D., Ph.D.
Calmette University Hospital of Lille
59037 Lille, France
ab-tonnel{at}chru-lille.fr
Drs. Tonnel and Tillie-Leblond report having received consulting fees from GlaxoSmithKline, AstraZeneca, Novartis, and Boehringer Ingelheim, and consulting fees from Merck Sharp & Dohme.
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