Case 14

Long History of Irritable bowl



Background



A 43-year-old man with a history of hypothyroidism and a long, subjective history of "irritable bowel."
The patient presented with a 9-month history of progressively worsening pruritic papules involving the elbows, scalp, lower back, and buttocks. He was initially treated for scabies with permethrin 5% cream but experienced no improvement in his symptoms. Over the subsequent 8 months, he was treated with triamcinolone 0.1% ointment, pimecrolimus cream, econazole cream, oral prednisone, and antihistamines without improvement. He described his pruritus as so severe that it impaired his ability to concentrate at work and sleep at night. The only other medication he takes regularly is levothyroxine. Biopsies were performed.
On examination, the patient was pleasant, alert, and oriented, but it was noted that he scratched repeatedly. He had excoriated papules and a few intact vesicles distributed on the bilateral elbows, lower back and buttocks, and scalp. A skin scraping for scabies was negative.
Routine staining with hematoxylin and eosin demonstrated neutrophilic infiltration of the dermal papillae with vesicle formation.The epidermis was unremarkable and there was no evidence of vasculitis. A biopsy submitted for direct immunofluorescence demonstrated 3+ granular staining of dermal papillary tips with immunoglobulin A (IgA) . There was 1+ scattered staining of dermal blood vessels with C3. IgG and IgM staining was negative.




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