CHIEF COMPLAINT: Eosinophilia.
REFERRING PHYSICIAN: Jane Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is (XX)-year-old who has had a longstanding problem with mild rhinitis and recurrent sinusitis. She blames recurrent sinus infections on secondary smoke exposure when she was working as a (XX). She has mild symptoms of rhinitis such as congestion and runny nose and intermittently takes loratadine tablets to help ward off sinusitis. She does not recall specific reactions to furred animals such as cats or dogs, dust, etc. but is bothered by smoke, insecticides and some cosmetics.
Back in late September, she had a sinus infection as well a sore in her nose that she blames on herpes. She started on Levaquin but a few days later noticed some red lesions on her shoulder and arm. They were somewhat itchy as she described them. Dr. John Doe saw her and thought this might be shingles, although he was not certain of it. She had some blood test done, which showed an elevated eosinophil level of 96 with a normal level of up to 50. Her sedimentation rate was 30, which was considered to be normal.
She went off the Levaquin. The lesions have actually not completely disappeared and still there is some redness at the site. It was advised that she should see an allergist because of the eosinophilia. She denies any history of asthma or wheezing. She feels that she might have seasonal allergies but does not really give a specific seasonal occurrence of the symptoms. She has no prior history of intestinal parasite infection, but she did once have traveler’s diarrhea when visiting (XX) and a skin rash attributed to some type of ocean-dwelling parasite.
ENVIRONMENT: She has 3 cats and 3 dogs. Nobody smokes in the house. She does not have air-conditioning. There is wall-to-wall carpeting.
REVIEW OF SYSTEMS: She had history of benign palpitations in the past. She has had low normal blood counts in the past. She has history of reflux and takes Protonix daily along with aspirin as a preventive. She occasionally gets migraine headaches. She had her tonsils removed years ago and has had gallbladder surgery. She also had a leg injury to her left lower leg after some plywood fell and denuded the skin. She has had a hysterectomy. She had an infective cat bite in (XX) on her hand. She tends to get large localized reactions with insect bites.
ALLERGIES: She had rash with Bactrim 5 to 6 years ago and hives with hydrocodone after a gallbladder surgery. Hepatitis B injection caused cellulitis.
FAMILY HISTORY: Negative for asthma and allergies.
SOCIAL HISTORY: She smoked 2-pack-a-day for 16 years up to about (XX) and then quit.
PHYSICAL EXAMINATION: She is a well-developed, well-nourished, alert, healthy-appearing (XX)-year-old Hispanic female in no acute distress. Height is 64 inches, weight 171 pounds and blood pressure 132/72. Skin: She has some residual red marks on her shoulder and upper arm in the biceps area. There are no hives and no eczema noted. TMs were normal. Nose: 2+, pale edematous turbinates with minimal discharge. Eyes: Normal conjunctivae. Oropharynx: Benign. Neck: No lymphadenopathy or mass. Lungs: Clear. Heart: Regular rate and rhythm without murmur. Abdomen: Soft without organomegaly or mass. Extremities: No clubbing, cyanosis or edema. Neurological: DTRs are symmetric.
ALLERGEN SKIN TEST: Prick skin tests were negative with a mildly positive histamine control. Intradermal tests were positive to mites DP 2+ and mites DF 1+. The former gave a 7 mm wheal and a 40 mm flare.
IMPRESSION:
1. Eosinophilia, probably secondary to her dust mite allergy and allergic rhinitis. Doubt there is any other cause for this. The eosinophilia is moderately elevated.
2. Drug reaction to Levaquin versus shingles since there are only 3 lesions that turned out to be somewhat tender. We do not believe this is a drug reaction and probably was shingles or herpes zoster. Furthermore, the lesions have persisted for many weeks after the initial episode.
3. Allergic rhinitis to the house dust mites.
4. Recurrent sinusitis, improved since she ceased secondary smoke exposure.
RECOMMENDATIONS:
1. Repeat eosinophil count in 2 months after she has had a chance to institute environmental control.
2. Environmental control measures for dust mites.
3. Avoid Bactrim and sulfonamide. We do not think we would permanently eliminate Levaquin, but if there are alternatives, we would suggest avoiding that class of medications for the time being.
4. Continue loratadine 10 mg tablet daily or p.r.n. for her rhinitis symptoms.
5. We would like to see the patient back only if her eosinophil count has not decreased significantly at the time we do the next blood test.
It was a pleasure to participate in her evaluation.
