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Ahead of print publication
A patient with lichen striatus-like eruption following intravenous contrast injection


1 Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of Dermatology, Kaohsiung Medical University Hospital; Department of Dermatology, College of Medicine, Kaohsiung Medical University; Department of Dermatology, Kaohsiung Municipal Siaogang Hospital; Department of Biotechnology, College of Life Science, Kaohsiung Medical University, Kaohsiung, Taiwan

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Date of Submission03-Feb-2021
Date of Decision16-Jun-2021
Date of Acceptance24-Sep-2021
Date of Web Publication16-Nov-2021
 


How to cite this URL:
Chiu LW, Su YC, Hu SC. A patient with lichen striatus-like eruption following intravenous contrast injection. Dermatol Sin [Epub ahead of print] [cited 2021 Dec 5]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=330500




Dear Editor,

Lichen striatus is an acquired linear dermatosis following Blaschko's lines. It usually occurs in the younger age group and is less commonly seen in adults. In recent years, there have been reports of lichen striatus in children and adults following pregnancy,[1] trauma,[2] viral infection,[3] vaccination,[4] interferon therapy,[5] and etanercept use.[6] We report an unusual case of lichen striatus-like eruption occurring after intravenous contrast medium injection.

A 50-year-old man with no previous underlying diseases presented to our outpatient clinic with mildly pruritic erythematous papules on his right anterior chest, right shoulder, and right upper arm for 5 days. Vesicles, pustules, bullae, and erosions were not seen. The papules were distributed in a linear fashion following Blaschko's lines [Figure 1]a and [Figure 1]b. He denied any application of topical products to the affected area or any recent medication intake. He had just undergone a head and neck computed tomography (CT) scan with contrast for the first time to survey a parotid mass 3 days before the skin eruption. Contrast medium with Ultravist (iopromide) 300 mg/ml was injected intravenously at his right cubital fossa. He denied any dyspnea, chest pain, burning sensation, skin rash, or signs of hypotension immediately after contrast injection. The CT scan was completed smoothly with no adverse events, and the results indicated a benign tumor in the left parotid gland.
Figure 1: (a) Erythematous papules on the right anterior chest, right shoulder, and right upper arm in a linear distribution following Blaschko's lines. (b) Close-up view of the erythematous papules.

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Skin biopsy showed a band-like infiltrate of mainly lymphocytes and histiocytes in the upper dermis and perivascular areas with interface dermatitis [Figure 2]a and [Figure 2]b. Periadnexal and perieccrine infiltrate of lymphocytes and histiocytes were also noted [Figure 2]c and [Figure 2]d. There were no eosinophils seen. The clinicopathological features were consistent with lichen striatus. Due to the absence of potential trigger factors apart from intravenous contrast medium and the timing of the skin eruption, contrast medium-induced lichen striatus was considered to be the most likely diagnosis. Linear lichenoid drug eruption was considered in the differential diagnosis, but it is unlikely due to the short latency period after drug infusion, the absence of lichen planus-like histopathological features such as saw-toothed acanthosis and wedge-shaped hypergranulosis, and the lack of eosinophils. Other diagnoses that may have a linear distribution include adult blaschkitis, linear lupus erythematosus, linear lichen planus, inflammatory linear verrucous epidermal nevus, and linear psoriasis, but these conditions are unlikely based on the different histology patterns. Oral antihistamines and topical betamethasone cream were prescribed, and the symptoms and skin lesions improved within 2 weeks. No postinflammatory hyperpigmentation or hypopigmentation was noted.
Figure 2: (a) Skin biopsy showed inflammatory infiltrate in the upper dermis, perivascular, periadnexal, and perieccrine regions (×10). (b) High-power view showing interface dermatitis (×200). (c) Periadnexal infiltrate of lymphocytes and histiocytes (×40). (d) Perieccrine infiltrate of lymphocytes and histiocytes (×100).

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Lichen striatus is an acquired inflammatory skin disorder which most often occurs in children and is characterized by a sudden eruption of erythematous papules mainly at the extremities. These papules are distributed in a unilateral linear manner that follows the  Lines of Blaschko More Details. Skin lesions typically resolve from 6 months to 1 year without treatment but may improve within 2–4 weeks with treatment.[1] The underlying pathogenesis of cutaneous lesions following Blaschko's lines has been proposed to be a manifestation of cutaneous mosaicism. Somatic mutations in a group of keratinocytes result in altered antigens, but the development of immune tolerance allows these cells to remain dormant. When patients are exposed to trigger factors such as drugs, vaccines, or viruses, a cross-reactive T-cell–mediated immune response is induced, which causes the loss of immune tolerance and the development of lichen striatus.[7] Recently, various authors have proposed that lichen striatus and adult blaschkitis are two similar entities which exist within the same disease spectrum, and therefore, distinction between the two may be unnecessary.[8]

Contrast media, especially iodine-based contrast media (such as iopromide), have been reported to have a higher risk of inducing allergic reactions, occurring in 0.05%–0.1% of patients.[9] Immediate cutaneous reaction is a form of type 1 hypersensitivity, with erythema and urticaria occurring within an hour following contrast injection. Delayed cutaneous reaction is seen from 1 h to several days after contrast exposure and has been proposed to be a T-cell–mediated immune response. Skin presentations of contrast allergy include maculopapular rash, urticaria, fixed drug eruption, Stevens–Johnson syndrome/toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and vasculitis.[9] In addition, lichenoid drug eruption has been reported to be rarely triggered by contrast media.

In this report, we present an unusual case of lichen striatus-like eruption, suspected to be induced by intravenous contrast medium. Clinicians should be aware of this clinical entity in patients undergoing radiographic procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest



 
  References Top

1.
Brennand S, Khan S, Chong AH. Lichen striatus in a pregnant woman. Australas J Dermatol 2005;46:184-6.  Back to cited text no. 1
    
2.
Shepherd V, Lun K, Strutton G. Lichen striatus in an adult following trauma. Australas J Dermatol 2005;46:25-8.  Back to cited text no. 2
    
3.
Hafner C, Landthaler M, Vogt T. Lichen striatus (blaschkitis) following varicella infection. J Eur Acad Dermatol Venereol 2006;20:1345-7.  Back to cited text no. 3
    
4.
Dragos V, Mervic L, Zgavec B. Lichen striatus in a child after immunization. A case report. Acta Dermatovenerol Alp Pannonica Adriat 2006;15:178-80.  Back to cited text no. 4
    
5.
Mask-Bull L, Vangipuram R, Carroll BJ, Tarbox MB. Lichen striatus after interferon therapy. JAAD Case Rep 2015;1:254-6.  Back to cited text no. 5
    
6.
Lora V, Kanitakis J, Latini A, Cota C. Lichen striatus associated with etanercept treatment of rheumatoid arthritis. J Am Acad Dermatol 2014;70:e90-2.  Back to cited text no. 6
    
7.
Taieb A, el Youbi A, Grosshans E, Maleville J. Lichen striatus: A blaschko linear acquired inflammatory skin eruption. J Am Acad Dermatol 1991;25:637-42.  Back to cited text no. 7
    
8.
Baek YS, Seo JY, Seo SH, Ahn HH, Song HJ, Kye YC, et al. Adult-onset lichen striatus versus adult blaschkitis: A clinicopathological review of 40 cases of acquired blaschkolinear inflammatory dermatosis. Eur J Dermatol 2019;29:281-6.  Back to cited text no. 8
    
9.
Rosado Ingelmo A, Doña Diaz I, Cabañas Moreno R, Moya Quesada MC, García-Avilés C, García Nuñez I, et al. Clinical practice guidelines for diagnosis and management of hypersensitivity reactions to contrast media. J Investig Allergol Clin Immunol 2016;26:144-55.  Back to cited text no. 9
    

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Correspondence Address:
Stephen Chu-Sung Hu,
Department of Dermatology, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung 807
Taiwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ds.ds_40_21



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