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Yellow Urticaria Secondary to Hyperbilirubinemia in a Patient with End-Stage Liver Disease

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Yellow Urticaria Secondary to Hyperbilirubinemia in a Patient with End-Stage Liver Disease Continuing Medical Education Yellow Urticaria Secondary to Hyperbilirubinemia in a Patient With End-Stage Liver Disease Samir B. Patel, MD; Diya F. Mutasim, MD GOAL To describe a case of yellow urticaria in a patient with end-stage liver disease OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Review drugs that may induce skin discoloration. 2. List which metals, foods, and metabolic abnormalities are associated with changes in skin color. 3. Discuss the mechanism involved in the presentation of yellow urticaria secondary to elevated bilirubin. CME Test on page 48. This article has been peer reviewed and Medicine is accredited by the ACCME to provide approved by Michael Fisher, MD, Professor of continuing medical education for physicians. Medicine, Albert Einstein College of Medicine. Albert Einstein College of Medicine designates Review date: June 2002. this educational activity for a maximum of 1.0 hour This activity has been planned and implemented in category 1 credit toward the AMA Physician’s in accordance with the Essential Areas and Policies Recognition Award. Each physician should claim of the Accreditation Council for Continuing Medical only those hours of credit that he/she actually spent Education through the joint sponsorship of Albert in the educational activity. Einstein College of Medicine and Quadrant This activity has been planned and produced in HealthCom, Inc. The Albert Einstein College of accordance with ACCME Essentials. Acute urticaria is characterized by pruritic, ery- plaques that are pink to erythematous. We report thematous, edematous plaques. We report the the case of a patient with an unusual clinical mani- case of a 48-year-old man with acute urticaria, festation of urticaria presenting as yellow plaques. whose lesions appeared yellow secondary to an The atypical color of our patient’s lesions was elevated bilirubin level. attributed to an elevated bilirubin level secondary to alcohol-induced end-stage liver disease. cute urticaria is a common condition that may be precipitated by a variety of stimuli, Case Report A including medications, infectious agents, A 48-year-old white man with alcohol-induced and physical factors.1 The lesions are characterized end-stage liver disease presented with a 5-day his- by pruritic, evanescent, well-defined, edematous tory of an intensely pruritic, yellow eruption involving the trunk and thighs. Lesions appeared, Dr. Patel is Chief Resident and Dr. Mutasim is Professor and enlarged, and resolved within several hours. There Chairman in the Department of Dermatology, University of was no prior history of similar eruption, quinacrine Cincinnati, Ohio. Reprints: Diya F. Mutasim, MD, Department of Dermatology, use, or excessive ingestion of carotene-containing University of Cincinnati, PO Box 670592, Cincinnati, foods or supplements. His medical history included OH 45267-0592 (e-mail: [email protected]). mild chronic renal insufficiency, anemia, ascites, VOLUME 70, JULY 2002 41 Urticaria Secondary to Hyperbilirubinemia Figure 1. Yellow, smooth, edematous plaques. Figure 2. A mild superficial perivascular infiltrate and dermal edema (H&E, original magnification ϫ40). and esophageal varices. The patient’s medications 0.0–0.3 mg/dL); and aspartate aminotransferase, included pantoprazole, fluoxetine, lactulose, and 47 U/L (reference range, 11–35 U/L). A complete zinc sulfate. Results of a physical examination blood count, renal profile, and alanine aminotrans- revealed multiple 2- to 4-cm well-defined, yellow, ferase levels were unremarkable. Treatment with smooth, edematous, and variably annular plaques fexofenadine 60 mg twice daily was initiated, with scattered on the trunk and thighs (Figure 1). prompt resolution of the eruption and symptoms Results of histopathologic examination revealed within 24 hours. Seven days after initial presenta- mild dermal edema and a mild superficial perivas- tion, physical examination results revealed only ill- cular infiltrate consisting of lymphocytes, eosino- defined, faintly yellow patches in locations where phils, and neutrophils characteristic of urticaria the lesions had resolved. (Figure 2). Special stains failed to reveal bilirubin. Laboratory studies yielded the following: total Comment bilirubin, 5.4 mg/dL (reference range, 0.2–1.0 mg/dL); High levels of bilirubin caused the unusual color of direct bilirubin, 1.5 mg/dL (reference range, our patient’s lesions. Changes in skin color may 42 CUTIS® Urticaria Secondary to Hyperbilirubinemia Causes of Skin Hyperpigmentation Category Etiology Skin Color Pigment Drugs Chlorpromazine Slate gray Melanin-drug complex2,3 Amiodarone Slate blue Melanin and lipofuscin granules4,5 Clofazimine Pink to pink-brown Lipofuscin and ceroid deposits6 Quinacrine Yellow Drug7,8 Minocycline Blue-gray Iron-drug metabolite complex9 Muddy brown Melanin10 Hydroquinone Blue-black Drug or drug metabolites11,12 Metals Argyria Slate blue Silver-melanin complexes13 Chrysiasis Slate blue Gold14 Mercury Slate gray Mercury-melanin granules15,16 Foods/ Supplements Carotene Yellow Carotene17 Lycopene Deep yellow to orange Lycopene17 Metabolic Generalized melanosis (metastatic melanoma) Dark brown to gray-black Melanin18 Alkaptonuria Blue-black Homogentisic acid19 Jaundice Yellow Bilirubin result from several etiologies (Table). Certain drugs silver-melanin complexes and gold, respectively.13,14 may induce skin discoloration. For example, chlor- Long-term application of mercury-containing creams promazine produces slate-gray skin because of may result in localized slate-gray skin secondary to melanin-chlorpromazine complexes,2,3 while amio- mercury-melanin granules.15,16 darone produces slate-blue skin because of melanin Several foods and supplements can alter skin color. and lipofuscin granules.4,5 Clofazimine causes a The typical yellow discoloration of carotenemia characteristic pink to pink-brown hue from results from excessive intake of carotene-containing deposits of lipofuscin and ceroid.6 Quinacrine foods, such as carrots, squash, spinach, mangoes, and deposition induces yellow discoloration and con- red palm oil.17 Lycopene, an isomer of carotene, tints centrates in the epidermis at levels 100 to 200 times the skin deep yellow to orange and is found in high the plasma concentration.7,8 Deposition of iron- concentration in rose hips, tomatoes, and bittersweet drug metabolites with minocycline use causes a berries.17 Carotene and lycopene exhibit special blue-gray pigmentation typically confined to the affinities for the epidermis.17 extremities.9 Another form of minocycline pig- Metabolic abnormalities also may contribute to mentation involves deposition of melanin in sun- changes in skin color. Generalized melanosis and exposed areas, resulting in a muddy brown melanuria have been reported in association with discoloration.10 Prolonged use of hydroquinone- excessive pigment deposition in metastatic containing preparations leads to exogenous melanoma. Patients exhibit a diffuse dark brown to ochronosis. Localized blue-black skin results gray-black discoloration.18 Alkaptonuria results from precipitation of drug or drug metabolites on from deposition of homogentisic acid secondary to degenerating collagen.11,12 homogentisic acid oxidase deficiency and manifests Deposition of metals may lead to diffuse or local- as a generalized blue-black color and black urine.19 ized discoloration. The diffuse slate-blue skin of Finally, jaundice, in the setting of hepatic disease, argyria and chrysiasis results from the deposition of results from deposition of excess bilirubin. VOLUME 70, JULY 2002 43 Urticaria Secondary to Hyperbilirubinemia Conclusion 7. Tanenbaum L, Tuffanelli DL. Antimalarial agents. End-stage liver disease is characterized by a Chloroquine, hydroxychloroquine, and quinacrine. Arch decreased hepatic capacity to conjugate bilirubin, Dermatol. 1980;116:587-591. the breakdown product of heme. This impairs the 8. Meyler L, ed. Side Effects of Drugs: Adverse Reactions as normal process of excretion of bilirubin via the Reported in the Medical Literature of the World. Amsterdam, stool. As a result, the excess bilirubin deposits in Netherlands: Excerpta Medica Foundation; 1966;5:353. tissues and associates with elastin, thereby yellowing 9. Okada N, Sato S, Sasou T, et al. Characterization of the skin. Because of bilirubin’s affinity for elastin, pigmented granules in minocycline-induced cutaneous the jaundice may persist for several days, despite a pigmentation: observations using fluorescence micro- normalized bilirubin.20 Similar mechanisms were scopy and high-performance liquid chromatography. Br J likely operative in our patient, with transport and Dermatol. 1993;129:403-407. deposition of bilirubin being enhanced because of 10. Simons JJ, Morales A. Minocycline and generalized cuta- the vasodilation and increased vascular permeability neous pigmentation. J Am Acad Dermatol. 1980;3:244-247. that is characteristic of urticaria. Elevated bilirubin 11. Phillips JI, Isaacson C, Carman H. Ochronosis in black and persistence of yellow skin despite resolution of South Africans who used skin lighteners. Am J the urticaria support deposition of bilirubin as a Dermatopathol. 1986;8:14-21. mechanism for the atypical color. Failure of special 12. Findlay GH, Morrison JG, Simson IW. Exogenous ochrono- stains to reveal bilirubin possibly was secondary to sis and pigmented colloid milium from hydroquinone inadequate tissue concentration. To our knowledge,
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