RHE1 It is not nice to fool with mother: Nature; Case of the herbal-induced rash. (RHeumatology).

RHE1 IT IS NOT NICE TO FOOL WITH MOTHER: NATURE: CASE OF THE HERBAL-INDUCED RASH. Paul J. Bennett, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga.

The objectives of this study were to recognize the prevalence of herbal medication use and possible side effects and to recognize the clinical presentation of eosinophilia-myalgia syndrome. A 40-year-old white woman with no significant medical history presented with a 5-month history of a slowly expanding rash on her lower trunk and proximal extremities associated with generalized fatigue. The rash was painless, nonpruritic and not associated with arthralgias, fever, or chills. The patient admitted to taking several herbal medications that she had recently stopped. Her physical examination was unremarkable except for a pink, blanchable, nontender, confluent, macular rash involving the lower abdomen and the proximal portions of the arms and legs. There were no bullae or pustules. Laboratory evaluation reveled a negative ANA rheumatoid factor, and SS-A and SS-B antibodies. The patient had normal levels of aldolase, CPK, and sedimentation rate. Her CBC was unremarkable except for the presence of 26% eosinophils. A deep fascial biopsy of one of the left thigh lesions revealed an inflammatory infiltrate of the fascia, consistent with ophilic fasciitis. Upon review of the patient's herbal medication list and available literature, the probable causative agents were glocosamine sulfate and the fever few leaf (Tanacetum parthenium). The patient was started on steroids with slow improvement. Eosinophilia-myalgia syndrome was first described in 1989 when it was observed in a group of patients who developed scleroderma-like skin changes, myalgias, eosinophilia, and histologic findings similar to eosinophilic fasciitis after ingestion of L-tryptophan manufactured by a single company. However, as this case illustrates, other agents, including herbal medications can precipitate a similar syndrome. Other clinical manifestations include low grade fever, fatigue, dyspnea, cough, arthralgias/arthritis, erythematous rashes, and myalgias. Myocarditis and pulmonary hypertension can occur. Usually significant peripheral eosinophilia is noted and striking tissue eosinophilia may be noted as well. Diagnosis is dependent on histologic findings from a deep biopsy, including fascia and muscle. Response to treatment is variable but patients may respond to steroids, plaquenil, methotrexate, D-penicillamine, and cimetidine. The course of the disease is poorly defined, but many patients spontaneously regress or remain unchanged for years. Use of herbal medications is becoming common since these products are widely advertised and readily available. However, clinical trials and adequate information on efficacy and adverse reactions are limited. This case stresses the importance of incorporating questions on the use of herbal medications routinely on medication history and the need to have a heightened awareness of their possible implication in disease.