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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 776-777 |
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| Localized Harlequin Color Change-Like Irritant Skin Reaction after Thoracentesis in an Adult |
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Chunyan Jiang1, Hongwei Li2
1 Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
2 Department of Internal Medicine and Geriatrics; Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, China
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Hongwei Li
Department of Internal Medicine and Geriatrics; Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University; Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_539_22
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How to cite this article:
Jiang C, Li H. Localized Harlequin Color Change-Like Irritant Skin Reaction after Thoracentesis in an Adult. Indian J Dermatol 2022;67:776-7 |
How to cite this URL:
Jiang C, Li H. Localized Harlequin Color Change-Like Irritant Skin Reaction after Thoracentesis in an Adult. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 31];67:776-7. Available from: https://www.e-ijd.org/text.asp?2022/67/6/776/370317 |
Sir,
A 66-year-old man was admitted for a 1-day history of fever and cough. He had a history of smoking but no history of allergy. On examination, his temperature was 39.0°C, with oxygen saturation 96% on room air. Chest auscultation revealed rales on the right side. Laboratory investigations showed elevated white blood cell count and neutrophils. Chest computed tomography (CT) revealed a 1.7 × 1.3 cm, thick-walled cavity lesion in the right upper lobe, ground-glass shadow in the right middle lobe, and a small amount of right pleural effusion.
He was diagnosed with pneumonia and suspected right upper lung cancer, and was treated with antibiotics. He improved, but repeated CT scan performed 2 weeks later showed increased amount of right pleural effusion. An ultrasound guided thoracentesis was performed and a chest tube was placed for pleural drainage. Skin disinfection with 0.5% iodine followed by local anaesthesia with 1% lidocaine was administered prior to the procedure. Twenty minutes later, a clearly demarcated, blanchable, rectangle erythema developed around, mostly above, the puncture point [Figure 1], without wheals, pruritus, vesicles, sweating or circumferential/contralateral palour. The colour change resolved spontaneously within 40 min [Figure 2]. During this episode, he reported no discomfort and the physical examination was unremarkable, with no changes in vital signs. | Figure 1: A clearly demarcated, rectangle erythema developed around, mostly above, the puncture point 20 min after thoracentesis
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The patient was eventually demonstrated with lung cancer and underwent surgical resection followed by radiation treatment and molecular targeted therapy. He remained well at 2-year follow-up and no such colour change was observed any more.
There were erythematous drip lines at the lower aspect of this geometric patch, suggesting irritant or allergic skin reaction to the preparation for the procedure. However, the shape and scope of the erythema were completely different from that of the disinfection area, which was round, centered on the puncture point. Moreover, no wheal or pruritus was observed during this episode. It is clear that no contact urticaria or contact dermatitis was present.
One differential diagnosis is Harlequin color change (HCC), which is a rare event that consists of sudden and transient episodes of demarcated erythema forming on half of the body. HCC was first described by Neligan and Strang in 1952.[1] It is most common in the newborn and can be a generalized phenomenon or only involve a specific body area such as hemifacial or hemiscrotal, although it has also been described in other age groups including adults, primarily located in the face and neck and mostly caused by a sympathetic disautonomy.[2] HCC of the newborn is thought to be secondary to a relative immaturity of hypothalamic control on the sympathetic peripheral vascular tonus.[3] Some drugs (especially anaesthetics and prostaglandin E) are thought to enhance this phenomenon through their influence on the peripheral vascular tone; but the aetiology remains unclear.[4] HCC of the newborn is considered to be an idiopathic, benign, and rapidly autoresolutive phenomenon, with no need for treatment. Beyond this age the search for an underlying cause should be pursued.
In our case, a diagnosis of 'typical' HCC seems unlikely because the erythema was very localized. However, our case indicates an unusual localized HCC-like irritant skin reaction due to the preparation for the thoracentesis in an adult, which we believe has not been recorded previously, and it is promptly reversible with drug withdrawal.
Patient consent for publication
Obtained.
Contributors
Chunyan Jiang: writing – original draft, review & editing. Hongwei Li: supervision, writing – review and editing.
Acknowledgments
We thank the patient in this manuscript for supporting on information collection as well as granting permission to publish this information.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Judy T, James B, Joseph ML Harlequin colour change: Unilateral erythema in a newborn. CMAJ 2010;182:E801. doi: 10.1503/cmaj.092038.  |
| 2. | Januário G, Salgado M. The Harlequin phenomenon. J Eur Acad Dermatol Venereol 2011;25:1381-4. |
| 3. | Valerio E, Barlotta A, Lorenzon E, Antonazzo L, Cutrone M. Harlequin color change: Neonatal case series and brief literature review. AJP Rep 2015;5:e73-76. |
| 4. | van den Berg G, Bakker H. Harlequin color change in a neonate. N Engl J Med 2020;382:456. doi: 10.1056/NEJMicm1907713. |
[Figure 1], [Figure 2] |
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