to report a first case of bullous pemphigoid ( bp ) following intravenous fluorescein for fundus angiography . clinical features : a 70-year - old male patient
he reported a history of fundus fluorescein angiography with a pre - diagnosis of senile macular degeneration 2 months prior to presentation . at that time , fluorescein extravasated at the antecubital region .
following the procedure , pruritus and erythema began at the wrists bilaterally , and quickly spread to the entire body .
the patient also reported a history of allergy to human albumin solution ( plamasteril ; abbott ) 15 years before , during bypass surgery .
on dermatologic examination , erythematous patches were present on the scalp , chest and anogenital region .
vesicles and bullous lesions were present on upper and lower extremities . on day 2 of hospitalization ,
the patient was treated with oral methylprednisolone 48 mg ( prednol ; mustafa nevzat ) , topical clobetasol dipropionate 0.05% cream ( dermovate ; glaxo smithkline ) , and topical 4% urea lotion ( excipial lipo ; orva ) for presumptive bullous pemphigoid .
skin punch biopsy provided tissue for histopathology , direct immunofluorescence examination , and salt extraction , which were all consistent with bp .
after 1 month , the patient was transferred to the intensive care unit with sepsis secondary to urinary tract infection ; he died 2 weeks later from sepsis and cardiac failure .
to our knowledge , this is the first reported case of bp following fundus fluorescein angiography in a patient with known human albumin solution allergy .
consideration should be made to avoid fluorescein angiography , change administration route , or premedicate with antihistamines in patients with known human albumin solution allergy .
a 70-year - old male patient was admitted to the intensive care unit ( icu ) with bp and sepsis .
the patient 's history was significant for fundus fluorescein angiography ( ffa ) 2 months prior to diagnosis of senile macular degeneration .
the procedure was complicated by fluorescein extravasation at the antecubital region . at that time , the patient experienced pruritus and erythema that began at the wrists and spread quickly to cover the entire body .
his past medical history was significant for essential hypertension , glaucoma , and senile macular degeneration .
his medications included oral metoprolol 50 mg ( beloc ) , oral aspirin 100 mg ( coraspin ) , and brimonidine tartrate 0.2% ( alphagan ) ophthalmic solution .
the patient also reported a history of allergy to human albumin solution ( plamasteril ; abbott ) , which he had received during bypass surgery 15 years before . on dermatological examination , erythematous patches were present on the scalp , chest and anogenital region .
the patient was treated for presumed bp with daily oral methylprednisolone 48 mg , topical clobetasol dipropionate 0.05% cream ( dermovate ; glaxo smithkline ) , and topical 4% urea lotion ( excipial lipo ; orva ) .
regression of the lesions began at day 6 , at which time daily oral azathioprine 150 mg ( imuran ) was added . following resolution of all lesions ,
the patient was discharged with prescriptions for oral methylprednisolone 40 mg , topical 4% urea lotion ( excipial lipo ; orva ) and oral azathioprine ( imuran ) 150 mg daily .
one month later , he was admitted to the icu with sepsis secondary to urinary tract infection due to underlying decreased immune response .
there has been considerable progress in understanding the physiopathology of bp during the past two decades .
several cases of bp in patients with diabetes mellitus , inflammatory bowel disease , rheumatoid arthritis , hashimoto 's thyroiditis , dermatomyositis , lupus erythematosus , myasthenia gravis and autoimmune thrombocytopenia have been reported [ 3 , 4 ] . although medications have been implicated in the development of bp , the mechanisms by which drugs can cause bp are unclear .
one hypothesis is that drugs may trigger bp in patients with underlying genetic susceptibility , either by modifying the immune response or by altering the antigenic properties of the epidermal basement membrane .
a case control study assessing long - term drug use and development of bp showed that diuretics ( particularly aldosterone antagonists ) and neuroleptics were used more frequently by bp patients than control patients .
because of these associations , potential drug causes should be considered in all bp patients .
fluorescein angiography is a relatively safe procedure , with a risk profile comparable to that of other intravenous radiocontrast media angiography [ 6 , 7 ] .
sodium fluorescein is a low - molecular - weight , highly water - soluble compound with fluorescent properties .
because of the physical properties of fluorescein , it is routinely used for medical and laser treatment of chorioretinal diseases .
the pathogenic and immune mechanisms that cause adverse reactions in 5% of patients receiving intravenous fluorescein are unknown .
adverse drug reactions to fluorescein are classified as mild , moderate , severe , and fatal .
severe adverse reactions ( 0.05% ) include cardiovascular shock , myocardial infarction , laryngeal edema , and bronchospasm , and require prolonged , intensive care .
patients with a previous reaction to colloidal plasma substitute have a 48% incidence of adverse events with subsequent tests .
although these rates are obviously high , we have no recent studies about the present rates [ 8 , 9 ] .
adverse reactions following intravenous fluorescein are very unusual , but a history of dye allergy , diabetes , or systemic arterial hypertension increases the risk of allergic reaction to fluorescein . prophylactic treatment , fluorescein desensitization or oral fluorescein angiography should be considered for high - risk patients .
other imaging techniques , like optical coherence tomography , should be considered as an alternative in selected cases . to our knowledge , this is the first reported case of fluorescein - induced bp in a patient with colloidal plasma substitute allergy .
the association between fundus fluorescein angiography and bp should be further investigated with a formal epidemiologic study .
 purposeto report a first case of bullous pemphigoid ( bp ) following intravenous fluorescein for fundus angiography . 
 clinical features : a 70-year - old male patient was admitted to the intensive care unit with bp and sepsis . 
 he reported a history of fundus fluorescein angiography with a pre - diagnosis of senile macular degeneration 2 months prior to presentation . at that time , fluorescein extravasated at the antecubital region . 
 following the procedure , pruritus and erythema began at the wrists bilaterally , and quickly spread to the entire body . 
 the patient also reported a history of allergy to human albumin solution ( plamasteril ; abbott ) 15 years before , during bypass surgery . 
 on dermatologic examination , erythematous patches were present on the scalp , chest and anogenital region . 
 vesicles and bullous lesions were present on upper and lower extremities . on day 2 of hospitalization , 
 tense bullae appeared on the upper and lower extremities . 
 the patient was treated with oral methylprednisolone 48 mg ( prednol ; mustafa nevzat ) , topical clobetasol dipropionate 0.05% cream ( dermovate ; glaxo smithkline ) , and topical 4% urea lotion ( excipial lipo ; orva ) for presumptive bullous pemphigoid . 
 skin punch biopsy provided tissue for histopathology , direct immunofluorescence examination , and salt extraction , which were all consistent with bp . 
 after 1 month , the patient was transferred to the intensive care unit with sepsis secondary to urinary tract infection ; he died 2 weeks later from sepsis and cardiac failure.conclusionsto our knowledge , this is the first reported case of bp following fundus fluorescein angiography in a patient with known human albumin solution allergy . 
 consideration should be made to avoid fluorescein angiography , change administration route , or premedicate with antihistamines in patients with known human albumin solution allergy . 
 the association between fundus fluorescein angiography and bp should be further investigated . 
Purpose
Conclusions
Case Report
Discussion