A 38-year-old man presents with itchy eyes, periorbital swelling, and an itchy red rash on his face and arms.

1. History

Mr. S, is a 38-year-old white man who presented to an otolaryngology clinic on a November day with complaints of itchy eyes, periorbital swelling, and an itchy red rash on his face and arms with an onset of one day prior. He reported no nasal congestion, nasal drainage, swelling of the lips, swelling of the tongue, shortness of breath, wheezing, or lightheadedness. He said that he had used diphenhydramine 50 mg the previous night and again in the morning, with minimal improvement in his symptoms. The patient reported no use of any new medications, soaps, lotions, or detergents. When questioned about his food intake, the patient stated he had not ingested any new or unusual foods immediately before the onset of his symptoms. 

The patient reported that his symptoms started the previous day while driving home from out of town. He had stopped for lunch and had eaten a hamburger during the drive. The evening before his symptoms occurred, he had steak for dinner. He had eaten all food items mentioned in the past without difficulty. The patient had been in Arkansas and was duck hunting over the weekend in a rice field. The patient stated that he is an avid hunter and spends a lot of time outdoors. He hunted in the same location the previous year and had no problems. The only change from the previous year was the addition of moldy corn stalks that were being used as cover. 

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His past medical history included allergic rhinitis, with positive skin testing to weeds, grasses, trees, molds, dust, and animal dander. He was highly reactive to weeds and reported early fall as the worst time of year with regard to his allergic rhinitis symptoms. The patient had been previously treated with sublingual immunotherapy to desensitize him to the known inhalant allergens, and his treatment was successfully discontinued 1 year before this visit. He stated that despite his allergic history, he never had a rash and swelling such as this occur before. The patient denied any knowledge of recent exposure to poison ivy or any recent tick bites. 

In addition to allergic rhinitis, the patient’s only other past medical history was surgical repair of a hernia at 4 years of age. He had no known drug allergies, and his medication list included fexofenadine 180 mg daily and fluticasone 50 µg per nasal inhalation daily. Family history included a mother with breast cancer. The patient reported occasional alcohol use and has never used tobacco products.