Flushing + Blushing + sweating

Question 1

Causes of flushing

Answer 1

Blushing vs flushing
Physiological vs Pathological
- physiological can be triggered by heat, infection, spicy foods, alcohol, hot foods, hot drinks
- pathological:
- rosacea
- malignancy
- drugs (CANOPY - Ca Ch blockers, ACEi, nicotinic acid, opiates, psych drugs)
- hormonal (menopause, oestrogen, thyroid, diabetes, cushings)
- anaphylaxis
- carcinoid
- phaeochromocytoma
- mastocytosis
- neurological - Frey syndrome, PArkinson, migraine

Question 2

Carcinoid features

Answer 2

Neuroendocrine tumour
Majority GIT (some bronchial)
Release of polypeptides into circulation (kallikrein, bradykinin)
Results in flushing, pruritus, increased intestinal motility/secretion (diarrhoea), wheeze, hypotension
PResentation can differ depending on site of tumour (foregut/midgut - note hindgut not active)

Question 3

Ix for carcinoid

Answer 3

Urinary 5-HIAA (serotonin product)
Urinary serotonin
Chromogranin A
Imaging (MRI/CT/US)

Question 4

Mx Carcinoid

Answer 4

octreotide

Question 5

Features phaeochromocytoma

Answer 5

Flushing (spontaneous or triggered), hypertension, sweating, tachycardia, piloerection, palpitations, sense of doom, chest pain
Signs of neurofibromatosis

Question 6

Ix for phaeochromocytoma

Answer 6

blood pressure
Urinary catecholamines/metanephrines
Plasma metanephrines
Imaging - CT/MRI/PET

Question 7

Mx for phaeochromocytoma

Answer 7

adrenalectomy, alpha/beta blockers, avoid triggers

Question 8

features mastocytosis

Answer 8

Flushing, sweating, GIT, respiratory symptoms, hypotension, syncope
Cutaneous - maculopapular cutaneous mastocytosis (UP, TMEP), mastocytoma, diffuse cutaneous mastocytosis
B symptoms, fatigue, weight loss, fractures (osteopenia)

Question 9

Ix mastocytosis

Answer 9

Skin bx (special ring block to minimise histamine release)
Look for increased mast cells (CKIT, CD117)
Serum tryptase
Urinary histamine products
FBC (blood dyscrasias), ELFTs
Abdominal USS (if HSM)
Bone DEXA
BM Bx

Question 10

Criteria for systemic mastocytosis

Answer 10

MAJOR
- Increased aggregates (At least 15) of mast cells in tissue (other than skin)
MINOR
- >25% Spindle shaped mast cells
- KIT mutation
- CD117 + CD2 +/- CD25
- elevated serum tryptase

Question 11

Mx mastocytosis

Answer 11

Avoid triggers (alcohol, codeine, opiates, NSAIDS, contrast, GA drugs, fish, cheese, strawberries, avocado, skin friction or rubbing, change in temperature)
Epipen, avoid isolated risky behaviour
H1 + H2 blockers
Montelukast
PPI
Sodium chromoglycate, ketotifen
Cool compress, TCS, UVB
Imatinib

Question 12

General management for flushing

Answer 12

Avoid triggers
Camouflage
Bromonidine 0.33%
B Blockers
Other specifics
Laser, Botox, sympathectomy