A 28-year-old woman who had a history of normal delivery noticed the target lesions on both forearms at 38 weeks and 5 days of the second pregnancy. Three days after the occurrence of erythema, she visited the antenatal clinic. She was administered 100 mg of hydrocortisone sodium phosphate for 2 days, but the erythema with strong pruritus expanded all over her body. She consulted our department 7 days after the appearance of erythema.
Examination:
Her body temperature was 37.6°C, and oedematous eczema was noticed on her abdomen, mainly around the stretch marks (Figure 1a). Also, erythema-like target lesions formed and scattered on the extremities (Figure 1b), but mucosa was not involved. She had no prior infection, medical history, oral medication, or allergic history.
Laboratory investigations: CRP, 0.38 mg/dL; WBC, 13.46 × 103/μL; band cells, 0.5%; segmented cells, 73.5%; monocytes, 2.5%; lymphocytes, 14%, eosinophils, 8.5%; D-dimer, 12.09 μg/mL; non-specific IgE, 174 IU/mL; C3, 151 mg/dL; C4, 29.3 mg/dL; CH50, 50.4 U/mL; urine protein, 30 mg/dL; urine blood, negative. No abnormalities were found in liver and renal function or electrolytes. Herpes simplex virus, varicella zoster virus, measles, and rubella were post-infection patterns, and autoantibodies indicated negative data for autoimmune disease.
The patient received an induced delivery for the full-term pregnancy and delivered safely the next day. After childbirth, the erythema immediately improved without treatment. Serum was collected 7 days before and 7 days after delivery and stored at −80°C before use. Two weeks after delivery, patch and prick tests were performed using her serums, and the results were negative. The serum IgG levels against dominant bacteria and fungus on human skin were as follows: Staphylococcus aureus A, 9.76 and 13.8 mg/L; S. aureus B, 26.6 and 40.9 mg/L; enterotoxin TSST, 30.2 and 47.0 mg/L; enterotoxin C, 9.35 and 16.0 mg/L; Malassezia, 2.98 and 5.30 mg/L; and Candida, 61.6 and 80.6 mg/L, before and after delivery, respectively. We also measured cytokine concentration in the serum: IFN-γ, TNF-α, TNF-β, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-9, IL-10, IL-12p70, IL-17A, IL-17F, IL-22, IL-33, GM-CSF, and TSLP by flow cytometric analyses using AimPlex (COSMO BIO Co., Ltd., Tokyo, Japan). Th2 cytokines, including IL-33, were elevated before delivery. On the other hand, inflammatory markers such as IL-12, TNF-α, and IFN-γ were unchanged before and after delivery.
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