Urticaria due to natto (fermented soybeans)

Abstract

2020. In association with these cutaneous findings the patient also reported recurrent headaches and a feeling of malaise.Patient 3 was a 10-year-old boy who visited our local Accident and Emergency department with spontaneous upper limb bruising (Fig. 1c). Again, like the other two patients, he detailed a history of relapsing-remitting cutaneous symptoms every 2-3 weeks, starting as erythematous macules, which then developed a bruise-like change. These findings resolved with gradual erythema.Screening for SARS-CoV-2 IgG antibodies, vasculitis and thrombophilia was negative in all three cases. Each child had a skin biopsy taken, which revealed features of red cell extravasation and mild dermal oedema. Patient 1 had scattered dermal eosinophils, and all had a mild perivascular inflammatory cell infiltrate composed of lymphocytes, histiocytes and neutrophils. There was no evidence of vasculitis and no history of patient-inflicted injury.Stress can manifest in a number of ways, including skin changes. We are increasingly seeing patients during the COVID-19 pandemic with unusual dermatoses that, following extensive exclusion of a number of organic causes, may point to a diagnosis of medically unexplained skin symptoms (dermatitis artefacta). Indeed, the scattered dermal eosinophils seen in one of our patients have been reported in burn-like injuries associated with dermatitis artefacta. 4 A similar presentation, Gardner-Diamond syndrome, has been proposed in young women. 5 Also known as psychogenic purpura, this rare condition is characterized by painful bruising on the extremities during times of stress. 5 Principally this is a diagnosis of exclusion and usually the cutaneous findings include tender ecchymoses.It remains unclear if COVID-19 infection or the stress of recent events due to the pandemic was the precipitant of the cutaneous findings in this cohort. As COVID-19 continues to spread worldwide, we highlight this unusual clinical entity presenting in our vulnerable paediatric/ adolescent population.