Flushing

 

Features of flushing:

(1) usually transient episodes that may be recurrent

(2) The reaction may be generalized, or limited to the face, neck, upper chest, or epigastric region.

 

Groups:

(1) peri- and postmenopausal women (including surgical) – responds to estrogen replacement

(2) drugs: vasodilators

(3) alcohol-induced, non-disulfiram like

(4) alcohol-induced, disulfiram like (unpleasant systemic reaction, discussed in Chapter 32)

(5) food and nutritional agents: monosodium glutamate (MSG), nicotinic acid, spicy food

(8) heat-induced (hot food or drink, oral thermal challenge)

(9) psychogenic (embarrassment)

(10) carcinoid and other solid tumors (thyroid, renal, etc.)

(11) histamine-related, including systemic mast cell, CML or basophil disorders

(12) exercise-related

 

Alcohol-related, non-disulfiram-like:

(1) ethnic (Japanese, Chinese, Mongol, some American Indians)

(2) carcinoid tumors

(3) histamine or tyramine in fermented beverages (beer or wine)

Mediators and Potentiators	Blocking Agent	Associations
histamine	H1/H2 blocker	mast cells, basophils
prostaglandins	NSAID, aspirin	islet cell tumors, mast cells, nicotinic acid
acetylcholine	atropine	glutamate
opiates	naloxone	chlorpropamide, morphine
substance P	substance P receptor antagonists	tumors
serotonin		mast cells, tumors
bradykinin		carcinoid, alcohol, catecholamines
catecholamines	alpha blocker <check on beta blocker>
gastrin, pentagastrin (via histamine)	somatostatin, cimetidine	gastric carcinoids
calcitonin (which increases prostaglandin synthesis)		medullary carcinoma of the thyroid

 

Laboratory findings:

(1) serotonin: urinary 5-HIAA

(2) mast cells: tryptase, prostaglandins

(3) opiates: drug levels

(4) catecholamines: metanephrines

(5) kinins (may be difficult to get reliable results)

(6) prostaglandins

 

Questions:

(1) family history of similar reaction to alcohol

(2) lifelong or new onset (ever normal) or onset after certain age

(3) recent weight loss

(4) menopause in women

(5) medications and any other drugs being taken

(6) chemical exposures

(7) food supplements and natural foods

(8) relation to hot food or drink

(9) other precipitating factors

(10) alleviating factors

(11) duration of flushing

(12) gastrointestinal changes

 

Examination:

(1) unpleasant feelings (retched)

(2) tachycardia or palpitations

(3) hives or urticaria

(4) headaches

(5) distribution of flushing: diffuse vs limited in extent

 

Differential diagnosis:

(1) red man syndrome

(2) photosensitivity

(3) burn (sunburn, thermal)

(4) rosacea