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Case Reports

Abstract

A 61-year-old female with obesity, chronic kidney disease, hypertension, and rheumatoid arthritis was hospitalized with severe thrombocytopenia and diagnosed with immune thrombocytopenic purpura (ITP) as well as copper deficiency. Her ITP was steroid-refractory, and she was started on four weekly doses of rituximab. Additionally, she was given IV copper starting with her third dose of rituximab. Four days after her copper infusion she developed conjunctival injection and red to violaceous pruritic and mildly painful papules starting on the hands and spreading to the bilateral upper and lower extensor extremities. A punch biopsy of her right posterior arm revealed a perivascular and interstitial lymphocytic infiltrate and interstitial macrophages between dermal collagen bundles. She was diagnosed with interstitial granulomatous dermatitis. She improved with steroids and mycophenolate mofetil. Copper has been reported to act as a sensitizer by diffusing through membranes and reacting with major histone compatibility molecules to induce T cell-mediated immunologic responses. There is some evidence that individuals with connective tissue diseases have an increased frequency of hypersensitivity reactions to metals such as nickel, mercury, and gold, which may have contributed to her interstitial granulomatous dermatitis given her history of rheumatoid arthritis. This case highlights a unique presentation of interstitial granulomatous dermatitis following IV copper infusion. The few reported cases in the literature of systemic allergic dermatitis secondary to copper were related to intrauterine devices, and to our knowledge there have been no reported cases of interstitial granulomatous dermatitis from IV copper.