    [Speaker A]: Sorry for making you wait.

    [Speaker B]: Hi, nice to meet you.

    [Speaker A]: All right. So I see you're mainly here because of the abnormal blood test, the ANA or.

    [Speaker B]: Yeah, I actually also had like. I can like, give you a brief summary.

    [Speaker A]: Sure, go ahead.

    [Speaker B]: My symptoms. So about like two years ago in June 2023.

    [Speaker A]: Okay.

    [Speaker B]: I had like a severe case of like acute hives. And like, and I've had no allergic reaction before and nothing has ever, like, nothing like this has ever. Yeah, like an allergic reaction. And it was like hives over my hands and my feet and some on my face as well. And I like, passive. I managed it using like prednisolone at that time and like some antihistamines.

    [Speaker A]: Okay.

    [Speaker B]: It lasted for like four or five days and then never occurred again. Two years later, February of this year, it happened again. Very similar symptoms. Hives also had some angioedema, very minor. But. But that's when I started taking the prednisolone again with a prescription from the doctor. And I did the six day course and like, most of the major symptoms subsided.

    [Speaker A]: Okay.

    [Speaker B]: But like since late Feb to now, I've had like hives, recurring hives, which like, has diminished significantly since then. But it's still like, I don't feel okay yet. It's still. Still been like, I often feel tingling sensations on my hands sometimes, usually at night when like the histamine cycle is high. Yeah, that's basically it.

    [Speaker A]: Okay. And have you seen an allergist?

    [Speaker B]: I did. So that's when I got the IGE test done, which showed a lot of like, positives on a lot of like, different foods. But, like, there is no clinical correlation. Like, there's no symptomatic correlation, honestly, because I've had nuts all my life before.

    [Speaker A]: They couldn't like, pinpoint to the actual trigger for these attacks.

    [Speaker B]: And then allergist also got me to do like, the chronic urticaria and all these antibody tests just to see if like, it's an autoimmune condition that might be triggering this. Which is why she suggested, like, after looking at the results, that you should go check up. And one more thing, one more thing is that like, since I moved to the U.S. this was three years ago, I've been having like chronic acidity, acid reflux.

    [Speaker A]: Okay.

    [Speaker B]: Yeah. And I have been taking like one famotidin, 10 milligrams a day to passively manage that.

    [Speaker A]: Okay.

    [Speaker B]: It reoccurs every day. And that's when I remember I have to take my femotidine and then it's Okay. I did do an endoscopy about two years ago where, like, it showed a borderline high eosinophil count. I haven't included that report. It was 15. It was just, like, all at the border of what they consider EOEG is.

    [Speaker A]: In a field count. In the blood test or in the biopsy?

    [Speaker B]: In the biopsy. Sorry. Yeah, in the biopsy. But then I didn't follow that up for two more years, and now I feel like they might be connected. Like, the EOE is also being caused by a food allergy, and this might just be a severe reaction to that. I don't know. I'm still following up with the egd, like, GI again, and I'm getting my endoscopy next week, so that should give us some more information, but that's most of the context.

    [Speaker A]: Let me see your most recent blood test with the eosinophils. You did blood test in March 15 and March 11?

    [Speaker B]: Yeah. There was a general blood work, then there was the IGE test, and then there was the. The one with the RNP antibodies.

    [Speaker A]: Labs. Let's see this one.

    [Speaker B]: I haven't included the endoscopy biopsy in that. I can send it over if you need it.

    [Speaker A]: Yeah, if you. Yeah, let me just see it.

    [Speaker B]: Sure.

    [Speaker A]: It was done two years ago, right?

    [Speaker B]: Yep.

    [Speaker A]: Okay. CBC.

    [Speaker B]: This is the biopsy.

    [Speaker A]: Okay. The biopsy from EGD done on June 6, 2023, which was showing mild chronic gastritis, negative 4H pylori. Intestinal metaplasia not identified. Esophageal mucosa with chronic nonspecific esophagitis featuring prominent intraepithelial eosinophils. Okay. Infiltrate five eosinophils, 15 eosinophils. The histological features show borderline high numbers of eosinophils, which may be seen in both reflux and eosinophilic esophagitis. Okay. All right. Negative for Barrett's esophages. No intestinal metaplasia in the esophagus and no fungal organism. So just the eosinophils in the esophagus. Okay, so they had the eosinophilic because vagitis in the differential. Okay, and you had that reflux for how long?

    [Speaker B]: For about three years now. Not before that. One more thing is, like, I looked at, like, I just Googled RNP antibodies and the one other thing. Yeah, yeah, which said, like, it's common with Raynaud's syndrome. I don't think I have Raynaud, because that's very extreme. But I. I'm always cold. My extremities.

    [Speaker A]: Okay. But you don't see color changes, but.

    [Speaker B]: Like, I'm always cold, and, like, I'm always having to have, like, a foot warmer and a desk warmer to, like, operate in the winters. Otherwise, my hands just get too cold.

    [Speaker A]: Very cold. Okay. Okay. Got you. Got you. So ezenophils from your last blood test was in the normal range, the eosinophil count. Okay. Because there's some conditions that can lead to eosinophilia count in the blood, which can be contributed to the esophagus. Also can be attributed to the allergy as well. But in the blood, he was totally fine. Okay. All right. Do you have any joint problem? Drain swelling, drain inflammation, drain stiffness. Nothing like that.

    [Speaker B]: Oh, yeah. I had. I forgot to mention this. During my second attack, like, in Feb, at the peak of when, like, the hives was really high, I was feeling very weird in my knees specifically.

    [Speaker A]: Okay.

    [Speaker B]: And the hives were also usually concentrated around my knees and around my elbows.

    [Speaker A]: Okay. Okay.

    [Speaker B]: But, like, my knees had a weird sensation that I've never had before. It was. Felt like it was swelling and a little bit of pain.

    [Speaker A]: Okay, so they were puffy.

    [Speaker B]: They were puffy.

    [Speaker A]: Okay. Okay. But beside this, any. Any problems with moving your fingers rest, elbows, shoulders, and the hips? No issues. And while you're having that puffiness around the knee from the skin rash, did you have difficulty moving your knee, ankles, or toes? No issues. All right, any history of butterfly rash on the face when you're exposed to the sun, or does the sun have anything to do with the rash?

    [Speaker B]: I don't suspect it.

    [Speaker A]: Okay.

    [Speaker B]: Both times it started like the acute attack started at night.

    [Speaker A]: Okay, what about any patches of hair loss, alopecia? Nothing like that. What about chronic fever?

    [Speaker B]: No.

    [Speaker A]: Night sweats, Drenching night sweats? No. Lymph nodes sticking out of your neck? Aren't pedal groin?

    [Speaker B]: No.

    [Speaker A]: Okay. Significant weight loss, losing weight out of nowhere? Nothing like that. All right, any significant dryness of the eyes that requires eye drops? What about dryness in the mouth?

    [Speaker B]: Not really.

    [Speaker A]: Okay, what about ulcers or sores inside.

    [Speaker B]: Your mouth occasionally, but, like, nothing from bite.

    [Speaker A]: From spicy food, usually bites. Bite, ulcer.

    [Speaker B]: Okay.

    [Speaker A]: All right. Any. Any problems with breathing, shortness of breath, cough, chest pain, anything like that? Any history of blood clots?

    [Speaker B]: No.

    [Speaker A]: Any history of hospital admission? Admitted to the hospital before?

    [Speaker B]: I have been, like, I had, like, a. What do you call it?

    [Speaker A]: Surgery.

    [Speaker B]: Oh, yeah. A laparotomy for what? For it was, like, an umbilical sinus. An infection in, like, the umbilicals.

    [Speaker A]: Okay.

    [Speaker B]: That they had to, like, clean up, essentially. And. Yeah.

    [Speaker A]: Where did the infection come from?

    [Speaker B]: We don't know.

    [Speaker A]: Okay, so you have like, a. Like a point or you had, like, a skin ruptured and pus came out?

    [Speaker B]: Yeah, the first symptoms were basically, I had pus coming out of my navel, and that's when they started doing the CT scans to figure out what it was. And then they had to, like, open me up and clean their face. Yeah, clean me.

    [Speaker A]: Okay, gotcha. Gotcha. Anyone in your family with any history of autoimmune disease or rheumatic disease?

    [Speaker B]: No.

    [Speaker A]: Okay. Do you mind if I examine you?

    [Speaker B]: No, of course not.

    [Speaker A]: All right. And are you currently taking anything for the allergy?

    [Speaker B]: If only. I feel, like, that tingly sensation. I just take an atrocin at night.

    [Speaker A]: Okay. And do you. You're not taking anything consistently promoted in, like I said. Oh, just. But for the allergy, nothing is consistent. And do you have, like, follow ups with the allergy or. That's the plan is whenever you get the info.

    [Speaker B]: I'm getting the endoscopy done on Monday, meeting the allergist again on Tuesday, seeing if I can get a skin allergy test done to identify that. A trigger.

    [Speaker A]: Okay, gotcha. Can I see your hand? All right, today. Do you have any skin rashes?

    [Speaker B]: No.

    [Speaker A]: And the skin rash would be? Hives. Itchy. Pain?

    [Speaker B]: Yeah, itchy. Hives raised. Bumps.

    [Speaker A]: Raised.

    [Speaker B]: Okay.

    [Speaker A]: Okay. All right. Okay. Can you lift your arms up behind your head, behind your back? Can you give me your hand? Can you squeeze my finger as tight as you can? Let it go. Can you do this? Can you push me away? Can you pull me in? Can you do this? Push me up, Push me down. All right. Can I feel your neck? Any lymph? No. No lymphadenopathy. Okay. Do you carry EpiPen or.

    [Speaker B]: No, I don't.

    [Speaker A]: Okay.

    [Speaker B]: But I was, like, I was expecting to get it prescribed from my allergist this time because the first symptoms were, like, in two years ago were, like, I don't know, six out of 10. The next one was seven out of 10 or eight out of 10 because I had, like, swelling on my face as well.

    [Speaker A]: Did you have any swelling inside your mouth? No, no, no swelling. Tongue, nothing like that.

    [Speaker B]: But, like, just to be safe, I think it'd be.

    [Speaker A]: Yeah, yeah, yeah, yeah, yeah. Let me see. Okay. Can you push me up with your thigh? Okay, push me up with your kick up, kick up. Okay, let me listen to you. Take a deep breath in. And out. Deeper, deep breath. All right. Maybe look inside your mouth. Can you open up? Can you lift your tongue up? Okay. All right, you can sit back down here. All right. So the marker that appears to what RNP is, is almost. It's very borderline. It's not concerning. But I would like to complete the workup for internal autoimmune disease by doing another blood test. But given your history, given your physical exam, you don't have any other classic features for any systemic autoimmune disease. But let's clear, let's have a clear mind and find out. Rule out everything else, especially with. But a N. A can. Can also be seen in normal population.

    [Speaker B]: Okay.

    [Speaker A]: So there is a high, high risk for false positive numbers.

    [Speaker B]: Okay.

    [Speaker A]: But we can complete, complete the evaluation and rule things out and do some blood tests today.

    [Speaker B]: Sure. Yeah.

    [Speaker A]: All right. And when you see the allergist, ask him if it's advisable to, to take the. To have like a EpiPen handy just in case.

    [Speaker B]: Yeah, I will do that.

    [Speaker A]: Okay. All right. And we can do like a televisit next week just to go over the labs.

    [Speaker B]: Okay.

    [Speaker A]: If everything comes back reassuring, then there is no need to follow the dermatology unless you do develop new symptoms. Maybe things are quite. But if there's any concern, maybe we set up like a follow up in person.

    [Speaker B]: That sounds good.

    [Speaker A]: All right.

    [Speaker B]: Yeah, perfect.

    [Speaker A]: So let's send for the World cup today. So let's do the A by the flat under flex, C3, C4 double stranded DNA and let's do RF and CCP, SSN. SSP, urine analysis and microalgame and creatinine. So let's see if anything comes back, anything concerning, we will discuss it. Otherwise just monitor.

    [Speaker B]: Okay, sounds good.

    [Speaker A]: All right.

    [Speaker B]: So this is going to be at like, like a blood test lab, like lab card.

    [Speaker A]: We can do it here. We have a lab here.

    [Speaker B]: Oh, that's. That'll be really nice.

    [Speaker A]: Yeah, Yeah, I think we can do it today and then by next week we'll have all the results back.

    [Speaker B]: Okay.

    [Speaker A]: Then we can meet virtually and discuss the lab results and discuss if anything else is concerned. Okay.

    [Speaker B]: Thank you so much.

    [Speaker A]: You're welcome. Do you have any other questions or any other concerns?

    [Speaker B]: No, not really. Yeah, I think I got covered everything. Yeah, I was just like this is just to be safe. I feel like I don't have any rheumatology related symptoms.

    [Speaker A]: Yeah. So systemic chromatic autoimmune disease. It's your immune system recognizing your own body as foreign object. So it starts fighting your own body. And it can affect any organ. It could be the skin, it could be the joints, it could be internal organs like the kidney, the heart, the lungs, the nervous system. Usually manifestation is a bit different. Some of these disease can be associated with allergy and anaphylaxis. That's why whenever you see an allergist, they run like a quick panel for rheumatic disease. But diagnosing rheumatic disease usually made by a criteria, clinical criteria and lab criteria. Having one positive blood test, very borderline, we see it a lot. Very non significant. It can be seen in normal population. We. It doesn't have any significance unless you do have other features or other criteria.

    [Speaker B]: Right.

    [Speaker A]: So I'm sending for other labs, criteria that can be seen in these conditions. And if they come back concerning, then we will, we will discuss it. All right? All right. I'll show you where to do the labs.

    [Speaker B]: Okay, perfect.

    [Speaker A]: And after that when you check out at the front desk, just ask them for a follow up in one.