What Cause of Cold and Flushing in a Basketball Player?

A 20-year-old white male collegiate basketball player has a 3-year history of marked facial and upper extremity flushing that occurs after about 20 minutes of indoor practice. The flushing is preceded by an intense sensation of coldness, and despite the very noticeable flushing, the involved areas are cold to the touch for some time. Hand exposure to ice water immersion is tolerated for only 60 seconds, with no unusual color sequelae. These events do not occur outdoors.

I have examined the patient during a flushing episode, and the affected areas (face; upper extremities; and to a lesser degree, thighs and pretibial areas) are initially quite cool despite the erythema. However, his vital signs and cardiac examination results are normal and no Raynaud phenomena are noted.

His height is 7 ft 3 in but no Marfanesque characteristics are present (although a stress echocardiogram is pending to definitively rule out Marfan syndrome). He takes no medications.

The patient also has marked foot hyperhidrosis. However, this condition is temporally unrelated to the flushing; it disappears in about an hour and is only bothersome when others comment on it.

What might these symptoms represent, and how should the patient be treated?

---- MD

This is a very interesting and challenging case. It is certainly not a classic presentation of any physical allergy. Nor is it typical of exercise-induced anaphylaxis, which more commonly features urticaria and probably hypotension during the episodes. It could be an unusual presentation of cholinergic urticaria. This type of urticaria typically presents with pinpoint hives with exercise or an increase in core temperature; this young man's rash might be pinpoint lesions that have coalesced. This hypothesis could be evaluated by having the player sit in a hot whirlpool bath until his temperature increases by 2°F. Reproduction of the rash would favor cholinergic urticaria, which is best treated with hydroxyzine (the lowest dose and frequency that alleviate symptoms). Hydroxyzine must be taken regularly, and tolerance of its sedative side effects is almost always achieved if the patient can adhere to the treatment for 2 weeks.

The fact that the symptoms only occur indoors suggests that there may be a "sensitizing" allergen that acts as a trigger to the episodes. If the condition is significantly bothersome, and the patient would adhere to desensitization shots, allergen testing by an allergist might be considered.

---- William W. Briner, Jr, MD
Medical Director, Sports Medicine Center
Lutheran General Hospital
Park Ridge, Ill