POSITIVE DIAGNOSIS:
The flush, or vasomotor breath, is a prominent transient erythema in the face. He is the witness of a diffuse increase skin blood flow, but is visible only in areas where the superficial vessels are particularly numerous: the face, ears, neck and upper chest. We distinguish flushes wet or dry, hot or cold, according to the association or not of sweats or subjective sensation of heat. These shades have a semiotic and pathophysiological interest that often allows an etiological orientation.
Vascular smooth muscle are under dual control: the autonomic nervous system and that of circulating vasoactive substances (histamine, prostaglandins, serotonin, acetaldehyde, etc.). The autonomic nervous system also governing sweating, damp flush is usually witnessed neurogenic vasodilatation or sometimes mediated by adrenaline or histamine. In contrast, other circulating vasoactive substances that induce generally dry flushes.
PHYSICAL EXAMINATION :
Examination:
The transient nature of the flush is questioning the core of the etiological investigation.
Chronological elements to assess the patient’s discomfort and evolution: seniority, initial and current frequency of the flush. rules unrest (perimenopause), surgical history such qu’ovariectomie or orchiectomy, and drug outlets are sought.We asked about the existence of predisposing factors: alcohol, hot drinks, food, drugs, exercise, emotion, stress, etc.The precession of pallor or cyanosis, accurate color and topography of erythema are unclear. The search for associated events is important: especially sweats (flushes especially neurogenic), hot flashes (menopause), bronchospasm, pruritus, urticaria (histamine), abdominal pain (histamine, ciguatera, gastrinoma), diarrhea (food poisoning, carcinoid gastrinoma), tachycardia, headache (pheochromocytoma), hypotension, anxiety.
Physical examination:
The exam is often poor and especially search the differential diagnoses of flushes, mainly erythema persistent, particularly in the context of lupus, drug photosensitivity or rosacea. The latter may, however, encourage a flush or appear after a long history of flushes.
In case of wet flush, usually neurogenic, neurological examination must be careful, especially looking for extrapyramidal syndrome, location of signs (of a brain tumor or spinal cord injury) or orthostatic hypotension (Riley- Day syndrome ) but also arterial hypertension (pheochromocytoma).
If flush dry, they are mostly signs of endocrine tumor or who are finding: thyroid nodule (medullary carcinoma), hepatomegaly (metastasis of an abdominal tumor or infiltration of mastocytosis), malnutrition, right heart failure, tricuspid and pulmonary puffs (carcinoid syndrome).
ETIOLOGY:
The main causes for flushes are listed in Box 1.
We distinguish the causes of dry flushes those wet flushes. This classification is usually just not absolute.
Box 1. Major causes of fl USHS
Flushes associated with food
alcoholic beverages (especially fermented wine, beer, sherry) and antabuse effect (see Box 2)
Mushrooms: black coprin
Ciguatera, scombroïdose
Histaminolibérateurs foods: eggs, chocolate, tomatoes,
strawberries, pineapple, exotic fruits, shellfish, fish
Lemon, spicy foods, cheese, peppers
Food additives: monosodium glutamate, sodium nitrite, sulphites your hot drinks
dumping syndrome
Flushes of neuropsychiatric origin
Emotions, anxiety, panic attack
brain tumors
spinal Cord injury
diencephalic epilepsy
Migraine and cluster headache
Parkinson disease
Menopause, andropause
Horner’s syndrome
Harlequin Syndrome
Syndrome Riley-Day
Streeten Syndrome (POTS or tachycardia syndrome
Postural orthostatic)
Frey syndrome
Flushes of endogenous vasoactive substances
carcinoid syndrome
vipoma
gastrinoma
insulinome
glucagonoma
medullary thyroid carcinoma
pheochromocytoma
Mastocytosis, basophilic leukemia
Rovsing syndrome
Kidney Cancer
POEMS syndrome
drug and toxic flushes (see Box 3)
Wet flushes:
Wet flushes are usually mediated by the autonomic nervous system, but sometimes by adrenaline or histamine.
Hyperthermia:
Among the wet flushes, those related to thermoregulation are the most frequent. Hyperthermia are simple diagnosis.They are linked to fever, physical exercise or a source external or intraoral heat (hot drinks).
These flushes are treated by removing their causes, hydration, antipyretics, cooling the face and possibly the introduction of ice in your mouth.
Menopause:
Menopause is a common cause of flush, that menopause is natural or due to ovariectomy, to ovarian ischemia after tubal ligation, the anti-estrogen use of LHRH agonists, danazol, etc. Patients are often hampered by awakenings in sweats. Menopausal flushes are secondary to sympathetic discharge linked to an imbalance of brain amines (norepinephrine and dopamine) due to estrogen deprivation. Other women are embarrassed by flushes that predominate in the week before their period. They may be in their thirties and often have irregular cycles.
Andropause:
Andropause is sometimes manifested by flushes.
These phenomena can be observed after orchiectomy, testicular ischemia during bilateral inguinal hernias cures under antiandrogens or GnRH agonists.
In these forms linked to deficits in sex hormones, hormone replacement therapy is often a simple solution. Other treatments are possible: clonidine, etc.
Emotions:
Psychological cause
Emotions are of course a common cause of wet flushes. This form mainly affects people psychologically sensitive, anxious gaze of others. The possible treatment involves psychotherapy, relaxation, hypnosis, biofeedback therapy.
Physiological cause:
Other topics are sensitive physiologically.
Home, minimal psychological responses lead to exaggerated physiological responses with dry mouth, palpitations, etc.
In this case, beta-blockers nadolol type or propranolol can be effective.
Anatomical cause:
Other subjects are anatomically predisposed.
These are little pigmented subjects with vascular superfi sky is particularly visible.
In this case, a simple makeup can be a solution.
Damage the walls of the third ventricle:
Lesions walls 3rd ventricle, causing autonomic disorders can be a cause of flushes.
Autonomic dysreflexia:
An autonomic dysreflexia may be due to transverse lesions of the cord. It causes a flush of the face, neck and shoulders, headaches and hyperhidrosis.
Epilepsy:
The diencephalic epilepsy can manifest bursts yawns and a suspension of consciousness with flush, profuse sweating, salivation, pilomotrice activity, mydriasis, tachycardia, hypertension and sphincter spasms, etc.
Treatment is AED. If the autonomic manifestations predominate, clonidine is used.
Streeten syndrome:
Streeten syndrome manifested by orthostatic tachycardia sometimes hypotension, wet flush, headache and purplish legs.
Diabetes:
In diabetes, neuropathy sometimes manifested by wet facial flushing, caused by a particular taste stimulus.
Unilateral Flush:
There are also rare cases of unilateral flush.
Horner’s syndrome:
A unilateral flush can be observed in the Horner syndrome: ptosis and miosis may be accompanied by decreased sweating and facial pallor ipsilateral but also flushes the other hemiface during hyperthermia or emotion. At a ganglionectomie sympathetic unilateral cervicodorsal, an emotion or heat sometimes causes a flush of the face on the healthy side while the other side is pale and dry.
Harlequin Syndrome:
In exceptional Harlequin syndrome, hemifacial a wet flush occurs in hot or effort, after cervical lesion generally sympathetic to the occasion with a twist of the thoracic spine.
Frey syndrome:
Frey syndrome is a common complication of parotid surgery. It is related to an abnormal communication between the parasympathetic fibers for parotid and sweat glands and vessels of the face. Meals, occur flush and sweating in front and below the ear.
Cluster headache and migraines face:
If cluster headache, there is a hemifacial pain with conjunctival hyperemia, tearing, rhinorrhea, and hemifacial hyperhidrosis flush. Painful periods lasting weeks to months. The patient then suffers daily by access of a half hour to two hours.
The treatment is similar to that of migraine.
Apart from this disease, authentic facial migraines exist, with pain, facial flushing and watery eyes often among known as migraine patients.
Other neurological:
Other neurological causes may cause flushes reached by the autonomic nervous system, Parkinson’s disease, family dysautonomic Riley-Day syndrome, spinal cord injuries or various tumors of the posterior fossa.
Dumping syndrome:
Dumping syndrome, or dumping syndrome, affects gastrectomized subjects. It occurs during a meal or shortly thereafter, when the sudden distension of the small intestine by the premature discharge of hyperosmolar contents of gastric stump.
It is manifested by a lipothymic discomfort with sweating, feeling hot, nausea, epigastric heaviness or pressure, feeling of weakness, dizziness, sometimes clouding or hypotension up to and collapse.
The table is increased when carbohydrate-rich meal and mitigated when supine.
Treatment includes a good chew, fractionated meal and not too high in carbohydrates.
Pheochromocytomas and poisoning histamine:
Pheochromocytomas and poisoning Histamine can produce wet flushes (see below, flushes endogenous vasoactive substances).
Dry flushes:
Dry flushes are usually due to vasoactive substances. There are two large frames: the endogenous substances and that of exogenous substances.
Flushes of endogenous vasoactive substances:
Carcinoid syndrome:
Carcinoid syndrome should be considered in cardiac valvulopathy flush-diarrhea-triad.
Other events may be associated: orthostatic hypotension, tachycardia, bronchospasm, right heart failure (for tricuspid valve disease or pulmonary).
Carcinoid syndrome is encountered in the presence of carcinoid tumors with preferential localization is the small intestine, but also the stomach, bile duct, pancreas or liver. In fact, this syndrome is very fickle in case of carcinoid tumor. It is most often seen where viable liver metastases due to a larger tumor mass and a reduction of the effect of hepatic first pass hormones pro duced. Other tumors may be associated with a carcinoid syndrome: including ovarian teratoma, lung cancer, tumors of glomus jugular, cervical cancer.
Carcinoid of hail gladly give flushes dark red or cyanotic, limited to the face and neck for a few seconds to minutes, and can induce a thick skin with telangiectasias of the face after a few years.
Stomach Carcinoid willingly give brown red flushes, which can affect the whole body for a few hours to a few days, possibly with pruritus.
Lung cancer rather give bright red flushing, possibly disseminated throughout the body for several hours to several days, and often associated with chemosis, facial edema, severe hypotension and oliguria.
Biologically, blood serotonin and urinary metabolite is assayed on 5-HIAA (5-hydroxyindole acetic acid). The severity of the flushes is not proportional to the levels of 5-HIAA, which is probably for the role of an associated hormone: histamine, catecholamine, gastrin, kinin, etc.
The treatment is surgery and chemotherapy, as well as the use of somatostatin analogs.
Pancreatic tumors:
* VIPoma:
VIPoma is usually a pancreatic tumor which secretes vasoactive-intestinalpeptide (VIP) and optionally prostaglandins.
It usually starts with the Verner-Morrison syndrome: prolonged diarrhea and massive fluid rebel with hypokalemia and dehydration.
Diagnosis is based on the rise in blood VIP and pancreatic scanner.
The treatment is surgery when possible. It allows healing in 50% of cases. Chemotherapy may be useful.
* Gastrinomas:
Gastrinomas are the cause of Zollinger-Ellison syndromes which combine multiple gastrointestinal ulcers and to recurrent diarrhea.
* Insulinomas:
Insulinomas typically manifest by weight gain associated with Whipple’s triad (frank hypoglycemia happy with neurological disorders, fasting, disappearing after resucrage).
* Glucagonomas:
Glucagonomas cause diabetes mellitus often associated with necrotic migratory erythema (80%).
Pheochromocytomas:
Pheochromocytomas can give flushes in addition to their traditional events (blood pressure [hypertension], headache, palpitations, pallor, profuse sweating, anxiety, etc.).
Diagnosis is on the rise methoxylated derivatives urinary catecholamines, scanner and possibly adrenal scintigraphy.
Treatment is based on alpha-blockers and surgery.
Medullary thyroid cancer:
Medullary thyroid cancer is a cancer cell C that secrete calcitonin and optionally amines. These hormones can manifest as flushes.
Diagnosis is allowed by the dosage of calcitonin, thyroid ultrasound and biopsy.
Treatment consists of surgery and chemoradiation.
Mastocytosis:
In mastocytosis, it is possible to observe flushes and other paroxysmal manifestations: palpitations, headache, pruritus, bronchospasm, digestive disorders, hypotension and tachycardia. There may hepatosplenomegaly.
Of urticaria pigmentosa lesions should be sought. They are reddish brown nodules, rubbed, become itchy, raised and surround themselves with an erythematous halo (Darier’s sign).
The diagnosis of mastocytair proliferation is possible on skin biopsies, bone or lymph node. The histaminurie 24 hours and blood tryptase are elevated.
Treatment is antihistamines H1 and H2, corticosteroids and chemotherapy (particularly cladribine).
Rovsing syndrome:
Rovsing syndrome includes flushing, abdominal pain, nausea and vomiting in a patient with horseshoe kidney.
These events are promoted by the anteflexion and hyperextension.
Flushes exogenous vasoactive substances:
Alcoholic beverages:
Alcoholic beverages are among the main drivers flushes toxic. In fact, this is especially red wine contains vasodilator molecules such as tyramine, phenolic flavonoids, tartaric acid, aldehydes and 2-phenylethylamine.
Nonsteroidal anti-inflammatory drugs, including aspirin, limit this type of flush. Some combinations of drug, toxic or food (Box 2) limit metabolism vasodilator molecules wine and majorise their effect (flushing, flushing, headache, vomiting) is the antabuse effect.
Box 2. antabuse effect: drugs and toxic leaders
Medication used to keep alcohol withdrawal
Disulfi train
Antiinfectives
Nitroimidazoles: metronidazole, ornidazole, tinidazole
Cephalosporins: latamoxef, cefamandole, cefoperazone, cefuroxime, cefotetan, ceftriaxone
chloramphenicol
griseofulvin
nonsteroidal antiandrogens
nilutamide
sulphonylureas
chlorpropamide
glibenclamide
glipizide
tolbutamide
anticancer
procarbazine
vasodilator
phentolamine
Mushrooms
black coprins
industrial solvents Trichloroethylene, xylene, dimethylformamide, butyraldoxine
Ciguatera:
Ciguatera poisoning is ciguatoxin, heat-stable toxin produced by a microorganism (Gambierdiscus toxicus) can accumulate in the flesh of carnivorous fish the Caribbean, New Caledonia and the South Pacific. The main fish in question are barracuda, grouper, conger eel, snapper, surgeon fish and amberjack.
A few hours after ingestion occur abruptly paresthesia of the extremities, abdominal pain, vomiting, diarrhea, pruritus, flushing and diffuse pains. Healing usually occurs after 3 weeks, sometimes leaving painful aftermath. During this period, events buckling under symptomatic treatment, but with a risk of recurrence, especially when alcohol taken.
Histamine poisoning:
The scombroïdose is intoxication by histamine, thermostable. It is formed by decarboxylation of histidine by a bacterial enzyme in poorly stored fish.
The histidine is abundant in tuna and mackerel (Scombridae fish), but also in
herring, sardines and anchovies. The fish has a happy or bitter spicy taste. The delay before the first manifestations is 10 to 30 minutes. These include: flushing, sweating, headache, abdominal pain, nausea, vomiting, diarrhea and possibly hives without fever for a period of less than 8 hours. The flush is more common in scombroïdose in ciguatera.Other foods are known as histaminolibérateurs: eggs, chocolate, tomatoes, strawberries, pineapple and other tropical fruits, shellfish, etc.
Other foods:
Some other foods can promote flushes: cheese, peppers, spicy foods, citrus, etc.
On spoiled food, Bacillus subtilis can grow and produce a toxin that gives, after a delay of several minutes to 3 hours, flushing, headache, vomiting and diarrhea.
Food additives may also be involved: monosodium glutamate (hardly used in some Chinese restaurants), sodium nitrite (found in smoked foods) and sulphites.
Carbon monoxide poisoning and hypercapnia:
In case of carbon monoxide poisoning, hypercapnia (especially in the sleep apnea syndrome), you can meet flushes and headaches.
Medications:
Many drugs can induce flushes and are listed in Box 3.
Box 3. Key and toxic drugs can induce flushes
Drugs responsible for antabuse effect (see Box 2)
Drugs used in cardiovascular pathologies vasodilators: calcium channel blockers, nitrates, angiotensin converting enzyme inhibitors, angiotensin II antagonists, pentoxifylline, iloprost, etc.
quinidine
protamine
Drug impotence
sildenafil
yohimbine
Moxisylyte
alprostadil
hypolipemic
nicotinic acid
Antiinfectives
rifampicin
vancomycin
Interferon-α
antiparkinsonian
bromocriptine
psychotropic
tricyclic antidepressants and certain neuroleptics (fluphenazine)
cyclosporine
corticosteroids
methylprednisolone
triamcinolone
calcitonin
Antiandrogens and antiestrogens
nilutamide
Cyproterone acetate
tamoxifen
Agonists of LH-RH
antidiuretic hormone
desmopressin
anticancer
procarbazine
doxorubicin
cisplatin
mithramycin
morphine
antiemetics
alizapride
metoclopramide
muscle relaxants
ritodrine
methocarbamol
Anesthetic
isoflurane
Carbon monoxide poisoning
Amyl nitrate (poppers)
CONCLUSION:
The causes are multiple flushes but are usually easy to find from the examination or after a thorough physical examination.
In the absence of guidance element, the patient may be sent to an internist or endocrinologist before sometimes conclude idiopathic flush. This is readily young women with flushes with palpitations, sometimes hypotension or syncope, or diarrhea, but without altering the general condition and with negative endocrine balance.
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