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Fundus fluorescein angiography is an invaluable and commonly used investigation for the management of various chorioretinal disorders. The complications occurring with this procedure are usually mild or rarely serious.1 We present the unusual case of a patient who developed patchy yellow discoloration of the skin following intravenous administration of fluorescein sodium.

Case report

A 56-year-old male was referred to us with decreased vision in the right eye of 6 months duration. He had low-grade-B-lymphoma of the central nervous system, for which he underwent surgery combined with radiotherapy and chemotherapy 4 years ago. On examination, best-corrected visual acuities were 6/36 in the right eye and 6/5 in the left eye. He was noted to have macular oedema in the right eye and signs of exudative retinopathy in the left eye. A fundus fluorescein angiogram was arranged to investigate his clinical signs. As part of this procedure, a 22-gauge cannula was inserted into the right antecubital vein. A bolus of 5 ml of 10% sodium fluorescein (Martindale, Essex) was injected. No extravasation or leakage of the dye into the surrounding skin was seen. Fifteen minutes after the injection, multiple areas of patchy yellow skin discoloration were noted on the lateral aspect of the right arm and the right side of the anterior chest wall. The pattern of discoloration did not conform to any blood vessel distribution (Figure 1 and Figure 2).

Figure 1
figure 1

Patient's right arm showing patchy yellow discoloration of the skin.

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Figure 2
figure 2

Right side of the patient's chest showing fluorescein staining of the skin on the anterior chest wall.

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The patient did not develop any other adverse reactions to the fluorescein dye. He was observed for an hour and no further discoloration or allergic reactions were found to develop. The quality of the fluorescein angiography pictures was good. He was discharged home with the advice to seek medical attention should he develop any late reactions. The other patients who received the same batch of fluorescein sodium did not show any similar reactions. The patient was reviewed a week later, and he reported that the discoloration had faded gradually over the following 4 days without the development of any other adverse reactions. No fiuther cutaneous fluorescein staining was seen. A diagnosis of slow flow retinopathy was made based on the clinical and angiographic findings. The patient was placed on anti-platelet agents and is currently under review.

Comment

Fundus fluorescein angiography has been regarded as a relatively safe procedure, although various adverse reactions have been reported.2 Frequently occurring side effects are usually mild and include nausea, vomiting, extravasation, and inadvertent arterial injection. Moderate reactions include urticaria, thrombophlebitis, syncope, pyrexia, and local tissue necrosis. Serious adverse reactions including laryngeal oedema, bronchospasm, anaphylaxis, circulatory shock, myocardial infarction, and arrest are rare. Numerous skin reactions following intravenous sodium fluorescein have been reported.1,2,3,4,5 These include urticarial skin rashes,1 fluorescein flushing of the forearm because of extravasation of the dye2 or inadvertent intra-arterial injection of the dye,3 generalised skin discoloration or pseudo-jaundice,4 psoriasiform drug eruption,5 phototoxic reactions, and skin necrosis with dye extravasation.2

We hypothesise that our patient's unusual patchy skin discoloration may be related to his lymphoproliferative disorder or the intensive treatment that he had received in the past for his lymphoma. Theoretically, patients with cutaneous infiltrations of B-cell lymphomas may be predisposed to such unusual patchy staining,6 but our patient was never known to have cutaneous infiltrations. The radiotherapy, chemotherapy, and the central venous catheter insertions in our patient in the past may have contributed to this cutaneous manifestation, but no such association has been reported before. The pathogenesis remains unclear in our patient.

To the best of our knowledge, no case of such unusual patchy fluorescein staining following an intravenous injection of fluorescein sodium has been described before. The observed reaction may perhaps be classified as extremely rare and as a mild and benign reaction.