Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 64-year-old male is here for evaluation of chronic urticaria and angioedema. His first symptoms appeared when he was 17-year-old and worsened in the last 1.5 years.
He has hives daily and angioedema symptoms affecting his lips 1-2/week. He also has complaints of delayed pressure urticaria affecting his hands, feet and gluteus (after prolonged sitting).
First episode of of urticaria when he was 16 years old that lasted for 2 months. Then urticaria began again 18 months ago and "cleared" in 6 months, after stopping lisinopril, only to reappear 5 months later. He has had chronic pressure urticaria on his hands and feet, and the gluteal area through the years. He does not want any steriods because they cause him to "blow up like a balloon."
Past medical history
GERD, Sleep Apnea, Diabetes Mellitus, Hypertension
Medications
Carvediol, cetirizine 10 mg po bid, Epi-Pen 0.3 mg/0.3 ml prn, losartan, omeprazole, ranitidine 150 mg po bid, insulin.
Physical examination
Skin: single hive - R forearm, 4-5 hives - back.
Laboratory results
CBC+DIFF: no eosinophilia.
Colonoscopy - approx. 3 years ago - normal as per patient.
CBCD and CMP - WNL.
ANA - neg.
ESR - 29.
What further testing would you recommend?
Testing for dermatographic reaction and pressure urticaria.
Physical urticaria testing:
- No dermatographic reaction to scratch with the tongue spatula on the volar surface of the forearm.
- Pressure urticaria test (he had approximately 15-pound bag over his right shoulder for 18 minutes) - he developed erythema and 3 hives in the area but no pruritus. We asked him to report delayed pressure urticaria if he develops any.
What is the most likely diagnosis?
Chronic urticaria and angioedema.
What would you recommend at this point?
Cetirizine 10 mg po bid.
Ranitidine 150 mg po bid.
Instructed to use EpiPen in case of severe angioedema or respiratory symptoms.
Laboratory workup:
- Total IgE
- Thyroid function tests (TFTs), for example, TSH, T4, and thyroid autoantibodies (antimicrosomal and antithyroglobulin antibody)
- Anti-FceR1 Autoantibodies
- Chronic urticaria index (positive if greater than 10) is a proprietary index that makes the diagnosis of autoimmune urticaria more likely
- C1q, C4, C2 levels
- C1-esterase inhibitor - qualitative and quantitative
- CH50, total hemolytic complement
- H. pylori workup, for example, H. pylori IgG (blood test)
- RF
Return to the clinic in 1 month.
Summary
Chronic spontaneous urticaria (CSU) is defined as the presence of urticaria with daily or almost daily symptoms for 6 weeks or more. CSU affects 0.1%-0.8% of the population. http://buff.ly/1rDwQ4P
Published: 05/12/2010
Updated: 05/12/2011
- Chronic urticaria index (positive if greater than 10) is a proprietary index that makes the diagnosis of autoimmune urticaria more likely
- C1q, C4, C2 levels
- C1-esterase inhibitor - qualitative and quantitative
- CH50, total hemolytic complement
- H. pylori workup, for example, H. pylori IgG (blood test)
- RF
Return to the clinic in 1 month.
Summary
Chronic spontaneous urticaria (CSU) is defined as the presence of urticaria with daily or almost daily symptoms for 6 weeks or more. CSU affects 0.1%-0.8% of the population. http://buff.ly/1rDwQ4P
Testing procedures for diagnosis of physical urticarias depend on the cause (stimulus):
- Dermographism: Stroking with narrow object, e.g. a tongue depressor
- Cold urticaria: ice cube test
- Heat urticaria: test tube water at 44°C (111°F)
- Pressure urticaria: Sandbag test or a bag with heavy books (Middleton's Allergy textbook, 2 volumes)
- Vibratory urticaria: vibration with laboratory vortex for four minutes
- Cholinergic urticaria: exercise for 15-20 minutes or leg immersion in 44°C (111°F) bath
- Aquagenic urticaria: challenge with tap water at various temperatures
References
Related reading
"Palmaris slapus abdominus" - more commonly known as dermatographic urticariahttp://goo.gl/JMM6e
Updated: 05/12/2011
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