Chronic spontaneous urticaria clinical case 7, Centre de Preuves en Dermatologie

chronic spontaneous urticaria Dec 19

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Chronic spontaneous urticaria with angioedema presenting at emergency services

Presentation

Mrs F., 24 years old, has had spontaneous chronic urticaria (CSU) for 1 year, and consults in the emergency ward for the occurrence of facial angioedema that appeared in the morning when she woke up. She has no extra-cutaneous signs, other than a slight feeling of dyspnoea. The interviewer finds she took an ibuprofen tablet and a tramadol tablet for a migraine the night before. On clinical examination, facial angioedema predominates on the eyelids and lips (photograph), which has already diminished since she woke up (3 hours ago), associated with diffuse patches of urticaria on the body. Blood pressure, heart rate and respiratory rate are normal, O₂ saturation is 99%. The respiratory system is normal upon examination.

Previous treatments

She usually takes desloratadine at a conventional dose (1 tablet per day), which she regularly forgets because her CSU causes her little discomfort.

Other elements

She has no particular antecedents. She takes estro-progestogen contraceptives.

What do you suggest?

See proposition

Proposition

Information

Reassure the patient: the condition is not life-threatening, as it is not an acute allergic urticaria (IgE-mediated). The time between the occurrence of angioedema and the intake of medication or food is long; there are no signs of severity or associated visceral involvement, and the feeling of dyspnoea is likely due to anxiety caused by the angioedema. It is also not a bradykinin angioedema, as rapid spontaneous regression and the coexistence of superficial plaques do not support this diagnosis.
Explain that the flare-up is likely due to the aggravating factor of taking a non-steroidal anti-inflammatory drug and an opioid.
No complementary investigation is necessary.

Treatment

The treatment is based on the increase of anti-H1 antihistamines: 4 anti-H1 tablets per os to be continued until improvement. It is not necessary to administer corticosteroids or adrenaline in this patient. There is no reason to hospitalise her.
Finally, explain to Mrs F. which medication to avoid in order to limit flare-ups, and how to intensify the treatment with anti-H1 antihistamines in the event of a flare-up.

References

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chronic spontaneous urticaria Dec 19