Case quiz by chronic urticaria disease.pptx

case

1. Case 1

2. History A 14-year-old female middle school student seen initially in the allergy clinic on October 2009. She described frequent attacks of itchy hives, swelling of lips, and eyelids. They were followed by dyspnea, wheezing, and dizziness spills. She gave history of four attacks over the last year. In all the attacks, her symptoms appeared during physical exertion immediately following the ingestion of her dinner that usually contains wheat bread, cheese, and eggs. Surprisingly, she could tolerate these foods if it was not followed by exercise. Moreover, her symptoms never occurred if a meal did not precede performing the exercise activity.

3. Cont. Her last attack was severe and occurred while jogging and running at the backyard immediately after having a slice of vegetarian pizza for which she attended the emergency room . She gave history of not taking any medication specifically nonsteroidal anti-inflammatory drugs (NSAIDs) before having exercise. Also, the attacks were not related to her menstruation. Review of her past medical history and family history were noncontributory.

4. Examination Dermographism test – negative The serum tryptase is not checked in the ED during the attacks. The allergy skin prick testing for common food showed a positive reaction to only wheat. A supervised graded oral challenge with wheat at rest was performed and was tolerated without any consequences.

5. Questions What is the diagnosis ? What is the management?

6. Case 2

7. History A 26-year-old woman attends the dermatology clinic complaining of a 4-month history of an itchy eruption. She describes the eruption as ‘cloud-like’. She previously suffered from eczema as a child but this rash is different. T he eruption waxes and wanes, with individual lesions lasting 8 to 12 hours, she is rarely clear of lesions for more than half a day. Sometimes she goes to bed with the eruption and wakes clear, but the opposite can also occur. She has never experienced angioedema. It is often worse perimenstrually . T he eruption is worse with exercise or a hot bath, but does not appear to be aggravated by pressure or cold. The eruption is partially attenuated by cetirizine 10 mg daily, which she is taking for her hay fever . Her only other medication is occasional ibuprofen for dysmenorrhoea . There is no family history of skin lesions. Both of her parents are well, although her mother has a diagnosis of osteoporosis and is on thyroxine replacement. On close questioning she admits that although circumstances at work are stable and have not changed for a longtime she is experiencing difficulty coping and frequently cries at work.

8. Examination On examination there are several scattered lesions over her trunk, limbs and face. They are composed of well-defined erythematous oedematous plaques surrounded by a pale ‘flare ’. The lesions vary in size and shape but not in morphology. U nable to elicit dermographism . The lesion ringed initially had disappeared by the time she presented to photography 2 hours later, with new lesions developing over adjacent skin. Following their resolution the lesions leave no persistent skin change. Although the eruption is pruritic there is no evidence of lichenification or excoriations. Blood pressure is 105/68 mmHg and pulse rate 102 beats/min. C ardiorespiratory system is otherwise normal. Her abdomen is soft and non-tender. You notice a degree of bilateral upper eyelid lag. She has a smoothly enlarged goitre and stretching her hands out she has a fine tremor.

9. Cont. N eurological system is normal. Urinalysis was negative for blood, white cells and glucose. T he patient to put on her coat and walk briskly up and down the corridor outside. After five minutes she returns with a marked aggravation of her eruption, which is now widespread and generalized over her trunk and proximal limbs. Investigations Full blood count – Normal Urea and electrolytes – Normal Liver function tests – N ormal

10. Questions How would you investigate this patient? What is the management?