Navigating the Diagnostic Challenges of Acute Idiopathic Urticaria and the Importance of Patient Education

Abstract

Background: Acute idiopathic urticaria affects 0.23% of the United States’ population. It causes pruritic, erythematous plaques that persist for weeks to months, and can occur secondary to medication, food, or recent infection. It is often mistaken for anaphylaxis, leading to treatment with epinephrine, antihistamines, and steroids. Case Description: A 23-year-old female experienced widespread urticaria one week after a respiratory illness. She began treating symptoms at home using benadryl, but presented to urgent care as symptoms worsened. Cetirizine and prednisone were started without relief. She had her first emergency room encounter later that night, where suspicion was high for anaphylaxis given her distress and physical exam findings. Epinephrine was given at that time with no change in her symptoms. After supportive care and ensuring she was stable, a diagnosis of post-viral urticaria was made. She was discharged home only to return to the emergency room the next day with an increase in anxiety due to facial swelling, describing herself as “unrecognizable”, though her physical exam remained unchanged from prior presentation. Overnight observation with dermatology consultation resulted in a second diagnosis of post-viral urticaria. She was instructed to continue cetirizine, hydroxyzine, and prednisone, and to follow up with dermatology. In total, the patient had two emergency room and two outpatient visits. Clinical Significance: Individuals with acute idiopathic urticaria present with symptoms similar to anaphylaxis, and while unlikely to be life-threatening, recurrent episodes of idiopathic urticaria can be distressing for the patient and result in multiple clinic visits. Conclusion: In an anxiety-inducing illness like acute urticaria, patients can experience significant distress resulting in multiple visits to the hospital and a strain on the healthcare system. Educating patients about their illness and return precautions can reduce anxiety over perception of disease severity and minimize repeat physician visits.