Diagnostics of chronic exercise-induced urticaria in a child (a case report)

Abstract

This article shows a case report of exercise-induced urticaria diagnosis in an 8-year-old boy. The aim of this work is to show diagnostic peculiarities of chronic urticaria with known trigger. The necessity of diagnostic algorithm fully implementation is emphasized, even in presence of a clear correlation with trigger factor (in this case – physical exertion). The described case is interesting because previously healthy child without anamnesis of allergic and another chronic disease developed urticaria and symptoms of angioedema without visible cause. Objective examination did not reveal any clinically significant abnormalities except moderate nasal congestion, which was neglected by both the patient and his parents. His was without a past medical history of fever. The child underwent laboratory and instrumental examinations: clinical blood, urine and biochemical tests, immunological tests (cell-mediated and humoral immunity, phagocytosis). Acute phase response was within normal ranges. Total IgE was increased to 100.5 IU/ml, increased levels of specific IgE to cat allergen (41.13 кU/l), serum ß-lactoglobulin of cow’s milk (2.95 кU/l) and lamb meat (0.41 кU/l) were detected. Autoserum test was positive (histamine – papula of 5 mm, hyperemia of 15 mm, negative control – 0, patient’s serum – papula of 16.5 mm, hyperemia of 24 mm); thyroid autoantibodies and thyroid hormone levels were within normal ranges. Tests for physical urticarial were performed: aquagenic, cold, heat, vibratory were negative, dermographic urticaria was positive, test with physical exercise (treadmill) was positive (small-sized wheals and lower eyelid angioedema developed on the 14th minute of sweating). Detailing of anamnestic data revealed an appearance of small wheals after emotional sufferings, and a single episode of difficulty breathing with urticaria and angioedema symptoms while playing football). Conclusions. Thus, extended detailed diagnostics of this clinical case has revealed the combined influence of several factors (dermographic, physical exertion, sensitization to some allergens, autoimmune variant of urticaria/angioedema) clarifying that symptoms could be mediated by both IgE- and non-IgE-dependent mechanism in the same patient. Primary diagnosis of “chronic exercise-induced urticaria” has been changed to “anaphylaxis” requiring another approach to treatment and follow-up.