Chronic Urticaria Leads to an Unexpected Diagnosis

Abstract

When 22-year-old B came into Three Village Allergy and Asthma on a sunny spring afternoon, she appeared to be having an allergic reaction. Localized areas of her skin had become swollen and had broken out in hives, causing uncomfortable and unceasing itchiness and turning the affected areas a dark, angry shade of red. Rashes from allergies are not unusual, especially in the spring, when flowers and other plants burst into bloom and expose people to a variety of pollens and other airborne allergens. Therefore, the case at first seemed routine. However, when Dr. Szema asked B to describe her symptoms, he noticed that two hallmarks of an airborne allergic reaction—sneezing and a runny nose—were conspicuously absent. In fact, other than the swelling and rash, B appeared to be in perfect health and had no known allergies. Intrigued, Dr. Szema probed for possible non-airborne allergy triggers but found none. B owned a dog, worked in a local store, and had previously been prescribed escitalopram, amphetamine and dextroamphetamine, and multivitamins, but none were new developments in her life, and the hives didn’t appear to have been caused by any of these factors. It also didn’t seem likely that the rash had been caused by accidental contact with an unknown allergen, as B had been suffering from this rash for 3 months, an improbably long time for an allergic reaction to persist without repeated exposure to the allergen. This detail proved to be crucial to discovering the underlying cause of B’s symptoms (Fig. 16.1).