Urticaria in a patient with <scp>COVID</scp> ‐19: Therapeutic and diagnostic difficulties

Abstract

Urticaria is an allergic skin condition with multifactorial etiology such as drugs, infections, psychological factors, and several others. Coronavirus disease (COVID-19) is an infectious disease caused by a novel coronavirus. Viral infections are one of the potential triggers of urticaria.1, 2 During COVID-19 pandemic influencing all the world, identifying and treating the cause of urticarial reactions in patients infected with coronavirus is a difficult condition for physicians. Apart from viral infection, medications administered to the patient or severe stress caused by the diagnosis of COVID can also cause urticaria. The critical course of the disease also restricts the treatment chosen for urticaria. A 64-year-old female patient was admitted to hospital with difficult breathing, fever, and cough. She was on metformin and a combination of irbesartan and hydrochlorothiazide treatment for years due to diabetes mellitus and hypertension. After a detailed investigation including thorax computed tomography and testing coronavirus, she was diagnosed as COVID-19. Days later, clinical condition of the patient worsened. She was treated with hydroxychloroquine, azithromycine, and oseltamivir in intensive care unit (ICU). Following 7-day ICU treatment, she got better and was taken to inpatient service. During the course of the disease, she had severe urticarial reactions involving all her body (Figure 1). She has no atopy in dermatological examination. In history, a similar reaction occurred 9 years ago lasting a few weeks. As etiology of her diffuse urticaria, viral infection itself, drugs she received, and psychological stress of the clinical condition were considered. However, the COVID-19 medication could not be stopped, and an effective steroid therapy could not be given. Cetirizine 10 mg tablet twice a day was given her. Urticarial reaction was partially controlled with this treatment. The patient is still in the quarantine process in terms of COVID and her general condition is good in this respect. COVID-19 is a fatal disease especially in elderly patients with underlying conditions. Drug reactions and urticaria are among its clinical manifestations.3 COVID-19 is also significantly associated with a number of psychological symptoms.4 Despite limited evidence, the combination of hydroxychloroquine and azithromycin with antiviral drugs is considered life-saving in patients with lung involvement, and this combination is a standard protocol for all serious COVID-19 patients in Turkey. That is, the patient has many potential reasons that could lead to urticaria. In acute urticaria cases, drugs are among the most common causes. The patient was given hydroxychloroquine, azithromycine, and oseltamivir. These agents could be the cause of her urticarial reaction. In normal circumstances, suspected agents should be stopped in order to observe the course. However, in this particular case they could not be stopped due to vital concerns. Psychological support is also limited in these hard circumstances. Dermatologists generally prefer to use systemic antihistamine agents. Systemic corticosteroids and other immunosuppresants are risky unless the infectious process has calmed down.5

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