Case history

Case history #1

A 50-year-old man with a past medical history of hypertension and a recent diagnosis of osteoarthritis presents to his primary care physician with complaints of hives over the past 2 weeks. He reports red and raised lesions that are intensely pruritic and involve his torso and bilateral extremities. He denies any swelling or pain associated with the episodes. The patient also denies any unusual food ingestions or recent changes in his environment (e.g., soaps, detergents). However, he has recently started using scheduled ibuprofen for osteoarthritis.

Case history #2

A 33-year-old woman with a past medical history of hypothyroidism presents with complaints of hives for the past 4 months. She describes red, raised, itchy lesions that involve her entire body, including her face. She also reports two episodes of face and tongue swelling, each of which prompted her to report to the nearest emergency department. In addition to itching, the lesions sometimes cause a burning sensation. The lesions and symptoms resolve over 24 to 36 hours. Despite countless attempts, she has not been able to associate the hives with any specific triggers. The patient voices extreme frustration and feelings of depression, which she attributes to her recent condition.

Other presentations

Patients may present with angio-oedema in the absence of any associated urticaria.[5] This should prompt additional evaluation for hereditary angio-oedema, acquired angio-oedema, or drug-related angio-oedema (e.g., ACE inhibitor-related). Patients may also present with joint pain.

For patients with urticaria, unusual features can include pain/burning rather than pruritus, lesions that last longer than 24 hours, or lesions that leave residual bruising or discoloration upon resolution. These features should raise the possibility of a different diagnosis, such as urticarial vasculitis. Urticarial vasculitis can also be found on biopsy in patients with evanescent hives lasting less than 24 hours.[6]

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