SARS‐Coronavirus‐2 and acute urticaria

A 51‐year‐old otherwise healthy woman presented to the emergency department with a 3‐day history of dry cough and arthralgias. Simultaneously, she developed widespread pruritic evanescent skin lesions (lasting <24 hours). The patient had not taken any medication before the onset of the symptoms. She had no recent contact with plants, chemicals, or topical products. She denied any urticarial lesions before, and no precipitating factors such as physical stimuli, cold, heat, or sun exposure were found. Review of systems was negative for diarrhea, dysphagia, or other suggestive symptoms of anaphylaxis.

Physical examination revealed multiple well‐demarcated erythematous edematous papules and plaques located on the trunk (Fig. 1), thighs, upper limbs, and predominantly on the facial area and dorsal aspects of bilateral hands (Fig. 2). The patient did not present angioedema or bronchospasm, and there was no swelling of the tongue, uvula, or peritonsillar area.

Figure 1.

Erythematous edematous papules on the trunk, raised above the skin, with diffuse underlying erythema

Figure 2.

Erythematous edematous papules and plaques on the fingers and the dorsal aspects of bilateral hands

Blood test showed lymphopenia and elevated C‐reactive protein (5.4 mg/l) and LDH (388 U/l). Chest radiography revealed bilateral pulmonary infiltrates. SARS‐Coronavirus‐2 (SARS‐CoV‐2) PCR was positive on nasopharyngeal swab, confirming the diagnosis of SARS‐CoV‐2 infection (COVID‐19).

The patient was admitted to the hospital with the diagnosis of bilateral pneumonia and acute urticaria in the context of COVID‐19. Treatment with loratadine 10 mg every 12 hours was initiated, with early improvement of pruritus and resolution of skin lesions within 2 days. The patient did not experience recurrent episodes of urticaria after 1 week of antihistaminic treatment.

Since its appearance in December 2019, SARS‐CoV‐2 infections have been growing exponentially, up to becoming a global health concern. Although this is a viral infection that affects mainly the respiratory tract, various skin manifestations have been notified in this context. ¹ , ² Recalcati ¹ conducted a retrospective analysis concluding that up to 20% of patients infected by SARS‐CoV‐2 developed cutaneous manifestations of the disease as erythematous rash, urticarial lesions, and chickenpox‐like vesicles. Other skin manifestations have been described in SARS‐CoV‐2 infection, such as livedo reticularis or Dengue‐like rash. ³ , ⁴

The association between urticaria and infectious diseases has been discussed for more than 100 years. However, this association with virus infections has rarely been reported in the literature. The lack of reported cases is probably because of the difficulty in establishing a cause‐and‐effect relationship.

We report a case of a woman with no previous history of urticaria who presented an episode of acute widespread urticaria as part of the clinical presentation of COVID‐19. Although various reports of COVID‐19‐related urticarial lesions have been released recently, the interest of our case is the onset of cutaneous symptoms at the beginning of the viral infection, without potentially causing drugs or other triggers. Henry et al. ⁵ described a similar case of COVID‐19‐related urticaria with no other precipitating factors. We have not found previous reported association of acute urticaria and coronavirus infection. ⁶

We consider it important to emphasize that SARS‐CoV‐2 and acute urticaria may be associated. Furthermore, the skin lesions might appear before the onset of the main respiratory symptoms, occurring at the early phase of the infection as part of the clinical presentation of COVID‐19.