An infant with COVID‐19 presenting with acute urticaria and angioedema

Dear Editor,

Various skin manifestations associated with COVID‐19 have been reported in recent publications. In cases earlier reported in children, it has been reported that exanthema and mucocutaneous findings which are a criterion of Kawasaki‐like or multisystem inflammatory syndrome in children (MIS‐C), have been detected. ¹ Papular, urticarial rashes, and purpuric lesions have been associated with COVID‐19 infection as uncommon symptoms. ² Acute urticaria/angioedema characterized by epidermal and/or subdermal swelling lasting less than 6 weeks can often be triggered by upper respiratory infections during childhood. Until recently, urticarial rash associated with COVID‐19 has been described in especially adult patients, but the number reported in children is very few. As a result of three meta‐analyses published, in the pediatric population, symptoms such as runny nose and nasal congestion are observed at a rate of 7–20%, while skin rash has been reported as less than 1%. ³ , ⁴ , ⁵ Here, we want to present an infant who presented with acute urticarial rash with angioedema who was diagnosed with COVID‐19, which has been reported much less frequently.

A 12‐month‐old healthy girl presented to the outside hospital 3 days prior because of itchy skin rash (urticaria) and eye edema (angioedema) that started on the trunk and spread to the whole body (Figs. 1 and 2). She was admitted to our hospital when her skin rash continued despite oral antihistaminic treatments and intramuscular methylprednisolone treatment given at an external center for 3 days. In the physical examination of the patient who was hospitalized with the prediagnosis of acute urticaria, resistant to therapy, there was no additional positive physical examination finding, except for erythematous and edematous rashes on the skin that lasted for 3 days. In her history, it was learned that there was a fever of 38°C for 1 day in the beginning of the rash but had disappeared with an antipyretic therapy. It was learned that there was no diarrhea, fatigue, anorexia, cough, or respiratory distress. The patient had no contact with a known COVID‐19 patient. There was no previous drug or food allergy or urticaria in her medical history. There was no history of allergy or atopy in the medical history of the family. When the laboratory examinations of the patient were performed, the COVID‐19 PCR result was positive, and the patient was then followed up in the COVID‐19 inpatient service. D‐dimer and C‐reactive protein elevation was present (Table 1). Twenty‐five OH vitamin D3 was found to be low. During the SARS‐CoV‐2 infection, we also checked a panel including respiratory tract viruses, 18 viruses from 9 virus groups (Influenza, Parainfluenza, Rhinovirus, Coronavirus, human Metapneumovirus, Bocavirus, Respiratory syncytial virus, Adenovirus, and Enterovirus), but it was found to be negative. Lung involvement was not detected in thoracic tomography. Hydroxyzine (1 mg/kg/day), systemic methylprednisolone (1 mg/kg/day), and phenyramine (1 mg/kg/day) treatments given for urticaria were thought to be resistant to treatment. Vitamin D (1,000 U/day) was added empirically to the patient's treatment. The patient's fever did not recur. The patient was discharged on the 5th day, after examinations for COVID‐19 returned to normal and urticaria regressed. Overall, the therapy lasted 10 days. After discharge, hydroxyzine and phenyramine treatments were continued to the follow‐up visit. On the 10th day, no pathology was observed in the physical examination and laboratory tests in the outpatient clinic control. Then, all medications were discontinued.

Figure 1.

Angioedema is observed over the eyes of the patient

Figure 2.

Urticarial plaque is seen over the dorsum of the patient

Table 1.

Laboratory parameters of our patient are shown

Parameters	Day 0	Day 10	Reference ranges
WBC (/mm3)	17,500	21.000	4,600–10,200
Hemoglobin (g/dl)	11.4	10.6	12.2–18.1
Hematocrit (%)	34.9	33.4	37.7–53.7
Absolute neutrophil count (/mm3)	12,500	16,500	2,000–6,900
Absolute lymphocyte count (/mm3)	3,440	3,000	600–3,400
Absolute eosinophil count (/mm3)	4	43	<700
C‐reactive protein (mg/l)	11.6	<3.3	0–5
Iron (µg/dl)	31.69	41	50–170
Ferritin (ng/ml)	167.23	49.32	4.6–204
Fibrinogen (mg/dl)	270	300	200–400
D‐dimer (ugFEU/l)	1,010	686	<500
LDH (U/l)	445	261.71	180–430
PT (sec)	12.2	10.7	8–13.2
APTT (sec)	26.5	34.8	18.5–33.5
INR	1.2	1.02	0.8–1.3
25‐OH D3 (µg/l)	14.32	–	>20
SARS‐CoV‐2 PCR	Posıtıve	Negatıve

APTT, activated partial thromboplastin time; INR, international normalized ratio; LDH, lactate dehydrogenase. PCR, polymerase chain reaction; PT, prothrombin time; WBC, white blood cell;

elIn most pediatric cases, the diagnosis of COVID‐19 may be delayed because of the cases presenting as an asymptomatic individual or with rare symptoms such as skin findings initially, or these patients may be missed without any diagnosis. ² , ³ , ⁴ , ⁵ Our case presented with isolated symptoms such as urticarial rash that started suddenly and had fever of 38°C for 1 day, and COVID‐19 was not considered by the pediatricians in which it was seen in the first place, and the patient was sent home with an antihistamine. This may pose a risk to ensuring the transmission control of SARS‐CoV‐2. Clinicians should be more careful in terms of the symptoms and positive physical examination findings of COVID‐19 in the pediatric population, especially because of the start of face‐to‐face education in schools and the removal of restrictions on children. With this presentation, when acute urticaria and/or angioedema is encountered and rarely occurs in the patient, it is of great importance to bring the COVID‐19 viral infection to mind and to narrow the contact circle and to treat the disease.