A 41-year-old previously healthy woman presents to her primary care provider with a 3-day history of generalized pruritic urticarial rash and swelling of her lip and bilateral eyelid, all beginning concurrently. She describes the skin lesions as migratory and involving the scalp, palms, soles, helix of both ears, trunk, and extremities, all lasting for a few hours. The eyelid and lip swelling spontaneously regressed within a few hours, although new urticarial lesions continue to appear throughout the body. 

The patient denies new exposure to foods, medications, over-the-counter medications, or herbal supplements as well as no known disease exposures. She denies any history of similar rashes.

Her medical history is remarkable for well-controlled focal impaired awareness seizures, seasonal allergies, and mild intermittent asthma. Current medications include oxcarbazepine 300 mg twice daily (taken for 20 years for seizures), cetirizine 10 mg daily (taken for several years for season allergy control), albuterol inhaler (used 3 to 4 times per year for asthma), and a multivitamin. She has a levonorgestrel intrauterine device in place. She is a lifelong nonsmoker; drinks 1 to 2 glasses of wine per week, and denies any illicit drug use. She is married with 4 school-aged children and is employed full time as a nurse practitioner in a family practice clinic. At the time of her initial presentation, she denies fever, chills, sore throat, cough, rhinorrhea, shortness of breath, or any gastrointestinal distress.  

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On examination, the patient does not appear to be in distress. Vital signs are as follows: temperature 37.6°C, blood pressure 116/64 mm Hg, respiratory rate 16 per minute, heart rate 56 beats per minute, and oxygen saturation 98% on room air. Her examination is remarkable for swelling of the bilateral eyelids, both lips, bilateral helix, and generalized urticarial rash, predominantly involving the extremities, scalp, and trunk. There are no signs of respiratory distress and lungs are clear to auscultation.  

She is treated symptomatically and prescribed 40 mg of prednisone daily for 5 days. She also continues on daily cetirizine. However, the urticarial lesions persist and, on day 3, she develops a sore throat, fever, myalgia, fatigue, and headache with progression of urticaria and recurrence in lip and eyelid swelling. Polymerase chain reaction (PCR) test is positive for SARS-CoV-2 on day 4 of the rash; her spouse also tests positive for COVID-19. She quarantines at home and is treated symptomatically with alternating acetaminophen and ibuprofen for pain and fever. For management of pruritus, cetirizine is increased to twice-daily dosing and famotidine is added.  

However, due to mild shortness of breath, spreading lesions, and increasing pruritus, she presents to the emergency department on day 10 of urticaria onset (6 days after her positive COVID-19 test). On examination, she does not appear to be in distress. Vital signs on admission are as follows: temperature 37.2°C, blood pressure 128/65 mm Hg, respiratory rate 20 per minute, heart rate 62 beats per minute, and oxygen saturation 97% on room air. Large erythematous urticarial welts are noted, most prominently on the extremities but also the trunk, scalp, palms, and soles (Figure 1). Her lips are markedly swollen, although eyelid swelling resolved. No other skin abnormalities are seen. There are no crackles or wheezes on chest examination. Complete blood count and metabolic panel are within normal limits. Sedimentation rate is modestly elevated at 22 mm/h (normal value 2 to 20 mm/h). Antinuclear antibody test is negative.

Figure 1. Large erythematous urticarial welts on back in a patient with COVID-19.
Credit: Kimberly M. Beckstrom, APRN, DNP, CNP