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\begin{document}

\title{Urticarial rash as the initial presentation of COVID-19 infection: a
case report}



\author[1]{Usamah  Al-Anbagi}%
\author[1]{Shybin  Usman}%
\author[1]{Abdulqadir Nashwan}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{June 16, 2024}


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\selectlanguage{english}
\begin{abstract}
During the COVID-19 pandemic, multiple skin manifestations have been
described. These include an urticarial rash, morbilliform rash,
maculopapular rash, vascular lesions, and varicella-like eruptions. A
30-year-old woman presented with a mild cough, then hives and pruritic
rash for 3 days, followed by fever, dyspepsia, and throat pain for one
day.%
\end{abstract}%



\sloppy


\subsubsection*{Urticarial rash as the initial presentation of COVID-19
infection: a case
report}

{\label{urticarial-rash-as-the-initial-presentation-of-covid-19-infection-a-case-report}}

Short title: Urticarial rash \& COVID-19

Usamah Al-Anbagi\textsuperscript{1}, Shybin Usman\textsuperscript{1},
Abdulqadir J. Nashwan\textsuperscript{2}

Medicine Department, Hazm Mebaireek General Hospital, Hamad Medical
Corporation, Doha, Qatar

Nursing Department, Hazm Mebaireek General Hospital, Hamad Medical
Corporation, Doha, Qatar

\textbf{Corresponding author:}

Mr. Abdulqadir J. Nashwan

anashwan@hamad.qa Tel: (+974) 40240487

Mob: (+974) 66473549 P.O. Box 3050

Hamad Medical Corporation, Doha, Qatar

\textbf{ABSTRACT}

During the COVID-19 pandemic, multiple skin manifestations have been
described. These include an urticarial rash, morbilliform rash,
maculopapular rash, vascular lesions, and varicella-like eruptions. A
30-year-old woman presented with a mild cough, then hives and pruritic
rash for 3 days, followed by fever, dyspepsia, and throat pain for one
day.

\textbf{Key Clinical Message}

The occurrence of cutaneous signs in COVID-19 is associated with disease
severity, although there is inadequate evidence to assess skin
manifestations' prognostic relevance. Skin manifestations are often
self-limiting and last six to eight days, although they may persist up
to 10 days.

\emph{Keywords: COVID-19; Urticarial rashes; Skin; SARS-CoV-2;
Dermatology}

\textbf{INTRODUCTION}

The \emph{SARS-CoV-2} (COVID-19) pandemic impacted around 472 million
people and killed around 6.09 million patients (1). Although the virus
is largely responsible for respiratory symptoms, a growing number of
dermatological signs and symptoms of this illness have been identified.
Several reports worldwide have identified a range of potential skin
manifestations of \emph{SARS-CoV-2} (COVID-19) (2-8). However, the
frequency of dermatological presentation (between 0.2\% to 29\%) and
also the timing of skin manifestations are difficult to ascertain
(9-11).

Here we have a case report of a young woman who initially presented with
a generalized pruritic urticarial rash ranging from one to seven
centimeters in diameter on the 6th of January 2022.

\textbf{CASE PRESENTATION}

A 30 years old lady with no co-morbidities and no significant past
medical history. She received her third booster dose of mRNA-1273
COVID-19 vaccine 5 days before presenting with symptoms.

The initial symptom was a mild dry cough. On the second day, she
developed a pruritic, erythematous macular rash on the back of her neck
and the volar aspect of her forearms. She did not self-medicate with
over-the-counter (OTC) medications and sought medical attention on an
outpatient basis. On evaluation, she was found to be COVID-19 Antigen
positive and was prescribed antihistamines.

On the fourth day of symptoms, she presented to the ED (emergency
department) with a worsening pruritic rash which had spread to involve
her neck, face, arms, trunk, and legs (Figures 1-3) and mild fever, and
dyspepsia.

She did not have shortness of breath, stridor, wheeze, chest pain, or
abdominal pain. She had no history of insect bites, exposure to new
foods, recent use of any medications, over-the-counter medications,
herbal supplements, and no known disease exposures. The patient denied
any past history of similar rashes or allergic reactions and also denied
any family history of the similar condition or skin diseases running in
her family.

\emph{Clinical Examination}

On~examination: The following were the vital signs: On room air, the
temp 37.9\selectlanguage{ngerman}°C, the blood pressure (BP) 114/72 mmHg, the respiratory rate
20 b/m, the heart rate 85 b/m, and the O\textsubscript{2} Sat was 99
percent.

She had widespread raised erythematous and pruritic lesions on her face,
trunk, bilateral upper and lower extremities consistent with an
urticarial rash (Figures 1-3). In addition, she had substantial pain as
a result of pruritus and a burning-like feeling in the lesions. The
remaining clinical examination, including the respiratory system, was
also unremarkable.

COVID-19 PCR test was positive, Chest X-ray was unremarkable, and EKG
revealed sinus tachycardia only. The other laboratory investigations
(see Table 1).

\emph{Differential Diagnosis}

Several etiologies are considered, such as COVID vaccine-induced, mast
cell defects, food-related allergies, autoimmune conditions, and
infectious causes. Because the urticarial rash appeared shortly before
her positive PCR test and she had accompanying moderate viral symptoms,
the urticaria is thought to be a presenting sign of her COVID-19
infection. A detailed history was taken and did not reveal any concern
for new exposure to food, use of over-the-counter medications, recent
use of any kind of medications or herbal supplements, as well as no
history of a similar attack; and it was unlikely to be an anaphylactic
reaction as it was progressive worsening over 3 days duration, other
suspected infection were excluded after screening and cultures. After
being diagnosed with COVID-19, a trial of observation with
antihistamines was felt.

\emph{Management \& Follow-up}

As infective causes were being considered, antibiotic coverage with
Ceftriaxone 2 gram and azithromycin 500 milligram once daily were
started on admission. It was discontinued on the third day when
preliminary blood culture reports came back negative. Steroids
(hydrocortisone IV one dose 200-milligram and then transitioned to oral
prednisolone 20 milligrams which was given for 4 days) and
antihistamines (diphenhydramine 25-milligram injection on need along
with oral fexofenadine 180 milligrams which was given daily for 5 days
then it was replaced with levocetirizine 5-milligram daily dose) and
emollient creams were given throughout the hospital stay for the
allergic symptoms. Deep Venous Thrombosis prophylaxis was provided with
enoxaparin 40-milligram subcutaneous injection daily. Oral esomeprazole
20-milligram was given for stress ulcer prophylaxis. She was discharged
on levocetirizine 5-milligram and esomeprazole 20-milligram once daily
for 5 days. She had an apparent improvement of rash after 2 days, with a
remaining mild itching and burning sensation. She was discharged home
safely on day 6 of hospitalization after all her workup was done, which
ruled out other suspected causes of her rashes.

\textbf{DISCUSSION}

Coronavirus disease (COVID-19) is caused by the severe acute respiratory
syndrome coronavirus 2 virus; which is a Ribonucleic acid (RNA) virus
that invades host cells through one receptor called
angiotensin-converting enzyme 2 (ACE2) receptor (12, 13) which is found
on small intestine enterocytes, epithelial cells of the lung alveolar,
heart, also the endocrine, and neurologic systems (10). Multiple
cutaneous symptoms have been seen and documented in people infected with
COVID-19. Furthermore, the presence of skin symptoms in COVID-19 has
been observed to vary between 0.2 - 29 percent (11); These include an
urticarial rash, Morbilliform rash, maculopapular rash, livedo
reticularis/racemosa-like pattern, vascular lesions, varicella-like
eruptions

The pathogenesis of COVID-19 urticaria is largely underdiagnosed. Still,
it might be mediated by the acute systemic inflammatory response to the
COVID-19~to acute infection, which results in mast cell activation and
the production of pro-inflammatory cytokines (14).

Skin manifestations associated with COVID-19 are often self-limiting and
do not lead to complications, and usually, the urticarial rash lasts
around Six to eight days and up to ten days (2, 15). Urticarial rashes
are mostly noted to occur simultaneously or after the onset of
non-cutaneous symptoms. The presence of skin and dermatological symptoms
in COVID-19 has been linked to disease severity; a Spanish research
linked the characteristics of maculopapular or urticarial lesions to the
severity of COVID-19 infection (2); on the other hand, in their
literature study of twenty-one patients, Sachdeva et al. claimed that
there is an implausible link between cutaneous lesions and COVID-19
infection severity (15).

Most of the patients achieved adequate symptom control with the use of
antihistamines treatment only, which can be used until they get
resolution~(14). Regarding glucocorticoids use, it may be considered
short-term additive therapy for severe symptoms refractory to 1 or more
antihistamines at maximum doses (16).

\textbf{CONCLUSION}

While the common COVID-19 infection presentation is respiratory
symptoms, physicians should not ignore other uncommon presentations like
dermatological findings and cutaneous manifestation, which are
increasingly being seen. Therefore, the management of urticaria is
focused on controlling symptoms and typically includes parenteral and
oral antihistamines and oral corticosteroids.

\textbf{Declarations}

\textbf{Ethics approval and consent to participate}

The article describes a case report. Therefore, no additional permission
from our Ethics Committee was required.

\textbf{Consent for publication}

The consent for publication was obtained from the patient.

\textbf{Availability of data and material}

All data generated or analyzed during this study are included in this
published article.

\textbf{Competing interests}

The authors declare that they have no competing interests.

\textbf{Funding}

This study was not funded.

\textbf{Authors' contributions}

UA, SU, AJN: Data Collection, Literature Search, Manuscript Preparation

All authors read and approved the final manuscript

\textbf{Acknowledgments}

Open Access funding provided by the Qatar National Library.

\textbf{Figure and Table Legends}

Table 1. Laboratory investigations

Figure 1. (Urticarial rash on the left hand)

Figure 2. (Urticarial rash on the right hand)

Figure 3. (Diffuse urticarial rash on the left upper extremity)

\textbf{REFERENCES}

1. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C,
Ortiz-Ospina E, et al. Coronavirus pandemic (COVID-19). Our world in
data. 2020.

2. Galván Casas C, Catala A, Carretero Hernández G, Rodríguez\selectlanguage{english}-Jimenez P,
Fernandez\selectlanguage{english}-Nieto D, Rodriguez\selectlanguage{english}-Villa Lario A, et al. Classification of the
cutaneous manifestations of COVID\selectlanguage{english}-19: a rapid prospective nationwide
consensus study in Spain with 375 cases. British Journal of Dermatology.
2020;183(1):71-7.

3. de Masson A, Bouaziz J-D, Sulimovic L, Cassius C, Jachiet M, Ionescu
M-A, et al. Chilblains is a common cutaneous finding during the COVID-19
pandemic: A retrospective nationwide study from France. Journal of the
American academy of dermatology. 2020;83(2):667-70.

4. Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Takeshita
J, et al. Pernio-like skin lesions associated with COVID-19: a case
series of 318 patients from 8 countries. Journal of the American Academy
of Dermatology. 2020;83(2):486-92.

5. Daneshgaran G, Dubin DP, Gould DJ. Cutaneous manifestations of
COVID-19: an evidence-based review. American journal of clinical
dermatology. 2020;21(5):627-39.

6. Tan SW, Tam YC, Oh CC. Skin manifestations of COVID-19: A worldwide
review. JAAD international. 2021;2:119-33.

7. Marzano AV, Genovese G, Moltrasio C, Gaspari V, Vezzoli P, Maione V,
et al. The clinical spectrum of COVID-19--associated cutaneous
manifestations: An Italian multicenter study of 200 adult patients.
Journal of the American Academy of Dermatology. 2021;84(5):1356-63.

8. Recalcati S, Gianotti R, Fantini F. COVID-19: The experience from
Italy. Clinics in Dermatology. 2021;39(1):12-22.

9. Guan W-j, Ni Z-y, Hu Y, Liang W-h, Ou C-q, He J-x, et al. Clinical
characteristics of coronavirus disease 2019 in China. New England
journal of medicine. 2020;382(18):1708-20.

10. Hamming I, Timens W, Bulthuis M, Lely A, Navis Gv, van Goor H.
Tissue distribution of ACE2 protein, the functional receptor for SARS
coronavirus. A first step in understanding SARS pathogenesis. The
Journal of Pathology: A Journal of the Pathological Society of Great
Britain and Ireland. 2004;203(2):631-7.

11. Gul U. COVID-19 and dermatology. Turkish journal of medical
sciences. 2020;50(8):1751-9.

12. Soliman A, Nair AP, Al Masalamani MS, De Sanctis V, Khattab MAA,
Alsaud AE, et al. Prevalence, clinical manifestations, and biochemical
data of type 2 diabetes mellitus versus nondiabetic symptomatic patients
with COVID-19: A comparative study. Acta Bio Medica: Atenei Parmensis.
2020;91(3):e2020010.

13. Iqbal F, Soliman A, De Sanctis V, Mushtaq K, Nair AP, Al Masalamani
MA, et al. Prevalence, clinical manifestations, and biochemical data of
hypertensive versus normotensive symptomatic patients with COVID-19: a
comparative study. Acta Bio Medica: Atenei Parmensis. 2020;91(4).

14. Abuelgasim E, Dona ACM, Sondh RS, Harky A. Management of urticaria
in COVID\selectlanguage{english}-19 patients: a systematic review. Dermatologic Therapy.
2021;34(1):e14328.

15. Sachdeva M, Gianotti R, Shah M, Bradanini L, Tosi D, Veraldi S, et
al. Cutaneous manifestations of COVID-19: Report of three cases and a
review of literature. Journal of dermatological science.
2020;98(2):75-81.

16. Pollack Jr CV, Romano TJ. Outpatient management of acute urticaria:
the role of prednisone. Annals of emergency medicine. 1995;26(5):547-51.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Lab Tests & Results & Normal values\tabularnewline
\midrule
\endhead
White cell count & 12\selectlanguage{ngerman}×109 cells/L & 4--10\selectlanguage{ngerman}×109 cells/L\tabularnewline
Red cell count & 5.2 x10\^{}6/uL & 3.8-4.8 x10\^{}6/uL\tabularnewline
Platelet & 367 x10\^{}3/uL & 150-400 x10\^{}3/uL\tabularnewline
C reactive protein & 129 mg/L & \textless{}8.0 mg/L\tabularnewline
Serum creatinine & 61 umol/L & 44-80 umol/L\tabularnewline
Serum Ferritin & 308.0 ug/L & 12-160 ug/L\tabularnewline
Urea & 3.0 mmol/L & 2.5-7.8 mmol/L\tabularnewline
Sodium & 137 & 135-145 mmol/L\tabularnewline
Potassium & 3.7 & 3.5-5.3 mmol/L\tabularnewline
Bilirubin & 27 umol/L & 0-21 umol/L\tabularnewline
Alanine Aminotransferase & 63 U/L & 0-33 U/L\tabularnewline
Aspartate Aminotransferase & 71 U/L & 0-32 U/L\tabularnewline
Procalcitonin & 0.15 ng/mL & \textless{}0.5 ng/mL\tabularnewline
Interleukin-6 & 74 pg/mL & \textless{}7 pg/mL\tabularnewline
\bottomrule
\end{longtable}

Table 1. Laboratory investigations

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