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Cholinergic urticaria after COVID-19 infection

  • Kosuke Ishizuka
    Correspondence
    Corresponding author: Kosuke Ishizuka. Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae, Kawasaki-city, Kanagawa pref. Japan, Tel. +81-44-977-8111, Fax. +81-44-975-0608
    Affiliations
    Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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  • Yoshiyuki Ohira
    Affiliations
    Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Published:November 06, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.10.008

      Key Words

      To the Editor:
      A 39-year-old Japanese woman developed a fever and cough and was diagnosed with coronavirus disease 2019 (COVID-19) infection two months prior. Both symptoms resolved spontaneously within a few days. However, one week later, tingling pain and wheals appeared over her entire body, sparing her head and the distal portion of the extremities. They appeared a few minutes after bathing and quickly resolved with cooling (Figure 1). The patient was diagnosed with cholinergic urticaria (CholU) using an acetylcholine injection test, which induced both pain and wheals. No suggestive findings of anhidrosis were observed in a thermoregulatory sweat test. Symptoms improved with oral administration of antihistamine.
      Figure 1
      Figure 1Tingling pain and wheals appeared a few minutes after bathing and quickly resolved with cooling.
      CholU is a skin disorder triggered by sweating or stimuli that simulate sweating such as bathing.
      • Fukunaga A
      • Washio K
      • Hatakeyama M
      • et al.
      Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management.
      It is common in young adults, and presents as a miliary to azuki bean-sized erythematous rash, but a rash does not always appear.
      • Fukunaga A
      • Washio K
      • Hatakeyama M
      • et al.
      Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management.
      Cholinergic urticaria may present with tingling pain rather than itching.
      • Fukunaga A
      • Washio K
      • Hatakeyama M
      • et al.
      Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management.
      Four subtypes of cholinergic urticaria have been proposed: Cholinergic urticaria with 1) poral occlusion; 2) acquired generalized hypohidrosis; 3) sweat allergy; and 4) idiopathic origin.
      • Nakamizo S
      • Egawa G
      • Miyachi Y
      • Kabashima K
      Cholinergic urticaria: pathogenesis-based categorization and its treatment options.
      Acetylcholine injection test is useful in the diagnosis of cholinergic urticaria.
      • Fukunaga A
      • Washio K
      • Hatakeyama M
      • et al.
      Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management.
      ,
      • Nakamizo S
      • Egawa G
      • Miyachi Y
      • Kabashima K
      Cholinergic urticaria: pathogenesis-based categorization and its treatment options.
      Antihistamines are an effective treatment for cholinergic urticaria, and in cases of cholinergic urticaria with a sweat allergy, desensitization therapy is added.
      • Bito T
      • Sawada Y
      • Tokura Y.
      Pathogenesis of cholinergic urticaria in relation to sweating.
      Even in the case of anhidrosis, improving the function of the sweat glands by increasing opportunities for sweating, such as exercise, can help prevent a recurrence.
      • Bito T
      • Sawada Y
      • Tokura Y.
      Pathogenesis of cholinergic urticaria in relation to sweating.
      Various infections can cause urticaria,
      • Wedi B
      • Raap U
      • Wieczorek D
      • Kapp A.
      Urticaria and infections.
      and urticaria has been reported to develop after COVID-19 infection.
      • Abuelgasim E
      • Dona ACM
      • Sondh RS
      • Harky A
      Management of urticaria in COVID-19 patients: A systematic review.
      Cholinergic urticaria can occur after a COVID-19 vaccination; however, cholinergic urticaria after a COVID-19 infection has not been previously reported.
      • Park HJ
      • Montgomery JR
      • Boggs NA
      Anaphylaxis After the Covid-19 Vaccine in a Patient With Cholinergic Urticaria.
      In conclusion, pain and wheals induced by thermal stimuli should be considered cholinergic urticaria, which can occur after COVID-19 infection.

      Authorship

      All authors had access to the data and a role in writing the manuscript.

      Declaration of Competing Interest

      None.

      Funding

      None.

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