Peanut Allergy Saves a Patient with Cold-Induced Hypotension and Urticaria
Article Outline
An 11-year-old girl with an allergy to peanuts had lightheadedness 15 minutes after she started swimming in the ocean. Friends noticed urticarial lesions on her legs and arms. She fainted within seconds after walking to the shoreline. Emergency personnel measured the child's blood pressure at 50/20 within 15 minutes after the reaction began. Because they thought she had ingested peanuts accidentally, she was sprayed with cold water to wash off any possible allergens. With continued hypotension and persistence of urticaria, she was given an injection of epinephrine. Immediately her blood pressure improved and the urticarial lesions resolved within minutes.
Based on the history of this reaction and other relevant past history, the child was seen in the allergy clinic and diagnosed with primary acute cold urticaria after a positive ice cube test (Figure).
Figure.
Wheal elicited with ice cube test.
Primary acute cold urticaria is a chronic physical urticaria associated with either localized or generalized pruritic wheals on the skin (with or without angioedema) in response to exposure to cold stimuli.1 Cold air, surfaces, or liquids may elicit a response, and severe systemic shock after immersion in cold water may place these patients at significant risk for a life-ending reaction. Diagnosis is made by the timed application of an ice cube to the skin. A wheal is elicited while the skin is rewarming (Figure). Acute cold urticaria management includes cold stimuli avoidance and the use of nonsedating second-generation antihistamines along with epinephrine as needed.2 Because this child had peanut allergy, an epinephrine auto-injector was available that proved beneficial in reversing the systemic hypotension and urticaria. Life-ending allergic reactions to peanuts and other foods often involve the skin, gastrointestinal tract, and, most importantly, the respiratory tract. The use of epinephrine in what was thought to be a life-threatening peanut allergic reaction saved this child's life.
References
- . The spectrum of acquired and familial cold-induced urticaria/urticaria-like syndromes. Immunol Allergy Clin North Am. 2004;24:259–286
- . High-dose desloratadine decreases wheal volume and improves cold provocation thresholds compared with standard-dose treatment in patients with acquired cold urticaria: a randomized, placebo-controlled, crossover study. J Allergy Clin Immunol. 2009;123:672–679
PII: S0022-3476(09)00967-6
doi:10.1016/j.jpeds.2009.09.052
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