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You are seeing Mrs. A, a 42-year-old woman, in dermatology consultation for recurrent swelling of the lips (see photo) and eyelids, associated with pruritic erythematous patches. Her main medical history includes endometriosis and kidney colic.
Recurrent swelling of the eyelids, lips, and sometimes extremities
Mrs. A works in a frozen foods department at a large retail chain.
She reports the appearance of pruritic erythematous patches on exposed areas of her body, associated with swelling of the lips and sometimes the eyelids when she enters the cold storage room, especially during the summer (high outdoor temperatures). The lesions resolve favorably within 20 to 30 minutes after warming up.
The ice cube test is positive.
Questions
What is your diagnosis? How would you classify the reaction?
The urticarial lesions, both superficial and deep (i.e., angioedema), remain localized; therefore, this corresponds to a level I severity according to Wanderer's classification, which is also the classification retained in the latest national recommendations for cold urticaria.
Given the presence of angioedemas, would you prescribe adrenaline?
No, these are episodes of localized deep urticaria without risk of asphyxiation. The management is similar to that of isolated superficial cold urticaria.
Since the episodes are relatively frequent, you have introduced treatment with antihistamines at a dosage of 2 tablets per day, allowing for good control of symptoms.
You see her again in consultation 9 months after starting treatment; she reports an episode of tongue angioedema with a sensation of laryngeal constriction, dysphonia, and difficulty breathing, occurring minutes after consuming ice cream.
She states that she was taken care of by emergency services and received several intravenous treatments, but she does not have the discharge report.
Does this new episode change the severity of the condition? And your prescription?
Yes, the patient has experienced an episode of laryngeal angioedema causing asphyxiation, corresponding to a level III severity according to the classification retained in the latest national recommendations for cold urticaria.
This episode necessitates the additional prescription of auto-injectable adrenaline, given the risk of asphyxiation and death.
What recommendations should be given to this patient?
The recommendations given to this patient will be those for patients with cold urticaria:
Physical protection against the cold.
Inform those around the patient.
Gradual entry into water when swimming in natural bodies of water; never swim alone; swim in areas where the patient can stand.
Strict contraindication to all extreme sports involving exposure to cold: scuba diving/snorkeling, skydiving, white-water sports, etc.
In the case of surgery, inform the anesthesia team so the patient can be warmed, including warming the IV fluids.
Given the history of laryngeal angioedema, the patient must always carry two auto-injectable adrenaline syringes with her.
Additionally, Mrs. A’s profession is highly exposed to the cold, and urticaria episodes occur during her work, so it is crucial for her to contact her occupational health physician to:
Assess the compatibility of the patient's health status with the job held and propose adjustments and adaptations to the workplace (reorganization of tasks and work time, material adaptations, or even a change of job, etc.).
Recommend possible professional reassignment or even career change.
If necessary, provide a statement of unfitness in case of inability and/or failure to implement adjustments, professional reassignment, etc.
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