Onset time for aspirin induced urticaria
Question:
5/25/2017
Patient is here for allergic reaction. Had an allergic reaction a couple weeks ago to unknown/hives over entire body, tongue swelled, almost passed out. Prior to reaction/normal states of health. That morning, had a headache, took an Excedrin (9am) which is not normal due to it having caffeine in it, caffeine usually causes chest pains. Three to four hours later (1pm) lunch - ate buffalo chicken sausage with celery salt and mustard (horse radish) from a meat market - has had it before. At 2pm at friend’s house working on car - hives appeared all over. Drove home - 15 minutes later felt lightheaded and visual disturbances.
Hives were 2/10 itchy
No shortness of breath/chest felt fine
Tongue didn't feel swollen
No GI symptoms
Wife picked him up to urgent care/steroid shot (no Epi)/neurological symptoms resolved in 20 minutes/doctor saw hives on "tongue" and speech was disrupted, was sent home 1.5 hours later - slowly felt better - hives started to go away by time he left - felt 80% better. After 24 hours, felt 100%.
History of hives, Benadryl resolved them/2 other times in the last 20 years/unknown Etiology/once at work with fiberglass and second was possible with driveway salt
No food allergies
No current prescription medications
No known drug allergies
Aspirin for occasional headaches with no issues/3-4 times per year
No issues with latex
No known issues with stinging objects
No EpiPen
No family history
Did not excercie that day
Two weeks later, patient had a mild version of the above. The only common exposure was Aspirin 12 hours to hives developing and was seen in UC and given steroids and H2 blocker. Since then he has been taking a daily antihistamines and no further events. He did take Aleve without problems. He has an epipen now. Labs were done 2 weeks after his event and normal for C3, C4, C1 inhibitor, tryptase. IgE was inadvertently done and elevated at 1090 (only reports mild allergic rhinitis, no asthma, no diarrhea/parasitic exposure history, otherwise healthy). He has been eating an unrestricted diet and limited food testing from the first food log was negative except horseradish at 0.87 and he was not exposed on the second event.
Aspirin (Excedrin on the first and aspirin on the second exposure) were the only commonalities we could find. Could aspirin related urticaria be delayed by 12 hours. Given his anaphylactic initial event, is there any other labs/work up you suggest. Should we repeat/trend the IgE.
Answer:
We have the expert answer below from Dr. David Lang:
These cases are always challenging. Foods are commonly suspected but frequently there’s not a direct temporal relationship that’s consistent. As you know, the positive predictive value for in vitro or cutaneous testing is only around 50%, so more frequently the findings that are remarkable, in the absence of a correlative history, are not clinically relevant. Aspirin or NSAIDs may account for such reactions, and it’s appropriate to recommend avoidance of these medications for patients such as this; however, the latency you describe makes aspirin or NSAID exposure an unlikely culprit.
This is not a history consistent with C1 inhibitor deficiency.
Serum tryptase was not elevated by your description, but this was obtained at a time separate from symptoms occurring.
You indicate the patient was seen in urgent care twice, but don’t state whether his BP was low or whether there were labs obtained in association with symptoms. I am assuming its NO for each.
You state: “taking a daily antihistamines and no further events.” You do not describe the specific regimen; however, I agree with this therapeutic approach and would recommend continuing this regimen for now, along with carrying injectable epinephrine, with the understanding that if another event occurs serum tryptase should be obtained. If elevated, this would be consistent with idiopathic anaphylaxis.
Hope this is helpful."
Patricia McNally, MD, FAAAAI