Exercise-Induced Urticaria: A Rare Case Report

Sijapati, Nikita; Sciturro, Monica; Le, Matthew; Lanza, Jesus; Mercado, Edgar; Seferovic, Admir

doi:10.7759/cureus.23062

Cited by 3 publications

(5 citation statements)

References 9 publications

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“…Exercise challenge test can be done in a clinical set-up to confirm the diagnosis. 9 This test was not performed in our patient because his initial blood investigations threw light on suspicion of muscle source altered AST in the form of isolated AST elevation. LDH was done to confirm the diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Exercise-induced urticaria is managed by avoiding food before and after exercise, use of mast cells stabilisers and antihistamines before exercise. 9 This is a case of severe exercise-induced urticaria with muscle injury with a risk of exertional rhabdomyolysis managed with moderation of exercise intensity and short course of anti-histamines.…”

Section: Discussionmentioning

confidence: 99%

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Exercise-induced urticaria with muscle injury: a case report

Mithra¹,

Narasingan²

2023

Int J Res Dermatol

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Exercise has become an integral part of life in this modern era due to sedentary lifestyle. Although, urticaria patients are being evaluated for all the common triggering factors like food, environmental allergens and infections, an entity called exercise induced urticaria often get missed. Exertional and asymptomatic rhabdomyolysis must be kept in mind during evaluation. A 27 year male patient was diagnosed with severe exercise induced urticaria with muscle injury. Patient developed urticaria within 30 minutes of strenuous exercise. Clinical history was insignificant for any allergen exposure except for clear history of urticaria once weekly after strenuous exercise. Patient also reported need for oral analgesics on the day of strenuous exercise indicating muscle injury. Asymptomatic phase correlated with abstinence of exercise. His lesions gradually got relieved with anti-histamines. Routine blood investigations were normal except elevation of aspartate aminotransferase (AST-354U/L), Lactate dehydrogenase (LDH-619U/L) and normal alanine aminotransferase (ALT-51U/L), altered AST/ALT ratio more than 6. Creatinine kinase (CK) can increase ten folds in healthy individuals following strenuous exercise. Hence, CK was not done for this patient. Aminotransferases may remain elevated even after normalisation of CK up to 2-3 weeks. LDH was done as an additional investigation. Simple routine investigation for altered AST and confirmation with LDH or CK for its source from muscle injury can be done. Severe exercise induced urticaria with muscle injury can be managed with moderation of exercise intensity along with short course of antihistamines owing to the benefit of exercise. This patient was followed up for 2 years and there was no episode of urticaria after stepping down the exercise intensity. Detailed history of exercise duration and intensity is required along with basic investigations for evaluating exercise induced urticaria. A sub-entity called severe exercise induced urticaria with muscle injury must be kept in mind due to the risk of asymptomatic or exertional rhabdomyolysis.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Exercise-induced urticaria with muscle injury: a case report

Mithra¹,

Narasingan²

2023

Int J Res Dermatol

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“…Treatment options for cholinergic urticaria include anti‐histamines, H1‐receptor antagonists, and other medications that suppress the immune system 5 . In some cases, avoiding triggers and adopting lifestyle changes, for example, regular exercise and stress management techniques, can also help to relieve the symptoms 53 . On the other hand, phototherapy and immunotherapy for cholinergic urticaria are less common, because of the potential side effects 54 .…”

Section: Discussionmentioning

confidence: 99%

“…5 In some cases, avoiding triggers and adopting lifestyle changes, for example, regular exercise and stress management techniques, can also help to relieve the symptoms. 53 On the other hand, phototherapy and immunotherapy for cholinergic urticaria are less common, because of the potential side effects. 54 Here, the transgenic mice with overexpressed AChE showed an alleviated inflammatory response under UVB irradiation and ACh stimulation.…”

Section: Author Contributionsmentioning

confidence: 99%

Acetylcholinesterase is regulated by exposure of ultraviolet B in skin keratinocytes: A potential inducer of cholinergic urticaria

Wu,

Xia,

Guo

et al. 2024

The FASEB Journal

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Cholinergic urticaria is a dermatological disease characterized by the presence of large patches of red skin and transient hives triggered by factors, such as exercise, sweating, and psychological tension. This skin problem is hypothesized to be attributed to a reduced expression of acetylcholinesterase (AChE), an enzyme responsible for hydrolyzing acetylcholine (ACh). Consequently, ACh is thought to the leak from sympathetic nerves to skin epidermis. The redundant ACh stimulates the mast cells to release histamine, triggering immune responses in skin. Here, the exposure of ultraviolet B in skin suppressed the expression of AChE in keratinocytes, both in in vivo and in vitro models. The decrease of the enzyme was resulted from a declined transcription of ACHE gene mediated by micro‐RNAs, that is, miR‐132 and miR‐212. The levels of miR‐132 and miR‐212 were markedly induced by exposure to ultraviolet B, which subsequently suppressed the transcriptional rate of ACHE. In the presence of low level of AChE, the overflow ACh caused the pro‐inflammatory responses in skin epidermis, including increased secretion of cytokines and COX‐2. These findings suggest that ultraviolet B exposure is one of the factors contributing to cholinergic urticaria in skin.

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“…Finally, the exercise itself can induce respiratory, systemic, and skin reactions [ 20 – 22 ]. Exercise-induced rhinitis is frequent, especially in outdoor sports such as winter athletes [ 23 ].…”

Section: Atopy and Eibmentioning

confidence: 99%

Exercise-induced bronchoconstriction, allergy and sports in children

Klain,

Giovannini,

Pecoraro

et al. 2024

Ital J Pediatr

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Exercise-induced bronchoconstriction (EIB) is characterized by the narrowing of airways during or after physical activity, leading to symptoms such as wheezing, coughing, and shortness of breath. Distinguishing between EIB and exercise-induced asthma (EIA) is essential, given their divergent therapeutic and prognostic considerations. EIB has been increasingly recognized as a significant concern in pediatric athletes. Moreover, studies indicate a noteworthy prevalence of EIB in children with atopic predispositions, unveiling a potential link between allergic sensitivities and exercise-induced respiratory symptoms, underpinned by an inflammatory reaction caused by mechanical, environmental, and genetic factors. Holistic management of EIB in children necessitates a correct diagnosis and a combination of pharmacological and non-pharmacological interventions. This review delves into the latest evidence concerning EIB in the pediatric population, exploring its associations with atopy and sports, and emphasizing the appropriate diagnostic and therapeutic approaches by highlighting various clinical scenarios.

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Exercise-Induced Urticaria: A Rare Case Report

Cited by 3 publications

References 9 publications

Exercise-induced urticaria with muscle injury: a case report

Exercise-induced urticaria with muscle injury: a case report

Acetylcholinesterase is regulated by exposure of ultraviolet B in skin keratinocytes: A potential inducer of cholinergic urticaria

Exercise-induced bronchoconstriction, allergy and sports in children

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