35 years old female suffering from recurrent painless nonitchy swelling for last 5 years. No h/o respiratory distress. No family history of such lesions. She is a known Hypertensive and for that she is on Telmisertan 40 mg/day. Patient has been treated with Levocetirizine 10mg twice a day for six months and Monteleukast 10 mg at night for six months, but no relief. Only responding to short courses of systematic Steroid 2 mg /kg with tapering dose. 1). Diagnosis 2). D/D 3). Investigations 4). Management. Please give your answers in chronological order.



1. Chronic urticaria (CU). ** Chronic urticaria (CU) is a disturbing allergic condition of the skin. Although frequently benign, it may sometimes be a red flag sign of a serious internal disease, which should be investigated for rule in or rule out....... ETIOLOGIES : PHYSICAL, INFECTIVE, VASCULITIC, PSYCHOLOGICAL and IDIOPATHIC. An AUTOIMMUNE basis of most of the ‘idiopathic’ forms is now hypothesized. ** Histamine released from mast cells is the major effector in PATHOGENESIS and it is clinically characterized by wheals that have a tendency to recur. 2; AUTOIMMUNE URTICARIA... ANGIONEUROTIC OÊDEMA... AUTOIMMUNE DISEASES..... PSYCHOLOGICAL DISTRESS. DEPRESSION AND OTHER CAUSES AS DISCUSSED BELOW..... 3.LABORATORY INVESTIGATIONS aimed at a specific etiology are not always conclusive, though may be suggestive of an underlying condition. A clinical SEARCH FOR associated SYSTEMIC DISEASE is strongly advocated under APPROPRIATE circumstances. 4. The MAINSTAY OF TREATMENT remains H1 ANTIHISTAMINICS. These may be COMBINED WITH complementary pharmacopeia in the form of H2 BLOCKERS, DOXEPIN, NIFEDIPINE and LEUKOTRIENE INHIBITORS. MORE RADICAL THERAPY :- In the form of IMMUNOGLOBULINS, PLASMAPHERESIS and CYCLOPHOSPHAMIDE may be required for recalcitrant cases.......   .**  A stepwise management results in favorable outcomes....... ** A single PATIENT MAY HAVE more than one type. Below is a list of some types of physical urticaria and their causes. Dermatographism/dermographism - Firm stroking Delayed pressure urticaria - Pressure Cold urticaria - Cold Aquagenic urticaria - Water exposure Cholinergic urticaria - Heat, exercise, or stress Solar urticaria - Sun exposure Vibratory urticaria - Vibration Autoimmune urticaria...... It is now well-established that about 30-50% patients with CU have circulating functional auto antibodies against the high-affinity IgE receptor (FCeRIa) or against IgE. Also, URTICARIA has been ASSOCIATED WITH A NUMBER OF AUTOIMMUNE DISEASES. A few of them are : SYSTEMIC LUPUS ERYTHEMATOSUS, CRYOGLOBULINEMIA, NEOPLASMS, JUVENILE RHEUMATOID ARTHRITIS (JRA) AUTOIMMUNE THYROID DISEASE, including GRAVES DISEASE. Urticaria is a feature of Muckle-Wells syndrome (AMYLOIYDOSIS, NERVE DEAFNESS and URTICARIA and SCHNITZLER SYNDROME (fever, joint/bone pain, monoclonal gammopathy and urticaria). INFECTIVE CAUSES : Infectious agents reported to cause urticaria include HEPATITIS B VIRUS,  STREPTOCOCCUS and MYCOPLASMA SPECIES,  HELICOBACTER PYLORI, MYCOBACTERIUM TUBERCULOSIS, and HERPES SIMPLEX VIRUS. Fungal infections such as ONYCHOMYCOSIS, TINEA PEDIS and CANDIDA have been considered as possible associations. CU has been associated with PARASITIC infestations such as STRONGYLOIDIASIS, GIARDIASIS and AMOEBIASIS....... MEDICATIONS: Urticaria may be caused or exacerbated by a number of drugs. More common culprits include ASPIRIN, OTHER nonsteroidal anti-inflammatory drugs (NSAID), OPIOIDS, ACE INHIBITORS, and ALCOHOL. Aspirin may exacerbate CU in 6.7-67% of patients. Other drugs implicated are ALCOHOL, NARCOTICS (CODEINE, MORPHINE) and oral CONTRACEPTIVES. CONTACTANTS: Contact urticaria syndrome refers to the onset of urticaria within 30-60 minutes of contact with an inciting agent. The lesions may be localized or generalized. Precipitating factors include LATEX (especially in health care workers), PLANTS, ANIMALS (eg, CATERPILLARS, DANDER), MEDICATIONS, and FOOD (eg, FISH, GARLIC, ONIONS, TOMATO). NEUROLOGICAL FACTORS: An Italian study, reported an association between CU and FIBROMYALGIA. The authors proposed that CU is a consequence of fibromyalgia-neurogenic skin inflammation. STRESS: PSYCHOLOGICAL FACTORS are reported to play a role in a number of patients. Zenon Brzoza et al in their study showed that the decline in dehydroepiandrosterone sulfate observed in CU is associated with PSYCHOLOGICAL DISTRESS. DEPRESSION may also cause or aggravate CU........

Good update

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Angioedema ? Hereditary? Acquired Dd- food allergy, insect bite, atopy, drug induced Inv- CBC, rle, complement c4,c1q n c1 esterase inh levels Treatment- avoid triggers Antihistamines, leucotriene antagonist, steroids, epinephrine inj For c1 esterase inh def- c1 esterase conc, eccalantine, icatibant

आयुर्वेद में इसे जीर्ण शीत पित्त कहते हैं। चिकित्सा संबंधी योग,,,, गाय के घी में काली मिर्च मिलाकर पिलाएं शीत पित्त भंजन रस सुबह शाम सेवन कराएं कामदुधा रस मोती युक्त 4 रत्ती शहद में मिलाकर सुबह-शाम सेवन कराएं चंन्दनासव खदिरारिष्ट दोनों को मिलाकर 25 ग्राम सुबह-शाम खाने के बाद दें


Agree with @Dr. Puranjoy Saha sir. D/D Angioneurotic edema.

Ans. 1. diagnosis chr Urticaria

Angioneurotic edema or Giant Urticaria. Because steroid gets relief.

Angioneurotic edema

Diagnosis Angionerotic Edema. Allergic reaction. Investigation CBC. E.S.R.Allergen Test. Tt Methylprednisolone 4mg tds.5days Taper dose.

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