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Urticaria (angioedema) and COVID- 19 infection
Mojgan Najafzadeh1, Fanila Shahzad1, Nader Ghaderi2, Kaveh Ansari3, Badie Jacob2, Andrew Wright2

1 School of Life Sciences, University of Bradford, Bradford, BD7 1DP, UK.
2 Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Duckworth Lane, BD9 6RJ
3 NIOC hospital Tehran, Tehran Province, Tehran, District 12, Saleh St, Iran

Date of presentation: The onset of symptoms began on the 5th of March 2020 with urticaria.
Case Presentation: An 80-year-old man presented with a two days history of daily generalized hives. The hives are pruritic, red wheals that range from 1.5 to 8.0 cm (0.5 to 3 in.) in diameter. He had an episode of lip, tongue and preorbital swelling associated with tightness of the throat. The patient was investigated for other differential diagnosis of urticaria at the time, such as parasitic and bacterial infection, for which negative results were found. On the 5th of March 2020 the patient reported these symptoms plus general malaise, fatigue, 37.9⁰C temperature and sore throat. The dry cough and an episode of unconsciousness were the other symptoms that the patient had experienced. Hypothyroidism and hypertension are in his medical history which are controlled with Levothyroxine 100 µg and Ramipril 10mg daily. After the unconsciousness episode, he was admitted at the hospital.
Physical Exam: He was re-evaluated on the 10th of March 2020, because he presented with an episode of unconsciousness, dry cough, general malaise, fatigue and with body temperature of 37.9°C.
Laboratory Findings:
The initial biochemical tests showed that the patient presented with low numbers of white blood cells (WBC) (WBC=2.75x103). The most hallmark issue which is lymphopenia was detected in this case (lymphocytes= 852). The other blood tests results were found to be normal. Real-time polymerase chain reaction (RT-PCR) for Covid19 was not performed due to the time lapse between starting the symptoms and hospital admission. By considering with sustained community transmission, RT-PCR of viral nucleic acid could be supported by more versatile diagnostic tools because of concern over false-negative results and limited availability. Therefore, the CT chest was carried out during the patient admission.
Pertinent imaging: CT chest was carried out during the patient admission which showed pneumonia with bilateral and subpleural areas of ground-glass opacification, consolidation affecting the lower lobes.
Treatment: The patient was admitted to National Oil Company of Iran Central Hospital. Treatment was started with Azithromycin 500 mg/daily at the hospital. At the time of his hospital admission, the patient was observed for his consciousness and lymphopenia. As a precaution, due to existing patient health conditions, hydroxychloroquine was not administrated. Five days after receiving treatment and observation, the patient's symptoms such as cough, fatigue and loss of appetite, had improved by 80%.
Lesson learned: This report highlights the unusual clinical presentation of a patient with COVID-19. There is a possibility a patient may initially present with a skin rash such as urticaria, however this skin manifestation can cloud the diagnosis and thus lead to misdiagnosis for another common disease. Despite skin manifestations such as urticaria displaying different laboratory findings to that seen of COVID-19, for example the high level of leukocytes seen in urticaria compared to leukopenia in COVID-19, researchers should look at the possibility of an alternative mechanism which can leads to the formation of such skin manifestations. This report presents evidence regarding a possible association between urticarial skin manifestations in the early stages of COVID-19 and thus its use as a possible early diagnostic indicator. Clinicians should take this report into considerations in order to prevent misdiagnosis as well to allow early diagnosis and better patient outcomes.