A case of acute exacerbation of chronic spontaneous urticaria due to COVID-19 immediately after omalizumab administration

A 57-year-old Japanese male visited our department with a 16-month history of chronic spontaneous urticaria (CSU) that had been turning for the worse in the last 6 weeks. He was taking oral epinastine, lafutidine, and montelukast. He had a history of renal cell carcinoma and diabetes mellitus. At presentation, urticaria control test (UCT) score was 7, and 7-day urticaria activity score (UAS7) was 28, indicating a severe condition. Serum IgE level was 246 IU/ml. Omalizumab (300 mg) therapy was initiated because his urticaria was intractable. However, he had a fever the day after the first omalizumab administration. Since the polymerase chain reaction (PCR) test was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the patient was hospitalized. On admission, the laboratory test showed normal white blood cell count (5300/µl) and elevated C-reactive protein (2.07 mg/dl) and IgE (507 IU/ml). Treatment with favipiravir (3600 mg on the first day and 1600 mg/day for following 4 days) and dexamethasone (6 mg/day) was started on the second day (Day 2) of admission. As the fever persisted, wheals with strong itch began to appear throughout the body (Figures 1 A, B) even with continuous epinastine, lafutidine, and montelukast. Because of persistent fever, exertional dyspnoea, and interstitial pneumonia identified by computed tomography (Figure 2), nafamostat and antibiotics were also administered. The plasma D-dimer concentration was 7.6 µg/ml at this time. His fever subsided on Day 9, and urticarial symptoms disappeared simultaneously. The D-dimer level was below the detection limit when the patient was discharged on Day 16. His urticaria was well controlled thereafter with epinastine, lafutidine, and montelukast. One month after the discharge, UCT score was 15. Since urticarial symptoms recurred 2 months after recovery from coronavirus disease 2019 (COVID-19) with UCT score 4, omalizumab was resumed, which rapidly improved the UCT score to 13 one month later.
In general, CSU can be exacerbated by viral infections. In addition, COVID-19 has been reported to complicate the symptoms of CSU [1]. Urticarial lesions accounted for 8.1–26.6% of cutaneous manifestation of COVID-19 [2]. In particular, it is reported that 10% of COVID-19-associated urticarial eruptions developed before the onset of its classical signs including fever and respiratory symptoms [3]. Furthermore, Kocatürk et al. published data of the patients affected by COVID-19...


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