Last months have been marked by the global spread of the severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible
for the coronavirus disease 19 (COVID-19) pandemic

Balduzzi V

Bernardini N

Maddalena P

Mambrin A

Marchesiello A

Michelini S

Potenza C.

Proietti I

Skroza N

Tolino E

Volpe S

English

Archivio della ricerca- Università di Roma La Sapienza

I M C A S : L E T T E RUrticaria in an infant with SARS-CoV-2 positivityDear Editor,Last months have been marked by the global spread of the severeacute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsiblefor the coronavirus disease 19 (COVID-19) pandemic.COVID-19 occurs predominantly with respiratory symptoms suchas cough and dyspnea in addition to fever, muscle pain and, occasion-ally, loss of smell and taste. Despite that, many reports haveestablished the clinical features of COVID-19 patients; some potentialdermatological patterns have been correlated to the disease (mac-ulopapular rashes: 47%, pseudo-chillblain acral lesions: 19%, urticariallesions: 19%, vesicular eruptions: 9%, livedo or necrosis: 6% of thestudy sample).1We present a case of a giant acute urticaria in an infant patientwith SARS-CoV-2 positivity, presenting only skin involvement.A 6-month-old, male infant, whose parents were positive toSARS-CoV-2, underwent polymerase chain reaction for COVID-19 bya nasopharyngeal smear test, with a positive result. Although his par-ents had respiratory symptoms, he was asymptomatic.Nevertheless, after 2 weeks, the infant developed a giant urti-caria, with multiple lesions, mainly affecting the trunk and limbs(Figures 1 and 2).After conducting an accurate medical history, the disease has notbeen correlated neither with drugs (topical or systemic), bacterial orparasitic infections, inhalant exposure or insect bites. Other allergiessuch as allergic rhinitis, atopic dermatitis and food allergy were notreported.Laboratory findings were within the normal ranges.Considering the positivity to COVID-19, the diagnostic hypothe-sis was urticaria triggered by viral infection.Therefore, the treatment with betamethasone (soluble tablets,0.5 mg/d for 7 days) led to clinical improvement. After 2 weeks, anew test for COVID-19 was conducted, with a negative result.Urticaria occurs quite often in pediatric population, with a preva-lence of 3.4% to 5.4%.2Anamnesis and clinical examination are crucial for infant patients,and often reveal an etiology.The causes of acute urticaria in pediatric subjects differ signifi-cantly from those in adults. Food allergies, viral infections and drug-related causes are predominant in infants, whereas chronic urticaria(CU) is mostly due to physical causes, even though, in most cases, CUin children is spontaneous and no trigger cause is found.3Furthermore, latest reports detected urticaria as a common, pro-dromal clinical finding among adult COVID-19 patients, with a vari-able timing of appearance: some lesions appearing before onset offever, while others 48 hours after.4Nevertheless, very few data are available concerning the correla-tion between urticaria and COVID-19 in infants.The evaluation of 140 COVID-19 patients from China revealedthat 1.4% reported CU. Moreover, interestingly, patient sampleranged from 25 to 87 years, and any infant patients were included.5In addition, Recalcati et al evidenced that 18 of 88 COVID-19-positive patients analyzed (20.4%) developed cutaneouslesions in course of the disease; urticaria was diagnosed in threecases.6In conclusion, we suggest to consider SARS-CoV-2 infection as apotential cause of urticaria in asymptomatic pediatric patients, theunknown carriers of the infection.F IGURE 1 Erythematous wheals localized on the left arm. Picturesent by patient's parents (teledermatology)Dermatologic Therapy Journal is partnering with IMCASAcademy.com to bring you the best ofIMCAS Alert, the online service that allows physicians to submit their difficult clinical cases andcomplications for quick advice from international experts.Received: 24 June 2020 Revised: 16 July 2020 Accepted: 19 July 2020DOI: 10.1111/dth.14043Dermatologic Therapy. 2020;e14043. wileyonlinelibrary.com/journal/dth © 2020 Wiley Periodicals LLC. 1 of 2https://doi.org/10.1111/dth.14043In our study, lack of maturation of innate and adaptive immunedefense mechanisms in infant could explain not only the susceptibilityinfectious disease, but also the resulting reduced inflammatoryresponse, which provide the absence of systemic symptoms.ACKNOWLEDGMENTThe parents have given written informed consent for publication.CONFLICT OF INTERESTThe authors declare no conflicts of interest.AUTHOR CONTRIBUTIONSConcetta Potenza, Nevena Skroza and Ilaria Proietti conceived of thepresented case report. Veronica Balduzzi, Anna Marchesiello andSimone Michelini wrote the manuscript. Nicoletta Bernardini,Alessandra Mambrin and Ersilia Tolino contributed to the final versionof the manuscript and supervised the project. Patrizia Maddalena andSalvatore Volpe contributed to the manuscript revisions. All authorsdiscussed the results and contributed to the final manuscript.Ilaria ProiettiAlessandra MambrinNicoletta BernardiniErsilia TolinoVeronica BalduzziPatrizia MaddalenaAnna MarchesielloSimone MicheliniSalvatore VolpeNevena SkrozaConcetta PotenzaDepartment of Medical-Surgical Sciences and Biotechnologies,Dermatology Unit “Daniele Innocenzi”, Sapienza University of Rome, PoloPontino, Terracina, ItalyCorrespondenceDr Ilaria Proietti, Department of Medical-Surgical Sciences andBiotechnologies, Dermatology Unit “Daniele Innocenzi”, SapienzaUniversity of Rome, “A. Fiorini” Hospital, Via Firenze, 1,04019 Terracina (LT), Italy.Email: proiettilaria@gmail.comORCIDIlaria Proietti https://orcid.org/0000-0003-3795-3190Nicoletta Bernardini https://orcid.org/0000-0002-6295-3574Ersilia Tolino https://orcid.org/0000-0001-7861-9338Anna Marchesiello https://orcid.org/0000-0002-5863-4829Simone Michelini https://orcid.org/0000-0002-3374-7384Salvatore Volpe https://orcid.org/0000-0002-6367-2344Nevena Skroza https://orcid.org/0000-0003-4478-5404REFERENCES1. Casas CG, Català A, Hernández GC, et al. Classification of the cutane-ous manifestations of COVID-19: a rapid prospective nationwide con-sensus study in Spain with 375 cases. Br J Dermatol. 2020;183(1):71-77. https://doi.org/10.1111/bjd.19163.2. Tang N, Mao MY, Zhai R, et al. Clinical characteristics of urticaria in chil-dren versus adults. Zhongguo Dang Dai Er Ke Za Zhi. 2017;19(7):790-795.3. Liu TH, Lin YR, Yang KC, Chou CC, Chang YJ, Wu HP. First attack ofacute urticaria in pediatric emergency department. Pediatr Neonatol.2008;49(3):58-64. https://doi.org/10.1016/S1875-9572(08)60014-5.4. Kaushik A, Parsad D, Kumaran MS. Urticaria in the times of COVID-19.Dermatol Ther. 2020;XXX:e13817. https://doi.org/10.1111/dth.13817.5. Zhang J-J, Dong X, Cao Y-Y, et al. Clinical characteristics of140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy.2020;75:1730-1741. https://doi.org/10.1111/all.14238.6. Recalcati S. Cutaneous manifestations in COVID-19: a first perspec-tive. J Eur Acad Dermatol Venereol. 2020;34(5):e212-e213. https://doi.org/10.1111/jdv.16387.F IGURE 2 Erythematous wheals localized on the left leg. Picturesent by patient's parents (teledermatology)2 of 2 IMCAS: LETTER

Urticaria in an infant with SARS-CoV-2 positivity

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Urticaria in an infant with SARS-CoV-2 positivity

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