Acute urticarial lesions may display central clearing with ecchymotic or haemorrhagic hue, often misdiagnosed as erythema
multiforme, serum-sickness-like reactions, or urticarial vasculitis. We report a case of acute annular urticaria with unusual
presentation occurring in a 20-month-old child to emphasize the distinctive morphologic manifestations in a single disease.
Clinicians who care for children should be able to differentiate acute urticaria from its clinical mimics. A directed history and
physical examination can reliably orientate necessary diagnostic testing and allow for appropriate treatment

Daronat, Jean-Marc

Deltour, Roger

Guerrier, Gilles

English

PubMed

Acute urticarial lesions may display central clearing with ecchymotic or haemorrhagic hue, often misdiagnosed as erythema multiforme, serum-sickness-like reactions, or urticarial vasculitis. We report a case of acute annular urticaria with unusual presentation occurring in a 20-month-old child to emphasize the distinctive morphologic manifestations in a single disease. Clinicians who care for children should be able to differentiate acute urticaria from its clinical mimics. A directed history and physical examination can reliably orientate necessary diagnostic testing and allow for appropriate treatment.</jats:p

Gilles Guerrier

Jean-Marc Daronat

Roger Deltour

Crossref

Case Reports in Dermatological Medicine

Unusual Presentation of Acute Annular Urticaria: A Case Report

Acute urticarial lesions may display central clearing with ecchymotic or haemorrhagic hue, often misdiagnosed as erythema multiforme, serum-sickness-like reactions, or urticarial vasculitis. We report a case of acute annular urticaria with unusual presentation occurring in a 20-month-old child to emphasize the distinctive morphologic manifestations in a single disease. Clinicians who care for children should be able to differentiate acute urticaria from its clinical mimics. A directed history and physical examination can reliably orientate necessary diagnostic testing and allow for appropriate treatment

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Hindawi Publishing Corporation
Case Reports in Dermatological Medicine
Volume 2011, Article ID 604390, 3 pages
doi:10.1155/2011/604390
Case Report
Unusual Presentation of Acute Annular Urticaria: A Case Report
GillesGuerrier,1,2 Jean-Marc Daronat,2 andRoger Deltour2
1Epicentre, 75011 Paris, France
2Agence de Sant´ e, Mata Utu, 986 Wallis, France
Correspondence should be addressed to Gilles Guerrier, guerriergilles@hotmail.com
Received 20 June 2011; Accepted 11 July 2011
Academic Editors: H. Nakano and J. C. Szepietowski
Copyright © 2011 Gilles Guerrier et al.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Acute urticarial lesions may display central clearing with ecchymotic or haemorrhagic hue, often misdiagnosed as erythema
multiforme, serum-sickness-like reactions, or urticarial vasculitis. We report a case of acute annular urticaria with unusual
presentation occurring in a 20-month-old child to emphasize the distinctive morphologic manifestations in a single disease.
Clinicians who care for children should be able to diﬀerentiate acute urticaria from its clinical mimics. A directed history and
physical examination can reliably orientate necessary diagnostic testing and allow for appropriate treatment.
1.Introduction
Acute annular urticaria, an acute urticarial hypersensitivity
syndrome, is a morphologic subtype of urticaria charac-
terized by the acute onset of blanchable annular, arcuate,
and polycyclic erythematous wheals that subsequently fade
within hours. However, lesions may display central clearing
with ecchymotic or haemorrhagic hue, often misdiagnosed
as erythema multiforme, serum-sickness-like reactions, or
urticarialvasculitis(Table 1).W er eportacaseofacut eann u-
lar urticaria with unusual presentation occurring in a 20-
month-old child to emphasize the distinctive morphologic
manifestations in a single disease.
2. Case Presentation
A 20-month-old boy was hospitalised in our ward with
the presence of erythematous-purpuric lesions, roundish in
shape,notitchy,1to5cmindiameter,localizedonthetrunk,
the neck, and upper limbs (Figure 1). His history revealed
that the eruption developed suddenly two hours ago, while
an upper respiratory tract infection with mild fever was
treated with aspirin during the previous days. The overall
general condition was good. There was no dermographism.
Mucous membranes and joints were not involved, and there
w a sn op e r i p h e r a lo e d e m a .T h eh a e m a t o l o g i c a lp a r a m e t e r s
were within normal limits. On admission, the patient was
treated with amoxicillin and systemic antihistamines. A
second urticarial eruption without any haemorrhagic hue
appeared the next day on the face, the trunk, and limbs
(Figure 2). This rash faded few hours once amoxicillin was
replaced by macrolides. One week after admission, the
individual lesions from the ﬁrst eruption resolved without
any sequelae. Levels of C3 and C4 were within normal limits,
as were IgA and IgE levels.
3. Discussion
Acute annular urticaria is reportedly more common in
c h i l d r e n4m o n t h st o4y e a r so fa g e[ 1]. The diagnosis is
typically made on clinical grounds and should not require
skin biopsy. Although absent in our case, facial and/or
acral edema is commonly seen in urticaria, with a reported
prevalence of 60% to 89% [2, 3]. Pruritus, an almost uni-
versal ﬁnding associated with urticaria, has been reported in
up to 94% of cases [4]. Many children with urticaria have a
history of infection or recent use of a systemic medication,
often an antibiotic or an antipyretic. Viral infection is the
more frequently associated pathogen at all ages [5]. In our
case, the second eruption might have possibly been avoided,
would amoxicillin not been prescribed, considering viral
infection as the most likely cause for the ﬁrst eruption
(normal haematological examination, low fever, and upper
respiratory tract infection). Moreover, choice of antibiotic2 Case Reports in Dermatological Medicine
Table 1: Distinguishing features of annular urticaria, erythema multiforme, and serum-sickness-like reactions.
Feature Annular urticaria Erythema multiforme Serum-sickness-like
reactions Urticarial vasculitis
Appearance of
individual
lesions
Annular and polycyclic
wheals with central clearing
or ecchymotic centres
Classic target lesion with
purpuric or dulsy, violaceous
centre (may blister), middle
ring of pallor and edema,
outer ring of erythema or
blisters
Polycyclic urticarial wheal
with central clearing, may
appear purpuric
Hives with dusky purpuric
centre
Location Trunk, extremities, face Involvement of palms, soles
common
Trunk, extremities, face,
lateral borders of hands
and feet
Trunk, extremities, face,
lateral borders of hands
and feet
Duration of
individual
lesions
<24h Days to weeks Days to weeks Days to weeks
Fixed lesions No Yes Yes Yes
Total duration
of rash 2–12 days 2-3 weeks 1–6 weeks 1–6 weeks
Mucous
membrane
involvement
Oral edema common, no
erosions or blisters
May see oral erosions or
blisters of lips, buccal mucosa,
and tongue, rarely involves
conjunctiva, nasal, or
urogenital mucosa, usually
involving only a single site
Oral edema common, no
erosions or blisters
May see oral erosions or
blisters of lips, buccal
mucosa, and tongue, may
involve conjunctiva, nasal,
or urogenital mucosa, may
involve several sites
Facial or acral
edema Common Rare Common Common
Dermographism Yes No No No
Fever Occasionally, low grade Occasionally, low grade Prominent, high grade Variable
Associated
symptoms Pruritus Mild pruritus or burning Myalgias, arthralgias,
lymphadenopathy Variable
Common
triggers
Viral illness, antibiotics,
immunizations
Herpes simplex virus, other
viral illness Antibiotics
Infections, autoimmune
processes, neoplastic
processes, drugs
Treatment
D i s c o n t i n u ea n yn e wo r
unnecessary antibiotics or
medications, combinations
of H1 and H2 antihistamines
may be helpful, systemic
steroids can be helpful in
more recalcitrant cases
Supportive care, early
institution of systemic
steroids can sometimes be
helpful
Discontinue any new
antibiotics or medications,
H1 and H2 antihistamines,
supportive care, consider
systemic steroids
Discontinue any new
antibiotics or medications,
H1 and H2 antihistamines,
supportive care, consider
systemic steroids
was not in line with recent guidelines for the diagnosis
of allergy to antibiotics or additives [6]. Aspirin may have
played a role in worsening the ﬁrst eruption, which lasted
longer than usually observed in acute urticaria. Although
antihistamines were discutable while itching was not present
in our case, the majority of patients require combinations
of systemic antihistamines to achieve satisfactory symp-
tomatic relief. Systemic corticosteroids are required only
in patients remaining symptomatic despite combination of
antihistamine therapy.
Acute annular urticaria is underrecognized as a result
of the paucity of reported cases in the literature mainly
due to similarities between distinct clinical entities, such as
erythema multiform or serum-sickness-like reactions. It has
been our experience that erythema multiforme is incorrectly
diagnosed in many patients with an urticarial drug eruption
because the edema from the urticaria can result in some
surrounding pallor and some central pallor or duskiness,
which can mimic a type of targetoid pattern. An important
distinction is the ﬂeeting duration of the lesions of urticaria,
which usually last minutes to hours as opposed to the
ﬁxed lesions of erythema multiform and serum-sickness-like
reactions, which typically last from days to weeks. Erythema
multiform represents a self-limiting cutaneous cytotoxic
hypersensitivity reaction mostly due to Herpes simplex virus
and generally requires symptomatic treatment only.Case Reports in Dermatological Medicine 3
Figure 1: Annular, arcuate, and polycyclic wheals with central
clearing and purpuric hue on the trunk.
Figure 2: Second eruption featuring small urticarial papules on
face, trunk, and limbs.
Serum sickness-like reactions are a recognizable reaction
to a drug. It has occurred most frequently following cefaclor,
but may occur with other cephalosporins, penicillins, or
other drugs. Prior treatment with the drug is not necessary.
The acute onset in a child of inﬂammatory, red papu-
lonodules that spread out into annular, urticarial plaques
with dusky centers is characteristic. The onset is usually
7–10 days after the causative drug was begun. There are
no true target lesions as with erythema multiforme, and
the lesions may expand but do not have the day-to-day
ﬂuctuation seen in urticaria. The child often has joint
pains and fever. Lymphadenopathy and renal involvement
usually do not occur, in contrast to true serum sickness. The
causative medication should be stopped. Corticosteroids can
be dramatically helpful, if needed.
Eruption in urticarial vasculitis is characterised by hives
with a dusky purpuric centre and usually resolves with
postinﬂammatory dyspigmentation. Although drugs are
sometimes implicated in urticarial vasculitis, the condition
is most often idiopathic; other causes include infections,
autoimmune processes, and neoplastic processes. When
distinguishing between urticarial vasculitis and urticarial
drug eruption on the basis of clinical clues proves diﬃcult,
a complete blood cell count, sedimentation rate, urinalysis,
and skin biopsy can be helpful. The treatment of this
condition includes discontinuation of the oﬀending agent,
administration of systemic antihistamines, and administra-
tion of a 2- to 3-week course of systemic corticosteroids for
more severe symptomatic cases.
Clinicians who care for children should be able to dif-
ferentiate acute urticaria from its clinical mimics. A directed
history and physical examination can reliably orientate
necessary diagnostic testing and allow for appropriate treat-
ment.
References
[1] L.Tamayo-Sanchez,R.Ruiz-Maldonado,andA.Laterza,“Acute
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ogy, vol. 14, no. 3, pp. 231–234, 1997.
[2] V. Legrain, A. Taieb, T. Sage, and J. Maleville, “Urticaria in
infants: a study of forty patients,” Pediatric Dermatology, vol.
7, no. 2, pp. 101–107, 1990.
[ 3 ]P .M o r t u r e u x ,C .L ´ eaut´ e-Labr` eze, V. Legrain-Lifermann, T.
Lamireau, J. Sarlangue, and A. Ta¨ ıeb, “Acute urticaria in
infancy and early childhood: a prospective study,” Archives of
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[4] K. N. Shah, P. J. Honig, and A. C. Yan, ““Urticaria multiforme”:
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[5] E. Novembre, A. Cianferoni, F. Mori et al., “Urticaria and
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[6] B. Thong and M. Blanca, “Advances in the understanding of
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Acute annular urticaria in infants and children,”

Acute urticaria in infancy and early childhood: a prospective study,”

Advances in the understanding of hypersensitivity reactions to drugs,”

Urticaria and urticaria related skin condition/disease in children,”

Urticaria in infants: a study of forty patients,”

Urticaria multiforme”: a case series and review of acute annular urticarial hypersensitivity syndromes in children,”

Unusual presentation of acute annular urticaria: A case report

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Unusual presentation of acute annular urticaria: A case report

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