NOT THE VACCINE, BUT ANAPHYLAXIS TO THE COVID-19 VIRUS ITSELF

ABSTRACT

SESSION TITLE Poster Cases in Asthma and Allergy SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: Anaphylaxis is an acute, potentially life-threatening, systemic allergic reaction that presents as a multitude of manifestations after exposure to an allergen. It is rare to have an anaphylactic reaction to the SARS-Cov-2 vaccine, however, we present a patient who had a prolonged anaphylactic reaction to the SARS-CoV-2 virus itself. CASE PRESENTATION A 23-year-old female with past medical history of chronic idiopathic urticaria and dermatographism presented with fatigue, rash, rhinitis, and lip swelling in the setting of being COVID-19 positive. She had received two doses of the Pfizer-BioNTech COVID-19 vaccine nine months prior without any adverse affects. During the SARS-CoV-2 Omicron variant surge, the patient was exposed to a family member who had contracted COVID-19 infection. Two days prior to presentation, she started having a diffuse rash throughout her body. In the Emergency Department, she was given IM epinephrine x2, IV Solu-Medrol and IV Benadryl with temporary improvement in her symptoms. She developed hypotension that required initiation of a continuous epinephrine infusion and was admitted to the Medical Intensive Care Unit. Each time the epinephrine was held, generalized urticaria recurred and she would become hypotensive with her systolic blood pressure decreasing below 80 mmHg. The urticaria completely resolved and her blood pressure improved when the epinephrine infusion was restarted. The patient was treated with remdesivir, Solu-Medrol, loratadine, and famotidine. She was able to be weaned off the epinephrine infusion over the course of four days. Immunological workup was unremarkable apart from elevation of IL-10 on her cytokine panel. DISCUSSION: The symptoms and syndromes associated with COVID-19 infection remain diverse and while urticaria has been a documented manifestation of the virus, it is uncommon (1). There is a single case report of an anaphylactic reaction in response to COVID-19 (2). Given our patient's symptoms were temporally related to the COVID-19 infection, we believe the SARS-COV-2 virus was the trigger. She did not have any other exposure during this time. This case is unique in that the virus not only triggered the urticaria, but that her symptoms persisted for four days. After receiving antiviral therapy plus steroids and antihistamines, her symptoms finally resolved. The SARS-COV-2 virus itself is primarily attacked by immune cells, including mast cells, which release an array of proinflammatory cytokines (3). We postulate that in our patient, her history of chronic urticaria predisposed her to an exaggerated inflammatory response. CONCLUSIONS: SARS-CoV-2 has clinically presented itself in a multitude of ways across many disciplines. In a patient with a history of urticaria, prolonged anaphylactic symptoms can be triggered by the virus itself. Reference #1 Adeliño R., Andrés-Cordón J.F., De la Cruz Martínez C.A. Acute urticaria with angioedema in the setting of coronavirus disease 2019. J Allergy Clin Immunol Pract. 2020;8(7)2386–2387. Reference #2 Alvarez-Perea A, Baeza ML. Anaphylactic shock following the diagnosis of coronavirus disease 2019. Ann Allergy Asthma Immunol. 2020;125(4)477-478. Reference #3 Kritas SK, Ronconi G, Caraffa A, Gallenga CE, Ross R, Conti P. Mast cells contribute to coronavirus-induced inflammation new anti-inflammatory strategy. J Biol Regul Homeost Agents. 2020 January-February,;34(1)9-14. 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