Acute Urticaria and Its Connection to SLE: A Patient's Journey

SLE & urticaria

Hello Doctor, my question is regarding an unexplained acute urticaria attack I experienced in early July this year.
Since then, I have been taking antihistamines, starting with Xyzal 1 tablet daily and now increasing to 1 tablet twice daily.
During this period, I had an asthma attack that required hospitalization (I have no prior history), and I also took corticosteroids for a while because the urticaria was not well controlled.
Later, I added Chlorpheniramine Maleate (CTM) 1 tablet three times daily.
Since I started taking Imuran last week, the rash has not reappeared, although I occasionally experience itching.
However, my cousin has Systemic Lupus Erythematosus (SLE), and she also had skin itching at my age, taking over a year of blood tests before being diagnosed.
My symptoms include occasional muscle aches or joint pain, and I had a large circular red rash on my foot.
Additionally, I have felt very fatigued since starting Imuran three days ago (which is not the case with antihistamines).
I have had two blood tests (in July and December of this year) showing C3 levels at 67-68 (slightly low), normal C4, ESR at 18, normal Anti-ds-DNA, and normal lupus anticoagulant.
The results of other tests are still pending.
I would like to ask if the two normal results can rule out SLE, as I have read cases in the literature where initial tests were normal but later became abnormal.
Therefore, I am a bit concerned and would like to hear your opinion.
Thank you!

Hua Hua, 20~29 year old female. Ask Date: 2018/12/19

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your message.
The diagnosis of lupus erythematosus indeed requires a combination of clinical symptoms and laboratory test results for greater accuracy.
For suspected cases, we also continue to monitor over a period of time rather than making hasty conclusions based on a single test result.
Therefore, I recommend that you continue to follow up at the rheumatology clinic and discuss closely with your physician.
If the side effects of the medication are already affecting your daily life, you can also discuss with your physician to evaluate whether there are alternative medications that can be considered.
The Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare, cares about you.

Reply Date: 2018/12/19

More Info

Acute urticaria, commonly known as hives, is a skin condition characterized by raised, itchy welts that can appear suddenly and may vary in size and shape. It can be triggered by various factors, including allergens, medications, infections, and even stress. In your case, it seems that the acute urticaria attack began without a clear cause, which can often be the case in idiopathic urticaria.
Your treatment regimen, which includes antihistamines like Xyzal and CTM, is standard for managing acute urticaria. Antihistamines work by blocking the action of histamine, a substance in the body that causes allergic symptoms. The addition of Imuran (azathioprine), an immunosuppressive medication, suggests that your healthcare provider is considering a more complex underlying issue, possibly related to autoimmune conditions.

The connection between acute urticaria and systemic lupus erythematosus (SLE) is an important consideration, especially given your family history. SLE is a chronic autoimmune disease that can affect multiple organ systems, including the skin, joints, and kidneys. Symptoms of SLE can be quite varied, and skin manifestations such as rashes and hives can occur. Your symptoms of muscle and joint pain, along with the presence of circular red rashes, could potentially align with SLE, but they are not definitive indicators on their own.

The laboratory tests you mentioned are crucial in evaluating the possibility of SLE. The complement levels (C3 and C4) you reported as being low can indicate increased consumption due to inflammation or immune complex formation, which is often seen in autoimmune diseases. However, normal levels of anti-ds-DNA and lupus anticoagulant are reassuring, as these tests are commonly associated with SLE. It is important to note that SLE can be a complex disease, and it is possible for patients to have normal serological tests early in the disease course, only to develop abnormalities later.

Given your symptoms and the family history of SLE, it is wise to continue monitoring your condition closely. The fatigue you are experiencing after starting Imuran could be a side effect of the medication, as immunosuppressants can sometimes lead to increased fatigue and other systemic effects. It is essential to communicate these symptoms to your healthcare provider, as they may need to adjust your treatment plan.

In conclusion, while the normal results for anti-ds-DNA and lupus anticoagulant are encouraging, they do not entirely rule out the possibility of SLE, especially given your symptoms and family history. Continuous monitoring and follow-up blood tests are essential to track any changes in your condition. It is also advisable to maintain an open line of communication with your healthcare provider regarding any new symptoms or concerns that arise. Early detection and management of autoimmune conditions can significantly improve outcomes and quality of life.

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