Acquired Cold-Induced Urticaria in Pediatric Patients: A 22-Year Experience in a Tertiary Care Center (1996-2017)
Christina S K Yee1, Kristel El Khoury1, Sultan Albuhairi1
1Division of Immunology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
Insights
Acquired cold-induced urticaria (ACU) in children can lead to severe anaphylaxis, especially during activities like swimming. A positive cold stimulation test (CST) significantly increases this risk, highlighting the need for caution and preparedness.
Area of Science:
- Pediatric Allergy and Immunology
- Dermatology
- Clinical Immunology
Background:
- Acquired cold-induced urticaria (ACU) is a rare condition that has been understudied in pediatric populations.
- Understanding the presentation and potential severity of ACU in children is crucial for timely diagnosis and management.
Purpose of the Study:
- To investigate the clinical presentation of acquired cold-induced urticaria in children.
- To assess the risk of anaphylaxis associated with ACU in pediatric patients.
- To identify factors that may predict severe reactions.
Main Methods:
- A retrospective chart review was conducted on 415 children diagnosed with ACU between 1996 and 2017.
- Data collected included patient demographics, atopic history, reaction severity, triggers, and cold stimulation test (CST) results.
- Statistical analysis was used to determine associations between variables and anaphylaxis risk.
Main Results:
- Of 415 pediatric ACU patients, 18.6% experienced anaphylaxis (grade 3 reactions), often triggered by swimming.
- A positive CST result was significantly associated with an increased risk of anaphylaxis (11.7% even with negative CST).
- Disease resolution was observed in 8.9% of patients, linked to a lack of prior anaphylaxis.
Conclusions:
- This study, the largest on pediatric ACU, indicates a substantial risk of anaphylaxis, with nearly a fifth of patients experiencing severe reactions.
- A positive CST is a key indicator for higher anaphylaxis risk in ACU.
- Recommendations include prescribing epinephrine and educating families on managing ACU triggers and severe reaction risks.
Background:
Acquired cold-induced urticaria (ACU) has not been well evaluated in pediatrics.
Objective:
To further evaluate the presentation of ACU in children and associated risk of anaphylaxis.
Methods:
A retrospective chart review was performed in children 18 years or younger diagnosed with ACU at Boston Children's Hospital (US, Northeast) from 1996 to 2017.
Results:
A total of 415 patients with ACU were identified, aged 4 months to 18.3 years at the time of diagnosis, with similar male:female distribution. Most patients had a history of atopic disease (78.3%), and 25.8% had other urticaria. Around two-third of patients experienced only localized cold-induced symptoms (grade 1), whereas 14.0% had diffuse cutaneous symptoms (grade 2) as the most severe reaction, and 18.6% experienced anaphylaxis (grade 3). Swimming triggered 77.6% of grade 3 reactions, whereas the rest were secondary to ingestion of cold food or beverages, or cold air or cold water exposure. Seven percent of subjects had more than 1 episode of anaphylaxis. Cold stimulation test (CST) was performed in 61.7% of patients, and the result was positive in 69.9% of those tested. Positive CST result was significantly associated with increased risk of anaphylaxis. There was a 11.7% rate of anaphylaxis among patients with negative CST result. Disease resolution at any point in the study period was documented in 8.9% of patients and was associated with a negative history of anaphylaxis.
Conclusions:
In the largest study to date on ACU, grade 3 reactions occurred in about a fifth of patients. Positive CST result was associated with a higher risk for anaphylaxis from ACU. Epinephrine prescription and patient/family counseling about risk factors for grade 3 reactions are recommended.
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