Age: 23.0
Sex: M
Vaccine: ANTH, TYP
Symptoms: Red blood cell sedimentation rate normal, Red cell distribution width normal, Rhinitis allergic, Thyroid function test normal, Tryptase
Clinical narrative: Initial onset of symptoms included pruritis and a "rash" which was later described as urticaria. Per recall, sx onset within 24-48 hrs of vaccine receipt; records note onset of symptoms between 1-7 days following vaccine receipt. Developed pruritis and hives the day after vaccine receipt, which continued almost daily through Feb 2021. Has had 3 Allergy evaluations -treated with different antihistamines.  Initial documentation of symptoms in Theater on 3 Nov 2017-reported 3-week history of pruritis; encounter also described "episodes of urticaria since receiving vaccines". No triggers identified. Treated with Zyrtec and Benadryl for breakthrough pruritis. Denies experiencing local vaccine site reaction. Denies angioedema, associated swelling of his throat/airway, wheezing, and cough, increased heart rate, vomiting and diarrhea, and dizziness and loss of consciousness within 1st few hours of vaccine. Does not recall having significant body aches, fever, headaches, and fatigue following vaccine. 9 Mar 2018, 1LT PA-C, FT Bliss - itching and rash x 7 months, noted to be worsening. No lesions on exam. Zyrtec 10 mg daily prescribed with Atarax 25 mg at night, and referral for an Allergy Consult. ESR, LFTs and Lipase ordered and returned WNL, except Aspartate Aminotransferase elevated - 90 (15-41). 19 Mar 2018, Dorctor, Allergy, chronic urticaria, with report of onset of pruritus and itchy welts beginning the day after vaccine receipt and continuing daily. At the time, symptoms were controlled on daily Zyrtec, with Atarax at night. No lesions on exam. ASSESSMENT: idiopathic urticaria, no identifiable source associated with his urticaria. At that time, hx and ROS did not suggest an underlying systemic process such as infection or autoimmune disease, but labs were ordered (i.e., CBC, CMP, Thyroid panel, 25-Hydroxy Vitamin D, IgE, Aeroallergen panel). Instructed to avoid tight clothing, heat, NSAIDS, and stress. No changes in medications. [Lab results essentially normal, except Vitamin D, 25-Hydroxy level was 8.3 (20.0-49.9); see below for Aeroallergen panel; prescribed an 8-week course of oral VIT D 50,000 UNITS once/week and oral Calcium/Vit D 600mg/400 IU twice daily.] 7 Feb 2019, DO, ENT Care -Eval of hives with CC:"urticaria". Reported 17 month hx of hives, with acute onset, initially all over his body, which since resolved and recurred intermittently in different locations. Described as severe, raised, and occurring as individual lesions. Reported improvement of symptoms with antihistamines. Hx notes angioedema - painful swelling of his hands which was very mild and occurred concurrently with onset of hives, and since occurred intermittently. Exam normal except inflammation of nasal mucosa. Allergen skin testing (aeroallergen) completed -"positive to all tested allergens except dog". ASSESSMENT: Urticaria, Allergic Rhinitis, Pruritus, and Nasal Obstruction. Prescribed Fexofenadine 180 mg daily and Levocetirizine (Xyzal) 5 mg once at bedtime. 12 Sep 2019, DO, ENT Care for f-u eval of urticaria. Encounter noted "skin lesions have remained the same and there are no current complaintsdaily rash, no throat edema, no trigger, meds help, but rash comes back." Exam without rashes or lesions present on skin or in mouth. Intranasal exam notes inflammation of nasal mucosa. ASSESSMENT: Urticaria and Allergic Rhinitis. Singular 10 mg daily prescribed. Between Jan 2020 and June 2020, Immunotherapy through Allergy Clinic  23 Nov 2020, Doctor, CC:"follow-up hives". A/P: Overall, based on review of previous notes, would seem c/w with CIU-however, unable at this time to elicit a history of any current skin lesions except possible fleeting presence of 1-2 mm papules. Patient currently taking Zyrtec 30mg daily- recommend increase to 40mg daily for 2-4 weeks. Can consider Xolair for CIU, but not likely to be effective if isolated chronic pruritus.