The purpose of this discussion is to apply pathophysiological concepts to a child presenting with dermatological dysfunction (urticaria). Related concepts will also be applied that includes alterations in immunity/inflammation, fluid and electrolytes, acid/base balance and pulmonary function.

YOUR JOB IS TO READ THE SENARIO BELOW THEN TO READ THE TWO STUDENT RESPONSES. RESPOND TO THE STUDENT RESPONSES. RESPONSES MUST BE FROM SCHOLARY SOURCES WITHIN THE LAST 5 YEARS: A 12-year-old boy is brought to the office for evaluation of hives. He has no significant past medical history and no history of allergies. He has just joined the middle school soccer team and noticed that he gets hives about 10 minutes into practice. The hives are itchy and consist of irregular blotches on his legs and trunk, about 10–20 cm in size, and they persist for about 30 minutes. He does not experience swelling of the lips or oropharynx and denies any wheezing or shortness of breath. His physical examination is normal without skin lesions or oral swelling at that moment, and his lungs are clear. After evaluation, he is diagnosed with urticaria. Discuss the likely cause of the patient’s urticaria. Describe the cellular mechanism of urticaria and how it leads to the signs and symptoms experienced by the patient. Describe the relationship between the patient’s symptoms and the concept of inflammation. What pharmacological and non-pharmacologic treatment options are available?  Discuss the complications of urticaria. What teaching would be appropriate to provide the parent and child about urticaria? Support your response with at least one current evidence based resource PLEASE REPLY TO TWO STUDENTS RESPONSES BELOW- FIRST STUDENT RESPONSE- The circumstances and details in this patient scenario suggest hives that are a result of cholinergic urticaria. Cholinergic urticaria is characterized as itchy wheals with surrounding redness that typically appears after diaphoresis from an increased body core temperature (Fukunaga et al., 2017). In this case, physical exercise has induced an increase in the core body temperature, likely causing sweating, thus causing the 12-year-old’s cholinergic urticaria symptoms. Individuals usually feel stinging and itching. Symptoms are typically exacerbated in hot weather (Fukunaga et al., 2017). While the patient scenario does not describe the weather or not it is indoor or outdoor soccer, weather is a variable to consider as hot weather can have an effect on the severity of symptoms. The symptoms of cholinergic urticaria typically subside within an hour (Fukunaga et al., 2017). These characteristics are consistent with the details and duration of the symptoms experienced by the 12-year-old boy. 2. Urticaria is caused by capillary vasodilation that contains a flow of protein-rich fluid that can resolve once the fluid is reabsorbed. Urticaria involves the degranulation of mass cells, which release histamine, proteases, and cytokines (Saini & Kaplan, 2018). This increases vascular permeability and causes edema, erythema, and pruritus (Saini & Kaplan, 2018). Wheals or hives are identified by this mast cell degranulation, edema, and an infiltrate of cells that are activated in immune responses, such as CD4+ lymphocytes, monocytes, basophils, eosinophils, neutrophils (Saini & Kaplan, 2018). Cholinergic agents, sweat allergy, and the inability to sweat normally are related to the symptoms of cholinergic urticaria (Fukunaga et al., 2017). 3. Vasodilation produces erythema and increased permeability, therefore this manifests as the rash, edema, pain, and pruritus seen in urticaria (Puxeddu et al., 2017). Circulating cytokines, such as IL-1 family cytokines and pro-inflammatory cytokine IL-18, are the biggest inducers of the acute inflammation phase. Patients also experience local inflammation due to leukocytes that infiltrate the skin (Puxeddu et al., 2017). 4. Because of the serum histamine level increase in cholinergic urticaria, non-sedating H1 receptor antagonists (HIRAs) is the first-line treatment. Acetylcholine antagonists, such as atropine and scopolamine, are also used to prevent the onset of cholinergic urticaria (Fukunaga et al., 2017). Furthermore, antihistamines are used to control symptoms of urticaria. Corticosteroids and an epinephrine auto-injector can also be used, especially if patients are not responding to other regimens (Kulthanan et al., 2016). Non-pharmacological treatment includes preventing and caring for dry skin by applying lotions and moisturizing the skin regularly. Staying hydrated aids in keeping the skin moist. Calamine lotion can be used to provide symptomatic relief (Kulthanan et al., 2016). 5. Upon the onset of symptoms and throughout daily management of urticaria, it is important to check for angioedema. Urticaria can present with angioedema, which involves edema in the deep dermis and subcutaneous fat. This includes areas, such as the lips, orbital tissues, hands, and tongues (Kulthanan et al., 2016). This can severely compromise an individual’s airway. 6. An incredibly important teaching point for parents and children is the possibility of angioedema with urticaria. Providers should provide details about urticaria, causes, and treatment options so they are actively involved in management as a team. The symptoms of urticaria can cause immense stress to patients, which can intensify symptoms (Kulthanan et al., 2016). It is important for patients to have a support system. Providers should provide resources of support for patients, parents, and families. References Fukunaga, A., Washio, K., Hatakeyama, M., Oda, Y., Ogura, K., Horikawa, T., & Nishigori, C. (2017). Cholinergic urticaria: epidemiology, physiopathology, new categorization, and management. Clinical Autonomic Research, 28(1), 103–113. https://doi.org/10.1007/s10286-017-0418-6 (Links to an external site.) Kulthanan, K., Tuchinda, P., Chularojanamontri, L., Chanyachailert, P., Korkij, W., Chunharas, A., & Wananukul, S. (2016). Clinical Practice Guideline for Diagnosis and Management of Urticaria. Asian Pacific Journal of Allergy and Immunology 34(1), 190–200. http://apjai-journal.org/wp-content/uploads/2016/10/3.-AP0817.pdf (Links to an external site.). Puxeddu, I., Pratesi, F., Ribatti, D., & Migliorini, P. (2017). Mediators of Inflammation and Angiogenesis in Chronic Spontaneous Urticaria: Are They Potential Biomarkers of the Disease? Mediators of Inflammation, 2017, 1–6. https://doi.org/10.1155/2017/4123694 (Links to an external site.) Saini, S. S., & Kaplan, A. P. (2018). Chronic Spontaneous Urticaria: The Devil's Itch. The Journal of Allergy and Clinical Immunology: In Practice, 6(4), 1107. https://doi.org/10.1016/j.jaip.2018.05.01 SECOND STUDENT RESPONSE- The 12-year-old boy brought to the office for evaluation for spontaneous hives post middle school soccer practice, presumably may have developed an allergy to the grass (assuming that is where soccer practice has taken place). The young boy is experiencing a cell mediated response from hives called urticaria. This dermal type of swelling or “edema” is a result from vascular dilation and leakage of fluid into the skin in response to molecules from mast cells (Hennino et al., Pathophysiology of urticaria). As we know from week 1, histamine increases vasodilation and is a chemical mediator in acute inflammatory responses. According to (McCance & Felver, 2019), areas of urticaria or lesions should resolve spontaneously within 24 hours, however it is possible new life-threatening lesions may occur. Antihistamines (medication that reduce inflammation or “H1 antagonists) reduce inflammation and may provide relief of itching. Corticosteroids may also be used in severe instances. Rarer forms of urticaria, also referred to as chronic or attacks lasting longer than six weeks may require long term treatment. Non-pharmacological methods of treatment include avoiding the allergen for a period of time. In this case, it might be no soccer or perhaps a sport where grass or environmental allergens are avoided...tennis perhaps? Education to provide to the child and parents would include keeping a daily record for a certain amount of time to track a pattern of event and flare up, any stressors that occur, recent illnesses, medications, and exposure to potential allergens. That way a pattern may be recognized in order to control symptoms. It Is also important for the parents and child to know how to appropriately utilize antihistamines and corticosteroids if applicable when flare ups occur. Lastly, when seek to immediate medical attention, especially in cases when urticaria persists for longer than six weeks or accompanied by more acute and serious symptoms, angioedema, shortness of breath, and /or fever. References: Hennino, A. A., Berard, F., Guillot, I., Saad, N., Rozieres, A., & Nicolas, J. (n.d.). Pathophysiology of urticaria. Retrieved October 04, 2020, from https://pubmed.ncbi.nlm.nih.gov/16461989/ McCance, K. L., & Felver, L. (2019). Study guide for Pathophysiology: The biologic basis for disease in adults and children, eighth edition. St. Louis, MO: Elsevier. Murren-Boezem, J. (Ed.). (2018, June). Hives (Urticaria) (for Parents) - Nemours KidsHealth. Retrieved October 04, 2020, from https://kidshealth.org/en/parents/hives.html (Links to an external site.) Thank you,