Hrev_master Question Given the clinical presentation and medical history, what is the most likely diagnosis for the rash shown in the pictures? 1) stress urticaria 2) dermatitis herpetiformis (Duhring’s Disease) 3) viral exanthem rash d) monkeypox rash Emergency Care Journal 2022; volume 18:10742 Correspondence: Giorgia Borio, Emergency Department, San Raffaele Hospital, Via Olgettina 60, Milan, Italy. E-mail: giorgia.borio1991@gmail.com Key words: Urticarial rash; COVID-19; skin; SARS-CoV-2. Contributions: GB and FF collected details of the case. GB drafted the manuscript. FF critically revised the manuscript. GB and FF approved the final version and stated the integrity of the whole work. Conflicts of interest: The authors declare no conflict of interest. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Giorgia Borio, giorgia.borio1991@gmail.com. Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Informed consent: The patient provided consent for the access to med- ical records at the time of admission. Received for publication: 15 July 2022. Accepted for publication: 28 July 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10742 doi:10.4081/ecj.2022.10742 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:10742] [page 1] Fever and acute urticaria in a young male patient Giorgia Borio,1,2 Federica Farolfi1,2 1Emergency Department, San Raffaele Hospital, Milan; 2Vita e Salute San Raffaele University, Milan, Italy A 23-year-old man presented to our emergency department with a new onset of low-grade fever associated with diffuse itching urticarial rash localized to his trunk and upper limbs. He denied respiratory and gastrointestinal symptoms. Peripheral oxygen saturation was 98% at room ambient. His past medical history was unremarkable, and he was not taking any medications. No history of allergies was reported. He denied traveling abroad, contact with animals, ingesting raw meat or fish, or taking med- icine. Laboratory results showed leukopenia with lymphocytope- nia and normal C-reactive protein value. Eosinophils were nor- mal. Hepatic and renal tests were all within the normal range. He was vaccinated with 3 doses of Comirnaty vaccine with no adverse reactions. Lung ultrasound showed A pattern without pleural effusion. The patient was discharged with oral steroids (prednisone 25 mg for three days with a progressive reduction in 10 days) and oral antihistamine (bilastine 10 mg daily for 10 days), and acetaminophen 1 gr if fever above 37.5°C, with com- plete resolution of the rash without sequelae in 10 days. Non commercial use only Answer Viral exanthem rash is the correct answer. A nasopharyngeal swab for SARS-CoV-2 was performed and resulted positive. A diagnosis of COVID-19 related urticarial rash was done. Skin rash can be an extrapulmonary manifestation of COVID-19, as well known for other viruses.1 The two most frequent COVID-19 cuta- neous lesions (16-19%) are urticarial rash and angioedema.2-4 Urticarial rash mainly involves the trunk and the limbs, and gener- alized itching is an accompanying common symptom. Hives usu- ally appear simultaneously with systemic symptoms of COVID- 19, and mean rash duration is about 7 days.2,3 These features seem to be associated with medium-high severity of COVID-19 even though no clear correlation between the cutaneous phenotype and the severity of COVID-19 has been found so far.5 No clear patho- genetic mechanism has been identified, but a role of hyperactive immune response, complement activation, and microvascular injury has been postulated.6 Few histopathological studies are available and mainly report vacuolar interface dermatitis.7 Therapy is based on low-dose systemic corticosteroids combined with non- sedating antihistamines.6 The resolution is generally complete without sequelae, as reported in our case. References 1. Molina-Ruiz AM, Santonja C, Rütten A, et al. Immunohistochemistry in the diagnosis of cutaneous viral infections--part I. Cutaneous viral infections by herpesviruses and papillomaviruses. Am J Dermatopathol 2015;37:1-14; quiz 12-4. 2. Galvan Casas C, Catala A, Carretero Hernandez G, et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020;183:71-7. 3. Pagali S, Parikh RS. Severe urticarial rash as the initial symp- tom of COVID-19 infection. BMJ Case Reports CP 2021;14:e241793. 4. Algaadi SA. Urticaria and COVID-19: A review. Dermatol Ther 2020;33:e14290. 5. Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol 2020;34:e212–3. 6. Bastoni D, Borio G, Rienzo P, et al. COVID-19 and cutaneous manifestations: two cases and a review of the literature. Emergency Care Journal 2022,18:10468. 7. Rodríguez-Jiménez P, Chicharro P, De Argila D, et al. Urticaria-like lesions in COVID-19 patients are not really urticaria - a case with clinicopathological correlation. J Eur Acad Dermatol Venereol 2020;34:e459-60. Images in Emergency [page 2] [Emergency Care Journal 2022; 18:10742] Non commercial use only