Concern for mold allergy

Patient is 29-year-old female who comes in with the chief complaint of hives, itching, and swelling. This began Thursday night. Prior to that she had kind of a stomach bug that occurred about five days before this and it has been going in her family. She has six people in her house and all of them have gotten this viral infection causing various symptoms. At that time she resolved it quite easily and then on Thursday began having these hives reaction. She has not noticed that it has been associated with after eating certain food. It seems to mostly happen in the evening and some in the morning and then kind of resolves throughout the day. She did end up having pretty significant reaction after exercising one of the days and had swelling of her eyes associated with it. She then went to primary health and they prescribed her prednisone to use until the swelling resolved, so she was on prednisone for a total of two days. She also has been taking Benadryl 15 mg every six hours to resolve the hives. She has been able to stop Benadryl for testing today. She did have a small outbreak of hives last night otherwise she has been fairly hives free or had minimal outbreaks since she has been off Benadryl for the last few days.

She admits to having some nasal stuffiness, mouth breathing, itching inside ears, and heartburn that happen occasionally and do not seemed to be associated with any seasonal variation. She denies any troubles with nasal polyps, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold. She does have some sinus infection occasionally. She has had TMJ and frequent headaches in the front and back of her head. She does use a neti pot for her nasal symptoms that are mostly associated with viral illnesses. She also uses ibuprofen and has moderate relief. She did have a CT of her sinuses done in 2010.

She denies any frequent ear infection.

She does admit to having eye itching, redness, tearing, dryness, burning, and eyelid swelling. This has been occurring just for the last five years especially with the hives and swelling.

She denies any history of wheezing or lung problems, frequent coughing spells, or recurrent night cough.

She denies any allergic skin problems in the past or currently. She has never been evaluated for allergies before.

ASSESSMENT:
1. Acute idiopathic urticaria, possibly viral-induced.
2. Concern for mold allergy.
3. History of penicillin allergy.

PLAN:
1. At this time, we discussed that her urticaria is probably most likely associated with the recent viral infection that is running through her home. I do not suspect that there are any mold problems in her home that are causing specific allergy as she was negative on skin testing today. She was also concerned about possibly being xylitol that she has been using in her food. She has used xylitol in the past but has gotten a new brand of xylitol. I encouraged her to try placing xylitol on her flexor surface and see if she has a reaction to it on her skin.
2. I encouraged her to try using Zyrtec 10 mg twice daily to see if this is enough to remain 95% control of her urticaria and angioedema. I will have her do this for at least four weeks and then slowly titrate off of Zyrtec to keep her house in remission.
3. If we have troubles with recurrence or poor control with the antihistamines, then we did discuss the other possibilities on the differential of it being associated with autoimmune presentation, malignancy, or other triggers in her environment that we have not discovered yet. So, she will come and see me again next month if this is the case and we will pursue blood testing and further rule out other etiologies of this urticaria reaction.

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