A 16-Year-Old Girl With a Rash and Shortness of Breath

Peter Huynh, MD

Disclosures

June 13, 2017

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 16-year-old girl presents to the emergency department with generalized pruritus, eye swelling, a full-body rash, and shortness of breath after playing basketball at school. She reports that she was playing basketball with her friends when she first noticed itchy palms. She stopped playing and washed her hands. The itch worsened and was followed by a rash and shortness of breath. She also felt that her throat was tightening, and she had difficulty swallowing. She was taken to the school nurse, paramedics were called, and she was brought to the local emergency department.

The patient has had several similar episodes within the past year and feels that the episodes are getting worse. The first episode occurred about 1 year ago while playing volleyball in a hot gym. She developed itchy palms and stopped to go drink some water; the itchiness went away without any medical attention. Recently, the episodes have been occurring more frequently and are more severe. Some episodes are associated with even mild physical exertion, especially when the temperature outside is hot. When she stops the physical activity, the symptoms typically go away. She cannot recall eating any specific foods that are related to her episodes. She is not taking any medications, vitamins, or herbal supplements.

The patient is otherwise healthy, with no significant medical history. She denies any malaise, fatigue, weight loss, nausea, vomiting, fever, or joint pain. She is in the 11th grade and does well in school, getting mostly A's and only a few B's. She wants to go to college. She has many friends at school. She enjoys biking, dancing, and texting. Occasionally, dancing causes her to feel itchy, but she just "takes a break," and the itch goes away.

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