HIVES - Nursing Case Study

Pathophysiology

• Primary mechanism: Hives, also known as urticaria, are caused by an allergic reaction which triggers certain cells (mast cells) in the skin to release histamine and other chemicals into the bloodstream. The release of these chemicals causes inflammation and fluid to accumulate in the skin, leading to the formation of welts or hives.

• Secondary mechanism: Chronic urticaria may involve an autoimmune response, where the body's immune system attacks its own tissues. In this case, the immune system produces antibodies that bind to mast cells, triggering the release of inflammatory substances.

• Key complication: In severe cases, hives may cause angioedema - swelling in deeper layers of the skin, often around the face and lips. This can lead to difficulty breathing and is considered a medical emergency.

Patient Profile

Demographics:

37 year old, female, high school teacher

History:

• Key past medical history: Diagnosed with HIVES (Histamine Intolerance Vital Eruption Syndrome) 2 years ago, occasional asthma, and anemia

• Current medications: Antihistamines, iron supplements, and inhalers for asthma

• Allergies: Penicillin, dust mites

Current Presentation:

• Chief complaint: Worsening skin rashes, shortness of breath, and fatigue

• Key symptoms: Intense itching, hives, difficulty in breathing, lowered stamina, occasional dizziness

• Vital signs: Blood pressure 98/65 mmHg, pulse 110 bpm, respiratory rate 24 breaths per minute, oxygen saturation 93%, body temperature 98.6°F

Section 1

Change in Patient Status:

The teacher returned to the clinic after three days, reporting that her symptoms had worsened despite adhering to her medication regimen. Her fatigue had intensified, and she was now experiencing persistent dizziness and occasional fainting spells. She also reported that her hives had spread to cover more of her body and that the itching had become unbearable. Her shortness of breath had also increased, and she had been using her inhaler more frequently.

On assessment, her blood pressure was slightly lower than her previous visit at 90/60 mmHg, and her pulse was elevated at 120 bpm. Her respiratory rate had increased to 26 breaths per minute, and her oxygen saturation dropped to 90%. The skin examination revealed extensive hives covering her trunk and limbs, with some areas showing signs of secondary infection due to scratching. Auscultation of the lungs revealed decreased breath sounds bilaterally, suggestive of a possible asthma exacerbation. These findings indicate a need for an urgent reassessment of her treatment plan and possibly hospital admission for further investigation and management.

Section 2

New Diagnostic Results:

Given the worsening of her symptoms and the significant changes in her vital signs, the healthcare team decided to conduct further diagnostic tests. A complete blood count was ordered, revealing a high eosinophil count of 12% (normal range is 1-6%), which could be indicative of an allergic reaction or an underlying autoimmune condition. Her CRP (C-reactive protein) level was also elevated at 30mg/L (normal range is below 10mg/L), suggesting an ongoing inflammatory process.

A chest X-ray was conducted due to her increased shortness of breath and decreased lung sounds, which showed bilateral infiltrates. This could be indicative of pneumonia or another inflammatory lung disease. A skin biopsy from one of the hive areas revealed dermal edema and infiltration of eosinophils, confirming a diagnosis of urticaria. These new diagnostic results not only confirmed the severity of the patient's condition but also revealed the possible underlying factors contributing to her worsening state. They necessitated an urgent reconsideration of her treatment regimen and further specialist input.

Section 3

New Complications:

Over the next 48 hours, the patient's condition deteriorated rapidly. Her respiratory status worsened, with her oxygen saturation levels dropping to 88% on room air, necessitating the initiation of supplemental oxygen via nasal cannula. Despite this, she remained tachypneic with her respiratory rate consistently above 24 breaths per minute. Her skin condition also worsened, with the hives spreading to her face and neck and becoming more pruritic and painful.

Her vital signs revealed a temperature of 38.7°C, heart rate of 110bpm, and blood pressure of 90/60 mmHg, indicating possible sepsis. Repeat labs showed an increase in her eosinophil count to 14% and her CRP to 35mg/L. Her WBC count was also elevated at 15,000/uL (normal range is 4,500-11,000/uL). This drastic change in her condition required urgent escalation of care and broadening of the differential diagnosis. The patient was started on broad-spectrum antibiotics with the suspicion of a severe bacterial infection, and a sepsis protocol was initiated. The healthcare team also reached out to a pulmonologist and allergist for further consultation given the complexity of her case.

Section 4

Change in Patient Status:

Following the initiation of the sepsis protocol and broad-spectrum antibiotics, the patient's condition continued to deteriorate. Her oxygen saturation levels dropped further to 85%, despite an increase in supplemental oxygen via the nasal cannula. Her respiratory rate increased to 28 breaths per minute, indicating further respiratory distress. A reevaluation of her skin showed that the hives had coalesced into large areas of erythema and swelling, extending to her upper chest. The patient reported increasing discomfort and a sensation of tightness in her throat.

In response to these developments, an arterial blood gas was obtained showing a PaO2 of 60mmHg, PaCO2 of 35mmHg, and a pH of 7.35 pointing towards a possible respiratory failure. Furthermore, her blood cultures came back positive for Staphylococcus aureus, confirming the suspicion of a severe bacterial infection. Her C-reactive protein level had also increased to 45mg/L, indicating a rise in systemic inflammation. This worsening condition required further escalation of care, including a possible transfer to the Intensive Care Unit for closer monitoring and management. Based on these findings, the healthcare team decided to consult an intensivist, and a discussion about intubation and mechanical ventilation was initiated.

Section 5

New Complications:

Despite the sepsis protocol and broad-spectrum antibiotics in place, the patient began to show signs of developing an allergic reaction to the antibiotic therapy. She developed a new rash that was different from her initial hives, and her throat tightness worsened. Notably, her blood pressure dropped to 90/60 mmHg, suggesting the possibility of anaphylaxis. Due to the severity of her symptoms, the team decided to administer epinephrine.

The patient was also experiencing an increased work of breathing, with decreased breath sounds in the lower lobes of both lungs, indicating possible development of atelectasis or pneumonia. Her supplemental oxygen requirement increased to maintain an oxygen saturation level above 90%. A chest X-ray was ordered to further evaluate her respiratory status. Despite these interventions, the patient remained tachypneic with a respiratory rate of 30 breaths per minute and her oxygen saturation fluctuated between 88-92%.

Given the patient's progressive respiratory distress and development of potential drug-induced anaphylaxis, her care was escalated. The decision was made to transfer the patient to the Intensive Care Unit (ICU) for closer monitoring and to manage her deteriorating condition effectively. The consultation with the intensivist led to the initiation of intubation and mechanical ventilation to secure her airway and ensure adequate oxygenation.