Can acute urticaria (hives) present with fever?

Can Acute Urticaria Present with Fever?

The answer is: Generally FALSE for typical acute urticaria, but TRUE in specific contexts—particularly autoinflammatory syndromes presenting with urticaria and certain infectious causes.

Standard Acute Urticaria Does NOT Include Fever

Most patients with ordinary acute urticaria do not have systemic reactions, including fever 1. The British Journal of Dermatology guidelines explicitly state that typical urticaria presents with short-lived itchy wheals, angioedema, or both, without mentioning fever as a characteristic feature 1.

• Acute urticaria is defined as spontaneous wheals lasting less than 6 weeks 1
• The primary symptoms are itchy wheals and/or angioedema 1
• Individual wheals typically last 2-24 hours in ordinary urticaria 1

Important Exceptions Where Fever DOES Occur

Autoinflammatory Syndromes

Autoinflammatory syndromes presenting with urticaria typically develop spontaneous wheals, pyrexia (fever), and malaise 1. These include:

• Cryopyrin-associated periodic syndromes (hereditary) 1
• Schnitzler syndrome (acquired) 1
• These conditions present with additional features beyond urticaria that define the disease phenotype 1

Acute Infectious Urticaria

Acute infectious urticaria can present with high fever, along with urticaria, angioedema, neutrophilia, and elevated C-reactive protein 2. This represents a distinct clinical entity where:

• Most patients had urticaria, angioedema, AND high fever 2
• The skin rash lasted more than 24 hours (longer than typical urticaria) 2
• Combination therapy with corticosteroids and antibiotics was more effective than single-agent treatment 2

Parasitic Infections with Urticarial Rash

Certain helminth infections can cause urticarial rash with fever during Loeffler's syndrome 1:

• Hookworm (Ancylostoma/Necator) can present with urticarial rash and fever 1
• Ascaris lumbricoides can present with urticarial rash and fever 1

Clinical Pitfall to Avoid

If a patient presents with urticaria AND fever, do not assume it is simple acute urticaria. Consider:

1. Autoinflammatory syndromes if fever is recurrent with urticaria 1
2. Infectious urticaria if accompanied by neutrophilia and elevated inflammatory markers 2
3. Parasitic infection if there is appropriate travel/exposure history 1
4. Anaphylaxis if there are other systemic symptoms, though fever is not typical 3

The erythrocyte sedimentation rate is usually normal in chronic ordinary urticaria but is always raised in autoinflammatory syndromes 1, providing a useful diagnostic clue when fever is present.