A 16-year-old girl was evaluated for an episode, which occurred while swimming in the sea, of widespread urticaria, weakness and pharyngeal constriction, tachycardia, paleness and collapse, which resolved with the administration of an oral antihistamine (epinephrine autoinjector was not available). Over the past year, she had also experienced recurring episodes of itchy wheals on her fingertips and hands after taking food from the refrigerator or washing salad with cold water, and a single episode of diffuse urticaria after another dive into the sea, and she reported an episodic sensation of pharyngeal constriction while eating ice cream. Physical examination was unremarkable. A skin test with ice application was performed (figure 1).

Our patient’s cold stimulation test, in which wheals appeared after applying ice to her forearm for 3 and 5 minutes.

What is the most likely diagnosis based on this clinical presentation and skin test?

Cryoglobulinemic vasculitis

Cold typical urticaria

Aquagenic urticaria

Cold atypical urticaria …