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There was no specific trigger associated with his symptoms. The patient developed an episode of hives in the winter shortly after cold exposure (figure 1). He was healthy previously. Other than positive dermatographism, the patient had a normal physical exam. His ice cube test was positive after 10?min and he was diagnosed with CU. Subsequently, he was treated with reactine (cetirizine) daily with a good response. Figure?1 Generalised urticaria developing after exposure to cold. Case 3 The third case is a 12-year-old boy who presented with three episodes of urticaria over a few months developing within minutes after swimming in a lake/pool. He presented initially with abdominal pain that developed within minutes after he dived into a lake. A few minutes after exiting the water, he lost consciousness and had a generalised seizure that lasted a few seconds. He had neither fever nor a preictal or postictal period. There was no previous history of seizures and no other cause of seizures was identified. His Crizotinib mother did not note any swelling of his tongue or difficulty in breathing. The second episode occurred a few minutes after swimming in a pool where he developed hives for 10?min that gradually disappeared. His third episode occurred when swimming in a lake where he developed oedema of his arms and knees that was painful. He had a positive ice cube test at 5 and 10?min (figure 2A,B). The patient's mother was concerned that he reacted to the algae or fish in the water, but skin testing was negative for fish, crustaceans and algae. Owing to the severity of his CU, he was advised to take second generation antihistamines 2?days prior to swimming and to avoid abrupt cold exposure (eg, jumping in a pool). Further, given his systemic symptoms, he was prescribed an epinephrine autoinjector and advised to have it available at all times. Figure?2 (A) Cold stimulation test (ice cube test): ice placed on the patient's volar surface of the forearm. (B) Positive ice cube test: urticaria after 5?min of ice placement and 5?min of rewarming. Investigations Given that history, physical signs and ice cube test are consistent with CU, no further investigations are needed in the cases described. However, in the absence of a clear physical trigger, further testing may be required to establish the diagnosis. Baseline complete blood count with differential is recommended in cases on chronic urticaria. Abnormal results might suggest the presence of an infectious or inflammatory process. Inflammatory markers such as erythrocyte sedimentation rate and C reactive protein can be useful in cases of a suspected autoimmune disease with the addition of antineutrophil antibody, rheumatoid factor, complement 3 and 4 (C3/C4), CH50, antidouble stranded DNA, antithyroglobulin/antithyroid peroxidase antibodies and antismooth muscle antibody.