Concomitant Urticaria Research Articles

Angioedema After Use of Recombinant Tissue-Type Plasminogen Activators in Stroke.

Angioedema without concomitant urticaria is a well-known complication of treatment with the recombinant tissue-type plasminogen activator (r-tPA) alteplase and its genetically modified variant tenecteplase. It is potentially lethal when causing airway obstruction and can require intubation. The latest guideline for the early management of patients with acute ischemic stroke from the American Heart Association/American Stroke Association advises to treat this complication initially by interfering with the histamine pathway. This article aims to clarify the pathophysiological mechanism of r-tPA-induced angioedema and provides several arguments that this condition is primarily bradykinin-mediated and hence should be treated initially by intervening with the bradykinin pathway. Second, other-less frequently reported-adverse symptoms after r-tPA therapy and their proposed pathophysiological mechanisms leading to specific treatment are described. This manuscript describes the need for an update of the section "3.5 IV alteplase" from the American Heart Association/American Stroke Association guideline to treat this r-tPA-induced angioedema adequately and prevent potentially fatal outcomes.

A survey on subtypes and clinical characteristics of 1061 patients with urticaria in the primary care institutes in Japan

The prevalence of urticaria has been reported mostly in Europe and North America. However, precise information regarding its subtypes and clinical characteristics in primary care practice, especially in Asian countries, are scant. Patients with urticaria and/or angioedema who visited nine primary clinics of accredited dermatologists and allergologists in Japan were recruited from October to November 2020. The information of age, sex, disease duration, urticaria control test (UCT), and concomitant urticaria subtypes were collected. A total of 1061 patients participated. The number of patients was high in the 20 to 50 age groups with a peak in the 40s. The most frequent urticaria subtype was chronic spontaneous urticaria (CSU) followed by dermographism, acute spontaneous urticaria (ASU), angioedema, and cholinergic urticaria (CholU) (66.8%, 22.7%, 18.9%, 14.1% and 5.7% in all patients with urticaria). CSU development increased with age from the 20s to 50s, especially in females. Dermographism had a peak in the 40s. ASU had bimodal peaks in childhood and in the 30s. CholU was common in males in the 10-20s. Most angioedema patients were female with an increase in their 30s. Angioedema was solely present in 14 of 1061 participants (1.3%), while 136 (12.8%) had angioedema concomitant with urticaria. UCT showed poorly controlled urticaria with lower scores in patients with concomitant CSU and other subtypes than in those with CSU alone. Urticaria tends to develop in young to middle-aged females. The most common urticaria subtype is CSU, while the number of patients with CholU is high and that of angioedema is low in Japan.

ALLERGIC ACUTE CORONARY SYNDROME

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kounis syndrome describes a unique phenomenon of acute coronary syndrome (ACS) in the presence of allergic or anaphylactic reactions. This syndrome is caused by inflammatory mediators - histamine being the most prominent - inducing coronary artery vasospasm. We present a case of allergic ACS in a patient with mast cell activation syndrome (MCAS). CASE PRESENTATION: A 35-year-old woman with a history of MCAS, chronic urticaria, migraines, severe persistent asthma, and recent DVT on therapeutic enoxaparin, was hospitalized for pain and edema concerning for an acute flare of MCAS. She was treated with oral steroids and a continuous intravenous diphenhydramine infusion. The patient later developed sepsis secondary to a staphylococcus aureus line infection and was started on cefazolin. Overnight, she developed asymptomatic diffuse ST elevations in addition to tachycardia with a rate in the 140s (baseline heart rate 100-130) and was found to have elevated troponins. Her initial troponin measurement was 0.28 and declined to 0.26 and 0.21. On physical exam she had scattered urticaria, tachycardia, normal heart sounds without a pericardial friction rub and was saturating well on room air. She was continued on steroids and diphenhydramine infusion with the addition of famotidine. She had no previous cardiac history and no significant family history of cardiovascular disease. TEE done 6 months prior was negative for mural thrombus and showed normal EF; echo the day after the onset of ST elevations showed no significant findings. DISCUSSION: Histamine induced coronary vasospasm may mimic classic ACS in patients undergoing an allergic reaction. Kounis syndrome is suspected to be largely underdiagnosed and should be considered in patients with anaphylactic or other allergic responses. Our patient likely had histamine-mediated ACS after initiation of cefazolin. Her troponin plateau makes ST-elevation myocardial infarction less likely. Other differentials to consider include myopericarditis given the diffuse ST elevations, however, given the onset in close proximity to new antibiotic initiation, her history is suspicious for an allergy mediated process. Furthermore, Kounis syndrome is more commonly found in individuals with other vasospastic conditions such as migraine. Treatment for allergic ACS includes management of underlying allergic response with corticosteroids and antihistamines; calcium channel blockers can also be considered. ACS protocol can be implemented in patients with underlying cardiac disease, but caution should be used with beta-blockers to avoid exacerbation of vasospasm. CONCLUSIONS: Patients undergoing an allergic reaction may experience classic signs and symptoms of ACS induced by histamine-mediated coronary vasospasm. Kounis syndrome is an important differential to consider in any allergy patient with new-onset ST changes or transient angina with or without concomitant urticaria. Reference #1: Kounis NG. Kounis syndrome: an update no epidemiology, pathogenesis, diagnosis and therapeutic management. CCLM. 2016; 54(10):1545–1559 Reference #2: Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract. 1991;45(2):121-128. Reference #3: Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med. 2016;54(10):1545-1559. doi:10.1515/cclm-2016-0010 DISCLOSURES: No relevant relationships by Jennifer Cortes, source=Web Response No relevant relationships by Kelly Roth, source=Web Response

Idiopathic nonhistaminergic acquired angioedema in a patient with coronavirus disease 2019

Idiopathic nonhistaminergic acquired angioedema in a patient with coronavirus disease 2019

Real-life treatment of cholinergic urticaria with omalizumab

Abstract Background Cholinergic urticaria (CholU), a frequent type of chronic inducible urticaria, presents with small itchy wheals upon physical exercise or passive warming. Omalizumab has been shown to be very effective in patients with chronic spontaneous urticaria. Whether or not omalizumab is also effective in CholU is largely unknown. Aim To assess the effectiveness of omalizumab treatment in CholU Method We assessed the effects of real life omalizumab treatment at standard and higher than standard doses in CholU patients including their time to response, the effects on concomitant urticaria forms and links to clinical features. Results Of 16 CholU patients treated with omalizumab, 11 (68%) reported a major or complete response, 2 patients reported a minor effect (13 %) and 3 patients (19%) showed no benefit. Omalizumab updosing led to complete response in 4 of 6 patients, who did not achieve controlled disease on standard dosed omalizumab therapy, i.e. 300 mg/4wks. Time to onset of benefit was fast, and concomitant urticaria forms showed similar response patterns. Treatment effects were linked to patient gender, with better responses in female patients (p Conclusion Omalizumab treatment is effective in the majority of CholU patients, especially in female patients. Most non-responders to standard-dosed omalizumab benefit from updosing. Our findings call for controlled clinical trials of omalizumab and other IgE-targeted treatments in CholU.

Prognostic factors in outcome of angioedema in the emergency department.

Angioedema is a transient, localized swelling caused by two distinct mechanisms, mediated by histamine and bradykinin, respectively, although a proportion of cases remain idiopathic. Studies that characterize undifferentiated angioedema presenting in emergency departments (EDs) are limited. This study investigates the presentation patterns of undifferentiated angioedema in the ED based on the presumed mechanism of swelling. Medical records from all ED visits to two tertiary care hospitals from July 2007 to March 2012 were electronically reviewed. Records with documented visible swelling on general inspection and/or fiberoptic laryngoscopy and a diagnostic code for anaphylactic shock, angioneurotic edema, allergy unspecified, defects in the complement system, or unspecified drug adverse effects were included. Demographic, clinical, and outcome data were collected via a standardized form. Data were analyzed descriptively, including frequencies and percentages for categorical data and means and SDs for continuous data. Predictors for admission were identified using multivariate logistic regression models. ED records from 527 visits for angioedema by 455 patients were included in the study. Annual rate of angioedema was 1 per 1000 ED visits. Urticaria was associated with peripheral (p = 0.008) and lip angioedema (p = 0.001), and the absence of urticaria correlated with tongue angioedema (p = 0.001) and trended toward correlation with pharyngeal angioedema (p = 0.056). Significant predictors of admission included nonsteroidal anti-inflammatory drug-induced angioedema (odds ratio [OR], 15.3), epinephrine treatment (OR, 8.34), hypotension (OR, 15.7), multiple-site angioedema (OR, 4.25), and pharyngeal (OR, 1.23) and tongue angioedema (OR, 4.62). Concomitant urticaria was associated with a significant longer stay in the ED (p < 0.001). The presence of urticaria correlated with the location of angioedema, need for airway management, length of ED visit, and recurrence. A detailed drug and family history, screening blood work for C1 esterase inhibitor deficiency when indicated, and prompt management of angioedema based on presumed mechanism of swelling are crucial steps in managing undifferentiated angioedema in ED.

Juvenile xanthogranuloma: Challenges in complicated cases

Juvenile xanthogranuloma (JXG) is one of the most common forms of non-Langerhans cell histiocytosis in children. Although it usually presents as a self-limited skin lesion with typical histopathology, JXG can be challenging to diagnose due to an atypical initial presentation with corresponding variable histopathology for different stages of development. We present challenging cases of JXG from Sydney Children's Hospital, collected over 10 years - two with multisystem involvement and concomitant urticaria, one associated with neurofibromatosis, and one case of giant JXG with an initial histopathological challenge. Although JXG has been reported with urticaria pigmentosa, in two of our cases persistent urticaria, in association with JXG is discussed.

GASTROENTEROLOGIC DISORDERS PRESENTING AS FOOD INTOLERANCE

Adverse reactions to foods may be divided broadly as food allergy (an immune-mediated phenomena) or food intolerance. 2 With the possible exception of anaphylaxis, most adverse reactions to foods can be confused with primary gastrointestinal disorders and vice versa. Symptoms mimicking gastroenteritis, including nausea, vomiting, crampy abdominal pain, watery diarrhea, and flatulence, may be provoked by specific foods in patients with true allergy; they may also experience concomitant urticaria, flushing, rhinitis, asthma, and possibly anaphylaxis. Most food allergies are IgE-mediated immediate hypersensitivity reactions, but immune complex formation and cell-mediated immune reaction account for a minority of cases. 9 Although the pathophysiologic basis of celiac sprue is not fully understood, it is usually classified as a food allergy. 2 Many patients who report food intolerance may in fact be suffering from gastrointestinal disorders. Individuals with lactase deficiency develop abdominal pain, bloating, and diarrhea after excessive intake of milk or dairy products; similarly, malabsorption of fructose and sorbitol may present as intolerance to fruits or “sugar-free” foods. Gastroesophageal reflux, pancreatitis, or delayed gastric emptying may be misdiagnosed as fatty food intolerance. Gastrointestinal toxicity from additives or chemical constituents of different foods may be confused with food intolerance. Finally, many patients (usually with functional bowel disease) seek medical care for a complex array of gastrointestinal and systemic symptoms erroneously attributed to food intolerance. In order that the reader may become familiar with the interactions between adverse food reaction and gastrointestinal diseases, we briefly discuss food allergy, gastrointestinal disorders presenting as food intolerance, and food intolerances commonly mistaken for gastrointestinal diseases.

Bilateral pleural effusion in a patient with urticarial vasculitis

A 32-year-old woman with a 6-year history of urticaria, acute anterior uveitis and mesangial glomerulonephritis developed bilateral pleural effusion. A thorough laboratory workup during repeated attacks of concomitant urticaria and bilateral pleural effusion together with the histopathological finding of the skin biopsy revealed normocomplementemic leukocytoclastic vasculitis. Bilateral pleural effusion should be included in the clinical spectrum of urticarial vasculitis syndrome.