Cold Urticaria Syndromes: Diagnosis and Management

Indurated Red Nodules and Plaques on the Thigh of a Female Patient

A woman in her 40s with a medical history of complex regional pain syndrome presented to the dermatology department for evaluation of a pruritic recurrent rash on her right anterior thigh. What is your diagnosis?

Serum Sickness-Like Reactions in Children-Is Lifelong Avoidance Indicated?

Serum sickness-like reactions (SSLRs) consist of urticaria or urticarial-like rashes with joint pain and variable features of fever, angioedema, and gastrointestinal distress. Allergists typically evaluate patients in the clinic for an implicated medication, such as an antibiotic or vaccine. Although SSLR may be mistaken for classical serum sickness or anaphylaxis owing to overlapping clinical features, there is minimal evidence for type I or type III hypersensitivity reactions. Despite recent studies showing antibiotic allergy is rarely verified, patients rarely undergo allergy evaluation. A difficulty is that there is no agreement about challenge procedures- multiple-day dosing protocols lead to a risk for hives and joint pain that does not occur with single-day challenges. In addition, tolerance of either challenge protocol does not fully prevent rashes and repeat episodes of SSLR in all nonallergic children who used the culprit or an unrelated antibiotic again. Owing to the distressing symptoms, lack of abortive therapies, and uncertainty with challenge, many health care professionals and families may prefer to bypass allergy evaluation and continue lifelong avoidance. However, medication allergy labels may be associated with poor health outcomes. Well-designed prospective studies are needed to provide better insight into the diagnosis, effective treatments, and true recurrence rates.

Cold-induced anaphylaxis: new insights into clinical and genetic characteristics

Introduction

The pathogenesis of cold urticaria (ColdU) and cold-induced anaphylaxis (ColdA) remains poorly understood, and ColdA is underrepresented in anaphylaxis literature. Laboratory features to guide management are largely unknown. This study evaluated basal serum tryptase (BST) and total immunoglobulin E (IgE) levels in ColdU and ColdA, their associations with clinical features, and the utility of testing for the KIT p.D816V variant in blood leukocytes and hereditary α-tryptasemia (HαT).

Methods

Ninety-two adults with ColdU were enrolled. ColdA was defined as a reaction involving skin and/or visible mucosal tissue with cardiovascular, respiratory, or gastrointestinal manifestations. Evaluations included patient history, standard cold stimulation testing (sCST) using an ice cube and TempTest®, and laboratory tests.

Results

ColdA was diagnosed in 35.9% of patients. ColdU phenotypes based on sCST included typical ColdU (52.2%), localized cold-reflex urticaria (5.4%), and ColdU with negative sCST (42.4%). Negative sCST, compared to typical ColdU, was associated with fewer ColdA cases (p = 0.004) but more spontaneous wheals (p < 0.001). ColdA patients more frequently exhibited generalized wheals (p = 0.047), skin angioedema (p = 0.007), oropharyngeal/laryngeal manifestations (p < 0.001), and itchy earlobes (p = 0.002) than non-ColdA patients. Elevated BST levels (>11.4 ng/mL) in 9.8% of patients were attributed to KIT p.D816V and/or HαT. KIT p.D816V was detected in 6.6% of ColdU and 6.3% of ColdA patients. HαT prevalence was higher in ColdU (10.9%) and ColdA (15.2%) than the general population (estimated at 5.7%; p = 0.041 and p = 0.038). Total IgE levels were significantly higher in ColdA than non-ColdA (p = 0.021).

Discussion

This study confirmed clinical features linked to ColdA previously identified by the multicenter COLD-CE study, including generalized wheals, skin angioedema, oropharyngeal/laryngeal manifestations, and itchy earlobes. We identified new high-risk features. ColdA is more frequently associated with typical ColdU than with ColdU with negative sCST, the latter being linked to spontaneous wheals. ColdA is additionally associated with higher total IgE levels. Furthermore, patients with ColdU and ColdA exhibit higher prevalence of KIT p.D816V and HαT compared to general population data, a finding not previously reported. Further research is needed to explore their clinical implications.

Research progress and immunological insights of shrimp allergens

Allergic diseases have become a major health issue in the 21st century. The FAO has pinpointed the eight most prevalent allergens worldwide, with shrimp allergy attracting global concern due to its escalating incidence. This review delves into the current knowledge of shrimp allergen types and traits, immune response mechanisms, advancements in cross-reactivity research, and breakthroughs in diagnostic and therapeutic methods. It highlights the variety of shrimp allergens, such as tropomyosin and arginine kinase, and concentrates on IgE-mediated immediate hypersensitivity reactions, involving mast cells and basophils, alongside the role of T cells and cytokines in non-IgE-mediated delayed hypersensitivity reactions. The exploration of cross-reactivity underscores the connection between shrimp allergy and allergies to other animals. Utilizing bioinformatics tools, including homology analysis, epitope prediction, and molecular modeling, has enhanced our comprehension of allergen molecular features. In treatment and diagnosis, innovative approaches like immunotherapy and gene editing technology hold potential to decrease allergic sensitivity, while emerging reduction techniques like heat treatment and enzymatic hydrolysis offer new strategies for the prevention and management of food allergies. The evolution of allergen detection and purification technologies has spurred innovation in testing methodologies, encompassing traditional in vivo tests like SPT and DBPCFC, in addition to a range of other techniques such as immunoassays, biochip technology, PCR, and histamine release experiments, propelling the instantaneous and accurate identification of allergens. These scientific breakthroughs not only expand our understanding of shrimp allergen biology but also lay the foundation for developing more effective allergy prevention and control strategies.

Cold-induced anaphylaxis triggered by drinking cold water

Cold urticaria is an inducible urticaria in which hives and angioedema appear after exposure to cold. The symptoms of cold urticaria often are limited to hives/angioedema. However, in up to 20% of cases, cold exposure may trigger anaphylaxis. We report the case of an 11-year-old boy previously diagnosed with chronic spontaneous urticaria who developed facial swelling, itchy hives, difficulty in breathing, vomiting and abdominal pain within 5 minutes of drinking cold water. He received a standard dose of non-sedating second-generation antihistamines at home. He was observed in the emergency room for 2 hours and discharged with an epinephrin autoinjector. During the subsequent outpatient clinic visit, an ice cube test was performed which confirmed the new diagnosis of comorbid cold-induced chronic urticaria. On further questioning, the parents reported occurrence of hives following swimming in the swimming pool. Cold-induced urticaria should be suspected in cases of anaphylaxis associated with cold exposure. Patients with chronic forms of urticaria who present with new anaphylaxis should be assessed for a potential concomitant cold-induced form.