The association of chronic urticaria and angioedema with autoimmune thyroiditis

Autoreactive IgE: Pathogenic role and therapeutic target in autoimmune diseases

Autoimmunity is the break of tolerance to self-antigens that leads to organ-specific or systemic diseases often characterized by the presence of pathogenic autoreactive antibodies (AAb) produced by plasmablast and/or plasma cells. AAb are prevalent in the general population and not systematically associated with clinical symptoms. In contrast, in some individuals, these AAb are pathogenic and drive the development of signs and symptoms of antibody-mediated autoimmune diseases (AbAID). AAb production, isotype profiles, and glycosylations are promoted by pro-inflammatory triggers linked to genetic, environmental, and hormonal parameters. Recent evidence supports a role for pathogenic AAb of the IgE isotype in a number of AbAID. Autoreactive IgE can drive the activation of mast cells, basophils, and other types of FcεRI-bearing cells and may play a role in promoting autoantibody production and other pro-inflammatory pathways. In this review, we discuss the current knowledge on the pathogenicity of autoreactive IgE in AbAID and their status as therapeutic targets. We also highlight unresolved issues including the need for assays that reproducibly quantify IgE AAbs, to validate their diagnostic and prognostic value, and to further study their pathophysiological contributions to AbAID.

Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review

Purpose

Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU.

Patients and methods

Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

Results

Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H₁-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU.

Conclusion

Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H₁- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.

Epidemiology of urticaria in China: a population-based study

Background:

Urticaria is a common skin disease characterized by episodes of wheals, and it has a negative effect on patients’ quality of life. Large-scale population-based epidemiological studies of urticaria are scarce in China. The aim of this survey was to determine the prevalence, clinical forms, and risk factors of urticaria in the Chinese population.

Methods:

This survey was conducted in 35 cities from 31 provinces, autonomous regions, and municipalities of China. Two to three communities in each city were selected in this investigation. Participants completed questionnaires and received dermatological examinations. We analyzed the prevalence, clinical forms, and risk factors of urticaria.

Results:

In total, 44,875 questionnaires were distributed and 41,041 valid questionnaires were collected (17,563 male and 23,478 female participants). The lifetime prevalence of urticaria was 7.30%, with 8.26% in female and 6.34% in male individuals (P < 0.05). The point prevalence of urticaria was 0.75%, with 0.79% in female and 0.71% in male individuals (P < 0.05). Concomitant angioedema was found in 6.16% of patients. Adults had a higher prevalence of urticaria than adolescents and children. Living in urban areas, exposure to pollutants, an anxious or depressed psychological status, a personal and family history of allergy, thyroid diseases, and Helicobacter pylori infection were associated with a higher prevalence of urticaria. Smoking was correlated with a reduced risk of urticaria.

Conclusion:

This study demonstrated that the lifetime prevalence of urticaria was 7.30% and the point prevalence was 0.75% in the Chinese population; women had a higher prevalence of urticaria than men. Various factors were correlated with urticaria.

Chronic urticaria and thyroid autoimmunity: a meta-analysis of case-control studies

PURPOSE

Autoimmunity has been implicated in some patients with idiopathic chronic urticaria (CU). Because of the frequency of autoimmune thyroid diseases, their association with CU deserves special attention. We tested both the existence and the extent of an association between thyroid autoimmunity and CU.

METHODS

A thorough search of PubMed, Scopus, Web of Science, and Cochrane databases was performed. Studies reporting the positivity rate for anti-thyroperoxidase antibodies (TPOAbs) in people with (cases) and without CU (controls) were included. Quality of the studies was assessed by the Newcastle-Ottawa Scale. Between-study heterogeneity was assessed by Cochrane Q and I2 tests, and the odds ratio (OR) for TPOAbs positivity was combined using random-effects models.

RESULTS

Nineteen studies provided information about TPOAbs positivity on 14,351 patients with CU and 12,404 controls. The pooled estimate indicated a more than fivefold increased risk of exhibiting TPOAbs positivity in the group with CU (pooled OR 5.18, 95% CI 3.27, 8.22; P < 0.00001). Correction for publication bias had a negligible effect on the overall estimate (pooled adjusted OR: 4.42, 95% CI 2.84, 6.87, P < 0.0001). Between‑study heterogeneity was established (I2 = 62%, Pfor heterogeneity = 0.0002) and when, according to meta‑regression models, a sensitivity analysis was restricted to the 16 studies with the highest quality scores, the OR for TPOAbs positivity rose to 6.72 (95% CI 4.56, 9.89; P < 0.00001) with no significant heterogeneity (I2 = 31%, Pfor heterogeneity = 0.11).

CONCLUSIONS

Patients with CU have a five-to-nearly sevenfold higher risk of displaying TPOAbs positivity. All patients with CU may well be offered a screening for thyroid autoimmunity.

Relationship between Chronic urticaria and autoimmune thyroid disease

Hives is an erythematous and itchy disease that commonly affects the trunk and the organs. Acute urticaria is a common disease and affects about 10%-20% of the population during its lifetime. In patients with chronic urticaria, about 25%-30% of cases, antithyroid peroxidase (TPO) was detected and Hashimoto's disease was diagnosed. This study aimed to evaluate the anti-TPO antibody in patients with chronic urticaria and the effect of treatment of levothyroxine on its recovery. In this study, 72 people with chronic urticaria and positive anti-TPO antibody were randomly divided into two groups. Low-dose antihistamine was administered to both groups, and the first group received levothyroxine at a dose of 50 μg/day. The severity of itching was evaluated according to the visual analog scale before and after therapy. There was no significant difference in the age, sex, thyroid-stimulating hormone (TSH), and anti-TPO between the two groups. Ninety-two patients were female. In this study, all patients took a small dose of loratadine. Relative healing was observed in both the groups. However, in a group of patients taking levothyroxine and loratadine, recovery was faster and patients with no itching were significantly more likely than the other groups. The prevalence of chronic urticaria and anti-TPO antibody in this study was very high and was due to sex hormones. Therefore, in young women with chronic urticaria, especially in refractory cases, they should be monitored for anti-TPO. Anti-TPO and TSH should be evaluated for the diagnosis and treatment of patients with urticaria or chronic angioedema. Levothyroxine therapy in hives and chronic urticaria is beneficial in the treatment of thyroid dysfunction.

Causal Relationship Between Anti-TPO IgE and Chronic Urticaria by In Vitro and In Vivo Tests

PURPOSE

Immunoglobulin (Ig) E autoantibodies against thyroid antigens such as thyroid peroxidase (TPO) have been demonstrated in chronic spontaneous urticaria (CSU) patients in higher frequency than healthy subjects. However, if these IgE autoantibodies can trigger urticaria is still a matter of study. The aim of this study was to investigate the relationship between concomitant IgE autoantibodies against thyroid antigens in CSU.

METHODS

Patients with CSU, healthy subjects and patients with autoimmune thyroid disease (ATD) were recruited. Total IgE and specific anti-TPO IgE and IgG were assessed in all subjects. The basophil activation test and skin tests with TPO were performed to demonstrate whether this antigen could selectively induce urticaria reaction in subjects with positive anti-TPO IgE.

RESULTS

Anti-TPO IgE was present in all 3 groups (CSU: 34.0%, ATD: 16.6%, healthy subjects: 8.1%). Anti-TPO IgE levels were higher in CSU patients, whereas anti-TPO IgG were higher in ATD patients. After exposure to TPO, CD203c expression from patients with CSU and anti-TPO IgE significantly increased in comparison to the other groups; 33.0% vs. 14.0% in ATD patients and 9.0% in control subjects (P < 0.05). Skin reactions with TPO were higher in patients with CSU according to the intradermal (CSU: 18.0%, ATD: 3.3%, control: 8.0%) and skin prick tests (12.0%, 0%, 0%, respectively). Passive transfer of anti-TPO IgE from a CSU patient to the skin of control subjects without anti-TPO IgE induced a positive skin reaction.

CONCLUSIONS

Anti-TPO IgE is not a specific biomarker for CSU. However, IgE against TPO plays a pathogenic role in inducing effector cell activation and skin exacerbation in some patients with CSU.

Thyroid function and thyroid autoantibodies in patients with chronic spontaneous urticaria

Introduction

Chronic urticaria (CU) is a skin disease caused by autoantibodies against high affinity immunoglobulin E (IgE) receptor and against IgE. It is characterized by hives, erythematous wheals and redness present minimum twice a week for at least 6 weeks. It is observed that there is a strong association between CU and autoimmune diseases, such as autoimmune thyroiditis (AT).

Aim

To verify the frequency of AT in patients suffering from chronic spontaneous urticaria (CSU) and to confirm the coexistence of CU and AT in the Polish population.

Material and methods

One hundred and forty-eight patients with CSU were included to the study. The presence of anti-thyroperoxydase antibodies (anti-TPO) and anti-thyroglobulin antibodies (anti-Tg) was checked and thyrotropin (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) concentration was measured. Results were compared with outcomes in a group of 35 patients with no history of skin disease.

Results

Thirty-three patients were diagnosed with AT. Frequency of elevated anti-TPO (p = 0.0045) and anti-Tg (p = 0.013) levels was much higher in patients with CU. A comparison of the current study and previous ones was conducted. In a group with CU, there was a higher risk of elevated anti-TPO (OR = 6.69) and anti-Tg (OR = 6.01) levels.

Conclusions

There is a statistically significant difference in the presence of AT between the patients with CU and the whole population. Doctors should consider examining patients with CU for AT. Adequate therapy and guidance for patients could be implemented at an early stage of thyroid disease and help induce remission of skin disorders.

Autoimmune comorbidity in chronic spontaneous urticaria: A systematic review

BACKGROUND AND OBJECTIVE

Numerous autoimmune diseases (AIDs) have been linked to chronic spontaneous urticaria (CSU). Here, we provide the first extensive and comprehensive evaluation of the prevalence of AIDs in patients with CSU and vice versa.

METHODS

A Pubmed and Google Scholar search was performed to identify studies reporting the prevalence of various AIDs in CSU and vice versa published before April 2017.

RESULTS

The prevalence of individual AIDs in CSU is increased (≥1% in most studies vs ≤1% in the general population). AIDs with relatively high prevalence in the general population are also quite common in CSU patients, whereas those with low prevalence remain a rare finding in CSU. The rates of comorbidity in most studies were ≥1% for insulin-dependent diabetes mellitus, rheumatoid arthritis (RA), psoriasis and celiac disease (CD), ≥2% for Graves' disease, ≥3% for vitiligo, and ≥5% for pernicious anemia and Hashimoto's thyroiditis. Organ-specific AIDs are more prevalent in CSU than systemic (multiorgan or non organ-specific) AIDs. >2% of CSU patients have autoimmune polyglandular syndromes encompassing autoimmune thyroid disease (ATD) and vitiligo or pernicious anemia. Antithyroid and antinuclear antibodies are the most prevalent AID-associated autoantibodies in CSU. >15% of CSU patients have a positive family history for AIDs. The prevalence of urticarial rash in AID patients is >1% in most studies. This rash is more prevalent in eosinophilic granulomatosis with polyangiitis, ATD, systemic lupus erythematosus, RA and CD.

CONCLUSIONS

CSU patients have an increased risk of AIDs, especially adult female patients and those with a positive family history and a genetic predisposition for AIDs, who should be screened for signs and symptoms of AIDs.

Comorbidity of chronic spontaneous urticaria and autoimmune thyroid diseases: A systematic review

Patients with chronic spontaneous urticaria (CSU) are widely held to often have other autoimmune disorders, including autoimmune thyroid disease. Here, we systematically evaluated the literature on the prevalence of thyroid autoimmunity in CSU and vice versa. There is a strong link between CSU and elevated levels of IgG antithyroid autoantibodies (AAbs), with most of a large number of studies reporting rates of ≥10%. Levels of IgG against thyroid peroxidase (TPO) are more often elevated in CSU than those of other IgG antithyroid AAbs (strong evidence). Levels of IgG antithyroid AAbs are more often elevated in adult patients with CSU than in children (strong evidence). Patients with CSU exhibit significantly higher levels of IgG antithyroid AAbs (strong evidence) and IgE-anti-TPO (weak evidence) than controls. Elevated IgG antithyroid AAbs in CSU are linked to the use of glucocorticoids (weak evidence) but not to disease duration or severity/activity, gender, age, or ASST response (inconsistent evidence). Thyroid dysfunction rates are increased in patients with CSU (strong evidence). Hypothyroidism and Hashimoto's thyroiditis are more common than hyperthyroidism and Graves' disease (strong evidence). Thyroid dysfunction is more common in adult patients with CSU than in children (strong evidence) and in female than in male patients with CSU (weak evidence). Urticaria including CSU is more prevalent in patients with thyroid autoimmunity than in controls (weak evidence). CSU can improve in response to treatment with levothyroxine or other thyroid drugs (strong evidence). Pathogenic mechanisms in CSU patients with thyroid autoimmunity may include IgE against autoantigens, immune complexes, and complement.

Autologous Serum and Plasma Skin Tests in Chronic Spontaneous Urticaria: A Reappraisal

AIM

The objective of this study was to assess autologous serum skin test (ASST) vs autologous plasma skin test (APST) response in chronic spontaneous urticaria (CSU) patients and study the significance of intensity of positive responses in relation to clinicoepidemiological parameters.

MATERIALS AND METHODS

One hundred CSU patients and 100 age and sex-matched controls were recruited. The demographic and clinical features were recorded in all patients and routine investigations were performed. ASST and APST tests were performed as per the standard guidelines.

RESULTS

The mean duration of illness was 4.85 ± 5.07 years, 90% patients were APST (+), 68% ASST (+), and 22 patients were only APST (+). Positive predictive value (PPV) of ASST and APST was 90.7% and 95.7%, respectively. A significant inverse association was seen between thyroid status and serum IgE levels with APST and ASST positivity.

CONCLUSION

APST appears to have better PPV and high intensity of positive response on autologous tests, and correlates with ANA positivity and angioedema.

Effect of Levothyroxine Treatment on Clinical Symptoms in Hypothyroid Patients with Chronic Urticaria and Thyroid Autoimmunity

BACKGROUND

Thyroid autoimmunity has been increasingly reported to be associated with chronic urticaria (CU), and the possible clinical benefit of thyroid hormone or anti-thyroid drugs in some CU patients with autoimmune thyroid disease has been studied. However, the effect of thyroid hormone or anti-thyroid drugs on clinical symptoms of CU remains unclear.

OBJECTIVE

We investigated the clinical response of urticaria to the treatment of thyroid dysfunction.

METHODS

Medical records of patients with CU evaluated for thyroid autoimmunity and thyroid function were collected and reviewed.

RESULTS

Of 184 patients with CU, 43 patients (23.4%) had thyroid autoantibodies and 26 patients (14.1%) had thyroid dysfunction. While none of the five patients with Graves' disease showed any improvement of urticaria after treatment with anti-thyroid drugs, two of the 10 patients with Hashimoto's thyroiditis showed improved urticaria after being treated with levothyroxine.

CONCLUSION

Although levothyroxine treatment was effective in a minority of patients with CU, there may be a causal relationship between CU and thyroid autoimmunity.

Correlation of serum antithyroid microsomal antibody and autologous serum skin test in patients with chronic idiopathic urticaria

BACKGROUND

About 25-45% of patients of chronic urticaria (CU) have been stated to have histamine releasing autoantibodies in their blood. The term autoimmune urticaria is increasingly being accepted for this subgroup of patients. Review of the literature suggests high autologous serum skin test (ASST) positivity and presence of antithyroid microsomal antibodies in patients with autoimmune urticaria.

AIMS

To study prevalence of ASST positivity and antithyroid microsomal antibodies in chronic "idiopathic" urticaria and to study the correlation between the two parameters.

METHODS

All patients of chronic idiopathic urticaria satisfying inclusion/exclusion criteria were enrolled in the study after written informed consent. Patients of CU secondary to infections and infestations, physical urticaria including dermatographism, mastocytosis, urticarial vasculitis and those on treatment with immunosuppressive drugs for urticaria were excluded from the study. In all of these patients, complete blood count; ASST, serum T3/T4/thyroid stimulating hormone levels, antithyroid microsomal antibody (AMA) levels were done. Statistical analysis was done by Chi-square test, Fisher exact test and Kappa statistics.

RESULTS

Study included 24 males and 26 females with mean age of 39.54 years. Majority of patients belonged to 20-40 years of age. Females showed more ASST positivity. A total of 12 out of 50 (24%) patients showed positive ASST. A total of four out of 12 (33.33%) had positive ASST and raised AMA levels.

CONCLUSION

Only 25% of patients of chronic idiopathic urticaria had positive ASST. ASST and AMA levels were positively correlated in our study. Further studies are required to authenticate this association.

Chronic urticaria in adults: state-of-the-art in the new millennium

Chronic urticaria has been explored in several investigative aspects in the new millennium, either as to its pathogenesis, its stand as an autoimmune or auto-reactive disease, the correlation with HLA-linked genetic factors, especially with class II or its interrelation with the coagulation and fibrinolysis systems. New second-generation antihistamines, which act as good symptomatic drugs, emerged and were commercialized over the last decade. Old and new drugs that may interfere with the pathophysiology of the disease, such as cyclosporine and omalizumab have been developed and used as treatments. The purpose of this article is to describe the current state of knowledge on aspects of chronic urticaria such as, pathophysiology, diagnosis and the current therapeutic approach proposed in the literature.

Hashimoto's disease is a frequent comorbidity and an exacerbating factor of chronic spontaneous urticaria

BACKGROUND

The precise pathogenesis of chronic spontaneous urticaria (CSU) remains unknown. However, an important association between CSU and autoimmune disorders such as Hashimoto's disease (HD) has been reported. We investigated the frequency of HD as a comorbidity of CSU and the prevalence rate of autoreactivity among CSU patients with HD.

PATIENTS AND METHODS

The presence of thyroid autoantibodies and the levels of thyroid hormones were examined in 40 CSU patients who showed urticaria symptoms for >4 weeks. Patients who were diagnosed with HD, including subclinical ones, and were in need of treatment received thyroid therapy, and the changes in their urticarial symptoms were observed. An autologous serum skin test (ASST) was also performed to examine the relation of CSU with autoreactivity.

RESULTS

Eleven of the 40 CSU patients were diagnosed with HD, and 4 of the 5 patients who received and completed thyroid therapy showed considerable remission of urticarial symptoms during and after treatment. In addition, the rate of positive ASST results tended to be higher in CSU patients with HD (5 of 7) than in those without HD (2 of 6).

CONCLUSIONS

The comorbidity rate of HD in CSU patients was high, and such patients tended to have a positive ASST. Thyroid therapy in CSU patients with HD can lead to a considerable remission of urticarial symptoms, which may suggest that HD is possibly involved in the aetiology of CSU, or is at least a potential exacerbating factor for CSU.

The prevalence of thyroid autoimmunity in patients with urticaria: a systematic review and meta-analysis

Thyroid autoimmunity is the most common organ-specific autoimmune disorder, which is characterized by the production of thyroid autoantibodies and lymphocytic infiltration into the thyroid. The majority cases of chronic urticaria have unknown (idiopathic) causes, with about 30-40 % possibly having an autoimmune substrate. Considering that autoimmune factors may be the common features of both thyroid autoimmunity and urticaria, it is likely that both entities may coexist within the same patient. A number of studies have investigated the association between thyroid autoimmunity and urticaria. However, most of these studies are relatively small sample size, the power achieved in those studies was not sufficient to detect whether there is an association between urticaria and thyroid autoimmunity. The aim of this study is to combine primary data from all relevant studies to produce reliable estimates of the associations between thyroid autoantibodies and urticaria. Literature databases were searched including Medline, Embase, Web of Science, Chinese Wanfang, and CBM databases from January 1980 to December 2013. A total of 14,203 urticaria cases and 12,339 non-urticaria controls were included in this study. From these data, the odds ratio (OR) with 95% confidence interval (95% CI) was calculated. The meta-analysis results showed that the prevalence of positive thyroid autoantibodies in patients with urticaria was higher than non-urticaria controls (TgAb: OR 6.55, 95% CI 3.19-13.42, P<0.00001, I2=67%; TmAb: OR 4.51, 95% CI 2.78-7.33, P<0.00001, I2=47%; TPOAb: OR 8.71, 95% CI 6.89-11.01, P<0.00001, I2=20%, respectively). The results of this meta-analysis suggested that patients with urticaria were more likely to have thyroid autoimmunity than the control groups.

Angioedema without urticaria in childhood

BACKGROUND

There has been no separate study investigating angioedema without urticaria (Aw/oU) exclusively in children so far. The purpose of this study was to investigate the frequency, clinical presentation, etiology, management and follow-up of Aw/oU in children.

METHODS

This is a prospective study that included all consecutive patients with a history of Aw/oU referred to our clinic between January 2011 and May 2012. A standard diagnostic and therapeutic algorithm was applied to all patients.

RESULTS

The frequency of Aw/oU was found to be 1.6% during the study period. An etiological factor could be found in only 45 patients (49%). The causes of Aw/oU were infection (21%), allergy (14%), thyroid autoimmunity (TA)-related (8%) and nonsteroid anti-inflammatory drug hypersensitivity (6%), and idiopathic angioedema (51%). There was no hereditary type I, II or acquired type of angioedema or rare syndromes associated with Aw/oU. The median follow-up was 16 months (range: 12-30 months). Antihistamine prophylaxis was initiated at therapeutic doses in 20 patients with frequently recurrent angioedema due to idiopathic and euthyroid TA-related Aw/oU for 3 months. These patients responded to antihistamine prophylaxis for 3 months. Four patients relapsed after cessation of prophylaxis at the end of 3 months. Antihistamine prophylaxis was prolonged to 6 months in three patients and to 9 months in one patient.

CONCLUSIONS

Angioedema without urticaria in children is a rare condition and no etiology can be identified in half of them. Antihistamine treatment alone is sufficient, and prognosis is good in recurrent non hereditary cases in a short-term follow-up period.

Chronic idiopathic urticaria and thyroid autoimmunity: perplexing association

Background:

Autologous serum skin test (ASST) is the most commonly used laboratory test to differentiate chronic autoimmune urticaria patients from chronic idiopathic urticaria patients without autoantibodies. Thyroid autoimmunity is the original paradigm for autoimmune disease in general and many previous studies show increased prevalence of thyroid autoantibodies and deranged thyroid hormone profile in chronic idiopathic urticaria patients.

Aim:

To find the association between thyroid autoimmunity and chronic autoimmune urticaria, if any.

Materials and Methods:

The chronic idiopathic urticaria patients were divided into two subgroups based on autologous serum skin test. Thyroid autoantibodies were estimated in 40 patients each of ASST positive and ASST negative groups. Further, thyroid hormone profile was done in cases with significant titers of thyroid autoantibodies. Forty patients, who had never suffered from urticaria, represented the control group.

Results:

The prevalence of thyroid autoantibodies did not differ significantly among the ASST positive (20%) and ASST negative patients (15%). The control group had low prevalence of these autoantibodies (5%).

Conclusion:

The almost equal prevalence of thyroid autoantibodies in two subgroups of chronic idiopathic urticaria patients suggests possibly the same etiopathogenesis of the two subgroups. The two subgroups probably form a continuum, or even may be the same entity.

Autologous Serum Skin Test versus Autologous Plasma Skin Test in Patients with Chronic Spontaneous Urticaria

Previous studies indicate that 25-45% of chronic urticaria patients have an autoimmune etiology. Autologous serum skin test (ASST) and autologous plasma skin test (APST) are simple tests for diagnosing chronic autoimmune urticaria (CAU). However, there are still some questions about the specificity of these tests. This study consisted of 50 patients with chronic spontaneous urticaria (CSU) and 50 sex- and age-matched healthy individuals aged 18 years, and older. A total of 31 (62%) patients and 5 (10%) control patients had positive ASST; 21 (42%) patients and 3 (6%) control patients had positive APST. Statistically significant differences were noted in ASST and APST positivity between the patient and control groups (ASST P < 0.001; APST P < 0.001). Thirteen (26%) patients and 5 (10%) control patients had antithyroglobulin antibodies or antithyroid peroxidase antibody positivity. No statistically significant differences were noted in thyroid autoantibodies between the patient and control groups (anti-TG P = 0.317; anti-TPO P = 0.269). We consider that the ASST and APST can both be used as in vivo tests for the assessment of autoimmunity in the etiology of CSU and that thyroid autoantibodies should be checked even when thyroid function tests reveal normal results in patients with CSU.

EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria

An autoimmune subset of chronic spontaneous urticaria is increasingly being recognized internationally, based on laboratory and clinical evidence that has accrued over the last 20 years. This evidence has been reviewed by a taskforce of the Dermatology section of the European Academy of Allergy and Clinical Immunology. Functional autoantibodies in chronic urticaria (CU) patient sera have been demonstrated against IgE and FcεRIα by basophil and mast cell histamine release assays and by basophil activation assays. Antibody specificity has been confirmed by immunoassay, but there is a poor correlation between functionality and immunoreactivity. Approximately 25% of CU patients have a positive basophil histamine release assay and show autoreactivity (a positive autologous serum skin test), whereas 50% are negative regarding both. Functionality of CU sera appears to be complement dependent on mast cells but not exclusively on basophils. Basophil activation by CU sera is predominantly restricted to IgG1 and IgG3 subclasses. Circumstantial evidence for CU being an autoimmune disease comes from an observed association with other autoimmune diseases, a strong association between serum functionality and HLA-DR4 haplotype and the good response of CU patients to immunotherapies. It was proposed that a study should be undertaken to prospectively validate potentially relevant clinical criteria (from the history, examination and routinely available clinical investigations) against a new 'gold standard' for the diagnosis of ACU (positive autoreactivity, functional bioassay and immunoassay) to define preliminary criteria sets for the diagnosis of ACU based on clinical and laboratory features with highest individual sensitivity and specificity.

PTPN22 polymorphism presumably plays a role in the genetic background of chronic spontaneous autoreactive urticaria

BACKGROUND

The association of chronic urticaria (CU) with autoimmune disorders is relatively well proved. Protein tyrosine phosphatase-22 (PTPN22) is considered to be one of the strongest genetic factors for human autoimmunity. We decided to evaluate whether additional, non 1858C>T, PTPN22 variants are independent contributors to the risk of CU occurrence in the Polish population.

METHODS

A total of 91 CU patients with a positive result of autologous serum skin test and 100 healthy volunteers were enrolled in the study. The Urticaria Activity Score was used in disease intensity assessment. In all subjects rs3811021, rs1310182 and rs2488457 polymorphisms were genotyped.

RESULTS

We found a higher prevalence of -1123 C allele among CU patients. No differences in the allele and genotype distribution were found in the other analyzed polymorphisms. Haplotype construction of the three SNPs revealed statistically significant CU association of rs2488457C, rs1310182T and rs3811021T.

CONCLUSIONS

Contrary to previous findings, the contribution of PTPN22 to disease susceptibility is suggested. We can speculate that CU is a genetically complex disease and that its occurrence needs multiple genetic and environmental risk factors.

The effect of L-thyroxine treatment on chronic idiopathic urticaria and autoimmune thyroiditis

Autoimmune thyroiditis (AT) is more prevalent in patients with chronic idiopathic urticaria CIU) than in the general population. Previous small studies without any controlled comparison reported that CIU remits in patients with CIU and AT treated with L-thyroxine. To determine whether l-thyroxine treatment can improve the clinical course of CIU in patients with the co-occurrence of AT and CIU. A total of 749 patients with CIU were retrospectively studied. Clinical and laboratory evaluation and classification of chronic urticaria were performed according to the EAACI/GA(2)LEN/EDF/WAO guidelines. After L-thyroxine treatment for 53 ± 19 days, euthyroidism was restored in all subjects. Urticaria activity score (UAS) was evaluated at baseline and after three and six months. The control group consisted of matched 44 euthyroid subjects with CIU. A total of 44 (5.9%) patients were diagnosed to have hypothyroidism related to AT. Autologous serum skin test (ASST) was found to be positive in 17 (38.6%) of them. There was no statistically significant difference in baseline UAS, between the ASST+ (3.94 ± 1.52) and the ASST- (3.63 ± 1.42; P = 0.27) hypothyroid subjects and the euthyroid CIU controls (3.73 ± 1.74). During the L-thyroxine treatment, a significant reduction of UAS was observed in both hypothyroid ASST+ and ASST- subjects. However, the mean UAS after three and six months of L-thyroxine treatment remained not significantly different from that in control euthyroid subjects with CIU. L-Thyroxine treatment has no effect on the course of CIU in patients with CIU and AT.

Autoimmune thyroid disease as a risk factor for angioedema in patients with chronic idiopathic urticaria: a case-control study

CONTEXT AND OBJECTIVE

An association between chronic idiopathic urticaria (CIU) and autoimmune thyroid disease (ATD) has been reported. However, there have not been any reports on whether ATD raises the risk of angioedema, which is a more severe clinical presentation of CIU. Thus, the aim of the present study was to evaluate whether the risk of angioedema is increased in patients with CIU and ATD.

DESIGN AND SETTING

Case-control study including 115 patients with CIU at a tertiary public institution.

METHODS

The patients were evaluated with regard to occurrence of angioedema and presence of ATD, hypothyroidism or hyperthyroidism.

RESULTS

Angioedema was detected in 70 patients (60.9%). There were 22 cases (19.1%) of ATD, 19 (16.5%) of hypothyroidism and nine (7.8%) of hyperthyroidism. The risk among patients with ATD was 16.2 times greater than among those without this thyroid abnormality (confidence interval, CI = 2.07-126.86). The odds ratio for hypothyroidism was 4.6 (CI = 1.00-21.54) and, for hyperthyroidism, 3.3 (CI = 0.38-28.36).

CONCLUSIONS

Patients with CIU and ATD presented greater risk of angioedema, which reinforces the idea that a relationship exists between this allergic condition and thyroid autoimmunity. This finding could imply that such patients require specifically directed therapy.

Idiopathic chronic urticaria and thyroid autoimmunity: Experience of a single center

Urticaria is one of the most frequent dermatosis, being its prevalence in general population estimated about 20%. This prospective case-control study was aimed at determining the prevalence of thyroid autoimmune disorders in a cohort of patients with chronic urticaria (CU), all living within an area with mild-to-moderate iodine deficiency. Fifty four consecutive patients affected by CU were recruited and compared to 108 healthy controls. Assessment of the thyroid function included measurement of serum concentrations of TSH, FT3, FT4, anti-thyreoglobulin (anti-TG) and anti-peroxidase (anti-TPO) antibodies. Ultrasound scan of the thyroid gland was performed in all subjects using a 7.5 MHz linear transducer. All subjects were followed up for 6 months. The prevalence of thyroid antibodies was significantly higher in our cohort of patients with CU than in controls (22% vs. 6.5 %). Hashimoto's thyroiditis was also more frequent in patients than controls (18.5% vs. 1.8%). These frequencies do not differ from those previously reported by some other authors and confirm the association between CU and thyroid autoimmunity also in the area of iodine deficiency. However, presence of antibodies or thyroiditis does not seem to influence clinical course of CU. These results suggest that screening for thyroid function may be useful in all the patients with CU.

Urticaria and thyroid autoimmunity

BACKGROUND

Chronic urticaria is a common clinical condition whose etiology, in about 75% of cases, is unknown and is therefore called chronic idiopathic urticaria (CIU). A link between CIU and autoimmune thyroid diseases was proposed several decades ago. Here we review this topic.

SUMMARY

Several studies have been performed to determine if and to what degree there is an association between CIU and autoimmune thyroid diseases, particularly autoimmune thyroiditis. Many of these studies were not well controlled, however. Approximately one-fourth of CIU patients have serological evidence of thyroid autoimmunity, suggesting that these two disorders are associated. The mechanisms for the apparent association between CIU and serological evidence of thyroid autoimmunity are not clear. There are no data regarding the correlations between CIU and histological features of autoimmune thyroiditis or hypothyroidism. Despite this, there are anecdotal reports regarding L-thyroxine administration in patients with CIU.

CONCLUSIONS

Screening for thyroid autoimmunity is probably useful in patients with CIU. More solid evidence, based on still lacking well-conducted controlled studies, is desirable to determine if there is a therapeutic role for L-thyroxine treatment in ameliorating the skin manifestations of urticaria.

First use of thymus transplantation therapy for FOXN1 deficiency (nude/SCID): a report of 2 cases

FOXN1 deficiency is a primary immunodeficiency characterized by athymia, alopecia totalis, and nail dystrophy. Two infants with FOXN1 deficiency were transplanted with cultured postnatal thymus tissue. Subject 1 presented with disseminated Bacillus Calmette-Guérin infection and oligoclonal T cells with no naive markers. Subject 2 had respiratory failure, human herpes virus 6 infection, cytopenias, and no circulating T cells. The subjects were given thymus transplants at 14 and 9 months of life, respectively. Subject 1 received immunosuppression before and for 10 months after transplantation. With follow up of 4.9 and 2.9 years, subjects 1 and 2 are well without infectious complications. The pretransplantation mycobacterial disease in subject 1 and cytopenias in subject 2 resolved. Subject 2 developed autoimmune thyroid disease 1.6 years after transplantation. Both subjects developed functional immunity. Subjects 1 and 2 have 1053/mm(3) and 1232/mm(3) CD3(+) cells, 647/mm(3) and 868/mm(3) CD4(+) T cells, 213/mm(3) and 425/mm(3) naive CD4(+) T cells, and 10 200 and 5700 T-cell receptor rearrangement excision circles per 100 000 CD3(+) cells, respectively. They have normal CD4 T-cell receptor β variable repertoires. Both subjects developed antigen-specific proliferative responses and have discontinued immunoglobulin replacement. In summary, thymus transplantation led to T-cell reconstitution and function in these FOXN1 deficient infants.

Activation of blood coagulation in autoimmune skin disorders

The immune system and blood coagulation are simultaneously activated in several inflammatory systemic disorders, such as lupus erythematosus, rheumatoid arthritis and inflammatory bowel diseases. Proinflammatory cytokines, such as IL-6 and TNF-alpha, induce the expression of tissue factor, the main initiator of blood coagulation. Activated proteases of coagulation in turn act on protease-activated receptors, inducing the expression of various proinflammatory cytokines. This cross-talk between inflammation and coagulation amplifies and maintains the activation of both systems. This review focuses on three skin disorders: chronic urticaria (CU), which is considered autoimmune in approximately 50% of cases, bullous pemphigoid (BP), which is the prototype of autoimmune blistering disease, and psoriasis, which is an immune-mediated dermatitis. In CU, the activation of coagulation, which is due to the involvement of eosinophils and tissue factor pathways with the generation of thrombin, has local implications by increasing dermal vascular permeability. Preliminary data indicate that anticoagulant treatment with heparin and warfarin may be effective in reducing the symptoms of this disorder. In BP, the activation of coagulation seems to have both local and systemic implications. Locally, eosinophils and thrombin participate in bulla formation and tissue damage; systemically, the activation of coagulation may explain the increased thrombotic risk observed in these patients. In psoriasis, the activation of coagulation seems to be mainly systemic, potentially contributing to the increased cardiovascular risk associated with this disease.

Activation of blood coagulation in chronic urticaria: pathophysiological and clinical implications

Chronic urticaria (CU) is a skin disorder characterized by the recurrent eruption of short-lived wheals accompanied by redness and itching for at least 6 weeks. The wheals can be associated with angioedema. CU is considered an autoimmune disease in about 50% of cases with the presence of circulating histamine releasing autoantibodies mainly directed against the high affinity IgE receptor FcepsilonRI on mast cells and basophils or against IgE. In several CU cases regarded as idiopathic; the actual pathophysiological mechanisms are still unknown. Some patients with CU do not respond to antihistamines and require the use of systemic steroids or cyclosporin, which are, however, not always effective. In CU, several investigators have demonstrated the activation of coagulation that is due to the involvement of eosinophils and a tissue factor pathway with generation of thrombin potentially contributing to an increased vascular permeability. CU patients often present with elevation of coagulation and fibrinolysis markers, such as prothrombin fragment F1+2 and D: -dimer, which correlate with the disease severity. Preliminary data indicate that anticoagulant treatment with heparin and warfarin may be effective in reducing the symptoms of this disorder. Taken together, all these findings provide the rationale for proposing clinical trials on the use of anticoagulant drugs as adjuvant treatment in CU patients.

Lack of a role for cross-reacting anti-thyroid antibodies in chronic idiopathic urticaria

The etiology of chronic idiopathic urticaria (CIU) is attributed to autoantibodies directed against the alpha-chain of the high-affinity IgE receptor (FcepsilonRIalpha) or IgE on mast cells in 30-60% of patients. Approximately 30% of CIU patients have Hashimoto's thyroiditis (HT). We investigated the pathophysiologic relationship of anti-thyroid and anti-FcepsilonRIalpha antibodies. Nine individuals with both CIU and HT underwent autologous serum skin testing (ASST) and sera were assayed for thyroid autoantibodies, thyroid-stimulating hormone, and anti-FcepsilonRIalpha antibodies. Serum samples were studied for their ability to activate a human mast cell line (LUVA) as determined by cysteinyl leukotriene (CysLT) production. Experiments were performed to determine whether epitope cross-reactivity could explain the high incidence of HT found in CIU patients. A significant proportion of CIU patients had a positive ASST (nine of six) and anti-FcepsilonRIalpha antibodies (six of nine). Incubation of patient sera with FcepsilonRIalpha, but not thyroglobulin or thyroid peroxidase, resulted in the decreased ability to detect anti-FcepsilonRIalpha antibodies. Incubation with thyroid antigens did not inhibit CysLT production by mast cells. Epitopic cross-reactivity does not explain the increased prevalence of HT found in CIU patients. The frequent concurrence of HT and CIU likely reflects a genetic tendency toward autoimmune diseases.

Levothyroxine versus ketotifen in the treatment of patients with chronic urticaria and thyroid autoimmunity

BACKGROUND

Thyroid hormone replacement therapy has previously been discussed as a feasible therapeutic approach in patients with chronic urticaria and/or angio-oedema (CUA) and thyroid autoimmunity (TA).

OBJECTIVE

The efficacy of levothyroxine was investigated in patients with CUA and TA by comparing it with ketotifen treatment.

METHODS

A total of 60 patients with CUA and TA were included in the study. Patients were divided into two groups, which were matched with respect to sex, age and symptom score. Each group consisted of 30 patients. Patients in one group were treated with ketotifen and the other with levothyroxine. After completion of the treatment periods, the pre- and post-treatment symptom scores, onset time of drug effects, duration of symptom-free period, recurrence ratios, recurrence times and side effects were evaluated for each drug. The two drugs were compared with each other according to these parameters.

RESULTS

Ketotifen treatment provided significant relief of symptoms. However, these beneficial effects were observed only in ongoing treatment. Symptoms reappeared in all patients during the drug-free follow-up period. On the other hand, 18 of 30 patients were completely improved and three patients partially improved with levothyroxine treatment. Symptoms did not recur in the completely improved patients.

CONCLUSION

Levothyroxine is an important and inexpensive treatment alternative in patients with CUA and TA.

EAACI/GA(2)LEN task force consensus report: the autologous serum skin test in urticaria

Injection of autologous serum collected during disease activity from some patients with chronic spontaneous urticaria (CU) into clinically normal skin elicits an immediate weal and flare response. This observation provides a convincing demonstration of a circulating factor or factors that may be relevant to the understanding of the pathogenesis and management of the disease. This test has become known as the autologous serum skin test (ASST) and is now widely practised despite incomplete agreement about its value and meaning, the methodology and the definition of a positive response. It should be regarded as a test for autoreactivity rather than a specific test for autoimmune urticaria. It has only moderate specificity as a marker for functional autoantibodies against IgE or the high affinity IgE receptor (FcepsilonRI), detected by the basophil histamine release assay, but high negative predictive value for CU patients without them. It is usually negative in other patterns of CU, including those that are physically induced. Positive ASSTs have been reported in some subjects without CU, including those with multiple drug intolerance, patients with respiratory allergy and healthy controls, although the clinical implications of this are uncertain. It is essential that failsafe precautions are taken to ensure that the patient's own serum is used for skin testing and aseptic procedures are followed for sample preparation and handling. CU patients with a positive ASST (ASST(+)) are more likely to be associated with HLADR4, to have autoimmune thyroid disease, a more prolonged disease course and may be less responsive to H1-antihistamine treatment than those with a negative ASST (ASST(-)) although more evidence is needed to confirm these observations conclusively.

Type 1 diabetes, autoimmune thyroid disease, and chronic urticaria

A 12-yr-old boy initially presented with chronic urticaria. Autoimmune thyroid disease was then diagnosed during routine evaluation. He developed type 1 diabetes shortly after thyroid hormone replacement was initiated. This case emphasizes the importance of routine screening for other autoimmune disorders in patients in whom one disorder is already present.

[Assessment of association between autoimmune thyroid disease and chronic urticaria]

Several studies found a higher prevalence of Autoimmune Thyroid Disease (ATD) in patients with Chronic Urticaria (CU). This relationship may be due to the possible autoimmune etiology in up to one third of the cases of Chronic Idiopathic Urticaria (CIU). However, the frequency of ATD ranged from 1.14% to 28.6%. The study began by determining whether there is an association between ATD and CU, in a population seen at the same clinic. We compared the frequency of anti-thyroid antibodies and thyroid dysfunction in 49 patients with CIU (group 1) and 112 controls (group 2). In order to support the result found, we studied the prevalence of CIU in 60 patients with ATD (group 3) and compared with 29 patients who had non-immune thyroid disease (NITD) (group 4). We did not find a statistical difference for the presence of anti-thyroid antibodies or thyroid dysfunction between groups 1 and 2 (12.24% x 9.82% and 12.24% x 7.14%, respectively). The same occurred for the presence of CIU among groups 3 and 4 (3.33% x 3.44%). In our study it was not possible to demonstrate a relationship between ATD and CIU, which means that different populations may present a higher or lower degree of association between these illnesses.

Autoimmunity and complement in the pathogenesis of chronic urticaria

Chronic urticaria is a debilitating skin disease that is believed to have an underlying autoimmune etiology in 35% to 50% of cases. Patients with autoimmune urticaria have functional antibodies in their sera that release histamine from basophils and mast cells. The C5a component of complement is required for mast cell degranulation in this process and at least augments basophil histamine release. In this article, the evidence that is key to our understanding of autoimmunity and complement in the pathogenesis of a subset of patients with chronic urticaria is outlined. Some of the issues in testing for and treating autoimmune urticaria are discussed.

The thyroid and urticaria

PURPOSE OF REVIEW

Although it is generally accepted that thyroid autoimmunity is more prevalent in patients with chronic urticaria than in the general population, the importance of this finding is unclear. In addition, there are reports that chronic urticaria remits in some but not all patients who have evidence of thyroid autoimmunity and are treated with l-thyroxine. This review will summarize the history of this controversy and suggest a possible role for thyroid autoimmunity in the pathophysiology of chronic urticaria.

RECENT FINDINGS

Important subsets of patients with chronic urticaria have autoantibodies to the high-affinity receptor for IgE (FcepsilonRI), anti-IgE, and antithyroid antibodies. Patients with chronic urticaria and biochemical evidence of thyroid autoimmunity may have active thyroid disease or may be clinically euthyroid. These patients are often poorly responsive to conventional therapy of urticaria and may have more chronic disease. New findings on the pathogenic effects of anti-FcepsilonRI auto-antibodies and of antithyroid antibodies have revealed a role for complement activation.

SUMMARY

Currently, there are no compelling arguments to decide whether or not thyroid autoimmunity plays a significant role in the pathogenesis of chronic urticaria. New developments concerning a role for complement activation in the pathogenesis of chronic urticaria may, however, lead to better understanding of this phenomenon in the future.

Urticária

A urticária apresenta-se com diversas formas clínicas e causas distintas. Constitui uma das dermatoses mais freqüentes: 15% a 20% da população têm pelo menos um episódio agudo da doença em sua vida, resultando em percentual que varia de um a 2% dos atendimentos nas especialidades de Dermatologia e Alergologia. A urticária é classificada do ponto de vista de duração da evolução temporal em aguda (inferior a seis semanas) ou crônica (superior a seis semanas). O tratamento da urticária pode compreender medidas não farmacológicas e intervenções medicamentosas, as quais são agrupadas em tratamentos de primeira (anti-histamínicos), segunda (corticosteróides e antileucotrienos) e terceira linha (medicamentos imunomoduladores). As medidas terapêuticas de segunda e terceira linha apresentam maiores efeitos adversos, devendo ser reservadas aos doentes que não apresentaram controle da doença com os de primeira linha, ou àqueles a respeito dos quais não é possível estabelecer uma etiologia, tal como nas urticárias auto-imunes.

Thyroid autoimmunity in chronic urticaria

BACKGROUND

Chronic urticaria (CU) is an autoimmune process in some patients. An association between CU and autoimmune thyroid disease has also previously been proposed. Our group has identified functionally significant histamine-releasing autoantibodies in one subset of CU patients (subset 1), predicted by positive autologous intradermal serum tests and positive histamine release from donor basophil leucocytes in vitro. Sera from a second subset of patients (subset 2), all of whom had positive autologous intradermal serum tests, failed to release histamine from donor basophils. A final disease subset (subset 3) has no identifiable skin reactivity (negative autologous serum skin test) or in vitro histamine releasing activity.

OBJECTIVES

In order to examine further the possible relationships between thyroid autoimmunity, thyroid dysfunction and CU, we have examined thyroid autoantibodies and thyroid-stimulating hormone (TSH) levels (an indirect measure of thyroid dysfunction) in the three CU subsets.

PATIENTS/METHODS

We studied 182 patients (69% female), of whom 90 had a positive autologous intradermal serum test.

RESULTS

Eighteen skin test-positive and four skin test-negative patients had thyroid microsomal antibodies (TMA). TSH outside the normal range was found in 13 skin test-positive and one skin test-negative patient. These findings represent clustering of TMA positivity [risk ratio (RR) 4.06, 95% confidence interval (CI) 1.56-10.6] and of abnormal thyroid function (RR 15.5, CI 2.07-11.6) among the skin test-positive patients. However, in the overall study group an elevated TSH was present in seven patients (3.8%, CI 1.6-7.8) comparable to the 5% expected prevalence in the community. Thyroglobulin antibodies (TGA) were present in two of 182 patients.

CONCLUSIONS

There were significant differences between skin test-positive and skin test-negative patients with regard to autoimmune thyroid disease. Evidence for autoimmune thyroid disease and abnormal thyroid function was largely found among the skin test-positive patients, supporting the theory of an autoimmune aetiology in this group.

Improvement of chronic idiopathic urticaria with L-thyroxine: a new TSH role in immune response?

BACKGROUND

The association between chronic idiopathic urticaria (CIU) and autoimmune thyroiditis (AT) is known, as well as major prevalence of antithyroid antibodies in the allergical subjects and other autoimmune diseases. We have evaluated the effects of l-thyroxine on clinical symptoms of CIU in AT patients suggesting the hypothesis of a new thyroid-stimulating hormone (TSH) role in immune system.

METHODS

In 20 female patients with CIU + AT, both hypothyroid and euthyroid, we have investigated the therapeutic effects of l-thyroxine dosed to suppress the TSH. Free-T3, Free-T4, TSH, antithyroperoxidase and antithyroglobulin antibodies, total immunoglobulin (Ig)E, Rheuma test and eritro-sedimentation rate were monitored during treatment.

RESULTS

In 16 patients a strong decrease of urticaria symptoms has happened after 12 weeks. The TPO Ab and HTG Ab clearly decreased in 14 patients. Furthermore, in two patients with rheumatoid arthritis and in two patients with pollen allergy a strong decrease of rheuma test titer and total IgE has happened.

CONCLUSION

The reason of AT is associated to CIU and others allergical and autoimmune diseases is poorly known. The exclusive hormonal therapy reduces the symptoms of CIU and inflammatory response in many chronic diseases associated to AT. We suggest a stimulatory effect of TSH able to produce considerable changes of the immune response and immune tolerance in patients with AT causing target organs damage. The causal mechanism involves immune, nervous and endocrine system, sharing a common set of hormones, cytokines and receptors, in a unique totally integrated loop (the neuro-immuno-endocrine axis).

Autoimmune urticaria

A growing body of evidence shows that at least 40% of patients with unexplained (idiopathic) chronic urticaria have clinically relevant functional autoantibodies to the high-affinity IgE receptor on basophils and mast cells. The term "autoimmune urticaria" is used for this subgroup of patients presenting with continuous ordinary urticaria. This article reviews the evidence for the autoimmune hypothesis and other nonantibody serum histamine-releasing factors in the etiopathogenesis of urticaria; defines autoimmune urticaria; looks at how autoimmune urticaria fits into existing classifications of urticaria; proposes diagnostic criteria that may be useful to the clinician; and reviews the management implications for patients with this subset of chronic disease.

Clinical and laboratory parameters in predicting chronic urticaria duration: a prospective study of 139 patients

BACKGROUND

Despite the disabling nature of chronic urticaria (CU), little is known about the disease's duration or the efficacy of adopting aggressive therapeutic regimens such as cyclosporine A.

OBJECTIVES

The aim of this study was to evaluate whether parameters such as angioedema, autologous serum test, anti-thyroid antibodies, and total IgE could predict both CU duration and severity.

PATIENTS AND METHODS

One hundred and thirty-nine patients suffering from CU were prospectively followed over a 5-year period for disease duration, severity and the presence of angioedema. Also investigated was the association between these clinical parameters and the subsequent detection of autologous serum test, anti-thyroid antibodies, and total IgE.

RESULTS

CU lasted over 1 year in more than 70% of cases and in 14% it still existed after 5 years. Angioedema co-existed or appeared during the course of CU in 40% of patients and was associated with disease duration. Autologous serum test and anti-thyroid antibodies were found positive in 28 and 12% of patients, respectively, compared to none of normal individuals, P = 0.001. CU duration was associated with the presence of both autologous serum test and anti-thyroid antibodies; however, autologous serum test and not anti-thyroid antibodies was found in association with CU severity.

CONCLUSION

We demonstrate for the first time that CU duration is associated with clinical parameters such as severity and angioedema, and with laboratory parameters such as autologous serum test and anti-thyroid antibodies. The ability to predict CU duration may facilitate decisions regarding the possible early initiation of cyclosporine A as a means by which to reduce disease severity and duration.

Basophil CD63 expression assay on highly sensitized atopic donor leucocytes-a useful method in chronic autoimmune urticaria

BACKGROUND

The autoimmune subclass of chronic idiopathic urticaria (CU) has been characterized by the occurrence of biologically relevant IgG antibodies against the IgE molecule or the alpha chain of the high-affinity Fcepsilon receptor (FcepsilonRIalpha) on basophils and mast cells. These antibodies are usually detected by autologous serum skin testing and confirmed by histamine release studies, immunoblotting, or enzyme-linked immunosorbent assay, but not always.

OBJECTIVES

To detect autoantibodies to the FcepsilonRIalpha in sera of CU patients by a modified serum-induced basophil activation test measured by flow cytometry (FCM) and to evaluate the relationship between the in vitro functional test, the autologous serum skin test (ASST), and the serum levels of IgE, eosinophil cationic protein (ECP) and antithyroid antibodies.

METHODS

Sera of 30 patients with CU and 26 patients with systemic autoimmune diseases (systemic lupus erythematosus, dermatomyositis) were tested for CD63 activation marker expression on basophils by FCM. Leucocytes from two highly sensitized atopic donors (D(A1,) D(A2)) and one non-atopic donor (D(NA)) were incubated with patients' sera and double-labelled with anti-IgE and anti-CD63 antibodies. Subsequently, the percentage of CD63-expressing basophils was determined by using FCM. In all CU patients an ASST was carried out and the serum IgE, and ECP levels and antithyroid antibodies were evaluated.

RESULTS

Twelve patients had a positive ASST and 14 patients a positive CD63 expression assay. There was a strong correlation between the ASST and CD63 assay. Sera from patients with systemic autoimmune diseases did not raise positive CD63 expression on basophils. There was a moderate negative correlation between the occurrence of atopic serum markers (IgE, ECP) and the ability of sera to induce CD63 expression on basophil cells of D(A2) (P < 0.05). The female sex was preponderant and antithyroid antibodies were more frequent.

CONCLUSIONS

Our new technical observation demonstrates that basophils of highly sensitized atopic donors can be successfully used without priming with IL-3 for the in-vitro flow cytofluorimetric diagnosis of CU. With this investigation the characterization of the autoimmune origin of CU is based on an objective in vitro technique.

Association between chronic urticaria and thyroid autoimmunity: a prospective study involving 99 patients

BACKGROUND

The association between chronic urticaria and thyroid autoimmunity has been a subject of debate. However, this link was suggested in studies searching thyroid microsomal antibodies (TMA), which are less sensitive and less specific than anti-thyroperoxidase antibodies, moreover these studies did not measure anti-TSH receptor antibodies, nor did they use a control group. As a consequence, the results of these studies are difficult to interpret.

OBJECTIVE

The aim of this study was to determine whether chronic urticaria is statistically associated with thyroid autoimmunity.

METHODS

In a prospective case-control study, we compared the frequency of thyroid autoantibodies in 45 patients with chronic urticaria and in 30 healthy adult volunteers; we also compared the frequency of chronic urticaria in 32 patients with thyroid diseases with thyroid autoantibodies and in 22 patients with thyroid diseases without thyroid autoantibodies. Thyroid autoantibodies and thyroid hormones were measured in all the subjects; antinuclear antibodies, rheumatoid factors, complement, IgE were assessed and routine laboratory tests were done in patients with chronic urticaria. Fisher's exact statistics were used to test our hypothesis.

RESULTS

The frequency of thyroid autoantibodies was significantly higher in patients with chronic urticaria than in healthy controls (26.7%/3.3%; p < 0.01). All the patients with thyroid autoantibodies had thyroid hormone concentrations within the normal limits. The frequency of chronic urticaria was not significantly different (12.5%/9.1%; p = 0.7) in patients with thyroid diseases with or without thyroid antibodies. The rest of the biological investigations revealed only 1 patient with connective tissue disease.

CONCLUSION

This study shows a significant association between chronic urticaria and thyroid autoimmunity, and that tests to detect thyroid autoantibodies are relevant in patients with chronic urticaria, whereas extensive laboratory tests are not.

Chronic urticaria and thyroid disease

Because the association of thyroid disease with pruritus and urticaria dates back more than 50 years, many investigators have commented on the possible link between autoimmune thyroid disease and chronic urticaria. This article summarizes an evolving body of literature linking these two conditions and discusses potential mechanisms as to how they concomitantly occur. Treatment options used to manage and control the urticaria are discussed with a focus on how the thyroid gland may have a role in the possible mechanism leading to chronic urticaria in this setting and how thyroid hormone may contribute to resolution of this condition.

The etiology of different forms of urticaria in childhood

Urticaria is a common disease in children. In contrast to the ease of its diagnosis, etiologic factors are often difficult to determine. In order to study whether differences exist among various forms of urticaria in childhood and whether the patterns of different types of urticaria differ between adults and children, we extensively studied the possible causes of urticaria in children. Fifty-four children (23 girls and 31 boys; ages 1-19 years) with various forms of urticaria were included in the study. In all cases, questions about food allergies, food additive intolerance, drug intake, signs of infection, causes of physical urticaria, insect bites, and personal and family history of atopy were asked. Clinical characteristics of the disease, such as duration, recurrence, and associated angioedema and symptoms of anaphylaxis were also investigated. Detailed laboratory tests, including serologic, autoimmune, and allergic analyses, were conducted to reveal the probable etiologies of urticaria. Of the study patients, 68.5% and 31.5% were diagnosed as having acute and chronic urticaria, respectively. The patient group with chronic urticaria was older and included more boys than the acute group. In the acute urticaria group, infection was the most frequently documented cause (48.6%), followed by drugs (5.4%), and food allergies (2.7%), whereas in chronic urticaria, physical factors were the leading cause (52.94%). The most frequently documented infection was urinary tract infection, followed by serologically determined infections of Chlamydia pneumoniae and Helicobacter pylori. In this study we found indications that infections were frequently associated with urticaria, which suggests that urticaria management should include a survey of certain infectious agents in addition to a detailed history.

Autoantibody production in chronic idiopathic urticaria is not associated with Helicobacter pylori infection

Chronic idiopathic urticaria (CIU) is a dermatological syndrome, characterized by raised erythematous skin lesions, that affects 20% of the general population and has been associated with autoimmunity. However, some reports have also suggested a close relationship between CIU and Helicobacter pylori infection, which is endemic in developing countries and associated with chronic gastritis, peptic ulcer disease, and gastric carcinoma. In the present study, we investigated the occurrence of autoantibodies in sera from 23 CIU subjects infected with H. pylori and from 23 CIU subjects without this infection. The presence of anti-thyroid antibodies was determined by indirect hemagglutination assay and the presence of autoantibodies to IgE and C1INH was determined by ELISA. Antibodies to thyroid antigens were detected at low titers from 100 to 400 in three of 23 (13%) CIU-infected subjects and in four of 23 (17%) CIU-noninfected subjects. The titers of anti-IgE autoantibodies were similar in these CIU groups, presenting absorbances of 1.16 +/- 0.09 and 1.07 +/- 0.16, respectively, while a titer of 1.14 +/- 0.15 was detected in the healthy control group. The concentration of anti-C1INH autoantibodies was the same in the CIU-infected and -noninfected subjects (7.28 +/- 1.31 and 7.91 +/- 2.45 ng/ml, respectively), and was 7.20 +/- 2.25 ng/ml in the healthy control group. However, the serum levels of complexed anti-C1INH antibodies were increased in CIU-infected subjects compared to CIU-noninfected subjects and healthy controls with an absorbance of 1.51 +/- 0.21 vs 1.36 +/- 0.16 and 1.26 +/- 0.23, respectively (P<0.05), indicating an impaired clearance of immune complexes in CIU-infected patients. In conclusion, no correlation was observed between H. pylori infection and autoantibody production in CIU patients consistent with reports of clinical studies.