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

Chronic Spontaneous Urticaria in Belgium: Deciphering the Clinical Profile and Treatment of Patients Visiting an Urban City Immunology Department

BACKGROUND

Chronic urticaria (CSU) is a chronic inflammatory mast cell-driven disorder of which reliable clinical data in Belgium are lacking. This study focusses on clinical characteristics of CSU patients presenting at an urban Immunology-Allergology department.

METHODS

Outpatients with CSU were included from 2018 to 2021. Clinical characteristics, Dermatology Life Quality Index (DLQI) and Urticaria activity score (UAS7) were collected by thorough anamnesis and questionnaires. Furthermore, patients underwent provocational testing, an autologous serum skin test (ASST) and a blood analysis.

RESULTS

The study included 49 CSU patients and 20 non-CSU subjects. CSU was distributed differently with age and sex, showing higher numbers in female patients below the age of 46 years. 67% of CSU patients had accompanying angioedema of which 9% were reported genital. CSU patients scored a mean 8/30 on their DLQI questionnaire. There was no significant difference in immunoglobulin E (IgE), C-reactive protein, and tryptase levels between CSU patients and controls. Oral glucocorticosteroids were prescribed in 23% of CSU patients during their disease course though only half of these patients had a severity grade 4 CSU. In 82% of the included CSU patients, Urticaria Control Test (UCT) scores were below 12. When we hypothetically considered low IgE levels and high IgG anti-thyroid peroxidase levels as differentiation marker for autoimmune (ai)CSU and non-aiCSU, we found that 4% of all included CSU patients could be considered aiCSU.

CONCLUSION

Generally, the inner-city population displayed the same clinical characteristics, as previous cohorts from Northern Europe. The relatively high rate of CSU patients receiving oral glucocorticosteroid treatment for their disease though not always classified as severe, underlines the need to train doctors of various specialties in the treatment algorithms of CSU. Furthermore, by looking at potential autoimmune characteristics, our findings open perspectives on the identification of new routinely used clinical parameters for the detection of aiCSU, a relatively small immunological subtype of CSU.

Dermatologic manifestations of thyroid disease: a literature review

Introduction

Thyroid hormone is considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3) further regulating various functions at a cellular level. Specifically, skin is considered an important target organ in which the thyroid hormone has a significant impact. Multiple skin diseases are associated with thyroid hormone dysregulation. However, other striking dermatologic manifestations are seen in nails and hair as well. Hypothyroidism, hyperthyroidism, and thyroid cancer can have an array of cutaneous manifestations, and we present the recent updates in this field.

Methods

A PubMed search was performed for updates in any new skin disease findings and treatments between 2010 and 2022. Research published in the past decade and previously known foundational skin findings associated with thyroid disease were presented in this review.

Conclusion

Cutaneous manifestations of thyroid disease is one of the first notable signs of thyroid hormone dysregulation. This article reviews the recent updates on the thyroid and skin interplay, and it further discusses overt visible findings and various available treatment modalities.

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.

Associations between phthalate exposure and thyroid function in pregnant women during the first trimester

Phthalates are a class of environmental endocrine disruptors. Previous studies have demonstrated that phthalate exposure can affect thyroid function; however, limited studies have assessed the associations between phthalate exposure and thyroid function, especially thyroid autoimmunity in pregnant women during the first trimester. We recruited participants from a cohort of pregnant women in Beijing, China, and collected urine samples to measure ten phthalate metabolites, serum samples to measure free thyroxine (FT₄), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb) during the first trimester. We included 325 pregnant women without thyroid diseases or dysfunction in this study. Associations between phthalate metabolites and thyroid function parameters were assessed with the Bayesian kernel machine regression (BKMR) model, multiple linear regression model, and restricted cubic spline. In the BKMR model analysis, compared to the 50th percentile, total urinary phthalate metabolites levels were negatively associated with serum TPOAb levels when phthalate metabolites were at or below the 40th percentile. Stratifying by body mass index, total urinary phthalate metabolites levels were negatively associated with serum TPOAb levels in normal weight women when phthalate metabolites were at or below the 45th percentile. However, total urinary phthalate metabolites levels were positively associated with serum TPOAb levels in underweight women when phthalate metabolites were at or below the 30th percentile. In restricted cubic spline analysis, L-shaped nonlinear associations of mono-(2-ethyl-5-carboxypentyl) phthalate (MECPP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), di-(2-ethylhexyl) phthalate (ΣDEHP), and inverted S-shaped nonlinear association of mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP) with TPOAb were observed. In conclusion, our findings suggest that phthalate exposure may affect thyroid autoimmunity in underweight pregnant women during early pregnancy, and the potential effects of phthalate exposure on thyroid autoimmunity may be nonlinear.

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.

Expertenkonsensus zu praxisrelevanten Aspekten bei der Behandlung der chronischen Urtikaria

Hintergrund: Die chronische Urtikaria (CU) ist eine häufige und für viele Patienten stark belastende Erkrankung. Die aktuelle Urtikaria-Leitlinie beschreibt die evidenzbasierte Diagnostik und Therapie der CU. Darüber hinaus treten jedoch oftmals Fragen im praktischen Alltag auf, die durch die Leitlinie nicht beantwortet werden.

Methoden: Im Mai 2020 fand ein digitales Treffen deutscher Urtikaria-Experten statt, in dem praxisrelevante Aspekte der Behandlung der CU erörtert und unterstützende Hilfestellungen für den klinischen Behandlungsalltag formuliert wurden. Die resultierenden Hinweise dieses Dokumentes fokussieren auf praktische Fragen und der hierzu verfügbaren Literatur und Erfahrungen der Teilnehmer.

Ergebnisse: Die Diagnose einer CU kann in kurzer Zeit mittels gründlicher Anamnese, einer körperlichen Untersuchung und einer laborchemischen Basisdiagnostik gestellt werden. Hierzu werden in dieser Arbeit praktische Empfehlungen für den Praxisalltag gegeben. Eine erweiterte Diagnostik ist nur in wenigen Fällen indiziert und sollte grundsätzlich parallel zu einer effektiven Therapie erfolgen. Generell gilt, dass die CU immer auf gleiche Weise zu therapieren ist, unabhängig davon, ob Quaddeln, Angioödeme oder beides auftreten. Eine symptomatische Therapie sollte nach dem von den Leitlinien empfohlenen Stufenschema erfolgen. Die vorliegende Publikation gibt hierzu praktische Hinweise für Fragen in der Praxis, wie zum Beispiel dem Vorgehen in der aktuellen COVID-19-Pandemie, dem kardialen Risiko unter höher dosierten H 1-Antihistaminika, der Selbstapplikation von Omalizumab sowie dem Impfen unter Omalizumab-Therapie. Zusätzlich zu den Behandlungsempfehlungen werden Themen wie die Dokumentation in der Praxis und Familienplanung bei Urtikaria besprochen.

Diskussion: Diese unterstützenden Behandlungsempfehlungen dienen als Ergänzung zu den aktuellen Leitlinien der CU und geben beim Umgang mit Patienten mit CU eine Hilfestellung für den Praxisalltag. Ziel ist es, dass Patienten, die unter einer CU leiden, mithilfe einer optimalen Therapie eine vollständige Beschwerdefreiheit erreichen.

Expert consensus on practical aspects in the treatment of chronic urticaria

Background

Chronic urticaria (CU) is a common disease which represents a considerable burden for many patients. The current urticaria guideline describes the evidence-based diagnosis and treatment of CU. In addition, however, questions often arise in everyday practice that are not addressed by the guideline.

Methods

In May 2020, a digital meeting with German urticaria experts was held, in which practical aspects of CU treatment were discussed and supporting aids for everyday clinical treatment formulated. The resulting advice in this document focus on practical questions and the available literature and experiences of the participants.

Results

The diagnosis of CU can be made in a short time by means of a thorough anamnesis, a physical examination, and a basic laboratory chemical diagnosis. For this purpose, practical recommendations for everyday practice are given in this paper. An extended diagnosis is only indicated in a few cases and should always be carried out in parallel with an effective therapy. In general, CU should always be treated in the same way, regardless of whether wheals, angioedema or both occur. Symptomatic therapy should be carried out according to the treatment steps recommended by the guidelines. This publication provides practical advice on issues in everyday practice, such as the procedure in the current coronavirus disease 2019 (COVID-19) pandemic, the cardiac risk under higher dosed H1 antihistamines, the self-administration of omalizumab as well as vaccination under omalizumab therapy. In addition to treatment recommendations, topics such as documentation in the practice and family planning with urticaria will be discussed.

Discussion

These supporting treatment recommendations serve as an addendum to the current CU guideline and provide support in dealing with CU patients in everyday practice. The aim is to ensure that patients suffering from CU achieve complete freedom of symptoms with the help of an optimal therapy.

Supplementary Information

The online version of this article (10.1007/s40629-021-00162-w) contains supplementary material, which is available to authorized users.

Chronic spontaneous urticaria and angioedema in a patient with autoimmune thyroid disease resolved after thyroidectomy

The link between chronic urticaria and accompanying thyroid disease is still not understood, with current treatment focusing on antihistamines and levothyroxine. A 35-year-old female patient presented with chronic idiopathic urticaria and facial angioedema for 9 months prior to evaluation. Oral corticosteroid therapy, antihistamines, leukotriene-antagonists, selenium, and omalizumab were all administered, with the disease relapsing within several days, accompanied with facial angioedema of varying severity. Laboratory results were negative for antinuclear antibodies (ANA) and cytoplasmic antineutrophil antibodies (ANCA). Immunoglobulins and complement levels were normal. Autologous serum testing, and skin-prick test for common inhalatory allergens were all normal. Levothyroxine was then administered with no effect on the symptoms. After considering all of the available treatment options, the patient decided to undergo total thyroidectomy. Urticaria and angioedema subsided on the third postoperative day, and she remains free of symptom recurrence during 10 months of postoperative follow-up. Her antiTPO titer decreased from > 1300 to 31.1 kIU/L and antiTG decreased from 272 to 4.9 kIU/L three months after the surgery. The most important element in this case report is an unexpected extra-thyroid presentation of an autoimmune thyroid disease, with a newly described association with facial angioedema. Additional important evidence may confirm the hypothesis that both conditions are indeed caused by a common immunological patohogenetic pathway that should be routinely evaluated in patients presenting with chronic idiopathic urticaria.

Presence of positive skin prick tests to inhalant allergens and markers of T2 inflammation in subjects with chronic spontaneous urticaria (CSU): a systematic literature review

BACKGROUND

Current guidelines do not recommend performing aeroallergen skin prick testing (SPT) in chronic spontaneous urticaria (CSU).

OBJECTIVE

The objective of this review was to investigate the presence of aeroallergen sensitization and markers of T2 inflammation in subjects with CSU.

METHODS

Systematic literature reviews to identify all studies that evaluated the presence of T2 markers of allergic inflammation in CSU subjects were performed.

RESULTS

In 16 studies that assessed the prevalence of positive SPT to multiple aeroallergens in CSU, 38.5% of CSU subjects had positive SPT. In three controlled studies, 34.2% of CSU subjects had positive SPT to multiple aeroallergens, compared to 13.6% of controls (p = 0.047). In 18 studies that assessed the prevalence of house dust mite (HDM) positive SPT in CSU, 27.5% of CSU subjects had positive SPT. In three controlled studies, 27.5% of CSU subjects had positive SPT to HDM, compared to 2.1% of controls (p = 0.047). Overall, CSU subjects were 3.1 times more likely to be aeroallergen-sensitized (95% CI 1.7-5.8, p = 0.0002) and 6.1 times more likely to be HDM-sensitized (95% CI 3.7-9.9, p < 0.00001) than controls. Mean total serum IgE (tIgE) levels were 238 kU/L and median tIgE levels were 164 kU/L, which was greater than the upper 90th percentile of normal (< 137 kU/L). Compared to healthy controls, CSU subjects were 6.5 times more likely to have IgG autoantibody against FcεR1α (p = 0.001), 2.4 times more likely to have IgG anti-IgE antibody (p = 0.03) and 5 times more likely to have anti-thyroid peroxidase (anti-TPO) antibody (p = 0.02). When corticosteroids were withheld for ≥ 28 days, mean blood eosinophil percentage was elevated at 5.9% (normal < 4%), but other studies reporting absolute count found the mean was in the normal range, 239 × 10 6 / L (normal < 400 × 10 6 / L).

CONCLUSION

Increased aeroallergen sensitization, tIgE, autoantibodies and blood eosinophil percentage in the CSU subjects indicates the possible importance of T2 inflammation in the pathogenesis of CSU. Further studies may be warranted to determine if specific allergen avoidance, desensitization or improvement in the mucosal allergic inflammation present in asthma and/or rhinitis has any benefit in the management of CSU.

Hypothyroidism-associated angioedema

We present a 41-year-old woman with hypothyroidism who presented to the emergency department with acute onset of angioedema and profound hypothyroidism. She required complex airway management and medical treatment before being discharged home 10 days later. This may be the first case of hypothyroidism-induced angioedema that was not associated with chronic urticaria or hives.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H₁ antihistamines alone or in combination with other classes of medications, including H₂ antihistamines, leukotriene receptor antagonists, or first-generation H₁ antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H₁ antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

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 Autoimmunity and Autoimmunity in Chronic Spontaneous Urticaria Linked to Disease Severity, Therapeutic Response, and Time to Remission in Patients with Chronic Spontaneous Urticaria

Background

Chronic spontaneous urticaria (CSU) is autoimmune in nature and associated with thyroid autoimmunity (TA), but evidence on autoimmunity in relation to CSU progression and prognosis is limited. We evaluated whether TA and autoimmunity in CSU are correlated with disease severity, therapeutic response, and time to remission and establish an association between CSU characteristics linked to thyroid autoantibody.

Methods

Medical records of patients diagnosed with urticaria attending outpatient dermatology clinic at a university-based hospital from 2013 to 2017 were retrospectively reviewed. Data on the clinical characteristics, laboratory investigations particularly thyroid antibody titers, autologous serum skin test (ASST) and autologous plasma skin test (APST) results and their link to disease severity, treatments, and time to remission of CSU patients were analyzed.

Results

Of 1,096 patients with urticaria, 60.2% had CSU. Three-hundred patients fulfilled the inclusion criteria for CSU with complete thyroid antibody testing. Positive TA was significantly associated with female gender and age > 35 years (p = 0.008). Antithyroid peroxidase (anti-TPO)-positive patients suffered from CSU longer than 12 and 18 months compared to anti-TPO-negative patients (100.0% vs. 82.6%, p = 0.042, and 100.0% vs. 75.9% p = 0.020, respectively). The presence of urticarial attacks > 4 days/week was significantly seen in ASST and APST-positive patients compared to those without (84.6% vs. 61.3%, p = 0.011, and 85.3% vs. 61.8%, p = 0.006, respectively). Positive APST patients were more difficult to treat than those with negative results (61.2% vs. 37.8%, p = 0.017).

Conclusions

Antithyroid peroxidase is a predictor of time to remission, while autologous skin testing is linked to disease severity (ASST and APST) and therapeutic response (APST) in CSU patients.

Assessment of circulating FCεRIa in Chronic Spontaneous Urticaria patients and its correlation with clinical and immunological variables

Chronic spontaneous urticaria (CSU) is a chronic type characterized by episodes of wheals with or without angioedema. Autoantibody against the alpha subunit of Fc epsilon receptor (FcεRIa) was detected in CSU patients' sera. The study aims to evaluate the clinical utility of skin tests in CSU patients. In addition, it assesses the presence of circulating FcεRIa in CSU patients and their correlation with other clinical and immunological variables. The study includes 40 healthy controls and 40 CSU patients who had urticaria symptoms for at least 8 weeks. All subjects underwent the following tests: autologous serum skin test (ASST), autologous plasma skin test (APST), immunoglobulin E (IgE), antinuclear antibodies (ANA), antithyroid antibodies (ATA). An in-house enzyme-linked immunosorbent assay was used for FcεRIa detection. The prevalence of ANA and ATA in CSU was 7.5% and 20% respectively. Total IgE was significantly higher in CSU than in controls (p < 0.0001). The study detected circulating antibody to FcεRIα in 2.5% of controls and 52.5% of CSU patients (p < 0.0001). The prevalence of antibody to FcεRIa was 27.3% and 83.3% of ASST negative and positive patients respectively (p = 0.0004). But the prevalence was 17.6% and 78.3% of APST negative and positive patients respectively (p = 0.0002). In conclusion, Circulating antibody to FcεRIa has a role in the pathogenic mechanisms of 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.

Potential blood biomarkers in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a mast cell-driven disease that is defined as the recurrence of weals, angioedema or both for > 6 weeks due to known or unknown causes. As of yet, disease diagnosis is purely clinical. Objective tools are needed to monitor the activity of CSU and the efficacy of treatment. Recently, several reports have suggested that blood parameters may be considered as potential disease-related biomarkers. Here, we reviewed available literature on blood biomarkers for CSU diagnosis, activity monitoring, duration, patient subgroup allocation or response to treatment. We performed a PubMed, Google Scholar and Web of Science search and identified and analysed 151 reports published prior to January 2016. We found strong evidence for significant differences between patients with CSU and healthy controls in blood levels or values of D-dimer, C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9), mean platelet volume (MPV), factor VIIa, prothrombin fragment 1 + 2 (F1 + 2), tumour necrosis factor, dehydroepiandrosterone sulphate and vitamin D. Also, there is strong evidence for a significant association between CSU activity and blood levels or values of D-dimer, F1 + 2, CRP, IL-6 and MPV. Strong evidence for reduced basophil count and high levels of IgG anti-FcεRI in the subgroup of CSU patients with positive autologous serum skin test was shown. In contrast, the evidence for all reported blood biomarkers for differentiating CSU from other diseases, or a role in prognosis, is weak, inconsistent or non-existent. Taken together, we identified 10 biomarkers that are supported by strong evidence for distinguishing patients with CSU from healthy controls, or for measuring CSU activity. There is a need for further research to identify biomarkers that predict outcome or treatment response in CSU.

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.

H1-antihistamine-refractory chronic spontaneous urticaria: it's worse than we thought - first results of the multicenter real-life AWARE study

BACKGROUND

Most data on chronic spontaneous urticaria (CSU) originate from highly selected patient populations treated at specialized centres. Little is known about CSU patient characteristics and the burden of CSU in routine clinical practice. AWARE (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) is an ongoing global study designed to assess chronic urticaria in the real-life setting.

OBJECTIVE

To describe the baseline characteristics of the first 1539 German AWARE patients with H1-antihistamine-refractory CSU.

METHODS

This prospective non-interventional study included patients (18-75 years) with a diagnosis of H1-antihistamine-refractory CSU for > 2 months. Baseline demographic and disease characteristics, comorbidities, and pharmacological treatments were recorded. Quality of life (QoL) was assessed using the dermatology life quality index (DLQI), chronic urticaria QoL questionnaire (CU-Q₂ oL), and angioedema QoL questionnaire (AE-QoL, in cases of angioedema). Previous healthcare resource utilization and sick leave data were collected retrospectively.

RESULTS

Between March and December 2014, 1539 patients were assessed in 256 sites across Germany. The percentage of females, mean age, and mean body mass index were 70%, 46.3 years, and 27 kg/m² , respectively. The mean urticaria control test score was 7.9, one in two patients had angioedema, and the most frequent comorbidities were chronic inducible urticaria (CIndU; 24%), allergic rhinitis (18.2%), hypertension (18.1%), asthma (12%), and depression (9.5%). Overall, 57.6% of patients were receiving at least one pharmacological treatment including second-generation H1-antihistamines (46.3%), first-generation H1-antihistamines (9.1%), and corticosteroids (15.8%). The mean DLQI, total CU-Q₂ oL, and total AE-QoL scores were 8.3, 36.2, and 46.8, respectively. CSU patients reported frequent use of healthcare resources, including emergency services (29.7%), general practitioners (71.9%), and additional allergists or dermatologists (50.7%).

CONCLUSIONS AND CLINICAL RELEVANCE

This study reveals that German H1-antihistamine-refractory CSU patients have high rates of uncontrolled disease, angioedema, and comorbid CIndU, are undertreated, have impaired QoL, and rely heavily on healthcare resources.

Increased Risk of Chronic Spontaneous Urticaria in Patients With Autoimmune Thyroid Diseases: A Nationwide, Population-based Study

There was no previous population-based study on the comparison of the risk of chronic spontaneous urticaria (CSU) between autoimmune thyroid diseases (AITD) and age- and gender-matched controls. The primary objective of this study was to evaluate the risk of CSU after diagnosis of AITD using national registry data from Korea. The secondary objective was to evaluate other risk factors of CSU. Based on the disease code diagnoses in 2003-2005, we composed an AITD group (n=3,659) and an age- and gender-matched control group (n=18,295). Each patient was tracked for whether CSU occurs or not until 2013. After adjusting for demographic differences and comorbidities, patients with AITD had a significantly higher rate of CSU compared to the control group (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.70; P<0.001). Among the AITD patients, the adjusted HR for CSU was higher in patients with Hashimoto's thyroiditis (HR, 1.50) than in those with Grave's disease (HR, 1.33), although the difference was not statistically significant (P=0.368). Analysis of CSU patients associated with AITD showed that female patients had a significantly higher risk of CSU compared to male ones (HR, 1.34; P=0.001) and that those with allergic rhinitis (HR, 1.51; P<0.001), atopic dermatitis (HR, 2.44; P<0.001), and asthma (HR, 1.50; P<0.001) had a significantly higher risk of CSU compared to patients without respective diseases. Our results demonstrated that AITD could be significantly associated with an increased risk of CSU.

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.

Does replacement of vitamin D reduce the symptom scores and improve quality of life in patients with chronic urticaria?

BACKGROUND

Vitamin D plays a key role in the immune responses generated by lymphocytes and antigen-presenting cells. Decreased vitamin 25-hydroxyvitamin D (25(OH)D) levels have been implicated in several allergic disorders and association between 25(OH)D levels and chronic urticaria (CU) symptom scores has been evaluated in a few studies. This study was performed to assess the effects of vitamin D supplementation on the symptoms and quality of life scores in chronic spontaneous urticaria (CSU) and to vitamin D levels in CSU patients in comparison with controls.

PATIENTS AND METHODS

Fifty-eight CSU patients and forty-five controls were included in the study. The patients were divided into two groups according to severity of the disease; as mild/moderate and severe urticaria. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were measured in serum of CSU patients and compared with the control groups. In patients with 25(OH)D concentrations lower than 30 µg/L, 300 000 IU/month of vitamin D3 supplementation was added to standard therapy. The clinical improvement was evaluated after 3 months with urticaria activity score (UAS4) and Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL).

RESULTS

Serum 25(OH)D concentration was significantly lower in CSU group compared to healthy subjects (p < 0.001). The prevalence of vitamin D deficiency (<20 (µg/L) and insufficiency (<30 µg/L) was significantly higher in CSU patients than control groups. In addition, 25(OH)D concentrations were significantly lower in both mild-moderate and severe CSU patients than those of the controls (p = 0.011 and p < 0.001, respectively). Ninety eight percent of patients (25(OH)D < 30 µg/L) were treated with vitamin D3 (300 000 IU/month) supplementation, and after 12 weeks, these patients showed significant improvements in UAS4 and CU-Q2oL scores.

CONCLUSION

This study support the contributing and beneficial effects of vitamin D in the treatment of CU. Replacement of vitamin D may provide improvement in both the severity of symptoms and the quality of life scores in these patients.

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.

Treatment of severely recalcitrant chronic spontaneous urticaria: a discussion of relevant issues

Chronic spontaneous urticaria (CSU) is a common disorder with a prevalence of 1% that is characterized by recurrent wheals, angioedema, or both. CSU is self-limited but in many patients symptoms recur for several years and can be refractory to standard therapies. In this review, we present an illustrative case of a female patient with CSU who, despite taking 15 antihistamines a day in addition to a number of second-line therapies, continued to be refractory to treatment. However, once we initiated subcutaneous treatment with omalizumab 300 mg every 4 weeks, she experienced rapid relief of her CSU symptoms. Through this case, we present a review of the relevant issues, including the efficacy of laboratory tests to identify the cause of a patient's CSU, the association between CSU and thyroid disease and its relevance to treatment options, the recommendation to increase antihistamine dose up to fourfold and possible adverse events associated with this treatment option. We also include a discussion of the use of second-line therapies as well as omalizumab in refractory CSU patients.

Evaluation of dermal symptoms in hypothyroidism and hyperthyroidism

Many symptoms arise in thyroid diseases. The aim of this study was to evaluate the dermal symptoms in hypothyroidism and hyperthyroidism. In this cross sectional study, 120 patients with hyperthyroidism and 50 patients suffering from hypothyroidism were studied. Cutaneous, hair and nail clinical symptoms were studied and registered in a special questionnaire. Mean age of patients suffering from hypothyroidism and hyperthyroidism were 38.24 +/- 14.45 and 25.86 +/- 14.69 years old. Dry and Coarse/rough skin were the most prevalent manifestations in the skin involvement in hypothyroidism since softness was the most prevalent ones in hyperthyroidism. Fragileness was the most prevalent symptom in patients with nail involvement in hypothyroidism since soft skin was the most prevalent ones in hyperthyroidism. Coarse/rough skin was observed more in patients with hair involvement in hypothyroidism since the most prevalent ones was separation of nail from its bed in hyperthyroidism. High prevalence of skin, hair and nail symptoms in thyroid patients, early diagnosis of the signs may be helpful in premature diagnosis and treatment of thyroid diseases.

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.

Chronic idiopathic urticaria and Graves' disease

Chronic urticaria is a common condition characterized by recurrent episodes of mast cell-driven wheal and flare-type skin reactions lasting for more than 6 weeks. In about 75% of cases, the underlying causes remain unknown, and the term chronic idiopathic urticaria (CIU) is used to emphasize that wheals develop independently of identified external stimuli. Although CIU affects about 1.0% of the general population, its etiopathogenesis is not yet well understood. It is now widely accepted that in many cases CIU should be regarded as an autoimmune disorder caused by circulating and functionally active IgG autoantibodies specific for the IgE receptor (FceRI) present on mast cells and basophils or for IgE itself. The well-known association of CIU with other autoimmune processes/diseases represents further indirect evidence of its autoimmune origin. Autoimmune thyroid diseases, especially autoimmune thyroiditis, represent the most frequently investigated diseases in association with CIU. Here we review this topic with particular regard to the association between Graves' disease and CIU. The possible pathogenetic mechanisms and the clinical implications of such an association are discussed.

Autoantibodies in chronic idiopathic urticaria and nonurticarial systemic autoimmune disorders

BACKGROUND

Chronic idiopathic urticaria (CU) has been associated with other autoimmune diseases and basophil-activating autoantibodies to FcεRI or IgE. It is unknown whether patients with systemicautoimmune diseases have a similar prevalence of these autoantibodies.

OBJECTIVE

To compare the prevalences of basophil-activating autoantibodies (elevated CU Index) in patients with CU, rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE). Clinical characteristics and laboratory studies were examined for an association with the CU Index.

METHODS

Adult patients, 27 with CU, 27 with RA, and 26 with SLE, and 20 healthy controls were compared on the basis of the CU Index panel, anti-IgE, and antithyroid antibodies.

RESULTS

The CU Index values were significantly higher in the CU group when compared with the RA group but not when compared with the SLE group. 33% of CU, 23% of SLE, 3.7% of RA, and 15% of controls had apositive CU Index. Elevated antithyroid antibody levels did not correlate with a positive CU Index in any of the groups. An elevated CU Index in the SLE group was not associated with age, sex, ethnicity, disease severity, or history of atopy.

CONCLUSION

The CU Index values were elevated in patients with CU and SLE. The presence of these autoantibodies did not correlate with disease activity or presence of thyroid antibodies. Functional autoantibodies may not be specific for chronic idiopathic urticaria, and their role in nonurticarial systemic autoimmune diseases requires further investigation.

Autoimmune thyroiditis in childhood

Autoimmune thyroiditis (AIT) is the most common thyroid disorder in the pediatric age range. The disease results from an as yet poorly characterized defect or defects in immunoregulation and a cascade of events progressing from lymphocyte infiltration of the thyroid, to T-cell- and cytokine-mediated thyroid follicular cell injury, and apoptotic cell death. Approximately 70% of disease risk has been attributed to genetic background with environmental factors being important in triggering disease in susceptible individuals. The contribution of individual genes is small and probably polymorphisms in multiple genes play a role. Some immuno susceptibility genes affect immune recognition or response in general, while others are thyroid-specific. Environmental agents may act through an epigenetic mechanism. Antibodies (Abs) to a variety of thyroid-specific antigens are detectable in a majority of patients, but the role of Abs in mediating cell injury and death is unclear and only thyrotropin (TSH) receptor Abs significantly affect thyroid function by interfering with (or stimulating) the action of TSH. Nonetheless, thyroid peroxidase (TPO) Abs and thyroglobulin (Tg) Abs, present in a majority of patients, are valuable diagnostically as markers of underlying autoimmune thyroid destruction. TSH receptor blocking Abs are found in ~18% of children and adolescents with severe hypothyroidism and, when persistent, may identify an adolescent likely to have a baby with TSH receptor blocking Ab-induced congenital hypothyroidism. AIT may coexist with other organ-specific autoimmune diseases. Although the most common age at presentation is adolescence, the disease may occur rarely in children <1 year of life.

The essential role of anti-thyroid antibodies in chronic idiopathic urticaria

BACKGROUND

An autoimmune etiology has been suggested in up to one-third of cases of chronic idiopathic urticaria (CIU), in which it has been proposed that a subset of cases are associated with thyroid autoimmunity. The objective of our present study was to verify the prevalence of thyroid antibodies in the patients with CIU.

METHODS

Sixty patients aged 12-51 years, who met criteria for CIU, and 40 aged-matched healthy controls (18 males and 22 females) were participated in this study. Serum anti-thyroid antibodies (ATAs), thyroid hormones, total immunoglobulin E (IgE), and food allergen-specific IgE antibodies were measured. The CIU group was treated with anti-H1 and anti-H2 histamines for 3 weeks.

RESULTS

The total ATA positive rate was 27.3% (33% males and 25% females) in the CIU group. The prevalence of anti-thyroglobulin antibodies, anti-TSH-receptor antibodies, and anti-thyroid peroxidase antibodies were 16.6%, 83.3%, and 8.3%, respectively. The thyroid hormones, T3, and T4, and the TSH were within the normal limits. The radioallergosorbent test was negative for food allergens, and only 18% of the patients had a total IgE concentration >200 IU/mL.

CONCLUSION

ATAs were found in 27% of the patients with CIU, but these antibodies did not dysregulate thyroid hormone secretion nor did they mediate any clinical manifestations.

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.

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.

Mercury and thyroid autoantibodies in U.S. women, NHANES 2007-2008

Associations between positive thyroid autoantibodies and total blood mercury in women were evaluated using the National Health and Nutrition Examination Survey (NHANES), 2007-2008. Women are at increased risk for autoimmune disorders, mercury exposure has been associated with cellular autoimmunity and mercury accumulates in the thyroid gland. We used multiple logistic regression to evaluate the associations between total bloodmercury and thyroglobulin autoantibody antibody positivity and thyroid peroxidase autoantibody positivity in non-pregnant, non-lactating women aged 20 and older not currently using birth control pills or other hormone therapies, adjusted for demographic factors, menopausal status, nutrient intake and urine iodine (n=2047). Relative to women with the lowest mercury levels (≤0.40 μg/L), women with mercury >1.81 μg/L (upper quintile) showed 2.24 (95% CI=1.22, 4.12) greater odds for thyroglobulin autoantibody positivity (p(trend)=0.032); this relationship was not evident for thyroid peroxidase autoantibody positivity. Results suggest an association between mercury and thyroglobulin autoantibody positivity.

The role of autoimmune testing in chronic idiopathic urticaria

BACKGROUND

The clinical implications of autoimmune testing in chronic idiopathic urticaria (CIU) are not well established.

OBJECTIVE

To identify the association of autoimmune biomarkers in CIU with disease severity.

METHODS

We retrospectively evaluated 195 patients with a diagnosis of CIU for the presence of antinuclear antibody (ANA), anti-thyroglobulin antibody (ATG), anti-thyroperoxidase antibody (ATPO), and Chronic Urticaria (CU) Index. The patients were categorized into controlled and refractory subgroups based on their response to antihistamines with or without a leukotriene receptor antagonist.

RESULTS

The percentage of patients with a positive test for ANA (titer>1:160), ATG, ATPO, and CU Index were 29%, 6%, 26%, and 38%, respectively. Among those tested, the percentage of patients categorized as refractory was significantly higher in those with a positive CU index (80% vs 46%; P = .01) or a positive ANA titer (50% vs 30%; P = .04) than those with negative test results; however, a similar relationship was not observed for ATPO or ATG antibodies. Odds ratios of individual or combinations of autoimmune biomarkers in CIU were examined for associations with refractoriness to antihistamines with or without a leukotriene receptor antagonist. The CU Index alone has an odds ratio of 4.5 (P = .005), whereas the combination of ANA, ATG, and ATPO has an odds ratio of 3.1 (P = .01) and ANA alone has an odds ratio of 2.3 (P = .04) for correlating with a refractory outcome.

CONCLUSION

Our data indicate the CU Index independently has the strongest correlation with disease severity followed by the combination of ANA, ATG, and ATPO and the ANA alone.

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.

Utility of routine laboratory testing in management of chronic urticaria/angioedema

BACKGROUND

Laboratory tests are routinely ordered to identify or rule out a cause in patients with chronic urticaria/angioedema (CUA). The results of these tests are usually within normal limits or unremarkable.

OBJECTIVE

To investigate the proportion of abnormal test results in patients with CUA leading to a change in management and in outcomes of care.

METHODS

Retrospective analysis of a random sample of adult patients with CUA from 2001-2009.

RESULTS

Cases totaled 356: 166 with urticaria and angioedema (AE), 187 with urticaria, and 3 with only AE. Patients were predominately women (69.1%) and white (75.6%), with a mean age of 48 ± 15 years. Abnormalities were commonly seen in complete blood counts (34%) and in complete metabolic panels (9.4%). Among the 1,872 tests that were ordered, results of 319 (17%) were abnormal. Of 356 patients, 30 underwent further testing because of abnormalities in laboratory work. This represented 30 of 1,872 tests (1.60%). Only 1 patient benefited from a subsequent change in management.

CONCLUSIONS

Laboratory testing in CUA patients referred for an Allergy and Immunology evaluation rarely lead to changes in management resulting in improved outcomes of care.

Chronic urticaria: etiology and natural course in children

BACKGROUND

Chronic spontaneous urticaria (CSU) in childhood is infrequent, and information about the disease in children is limited. We attempted to investigate its etiologic factors, natural course, and predictors of prognosis.

METHODS

All children aged ≤ 18 years followed for CSU during an 8-year period were analyzed retrospectively, and the final outcomes were queried via a telephone interview.

RESULTS

One hundred patients (male/female ratio 1.27) with a median age of 9.2 years (range 0.7-17.2) at symptoms onset were evaluated. The median follow-up was 2.5 years (range 0.2-18.1). An autologous serum skin test was positive in 46.7% of the subjects (n = 45), with a female predominance (71.4%) (p = 0.023). In 13.8% of the children, ANA titers were over 1/100. Food allergy (n = 1), thyroid autoantibodies (n = 3), possible collagen disease (n = 1), and drug usage (deferoxamine) (n = 1) were found to be associated factors. Infections could not be confirmed as the cause of CSU. Recovery was seen in 16.5, 38.8, and 50.0% of the children after 12, 36, and 60 months, respectively. Though in multivariate analysis none of the factors, including age, gender, autologous serum skin test positivity, the presence of angioedema, or other allergic diseases, appeared to predict the prognosis, in univariate analysis being female and being older than 10 years of age predicted an unfavorable prognosis.

CONCLUSION

The etiology of CSU in children is mainly related to an autoreactive background, as in adults. CSU has a favorable prognosis, and resolution is seen in half of the children within 5 years. Girls older than 10 years may have an unfavorable prognosis.

Diseases associated with thyroid autoimmunity: explanations for the expanding spectrum

Anyone who has been in an endocrine clinic will appreciate that associations exist between autoimmune thyroid disease (AITD) and other autoimmune disorders. However, the full extent of these associations is still not fully appreciated, and new associations are being uncovered which may shed new light on the pathogenic basis for these connections, and the underlying reasons for them are only now becoming understood. This review is based on the British Thyroid Association Pitt-Rivers Lecture 2010. The first section provides an update on studies which have detailed the strength of various autoimmune disease associations, the second section discusses the environmental and genetic factors which underlie these associations and the final section describes some recently identified, unexpected AITD associations. Unravelling these associations further will illuminate the pathogenesis of autoimmune diseases and offers the prospect of new therapeutic approaches.

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.

Omalizumab therapy in three patients with chronic autoimmune urticaria

Chronic urticaria is a common skin disease. In about 45% of patients the cause is an autoantibody directed at the α-subunit of the high-affinity IgE receptor (chronic autoimmune urticaria; CAU). Omalizumab is a monoclonal anti-IgE antibody that has a proven role in the treatment of various allergic diseases. We gave omalizumab once every month for 16 weeks to three patients that were refractory to standard treatment, including high doses of antihistamines, leukotriene receptor antagonist, and corticosteroid. There was dramatic improvement in the primary efficacy variable--the change in mean urticaria activity score (UAS) from baseline (i.e., the average over the first 4-week period before omalizumab) to the final 4-week period of omalizumab treatment. There was improvement in the secondary efficacy variables, which included change from baseline in interference with sleep, interference with daily activities, daily diary record of urticaria signs and symptoms based on a scoring system, and rescue medication use. These improvements persisted for 12 weeks after discontinuation of the drug. Omalizumab may have a role in treating refractory cases of CAU.