The international EAACI/GA²LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria

This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA²LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous or inducible urticaria is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Expert consensus on the use of omalizumab in chronic urticaria in China

Chronic urticaria (CU) is a debilitating skin disease that lasts for more than 6 weeks with wheals and/or angioedema, including chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU). In China, the prevalence of this disease is high, more than 1%, and on the rise. CU has a major impact on the quality of life (QoL) of patients who frequently experience sleep disturbance, depression, and anxiety. Nearly one-third of patients with CSU, in China, are resistant to second-generation H₁-antihistamines (sgAHs), even at a fourfold dose (second line; off-label). Omalizumab is approved for the treatment of CSU treatment in Europe and shows remarkable efficacy and safety. In China, regulatory approval for the use of omalizumab is pending, and its use in clinical practice varies widely. Consensus on omalizumab CU treatment in China is urgently needed. The aim of this article is to propose a practical omalizumab treatment algorithm for the management of antihistamine-resistant CSU and CIndU in adults and special population including children and adolescents, and pregnant or breast feeding women, to guide daily clinical practice in China. In the development of this consensus, an expert group including mainly dermatologists, allergists, but also pulmonologists, ENTs, immunologists, and pediatricians in Allergic Disease Prevention and Control Committee, Chinese Preventive Medicine Association, reviewed the existing evidence and developed consensus on the use of omalizumab in CU patients from China. The goal of this consensus is to assist clinicians in making rational decisions in the management of refractory CU with omalizumab. The key clinical questions covered by the treatment algorithm are: 1) Omalizumab treatment routine strategy in both CSU and CIndU patients; 2) Recommended dose and treatment duration for different age stratification; 3) Treatment duration for CU patients with other allergic comorbidities; 4) Recommendation on omalizumab stopping strategy.

Risk factors for systemic reactions in typical cold urticaria: Results from the COLD-CE study

BACKGROUND

Cold urticaria (ColdU), that is, the occurrence of wheals or angioedema in response to cold exposure, is classified into typical and atypical forms. The diagnosis of typical ColdU relies on whealing in response to local cold stimulation testing (CST). It can also manifest with cold-induced anaphylaxis (ColdA). We aimed to determine risk factors for ColdA in typical ColdU.

METHODS

An international, cross-sectional study COLD-CE was carried out at 32 urticaria centers of reference and excellence (UCAREs). Detailed history was taken and CST with an ice cube and/or TempTest^® performed. ColdA was defined as an acute cold-induced involvement of the skin and/or visible mucosal tissue and at least one of: cardiovascular manifestations, difficulty breathing, or gastrointestinal symptoms.

RESULTS

Of 551 ColdU patients, 75% (n = 412) had a positive CST and ColdA occurred in 37% (n = 151) of the latter. Cold-induced generalized wheals, angioedema, acral swelling, oropharyngeal/laryngeal symptoms, and itch of earlobes were identified as signs/symptoms of severe disease. ColdA was most commonly provoked by complete cold water immersion and ColdA caused by cold air was more common in countries with a warmer climate. Ten percent (n = 40) of typical ColdU patients had a concomitant chronic spontaneous urticaria (CSU). They had a lower frequency of ColdA than those without CSU (4% vs. 39%, p = .003). We identified the following risk factors for cardiovascular manifestations: previous systemic reaction to a Hymenoptera sting, angioedema, oropharyngeal/laryngeal symptoms, and itchy earlobes.

CONCLUSION

ColdA is common in typical ColdU. High-risk patients require education about their condition and how to use an adrenaline autoinjector.

Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study

BACKGROUND

Chronic urticaria (CU) predominantly affects women, and sex hormones can modulate disease activity in female CU patients. As of now, the impact of pregnancy on CU is largely unknown.

AIM

To analyze the course and features of CU during and after pregnancy.

PATIENTS AND METHODS

PREG-CU is an international, multicenter study of the Urticaria Centers of Reference and Excellence (UCARE) network. Data were collected via a 47-item questionnaire completed by CU patients, who became pregnant within the last 3 years.

RESULTS

A total of 288 pregnancies of 288 CU patients from 13 countries were analyzed (mean age at pregnancy: 32.1 ± 6.1 years, duration of CU: 84.9 ± 74.5 months; CSU 66.9%, CSU + CIndU 20.3%, CIndU 12.8%).During pregnancy, 51.1% of patients rated their CU as improved, 28.9% as worse, and 20.0% as unchanged.CU exacerbations most commonly occurred exclusively during the third trimester (in 34 of 124 patients; 27.6%) or the first (28 of 124; 22.8%). The risk factors for worsening of CU during pregnancy were having mild disease and no angioedema before pregnancy, not taking treatment before pregnancy, CIndU, CU worsening during a previous pregnancy, treatment during pregnancy, and stress as a driver of exacerbations. After giving birth, urticaria disease activity remained unchanged in 43.8% of CU patients, whereas 37.4% and 18.1% experienced worsening and improvement, respectively.

CONCLUSIONS

These results demonstrate the complex impact of pregnancy on the course of CU and help to better counsel patients who want to become pregnant and to manage CU during pregnancy.

The Emerging Role of Mast Cells in Response to Fungal Infection

Mast cells (MCs) have been considered as the core effector cells of allergic diseases. However, there are evidence suggesting that MCs are involved in the mechanisms of fungal infection. MCs are mostly located in the border between host and environment and thus may have easy contact with the external environmental pathogens. These cells express receptors which can recognize pathogen-associated molecular patterns such as Toll-like receptors (TLR2/4) and C-type Lectins receptors (Dectin-1/2). Currently, more and more data indicate that MCs can be interacted with some fungi (Candida albicans, Aspergillus fumigatus and Sporothrix schenckii). It is demonstrated that MCs can enhance immunity through triggered degranulation, secretion of cytokines and chemokines, neutrophil recruitment, or provision of extracellular DNA traps in response to the stimulation by fungi. In contrast, the involvement of MCs in some immune responses may lead to more severe symptoms, such as intestinal barrier function loss, development of allergic bronchial pulmonary aspergillosis and increased area of inflammatory in S. schenckii infection. This suggests that MCs and their relevant signaling pathways are potential treatment regimens to prevent the clinically unwanted consequences. However, it is not yet possible to make definitive statements about the role of MCs during fungal infection and/or pathomechanisms of fungal diseases. In our article, we aim to review the function of MCs in fungal infections from molecular mechanism to signaling pathways, and illustrate the role of MCs in some common host-fungi interactions.

Practical algorithm to inform clinical decision-making in the topical treatment of atopic dermatitis

Atopic dermatitis is a chronic relapsing, inflammatory skin disorder associated with skin barrier dysfunction, the prevalence of which has increased dramatically in developing countries. In this article, we propose a treatment algorithm for patients with mild-to-moderate and severe atopic dermatitis flares in daily clinical practice. An international panel of 15 dermatology and allergy experts from eight countries was formed to develop a practical algorithm for the treatment of patients with atopic dermatitis, with a particular focus on topical therapies. In cases of mild-to-moderate atopic dermatitis involving sensitive skin areas, the topical calcineurin inhibitor pimecrolimus should be applied twice daily at the first signs of atopic dermatitis. For other body locations, patients should apply a topical calcineurin inhibitor, either pimecrolimus or tacrolimus, twice daily at the first signs of atopic dermatitis, such as pruritus, or twice weekly in previously affected skin areas. Emollients should be used regularly. Patients experiencing acute atopic dermatitis flares in sensitive skin areas should apply a topical corticosteroid twice daily or alternate once-daily topical corticosteroid/topical calcineurin inhibitor until symptoms improve. Following improvement, topical corticosteroid therapy should be discontinued and patients switched to a topical calcineurin inhibitor. Maintenance therapy should include the use of pimecrolimus once daily for sensitive areas and tacrolimus for other body locations. This treatment algorithm can help guide clinical decision-making in the treatment of atopic dermatitis.

The global impact of the COVID-19 pandemic on the management and course of chronic urticaria

INTRODUCTION

The COVID-19 pandemic dramatically disrupts health care around the globe. The impact of the pandemic on chronic urticaria (CU) and its management are largely unknown.

AIM

To understand how CU patients are affected by the COVID-19 pandemic; how specialists alter CU patient management; and the course of CU in patients with COVID-19.

MATERIALS AND METHODS

Our cross-sectional, international, questionnaire-based, multicenter UCARE COVID-CU study assessed the impact of the pandemic on patient consultations, remote treatment, changes in medications, and clinical consequences.

RESULTS

The COVID-19 pandemic severely impairs CU patient care, with less than 50% of the weekly numbers of patients treated as compared to before the pandemic. Reduced patient referrals and clinic hours were the major reasons. Almost half of responding UCARE physicians were involved in COVID-19 patient care, which negatively impacted on the care of urticaria patients. The rate of face-to-face consultations decreased by 62%, from 90% to less than half, whereas the rate of remote consultations increased by more than 600%, from one in 10 to more than two thirds. Cyclosporine and systemic corticosteroids, but not antihistamines or omalizumab, are used less during the pandemic. CU does not affect the course of COVID-19, but COVID-19 results in CU exacerbation in one of three patients, with higher rates in patients with severe COVID-19.

CONCLUSIONS

The COVID-19 pandemic brings major changes and challenges for CU patients and their physicians. The long-term consequences of these changes, especially the increased use of remote consultations, require careful evaluation.

The Diagnosis and Management of Allergic Reactions Caused by Chinese Materia Medica

Traditional Chinese medicines (TCM) have been used in China for thousands of years. Although TCM has been generally perceived to be safe, adverse reactions to Chinese materia medica (CMM) have been reported. Most of the adverse reactions are allergic in nature, but other mechanisms may play a role. This review focuses on the mechanism and clinical presentation of these allergic reactions. Allergic reactions can occur as a result of the active and inactive ingredients of CMM. Impurities and chemicals generated during the production process can also lead to allergic or adverse reactions. Environmental factors such as temperature, humidity, and light can cause changes in the allergenicity of drugs. Human error in formulating CMM drugs also contributes to adverse drug reactions. The management of allergic reactions to CMM includes taking a good history, avoidance of medications in the same class as those which caused prior reactions, the proper training of staff, adherence to manufacturer guidelines and expiration dates, evaluation of benefit and risk balance, and the formulation of a risk management strategy for the use of CMM. A small test dose of a considered drug before using, improvements in drug purification technology, and proper storage and clinical administration help reduce allergic reactions due to CMM.

TSN inhibits cell proliferation, migration, invasion, and EMT through regulating miR-874/HMGB2/β-catenin pathway in gastric cancer

Gastric cancer (GC) is the second leading cause of cancer-associated deaths worldwide. Tanshinone IIA (TSN) is the pure extract from the root of red-rooted salvia and has been reported to inhibit the progression of GC cells. In this study, we investigated the microRNA (miRNA) mediated gene repression mechanism in TSN-administrated GC condition. The cell viability of GC was determined by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) assay. Cell migration and invasion were detected by transwell assays. The expression levels of epithelial-mesenchymal transition (EMT)-associated proteins (N-cadherin, vimentin, E-cadherin), High-mobility group box proteins 2 (HMGB2), β-catenin pathway-related proteins (β-catenin, c-myc, cyclin D1) were detected by western blot analysis in TSN/GC. The expression patterns of miR-874 and HMGB2 in GC were determined by quantitative real-time polymerase chain reaction (qRT-PCR). The potential miR-874-targeted HMGB2 was searched via bioinformatics methods and identified by dual-luciferase reporter assays, RNA immunoprecipitation (RIP) assays, and RNA pull-down assays. Xenograft tumor model was used to evaluate biological function in vivo. TSN limited the proliferation, migration, invasion, EMT progression in GC, and these results could be inverted by the silencing of miR-874. Moreover, the putative binding sites between miR-874 and HMGB2 were predicted by starBase software online. Meanwhile, enforced expression of HMGB2, negatively correlated with that of miR-874, reversed the positive effects of TSN administration on cells. Mechanically, TSN restrained the GC progression by miR-874/HMGB2/β-catenin signaling in vitro. Additionally, in vivo experiments confirmed that TSN inhibited the GC progression as well. TSN restrained the GC progression by regulating miR-874/HMGB2/β-catenin pathways in vitro and in vivo.

Skin Mast Cells Contribute to Sporothrix schenckii Infection

Background:Sporothrix schenckii (S. schenckii), a dimorphic fungus, causes sporotrichosis. Mast cells (MCs) have been described to be involved in skin fungal infections. The role of MCs in cutaneous sporotrichosis remains largely unknown.

Objectives: To characterize the role and relevance of MCs in cutaneous sporotrichosis.

Methods: We analyzed cutaneous sporotrichosis in wild-type (WT) mice and two different MC-deficient strains. In vitro, MCs were assessed for S. schenckii-induced cytokine production and degranulation after incubation with S. schenckii. We also explored the role of MCs in human cutaneous sporotrichosis.

Results: WT mice developed markedly larger skin lesions than MC-deficient mice (> 1.5 fold) after infection with S. schenckii, with significantly increased fungal burden. S. schenckii induced the release of tumor necrosis factor alpha (TNF), interleukin (IL)-6, IL-10, and IL-1β by MCs, but not degranulation. S. schenckii induced larger skin lesions and higher release of IL-6 and TNF by MCs as compared to the less virulent S. albicans. In patients with sporotrichosis, TNF and IL-6 were increased in skin lesions, and markedly elevated levels in the serum were linked to disease activity.

Conclusions: These findings suggest that cutaneous MCs contribute to skin sporotrichosis by releasing cytokines such as TNF and IL-6.

[Effect of primary cilia expression rate on Wnt/β signaling pathway in tibial growth plate chondrocytes from chronic renal insufficiency young rats]

Objective: To observe the effect of primary cilia expression rate on Wnt/β signaling pathway in tibial growth plate chondrocytes from chronic renal insufficiency (CRI) young rats. Methods: Male 2-week-old SD rats were randomly divided into two groups: (1) Sham group: only the left ureter was exposed (n=6); (2) CRI group: the left ureter was ligated (n=6). Rats were sacrificed 2 weeks after the operation and the primary cilia expression rate of growth plate chondrocytes and key protein β-catenin in Wnt/β signaling pathway were observed in histological section of tibia specimen. Chondrocytes isolated from growth plate in two groups were cultured in vitro to P3 generation. The primary cilia expression rate and the level of β-catenin were measured. The primary cilia expression rate was detected by agonists and antagonists Wnt/β signaling pathway in chondrocytes of CRI group. The level of β-catenin was detected by using serum-free culture and chloral hydrate to intervene chondrocytes in CRI group. Results: The primary cilia expression rate of growth plate chondrocytes in histological section of tibia specimen in CRI group was higher than that in Sham group [(17.5±7.7)% vs (8.7±3.6)%, t=3.237, P=0.005], and the level of β-catenin was higher in CRI group (5.1±0.7 vs 1.9±0.8, t=6.731, P<0.001). The primary cilia expression rate of growth plate chondrocytes cultured in vitro in CRI group was higher than that in Sham group [(20.9±8.1)% vs (11.8±4.7)%, t=3.073, P=0.007], and the level of β-catenin was higher in CRI group (0.49±0.12 vs 0.25±0.11, t=3.297, P=0.011). There was no significant change in primary cilia expression rate after intervention by using Wnt/β signaling agonists and antagonists to change the level of β-catenin [agonists group: (21.3±7.6)%, control: (20.6±6.8)%, antagonists group: (22.4±6.2)%, F=0.173, P=0.842]. The level of β-catenin was significantly changed after intervention by using serum-free culture, chloral hydrate to alter the primary cilia expression rate (serum-free culture group: 0.61±0.23, control: 0.39±0.24, chloral hydrate group: 0.15±0.11, F=6.476, P=0.012). There was a positive correlation between the level of β-catenin and primary cilia expression rate. Conclusion: The primary cilia expression rate and the level of Wnt/β signaling pathway were higher in tibial growth plate chondrocytes in CRI rats model, and primary cilia might have positive regulatory effects on the Wnt/β signaling pathway.

Using IFN-γ antibodies to identify the pathogens of fungal rhinosinusitis: A novel immunohistochemical approach

Fungal rhinosinusitis (FRS) is commonly caused by various Aspergillus species (spp) and Mucorales fungi, and the treatment and prognosis of cases differ depending on the causative fungus. The present study describes a novel immunohistochemical method that has high sensitivity and specificity for distinguishing between these two types of fungi in patients with FRS. Three groups were included in the study. Group A included formalin-fixed paraffin-embedded blocks of 51 nasal tissue specimens of patients with FRS (27 Aspergillus spp and 24 Mucorales) that were continuously obtained from the Department of Pathology of Tongren Hospital in Beijing as the experimental group and 34 cultures (26 Aspergillus spp and 8 Mucorales) of FRS that were randomly selected from the bacterial laboratory of Tongren Hospital in Beijing to verify the staining results of the paraffin-embedded blocks. Formalin-fixed paraffin-embedded blocks of 10 esophageal cancer specimens were included in Group B as the positive control group. All specimens in Groups A and B were stained with interferon-γ (IFN-γ) antibody. Group C consisted of the same specimens as described in Group A, however, when performing the immunohistochemical assay, IFN-γ antibody was replaced by PBS and this served as the negative control group. The differences in IFN-γ immunohistochemical staining between Aspergillus spp and Mucorales were analyzed. Staining of IFN-γ in paraffin-embedded samples was positive in 92.6% (25/27) of specimens in which Aspergillus spp were the causative pathogen, which was significantly higher compared with specimens in which Mucorales was causative (P<0.001), with only 4.2% (1/24) of specimens staining positive for IFN-γ. Immunohistochemical staining of cell cultures was 100% positive for Aspergillus spp, whereas all Mucorales were negative. Thus, the results of the current study indicated that IFN-γ antibody immunohistochemical staining may be used as a novel diagnostic tool to distinguish between Aspergillus spp and Mucorales when identifying the causative agent in FRS, providing a useful supplementary test to the current immunohistochemical methods in the clinical diagnosis of FRS.

[RNA interference targeting DNA-PKcs inhibits glioma cells malignancies and enhances temozolomide sensitivity]

Objective: To investigate the effect of DNA dependent protein kinase catalytic subunit (DNA-PKcs) on glioma proliferation, invasion and temozolomide sensitivity, and also to explore the potential mechanisms. Methods: Human glioma cell lines H4 and U87 were chosen to carry out RNA interference transfection, and then divided into negative control group (blank group) and siRNA group (test group). The knockdown efficacy of DNA-PKcs siRNA was tested by quantitative PCR and Western blot. The MTS assay and Transwell assay were used to investigate the effect of DNA-PKcs knockdown on glioma cell growth and invasion, respectively. We also used MTS assay to investigate the IC(50) value of temozolomide in negative control group and siRNA groups. Result: Compared with blank group, DNA-PKcs specific siRNA significantly downregulated both mRNA and protein level of DNA-PKcs. MTS assay results demonstrated that 72-hours proliferation of test group were only 52.48%, 54.70% (H4) and 52.98%, 50.45% (U87) of the blank group's counterpart. Transwell assay results showed that the invasiveness abilities of blank and test groups were 1.00±0.03, 0.41±0.05, 0.39±0.04 (H4) and 1.00±0.02, 0.28±0.04, 0.27±0.04 (U87). Moreover, knockdown of DNA-PKcs significantly decreased the temozolomide IC(50) value (H4: 249±27, 97±39, 88±35; U87: 485±41, 86±49, 73±38). Further we applied the Western blot to reveal the mechanism of inhibitory effect of DNA-PKcs knockdown on glioma malignancies and temozolomide sensitivity. We found that downregulation of DNA-PKcs reduced the activity of AKT signal and the expression of its downstream effectors, such as c-Myc, MMP9, and Survivin. Conclusion: RNA interference targeting DNA-PKcs could inhibit glioma malignancies and enhance temozolomide sensitivity. The inhibitory effect of DNA-PKcs knockdown on those biological activities were mainly through inhibition of AKT signal and its downstream effectors.

High diversity of airborne fungi in the hospital environment as revealed by meta-sequencing-based microbiome analysis

Invasive fungal infections acquired in the hospital have progressively emerged as an important cause of life-threatening infection. In particular, airborne fungi in hospitals are considered critical pathogens of hospital-associated infections. To identify the causative airborne microorganisms, high-volume air samplers were utilized for collection, and species identification was performed using a culture-based method and DNA sequencing analysis with the Illumina MiSeq and HiSeq 2000 sequencing systems. Few bacteria were grown after cultivation in blood agar. However, using microbiome sequencing, the relative abundance of fungi, Archaea species, bacteria and viruses was determined. The distribution characteristics of fungi were investigated using heat map analysis of four departments, including the Respiratory Intensive Care Unit, Intensive Care Unit, Emergency Room and Outpatient Department. The prevalence of Aspergillus among fungi was the highest at the species level, approximately 17% to 61%, and the prevalence of Aspergillus fumigatus among Aspergillus species was from 34% to 50% in the four departments. Draft genomes of microorganisms isolated from the hospital environment were obtained by sequence analysis, indicating that investigation into the diversity of airborne fungi may provide reliable results for hospital infection control and surveillance.

International Society of Human and Animal Mycology (ISHAM)-ITS reference DNA barcoding database--the quality controlled standard tool for routine identification of human and animal pathogenic fungi

Human and animal fungal pathogens are a growing threat worldwide leading to emerging infections and creating new risks for established ones. There is a growing need for a rapid and accurate identification of pathogens to enable early diagnosis and targeted antifungal therapy. Morphological and biochemical identification methods are time-consuming and require trained experts. Alternatively, molecular methods, such as DNA barcoding, a powerful and easy tool for rapid monophasic identification, offer a practical approach for species identification and less demanding in terms of taxonomical expertise. However, its wide-spread use is still limited by a lack of quality-controlled reference databases and the evolving recognition and definition of new fungal species/complexes. An international consortium of medical mycology laboratories was formed aiming to establish a quality controlled ITS database under the umbrella of the ISHAM working group on "DNA barcoding of human and animal pathogenic fungi." A new database, containing 2800 ITS sequences representing 421 fungal species, providing the medical community with a freely accessible tool at http://www.isham.org/ and http://its.mycologylab.org/ to rapidly and reliably identify most agents of mycoses, was established. The generated sequences included in the new database were used to evaluate the variation and overall utility of the ITS region for the identification of pathogenic fungi at intra-and interspecies level. The average intraspecies variation ranged from 0 to 2.25%. This highlighted selected pathogenic fungal species, such as the dermatophytes and emerging yeast, for which additional molecular methods/genetic markers are required for their reliable identification from clinical and veterinary specimens.