[Urticarial vasculitis]

Urticarial vasculitis is defined by association of an urticaria and/or angio oedema and a vasculitis of the small dermal vessels, leucocytoclastic or mononuclear. Sometimes it is an acute urticaria, of infectious or drug origin. Urticarian vasculitis may also be due to pressure or cold. But usually, it is a chronic urticaria that readily accompanies systemic signs and immunological anomalies, in particular hypocomplementemia. The clinical-biological picture becomes a true entity or is associated with another condition, most often a collagenosis.

ACE inhibitor-induced angioedema. Incidence, prevention and management

Available information from 1980 to 1997 on angiotensin converting enzyme (ACE) inhibitor-induced angioedema and its underlying mechanisms are summarised and discussed. The incidence of angioedema is low (0.1 to 0.2%) but can be considered as a potentially life-threatening adverse effect of ACE inhibitor therapy. This adverse effect of ACE inhibitors, irrespective of the chemical structure, can occur early in treatment as well as after prolonged exposure for up to several years. The estimate incidence is quite underestimated. The actual incidence can be far higher because of poorly recognised presentation of angioedema as a consequence of its late onset in combination with usually long term therapy. Also, a spontaneous reporting bias can contribute to an actual higher incidence of this phenomenon. The incidence can be even higher (up to 3-fold) in certain risk groups, for instance Black Americans. Treatment includes immediate withdrawal of the ACE inhibitor and acute symptomatic supportive therapy followed by immediate (and long term) alternative therapy with other classes of drugs to manage hypertension and/or heart failure. Preclinical and clinical studies for the elucidation of the underlying mechanism(s) of ACE inhibitor-associated angioedema have not generated definite conclusions. It is suggested that immunological processes and several mediator systems (bradykinin, histamine, substance P and prostaglandins) are involved in the pathogenesis of angioedema. A great part of all reviewed reports suggest a relationship between ACE inhibitor-induced angioedema and increased levels of (tissue) bradykinin. However, no conclusive evidence of the role of bradykinin in angioedema has been found and an exclusive role of bradykinin seems unlikely. So far, no clear-cut evidence for an immune-mediated pathogenesis has been found. In addition, ACE gene polymorphism and some enzyme deficiencies are proposed to be involved in ACE inhibitor-induced angioedema. Progress in pharmacogenetic and molecular biological research should throw more light on a possible genetic component in the pathogenesis of ACE inhibitor-associated angioedema.

Acute annular urticaria in infants and children

Characteristic features of acute annular urticaria in 34 infants and small children were large, erythematous annular and polycyclic lesions with violaceous centers, eyelid, hand, and foot edema, absence of angioedema of the airway, absence of pruritus, spontaneous resolution in 8 to 10 days, and frequent history of furazolidone medication for diarrhea. Nondermatologists often misdiagnose acute annular urticaria as erythema multiforme and unnecessarily overtreat patients. The differential diagnosis with other conditions presenting with annular lesions in children is discussed.

Acquired angioedema

Acquired angioedema (AAE) is a rare disorder that has been categorized into two forms, AAE-I and AAE-II. AAE-I is associated with other diseases, most commonly B-cell lymphoproliferative disorders. AAE-II is defined by the presence of an autoantibody directed against the C1-inhibitor molecule. Differentiating AAE-I from AAE-II is vital because different therapeutic interventions are required for each type. This review summarizes the clinical aspects, pathophysiology, and management of AAE compared with the types of hereditary angioedema.

Acquired C1-esterase inhibitor deficiency: three case reports and commentary on the syndrome

Acquired C1-esterase inhibitor deficiency is a rare syndrome which usually presents with episodes of angioedema. Most patients have an underlying lymphoproliferative disorder. It is important to gastroenterologists, haematologists, immunologists and dermatologists, as these are the more likely specialties to which the patient will present. Recognition of the syndrome is important not only for diagnostic purposes but for investigating and treating any associated underlying lymphoproliferative disorders. In some instances the angioedema may precede the lymphoma by many years. Optimal patient management requires that both angioedema and the underlying lymphoma be recognized and treated.

Urticaria and angioedema: a clinical spectrum

OBJECTIVE

The objective of this review is to give the reader a global insight into the spectrum of urticaria, focusing on differential diagnosis and pathogenic mechanisms. This review will define the role of the mast cell, explore a possible autoimmune basis for urticaria, and examine the purported role of food allergy in chronic urticaria. Last, the work-up and treatment of urticaria will be discussed in the context of the histologic diagnosis.

STUDY SELECTION

The relevant past medical literature will be reviewed in the context of new and novel research into the mechanisms of chronic urticaria.

RESULTS

Urticaria can be classified histopathologically into the following three categories: (1) neutrophilic vasculitis, (2) polymorphous perivascular infiltrate, and (3) sparse perivascular lymphocytic infiltrate. Each of the above histologic patterns correlates with a distinct clinical entity and the work-up and treatment of urticaria will be related to each of the above histologic types.

CONCLUSIONS

Urticaria and angioedema are frustrating problems for both physicians and their patients; however, the problem can best be approached by considering urticaria as a symptom that may be part of a larger clinical spectrum. The physical examination and medical history remain the two most important pieces of information. The allergist frequently overlooks the value of a skin biopsy as an aid in sorting out the pathophysiology of urticaria and the biopsy results may help to classify urticaria into subgroups which respond differently to treatment.

Acquired deficiency in C1-inhibitor associated with signet ring cell gastric adenocarcinoma: a probable connection of antitumor-associated antibodies, hemolytic anemia, and complement turnover

BACKGROUND

Acquired deficiency in C1-inhibitor (C1-INH) associated with malignancy is often asymptomatic because clinical manifestations are not dependent on a critical complement threshold (in contrast to hereditary C1-INH deficiency). Increased complement consumption involving different kinds of antibodies is the postulated mechanism for this disease, but other factors must play an important role.

CASE REPORT

A 76-year-old woman with unremarkable medical history experienced three episodes of angioedema over 6 months. Investigations revealed a complement profile characteristic of acquired deficiency in C1-INH, a hemolytic anemia, and a signet ring cell adenocarcinoma (linitis plastica). A gastrectomy and a splenectomy were performed. The postoperative course was characterized by a complete disappearance of the symptoms of angioedema and hemolytic anemia. A local recurrence of the tumor 5 months later could not be resected. The patient died 17 months after the initial surgery was performed.

RESULTS

Quantitative and functional analyses of the complement factors showed persistent excessive complement consumption. Markers of hemolytic anemia disappeared after tumor removal but recurred in the second part of the disease evolution. Immunohistochemical findings in tumor tissue showed loss of normal blood group antigens but expression of Lea antigen, as well as C1q deposition.

CONCLUSION

To explain the whole clinical and laboratory picture, we hypothesize a connection between tumor immunohistochemical profile, complement consumption, and hemolytic anemia. Tumor cell surface antigens might lead to a permanent but asymptomatic complement consumption that is worsened and becomes clinically manifest by superimposed hemolytic anemia caused by cross-reactive antibodies to newly expressed blood group antigens on tumor cells. This hypothesis should be confirmed by other observations.

Angioedema secondary to angiotensin-converting enzyme inhibitors

Angioedema secondary to angiotensin-converting enzyme (ACE) inhibitors is rare, but it is a side effect which is likely to be seen more frequently because of the increased use of these drugs to treat cardiac failure and hypertension. Presentation is variable and the diagnosis may go unrecognized for many months or years. The cases reported illustrate problems both in the diagnosis and management of this life-threatening condition.

[Necrobiotic xanthogranuloma in IgG kappa plasmacytoma and Quincke edema]

Necrobiotic xanthogranuloma is a non-X histiocytosis with unknown pathogenesis. It is associated with paraproteinaemia, and in rare cases with multiple myeloma. A decreased level of C1 inhibitor has been found in several cases without clinical manifestations of Quincke oedema. We report on a patient with necrobiotic xanthogranuloma and myeloma, in whom we found a decreased level of C1 inhibitor and recurrent episodes of manifest Quincke oedema. The indirect detection of auto-antibodies against the paraprotein with development of immune complexes is regarded as an explanation for the consumption of the C1 inactivator and the manifestation of Quincke oedema. The possibility of a causal relationship between paraproteinaemia and necrotic xanthogranuloma is discussed.

[Episodic angioedema with eosinophilia]

In 1984, Gleich et al. originally reported a novel syndrome of episodic angioedema with eosinophilia. The syndrome is characterized by recurrent angioedema, urticaria, weight gain, elevated IgM levels, marked blood eosinophilia, and eosinophil infiltrates in the dermis. It has also been observed that activated CD4+ T cells are present in the dermis of patients with this syndrome, suggesting that T cell-derived cytokines especially IL-5 might be involved in the migration and activation of eosinophils in the skin. Indeed, it has recently been reported that serum IL-5 levels elevate during clinical exacerbation of this syndrome. However, it still remains to be elucidated what antigen periodically activates CD4+ T cells, what factor(s) determine selective migration of eosinophils into the skin, and so on.

Abdominal attack of hereditary angioedema associated with marked leucocytosis. A case report

Hereditary angioedema (HAE) attacks are not usually associated with an increase of peripheral blood leucocytes. In a 25-year-old woman suffering from HAE a marked leucocytosis (31,000/mm3) with polynucleosis was observed during a severe attack of the disease. Awareness of the underlying disease, physical examination and the results of instrumental investigations allowed for appropriate treatment avoiding invasive procedures. A leucocytosis of the severity observed in our patient suggests that the abdominal attack of HAE can involve the peritoneum as well as the intestinal mucosa. Thus, in a patient with an attack of abdominal pain the presence of leucocytosis does not exclude the diagnosis of HAE.

Fatal angioedema associated with captopril

A markedly hypertensive, 70-year-old, black man had been on captopril for 2 years when he rapidly developed obstructive angioedema. The initial sign of difficulty in understanding his speech progressed to severe laryngeal and glossal edema over a 3 1/2 h period. His airway became obstructed less than a minute after arrival at the emergency room. Oral intubation was unsuccessful, and a difficult tracheostomy was too late to save the patient. The death was reported to the medical examiner because of its sudden and unusual nature. The risk of angioedema while on angiotensin converting enzyme inhibitor therapy has been noted previously in the clinical literature. Because of the sudden onset and possible confusion with an allergic reaction, this entity is brought to the attention of the forensic medical community.

Ophthalmic manifestations of chronic angioedema with necrotizing vasculitis

Anatomic features unique to periocular tissues alter the clinical appearance of angioedema, making it difficult to distinguish from cellulitis and other inflammatory conditions. Two patients had prominent periocular manifestations of chronic angioedema with necrotizing vasculitis, a systemic disease often associated with multiorgan involvement. The diagnosis was established by exclusion of other inflammatory disorders and confirmed by biopsy. The scarcity of reports in the ophthalmic literature on chronic angioedema of the eyelids may be caused by its underrecognition. The distinction between chronic angioedema and typical angioedema or urticaria is important because of differences in their diagnostic evaluation, treatment, and prognosis.

Immunopathology of urticaria

Actual concepts of urticaria immunopathology are briefly discussed, emphasizing the cytokine and inflammatory cells network.

Blepharochalasis. A review of 30 cases

This paper presents the findings in a series of 30 patients with blepharochalasis, including the age of onset, sex, predisposing factors, symptoms and signs, frequency and duration of attacks, and length of the history. There were 16 bilateral and 14 unilateral cases. The condition can be divided into an active (early) and a quiescent (late) stage. The active stage is further subdivided into intumescent (hypertrophic) and atrophic forms. The sequelae included excess thin skin, fat herniation, lacrimal gland prolapse, ptosis, blepharophimosis, pseudoepicanthic fold, proptosis, conjunctival injection and cysts, entropion, and ectorpion. Surgery primarily involved blepharoplasty, ptosis correction, and lateral canthal reattachment alone or in combination. The pathology showed a variable picture of epithelial atrophy, vasculitis, and loss of elastic fibers, which did not greatly help to differentiate blepharochalasis from angioedema, lymphedema, dermatochalasis, tumors and infiltrations, and floppy lid syndromes. Blepharochalasis is probably a localized angioedema. The diagnosis depends on the clinical features of intermittent attacks of localized swelling affecting one or more eyelids associated with thinning of the skin giving either an intumescent (hypertrophic) or atrophic appearance in the active stage of the condition and progressing to atrophic changes in the quiescent (late) stage.

Loiasis in endemic and nonendemic populations: immunologically mediated differences in clinical presentation

To define the clinical spectrum of loiasis more precisely and to begin to assess the immunologic basis for the difference in clinical manifestations between visitors to endemic areas and natives of these areas, 51 West African patients with loiasis were evaluated and compared with 42 infected expatriates. Microfilaremia was present in 90% and Calabar swellings in only 16% of the endemic patients. Conversely, only 10% of the expatriates were microfilaremic while 95% complained of Calabar swellings. The endemic population showed significantly decreased levels of peripheral blood eosinophils, parasite-specific IgG, and lymphocyte proliferation to parasite antigens compared with the nonendemic population. These findings support the hypothesis that differences in the modulation of the immune response to parasite antigen are responsible for the observed differences in clinical presentation between expatriate and endemic populations with loiasis.

Hereditary angioneurotic edema in the puerperium. A case report

Hereditary angioneurotic edema is a potentially fatal condition. Below is described the first reported case of the initial presentation of the condition precipitated by vaginal delivery.

Episodic angioedema with eosinophilia (Gleich syndrome)

A case of episodic angioedema with hypereosinophilia or otherwise called Gleich's syndrome is reported. The patient was a young woman with a six-year history of recurrent angioedema, itchy urticaria, rapid weight gain and hypereosinophilia. The main clinical, laboratory, and immunological findings included systemic angioedema, urticaria, 12% weight gain and leucocytosis (69.150 WBC/cu mm) with eosinophils of 75.6%. Circulating IgM, IgE, and T-helper lymphocyte were elevated. Skin biopsy showed an important perivascular eosinophil infiltration. The absence of concomitant allergic, malignant and connective disorders, and a dramatic clinical improvement with a fall of the eosinophil count to normal levels following corticosteroid therapy was the basis for our diagnosis.

Urticaria in infants: a study of forty patients

A retrospective study was carried out in 40 infants, age 1 to 24 months, with urticaria. Acute urticaria was seen most frequently (85%), followed by recurrent (10%) and chronic disease (5%). Several clinical features such as frequency of angioedema and hemorrhagic lesions appeared to be specific to urticaria in infants. An underlying cause was identified or suspected in 65% of cases: foods in 25%, and drugs and infections in 37.5%. Under 6 months of age, all infants had acute urticaria and 75% had cow's milk allergy. After 6 months of age, the main causes were drug intake (mostly aspirin and amoxicillin) and/or infections (mainly viral) (50%). Atopy was not overrepresented (20%), although a possible link between atopy and recurrent urticaria was noted. After a follow-up of 2 to 7.5 years, 96% of patients were symptom free. Thus, our results indicate that clinical and etiologic features of urticaria in infants are somewhat different from those of adults and children.

Angioedema, elephantiasis nostras, and cheilitis granulomatosa

Angioedema of the face is a common entity seen by the allergist, but other less common conditions should also be considered in the differential diagnosis of facial swelling. Elephantiasis nostras is a rare condition that can result in persistent swelling of the lips secondary to recurrent attacks of lymphangitis caused by bacterial infection. Cheilitis granulomatosa is a disorder that may also present with lip swelling. We present a patient with persistent swelling of his lips who was referred to our service to consider an allergic cause. The clinical findings of persistence of the swelling without improvement after therapy with corticosteroids and antihistamines are considered consistent with elephantiasis nostras or cheilitis granulomatosa. The histopathologic findings in this case revealed epithelioid cell granulomas, which are consistent with cheilitis granulomatosa. These two disorders should be included in the differential diagnosis of localized swelling of the face.

[Hereditary angioedema due to C1-esterase inhibitor deficiency]

The paper presents a case of family oedema by shortage of C1-esterase inhibitor, characterized by appearance at an early age (8 months), participation in some attacks of nasal mucous membrane, with nasal obstruction and sinusal manifestations and also the abnormally long period, up to 9 days, of some localized oedemas. The crises were absent during pregnancy. The study of four generations of the family showed the predominantly hereditary character of the genetic transmission. Two cases in which the disease apparently "overleapt" a generation, as clinical manifestations, were presented.

Pirenzepine treatment in urticaria-angioedema syndrome caused by adverse reactions to foods

An increased gastroenteric mucosal permeability is generally considered a pathophysiological mechanism in the urticaria-angioedema syndrome caused by adverse reactions to foods. Since pirenzepine, an antimuscarinic receptor drug, exerts a cytoprotective activity on digestive mucosa, the authors evaluated the clinical efficacy of pirenzepine and terfenadine (antihistamine), alone or associated, in the treatment of patients with urticaria-angioedema syndrome due to food allergy. Furthermore, additional endoscopy and biopsy studies were performed in order to provide experimental evidence about the cytoprotective activity of this treatment. The results of the present investigation confirm the clinical efficacy, with improvement of histological parameters, of pirenzepine treatment in adverse reactions to foods, as previously demonstrated by our group, and suggest further investigations on the functional mucosal impairment hypothesized in this pathological condition.