Cold urticaria. Immunologic studies

Dermo-distortive urticaria: an autosomal dominant dermatologic disorder

A new hereditary physical urticaria, dermo-distortive urticaria (DDU), is described in a Christian Lebanese family. DDU is characterized by the appearance of pruritic, erythematosus, edematous, cutaneous swelling confined to the stimulated area in response to stimuli that vibrate or stretch the skin in a repetitive manner. The lesions appear within several minutes after stimulation and disappear within an hour. Extensive stimulation causes not only local urticaria but also a systemic response of faintness, headache, and facial erythema. Other than these annoying reactions, no other morbidity is associated with this disorder. While this disorder is certainly uncommon and its manifestations are more annoying than life threatening, it may be an important example of a heritable defect of inflammation control mechanisms. Although the mediator for the urticaria and systemic response was not isolated, a likely candidate is histamine. Computer analysis of the phenotype of 219 relatives in 6 generations shows that DDU is transmitted as an autosomal dominant trait with high penetrance. DDU is clinically distinct from hereditary angioneurotic edema, pressure urticaria, and dermographia. It is similar to vibratory angioedema (VA), but sufficient evidence to prove that DDU and VA are identical is not available.

Cold urticaria associated with immunoglobulin M serum factor

A case of cold urticaria, thought to be due to IgM, is presented. Passive transfer (PT) activity was manifested in cryoglobulin-free serum and in up to 20-fold dilutions of fraction I, the IgM-containing fraction obtained by Sephadex G-200 column chromatography. PT test results were positive with serum absorbed with cold agglutinins, and with heat-treated (56 degrees C, 4 hr) serum. These results were negative with cryoglobulin and after absorbing the supernatant of fraction I with anti-IgM. Skin adhesion time was within 24 hr. The in vivo histamine release during cold stimulation was recorded and in this patient, antihistamine administration proved the best method to alleviate the symptoms.

Release of mast-cell mediators and alterations in lung function in patients with cholinergic urticaria

Cholinergic urticaria was elicited in seven subjects by experimental challenge that consisted of running on a treadmill in a plastic occlusive suit. A sensation of generalized warmth of the skin was followed by pruritus, erythema, urticaria, and transient respiratory-tract symptoms consisting of shortness of breath or wheezing or both. Statistically significant falls in one-second forced-expiratory volumes (FEV1), maximal midexpiratory flow rates (MMF), and specific conductance (SGaw) and a rise in residual volume were detected. The serum histamine concentration rose, with an augmentation of eosinophil and neutrophil chemotactic activities. Gel-filtration chromatography showed that the eosinophil chemotactic activity consisted of at least two principles. The chemotactic activities are similar in magnitude to those recognized in other skin disorders dependent on mast cells. These observations extend to the lungs the manifestations of a condition previously thought to be restricted to the skin.

Immunological parameters and alpha 1-antitrypsinin chronic urticaria

Serum immunoglobulins, complement and alpha 1-antitrypsin were assayed in forty-eight patients with chronic urticaria. Thirteen cases had chronic cold urticaria and thirty-two had chronic idiopathic urticaria. Elevated mean serum IgM was found in chronic cold urticaria. Seven patients had partial immunoglobulin deficiencies. IgE was elevated in sixteen cases of chronic idiopathic and in two with chronic cold urticaria. Eight patients had depressed serum total haemolytic complement activity. Low C3 and normal C4 serum protein concentrations in four cases suggested alternative complement pathway activation. Twenty of forty-six patients were atopic, although specific allergies responsible for the urticaria were not identified in any of them. alpha 1-antitrypsin levels were normal in all patients. The data suggest that the aetiology and pathogenesis of chronic urticarias in this study are heterogeneous. No evidence of abnormality of the protease inhibitor system in either chronic idiopathic or chronic cold urticaria was found.

Mast cell-mediated reactions of host defense and tissue injury: the regulatory role of eosinophil polymorphonuclear leukocytes

Immunological stimulation of mast cells, by way of either IgE- or IgG-directed reactions, initiates the rapid release of an array of chemical mediators. The predominant local tissue effects of these mediators collectively constitute a defensive response of the host. The early humoral phase of defense is exemplified by the alterations in microvascular permeability induced by histamine which provide a local concentration of immunoglobulins and complement components. The later cellular phase of defense is composed of the PMN leukocytes that accumulate in response to mast cell-derived chemotactic principles and which phagocytose and degrade opsonized foreign material, thus eliminating the inciting stimulus. Of the several endogenous regulatory mechanisms which act to contain the immediate hypersensitivity reaction, the eosinophil has a special role since it is specifically attracted to sites of mast cell activation and has selective concentrations of several enzymes which degrade the mast cell-derived chemical mediators. Failure of the local regulatory processes can permit the mast cell responses of host defense to become pathological reactions leading to tissue injury by virtue of persistence of high levels of humoral mediators and/or increasing infiltration with PMN leukocytes.

Cold urticaria. Recognition and characterization of a neutrophil chemotactic factor which appears in serum during experimental cold challenge

Sera were obtained from the venous effluents of cold-challenged arms of patients with idiopathic cold urticaria without plasma or serum cryoproteins; these sera exhibited increased neutrophil chemotactic activity without alterations of the complement system. A two- to fourfold augmentation of the base-line neutrophil chemotactic activity of serum from the immersed extremity began within 1 min, peaked at 2 min, and returned to base-line levels within 15 min, whereas there was no change in the serum chemotactic activity in the control arm. The augmented chemotactic activity in the serum specimens from the challenged arm of each patient appeared in a high molecular-weight region, as assessed by the difference in activity recovered after Sephadex G-200 gel filtration of the paired lesional and control specimens. Sequential purification of this high molecular-weight activity by anion- and cation-exchange chromatography revealed a single peak of activity at both steps. The partially purified material continued to exhibit a high molecular weight, being excluded on Sepharose 4B, and had a neutral isoelectric point. The partially purified material showed a preferential chemotactic activity for neutrophilic polymorphonuclear leukocytes, required a gradient for expression of this function, and exhibited a capacity to deactivate this cell type. This active principle, termed high molecular-weight neutrophil chemotactic factor, exhibited a time-course of release that could be superimposed upon that of histamine and the low molecular-weight eosinophil chemotactic factor and may represent another mast cell-derived mediator.

Cold urticaria: release into the circulation of histamine and eosinophil chemotactic factor of anaphylaxis during cold challenge

Patients with idiopathic acquired cold-induced urticaria were evaluated for the release of the preformed mast-cell mediators of immediate-type hypersensitivity during a study in which one arm was immersed in ice water while the other arm remained as a control. Blood specimens were obtained from each arm serially over a one-hour interval, and serum speciments were assessed for histamine, eosinophil chemotactic factor of anaphylaxis, and complement components. Levels of histamine and eosinophil chemotactic factor rose in the arm subjected to cold immersion for three minutes, with peak values occurring between two and five minutes and returning to base line by 30 minutes. No changes occurred in the control arm or in the immersed arm of normal subjects. Assessment of the classical and alternative complement pathways showed no abnormalities. This initial observation of release of eosinophil chemotactic factor of anaphylaxis in vivo along with histamine assigns the mast cell a central role in cold urticaria.

In vivo studies of mediator release in cold urticaria and cholinergic urticaria

Six patients with cold urticaria were found to possess elevated plasma histamine levels after cold challenge by placing one hand in ice water for 4 minutes. A single patient became hypotensive during the procedure and had a level of 260 ng/ml. histamine in the venous effluent from his hand. No elevation of plasma serotonin or bradykinin was observed. Two patients with cholinergic urticaria possessed elevated plasma histamine levels during and after vigorous exercise for 10 minutes; these patients also gave a positive test for vibration-induced angioedema. A single patient with cholinergic urticaria possessed elevated baseline serotonin levels and elevated levels during and after exercise but no elevation of plasma histamine or bradykinin. The results suggest that histamine is the major mediator of urticaria and hypotension in cold urticaria. Histamine also appears to be released coincident with the development of urticaria in some patients with cholinergic urticaria, while elevated serotonin levels in a single atypical patient suggest that a subpopulation of patients with cholinergic urticaria possess a different pathogenesis.