Progesterone-responsive urticaria and eosinophilia

Effect of Puberty, Menstruation, Pregnancy, Lactation, and Menopause on Chronic Urticaria Activity

BACKGROUND

Chronic urticaria (CU) is a systemic disorder which is characterized by recurrent wheals and/or angioedema lasting more than 6 weeks. Sex hormones have been suggested to play a role in CU pathogenesis, however, their clinical implications have not been adequately described in the literature.

OBJECTIVE

To determine whether conditions that change sex hormone levels such as puberty, menstruation, pregnancy, breastfeeding, and menopause affect the course of CU.

METHODS

This cross-sectional questionnaire study was conducted on female CU patients at Okmeydani Training and Research Hospital UCARE Center between 2016 and 2017. The open-ended questionnaire consisted of questions evaluating the effects of hormonal changes on disease course.

RESULTS

A total of 111 female CU patients were included in the analysis. During the perimenstrual period, CU symptoms worsened in 29% of patients but improved in 4.8%. The disease course did not change in the majority of patients during puberty, pregnancy, lactation, or menopause (100%, 96%, 83.8%, and 95.6%, respectively).

CONCLUSIONS

Contrary to expectations, a change in sex hormone levels had no effect on the course of CU in the majority of cases. However, disease activity increased in one-third of CU patients during the perimenstrual period.

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.

Autoimmune Progesterone Dermatitis: A Systematic Review

ABSTRACT

Autoimmune progesterone dermatitis (AIPD) is a cyclical, cutaneous reaction to endogenous progesterone that occurs throughout the menstrual cycle. The cutaneous manifestations of AIPD vary greatly from patient to patient, ranging anywhere from urticaria to erythema multiforme to anaphylaxis. As such, recognition, diagnosis, and management of this condition are difficult for clinicians. In the present article, we conducted a systematic review of 112 articles and 132 individual cases to summarize the clinical features and presentation of AIPD while also summarizing the successes and failures of different treatment plans. Despite the great variety in clinical presentations, it is clear from the data that ovulation-suppressing medical therapies and surgery have the greatest success in treating AIPD, whereas more commonly used therapies such as antihistamines and systemic corticosteroids frequently fail in providing any relief. Further research is necessary to determine the exact pathogenesis of AIPD and allow for more targeted treatment.

Does omalizumab treatment affect serum dehydroepiandrosterone sulphate levels in chronic idiopathic urticaria?

INTRODUCTION

It is known that serum dehydroepiandrosterone sulphate (DHEA-S) levels are low in patients with chronic idiopathic urticaria.

AIM

In the study, the effect of the drug on the DHEA-S serum levels and its correlation with the remission and relapse times of the disease was investigated.

MATERIAL AND METHODS

Fifty-seven patients with chronic idiopathic urticaria who were referred to our hospital and 20 healthy volunteers were included in the study. A subcutaneous injection of 300 mg omalizumab was administered to the patient group. Drug injections at this dose were completed (6 injections in total, one per month). Relations between serum DHEA-S levels and relapse rates, treatment response and remission duration of the patients and control group were investigated in the groups.

RESULTS

Median DHEA-S value before treatment was 116.3 (21.5-448.7) µg/dl; the median DHEA-S value measured after 3 months was 98.4 (10.0-410.0) µg/dl (p = 0.003). The median DHEA-S value before treatment was 123.1 (21.5-299.6) µg/dl when the initial and 3-month DHEA-S levels of the 34 complete remission patients were compared; after 3 months the value was 100.4 (23.1-301.9) µg/dl (p = 0.021).

CONCLUSIONS

This is the first study to investigate the effect of omalizumab treatment on DHEA-S levels in the treatment of chronic urticaria according to our literature review. The DHEA-S levels were found to be significantly lower after omalizumab therapy but not related to remission and relapse times.

Progesterone induces mucosal immunity in a rodent model of human taeniosis by Taenia solium

More than one quarter of human world's population is exposed to intestinal helminth parasites. The Taenia solium tapeworm carrier is the main risk factor in the transmission of both human neurocysticercosis and porcine cysticercosis. Sex steroids play an important role during T. solium infection, particularly progesterone has been proposed as a key immunomodulatory hormone involved in susceptibility to human taeniosis in woman and cysticercosis in pregnant pigs. Thus, we evaluated the effect of progesterone administration upon the experimental taeniosis in golden hamsters (Mesocricetus auratus). Intact female adult hamsters were randomly divided into 3 groups: progesterone-subcutaneously treated; olive oil-treated as the vehicle group; and untreated controls. Animals were treated every other day during 4 weeks. After 2 weeks of treatment, all hamsters were orally infected with 4 viable T. solium cysticerci. After 2 weeks post infection, progesterone-treated hamsters showed reduction in adult worm recovery by 80%, compared to both vehicle-treated and non-manipulated infected animals. In contrast to control and vehicle groups, progesterone treatment diminished tapeworm length by 75% and increased proliferation rate of leukocytes from spleen and mesenteric lymph nodes of infected hamsters by 5-fold. The latter exhibited high expression levels of IL-4, IL-6 and TNF-α at the duodenal mucosa, accompanied with polymorphonuclear leukocytes infiltration. These results support that progesterone protects hamsters from the T. solium adult tapeworm establishment by improving the intestinal mucosal immunity, suggesting a potential use of analogues of this hormone as novel inductors of the gut immune response against intestinal helminth infections and probably other bowel-related disorders.

A case of autoimmune progesterone dermatitis misdiagnosed as allergic contact dermatitis

Autoimmune progesterone dermatitis is a rare autoimmune response to endogenous progesterone that usually occurs in fertile females. Cutaneous or mucosal lesions develop cyclically during the luteal phase of the menstrual cycle when progesterone levels are elevated. Symptoms usually start 3-10 days before menstruation and resolve 1-2 days after menstruation ceases. We report the case of a 48-year-old woman with intermittent eczematous skin lesions of the legs, forearms, and buttocks. She was diagnosed with allergic contact dermatitis, and topical steroids were prescribed. Her skin eruptions waxed and waned for 6 years and were associated with her menstrual cycle. We performed an intradermal test using progesterone, which was positive, and prescribed gonadotropin-releasing hormone analogues monthly for 3 months. The patient's skin lesions improved, confirming the diagnosis. Autoimmune progesterone dermatitis should be included in the differential diagnosis of recurrent eczema that is refractory to treatment in women of child-bearing age.

The role of female sex hormones in the development and severity of allergic and non-allergic asthma

Allergic asthma is usually diagnosed by the presence of variable airway obstruction, bronchial hyperresponsiveness, and allergy. However, a significant proportion of adult asthma patients (up to 40%) are non-allergic. Patients with non-allergic asthma often have a later disease onset and greater disease severity, as reflected by more severe airway obstruction and bronchial hyperresponsiveness. Furthermore, females have a higher risk of developing non-allergic asthma. The latter suggests that hormone-related events play an important role in the development and severity of adult-onset non-allergic asthma. This paper describes the associations between asthma and hormonal changes throughout the female life-span, such as those associated with the monthly cycle of menstruation and menopausal hormonal changes.

Autoimmune progesterone dermatitis in a patient with endometriosis: case report and review of the literature

Autoimmune progesterone dermatitis (APD) is a condition in which the menstrual cycle is associated with a number of skin findings such as urticaria, eczema, angioedema, and others. In affected women, it occurs 3–10 days prior to the onset of menstrual flow, and resolves 2 days into menses. Women with irregular menses may not have this clear correlation, and therefore may be missed. We present a case of APD in a woman with irregular menses and urticaria/angioedema for over 20 years, who had not been diagnosed or correctly treated due to the variable timing of skin manifestations and menses. In addition, we review the medical literature in regards to clinical features, pathogenesis, diagnosis, and treatment options.

Perimenstrual asthma: a syndrome without known cause or cure

Perimenstrual worsening of asthma has been documented in 30% to 40% of asthmatic women. This increase in symptoms has been backed up by increased health care use perimenstrually, as well as by cyclic variation in peak expiratory flows. The cause of perimenstrual asthma (PMA) remains unclear. Fluctuations in hormone levels, their ratios, or both are a plausible explanation but have not been demonstrated with any consistency. Influences of sex hormones on inflammation is an area of future research, as are hormone-induced changes in smooth muscle function and beta-adrenergic receptors, prostaglandin levels, and fluid retention in the bronchial mucosa. In the light of the high prevalence of PMA, it is difficult to understand why there has been no randomized controlled trial of hormone therapy. Nevertheless, several case reports have suggested beneficial effects of estrogens, progestins, and their combination. In light of these positive case reports, well-designed, double-blind studies of sufficient sample size should now be performed to give treatment of PMA an evidence base.

Autoimmune progesterone dermatitis and its manifestation as anaphylaxis: a case report and literature review

OBJECTIVE

Autoimmune progesterone dermatitis is a rare cyclic premenstrual reaction to progesterone produced during the luteal phase of a woman's menstrual cycle with a variety of presentations including erythema multiforme, eczema, urticaria, angioedema, and progesterone-induced anaphylaxis. We present a case of progesterone-induced anaphylaxis and a review of literature focusing on its diagnosis and therapy.

DATA SOURCES

We surveyed all the literature in English back to 1921 when the first case was published. First, we researched the terms progesterone anaphylaxis, autoimmune progesterone dermatitis, cyclic urticaria, using the PubMed resource. Then we included articles found within these publications' reference sections.

STUDY SELECTION

We selected articles based on whether the cases described appeared to fit the description of the entity autoimmune progesterone dermatitis. All cases included had dermatologic reactions occurring during the luteal phase of the menstrual period, positive skin or intramuscular reactions to progesterone, and treatment amenable to anovulatory agents and/or hysterectomy with bilateral salpingo-oophorectomy.

RESULTS

We found approximately 50 published cases of autoimmune progesterone dermatitis, and only nine known cases of its manifestation as anaphylaxis. These cases, including the case described by us, are summarized, and successful diagnostic and therapeutic approaches in the literature are reviewed.

CONCLUSIONS

Autoimmune progesterone dermatitis is a rare entity associated with progesterone production of the luteal phase of a woman's menstrual cycle. It can be diagnosed using intradermal or intramuscular progesterone tests and can be treated by disrupting the ovulation cycle using specific medications or by oopherectomy.

Evaluation of progesterone receptor expression in eosinophils using real-time quantitative PCR

Progesterone has been shown in many instances to have immune-suppressant activities. Most of these activities have been investigated in the light of general immune suppression or with a focus on lymphocytes. However, many clinical and in vitro studies have shown that progesterone also has a suppressive effect on eosinophilia. This effect so far has not been thoroughly investigated. The purpose of this study was to evaluate whether the effect is mediated via the classical progesterone receptor (PR). We developed a new real-time quantitative PCR (RQ-PCR) for the analysis and quantification of expression of the classical PR. The test was first validated both on breast cancer cell lines and on breast cancer biopsies. Subsequently, when using eosinophils isolated from peripheral blood of healthy volunteers, we could not find evidence for the expression of PR. These data suggest that the effects of progesterone on eosinophils are not mediated by the classical PR.

Anaphylactoid reactions associated with menstruation affecting two sisters

Cyclical anaphylactoid reactions associated with menstruation are exceedingly rare. We report two sisters who were both affected, one severely and one mildly. Treatment involved suppression of menstruation and use of a cyclooxygenase-2 (COX-2) inhibitor. An abnormal reaction to prostaglandins, perhaps produced by COX-2 enzyme activity in the endometrium, is a possible mechanism.

Expression of oestrogen and progesterone receptors by mast cells alone, but not lymphocytes, macrophages or other immune cells in human upper airways

BACKGROUND

Nasal polyposis often coexists with asthma in airway inflammatory conditions characterised by the infiltration of a range of immune cells. A potentially important role for ovarian hormones has been implicated in airway inflammation but the cellular target for such action is not known.

METHODS

Expression of oestrogen receptors (ER) and progesterone receptors (PR) was examined using immunohistochemistry in formalin fixed nasal polyp tissues from 47 subjects. The cells positive for ER or PR were confirmed by spatial location, dual immunolabelling, and histochemical staining.

RESULTS

Consistent with the known features of nasal polyps, CD4+ (T helper/inducer), CD8+ (cytotoxic/suppressor), CD68+ (macrophages), mast cells, eosinophils and neutrophils were all clearly detected by their relevant monoclonal antibodies or appropriate histochemical staining, but only mast cells tested positive for ER/PR labelling with their polyclonal and monoclonal antibodies. The frequencies for expression were 61.7% for ER positive and 59.6% for PR positive cells. The expression of ER/PR was independent of patient sex and age but was highly correlated with the numbers of mast cells (r = 0.973, p<0.001 for ER; r = 0.955, p<0.001 for PR). Fewer than 5% of mast cells were found to be negative for ER/PR expression.

CONCLUSIONS

Mast cells alone, but not lymphocytes, macrophages, or other immune cells, express ER/PR in human upper airways. Numerous ER/PR positive mast cells exist in nasal polyps, indicating that this may be a major route for the involvement of sex hormones in airway inflammation when exposed to the higher and varying concentration of oestrogen and progesterone characteristic of females.

Prevention of severe premenstrual asthma attacks by leukotriene receptor antagonist

BACKGROUND

The etiology and treatment of premenstrual exacerbations of asthma (PMA) remain uncertain.

OBJECTIVE

We investigated the role of cellular mediators released from inflammatory cells in the airflow limitation during PMA.

METHODS

Serum levels of leukotriene (LT) B(4), LTC(4), platelet- activating factor, histamine, IL-1beta, IL-4, IL-5, IL-6, and GM-CSF were measured at different time points, first just before or during menstruation when the peak expiratory flow rate (PEFR) began to decrease precipitously and second during the menstrual midcycle week (days 10-16) when the PEFR returned to baseline values in patients with PMA and in age-matched asthma patients without PMA at the same intervals.

RESULTS

Serum levels of LTC(4) were significantly higher during exacerbations of asthma than after recovery (69.0 +/- 16.0 pg/mL vs 24.0 +/- 9.5 pg/mL, P <.05), whereas those of IL-1beta, IL-4, IL-5, IL-6, GM-CSF, histamine, LTB(4), and platelet-activating factor did not differ between 2 periods in 5 patients with PMA. In contrast, in 5 asthmatic patients without PMA serum levels of cellular mediators did not differ between corresponding periods. Oral administration of pranlukast, an LT receptor antagonist (225 mg twice daily), significantly reduced decreases in PEFR from the baseline values (110 +/- 21 L/min with pranlukast vs 233 +/- 20 L/min without pranlukast, P <.01) in association with an improvement of asthma symptom scores (6.5 +/- 1. 1 with pranlukast vs 9.8 +/- 0.7 without pranlukast, P <0.05) in 5 patients with PMA.

CONCLUSION

LTs are partly involved in the pathogenesis of PMA, and LT receptor antagonists may be useful for preventing airflow obstruction in patients with PMA.

The influence of female sex hormones on nasal reactivity in seasonal allergic rhinitis

BACKGROUND

This study aimed to investigate whether the hormone peaks of estrogen and progesterone could influence the extent of the allergic reaction in grass-pollen-allergic women.

METHODS

Twenty-three allergic women with seasonal allergic rhinitis due to grass pollen were included in this trial. Twelve were taking oral contraceptives (OC) (control group), and 11 were taking no pill (target group). The subjects were challenged with grass pollen by nasal provocation test around day 14 of their menstrual cycle (ovulation day) and again at the end of the cycle (day 27). The primary criteria were the subjective nasal symptoms rhinorrhea, nasal blockage, itching, and sneezing. A further criterion was the objectively measured nasal mucosal swelling, assessed by active anterior rhinomanometry. All criteria were evaluated before and 15 min after provocation, and the hormone status was determined on each investigation day.

RESULTS

Comparisons of symptoms between the groups resulted in P values of > 0.05 for all symptoms at both visits except the symptom blocked nose, which was significantly lower (P=0.03) in the patients with OC intake at visit 2, and the symptom sneezing, which showed a significantly (P=0.02) higher increase in patients taking OC at the end of the cycle. The flow decrease reached a greater extent in the target group than in the controls.

CONCLUSIONS

These results indicate a correlation of the hormonal situation and the nasal allergic reactivity. OC intake led to an intensifying of neurogenic symptoms near the end of pill intake, a result which could be due to a protective effect of the endogenous progesterone, in contrast to the orally administered hormones.

Influence of the menstrual cycle on skin-prick test reactions to histamine, morphine and allergen

The purpose of this study was to examine the possible influence of the phases of the menstrual cycle on dermal reactivity to skin-prick testing. We studied 15 atopic, menstruating women with seasonal rhinoconjunctivitis and/or asthma, with known sensitivity to olive and parietaria (mean age 25.2 years) and 15 non-atopic, healthy, female controls (mean age 24.7 years). Skin-prick tests with histamine, morphine, and in the atopic group with parietaria/and/or olive, were repeated three times during the same menstrual cycle, corresponding to bleeding (day 1-4), midcycle (day 12-16) and the late progesterone phase (day 24-28). None of the patients had received oral antihistamines or exogenous hormones for at least 1 month prior to testing. Results indicate a significant increase in weal-and-flare size to histamine, morphine, and parietaria on days 12-16 of the cycle, corresponding to ovulation and peak oestrogen levels. This was observed in both atopic and non-atopic women. Differences in skin reactivity to histamine and morphine between the groups were not significant. Therefore, in women, the phase of the menstrual cycle is another factor that may influence skin-test results.