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Martínez ES, Duschner N, Schaller J. A cyclic dermatosis. J Dtsch Dermatol Ges 2024. [PMID: 39092665 DOI: 10.1111/ddg.15485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 08/04/2024]
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Chiarella SE, Buchheit KM, Foer D. Progestogen Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3606-3613.e2. [PMID: 37579875 PMCID: PMC10841326 DOI: 10.1016/j.jaip.2023.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
Progestogen hypersensitivity (PH) is a heterogeneous disease characterized by diverse cutaneous manifestations, bronchospasm, and/or anaphylaxis. Possible triggers include ovarian progesterone and exogenous progestogens. The timing of symptoms is critical to diagnose PH: during the luteal phase of the menstrual cycle for the endogenous form and after exposure to progestins for exogenous PH. Diagnostic modalities such as progesterone skin testing have low sensitivity and specificity for PH. When exogenous PH is suspected, the allergist should consider a progestogen challenge. Treatment strategies should be tailored for each patient, including symptom-directed therapies, ovulation suppression, and progesterone desensitization. Future studies should explore the mechanisms of PH, validation of diagnostic criteria, and standardization of treatment strategies.
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Affiliation(s)
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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Brás-Cruz R, David F, Morais Ferreira R, Rosário C. Progesterone hypersensitivity: a cyclical history. BMJ Case Rep 2023; 16:e256353. [PMID: 37996147 PMCID: PMC10668137 DOI: 10.1136/bcr-2023-256353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Hypersensitivity reaction to progesterone is rare, with less than 200 cases reported. It occurs mainly in women in their third decade of life and can have a heterogeneous presentation (cutaneous and/or systemic), with temporal relation to serum levels of progesterone. Diagnosis is based on history and physical examination, supported by skin tests. We describe the case of a woman in her late 20s with pruritic erythema on the chest that manifested in the luteal phase of the menstrual cycle, with spontaneous resolution in less than 5 days, without secondary scarring. The histological diagnosis was non-specific, with evidence of interface dermatitis, but positive skin tests supported the diagnosis of autoimmune progesterone dermatitis. It is intended to alert to the manifestations of a pathology that is rare and difficult to diagnose but with a great impact on daily life.
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Affiliation(s)
- Rute Brás-Cruz
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipa David
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
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Dhaliwal G, Batra J, Ankireddypalli AR, Gorle S, Kanugula AK, Kaur J. Progesterone Hypersensitivity Induced by Exogenous Progesterone Exposure. Cureus 2023; 15:e44776. [PMID: 37680259 PMCID: PMC10481886 DOI: 10.7759/cureus.44776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/09/2023] Open
Abstract
Progesterone hypersensitivity (PH) is a rare hypersensitivity reaction to either endogenous or exogenous progesterone. There are around 200 reported cases of progesterone hypersensitivity in the medical literature. We present the case of a 31-year-old female who presented with cyclical urticaria and angioedema after exogenous progesterone exposure. Her symptoms would begin a few days before her menstrual cycle began and resolve after menstruation. She only had partial recovery of her symptoms with antihistamines, steroids, montelukast, and omalizumab. She needed treatment with oral contraceptives and had a resolution of symptoms, but subsequently developed a recurrence again. Given the rarity of this condition, the diagnosis is often delayed. This diagnosis should be considered for women of reproductive age who present with cyclic hypersensitivity or allergic symptoms.
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Affiliation(s)
| | - Jaskaran Batra
- Internal Medicine, University of Pittsburgh Medical Center (UPMC), McKeesport, USA
| | | | - Swathi Gorle
- Internal Medicine, Wellstar Spalding Regional Medical Center, Griffin, USA
| | | | - Jasleen Kaur
- Endocrinology, Diabetes and Metabolism, HealthPartners, Minneapolis, USA
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Patel DH, Fine LM, Bernstein JA. A focused report on progestogen hypersensitivity. Expert Rev Clin Immunol 2023; 19:357-363. [PMID: 36800518 DOI: 10.1080/1744666x.2023.2182292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Progestogen Hypersensitivity (PH) is caused by increased sensitivity to either exogenous or endogenous progestogens. It is characterized by recurrent cutaneous eruptions including erythema multiforme, eczema, urticaria, and angioedema, which may be associated with systemic symptoms including asthma and anaphylaxis. AREAS COVERED Symptoms may be persistent or cyclical, coinciding with progestogen levels. With increased use of oral contraceptives and hormonal treatments for fertility, the prevalence of PH is expected to continuously increase. Several proposed immunological mechanisms, diagnostics, and treatment modalities have been proposed. Most treatments focus on suppressing ovulation and progesterone secretion or inducing tolerance through progesterone desensitization. EXPERT OPINION Although there has been increased recognition both clinically and in the medical literature, there is still a general lack of knowledge of PH and its clinical features in the medical community. An improved understanding of the underlying pathophysiology as well as more available commercial testis, such as ELISA that accurately measures specific IgE to progesterone, are expected to broaden and improve opportunities for disease recognition and symptom control. It is essential for physicians across specialties to recognize how to diagnose PH and either manage this condition or refer these patients to a specialist with experience treating PH.
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Affiliation(s)
- Diti H Patel
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Lauren M Fine
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jonathan A Bernstein
- Department of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Abstract
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.
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Nguyen SMT, Rupprecht CP, Haque A, Pattanaik D, Yusin J, Krishnaswamy G. Mechanisms Governing Anaphylaxis: Inflammatory Cells, Mediators, Endothelial Gap Junctions and Beyond. Int J Mol Sci 2021; 22:ijms22157785. [PMID: 34360549 PMCID: PMC8346007 DOI: 10.3390/ijms22157785] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is a severe, acute, life-threatening multisystem allergic reaction resulting from the release of a plethora of mediators from mast cells culminating in serious respiratory, cardiovascular and mucocutaneous manifestations that can be fatal. Medications, foods, latex, exercise, hormones (progesterone), and clonal mast cell disorders may be responsible. More recently, novel syndromes such as delayed reactions to red meat and hereditary alpha tryptasemia have been described. Anaphylaxis manifests as sudden onset urticaria, pruritus, flushing, erythema, angioedema (lips, tongue, airways, periphery), myocardial dysfunction (hypovolemia, distributive or mixed shock and arrhythmias), rhinitis, wheezing and stridor. Vomiting, diarrhea, scrotal edema, uterine cramps, vaginal bleeding, urinary incontinence, dizziness, seizures, confusion, and syncope may occur. The traditional (or classical) pathway is mediated via T cells, Th2 cytokines (such as IL-4 and 5), B cell production of IgE and subsequent crosslinking of the high affinity IgE receptor (FcεRI) on mast cells and basophils by IgE-antigen complexes, culminating in mast cell and basophil degranulation. Degranulation results in the release of preformed mediators (histamine, heparin, tryptase, chymase, carboxypeptidase, cathepsin G and tumor necrosis factor alpha (TNF-α), and of de novo synthesized ones such as lipid mediators (cysteinyl leukotrienes), platelet activating factor (PAF), cytokines and growth factors such as vascular endothelial growth factor (VEGF). Of these, histamine, tryptase, cathepsin G, TNF-α, LTC4, PAF and VEGF can increase vascular permeability. Recent data suggest that mast cell-derived histamine and PAF can activate nitric oxide production from endothelium and set into motion a signaling cascade that leads to dilatation of blood vessels and dysfunction of the endothelial barrier. The latter, characterized by the opening of adherens junctions, leads to increased capillary permeability and fluid extravasation. These changes contribute to airway edema, hypovolemia, and distributive shock, with potentially fatal consequences. In this review, besides mechanisms (endotypes) underlying IgE-mediated anaphylaxis, we also provide a brief overview of IgG-, complement-, contact system-, cytokine- and mast cell-mediated reactions that can result in phenotypes resembling IgE-mediated anaphylaxis. Such classifications can lead the way to precision medicine approaches to the management of this complex disease.
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Affiliation(s)
| | | | - Aaisha Haque
- The Bill Hefner VA Medical Center, Salisbury, NC 27106, USA;
| | - Debendra Pattanaik
- Division of Allergy and Immunology, UT Memphis College of Medicine, Memphis, TN 38103, USA;
| | - Joseph Yusin
- The Division of Allergy and Immunology, Greater Los Angeles VA Medical Center, Los Angeles, CA 90011, USA;
| | - Guha Krishnaswamy
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27106, USA;
- The Bill Hefner VA Medical Center, Salisbury, NC 27106, USA;
- Correspondence:
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Varghese A, Paul T, Kim H, Van Uum S, Vadas P, Azzola A. Effect of omalizumab for autoimmune progesterone dermatitis refractory to bilateral oophorectomy: a case report. Allergy Asthma Clin Immunol 2021; 17:58. [PMID: 34120629 PMCID: PMC8201679 DOI: 10.1186/s13223-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 06/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autoimmune progesterone dermatitis (APD) is a rare skin condition caused by sensitivity to high levels of progesterone secreted during the luteal phase of the menstrual cycle. This may be due to various pathophysiological mechanisms including a Type I and Type IV hypersensitivity reaction. Here we present the case of a patient with APD whose episodic flares were controlled by the addition of omalizumab, after a bilateral oophorectomy failed to resolve her symptoms. CASE PRESENTATION A 34-year-old female presented to our Endocrine clinic with marked Cushingoid features secondary to high-dose oral prednisone prescribed for APD diagnosed 6 years earlier. She first developed a pruritic maculopapular rash on her arms and legs just after the birth of her second child in 2009. The rash was also associated with headaches and diffuse angioedema. Symptoms occurred for 1-2 weeks, in a cyclical fashion, during the luteal phase of each menstrual cycle and subsided within a few days after menses. The severity of symptoms increased as time went on, and flare-ups began to also include dyspnea, nausea, vomiting and abdominal pain. Her symptoms improved with administration of oral prednisone, but she continued to experience breakthrough symptoms. After multiple failed treatment modalities, she elected bilateral oophorectomy in 2018. However, her symptoms of APD persisted and she still required high-dose oral prednisone. Her condition was further complicated by vasomotor menopausal symptoms and progressive iatrogenic Cushing's syndrome. She eventually was started on Omalizumab, which suppressed further recurrences of APD symptoms and allowed her to wean off prednisone. Vasomotor menopausal symptoms responded well to the addition of conjugated estrogens with bazedoxifene. However, her symptoms of diffuse bony pain and arthralgias which started whilst on prednisone have persisted in spite of discontinuing prednisone. CONCLUSIONS To our knowledge, this is only the third case of APD which was successfully treated with Omalizumab and the first case where a bilateral oophorectomy failed to resolve symptoms of APD in the literature. This case also demonstrates the complications of vasomotor menopausal symptoms secondary to a bilateral oophorectomy, as well as the adverse effects of long-term glucocorticoid therapy.
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Affiliation(s)
- Akshay Varghese
- Division of Internal Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada.
| | - Terri Paul
- Division of Endocrinology and Metabolism, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Stan Van Uum
- Division of Endocrinology and Metabolism, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Peter Vadas
- Division of Clinical Immunology and Allergy, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alescia Azzola
- Division of Internal Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Geros H, Maor D, Higgins C, Bala HR, Nixon R. Intradermal testing for autoimmune progesterone dermatitis: should we be basing the diagnosis on it? Clin Exp Dermatol 2021; 46:906-909. [PMID: 33811662 DOI: 10.1111/ced.14664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 11/28/2022]
Abstract
Autoimmune progesterone dermatitis (APD) is a rare skin disorder with varying presentations, resulting from hypersensitivity to endogenous progesterone during the luteal phase of the menstrual cycle. The diagnosis has been traditionally confirmed with intradermal progesterone testing (IPT) or intramuscular challenge with progesterone or its derivatives. We present a case of a 31-year-old woman with suspected APD who underwent IPT to progesterone. The patient's cyclical symptoms, positive skin reaction and symptoms following IPT were sufficient to make a diagnosis of APD. However, we also tested 10 healthy female controls without symptoms of APD, and found that 9 of these also developed positive skin reactions to intradermal progesterone at 15 min, 24 and 48 h, albeit to a lesser extent. Therefore, these results raise doubts about the validity of using IPT to make a diagnosis of APD. Further research on appropriate testing is needed.
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Affiliation(s)
- H Geros
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - D Maor
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - C Higgins
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - H R Bala
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - R Nixon
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
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Hormonal Effects on Urticaria and Angioedema Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2209-2219. [PMID: 33895364 DOI: 10.1016/j.jaip.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/02/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.
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12
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Klangsin S, Suwanrath C, Wattanakumtornkul S. A case report of eosinophilia associated with an etonogestrel implant. Contraception 2021; 104:442-443. [PMID: 33753062 DOI: 10.1016/j.contraception.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
Progestogen hypersensitivity is a rare adverse effect of endogenous and exogenous progestogens. Etonogestrel implant is very effective for contraception; however, a few progestogen hypersensitivity cases have been reported. Here, we present a case of delayed-type progestogen hypersensitivity with marked eosinophilia against etonogestrel that resolved after implant removal.
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Affiliation(s)
- Satit Klangsin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Saranya Wattanakumtornkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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13
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Aghazadeh N, Chattha AJ, Hartz MF, Davis DMR. Autoimmune progesterone dermatitis in the adolescent population. Pediatr Dermatol 2021; 38:380-384. [PMID: 33368681 DOI: 10.1111/pde.14423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Autoimmune progesterone dermatitis (APD) is a rare autoimmune hypersensitivity reaction that occurs cyclically at the peak of endogenous progesterone production during the menstrual cycle in women. No study characterizing APD in the adolescent population is found; it appears likely to be underdiagnosed and undertreated. METHODS A retrospective, single-center, review of all adolescent and pediatric patients (<20 years old at onset) with documented diagnosis of APD. RESULTS Seventeen adolescent APD patients were included (mean age at diagnosis: 14.4 ± 2 years, mean interval of 13.6 ± 11.1 months between symptom onset and diagnosis). Twelve patients presented with urticaria, two with fixed drug eruption. Erythema multiforme, eczema, and recurrent aphthous stomatitis were present in one patient each. Exposure to exogenous progestin was present in two patients prior to disease onset. Progesterone skin test was performed in six patients with positive results in two. Fourteen patients received antihistamines and/or a topical corticosteroid. Combined oral contraceptives (COCs) were given to eleven patients, in seven via continuous daily dosing. Gonadotropin-releasing hormone agonist (GnRHa) was used in five, progesterone desensitization in four, omalizumab in two, and danazol in one patient. CONCLUSIONS Adolescent APD is associated with a significant delay in diagnosis. The most common manifestation is urticaria. Exogenous exposure to progestins is uncommon in adolescent APD. Continuous COC, GnRHa, and progesterone desensitization have been used to control symptoms. Large, multicenter studies are required to better define, diagnose, and treat this under recognized condition among adolescent patients.
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Affiliation(s)
| | - Asma J Chattha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Martha F Hartz
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dawn Marie R Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Al-Amad SH. Ulcerative Stomatitis as the Sole Manifestation of Progesterone Hypersensitivity. Oman Med J 2020; 35:e202-e2020. [PMID: 33274071 PMCID: PMC7700113 DOI: 10.5001/omj.2020.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 02/01/2020] [Indexed: 11/03/2022] Open
Abstract
Oral mucosal involvement of autoimmune progesterone dermatitis is exceedingly rare. This report presents a woman with very painful ulcerative stomatitis that recurred with every menstrual period, in the absence of other clinical manifestations. Ulcers were eventually controlled with oral tamoxifen treatment for three months. Subsequent follow-up visits showed complete resolution of her oral ulcerative lesions. The non-specific nature of her oral ulcers resulted in multiple medical and dental consultations and a delay in reaching the final diagnosis. Clinicians should be aware of the possibility of progesterone hypersensitivity when painful oral ulcerative lesions appear concurrently with each progesterone surge.
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Affiliation(s)
- Suhail H Al-Amad
- College of Dental Medicine University of Sharjah Consultant Oral Medicine, University Hospital Sharjah, Sharjah, UAE
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15
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Bernstein JA. Progestogen Sensitization: a Unique Female Presentation of Anaphylaxis. Curr Allergy Asthma Rep 2020; 20:4. [PMID: 31993777 DOI: 10.1007/s11882-020-0900-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Progestogen hypersensitivity (PH) is a condition which typically occurs in women in childbearing years with a spectrum of symptoms ranging from urticaria with or without angioedema, dermatitis to systemic anaphylaxis. Herein, a clinical case of PH is presented followed by a discussion on the evaluation, diagnosis, and management of PH. RECENT FINDINGS Progestogen hypersensitivity (a.k.a. "autoimmune progesterone dermatitis") symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. This condition can be difficult to recognize due to its heterogeneous clinical presentation. The mechanism of PH is believed to be primarily IgE-mediated; however, less commonly other immune responses may be involved. There is now a useful progesterone specific IgE immunoassay to assist in diagnosis and well-defined treatment algorithms that can be used to successfully manage PH. The epidemiology of PH is still poorly elucidated but is likely to be encountered by clinicians and especially allergists given the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone required to support pregnancy in IVF. Including PH in the differential diagnosis of women presenting with cyclic hypersensitivity will accelerate diagnosis and successful management of this condition.
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Affiliation(s)
- Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML #563, Cincinnati, OH, USA.
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16
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Bhardwaj N, Jindal R, Chauhan P. Autoimmune progesterone dermatitis presenting as fixed drug eruption. BMJ Case Rep 2019; 12:12/11/e231873. [DOI: 10.1136/bcr-2019-231873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Autoimmune progesterone dermatitis (APD) is a rare disorder that presents as recurrent cyclical cutaneous eruptions during the premenstrual period when progesterone level is elevated. It does not have a specific cutaneous manifestation of its own and presents with a multitude of common cutaneous conditions, thus making it a diagnostic challenge. We describe the case of a young woman who presented with a hyperpigmented patch on her left thigh, over which she developed recurrent erythema, pain and itching, starting 2 days before her menstrual cycle and resolving within 2 days after menstruation. Intradermal progesterone sensitivity test was positive. Histopathology of hyperpigmented patch showed features of fixed drug eruption. A diagnosis of APD presenting as fixed drug eruption was made. She was treated with oral contraceptive pills with significant improvement. This case has been reported because of its rarity and to highlight the clinical implications this condition can pose if diagnosis is not sought timely.
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17
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Zachary C, Fackler N, Juhasz M, Pham C, Mesinkovska NA. Catamenial dermatoses associated with autoimmune, inflammatory, and systemic diseases: A systematic review ,. Int J Womens Dermatol 2019; 5:361-367. [PMID: 31909158 PMCID: PMC6938828 DOI: 10.1016/j.ijwd.2019.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/08/2019] [Accepted: 09/26/2019] [Indexed: 11/29/2022] Open
Abstract
Background Sex hormones are important in female sexual physiology, growth, and homeostasis. Through skin receptors, sex hormones contribute to the dermatologic pathology known as catamenial dermatoses. Objective This study aims to summarize the literature on catamenial dermatoses and menses-induced exacerbations of chronic dermatoses. Methods This systematic review used the PRISMA method. PubMed was searched using the terms “menses” and “skin” in July 2018, and an assessment was conducted of the relevant literature on skin diseases related to non-pathologic menstruation, such as polycystic ovarian syndrome. Pathology associated with androgenetic acne was excluded from the study. Results A total of 102 studies with 1269 female patients were included. The most commonly reported primary catamenial dermatoses were autoimmune progesterone dermatitis and autoimmune estrogen dermatitis. The most commonly reported chronic skin disorders exacerbated by menses were psoriasis, Behcet’s disease, and eczematous dermatoses. Conclusion Physicians should be aware of the nature of catamenial dermatoses and their presentation with normal sexual physiology. Patients with chronic dermatoses should be appropriately counseled on menstruation-related exacerbations. Further research needs to be conducted to determine the interplay between immune regulation and sex hormones in catamenial dermatoses and to elucidate effective therapies.
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Affiliation(s)
- Cameron Zachary
- Georgetown University, School of Medicine, Washington, D.C., United States.,University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Nathan Fackler
- Georgetown University, School of Medicine, Washington, D.C., United States.,University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Margit Juhasz
- University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Christine Pham
- University of California, Irvine, Department of Dermatology, Irvine, CA, United States.,University of California, Irvine, School of Medicine, Irvine, CA, United States
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18
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Benagiano G, Benagiano M, Bianchi P, D'Elios MM, Brosens I. Contraception in autoimmune diseases. Best Pract Res Clin Obstet Gynaecol 2019; 60:111-123. [PMID: 31160225 DOI: 10.1016/j.bpobgyn.2019.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/18/2022]
Abstract
Autoimmune diseases (AIDs) affect women and men with a 2:1 ratio, which suggests that hormonal contraceptives play a role in their clinical course. Combined oral contraceptives have complex, sometimes contradictory, effects on AIDs; they can worsen the situation in women with systemic lupus erythematosus and with anti-phospholipid syndrome, conditions in which they are contraindicated. Early studies indicated a positive effect on rheumatoid arthritis (RA), whereas more recent trials failed to do so, possibly because of the lowering of oestrogen content. Evidence of effects on multiple sclerosis (MS) is conflicting: risk may vary depending on the progestin used. Minor adverse effects may exist on inflammatory bowel diseases, and no significant effect was found on autoimmune thyroid diseases. Women can become sensitised to sex hormones. Progestin-only contraceptives may be used, although copper-releasing intra-uterine devices represent the best option. Finally, several organisations have issued guidelines for contraceptive use in women with AIDs.
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Affiliation(s)
- Giuseppe Benagiano
- Department of Obstetrics, Gynaecology and Urology, Policlinico Umberto I°, Sapienza University of Rome, Rome, Italy
| | - Marisa Benagiano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Bianchi
- Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Mario Milco D'Elios
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Ivo Brosens
- Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium
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19
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Ghosh D, Bernstein JA. Development of a progesterone-specific IgE assay for diagnosing patients with suspected progestogen hypersensitivity. Ann Allergy Asthma Immunol 2019; 122:616-622. [PMID: 30953782 DOI: 10.1016/j.anai.2019.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/17/2019] [Accepted: 03/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Progesterone hypersensitivity (PH) manifests as a spectrum of allergic symptoms during the luteal phase of the menstrual cycle. Confirming progesterone-specific immunoglobulin E (IgE; sIgE) by skin testing is unreliable because of irritant responses. OBJECTIVE To develop a progesterone sIgE assay to assist in diagnosing PH. METHODS A progesterone-bovine serum albumin (BSA) conjugate was characterized and used to analyze sera collected from women in our center with suspected PH in a 1-batch enzyme-linked immunosorbent assay (ELISA) to establish high, low and negative cut-points. Sera collected from healthy nonatopic female subjects and from women with classical PH symptoms were included as negative and positive controls, respectively. Values exceeding the average negative control (OD + 3× the standard deviation) were considered positive. These cut-points were subsequently used to establish positive and negative results for serum from women with suspected PH received from other centers. A subset of high positive sera was used for ELISA-inhibition and in a beta-hexosaminidase mediator release assay to evaluate the specificity and functional relevance of progesterone-specific serum IgE, respectively. The numbers of true negative, false negative, true positive, and false positive samples were determined. RESULTS The direct progesterone sIgE ELISA results ranged from high positive to low positive and negative compared with healthy nonatopic control sera. Enzyme-linked immunosorbent assay inhibition and beta-hexosaminidase mediator release confirmed specificity and functional relevance of progesterone-sIgE, respectively. The sensitivity, specificity positive predictive values and negative predictive values were found to be 82%, 100%, 86%, and 100%, respectively, using the mediator release assay results as the gold standard. CONCLUSION This assay has a good specificity and positive predictive value for screening women with suspected PH for progesterone sIgE.
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Affiliation(s)
- Debajyoti Ghosh
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati, Cincinnati, OH
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati, Cincinnati, OH.
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20
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Lavery WJ, Bernstein JA. Cyclical hypersensitivity, anaphylaxis, and related hormonal reaction. Ann Allergy Asthma Immunol 2018; 122:140-147. [PMID: 30468931 DOI: 10.1016/j.anai.2018.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 11/16/2022]
Affiliation(s)
- William J Lavery
- Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan A Bernstein
- Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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21
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Foer D, Buchheit KM. Presentation and natural history of progestogen hypersensitivity. Ann Allergy Asthma Immunol 2018; 122:156-159. [PMID: 30712576 DOI: 10.1016/j.anai.2018.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/05/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To review the published medical literature on the clinical presentation, risk factors, and natural history of hypersensitivity reactions to progestogens. DATA SOURCES Through the use of PubMed, we conducted a review of allergy, dermatology, and obstetric literature for cases and case series of patients with hypersensitivity reactions to exogenous or endogenous progestogens. There are no longitudinal, prospective studies related to progestogen hypersensitivity. STUDY SELECTIONS Publications were selected that described cases that were clinically consistent with progesterone hypersensitivity and positive test results or clear symptoms with exposure to progestogens to confirm the diagnosis. RESULTS Progestogen hypersensitivity symptoms can be triggered by endogenous progesterone or exogenous progestins used for contraception or fertility treatments. Symptoms are varied and include dermatitis, urticaria, asthma, and anaphylaxis. CONCLUSION Although the medical literature on progestogen hypersensitivity is limited to case reports and small case series, significant heterogeneity exists in clinical presentation among patients.
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Affiliation(s)
- Dinah Foer
- Jeff and Penny Vinik Center for Allergic Diseases Research, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kathleen M Buchheit
- Jeff and Penny Vinik Center for Allergic Diseases Research, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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22
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Abstract
PURPOSE OF REVIEW Progestogen hypersensitivity (PH) is a rare disorder which usually occurs in women of childbearing age with symptoms ranging from urticaria with or without angioedema, multiple organ involvement consistent with allergic anaphylaxis, to a spectrum of other non-evanescent skin eruptions. In this review, we present a clinical vignette of PH and discuss the clinical presentation and proposed pathomechanisms, diagnosis, and treatment of PH. RECENT FINDINGS The hypersensitivity symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. Recognition of this condition can be challenging to the clinician due to its heterogeneous clinical presentation. It has been recently proposed to use the new term "progestogen hypersensitivity" to replace "autoimmune progesterone dermatitis" due to the lack of evidence supporting an autoimmune mechanism for this disorder. In addition, diagnostic and treatment algorithms are now available that can lead to successful management of this condition. More new developments of Progesterone desensitization protocols are now available which appear to be the safest and most effective long-term treatment option for PH. With the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone to support pregnancy in in vitro fertilization, there is likely to be a higher prevalence of PH in the future than currently recognized. Therefore, the allergist-immunologist will be required to collaborate with gynecologists and reproductive endocrinologists to diagnose and treat this condition.
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Affiliation(s)
- Rung-Chi Li
- Mid-Atlantic Permanente Medical Group, Baltimore, MD, USA
| | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML #563, Cincinnati, OH, 45267-0563, USA.
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23
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Lin K, Rasheed A, Lin S, Gerolemou L. Catamenial anaphylaxis: a woman under monthly progesterone curse. BMJ Case Rep 2018; 2018:bcr-2017-222047. [DOI: 10.1136/bcr-2017-222047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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24
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Untersmayr E, Jensen AN, Walch K. Sex hormone allergy: clinical aspects, causes and therapeutic strategies - Update and secondary publication. World Allergy Organ J 2017; 10:45. [PMID: 29308112 PMCID: PMC5745953 DOI: 10.1186/s40413-017-0176-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/06/2017] [Indexed: 12/05/2022] Open
Abstract
Sex hormone allergy as a clinical syndrome has been known for almost a century. Due to the diversity of clinical presentation regarding symptoms and disease patterns, the optimal patient care represents an enormous interdisciplinary challenge. Frequently, hypersensitivity reactions affect more than one sex hormone and double positive tests for estrogen and progesterone have been described. Since the menstrual cycle dependent symptoms range from skin afflictions, gynecological problems to non-specific reactions, different pathophysiological mechanisms seem likely. Various desensitization protocols are described as causal treatment options, but are rarely applied in clinical routine. Consequently, major research efforts with a quick translation of therapeutic interventions into clinical practice will be crucial to help affected patients in the future.
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Affiliation(s)
- E Untersmayr
- Institute for Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - A N Jensen
- AllergyCare - Allergy Diagnosis and Study Center Vienna, Vienna, Austria
| | - K Walch
- Department of Gynecological Endocrinology and Reproductive Medicine, Clinic of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
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25
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Foer D, Buchheit KM. Progestogen Hypersensitivity: An Evidence-Based Approach to Diagnosis and Management in Clinical Practice. Immunol Allergy Clin North Am 2017; 37:773-784. [PMID: 28965640 DOI: 10.1016/j.iac.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Heterogeneous presentations of disease pose particular diagnostic and management challenges to the clinician. Progestogen hypersensitivity (PH) classically consists of hypersensitivity symptoms to endogenous progesterone during the luteal phase of the menstrual cycle. However, with the rise of assisted fertility and the exponential growth in the use of exogenous progestins for contraception, PH's prevalence and symptom heterogeneity have increased. In this article, we focus on the clinical approach to PH diagnosis with an emphasis on key elements of the history, physical, and testing modalities. We also review the current evidence for successful management and treatment across a broad range of patients.
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Affiliation(s)
- Dinah Foer
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Kathleen M Buchheit
- Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA
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26
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Abstract
Anaphylaxis is a systemic, life-threatening disorder triggered by mediators released by mast cells and basophils activated via allergic (IgE-mediated) or nonallergic (non-IgE-mediated) mechanisms. It is a rapidly evolving, multisystem process involving the integumentary, pulmonary, gastrointestinal, and cardiovascular systems. Anaphylaxis and angioedema are serious disorders that can lead to fatal airway obstruction and culminate in cardiorespiratory arrest, resulting in hypoxemia and/or shock. Often, these disorders can be appropriately managed in an outpatient setting; however, these conditions can be severe enough to warrant evaluation of the patient in the ED and in some cases, hospitalization, and management in an ICU. Reports suggest that underdiagnosis and undertreatment of anaphylaxis are common. Several new syndromes have been described recently including bird-egg, pork-cat, delayed allergy to mammalian meat and a diverse group of mast cell activation disorders. Conditions such as postural orthostatic tachycardia syndrome, carcinoid syndrome, Munchausen stridor, and factitious anaphylaxis can present similarly and need to be included in the differential diagnosis. Anaphylaxis is a clinical diagnosis, but plasma tryptase and urinary histamine levels are often elevated, allowing diagnostic confirmation; however, diagnostic testing should not delay treatment as results may not be immediately available. The sine qua non of treatment is avoidance of any known triggers and epinephrine, which should never be delayed if this disorder is suspected. Secondary treatments include fluids, bronchodilators, antihistamines, and glucocorticoids. Patients with cardiopulmonary arrest or airway or vascular compromise require mechanical ventilation, vasopressors, and other advanced life support in the ICU.
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27
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Buchheit KM, Bernstein JA. Progestogen Hypersensitivity: Heterogeneous Manifestations with a Common Trigger. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:566-574. [DOI: 10.1016/j.jaip.2017.01.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 11/29/2022]
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Wunschel J, Poole JA. Intrauterine uterine contraception and chronic urticaria: a case series. Ann Allergy Asthma Immunol 2017; 118:378-380. [PMID: 28111112 DOI: 10.1016/j.anai.2016.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/18/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Javen Wunschel
- Pulmonary, Critical Care, Sleep & Allergy Division, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jill A Poole
- Pulmonary, Critical Care, Sleep & Allergy Division, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
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29
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Kim YC, Choi KH, Kang DY, Sohn KH, Cho SH, Min KU, Kang HR. A case of oral desensitization for hypersensitivity to exogenous progesterone. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.5.294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Young-Chan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Yoon Kang
- Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung Hee Sohn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Up Min
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Korea
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DeRosa A, Adams S, Fee EK. Progressively Worsening Cyclic Rash: Diagnosis and Approach to Care. J Osteopath Med 2016; 115:738-44. [PMID: 26618820 DOI: 10.7556/jaoa.2015.150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Autoimmune progesterone dermatitis (AIPD) is an uncommon condition in which allergic dermatitis to endogenous progesterone manifests in cyclic cutaneous eruptions. In this case series, we present 3 patients with AIPD, each with unique presentations and medical histories emblematic of the disease. Cyclic dermatitis related to menses in a premenopausal woman should raise high clinical suspicion for AIPD, especially in the primary care or emergency setting. Because of the rarity of this disorder, this case series seeks to describe AIPD to medical providers of young women, as well as present relevant literature related to the disease. We propose clinical considerations for women of reproductive age with AIPD.
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31
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James T, Ghaferi J, LaFond A. The histopathologic features of autoimmune progesterone dermatitis. J Cutan Pathol 2016; 44:70-74. [DOI: 10.1111/cup.12848] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/02/2016] [Accepted: 09/24/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Travis James
- Department of Dermatology; St. Joseph Mercy Hospital; Ypsilanti MI 48197 USA
| | - Jessica Ghaferi
- Department of Dermatology; St. Joseph Mercy Hospital; Ann Arbor MI USA
| | - Ann LaFond
- Department of Dermatology; St. Joseph Mercy Hospital; Ann Arbor MI USA
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32
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Foer D, Buchheit KM, Gargiulo AR, Lynch DM, Castells M, Wickner PG. Progestogen Hypersensitivity in 24 Cases: Diagnosis, Management, and Proposed Renaming and Classification. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:723-9. [PMID: 27090357 DOI: 10.1016/j.jaip.2016.03.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/29/2016] [Accepted: 03/08/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Autoimmune progesterone dermatitis is a poorly recognized syndrome associated with a hypersensitivity to progestogens. Symptoms present heterogeneously, which may complicate diagnosis. Management has generally centered on symptomatic control with medication. Recently, an increasing number of cases have been reported with in vitro fertilization (IVF). Desensitization to progestogens is suggested as an approach to tolerate fertility treatments and provide symptom control. OBJECTIVES To describe the diagnosis and management of progestogen hypersensitivity (PH) and to detail the use of desensitization. We also propose a new terminology of progestogen hypersensitivity instead of autoimmune progesterone dermatitis, and a classification system based on exogenous and endogenous progestogen triggers to facilitate diagnosis and management. METHODS Twenty-four cases of PH were evaluated retrospectively. Symptom presentation, diagnostic modalities, desensitization protocols, and outcomes were analyzed. RESULTS Symptom onset was classified as a reaction to either endogenous progesterone (42%) or exogenous progestogens (58%). Symptoms were heterogeneous and included cyclical dermatitis, urticaria, angioedema, asthma, and anaphylaxis. Triggers were also heterogenous and included progesterone as well as progestins. Eleven patients underwent intramuscular (27%) or oral (73%) desensitization. Desensitization resulted in symptom control in 8 patients, IVF medication tolerance in 3 patients, and 2 pregnancies. CONCLUSIONS This is the largest case series of patients with PH with successful treatment outcomes. The new terminology progestogen hypersensitivity more accurately represents the diversity of presentations to endogenous or exogenous progestogens. We demonstrate that progestogen desensitization is successful in multiple patients and can result in symptom control and fertility. Women with cyclical allergic symptoms, including those undergoing IVF, should be evaluated for PH.
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Affiliation(s)
- Dinah Foer
- Division of Internal Medicine, Department of Medicine, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston, Mass
| | - Kathleen M Buchheit
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, BWH, Harvard Medical School, Boston, Mass
| | - Antonio Rosario Gargiulo
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, BWH, Harvard Medical School, Boston, Mass
| | - Donna Marie Lynch
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, BWH, Harvard Medical School, Boston, Mass
| | - Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, BWH, Harvard Medical School, Boston, Mass
| | - Paige G Wickner
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, BWH, Harvard Medical School, Boston, Mass.
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33
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Nguyen T, Razzaque Ahmed A. Autoimmune progesterone dermatitis: Update and insights. Autoimmun Rev 2015; 15:191-7. [PMID: 26554933 DOI: 10.1016/j.autrev.2015.11.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/06/2015] [Indexed: 01/29/2023]
Abstract
UNLABELLED Autoimmune progesterone dermatitis (APD) is rare autoimmune hypersensitivity reaction to the fluctuations of endogenous progesterone during a woman's menstrual cycle. It has a wide spectrum of clinical presentations including urticaria, eczema and vesiculobullous eruptions. The disease course depends on treatment modality. The pathogenic mechanisms of APD remain to be elucidated. OBJECTIVE We aim to review the literature on APD and evaluate the different theories of pathogenesis and treatments for this condition. METHODS A review of the English literature on APD was performed using PubMed, EMBASE and MEDLINE. RESULTS 89 patients are included in this review. Initial symptom development in association with the menstrual cycle was reported in 65 (73%) patients. In some patients, it occurred shortly after hormone therapy (8.9%) or in relation to a pregnancy (14.6%). Associated factors were not defined in three patients (3.4%). Nearly 45% had a history of exposure to exogenous progesterone. Diagnosis of APD was usually confirmed with an intradermal progesterone sensitivity test. The goal of treatment was to suppress progesterone secretion through anovulation. Some cases were controlled with oral contraceptives or conjugated estrogen, while some patients had complete resolution post-hysterectomy. CONCLUSION The wide spectrum of clinical presentations, histology, and response to therapy would suggest that there are multiple subsets in APD. The increase in the levels of progesterone may also influence the clinical profile and the corresponding immunological response. Further research on the pathogenesis of APD is required to provide a satisfactory treatment modality.
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Affiliation(s)
- Tegan Nguyen
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA
| | - A Razzaque Ahmed
- Center for Blistering Diseases, Department of Dermatology, Tufts University School of Medicine, Boston, MA, USA.
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Salari Rad M, Bolvardi E, Salari Rad S. Autoimmune Progesterone Dermatitis With Angioedema Caused by Exogenous Progesterone in a Pregnant Woman: A Case Report. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2015. [DOI: 10.17795/rijm29765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wingate-Saul L, Rymer J, Greaves MW. Chronic urticaria due to autoreactivity to progesterone. Clin Exp Dermatol 2015; 40:644-6. [PMID: 25754829 DOI: 10.1111/ced.12632] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2014] [Indexed: 11/30/2022]
Abstract
A 23-year-old, regularly menstruating woman presented with recurrent urticarial eruptions, which occurred premenstrually. A skin prick test was positive for progesterone, but the urticaria was unresponsive to standard treatments. The patient was treated with goserelin (Zoladex), which suppressed her menstrual cycle, leading to the resolution of her symptoms. Subsequent flares were controlled by further goserelin injections, and the urticaria is currently in remission. However, the risks of inducing menopause artificially are significant, and alternative long-term solutions may need to be considered in the event of a relapse.
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Affiliation(s)
| | - J Rymer
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M W Greaves
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, Sheikh J, Weldon D, Zuraw B, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133:1270-7. [DOI: 10.1016/j.jaci.2014.02.036] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
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Lieberman P. Catamenial Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:358-9. [DOI: 10.1016/j.jaip.2014.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/24/2014] [Indexed: 11/25/2022]
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Ellaithy MI, Fathi HM, Farres MN, Taha MS. Skin test reactivity to female sex hormones in women with primary unexplained recurrent pregnancy loss. J Reprod Immunol 2013; 99:17-23. [PMID: 23816482 DOI: 10.1016/j.jri.2013.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 04/10/2013] [Accepted: 04/23/2013] [Indexed: 01/06/2023]
Abstract
The objective was to examine the hypothesis that primary unexplained recurrent pregnancy loss might be associated with an inappropriate immunologically mediated response to progesterone and/or estrogen. This prospective study included 47 women with two or more documented consecutive early pregnancy losses of unknown etiology, and no previous history of deliveries. Intradermal skin testing was performed in the luteal phase of the cycle (days 16-20) using estradiol benzoate, progesterone, and a placebo of refined sesame oil. Immediate (20 min) and late (24h and 1 week) skin test readings for all cases were compared with those of 12 parous women of comparable age with no history of spontaneous miscarriages, premenstrual disorders, pregnancy, or sex hormone-related allergic or autoimmune diseases. Main outcome measure was skin test reactivity to estradiol and/or progesterone. Immediate skin test reactivity to both hormones was observed among half of the cases at 20 min. A papule after 24h, which persisted for up to 1 week, was observed among 32 (68.1%) and 34 (72.3%) cases at the sites of estrogen and progesterone injection, respectively. 55.3% of cases had combined skin test reactivity to both estradiol and progesterone at 1 week. All women in the control group showed absence of skin test reactivity for both estradiol and progesterone at 20 min, 24h, and 1 week. None of the subjects in either group showed skin test reactivity to placebo. There is an association between primary unexplained recurrent pregnancy loss and skin test reactivity to female sex hormones.
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Affiliation(s)
- Mohamed I Ellaithy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
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Bauer CS, Kampitak T, Messieh ML, Kelly KJ, Vadas P. Heterogeneity in presentation and treatment of catamenial anaphylaxis. Ann Allergy Asthma Immunol 2013; 111:107-11. [PMID: 23886228 DOI: 10.1016/j.anai.2013.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 05/30/2013] [Accepted: 06/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few reports have documented the uncommon association of the female menstrual cycle with anaphylaxis, an entity known as cyclic or catamenial anaphylaxis. OBJECTIVE To examine cases of perimenstrual anaphylaxis, focusing on differences in presentation and response to treatment, in the hopes of enriching the description of this rare entity. METHODS A cohort of 8 women with catamenial anaphylaxis were identified and retrospectively compared with regard to age at onset, organ involvement, diagnostic studies, and response to therapy. RESULTS The median age at onset was 34 years (range, 14-40 years), and the median number of perimenstrual anaphylactic episodes at presentation was 10 per patient (range, 4-24 per patient). Most had cutaneous and gastrointestinal symptoms. The results of extensive investigations for anaphylactic triggers were negative, and masquerading conditions, such as carcinoid syndrome, pheochromocytoma, and systemic mastocytosis, were ruled out in all patients. Skin test results for progesterone were negative in all but 1 of 4 patients tested. None had elevated total serum IgE levels. Response to suppressive treatments regimens varied considerably, but none treated with high-dose systemic steroids had improvement. Similarly, ketotifen, celecoxib, rofecoxib, and oral contraceptives failed to control the anaphylactic reactions. Although antihistamines failed in 7 patients, 1 had improvement. Others responded to leuprolide, medroxyprogesterone, or salpingo-oophorectomy. CONCLUSION Whether the mechanism causing cyclical anaphylaxis may involve hypersensitivity to progesterone or prostaglandins, the variable response to suppressive medications in these cases suggests that catamenial anaphylaxis is a heterogeneous disorder in which a number of mechanisms and mediators may play a role. It is an emergent and probably underrecognized entity in the medical literature.
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Affiliation(s)
- Cindy S Bauer
- Division of Allergy, Asthma, and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Krachudel J, Bondzio A, Einspanier R, Einspanier A, Gottschalk J, Kuechenmeister U, Muennich A. Luteal insufficiency in bitches as a consequence of an autoimmune response against progesterone? Theriogenology 2013; 79:1278-83. [DOI: 10.1016/j.theriogenology.2013.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/23/2013] [Accepted: 02/27/2013] [Indexed: 11/16/2022]
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Autoimmune progesterone dermatitis: a case report. Case Rep Obstet Gynecol 2012; 2012:757854. [PMID: 22924142 PMCID: PMC3423662 DOI: 10.1155/2012/757854] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/19/2012] [Indexed: 11/29/2022] Open
Abstract
Background. Autoimmune progesterone dermatitis is a rare cyclic premenstrual allergic reaction to progesterone produced during the luteal phase of a woman's menstrual cycle. Patients present with a variety of conditions including erythema multiforme, eczema, urticaria, angioedema, and progesterone-induced anaphylaxis. Case. Thirty-eight-year-old woman G2P2002 presents with erythema multiforme and urticarial rash one week prior to her menses starting one year after menarche. She was treated with oral contraceptive pills and the symptoms resolved. Conclusion. This is a typical case of progesterone autoimmunity. The diagnosis is based on cyclic nature of the dermatitis. This differentiates the condition from other allergies or systemic diseases with skin manifestations. Inhibition of ovulation in such cases results in decrease in progesterone secretion and prevention of symptoms.
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Le K, Wood G. A case of autoimmune progesterone dermatitis diagnosed by progesterone pessary. Australas J Dermatol 2011; 52:139-41. [PMID: 21605100 DOI: 10.1111/j.1440-0960.2011.00753.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Autoimmune progesterone dermatitis is a rare, cyclical eruption that occurs in the luteal phase of the menstrual cycle and during pregnancy. Many manifestations have been reported including cyclical eczema, urticaria, erythema multiforme, stomatitis and even anaphylaxis. The condition spontaneously resolves after menopause. As histopathology is non-specific, the diagnosis rests on history with precipitation of the eruption by a progesterone challenge, usually by the intradermal, intramuscular or oral route. We present the case of a 34-year-old woman with a premenstrual papular and eczematous eruption that was exacerbated after pregnancy. Biopsy showed subacute spongiotic dermatitis. To confirm the diagnosis, we used an intravaginal progesterone pessary as a provocation challenge. There was recurrence of the rash 12 h after insertion of the pessary with spontaneous resolution thereafter. We propose that use of a progesterone pessary is an effective tool in the diagnosis of autoimmune progesterone dermatitis.
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Affiliation(s)
- Katie Le
- Skin and Cancer Foundation, Sydney, New South Wales, Australia.
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Medeiros S, Rodrigues-Alves R, Costa M, Afonso A, Rodrigues A, Cardoso J. Autoimmune progesterone dermatitis: treatment with oophorectomy. Clin Exp Dermatol 2011; 35:e12-3. [PMID: 20500158 DOI: 10.1111/j.1365-2230.2009.03217.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Medeiros
- Department of Dermatology, Curry Cabral Hospital, Lisbon, Portugal.
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Browne F, Wilkinson SM. Effective prescribing in steroid allergy: Controversies and cross-reactions. Clin Dermatol 2011; 29:287-94. [DOI: 10.1016/j.clindermatol.2010.11.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bernstein IL, Bernstein DI, Lummus ZL, Bernstein JA. A case of progesterone-induced anaphylaxis, cyclic urticaria/angioedema, and autoimmune dermatitis. J Womens Health (Larchmt) 2011; 20:643-8. [PMID: 21417747 DOI: 10.1089/jwh.2010.2468] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Women have exhibited anaphylaxis, urticaria/angioedema, and autoimmune progesterone dermatitis (APD) coinciding with the progesterone premenstrual rise. We report a detailed immunological evaluation of such a woman responsive to a gonadotropin hormone-releasing agonist (GHRA). METHODS Skin testing, enzyme-linked immunosorbent assays (ELISAs), leukocyte histamine release (LHR), and inhibition assays were performed to demonstrate progesterone immunoresponsiveness. RESULTS Serum specific-progesterone immunoglobulin G (IgG) and IgE were detected initially and disappeared 6 months after GHRA treatment. Dose-response LHR using patient basophils was observed for different hormones but after 3 months persisted only for 5β-pregnanediol. Preincubation with mouse antiprogesterone monoclonal antibody (PmAb) or mifepristone, a progesterone inhibitor, over a range of doses inhibited specific progesterone-induced LHR. Experiments with varying progesterone concentrations and a fixed dose of anti-IgE resulted in 100% LHR at a concentration as low as 0.016 nmol/mL, which, without anti-IgE, failed to release histamine. CONCLUSIONS This is the first report of combined recurrent anaphylaxis, cyclic urticaria/angioedema, and APD induced by immunoresponsiveness to progesterone.
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Affiliation(s)
- I Leonard Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0563, USA
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Lee MK, Lee WY, Yong SJ, Shin KC, Lee SN, Lee SJ, Lee JH, Kim SH. A case of autoimmune progesterone dermatitis misdiagnosed as allergic contact dermatitis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2011; 3:141-4. [PMID: 21461257 PMCID: PMC3062796 DOI: 10.4168/aair.2011.3.2.141] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 11/22/2010] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Myoung Kyu Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Poffet F, Abraham S, Taramarcaz P, Fontao L, Borradori L. Autoimmune Progesterone Dermatitis: Potential Role of Cutaneous Angiogenin Expression? Dermatology 2011; 223:32-5. [DOI: 10.1159/000329427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Prieto-Garcia A, Sloane DE, Gargiulo AR, Feldweg AM, Castells M. Autoimmune progesterone dermatitis: clinical presentation and management with progesterone desensitization for successful in vitro fertilization. Fertil Steril 2010; 95:1121.e9-13. [PMID: 21092951 DOI: 10.1016/j.fertnstert.2010.10.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 09/20/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To report clinical cases of autoimmune progesterone (P) dermatitis, its relationship to IVF, and the potential for P desensitization to treat these cases to achieve viable pregnancies. DESIGN Clinical description. SETTING Institutional hospitalary practice. Allergy Division. PATIENT(S) Six patients from the Allergy Clinic consulting for cyclic rashes or anaphylaxis related to the luteal phase of the menstrual cycle. Three of the conditions were related to IVF. INTERVENTION(S) Skin tests were performed with P. For IVF, rapid 8- and 10-step P desensitization protocols were performed, with increasing doses administered every 20 minutes via intravaginal suppositories. A rapid oral desensitization protocol was performed in one patient who required an oral contraceptive for uterine bleeding. MAIN OUTCOME MEASURE(S) Progesterone skin test results. Tolerance to P desensitization. Achievement of viable pregnancies. RESULT(S) Skin tests were positive in all patients and negative in 10 controls. Desensitization was successful in four patients: three patients for IVF, resulting in viable pregnancies. Another patient achieved tolerance to oral contraceptives. CONCLUSION(S) Women with autoimmune P dermatitis can be desensitized successfully to P. We provide the first evidence of successful P desensitization in patients requiring IVF culminating in successful pregnancies.
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Affiliation(s)
- Alicia Prieto-Garcia
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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