Increased mean platelet volume and C-reactive protein levels in patients with chronic urticaria with a positive autologous serum skin test

Chronic spontaneous urticaria: Focus on pathophysiology to unlock treatment advances

Chronic spontaneous urticaria (CSU) is a debilitating skin disease characterized by intensely itchy wheals, angioedema, or both. Symptoms recur spontaneously, on a near-daily basis, over >6 weeks; many patients experience flare-ups over several years and, consequently, reduced quality of life. Differences between the inflammatory profiles of the skin of CSU patients (wheals and nonlesional sites) and healthy controls indicate that key drivers such as mast cells, eosinophils, and basophils interact, release vasoactive mediators, and prime the skin, leaving patients predisposed to symptoms. Many cytokines and chemokines involved in these inflammatory networks and their corresponding intracellular signaling cascades have been identified. These insights informed the development of therapies such as omalizumab, dupilumab, and Bruton's tyrosine kinase (BTK) inhibitors, marking a renewed focus on pathogenesis in CSU clinical research. Despite progress, current therapies provide symptomatic control but do not appear to redress the inflammatory balance in the skin permanently. A deeper understanding of CSU pathogenesis will permit a more targeted approach to developing novel treatments with curative intent. Here, we review what is known about the pathogenesis of CSU and consider how this can be used to identify rational targets to improve patient care further.

Urticaria and Angioedema: Understanding Complex Pathomechanisms to Facilitate Patient Communication, Disease Management, and Future Treatment

Chronic spontaneous urticaria (CSU) is primarily a T2-dominant disease with a complex genetic background. Skin mast cell activation can be induced not only via the IgE-FcεRI axis but also from several other distinct mechanisms, molecules, and receptors involved in CSU onset, persistence, and exacerbation. These include autoallergy, autoimmunity, central or peripheral neuroimmune dysregulation, activation of both extrinsic and intrinsic coagulation pathways, and microbial infections. Besides mast cells, recent reports suggest the active and direct involvement of basophils and eosinophils. Several biological characteristics or biomarkers have been linked with CSU's known endotypes and may help forecast therapeutic responses. The introduction of biologic therapy for CSU has been a major advance in the last 10 years. The cornerstone of angioedema (AE) pathogenesis is increased vascular permeability and plasma leakage into the deeper dermis and subcutis, either mediated by histamine or bradykinin (BK). C1-inhibitor deficiency, hereditary or acquired, is the primary cause of BK-mediated AE due to increased plasma BK concentration. Other complex conditions have been identified, with some likely involving contact system dysregulation and other putative mechanisms related to vascular endothelial dysfunction. The approval of multiple hereditary-AE-specific therapies for both prevention and acute attacks has revolutionized treatment of this disease. Any new knowledge of the pathogenesis of CSU and AE offers the opportunity to improve patient information, physician-patient communication, prediction of therapeutic responses, selection of precise tailor-made treatment for each patient, and exploration of novel treatment options for those who do not achieve disease control with current medications.

The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

BACKGROUND

In chronic spontaneous urticaria (CSU), the guidelines recommend very limited diagnostic procedures during the routine workup, although additional investigations might be indicated in some patients with CSU. For physicians treating patients with CSU, it is often difficult to decide which diagnostic tests are useful.

OBJECTIVE

To provide recommendations on what diagnostic tests should be performed on which patients with CSU.

METHODS

We performed an extensive literature search on the respective topics and identified relevant questions that should prompt diagnostic procedures based on the published evidence and expert consensus among all authors.

RESULTS

We provide questions, diagnostic testing, where appropriate, and recommendation that should be included when assessing the history of a patient with CSU, to explore and rule out differential diagnoses, to assess patients for underlying causes and modifying conditions, to explore patients for comorbid diseases and consequences of having CSU, and to assess patients for CSU components that can help to predict their disease course and response to treatment.

CONCLUSIONS

Here, we provide physicians treating patients with CSU with information about which clues should lead to which tests and why.

Biomarkers of chronic spontaneous urticaria and their clinical implications

Introduction: Chronic spontaneous urticaria (CSU) is a frequent disorder in which activation of effector cells and histamine release can be induced via several distinct pathogenetic mechanisms. Much work has been carried out to identify biomarkers useful for classifying CSU patients, and to predict their response to currently available treatments.Areas covered: The recent literature dealing with CSU biomarkers was screened in PubMed and Google Scholar using 'chronic spontaneous urticaria', 'biomarker', 'diagnosis', 'therapy' and 'treatment response' as key words. The characteristics found in relevant papers were divided into clinical and serological biomarkers of (a) clinical severity/disease activity, and (b) response to treatments.Expert opinion: A diagnostic biomarker for CSU is still missing. Most biomarkers described so far do not seem to possess sufficient specificity for this disease. Basopenia and the activation of the coagulation cascade might be biomarkers of disease activity and severity, but information available so far is insufficient to consider their routine use. Markers suggesting IgG-mediated autoimmunity (autologous serum skin test, basophil activation/histamine release assays, low total IgE) seem to identify patients less prone to respond to omalizumab but responsive to cyclosporine. In contrast, 'autoallergy' (i.e. the presence of IgE to autoallergens), which is often associated with elevated IgE levels seems to identify patients who will respond to omalizumab.

Hematologic parameters as biomarkers for antihistamine and omalizumab resistance in chronic spontaneous urticaria

Background: Biomarkers of resistance to H₁-antihistamines (AH) and omalizumab in chronic spontaneous urticaria (CSU) are still a matter of debate. Objective: To identify clinical and laboratory attributes of the patient that may be predictive of AH and omalizumab resistance in CSU. Methods: We conducted a retrospective observational study by using the electronic patient record data base of patients with CSU and of sex- and age-matched controls. Patients with CSU were divided into three study groups: the CSU group, patients who responded to AHs; the antihistamine-resistant CSU (AH-CSU) group, patients refractory to a fourfold AH dose; and the control group, composed of a random sample of age- and sex-matched subjects, with a case-control ratio of 1:2. The patients in the AH-CSU group treated with omalizumab were compared according to the response or resistance to omalizumab. Results: A total of 106 subjects in the AH-CSU group, 483 in the CSU group, and 1198 in the control group were compared. Both AH-CSU (112.7 ± 43.1 kU/mL) and CSU (129.5 ± 52.4 kU/mL) groups were associated with higher plasma total IgE levels than control group (103.2 ± 49.5 kU/mL; p < 0.001). The AH-CSU group was characterized by a higher plasma high-sensitivity C-reactive protein level (6.4 ± 3.7 mg/L) than the CSU group (4.3 ± 1.4 mg/L; p < 0.001) and the control group (3.1 ± 1.8 mg/L; p < 0.001). The AH-CSU and CSU groups were characterized by a lower mean ± standard deviation basophil counts (0.18 ± 0.16 cells ×10⁹/L and 0.19 ± 0.11 cells ×10⁹/L, respectively) than the control group (0.22 ± 0.09 cells ×10⁹/L; p < 0.001). The mean platelet volume was higher in the AH-CSU group (11.2 ± 0.3 fL) than in the CSU group (11.1 ± 0.4 fL; p = 0.002) and in the control group (10.3 ± 0.4 fL; p < 0.001). There were no significant differences in the mean levels of lymphocytes, monocytes, eosinophils, basophils, and platelets, and the rates of eosinopenia and basopenia between the patients in the AH-CSU group who responded to and those who were resistant to omalizumab. Conclusion: This study provided additional data of interest to examine the pathophysiologic role of low-grade inflammation and basopenia in patients with CSU and resistant to AHs and omalizumab.

Participation of the coagulation system and fibrinolysis as well as selected biomarkers in pathogenesis of chronic urticaria with various activity degree

Introduction

Chronic urticaria is a complex disease process in which chronic spontaneous urticaria (CSU) and chronic inducible urticaria are distinguished. Its etiopathogenesis still remains unknown. Some recent studies indicated a significant participation of vitamin D in the etiopathogenesis of urticaria. In 40–50% of patients with CSU on the basis of the positive result of the autologous serum skin test (ASST), autoimmunological background of the disease is diagnosed. Moreover, numerous test results confirm involvement of the coagulation system/fibrinolysis and non-infectious inflammatory factors in the pathophysiology of CSU.

Aim

To determine whether some factors may play a role in pathogenesis and contribute to the severity of chronic spontaneous urticaria.

Material and methods

One hundred and forty-two patients with diagnosed CSU were enrolled in the study. The activity of urticaria was assessed using the UAS-7 (Urticaria Activity Score). The study participants were divided into 4 groups depending on the UAS-7. ASST was performed and blood was collected to determine the biomarkers (CRP, vitamin D, D-dimers, fibrinogen, MPV, PLT).

Results

Statistical analysis was performed using Statistica 13. A statistically significant difference between groups with various activity of urticaria in D-dimer concentration average values (p < 0.05) was observed. Moreover, a statistically significant negative correlation between activity of urticaria and vitamin D concentration (p < 0.001) was noted.

Conclusions

Our results might support the possible involvement of both coagulation and fibrinolysis pathway and vitamin D in the urticaria pathomechanism. Further prospective studies in larger populations conducted at multiple centres are required to expand further our findings.

The Antimicrobial Cathelicidin CRAMP Augments Platelet Activation during Psoriasis in Mice

Platelet-associated complications including thrombosis, thrombocytopenia, and haemorrhage are commonly observed during various inflammatory diseases such as psoriasis. Although several mechanisms that may contribute to the dysfunction of platelets during inflammatory diseases have been reported, knowledge on the primary molecules/mechanisms that underpin platelet-associated complications in such conditions is not fully established. Here, we report the significance of the mouse antimicrobial cathelicidin, mouse cathelicidin-related antimicrobial peptide (mCRAMP) (an orthologue of LL37 in humans), on the modulation of platelet reactivity during psoriasis using Imiquimod-induced psoriasis in mice as an inflammatory disease model for psoriasis vulgaris in humans. The activation of platelets during psoriasis is increased as evidenced by the elevated levels of fibrinogen binding and P-selectin exposure on the surface of platelets, and the level of soluble P-selectin in the plasma of psoriatic mice. The skin and plasma of psoriatic mice displayed increased levels of mCRAMP. Moreover, the plasma of psoriatic mice augmented the activation of platelets obtained from healthy mice. The effect of mCRAMP is partially mediated through formyl peptide receptor 2/3 (Fpr2/3, the orthologue to human FPR2/ALX) in platelets as a significant reduction in their activation was observed when FPR2/ALX-selective inhibitors such as WRW₄ or Fpr2/3-deficient mouse platelets were used in these assays. Since the level of antimicrobial cathelicidin is increased in numerous inflammatory diseases such as psoriasis, atherosclerosis, and inflammatory bowel disease, the results of this study point towards a critical role for antimicrobial cathelicidin and FPR2/ALX in the development of platelet-related complications in such diseases.

Combination therapy with omalizumab and an immune-suppressive agent for resistant chronic spontaneous rrticaria - A real-life experience

Background

Chronic Spontaneous Urticaria (CSU) is a relatively common immune mediated disease that can be effectively treated nowadays. Nevertheless, for some patients remission cannot be achieved following current treatment recommendations, defined as resistant CSU (r-CSU). Treating r-CSU is challenging, and, currently, there are no recommended interventions. In this real-life study we describe successful therapy of 18 r-CSU patients using an "intensified protocol" of anti-IgE-antibody (omalizumab) concomitantly with an immunosuppressant. We defined the r-CSU phenotype and compared it to omalizumab-responsive CSU (Or-CSU) phenotype.

Methods

Clinical and serological data of 72 CSU patients (ie, 18 r-CSU and 54 age and sex matched Or-CSU) were retrospectively collected and analyzed. All patients were diagnosed with CSU for ≥6 months and treated at the Sheba Medical Center during 2013–2018.

Results

Of 289 CSU patients, 18 (6%) were diagnosed with r-CSU and treated with the "intensified protocol" including omalizumab and cyclosporine-A (16p), methotrexate (1p), and azathioprine (1p). Of which, 14/18 (78%) achieved complete remission, 2/18 (11%) partial remission, and 2/18 (11%) no remission. During follow-up no serious adverse events were documented. r-CSU patients received higher doses of antihistamine (p < 0.0001) and omalizumab (425 ± 58 mg/month vs. 283 ± 86 mg/month; p < 0.0001) compared to Or-CSU. The r-CSU phenotype was linked with concomitant autoimmunity (p = 0.0005) and a lower level of IgE prior to initiation of therapy (p = 0.027).

Conclusion

r-CSU may be a distinct CSU phenotype characterized by severe disease, concomitant autoimmunity, and lower baseline-IgE levels (low "autoallergy"). An "intensified protocol" with omalizumab and an immunosuppressive agent was found to be efficacious and safe for r-CSU. Further larger studies are required to verify these results.

Blastocystis, urticaria, and skin disorders: review of the current evidences

Blastocystis is one of the most common intestinal protozoan parasites worldwide, which is linked to cutaneous lesions and urticaria. In a setting of systematic review, the data on the association of Blastocystis infection with cutaneous lesions were searched in order to summarize the main clinical symptoms, diagnostic methods, treatment, and outcome of the patients. The search identified 28 eligible articles, including 12 cross-sectional studies and 16 case reports/case series (including 23 cases). A diverse spectrum of skin symptoms, mainly urticaria, rash, and itching, was reported from the studies. Of the 23 infected cases with the skin symptoms, gastrointestinal symptoms were reported from the 16 cases, whereas 7 cases with urticaria had asymptomatic infection. The most frequent subtypes were ST1, ST2, and ST3, respectively. Metronidazole, paromomycin, and tinidazole were the most prescribed drugs in patients with single Blastocystis infection. Notably, urticaria and other cutaneous symptoms of all treated patients were resolved after treatment. In conclusion, this study indicates that Blastocystis infection can be a neglected cause of urticaria and skin disorders. Since the treatment of Blastocystis infection is simple, screening and treatment of this infection should be considered in patients with urticaria and other skin disorders.

Omalizumab does not lead to a distinct alteration in hematological parameters and complete blood count-derived inflammation biomarkers except for basophil count

PURPOSE

Omalizumab is a monoclonal anti-IgE antibody used to treat patients with chronic spontaneous urticaria by decreasing free IgE levels. Omalizumab may have an anti-inflammatory effect by inhibiting T-cell activation and inducing eosinophil apoptosis. In this study, we evaluated the effect of omalizumab on hematological parameters and inflammation biomarkers in patients with chronic spontaneous urticaria.

METHODS

Between July 2018 and November 2019, medical records of 60 patients (44 female, 16 male) with chronic spontaneous urticaria who were treated with omalizumab were reviewed retrospectively. Hematological parameters and inflammation biomarkers including the neutrophil/lymphocyte, monocyte/lymphocyte, platelet/lymphocyte and mean platelet volume/platelet count ratios were compared before and after 12 weeks of omalizumab treatment.

RESULTS

The absolute count of basophils and percentage of basophils increased significantly after omalizumab treatment (p = 0.04, p = 0.004). The absolute count of eosinophils, percentage of eosinophils, neutrophil/lymphocyte, monocyte/lymphocyte, and mean platelet volume/platelet ratios decreased, while platelet/lymphocyte ratio increased after omalizumab treatment. Nevertheless, these changes were not statistically significant.

CONCLUSIONS

Increased basophil counts suggest that omalizumab has a crucial effect through basophils in chronic spontaneous urticaria. Further studies focussing on basophils may contribute to the literature both to elucidate the etiopathogenesis of urticaria and to improve novel treatment agents for the disease. On the other hand, our study revealed that omalizumab did not have a distinct effect on complete blood count-derived inflammation biomarkers and thus inflammation.

Emerging Biomarkers and Therapeutic Pipelines for Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as the appearance of evanescent wheals, angioedema, or both, for at least 6 weeks. CSU is associated with intense pruritus and poor quality of life, with higher odds of reporting depression, anxiety, and sleep difficulty. As of yet, the assessment of the activity and course of the disease along with the response to several treatments in CSU are based purely on the patient's medical history and the use of the patient-reported outcomes. Recently, several reports have suggested that certain parameters could be considered as potential disease-related biomarkers. Moreover, with the advent of such biomarkers, newer biologic agents are coming forth to revolutionize the management of potential refractory diseases such as CSU. The purpose of this article is to review the most promising biomarkers related to important aspects of CSU, such as the disease activity, the therapeutic response, and the natural history of the disease, and discuss the mechanisms of action and therapeutic effectiveness of the latest agents available or currently under investigation for the management of antihistamine-refractory CSU. The knowledge of these features could have an important impact on the management and follow-up of patients with CSU.

Biomarkers In Chronic Spontaneous Urticaria: Current Targets And Clinical Implications

Chronic urticaria (CU) is a mast cell-driven disease characterized by the development of wheals, angioedema, or both for more than 6 weeks. The two major sub-types are chronic spontaneous urticaria (CSU) and inducible urticaria. In the last decade different pathophysiological mechanisms, potentially responsible for the development of the disease, have been described. It is likely that the activation of mast cells and basophils in CSU can be the results of immune system dysregulation, activation of the inflammatory cascade, and of the extrinsic coagulation pathway. Some of the mediators involved in the pathophysiological mechanisms of CSU have recently been identified as potential biomarkers useful for the diagnosis, follow-up, and management of the disease, even if they are not yet available in clinical practice. Thus, in this review we discuss new insights in the mediators involved in the pathogenesis of CSU, highlighting their potential role as biomarkers in the activity and progression of the disease and response to therapies.

Platelets in Skin Autoimmune Diseases

Systemic lupus erythematosus (SLE), systemic sclerosis (SSc), and small vessel vasculitis are three autoimmune diseases frequently manifested in the skin. They share common pathogenic features, including production of autoantibodies, loss of tolerance to self-antigens, tissue necrosis and fibrosis, vasculopathy and activation of the coagulation system. Platelets occupy a central part within the coagulation cascade and are well-recognized for their hemostatic role. However, recent cumulative evidence implicates their additional and multifaceted immunoregulatory functions. Platelets express immune receptors and they store growth factors, cytokines, and chemokines in their granules enabling a significant contribution to inflammation. A plethora of activating triggers such as damage associated molecular patterns (DAMPs) released from damaged endothelial cells, immune complexes, or complement effector molecules can mediate platelet activation. Activated platelets further foster an inflammatory environment and the crosstalk with the endothelium and leukocytes by the release of immunoactive molecules and microparticles. Further insight into the pathogenic implications of platelet activation will pave the way for new therapeutic strategies targeting autoimmune diseases. In this review, we discuss the inflammatory functions of platelets and their mechanistic contribution to the pathophysiology of SSc, ANCA associated small vessel vasculitis and other autoimmune diseases affecting the skin.

Cutting Edge: Biomarkers for Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined by the appearance of wheals and a variable presence of angioedema which persists for at least 6 weeks. It represents the most common subtype of chronic urticaria and is gaining importance in civil society because of its association with impaired quality of life. Moreover, CSU has a growing impact on national health systems representing a great burden due to its variable rate of response to the approved therapies. In this scenario, the identification of clinical and molecular biomarkers is of pivotal importance. Some groups are trying to detect molecules which would be able to help clinicians in reaching a proper diagnosis; additionally, the opportunity to describe disease severity which leads to cluster patients in different groups could fill the gap in the numerous unmet clinical needs. Several biomarkers are currently being studied with the purpose to predict the response to a defined therapy; unfortunately, none of them are ready to be translated from bench to bedside.

Evaluation of carotid intima media thickness and hematologic inflammatory markers in patients with chronic spontaneous urticaria

Introduction

Low grade inflammation is associated with chronic spontaneous urticaria (CSU) and atherosclerosis. There are little data on the relationship between urticarial inflammation and atherosclerosis. The neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and mean platelet volume (MPV) have recently been studied in many diseases as a biomarker of inflammation.

Aim

To evaluate hematologic inflammatory parameters and subclinical atherosclerosis in CSU patients.

Material and methods

C-reactive protein (CRP), NLR, PLR, MPV and carotid intima media thickness (CIMT) in CSU patients were compared with healthy controls. Thirty CSU patients and 30 healthy controls participated in the study.

Results

Thirty CSU patients and 30 healthy controls participated in the study. 53.3% of the patient group were females, 46.7% were males and the mean age was 37.7 ±7.7. 53.3% of the healthy control group were females, 46.7% were males and the mean age was 37.1 ±7.2. Body mass index was 24.63 ±2.7 kg/m² in the patient group and 24.83 ±2.5 kg/m² in the control group. Left and right CIMT and CRP values were higher in CSU patients and high-density lipoproteins (HDL) values were lower in the CSU patients. There was a positive correlation between the right and left CIMT and urticaria activity severity 4 (UAS4), disease severity, and triglycerides in the patient group, also a negative correlation was found between the right and left CIMT and the HDL values. C-reactive protein was also correlated with UAS4 and disease severity.

Conclusions

This is the first study to evaluate subclinical atherosclerosis in CSU patients. Chronic spontaneous urticaria may be associated with an increased atherosclerotic risk. Serum CRP concentration can also be used as an objective parameter to evaluate disease severity.

The effect of omalizumab on hematological and inflammatory parameters in patients with chronic spontaneous urticaria

PURPOSE

The mechanism of action of omalizumab in chronic spontaneous urticaria (CSU) is not exactly known. In previous studies, d-dimer which is a fibrin-degradation product and interleukin-31 which has a role in inflammation were found to be decreased in patients with chronic urticaria treated with omalizumab. However, to our knowledge, there is no study on the effects of omalizumab on the ratio of neutrophil to lymphocyte (NLR) and the ratio of platelet to lymphocyte (PLR) which are inflammatory parameters in patients with CSU in the PubMed database. In this study, we aimed to evaluate the effects of omalizumab on hematological and inflammatory parameters in patients with CSU.

MATERIALS AND METHODS

One hundred six CSU patients treated with omalizumab were evaluated retrospectively. Complete blood count (CBC) and C-reactive protein (CRP) levels before treatment and at the third month of treatment were recorded. NLR and PLR were calculated from the CBC results. CBC parameters, CRP levels, NLR and PLR of the patients before treatment and at the end of third month of treatment were compared.

RESULTS

There was a significant decrease in white blood cell count, platelet count, neutrophil count, CRP level, NLR and PLR and a significant increase in mean platelet volume and eosinophil count with omalizumab treatment in CSU patients (p < 0.05). Basophil count increased; but there was no statistically significant difference (p = 0.293).

CONCLUSION

This study shows that omalizumab has not only anti Ig E effect, but also it may have inhibitory effects on inflammation and coagulation in patients with CSU. Further prospective studies are warranted in order to evaluate the effect of omalizumab on hematological and inflammatory parameters and correlation between omalizumab response rate and these inflammatory parameters in patients with CSU.

C-reactive protein is linked to disease activity, impact, and response to treatment in patients with chronic spontaneous urticaria

BACKGROUND

Elevated levels of C-reactive protein (CRP), a sensitive marker of inflammation, have been consistently reported in chronic spontaneous urticaria (CSU). Here, we retrospectively analyzed data from 1253 CSU patients from 2 centers to answer the following questions: (i) What is the prevalence of elevated levels of CRP in CSU? (ii) Why do CSU patients show elevated levels of CRP? (iii) Are elevated CRP levels relevant?

METHODS

Serum levels of CRP were measured by the nephelometric method. We collected information regarding various laboratory tests including ESR, CBC with differential, D-dimer, fibrinogen, C3, C4, IL-6, etc. For most patients, we also collected data on age, gender, duration of CSU, presence of angioedema, activity (UAS at the time of blood sampling and for 7 days), quality of life (CU-Q2oL and/or DLQI), comorbidities and possible causes of CSU, and autologous serum skin test (ASST) response. The efficacy of second-generation antihistamines was evaluated on the day of blood collecting.

RESULTS

One-third of CSU patients had elevated levels of CRP. Higher levels of CRP were associated with ASST positivity (P = .009) and arterial hypertension (P = .005), but not with other possible causes or comorbidities of CSU. C-reactive protein correlated with urticaria activity (P < .001), quality of life impairment (P = .026), and inflammatory and coagulation markers (P < .001). C-reactive protein levels were significantly higher in nonresponders to antihistamines as compared to responders (P < .001).

CONCLUSION

Elevated levels of CRP are common and relevant in CSU patients. The assessment of CRP levels may help to optimize the management of patients with CSU.

Association between multimorbidity and mean platelet volume in diabetic patients with acute myocardial infarction

AIMS

Diabetes mellitus (DM) is one of the most frequently detected conditions in multimorbid disease clusters. Platelet activation is one of the key mechanisms underlying atherothrombosis in acute myocardial infarction. Available data link mean platelet volume (MPV) to poor prognosis not only in cardiovascular and non-cardiovascular disease. Given the lack of research data on the association between disease clusters and MPV, we have set out to investigate the link between multimorbidity and MPV in diabetic patients with acute myocardial infarction.

METHODS

A total of 277 patients with DM and STEMI undergoing primary percutaneous coronary intervention were enrolled. Based on the number of comorbidities the study population was divided into two groups: group 1 (N = 58) with ≤ 1 comorbidity and group 2 (N = 219) with ≥ 2 comorbidities. A subanalysis was performed within the multimorbidity group: group 2A with two or three comorbidities (N = 156) and group 2B with at least four comorbidities (N = 63).

RESULTS

In the study population, 15.9% of patients had one comorbidity, and 22.0, 34.3, and 22.7% of patients had two, three, or at least four comorbid conditions, respectively. Both MPV and PDW were elevated in multimorbid patients (9.3 vs 10.8 fl and 9.5 vs 10.3 fl, respectively). The highest platelet volume indices were observed in patients with at least four comorbid conditions. There was a moderate positive correlation between MPV and the total number of comorbidities, the number of CVD comorbidities, and the number of non-CVD comorbidities.

CONCLUSIONS

These findings indicate that multimorbidity is associated with an increase in platelet volume indices. MPV values increased with the increasing number of comorbid conditions. Importantly, MPV values were elevated in some, but not all CVD and non-CVD conditions.

Potential blood biomarkers in chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is a mast cell-driven disease that is defined as the recurrence of weals, angioedema or both for > 6 weeks due to known or unknown causes. As of yet, disease diagnosis is purely clinical. Objective tools are needed to monitor the activity of CSU and the efficacy of treatment. Recently, several reports have suggested that blood parameters may be considered as potential disease-related biomarkers. Here, we reviewed available literature on blood biomarkers for CSU diagnosis, activity monitoring, duration, patient subgroup allocation or response to treatment. We performed a PubMed, Google Scholar and Web of Science search and identified and analysed 151 reports published prior to January 2016. We found strong evidence for significant differences between patients with CSU and healthy controls in blood levels or values of D-dimer, C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9), mean platelet volume (MPV), factor VIIa, prothrombin fragment 1 + 2 (F1 + 2), tumour necrosis factor, dehydroepiandrosterone sulphate and vitamin D. Also, there is strong evidence for a significant association between CSU activity and blood levels or values of D-dimer, F1 + 2, CRP, IL-6 and MPV. Strong evidence for reduced basophil count and high levels of IgG anti-FcεRI in the subgroup of CSU patients with positive autologous serum skin test was shown. In contrast, the evidence for all reported blood biomarkers for differentiating CSU from other diseases, or a role in prognosis, is weak, inconsistent or non-existent. Taken together, we identified 10 biomarkers that are supported by strong evidence for distinguishing patients with CSU from healthy controls, or for measuring CSU activity. There is a need for further research to identify biomarkers that predict outcome or treatment response in CSU.

Blood mean platelet volume and platelet lymphocyte ratio as new predictors of hip osteoarthritis severity

Osteoarthritis (OA) is a low grade systemic inflammatory disease in which many inflammatory mediators are known to be elevated in the peripheric blood. Blood platelet lymphocyte ratio (PLR) and mean platelet volume (MPV) are accepted as novel markers in many of the systemic inflammatory disorders, but have not been investigated in synovitis-free radiographic OA yet.The aim of this study was to evaluate the levels of blood PLR and MPV in radiographic hip OA. A total of 880 patients were evaluated retrospectively and after certain exclusion criteria, 237 of them who have primary hip OA were included. Age, sex, height, weight, body mass index, neutrophil, lymphocyte and platelet counts, erythrocyte sedimentation rate (ESR), PLR, and MPV levels were recorded, Kellgren-Lawrence (KL) grading of the hip joints were performed. Patients were then divided into 2 groups as KL grades 1 to 2 (mild-moderate) and KL grades 3 to 4 (severe) hip OA.Mean age, mean neutrophil, lymphocyte and platelet counts, mean MPV, mean PLR, and mean ESR were statistically significantly different between mild/moderate hip OA group and severe hip OA group. In univariate analysis, older age and higher MPV, PLR, and ESR were severely associated with severe hip OA. In multiple logistic regression analysis, MPV, PLR, and ESR emerged as independent predictors of severe hip OA.The results of the present study, for the first time in the literature, suggest blood PLR and MPV as novel inflammatory markers predicting the radiographic severity of hip OA in the daily practice.

Comorbidity and pathogenic links of chronic spontaneous urticaria and systemic lupus erythematosus--a systematic review

Chronic spontaneous urticaria (CSU) is a common mast cell-driven disease characterized by the development of wheals (hives), angioedema (AE), or both for > 6 weeks. It is thought that autoimmunity is a common cause of CSU, which is often associated with autoimmune thyroiditis, whereas the link to other autoimmune disorders such as systemic lupus erythematosus (SLE) has not been carefully explored. Here, we systematically reviewed the existing literature for information on the prevalence of CSU in SLE (and vice versa) and we examined the possible clinical and pathogenetic relationship between CSU and SLE. The prevalence of CSU and CSU-like rash in SLE was investigated by 42 independent studies and comorbidity in adult patients reportedly ranged from 0% to 21.9% and 0.4% to 27.5%, respectively (urticarial vasculitis: 0-20%). In children with SLE, CSU was reported in 0-1.2% and CSU-like rash in 4.5-12% (urticarial vasculitis: 0-2.2%). In contrast, little information is available on the prevalence of SLE in patients with CSU, and more studies are needed to determine the rate of comorbidity. Recent insights on IgG- and IgE-mediated autoreactivity suggest similarities in the pathogenesis of CSU and SLE linking inflammation and autoimmunity with the activation of the complement and coagulation system. Future studies of patients with either or both conditions could help to better define common pathomechanisms in CSU and SLE and to develop novel targeted treatment options for patients with CSU and SLE.

The Role of Platelets in Chronic Urticaria

BACKGROUND

Platelets are implicated in many pathophysiological processes, including inflammation and immunity. Ever-growing evidence suggests the active involvement of platelets in the pathogenesis of various inflammatory disorders, including cutaneous inflammatory diseases. A limited number of studies have investigated the role of platelets in chronic urticaria (CU). In this review, we summarize the current knowledge regarding the role of platelets in chronic spontaneous and inducible urticarias.

METHODS

A literature search was performed using PubMed and Google Scholar, and the references of relevant literature were reviewed.

RESULTS

Overall, in CU patients, conflicting results have been obtained from the assessment of platelet indices, such as mean platelet volume, platelet count and distribution width, as well as markers of platelet aggregation and activation. Nevertheless, a few studies showed significant changes of such parameters in CU patients compared to controls, in apparent correlation with clinical severity, autoreactivity and/or inflammatory status.

CONCLUSIONS

In the absence of definitive conclusions, the pathogenic role of platelets in CU needs to be further explored. Platelets might represent a link between inflammation, coagulation and histamine release in the pathophysiological network of CU.

Is enhanced platelet activation the missing link leading to increased cardiovascular risk in psoriasis?

BACKGROUND

Psoriasis is an immune mediated inflammatory skin disease associated with systemic inflammation resulting in increased risk for associated cardiovascular co-morbidities. The role of platelet activation in the pathophysiology of this condition has not been clearly studied. We undertook to study the platelet activation markers in psoriasis, as compared to controls and to identify its association with disease severity in psoriasis.

METHODS

Sixty-two patients with psoriasis and 62 age and gender matched healthy controls were enrolled in this cross-sectional study. The severity of the disease was assessed using the psoriasis area severity index (PASI) scoring. The platelet indices [mean platelet volume (MPV) and platelet distribution width (PDW)] were estimated by an automated haematological laser optical analyzer. Plasma soluble P-selectin and platelet derived microparticle (PDMP) concentrations, serum high sensitivity C-reactive protein (hs-CRP) and interleukin (IL)-6 concentrations were estimated in all study participants. Platelet aggregation was assessed using adenosine diphosphate (ADP) as aggregating agent.

RESULTS

We observed that there was significantly higher platelet indices (MPV and PDW) in patients with psoriasis, when compared to controls. Plasma soluble P-selectin concentrations, PDMP and platelet aggregation were significantly elevated in patients with psoriasis, as compared to controls. We also found significantly higher concentrations of hs-CRP and IL-6 in patients with psoriasis, as compared to controls. Platelet activation and systemic inflammation markers correlated positively with PASI, except PDW. We also observed significant positive correlation between platelet activation and systemic inflammation in psoriasis.

CONCLUSION

Significant platelet activation and systemic inflammation were observed in patients with psoriasis, especially when associated with severe disease. The increased platelet activation might be the missing link between the persistent inflammation and the development of atherosclerotic plaque leading onto cardiovascular co-morbidities seen associated with psoriasis.

Analysis of circulating vascular endothelial growth factor and its soluble receptors in patients with different forms of chronic urticaria

Background. Vascular endothelial growth factor (VEGF) is a powerful enhancer of vascular permeability and inflammatory response; however its significance in chronic urticaria is poorly recognised. Aim. To compare free circulating levels of VEGF and its soluble receptors (sVEGFR1 and VEGFR2) in patients with different forms of chronic urticaria. Methods. The concentrations of VEGF and its receptors in plateletpoor plasma (PPP)/plasma were measured using enzyme-linked immunosorbent assay in chronic urticaria: (1) chronic spontaneous urticaria (CSU) with positive autologous serum skin test (ASST), (2) CSU with negative response to ASST, (3) CSU with concomitant euthyroid Hashimoto's thyroiditis (CSU/Hashimoto), (4) delayed pressure urticaria (DPU), and the healthy subjects. Results. There were no significant differences in VEGF concentration in PPP between CSU groups and the healthy subjects. Contrary, VEGF concentration was significantly higher in DPU and CSU/Hashimoto patients as compared with the healthy subjects and CSU groups. Furthermore, VEGF value in CSU/Hashimoto patients during the remission was similar to that of the active period and significantly higher than the healthy subjects; VEGF concentration was significantly correlated with TSH. Plasma concentrations of sVEGF1 and sVEGF2 were similar in chronic urticaria patients and the healthy subjects. Conclusions. Increased free circulating VEGF concentration may result from the urticarial process itself as well as concomitant Hashimoto's thyroiditis.

The role of mean platelet volume as an inflammatory marker in children with chronic spontaneous urticaria

BACKGROUND

Previous studies have shown that platelets are involved in the inflammatory process. Mean platelet volume (MPV) has been frequently used as an inflammatory marker in various diseases associated with inflammation. The role of MPV in children with chronic spontaneous urticaria (CU), however, has not yet been evaluated. In this study we compared MPV levels between children with and without CU.

METHODS

Children with CU and age-matched healthy children were enrolled in the study. Complete blood count and C-reactive protein (CRP) levels were assessed in children with CU whilst MPV levels were compared between children with and without CU.

RESULTS

Forty children with CU (19 males; mean age: 8.0 ± 3.8 year; range: 3-15 years) and 40 healthy children (17 males; mean age: 6.9 ± 3.0 year; range: 2-14 year) were enrolled on the prospective, case-control study. MPV (fL) levels were significantly lower in children with CU when compared to healthy children (7.42 ± 0.77 and 7.89 ± 0.65, respectively; p=0.004). Both mean platelet number and median CRP levels were significantly higher in children with CU when compared to healthy children (p=0.008, p=0.014, respectively).

CONCLUSION

To our knowledge, this study is the first to evaluate the role of MPV as an inflammatory marker in children with CU. A decline in MPV may be considered as an indicator of inflammation in children with CU.

Platelet and other hemostatic characteristics in patients with chronic urticaria

Several publications have pointed out the importance of coagulation and fibrinolysis in the occurrence of chronic urticaria (CU), but only a few indicated the direct role of platelets. We assessed platelet aggregation and evaluated parameters of coagulation and fibrinolysis in patients with CU. Patients (n = 34) diagnosed as having CU and 36 healthy controls were enrolled. Platelet aggregation was assayed using an impedance aggregometer and adenosine diphosphate, arachidonic acid, thrombin receptor-activating peptide (TRAP), and ristocetin as agonists. In patients with CU, significantly decreased platelet aggregation to some agonists (ristocetin and TRAP) was observed. The D-dimer levels were elevated, mean platelet volume was decreased, but no alteration was observed in other coagulation assays. Elevated D-dimer levels indicated that coagulation and fibrinolysis are activated in the patients with CU. Evaluation of platelet function may contribute to identify the role of these cells in the pathogenesis of CU.

Chronic idiopathic angioedema: a single center experience

OBJECTIVE

Chronic idiopathic angioedema (CIA) is defined as three or more episodes of angioedema in a period of > 6 months without a clear etiology. In the study, we tried to explore clinical and laboratory characteristics of patients with CIA unaccompanied by urticaria.

METHODS

We retrospectively reviewed clinical and laboratory characteristics of 1238 patients with chronic urticaria and/or angioedema referred to our allergy clinic.

RESULTS

Eight hundred and forty-one (67.9%) subjects had chronic urticaria without angioedema (CU Group), 323 (26.1%) had both urticaria and angioedema (CU + CA group), and 74 (5.9%) had chronic angioedema without urticaria (CA). In 29 (39.2%) cases of CA, no etiologic factor of angioedema was discovered, thus the patients were defined as having chronic idiopathic angioedema (CIA Group). Twenty-two (75.8%) subjects had antihistamine-responsive CIA and seven (24.1%) had antihistamine-unresponsive CIA. There were no statistically significant differences in clinical (except of urticarial eruptions) and laboratory characteristics between CU, CA + CU, and CIA groups. Antihistamine responsive and antihistamine-unresponsive CIA groups had no distinguishable clinical or laboratory features.

CONCLUSIONS

We suppose that CIA, at least its antihistamine-responsive form, represents a rare form of chronic spontaneous urticaria. The reasons why in CIA there are no other clinical signs of mast cell/basophil activation, such as pruritus, urticarial, and dermatographism, are largely unknown and have to be elucidated in future studies.

The association between platelet count and acute phase response in chronic spontaneous urticaria

Background. The platelet parameters and C-reactive protein (CRP) are markers reflecting a systemic inflammatory response. Among those, CRP is one of the major proteins helpful in determination of severity/activity of chronic spontaneous urticaria (CSU). Aim. To determine relationships between platelet activation indices and serum concentration of CRP, the best marker of acute phase response, and their potential clinical use in CSU patients. Methods. Mean platelet volume (MPV), platelet distribution width (PDW), and platelet count as well as serum CRP concentration were measured in CSU patients, showing different degrees of urticarial severity, and in the healthy subjects. Results. No significant differences were found in MPV and PDW between CSU group and the healthy subjects. The platelet count was significantly higher in moderate-severe CSU than that of the controls and mild CSU patients. Serum CRP concentrations were significantly higher in CSU patients as compared with the healthy subjects and significantly correlated with the platelet count in CSU patients. Conclusions. Acute phase response in CSU is associated with the increased number of circulating platelets in patients with more severe symptoms. It seems that simple determination of platelet size indices is not a reliable indicator of CSU severity/activity.

Chronic urticaria and coagulation: pathophysiological and clinical aspects

Chronic urticaria (CU) is a widespread skin disease, characterized by the recurrence of transient wheals and itch for more than 6 weeks. Besides autoimmune mechanisms, coagulation factors, in particular tissue factor and thrombin, might also participate in the disease pathophysiology. Tissue factor expressed by eosinophils can induce activation of blood coagulation generating thrombin which in turn can increase vascular permeability both directly, acting on endothelial cells, and indirectly, inducing degranulation of mast cells with release of histamine, as demonstrated in experimental models. D-dimer, a fibrin degradation product, generated following activation of the coagulation cascade and fibrinolysis, has been found to be increased during urticaria exacerbations; moreover, it has been proposed as a biomarker of severity and resistance to H1-antihistamines in CU patients. The possible role of coagulation in CU is also supported by case reports, case series and a small controlled study showing the efficacy of anticoagulant therapy in this disease. The purpose of this review was to summarize the available data on the possible contribution of coagulation to the pathophysiology of CU focusing on clinical aspects and possible future therapeutic developments.

Relationship between vitamin D status and the inflammatory state in patients with chronic spontaneous urticaria

Background

Chronic spontaneous urticaria (CSU) is an immune-inflammatory disease, characterized by acute phase response (APR) and immune activation. There has been increasing evidence showing that vitamin D deficiency/insufficiency is associated with increased incidence and/or severity of immune-inflammatory disorders.

Aim

To assess relationship between vitamin D status and C-reactive protein (CRP), a nonspecific inflammatory marker of CSU activity.

Methods

Concentrations of CRP and 25-hydroxyvitamin D [25(OH)D], a biomarker of vitamin D status were measured in serum of CSU patients and compared with the healthy controls.

Results

Serum 25(OH)D concentration was significantly lower in CSU group as compared with the normal subjects. The prevalence of vitamin D deficiency (< 20 ng/ml) was significantly higher in patients with CSU than among normal population. There were no significant differences in prevalence of 25(OH)D insufficiency between the groups. Serum CRP concentrations were significantly higher in CSU patients as compared with the healthy subjects. There were no significant correlations between CRP and 25(OH)D concentrations in CSU patients.

Conclusions

CSU is associated with lower serum 25(OH)D concentration and higher prevalence of its deficiency. The results failed to show any effect of vitamin D status on circulating CRP concentrations in CSU. A potential role of vitamin D in pathogenesis and/or additive therapy of CSU needs to be examined in other cohorts of CSU patients as well as in larger studies.

Increased serum complement C3 and C4 concentrations and their relation to severity of chronic spontaneous urticaria and CRP concentration

Chronic spontaneous urticaria (CU) is associated with activation of the acute phase response (APR). Nevertheless, APR-associated proteins have not been well characterized as potential biomarkers of the disease severity. To assess the pattern of complement proteins C3 and C4 – the acute phase reactants in patients with CU. C3, C4 and CRP concentrations were measured in serum of 70 patients showing different degrees of urticarial severity as well as in 33 healthy subjects. Serum C3 and C4 concentrations were significantly increased in CU patients as compared with the healthy subjects and exceed the normal lab range by about 5% and 10%, respectively. Significant differences were found between patients with mild and increased CU severity. In addition, significant correlations were observed between C3, C4 and CRP concentrations. More severe CU is characterized by higher production of C3 and C4 complements accompanied by parallel changes in CRP concentration.

Platelet activation in chronic urticaria and its correlation with disease severity

Chronic urticaria (CU) is characterized by the occurrence of wheals lasting for more than 6 weeks. The role of platelet activation in the pathophysiology of this condition has not been clearly studied. We undertook a cross-sectional study among 45 patients with CU and 45 age- and gender-matched healthy controls. The severity of the disease was assessed using the urticaria severity score. The autologous plasma skin test (APST) was done in all cases of CU. The platelet count and indices were estimated by an automated haematological laser optical analyzer. Platelet aggregation and soluble P-selectin levels were estimated in all study participants. It was observed that there was a significantly higher mean platelet volume (MPV) and platelet distribution width (PDW) in patients with CU when compared to controls. Platelet aggregation and soluble P-selectin levels were significantly higher in patients with CU, as compared to controls. Urticaria severity score correlated positively with platelet aggregability and soluble P-selectin levels. APST-positive patients had significantly higher platelet aggregation and higher soluble P-selectin levels, when compared to the APST-negative patients, indicating more platelet activation in the autoimmune group. There is significant platelet activation in patients with CU, especially in those with autoreactivity.

Are platelet volume indices of clinical use? A multidisciplinary review

Platelet size correlates with platelet activity and can be assessed by platelet volume indices (PVI). The PVI, mean platelet volume (MPV), is universally available with routine blood counts by automated hemograms and therefore is an attractive index to study in clinical scenarios. PVI are useful in assessing the etiology of thrombocytopenia. In addition, a normal platelet distribution width in the setting of thrombocytosis is highly suggestive of a reactive etiology. Higher MPV is also associated with the presence of cardiovascular risk factors, chest pain due to acute coronary syndrome, and adverse outcome after acute coronary syndrome. Results from studies evaluating MPV in patients with peripheral artery disease, unprovoked deep vein thrombosis, and pulmonary embolism further advocate a potential role for MPV in identifying patients at high risk of thrombosis. Nevertheless, most of these data come from retrospective studies some of which have small study populations and confounding factors influencing platelet volume. Moreover, the cut-off values derived from these retrospective studies have not been validated prospectively. Despite the potential for clinical utility evident from these studies, the above-mentioned flaws together with technical problems in measuring MPV currently limit its clinical usefulness. Our review provides a perspective on PVI's potential clinical use.

Chronic urticaria and autoimmunity: associations found in a large population study

BACKGROUND

Chronic urticaria (CU) is a common disease in which most cases were considered to be idiopathic. Recent evidence indicates that at least a subset of cases of chronic idiopathic urticaria are autoimmune in origin.

OBJECTIVE

We aimed to characterize the association between CU, autoimmune diseases, and autoimmune/inflammatory serologic markers in a large unselected population.

METHODS

Data on 12,778 patients given a diagnosis of CU by either allergy or dermatology specialists during 17 years in a large health maintenance organization in Israel were collected. For each patient, we collected information on diagnosis of major, well-defined autoimmune diseases and autoimmunity- and inflammatory-related serologic markers. Similar data were collected for a control group comprised of 10,714 patients who visited dermatologists, family physicians, or allergy specialists and had no indication of CU.

RESULTS

Having CU was associated with an increased odds ratio for hypothyroidism, hyperthyroidism, and antithyroid antibodies. Female patients with CU had a significantly higher incidence of rheumatoid arthritis, Sjögren syndrome, celiac disease, type I diabetes mellitus, and systemic lupus erythematosus, mostly diagnosed during the 10 years after the diagnosis of CU. High mean platelet volume, positive rheumatoid factor, and antinuclear antibodies were all significantly more prevalent in patients with CU.

CONCLUSIONS

A strong association was found between CU and major autoimmune diseases. A common pathogenic mechanism is implied by the high prevalence of autoantibodies and the existence of a chronic inflammatory process expressed by the high mean platelet volume. These findings have implications for the diagnosis, management, and prognosis of patients with CU.

Acute-phase response in chronic urticaria

The patterns of acute-phase response (APR) biomarkers differ upon various inflammatory conditions. Little information is available on the systemic inflammatory response in urticaria/angio-oedema. It has been shown that concentrations of circulating APR biomarkers, IL-6 and C-reactive protein (CRP), are elevated more in severe chronic urticaria (CU) than in patients showing milder urticarial symptoms. It is not clear whether the increase of IL-6 and CRP is merely an epiphenomenon or may contribute to the pathogenesis of CU. It is tempting to speculate that mediators of APR may enhance urticarial inflammation. In addition, there is some association between APR and activation of coagulation/fibrinolysis in CU. It is well known that even slight elevation in CRP baseline concentration is enough to produce significant increase in cardiovascular risk. In this light, one should ask whether CU patients, in particular those showing stronger systemic inflammatory response and long-lasting course are more vulnerable to the cardiovascular events. Apart from highly troublesome symptoms and low quality of life, CU may then involve some remote, serious systemic consequences. Taken together, CU can be identified as a mast cell- and basophil-dependent inflammatory disorder of the skin, which is accompanied by APR. Characterization of APR in CU may appear essential for an insight into the activity of this disease and for assessment of the inflammation degree. Moreover, measurement of these biomarkers might be particularly relevant while assessing CU patients demanding an anti-inflammatory or immunosuppressive therapy. This review summarizes information regarding APR in the course of urticaria/angio-oedema.