Immunohistological comparison of granulated cell proteins in induced immediate urticarial dermographism and delayed pressure urticaria lesions

Shedding light on dermographism: a narrative review

Dermographism is a common subtype of chronic urticaria. It generally manifests as a linear wheal after scratching or friction, with or without angioedema. The pathophysiology is not clear, but currently, we believe that the stimulation of the skin by mechanical stress leads to the activation of mast cells, which provoke the release of histamine and pro-inflammatory mediators, ultimately forming wheal along the stressed area. The gold standard for diagnosis is a medical history and provocation test or dermatographic test. As one of the subtypes of chronic urticaria, the Urticaria Control Test (UCT), Chronic Urticaria Quality of Life questionnaire (CU-Q2oL), and Dermatology Life Quality Index (DLQI) are also effective tools for evaluating disease control in dermographism patients. In addition to avoiding triggers, nonsedating H1 antihistamines are the first-line medications recommended by EAACI and other guidelines; for those who do not respond to standard doses, the recommended dosage can be increased up to 4 times. When necessary, the off-label use of omalizumab can be considered, and some drugs with potential therapeutic effects are still being explored. However, there is still a lack of biomarkers for predicting disease severity, efficacy, and prognosis. Here, we review what we know about dermographism and some points that need exploration in the future.

Blistering Disorders of the Foot

ABSTRACT

Multiple pathophysiologic and biomolecular processes lead to bullae, including disruption of adhesion molecules, accumulation of cell injury, and traumatic injury. Blistering disorders of the foot can cause symptoms such as pruritus, pain, and drainage and significantly impact quality of life. Microbiologic and histopathologic examination of tissue specimens should be considered for concerns regarding atypical etiology.This retrospective case series describes patients seen in a community hospital outpatient wound center in southeastern Wisconsin between January 2021 and June 2023 for atypical blistering disorders of the foot. The cases herein describe the history, clinical presentation, and treatment of three atypical blistering disorders of the foot. An 86-year-old man presented complaining of intensely pruritic blistering lesions to both feet. Histopathologic findings indicated eosinophilic infiltrate, and the patient was treated for an eosinophilic drug reaction. A 65-year-old man presented complaining of multiple painful blisters to the plantar aspect of both feet. Histopathologic examination of unroofed blister indicated bullous tinea. Finally, a 44-year-old man with long-standing type 1 diabetes presented complaining of a several-week history of a single blister to his anterior right foot of unknown etiology. The patient was diagnosed with bullosis diabeticorum.Blistering disorders of the foot are diagnostic challenges; diagnostic clarity is assisted by thorough history, clinical presentation, treatment response, microbial analysis, and histopathologic findings.

Successful treatment of delayed pressure urticaria with 300 mg of omalizumab every 14 days

Delayed pressure urticaria is a rare form of chronic inducible urticaria characterized by erythematous-painful plaques that develop in areas of the skin exposed to prolonged pressure. Its treatment is very difficult, and its response to antihistamines is variable. Cases of delayed pressure urticaria, which have been completely controlled with the use of omalizumab in recent years, have been reported.

The pseudoallergen receptor MRGPRX2 on peripheral blood basophils and eosinophils: Expression and function

BACKGROUND

Mas-related G protein-coupled receptor X2 (MRGPRX2) is regarded as a mast cell-specific receptor mediating non-IgE-dependent activation. We aimed to investigate whether human basophils and eosinophils express functional MRGPRX2.

METHODS

Flow cytometry, immunocytochemistry, immunofluorescence, Western blot, and RT-PCR were performed in highly purified peripheral blood basophils and eosinophils of atopic and nonatopic donors. To assess functional activity, fluorescent avidin-based degranulation assay, calcium mobilization, cytokine production in supernatants, assessment of viability/apoptosis, and tricolor granulocyte activation test were used.

RESULTS

MRGPRX2 was significantly expressed by basophils and eosinophils but not neutrophils. Functional capacity was shown by anti-MRGPRX2 mAb-induced calcium influx and concentration-dependent induction of degranulation. Sequential stimulation in the calcium mobilization assay gave no evidence for desensitization or receptor internalization. Anti-MRGPRX2 mAb significantly promoted survival. Inhibition of apoptosis could be due to released IL-3, IL-5, and GM-CSF found in supernatants. Short-term incubation with IL-3 dose-dependently upregulated MRGPRX2 expression in both, stimulation for 24 hours with anti-IgE, C5a, fMLP, and IL-3 in basophils and by IL-3, IL-5, and IL-33 in eosinophils. Among known mast cell MRGPRX2 agonists ciprofloxacin but not PMX-53 was functional on basophils and eosinophils. In basophils of allergic subjects, tricolor granulocyte activation test using grass pollen demonstrated MRGPRX2 upregulation associated with degranulation and CD63 expression.

CONCLUSION

Unraveling the regulation and signaling mechanisms of MRGPRX2 on basophils and eosinophils might enable the development of new therapeutic strategies to prevent or inhibit allergic and nonallergic hypersensitivity. Moreover, addressing MRGPRX2 might have potential for diagnostic purposes in (drug) hypersensitivity.

Dermatologic Manifestations of the Hypereosinophilic Syndromes

Skin is a commonly affected organ in hypereosinophilic syndromes (HES). Cutaneous lesions may be an important presenting sign, may be extremely debilitating, and often reflect disease activity in HES. Recognition of dermatologic manifestations is important in approaching diagnosis and treatment of HES. This article reviews cutaneous involvement in HES and other eosinophil-associated skin diseases.

Evaluation of patients with symptomatic dermographism

BACKGROUND

Dermographism or 'simple' dermographism, which has been noted in about 1.5% to 5% of healthy individuals, is regarded as a normal physiological phenomenon. However, in symptomatic dermographism (SD), even light pressure or rubbing from clothes may provoke widespread weal-and-flare reactions with itching and burning. It is one of the dermatologic diseases that negatively impacts quality of life.

OBJECTIVE

We aimed to reveal triggering factors and/or associated clinical conditions in patients with SD.

METHODS

Forty patients (28 women and 12 men) with SD whose ages varied between 7 and 65 (30.3 +/- 10.7) participated in the study. Patients having chronic idiopathic urticaria, other types of physical urticaria and cutaneous/systemic mastocytosis were excluded. The diagnosis of SD was confirmed by stroking the skin of the back with a tongue blade. This procedure elicited within minutes a linear weal with a flare and severe itching. In light of the history, physical examination, skin prick test (SPT) with aeroallergens and laboratory results, a possible relationship of certain triggering factors and/or associated diseases (psychic factors, atopy, thyroid diseases, diabetes, menopause, infectious, systemic or malignant diseases, history of scabies, and history of drug reaction) to SD were investigated.

RESULTS

The duration of SD varied between 10 days and 10 years (mean: 20.8 months). Psychic factors were found to play the initial triggering role in 12 patients (30%). Five patients (12.50%) were atopic, and they had SPT reactivity to house dust mites. Three female patients (7.50%) defined that their complaints began following drug-induced urticarial rash. Two patients (5%) had hyperthyroidism, and one of the patients with SD of 1-month duration had type-II diabetes mellitus. A female patient defined that her complaints began during the onset of menopausal period. SD was observed with scabies in one patient; and after poststreptococcal glomerulonephritis in a 7-year-old girl. No autoimmune, malignant or other systemic diseases were found in patients with SD.

CONCLUSIONS

Contrary to commonly held opinion, SD may be associated with some diseases and/or triggered by some conditions. In this study, a close temporal relationship between the appearance of SD and psychic factors, drug reactions and scabies was documented. The relation between SD and atopy, hyperthyroidism, diabetes mellitus, menopause and glomerulonephritis seemed unclear.

Late-phase urticaria Update

In ordinary urticaria, individual lesions disappear within 24 hours. However, we sometimes encounter patients whose eruptions last longer than 24 hours, but without evidence of vasculitis or a history of exposure to pressure. In these patients, histology reveals a perivascular infiltration, predominantly of eosinophils, depending on the timing of the biopsy. Unlike urticarial vasculitis, no immunoglobulins, complement deposition, or endothelial fibrinoid degeneration is observed. The peripheral eosinophil counts and serum complement levels appear within normal range. No protein urea or joint pain is observed, and the lesions can be controlled only by systemic glucocorticoids. We recognize such a urticarial reaction as a different clinical entity than usual urticaria, which is presumably mediated by late-phase inflammatory reaction in immediate hypersensitivity.

Pharmacological, pharmacokinetic and clinical properties of olopatadine hydrochloride, a new antiallergic drug

Olopatadine hydrochloride (olopatadine, 11-[(Z)-3-(dimethylamino)propylidene]-6,11-dihydrodibenz[b,e]oxepin-2-acetic acid monohydrochloride) is a novel antiallergic/histamine H1-receptor antagonistic drug that was synthesized and evaluated in our laboratories. Oral administration of olopatadine at doses of 0.03 mg/kg or higher inhibited the symptoms of experimental allergic skin responses, rhinoconjunctivitis and bronchial asthma in sensitized guinea pigs and rats. Olopatadine is a selective histamine H1-receptor antagonist possessing inhibitory effects on the release of inflammatory lipid mediators such as leukotriene and thromboxane from human polymorphonuclear leukocytes and eosinophils. Olopatadine also inhibited the tachykininergic contraction in the guinea pig bronchi by prejunctional inhibition of peripheral sensory nerves. Olopatadine exerted no significant effects on action potential duration in isolated guinea pig ventricular myocytes, myocardium and human ether-a-go-go-related gene channel. Olopatadine was highly and rapidly absorbed in healthy human volunteers. The urinary excretion of olopatadine accounted for not less than 58% and the contribution of metabolism was considerably low in the clearance of olopatadine in humans. Olopatadine is one of the few renal clearance drugs in antiallergic drugs. Olopatadine was shown to be useful for the treatment of allergic rhinitis and chronic urticaria in double-blind clinical trials. Olopatadine was approved in Japan for the treatment of allergic rhinitis, chronic urticaria, eczema dermatitis, prurigo, pruritus cutaneous, psoriasis vulgaris and erythema exsudativum multiforme in December, 2000. Ophthalmic solution of olopatadine was also approved in the United States for the treatment of seasonal allergic conjunctivitis in December, 1996 (Appendix: also in the European Union, it was approved in February 2002).

Polymorphic eruption of pregnancy and herpes gestationis: comparison of granulated cell proteins in tissue and serum

Polymorphic eruption of pregnancy (PEP) and herpes gestationis (HG) are pregnancy-related dermatoses of unknown aetiology with eosinophil infiltration which, at early stages, may show similar clinical and histopathological features. To determine the relative contributions of eosinophils, neutrophils and mast cells to the pathogenesis of PEP and HG through deposition of granule proteins, we studied tissue and serum from 15 patients with PEP and 10 with HG. Using indirect immunofluorescence with antibodies to human eosinophil granule major basic protein (MBP), eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP), neutrophil elastase and mast cell tryptase, we determined and compared cellular and extracellular staining patterns in lesional skin biopsy specimens and, using immunoassay, measured MBP, EDN, and ECP in patients' sera. Eosinophil infiltration and extracellular protein deposition of all three eosinophil granule proteins were present in both PEP and HG indicating a pathogenic role for eosinophils in both diseases. Staining for eosinophil granule proteins was especially prominent in urticarial lesions and around blisters in HG. EDN and ECP serum levels in PEP and ECP serum levels in HG were significantly increased compared with those in normal pregnant and normal nonpregnant serum. Neutrophils were more prominent in HG specimens than in PEP specimens; extracellular neutrophil elastase was minimally present and similar in both diseases. Mast cell numbers and extracellular tryptase deposition did not differ between the two diseases and did not differ from mast cell counts in skin of normal pregnant women. This study shows that eosinophil granule proteins are deposited extracellularly in tissue and are increased in serum in both PEP and HG. Moreover, eosinophil involvement in the two diseases is more consistent than neutrophil and mast cell involvement. Comparatively, tissue eosinophil infiltration and extracellular protein deposition is more extensive in HG than in PEP, suggesting that eosinophil involvement is greater in the pathogenesis of HG than PEP and similar to that found in bullous pemphigoid.

Cutaneous inflammatory cell infiltrate in chronic idiopathic urticaria: comparison of patients with and without anti-FcepsilonRI or anti-IgE autoantibodies

BACKGROUND

Previous studies defining the histopathologic features of patients with chronic idiopathic urticaria (CIU) were performed on wheals of uncertain duration and before the identification of functional autoantibodies against FcepsilonRI and/or IgE, now known to be present in approximately 30% of patients with CIU.

OBJECTIVE

We sought to determine the timing of the inflammatory infiltrate in the wheals of patients with CIU and to detect differences between patients with and without autoantibodies.

METHODS

Immunohistochemistry was used to identify neutrophils (neutrophil elastase), T lymphocytes (CD3), and activated eosinophils (EG2) in biopsy specimens from uninvolved skin and wheals present for less than 4 hours and greater than 12 hours in 22 patients with CIU, as well as in biopsy specimens from the skin of 12 healthy control subjects. Patients were identified as having functional autoantibodies on the basis of their serum-evoked histamine release in vitro from the basophils of 2 healthy donors.

RESULTS

EG2(+), neutrophil elastase+, and, to a lesser extent, CD3(+) cells were found in greater numbers in wheals undergoing biopsy at less than 4 and greater than 12 hours than in uninvolved skin (P <.05). Patients without autoantibodies (n = 12) had significantly more EG2(+) cells in wheals of greater than 12 hours' duration than patients with autoantibodies (n = 10; P =.02). There was no other difference between patients with and without autoantibodies in the cutaneous cellular infiltrate.

CONCLUSION

Neutrophil and eosinophil accumulation occurs early in the evolution of a wheal in patients with CIU, but eosinophil activation may occur later or be more persistent in patients without autoantibodies.

Further evidence for allergic pathophysiology in allergic fungal sinusitis

Controversy continues over whether allergic fungal sinusitis represents a true allergy, an infection, or a point somewhere along a spectrum between allergy and infection. The present study describes two experiments that add weight to the argument that allergic fungal sinusitis (AFS) is truly an immunologically mediated hypersensitivity and not a form of infection. In the first experiment, eight patients with Bipolaris culture-positive AFS were prospectively evaluated with Bipolaris antigen skin testing and with inhibition radioallergosorbent (RAST) and enzyme-linked immunosorbent assay (ELISA) for Bipolaris-specific IgE and IgG antibodies. The Bipolaris AFS cases were compared with 10 control patients with no history of AFS. All eight AFS cases demonstrated positive skin testing to Bipolaris and in addition, all tested positive by RAST and ELISA for IgE and IgG Bipolaris antibodies, respectively. In the control group one patient had a positive skin test, ELISA, and RAST and one additional patient had a positive ELISA only. Good correlation was noted between skin test, RAST, and ELISA results. In the second experiment, sinus mucosa from 14 AFS patients and 10 control patients with other forms of surgical sinus disease was analyzed by immunohistocytochemistry for the eosinophilic inflammatory mediators major basic protein (MBP) and eosinophil derived neurotoxin (EDN) and the neutrophil mediator neutrophil elastase. All AFS cases demonstrated evidence of eosinophilic mediator release, and MBP and EDN predominated over neutrophil elastase. In the control group eosinophil and neutrophil mediator release in sinus mucosa was equal. The two experiments support the concept that AFS is an antigen-triggered, IgE- and IgG-mediated hypersensitivity response with a late-phase inflammatory reaction involving release of eosinophilic mediators.

Exaggerated arthropod-bite lesions in patients with chronic lymphocytic leukemia: a clinical, histopathologic, and immunopathologic study of eight patients

BACKGROUND

Unusual papulovesicular lesions resembling arthropod bites have been described in patients with chronic lymphocytic leukemia (CLL).

OBJECTIVE

Our purpose was to describe and characterize further the clinical, histopathologic, and immunopathologic features of these lesions.

METHODS

Eight patients were identified retrospectively who had CLL and characteristic skin lesions. Clinical and histologic features were recorded. Skin biopsy specimens were analyzed immunohistochemically for eosinophil granule major basic protein, eosinophil-derived neurotoxin, neutrophil elastase, and mast cell tryptase.

RESULTS

The clinical features, including the lesional distribution, suggested arthropod bites, although most patients could not recall having been bitten. Mixed T- and B-cell lymphoid cell infiltrates were present within lesions, along with prominent eosinophil infiltration and eosinophil granule protein deposition.

CONCLUSION

Exuberant papulovesicular lesions develop in patients with CLL apparently as an exaggerated response to arthropod bites. Prominent eosinophil infiltration and degranulation within these lesions likely contribute to the severity of symptoms.