Autologous serum skin test in chronic idiopathic urticaria: prevalence, correlation and clinical implications

Some cases of chronic idiopathic urticaria (CIU) have histamine-releasing IgG autoantibodies in their blood. This disease subgroup is called "autoimmune urticaria". To date, the autologous serum skin test (ASST) is the best in vivo clinical test for the detection of basophil histamine-releasing activity in vitro. This study aimed to find the prevalence of ASST positive cases in Thai patients with CIU, to identify factors related to the positivity of ASST and to find the clinical implications of ASST in CIU. A retrospective study was performed among 85 CIU patients who attended the Urticaria Clinic at the Department of Dermatology, Siriraj Hospital and were willing to perform ASST, from January 2002 to December 2003. Twenty-one (24.7%) patients had a positive ASST. There was no significant difference between patients with positive ASST and negative ASST as to the severity of the disease (wheal numbers, wheal size, itching scores and the extent of body involvement) as well as the duration of the disease.     

Direct immunofluorescence study in patients with lichen planus

BACKGROUND: Direct immunofluorescence (DIF) studies in patients with lichen planus (LP) show the deposition of multiple immunoglobulins (Igs) at the cytoid bodies (CBs) and fibrin at the dermoepidermal junction (DEJ). The deposition of Ig at the DEJ, as in patients with lupus erythematosus (LE), is occasionally found. For cases with no specific clinical and histologic characteristics, or with ambiguous features, DIF studies may be helpful in disease differentiation. METHODS: From 1996 to 2004, data from 72 patients with LP, diagnosed on the basis of clinical and histologic criteria at the Department of Dermatology, Siriraj Hospital, Bangkok, Thailand, were collected. The results of DIF studies were analyzed. RESULTS: Deposits at the DEJ and CBs were detected in 53% and 60% of cases, respectively. A combination of DEJ (mostly fibrin) and CB (mostly IgM) deposits was found in 38% of cases. A combination of IgM and other immunoreactant deposits, including fibrin at the CBs, was found in 56% of cases. CONCLUSIONS: This study showed that the positive yield of DIF in LP was 75%. Shaggy fibrin deposition at the DEJ, which is the single best indicator in the diagnosis of LP, was found in 56% of cases. The presence of CBs only, which is a poorer indicator than the shaggy deposition of fibrin along the DEJ, was found in 22% of cases. There were no statistically significant differences in positive DIF yield between specimens derived from glabrous skin and oral lesions (P = 0.67). Forty-four per cent of cases had immunoreactants other than fibrin deposited along the DEJ, which resembled those of LE.     

Does omalizumab modify a course of recalcitrant chronic spontaneous urticaria?: A retrospective study in Asian patients

Omalizumab has been approved for the treatment of recalcitrant chronic spontaneous urticaria (CSU). However, it remains unanswered whether omalizumab modifies a CSU course. We aimed to study a course of CSU after omalizumab treatment in an Asian population. Medical records of recalcitrant CSU patients who attended Siriraj Hospital between 2013 and 2017 were reviewed. All patients receiving omalizumab treatment were followed after the first injection for at least 1 year. Of 15 patients receiving omalizumab treatment, 11 patients (73.3%) responded well to 150 mg while the rest required 300 mg. The median follow‐up period was 18 months (range, 13.5–25.3). Three patterns of response were proposed and measured: excellent (disease remission over than 6 months) was found in 20%; good (injection interval extended longer than 6 months) was found in 27%; and modest (frequently required injections) was found in 53%. The mean duration of complete remission was 33 weeks (range, 26–38). Two‐thirds of patients had disease relapse and required omalizumab injections to control symptoms. The other third did not show relapses for at least 69 weeks of the follow‐up period. After 1 year of treatment, Kaplan–Meier curves estimated that a higher percentage (86.7%) of recalcitrant CSU patients receiving omalizumab treatment would be free of symptoms (weekly Urticaria Activity Score = 0) without prednisolone and/or cyclosporin as compared with 42% of patients not receiving omalizumab treatment. In conclusion, patients seem to be easily and safely manageable with omalizumab. Prednisolone and cyclosporin could be discontinued in all patients. Further studies are needed to conclude whether omalizumab can exactly modify CSU.     

Drug‐induced angioedema without urticaria: prevalence and clinical features

Background Angioedema without urticaria can be caused by drugs. The purpose of our study was to assess the prevalence and clinical features of patients with drug‐induced angioedema without urticaria. Methods This study retrospectively reviewed case records at Siriraj Hospital, between January 2007 and December 2008. Patients aged at least 15 years were included. Results The prevalence of drug‐induced angioedema without urticaria among patients with adverse drug reactions was 2.3%/year. Non‐steroidal anti‐inflammatory drugs (NSAID) were the most common cause (50%), followed by antibiotics (20%). The commonest NSAID which induced angioedema were ibuprofen and diclofenac. The common sites were periorbital area (67.3%) and lips (27.6%). The median duration of suspected drug therapy before the development of angioedema was 1 day with the range of 10 min to 23 days. Conclusions Non‐steroidal anti‐inflammatory drugs and antibiotics were the most common drugs causing angioedema without urticaria. The duration of onset ranged from minutes to days. After stopping the suspected drugs, symptoms disappeared within 2–5 days in most patients.     

Lesional T-cell subset in leprosy and leprosy reaction

BACKGROUND: The T-cell-mediated immune response plays an important role in leprosy. The in situ proportion and pattern of distribution of T-cell subsets in leprosy skin lesions have been studied, but no conclusion could be drawn. METHODS: We used monoclonal antibodies for T-helper and T-suppressor surface antigen to define the nature of dermal infiltration in 17 cases of nonreactional leprosy and 20 cases of reactional leprosy. RESULTS: We found T helper admixed with T suppressor in an aggregated pattern in the granulomas of most cases of nonreactional leprosy and in type I reactional leprosy, but a diffuse infiltrate throughout the dermis of type II reactional leprosy. The T-helper/suppressor ratio was 1.68 in tuberculoid and 1.5 in lepromatous cases. The T-helper/ suppressor ratios of borderline tuberculoid (3.11) and type I reactional leprosy (2.54) were not statistically different. The T-helper/suppressor ratio of type II reactional leprosy (5.83) was statistically higher than nonreactional lepromatous cases. CONCLUSIONS: The alteration of the T-helper/suppressor ratio in our study is mainly due to the reduction of T-suppressor cells in the dermal infiltrates, especially in type II reactional leprosy. Further studies of T-suppressor functions may be important in the pathogenesis of leprosy.     

Angiocentric T-cell lymphoma of the pancreas presenting as late-onset diabetes mellitus with diabetic retinopathy

Pancreatic lymphoma presenting with clinical diabetes mellitus (DM) is rare. We report angiocentric T-cell lymphoma of the pancreas in a 65-year-old Thai woman who presented with progressive deterioration of visual acuity of both eyes. She had diabetic retinopathy (DR) diagnosed only 20 months after the diagnosis of DM at the age of 63. She later developed erythematous rashes, fever, and deterioration of consciousness; she eventually died of shock. A skin biopsy and bone marrow examination revealed angiocentric T-cell lymphoma. At autopsy, the pancreas and both eyes were extensively infiltrated by lymphoma. Widespread involvement of nearly all organs but superficial lymphadenopathy was detected. In contrast to other typical cases of long-standing DM, only mild atherosclerosis was noted, and no DR was found. To the best of our knowledge, this is the first case of lymphoma involving the pancreas and both eyes producing clinical DM and DR.     

Diagnostic value of IgM deposition at the dermo–epidermal junction

Background Granular immunoglobulin M (IgM) deposits at the dermo–epidermal junction (DEJ) are common in lupus erythematosus (LE); however, weak, interrupted, linear and granular patterns of IgM at the DEJ have been reported in sun-exposed skin in normal adults and in a heterogeneous group of diseases.
Materials and methods We analyzed 200 patients with positive IgM direct tissue immunofluorescence deposition at the DEJ, alone or in combination with other immunoreactants, in order to determine the diagnostic significant of IgM deposition at the DEJ.
Results IgM deposition at the DEJ, commonly in combination with other immunoreactants, was associated with LE in 57.5% of patients. In cases with IgM deposition alone at the DEJ, only 12% had LE (strong intensities). IgM deposition at the DEJ was associated with other dermatoses in 42.5% of patients. In non-lupus patients, IgM deposition was the sole finding in 59% of cases, and was weaker and more focal than in LE patients.
Conclusions IgM deposition at the DEJ in patients with LE tends to exhibit a strong intensity and is commonly detected in combination with other immunoreactants. IgM deposition alone at the DEJ, especially of weak intensity or focal in pattern, is noted in non-lupus patients, and has less diagnostic significance.