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Successful Treatment of Refractory Cholinergic Urticaria with Omalizumab in a Pediatric Patient
AB28 Abstracts
SATURDAY
101
Age-Dependent Increase in Oral Steroid Utilization in the Treatment of Chronic Urticaria Roxana I. Siles, MD, Meng Xu, Fred H. Hsieh, MD; Cleveland Clinic Foundation, Cleveland, OH. RATIONALE: Chronic urticaria (CU) varies in disease frequency and severity. Systemic steroids are often utilized when antihistamine therapy fails to provide adequate symptom relief. We sought to identify distinguishing features of subjects with CU who required oral steroid therapy for control. METHODS: We report a retrospective chart review of 206 subjects with CU who had demographic, clinical, and treatment data recorded under an IRB-approved protocol. RESULTS: We identified 57 subjects with CU who were prescribed oral steroids and 149 subjects with CU who did not require oral steroids. As expected, CU subjects requiring oral steroids had a more severe course as assessed by requiring higher doses of non-sedating antihistamines (p50.02) and sedating antihistamines (p<0.001), more emergency room visits for CU (p<0.001), and had more frequent concomitant angioedema (p50.04). After dividing the cohort into four quartiles, we found a trend towards older subjects requiring steroid therapy for CU control, from 17% requiring steroids (age<28 yo) to 33% requiring steroids (age>54 yo), p50.05 by Chi-squared analysis. All other variables were not statistically significant among these two groups. CONCLUSIONS: A trend towards older CU subjects requiring steroid therapy for treatment of a more severe course was identified. Increased age as a risk factor for CU disease severity has not been conclusively identified in the past.
102
"Choosing Wisely" Diagnostic Tests in Chronic Urticaria: Does Screening for H. Pylori, Vitamin D Deficiency and AntiFceri Antibodies Have a Role? Ashvini Varadhi, MD1, Andrew Nickels, MD1,2, Eileen Wang, MD2, Joseph Hageman, MD1, Vesselin Dimov, MD1,2; 1Department of Pediatrics, University of Chicago, Chicago, IL, 2Department of Medicine, University of Chicago, Chicago, IL. RATIONALE: Chronic urticaria (CU) is a common and potentially disabling clinical condition; the utility of laboratory investigation in CU is unclear. We summarized a diagnostic approach including history, physical examination, and a screening panel of H. pylori IgG, vitamin D, and antiFceRI antibodies (Ab). H. pylori infection and vitamin D deficiency are treatable, while anti-FceRI Ab aid in prognostication in terms of disease severity and duration. METHODS: A retrospective chart review included 29 adults referred to a tertiary care center because of CU perceived as difficult to treat by referring physicians. Review included demographics and history (duration of CU, angioedema, and dermatographism), with a diagnostic panel of H. pylori IgG, 25-OH vitamin D level, and anti-FceRI Ab. RESULTS: Age range 19 to 72 years; 24 female, 5 male. Duration of CU ranged from 6 weeks to 20 years, 14/28 (50%) with duration > 1 year. A total of 15/29 (51%) patients had history of angioedema and 3/9 (33%) had dermatographism. Diagnostic testing revealed 7/27 (26%) patients had +H. pylori IgG, 8/27 (30%) had +anti-FceRI Ab, and 6/19 (32%) had 25-OH vitamin D levels 10-25 ng/mL. Patients without documentation of lab values were omitted from calculation of percentages. CONCLUSIONS: The utilization of a limited diagnostic screening panel in adults with severe CU yielded positive results that allowed further treatment options, such as treatment of H. pylori (26%), vitamin D deficiency (32%), and the diagnosis of chronic autoimmune urticaria (30%). A prospective study is warranted to analyze the outcomes and cost analysis of this testing approach.
J ALLERGY CLIN IMMUNOL FEBRUARY 2013
103
Prevalence of Helicobacter Pylori Infection and Chronic Urticaria James A. Loh, MD1, Amin S. Kanani, MD2, Donald F. Stark, MD, FAAAAI3; 1University of Alberta, Edmonton, AB, Canada, 2University of British Columbia, Vancouver, BC, Canada, 3The University of British Columbia, Vancouver, BC, Canada. RATIONALE: Chronic urticaria is a common condition seen in medical practice. This condition is defined as skin whealing persisting greater than 6 weeks. Chronic urticaria can have multiple causative factors with Helicobacter pylori being an important one. Remission of chronic urticaria is associated with eradication of Helicobacter pylori. METHODS: A retrospective chart review on 266 adult patients with chronic urticaria were assessed for Helicobacter pylori infection via Helicobacter pylori serology. RESULTS: From the 266 chronic urticaria patients reviewed, 44/266 (16.5 %) had Helicobacter pylori infection. However, only 9 of the 44 Helicobacter pylori infected patients responded to follow up. 3/9 (33.3%) Helicobacter pylori infected patients showed complete urticaria regression within 1-2 months after triple anti-Helicobacter pylori therapy. 4/9 (44.4%) showed improvement of their urticaria within 1-2 months after triple antiHelicobacter pylori treatment; however, they still needed medication to treat their urticaria. CONCLUSIONS: We confirm that Helicobacter pylori investigations should be included in diagnostic workup for chronic urticaria. In patients with positive Helicobacter pylori serology, the use of triple antiHelicobacter pylori can be an effective treatment for chronic urticaria.
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Successful Treatment of Refractory Cholinergic Urticaria with Omalizumab in a Pediatric Patient Selene K. Bantz, MD, Jose G. Calderon, MD, David H. Dreyfus, MD, PhD, FAAAAI; Yale University School of Medicine, New Haven, CT. RATIONALE: Cholinergic urticaria is triggered by an increase in body temperature. Symptoms are frequently mild and respond to antihistamines, but severe and refractory symptoms can occur. There have been mixed reports of success with omalizumab, a monoclonal antibody that selectively binds to IgE, in the treatment of cholinergic urticaria in adults. METHODS: A 14 year old male presented with intermittent episodes of urticaria, primarily affecting his trunk, back, and bilateral upper extremities, causing a burning and tingling sensation. The urticaria occurred about four times per day, lasting up to 30 minutes, and was triggered by emotions such as anger, joy with laughter, and embarrassment, as well as by hot showers and physical activity. The patient had a negative endocrinology workup including negative antibodies to thyroglobulin, thyroid peroxidase, and dsDNA. CU Index was 3.7 and total IgE was 54 kU/mL. Over six months, numerous medications were tried unsuccessfully. He had partial response to antihistamines and acyclovir, but nothing provided him complete relief, including combinations of cetirizine, hydroxyzine, fexofenadine, montelukast, clemastine, chlorpheniramine, cyproheptadine, oral corticosteroids, colchicine, propranolol, doxepin, nifedipine, and raltegravir. The patient was then given 150mg omalizumab. RESULTS: After one week he developed improvement of urticaria and after two weeks he had complete resolution. After three weeks, he had breakthrough urticaria, so he was started on 150mg omalizumab every two weeks. He has since been well controlled without urticaria for over two months. CONCLUSIONS: To our knowledge, this is the first reported case of cholinergic urticaria successfully treated with omalizumab in a pediatric patient.
SATURDAY
101
Age-Dependent Increase in Oral Steroid Utilization in the Treatment of Chronic Urticaria Roxana I. Siles, MD, Meng Xu, Fred H. Hsieh, MD; Cleveland Clinic Foundation, Cleveland, OH. RATIONALE: Chronic urticaria (CU) varies in disease frequency and severity. Systemic steroids are often utilized when antihistamine therapy fails to provide adequate symptom relief. We sought to identify distinguishing features of subjects with CU who required oral steroid therapy for control. METHODS: We report a retrospective chart review of 206 subjects with CU who had demographic, clinical, and treatment data recorded under an IRB-approved protocol. RESULTS: We identified 57 subjects with CU who were prescribed oral steroids and 149 subjects with CU who did not require oral steroids. As expected, CU subjects requiring oral steroids had a more severe course as assessed by requiring higher doses of non-sedating antihistamines (p50.02) and sedating antihistamines (p<0.001), more emergency room visits for CU (p<0.001), and had more frequent concomitant angioedema (p50.04). After dividing the cohort into four quartiles, we found a trend towards older subjects requiring steroid therapy for CU control, from 17% requiring steroids (age<28 yo) to 33% requiring steroids (age>54 yo), p50.05 by Chi-squared analysis. All other variables were not statistically significant among these two groups. CONCLUSIONS: A trend towards older CU subjects requiring steroid therapy for treatment of a more severe course was identified. Increased age as a risk factor for CU disease severity has not been conclusively identified in the past.
102
"Choosing Wisely" Diagnostic Tests in Chronic Urticaria: Does Screening for H. Pylori, Vitamin D Deficiency and AntiFceri Antibodies Have a Role? Ashvini Varadhi, MD1, Andrew Nickels, MD1,2, Eileen Wang, MD2, Joseph Hageman, MD1, Vesselin Dimov, MD1,2; 1Department of Pediatrics, University of Chicago, Chicago, IL, 2Department of Medicine, University of Chicago, Chicago, IL. RATIONALE: Chronic urticaria (CU) is a common and potentially disabling clinical condition; the utility of laboratory investigation in CU is unclear. We summarized a diagnostic approach including history, physical examination, and a screening panel of H. pylori IgG, vitamin D, and antiFceRI antibodies (Ab). H. pylori infection and vitamin D deficiency are treatable, while anti-FceRI Ab aid in prognostication in terms of disease severity and duration. METHODS: A retrospective chart review included 29 adults referred to a tertiary care center because of CU perceived as difficult to treat by referring physicians. Review included demographics and history (duration of CU, angioedema, and dermatographism), with a diagnostic panel of H. pylori IgG, 25-OH vitamin D level, and anti-FceRI Ab. RESULTS: Age range 19 to 72 years; 24 female, 5 male. Duration of CU ranged from 6 weeks to 20 years, 14/28 (50%) with duration > 1 year. A total of 15/29 (51%) patients had history of angioedema and 3/9 (33%) had dermatographism. Diagnostic testing revealed 7/27 (26%) patients had +H. pylori IgG, 8/27 (30%) had +anti-FceRI Ab, and 6/19 (32%) had 25-OH vitamin D levels 10-25 ng/mL. Patients without documentation of lab values were omitted from calculation of percentages. CONCLUSIONS: The utilization of a limited diagnostic screening panel in adults with severe CU yielded positive results that allowed further treatment options, such as treatment of H. pylori (26%), vitamin D deficiency (32%), and the diagnosis of chronic autoimmune urticaria (30%). A prospective study is warranted to analyze the outcomes and cost analysis of this testing approach.
J ALLERGY CLIN IMMUNOL FEBRUARY 2013
103
Prevalence of Helicobacter Pylori Infection and Chronic Urticaria James A. Loh, MD1, Amin S. Kanani, MD2, Donald F. Stark, MD, FAAAAI3; 1University of Alberta, Edmonton, AB, Canada, 2University of British Columbia, Vancouver, BC, Canada, 3The University of British Columbia, Vancouver, BC, Canada. RATIONALE: Chronic urticaria is a common condition seen in medical practice. This condition is defined as skin whealing persisting greater than 6 weeks. Chronic urticaria can have multiple causative factors with Helicobacter pylori being an important one. Remission of chronic urticaria is associated with eradication of Helicobacter pylori. METHODS: A retrospective chart review on 266 adult patients with chronic urticaria were assessed for Helicobacter pylori infection via Helicobacter pylori serology. RESULTS: From the 266 chronic urticaria patients reviewed, 44/266 (16.5 %) had Helicobacter pylori infection. However, only 9 of the 44 Helicobacter pylori infected patients responded to follow up. 3/9 (33.3%) Helicobacter pylori infected patients showed complete urticaria regression within 1-2 months after triple anti-Helicobacter pylori therapy. 4/9 (44.4%) showed improvement of their urticaria within 1-2 months after triple antiHelicobacter pylori treatment; however, they still needed medication to treat their urticaria. CONCLUSIONS: We confirm that Helicobacter pylori investigations should be included in diagnostic workup for chronic urticaria. In patients with positive Helicobacter pylori serology, the use of triple antiHelicobacter pylori can be an effective treatment for chronic urticaria.
104
Successful Treatment of Refractory Cholinergic Urticaria with Omalizumab in a Pediatric Patient Selene K. Bantz, MD, Jose G. Calderon, MD, David H. Dreyfus, MD, PhD, FAAAAI; Yale University School of Medicine, New Haven, CT. RATIONALE: Cholinergic urticaria is triggered by an increase in body temperature. Symptoms are frequently mild and respond to antihistamines, but severe and refractory symptoms can occur. There have been mixed reports of success with omalizumab, a monoclonal antibody that selectively binds to IgE, in the treatment of cholinergic urticaria in adults. METHODS: A 14 year old male presented with intermittent episodes of urticaria, primarily affecting his trunk, back, and bilateral upper extremities, causing a burning and tingling sensation. The urticaria occurred about four times per day, lasting up to 30 minutes, and was triggered by emotions such as anger, joy with laughter, and embarrassment, as well as by hot showers and physical activity. The patient had a negative endocrinology workup including negative antibodies to thyroglobulin, thyroid peroxidase, and dsDNA. CU Index was 3.7 and total IgE was 54 kU/mL. Over six months, numerous medications were tried unsuccessfully. He had partial response to antihistamines and acyclovir, but nothing provided him complete relief, including combinations of cetirizine, hydroxyzine, fexofenadine, montelukast, clemastine, chlorpheniramine, cyproheptadine, oral corticosteroids, colchicine, propranolol, doxepin, nifedipine, and raltegravir. The patient was then given 150mg omalizumab. RESULTS: After one week he developed improvement of urticaria and after two weeks he had complete resolution. After three weeks, he had breakthrough urticaria, so he was started on 150mg omalizumab every two weeks. He has since been well controlled without urticaria for over two months. CONCLUSIONS: To our knowledge, this is the first reported case of cholinergic urticaria successfully treated with omalizumab in a pediatric patient.