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Chronic idiopathic urticaria Autoimmune urticaria Anti Fc

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Chronic idiopathic urticaria Autoimmune urticaria Anti Fc Powered By Docstoc
					                                                                                              2008   19   27-35




                                                           E                      E




                                                   E




                                     ( Chronic idiopathic urticaria )
                                     ( Autoimmune urticaria )
             Anti-Fc   RI (                             E             )
                                     ( Thyroid autoimmunity )
                              (                       )




                                                                          ( wh eal )
                                                       ( family Urticaceae/nettle family )
       ( urticaria )              hives   nettle
rash                                                                                  ( Urtica thunbergiana )
             704        138
28




           ( Laportea pterostigma )
                                                                                                             24
                                       (                   )
                                                               1
                                                                                                                             ( urticari-
                                                                           al vasculitis )
( idiopathic )

                                                                                                                         ..
                                                                                                ( SLE )              ( Sjogre n's syn-
( physical urticaria )                                                     drome )                             ( cryoglobulinemia )
                                                                                                                    10



                                           ( chronic idiopathic
urticaria, CIU )                                                           ( type I/immediate-type hypersensitivity )
                                                                                                    IgE                       ( cross-
                                 ( basophil )                              link )
( dermal mast cell )                                                   E   IgE            -Fc RI
      ( high affinity IgE receptor                     Fc RI )                                                                       CIU
                                                  2
                    -anti-Fc RI antibodies                         (
           )                                     E ( IgE )
                                                 3,4
                         -anti-IgE antibodies


(                            )                                                                 F c RI
                         ( mediator )                                                                                      wheal-and-
                                                                           flare
                                                 5,6
                 (autoimmune urticaria )                                           1986         Grattan             CIU
                                  CIU                                              ( autologous serum )                            ( intra-
                                                                           dermal injection )                wheal-and-flare
                                 7,8


                                                                                     11
                                                           ( Helico-                                                          -
                                                       9
bacter pylori )                                                                             ( autologous serum skin test, ASST )
                                                                                                      CIU
                                                                                               12



                                                                                                                   ( histamine releas-
                                                                           ing factors )
                                 wheal-and-flare                                   CIU


                                 (                         )                                                         G ( IgG )
                                                                                     13
                                                                                            Hide            1993
                                 wheal (          )                                         Fc RI           ( recombinant soluble alpha
               flare (           )                             ( axon      chain of the Fc RI, sFc RI         )                    IgG
reflex )
      ( angioedema )
                                                                                                                                                                 29




                              IgE           ( Fc RI )                                ml              (          10          g/ml                             )
     - a n t i - Fc R I             -                       IgE                      0.05 ml                                                                     30
                               14


IgE                                  -anti-IgE                                                                                    1.5 mm
                              IgE                                 IgE        ( IgE                   ASST                                                80%
sensitized )
                                               15
        IgE                                                                                                             (                            )
                                                                   ( basophil                        50%
histamine release assay )                                         CIU                                    50%
                                                                                                                                                     (
                                                                                                                                         6
                                                                                                                    )


                                                                                                         ( mast cell-specific histamine releasing
                  15
                                                                                     factor )
                                                                                                                                         21


                                        a n t i - Fc R I
                                                                                                                                                     2
                       ( Western blot )
             ( e nz yme -linke d immunosorbent a ssay,                                                                        ASST
              16,17                                                                                                                                      22,23
ELISA )
                           ( SLE )                  ( dermatomyositis )                                                                        - a n t i - Fc R I
                            ( pemphigus vulgaris )                                       anti-IgE-
( bullous pemphigoid )                                                                                                             1993              Rose
        17                                                                                 24
                                                                                     Bona
( intravenous immunoglobulin, IVIG )                                                                                              ( 1)
        18
                                                                                     T
                                                     ( non-functional )                    ( 2)
                                                                                                         (3)
                                                             IgG2            IgG4        CIU                                                       (1)       CIU
                  CIU                                               IgG1                                            ASST
                   17,19                                                                                                                      25
IgG3                                                              CIU                                      wheal-and-flare                         ( 2 )
        50%            60%                 ASST
                                                                                                                             26
                                                                            ( 25%    CIU                                           ( 3)
              5                                                                                                                           26,27
     40% )                    35%          40%        anti-Fc           RI                                              CIU
                                                        3,15,20
3      5%          10%               anti-IgE
                                                                                                               24
                                                                                                                                                    CIU
                                                             4
                                    ( gold standard )                                                      CIU
                                                                                                      ( HLA )                      HLA              DRB1*04
        ASST                                                                         ( DR4 )              DQB1*0302 ( DQ8 )                        CIU
12                                                                                              28
                                                                   30                                                             CIU
                                                                                                                    CIU
             0.05 ml                           (                        )    0.05
30




                                                                                                36
                                                                                                         To u b i
                                                                                                  24                   70%
                                                                                            50%
                                                 CIU                                        52%                                                       16%
                                                                                                                                                               35
          ( antithyroid antibodies, ATAs )
               7,8
                                                                              anti-
thyroglobulin ( anti-TG )                          anti-thyroperoxidase/                                          50       70
microsomal ( anti-TPO )                                            Leznoff                                                                                     80
1983                                                          microsomal
                                                                               29       7
                          12%                                      5.6%                       Lanigan                  A           50
Tu r k t a s                                                                                                           B          50
            11.7%            anti-TG                        9.57%         microso-                                     C          50
mal                                               3.7%                                                                            A      28%
                                                                                                             B         C                              4%        6%
                     30
                          Gaig                   CIU            14.7%                                                 A           B     C
                     31
                          Zauli                    122        CIU
                                                                                                                                                      37
35        ( 29% )           anti-TG              anti-TPO          anti-TSH re-             ( thyroid autoimmunity )
ceptor                            14                                                                                            anti-Fc RI                 (
                                                                               32
                            ( T SH )                                                                                            ASST              )
Asero                       257                                               66                                      Kikuchi
( 26% )                                                       46                                                                                                282
                     16                                                  4
                             33
                                       Verneuil                          45                                                           27.7%
                            30
                             26.7%                                 3.3%               10.9% ( p<0.001 )
                                                                                                                                             38
                                                                                                                  a n t i - Fc R I                         Fusari
                                                                                               82
     34
           To u b i                          139                                                            ASST                        62%
          17          ( 12% )                (                           )                                                        ASST                         39%
                                        35
                      ( p=0.004 )                                                     ( p>0.05 ns )                        28           ASST
                     12%         29%                                                                                                         ( 14          ) ASST
                     ( 1%        10% )                                                                                                  15                          13
                                                               8
                                                                                        ASST                  ( 86.7% )
                                                                                         13                       1        ( 8 % ) ASS T
                                                                                                    39
                                                        Ve r n e u i l                ( p<0.001 )


               (
                                                       34
                                             )               Kandeel                  IgE
     CIU
                                                                                                            7,8
          ( Hashimoto thyroiditis )
                                                                                                                                                       31




                 ( thyroxine )                                                                We d i
                         ( euthyroid )                                                                      91%
40,41
                                               47%                                                                   50%
                         42                                                                        55
                                                                                                           Di Ca mpli
                                                                                                amoxicillin         clarithromycin                lanso-
                                                                                 prazole                                                    88%
                                          8


                                                                                                                                                  56


                                                                                             Schnyder
                 A       B                                    ( pre-icteric           ( double-blind placebo-controlled crossover study )
                                                43,44
phase )                                                       A                  46                                 12                       amoxi-
                                                                                 cillin      lansoprazole                                         3
                                                                                                                                       57
                                  B                                                                           1                               Erel
                                                                                        39                          29
                                                                                                                            58
                                      85
    17.6%            B                                                                                                                             2003
                                      5%                                              Federman
                                                              45
                                                                                      10
                         9%                                        B                  30.9%
                                                                                 21.7%
            46
                                                                                 13.5%                                               ( odds ratio )
        C                                                     ( pre-icteric      2.9 ( 95%                1.4-6.8        P =.005 )
                                                         47
phase )

                                          48                                                                                                 59
                     C                                                      21
                                                                   49
                         58                                             24%
            C                             ( anti-HCV )                                              /
22% C                         RNA                         1692
                              C                                                                                                      H1
1.1%                                                                             /H1                    ( H1 antihistamine/histamine H1 re-
                                      C                                 C        ceptor antagonist )
                                                                                        60
                                      0        2%
    50-54
                                                                                                                    acrivastine ( Semprex )
                                                    ( He licobac ter             cetirizine ( Zyrtec )        desloratidine ( Clarinex )
pylori )                                                                         fexodenadine ( Allegra )           levocetirizine ( Xyzal )
                                                                                 loratadine ( Clarityne )         mizolastine


                                                                                                                                     c h l o r p h e n i-
                                                        ( m ol e c u la r        ramine       diphenhydramine ( Benadryl)                    hydrox-
                                                9
mimicry )                                                                        yzine ( Vistaril )
32




                                            (     Allegra                                            30              prednisolone
                                                                                                               60
     240 mg )
                       6,60
                                            H2
                                                                                          66
                                                 H2
       ( flare )
                       H1                                   H2                                                                                cy-
                       61
                                                            H1          H2     closporin (              )                        30
                                            H2                          H1                      ASST
                               H1                                                              20           cyclosporin
                              H1                                                     19
                                       60
                H2                               Doxepin ( Sinequan )                                               ASST
                                                         H1       H2                                                         5
                                                                                                            67
                                                                                  20
                               6,60
                                                                                                                                              cy-
                                                                                                            68
                                                                               closporin                            Cyclosporin
                                            ( leukotriene receptor an-         2.5~5 mg/kg/day
tagonist )                                                                                                                   Greaves
                                                                  m o n-
telukast      zafirlukast                                             30
                                                                                                                                          6
                CIU                                                                                                 cyclosporin
     ( single blind placebo-controlled crossover study )                       cyclosporin                                 tacrolimus
             montelukast                    cetirizine      cetirizine         methotrexate         hydroxychloroquine
                                                                       62         69-71
                                      cetirizine                                                                                       ( in tr a -
                                                      desloratadine            ve nous immunoglobulin, IVIG )
                                                                                                       26,27
       montelukast                         desloratadine              m o n-   ( plasmapheresis )
telukast                                                          deslo-
ratadine                                        montelukast
                63
                               zafirlukast
                            cetirizine                zafirlukast
                               zafirlukast                  ASST
                       ASST                                       zafir -            Anti-Fc RI           anti-IgE
                                      64
lukast
                     zafirlukast                                  z a f i r-
                               65
lukast
                                                                 H2
                               H1




                                                                                                                                  72
                                                                                                                                             33




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34




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                                                                                                                                          35




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                                Chronic Idiopathic Urticaria
                                                                              1
                                    Chia-Tse Weng, Yi-Hsing Chen , and Ming-Fei Liu




               Chronic idiopathic urticaria is recurrent itchy wheals with daily or almost daily occurrence for at least 6 weeks,
          without obvious cause. Eighty to 90% of these patients have no specific external cause for their disease, which
          is therefore labeled idiopathic before. It is now recognized that as many as 30-50% of patients show evi-
          dence of autoantibodies directed against either the high-affinity IgE receptor or, less frequently, against IgE. The
          term autoimmune urticaria is used increasingly nowadays to reflect advances in knowledge about these func-
          tional autoantibodies that activate mast cells and basophils. Autologous serum skin test is a useful in vivo screen-
          ing test for autoimmune urticaria, with both sensitivity and specificity about 80%. It is generally accepted that thy-
          roid autoimmunity is more prevalent in patients with chronic urticaria. However, antithyroid antibodies are not a
          direct causative agent in chronic urticaria. It appears more likely that antithyroid antibodies and anti-IgE receptor
          antibodies are associated, but just parallel, autoimmune events. The role of infections in chronic urticaria remains
          intriguing but unresolved. The prevalence of Helicobacter pylori infection in chronic urticaria is similar to that found
          in the general population. However, patients with chronic urticaria may differ in their immune response to infec-
          tions or may develop infection-induced autoreactivity/ autoimmunity. Remission or improvement of chronic ur-
          ticaria after H. pylori eradication was shown is some studies. Non-sedating histamine receptor antagonists should
          be used as first-line agents in the treatment of these patients; however, identification of patients with autoimmune
          urticaria is of increasing importance because of immunotherapy. Cyclosporin, intravenous immunoglobulin or
          plasmapheresis has been reported to be successful in severely affected refractory patients. ( J Intern Med Taiwan
          2008; 19: 27- 35 )