Report of a Case of Cold Urticaria Following Cryotherapy – Need for Screening for Untoward Effects of Cryotherapy in Physical Therapy Clinical Practice

Introduction:Musculoskeletal rehabilitation is one of the frontline domains in physical therapy practice. In most countries, physical therapists prefer independent practice with referrals from general practitioners and orthopedic surgeons. Under these circumstances, the physical therapist may be the first contact professional handling these individuals who may not have adequate medical records with their personal medical history. Cryotherapy for pain relief could be the first choice of pain management opted by a musculoskeletal therapist. That is when both the therapist and the patient have to be aware of the undesirable effects of cryotherapy application and its potential local and systemic complications. The outcome of this paper could be an initiative for a standardized screening process to be incorporated into physical therapy practice. Clinical Findings:A 30-year-old man with left knee pain who underwent exercise therapy in the physiotherapy unit of a tertiary care center developed erythematous rashes around the knee following ice application. It was noted that the patient was not aware of the same in the past. The patient was attended by a dermatologist, and a diagnosis of cold urticaria was made following confirmation with cold stimulation test. Conclusion:From this study, it may be concluded that the awareness of cold-induced urticaria has to be emphasized on both patients and health care professionals. A simple screening protocol should be made mandatory in orthopedic physical therapy practice, which would suffice this purpose. Keywords: Urticaria, cryotherapy, Physical therapy

Cold urticaria and your risk of anaphylaxis

Cold urticaria (CU) is characterized by the appearance of wheals or angioedema after exposure to cold. It presents with mild to severe symptoms and can even lead to anaphylaxis. The risk of systemic reactions is high. We discuss this important pathology and show its strong relationship with anaphylaxis. Cold weather is one of the most common triggers for the onset of symptoms, with variables including humidity and thermal sensation. It is divided into acquired or familial forms. The diagnosis is made in patients with a medical history suggestive of the disease and should be confirmed with a stimulation test. The central aspect of treatment is to avoid cold stimuli. The prescription of self-injectable epinephrine for groups that are at high risk of systemic reactions is ideal. In conclusion, health professionals should be aware of CU in order to recognize the risk of anaphylaxis in these patients.

ANALYSIS OF INTERFERON-I SIGNALING ACTIVITY IN CHILDREN WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS OF A PILOT PROSPECTIVE STUDY

The interferon system (IFN) is a group of signaling molecules with antiviral, antitumor and antiproliferative effects. The most studied signaling pathway is mediated by IFN type I. Mutations of IFN-I-regulated genes are involved in the pathogenesis of systemic lupus erythematosus (SLE). Interferon index (IFN-I-index) – a quantitative indicator of the level of expression of IFN-Iregulated genes – is used to assess the activity of the interferon system. Objective of the study: to assess the level of the IFN-I index in children with SLE, as well as to compare the clinical and laboratory characteristics of patients with high and normal levels of the IFN-I-index. Materials and methods of research: 40 patients (girls – 83%, boys – 17%) under 18 years of age with SLE diagnosed in accordance to the SLICC 2012 criteria were included in a multicenter prospective open uncontrolled nonrandomized continuous study. The age of the patients was 15,2 (12,5 ; 16,7) years. All of them underwent examination and treatment in the Pediatric department № 3 at the clinic of the St. Petersburg State Pediatric Medical University and in the Pediatric department of the Almazov National Medical Research Center. The IFN-I index was determined by real-time PCR with a quantitative assessment of the expression of 5 genes induced by IFN-α and β. Results: aggravated family history of rheumatic diseases was noted in 8 patients: SLE – in 3 (8%), rheumatoid arthritis – in 3 (8%), cold urticaria – in 2 (5%). The average age of onset of the disease is 12 years. The most common clinical manifestations were lesions of the skin, joints, mucous membranes, central nervous system, kidney and fever. 31 patients (78%) had an increased IFN-I index. All cases of kidney failure were observed only in patients with a high IFN index (36% vs 0%, p=0,036). Patients with increased IFN-I-index had statistically significant increased levels of antinuclear (87% vs 56%, p=0,043) and rheumatoid factors (36% vs 0%, p=0,036), higher ECLAM index values (3,0 vs 1.0, p=0,048), ferritin levels (p=0,0008) and, as a consequence, the need for more intensive immunosuppressive therapy (using rituximab and cyclophosphamide) compared with patients with normal IFN-Iindex. A positive statistically significant correlation of the IFN-I index with male sex (r=0,41, p=0,008), nephritis (r=0,35, p=0,026), livedoid rash (r=0,38, p=0,017 ), Raynaud's phenomenon (r=0,37, p=0,018), high antinuclear factor (r=0,82, p=0,001), rheumatoid factor (r=0,654, p=0,011), antibodies to Sm antigen (r=0,57, p=0,034), as well as a negative relationship with anemia (r=–0,67, p=0,009). Conclusion: IFN-I-index can be considered as a surrogate biomarker of activity and prognosis of SLE. Further research is required to validate its diagnostic role.

Cryoglobulins, Cryofibrinogens, and Cold Agglutinins in Cold Urticaria: Literature Review, Retrospective Patient Analysis, and Observational Study in 49 Patients

IntroductionCryoproteins, such as cryoglobulins, cryofibrinogens and cold agglutinins, precipitate at low temperatures or agglutinate erythrocytes and dissolve again when warmed. Their pathogenetic and diagnostic importance in cold urticaria (ColdU) is unclear. In this study, we aimed to characterize the prevalence of cryoproteins in patients with ColdU.MethodsWe conducted 3 analyses: i) a systematic review and meta-analysis of published data using an adapted version of the Joanna Briggs Institute’s critical appraisal tool for case series, ii) a retrospective analysis of 293 ColdU patients treated at our Urticaria Center of Reference and Excellence (UCARE) from 2014 to 2019, and iii) a prospective observational study, from July 2019 to July 2020, with 49 ColdU patients as defined by the EAACI/GA2LEN/EDF/UNEV consensus recommendations.ResultsOur systematic review identified 14 relevant studies with a total of 1151 ColdU patients. The meta-analyses showed that 3.0% (19/628), 1.1% (4/357) and 0.7% (2/283) of patients had elevated levels of cryoglobulins, cryofibrinogens and cold agglutinins, respectively. Our retrospective analyses showed that cryoproteins were assessed in 4.1% (12/293) of ColdU patients. None of 9 ColdU patients had cryoglobulins, and one of 5 had cold agglutinins. In our prospective study, none of our patients had detectable cryoglobulins (0/48) or cryofibrinogens (0/48), but 4.3% (2/46) of patients had cold agglutinins (without any known underlying autoimmune or hematological disorder).ConclusionOur investigation suggests that only very few ColdU patients exhibit cryoproteins and that the pathogenesis of ColdU is driven by other mechanisms, which remain to be identified and characterized in detail.