Cross-Sectional Study of Cholinergic Urticaria Subtypes And Bronchial Hyperresponsiveness

Background: Cholinergic urticaria (CholU) is classified into several subtypes: 1) conventional sweat allergy-type CholU (conventional SAT-CholU), 2) CholU with palpebral angioedema (CholU-PA), 3) CholU with acquired anhidrosis and/or hypohidrosis (CholU-Anhd); 1) and 2) include SAT based on pathogenesis. There have been no studies on differences in the prevalence of bronchial asthma among the subtypes. We evaluated the bronchial responsiveness of each subtype. Methods: We analyzed bronchial responsiveness using the methacholine dose indicator Dmin, respiratory symptoms, and exhaled nitric oxide (FeNO). Results: Median log10 Dmin (interquartile range) of patients with conventional SAT-CholU (n=11), CholU-PA (n=11), and CholU-Anhd (n=11) was 0.381 (−0.829, 1.079), 0.717 (0.249, 0.787), and 1.318 (0.121, 1.699), respectively (p=0.516). Respiratory symptoms evaluated using the International Primary Care Airways Group questionnaire were less frequently observed in CholU-Anhd (0 [0, 1]) than in conventional SAT-CholU (1 [0–2]) or CholU-PA (1 [1–3]) (p=0.049). FeNO of patients with conventional SAT-CholU, CholU-PA, and CholU-Anhd was 23 (18.5, 65.0), 39 (32.0, 59.5), and 25 (19.0, 33.0) ppb, respectively (p=0.237). Conclusions: Log Dmin tended to be lower in patients with SAT-CholU than in those with CholU-Anhd. Distinguishing between CholU subtypes may reveal different degrees of bronchial responsiveness based on a distinct pathogenesis.

Cross-sectional Study of Cholinergic Urticaria Subtypes and Bronchial Hyperresponsiveness

BackgroundCholinergic urticaria (CholU) is classified into several subtypes: 1) conventional sweat allergy-type CholU (conventional SAT-CholU), 2) CholU with palpebral angioedema (CholU-PA), 3) CholU with acquired anhidrosis and/or hypohidrosis (CholU-Anhd), and other rare type; 1) and 2) include SAT based on pathogenesis. There have been no studies on differences in the prevalence of bronchial asthma among the CholU subtypes. This is investigated in the present study by evaluating the bronchial responsiveness of each subtype.MethodsPatients 16–80 years of age with CholU were enrolled. We analyzed bronchial responsiveness, respiratory symptoms, and exhaled nitric oxide (FeNO). Bronchial responsiveness was assessed using the methacholine dose indicator Dmin.ResultsA total of 11 patients with conventional SAT-CholU, 11 with CholU-PA, and 11 with CholU-Anhd were enrolled. Median log10 Dmin (interquartile range) of patients with conventional SAT-CholU, CholU-PA, and CholU-Anhd was 0.381 (−0.829, 1.079), 0.717 (0.249, 0.787), and 1.318 (0.121, 1.699), respectively (p=0.516). Dmin was lower in patients with SAT (conventional SAT-CholU and CholU-PA) than in those with CholU-Anhd, although the differences among the 3 types were not significant. Respiratory symptoms evaluated using the International Primary Care Airways Group questionnaire were less frequently observed in CholU-Anhd (0 [0, 1]) than in conventional SAT-CholU (1 [0–2]) or CholU-PA (1 [1–3]) (p=0.049). FeNO of patients with conventional SAT-CholU, CholU-PA, and CholU-Anhd was 23 (18.5, 65.0), 39 (32.0, 59.5), and 25 (19.0, 33.0) ppb, respectively (p=0.237). One of 11 conventional SAT-CholU patients (9.1%) and 6 of 11 CholU-PA patients (54.5%) required treatment for bronchial asthma.ConclusionsLog Dmin tended to be lower in patients with SAT-CholU than in those with CholU-Anhd. Distinguishing between CholU subtypes may reveal different degrees of bronchial responsiveness based on a distinct pathogenesis.Trial registration numberUMIN 000025669; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000027550

Acquired Idiopathic Generalized Anhidrosis (AIGA) and Its Complications: Implications for AIGA as an Autoimmune Disease

Acquired idiopathic generalized anhidrosis (AIGA) is a rare disorder in which systemic anhidrosis/hypohidrosis occurs without causative dermatological, metabolic or neurological disorder. Most cases of AIGA have been reported in Asia, especially in Japan, but there have been only a few reports in Europe and the United States. Severe AIGA may result in heatstroke and can reduce quality of life due to restriction of exercise and outdoor works. AIGA is often accompanied by cholinergic urticaria (CholU), and it is thought that AIGA and CholU with anhidrosis/hypohidrosis belong to the same spectrum of the disease. However, the pathophysiology of AIGA has not yet been clarified. Decreased expression of cholinergic receptor M3 on the epithelial cells of eccrine sweat glands is often accompanied by T cell infiltration around eccrine apparatus, suggesting an immunological mechanism of disordered perspiration. AIGA is occasionally associated with various complications indicative of autoimmune disorders. The association of autoimmune complications further suggests that AIGA is an autoimmune disorder. Studies on complications may lead to a better understanding of the pathophysiology of AIGA.

Cholinergic urticaria: novel aspects of pathogenesis, diagnosis and management

Cholinergic urticaria (CholU) is a chronic inducible urticaria, characterised by itchy pinpoint wheals up to 3 mm in diameter, surrounded by a prominent flare, that occur following an exposure to characteristic triggers such as active or passive heating, physical exercise, emotions, hot or spicy foods. Key pathophysiologic mechanisms include immediate hypersensitivity to autologous sweat antigens, functional sweating disorders, impaired acethylcholine metabolism, abnormal skin vascular permeability and disturbed skin innervation. Clinical manifestations of CholU may vary from typical itchy pinpoint urticarial lesions, angioedema to anaphylaxis. Atypical CholU forms include cholinergic pruritus, cholinergic dermographism, cold cholinergic urticaria and persistent cholinergic erythema. The diagnosis of cholinergic urticaria relies on patients history, сlinical manifestations and challenge tests. Treatment options include nonsedating H1 antihistamines in standard or increased doses. The evidence is accumulating for the use of biological treatment with omalizumab in cholinergic urticaria. The prospect of personalized treatment of cholinergic urticaria include autologous sweat desensitization. The main research efforts in ColdU are directed at optimizing diagnostic approaches and developing innovative therapeutic options.

Anaphylaxis After the Covid-19 Vaccine in a Patient With Cholinergic Urticaria

ABSTRACT Cholinergic urticaria is a common disorder that has been associated with anaphylaxis. We report the events, workup, and eventual second dose vaccination of a patient at the Walter Reed National Military Medical Center, who had immediate anaphylaxis after administration of the first Pfizer-BioNTech Covid-19 (BNT162b2) vaccine dose. During the initial evaluation after anaphylaxis, the patient described a history of symptoms suspicious for cholinergic urticaria but had never had this condition confirmed with standardized testing. After the episode of anaphylaxis, we performed several studies including immediate hypersensitivity skin testing, which did not demonstrate vaccine or component sensitization. We then performed an exercise provocation challenge and confirmed the diagnosis of cholinergic urticaria. These results, combined with the patient history, suggested that the episode of anaphylaxis was most likely driven by a severe flare of cholinergic urticaria. After obtaining the patient’s consent, she received and tolerated her second dose without any objective findings of anaphylaxis. We conclude that patients with mast cell disorders or anaphylaxis after their first Covid-19 immunization will benefit from referral to an allergist since receipt of their second Covid-19 immunization may be possible.

Cholinergic Urticaria Associated with Acquired Generalized Hypohidrosis: Two Case Reports and Review of the Literature

Cholinergic urticaria is a relatively common condition defined by itching, redness and whealing induced by exercise and passive warming. In turn, acquired idiopathic generalized anhidrosis is a rare disorder of unknown pathogenesis, characterized by an impairment in total body sweating despite exposure to heat or exercise. We report two cases of this extremely rare association of cholinergic urticaria and acquired generalized hypohidrosis, and briefly review current knowledge with regard to classification, ethiopathogenesis and therapeutic options.

Chronic urticaria associated with high-risk occupations

In their line of duty, firefighters and rescuers are exposed to a combination of adverse factors, which necessitates monitoring their health. This review covers the most common variants of urticaria associated with high-risk occupations, such as cholinergic urticaria, food-induced anaphylaxis and exercise-induced urticaria, cold and stress-induced urticaria. The analysis includes the relevant research results published up to 2020; the discussion outlines the possible pathogenesis mechanisms of chronic urticaria.