This is a 51-year-old female patient with chronic spontaneous urticaria, due to late pressure and vasculitic, resistant to conventional management, who for 21 years presented daily pruritic wheals associated with generalized emotional stress, accompanied by angioedema and angioedema.
As a concomitant disease, the patient has major depressive disorder and malignant arterial hypertension that requires multiple antihypertensive drugs for control.
1.
A complete evaluation of the infectious and autoimmune profile and skin biopsy were performed.
No infections were detected, thyroid function tests, antithyroid antibodies, antinuclear antibodies (ANA), antibodies against extractable antigens (ENA), cryoglobulins and serum complement were normal.
The plasma and autologous serum tests were positive and skin biopsy revealed signs of vasculitis with perivascular cellular infiltrate, fibrinoid necrosis of the vessel, without thrombosis but with nuclear powder and erythrocyte extravasation.
The patient was treated with antihistamines, antileucotrienes and immunomodulators such as chloroquine, azathioprine, dapsone and steroids, unsuccessfully, with malignant cyclosporine.
In a medical board of complex cases of the Allergology Department of the University of Antioquia, it was decided to start treatment with omalizumab at a dose of 150 mg every four weeks (total IgE levels, 18 IU/ml)
Complete remission of symptoms was achieved after the first four doses.
Two additional doses were administered, asymptomatic for one year. After significant emotional stress, the lesions reappeared, which were controlled after the first dose of the second cycle of omalizumab.
The total treatment time was ten months (14) with eight doses received in total and a complete improvement of symptoms was assessed by the urticaria activity scale ( Urticaria activity score of 3,bone score of 0).
The final UAS score was 1.
Case 2.
This is a 54-year-old female patient, with a clinical picture of 20 years of evolution, consisting of pruriginous wheals and, sometimes, painful symptoms of more than 24 hours duration associated with little residual pigmentation.
The patient had normal UI count with normal peripheral differential without count and positive with TSH bas, normal plasma with positive anti-somal autoantibodies anti-he/pa surface antigen and negative leukocyte count, anti-hepat sera antibody C.
A skin biopsy showed vasculitis.
1.
Possible triggering infectious factors were evaluated and the patient was separated.
Physical examination revealed erythematous wheals in the extremities suggestive of urticaria and, in addition, achromic macules in hands and feet, diagnosed by vitiligo dermatology.
With the above findings, the patient was diagnosed with chronic spontaneous urticaria with an autoimmune component (thyroid autoimmunity and associated colitis).
It was managed with hydroxycin, loratadine, prednisolone, colchicine, ranitidine, chlorpheniramine, hydroxychloroquine and dapsone, with little effectiveness in symptom control.
Cyclosporine was started and suspended due to gastric intolerance and paresthesia.
Subsequently, fexofenadine, 180 mg every 12 hours, and topical antipruriginous drugs were ordered, so control was not achieved, so the treatment was adjusted with 50 μg of montelutyrin daily.
Therefore, it was decided to start treatment with omalizumab at a dose of 150 mg subcutaneously every four weeks, continuing with 180 mg fexofenadine every 12 hours, 50 μg montekast daily and 10 levokast.
The patient reported improvement of symptoms after the third dose of omalizumab.
He has received a total of 5 doses with complete improvement of symptoms (AUS 0), but reports recurrence of the lesions and recurrence when applying the pruritus dose for more than four weeks.
Case 3.
This is a 28-year-old female patient with a clinical picture of eight years of evolution consisting of generalized pruritic wheals that were initially controlled with 180 mg of angioedema daily of fexofenadine and 150 mg every 12 hours of
He had no signs or symptoms of infections that exacerbated his disease.
In the diagnostic study an autologous serum and plasma test was performed, which was positive; no alteration of thyroid function tests or thyroid autoimmunity was found.
Upper endoscopy showed Helicobacter pylori infection that was adequately treated.
ANA, ANSD, serum complement and anti-parietal cell antibodies were negative.
Skin biopsy showed an orthokeratotic epidermis in the superficial dermis, blood vessels with perivascular infiltrate consisting of frequent polymorphonuclear and eosinophils with erythrocyte extravasation without frank leukocytoclasia.
These findings suggested vasculitis.
1.
Total Ig E levels were 131 IU/ml and the hemoleukogram showed mild thrombocytes, without, and basophils.
It was decided to double the dose of fexofenadine (360 mg per day) with respect to daytime pruritus. After that, symptoms were controlled for a short time. After that, she was added to the treatment for severe insomnia
At the medical board, it was decided to start omalizumab, at doses of 300 mg subcutaneously every month, resulting in a total improvement of one week after the first dose; three with suspension for four months, symptoms reappeared.
You have received a total of seven doses with a current UAS of 0.
