Patient with vasculitic autoimmune and PRESSURE urticaria successfully treated with omalizuamb

Background: The omalizumab has been successfully used in patient with physical, autoimmune and vasculitic urticaria but in our knowledge there are no reports of patients in whom these conditions coexist and report improvement with this treatment.

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Objective: To present the case of a 50 year-old patient with vasculitic, pressure and autoimmune urticaria resistant to traditional management lines who has had for 19 years pruriginous hives  that were present daily, involving the whole body accompanied by angioedema  and occasionally  with dyspnea, those symptoms  worsened with pressure and emotional stress.  

As comorbidity the patient suffer depression and malignant hypertension that requires multiple antihypertensive drugs

Method:  For patient's study the autoimmune and infectious whole profile was evaluated besides evaluating physical stimuli as triggered of the urticaria and skin biopsy.  Infections were not detected, the TSH, antithyroid antibodies, antinuclear antibodies, antiextractable nuclear antigens, cryoglobulins and complement levels were normal. Also was carried out autologous serum skin test that showed autoreactivity and the skin biopsy revealed vasculitic signs 

The patient received combined management by allergology, rheumatology and internal medicine, without improvement with antihistamines, antileukotriene and immunomodulators like cloroquine, azatioprine, colchicine and steroids, the cyclosporine was contraindicated by its malignant hypertension.

Therefore we decided to begin treatment with omalizumab at doses of 150 mg monthly (total IgE 18 UI/ml) associated to antihistamine and antileukotriene.

Result:  After 3 doses of this therapy hives and angioedema remission was obtained and lasted for two months. 

Conclusion: The omalizumab can be an option in patients with vasculitic, pressure and autoimmune urticaria resistant to others management lines, being even safer than steroids and immunomodulators. The low levels of our patient's total IgE make to think that the effect of this medication is not only Ig E dependent as has been suggested by several authors.