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LETTER TO EDITOR
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 106-107

Purpuric autologous serum skin test in urticaria: Is it mere a chance occurrence or a marker of strong autoimmunity


Department of Dermatology, DR RMLH ABVIMS, New Delhi, India

Date of Submission09-Dec-2020
Date of Acceptance06-Dec-2021
Date of Web Publication08-Jul-2022

Correspondence Address:
Dr. Seema Rani
Department of Dermatology, DR RMLH ABVIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijaai.ijaai_67_20

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How to cite this article:
Rani S, Agarwal A. Purpuric autologous serum skin test in urticaria: Is it mere a chance occurrence or a marker of strong autoimmunity. Indian J Allergy Asthma Immunol 2021;35:106-7

How to cite this URL:
Rani S, Agarwal A. Purpuric autologous serum skin test in urticaria: Is it mere a chance occurrence or a marker of strong autoimmunity. Indian J Allergy Asthma Immunol [serial online] 2021 [cited 2022 Dec 2];35:106-7. Available from: https://www.ijaai.in/text.asp?2021/35/2/106/350082



Sir,

A-55-year-old female presented with a history of poorly controlled urticaria for 3 years duration. She had no history of joint pain, photosensitivity, and angioedema. All her routine investigations were within the normal limits. C-reactive protein (CRP), anti-streptolysin (ASO), autoimmune profile, including anti-nuclear antibodies (ANA), rheumatoid factor, and thyroid- auto antibodies- thyroid peroxidase antibodies (Anti-TPO) were sent. Urticaria activity score (UAS-7) was calculated by adding the scores of number of wheals and severity of itching was 21 (0–42). Autologous serum skin test (ASST) done by injecting intradermal 0.1 ml of autologous serum, saline (negative control) on the volar aspect of left forearm with a gap of 5 cm between injection site. Her ASST showed strongly positive result with well-formed purpura at the test site [Figure 1]. ANA, Anti Ds DNA antibodies, R. A. factor, and anti-TPO were positive [Table 1]. Serum IgE, complements level C3, C4, ASO, CRP, and coagulation profile were normal. A diagnosis of chronic autoimmune urticaria with systemic lupus erythematosus (SLE) was made. She was being sent to rheumatology-clinic for further management.
Figure 1: Well formed purpuric lesion at the site of autologous serum injection (strongly positive autologous serum skin test)

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Table 1: Serum investigations comparable with normal value

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Chronic spontaneous urticaria (CSU) is associated with autoimmunity in approximately 45% of patients. CSU is more prevalent in females and have much higher odds of developing other autoimmune conditions versus men. The autoimmune process in CSU overlaps with many other autoimmune diseases including autoimmune thyroid disease, SLE, Sjogren's syndrome, celiac disease, rheumatoid arthritis, polymyositis, dermatomyositis. The prevalence of CSU in patients with SLE ranges from 0% to 22% depending on the individual study.[1] CSU and SLE share a higher prevalence of autoantibodies to high-affinity IgE receptor (FceRI) and IgE and that some autoantibodies may be specific only for CSU or SLE, whereas other autoantibodies may be present in both conditions.[2],[3] ASST is a simple in vivo clinical test for the detection of basophil histamine-releasing activity, however, this bioassay is difficult to standardize routinely, hence ASST is considered as a bedside clinical test and positive result can detect the presence of autoimmunity rather than directly indicative of autoimmune urticaria. The percentage of positive ASST results ranges between 4.1% and 76.5%[4] and indicates the presence of functional autoantibodies or histamine-releasing factors in serum. Chronic urticarial rash (CUR) is a common feature in SLE. The two most common underlying causes of CUR in SLE are CSU and urticarial vasculitis.[5] The prevalence of CSU and CSU-like rash in adult patients with SLE was found to range from 0%–21.9% to 0.4%–27.5%, respectively.[5] SLE and CSU often coexist, especially in female patients and patients with CSU have an increased risk of developing SLE.[6] CSU can be the first manifestation of SLE, and in most cases, CSU precedes SLE onset by 10 years. CSU may indicate a severe course of SLE with unfavorable prognosis.[7]

In our case, the patient had poorly controlled Urticaria with strongly positive ASST in the form of purpura without any associated symptoms of pain, burning or stinging, pruritus, edema, and ulceration which could happen in the case of extravasation injury. Explanation of the well-formed purpura at the ASST site, which is uncommon and unique manifestation to be happen in chronic urticaria could be because of patient's underlying strong autoreactivity or just a chance occurrence could not exactly be determined.


  Conclusion Top


It is important to evaluate chronic urticaria not responding to conventional treatment, as positive autoimmune markers associated with prolonged disease duration and active disease (UAS).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Department of Dermatology, Dr. RMLH ABVIMS, New Delhi.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carneiro JR, Sato EI. Double blind, randomized, placebo controlled clinical trial of methotrexate in systemic lupus erythematosus. J Rheumatol 1999;26:1275-9.  Back to cited text no. 1
    
2.
Cho CB, Stutes SA, Altrich ML, Ardoin SP, Phillips G, Ogbogu PU. Autoantibodies in chronic idiopathic urticaria and nonurticarial systemic autoimmune disorders. Ann Allergy Asthma Immunol 2013;110:29-33.  Back to cited text no. 2
    
3.
Gruber BL, Kaufman LD, Marchese MJ, Roth W, Kaplan AP. Anti-IgE autoantibodies in systemic lupus erythematosus. Prevalence and biologic activity. Arthritis Rheum 1988;31:1000-6.  Back to cited text no. 3
    
4.
Konstantinou GN, Asero R, Maurer M, Sabroe RA, Schmid-Grendelmeier P, Grattan CE. EAACI/GA(2)LEN task force consensus report: The autologous serum skin test in urticaria. Allergy 2009;64:1256-68.  Back to cited text no. 4
    
5.
Kolkhir P, Pogorelov D, Olisova O, Maurer M. Comorbidity and pathogenic links of chronic spontaneous urticaria and systemic lupus erythematosus – A systematic review. Clin Exp Allergy 2016;46:275-87.  Back to cited text no. 5
    
6.
Confino-Cohen R, Chodick G, Shalev V, Leshno M, Kimhi O, Goldberg A. Chronic urticaria and autoimmunity: Associations found in a large population study. J Allergy Clin Immunol 2012;129:1307-13.  Back to cited text no. 6
    
7.
Cardinali C, Caproni M, Bernacchi E, Amato L, Fabbri P. The spectrum of cutaneous manifestations in lupus erythematosus – The Italian experience. Lupus 2000;9:417-23.  Back to cited text no. 7
    


    Figures

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    Tables

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