Thursday, January 22, 2009

Helicobactor pylori infection and Urticaria

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  1. Breath Test For Helicobacter Pylori - Diagnostic Tests

    What is the H. pylori breath test?
    The H. pylori breath test is a simple and safe test used to detect an active H. pylori infection.

    What is H. pylori?
    Helicobacter pylori (abbreviated as H. pylori) is a bacteria that can infect the stomach or duodenum (first part of the small intestine). If left untreated, H. pylori bacteria can cause gastritis (an inflammation or irritation of the stomach lining) and duodenal or gastric ulcers. In addition, infection with H. pylori increases the risk of other diseases and is also a risk factor for gastric cancer.

    Accurate detection of H. pylori is the first step toward curing stomach and intestinal ulcers, and preventing the development of more serious gastrointestinal problems.

    What happens during the test?
    During the test, you will be asked to exhale into a balloon-like bag. The air you breathe into this bag is tested to provide a basis for comparison (called a baseline sample). You will then be asked to drink a small amount of a pleasant lemon-flavored solution. Fifteen minutes after drinking the solution, a second breath sample will be taken. The air you breathe into this bag is tested for an increase in carbon dioxide.

    Guidelines before the procedure

    Special conditions
    Be sure to tell your doctor if you are allergic to any medicines or if you are phenylketonuric.

    Medications
    Four weeks before the test do not take any antibiotics or Pepto Bismol® (oral bismuth subsalicylate).
    Two weeks before the test do not take any prescription or over-the-counter proton pump inhibitors (Prilosec® [omeprazole], Prevacid® [lansoprazole], Protonix® [pantoprazole], Aciphex® [rabeprazole] or Nexium® [esomeprazole])
    Please note: Do not stop taking any other medicine without first talking with your doctor.

    Eating and drinking
    One hour before the test do not eat or drink anything (including water).

    On the day of the procedure
    A health care provider will explain the procedure in detail and answer any questions you might have. The procedure lasts about 20 to 30 minutes.

    After the procedure
    Your breath samples are sent to the laboratory where they are tested.
    You may resume your normal activities.
    You may resume your normal diet and medicines unless you have other tests that require dietary restrictions.
    Test results
    Your doctor will notify you as soon as your laboratory test results are available.
    If the test indicates that you do have a H. pylori infection, it can be treated with antibiotics.
    One month after antibiotic treatment your doctor might order a repeat breath test to make sure the infection has been cured.
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  2. World Allergy Organization Journal:
    September 2009 - Volume 2 - Issue 9 - pp 213-217
    doi: 10.1097/WOX.0b013e3181bb965f
    Reviews
    Eosinophils in Chronic Urticaria: Supporting or Leading Actors?
    Asero, Riccardo MD; Cugno, Massimo MD; Tedeschi, Alberto MD

    Abstract
    Although their number may be increased in skin lesions, eosinophils have been rather neglected as possible participants to the pathogenesis of chronic urticaria because of the absence of peripheral eosinophilia in patients with this disease. However, recent data suggest a potentially relevant role played by activated eosinophils both in triggering the tissue factor pathway of coagulation cascade and as a source of vascular endothelial growth factor. Such phenomena seem more pronounced in patients showing a more severe disease. The present study will rediscuss the potential role of this cell line in chronic urticaria in the light of these recent observations.

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  3. Urticaria
    By: Priyanka Gupta, MD


    Urticaria (“hives”) is characterized by erythematous, edematous wheals of the superficial layers of the skin or mucus membranes. The lesions are blanchable, can range in size and can appear anywhere on the body. Typical urticarial lesions last less than 24 hours and do not bruise or scar. Angioedema frequently seen with urticaria occurs in the deeper layers of the skin and is characterized by well-demarcated areas of swelling that are non-pitting and are usually non-pruritic.
    Urticaria is usually classified as either acute or chronic. Urticarial lesions that last for less than 6 weeks are called acute urticaria, and continuous or frequent urticarial lesions that last for 6 weeks or longer are defined as chronic.

    Urticaria affects an estimated 20 percent of the population at one time or another in their lives. Acute urticaria may occur at any age and is the form seen most commonly in children. Chronic urticaria occurs more frequently in adults than in the pediatric population.

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  4. Histologically, urticaria is characterized by dilation of small blood vessels and by edema caused by various factors, including mast cells and their mediators (i.e., bradykinin and prostaglandins), histamine-releasing factors, neuropeptides and inflammatory cells (i.e., monocytes and T-lymphocytes).

    Acute urticaria is frequently due to certain foods, additives, preservatives, dyes, medications, insect stings and infections. Foods such as eggs, nuts and shellfish are common causes of acute urticaria. Medications such as aspirin, ibuprofen and antibiotics (especially penicillin and sulfa) also, are common causes of acute urticaria. Any infection can cause hives; common infections causing hives include the common cold, strep throat, infectious mononucleosis and hepatitis. In most of these cases, when the trigger for the hives is removed or avoided, the hives resolve.

    The causes of chronic urticaria in 50% or greater of the cases cannot be identified – in this instance, the condition is called chronic idiopathic urticaria. There is a body of evidence that suggests that chronic urticaria may be an immune-mediated inflammatory disease (IMID). A higher prevalence of thyroid autoantibodies (either antithyroid peroxidase or antithyroglobulin) has been recognized in patients with chronic urticaria. Other autoantibodies (i.e., antinuclear antibodies and anti-intrinsic factor) also have been seen in patients with chronic urticaria. A number of systemic diseases are also associated with urticaria, such as systemic lupus erythematosus, rheumatoid arthritis, lymphoreticular malignancies and thyroid disease.

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  5. The physical urticarias represent a subgroup of chronic urticarias in which wheals can be induced by a physical stimulus such as cold, heat, pressure, vibration, sunlight, water and exercise. The most common physical urticaria is dermatographism, which literally means “writing on the skin”. These hives appear within a few minutes of scratching along an area of the skin and usually resolve fairly quickly.

    There are also several rare inherited disorders that are associated with urticaria and angioedema, and will not be discussed in the scope of this article.

    The history and physical examination are essential in the evaluation of a patient with urticaria. A detailed history of drug and new food exposure is imperative. If there are signs of a systemic disease or infection in the physical exam, appropriate lab work should be ordered. If there is not an obvious etiology of the urticaria, especially for chronic urticaria, then diagnostic evaluation including a complete blood count, urinalysis, TSH, ANA, and comprehensive metabolic panel may be necessary.

    A single episode of uncomplicated hives does not usually need extensive testing. An episode of hives complicated by swelling or trouble breathing requires immediate evaluation in the emergency room. Allergy skin testing or RAST testing may provide useful information in cases where food allergies are suspected. Skin biopsy tests are usually performed only if urticarial lesions persist for more than 24 hours and when the lesions suggest underlying vasculitis.

    If a causative factor can be identified, the best treatment is to avoid or eliminate that trigger. Persons with physical urticaria should try to avoid exposure to that physical stimulus, if possible. Drug therapy should be aimed at relieving most symptoms while keeping drug side effects to a minimum. Antihistamines, especially combinations of H1 and H2 blockers, still remain the mainstay of treatment. Leukotriene antagonists, such as Singulair, have also been tried with some success. Tricyclic antidepressants, such as doxepin, have histamine-blocking properties and can be effective antiurticarial agents; but, they do have many side effects. For severe urticaria and angioedema, corticosteroids may be necessary; but, prolonged use should be avoided because of the potential side effects. Immunomodulators, such as cyclosporine and cyclophosphamide, have been used for refractory urticaria. In some instances, a referral to an Allergist may be necessary to help with medical management of the urticaria.

    Priyanka Gupta, MD, a BCMS member and Allergy/ Immunology and Internal Medicine physician, practices at Central Texas Allergy & Asthma, in San Antonio on Judson Road and in New Braunfels, TX.

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  6. 2009 Jan;88(1):23-31.

    Neutrophilic urticarial dermatosis: a variant of neutrophilic urticaria strongly associated with systemic disease. Report of 9 new cases and review of the literature.
    Kieffer C, Cribier B, Lipsker D.

    The Université Louis Pasteur, Hôpitaux Universitaires, Strasbourg, France.

    We conducted the current study to define within the spectrum of the neutrophilic dermatoses a group of patients with an urticarial rash clinically and a neutrophilic dermatosis histopathologically. We reviewed the literature on neutrophilic urticaria and we report here a series of patients with this unique presentation. We reviewed all cutaneous biopsies submitted to our department between 2000 and 2006 in which histopathologic evaluation was compatible with this entity. We then retrieved the patient medical records and obtained information about follow-up and associated diseases. This allowed us to identify 9 patients with an urticarial eruption that was characterized histopathologically by a perivascular and interstitial neutrophilic infiltrate with intense leukocytoclasia but without vasculitis and without dermal edema. Four patients also had small foci of necrobiotic collagen bundles. The eruption consisted of pale, flat or only slightly raised, nonpruritic macules, papules, or plaques. Elementary lesions resolved within 24 hours. Purpura, angioedema, and facial swelling were not seen, but dermographism was present in 1 patient. Six patients had fever, 7 had polyarthritis, and 6 had leukocytosis. Seven patients had associated systemic diseases: adult-onset Still disease (3 patients), systemic lupus erythematosus (3 patients), and Schnitzler syndrome (1 patient).A similar rash has been reported previously in the literature, mostly in patients with systemic inflammatory diseases, but the majority of patients reported under the undefined designation of "neutrophilic urticaria" did have a different clinicopathologic presentation. Thus, we suggest naming this eruption "neutrophilic urticarial dermatosis," to emphasize that this entity expands the broad group of cutaneous manifestations of neutrophilic aseptic disease. This entity bears important medical significance as it is strongly indicative of an associated systemic disease, mainly Schnitzler syndrome, adult-onset Still disease, lupus erythematosus, and the hereditary autoinflammatory fever syndromes.

    PMID: 19352297 [PubMed - indexed for MEDLINE]

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