ARTICLE
A 53-year-old man was referred for investigation of chronic urticaria
of 9 months duration. His medical background was unremarkable except for
reactive depression and 3 syncopal attacks. Physical examination was normal.
Routine laboratory tests were negative. No explanation was found for his
syncope. Prick-tests to controls showed: histamine /codeine +; prick-tests
to a panel of pneumallergens were negative. These tests stressed the patient
considerably and he developed urticarial papules surrounded by halos of
vasoconstriction (Fig. 1).
Propranolol 20 mg t.i.d. was started, which suppressed both the urticaria
and the syncope. The b-blocker was stopped and the urticaria recurred.
Treatment was resumed and has brought about complete control, up to the
follow-up of 21 months.
Adrenergic urticaria
Adrenergic urticaria (AU) has only been recognized since 1985 [1]. It
can be distinguished from cholinergic urticaria by its elementary lesion:
a small papule surrounded by a white halo of vasoconstriction, and by
its trigger i.e. stress (Table
I).
Comments
Very few cases have been reported and as far as we know this is only
the 6th case [1-3]. Intradermal tests with catecholamines reproduce the
elementary lesion. Therapy may seem odd, even paradoxical, as ß-blockers
may induce anaphylactic shock [4].
The mechanism is still not clear. However, one
thing is certain: the papule is not histamine-induced since histamine
test is negative during the urticcarie and ß-blockers are effective.
The stimulus seems to be neuropeptidic with a preponderance of adrenaline
versus noradrenaline reactions, and other neuropeptides. Total
serum IgE is usually raised and an allergenic stimulation has been hypothesized.
This condition seems to be underestimated, perhaps
mistaken for cholinergic urticaria, which is often recorded in the patient
history. The pruritic urticarial papules and plaques of pregnancy (PUPPP)
may look like AU, with their white perilesionnel halo [5], but AU has
not been described during pregnancy.
In summary, AU should be suspected in a patient with the typical clinical
presentation: pruritic papule with a halo of vasoconstriction, triggered
by stress, as the treatment is specific. It should be suspected too, in
some patients considered as having cholinergic urticaria, as soon as the
trigger factor seems to be atypical and unresponsive to the usual treatment.
REFERENCES
1. Shelley WB, Shelley ED. Adrenergic urticaria: a new form of stress-induced
hives. Lancet 1985; 2: 1031-3.
2. Vithayasai P, Vithayasai V. Adrenergic urticaria: a first report
from Thailand. J Med Assoc Thai 1989; 72: 478-80.
3. Haustein UF. Adrenergic urticaria and adrenergic pruritis. Acta
Derm Venereol 1990; 70: 82-4.
4. Howard PJ, Lee MR. Beware beta-adrenergic blockers in patients with
severe urticaria! Scott Med J 1988; 33: 344-5.
5. Lawley TJ, Hertz KC, Wade TR, Ackerman AB, Katz SI. Pruritic urticarial
papules and plaques of pregnancy. JAMA 1979; 241: 1696-9.
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