VOLUME NUMBER
87 1, PART 1
Correspondence
REFERENCES
Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlledfood challenge (DBPCFC) as an office procedure: a manual. J ALLERGYCLM IMMLINOL1988;82:986-99. Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunologic findings. J Paediatr 1986;109:270-6. Hill DJ, Duke AM, Hosking CS, Hudson IL. Clinical manifestationsof cow’s milk allergy in childhood. II. The diagnostic value of skin tests and RAST. Clin Allergy 1988;18:481-90.
Systemic cold urticaria cold urticaria)
(atypical
acquired
To the Editor:
Kivity et al.’ described six patients with cold u&aria characterizedby the developmentof hives after exposureto ambient 4” C temperature. The u&aria could not be reproduced by direct ice cube challengesto the skin and was diagnosedas “systemic cold urticaria”per Kaplan’? criteria. The authors state that to the best of their knowledge, “only one patient has been describedas having such a syndrome.“* There are three other articles’” that also describedthis syndrome. As Kivity et al.’ indicated, the description by Sarkany and Gaylarde3of three patients with cold u&aria and with a negative ice cube test may have representedsystemic cold urticaria. Two of these casesmost likely had systemic cold urticaria becausetheir urticaria was induced by general body cooling and not by the application of ice to the skin. In 1980, Illig et aL4 extensively studied a similar case that was referred to as generalizedcold urticaria. In our series,5 systemiccold urticaria (atypical acquiredcold urticaria) represented16% (8/50) of patients with acquiredcold urticaria syndromes. The article by Kivity et al.’ further confirms that systemic cold urticaria may be more common than previously recognized.
137
misdiagnosea patient as having systemic cold urticaria if the cold stimulation test was only performed for a short duration. To complicate mattersfurther, there is evidencethat some patients with cold u&aria exhibit sensitivity to cold only on certain areas of the body.6 For example, cold-stimulus testing may be negative on the arm and positive on the thigh. Careful interviewing of patientsmay indicate regional cold sensitivity. Patients with unrecognizedregional cold sensitivity may be misdiagnosed as having systemic cold u&aria if they are tested only at the unresponsive skin site. The greater frequency of systemic cold u&aria should stimulate study of the natural history of these syndromes.
After severalyears of follow up, we have observed several patients with PACU in whom the cold-stimulation test spontaneously converted to a negative result. Several of these patients continued to exhibit cold-induced hives in ambient cold air despite having a negative cold-stimulation test. If these patients were evaluatedfor the first time without any prior knowledge of their positive cold-stimulation test, they would have been misdiagnosed as having systemic cold u&aria. Mathews and Pan* also describeda caseof PACU with a positive cold-stimulation test, which, 8 years later, exhibited a negative cold-stimulation test and evidence of another atypical cold u&aria syndrome, that is, colddependentdermatographism.These examples raise an obvious question. Does systemic cold u&aria represent an end stage of PACU or does this entity develop de novo? Only long-term follow-up studies will clarify this question. In this regard, it would be useful to know if Kivity et al.’ followed their patients during an extended period of time. Alan A. Wanderer, MD Clinical Professor of Pediatrics University of Colorado Health Sciences Center
The study by Sarkany and Gaylarde’ of three atypical cases of cold urticaria exemplifies the polymorphism of cold u&aria syndromes. In one of these patients, the urticarial
Allergy and Asthma Consultants 3601 S. Pennsylvania Englewood, CO 80110
reaction could not be reproducedby ice contact to the skin but was induced by application of a warmer temperature stimulus (8” to 10” C) to the skin. Other investigator@ 7 have similarly observed that to elicit an urticarial response, some patients with cold urticaria must be stimulated at specific temperature thresholds that are warmer than ice temperature (0” to 4” C). It would be useful to know whether Kivity et al.’ tested their patients’ skin with a wide spectrum
of cold-temperaturechallenges. The duration of the cold-stimulation test is another variable that must be appreciatedwhen patients with cold urticaria are evaluated. Very sensitive patients with primary acquired cold u&aria (PACU) will exhibit positive induc-
tion of a wheal after a short application (usually 3 minutes or less) of an ice cube (0” to 4” C) to the skin. At the other extreme, there are patients with PACU in whom a longer duration of cold stimulation (up to 10 minutes or more) is required before a wheal can be induced. Thus, one might
REFERENCES
1. Kivity S, Schwartz Y, Wolf R, Topilsky M. Systemic coldinduced urticaria-clinical and laboratory characterization. J ALLERGYCLIN IMMUNOL 1990,85:52-4. 2. Kaplan AP. Unusual cold-induced disorders: cold-dependent dermatcgraphismand systemic cold urticaria. J ALLERGYCLIN IMMUNOL 1984;73:453-6. 3. Sarkany I, Gaylarde PM. Negative reactions to ice in cold ur-
ticaria. Br J Dermatol 1971;85:46-8. 4. Illig L, Paul E, Bxuck K, Schwennicke HP. Experimental in-
vestigations on the trigger mechanism of the generalized type of heat and cold u&aria by means of a climatic chamber. Acta
DermVenereol(Stock@1980;60:373-80. 5. Wanderer AA, Grandei KE, WassermanSI, Farr RS. Clinical
characteristicsof cold-induced systemic reactions in acquired cold urticaria syndromes: recommendationsfor prevention of this complication and a proposal for a diagnostic classification of cold urticaria. J ALLERGYCLIN IMMIJNOL1986,78:417-23.
138
J ALLERGY
Correspondence
6. Sibbald RG. Physical urticaria. Dermatol Clin 1984;3:62-4. 7. Wanderer AA. Cold urticaria syndromes: historical background, diagnostic classification. clinical and laboratory characteristics. pathogcnesis, and management [CME article]. J Al.1 ERGY CI.IN IMMIJNOI. I990:85:96.5-8 I. 8. Mathews KP. Pan PM. Postexercise hyperhistaminemia. dermographia. and wheezing. Ann Intern Med 1970:72:241-O.
CL’%. .MMUNCL. :A’YIJAW “971
We believe that our group represents one type 01 :hc whole spectrum of atypical cold urticarias. and thcrdor~c. we described them in detail. In regard to the long-term follow-up in out p,mcnr\. ;tll of our patients continued to suffer from their III~L’u
Reply To the Editor:
We thank Dr. Wanderer for his kind comments as cxpressed
in his letter.
We would agree with his comments that systemic cold urticaria is more common than previously recognized. as cited in his article.’ In addition, we are most likely dealing with different types of systemic cold urticaria rather than one entity. Many factors determined the appearance of the utticarial rash, as stated previously.’ ’ Contrary to what was described by Sarkany et al. ,’ our group4 required the same type of exposure for developing the rash. Each of our patients had challenge tests in an environmental chamber, whereas none of the patients described by Wanderer’ were challenged, and therefore, their diagnosis was made only by history.
REFERENCES Wanderer AA. Grandel KE. Wasserman SI. Fatr RS. Chnical characteristics of cold-induced systemic reactions rn acquired cold urticaria syndromes: recommendations for prevention of thib complication and a proposal for a diagnostic classilication of cold utticaria. J ALLERGY CLIN IMMUNOI 19X6:78:417-23 lllig L, Paul E, Bruck K. Schwennicke HP. Experimental investigations on the trigger mechanism of the generalized type of heat and cold urticaria by means of a climatic chamber. Acta Derm Venereol (Stockh) 1980;60:373-80. Sarkany I. Gaylarde PM. Negative reactions to rcc In cold m ticaria. Br J Dermatol 1971;85:46-X. Kivity S, Schwarz Y. Wolf R. Topilsky M Systemtc coldinduced urticaria-clinical and laboratory charactertzation. J AL.I.FRGY CLIN IMMUNOI. 1990:85:53--4.
87 1, PART 1
Correspondence
REFERENCES
Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlledfood challenge (DBPCFC) as an office procedure: a manual. J ALLERGYCLM IMMLINOL1988;82:986-99. Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunologic findings. J Paediatr 1986;109:270-6. Hill DJ, Duke AM, Hosking CS, Hudson IL. Clinical manifestationsof cow’s milk allergy in childhood. II. The diagnostic value of skin tests and RAST. Clin Allergy 1988;18:481-90.
Systemic cold urticaria cold urticaria)
(atypical
acquired
To the Editor:
Kivity et al.’ described six patients with cold u&aria characterizedby the developmentof hives after exposureto ambient 4” C temperature. The u&aria could not be reproduced by direct ice cube challengesto the skin and was diagnosedas “systemic cold urticaria”per Kaplan’? criteria. The authors state that to the best of their knowledge, “only one patient has been describedas having such a syndrome.“* There are three other articles’” that also describedthis syndrome. As Kivity et al.’ indicated, the description by Sarkany and Gaylarde3of three patients with cold u&aria and with a negative ice cube test may have representedsystemic cold urticaria. Two of these casesmost likely had systemic cold urticaria becausetheir urticaria was induced by general body cooling and not by the application of ice to the skin. In 1980, Illig et aL4 extensively studied a similar case that was referred to as generalizedcold urticaria. In our series,5 systemiccold urticaria (atypical acquiredcold urticaria) represented16% (8/50) of patients with acquiredcold urticaria syndromes. The article by Kivity et al.’ further confirms that systemic cold urticaria may be more common than previously recognized.
137
misdiagnosea patient as having systemic cold urticaria if the cold stimulation test was only performed for a short duration. To complicate mattersfurther, there is evidencethat some patients with cold u&aria exhibit sensitivity to cold only on certain areas of the body.6 For example, cold-stimulus testing may be negative on the arm and positive on the thigh. Careful interviewing of patientsmay indicate regional cold sensitivity. Patients with unrecognizedregional cold sensitivity may be misdiagnosed as having systemic cold u&aria if they are tested only at the unresponsive skin site. The greater frequency of systemic cold u&aria should stimulate study of the natural history of these syndromes.
After severalyears of follow up, we have observed several patients with PACU in whom the cold-stimulation test spontaneously converted to a negative result. Several of these patients continued to exhibit cold-induced hives in ambient cold air despite having a negative cold-stimulation test. If these patients were evaluatedfor the first time without any prior knowledge of their positive cold-stimulation test, they would have been misdiagnosed as having systemic cold u&aria. Mathews and Pan* also describeda caseof PACU with a positive cold-stimulation test, which, 8 years later, exhibited a negative cold-stimulation test and evidence of another atypical cold u&aria syndrome, that is, colddependentdermatographism.These examples raise an obvious question. Does systemic cold u&aria represent an end stage of PACU or does this entity develop de novo? Only long-term follow-up studies will clarify this question. In this regard, it would be useful to know if Kivity et al.’ followed their patients during an extended period of time. Alan A. Wanderer, MD Clinical Professor of Pediatrics University of Colorado Health Sciences Center
The study by Sarkany and Gaylarde’ of three atypical cases of cold urticaria exemplifies the polymorphism of cold u&aria syndromes. In one of these patients, the urticarial
Allergy and Asthma Consultants 3601 S. Pennsylvania Englewood, CO 80110
reaction could not be reproducedby ice contact to the skin but was induced by application of a warmer temperature stimulus (8” to 10” C) to the skin. Other investigator@ 7 have similarly observed that to elicit an urticarial response, some patients with cold urticaria must be stimulated at specific temperature thresholds that are warmer than ice temperature (0” to 4” C). It would be useful to know whether Kivity et al.’ tested their patients’ skin with a wide spectrum
of cold-temperaturechallenges. The duration of the cold-stimulation test is another variable that must be appreciatedwhen patients with cold urticaria are evaluated. Very sensitive patients with primary acquired cold u&aria (PACU) will exhibit positive induc-
tion of a wheal after a short application (usually 3 minutes or less) of an ice cube (0” to 4” C) to the skin. At the other extreme, there are patients with PACU in whom a longer duration of cold stimulation (up to 10 minutes or more) is required before a wheal can be induced. Thus, one might
REFERENCES
1. Kivity S, Schwartz Y, Wolf R, Topilsky M. Systemic coldinduced urticaria-clinical and laboratory characterization. J ALLERGYCLIN IMMUNOL 1990,85:52-4. 2. Kaplan AP. Unusual cold-induced disorders: cold-dependent dermatcgraphismand systemic cold urticaria. J ALLERGYCLIN IMMUNOL 1984;73:453-6. 3. Sarkany I, Gaylarde PM. Negative reactions to ice in cold ur-
ticaria. Br J Dermatol 1971;85:46-8. 4. Illig L, Paul E, Bxuck K, Schwennicke HP. Experimental in-
vestigations on the trigger mechanism of the generalized type of heat and cold u&aria by means of a climatic chamber. Acta
DermVenereol(Stock@1980;60:373-80. 5. Wanderer AA, Grandei KE, WassermanSI, Farr RS. Clinical
characteristicsof cold-induced systemic reactions in acquired cold urticaria syndromes: recommendationsfor prevention of this complication and a proposal for a diagnostic classification of cold urticaria. J ALLERGYCLIN IMMIJNOL1986,78:417-23.
138
J ALLERGY
Correspondence
6. Sibbald RG. Physical urticaria. Dermatol Clin 1984;3:62-4. 7. Wanderer AA. Cold urticaria syndromes: historical background, diagnostic classification. clinical and laboratory characteristics. pathogcnesis, and management [CME article]. J Al.1 ERGY CI.IN IMMIJNOI. I990:85:96.5-8 I. 8. Mathews KP. Pan PM. Postexercise hyperhistaminemia. dermographia. and wheezing. Ann Intern Med 1970:72:241-O.
CL’%. .MMUNCL. :A’YIJAW “971
We believe that our group represents one type 01 :hc whole spectrum of atypical cold urticarias. and thcrdor~c. we described them in detail. In regard to the long-term follow-up in out p,mcnr\. ;tll of our patients continued to suffer from their III~L’u
Reply To the Editor:
We thank Dr. Wanderer for his kind comments as cxpressed
in his letter.
We would agree with his comments that systemic cold urticaria is more common than previously recognized. as cited in his article.’ In addition, we are most likely dealing with different types of systemic cold urticaria rather than one entity. Many factors determined the appearance of the utticarial rash, as stated previously.’ ’ Contrary to what was described by Sarkany et al. ,’ our group4 required the same type of exposure for developing the rash. Each of our patients had challenge tests in an environmental chamber, whereas none of the patients described by Wanderer’ were challenged, and therefore, their diagnosis was made only by history.
REFERENCES Wanderer AA. Grandel KE. Wasserman SI. Fatr RS. Chnical characteristics of cold-induced systemic reactions rn acquired cold urticaria syndromes: recommendations for prevention of thib complication and a proposal for a diagnostic classilication of cold utticaria. J ALLERGY CLIN IMMUNOI 19X6:78:417-23 lllig L, Paul E, Bruck K. Schwennicke HP. Experimental investigations on the trigger mechanism of the generalized type of heat and cold urticaria by means of a climatic chamber. Acta Derm Venereol (Stockh) 1980;60:373-80. Sarkany I. Gaylarde PM. Negative reactions to rcc In cold m ticaria. Br J Dermatol 1971;85:46-X. Kivity S, Schwarz Y. Wolf R. Topilsky M Systemtc coldinduced urticaria-clinical and laboratory charactertzation. J AL.I.FRGY CLIN IMMUNOI. 1990:85:53--4.
