Omalizumab. Application for urticarial vasculitis

Description of the case.

The patient, a 68-year-old man, complained of painful eruptions localized on the skin of the trunk and extremities. Clinically, the rash was erythematous infiltrated annular formations (see picture).

According to the patient, the rash appeared more than a day ago. At admission the patient had no signs of angioedema, inflammatory arthropathy, lymphadenopathy, uveitis and serositis. Body temperature was within normal limits. Shortly before the appearance of the rash, the patient suffered a purulent infection of the big toe, about which he was taking penicillin. In the anamnesis: prosthetics of the knee joint, basiolioma of the forehead skin (surgically removed).

In the laboratory examination, antineutrophil cytoplasmic (ANCA) and antinuclear antibodies (ANA) were not identified, in the urine - a slight proteinuria. A biopsy of the skin was performed: a histological picture of leukocytoclastic vasculitis with a perivascular neutrophil infiltrate, typical of urticarial vasculitis (see figure).

Appointed prednisolone in a dose of 37.5 mg / day for a week, against the background of treatment there is an improvement in clinical status. The dose of prednisolone subsequently gradually decreased until it was completely discontinued after one and a half weeks. After three months there is a relapse of skin rash. Appointed dapsone in a dose of 50 mg twice a day for a month without significant clinical effect.In this regard, it was decided to start therapy with omalizumab 300 mg subcutaneously 1 time per month, against which there is complete remission of the disease and a regression of symptoms. Six months later, remission remains.

Discussion

Urticary vasculitis is one of the skin vasculitides. Clinically, urticaria vasculitis may resemble hives, but the rashes have several characteristic features: 1) they usually persist for significantly longer than a day, 2) patients complain more often of burning than itching, 3) their resolution is accompanied by hyperpigmentation. Histologically, the disease is a leukocytoclastic vasculitis with a perivascular infiltrate of a mixed nature (mainly from lymphocytes, neutrophils and eosinophils, as well as fibrin deposits). Depending on the concentration of complement in the blood, urticarial vasculitis is classified into normocomplamenic and hypocomplexemic. The latter is often accompanied by concomitant symptoms, such as angioedema, chest pain, abdominal pain, fever, arthralgia, etc.Most cases are idiopathic. Common treatment regimens include antihistamines and systemic immunosuppressants such as corticosteroids, colchicine or hydroxychloroquine.

Omalizumab is a drug based on human monoclonal antibodies directed against immunoglobulins of class IgE.

The main field of application of omalizumab is resistant asthma of severe course. In addition, clinical studies have shown that omalizumab is an effective and safe drug for chronic urticaria. This case illustrates the potential efficacy of the drug in urticaria vasculitis, which, however, should be confirmed in prospective studies.