Al-Sadat Mosbeh1*, Ahmed Aladl2, Al-Sayed Tealeb3 and Mohammed Salah Ali4
Department of Dermatology, Faculty of Medicine Al-Azhar University, Cairo, Egypt
Received: 23 October, 2017; Accepted: 30 October, 2017; Published: 31 October, 2017
Al-Sadat Mosbeh, Department of Dermatology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt, E-Mail:
Mosbeh AS (2017) Role of Helicobacter Pylori in Chronic Urticaria among Egyptian Patients with Dyspepsia: A case–control study. Int J Dermatol Clin Res 3(1):026-031. DOI: 10.17352/2455-8605.000023
© 2017 Mosbeh AS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
hronic urticaria; Helicobacter Pylori; Egypt
Background/Objective: Chronic urticaria is one of the most frequent skin diseases and still its etiology is recognized only in a minority of cases. Some recent studies point out to infections due to Helicobacter Pylori as being of major importance in the pathogenesis of chronic urticaria. This study aimed to find out the association of chronic urticaria with H. pylori.
Patients and methods: A case-control study was conducted in cairo within the period of Jan 1st, 2016 to January 1st, 2017. The study included 100 cases with chronic urticaria and 100 controls that were free from features of chronic urticaria. Data was collected through direct interview and the results of laboratory investigations were recorded in a specially designed questionnaire. Enzyme-linked immunosorbent assay test was used for detection of Helicobacter pylori antigen in the stool sample. Also gastric endoscope and gastric biopsys were done in addition to histopathological assessment by H&E and Geimsa stain for detection of Helicobacter Pylori. Endoscope was done for patient who was positive stool antigen test. Triple therapy were given for patients in addition to antihistamine to evaluated effect of eradication for helicobacter pylori on chronic urticaria.
Conclusion: The age of the 100 cases and 100 controls enrolled ranged from 18 to 67 years. Stool for Helicobacter pylori antigen test was positive in 65% of cases and 29% of controls (P <0.05). The mean age ± SD of positive Helicobacter pylori patients were 33.2 ± 10.4 years, with male to female ratio 1:1.69.
Discussion: There was a strong association of chronic urticaria with Helicobacter pylori infection. Investigating for Helicobacter pylori in all cases of chronic urticaria and conducting further trials on Helicobacter pylori eradication is recommended.
Urticaria is a group of disorders that share a distinct skin reaction pattern, namely the occurrence of itchy wheals anywhere on the skin. Wheals are short-lived elevated erythematous lesions ranging from a few millimeters to several centimeters in diameter and can become confluent . Angioedema is an acute, evanescent, circumscribed edema that usually affects the eyelids, lips, lobes of the ears, and external genitalia, mucous membrane of gastrointestinal and respiratory tracts, resulting in abdominal pain, coryza and asthma. The swelling occurs in the deeper parts of the skin or the subcutaneous tissues . Acute urticaria evolves over days to weeks, producing evanescent wheals that individually rarely last more than 12 h, with complete resolution of the urticarial within six weeks of onset. Daily or most daily episodes of urticaria and/or angioedema lasting more than six weeks are designated chronic urticaria. Chronic urticaria predominantly affects adults and is twice as common in women as in men . Chronic urticaria is a frustrating problem for both physicians and patients . Possible eliciting factors of Chronic urticaria revealed focal infection as the cause of urticaria in 43% of the patients, out of which Helicobacter Pylori (H. Pylori) was responsible for 60% . Recent observations had suggested a possible etiopathogenic role of H. Pylori in some cases of Chronic urticarial . Chronic infections and parasitic infestations have long been suggested to be an important causal factor for chronic urticaria, but this has never been consistently proven. It has been approximately 15 years since H. Pylori was first isolated from the human stomach . H. Pylori, a microaerophilic gram -negative bacteria, is associated with the duodenal and gastric ulcer, gastric cancer, and atrophic gastritis and is a ubiquitous infection in the population . Its prevalence is directly proportional to age and inversely correlated with socio-economic status in developing countries . There is increasing evidence for systemic effects of gastric H. Pylori infection, which may be involved in extra gastrointestinal disorders such as vascular, autoimmune and skin diseases. A possible relationship between chronic idiopathic urticaria and H. Pylori infection has been suggested in preliminary studies, in which antibiotic eradication of H. Pylori lead to regression of urticaria in up 100% of cases [9-11]. Regarding the possible mechanisms involved in the relationship between H. Pylori infection and chronic urticaria, a number of speculations and theories have been put forward. One possible explanation might be that the immunologic stimulation induced by infection might, through mediator release, causes a non-specific increase of the skin vessel sensitivity to agents increasing vascular permeability . A number of agents might act through this mechanism. As a matter of fact, increased production of interleukin 8 (IL-8), platelet-activating factor (PAF) and leukotrienes (LT) B4 and C4 has been observed in the gastric mucosa of H. Pylori infected patients and these mediators exert evident actions on the skin [13,14]. Another possibility would be that urticaria patients might develop specific IgE antibodies to H. Pylori, an attractive explanation that still requires confirmation . In this context, Liutu et al. , have reported greater rates of total IgE increase in patients with chronic urticariaand H. Pylori infection than in those with chronic urticaria but without such infection. There have also been observations reported of increased serum H. Pylori IgE and basophil-bound IgE in subjects with infection , and increased basophil counts in peripheral blood in patients with dyspepsia and H. Pylori positivity have also been reported [18,19]. Since no study have been conducted concerning the role of H. Pylori in patients with chronic urticaria in Cairo, we carried out this study to overcome this gap and to provide a baseline data for future studies on this subject. This study aimed to find out the association of chronic urticarial with H. Pylori, and to estimate disease risk associated with H. Pylori. It also aimed to identify the association of cases and controls with socioeconomic factors including age, sex, occupation, educational level and the residence.
Patients and Methods
It is a prospective study was performed in dermatology departments, at Al-Azhar Univerisity Hospitals, Cairo, Egypt. The study was conducted within the period of January 1st, 2016 to March 1st, 2017. A convenience sampling method was used for selecting the cases. Any patient with urticaria for more than six weeks was included in the study. Full clinical (Figure 1) and laboratory tests were conducted to exclude those patients with any finding which may be a cause of the urticaria. For the controls, an equal number of persons was chosen and matched by age and gender with cases and free from features of urticaria, gastrointestinal symptoms and any other condition in which H. Pylori may exist. As a result, 100 persons were identified for the cases and 100 for the controls as a sample size for the current study. The followings patients were excluded from the study; patients suffered from physical urticaria, patients consuming proton pump inhibitor within two weeks, antibiotic and Bismuth within four weeks preceded enrolling in the study. The data was collected through direct interview and clinical examination of the patients and controls, in addition to the results of the laboratory findings. The purpose of the study was explained for each participant and verbal consent was obtained from them before inclusion in the study, and anyone wasn’t interested to be involved the study was excluded. An anonymous questionnaire form was prepared to collect data, and filled by the researcher through direct interview. The questionnaire was composed of two parts; the first part was composed of data about socio-demographic characteristics of the study sample e.g. age, sex, residency, marital status, educational level and occupation, while the second part was composed of data about history, clinical and laboratory findings from the study sample. The following laboratory investigations were applied to all the participants in the study: complete blood count (hemoglobin, white blood cells, differential count), erythrocyte sedimentation rate, thyroid function test, hepatitis B virus, hepatitis C virus, general urine examination, general stool examination and H. pylori antigen detection in stool by enzyme linking immunosorbent assay (ELISA) test. H. Pylori antigen Enzyme Immunoassay test (EIA) KIT was used for detection of H. Pylori antigen in the stool sample with specificity 98% and sensitivity 95% of the test . The H. Pylori Antigen EIA test Kit is a solid phase EIA based on sandwich principle for the qualitative and quantitative detection of H. Pylori antigen in stool . Also, Skin biopsy was done for every patient with 5 ml punch biopsy under local anaethesia and histopathological asseseement was done (Figures 2,3). In addition, gastric endoscope and gastric biopsys were done in addition to histopathological assessment by H&E and Geimsa stain for detection of Helicobacter Pylori (Figures 4-6). Endoscope was done for patient who was positive stool antigen test.