Treatment of acquired cold urticaria with rupatadine

uids was maximally increased. BPremained stable; pulse rate normalizedafter 15 min. A local reaction(30 · 35 mm wheal, 70 · 80 mm are)developed at the venom injection site in20 min; residual ushing and the cuta-neous reaction were still present beyondone hour. Tryptase showed mild increasecompared to the levels prior to reducingomalizumab (Fig. 1, Phase II).Thereafter, anti-IgEdosewas increasedto 300 mg and patient remained com-pletely free of any adverse eect. Themorning of course No. 13th venom skintests were performed and were positiveagain (10 · 13 mmW, 20 · 47F, at 1 lg/ml) for the rst time since Omalizumabtreatment had been initiated; tryptase –measured on that morning – showedcontinuous mild increase (Fig. 1).Subsequently, for nancial and conve-nience reasons, a gradual increase in thecourse interval was attempted; uponreaching 35 days (17th course) patientdeveloped facial ushing (no subjectivesensation) 20 min post-VimRx; arewithout wheal, was noted at the venominjection site. The combined treatmentschedule was again changed to 30-dayintervals and has been continueduneventfully thereafter (courses No.24–26) on an outpatient basis. ID venom-Skin tests performed during the latestsession were negative up to the concen-tration of 1 lg/ml. Tryptase, drawn2 weeks later, dropped to 18.3 mcg(Fig. 1, Phase II).In conclusion, the present case-studyon the protective eect of omalizumabin systemic mastocytosis undergoingVImRx, suggests that the benecial eectappears to require higher than the rec-ommended omalizumab dose and strictly30-day administration intervals; theoccurrence of mild cutaneous and car-diovascular signs, the immediate localreaction at the venom injection site andthe conversion to skin test positivity,observed upon either omalizumabs dosereduction or increased treatment-interval,suggest that no immunologic changeshave occurred because of VImRx.It appears logical to speculate that theexcellent response noted during Phase Iof this study is exclusively due to oma-lizumabs mast cell stabilizing and prob-ably other actions (5, 6); the changesnoted in serum tryptase are in agreement.Obviously, this concept questions thelogic of continuing VImRx. However, novalid conclusions can be drawn from asingle case and the present ndings needto be conrmed; because of the lowsystemic mastocytosis with venomanaphylaxis prevalence, a multicenter-study would be appropriate.No nancial or other relations with themanufacturing company of either drugused in this case study.