Chronic urticaria and angioedema with concomitant eosinophilic vasculitis due to Trichinella infection.

78 Letters to the Editor Sir, Acute and chronic urticaria are very common. Underlying causes can be highly heterogeneous. Various drugs, physical factors, auto-immunological factors, allergic and pseudoallergic reactions or infections can result in the clinical manifestation of urticaria, which is a symptom rather than a distinct disease. The most common infections are Helicobacter pylori, streptococcal or viral infections (1). Rare causes are protozoa, helminths or other parasitic infections (2). We report here a very rare case of eosinophilic vasculitis in urticaria associated with trichinella infection. A 63-year-old woman had had severe attacks of urticaria for months with coexistent facial and pharyngeal angioedema, persisting for more than 24 h. As a consequence she had been treated several times by an emergency physician and at an in-patient clinic. Searching for underlying causes, an eosinophilic cell count up to 60.9% (normal range 0–7%) with accompanying leukocytosis of 20.5 exp 9 /l (normal range 4.0–9.0 exp 9 /l) and moderately increased levels of C-reactive protein (CRP) of 18 mg/l (normal range <5 mg/l) was found, in addition to moderate pleural effusions. Allergological or neoplastic foci could be excluded by screening examinations and blood tests. Skin biopsies showed eosinophilic perivascular and interstitial dermatitis, which was interpreted as an early sign of eosinophi-lic vasculitis (Fig. 1). Neither leukocytoclasia nor abundant neutrophilic granulocytes were found. Following oral dapsone, 50 mg/day, and oral histamine receptor blocker (fexofenadine 180 mg/day), the patient recovered temporarily, followed by a severe relapse of urticaria, progressive myasthenia and distinctly deteriorated general condition. The peripheral eosinophilic cell count eventually increased to well over 60%, with accompanying leukocytosis of 29.2 exp 9 /l. Further clinical examination excluded hemato-oncological disease, intestinal helminths or bacterial infection. However, a distinctly elevated antibody titre of 1:1024 to trichinella spiralis was found by immunofluorescence test. A detailed re-anamnesis showed that the patient had sometimes eaten home-slaughtered pork. Myasthenia and muscle pain correlated with pathological electromyography and unspecific myopathic changes in the muscle biopsy, but muscle biopsy failed to detect encysted trichinosis. Creatine kinase was in the normal range. Neurolo-gical or ocular manifestations of trichinosis could be excluded. Based on the diagnosis of acute trichinosis, oral prednisolone pulse in combination with mebendazole and a second course of albendazole was initiated. Laboratory parameters and overall clinical symptoms both improved, with persistent absence of urticaria and other symptoms, after a second course of treatment 4 weeks later, accompanied by complete normalization of …