Download Comparative evaluation of autologous serum skin test and

Journal of Pakistan Association of Dermatologists 2013; 23 (4): 378-383.
Original Article
Comparative evaluation of autologous serum
skin test and autologous plasma skin test in
chronic urticaria
Sohail Ali Baig, C Balachandran, Sudhir Nayak
Department Of Dermatology, Kasturba Medical College, Manipal, Manipal University, India
Abstract
Objective To compare autologous serum skin test (ASST) and autologous plasma skin test (APST)
in the diagnosis of autoimmune urticaria
Patients and methods A prospective study was done in patients with chronic urticaria. Autologous
plasma and serum skin tests were performed in all patients who were meeting the inclusion and
exclusion criteria and readings were taken at the end of 30 minutes.
Results Fifty-nine patients (Males-25 and Females-34) were enrolled in the study. ASST was
positive in 24 (40.7%) and APST was positive in 27 (45.8%) out of 59 patients. 20 (33.9%) were
positive to both ASST and APST, 28 (47.5%) were negative to both ASST and APST.
Conclusion ASST and APST are two simple, inexpensive and easy to do in-office procedures
which can be used to diagnose autoimmune urticaria. APST was slightly superior to ASST in
diagnosing autoimmune urticarial in our study. Although many patients showed positivity to both
tests, significant numbers of patients were positive to only one test. We thus recommend the
performance of both ASST and APST in all patients of chronic urticaria to detect those patients of
chronic autoimmune urticaria.
Key words
Autologous serum skin test, autologous plasma skin test, autoimmune chronic urticaria
Introduction
Chronic urticaria is one of the commonest
dermatological problems encountered in clinical
practice which is characterized by wheals
occurring daily or almost daily for duration of
more than 6 weeks. The term chronic idiopathic
urticarial is used when no definitive cause for
urticarial can be ascertained.1 Autoimmune
urticarial is used to refer to those patients with
Address for correspondence
Dr. Sudhir Nayak U.K.,
Assistant Professor,
Department of Dermatology,
Kasturba Medical College, Manipal University,
Manipal-576104, India
Ph#: 9900412394
Email: [email protected]
chronic urticaria who tend to have histamine
releasing autoantibodies and who tend to
develop wheal and flare response on intradermal
testing with their own sera.2 The gold standard
tests for the detection of autoimmune urticaria
are the basophil histamine release assay and
flow cytometric basophil activation test.3 The
commonly utilized clinical test for detection of
autoantibodies is the autologous serum skin test
(ASST) which has a sensitivity of 70% and
specificity of 80% and is considered as a
screening test.3,4 Another test which has found
favour among clinicians in detection of
autoimmune urticarial is the autologous plasma
skin test (APST), which is considered to be more
sensitive.4
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Journal of Pakistan Association of Dermatologists 2013; 23 (4): 378-383.
This study was undertaken to investigate skin
autoreactivity in chronic idiopathic urticaria by
using plasma anticoagulated with sodium citrate
and compare autologous plasma skin test
(APST) with autologous serum skin test
(ASST).
Patients and methods
A case-control study was conducted at the
department of dermatology in a tertiary care
hospital. Inclusion criteria of study were:
patients with history of wheals of more than 6
months duration. Following patients were
excluded: patients on oral corticosteroids for
past 1 month, patients on oral anti-histamines for
past 72 hours, pregnant and lactating women,
patients with urticarial vasculitis, patients with a
history of type I hypersensitivity, patients with
physical
urticaria
other
than
simple
dermographism.
Patients selected on the basis of inclusion and
exclusion criteria were enrolled in the study and
an informed written consent was obtained. 5ml
of venous blood was obtained in two different
containers. To one of the containers, sodium
citrate was pre-added to obtain plasma. Both the
containers were centrifuged at 2500 rpm for 5
minutes within 5 minutes of blood withdrawal.
Using an insulin syringe 0.05ml of thus obtained
serum, plasma and saline were administered
intradermally on the volar aspect of the forearm
and reading was taken at the end of 30mins. The
formation of wheal of at least 3mm with
simultaneous development of erythema was
considered as a positive reaction when
accompanied with a negative reaction to saline.
Results
Fifty-nine patients were included in the study of
whom 25 were males and 34 were females. The
mean age of the patients was 34 years. Routine
laboratory investigations like complete blood
picture, urine examination, renal, liver and
thyroid function tests were normal in all
patients.
ASST was positive in 24 (40.7%) and APST
was positive in 27 (45.8%) out of 59 patients. 20
(33.9%) were positive to both ASST and APST,
28 (47.5%) were negative to both ASST and
APST. Seven patients were APST positive and
ASST negative, and 4 negative for APST and
positive ASST (Table 1). McNemar test showed
no statistical significance.
Table 1 Frequency of positive results with autologous plasma skin test (APST) with autologous serum skin test (ASST).
APST positive
APST negative
Total
ASST positive
20 (33.9%)
4(6.8%)
24 (40.7%)
ASST negative
7 (11.9%)
28 (47.4%)
35 (59.3%)
Total
27 (45.8%)
32 (54.2%)
59 (100%)
Table 2 Frequency of positive results with autologous plasma skin test (APST) in patients with history of angioedema.
APST positive
APST negative
Total
Angioedema history present
16
8
24
Angioedema history absent
11
24
35
Total
27
32
59
Table 3 Frequency of positive results with autologous serum skin test (ASST) in patients with history of angioedema.
ASST positive
ASST negative
Total
Angioedema history present
15
9
24
Angioedema history absent
9
26
35
Total
24
35
59
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Journal of Pakistan Association of Dermatologists 2013; 23 (4): 378-383.
16
14
12
10
8
Males
6
Females
4
2
0
APST
ASST
Figure 1 Gender wise positivity of autologous plasma skin test (APST) with autologous serum skin test (ASST).
Table 4 Autologous serum skin test (ASST) positivity in various studies.
Study
Year of
ASST positives
publication
Sajedi et al..[1]
2011
38/58 (65.5%)
Irinyi et al. [3]
2012
34/46 (74%)
Sabroe et al. [6]
1999
38/54 (70%) #
Nettis et al. [7]
2003
54/125 (43%)
Yildiz et al. [8]
2011
26/42 (62%)
Krupashankar et al. [9]
2012
47/80 (58.7%)
Bakos et al. [10]
2003
26/48 (54.2%)
George et al. [11]
2008
34/100 (34%)
Godse [12]
2008
14/30 (46.7%)
Asero et al. [13]
2006
51/96 (53%)*
Metz et al. [14]
2009
75/200 (37.5%)
Nettis et al. [15]
2002
42/102 (41.2%)
Staubach [16]
2006
53/135 (39.2%)
Bajaj [17]
2007
195/394 (49.5%)
Present study
24/59 (40.7%)
Note: # ASST was measured with varying diameters in the study, but 38/54 were for the criteria of serum wheal diameter ≥
1.5mm
Table 5 Comparative analysis of autologous serum skin test (ASST) and autologous plasma skin test (APST) in various
studies.
Study
ASST positives
APST positives Both ASST and ASST alone
APST alone
Both ASST
APST positive
positive
positive
and APST
negative
Sajedi et al. [1]
38/58 (65.5%)
45/48 (77.6%)
37/58 (63.8%)
1/58 (1.7%)
8/58 (13.8%)
12/58 (20.7%)
Yildiz et al. [8]
26/42 (62%)
28/42 (67%)
26/42 (61.9%)
0
2/42 (4.8%)
14/42 (33.3%)
Godse [12]
14/30 (46.7%)
14/30 (46.7%)
14/30 (46.7%)
0
0
16/30 (53.3%)
Asero et al. [13]
51/96 (53%)*
61/71 (86%)
40/41 (98%)
1
21/30 (70%)
9
Metz et al. [14]
75/200 (37.5%)
86/200 (43%)
57/200 (28.5%) 18/200 (9%) 29/200 (14.5%) 96/200 (48%)
Present study
24/59 (40.7%)
27/59 (45.8%)
20/59 (33.9%)
4/59 (6.8%)
7/59 (11.9%)
28/59 (47.4%)
Note: * only 71 out of 96 patients were subjected to APST with sodium citrate. 25 patients were subject to potassium EDTAAPST-potassium, but as potassium EDTA led to non-specific reactions, these patients were excluded. Only the remaining 71
patients were subject to APST- sodium citrate.
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Journal of Pakistan Association of Dermatologists 2013; 23 (4): 378-383.
Table 6 Diagnostic criteria for positive autologous serum skin test (ASST) and autologous plasma skin test (APST) in
various studies.
Study and year of
Criteria for ASST positive
Criteria for APST positive
publication
Sajedi et al. [1], 2011
Wheal at least 3mm more than saline and
Patients with saline wheal >3mm and patients
histamine wheal also at least 3mm more than
with difference in wheal diameter < 3mm
saline
between histamine and saline were excluded.
Wheal of plasma not mentioned
Irinyi et al. [3], 2012
Wheal with diameter ≥1.5mm of saline at 30
Not done
min
Sabroe [6], 1999
Wheal with diameter ≥1.5mm of saline at 30
Not done
min (Recommended). Other diameter ranging
from 0.5mm to 2.5mm was also considered.
Nettis et al. [7], 2003
Wheal with diameter ≥1.5mm of saline at 30
Not done
min
Yildiz et al. [8], 2011
Wheal red and diameter ≥1.5 mm of saline at
Wheal more than 3mm and ASST, sodium
30 min
citrate skin test and saline skin test negative
Krupashankar et al. [9],
Wheal red and with diameter ≥ 1.5 mm of
Not done
2012
saline at 30 min.
Bakos et al. [10], 2003
Wheal at least 1.5mm diameter more than
Not done
saline at 30 min
George et al. [11], 2008
Wheal red with diameter ≥ 1.5mm of saline at
APST not done
30 min
Godse [12], 2008
Wheal and flare reaction with wheal diameter
Wheal and flare reaction with wheal diameter at
at least 1.5mm more than saline at 30 min
least 1.5mm more than saline at 30 min
Nettis et al. [15], 2002
Wheal of serum at least 1.5 mm more than
APST not done
saline induced wheal at 30 min and reassessed
at 60 min
Staubach [16], 2006
Wheal at least 1.5mm more than wheal of
APST not done
human serum albumin at 30 min
Bajaj [17], 2007
Average of 2 perpendicular diameters of
APST not done
serum ≥1.5mm of saline at 30 min
Present study, 20013
Wheal of at least 3mm with accompanying
Wheal of at least 3mm with accompanying flare
flare and no wheal with saline at the end of
and no wheal with saline at the end of 30mins
30mins
13 (52%) of 25 male patients were positive for
ASST. 11 (32.4%) of the 34 female patients
were positive for ASST. There was no statistical
significance as per Pearson Chi-square test.
However statistical significance as per Pearson
Chi-square test (0.071) was noted in the APST
results, with 15 (60%) males and 12 (35.3%)
female patients being positive for APST.
Out of the 59 patients, twenty four patients had
associated angioedema. Out of the 24 patients,
APST and ASST were positive in 16 and 15
patients respectively, which was statistically
significant (Tables 2 and 3).
Discussion
Autoimmune urticaria comprises nearly 35% of
all chronic urticaria patients.5 Autoimmune
urticaria is often associated with other
autoimmune diseases and is often refractory to
standard doses of anti-histamines. Ruling out
autoimmune urticaria is therefore prudent before
labeling a person as having chronic idiopathic
urticaria. Tests like western blot, basophil
histamine release assays and enzyme-linked
immunosorbent assay (ELISA) for detection of
functional autoantibodies are expensive and not
easily available.6 ASST and ASPT are two
inexpensive, easy to do common tests that can
be performed clinical set up. The sensitivity and
specificity of the tests tend to vary from study to
do. ASST is considered to be positive only
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Journal of Pakistan Association of Dermatologists 2013; 23 (4): 378-383.
during stage of clinically activity.2 APST on the
other hand tends to remain positive even after
cessation of clinical activity.4 Plasma contains
complements, coagulation factors and proteins
than serum and thus plasma is considered to be
more autoreactive than serum.1,8
(62.5%) patients, respectively. Angioedema was
present in 9/35 (25.7%) ASST-negative and 8/32
(25%) APST-negative patients. A previous study
reported 29/42 (69%) of angioedema patients
with a positive ASST and angioedema in 26/60
(43.3%) patients.15
In our study ASST was positive in 24/49
(40.7%). This is similar to earlier reported
studies which have reported a positive ASST
ranging from 34% to 74% (Table 4). In our
study a positivity of APST was seen in 27/59
(45.8%) patients was seen. This was almost
similar to previous studies which showed a
positivity of 43% to 86%.1,8,12-14 Our study had
values similar to Godse et al.12 (46.7%) and
Metz et al.14 (43%).
Conclusion
Eleven out of the fifty nine patients were
positive to either ASST or APST (Table 5).
Thus if only one of these were performed, then a
significant percentage of patients would miss the
diagnosis of autoimmune urticaria and would
have been erroneously labeled as idiopathic.
Variation in the diagnostic criteria for size of
wheals has been cited as a reason for the
variation in positivity in various studies (Table
6). Most studies for ASST have used the
development of wheal at least 1.5 mm more in
diameter than saline as the diagnostic criteria.3,612 In our study, we had wheal with more than
3mm with plasma and serum with an
accompanying flare and an absence of wheal
with saline as diagnostic criteria. This strict
absence of reaction to negative control as
diagnostic criteria was in comparison to other
studies. In spite of such stringent diagnostic
criteria, we had results which were comparable
with previous studies.
Out of 24 patients with angioedema, ASST and
APST were positive in 16 (66.7%) and 15
ASST is perhaps the commonest test performed
for evaluation of patients with chronic
autoimmune urticaria. Both ASST and APST are
inexpensive, easy to perform office based
procedures with relatively low downtime for
results. In our study, we found out that APST
was positive in more patients than ASST.
Although patients positive for one test were
positive for the other test in majority of the
patients in our study there was a significant
number of patients who were positive to only
one test. We thus recommend the performance
of both ASST and APST in all patients of
chronic urticaria to detect those patients of
chronic autoimmune urticaria. Further studies
with a larger sample size are advocated.
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