Correspondence In re: JACI 1991;87:98-103
symptomshad startedso early in the fall that the outdoor temperature had fallen only to 39” F on the night of the To the Editor: seasonal onset. (Thepatienthadbeenworkingthemidnight I recently receiveda letter from GeorgesM. Halpern, shift for several years.) The patientnoted that symptoms MD, regardinghis performanceof a study similarto the occurred only on the faceandneck, andnot on the armsor one we conductedon “Modification of the FAST as an hands, which were alsoexposedto the air at that time of Inhibition Assay for Determinationof Cross-reactivity the season. Drinking icedbeverages and cold-waterswimamongAeroallergens.”Dr. Halpem’sstudy waspublished ming had never provoked symptoms.There was no past asan abstractin The Journal of Allergy and Clinical Imhistory of urticiara, eczema,or asthma. munology, 1985;75:196. Clinical examinationdisclosedminimaltanningof the Dr. Halpemhasrequestedthat we includethe aboveskin in any location, and no observablecutaneousabnormentionedreferencein our referencesandthat mentionbe malities in the distributionof historicalsymptoms.Blood madeto hisstudypublicationin The Journalof Allergy and testswere normal, includingcompleteblood cell count, Clinical Immunology. We considerDr. Halpem’sstudyreserology,proteinelectrophoresis, erythrocytesedimentation sultsconfirmationof the datawe published. rate, cryoglobulinassays,andcomplement studies.TheiceChester T. Stafford, MD cubetest wasnegativeon the arms,chest, andback, but Professor of Medicine and Pediatrics positive on the forehead.To investigatefurther the lightAllergy-Immunology Section headedness symptoms,the patientwalkedoutdoorsfor 15 Medical College of Georgia minutes(ambientair temperature0” F) and wasobserved Augusta, GA 30912-3790 on returnto the office. Within 5 minutesof returnto room l/8/31534 temperature,there was erythemaand angioedema of the face, scalp(hair wassubstantiallythinnedby male-pattern baldness),and neck, and moderatelyseverehoarseness. A Regional expression of cold urticaria flow-volumecurve revealedno evidenceof lower airway To the Editor: expiratory obstruction,however.The blood pressurewas Kurtz andKaplan’haverecentlyreportedapatientwhose unchangedfrom baselinelevels in spiteof the provoked manifestations of coldurticariawereanatomicallyrestricted lightheadedness. No changein hearingaccompaniedthe to the skinof headandneck. Little is knownregardingthe lightheadedness, and the hands,which had alsobeenexepidemiologyof the cold urticariasyndromes,but clinical posedto the cold air, werenormal. experiencesuggests that suchanatomicrestrictionis quite Because antihistamine therapyhadalreadyfailed,theoral unusual.Recently,a similarpatientwasevaluatedat Mayo useof cromolynwasprescribed,400 mg four timesdaily. Clinic with the distinctionthat mucosalinvolvementin the Thissuccessfully relievedall the symptoms andallowedthe upperairway wasalsoa feature. patient to return to work. A trial of ketotifen, up to 8 The patientwasa 38-year-oldsteelworkerwith a 3-year mgiday, waswithout benefit. historyof symptoms.Hisjob involved driving a smalltrain Thiscaseappearsto illustratethat regionalcold urticaria that transportedingot steelfrom the soaking-pitsbuilding may occur in noncontiguous tissues(skin and larynx) and of the steelplantto an adjacentbuildingin which the basic raisesthe questionof whethersomemediatorsmay be caoxygenprocesswashoused.In wintertime,thisjob entailed pableof causingthe nonspecificsymptomof lightheadedshuttling frequently betweena very warm environment nesswithout alteration in systemicblood pressure.As (soakingpits hold ingot steelat temperatures not far below pointedoutby Kurtz andKaplan,anatomicrestrictionmakes the liquid-solidtransitionpoint for alloy steel,makingthe involvementof a humoralfactor anunattractivehypothesis. generalwork areaaroundthemquite hot at times)andthe A regionalabnormalityof mastcellsappears a lessattractive outdoorcold environment.The worker reportedthat after hypothesisthananabnormalityof theneuronalsensorynettwo suchtrip cycles, he experiencedredness,itching, and work, particularlythe substance P peptidergicsensorynetswellingof the face and scalpand hoarseness associated work. The strainedvoice of a blushingpersonunderduress with a dry cough. He had not experienceddyspneaor suggests that innervativepathwayslinking skinof the blush wheeze,and nasalsymptomswere minimalif they were areaandlarynx likely exist. presentat all. He had observeda gradualprogressionof Cold urticaria lendsitself to clinical investigations,but symptomatology during the past3 years, in that the onset the anatomicallyrestrictedtypes may be rare in clinical of symptomsin the fall hadoccurredearlier(i.e., at milder practice. It would be of interestto hearof other casesso degreesof outdoorcoolness),the time to resolutionof the that a pool of potentialresearchsubjectscouldbe identified rednessand swellingof the face increased(from several for future studies. hoursafter endof shift to asmuchas 10hours),andmost Daniel E. Maddox, MD recently, somenonvertiginouslightheadedness hadbecome Assistant Professor of Internal Medicine regularly associated with cutaneoussymptoms.The comMayo Medical School pany nursehad measured the blood pressureduringtimes Rochester, MN 55905 of the lightheadedness, andtherewasno hypotensionnor reductionfrom baselinelevels.An antihistamine prescribed REFERENCE by the companydoctor initially had beenhelpful but was 1. Kmtz AS, Kaplan AP. Regional experession of cold urticaria [Briefcommu]. J ALLERGYCLIN IMMUNOL 1990;86:272-3. now ineffective. In the year we first observedthe patient, 682
symptomshad startedso early in the fall that the outdoor temperature had fallen only to 39” F on the night of the To the Editor: seasonal onset. (Thepatienthadbeenworkingthemidnight I recently receiveda letter from GeorgesM. Halpern, shift for several years.) The patientnoted that symptoms MD, regardinghis performanceof a study similarto the occurred only on the faceandneck, andnot on the armsor one we conductedon “Modification of the FAST as an hands, which were alsoexposedto the air at that time of Inhibition Assay for Determinationof Cross-reactivity the season. Drinking icedbeverages and cold-waterswimamongAeroallergens.”Dr. Halpem’sstudy waspublished ming had never provoked symptoms.There was no past asan abstractin The Journal of Allergy and Clinical Imhistory of urticiara, eczema,or asthma. munology, 1985;75:196. Clinical examinationdisclosedminimaltanningof the Dr. Halpemhasrequestedthat we includethe aboveskin in any location, and no observablecutaneousabnormentionedreferencein our referencesandthat mentionbe malities in the distributionof historicalsymptoms.Blood madeto hisstudypublicationin The Journalof Allergy and testswere normal, includingcompleteblood cell count, Clinical Immunology. We considerDr. Halpem’sstudyreserology,proteinelectrophoresis, erythrocytesedimentation sultsconfirmationof the datawe published. rate, cryoglobulinassays,andcomplement studies.TheiceChester T. Stafford, MD cubetest wasnegativeon the arms,chest, andback, but Professor of Medicine and Pediatrics positive on the forehead.To investigatefurther the lightAllergy-Immunology Section headedness symptoms,the patientwalkedoutdoorsfor 15 Medical College of Georgia minutes(ambientair temperature0” F) and wasobserved Augusta, GA 30912-3790 on returnto the office. Within 5 minutesof returnto room l/8/31534 temperature,there was erythemaand angioedema of the face, scalp(hair wassubstantiallythinnedby male-pattern baldness),and neck, and moderatelyseverehoarseness. A Regional expression of cold urticaria flow-volumecurve revealedno evidenceof lower airway To the Editor: expiratory obstruction,however.The blood pressurewas Kurtz andKaplan’haverecentlyreportedapatientwhose unchangedfrom baselinelevels in spiteof the provoked manifestations of coldurticariawereanatomicallyrestricted lightheadedness. No changein hearingaccompaniedthe to the skinof headandneck. Little is knownregardingthe lightheadedness, and the hands,which had alsobeenexepidemiologyof the cold urticariasyndromes,but clinical posedto the cold air, werenormal. experiencesuggests that suchanatomicrestrictionis quite Because antihistamine therapyhadalreadyfailed,theoral unusual.Recently,a similarpatientwasevaluatedat Mayo useof cromolynwasprescribed,400 mg four timesdaily. Clinic with the distinctionthat mucosalinvolvementin the Thissuccessfully relievedall the symptoms andallowedthe upperairway wasalsoa feature. patient to return to work. A trial of ketotifen, up to 8 The patientwasa 38-year-oldsteelworkerwith a 3-year mgiday, waswithout benefit. historyof symptoms.Hisjob involved driving a smalltrain Thiscaseappearsto illustratethat regionalcold urticaria that transportedingot steelfrom the soaking-pitsbuilding may occur in noncontiguous tissues(skin and larynx) and of the steelplantto an adjacentbuildingin which the basic raisesthe questionof whethersomemediatorsmay be caoxygenprocesswashoused.In wintertime,thisjob entailed pableof causingthe nonspecificsymptomof lightheadedshuttling frequently betweena very warm environment nesswithout alteration in systemicblood pressure.As (soakingpits hold ingot steelat temperatures not far below pointedoutby Kurtz andKaplan,anatomicrestrictionmakes the liquid-solidtransitionpoint for alloy steel,makingthe involvementof a humoralfactor anunattractivehypothesis. generalwork areaaroundthemquite hot at times)andthe A regionalabnormalityof mastcellsappears a lessattractive outdoorcold environment.The worker reportedthat after hypothesisthananabnormalityof theneuronalsensorynettwo suchtrip cycles, he experiencedredness,itching, and work, particularlythe substance P peptidergicsensorynetswellingof the face and scalpand hoarseness associated work. The strainedvoice of a blushingpersonunderduress with a dry cough. He had not experienceddyspneaor suggests that innervativepathwayslinking skinof the blush wheeze,and nasalsymptomswere minimalif they were areaandlarynx likely exist. presentat all. He had observeda gradualprogressionof Cold urticaria lendsitself to clinical investigations,but symptomatology during the past3 years, in that the onset the anatomicallyrestrictedtypes may be rare in clinical of symptomsin the fall hadoccurredearlier(i.e., at milder practice. It would be of interestto hearof other casesso degreesof outdoorcoolness),the time to resolutionof the that a pool of potentialresearchsubjectscouldbe identified rednessand swellingof the face increased(from several for future studies. hoursafter endof shift to asmuchas 10hours),andmost Daniel E. Maddox, MD recently, somenonvertiginouslightheadedness hadbecome Assistant Professor of Internal Medicine regularly associated with cutaneoussymptoms.The comMayo Medical School pany nursehad measured the blood pressureduringtimes Rochester, MN 55905 of the lightheadedness, andtherewasno hypotensionnor reductionfrom baselinelevels.An antihistamine prescribed REFERENCE by the companydoctor initially had beenhelpful but was 1. Kmtz AS, Kaplan AP. Regional experession of cold urticaria [Briefcommu]. J ALLERGYCLIN IMMUNOL 1990;86:272-3. now ineffective. In the year we first observedthe patient, 682
