Can Helicobacter pylori infection cause urticaria and angioedema?

Can Helicobacter pylori infection cause urticaria and angioedema?

Yes.

Helicobacter pylori (Hp) infection has been implicated in chronic urticaria. Despite the fact that a causal association between the infection and the development of urticaria has not been definitely established, treatment of Hp often leads to symptom remmission.

Helicobacter pylori, the most important cause of gastritis and peptic ulcer, has also been associated with several extradigestive diseases.

A study assessed the prevalence of Helicobacter pylori infection and the effects of bacterium eradication in 42 consecutive patients affected by idiopathic chronic urticaria. Helicobacter pylori was assessed by [13C]urea breath test. Amoxicillin, clarithromycin, and lansoprazole were given to infected patients for seven days. 55% of patients proved to be infected by Helicobacter pylori. 88% of infected patients in whom the bacterium was eradicated after therapy showed a total or partial remission of urticaria symptoms. Symptoms remained unchanged in all uninfected patients.

The study authors concluded that Helicobacter pylori affects a high percentage of patients with idiopathic chronic urticaria; however, typical gastrointestinal symptoms do not identify infection status. Bacterium eradication is associated with a remission of urticaria symptoms.

In another study of 100 patients with chronic urticaria (mean duration 33 months), 26 had Helicobacter pylori-associated gastritis. High prevalence of H. pylori gastritis was found since 47% of patients showed elevated H. pylori-specific IgA and/or IgG antibodies. 27 patients underwent endoscopy and in all but 1 (96%) antral H. pylori infection was found. In contrast, a prevalence rate of 37% among asymptomatic adults has been published. Disappearance (67%) or improvement of urticaria (24%) occurred in most antimicrobially treated patients after 3-12 weeks. In contrast, only 50% of untreated H. pylori-seropositive patients with chronic urticaria showed spontaneous remission or improvement within 12 weeks.

Prevalence of H. pylori infection may even be underestimated since only 27/100 patients underwent endoscopy. It is suggested that H. pylori infection may be present at least in all seropositive subjects (47%).

The authors concluded that measurement of H. pylori-specific antibodies and/or gastroscopy should be included in the diagnostic management of chronic urticaria to identify patients who may profit from eradication treatment.

Diagnosis of Helicobacter pylori infection: 13C urea breath test or the stool antigen test as “test and treat strategy”. BMJ, 2012.

H. pylori eradication therapy

If patient is taking a NSAID (including aspirin), it should be discontinued if possible.

The typical H. pylori eradication therapy includes triple therapy (a PPI plus 2 antibiotics). Triple therapy has been historically preferred over quadruple therapy (a PPI plus bismuth plus 2 antibiotics) because it is simpler.

However, bismuth-based regimens and sequential therapy (i.e., 5 days of a PPI plus amoxicillin, followed by 5 days of a PPI plus clarithromycin and tinidazole) are now preferred due to problems with increasing antibiotic resistance with H. pylori.

All regimens contain antibiotics and therefore may cause diarrhea, increase the risk of opportunistic infections, and interfere with absorption of many other drugs, including oral contraceptives.

If the patient is allergic to penicillins, a regimen that includes metronidazole instead of amoxicillin should be given.

Treatment course: 7 days (quadruple therapy), 10 days (sequential therapy), or 14 days (triple therapy). Check for eradication of H pylori 1 month after the end of therapy.

Quadruple therapy for 7 days

omeprazole 20 mg orally twice daily (or lansoprazole 30 mg orally twice daily, or esomeprazole 40 mg orally twice daily)

AND

bismuth subsalicylate 525 mg orally four times daily

AND

metronidazole 500 mg orally four times daily

AND

tetracycline 500 mg orally four times daily

Sequential therapy for 10 days

omeprazole 20 mg orally twice daily (or lansoprazole 30 mg orally twice daily, esomeprazole 40 mg orally twice daily)

AND

amoxicillin 1000 mg orally twice daily on days 1-5

AND

clarithromycin 500 mg orally twice daily on days 6-10

AND

tinidazole 500 mg orally twice daily on days 6-10

Triple therapy for 14 days

omeprazole 20 mg orally twice daily (or lansoprazole 30 mg orally twice daily, esomeprazole 40 mg orally twice daily)

AND

clarithromycin 500 mg orally twice daily

AND

amoxicillin 1000 mg orally twice daily or metronidazole 500 mg orally twice daily

Source: Peptic ulcer disease, Epocrates, BMJ.

References:

The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria. Journal of the American Academy of Dermatology, Volume 49, Issue 5 , Pages 861-864, November 2003.

Beneficial effects of Helicobacter pylori eradication on idiopathic chronic urticaria. Di Campli C; Gasbarrini A; Nucera E; Franceschi F; Ojetti V; Sanz Torre E; Schiavino D; Pola P; Patriarca G; Gasbarrini G. Dig Dis Sci 1998 Jun;43(6):1226-9.
Prevalence of Helicobacter pylori-associated gastritis in chronic urticaria. Wedi B; Wagner S; Werfel T; Manns MP; Kapp A. Int Arch Allergy Immunol 1998 Aug;116(4):288-94.
Asthma: The secret face of H. pylori. Early infection with H. pylori prevents asthma in a T reg cell-dependent manner http://bit.ly/pHl6dm
H. pylori eradication provides benefits to patients with functional dyspepsia http://goo.gl/UwxsT
The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria. Journal of the American Academy of Dermatology, Volume 49, Issue 5 , Pages 861-864, November 2003.
H. pylori image courtesy of www.hpylori.com.au.

Comments from Twitter:

@ChazzaiA: I didn't know that until Twitter told me - MT @AllergyNet Important cause. @DrVes: Can H. pylori cause chronic urticaria? goo.gl/3gTI

@AllergyNet (Dr John Weiner): Can H. pylori infection cause urticaria? http://t.co/fZmqNfr-- Yes. I agree. Always worth 'H.pyl breath test' in chronic hives.

@DrVes: H. pylori diagnostic test of choice in CIU here is H. pylori IgG, followed by triple therapy, if positive.

@AllergyNet: Interesting. In Australia, serology for H. pylori only used for survey studies, dropped in favor of breath test to detect active infection. Important cause. Breathtest used in Australia to diagnose it.

@Allergy: I was reviewing CIU in UpToDate recently and they also recommend H. pylori IgG - there are regional differences in practice between U.S. and AUS. Stool test for H. pylori antigen is another useful test.

@MatthewBowdish (Matthew Bowdish MD): I've had only one patient test positive to H pylori AND respond to abx. She's still hive-free & off meds after 2 years.

@AllergyNet (Dr John Weiner): I get a few a year. Do you test all chronic urticaria patients, do you use serology or breath test, do you treat all positive even if asymptomatic?

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