Sunday, June 21, 2020

Ch 6. Candidate treatments - immunity to coronaviruses in context of COVID-19

What medications are candidates for COVID-19 treatment?
  1. Medicines the attack the virus, such as remdesivir.
  2. Medicines that boost an APPROPRIATE immune response.
  3. Medicines that calm down an INAPPROPRIATE immune response, and
  4. Medicines that can do both 1 and 3 such as hydroxychloroquine (HCQ).

COVID-19 virus, immune response and medication options

1. Medicines the attack the virus

Why is Remdesivir a candidate to treat COVID-19?
This medicine has shown anti-virus activity. It binds and blocks an enzyme needed for the virus to make more copies of itself (Chapter 1). In experiments, animals treated with remdesivir had lower lung virus levels. They also had less lung damage than those who did not receive it.
Others like favipiravir are also being tried out.

2. Medicine that boost an APPROPRIATE immune response.

What is convalescent plasma?
When a person has recovered from COVID-19 infection, their blood has antivirus antibodies (Chapter 3). Plasma is part of blood that is rich in antibodies. Purifying plasma of such person provides COVID fighting antibodies.

How could convalescent plasma help?
Antibodies to the virus interfere with virus in several ways. Antibodies can bind to a virus particle. They can block a virus from entering new healthy cells. They can also activate immune cells to kill virus containing cells.

3. Medicines that calm down an INAPPROPRIATE immune response

How could medicines that calm down an INAPPROPRIATE immune response help?
A cytokine storm is an excessive immune response that can damage organs (Chapter 5). Medicines to calm an overactive immune system are helpful. Dexamethasone (a corticosteroid, also known as steroid) acts in this manner. Other medicines (tocilizumab, tofacitinib, ruxolitinib) act to block effects of specific cytokines involved in cytokine storm. Azithromycin a common antibiotic also has immune regulating properties.

4. Medicines that can do both 1 and 3 

Why is HCQ a candidate to treat COVID-19?
HCQ interferes with virus sticking to its receptor on cell (ACE2). It interferes with blending of virus with membranes of lung cells. These actions reduce entry of virus into cells. It can also block virus leaving the cell (Chapter 1). Finally, HCQ has effects on immune system, which may be beneficial in a cytokine storm (Chapter 5).

How does HCQ affect immune function?
Hydroxychloroquine (HCQ) can pass into our cells with ease. HCQ accumulates inside parts of the cell called lysosome. In immune cells, lysosome deals with processing and secretion of proteins. By increasing in the lysosome, HCQ interferes with its function in immune cell. HCQ can also block proteins recognizing "danger signals". This reduces the activation of early immune cells (Chapter 3). This is the reason patients with certain autoimmune diseases like SLE (lupus) take HCQ. It is the reason for treating joint inflammation in rheumatoid arthritis.

Why is HCQ used in prevention or treatment of malaria?
The same principle of lysosome interference works malaria parasite. In the lysosome of malaria parasite HCQ interferes with digestion of blood proteins. Thus, it is effective anti-malarial.

The medications listed above are all under trials to see which of these actually makes an impact on outcome of COVID-19 infection.

COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at Accessed [6-21-2020].

Friday, June 19, 2020

Ch 5. A storm is coming - immunity to coronaviruses in context of COVID-19

What will this section talk about?
Cytokine storm, a hyper-immune reaction that can cause damage.

Readability grade 7
Reading time approximately 4:25 minutes

In the previous sections we have seen two possible outcomes. One, seen in majority of cases, is an appropriate immune response which eliminates the virus (Chapter 4). The other, if there is no or poor immune response to virus infection, virus overwhelms quickly causing death (Chapter 2). There is a third possible outcome which has gotten much attention and can also be problematic. This is an intense immune response to the virus called "cytokine storm", and damages organs. These outcomes are represented in figure below
Outcomes depending on immune response to virus infection

What other conditions can cytokine storm happen in?
The cytokine storm is an excessive and uncontrolled immune response. The abnormal immune response damages the health of the host and can lead to death. Besides COVID-19, it is also seen in other medical conditions. These other conditions can be other infections or non-infectious. Reports suggest that even some medications can be cause of cytokine storm. At the heart of the “cytokine storm”, are powerful chemicals called cytokines.

What do cytokines do?
The cells of immune system make cytokines for help with immune response. For example, an early immune cell will communicate with helper cell (Chapter 3) by cytokines. This signal may say to helper cell that infection is bacterial. The helper cells then, through different cytokines inform others (B-cells) to make antibodies. Thus, in the simplest of terms, cytokines are language, a communication between immune cells. Every unique immune cell type has its ability to signal and relaying it forward. A cytokine "storm" then is an excessive chaotic communication. This leads to hyper-activation and damage from this uncontrolled immune activity.

Are there different types of cytokines?
There are 5 major types of cytokines based on their function.
1. Some regulate early immune response, have anti-virus properties. (Interferons, discussed in Chapter 1)
2. Some promote inflammation. (Interleukins)
3. Some help direct movement of immune cells (Chemokines).
4. Some help different types of immune cells grow and survive (stimulating factors).
5. Some cause direct damage to diseased cells. A virus infected cell or cancer cells are examples. (tumor necrosis factor).

How does a cytokine storm start?
The start of a cytokine storm is local inflammation spilling over into the rest of the body. This happens by spreading of the immune cells and cytokines through blood. Many are familiar with the symptoms of local inflammation. For example, a local infection such an abscess or boil causes the affected part feels 1. Warm, there is 2. Redness, 3. Pain, 4. Swelling, and 5. Loss or reduced function. All 5 effects are results of immune system trying to remove the threat of local infection

How does a cytokine storm damage tissue?
In a rapid infection or an overstimulated immune system, the effects occur all over the body. Factors responsible for local symptoms spill over into other organs via blood. The lung and kidneys due to their high blood flows are at high risk from damage. Sepsis, a condition of excessive immune response to blood stream infection, is similar. In COVID-19, the lung gets affected three times. First, from infection of the virus in lung cells. Second, from immune response to kill the virus infected lung cells. Third, if cytokine storm occurs, immune damage to lung. This may be a basis for the severe and sudden cause of respiratory failure in COVID-19.

How common is a cytokine storm?
Cytokine storm is a less common outcome even in COVID-19 infection. Not every one will end up with a cytokine storm outcome. Evidence suggests genetic factors could increase or decrease the risk developing cytokine storm. These genetic differences are in genes responsible for “danger signal” detection (Chapter 1 and Chapter 3) , or cytokine production.

How can a cytokine storm be treated?
At present most treatment is symptom based. The goal of treatment for cytokine storm is to support vital organs like circulation (heart pump machine), respiratory (ventilators), kidneys (dialysis) etc until body recovers. Some medications like dexamethasone are corticosteroids (commonly known as steroids) and have shown benefit by calming down inflammation from over active immune system. Other medications to block cytokines are also available but their benefit is not clear.

Previous section: Ch 4. A favorable outcome - immunity to coronaviruses in context of COVID-19
Next Section: Ch 6. Candidate treatments for COVID-19 infection
List of all chapters 

Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. Into the eye of the cytokine storm. Microbiol. Mol. Biol. Rev.. 2012 Mar 1;76(1):16-32.

Tuesday, June 16, 2020

Ch 4. A favorable outcome - immunity to coronaviruses in context of COVID-19

Reading time: approx 3:29 minutes
Readability: Grade 8

Today's chapter discusses the situation where we overcome the virus infection. In case of coronavirus infection, this is the most common scenario where infections are without symptoms or have mild to moderate symptoms and disease does not progress.

In the previous sections, we have seen infected cells make a protein to boost defenses. They (infected cells) and immune cells also release other chemicals causing a fever. Fever is important to increase metabolism activity of cell and slow virus production. Many other proteins (called interleukins) activate other parts of the immune system. The scout cells (Ch 3), deliver pieces of virus/infected cells to special adaptive immune cells. The CD4 helper cells produce many chemicals needed to fight virus. Some of these increase the killing capacity of innate killer cells. Others direct antibody making cells to start making anti-virus antibodies. Yet another group, powers up the advanced killer cells to end virus containing cells. Killing virus infected cells is similar to a controlled burn to stop a forest fire. By killing cells infected with virus, the virus cannot spread.

Summary of events of a successful elimination of viral infection (connect the numbers with the detail below)

An appropriate response to viral infections (see figure)

1) Early responses can hold off the virus from spreading

2) Interferons produced by cells can boost and get rid of virus and virus infected cells.

3) Innate troops can cause activation of cell damage systems to limit virus spread

4) Scout of innate system pick up dead/dying cells with dead virus parts

5) These scouts deliver the virus parts to adaptive/advanced immune response cells

6) Helper cells coordinate and command the a virus specific response

7) Helper cells boost activation of cell damage systems of innate troops and killers

8) Helper cells tell antibody making cell to start making anti-virus antibodies. Antibodies can block and neutralize virus outside cells.

9) Helper cells boost killing power of killer cells, so they

10) Rid of virus and the virus infected cell.

If everything goes according to plan, the viral infection (be it coronavirus or flu virus), stops. The immune system had done a good job of eliminating the virus. Some parts of immune system save the information as memory cells in case this virus attacks us again.

- Braciale, Thomas J., Jie Sun, and Taeg S. Kim. "Regulating the adaptive immune response to respiratory virus infection." Nature Reviews Immunology 
- Swain, Susan L., K. Kai McKinstry, and Tara M. Strutt. "Expanding roles for CD4+ T cells in immunity to viruses." Nature Reviews Immunology 12.2 (2012): 136-148.2.4 (2012): 295-305.
- Prompetchara, Eakachai, Chutitorn Ketloy, and Tanapat Palaga. "Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic." Asian Pac J Allergy Immunol 38.1 (2020): 1-9.

Next section:
Previous section: Ch 3. Meet your defense forces - immunity to coronaviruses in context of COVID-19

List of all chapters

Sunday, June 14, 2020

Ch 3. Meet your defense forces - immunity to coronaviruses in context of COVID-19

Reading time: 2:07 minutes
Readability: Grade 8

In the previous chapter we saw the consequences of an unchecked viral infection. Before discussing immune function, we need to understand components of the immune system. If we start out by naming the many types of immune cells it can get overwhelming. A function-based approach, lets us appreciate the diversity of immune cells.

There are 2 broad division of the immune response which are further subdivided into other special units (Figure 1)

Figure 1: Function based classification of immune system

1) Innate:

This is an ancient defense system present in all living beings. Plants, fungi, insects, and primitive many-celled organisms have this as the main defense. This early response system is not specific, it can only distinguish what is part of self from enemy. A familiar blood test - WBC count measures the number of white cells in blood, a part of the innate immune system. Its advantage is early response, but it cannot learn and remember past experience.

The cells in this system can be troops or scouts, though each type can do a little of both. Troops have tools to fight and kill infectious organisms. They don’t need extensive training, and develop in large numbers in bone marrow. These properties make them ideal cells to arrive at the scene of an infection early on. A neutrophil is a troop class cell that attacks bacteria that are outside the cell. A “natural killer” cell is troop class, which will kill a virus by killing the cell where virus makes home.

The scouts sample the battlefield to pick up pieces of the dead enemy to identify who has attacked us. This important information is necessary engage special forces of the advanced immune response. Bacteria, virus, fungus, or parasite each need a different advanced immune response. Scouts (antigen presenting cells) are a crucial link between early and advanced response.

2) Adaptive

This immune system engages later in infection. It adapts to the type and strength of infection which is why its called adaptive. A virus causing illness will need different response from bacteria. This system has a cell based response (T cells) to fight infection. The killer cells (CD8 T cells) kill infections (viruses, TB bacterium) that hide inside the cell. 'Helper' cells (CD4 T cells) help, co-ordinate, command the adaptive immune response.

The reason why HIV is so devastating is because the HIV virus eliminates these helpers. By taking out, commanders, HIV causes AIDS and infections that otherwise we can handle.

This system also includes the antibody response. These are proteins produced by B-cells of the adaptive immune system. Antibodies can attack any organisms that are in the blood stream and in tissue but outside of the cells. Antibodies blocks and neutralizes virus before it enters and hides in a cell. Many vaccines work as they designed to induce a strong antibody response.

With coronavirus, we are starting to understand which parts of the immune system engage. The early innate system arrives at site of damage from virus. Killer cells and antibodies play a role. In the later chapters we will see each of these in detail.

Next section: Ch 4. A favorable outcome - immunity to coronaviruses in context of COVID-19
Previous section: Ch 3. Meet your defense forces - immunity to coronaviruses in context of COVID-19
List of all chapters

Friday, June 12, 2020

Ch 2. No defenders to help - Immunity to coronaviruses in context of COVID-19

Reading time: 1:39 minutes
Readability: Grade 8

In chapter 1, we discussed how coronavirus enters the lung cells. We saw how infected lung cells raise alarm and boost defenses (interferon response). The virus using its ability to block the interferon response, continues to multiply. While the virus infects and spreads, the immune system is gearing up for a confrontation. The battle lines drawn, preparations on going. The immune system must end the enemy with precise swift action, if does not, the outcome is bad. If it does attack the enemy but without precision, there is price to pay. For now, lets see what would be the outcome if we fail to check the virus.

What if there was no defense against infections or no immune system to keep us healthy?

The outcome for a virus infected cell if anti-virus defenses do not work is inevitable cell death. The virus does it with relentless repetition and efficiency. Virus uses the infected cell to make more viruses, controlling it, damaging it from within. The new viruses made, leave the cell to go and infect more cells. These actions of the virus ravage the cell to the point where the cell cannot carry out its own functions. In the end, after the virus has completely used the resources, the cell withers away. The dying cell bursts, releasing everything inside including remaining virus particles. This continues over and over, until there is overwhelming infection in the body.

Viral induced cell-death: a cycle of damage and death
In a weakened or no immune system, there is no barrier to overwhelming infection and death. Therefore, people with broken and weak immune system are at a tremendous risk of deadly infection. Who might these people be who are at increased risk?

People who are born with defective immune system, are especially at risk. These disorders called "Primary immune deficiency disorders" are inherent and inherited disorders. These rare devastating diseases can cause trivial infections to become deadly in these patients*. They are called primary because, the defect is in the immune system itself. A second group at risk, are those with secondary immune deficiency. This is due to another condition (or medication) suppressing immunity. Common causes are malnutrition, wasting diseases, medicines like cancer treatment (Chemo) or immune suppressants. Smoking, liver or kidney diseases, organ transplants also affect immune health increasing COVID-19 risk.

2 types of immune deficiencies

*a good resource is for further reading.

Next section: Ch 3. Meet your defense forces - immunity to coronaviruses in context of COVID-19
Previous section: Ch 1. A war within - Immunity to coronaviruses in context of COVID-19
List of all chapters

Thursday, June 11, 2020

Ch 1. A war within - Immunity to coronaviruses in context of COVID-19

Chapter 1
Reading time: 1:43 minutes
Readability: Grade 8

Novel coronavirus SARS-Cov2 has ravaged the world with the COVID-19 pandemic. The purpose of this series is to highlight the many ways the virus and the immune system engage in war games. We will uncover espionage, understand intricate diplomacy as the virus and cells interact. We will flinch at unforgiving brutality and the bizarre consequences of a struggle to prevail.

Coronavirus (like any other viruses) lives inside human cells. Initial site of infection and home for the virus are the cells lining the respiratory tract. ACE2, a protein on surface of special lung cells (type 2 cells) allows virus to bind to cell surface. This protein is important for our health, and the virus latches on, to its advantage. Once the virus makes home inside the lung cells, it starts multiplying.
Fig 1. A Trojan horse: virus uses our protein to get inside the cells
The infected cells begin to look ill, with a change in expression of proteins on surface. These 'danger patterns' signal for attention and are a cue for immune system to respond. While the flags are being put up to raise an alarm, infected cells try and limit this enemy from within. To reduce virus spread, infected cells make proteins (called interferons) to block virus functions. These interferons boost the protective defenses of other, non-infected cells. A successful interferon response should suppress viral infection at an early stage.
Fig 2. A sick cell and a plea for help, defenses engage
It turns out that coronavirus infection has 3 stages. Stage 1 is an infected person who has no symptoms. Stage 2 is an infected person with mild symptoms and stage 3 is an infected person with severe symptoms. At present 15 to 20% of total infected people progress to severe symptoms (stage 3). This number is higher in persons above age 65 years of age. Thus, stage 1 and some stage 2 infected patients could, in theory limit the infection.

Things, yet are not straightforward as it were. The coronavirus has tools to counteract the very mechanism that can help humans. In a strategic countermove, the covid-19 virus blocks the ability to make interferon. It neutralizes the 'sensor' proteins inside the cell. This handicaps the cell to detect the virus and interferes interferon production. Besides effect on interferon production, the viruses cripple the response to the rest. This allows the virus to keep infecting more cells, spreading fast causing damage. The virus copies itself into millions of viruses, setting a stage for a battle where both armies number in millions.

- Li G, Fan Y, Lai Y, et al. Coronavirus infections and immune responses. J Med Virol. 2020;92(4):424‐432. doi:10.1002/jmv.25685
- Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pac J Allergy Immunol. 2020 Mar 1;38(1):1-9.
- Fung, To Sing, and Ding Xiang Liu. "Human Coronavirus: Host-Pathogen Interaction." Annual review of microbiology 73 (2019): 529-557.

Next section: Ch 2. No defenders to help - Immunity to coronaviruses in context of COVID-19
List of all chapters

Tuesday, June 9, 2020

Lifestyle recommendations in management of chronic hives

The previous section discussed the role of medications in management of chronic hives. Medications are effective, but life style changes also impact chronic urticaria.

In 2013, Omalizumab (Xolair) injection trial worked in patients failing high dose antihistamines. In the study, Omalizumab  improved hive and  itch symptoms. Similarly, the placebo group also showed significant  (30-33%) reduction in symptoms  but less than Omalizumab. So what might be the cause  of this placebo benefit?
It is my hypotheses that,

"The  patients knew their adversary and had a greater understanding of the disease process. They were ‘at peace’ with their hives. Their anxiety was less. They were also likely not attributing their hives to 'being allergic to everything'. The exhaustion and stress of hyper-vigilance (being super aware of all actions) reduced."

This brings us to lifestyle recommendations:

1. Take actions to reduce stress. Identify any personal, professional or physical stressors. Once identified, take steps to reduce them.
2. Yoga, meditation and mindfulness help. Anything that can help take your mind off the itching can help the medications help you better
3. Take control of your anxiety. Recognize the contribution of the  positive feed-forward loop where anxiety can  worsen hives.  Worse hives, lead to more anxiety. You get  the picture.

The feed forward loop between anxiety and hives

4. Try to get as much of restful sleep as possible. Sleep is an  unrecognized victim of chronic hives. People with uncontrolled hives do not sleep well for many reasons. Waking up several times a  night to scratch all over is an obvious cause. Medications necessary  to control hives (antihistamines in high  doses) can affect sleep quality.

The feed forward loop between poor sleep and hives

5. Weight can have an adverse impact. The documentary ‘fat, sick and nearly dead’, is about a person whose hives resolve with weight loss. It could be worth  trying since there is not much to lose (except weight). High dose  antihistamines stimulate appetite contributing to weight gain. Corticosteroids (e.g. prednisone) can also cause weight gain. This weight - hives relation could be the third positive feed forward loop.

The feed forward loop between weight gain and hives

6. Take your medications of time!

The steps above should be complementary to the medication regimen as prescribed by your physician.

To jump directly to other sections on this topic
  1. Why do I get hives all the time with seemingly no cause?
  2. What if my hives bruise, blister, scar or heal with marks on skin?
  3. What is happening in skin that leads to chronic hives? 
  4. How to effectively manage hives and why do antihistamines work in most cases?

Monday, June 8, 2020

Why the management of hives and itching in chronic hives (urticaria) may require a higher dose of medications

Disclaimer: Following is not medical advice, please discuss with your physician before making any medical decisions. In the preceding section, we discussed the chemicals released by immune cells that cause effects leading to wheals and itching. Management of hives thus depends on systematically blocking these chemicals released so that they cannot do what they are designed to do. So, 

Due to the predominant role of locally produced histamine, it is clear why antihistamines play such a central role in management of hives. In fact, experts treating chronic hives often recommend daily antihistamines such as cetirizine (e.g. Zyrtec or its generic equivalents), Fexofenadine (e.g. Allegra or its generic equivalents), or Loratidine (e.g. Claritin or its generic equivalent) sometimes in double, triple or even quadruple doses! What would the reason be for this? It comes down to the fact that to cause its mayhem, histamine has to bind to its receptor on cells. Histamine binds to its receptor in a reversible manner, so when an antihistamine comes along, it kicks off the histamine from the receptor and occupies the same place on the receptor site, thus preventing histamine from doing its thing.

Why antihistamines in high doses are often suggested in management of hives

If high dose histamine-1 receptor blockers are not enough, then physicians will often recommend a Histamine-2 receptor blocker. Once the histamine receptor -1 is bound and out of commission, and a person is still having problems with hives, then the next target is to block the histamine 2 receptor. This property belongs to a class of medications, whose most famous role is to suppress acid in stomach. Yep, Ranitidine (Zantac etc, withdrawn from market in 2020) and Famotidine (Pepcid etc) are sold over the counter as acid reflux medications for heart burn. Interestingly, they achieve this by blocking the histamine-2 receptor on stomach lining which reduced acid being produced.

If a person is still breaking out in hives in spite of being on high dose H1 blocking medications, then the next step is to target the Leukotrienes that are also thought to be involved in some patients. This is achieved by a prescription medication called Singulair or Montelukast. This drug blocks the leukotrienes from binding to its receptors and thus blocking their action.

A representation of the ways in which these drugs can help control itching and hiving is given in figure below.

Why the management of hives involves medications such as anti-histamines, acid-reducing medications and Montelukast

Thus you can appreciate that the key to managing the terrible symptoms of chronic hives are sequential and systematic blockade of the pathways involved in the genesis of hives. In fact, the options do not end with the above drug, depending how severe the hives are the options can extend further down the list as noted in the figure below with the last choices being some harsh medications with fair amount of side effects such as immuno-modulators and immuno-suppressants. The last two are almost like 'weak chemo' type medications that are needed to regulate or suppress the immune system, so as to not keep producing those inflammatory chemicals we spoke about earlier.

The inverted triangle of medication choices for hives: More patient can be controlled with the earlier steps and fewer and fewer patient require the progression steps
Hopefully, this article has made clear why the medications in chronic hives are the to be tried the way they are.

To jump directly to other sections in this topic
  1. Why do I get hives all the time with seemingly no cause?
  2. What if my hives bruise, blister, scar or heal with marks on skin?
  3. What is happening in skin that leads to chronic hives? 
  4. What are lifestyle recommendations in management of chronic hives?

Sunday, June 7, 2020

What is happening in skin that leads to chronic hives?

A useful pathway gone awry

It all begins right at the interface of blood vessel and the tissue.  Blood vessels are present in all tissues. These pipes (vessels) lined by a special layer  of cells called ‘endothelial cells’ carry components of blood. Endothelial cells fit into each other like ‘paver stone’. Under normal situations, cells fit tight to keep the ‘pipe’ from leaking. Blood flows through and very little fluid (plasma) leaks out into the tissue. The hives occur due to leakage of fluid into tissue more than normal. This leads to expansion of tissue spaces with fluid. Under the skin this looks like a hive (wheal) and in deeper tissue can present as angioedema. Thus, angioedema is the same process but in a different location.

A simple version of events is in the diagram that follows,

A process diagram showing why hives cause swelling and itch

A bit more detailed explanation is in the remainder of the article if you still are interested.

If this tissue swelling process is a problem, why do we even have it in the first place? Under specific situations, this process is useful and serves a purpose.  For example, when we are bit by a mosquito, or stub a toe, there is tissue damage.  Injury causes local inflammation and the blood vessels to be leaky, to begin repair. Therefore, mosquito bites wheal and a stubbed toe swells. This leaked fluid, rich in plasma proteins and healing factors starts tissue repair.

The main chemical that is known to cause this is histamine, released by the immune cells in the tissue. So in the discussion of triggers of acute hives, Histamine released from immune cells in allergic reaction or infection triggers hives. Thus, hives can either be local response to injury, or generalized immune activation.

The problem becomes chronic when tissue immune cells release histamine without provocation. This happens over and over again, without an obvious trigger, or specific purpose.
Thus chronic hives are due to,
  • Inappropriate release of histamine from skin immune cells (such as the mast cell)
  • Histamine causes endothelial lining to leak. This in turn causes fluid to move into the tissue from circulation.
  • This leaked fluid with expanded tissue spaces, manifests as hive (under skin). Swelling in deep tissue becomes angioedema.
  • Histamine will also stimulate the itch nerve fibers stimulating a profound itch. Angioedema (deep tissue swelling) does not itch but the area can feel numb. Pain and pressure fibers send signals to brain so a swollen lip feels as if a dentist anesthetized it.
In chronic secondary urticaria, another disease, triggers immune cells to release histamine. Appearance of chronic hives is then a symptom of that underlying condition

A simplified flow diagram showing the cascade of events leading to hives (click for higher resolution image)

Histamine is not the only chemical released by the skin/tissue immune cells. It is but, the most famous and primary culprit. The immune cells produce other inflammatory chemicals leukotrienes (LTs) , prostaglandins (PGs), chemokines, cytokines.  These are all potent molecules like histamine. There are also other immune factors we may not even have discovered, all involved in the process outlined above.

Histamine  (acting through its receptor(s) is the primary chemical playing a role in hives, though some other can also participate. (Click for higher resolution)

It is easy to recognize the complexity of the pathways in perpetuation of chronic hives. To jump directly to other sections in this topic
  1. Why do I get hives all the time with seemingly no cause?
  2. What if my hives bruise, blister, scar or heal with marks on skin?
  3. How to effectively manage hives and why do antihistamines work in most cases?
  4. What are lifestyle recommendations in management of chronic hives?

What if my hives bruise, blister, scar or heal with marks on skin?

There are some clinical features that can help a physician to distinguish whether the chronic hives may be the idiopathic kind or the secondary kind. A clue could lie in the answer to a very important question: What if my hives bruise, blister, scar or heal with marks on skin? or leave with no trace leaving a normal looking skin?

Not all chronic hives are the same, look for red-flag symptoms

Most people which chronic hives will have the chronic idiopathic variety as it is the vastly more common of the two. There are some features that can distinguish the more benign chronic idiopathic hives from chronic secondary hives but these are not hard and fast rules. Hives in chronic idiopathic urticaria are usually transient, fleeting (appear and disappear in less than couple hours, at most 1 day only to reappear in another location – thus they tend to ‘move’ around), they go away leaving a normal looking skin, and never blister, scar or heal with discolored bruises. All these properties (lasting longer than a day, don't move around and have some of the other skin changes) are often seen in chronic secondary urticaria, since main driver of hives in this case (and the skin changes) is a ‘bad’ type of inflammation.

The major types of chronic urticaria

Chronic idiopathic urticaria, can be further divided into chronic spontaneous urticaria (hives that come on their own without any provocation or trigger) or chronic inducible urticaria (hives that be induced by physical triggers like pressure, scratching the skin, hives from sunlight, heat etc). There is a large degree of overlap between these two clinically, and it is rare to find a pure inducible urticaria patient as most will have some component of spontaneous hiving.

There is a special type of chronic idiopathic urticaria, a third variety that has a mix of idiopathic as well as secondary urticaria features. This is called chronic autoimmune urticaria (confusing nomenclature but that's how it is widely known). This urticaria overall behaves like the idiopathic chronic hives clinically (skin changes similar to idiopathic kind) but is associated with presence of autoimmune antibodies to thyroid (TPO or thyroid peroxidase antibodies) . These auto-antibodies give rise to the ‘autoimmune’ in the name but are thought to have no role in the causation of hives. Some experts seem to think that presence of these TPO antibodies is a marker that these hives could last longer or be more difficult to control, but they themselves have no role in the development of actual hives.

Why do I get hives all the time with seemingly no cause?

If you suffer from hives for months without many other symptoms, you may be suffering from a condition called 'Chronic Urticaria'. Chronic (urticaria) hives are hives that last 6 weeks or more. This 6 week cut-off is important as hives that last for longer than 6 weeks are rarely caused by an external cause (trigger). The culprit for most hives cannot be identified in majority of cases.

Six-week cut-off is important

Acute hives, i.e. hives that last for a few days or few weeks (but less than six weeks) may be on occasion be tracked back to an external ‘trigger’. These triggers can be an allergy (a new medication, new food, new thing that you may come in contact with or environmental allergen breathed in etc). More commonly, acute hives can be part of a recent or ongoing infection (common viral or bacterial infections) can manifest with hives as ‘by-product’ of the immune activation necessary to treat the infection.

Acute hives can have triggers

Chronic hives, they are another story..When hives last as long as what people with chronic hives suffer from (often several months, years or even decades), this is not an a ‘reaction’ to an external trigger (as in case of acute hives) but a reflection of an ‘internal issue manifesting on surface’. This manifestation is in form of chronic hives, and thus they are a symptom of an internal disorder. Now, this internal disorder can be as a result of subtle or significant disturbances. And this can be found by doing common laboratory testing, such as complete blood count, liver, kidney, thyroid function or a urine analysis and occasionally markers of inflammation (either ESR – erythrocyte sedimentation rate, also called ‘sed rate’) or CRP (C-reactive protein).

If the common tests are normal, and a person has chronic hives, it is presumed that this internal issue is subtle and the disease is called Chronic Idiopathic Urticaria (CIU). If there is obvious abnormality in any of the common tests, then the test can possibly point towards a potential cause of hives and is called Chronic Secondary Urticaria ("secondary", since it is as a result of, or secondary to this other condition, that is driving the hives). Thus there are 2 main categories of chronic hives, chronic idiopathic (spontaneous) urticaria OR Chronic secondary urticaria.
Classification of hives based on how long you've had them

Chronic idiopathic urticaria is more like a nuisance - a ‘tendency’ to hive. There is no ‘smoking gun’ pointing to the cause and a person just hives as part of who they are. Sometimes, people suffering from chronic hives drive themselves crazy thinking they are allergic to this or that. They may question whether they are now allergic to banana, since they broke out in to a hive-rash after having a banana an hour ago, but they’ve had bananas all their life! Or it was something around the house, a new perfume, a new soap and the list goes on and on...many patients of chronic hives may mistakenly attribute all of their hive flares to an ‘allergy’ and have an exceptionally long list of things they are allergic to. In reality, the hives are just how they are, ‘it just is’, a nuisance, a manifestation of a subtle internal issue, no more.

Chronic secondary urticaria is a symptom on another problem, one that is lurking just underneath the surface and chooses to declare itself in form of bothersome hives. Often conditions that can present with chronic secondary urticaria are inflammatory, autoimmune conditions, blood disorders, cancers, chronic infections etc. Fortunately, these very conditions can be detected by routine tests and which is why it is important to obtain routine testing in chronic urticaria.

To jump to other sections in this topic
  1. What if my hives bruise, blister, scar or heal with marks on skin?
  2. What is happening in skin that leads to chronic hives? 
  3. How to effectively manage hives and why do antihistamines work in most cases?
  4. What are lifestyle recommendations in management of chronic hives?

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