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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The relationship between urticaria and viral infections of the liver is controversial&#46; Some authors have even recently proposed that serology testing for hepatitis B virus &#40;HBV&#41; and hepatitis C virus &#40;HCV&#41; infections in patients with chronic urticaria is not cost-effective&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Hepatitis infections&#44; however&#44; particularly those caused by HBV&#44; are relatively common in patients with chronic urticaria&#44; although no more common than in the general population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 46-year-old woman with celiac disease and chronic HBV infection was referred to our department for evaluation of a 4-year history of evanescent wheals and angioedema&#46; Treatment with 4-fold doses of antihistamines did not achieve adequate control of the urticaria&#44; with Urticaria Activity Scores over 7 days &#40;UAS7&#41; of more than 28 points&#46; Additional tests showed immunoglobulin &#40;Ig&#41; levels above 200<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#44; normal D-dimer levels&#44; and positive HBV serology &#40;positive anti-HB core antibody&#44; negative HB surface antigen&#41; consistent with chronic HBV infection&#46; The initial viral load was 5630<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; The patient was started on omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 4 weeks&#46; She responded after the first dose&#44; reaching a UAS7 score of 0&#46; At 6 months&#44; the viral load had fallen to 900<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; Considering the favorable response&#44; the treatment was discontinued after 4 months of an optimized regimen of omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks&#46; The urticaria recurred&#44; however&#44; at 4 weeks &#40;UAS7<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>28&#41;&#46; Determination of viral load at 3 months showed an increase to 15<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; Omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks was restarted and again induced an early response&#44; with a UAS7 score of less than 6 points&#46; Three months after reinitiation of treatment&#44; the viral load had again decreased to 630<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; The patient&#39;s urticaria is currently under complete control with omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Urticaria and urticarial vasculitis are relatively common extrahepatic manifestations of HBV and HCV infections&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Little evidence is available on the relationship between viral hepatitis treatment and improvement of urticaria&#46; Curative treatment of hepatitis C poses a rather different scenario to that observed with noncurative treatment of hepatitis B&#46; Improvements in urticaria and urticarial vasculitis were described in a series of patients treated for HCV infection&#44; but just 7 patients were studied&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The evidence in the case of HBV infection is limited to 16 patients&#44; none of whom showed improvements in urticaria after chronic antiviral treatment&#46; The above findings suggest that the presence of urticaria may not justify antiviral treatment in patients with urticaria and concomitant HBV infection&#46; The different serologic profiles of HBV infection are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the controversy surrounding the pathophysiologic relationship between urticaria and HBV infection&#44; notable changes in viral load have been observed in relation to urticaria activity and treatment with omalizumab&#46; Chicharro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> were the first authors to describe changes in load during omalizumab treatment&#44; and to our knowledge&#44; we are the second&#46; It seems clear that the increases in load coincided with greater urticaria activity&#46; Likewise&#44; lower loads were observed in the presence of little or no urticaria activity&#46; Although the effect may be causal&#44; there are certain aspects that suggest a possible relationship between the 2 entities&#46; On the one hand&#44; it is known that omalizumab is capable of reducing plasma concentrations of IgE&#44; possibly inducing polarization towards type 1 helper &#40;T<span class="elsevierStyleInf">H</span>1&#41; cells and increasing the release of interferon &#947;&#44; whose antiviral properties are well known&#46; On the other hand&#44; increased production and release of a protein known as Fv has been detected in patients with chronic viral infections of the liver&#44; mainly due to HBV&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Protein Fv acts as a superantigen&#46; It interacts with the V<span class="elsevierStyleInf">H</span>3 domain of IgE&#44; possibly activating mast cells and basophils and&#44; as a result&#44; triggering urticaria&#46; In vitro studies have additionally shown that protein Fv is capable of directly activating basophils&#44; increasing the secretion of interleukin 4&#44; favouring polarization towards the T<span class="elsevierStyleInf">H</span>2 pathway&#44; and stimulating the production of IgE by B cells and plasma cells&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> This increase in IgE levels is particularly interesting considering that patients with elevated IgE respond better to omalizumab&#46; Elevated levels of C5a<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> and C1q<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> deposits have also been detected in blood vessels in biopsy specimens taken from urticarial wheals&#44; indicating a pathophysiologic link between urticaria and liver virus infection&#46; Nonetheless&#44; and despite the evidence available&#44; it is difficult to establish a clear or direct relationship between the 2 entities&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment of patients with viral infections of the liver and urticaria inadequately controlled with antihistamines and omalizumab also poses dilemmas&#46; Although the immunosuppressive properties of cyclosporine are well known among dermatologists&#44; this drug also has certain antiviral properties&#46; Extreme caution must be exerted in patients with associated jaundice and a cholestatic pattern of liver injury&#44; since interference with NTCP transporter activity<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> can cause fatal hepatitis&#46; Cyclosporine&#44; however&#44; is not absolutely contraindicated in patients with chronic HBV infection&#44; as long as HBsAg is negative&#46; HBsAg-positive patients have a moderate risk of hepatitis reactivation&#44; hence the recommendation to administer an antiviral together with cyclosporine&#46; These patients require more rigorous blood testing than usual&#44; as well as joint follow-up with the relevant hospital specialist&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; there is a certain pathophysiologic relationship between chronic liver virus infections and urticaria&#44; as well as a relationship between changes to viral load and changes to urticaria activity&#46; Omalizumab can be considered a safe and effective treatment for patients with this complex profile&#44; and cyclosporine can even be considered in refractory cases&#46; Based on the limited evidence available&#44; the presence of urticaria alone does not justify the use of antiviral treatment&#44; although decisions should always be taken on a case-by-case basis&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antiviral treatment for HBV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43; &#40;IgG&#41;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Infection resolved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Antiviral treatment not needed&#59; no risk of viral reactivation with immunosuppressants &#40;e&#46;g&#46;&#44; cyclosporine&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">IgG &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Chronic infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Low risk of HBV reactivation&#59; strict follow-up during treatment with immunosuppressants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43; &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Vaccinated patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No risk of hepatitis&#59; antibody determination to assess serologic status &#40;revaccinate if necessary&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Patient not in contact with HBV or vaccinated &#40;susceptible to infection&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Referral to preventive medicine to schedule vaccination before initiation of immunosuppressive treatment&nbsp;\t\t\t\t\t\t\n
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Case and Research Letter
Changes in Liver Viral Load in Hepatitis B Virus Infection During Treatment of Chronic Urticaria With Omalizumab: Is There a Pathophysiologic Relationship Between the 2 Diagnostic Entities?
Cambios en la carga viral hepática del virus B durante el tratamiento de la urticaria crónica con omalizumab, ¿existe relación fisiopatológica entre ambas entidades?
F.J. Navarro-Triviñoa,
Autor para correspondencia
fntmed@gmail.com

Corresponding author.
, R. Ruiz-Villaverdeb
a Departamento de Eczema de Contacto e Inmunoalergia, Dermatología, Hospital Universitario San Cecilio, Granada, Spain
b Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The relationship between urticaria and viral infections of the liver is controversial&#46; Some authors have even recently proposed that serology testing for hepatitis B virus &#40;HBV&#41; and hepatitis C virus &#40;HCV&#41; infections in patients with chronic urticaria is not cost-effective&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Hepatitis infections&#44; however&#44; particularly those caused by HBV&#44; are relatively common in patients with chronic urticaria&#44; although no more common than in the general population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 46-year-old woman with celiac disease and chronic HBV infection was referred to our department for evaluation of a 4-year history of evanescent wheals and angioedema&#46; Treatment with 4-fold doses of antihistamines did not achieve adequate control of the urticaria&#44; with Urticaria Activity Scores over 7 days &#40;UAS7&#41; of more than 28 points&#46; Additional tests showed immunoglobulin &#40;Ig&#41; levels above 200<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#44; normal D-dimer levels&#44; and positive HBV serology &#40;positive anti-HB core antibody&#44; negative HB surface antigen&#41; consistent with chronic HBV infection&#46; The initial viral load was 5630<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; The patient was started on omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 4 weeks&#46; She responded after the first dose&#44; reaching a UAS7 score of 0&#46; At 6 months&#44; the viral load had fallen to 900<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; Considering the favorable response&#44; the treatment was discontinued after 4 months of an optimized regimen of omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks&#46; The urticaria recurred&#44; however&#44; at 4 weeks &#40;UAS7<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>28&#41;&#46; Determination of viral load at 3 months showed an increase to 15<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; Omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks was restarted and again induced an early response&#44; with a UAS7 score of less than 6 points&#46; Three months after reinitiation of treatment&#44; the viral load had again decreased to 630<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#46; The patient&#39;s urticaria is currently under complete control with omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg every 6 weeks&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Urticaria and urticarial vasculitis are relatively common extrahepatic manifestations of HBV and HCV infections&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Little evidence is available on the relationship between viral hepatitis treatment and improvement of urticaria&#46; Curative treatment of hepatitis C poses a rather different scenario to that observed with noncurative treatment of hepatitis B&#46; Improvements in urticaria and urticarial vasculitis were described in a series of patients treated for HCV infection&#44; but just 7 patients were studied&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The evidence in the case of HBV infection is limited to 16 patients&#44; none of whom showed improvements in urticaria after chronic antiviral treatment&#46; The above findings suggest that the presence of urticaria may not justify antiviral treatment in patients with urticaria and concomitant HBV infection&#46; The different serologic profiles of HBV infection are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the controversy surrounding the pathophysiologic relationship between urticaria and HBV infection&#44; notable changes in viral load have been observed in relation to urticaria activity and treatment with omalizumab&#46; Chicharro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> were the first authors to describe changes in load during omalizumab treatment&#44; and to our knowledge&#44; we are the second&#46; It seems clear that the increases in load coincided with greater urticaria activity&#46; Likewise&#44; lower loads were observed in the presence of little or no urticaria activity&#46; Although the effect may be causal&#44; there are certain aspects that suggest a possible relationship between the 2 entities&#46; On the one hand&#44; it is known that omalizumab is capable of reducing plasma concentrations of IgE&#44; possibly inducing polarization towards type 1 helper &#40;T<span class="elsevierStyleInf">H</span>1&#41; cells and increasing the release of interferon &#947;&#44; whose antiviral properties are well known&#46; On the other hand&#44; increased production and release of a protein known as Fv has been detected in patients with chronic viral infections of the liver&#44; mainly due to HBV&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Protein Fv acts as a superantigen&#46; It interacts with the V<span class="elsevierStyleInf">H</span>3 domain of IgE&#44; possibly activating mast cells and basophils and&#44; as a result&#44; triggering urticaria&#46; In vitro studies have additionally shown that protein Fv is capable of directly activating basophils&#44; increasing the secretion of interleukin 4&#44; favouring polarization towards the T<span class="elsevierStyleInf">H</span>2 pathway&#44; and stimulating the production of IgE by B cells and plasma cells&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> This increase in IgE levels is particularly interesting considering that patients with elevated IgE respond better to omalizumab&#46; Elevated levels of C5a<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> and C1q<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> deposits have also been detected in blood vessels in biopsy specimens taken from urticarial wheals&#44; indicating a pathophysiologic link between urticaria and liver virus infection&#46; Nonetheless&#44; and despite the evidence available&#44; it is difficult to establish a clear or direct relationship between the 2 entities&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The treatment of patients with viral infections of the liver and urticaria inadequately controlled with antihistamines and omalizumab also poses dilemmas&#46; Although the immunosuppressive properties of cyclosporine are well known among dermatologists&#44; this drug also has certain antiviral properties&#46; Extreme caution must be exerted in patients with associated jaundice and a cholestatic pattern of liver injury&#44; since interference with NTCP transporter activity<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> can cause fatal hepatitis&#46; Cyclosporine&#44; however&#44; is not absolutely contraindicated in patients with chronic HBV infection&#44; as long as HBsAg is negative&#46; HBsAg-positive patients have a moderate risk of hepatitis reactivation&#44; hence the recommendation to administer an antiviral together with cyclosporine&#46; These patients require more rigorous blood testing than usual&#44; as well as joint follow-up with the relevant hospital specialist&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; there is a certain pathophysiologic relationship between chronic liver virus infections and urticaria&#44; as well as a relationship between changes to viral load and changes to urticaria activity&#46; Omalizumab can be considered a safe and effective treatment for patients with this complex profile&#44; and cyclosporine can even be considered in refractory cases&#46; Based on the limited evidence available&#44; the presence of urticaria alone does not justify the use of antiviral treatment&#44; although decisions should always be taken on a case-by-case basis&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antiviral treatment not needed&#59; no risk of viral reactivation with immunosuppressants &#40;e&#46;g&#46;&#44; cyclosporine&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&#47;&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IgG &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low risk of HBV reactivation&#59; strict follow-up during treatment with immunosuppressants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43; &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>IU&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccinated patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No risk of hepatitis&#59; antibody determination to assess serologic status &#40;revaccinate if necessary&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Patient not in contact with HBV or vaccinated &#40;susceptible to infection&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to preventive medicine to schedule vaccination before initiation of immunosuppressive treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Serologic Profiles of HBV Infection&#46;</p>"
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