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Ebo DG, Bahri R, Tontini C, Van Gasse AL, Mertens C, Hagendorens MM, Sabato V, Elst J. Mast cell versus basophil activation test in allergy: Current status. Clin Exp Allergy 2024. [PMID: 38686464 DOI: 10.1111/cea.14487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
In the past two decades, we witnessed the evolution of the basophil activation test (BAT) from mainly research applications to a potential complementary diagnostic tool to document IgE-dependent allergies. However, BAT presents some technical weaknesses. Around 10%-15% of tested patients are non-responders, BAT can be negative immediately post-reaction and the use of fresh basophils, ideally analysed within 4 h of collection, restricts the number of tests that can be performed per sample. The need for fresh basophils is especially limiting when conducting batch analyses and interlaboratory comparisons to harmonize BAT methodology. These limitations significantly hinder the wider application of BAT and urge the development of alternative testing, such as the mast cell activation test (MAT). The essential difference between BAT and MAT is the heterogeneity of the starting material used to perform the assays. Mast cells are tissue-resident, so cannot be easily accessed. Current alternative sources for functional studies are generating primary human mast cells, differentiated from donor progenitor cells, or using immortalized mast cell lines. Hence, the methodological approaches for MAT are not only vastly different from BAT, but also different among MAT protocols. This review summarizes the advantages and disadvantages of BAT and MAT assays, dedicating special attention to elucidating the key differences between the cellular sources used and provides an overview of studies hitherto performed comparing BAT and MAT in the diagnosis of IgE-mediated food and drug allergies.
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Affiliation(s)
- Didier G Ebo
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
- Immunology - Allergology AZ Jan Palfijn, Ghent, Belgium
| | - Rajia Bahri
- Lydia Becker Institute of Immunology and Inflammation, Division of Musculo-skeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Core Technology Facility, University of Manchester, Manchester, UK
| | - Chiara Tontini
- Lydia Becker Institute of Immunology and Inflammation, Division of Musculo-skeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Core Technology Facility, University of Manchester, Manchester, UK
| | - Athina L Van Gasse
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
- Paediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
| | - Christel Mertens
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
| | - Margo M Hagendorens
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
- Paediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
| | - Vito Sabato
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
| | - Jessy Elst
- Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital and Infla-Med Centre of Excellence Antwerp University, Antwerpen, Belgium
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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Rukasin CRF, Rank MA, Park MA, Yee CI, Volcheck GW. A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00342-8. [PMID: 38580206 DOI: 10.1016/j.jaip.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Christine R F Rukasin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Claire I Yee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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Mayorga C, Ariza A, Muñoz-Cano R, Sabato V, Doña I, Torres MJ. Biomarkers of immediate drug hypersensitivity. Allergy 2024; 79:601-612. [PMID: 37947156 DOI: 10.1111/all.15933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/29/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
Immediate drug hypersensitivity reactions (IDHRs) are a burden for patients and the health systems. This problem increases when taking into account that only a small proportion of patients initially labelled as allergic are finally confirmed after an allergological workup. The diverse nature of drugs involved will imply different interactions with the immunological system. Therefore, IDHRs can be produced by a wide array of mechanisms mediated by the drug interaction with specific antibodies or directly on effector target cells. These heterogeneous mechanisms imply an enhanced complexity for an accurate diagnosis and the identification of the phenotype and endotype at early stages of the reaction is of vital importance. Currently, several endophenotypic categories (type I IgE/non-IgE, cytokine release, Mast-related G-protein coupled receptor X2 (MRGPRX2) or Cyclooxygenase-1 (COX-1) inhibition and their associated biomarkers have been proposed. A precise knowledge of endotypes will permit to discriminate patients within the same phenotype, which is crucial in order to personalise diagnosis, future treatment and prevention to improve the patient's quality of life.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
| | - Adriana Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
| | - Rosa Muñoz-Cano
- Allergy Department, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology, Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Inmaculada Doña
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
| | - Maria J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina - IBIMA Plataforma BIONAND, Málaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
- Medicine Department, Universidad de Málaga-UMA, Málaga, Spain
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Mayorga C, Çelik GE, Pascal M, Hoffmann HJ, Eberlein B, Torres MJ, Brockow K, Garvey LH, Barbaud A, Madrigal-Burgaleta R, Caubet JC, Ebo DG. Flow-based basophil activation test in immediate drug hypersensitivity. An EAACI task force position paper. Allergy 2024; 79:580-600. [PMID: 38084472 DOI: 10.1111/all.15957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 12/22/2023]
Abstract
Diagnosing immediate drug hypersensitivity reactions (IDHRs) can pose a significant challenge and there is an urgent need for safe and reliable tests. Evidence has emerged that the basophil activation test (BAT), an in vitro assay that mirrors the in vivo response, can be a complementary test for many drugs. In this position paper, members of Task Force (TF) "Basophil activation test in the evaluation of Drug Hypersensitivity Reactions" from the European Academy of Allergy and Clinical Immunology (EAACI) present the data from a survey about the use and utility of BAT in IDHRs in Europe. The survey results indicate that there is a great interest for using BAT especially for diagnosing IDHRs. However, there are still main needs, mainly in the standardization of the protocols. Subsequently consensus-based recommendations were formulated for: (i) Technical aspects of BAT in IDHRs including type of sample, management of drugs, flow cytometry protocols, interpretation of the results; and (ii) Drug-specific aspects that should be taken into account when performing BAT in relation to betalactams, neuromuscular blocking agents, fluoroquinolones, chlorhexidine, opioids, radio contrast media, chemotherapeutics, biological agents, nonsteroidal anti-inflammatory drugs, COVID vaccine, and excipients. Moreover, aspects in the evaluation of pediatric population have also been considered. All this indicates that BAT offers the clinician and laboratory a complementary tool for a safe diagnostic for IDHRs, although its place in the diagnostic algorithm depends on the drug class and patient population (phenotype, geography, and age). The standardization of BAT is important for generalizing this method beyond the individual laboratory.
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Affiliation(s)
- C Mayorga
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
| | - G E Çelik
- Department of chest disease, Division of Allergy & Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - M Pascal
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Immunology Department, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - H J Hoffmann
- Department of Clinical Medicine and Department of Clinical Immunology, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - B Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - M J Torres
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Medicine Department, Malaga University, Málaga, Spain
| | - K Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - L H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen and Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - A Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP.Sorbonne Université, Hôpital Tenon, Département de dermatologie et allergologie, Paris, France
| | - R Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - J C Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - D G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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Vlaeminck N, Poorten MLVD, Nygaard Madsen C, Bech Melchiors B, Michel M, Gonzalez C, Schrijvers R, Elst J, Mertens C, Saldien V, Vitte J, Garvey LH, Sabato V, Ebo DG. Paediatric perioperative hypersensitivity: the performance of the current consensus formula and the effect of uneventful anaesthesia on serum tryptase. BJA OPEN 2024; 9:100254. [PMID: 38261931 PMCID: PMC10797541 DOI: 10.1016/j.bjao.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/16/2023] [Indexed: 01/25/2024]
Abstract
Background Paired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children. Methods We prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60-90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark. Results We observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L-1 (-15.9%; P<0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST>bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% vs 31.9%, P<0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3-4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% vs 61.8%; P=0.008 and 78.0% vs 48.8%; P<0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively. Conclusions This is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST>bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.
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Affiliation(s)
- Nils Vlaeminck
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Marie-Line van der Poorten
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Belgium
| | - Cecilie Nygaard Madsen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Birgitte Bech Melchiors
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Université, MEPHI, Marseille, France
- IHU Méditerranée Infection, Marseille, France
- CHU Nîmes, Laboratoire d’Immunologie, Nîmes, France
| | - Constance Gonzalez
- Aix-Marseille Univ, University Hospitals of Marseille, Laboratoire d’Immunologie, Marseille, France
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Jessy Elst
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Christel Mertens
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Vera Saldien
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Joana Vitte
- University of Reims Champagne-Ardenne, INSERM UMR-S 1205 P3CELL and Immunology Laboratory, University Hospital of Reims, Reims, France
| | - Lene H. Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vito Sabato
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Didier G. Ebo
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
- Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
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Elst J, Van Houdt M, van der Poorten MLM, Van Gasse AL, Mertens C, Toscano A, Beyens M, De Boeck E, Sabato V, Ebo DG. Comparison of the passive mast cell activation test with the basophil activation test for diagnosis of perioperative rocuronium hypersensitivity. Br J Anaesth 2024; 132:483-490. [PMID: 37031026 DOI: 10.1016/j.bja.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/08/2023] [Accepted: 02/27/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Rocuronium is a major cause of perioperative hypersensitivity (POH). Skin tests (STs) and quantification of specific immunoglobulin E antibodies (sIgEs) can yield incongruent results. In such difficult cases, the basophil activation test (BAT) can be helpful. Here, we evaluated the passive mast cell activation test (pMAT) as a substitute of BAT as part of the diagnostic tests for rocuronium allergy. METHODS Sera from patients with a suspected POH reaction potentially related to rocuronium were included. All patients had a complete diagnostic investigation, including STs, quantification of sIgEs to morphine and rocuronium, and BAT. For execution of pMAT, human mast cells were generated from healthy donor peripheral blood CD34+ progenitor cells and sensitised overnight with patient sera. RESULTS In total, 90 sera were studied: 41 from ST+sIgE+ patients, 13 from ST-sIgE- patients, 20 from ST+sIgE- patients, and 16 from ST-sIgE+ patients. According to BAT results, patients were further allocated into subgroups. Of the 38 BAT+ patients, 25 (66%) showed a positive pMAT as well. Of the 44 BAT- patients, 43 (98%) also showed a negative pMAT. Mast cells that were not passively sensitised did not respond to rocuronium. CONCLUSIONS We show that the pMAT, in many cases, can substitute for BAT in the diagnosis of rocuronium hypersensitivity and advance diagnosis in difficult cases with uncertain ST or sIgE results when BAT is not locally available.
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Affiliation(s)
- Jessy Elst
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line M van der Poorten
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Paediatrics and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Paediatrics and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Alessandro Toscano
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Michiel Beyens
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Evelien De Boeck
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium.
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Khan DA, Phillips EJ, Accarino JJ, Gonzalez-Estrada A, Otani IM, Ramsey A, Arroyo AC, Banerji A, Chow T, Liu AY, Stone CA, Blumenthal KG. United States Drug Allergy Registry (USDAR) grading scale for immediate drug reactions. J Allergy Clin Immunol 2023; 152:1581-1586. [PMID: 37652140 PMCID: PMC10872843 DOI: 10.1016/j.jaci.2023.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND There is no accepted grading system classifying the severity of immediate reactions to drugs. OBJECTIVE The purpose of this article is to present a proposed grading system developed through the consensus of drug allergy experts from the United States Drug Allergy Registry (USDAR) Consortium. METHODS The USDAR investigators sought to develop a consensus severity grading system for immediate drug reactions that is applicable to clinical care and research. RESULTS The USDAR grading scale scores severity levels on a scale of 0 to 4. A grade of no reaction (NR) is used for patients who undergo challenge without any symptoms or signs, and it would confirm a negative challenge result. A grade 0 reaction is indicative of primarily subjective complaints that are commonly seen with both historical drug reactions and during drug challenges, and it would suggest a low likelihood of a true drug allergic reaction. Grades 1 to 4 meet the criteria for a positive challenge result and may be considered indicative of a drug allergy. Grade 1 reactions are suggestive of a potential immediate drug reaction with mild symptoms. Grade 2 reactions are more likely to be immediate drug reactions of moderate severity. Grade 3 reactions have features suggestive of a severe allergic reaction, whereas grade 4 reactions are life-threatening reactions such as anaphylactic shock and fatal anaphylaxis. CONCLUSION This proposed grading schema for immediate drug reactions improves on prior schemata by being developed specifically for immediate drug reactions and being easy to implement in clinical and research practice.
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Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - John J Accarino
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic, Phoenix, Ariz
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, Calif
| | - Allison Ramsey
- Rochester Regional Health, Rochester, NY; Department of Allergy/Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anna Chen Arroyo
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Timothy Chow
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex; Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Anne Y Liu
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif; Division of Infectious Disease, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Kimberly G Blumenthal
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Ebo DG, van der Poorten MLM, Hopkins PM. Suspected perioperative anaphylaxis: are we making the correct diagnosis? Br J Anaesth 2023:S0007-0912(23)00235-0. [PMID: 37271719 DOI: 10.1016/j.bja.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
We provide a commentary on aspects of a prospective study of the epidemiology of perioperative anaphylaxis in Japan (Japanese Epidemiologic Study for Perioperative Anaphylaxis [JESPA]). Accurate diagnosis of perioperative anaphylaxis is important for research but essential for clinical safety. We evaluate the diagnostic approach used in the JESPA study and caution against over-reliance on diagnostic tests that lack sensitivity and specificity when clinical data suggest an immediate perioperative hypersensitivity reaction is likely.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Savic L, Volcheck GW, Garvey LH. Treatment of perioperative anaphylaxis: room for improvement? Br J Anaesth 2023:S0007-0912(23)00229-5. [PMID: 37244833 DOI: 10.1016/j.bja.2023.04.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/29/2023] Open
Abstract
Perioperative anaphylaxis is associated with significant morbidity and mortality. Prompt and appropriate treatment is required for optimal outcome. Despite general knowledge of this condition, delays occur in the administration of epinephrine and in particular the use of i.v. route of administration in the perioperative setting. Barriers should be addressed to allow prompt utilisation of i.v. epinephrine in perioperative anaphylaxis.
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Affiliation(s)
- Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lene H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.
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10
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Ebo DG, Vlaeminck N, van der Poorten MLM, Elst J, Toscano A, Van Gasse AL, Hagendorens MM, Aerts S, Adriaensens I, Saldien V, Sabato V. A quarter of a century fundamental and translational research in perioperative hypersensitivity and anaphylaxis at the Antwerp university hospital, a Belgian Centre of Excellence of the World Allergy Organization. World Allergy Organ J 2023; 16:100759. [PMID: 37025251 PMCID: PMC10070178 DOI: 10.1016/j.waojou.2023.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 04/03/2023] Open
Abstract
Perioperative hypersensitivity constitutes an important health issue, with potential dramatic consequences of diagnostic mistakes. However, safe and correct diagnosis is not always straightforward, mainly because of the application of incorrect nomenclature, absence of easy accessible in-vitro/ex-vivo tests and uncertainties associated with the non-irritating skin test concentrations. In this editorial we summarize the time line, seminal findings, and major realizations of 25 years of research on the mechanisms, diagnosis, and management of perioperative hypersensitivity.
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Cai H, Liu X, Wang D, Li W, Ma H, Zhao J. Management of Suspected Life-Threatening Perioperative Anaphylaxis and Risk Factors for Near-Fatal and Fatal Outcomes: A Retrospective Study in China. Ther Clin Risk Manag 2023; 19:383-394. [PMID: 37193306 PMCID: PMC10183184 DOI: 10.2147/tcrm.s406515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023] Open
Abstract
Purpose Perioperative anaphylaxis (POA) is an acute severe systemic hypersensitivity reaction characterized by life-threatening respiratory and circulatory collapse. In our previous study, we reported the epidemiology of suspected POA in China. In the present study, we aimed to elucidate the management and outcomes of these cases and further verify the risk factors for near-fatal and fatal outcomes. Patients and Methods This was a retrospective study of 447 cases of suspected life-threatening POA encountered at 112 tertiary hospitals in mainland China between September 2018 and August 2019. Patient characteristics, symptoms, duration of hypotension, treatments, and clinical outcomes were documented. Bivariate logistic regression was used to identify risk factors for near-fatal and fatal outcomes. Results Most cases of suspected POA (89.9%) were recognized and treated within 5 min. Epinephrine was administered as the initial treatment in 232 (51.9%) cases. Corticosteroids (26.6%), other vasoactive drugs (18.3%), and bronchodilators (1.6%) were also administered as the initial treatment instead of epinephrine. The initial dosage of epinephrine (median, 35 µg) was insufficient according to the anaphylaxis guidelines. On multivariable analysis, age ≥65 years (odds ratio [OR] 7.48; 95% confidence interval [CI]: 1.33-41.87, P=0.022), ASA physical status IV (OR 17.68; 95% CI: 4.53-68.94; P<0.001), and hypotension duration ≥15 min (OR 3.63; 95% CI: 1.11-11.87; P=0.033) were risk factors for fatal and near-fatal outcomes. Conclusion Most cases in this study were managed in a timely manner, but the epinephrine application should be optimized according to the guidelines. Age ≥65 years, ASA physical status IV, and long-term hypotension were risk factors for near-fatal and fatal outcomes.
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Affiliation(s)
- Huamei Cai
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Xiaowen Liu
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Dingyi Wang
- National Center for Respiratory Medicine & National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine & Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Department of Clinical Research and Data Management Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Weixia Li
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Hongli Ma
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
- Correspondence: Jing Zhao, Department of Anesthesiology, China- Japan Friendship Hospital, No. 2 Yinghua East Road, Beijing, 100029, People’s Republic of China, Tel +86 010 8420 5876, Email
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Could Artificial Intelligence Prevent Intraoperative Anaphylaxis? Reference Review and Proof of Concept. Medicina (B Aires) 2022; 58:medicina58111530. [PMID: 36363487 PMCID: PMC9694532 DOI: 10.3390/medicina58111530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 01/25/2023] Open
Abstract
Drugs and various medical substances have been used for many decades to diagnose or treat diseases. Procedures like surgery and anesthesia (either local or general) use different pharmacological products during these events. In most of the cases, the procedure is safe and the physician performs the technique without incidents. Although they are safe for use, these substances (including drugs) may have adverse effects, varying from mild ones to life-threatening reactions in a minority of patients. Artificial intelligence may be a useful tool in approximating the risk of anaphylaxis before undertaking a medical procedure. This material presents these undesirable responses produced by medical products from a multidisciplinary point of view. Moreover, we present a proof of concept for using artificial intelligence as a possible guardship against intraoperative anaphylaxis.
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14
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Making a Diagnosis in Allergic Reactions Occurring in the Operating Room. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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van der Poorten MLM, Vlaeminck N, Van Pée J, Thiele N, Smout K, Elst J, Toscano A, Van Gasse AL, Hagendorens MM, Aerts S, Adriaensens I, Sermeus LA, Garvey LH, Sabato V, Ebo DG. Drug provocation tests with hypnotics, opioids, and neuromuscular blocking agents in the diagnosis of suspected perioperative hypersensitivity. Br J Anaesth 2022; 129:e119-e122. [DOI: 10.1016/j.bja.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
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16
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van der Poorten MLM, Walschot M, Faber M, Elst J, Van Gasse AL, De Puysseleyr L, Mertens CM, Hagendorens MM, Garvey LH, Sabato V, Ebo DG. Reliability of Early and Late Testing for Suspected Perioperative Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1057-1062.e2. [PMID: 34767998 DOI: 10.1016/j.jaip.2021.10.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The optimal timing of diagnostic testing for perioperative hypersensitivity (POH) remains unknown. It has been recommended that investigation is best carried out at least 4 to 6 weeks after the event. On the other hand, guidelines discourage the use of in vitro tests later than 3 years after the index reaction. OBJECTIVE This retrospective study aimed to assess the reliability of early and late skin tests (STs). It also attempted to verify whether discouraging late ex vivo and in vitro tests is substantiated. METHODS For the first aim, patients were stratified over three epochs: an early timing group, with investigations performed within 6 weeks; a recommended timing group, with tests performed between 6 weeks and 6 months; and a late timing group, tested later than 6 months after the event. For the second study purpose, we studied the reliability of specific IgE quantification and basophil activation test rocuronium within 6 weeks and after 3 years in patients who experienced an ST-proven POH to rocuronium. RESULTS A total of 677 patients were included. Based on a positive ST result, a causative agent was found in 74.2% of the early timing group, 62.6% of the recommended timing group, and 50% of the late timing group. A positive specific IgE for rocuronium or morphine was found in 80% of patients tested within 6 weeks, 63% of patients tested between 6 weeks and 3 years, and 50% of patients tested more than 3 years after the event. A positive basophil activation test was found in 83.3%, 51%, and 20%, respectively, of patients. CONCLUSIONS Our data confirm that evaluation of drug allergy for suspected POH can be performed before 6 weeks after the event, and there is no maximal upper time limit disclosing ex vivo and in vitro testing.
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Affiliation(s)
- Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Mark Walschot
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Margaretha Faber
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Leander De Puysseleyr
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Christel M Mertens
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vito Sabato
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, and Rheumatology, Antwerp University Hospital, and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium.
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Kosciuczuk U, Knapp P. What do we know about perioperative hypersensitivity reactions and what can we do to improve perioperative safety? Ann Med 2021; 53:1772-1778. [PMID: 34632895 PMCID: PMC8510593 DOI: 10.1080/07853890.2021.1976818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/31/2021] [Indexed: 11/05/2022] Open
Abstract
Hypersensitivity reactions are an important aspect of perioperative care and are a crucial interdisciplinary issue in anaesthesiological practice, as well as allergological and laboratory diagnostics. This phenomenon was observed as early as the 1980s and 1990s in Western European countries, and knowledge on this subject has grown significantly over time. Although hypersensitivity reactions are not frequent events (the incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations), their courses are unfortunately serious and life-threatening. It should also be noted that there is no information regarding the occurrence of perioperative hypersensitivity reactions in many countries. Hence, global assessment of the problem is underestimated. The primary source of actual knowledge comes from epidemiological studies, which indicate an increasing frequency of hypersensitivity reaction occurrence and changes in aetiological factors. The first report from France (1984 to 1989) described two main causes - neuromuscular blocking agents and hypnotic agents. The following years confirmed an increase in perioperative hypersensitivity reactions associated with latex and antibiotics. The most recent data from the National Audit Project 6 indicated increased participation of antibiotics, chlorhexidine, and contrast agents. The results of epidemiological analyses are the basis of medical management guidelines and practice modification. Thanks to the activity of many organisations monitoring the intensity and nature of perioperative hypersensitivity reactions, guidelines for diagnostics and management have been developed. This article presents the results of numerous studies, including the first and the most recent, from various geographical regions. The clinical significance, pathogenesis mechanisms are also discussed. This publication also presents important directions for further scientific and epidemiological research on perioperative hypersensitivity reactions.Key messagesThe incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations.Reactions may occur during the first episode of anaesthesia, most frequently in the induction of general anaesthesia, and much less frequently during postoperative follow-up.The first reports of perioperative hypersensitivity reaction come from the 1990s, and knowledge on this subject has grown significantly over time.In many countries, multidisciplinary teams and organisations have been established to identify, monitor the occurrence of this phenomenon, and have set the directions of medical activities and have changed the rules and recommendations.There is no information about the occurrence of perioperative hypersensitivity reactions in many countries, and global assessment of the problem is underestimated. Additionally, there is a great need to develop a system to monitor their occurrence in other countries.The long-term epidemiologic studies have demonstrated variability in pharmacologic triggers. However, the main pharmacological substances (antibiotics, muscle relaxants, disinfectans, contrast agents) are related to aspects of patient safety during anaesthesia.
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Affiliation(s)
- Urszula Kosciuczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Bialystok, Białystok, Poland
| | - Pawel Knapp
- Department of Gynecology and Gynecological Oncology, Medical University of Bialystok, Białystok, Poland
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18
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Abstract
Perioperative anaphylaxis is a potentially life-threatening and under-recognized event most commonly caused by antibiotics, neuromuscular blocking agents, dyes, latex, and disinfectants. This review provides updates in the epidemiology and pathogenesis of perioperative anaphylaxis, discusses culprit agents, and highlights the tenets of management including a comprehensive allergy evaluation.
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Affiliation(s)
- Mitchell M Pitlick
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
| | - Gerald W Volcheck
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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19
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on how best to manage the investigation of suspected perioperative hypersensitivity reactions based on recent literature and key publications. RECENT FINDINGS In the past two years, several very important initiatives have been taken in the field of perioperative hypersensitivity. The 6th national audit project in the United Kingdom has provided new knowledge through a series of studies, including a nationwide prospective study, and the European Academy of Allergy and Clinical Immunology has commissioned a position paper with updated recommendations for investigations. Lastly, a large international working group comprising experts in anesthesiology, allergology, and immunology, the International Suspected Perioperative Allergic Reactions group, has published a series of articles providing updates and new insights into several different key areas of perioperative hypersensitivity. SUMMARY The investigation of perioperative hypersensitivity reactions is highly complex and aims to identify the correct culprit to ensure future avoidance but also to disprove allergy to other suspected culprits, making them available for subsequent anesthesia. To achieve this, close collaboration between anesthesiologists and allergists is called upon to ensure the best possible outcome for the patient.
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20
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Bogas G, Doña I, Dionicio J, Fernández TD, Mayorga C, Boteanu C, Montañez MI, Al-Ahmad M, Rondón C, Moreno E, Laguna JJ, Torres MJ. Diagnostic Approach of Hypersensitivity Reactions to Cefazolin in a Large Prospective Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4421-4430.e4. [PMID: 34464750 DOI: 10.1016/j.jaip.2021.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cefazolin is a common trigger of perioperative anaphylaxis. The diagnostic approach is controversial because the optimal concentration for skin testing is uncertain, drug provocation tests (DPTs) are contraindicated in severe reactions, and in vitro tests are not thoroughly validated. OBJECTIVE We aimed to characterize a large number of patients reporting cefazolin allergic reactions and to analyze the diagnostic role of in vivo and in vitro tests. METHODS We prospectively evaluated patients with suspicion for allergic reactions to cefazolin by clinical history, skin tests (STs), and, if negative, DPT. In a subgroup of patients, basophil activation test (BAT) and radioallergosorbent test were done before allergologic workup was performed and the final diagnosis was achieved. RESULTS We evaluated 184 patients, 76 of whom were confirmed as allergic (41.3%), 90 were nonallergic (48.9%), and 18 were nonconfirmed (9.8%). All patients reporting anaphylactic shock and most reporting anaphylaxis were confirmed to be allergic (P < .001). Forty allergic patients (52.6%) were confirmed by STs, 22 by DPT (28.9%), and 14 by clinical history (18.4%). All subjects manifesting exanthemas and pruritus were nonallergic. The BAT sensitivity was 66.7% when CD63 and CD203c were combined as activation markers. Six of 8 patients with negative STs and positive DPT had a positive BAT. CONCLUSIONS Patients allergic to cefazolin often reported severe immediate-type reactions. Skin tests enabled a diagnosis in half of patients when using cefazolin at 20 mg/mL. Unfortunately, DPT could not be performed in all patients owing to reaction severity, which makes BAT a promising diagnostic tool. Further research is needed to clarify the underlying mechanisms, especially in severe reactions.
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Affiliation(s)
- Gador Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Inmaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | | | - Tahia D Fernández
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Department of Cell Biology, Genetics, and Physiology, Universidad de Málaga, Málaga, Spain
| | - Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Cosmin Boteanu
- Allergy Section, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - María I Montañez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait; Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Carmen Rondón
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Esther Moreno
- Allergy Service, University Hospital of Salamanca., Salamanca, Spain
| | - Jose J Laguna
- Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Faculty of Medicine, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Maria J Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA-ARADyAL, Málaga, Spain; Allergy Unit, Hospital de la Cruz Roja, Madrid, Spain; Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain; Department of Medicine, Universidad de Málaga, Málaga, Spain.
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21
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Abstract
Perioperative anaphylaxis (PA) is a rare but life-threatening condition that poses diagnostic and management challenges in the operating room. The incidence of severe perioperative reactions is estimated to be approximately 1:7000-10,000. Management involves both immediate stabilization of the patient and identifying the culprit agent. Identification is essential to prevent recurrence of the event in subsequent surgeries and to avoid unnecessary labeling of drug allergy. Identifying all possible exposures including medications, disinfectants, latex, and dyes and choosing the appropriate tests are essential for proper evaluation. To identify the culprit, primary testing modalities include tryptase at the time of the reaction with subsequent levels and skin testing with nonirritating concentrations to the medications and substances utilized during the procedure and those potentially used as alternates. This strategy provides guidance for future surgeries and procedures. Close collaboration between the allergy, anesthesiology, and surgery teams is essential for appropriate management of these patients at the time of the reaction, during the post event evaluation and in preparation for subsequent surgeries.
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Ebo DG, De Puysseleyr LP, Van Gasse AL, Elst J, Poorten MLVD, Faber MA, Mertens C, Van Houdt M, Hagendorens MM, Sermeus L, Vitte J, Moise M, Garvey LH, Castells MC, Tacquard C, Mertes PM, Schwartz LB, Sabato V. Mast Cell Activation During Suspected Perioperative Hypersensitivity: A Need for Paired Samples Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3051-3059.e1. [PMID: 33862269 DOI: 10.1016/j.jaip.2021.03.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/12/2021] [Accepted: 03/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perioperative hypersensitivity (POH) reactions constitute a significant clinical and diagnostic challenge. A transient increase in serum tryptase during POH reflects mast cell activation (MCA) and helps to recognize an underlying hypersensitivity mechanism. OBJECTIVE To determine the diagnostic performance of different tryptase decision thresholds based on single and paired measurements to document MCA in suspected POH. METHODS Acute serum tryptase (aST) and baseline serum tryptase (bST) samples were obtained from patients referred to our outpatients clinic because of clinical POH. Tryptase samples from controls were obtained before induction (Tt0) and 1.5 hours after induction (Tt1) in uneventful anesthesia. Different cutoff points for tryptase increase over bST and the percentage increase in tryptase (%T) were calculated and compared with existing thresholds: aST > [1.2 × (bST) + 2] (consensus formula), aST higher than 11.4 ng/mL, and aST higher than 14 ng/mL. RESULTS Patients with POH had higher bST and aST levels compared with controls (respectively 5.15 vs 2.28 ng/mL for bST and 20.30 vs 1.92 ng/mL for aST). The consensus formula and a tryptase increase over bST of greater than or equal to 3.2 ng/mL held the highest accuracies to document MCA in POH (respectively 81% and 82%). A bST of higher than 8 ng/mL was present in 4% of controls, 5% of patients with grade 1 POH, 24% of patients with grade 2 POH, 15% of patients with grade 3 POH, and 17% of patients with grade 4 POH. CONCLUSIONS Our data endorse the consensus formula for detection of MCA in POH. Furthermore, it shows that a bST of higher than 8 ng/mL was associated with occurrence of anaphylaxis.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.
| | - Leander P De Puysseleyr
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line van der Poorten
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, Department of Paediatrics and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium
| | - Luc Sermeus
- Department of Anaesthesia, Antwerp University Hospital, Antwerp, Belgium
| | - Joana Vitte
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; IDESP, INSERM, University of Montpellier, Montpellier, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Michel Moise
- Aix-Marseille University, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, Ha, Denmark
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, Strasbourg, France
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunologie, Virginia Commonwealth University, Richmond, Va
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
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23
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Vitte J, Sabato V, Tacquard C, Garvey LH, Michel M, Mertes PM, Ebo DG, Schwartz LB, Castells MC. Use and Interpretation of Acute and Baseline Tryptase in Perioperative Hypersensitivity and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2994-3005. [PMID: 33746087 DOI: 10.1016/j.jaip.2021.03.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
Paired acute and baseline serum or plasma tryptase sampling and determination have recently been included as a mechanistic approach in the diagnostic and management guidelines of perioperative immediate hypersensitivity and anaphylaxis. The timing of this paired sampling is clearly defined in international consensus statements, with the optimal window for acute tryptase sampling between 30 minutes and 2 hours after the initiation of symptoms, whereas baseline tryptase should be measured in a sample collected before the event (preop) or at least 24 hours after all signs and symptoms have resolved. A transient elevation of the acute tryptase level greater than [2 + (1.2 × baseline tryptase level)] supports the involvement and activation of mast cells. Here, we provide the clinical, pathophysiological, and technical rationale for the procedure and interpretation of paired acute and baseline tryptase. Clinical examples, up-to-date knowledge of hereditary α-tryptasemia as a frequent cause of baseline tryptase of 7 μg/L and higher, mastocytosis, other clonal myeloid disorders, cardiovascular or renal failure, and technical improvements resulting in continued lowering of the 95th percentile value are discussed. Clues for improved management of perioperative immediate hypersensitivity and anaphylaxis include (1) sustained dissemination and implementation of updated guidelines; (2) preoperative sample storage for deferred analysis; (3) referral for thorough allergy investigation, screening for mast cell-related disorders, and recommendations for future anesthetic procedures; and (4) sustained collaboration between anesthesiologists, immunologists, and allergists.
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Affiliation(s)
- Joana Vitte
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; IDESP, INSERM UMR UA11, University of Montpellier, Montpellier, France
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunology, Virginia Commonwealth University, Richmond, Va
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Kalangara J, Vanijcharoenkarn K, Lynde GC, McIntosh N, Kuruvilla M. Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management. Curr Allergy Asthma Rep 2021; 21:4. [PMID: 33409706 DOI: 10.1007/s11882-020-00980-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation. RECENT FINDINGS Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.
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Affiliation(s)
- Jerry Kalangara
- Division of Pain Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Health Care System, Decatur, GA, USA
| | - Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nichole McIntosh
- Atlanta VA Health Care System, Decatur, GA, USA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Merin Kuruvilla
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA.
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25
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Mueller‐Wirth N, Buenter A, Jörg L, Ebo DG, Glatz M, Fernando SL, Spoerl D, Helbling A, Hausmann O, Gupta N, Pichler WJ. IgE-mediated chlorhexidine allergy-Cross-reactivity with other biguanide disinfectants. Allergy 2020; 75:3237-3247. [PMID: 32678912 DOI: 10.1111/all.14497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chlorhexidine (CHX) is a widely utilized disinfectant that can cause IgE-mediated urticaria/anaphylaxis. The cross-reactivity of patients with IgE-mediated CHX allergy with other disinfectants, which share structural similarities with CHX like polyhexanide (polyhexamethylene biguanide; PHMB), alexidine (ALX), or octenidine (OCT), is unknown. METHODS Forty-four patients with anaphylaxis or urticaria upon CHX exposure and positive skin prick test (SPT) and/or positive CHX ImmunoCAP test (Phadia TFS, Uppsala, Sweden) were recruited. IgE to the biguanide and/or hexamethylene structure was investigated with PHMB ImmunoCAP (n = 32) and by basophil activation tests (BAT) with CHX and ALX (n = 37). Inhibition tests of CHX and PHMB ImmunoCAPs by CHX, ALX, PHMB, and OCT were performed. RESULTS IgE reactivity to PHMB as surrogate marker for biguanide/hexamethylene reactivity was detected in 5/32 sera. Seven of 37 patients showed a positive BAT with ALX, but only under optimized conditions. Binding to CHX ImmunoCAP was inhibited by ALX in 1/32 sera, and binding to PHMB was blocked by ALX (1/5) and by OCT in another (1/5). In SPT, 9/10 patients were positive for CHX and 3 of them with ALX (only at highest concentration at 5 mg/mL). A further patient reacted primarily with OCT and showed IgE cross-reactivity with CHX, ALX, and PHMB. CONCLUSION The IgE response to CHX seems polyclonal. The chloroguanide ending of CHX is the main epitope for the IgE and is suitable as screening assay to detect CHX reactivity. IgE-reactivities with the biguanide or hexamethylene components of other disinfectants (ALX, PHMB) can be detected by SPT, PHMB ImmunoCAP, and ALX-BAT in 15%-33% of CHX-allergic patients.
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Affiliation(s)
| | - Antonia Buenter
- ADR‐AC GmbH Bern Switzerland
- Dep. of Rheumatology, Immunology and Allergology, Inselspital University of Bern Bern Switzerland
| | - Lukas Jörg
- Dep. of Rheumatology, Immunology and Allergology, Inselspital University of Bern Bern Switzerland
| | - Didier G. Ebo
- Department of Immunology ‐ Allergology – Rheumatology and the Infla‐Med Centre of Excellence University AntwerpAntwerp University Hospital Antwerpen Belgium
| | - Martin Glatz
- Allergiestation University of Zurich Zurich Switzerland
| | - Suran L. Fernando
- Faculty of Medicine and Health (Immunology and Infectious Diseases) University of Sydney Sydney NSW Australia
| | - David Spoerl
- Department of Clinical Immunology and Allergy HUG Geneva Geneva Switzerland
| | - Arthur Helbling
- Dep. of Rheumatology, Immunology and Allergology, Inselspital University of Bern Bern Switzerland
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26
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Elst J, van der Poorten MLM, Faber MA, Van Gasse AL, Garvey LH, Bridts CH, De Puysseleyr LP, Mertens C, Hagendorens MM, Sabato V, Ebo DG. Mast cell activation test in chlorhexidine allergy: a proof of concept. Br J Anaesth 2020; 125:970-975. [DOI: 10.1016/j.bja.2020.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/02/2020] [Accepted: 06/20/2020] [Indexed: 12/20/2022] Open
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27
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Van Der Poorten MLM, Molina-Molina G, Van Gasse AL, Hagendorens MM, Faber MA, De Puysseleyr L, Elst J, Mertens CM, Horiuchi T, Sabato V, Ebo DG. Application of specific-to-total IgE ratio does not benefit diagnostic performance of serologic testing for rocuronium allergy. Br J Anaesth 2020; 125:e443-e446. [DOI: 10.1016/j.bja.2020.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022] Open
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28
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Ariza A, Mayorga C, Bogas G, Barrionuevo E, Torres MJ, Doña I, Fernandez TD. Advances and novel developments in drug hypersensitivity diagnosis. Allergy 2020; 75:3112-3123. [PMID: 32990987 DOI: 10.1111/all.14603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
A correct diagnosis of drug hypersensitivity reactions (DHRs) is very important for both the patient and health system. However, DHRs diagnosis is complex, time consuming, requires trained personnel, is not standardized for many drugs, involves procedures not exempt of risk, and in most cases lacks standardized in vivo and in vitro tests. Thus, there is an urgent need for improving the different approaches to diagnose patients with suspected DHRs. In this review, we have analyzed the advances performed in immediate and nonimmediate DHRs diagnosis during the last two years and obtained several conclusions: the significant heterogeneity in current practice among centers illustrates the need to re-evaluate, update, and standardize in vivo tests and protocols for the diagnosis and management of patients with suspected drug allergy. Regarding in vitro tests, the latest studies have focused on increasing their sensitivity or on establishing the sensitivity and specificity for the tests performed with new drugs. There seems to be a consensus about combining in vivo and in vitro tests as the best way to increase the diagnostic accuracy.
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Affiliation(s)
- Adriana Ariza
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Gador Bogas
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Esther Barrionuevo
- Asthma and Immunoallergic Diseases Research Group Instituto de Investigación Hospital 12 de Octubre (i+12)‐ARADyAL Madrid Spain
- Allergy Unit Hospital Universitario 12 de Octubre Madrid Spain
| | - Maria J. Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Departamento de Medicina Universidad de Málaga Málaga Spain
| | - Inmaculada Doña
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Departamento de Biología Celular, Genética y Fisiología Universidad de Málaga Málaga Spain
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29
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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30
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Gonzalez-Estrada A, Carrillo-Martin I, Renew JR, Rank MA, Campbell RL, Volcheck GW. Incidence of and risk factors for perioperative or periprocedural anaphylaxis in the United States from 2005 to 2014. Ann Allergy Asthma Immunol 2020; 126:180-186.e3. [PMID: 33068738 DOI: 10.1016/j.anai.2020.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/16/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The estimated worldwide incidence of perioperative or periprocedural anaphylaxis (PA) is between 1 in 1250 and 1 in 20,000 procedures. OBJECTIVE To evaluate the incidence of PA in the United States and compare patient characteristics and underlying risk factors using a large national database. METHODS Using deidentified data from the nationwide inpatient sample from 2005 to 2014, we identified cases of PA through the International Classification of Diseases, Ninth Revision, Clinical Modification codes and conducted a retrospective analysis. RESULTS Among 35,647,347 surgeries and procedures, there were 5458 (0.015%) PA cases identified. The incidence of PA was 15.3 cases per 100,000 procedures. When compared with controls, PA cases had an increased mortality (3.4% vs 1.4%; P < .001), median length of stay (5 vs 3 days; P < .001), and median hospital cost ($45,155 vs $24,734; P < .001). The age group between 18 and 34 years (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.13-1.58; P < .001) and female sex (OR, 1.40; 95% CI, 1.31-1.49; P < .001) were associated with increased odds of PA. Transplant (OR, 3.35; 95% CI, 2.59-4.34; P < .001), hematologic (OR, 1.63; 95% CI, 1.30-2.05; P < .001), vascular (OR, 1.49; 95% CI, 1.30-1.67; P < .001), and cardiac (OR, 1.47; 95% CI, 1.30-1.67; P < .001) procedures were at increased risk for PA. Several comorbidities were associated with PA including chronic pulmonary disease (OR, 1.41; 95% CI, 1.31-1.51; P < .001). CONCLUSION The incidence of PA is 1 in 6531 procedures, with a mortality of 1 in 191,652 procedures. PA has worsening outcomes compared with controls. The risk factors of PA include age, sex, procedure type, and comorbidities.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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31
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Ebo DG, Bridts CH, Rihs HP. Hevea latex-associated allergies: piecing together the puzzle of the latex IgE reactivity profile. Expert Rev Mol Diagn 2020; 20:367-373. [PMID: 32056456 DOI: 10.1080/14737159.2020.1730817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: IgE-mediated Hevea latex allergy and associated food-allergies constitute a significant health issue with serious consequences of diagnostic error. Hence, there is a need for more reliable confirmatory diagnostics.Areas covered: Here, we summarize the major limitations of conventional tests using native extracts and describe how piecing together the IgE reactivity profile can benefit correct diagnosis in difficult cases in whom conventional tests yield equivocal or negative results. A diagnostic algorithm integrating traditional sIgE and component-resolved diagnosis (CRD) is presented.Expert opinion: Moreover, it is clear that the discoveries in the field of the Hevea latex proteome will contribute to our understandings and accurate approach of sometimes complex cross-reactivity phenomena that extend beyond the 'latex-fruit syndrome.'
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Affiliation(s)
- Didier G Ebo
- University of Antwerp - University Hospital of Antwerp, Immunology-Allergology-Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Department of Immunology and Allergology, Jan Palfijn Ziekenhuis Gent, Ghent, Belgium
| | - Chris H Bridts
- University of Antwerp - University Hospital of Antwerp, Immunology-Allergology-Rheumatology, Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Hans-Peter Rihs
- Ruhr-University Bochum, IPA - Institute for Prevention and Occupational Medicine, Bochum, Germany
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Specific IgE to cefazolin: Does it benefit diagnosis? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2932-2934. [DOI: 10.1016/j.jaip.2019.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 01/25/2023]
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