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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy: Mechanisms, Diagnosis, and Management. Med Clin North Am 2024; 108:671-685. [PMID: 38816110 DOI: 10.1016/j.mcna.2023.08.009] [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] [Indexed: 06/01/2024]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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2
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Bakshi D, Tang X, Waserman S. A case of pediatric serum sickness like reaction (SSLR) after a 2-month re-exposure to amoxicillin. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:29. [PMID: 38561790 PMCID: PMC10985844 DOI: 10.1186/s13223-024-00887-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Serum-sickness like reactions (SSLRs) to amoxicillin have been documented in the medical literature. Beta-lactams are important and commonly used medications especially in the pediatric population. Often, SSLRs present within days of and during first exposure/ingestion to the offending agent. We described a unique case of a 4-year-old boy who presented with symptoms of amoxicillin SSLR following his second course of amoxicillin with only 2 months and 10 days between his second and first course. CASE PRESENTATION A 4-year-old boy presented to hospital with a pruritic rash on day 7 of a 10-day course of amoxicillin for otitis media accompanied by fever (38.7 degrees Celsius). On day 7 of his second course of amoxicillin, which was separated from his first course by only 2 months and 10 days, his mother noticed erythematous, raised, pruritic lesions with central clearing on his sternum. He presented to the ED with emesis, progression of the rash to his torso, back, legs, and face, hypotension, angioedema, and joint pain. His bloodwork demonstrated a leukocytosis of 18.6 × 109 g/L with neutrophilic predominance and thrombocytosis with a platelet count of 653 × 109 g/L. He was treated with 5 mg oral cetirizine daily and 1 mg/kg oral prednisone which improved his rash and angioedema. He was managed with up to 4 times the usual dose of cetirizine. He was assessed in our outpatient clinic as an outpatient and penicillin skin testing was unremarkable. A diagnosis of a probable SSLR to amoxicillin was made. CONCLUSION We report an unusual presentation of SSLR following re-exposure to amoxicillin. Our case highlights that patients with previous asymptomatic exposure to amoxicillin can develop SSLR with repeat exposure. Although it is not uncommon for children to develop amoxicillin SSLRs after previous exposure to the drug, this case is unique because of its short time course of 2 months and 10 days months between drug courses. Penicillins are commonly used in the pediatric population. Therefore, it is important to correctly characterize adverse drug reactions to broaden our understanding of SSLRs, prevent unnecessary avoidance of the triggering agent, and improve patient management.
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Affiliation(s)
- Devyani Bakshi
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Xinxin Tang
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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3
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Sekerel BE, Ilgun Gurel D, Sahiner UM, Soyer O, Kocaturk E. The many faces of pediatric urticaria. FRONTIERS IN ALLERGY 2023; 4:1267663. [PMID: 38026129 PMCID: PMC10655015 DOI: 10.3389/falgy.2023.1267663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Urticaria is a common disease that can affect individuals of all age groups, with approximately one-quarter of the population experiencing it at least once in their lifetime. Lesions characterized by erythema and itchy hives can appear anywhere on the body. These can vary in size ranging from millimeters to centimeters, and typically clear within 24 h. About 40% of patients with urticaria have accompanying angioedema, which involves localized deep tissue swelling. Urticaria usually occurs spontaneously and is classified into acute and chronic forms, with the latter referring to a condition that lasts for more than 6 weeks. The prevalence of chronic urticaria in the general population ranges from 0.5% to 5%, and it can either be inducible or spontaneous. The most common form of pediatric urticaria is acute and is usually self-limiting. However, a broad differential diagnosis should be considered in children with urticaria, particularly if they also have accompanying systemic complaints. Differential diagnoses of pediatric urticaria include chronic spontaneous urticaria, chronic inducible urticaria, serum sickness-like reaction, urticarial vasculitis, and mast cell disorders. Conditions that can mimic urticaria, including but not limited to cryopyrinopathies, hyper IgD syndrome, Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPs), and Schnitzler syndrome should also be considered. The many faces of pediatric urticaria can be both easy and confusing. A pragmatic approach relies on clinical foresight and understanding the various forms of urticaria and their potential mimickers. This approach can pave the way for an accurate and optimized diagnostic approach in children with urticaria.
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Affiliation(s)
- Bulent Enis Sekerel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Deniz Ilgun Gurel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Umit Murat Sahiner
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Ozge Soyer
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Emek Kocaturk
- Department of Allergology, Charite University School of Medicine, Berlin, Germany
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Green EA, Fogarty K, Ishmael FT. Penicillin Allergy. Prim Care 2023; 50:221-235. [PMID: 37105603 DOI: 10.1016/j.pop.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Allergy to penicillin can occur via any of the 4 types of Gel-Coombs hypersensitivity reactions, producing distinct clinical histories and physical examination findings. Treatments include penicillin discontinuation, and depending on the type of reaction, epinephrine, antihistamines, and/or glucocorticoids. Most beta-lactams may be safely used in penicillin-allergic patients, with the possible exception of first-generation and second-generation cephalosporins. Penicillin testing includes skin testing, patch testing, and graded challenge. The selection of the type of testing depends on the clinical setting, equipment availability, and type of hypersensitivity reaction. Desensitization may be used in some cases where treatment with penicillins is essential.
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Affiliation(s)
- Estelle A Green
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Kelan Fogarty
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA
| | - Faoud T Ishmael
- Pennsylvania State University, College of Medicine University Park, 1850 East Park Avenue, State College, PA 16803, USA; Mount Nittany Health, 1850 East Park Avenue, State College, PA 16803, USA.
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5
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Antibiotic Allergy De-Labeling: A Pathway against Antibiotic Resistance. Antibiotics (Basel) 2022; 11:antibiotics11081055. [PMID: 36009924 PMCID: PMC9404790 DOI: 10.3390/antibiotics11081055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 12/10/2022] Open
Abstract
Antibiotics are one of the most frequently prescribed drugs. Unfortunately, they also are the most common cause for self-reported drug allergy, limiting the use of effective therapies. However, evidence shows that more than 90% of patients labeled as allergic to antibiotics are not allergic. Importantly, the label of antibiotic allergy, whether real or not, constitutes a major public health problem as it directly impacts antimicrobial stewardship: it has been associated with broad-spectrum antibiotic use, often resulting in the emergence of bacterial resistance. Therefore, an accurate diagnosis is crucial for de-labeling patients who claim to be allergic but are not really allergic. This review presents allergy methods for achieving successful antibiotic allergy de-labeling. Patient clinical history is often inaccurately reported, thus not being able to de-label most patients. In vitro testing offers a complementary approach but it shows limitations. Immunoassay for quantifying specific IgE is the most used one, although it gives low sensitivity and is limited to few betalactams. Basophil activation test is not validated and not available in all centers. Therefore, true de-labeling still relies on in vivo tests including drug provocation and/or skin tests, which are not risk-exempt and require specialized healthcare professionals for results interpretation and patient management. Moreover, differences on the pattern of antibiotic consumption cause differences in the diagnostic approach among different countries. A multidisciplinary approach is recommended to reduce the risks associated with the reported penicillin allergy label.
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6
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Güngörer V, Ertan K, Arslan Ş. Diagnosis that clinicians don't think of, serum sickness-like reaction. Pediatr Int 2022; 64:e14740. [PMID: 34676635 DOI: 10.1111/ped.14740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/03/2021] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Vildan Güngörer
- Departments of Pediatric Rheumatology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Kübra Ertan
- Departments of Pediatrics, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Şükrü Arslan
- Departments of Pediatric Rheumatology, Selcuk University Faculty of Medicine, Konya, Turkey
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7
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Del Pozzo-Magaña BR, Abuzgaia A, Murray B, Rieder MJ, Lazo-Langner A. Paediatric serum sickness-like reaction: A 10-year retrospective cohort study. Paediatr Child Health 2021; 26:428-435. [PMID: 34777661 DOI: 10.1093/pch/pxab003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background Serum sickness-like reaction (SSLR) is an acute inflammatory condition affecting predominantly children. The pathophysiology remains unclear, but drugs are considered the main trigger. Objective The aim of this study was to describe the clinical and laboratory features, triggers, and treatment modalities in children diagnosed with SSLR. Methods We conducted a 10-year retrospective cohort study including all paediatric patients (0 to 18 years old) with query SSLR referred to the Adverse Drug Reactions Clinic at the Children's Hospital of Western Ontario. Diagnostic criteria included acute skin rash plus joint inflammation with or without fever. Results We included 83 patients (47 females). Age ranged from 11 months to 12 years (mean 3.2 years). Amoxicillin was the trigger in 82.7% of patients. The mean time between the exposure to the triggering drug and the development of the symptoms was 8.5 days. Urticaria-like and Erythema multiforme-like lesions were present in 35% and 38.5% of the cases, respectively. Joint inflammation affecting hands/feet was present in 60%. Pruritus, lip/eye swelling, and fever were reported in 33, 31, and 45% of patients, respectively. The lymphocyte toxicity assay (LTA) showed incremental T-cell toxicity in 32 of 34 patients. Children that received treatment with antihistamines/nonsteroidal anti-inflammatory drugs (NSAIDs) plus oral steroids had a mean recovery time shorter than those treated only with antihistamines/NSAIDs (6 versus 8 days; P=0.09). Conclusions In our study, SSLR was mostly triggered by amoxicillin and had a mean time presentation of 8.5 days. Further prospective and well-conducted studies are needed.
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Affiliation(s)
- Blanca R Del Pozzo-Magaña
- Department of Paediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Western University and London Health Sciences Centre, London Ontario, Canada
| | - Awatif Abuzgaia
- Department of Paediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Western University and London Health Sciences Centre, London Ontario, Canada
| | - Barbara Murray
- Department of Paediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Western University and London Health Sciences Centre, London Ontario, Canada
| | - Michael J Rieder
- Department of Paediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Western University and London Health Sciences Centre, London Ontario, Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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8
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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Lalosevic MS, Lalosevic J, Stjepanovic M, Stojanovic M, Stojkovic M. Drug Induced Cutaneous Manifestations due to Treatment of Gastrointestinal Disorders. Curr Drug Metab 2021; 22:99-107. [PMID: 33198613 DOI: 10.2174/1389200221999201116143109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 01/19/2023]
Abstract
Cutaneous manifestations due to drugs used in the treatment of gastrointestinal disorders are multiple and common. Adequate diagnosis is of great importance, bearing in mind that the therapeutic regimen depends on its diagnosis. In this review, we provided an overview of the most common drug-induced skin lesions with a detailed explanation of the disease course, presentation and treatment, having in mind that in recent years, novel therapeutic modalities have been introduced in the treatment of various gastrointestinal disorders, and that incidence of cutaneous adverse reactions has been on the rise.
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Affiliation(s)
- Milica S Lalosevic
- Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jovan Lalosevic
- Clinic of Dermatovenereology, Clinical Center of Serbia, Belgrade, Serbia
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10
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Skin Testing for Penicillin Allergy: a Review of the Literature. Curr Allergy Asthma Rep 2021; 21:21. [PMID: 33738621 DOI: 10.1007/s11882-021-00997-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Self-reported penicillin allergies are frequently reported, though more than 95% of those are not truly allergic when challenged. These patients are more likely to receive alternative antibiotic regimens resulting in the use of broad-spectrum antibiotics that may be less effective, more toxic, and/or more expensive than preferred agents. Given the significant burden on patient outcomes and the healthcare system, the ability to reconcile an allergy and broaden future antibiotic options is essential. RECENT FINDINGS This is a narrative review describing risk stratification for penicillin skin testing, practical advice for implementation, and future directions. A summary of studies within the last 5 years is provided. The trend over the past several years has been to offer oral drug challenges to low-risk patients and skin testing to high-risk patients with a reported penicillin allergy. This review provides support for risk stratification assessment of reported penicillin allergy to optimize antibiotic use and prevent emergence of antimicrobial resistance.
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11
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Serum Sickness following Tetanus Toxoid Injection. Case Rep Pediatr 2021; 2021:6680979. [PMID: 33532106 PMCID: PMC7840246 DOI: 10.1155/2021/6680979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/04/2021] [Accepted: 01/15/2021] [Indexed: 11/23/2022] Open
Abstract
Serum sickness is an allergic reaction that frequently occurs in patients after the injection of foreign protein or serum. It is characterized by fever, skin rash, enlarged lymph nodes, and painful joints. In this case, we describe a case of 6-year-old girl who developed a rash and arthralgia after being vaccinated with tetanus toxoid injection after a cut wound.
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12
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Delli Colli L, Gabrielli S, Abrams EM, O'Keefe A, Protudjer JL, Lavine E, Pitt T, Atkinson A, Eiwegger T, McCusker C, Ben-Shoshan M. Differentiating Between β-Lactam-Induced Serum Sickness–Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:916-921. [DOI: 10.1016/j.jaip.2020.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
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13
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Mohsenzadeh A, Movahedi M, Saatchi M, Parvaneh N, Shariat M, Aghamohammadi A, Gharagozlou M. Serum sickness-like reactions in Iranian children: a registry-based study in a referral center. Allergol Immunopathol (Madr) 2020; 48:424-429. [PMID: 32653225 DOI: 10.1016/j.aller.2019.07.012] [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: 05/26/2019] [Accepted: 07/26/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Considering that no studies have been done on a comprehensive review of Serum sickness-like reactions patients (SSLRs) at a referral center in Iran so far, this study aimed to determine the clinical and laboratory characteristics of children with SSRL in Tehran Children's Medical Center. PATIENTS The present study was a registry-based study in which the data of 94 SSLRs patients registered in a two-year period were investigated. Confirmation of fever, rash, urticaria, arthralgia / arthritis and history of antibiotic consumption up to three weeks before were the criteria for the diagnosis. RESULTS Fifty-one (54 %) patients were male with mean age of 56 ± 30 months and there was no significant difference in the age of the two genders. The mean onset of symptoms before hospitalization were 3.8 ± 2.7 days (1-14 days); this mean was significantly higher in males than in females (4.6 ± 2.9 versus 2.9 ± 1.7 days, P-value = 0.003). Among antibiotics, Co-amoxiclav and Cefixime antibiotics had the most frequency by 31 % and 33 %, respectively as the most important incidence factor of SSLRs. The mean duration of consumption of culprit medications in the incidence of SSLRs was 5.6 ± 2.9 days with a range of 1-15 days. CONCLUSIONS This study showed that among the antibiotics, Co-amoxiclav and Cefixime are more prevalent and a review of prescribing these two antibiotics for the treatment of the children's infections is essential if this finding is confirmed by other Iranian scholars.
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Abstract
Drug eruptions in children are common but in general less studied than their adult counterparts. Aside from having significant impact on the child's health and quality of life, these reactions can limit what medications the patient can receive in the future. Familiarity with pediatric drug eruptions is important for accurate diagnosis and to prevent future recurrence or ineffective therapy. Our current understanding of how drug reactions differ mechanistically between children and adults is poor. There are multiple factors that could be contributing to the differing incidence, presentation, and treatment modalities offered to pediatric versus adult patients. For many of these cutaneous drug reactions, the treatment regime is not standardized, being based primarily on case reports. Although not comprehensive, this review highlights common pediatric drug eruption patterns and discuss diagnostic mimickers. Five cutaneous adverse drug reactions in the pediatric population are presented: morbilliform (exanthematous) eruptions, urticarial eruptions, serum sickness-like reactions, fixed drug eruptions, and DRESS syndrome. Clinical features, diagnostic workup, and management are discussed with an emphasis on the pediatric population.
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Affiliation(s)
- EmilyD Nguyen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA; Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Colleen K Gabel
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA; University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - JiaDe Yu
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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15
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Abstract
Drug hypersensitivity reactions (DHRs) may be classified based on timing (immediate vs delayed), mechanisms, and pattern of clinical manifestations. Management may include selection of alternative, non-cross reactive agents, drug allergy testing, graded challenge and/or desensitization. Immediate skin testing only identifies risk for immediate-type allergic DHR and has a negative predictive value for only a limited number of drugs (eg, penicillin). Desensitization induces a temporary state of tolerance that is maintained only so long as the drug is continued. This article discusses special considerations about antibiotics, angiotensin-converting enzyme inhibitors, anesthetic agents, aspirin and nonsteroidal antiinflammatory drugs, radiocontrast media, and chemotherapeutic agents.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis University Allergy & Immunology, 1402 South Grand Boulevard Room M 157, St Louis, MO 63104, USA.
| | - Jason K Lam
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis University Allergy & Immunology, 1402 South Grand Boulevard Room M 157, St Louis, MO 63104, USA
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16
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Collins C. The Low Risks and High Rewards of Penicillin Allergy Delabeling: An Algorithm to Expedite the Evaluation. J Pediatr 2019; 212:216-223. [PMID: 31253408 DOI: 10.1016/j.jpeds.2019.05.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/15/2019] [Accepted: 05/24/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Cathleen Collins
- Division of Allergy Immunology, Department of Pediatrics, University of California San Diego and Rady Children's Hospital San Diego, San Diego, CA.
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17
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Tawanwongsri W, Wattanakrai P. Serum Sickness after Equine Rabies Immunoglobulin in Identical Male Twins: Two Case Reports. Case Rep Dermatol 2019; 11:40-47. [PMID: 31043938 PMCID: PMC6477471 DOI: 10.1159/000497053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/17/2019] [Indexed: 11/19/2022] Open
Abstract
We, hereby, report two cases of serum sickness in adult male identical twins who had received equine rabies immunoglobulin as a postexposure rabies treatment after cat scratches. The younger brother developed low-grade fever, polyarthritis, and multiple erythematous maculopapular eruptions, whereas low-grade fever and urticaria-like eruptions were detected in the elder brother. Both patients received a 7-day course of low-dose prednisolone and achieved good responses without recurrent attacks.
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Affiliation(s)
- Weeratian Tawanwongsri
- Division of Dermatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Penpun Wattanakrai
- Division of Dermatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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18
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The Importance of Delabeling β-Lactam Allergy in Children. J Pediatr 2019; 204:291-297.e1. [PMID: 30322703 DOI: 10.1016/j.jpeds.2018.09.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/09/2023]
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Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. Urticaria: A comprehensive review. J Am Acad Dermatol 2018; 79:599-614. [DOI: 10.1016/j.jaad.2018.01.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ben-Shoshan M, Grattan CE. Management of Pediatric Urticaria with Review of the Literature on Chronic Spontaneous Urticaria in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1152-1161. [PMID: 29550102 DOI: 10.1016/j.jaip.2018.02.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/05/2018] [Accepted: 02/16/2018] [Indexed: 12/26/2022]
Abstract
There are substantial knowledge gaps related to diagnosis and management of pediatric cases of chronic urticaria, and in particular chronic spontaneous urticaria (CSU). In this article we aimed to review the diagnosis and management of chronic urticaria in children and CSU in particular. We conducted a systematic review of articles published in English and French on pediatric CSU management in the last 10 years. We included experimental studies (eg, randomized controlled trials), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, case-control studies, and case reports). Our findings highlight the efficacy of second-generation antihistamines for the treatment of CSU in children and supports the use of omalizumab for more severe cases. However, our study also reveals severe knowledge gaps related to the best management strategy in children with more severe/refractory cases of CSU. Future studies are required to establish the beneficial effect of high doses of second-generation antihistamines as well as the effectiveness and safety of omalizumab and other biologics in young children.
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Affiliation(s)
- Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada.
| | - Clive E Grattan
- St John's Institute of Dermatology, Guy's Hospital, London, United Kingdom
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McNulty CMG, Park MA. Delayed Cutaneous Hypersensitivity Reactions to Antibiotics: Management with Desensitization. Immunol Allergy Clin North Am 2017; 37:751-760. [PMID: 28965638 DOI: 10.1016/j.iac.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Successful desensitization to mild to moderate delayed cutaneous adverse reaction to antibiotics has been described in a limited number of antibiotics and found to be safe. However, there are ample opportunities to standardize protocols for delayed cutaneous adverse reactions to antibiotics.
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Affiliation(s)
- Caitlin M G McNulty
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Yorulmaz A, Akın F, Sert A, Ağır MA, Yılmaz R, Arslan Ş. Demographic and clinical characteristics of patients with serum sickness-like reaction. Clin Rheumatol 2017; 37:1389-1394. [DOI: 10.1007/s10067-017-3777-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/12/2017] [Accepted: 07/19/2017] [Indexed: 12/26/2022]
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Dodiuk-Gad RP, Chung WH, Shear NH. Adverse Medication Reactions. CLINICAL AND BASIC IMMUNODERMATOLOGY 2017. [PMCID: PMC7123512 DOI: 10.1007/978-3-319-29785-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cutaneous adverse drug reactions (ADRs) are among the most frequent adverse reactions in patients receiving drug therapy. They have a broad spectrum of clinical manifestations, are caused by various drugs, and result from different pathophysiological mechanisms. Hence, their diagnosis and management is challenging. Severe cutaneous ADRs comprise a group of diseases with major morbidity and mortality, reaching 30 % mortality rate in cases of Toxic Epidermal Necrolysis. This chapter covers the terminology, epidemiology, pathogenesis and classification of cutaneous ADR, describes the severe cutaneous ADRs and the clinical and laboratory approach to the patient with cutaneous ADR and presents the translation of laboratory-based discoveries on the genetic predisposition and pathogenesis of cutaneous ADRs to clinical management guidelines.
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Patterson-Fortin J, Harris CM, Niranjan-Azadi A, Melia M. Serum sickness-like reaction after the treatment of cellulitis with amoxicillin/clavulanate. BMJ Case Rep 2016; 2016:bcr-2016-217608. [PMID: 27756758 DOI: 10.1136/bcr-2016-217608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Serum sickness-like reaction is a rare disease presentation. We describe a case of a man aged 58 years who presented with acute-onset polyarthralgia, intense pruritus of hands and feet, fever to 39.5°C and leucocytosis to 17.2×103/mm3 5 days after completing a 10-day course of amoxicillin/clavulanate for the treatment of finger cellulitis. With history, symptoms, physical examination findings and reported cases in the literature of serum sickness-like reactions to amoxicillin, a clinical diagnosis of serum sickness-like reaction was made. The patient was treated with non-steroidal anti-inflammatories with improvement in symptoms by the time of discharge.
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Affiliation(s)
| | - Che Mathew Harris
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Michael Melia
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Single nonsteroidal anti-inflammatory drug induced serum sickness-like reaction to naproxen in a patient able to tolerate both aspirin and ibuprofen. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:160-1. [DOI: 10.1016/j.jaip.2015.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/03/2015] [Accepted: 07/21/2015] [Indexed: 11/19/2022]
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Rodilla EM, González ID, Yges EL, Bellido FJM, Bara MTG, Toledano FL. Immunological aspects of nonimmediate reactions to β-lactam antibiotics. Expert Rev Clin Immunol 2014; 6:789-800. [DOI: 10.1586/eci.10.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
In this study, the case of a 48-year-old man with severe serum sickness reaction in response to H1N1 influenza immunization is reported. He presented with renal failure and several of the classic signs reported in early descriptions of serum sickness by Clemens von Pirquet and Bela Schick including lymphadenopathy, urticarial skin eruption and facial edema. Serum immunologic studies and tissue histology/immunohistochemistry assisted in firmly establishing the diagnosis in this case. With appropriate therapy, the patient's rash, edema and lymphadenopathy resolved and normal renal function returned. This first reported case of severe serum sickness to H1N1 vaccine is particularly important in light of the Centers for Disease Control and Prevention's recommendation for universal vaccination against influenza, including H1N1, in patients 6 months and older. With increasing numbers of patients receiving this vaccine, even rare adverse reactions may be experienced by numerous individuals. It is imperative that clinicians remain vigilant about possible reactions and quickly institute appropriate therapy.
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Padial A, Antunez C, Blanca-Lopez N, Fernandez TD, Cornejo-Garcia JA, Mayorga C, Torres MJ, Blanca M. Non-immediate reactions to β-lactams: diagnostic value of skin testing and drug provocation test. Clin Exp Allergy 2008; 38:822-8. [DOI: 10.1111/j.1365-2222.2008.02961.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lopez S, Blanca-Lopez N, Cornejo-Garcia JA, Canto G, Torres MJ, Mayorga C, Blanca M. Nonimmediate reactions to betalactams. Curr Opin Allergy Clin Immunol 2007; 7:310-6. [PMID: 17620822 DOI: 10.1097/aci.0b013e3281e209fe] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nonimmediate reactions to beta-lactams include several clinical entities, from maculopapular rash to severe reactions such as Steven-Johnson syndrome. Toxic epidermal necrolysis and organ-specific reactions may also occur. RECENT FINDINGS Progress has been made in understanding the role of the immunological system in nonimmediate reactions to beta-lactams. Different T-cell subsets recognize beta-lactams after haptenation of serum or cell proteins in the context of major histocompatibility complex. Studies using T-cell lines and clones have shown that a heterogeneous response is generated, with the expression of different cytokine profiles. Betalactams also act on dendritic cells, inducing changes that enable them to interact with naïve lymphocytes, becoming memory T cells. Tissue-activated CD4 and CD8 cells express perforin and other cytotoxic mediators that elicit the lesions. Studies on the clinical course of these entities indicate that cells migrate, establishing a recirculation with homing to the skin and back to the circulation. These cells thus participate not only in skin lesions but probably also in the repair process. SUMMARY Understanding the immunological mechanisms involved in nonimmediate reactions to beta-lactams has improved over the last few years, with better definition of the different T-cell subpopulations involved. Experimental studies and monitoring of the response support the implication of different cell subsets.
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Affiliation(s)
- Soledad Lopez
- Research Laboratory, Carlos Haya Hospital-Fundacion IMABIS, Málaga, Spain
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Clark BM, Kotti GH, Shah AD, Conger NG. Severe Serum Sickness Reaction to Oral and Intramuscular Penicillin. Pharmacotherapy 2006; 26:705-8. [PMID: 16718943 DOI: 10.1592/phco.26.5.705] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Serum sickness is a type III hypersensitivity reaction mediated by immune complex deposition with subsequent complement activation, small-vessel vasculitis, and tissue inflammation. Although the overall incidence of serum sickness is declining because of decreased use of heterologous sera and improved vaccinations, rare sporadic cases of serum sickness from nonprotein drugs such as penicillins continue to occur. Drug-induced serum sickness is usually self-limited, with symptoms lasting only 1-2 weeks before resolving. We report an unusual case of a severe and prolonged serum sickness reaction that occurred after exposure to an intramuscular penicillin depot injection (probable relationship by Naranjo score) and discuss how pharmacokinetics may have played a role. Clinicians should be familiar with serum sickness reactions particularly as they relate to long-acting penicillin preparations. Accurate diagnosis in conjunction with cessation of drug exposure and prompt initiation of antiinflammatory treatment with corticosteroids can produce complete recovery
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Affiliation(s)
- Brychan M Clark
- Department of Infectious Diseases, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas 78236, USA.
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Cárdenas Contreras R, Hidalgo Natera A, Najem Risk N, Canto Díez G. [Serum disease syndrome. Apropos of one case]. Rev Clin Esp 2006; 205:632. [PMID: 16527190 DOI: 10.1016/s0014-2565(05)72662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Adverse cutaneous reactions to drugs are frequent, affecting 2% to 3% of all hospitalized patients. Fortunately, only about 2% of adverse cutaneous reactions are severe and very few are fatal. Stevens-Johnson syndrome and toxic epidermal necrolysis are severe life-threatening diseases with a mortality rate reaching 30%, and only prompt recognition and diagnosis, withdrawal of the offensive drug, and referral to an intensive care unit or burn care unit might improve the prognosis and save the patient's life. Drug eruption with eosinophilia and systemic symptoms syndrome, formerly termed drug hypersensitivity syndrome, is a rather distinct severe adverse drug reaction (ADR) characterized by eruption, fever, lymph node enlargement, and single or multiple organ involvement, with a high morbidity and a mortality rate of 10%. These severe ADRs, together with serum sickness-like syndrome, are discussed in this review. Other severe reactions, such as anaphylaxis and vasculitis, are discussed elsewhere in this issue. Although most of the readers, particularly those in the outpatient arena, will not be treating these patients, they are the ones who will see them first, diagnose them, realize the potential danger in their condition, and refer them to the appropriate treatment venue. Therefore, dermatologists should be familiar with these conditions and be prepared to handle them adequately.
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Affiliation(s)
- Ronni Wolf
- Dermatology Unit, Kaplan Medical Center, 76100 Rechovot, Israel.
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