Severe Stevens-Johnson syndrome induced by contrast medium iopentol (ImagopaqueR)

Contrast Reactions and Approaches to Staffing the Contrast Reaction Management Team

RATIONALE AND OBJECTIVES

Managing contrast reactions is critical as contrast reactions can be life-threatening and unpredictable. Institutions need an effective system to handle these events. Currently, there is no standard practice for assigning trainees, radiologists, non-radiologist physicians, or other non-physician providers for management of contrast reaction.

MATERIALS AND METHODS

The Association of Academic Radiologists (AAR) created a task force to address this gap. The AAR task force reviewed existing practices, studied available literature, and consulted experts related to contrast reaction management. The Society of Chairs of Academic Radiology Departments (SCARD) members were surveyed using a questionnaire focused on staffing strategies for contrast reaction management.

RESULTS

The task force found disparities in contrast reactions management across institutions and healthcare providers. There is a lack of standardized protocols for assigning personnel for contrast reaction management.

CONCLUSION

The AAR task force suggests developing standardized protocols for contrast reaction management. The protocols should outline clear roles for different healthcare providers involved in these events.

Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis; Extensive Review of Reports of Drug-Induced Etiologies, and Possible Therapeutic Modalities

Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis are adverse hypersensitivity reactions that affect the skin and mucous membranes. They are characterised by erythematous macules and hemorrhagic erosions of the mucous membranes. Epidermal detachments of varying degrees of severity also occur in these conditions. Various aetiologies are associated with these conditions, with adverse drug reaction being the most common. Though the worldwide incidence of these conditions is recorded as low, diverse types of medication are being observed to lead to these conditions. This review compiles information on the details of Stevens-Johnson syndrome and Toxic Epidermal Necrolysis, the pathophysiology, therapeutic management, and largely considers the drug-induced etiologies associated with these conditions.

Oral lesions associated with Nevirapine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis: A report of 10 cases

Stevens–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are closely related severe, acute mucocutaneous reactions usually caused by drugs. They are acute life-threatening conditions and cause widespread necrosis of the epithelium. There is persistence of a high risk of SJS or TEN in relation to human immunodeficiency virus (HIV) infection associated with exposure to nevirapine (NVP). In this article, we present nine cases of SJS and one case of TEN in HIV-seropositive individuals who developed cutaneous, oral, ocular and genital lesions while being treated with NVP.

A practical guide to diagnose lesser-known immediate and delayed contrast media-induced adverse cutaneous reactions

The terms "immediate" and "delayed" adverse reactions induced by contrast media (CM) refer to the reactions' onset but do not provide substantial information concerning the clinical manifestation, the potential risk factors, the treatment modalities, or prevention. Because a variety of different reactions caused by different pathophysiological mechanisms may arise immediately or be delayed after CM injection, and because these need different management, the aim of the present paper is to present the clinical features and to exactly characterize lesser-known cutaneous reactions. A thorough knowledge of the clinical features, their adequate treatment, and, possibly, the subsequent diagnostic procedure for preventing recurrence after reexposure to CM would improve patient management.

X-ray contrast media--an overview

X-ray contrast media are chemically inert drugs which are given intravascularly in very high amounts within a very short time period. Although they are regarded as relatively safe drugs, adverse reactions can occur: these are normally divided into immediate and delayed reactions. The latter appear hours to days after injection. Immediate reactions have been drastically reduced since the introduction of non-ionic monomers and non-ionic dimers. However, the delayed reactions still occur in a frequency of 1-3% in X-ray contrast media exposed patients. The majority of these reactions are mild and manifest as skin eruption, but severe reactions can also occur. Further improvement of the safety of these drugs is only possible with a better understanding of etiologies behind the observed adverse reactions.

The immunological and clinical spectrum of delayed drug-induced exanthems

PURPOSE OF REVIEW

Drug-induced exanthems are the most common manifestations of drug hypersensitivity and are observed in as much as 2-3% of hospitalized patients. Here we summarize new concepts of the immune mechanisms underlying various forms of drug-induced exanthems.

RECENT FINDINGS

Alpha-betaTCR+, CD4 and CD8+ T cells are involved in different drug hypersensitivity reactions. Their function determines the clinical picture. In maculopapular, bullous and pustular exanthems cytotoxic T cells are involved, while a high IL-5 and eotaxin production by tissue cells is frequently found in maculopapular and occasionally in bullous and in pustular exanthems. High IL-8 (CXCL-8) and granulocyte-macrophage colony stimulating factor production by T cells is a hallmark of pustular drug exanthems. In the most severe and potentially life-threatening forms of exanthems (Stevens-Johnson syndrome/toxic epidermal necrolysis) cytotoxic CD8+ T cells with natural killer cell markers can be found in the blister fluid.

SUMMARY

These findings are the basis for a new subclassification of delayed, type IV hypersensitivity reactions into type IVa (T helper type 1 cells, e.g. tuberculin reaction and contact dermatitis), IVb (T helper type 2 cells, maculopapular exanthem with eosinophilia), IVc (cytotoxic T cells, contact dermatitis, maculopapular and bullous exanthem), and IVd reactions (CXCL-8/granulocyte-macrophage colony stimulating factor-producing T cells and neutrophil attraction, pustular exanthems), by which, in most reactions, various mechanisms occur together but one reaction dominates the clinical picture.