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Niedoszytko M, Gorska A, Brockow K, Bonadonna P, Lange M, Kluin-Nelemans H, Oude-Elberink H, Sabato V, Shoumariyeh K, von Bubnoff D, Müller S, Illerhaus A, Doubek M, Angelova-Fischer I, Hermine O, Arock M, Elena C, Malcovati L, Yavuz AS, Schug TD, Fortina AB, Judit V, Gotlib J, Panse J, Vucinic V, Reiter A, Schwaab J, Triggiani M, Mattsson M, Breynaert C, Romantowski J, Zanotti R, Olivieri E, Zink A, van de Ven A, Stefan A, Barete S, Caroppo F, Perkins C, Kennedy V, Christen D, Jawhar M, Luebke J, Parente R, Levedahl K, Hadzijusufovic E, Hartmann K, Nedoszytko B, Sperr WR, Valent P. Prevalence of hypersensitivity reactions in various forms of mastocytosis: A pilot study of 2485 adult patients with mastocytosis collected in the ECNM registry. Allergy 2024. [PMID: 38651829 DOI: 10.1111/all.16132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Hypersensitivity reactions (HR) are common in mastocytosis. However, little is known about triggers and risk factors. The registry of the European Competence Network on Mastocytosis (ECNM) enables reliable studies in a larger cohort of mastocytosis patients. We assessed prevalence, triggers and risk factors of HR in adults with mastocytosis in the ECNM registry. METHODS Data were collected in 27 ECNM centers. We analyzed potential triggers (Hymenoptera venoms, food, drug, inhalant and others) and risk factors at diagnosis and during follow-up. The study group consisted of 2485 adults with mastocytosis, 1379 women (55.5%) and 1106 men (44.5%). Median age was 48.2 years (range 18-91 years). RESULTS Nine hundred and forty eight patients (38.1%) reported one or more HR`. Most common triggers were Hymenoptera venoms in cutaneous mastocytosis (CM) and indolent systemic mastocytosis (ISM), whereas in advanced SM (advSM), most common elicitors were drugs, including nonsteroidal anti-inflammatory agents and penicillin. In multivariate analyses, tryptase level < 90 ng/mL, <15% infiltration by mast cells in bone marrow biopsy-sections, and diagnosis of ISM were identified as independent risk factors for HR. For drug-induced HR, prominent risk factors were advSM and high tryptase levels. New reactions were observed in 4.8% of all patients during 4 years follow-up. CONCLUSIONS HR are mainly triggered by Hymenoptera venoms in patients with CM and ISM and by drugs in patients with advSM. Tryptase levels <90 ng/mL, mast cell bone marrow infiltration <15%, and WHO category ISM are predictors of HR. New HR occur in 4.8% of all patients within 4 years.
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Affiliation(s)
- Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Aleksandra Gorska
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Hanneke Kluin-Nelemans
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Vito Sabato
- Department of Immunology, Allergology Rheumatology University of Antwerp and Antwerp University Hospital, Edegem, Belgium
| | - Khalid Shoumariyeh
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany and German Cancer Consortium (DKTK), Partner Site Freiburg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dagmar von Bubnoff
- Dagmar von Bubnoff, Department of Dermatology, Allergy and Venerology, University of Schleswig Holstein, Lübeck, Germany
| | - Sabine Müller
- Department of Dermatology, Medical Centre-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | | | - Olivier Hermine
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Michel Arock
- Department of Hematological Biology and CEREMAST, Pitié-Salpêtrière Hospital, Paris Sorbonne University, Paris, France
| | - Chiara Elena
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Luca Malcovati
- Department of Hematology, Fondazione IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Akif Selim Yavuz
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Türkiye
| | | | - Anna Belloni Fortina
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | | | - Jason Gotlib
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | | | - Andreas Reiter
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | - Juliana Schwaab
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | | | - Christine Breynaert
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology ResearchGroup and MASTeL, University Hospitals Leuven, Leuven, Belgium
| | - Jan Romantowski
- Department of Allergology, Medical University of Gdansk, Gdansk, Poland
| | - Roberta Zanotti
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Elisa Olivieri
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alexander Zink
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, School of Medicine, Munich, Germany
| | - Annick van de Ven
- Department of Allergology, University Medical Center, Groningen, The Netherlands
| | - Alex Stefan
- Clinic for Hematology and Oncology, Kepler University Hospital, Linz, Austria
| | - Stephane Barete
- Unit of Dermatology and CEREMAST, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France
| | - Francesca Caroppo
- Pediatric Dermatology, Internal Medicine, Azienda Ospedaliera, Università di Padova, Padova, Italy
| | - Cecelia Perkins
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Vanessa Kennedy
- Stanford University, School of Medicine, Hematology Clinic, Stanford, USA
| | - Deborah Christen
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Center for Integrated Oncology Aachen, Bonn Cologne, Duesseldorf (CIO ABCD), Aachen, Germany
| | - Mohamad Jawhar
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
- Department of Hematology and Oncology, Helios Pforzheim, Pforzheim, Germany
| | - Johannes Luebke
- Universitätsmedizin Mannheim, III.Medizinische Klinik, Mannhein, Germany
| | | | - Kerstin Levedahl
- Uppsala University Hospital, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Emir Hadzijusufovic
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Boguslaw Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Gdansk, Poland
- Invicta Fertility and Reproductive Center, Molecular Laboratory, Sopot, Poland
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
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Baig M, Nanjappa NC, Perkins GB, Di Lernia R, Thiruvenkatarajan V, Hissaria P. Basophil activation test in the diagnostic workup of perioperative anaphylaxis due to neuromuscular blocking agents: A case series and implications for practice. Anaesth Intensive Care 2024:310057X241232420. [PMID: 38649299 DOI: 10.1177/0310057x241232420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
In Australia, neuromuscular blocking agents are the leading cause of perioperative anaphylaxis. Current investigation of suspected anaphylaxis includes tryptase levels, serum immunoglobulin E (IgE) levels, and skin testing, including intradermal testing and skin prick testing. The gold standard for the diagnosis of a hypersensitivity reaction is a challenge test, but this poses a risk to patient safety. An alternative test, known as the basophil activation test (BAT) is a form of cellular in vitro testing using flow cytometry to measure the degree of basophil degranulation within a sample of blood following exposure to an allergen. This acts as a surrogate marker for mast cell and basophil activation, thereby identifying IgE-mediated allergy. It is most commonly used to supplement equivocal findings from initial in vitro testing to assist in confirming the diagnosis of a hypersensitivity reaction and identify the causative agent. We present a case series in which five patients with suspected anaphylaxis underwent a BAT, demonstrating its role and limitations in allergy testing within Australia.
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Affiliation(s)
- Mahanoor Baig
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
| | - Nagesh C Nanjappa
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
| | - Griffith B Perkins
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
- SA Pathology, Adelaide, Australi
| | - Rachel Di Lernia
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia
| | - Venkatesan Thiruvenkatarajan
- Department of Anaesthesia, Queen Elizabeth Hospital, Adelaide, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
| | - Pravin Hissaria
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Australia
- SA Pathology, Adelaide, Australi
- Department of Allergy and Immunology, Royal Adelaide Hospital, Adelaide, Australia
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Rathod S, Hoshitsuki K, Zhu Y, Ramsey M, Fernandez CA. Asparaginase-specific basophil recognition and activation predict Asparaginase hypersensitivity in mice. Front Immunol 2024; 15:1392099. [PMID: 38686384 PMCID: PMC11057047 DOI: 10.3389/fimmu.2024.1392099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024] Open
Abstract
Background Asparaginase (ASNase) is a crucial part of acute leukemia treatment, but immune responses to the agent can reduce its effectiveness and increase the risk of relapse. Currently, no reliable and validated biomarker predicts ASNase-induced hypersensitivity reactions during therapy. We aimed to identify predictive biomarkers and determine immune cells responsible for anaphylaxis using a murine model of ASNase hypersensitivity. Methods Our preclinical study uses a murine model to investigate predictive biomarkers of ASNase anaphylaxis, including anti-ASNase antibody responses, immune complex (IC) levels, ASNase-specific binding to leukocytes or basophils, and basophil activation. Results Our results indicate that mice immunized to ASNase exhibited dynamic IgM, IgG, and IgE antibody responses. The severity of ASNase-induced anaphylaxis was found to be correlated with levels of IgG and IgE, but not IgM. Basophils from immunized mice were able to recognize and activate in response to ASNase ex vivo, and the extent of recognition and activation also correlated with the severity of anaphylaxis observed. Using a multivariable model that included all biomarkers significantly associated with anaphylaxis, independent predictors of ASNase-induced hypersensitivity reactions were found to be ASNase IC levels and ASNase-specific binding to leukocytes or basophils. Consistent with our multivariable analysis, we found that basophil depletion significantly protected mice from ASNase-induced hypersensitivity reactions, supporting that basophils are essential and can be used as a predictive marker of ASNase-induced anaphylaxis. Conclusions Our study demonstrates the need for using tools that can detect both IC- and IgE-mediated hypersensitivity reactions to mitigate the risk of ASNase-induced hypersensitivity reactions during treatment.
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Affiliation(s)
| | | | | | | | - Christian A. Fernandez
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States
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Le Baron Q, Bourneau-Martin D, Babin M, Gouraud A, Tauber M, Fresse A, Lebrun-Vignes B, Delaunay J, Morisset M, Briet M. Cross-reactivity among and between macrolides, lincosamides, and streptogramins: Study on the French pharmacovigilance database. Fundam Clin Pharmacol 2024. [PMID: 38590045 DOI: 10.1111/fcp.13005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypersensitivity reactions (HSR) are reported for the macrolides, lincosamides, and streptogramins (MLS) antibiotic family. Data about cross-reactivity among and between MLS remain scarce or controversial. OBJECTIVES The aim of this study was to provide an overview of hypersensitivity cross-reactions among MLSs based on data extracted from the French National Pharmacovigilance Database (FPVD). METHODS Cases of HSR to MLSs reported between January 1985 and December 2019 were extracted from the FPVD using standardized MedDRA queries (SMQ). Cases including an allergological test involving multiple MLSs and giving at least one positive result were included. RESULTS Of the 8394 cases reviewed, 149 were included. HSR mainly involved pristinamycin (n = 83; 53.2%) and spiramycin (n = 31; 19.9%). HSR to MLS was immediate in 54 cases and delayed in 94 cases. Skin tests represented the majority of the allergological tests performed (n = 728; 84.7%), followed by reintroduction tests (n = 79; 9.2%). Eighty-six cross-reactivities among MLS were identified in 62 cases (41.6%). All the 25 explorations performed for streptogramins showed cross-reactivities, but only 30/253 among macrolides (11.9%). Cross-reactivities between the three MLS were observed in 31/322 (9.6%) of the allergological explorations. CONCLUSION This study highlights the possibility of cross-reactivity among and between MLSs. Dermatologists and allergologists managing patients with HSR to MLSs should be aware of a risk of cross-reactivity among the macrolides and between the different classes of MLS and to perform MLSs allergological testing before recommending an alternative antibiotic, especially in severe drug hypersensitivity from the MLS family.
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Affiliation(s)
- Quentin Le Baron
- Department of Pharmacology-Toxicology and Pharmacovigilance, University Hospital of Angers, Angers, France
| | - Delphine Bourneau-Martin
- Department of Pharmacology-Toxicology and Pharmacovigilance, University Hospital of Angers, Angers, France
| | - Marina Babin
- Department of Pharmacology-Toxicology and Pharmacovigilance, University Hospital of Angers, Angers, France
| | | | - Marie Tauber
- Department of Allergology and Clinical Immunology, Inserm 1111 CIRI, CHU Lyon, Lyon, France
- French Investigators for Skin Adverse Reactions to Drugs (FISARD) group from the French Society of Dermatology, Paris, France
| | | | - Bénédicte Lebrun-Vignes
- French Investigators for Skin Adverse Reactions to Drugs (FISARD) group from the French Society of Dermatology, Paris, France
- CRPV Paris Pitié-St Antoine, APHP, Sorbonne Université, Paris, France
| | - Juliette Delaunay
- French Investigators for Skin Adverse Reactions to Drugs (FISARD) group from the French Society of Dermatology, Paris, France
- Department of Dermatology, University Hospital of Angers, Angers, France
| | - Martine Morisset
- Department of Pneumology, University Hospital of Angers, Angers, France
| | - Marie Briet
- Department of Pharmacology-Toxicology and Pharmacovigilance, University Hospital of Angers, Angers, France
- Univ Angers, Inserm, CNRS, MITOVASC, Equipe CarMe, SFR ICAT, Angers, France
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Luo L, Chen N, Li Z, Zhao C, Dong Y, Wang L, Li X, Zhou W, Li Y, Gao C, Guo X. Knowledge mapping and global trends of drug hypersensitivity from 2013 to 2023: A bibliometric analysis. Immun Inflamm Dis 2024; 12:e1245. [PMID: 38629759 PMCID: PMC11022627 DOI: 10.1002/iid3.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/27/2024] [Accepted: 03/31/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Drug hypersensitivity is a major global public health issue with a significant increase in prevalence in populations. Here, we provide a deep insight into the frontier hotspot and future direction in the field of drug hypersensitivity. METHODS A knowledge map is portrayed based on publications related to drug hypersensitivity from Web of Science Core Collection using CiteSpace. Co-occurrence relationships of countries, institutes, authors, journals, references, and keywords are constructed. According to the co-occurrence relationships, hotspots and future trends are overviewed. RESULTS The United States ranked first in the world and China with the second highest publications was the only developing country. Torres, Mayorga, and Blanca were highly productive authors. Harvard University was the institution with the most research publications. Keywords co-occurrence analysis suggested applications in emerging causes, potential mechanisms, and clinical diagnosis as the research hotspots and development frontiers. CONCLUSION Research on drug hypersensitivity is in a rapid development stage and an emerging trend in reports of anaphylaxis to polyethylene glycols is identified. Developing algorithms for understanding the standardization process of culprit drugs, clinical manifestations, and diagnostic methods will be the focus of future direction. In addition, a better understanding of the mechanisms to culprit drugs with immunological precise phenotypic definitions and high-throughput platforms is needed.
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Affiliation(s)
- Li Luo
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Niannian Chen
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Zhanpeng Li
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Chunmei Zhao
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Yiming Dong
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Likai Wang
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Xiaoqian Li
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Wenchao Zhou
- School of Public Health, Academy of Medical ScienceShanxi Medical UniversityTaiyuanChina
| | - Yingna Li
- First Clinical Medical CollegeShanxi Medical UniversityTaiyuanChina
| | - Cairong Gao
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Xiangjie Guo
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
- Translational Medicine Research CenterShanxi Medical UniversityTaiyuanChina
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Bumrungratanayos N, Tungjitviboonkun S. First Case Report of Deferiprone-Induced Anaphylactic Reaction. Cureus 2024; 16:e57847. [PMID: 38596210 PMCID: PMC11002473 DOI: 10.7759/cureus.57847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
A 56-year-old Thai male, known for allergies to penicillin, sulfa, and lincosamide, presented with hyperferritinemia. Upon initiating deferiprone therapy, the patient experienced recurrent episodes of dyspnea, culminating in anaphylactic shock. Treatment included subcutaneous epinephrine, intravenous chlorpheniramine, and hydrocortisone, which led to symptom resolution. This case constitutes the first case report of deferiprone-associated anaphylactic reactions.
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Affiliation(s)
- Naharuthai Bumrungratanayos
- Internal Medicine, Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, THA
- Internal Medicine, Sirindhorn Hospital, Bangkok, THA
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Bavbek S, Kepil Özdemir S, Bonadonna P, Atanaskovic-Markovic M, Barbaud A, Brockow K, Laguna Martinez J, Nakonechna A, Pagani M, Arcolacı A, Lombardo C, Torres MJ. Hypersensitivity reactions to proton pump inhibitors. An EAACI position paper. Allergy 2024; 79:552-564. [PMID: 38013608 DOI: 10.1111/all.15961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Proton pump inhibitors (PPIs) are invaluable therapeutic options in a variety of dyspeptic diseases. In addition to their well-known risk profile, PPI consumption is related to food and environmental allergies, dysbiosis, osteoporosis, as well as immediate and delayed hypersensitivity reactions (HSRs). The latter, although a rare event, around 1%-3%, due to the extraordinarily high rate of prescription and consumption of PPIs are related to a substantial risk. In this Position Paper, we provide clinicians with practical evidence-based recommendations for the diagnosis and management of HSRs to PPIs. Furthermore, the unmet needs proposed in the document aim to stimulate more in-depth investigations in the topic.
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Affiliation(s)
- Sevim Bavbek
- Division of Immunology and Allergy, Department of Chest Diseases, School of Medicine, Ankara University, Ankara, Turkey
| | - Seçil Kepil Özdemir
- Department of Chest Diseases, Allergy and Immunology Unit, İzmir Faculty of Medicine, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, İzmir, Turkey
| | | | - Marina Atanaskovic-Markovic
- Department of Allergology and Pulmonology, Faculty of Medicine, University of Belgrade, University Children's Hospital, Belgrade, Serbia
| | - Annick Barbaud
- Département de dermatologie et allergologie, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Jose Laguna Martinez
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, Madrid, Spain
| | - Alla Nakonechna
- Allergy and Clinical Immunology Department, University of Liverpool, Royal Preston Hospital, Lancashire Teaching Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Mauro Pagani
- Medicine Department, Medicine Ward Mantova Hospital, ASST di Mantova, Mantova, Italy
| | | | - Carla Lombardo
- Division of Dermatology and Allergy, APSS - Trento Hospital, Trento, Italy
| | - Maria J Torres
- Allergy Unit, Regional University Hospital of Malaga, IBIMA-UMA-ARADyAL, Malaga, Spain
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Bayrak Durmaz MS, Unutmaz DG, Demir M, Goksel O, Dursun AB, Bavbek S. Hypersensitivity Reactions to Taxanes: A Multicenter Study for Outcomes and Safety of Rapid Drug Desensitization. Allergy Asthma Immunol Res 2024; 16:142-153. [PMID: 38528382 DOI: 10.4168/aair.2024.16.2.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/28/2023] [Indexed: 03/27/2024]
Abstract
PURPOSE Taxanes can cause hypersensitivity reactions (HSRs), which pose a significant challenge in the treatment of malignancies. Patients who are eligible for rapid drug desensitization (RDD) can continue treatment; however, some patients experience breakthrough reactions (BTRs). Data about risk factors for BTRs during RDDs in patients with HSRs to taxanes are limited. METHODS This was a multicenter, retrospective study of patients with immediate-HSRs to taxanes. Initial HSRs were classified as grade 1, 2, or 3 based on severity. Prick/intradermal skin tests were performed with implicated taxanes. A 12-step protocol was used during RDD. RESULTS The study comprised 75 patients (F/M: 63/12, mean age 49.92 ± 11.72 years, 43 HSRs to paclitaxel, 32 HSRs to docetaxel). The majority of reactions (86.7%) occurred during the first or second exposure. The prevalence of drug allergy history was higher in patients with paclitaxel HSR than in those with docetaxel HSR, although it was not statistically significant (23.3% vs. 6.3%). The initial HSRs were mostly grade 2 (n = 50, 66.7%) or grade 3 (n = 22, 29.3%). Skin tests with implicated taxanes were done on 48 patients, and the rate of positive response in patients with grade 1, 2, and 3 initial HSRs were 50%, 17.6%, and 16.7%, respectively. . A total of 255 RDDs were completely performed, although BTRs occurred in 27 (grade 1, 55.6%; grade 2, 40.7%; grade 3, 3.7%). There were no statistically significant correlations between the risk of BTR and age, drug cycle, gender, positivity of skin test or atopy. The step reduction was successfully done on 9 eligible patients with mild or moderate HSRs during the 12-step RDDs. CONCLUSIONS Our experience demonstrates a 100% success rate in completing the 255 RDDs for taxanes, affirming the safety and efficacy of the RDD within the study population.
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Affiliation(s)
- Makbule Seda Bayrak Durmaz
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Done Gulcin Unutmaz
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Meryem Demir
- Division of Immunology and Allergy, Department of Chest Diseases, Ege University School of Medicine, Izmir, Turkey
| | - Ozlem Goksel
- Division of Immunology and Allergy, Department of Chest Diseases, Ege University School of Medicine, Izmir, Turkey
| | - Adile Berna Dursun
- Division of Immunology and Allergy, Department of Chest Diseases, Memorial Ankara Hospital, Ankara, Turkey
- Division of Immunology and Allergy, Department of Chest Diseases, Lokman Hekim University Hospital School of Medicine, Ankara, Turkey
| | - Sevim Bavbek
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey.
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9
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Torres MJ, Doña I. Drug hypersensitivity: Past, present and future. Allergy 2024; 79:549-551. [PMID: 38363030 DOI: 10.1111/all.16050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Maria J Torres
- Allergy Unit, IBIMA-Regional University Hospital of Malaga, UMA, RETICS ARADyAL, BIONAND, Malaga, Spain
| | - Inmaculada Doña
- Allergy Unit, IBIMA-Regional University Hospital of Malaga, UMA, RETICS ARADyAL, BIONAND, Malaga, Spain
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10
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Felix MMR, Kuschnir FC, Boechat JL, Castells M. Recent findings on drug hypersensitivity in children. Front Allergy 2024; 5:1330517. [PMID: 38384771 PMCID: PMC10879301 DOI: 10.3389/falgy.2024.1330517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Drug hypersensitivity reactions (DHR) in children have a significant impact on clinical practice and public health. Both under-diagnosis (due to under-reporting) and over-diagnosis (due to the overuse of the term "allergy") are potential issues. The aim of this narrative review is to describe the most recent findings of DHR in children/adolescents and gaps regarding epidemiology, antibiotic allergy, antiepileptic hypersensitivity, vaccine allergy, and severe cutaneous adverse reactions (SCAR) in this age group.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Department of General Medicine, School of Medicine and Surgery, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fábio Chigres Kuschnir
- Department of Pediatrics, Faculty of Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Laerte Boechat
- Clinical Immunology Service, Internal Medicine Department, Faculty of Medicine, Universidade Federal Fluminense, Niterói, Brazil
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mariana Castells
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
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11
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Mota D, Miranda J, Carneiro-Leão L, Cernadas J. Fixed drug eruption caused by iodinated contrast media: An unusual hypersensitivity reaction. Contact Dermatitis 2024; 90:199-200. [PMID: 38010162 DOI: 10.1111/cod.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Diogo Mota
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Miranda
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Leonor Carneiro-Leão
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Josefina Cernadas
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
- Hospital Lusíadas Porto, Porto, Portugal
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12
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Bui VL, Alvarez-Arango S, Stevenson JM. Pharmacogenetics to prevent hypersensitivity reactions to antiepileptic drugs: is testing performed when indicated? Pharmacogenet Genomics 2024; 34:16-19. [PMID: 37830946 PMCID: PMC10841751 DOI: 10.1097/fpc.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Extensive scientific evidence consistently demonstrates the clinical validity and utility of HLA-B*15:02 pre-screening in averting severe cutaneous adverse reactions (SCARs), namely Stevens-Johnson syndrome and toxic epidermal necrolysis, associated with carbamazepine or oxcarbazepine usage. Current practice guidelines and drug labeling actively advocate for pharmacogenetic pre-screening before initiating these antiepileptic drugs (AED), with particular emphasis on patients of Asian descent. However, there is a potential need to strengthen compliance with these recommendations. This retrospective study aimed to describe the pharmacogenetic pre-screening, documentation, and SCARs incidence for patients of Asian ancestry initiated on carbamazepine or oxcarbazepine at a large Northeastern USA healthcare system. Between 1 July 2016 and August 1, 2021, 27 patients with documented Asian heritage in the electronic health record (EHR) were included. The overall rate of HLA-B*15:02 pre-screening before carbamazepine or oxcarbazepine initiation was 4%. None who underwent pharmacogenetic pre-screening carried the associated HLA-B risk allele, and no SCARs were reported. Notably, pharmacogenetic results were not discretely entered into the EHR, and the results were only found as attached documents in the miscellaneous section of the EHR. There remains a significant opportunity for improving HLA-B*15:02 pre-screening for patients starting carbamazepine and oxcarbazepine to prevent SCARs in the USA.
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Affiliation(s)
- Vy L. Bui
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Santiago Alvarez-Arango
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James M. Stevenson
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Gardner J, Hammond S, Jensen R, Gibson A, Krantz MS, Ardern‐Jones M, Phillips EJ, Pirmohamed M, Chadwick AE, Betts C, Naisbitt DJ. Glycolysis: An early marker for vancomycin-specific T-cell activation. Clin Exp Allergy 2024; 54:21-33. [PMID: 38177093 PMCID: PMC10953384 DOI: 10.1111/cea.14423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 11/01/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Vancomycin, a glycopeptide antibiotic used for Gram-positive bacterial infections, has been linked with drug reaction with eosinophilia and systemic symptoms (DRESS) in HLA-A*32:01-expressing individuals. This is associated with activation of T lymphocytes, for which glycolysis has been isolated as a fuel pathway following antigenic stimulation. However, the metabolic processes that underpin drug-reactive T-cell activation are currently undefined and may shed light on the energetic conditions needed for the elicitation of drug hypersensitivity or tolerogenic pathways. Here, we sought to characterise the immunological and metabolic pathways involved in drug-specific T-cell activation within the context of DRESS pathogenesis using vancomycin as model compound and drug-reactive T-cell clones (TCCs) generated from healthy donors and vancomycin-hypersensitive patients. METHODS CD4+ and CD8+ vancomycin-responsive TCCs were generated by serial dilution. The Seahorse XFe96 Analyzer was used to measure the extracellular acidification rate (ECAR) as an indicator of glycolytic function. Additionally, T-cell proliferation and cytokine release (IFN-γ) assay were utilised to correlate the bioenergetic characteristics of T-cell activation with in vitro assays. RESULTS Model T-cell stimulants induced non-specific T-cell activation, characterised by immediate augmentation of ECAR and rate of ATP production (JATPglyc). There was a dose-dependent and drug-specific glycolytic shift when vancomycin-reactive TCCs were exposed to the drug. Vancomycin-reactive TCCs did not exhibit T-cell cross-reactivity with structurally similar compounds within proliferative and cytokine readouts. However, cross-reactivity was observed when analysing energetic responses; TCCs with prior specificity for vancomycin were also found to exhibit glycolytic switching after exposure to teicoplanin. Glycolytic activation of TCC was HLA restricted, as exposure to HLA blockade attenuated the glycolytic induction. CONCLUSION These studies describe the glycolytic shift of CD4+ and CD8+ T cells following vancomycin exposure. Since similar glycolytic switching is observed with teicoplanin, which did not activate T cells, it is possible the master switch for T-cell activation is located upstream of metabolic signalling.
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Affiliation(s)
- Joshua Gardner
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | | | - Rebecca Jensen
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Andrew Gibson
- Murdoch UniversityInstitute for Immunology & Infectious DiseasesPerthWestern AustraliaAustralia
| | - Matthew S. Krantz
- Vanderbilt Institute for Infection, Immunology and InflammationVanderbilt UniversityNashvilleTennesseeUSA
| | - Michael Ardern‐Jones
- Clinical Experimental SciencesUniversity of Southampton Faculty of Medicine, Sir Henry Wellcome Laboratories, Southampton General HospitalSouthamptonUK
| | - Elizabeth J. Phillips
- Vanderbilt Institute for Infection, Immunology and InflammationVanderbilt UniversityNashvilleTennesseeUSA
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Amy E. Chadwick
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Catherine Betts
- Clinical Pharmacology & Safety SciencesAstraZeneca R&DCambridgeUK
| | - Dean J. Naisbitt
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
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14
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Castagna J, Chasset F, Autegarden JE, Le Thai C, Amsler E, Barbaud A, Soria A. Assessing delayed penicillin hypersensitivity using the PENFAST+ score. Front Allergy 2023; 4:1302567. [PMID: 38026134 PMCID: PMC10680989 DOI: 10.3389/falgy.2023.1302567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Approximately 10% of individuals report a suspected allergy to penicillin, but according to allergy work-ups, only 10%-15% of them are truly allergic. A clinical decision score, the PEN-FAST, was developed and validated to identify adults with low-risk penicillin allergy. Objectives The objective of this study was to improve the performance of the PEN-FAST score, particularly for those with delayed hypersensitivity (HS), by improving the negative predictive value. Methods STEP 1: Retrospective evaluation of the PEN-FAST score in patients with proven immediate and delayed penicillin allergy. STEP 2: Identification of additional criteria among Step 1 patients misclassified by PEN-FAST score. Development of the PEN-FAST+ score using multivariable logistic regression in a prospective cohort of patients with a suspicion of HS to penicillin. STEP 3: Comparison of diagnostic performances of PEN-FAST and PEN-FAST+ scores. Results The PEN-FAST score showed limitations in predicting the relapse of immediate skin HS or delayed maculopapular exanthema, with 28.6% and 38.4% of patients misclassified, respectively. We identified two potential additional criteria: skin rash lasting more than 7 days and immediate reaction occurring in less than 1 h (generalized or localized on palmoplantar area or scalp itching/heat feeling). A total of 32/252 (12.7%) patients were confirmed to be allergic to penicillin. With PEN-FAST, 37% of patients (n = 10) with delayed allergic penicillin HS were misclassified. With PEN-FAST+, 3 patients with delayed HS confirmed by a ST (11.1%) were misclassified. The AUC was significantly higher for PEN-FAST+ than PEN-FAST (85% vs. 72%, p = 0.03).
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Affiliation(s)
- Julie Castagna
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - François Chasset
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
- Centre d’Immunologie et de Maladies Infectieuses, Cimi-Paris, INSERM, Paris, France
| | - Jean-Eric Autegarden
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Claire Le Thai
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Emmanuelle Amsler
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Annick Barbaud
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, Institut Pierre Louis d’Epidémiologie et de Sante Publique, Paris, France
| | - Angèle Soria
- Médecine Sorbonne Université, Service de dermatologie et d’allergologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
- Centre d’Immunologie et de Maladies Infectieuses, Cimi-Paris, INSERM, Paris, France
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15
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Martino JG, Cang W, Jaskowiak J, Tavakoli A, Clapp C, Marro H, Kim A. Implementation of a multidisciplinary inpatient drug desensitization program. Am J Health Syst Pharm 2023; 80:1670-1676. [PMID: 37605927 DOI: 10.1093/ajhp/zxad189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE The purpose of this project was to analyze the process of adult inpatient drug desensitization and to create a multidisciplinary standardized procedure with the aim of improving patient safety, efficiency, length of stay, and patient satisfaction. SUMMARY A team consisting of physicians, pharmacists, nurses, critical care specialists, and operational capacity managers was created. The electronic health system was queried to evaluate the frequency of desensitizations, level of care, implicated medications, and length of stay. An electronic desensitization request form was created along with a desensitization team and email listserver for notification of key stakeholders. CONCLUSION A standardized, safe, and efficient process for inpatient drug desensitization requires advance planning and participation from all disciplines involved. Operational and logistical aspects of desensitization are crucial components of rapid drug desensitization. A structured, multidisciplinary approach to inpatient desensitization is feasible.
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Affiliation(s)
- Janine G Martino
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - William Cang
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - Jaclyn Jaskowiak
- Department of Pharmacy, Jacobs Medical Center, UC San Diego Health, La Jolla, CA, USA
| | - Aran Tavakoli
- Department of Nursing Education, Development and Research, UC San Diego Health, San Diego, CA, USA
| | - Christopher Clapp
- Department of Nursing Education, Development and Research, UC San Diego Health, San Diego, CA, USA
| | - Hannah Marro
- Department of Nursing, Medical and Surgical ICU, UC San Diego Health, La Jolla, CA, USA
| | - Alexander Kim
- Department of Patient Flow/ Capacity Management, UC San Diego Health, La Jolla, CA, USA
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16
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Ng TTW, Davel S, O’Connor KD. Sulfasalazine-Induced Delayed Hypersensitivity Reaction Presenting as Fever, Aseptic Meningitis, and Mesenteric Panniculitis in a Patient with Seronegative Arthritis. Am J Case Rep 2023; 24:e941623. [PMID: 37924204 PMCID: PMC10630587 DOI: 10.12659/ajcr.941623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/26/2023] [Accepted: 09/12/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND An 82-year-old woman presented with acute pyrexial illness and mesenteric panniculitis and developed biochemical aseptic meningitis (cerebrospinal fluid pleocytosis with no identifiable pathogen). Investigation determined her illness was likely a delayed hypersensitivity reaction caused by sulfasalazine. Sulfasalazine-induced aseptic meningitis is a rare condition often diagnosed late in a patient's admission owing to initial non-specific illness symptomatology requiring the exclusion of more common "red flag" etiologies, such as infection and malignancy. CASE REPORT An 82-year-old woman with a history of recurrent urinary tract infections and seronegative arthritis presented with a 3-day history of fatigue, headache, dyspnea, and lassitude. On admission, she was treated as presumed sepsis of uncertain source owing to pyrexia and tachycardia. Brain computer tomography (CT) revealed no acute intracranial abnormality. Furthermore, CT of the chest, abdomen, and pelvis did not reveal any source of sepsis or features of malignancy. After excluding infective etiologies with serological and cerebrospinal fluid testing, sulfasalazine-induced aseptic meningitis (SIAM) was diagnosed. The patient was then commenced on intravenous steroids, resulting in immediate defervescence and symptom resolution. CONCLUSIONS SIAM remains a diagnostic challenge since patients present with non-specific signs and symptoms, such as pyrexia, headaches, and lassitude. These patients require a thorough investigative battery starting with anamnesis, physical examination, biochemical testing, and radiologic imaging. This case illustrates the need for a high suspicion index of drug-induced hypersensitivity reaction in a rheumatological patient with pyrexial illness where infective etiologies have been confidently excluded. Prompt initiation of intravenous steroids in SIAM provides a dramatic recovery and resolution of symptoms.
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Affiliation(s)
- Tristen Tze Wei Ng
- Department of General Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia
- Department of Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sue Davel
- Department of General Medicine, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Kevin David O’Connor
- Stroke Unit, Joondalup Health Campus, Joondalup, Western Australia, Australia
- Department of Immunology, Royal Perth Hospital, Perth, Western Australia, Australia
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17
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Levenberg G, Bleier J, Leibowitz A, Salomon O, Misgav M, Agmon-Levin N, Shavit R. Nsaids Linked to IgA-Mediated Hypersensitivity Vasculitis and Purpura Fulminans-Like Eruption. Eur J Case Rep Intern Med 2023; 10:004072. [PMID: 37920231 PMCID: PMC10619524 DOI: 10.12890/2023_004072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 11/04/2023] Open
Abstract
Background IgA vasculitis and hypersensitivity reactions following exposure to non-steroidal anti-inflammatory drugs (NSAIDs) are very rarely associated with purpura fulminans (PF). The latter is a coagulation event characterised by decreased levels of protein C and a rapidly progressive purpuric rash, often leading to ischaemia, amputations and death. Case summary A previously healthy 66-year-old man presented with a vasculitic rash and abdominal pain following exposure to naproxen (NSAID), which quickly deteriorated to purpura fulminans-like eruption and skin necrosis, mainly involving the face and hands. The presence of IgA sediments on skin biopsy and decreased levels of complement as well as protein C pointed to an immune-mediated inflammatory process. Dramatic clinical escalation with immediate risk to organs and life required an aggressive and broad-spectrum therapeutic approach in an intensive care setting. Clinical improvement and complete reconstitution of protein C were achieved following plasma exchange with fresh frozen plasma (FFP) and immunosuppression with glucocorticoids with no persistent organ damage. Conclusions This rare case illustrates the catastrophic cross links between NSAIDs, IgA-mediated hypersensitivity vasculitis and purpura fulminans-like syndrome. A high index of suspicion is required for the evaluation of environmental exposures such as drugs and infections in patients with vasculitis and/or purpura. A rapid and comprehensive therapeutic approach should be implemented to avoid multi-organ damage, amputations and death. Complete avoidance of the offending agent is key for future prevention of recurrence. LEARNING POINTS This case illustrates a rare cross link between a commonly used drug (NSAIDs) and severe, life-threatening hypersensitivity reactions (IgA vasculitis and purpura fulminans-like eruption).These events require a high index of suspicion and emphasise the importance of considering environmental exposures such as drugs in the immediate diagnosis of both conditions.In addition to long-term drug avoidance, early and aggressive interventions are required to avoid organ damage, amputations or death.
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Affiliation(s)
- Guy Levenberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Bleier
- Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Avshalom Leibowitz
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine D, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Ophira Salomon
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Thrombosis and Haemostasis Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Mudi Misgav
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Thrombosis and Haemostasis Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Nancy Agmon-Levin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Clinical Immunology, Angioedema and Allergy Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Ronen Shavit
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Clinical Immunology, Angioedema and Allergy Institute, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
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18
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Pichler WJ, Thoo L, Yerly D. Drug hypersensitivity and eosinophilia: The decisive role of p-i stimulation. Allergy 2023; 78:2596-2605. [PMID: 37395496 DOI: 10.1111/all.15795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
Eosinophilia is a common finding in drug hypersensitivity reactions (DHR). Its cause is unclear, as neither antigen/allergen-driven inflammation nor clonal expansion is involved. Most delayed-DHRs are due to p-i (pharmacologic interaction of drugs with immune receptors). These are off-target activities of drugs with immune receptors that result in various types of T-cell stimulation, some of which involve excessive IL-5 production. Functional and phenotypic studies of T-cell clones and their TCR-transfected hybridoma cell lines revealed that some p-i-induced drug stimulations occur without CD4/ CD8 co-receptor engagement. The CD4/CD8 co-receptors link Lck (lymphocyte-specific protein tyrosine kinase) and LAT (linker for activation of T cells) to the TCR. Alteration of Lck or LAT can result in a TCR signalosome with enhanced IL-5 production. Thus, if a more affine TCR-[drug/peptide/HLA] interaction allows bypassing the CD4 co-receptor, a modified Lck/LAT activation may lead to a TCR signalosome with elevated IL-5 production. This "IL-5-TCR-signalosome" hypothesis could also explain eosinophilia in superantigen or allo-stimulation (graft-versus-host disease), in which evasion of CD4/CD8 co-receptors has also been described. It may open new therapeutic possibilities in certain eosinophilic diseases by directly targeting the IL-5-TCR signalosome.
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19
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Line J, Saville E, Meng X, Naisbitt D. Why drug exposure is frequently associated with T-cell mediated cutaneous hypersensitivity reactions. Front Toxicol 2023; 5:1268107. [PMID: 37795379 PMCID: PMC10546197 DOI: 10.3389/ftox.2023.1268107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Cutaneous hypersensitivity reactions represent the most common manifestation of drug allergy seen in the clinic, with 25% of all adverse drug reactions appearing in the skin. The severity of cutaneous eruptions can vastly differ depending on the cellular mechanisms involved from a minor, self-resolving maculopapular rash to major, life-threatening pathologies such as the T-cell mediated bullous eruptions, i.e., Stevens Johnson syndrome/toxic epidermal necrolysis. It remains a significant question as to why these reactions are so frequently associated with the skin and what factors polarise these reactions towards more serious disease states. The barrier function which the skin performs means it is constantly subject to a barrage of danger signals, creating an environment that favors elicitation. Therefore, a critical question is what drives the expansion of cutaneous lymphocyte antigen positive, skin homing, T-cell sub-populations in draining lymph nodes. One answer could be the heterologous immunity hypothesis whereby tissue resident memory T-cells that express T-cell receptors (TCRs) for pathogen derived antigens cross-react with drug antigen. A significant amount of research has been conducted on skin immunity in the context of contact allergy and the role of tissue specific antigen presenting cells in presenting drug antigen to T-cells, but it is unclear how this relates to epitopes derived from circulation. Studies have shown that the skin is a metabolically active organ, capable of generating reactive drug metabolites. However, we know that drug antigens are displayed systemically so what factors permit tolerance in one part of the body, but reactivity in the skin. Most adverse drug reactions are mild, and skin eruptions tend to be visible to the patient, whereas minor organ injury such as transient transaminase elevation is often not apparent. Systemic hypersensitivity reactions tend to have early cutaneous manifestations, the progression of which is halted by early diagnosis and treatment. It is apparent that the preference for cutaneous involvement of drug hypersensitivity reactions is multi-faceted, therefore this review aims to abridge the findings from literature on the current state of the field and provide insight into the cellular and metabolic mechanisms which may contribute to severe cutaneous adverse reactions.
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Affiliation(s)
| | | | | | - Dean Naisbitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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20
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Cortellini G, Raiteri A, Biagioni B, Liberati S, Lippolis D, Cortellini G, Piscaglia F. Taxanes hypersensitivity is not a risk factor for severe reactions to SARS-CoV-2 vaccines. Eur Ann Allergy Clin Immunol 2023; 55:229-234. [PMID: 36047485 DOI: 10.23822/eurannaci.1764-1489.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Summary Background. Hypersensitivity reactions (HSR) to taxanes have been related to a complement activation by their excipients, polyoxyethylated castor oil and Polysorbate 80, structurally related to those of SARS-CoV-2 vaccines. The aim of this study was to verify the presence of a higher risk of HSR to SARS-CoV-2 vaccines in patients with history of HSR to taxanes. Methods. Patients with history of HSR to taxanes were evaluated before the vaccination in our center and underwent skin tests for PEG and Polysorbate 80 (PandP). Some patients completed the vaccination course in other centers without prior PandP skin tests because they had not manifested taxanes hypersensitivity before vaccination, or because those tests were not available. Results. 50 patients were evaluated. 100% of patients with history of hypersensitivity to taxanes completed the vaccine course with no cases of anaphylaxis. 33 underwent skin tests for PandP before the vaccination and no correlation was found between the positivity of PandP and taxanes skin tests (p = 0.538). 7 patients developed mild symptoms during skin tests and vaccination, similar but weaker than those suffered at the time of the taxane infusion, independently from the results of skin tests. Conclusions. In our cohort patients with history of reaction to taxanes were not at higher risk to develop anaphylaxis to SARS-CoV-2 vaccines. However, a common non-IgE mediated mechanism behind those HSRs cannot be completely excluded. This can only account for mild and harmless symptoms in case of SARS-CoV-2 vaccines. However, prudence is still recommended in these patients.
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Affiliation(s)
- G Cortellini
- Interdipartimental Allergy Unit, Azienda Sanitaria Romagna, Ravenna, Italy
| | - A Raiteri
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - B Biagioni
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - S Liberati
- Interdipartimental Allergy Unit, Azienda Sanitaria Romagna, Ravenna, Italy
| | - D Lippolis
- Interdipartimental Allergy Unit, Azienda Sanitaria Romagna, Ravenna, Italy
| | - G Cortellini
- Emergency Unit, Riccione Hospital, Azienda Sanitaria Romagna, Ravenna, Italy
| | - F Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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21
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Božan M, Vukičević Lazarević V, Marković I, Morović‐Vergles J, Mitrović J. Alpha-gal syndrome-Food or drug allergy: A case report. Clin Case Rep 2023; 11:e7830. [PMID: 37636877 PMCID: PMC10448237 DOI: 10.1002/ccr3.7830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023] Open
Abstract
Alpha-gal syndrome is an immunoglobulin E-mediated hypersensitivity characterized by delayed allergic reactions to ingested products containing alpha-gal carbohydrate. We present a patient with recurrent urticaria and suspected repaglinide hypersensitivity, who was eventually diagnosed with alpha-gal syndrome, wanting to emphasize possible drug allergy misdiagnosis and required caution with the medication choice.
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Affiliation(s)
- Marina Božan
- Special Hospital for Pulmonary DiseasesZagrebCroatia
| | | | - Ivan Marković
- Special Hospital for Pulmonary DiseasesZagrebCroatia
| | - Jadranka Morović‐Vergles
- Division of Clinical Immunology, Allergology and Rheumatology, Department of Internal MedicineDubrava University HospitalZagrebCroatia
- School of MedicineUniversity of ZagrebZagrebCroatia
| | - Joško Mitrović
- Division of Clinical Immunology, Allergology and Rheumatology, Department of Internal MedicineDubrava University HospitalZagrebCroatia
- School of Medicine and Faculty of Pharmacy and BiochemistryUniversity of ZagrebZagrebCroatia
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22
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Brockow K, Wurpts G, Trautmann A, Pfützner W, Treudler R, Bircher AJ, Brehler R, Buhl T, Dickel H, Fuchs T, Jakob T, Kurz J, Kreft B, Lange L, Merk HF, Mockenhaupt M, Mülleneisen N, Ott H, Ring J, Ruëff F, Sachs B, Sitter H, Wedi B, Wöhrl S, Worm M, Zuberbier T. Guideline for allergological diagnosis of drug hypersensitivity reactions: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) in cooperation with the German Dermatological Society (DDG), the Association of German Allergologists (ÄDA), the German Society for Pediatric Allergology (GPA), the German Contact Dermatitis Research Group (DKG), the German Society for Pneumology (DGP), the German Society of Otorhinolaryngology, Head and Neck Surgery, the Austrian Society of Allergology and Immunology (ÖGAI), the Austrian Society of Dermatology and Venereology (ÖGDV), the German Academy of Allergology and Environmental Medicine (DAAU), and the German Documentation Center for Severe Skin Reactions (dZh). Allergol Select 2023; 7:122-139. [PMID: 37705676 PMCID: PMC10495942 DOI: 10.5414/alx02422e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/30/2023] [Indexed: 09/15/2023] Open
Abstract
Not available.
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Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich
| | - Gerda Wurpts
- Department of Dermatology and Allergology, Germany, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen
| | - Axel Trautmann
- Department of Dermatology and Allergology, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg
| | - Wolfgang Pfützner
- Department of Dermatology and Allergology, University Hospital Giessen and Marburg, Marburg
| | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, University of Leipzig, Leipzig, Germany
| | - Andreas J. Bircher
- Facoltà di Scienze biomediche, Università della Svizzera italiana, Lugano, and Department of Dermatology and Allergology, University Hospital Basel, Switzerland
| | | | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen
| | - Heinrich Dickel
- Department of Dermatology, Venerology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum
| | - Thomas Fuchs
- Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Hospital, Justus-Liebig University, Gießen
| | - Julia Kurz
- Department of Dermatology and Allergology, University Hospital Giessen and Marburg, Marburg
| | - Burkhard Kreft
- Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale)
| | - Lars Lange
- Pediatric Clinic, Marienhospital Bonn, Bonn
| | - Hans F. Merk
- Department of Dermatology and Allergology, Germany, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen
| | - Maja Mockenhaupt
- Documentation Center for Severe Skin Reactions, Department of Dermatology and Venereology, University Medical Center Freiburg, Freiburg
| | | | - Hagen Ott
- Children’s and Youth Hospital Auf der Bult, Hanover
| | - Johannes Ring
- Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich
| | - Franziska Ruëff
- Department of Dermatology and Allergology, Allergy Center, Ludwig Maximilian University of Munich
| | - Bernhardt Sachs
- Department of Dermatology and Allergology, Germany, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen
| | - Helmut Sitter
- Institute for Theoretical Surgery, Philipps University of Marburg, Marburg
| | - Bettina Wedi
- Hanover Medical School, Department of Dermatology, Allergology and Venereology, Hanover, Germany
| | - Stefan Wöhrl
- Floridsdorf Allergy Center (FAZ), Vienna, Austria, and
| | - Margitta Worm
- Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Torsten Zuberbier
- Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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23
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Rodríguez-Pérez R, de las Vecillas L, Cabañas R, Bellón T. Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions. Int J Mol Sci 2023; 24:12577. [PMID: 37628756 PMCID: PMC10454098 DOI: 10.3390/ijms241612577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Drug hypersensitivity reactions are a serious concern in clinical practice because they can be severe and result in lifelong sequelae. An accurate diagnosis and identification of the culprit drug is essential to prevent future reactions as well as for the identification of safe treatment alternatives. Nonetheless, the diagnosis can be challenging. In vivo and in vitro tests can be helpful, although none are conclusive; therefore, the tests are not usually performed in isolation but as part of a diagnostic algorithm. In addition, some in vitro tests are only available in research laboratories, and standardization has not been fully accomplished. Collaborating research is needed to improve drug hypersensitivity reaction diagnosis. In this review, we update the current available in vivo and in vitro tools with their pros and cons and propose an algorithm to integrate them into clinical practice.
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Affiliation(s)
- Rosa Rodríguez-Pérez
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
| | - Leticia de las Vecillas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
| | - Rosario Cabañas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER U754), 28046 Madrid, Spain
| | - Teresa Bellón
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- PIELenRed Consortium, 28046 Madrid, Spain
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24
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Molleti RR, Bidell MR, Tatara AW. Fidaxomicin-Associated Hypersensitivity Reactions: Report of a Morbilliform Drug Eruption. J Pharm Pract 2023; 36:993-997. [PMID: 36112954 DOI: 10.1177/08971900221078780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
PurposeWe report a probable case of morbilliform drug eruption secondary to fidaxomicin in a patient with Clostridioides difficile infection (CDI). Summary: A 62-year-old female presented to our institution's emergency department (ED) with symptoms consistent with Clostridioides difficile infection. The patient was prescribed 2 weeks of oral vancomycin for CDI prior to presentation. Given insufficient response to vancomycin, the patient was started on fidaxomicin with a planned 10-day course. After 2 doses of fidaxomicin, the patient developed a rash on her back that spread within 24 hours. The patient did not experience relief upon administration of a variety of medications for allergic reaction. Improvement was noted upon discontinuation of fidaxomicin. The Food and Drug Administration reports that < 2% of adults treated with fidaxomicin experience a rash as an adverse effect. Conclusion: Fidaxomicin was a probable cause of morbilliform drug eruption in our patient with CDI. The patient improved upon discontinuation of fidaxomicin.
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Affiliation(s)
- Radha R Molleti
- Department of Pharmacy, Memorial Hermann Memorial City Hospital, Houston, Texas, USA
| | - Monique R Bidell
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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25
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Lendal V, Fransson S, Mosbech H, Boel JB, Kahlhofen N, Blom LH, Poulsen LK, Garvey LH. Specific IgE to penicillin minor determinants in patients with suspected penicillin allergy. Clin Exp Allergy 2023; 53:887-890. [PMID: 37246578 DOI: 10.1111/cea.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Victor Lendal
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Holger Mosbech
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Bredtoft Boel
- Department of Clinical Microbiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Natasha Kahlhofen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lars H Blom
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lars K Poulsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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26
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Moral L, Mori F. Drug provocation tests in children: All that glitters is not gold. Pediatr Allergy Immunol 2023; 34:e14002. [PMID: 37622259 DOI: 10.1111/pai.14002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
A proper allergy work-up, based on the gold standard drug provocation test (DPT), usually rules out suspected drug hypersensitivity in children. These tests are generally open, given their high efficiency compared with double-blind placebo-controlled DPTs. Although their negative predictive value is excellent, no studies have calculated their positive predictive value, highly dependent on the prevalence of the disease. Most studies have found a rate of <5%-10% of true beta-lactam hypersensitivity in children. Given this low prevalence (pre-test probability), a few false-positive results can significantly reduce the estimated positive predictive value. False positives may arise from the nocebo effect during the test, including nocebo by proxy, or from observer bias, which depends on professional expertise and organizational circumstances. Some studies have found a high rate of tolerance on a second DPT in children who failed the first, but these results may be affected by the interval between the two tests, of a year or more in most cases, reflecting a loss of hypersensitivity over time. Taking into account the low rate of positive DPTs, with commonly mild reactions, we suggest confirming nonsevere positive DPTs with a second provocation performed soon after the first, especially in the case of beta-lactam antibiotics, in order to improve the diagnostic accuracy, de-label more patients, and achieve a better estimation of true drug hypersensitivity prevalence. In case of mild immediate reactions, the potential benefits of a second DPT should be carefully weighed against the risk of anaphylaxis.
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Affiliation(s)
- Luis Moral
- Pediatric Allergy and Respiratory Unit, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital, IRCCS Florence, Florence, Italy
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27
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Manieri E, Dondi A, Neri I, Lanari M. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome in childhood: a narrative review. Front Med (Lausanne) 2023; 10:1108345. [PMID: 37575981 PMCID: PMC10421667 DOI: 10.3389/fmed.2023.1108345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Despite being rare, the Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome is a serious, possibly fatal condition that may affect both adults and children who may be also burdened by delayed sequelae. It is an adverse drug reaction characterized by widespread skin involvement, fever, lymphadenopathy, visceral involvement, and laboratory abnormalities (eosinophilia, mononucleosis-like atypical lymphocytes). It is more frequently triggered by anticonvulsants, sulphonamides, or antibiotics, the latter being responsible for up to 30% of pediatric cases. The disease typically develops 2-8 weeks after exposure to the culprit medication, with fever and widespread skin eruption; mild viral prodromes are possible. Unfortunately, diagnosis is challenging due to the absence of a reliable test; however, a score by the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) allows to classify suspect patients into no, possible, probable, or definite DRESS cases. Moreover, rapid-onset DRESS syndrome has been described in recent years. It affects children more often than adults and differs from the most common form because it appears ≤15 days vs. >15 days after starting the drug, it is usually triggered by antibiotics or iodinated contrast media rather than by anticonvulsants and has a higher presence of lymphadenopathy. Differential diagnosis between rapid-onset antibiotic-driven DRESS syndrome, viral exanthems, or other drug eruptions may be challenging, but it is mandatory to define it as early as possible to start adequate treatment and monitor possible complications. The present review reports the latest evidence about the diagnosis and treatment of pediatric DRESS syndrome.
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Affiliation(s)
- Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Iria Neri
- Division of Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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28
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Bin Rubaian NF, Aljalfan AA, Almuhaidib SR. Management of coronavirus disease 2019 vaccine-induced cutaneous complications: A comprehensive literature review. J Family Community Med 2023; 30:161-170. [PMID: 37675215 PMCID: PMC10479027 DOI: 10.4103/jfcm.jfcm_3_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 09/08/2023] Open
Abstract
Despite the numerous reports of cutaneous manifestations associated with vaccines for coronavirus disease 2019 (COVID-19), the relationship between COVID-19 vaccines and cutaneous side effects remains unevaluated. In this review, we examine these manifestations and their management. Reported dermatoses included injection-site reaction (early and delayed), type I allergic reaction, morbilliform eruption, pityriasis rosea, Sweet syndrome, lichen planus, psoriasis, herpes zoster reactivation, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis (TEN). The most common COVID-19 vaccination-related cutaneous manifestations are delayed local reactions, approximately 66% of which are associated with the Moderna vaccine, and 33% with the Pfizer vaccine. Aside from mild injection-site reactions, severe reactions include anaphylaxis and TEN. Most reactions, except for Stevens-Johnson syndrome and anaphylaxis, though unpredictable and unpreventable are mild and can be treated symptomatically. Findings from this review should allow primary care physicians and dermatologists to reach faster diagnosis and initiate prompt intervention.
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Affiliation(s)
- Nouf F. Bin Rubaian
- Department of Dermatology, King Fahad University Hospital, Al-Khobar, Saudi Arabia
| | - Abdullah A. Aljalfan
- Department of Dermatology, King Fahad University Hospital, Al-Khobar, Saudi Arabia
| | - Serene R. Almuhaidib
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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29
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Coromilas AJ, Divito SJ, Phillips EJ, Micheletti RG. Physical and mental health impact of Stevens-Johnson syndrome/toxic epidermal necrolysis and post-hospital discharge care: Identifying practice gaps. JAAD Int 2023; 11:88-89. [PMID: 36941915 PMCID: PMC10023849 DOI: 10.1016/j.jdin.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Alexandra J. Coromilas
- Department of Dermatology, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York
- Correspondence to: Alexandra J. Coromilas, MD, Department of Dermatology, Columbia University, 161 Fort Washington Ave, 12th Floor, New York, NY 10032
| | - Sherrie J. Divito
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert G. Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Silva MIT, Cosme J, Lorenzo C, Virtuoso J, Gomes R, Pedro E, Neves AM, Lopes A. Hypersensitivity to Non-Steroidal Anti-Inflammatory Drugs on a pediatric Portuguese cohort. Eur Ann Allergy Clin Immunol 2023. [PMID: 37249059 DOI: 10.23822/eurannaci.1764-1489.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Summary Background. Non-steroidal anti-inflammatory drugs (NSAID)/analgesics (paracetamol) are among the most common causes of drug hypersensitivity reactions in children, with a reported prevalence of around 0.3% in the pediatric population. Paracetamol and ibuprofen are the most commonly reported culprits in the pediatric population. Our objective was to describe the allergy workup to NSAID/paracetamol of a pediatric population monitored in an allergy outpatient clinic. Methods. Retrospective observational study by consulting the medical records of patients evaluated in a pediatric outpatient clinic with history of NSAID/paracetamol, between January 2016 to August 2022. Results. A total of 43 patients have been evaluated for NSAID/paracetamol suspected allergy: 53.5% females, mean age of 9.8 ± 5.1 years, 47.7% atopic. The drugs reported as culprits were: ibuprofen (75.6%), paracetamol (17.8%), metamizole (4.4%) and naproxen (2.2%) and clinical manifestations were mainly urticaria/angioedema and maculopapular exanthema. Skin tests were performed in 7 patients: paracetamol (n = 5) and metamizole (n = 2), which were all negative. Fourty-six drug provocation tests were performed: 28 with the culprit drug and 18 with an alternative one; only 2 were positive (ibuprofen - culprit NSAID group): one immediate periorbital angioedema and one delayed lip edema with oropharyngeal tightness. Conclusions. The investigation of allergy to NSAID/paracetamol in children remains a challenge. In our population, ibuprofen was the most common NSAID reported. There were only 2 (4.3%) mild reactions on DPT. We could allow the use of the culprit NSAID/analgesic in 11 patients and an alternative one in 9 patients. This study highlights the importance of DPT in children for a correct diagnosis of NSAID hypersensitivity and selection of an alternative drug.
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Affiliation(s)
- M I T Silva
- Department of Immunoallergology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - J Cosme
- Department of Immunoallergology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - C Lorenzo
- Department of Pediatric, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - J Virtuoso
- Department of Pediatric, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Department of Pediatric, Unidade Local de Saúde da Guarda, Hospital Sousa Martins, Guarda, Portugal
| | - R Gomes
- Department of Pediatric, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - E Pedro
- Department of Immunoallergology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - A M Neves
- Department of Pediatric, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - A Lopes
- Department of Immunoallergology, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
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31
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Saretta F, Tomei L, Mori F, Mayorga C. In vitro diagnostic testing for drug allergy in children. Pediatr Allergy Immunol 2023; 34:e13955. [PMID: 37102390 DOI: 10.1111/pai.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
Diagnosing Drug Hypersensitivity Reactions (DHRs) could be a complicated process especially in children, since allergic-like manifestation at this age is more often the expression of concomitant infections rather than a actual DHRs. In vivo tests are usually suggested as a first step; however, prick and intradermal tests could be painful and have shown different sensitivity and specificity among published studies. In some cases, in vivo tests such as Drug Provocation test (DPT) could be even contraindicated. Therefore, the need for in vitro testing is compelling, to add useful information along the diagnostic pathway and to limit the need of DPT. In this review, we analyze the different types of in vitro tests, focusing on those used more widely such as specific IgE and on those that are still for research settings, such as basophil activation test and lymphocyte transformation test, but that have shown some useful diagnostic potential.
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Affiliation(s)
- Francesca Saretta
- Pediatric Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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32
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Kong Cardoso B, Silva L, Magalhães AM, Farinha SM, Antunes T, Mourato C, Tomaz E, Inácio F. Primary care doctors' attitude towards drug allergy in Portugal: a questionnaire. Eur Ann Allergy Clin Immunol 2023; 55:57-67. [PMID: 33980004 DOI: 10.23822/eurannaci.1764-1489.216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Summary Background. The aim of the study was to learn about perception of drug allergy by general practitioners (GP) from continental Portugal, identify difficulties and educational needs for its management. Methods. A total of 372 answers were obtained. A questionnaire was addressed to GPs. Results. The most commonly identified drugs were antibiotics for 65.3% of the GPs and skin was the most commonly affected organ for 65.8%. Drug allergy was considered as very important in clinical practice by 73.7%, but difficulties in recognizing it were stated by 70.2%. Further education in this field wouldbe welcome by 97.8% of the doctors. The collaboration of Immunoallergology centers was considered non satisfactory by 39.8% of GPs and 45.7% of them stated that two-thirds of the suspected reactions were not investigated. Conclusions. These points deserve consideration in future health educational and organizational strategies.
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Affiliation(s)
- B Kong Cardoso
- Immunoallergology Service, Hospital Center of Setúbal, Setúbal, Portugal
| | - L Silva
- USF Luísa Todi, ACES Arrábida, Lisbon and Tagus Valley Regional Health Administration (ARSLVT), Lisbon and Tagus Valley, Lisbon, Portugal
| | - A M Magalhães
- USF Santiago, ACES Arrábida, Lisbon and Tagus Valley Regional Health Administration (ARSLVT), Lisbon and Tagus Valley, Lisbon, Portugal
| | - S M Farinha
- Immunoallergology Service, Hospital Center of Setúbal, Setúbal, Portugal
| | - T Antunes
- USF Santiago, ACES Arrábida, Lisbon and Tagus Valley Regional Health Administration (ARSLVT), Lisbon and Tagus Valley, Lisbon, Portugal
| | - C Mourato
- USF Luísa Todi, ACES Arrábida, Lisbon and Tagus Valley Regional Health Administration (ARSLVT), Lisbon and Tagus Valley, Lisbon, Portugal
| | - E Tomaz
- Immunoallergology Service, Hospital Center of Setúbal, Setúbal, Portugal
| | - F Inácio
- Immunoallergology Service, Hospital Center of Setúbal, Setúbal, Portugal
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Kolkhir P, Ali H, Babina M, Ebo D, Sabato V, Elst J, Frischbutter S, Pyatilova P, Maurer M. MRGPRX2 in drug allergy: What we know and what we do not know. J Allergy Clin Immunol 2023; 151:410-412. [PMID: 36089079 PMCID: PMC9905269 DOI: 10.1016/j.jaci.2022.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/19/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Pavel Kolkhir
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Hydar Ali
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa
| | - Magda Babina
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Didier Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, 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 University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Stefan Frischbutter
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Polina Pyatilova
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Maurer
- Fraunhofer Institute for Translational Medicine and Pharmacology, Allergology and Immunology, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Stonerock D, Hallo-Carrasco A, Edwards M, Porter SB, Epps KL, Gonzalez-Estrada A. Pharmacist-led improvement in perioperative antibiotic selection for patients with a penicillin allergy label. Am J Health Syst Pharm 2023; 80:e111-e118. [PMID: 36680795 DOI: 10.1093/ajhp/zxad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Surgical patients with a penicillin allergy label (PAL) are less likely to receive β-lactams for surgical site infection (SSI) prophylaxis and more likely to receive second-line antibiotics, which may increase the risk of SSI, drug toxicities, and associated costs. We assessed the impact of implementing a pharmacist-led quality improvement project to increase the use of cefazolin as a first-line agent in this population. SUMMARY After implementation of a pilot project in December 2021, all patients with a PAL and orders for preoperative antibiotics were risk stratified into high- or low-risk categories by a pharmacist. For the low-risk group, cefazolin was recommended. For the high-risk group, cefazolin was avoided and a second-line agent was administered. Our analysis compared 422 preintervention patients (August 15 to November 15, 2021) to 492 postintervention patients (December 15 to March 15, 2022). During the postintervention period, β-lactam usage increased (from 12.6% to 37.8%, P < 0.001), while usage of vancomycin (45.5% vs 29.5%, P < 0.001) and other second-line antibiotics (87.4% vs 62.2%, P < 0.001) declined. There were no adverse reactions reported in the preintervention cohort, with 2 potential adverse reactions reported after the intervention (0% vs 0.4%, P = 0.190). Medication costs based on claims data were 50% to 80% lower for patients receiving cefazolin. CONCLUSION In our cohort, a pharmacy-led antibiotic selection algorithm for patients with a PAL receiving perioperative antimicrobial prophylaxis resulted in increased use of β-lactam antibiotics, decreased use of second-line antibiotics, and decreased costs without a significant change in the incidence of adverse reactions.
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Affiliation(s)
| | - Alejandro Hallo-Carrasco
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Edwards
- Division of Advanced GI and Bariatric Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Kevin L Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, FL, USA
| | - Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy, and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
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Chu MT, Chang WC, Pao SC, Hung SI. Delayed Drug Hypersensitivity Reactions: Molecular Recognition, Genetic Susceptibility, and Immune Mediators. Biomedicines 2023; 11:biomedicines11010177. [PMID: 36672685 PMCID: PMC9855900 DOI: 10.3390/biomedicines11010177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
Drug hypersensitivity reactions are classified into immediate and delayed types, according to the onset time. In contrast to the immediate type, delayed drug hypersensitivity mainly involves T lymphocyte recognition of the drug antigens and cell activation. The clinical presentations of such hypersensitivity are various and range from mild reactions (e.g., maculopapular exanthema (MPE) and fixed drug eruption (FDE)), to drug-induced liver injury (DILI) and severe cutaneous adverse reactions (SCARs) (e.g., Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP)). The common culprits of delayed drug hypersensitivity include anti-epileptics, antibiotics, anti-gout agents, anti-viral drugs, etc. Delayed drug hypersensitivity is proposed to be initiated by different models of molecular recognition, composed of drug/metabolite antigen and endogenous peptide, HLA presentation, and T cell receptor (TCR) interaction. Increasing the genetic variants of HLA loci and drug metabolic enzymes has been identified to be responsible for delayed drug hypersensitivity. Furthermore, preferential TCR clonotypes, and the activation of cytotoxic proteins/cytokines/chemokines, are also involved in the pathogenesis of delayed drug hypersensitivity. This review provides a summary of the current understanding of the molecular recognition, genetic susceptibility, and immune mediators of delayed drug hypersensitivity.
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Affiliation(s)
- Mu-Tzu Chu
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
| | - Wan-Chun Chang
- Division of Translational Therapeutics, Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Shih-Cheng Pao
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Institute of Pharmacology, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Shuen-Iu Hung
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan
- Institute of Pharmacology, School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Drug Hypersensitivity Clinical and Research Center, Department of Dermatology, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Correspondence: or ; Tel.: +886-3-3281200 (ext. 7806)
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Abstract
Virus infections and T-cell-mediated drug hypersensitivity reactions (DHR) can influence each other. In most instances, systemic virus infections appear first. They may prime the reactivity to drugs in two ways: First, by virus-induced second signals: certain drugs like β-lactam antibiotics are haptens and covalently bind to various soluble and tissue proteins, thereby forming novel antigens. Under homeostatic conditions, these neo-antigens do not induce an immune reaction, probably because co-stimulation is missing. During a virus infection, the hapten-modified peptides are presented in an immune-stimulatory environment with co-stimulation. A drug-specific immune reaction may develop and manifest as exanthema. Second, by increased pharmacological interactions with immune receptors (p-i): drugs tend to bind to proteins and may even bind to immune receptors. Without viral infections, this low affine binding may be insufficient to elicit T-cell activation. During a viral infection, immune receptors are more abundantly expressed and allow more interactions to occur. This increases the overall avidity of p-i reactions and may even be sufficient for T-cell activation and symptoms. There is a situation where the virus-DHR sequence of events is inversed: in drug reaction with eosinophilia and systemic symptoms (DRESS), a severe DHR can precede reactivation and viremia of various herpes viruses. One could explain this phenomenon by the massive p-i mediated immune stimulation during acute DRESS, which coincidentally activates many herpes virus-specific T cells. Through p-i stimulation, they develop a cytotoxic activity by killing herpes peptide-expressing cells and releasing herpes viruses. These concepts could explain the often transient nature of DHR occurring during viral infections and the often asymptomatic herpes-virus viraemia after DRESS.
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Affiliation(s)
| | - Marie-Charlotte Brüggen
- Allergy Unit, Department of Dermatology, University Hospital Zürich, Zürich, Switzerland.,Faculty of Medicine, University Zürich, Zürich, Switzerland.,Christine Kühne - Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
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Hirai S, Yamamoto-Hanada K, Kabashima S, Fukuie T, Shoji K, Ozawa K, Sago H, Ohya Y. [ANTIMICROBIAL ALLERGY ASSESSMENT DURING PREGNANCY FOR APPROPRIATE ANTIMICROBIAL USE AT DELIVERY]. Arerugi 2023; 72:1223-1229. [PMID: 38092398 DOI: 10.15036/arerugi.72.1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Avoidance of suspect drugs based solely on a history of drug allergy is detrimental to disease outcomes. Many antimicrobial allergy labels are not usually true allergy. Some studies have demonstrated that antimicrobial allergy assessments can be safely performed on pregnant women. The purpose of this study was to examine the usefulness of antibiotic allergy assessment during pregnancy in Japan. METHODS We reviewed pregnant women who reported antimicrobial allergies and were referred to the allergy center. Allergists conducted an interview and skin test and selected antibiotics that could be used at delivery. RESULTS Twenty-four pregnant women were referred to as having antimicrobial allergies. Most of the suspected antimicrobials were cephalosporin (13 cases, 52%) and penicillin (9 cases, 36%). Five women were ruled out only by our interviews. Of the remaining 20 cases, 10 were immediate type, 6 were non-immediate type, and 4 were unknown. All 21 pregnant women who needed antimicrobials were able to use the first-line drugs (β-lactam antimicrobials) at the time of delivery. No surgical site infections or allergic reactions were observed. CONCLUSION Pregnant women with antimicrobial allergy labels could be evaluated by antimicrobial allergy assessment during pregnancy, and first-line antimicrobials were safely and properly used at delivery.
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Affiliation(s)
- Seiko Hirai
- Allergy Center, National Center for Child Health and Development
| | | | | | - Tatsuki Fukuie
- Allergy Center, National Center for Child Health and Development
| | - Kensuke Shoji
- Division of Infectious Diseases, National Center for Child Health and Development
| | - Katsusuke Ozawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development
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Popiolek I, Blasiak M, Kozak A, Pietak E, Bulanda M, Porebski G. Diagnostic Value of Oral Provocation Tests in Drug Hypersensitivity Reactions Induced by Nonsteroidal Anti-Inflammatory Drugs and Paracetamol. Diagnostics (Basel) 2022; 12:diagnostics12123074. [PMID: 36553081 PMCID: PMC9777020 DOI: 10.3390/diagnostics12123074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Oral drug provocation tests (DPT) are the basic diagnostic tool for the detection of hypersensitivity to non-opioid analgesics and for selecting a safe alternative for a patient. They are of great practical importance due to their common use, but the data on the follow-up of patients after negative DPT are still very scarce. We examined the further fate of 164 such adult patients after negative NSAID or paracetamol tests and analyzed which excipients in the studied drugs they could be exposed to after the diagnostic workup. A structured medical interview was performed 32.9 months (mean) after the provocation tests. Of the 164 patients, 131 (79.9%) retook the tested drug and 12 developed another hypersensitivity reaction, giving the estimated negative predictive value of 90.8%. These reactions were induced by acetylsalicylic acid, paracetamol, meloxicam, and diclofenac, and were clinically similar to the initial ones (most commonly urticaria and angioedema). There are 93 generics of these drugs on the local market, containing a total of 33 excipients for which hypersensitivity reactions have been reported. All available generics contain such excipients. Thirty-one patients (20.1%) did not take the previously tested drug again, most often because it was not needed or because they were afraid of another reaction. DPT with analgesics has a high diagnostic performance. A minority of patients had relapsed after reexposure. One of the underestimated reasons for this may be drug excipients provoking a reaction, so it is advisable to use exactly the same medical product that has been negatively tested. Many patients avoid reexposure to a given drug, despite negative tests, therefore very reliable patient education in connection with DPT is highly needed.
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Affiliation(s)
- Iwona Popiolek
- Department of Toxicology and Environmental Diseases, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Magdalena Blasiak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Aleksandra Kozak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Ewelina Pietak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Malgorzata Bulanda
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
- Correspondence: ; Tel.: +48-12-424-86-38
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Thomson P, Hammond S, Naisbitt DJ. Pathology of drug hypersensitivity reactions and mechanisms of immune tolerance. Clin Exp Allergy 2022; 52:1379-1390. [PMID: 36177544 DOI: 10.1111/cea.14235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/08/2022] [Accepted: 09/25/2022] [Indexed: 01/26/2023]
Abstract
Immune-mediated type IV adverse drug reactions are idiosyncratic in nature, generally not related to the primary or secondary pharmacology of the drug. Due to their complex nature and rarity, these iatrogenic reactions are seldom predicted or encountered during preclinical/early clinical development stages, and often precipitate upon exposure to wider populations (i.e. phase III onwards). They confer a burden on the healthcare sector in both a clinical and financial sense presenting a severe impediment to the drug discovery and development process. Research over the past 50 years has improved our understanding of these reactions markedly as both in vitro and in vivo studies have placed the role of the immune system, in particular; drug-responsive T cells, firmly in the spotlight as the mediators of these reactions. Indeed, the role of different populations of T cells in adverse events and the interaction of drug molecules with HLA proteins expressed on the surface of antigen-presenting cells is of considerable interest. Herein, this review examines the pathways of immune-mediated adverse events including the various T cell subtypes implicated and the mechanisms of T cell activation. Additionally, we address the enigma of immunological tolerance and explore the role tolerance plays in determination of susceptibility to such adverse events even in individuals carrying immunogenic liabilities.
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Affiliation(s)
- Paul Thomson
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | - Sean Hammond
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK.,ApconiX, Alderley Park, Alderley Edge, UK
| | - Dean J Naisbitt
- Department of Molecular and Clinical Pharmacology, MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
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Ryder CY, Matthews NH, Lowe L, Wang F. A striking presentation of pustular Sweet syndrome induced by trimethoprim-sulfamethoxazole. Australas J Dermatol 2022; 63:e356-e359. [PMID: 35866718 PMCID: PMC9796284 DOI: 10.1111/ajd.13897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/18/2022] [Accepted: 07/08/2022] [Indexed: 01/02/2023]
Abstract
We describe a strikingly robust presentation of trimethoprim-sulfamethoxazole (TMP-SMX)-induced pustular Sweet syndrome and discuss how to distinguish it from iododerma and other neutrophil-rich conditions. A review of the literature indicates that TMP-SMX-induced Sweet syndrome (SS) may have higher rates of neutrophilia and greater ocular, mucosal, and musculoskeletal involvement compared to SS from other drugs. Recognizing these features and identifying the offending agent are critical for correctly diagnosing TMP-SMX-induced SS in a timely manner.
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Affiliation(s)
| | - Natalie H. Matthews
- Department of DermatologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Lori Lowe
- Department of DermatologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA,Department of PathologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Frank Wang
- Department of DermatologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Iriarte C, Karim SA, Nassim JS, Grenier PO, Massey KJ. Infantile Stevens Johnson syndrome and toxic epidermal necrolysis: A systematic review of clinical features and outcomes in children ages 12 months and under. Pediatr Dermatol 2022; 39:876-882. [PMID: 35676891 DOI: 10.1111/pde.15047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening mucocutaneous hypersensitivity reactions that carry significant morbidity and mortality. While clinical features are well documented in adult and pediatric patients, infantile cases are rarely reported. Our objective was to synthesize clinical features and outcomes in this population. METHODS A literature search was performed from three large databases (PubMed, EMBASE, and Web of Science) to systematically identify reports of SJS/TEN in the infantile period (defined as less than 12 months of age) between 1962 and 2019. Cases determined to represent SJS/TEN based on defined criteria were included. Each case was scored based on Quality Rating Scheme for Studies and Other Evidence. The initial search yielded 4856 publications, of which 19 (n = 26) met final inclusion criteria. RESULTS All cases for which body surface area (BSA) involvement was available or able to be approximated (n = 18/26) met criteria for TEN. All cases (n = 26) had mucous membrane involvement, with the oral mucosa most commonly affected (85.7%). Mortality was high within our population with 39.1% of infants expiring, 77.8% secondary to bacterial sepsis. The most common triggers were medications (52.4%), infections (33.3%), and vaccinations (14.3%). CONCLUSIONS This review highlights several unique clinical findings amongst infants with SJS/TEN, including increased BSA involvement, higher rates of bacterial sepsis, and higher mortality rates compared to older children and adults. Infants are more likely to present as TEN over SJS. More research is needed to identify triggers, successful treatments, and specific outcomes in this population.
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Affiliation(s)
- Christopher Iriarte
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sabrina A Karim
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Janelle S Nassim
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Pierre-Olivier Grenier
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Krystal Jones Massey
- Dermatology Program, Department of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Cheyenne Skin Clinic, Cheyenne, Wyoming, USA
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Kowalik A, de Monestrol I, Sorjonen K, Brockow K, Gülen T. Antibiotic hypersensitivity in cystic fibrosis - Low frequency of anaphylaxis over 16 000 courses. Br J Clin Pharmacol 2022; 88:4845-4853. [PMID: 35671007 PMCID: PMC9796175 DOI: 10.1111/bcp.15434] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 01/01/2023] Open
Abstract
AIMS Drug hypersensitivity reactions (DHR) to antibiotics are common and a substantial issue in managing patients with cystic fibrosis (CF). This study aimed to assess the prevalence and clinical features as well as risk factors of DHR to antibiotics in CF. METHOD A 20-year retrospective study was conducted among 226 CF patients (100 children and 126 adults) attending our centre. The Swedish Registry for Cystic Fibrosis and electronic medical records enabled us to ascertain the number and routes of antibiotic courses. All suspected DHR were evaluated. RESULTS The patients had a total of 16 910 antibiotic courses, of which 6832 (40%) were intravenously administered. Of 226 enrolled CF patients, 70 (31%) developed overall 131 DHR to antibiotics. The prevalence of DHR increased with advancing age (P < .001). Beta-lactams elicited 71% of all DHR and piperacillin was the most common single culprit (30% of intravenous and 24% of all DHR). Reactions were mild to moderate and mostly limited to skin; no severe cutaneous adverse reactions were observed. Additionally, anaphylaxis was rare, constituting 2.3% (3/131) of all DHR. Patients with DHR were exposed to significantly more courses of antibiotics than those without DHR (median 124 vs. 46, retrospectively, P < .001). CONCLUSIONS DHR to antibiotics, particularly to beta-lactams, are increased in CF patients, and associated with a higher number of cumulative exposures because of recurrent infections. However, severe cutaneous or systemic DHR, such as anaphylaxis, appear to be rare.
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Affiliation(s)
- Aleksandra Kowalik
- Stockholm Cystic Fibrosis CentreKarolinska University Hospital HuddingeStockholmSweden
| | - Isabelle de Monestrol
- Stockholm Cystic Fibrosis CentreKarolinska University Hospital HuddingeStockholmSweden,Department of Clinical Science, Intervention and Technology, Division of PediatricsKarolinska InstitutetStockholmSweden
| | - Kimmo Sorjonen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of MedicineTechnical University of MunichMunichGermany
| | - Theo Gülen
- Department of Respiratory Medicine and AllergyKarolinska University Hospital HuddingeStockholmSweden,Department of Medicine HuddingeKarolinska InstitutetStockholmSweden,Department of Medicine SolnaKarolinska InstitutetStockholmSweden
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Kan AKC, Wong TTH, Chiang V, Lau CS, Li PH. Chronic Spontaneous Urticaria in Hong Kong: Clinical Characteristics, Real-World Practice and Implications for COVID-19 Vaccination. Allergy Asthma Immunol Res 2022; 15:32-42. [PMID: 36693356 PMCID: PMC9880305 DOI: 10.4168/aair.2023.15.1.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE The real-world management and clinical characteristics of chronic spontaneous urticaria (CSU) in Hong Kong and its implications for coronavirus disease 2019 (COVID-19) vaccination are unknown. We investigated the clinical characteristics of patients with CSU and the role of an immunologist-led Urticaria Clinic as well as the impact of CSU on COVID-19 vaccine uptake in Hong Kong. METHODS Longitudinal clinical data of 257 CSU patients were collected and analyzed. Association analyses were performed to identify the relationships between variables and factors associated with COVID-19 vaccine uptake. RESULTS After the immunologist review, the Weekly Urticaria Activity Score (UAS7) was significantly lower than baseline (median: 0.00 vs. 12.0, P < 0.001). Changes in UAS7 were significantly greater among patients with baseline UAS7 ≥ 16 compared to those with UAS7 < 16 (median: -24.0 vs. -2.00, P < 0.001). CSU patients had lower COVID-19 vaccination rates than the general population with only 176 (68.5%) and 165 (65.0%) receiving at least one dose and 2 doses of vaccination, respectively. The presence of concomitant suspected drug allergy was associated with lower COVID-19 vaccine uptake (odds ratio [OR], 0.47; P = 0.010), while regular pharmacological treatment was associated with higher COVID-19 vaccine uptake among CSU patients (OR, 3.79; P = 0.010). CONCLUSIONS A dedicated immunologist-led Urticaria Clinic may effectively improve CSU management and outcomes in Hong Kong.
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Affiliation(s)
- Andy Ka Chun Kan
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Thomas Tsz Hang Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
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Costa Carvalho J, Alen Coutinho I, Matos AL, Alves P, Ramos L, Gonçalo M. Patch testing for cutaneous adverse drug reactions in a paediatric population: A retrospective review. Contact Dermatitis 2022; 87:373-376. [PMID: 35638861 DOI: 10.1111/cod.14167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/02/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jóni Costa Carvalho
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Iolanda Alen Coutinho
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Ana Luísa Matos
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Pedro Alves
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Leonor Ramos
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
- Dermatology Department, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Masmoudi HC, Afify N, Alnaqbi H, Alhalwachi Z, Tay GK, Alsafar H. HLA pharmacogenetic markers of drug hypersensitivity from the perspective of the populations of the Greater Middle East. Pharmacogenomics 2022; 23:695-708. [PMID: 35971864 DOI: 10.2217/pgs-2022-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Specific HLA associations with drug hypersensitivity may vary between geographic regions and ethnic groups. There are little to no data related to HLA-drug hypersensitivity on populations who reside in the Greater Middle East (GME), a vast region spanning from Morocco in the west to Pakistan in the east. In this review, the authors intended to summarize the significant HLA alleles associated with hypersensitive drug reactions induced by different drugs, as have been found in different populations, and to summarize the prevalence of these alleles in the specific and diverse populations of the GME. For example, HLA-B*57:01 allele prevalence, associated with abacavir-induced hypersensitivity, ranges from 1% to 3%, and HLA-DPB1*03:01 prevalence, associated with aspirin-induced asthma, ranges from 10% to 14% in the GME population. Studying pharmacogenomic associations in the ethnic groups of the GME may allow the discovery of new associations, confirm ones found with a low evidence rate and enable cost-effectiveness analysis of allele screening before drug use.
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Affiliation(s)
- Hend Chaker Masmoudi
- Center for Biotechnology, Khalifa University of Science & Technology, Abu Dhabi, United Arab Emirates.,Pharmaceutical Sciences Department, Faculty of Pharmacy of Monastir, Monastir, 5000, Tunisia.,Department of Histology & Cytogenetics, Institute Pasteur de Tunis, Tunis, 1002, Tunisia
| | - Nariman Afify
- College of Medicine & Health Sciences, Khalifa University of Science & Technology, Abu Dhabi, P.O. Box 127788, United Arab Emirates
| | - Halima Alnaqbi
- Center for Biotechnology, Khalifa University of Science & Technology, Abu Dhabi, United Arab Emirates.,Department of Biomedical Engineering, Khalifa University of Science & Technology, Abu Dhabi, P.O. Box 127788, United Arab Emirates
| | - Zainab Alhalwachi
- Center for Biotechnology, Khalifa University of Science & Technology, Abu Dhabi, United Arab Emirates
| | - Guan K Tay
- Center for Biotechnology, Khalifa University of Science & Technology, Abu Dhabi, United Arab Emirates.,Faculty of Health & Medical Sciences, UWA Medical School, University of Western Australia, Perth, 6009, Western Australia.,School of Medical & Health Sciences, Edith Cowan University, Joondalup, 6027, Western Australia
| | - Habiba Alsafar
- Center for Biotechnology, Khalifa University of Science & Technology, Abu Dhabi, United Arab Emirates.,College of Medicine & Health Sciences, Khalifa University of Science & Technology, Abu Dhabi, P.O. Box 127788, United Arab Emirates.,Department of Biomedical Engineering, Khalifa University of Science & Technology, Abu Dhabi, P.O. Box 127788, United Arab Emirates
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Lian BSY, Lee HY. Managing the ADR of Stevens-Johnson syndrome/toxic epidermal necrolysis. Expert Opin Drug Saf 2022; 21:1039-1046. [PMID: 35878014 DOI: 10.1080/14740338.2022.2106367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening adverse drug reactions that are collectively known as epidermal necrolysis. The abrupt detachment of the skin and mucositis results in systemic complications such as fluid and electrolyte disturbances, hypothermia, sepsis, organ failure, and death. Management is multidisciplinary and complex. AREAS COVERED This present article reviews the principles and best practices in the care of patients with epidermal necrolysis. These include having prompt admissions to optimal care facilities, coordinated specialized care during the acute phase, as well as long-term follow-up to manage chronic sequelae. EXPERT OPINION Patients with epidermal necrolysis should be managed in specialized/reference centers that are experienced with the management of the disease. Multi-disciplinary supportive care remains the cornerstone. Current evidence precludes definitive recommendation on any immunomodulatory agent as treatment. Long-term follow-up is required in order to diagnose and treat any chronic sequelae.
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Affiliation(s)
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital Singapore, Singapore.,Allergy Centre, Singapore General Hospital Singapore, Singapore.,Duke-NUS Medical School, Medicine Academic Clinical Programme, Singapore
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Marković I, Božan M, Perković T, Paušek K, Nedeljković V, Perković M, Kelava T, Artuković M, Stipić Marković A. Incidence of immediate allergic reactions to mRNA COVID-19 vaccines in adults with drug allergies and other allergic disorders. Medicine (Baltimore) 2022; 101:e29571. [PMID: 35905225 PMCID: PMC9333079 DOI: 10.1097/md.0000000000029571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Concerns have been raised about allergic reactions to messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccines. A history of allergic reactions, including anaphylaxis to drugs, has been frequently reported in individuals with anaphylaxis to mRNA vaccines. To estimate the rate of immediate allergic reactions in patients with a history of drug allergy or other allergic disorders. We included adult patients who had received at least 1 dose of an mRNA COVID-19 vaccine at the Special Hospital for Pulmonary Diseases between March 1, 2021, and October 1, 2021, and who reported a history of drug allergy or other allergic diseases (asthma, allergic rhinitis, atopic dermatitis, food or insect venom allergy, mastocytosis, idiopathic anaphylaxis, acute or chronic urticaria, and/or angioedema). Immediate allergic reactions, including anaphylaxis, occurring within 4 hours of vaccination were recorded. Six immediate allergic reactions were noted in the cohort of 1679 patients (0.36%). One patient experienced anaphylaxis (0.06%), which resolved after epinephrine administration, and the other reactions were mild and easily treatable. Most patients with a history of allergies can safely receive an mRNA COVID-19 vaccine, providing adequate observation periods and preparedness to recognize and treat anaphylaxis.
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Affiliation(s)
- Ivan Marković
- Special Hospital for Pulmonary Diseases, Zagreb, Croatia
- *Correspondence: Ivan Marković, Special Hospital for Pulmonary Diseases, Rockefellerova 3, 10000 Zagreb, Croatia (e-mail: )
| | - Marina Božan
- Special Hospital for Pulmonary Diseases, Zagreb, Croatia
| | | | | | | | | | - Tomislav Kelava
- Department of Physiology and Immunology, University of Zagreb, School of Medicine, Zagreb, Croatia
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Mori F, Saretta F, Liotti L, Giovannini M, Castagnoli R, Arasi S, Barni S, Mastrorilli C, Pecoraro L, Caminiti L, Marseglia GL, Barbaud A, Novembre E. Linear Immunoglobulin a Bullous Dermatosis in Children. Front Pediatr 2022; 10:937528. [PMID: 35874598 PMCID: PMC9304959 DOI: 10.3389/fped.2022.937528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/20/2022] [Indexed: 02/03/2023] Open
Abstract
Linear Immunoglobulin A Bullous Disease (LABD) is a rare dermatosis whose pathomechanisms are not yet completely understood. LABD has different features characterizing adults and children in terms of potential triggers, clinical manifestations, and prognosis. The aim of the present study is to review all neonatal and pediatric cases of LABD and summarize the major characteristics. Childhood LABD is mainly idiopathic with a benign prognosis. Neonatal cases are difficult to differentiate from infectious diseases and usually have a poor prognosis. Drugs are one of the possible triggers that can activate autoimmune responses through antigen mimicry and epitope spreading as well as different stimuli (e.g., infections, inflammatory diseases, trauma). The gold standard for the diagnosis is based on direct immunofluorescence. Prognosis is generally favorable but often depends on the prompt dermatological diagnosis, treatment and follow-up guaranteed by a multidisciplinary team, including pediatricians for this group of age.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Lucia Liotti
- Department of Pediatrics, Salesi Children's Hospital, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Riccardo Castagnoli
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Annick Barbaud
- Sorbonne Universités, Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Mori F, Crisafulli G, Bianchi A, Bottau P, Caimmi S, Franceschini F, Liotti L, Paglialunga C, Saretta F, Caffarelli C. Drugs and Vaccines Hypersensitivity in Children with Mastocytosis. J Clin Med 2022; 11:3153. [PMID: 35683540 DOI: 10.3390/jcm11113153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023] Open
Abstract
Mastocytosis, a heterogeneous mastcell disease, include three different entities: cutaneous mastocytosis, systemic mastocytosis (SM) and mast-cell sarcoma. Tryptase levels can differentiate cutaneous mastocytosis from SM. In mastocytosis, quick onset drug hypersensitivity reactions (DHRs) that are facilitated by mastcell mediators, are investigated in adults. Due to the limited number of children with mastcell disease and increased serum tryptase levels, the role of drugs in this age group is less studied. In this review, we critically assessed relevant papers related with immediate DHRs in children with mastocytosis and discuss practical issues of the management. In childhood mastocytosis, anaphylaxis is frequently idiopathic, and elevated level of basal tryptase, and high burden of disease may increase the risk. Among drugs, antibiotics, NSAIDs and opioids can potentially induce anaphylaxis, anyway avoidance should be recommended only in case of previous reactions. Moreover, vaccinations are not contraindicated in patients with mastocytosis. The risk of severe systemic reactions after drugs intake seems to be extremely low and in general lower in children than in adults. Anyway, studies on this topic especially focusing on children, are missing to state final recommendations.
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Frachowicz-Guerreiro K, Wardzyńska A, Kowalski ML. Allergy clinic patients' drug hypersensitivity. Allergol Immunopathol (Madr) 2022; 50:77-84. [PMID: 35527659 DOI: 10.15586/aei.v50i3.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/02/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Drug hypersensitivity reaction (DHR) is a common reason for an allergology con- sultation, during which it is not only necessary to gather a thorough medical history, but also to propose and perform diagnostic tests. OBJECTIVES The aim of the study was to retrospectively assess the patients with a profile of preliminary drug hypersensitivity diagnosis, the usefulness of NSAID hypersensitivity classifica- tion in outpatient practice, and to analyze the results of skin, provocation, and drug tolerance tests performed in Immunology and Allergy Clinic patients. METHODS Around 501 medical records of patients referred to the academic allergy outpatient clinic from 2011 to 2019, and had a preliminary drug hypersensitivity diagnosis were analyzed. The diagnostic and drug tolerance tests results carried out in 269 patients of the Clinic from 2009 to 2019 were then evaluated. RESULTS Among the patients referred due to suspected drug hypersensitivity, the majority (n=338, 67.5%) were believed to be hypersensitive to NSAIDs and antibiotics (n=272, 54.3%). In patients with hypersensitivity to NSAIDs, the mixed pattern was the most prevalent (n=73, 21.6%), followed by NECD (n=64, 18.9%) and NIUA (n=55, 16.3%). The second most common drug causing DHR were the antibiotics, mainly β-lactams (n=160, 58.8%), followed by macrolides (n=35, 12.9%). In hypersensitivity caused due to β-lactams, the delayed form was predominant (n=24, 15%) with manifested skin symptoms (n=74, 46.3%). Non-steroidal anti-inflammatory drugs (n=21, 42.9%), followed by antibiotics (n=11, 22.5%) were the commonest causes of ana- phylaxis, as reported by 49 patients. CONCLUSION The study shows that a majority of patients with suspected drug hypersensitivity can be classified under the hypersensitivity umbrella based on their medical history, which is the basis for further diagnostic process.
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