Potencial do teste IGRA (Interferon Gama Release Assay) para o diagnóstico de tuberculose ocular. Revisão e análise comparativa com o teste tuberculínico cutâneo (PPD) / The potential of the IGRA (Interferon Gamma Release Assay) test for the diagnosis of ocular tuberculosis. Review and comparative analysis with the tuberculosis skin test

Resumo A detecção precisa da infecção latente por tuberculose está se tornando cada vez mais importante devido ao aumento do uso de medicamentos imunossupressores e da epidemia do vírus da imunodeficiência humana, o que aumentou o risco de reativação à tuberculose ativa (TB). O Teste IGRA QuantiFERON® TB Gold apresenta vantagens frente ao teste de PPD como por exemplo, requer somente uma coleta de amostra sanguínea ; não há necessidade que o paciente retorne ao laboratório para leitura e interpretação dos resultados; Os resultados são objetivos, não requerem interpretação do leitor ou interferência de critérios subjetivos; trata-se de um teste in vitro, portanto não há "efeito booster" (potenciação da reação tuberculínica); o teste não é afetado por vacinação prévia por BCG ou infecção por outras espécies de micobactérias. Limitações são descritas, apesar de raras, como reações cruzadas deste método com infecções por algumas espécies de micobactérias não-tuberculosis (incluindo Mycobacterium kansasii, Mycobacterium szulgai e Mycobacterium marinum). Ainda há poucos dados sobre o teste IGRA em certas populações, como por exemplo, em crianças, pacientes imunocomprometidos e mulheres grávidas. Nestes grupos, a interpretação do teste pode ser difícil e mais estudos se fazem necessários.

Abstract Precise detection of latent tuberculosis infection is becoming increasingly important due to increased use of immunosuppressive drugs and the human immunodeficiency virus epidemic , which increased the risk of reactivation to active tuberculosis (TB).The QuantiFERON® TB Gold IGRA Test has advantages over the skin test for TB, otherwise known as a Mantoux tuberculin test, for example, requires only a blood sample collection; there is no need for the patient to return to the laboratory for reading and interpretation of the results; The results are objective, do not require interpretation of the reader or interference of subjective criteria; it is an in vitro test, so there is no "booster effect" (potentiation of the tuberculin reaction); the test is not affected by prior BCG vaccination or infection with other species of mycobacteria. Limitations are described, although rare, as cross-reactions of this method with infections by some species of non-tuberculosis mycobacteria (including Mycobacterium kansasii, Mycobacterium szulgai and Mycobacterium marinum). There is still little data on the IGRA test in certain populations, such as in children, immunocompromised patients and pregnant women. In these groups, the interpretation of the test can be difficult and more studies are needed.

Intradermal skin tests for rocuronium and cisatracurium in patients with a history of allergy: a retrospective study / 대한마취과학회지

BACKGROUND: Neuromuscular blocking agents (NMBAs) are a leading cause of perioperative anaphylaxis. However, the performance of systematic screening skin tests to detect reactions for NMBAs prior to general anesthesia is not recommended. We retrospectively examined intradermal tests (IDTs) for rocuronium and cisatracurium in patients with a history of allergy. METHODS: We reviewed the records of patients who underwent IDTs for NMBAs between January 1 and December 31, 2016. We analyzed the patients’ allergy histories and skin test results for NMBAs. RESULTS: The overall prevalence of positive IDTs was 5.8% (26/451), and there was no significant difference in prevalence among allergy types (P = 0.655). In logistic regression analysis, there was no allergy history that had a significant effect on positive IDT for NMBAs. CONCLUSIONS: We found no association between allergy history and positive skin test for NMBAs. Therefore, a systematic screening test for NMBAs or other anesthetic agents before anesthesia is not considered necessary even in patients with an allergy history.

Relación entre el Nivel de Vitamina D y Urticaria Crónica Espontánea

Antecedentes: Se ha incrementado la evidencia que demuestra la conexión entre la diferencia/insuficiencia de Vitamina D con aumento de la incidencia, severidad y actividad de trastornos inmunes-inflamatorios. La urticaria crónica es un trastorno de la piel caracterizado por ronchas recurrentes durante más de 6 semanas, y se divide en espontánea o inducible por estímulos físicos. El objetivo principal del siguiente trabajo fue estudiar la relación que pueden tener los niveles de Vitamina D en suero de pacientes con diagnóstico de urticaria crónica espontánea (UCE) que asisten al Servicio de Alergia e Inmunología del Hospital Nacional de Clínicas y compararlos con un grupo control de pacientes sin urticaria. Material y Métodos: Es un estudio descriptivo, prospectivo en donde se estudiaron 27 pacientes con diagnóstico de urticaria crónica espontánea. Luego de confeccionar Historia Clínica compatible con el diagnóstico, se les otorgó un test (UAS7) para evaluar la gravedad de la enfermedad, se realizaron prubeas cutáneas con aeroalergénos y alimentos, se realizó test intradérmico de suero autólogo, laboratorio que incluía además el hemograma, el perfil tiroideo y hepático, serología para virus (Hepatitis B y C, VDRL y HIV), se dosaron niveles de Ig A, G, M, E, y de Vitamina D (D2+D3) a todos los pacientes para luego analizar los resultados y comparar con un grupo control de 16 adultos sanos. Resultados: Hubo diferencias significativas entre los valores séricos de Vitamina D del grupo con urticaria crónica con respecto al control p<0,0001. Conclusión: Este estudio encontró que los pacientes con UCE tienen valores séricos disminuidos de Vitamina D. Son necesarios más estudios acerca del rol de la Vitamina D en la patogénesis de la Urticaria Crónica.

Evidence demostrates the connection between vitamin D deficiency/insufficiency with increased incidence, severity and activity of immune-inflammatory disorders. Chronic urticaria is a skin disorder characterized by recurring hives for mores than 6 weeks, and is divided into spontaneous or inducible by physical stimuli. The main objective of this study was to study the relationship that serum vitamin D levels may have in patients diagnosed with Spontaneous Chronic Urticaria (SCU) who attend the Allergy and Immunology Service of the National Hospital of Clinics and compare them with a control group of patients without urticaria. Materla and Methods: This is a prospective descriptive study in which 27 patients with chronic urticaria spontaneously diagnosed were studied. After making clinical history compatible with the diagnosis, they were given a test (UAS7) to evaluate the severity of the disease. In adition to the hemogram, the thyroid and hepatic profile, serology for virus (Hepatitis B, C, VDRL and VIH), serum levels of immunoglobulins A, G, M, E and vitamin D (D2+D3) to all patients and then analyzed the results and compared with a control group of 16 healthy adults. Results: There were significant differences between serum vitamin D levels in the group with chronic urticaria compared to the control group (p<0,0001) Conclusion: This study found that patients with SCU have decreased serum vitamin D values. More studies are needed about the role of vitamin D in the pathogenesis of UC.

Immediate-type hypersensitivity response to systemic hydrocortisone sodium succinate

Immediate-type hypersensitivity responses to systemic corticosteroids are rare despite their widespread use. It is still controversial whether the responses rarely occur or are underdiagnosed in clinical settings. Many cases probably remain underdiagnosed because the symptoms often mimic symptoms of underlying diseases. This case report describes a 73-year-old man who had immediate hypersensitivity reactions after intravenous administration of hydrocortisone, which was primarily intended to prevent hypersensitivity reactions to contrast media. Whole body rash with pruritus developed shortly after the steroid injection. Since the patient already experienced rash and itching sense after contrast media and antihistamine injection, we conducted skin testing to figure out which drug triggered the hypersensitivity reactions. Intradermal skin tests revealed a positive response to hydrocortisone sodium succinate, which suggested his hypersensitivity reactions were developed by hydrocortisone. Being a common therapy for allergic reaction, corticosteroids themselves are rarely suspected of causing hypersensitivity reactions. Considering there is no typical symptom or standard diagnostic test, awareness of corticosteroid hypersensitivity reactions is of importance to make the diagnosis.

Consecutive anaphylaxis due to rocuronium and cisatracurium during general anesthesia: A case report

We experienced anaphylaxis during general anesthesia twice in the same patient. After the first incidence of anaphylaxis at the induction of anesthesia, we speculated that the allergen was rocuronium. Thus, we administered sugammadex as well as a vasopressor to treat the anaphylaxis and the vital signs gradually recovered to nearly normal. Thereafter, we could not avoid the administration of another muscle relaxant, cisatracurium, since the patient moved uncontrollably after the surgery was restarted. A second anaphylactic event then occurred. We speculated that the second allergen was cisatracurium and stopped using it. The results of the investigation after the surgery showed that the allergens were indeed rocuronium and cisatracurium. When we encounter anaphylaxis during general anesthesia, it is necessary to suspect all administered medicines as the cause, with the potential of two or more causes, especially with muscle relaxants.

Sensitization study of dogs with atopic dermatitis in the central region of Rio Grande do Sul / Estudo da sensibilização de cães com dermatite atópica na região central do Rio Grande do Sul

Canine atopic dermatitis (CAD) is a common dermatosis, defined as a genetic-related disease which predisposes to skin inflammation and pruritus, associated to a IgE-specific response in most of cases. Clinical diagnosis may be later complemented by skin allergy and/or serological tests. The aim of these tests is to identify possible allergens in order to enable the clinicians to select candidate antigens for allergen specific immunotherapy. In the present study 58 CAD positive animals were tested. All were submitted to the intradermal test (IDT) and screened for the presence of antibodies against different antigens using ELISA. The obtained results show a high prevalence of sensitization among the tested dogs to house dust mites and to pollen ofC. dactylon. With this work it was possible to identify the main allergens involved in immunological response of dogs with CAD living in central area of Rio Grande do Sul.

A dermatite atópica canina (DAC) é uma dermatose comum, definida como doença de cunho genético que predispõe à inflamação e ao prurido cutâneo, associados à resposta IgE específica na maior parte dos casos. O diagnóstico da DAC é clínico e pode ser posteriormente complementado por testes alérgicos cutâneos e/ou sorológicos. O objetivo desses testes é identificar possíveis alérgenos e, com isso, possibilitar ao clínico a seleção de antígenos candidatos para a imunoterapia alérgeno-específica. No presente estudo, foram testados 58 animais diagnosticados para DAC. Todos os animais foram submetidos ao teste cutâneo intradérmico (TID), e amostras de sangue foram coletadas para a realização de testes sorológicos. Os resultados obtidos demonstraram elevada prevalência de sensibilização aos ácaros domiciliares e ao pólen da gramínea C. dactylon nos cães testados. Com este trabalho, foi possível identificar os principais alérgenos envolvidos na resposta imunológica de cães atópicos residentes na região central do Rio Grande do Sul.

Raw shiitake-induced systemic allergic contact dermatitis

It has been reported that ingestion of raw or undercooked shiitake mushrooms is associated with various adverse food reactions. A 58-year-old man presented with pruritic and maculopapular rashes on the trunk and extremities starting 1 day after ingestion of partially uncooked shiitake mushrooms. A probable diagnosis of systemic allergic contact dermatitis was made. Raw and cooked shiitake mushroom-derived allergen extracts were prepared, and patch and intradermal tests with delayed readings were performed. The case showed positive intradermal test results with delayed readings to the raw, but not cooked, extracts. The case suggests that ingestion of uncooked shiitake mushrooms may induce systemic allergic contact dermatitis through type IV hypersensitivity reaction.

Comparison of rapid screening immunoassay and intradermal test for canine atopic dermatitis / 동물의과학연구지

The intradermal test (IDT) has been developed for confirming diagnosis of canine atopic dermatitis (CAD). Prior to performing IDT, rapid immunoassay (Allercept E-screen 2nd generation; ES2G) can detect allergen-specific immunoglobulin E (IgE) antibodies in canine serum. The objective of this study was to evaluate agreement between IDT and immunoassay in diagnosis of CAD in domestic atopic dogs. Forty dogs were diagnosed with CAD in accordance with Favrot's criteria. Intradermal testing was performed using 39 selected allergens. ES2G detected IgE antibodies specific for three allergen groups, including indoor allergens, grasses and weeds, and trees. Among 19 dogs diagnosed by IDT, the highest positivity was observed in house dust mites, followed by molds, epidermis and inhalants, house dust, and weeds. A total of 28 atopic dogs were evaluated by rapid ES2G immunoassay. Indoor allergens showed the strongest positive reaction, followed by grasses/weeds and trees. IDT and ES2G were performed concurrently in 17 dogs. The results of ES2G showed slight agreement with those of IDT. Level of agreement was highest for indoor allergens, which showed a predictive positive value of 100% in ES2G. These results indicate that a rapid immunoassay may be valuable for predicting the results of IDT in atopic dogs sensitized to indoor allergens.

Flare Up Reaction During Provocation Test to Glatiramer Acetate in a Patient With Allergy to Interferon Beta1a

Glatiramer acetate (GA) is a synthetic amino acid polymer, used for relapsing-remitting multiple sclerosis. The most common adverse effect of GA is a skin reaction at the injection site with a probable IgE-mediated mechanism. We report a case of a 45-year-old woman with multiple sclerosis and urticaria to interferon-beta1a, who underwent a challenge test to GA. She presented itching wheals at the intradermal sites. A month later the patient repeated the test and presented the same reactions of the first test. The next day she continued the test with subcutaneous injections. One hour later she presented a flare up of the reactions appeared during the previous 2 tests. No reactions appeared at the subcutaneous injection sites. The patient also presented dyspnea. Flare-up reactions are characterized by the reactivation of previously positive reactions to intradermal or skin tests triggered by patch testing and after systemic provocation with an allergen. The phenomenon is not common to drugs. The mechanisms involved in this reaction seem to be heterogeneous and are not completely understood. To our knowledge this is the first case of allergic reaction to GA manifested as a flare-up reaction during challenge test.

Recurrent intradialytic heparin induced anaphylaxis: workup and management

Heparin has been widely used for intradialytic anticoagulation since the 1940s. Heparin induced anaphylaxis can be life threatening, mandating early recognition and intervention. However, due to its relative rarity many physicians remain unaware. We report the case of a 70-year-old woman requiring dialysis, who developed recurrent anaphylaxis to intradialytic heparin. We describe a systematic approach to confirm the suspected heparin allergy, which must include an evaluation of predisposing factors, the dialysis equipment and concomitant medications. Further workup for safe alternatives employing skin prick and intradermal tests, as well as provocation tests are discussed.

A Case of Autoimmune Progesterone Dermatitis Misdiagnosed as Allergic Contact Dermatitis

Autoimmune progesterone dermatitis is a rare autoimmune response to endogenous progesterone that usually occurs in fertile females. Cutaneous or mucosal lesions develop cyclically during the luteal phase of the menstrual cycle when progesterone levels are elevated. Symptoms usually start 3-10 days before menstruation and resolve 1-2 days after menstruation ceases. We report the case of a 48-year-old woman with intermittent eczematous skin lesions of the legs, forearms, and buttocks. She was diagnosed with allergic contact dermatitis, and topical steroids were prescribed. Her skin eruptions waxed and waned for 6 years and were associated with her menstrual cycle. We performed an intradermal test using progesterone, which was positive, and prescribed gonadotropin-releasing hormone analogues monthly for 3 months. The patient's skin lesions improved, confirming the diagnosis. Autoimmune progesterone dermatitis should be included in the differential diagnosis of recurrent eczema that is refractory to treatment in women of child-bearing age.

Allergic skin test / 소아과

Allergy skin prick test and intradermal test represent one of the major tools in the diagnosis of IgE- mediated diseases like as atopic asthma, allergic rhinitis, atopic dermatitis, food and drug allergy, and insect bite when properly performed. Skin tests are of particular importance in fields such as allergen standardization, pharmacology, and epidemiology. Even if skin tests seem easy to perform, adequate and proper interpretation requires well-trained physicians who can recognize the numerous factors that may modify the results of skin tests.

Evaluation of Diagnostic Utility of Intradermal Test for the Diagnosis of Clonorchis sinensis Infestation / 대한임상미생물학회지

BACKGROUND: The intradermal test for the screening of Clonorchis sinensis is difficult to interpret because the sensitivity and persistence rates of reactions after treatment are not well known. METHODS: Stool egg examinations and intradermal tests for C. sinensis and Paragonimus westermani were performed for 1,207 persons who lived in endemic areas of C. sinensis infestation, and epidemiologic data were also surveyed. RESULTS: The infestation rate of C. sinensis was 12% (male 14%, female 9%). It was higher in Southeastern area of Gyungsang Namdo Province and Ulsan (22%) than in Busan (10%), whereas much higher in Gangseo/Buk/Sasang (28%) than in other areas of Busan. The performance of C. sinensis intradermal test was as belows; sensitivity 45%, specificity 80.8%, positive predictive value 24%, negative predictive value 92%, and diagnostic efficiency 77%. Positive C. sinensis intradermal reaction persisted for longer than 40 years after treatment of C. sinensis infestation in at least 30% of patients. C. sinensis intradermal reaction turned to be positive within 4 months after intake of raw fish in more than half the patients. CONCLUSION: The infestation rate of C. sinensis was still very high in inhabitants around Nakdong River, an endemic area. We think that C. sinensis intradermal test is inadequate to diagnose current clonorchiasis.

Adverse reactions to allergen injection : The siriraj experience.

A retrospective review of the medical records of adult patients, who had skin testing and allergen immunotherapy at the ENT Allergy Clinic, from January 1987 to December 1999 was performed, to ascertain the incidence of adverse reactions to allergen injection. For skin prick testing, 5,879 patients with 82,306 skin tests were recorded with no adverse systemic reaction. For intradermal testing, 5,490 patients with approximately 109,800 tests were recorded and two patients developed mild systemic reactions which were probably related to the test. The systemic reaction rate to intradermal skin testing was therefore 36.4 per 100,000 patients or 2.2 systemic reactions per 100,000 intradermal tests. The overall reaction rate to both types of allergy skin test in 11,369 patients tested for aeroallergens was 0.018% or 17.6 systemic reactions per 100,000 patients. Concerning immunotherapy 42,810 allergen injections were recorded, the rate of excessive local reactions was 4.8% (4.08% were immediate and 0.77% were delayed types), the rate of systemic allergic reactions was 0.08%. None of the reactions was fatal. In a prospective study conducted from January 2000 to December 2001, 4,764 allergen injections were performed with 27 systemic reactions occurring in 23 patients (7 men and 16 women). Twenty-two events were classified as mild to moderate (0.46%) and 5 events were acute severe reactions (0.11%). No cases of hypotension and laryngeal edema were observed and none of the reactions was fatal. The possible risk factors for developing a systemic reaction during immunotherapy in this study were :- vaccines comprising grass/weed pollen or house-dust mite, an increased dose, symptomatic asthmatics, prior systemic reactions and changing to a new vial. The incidence of adverse reaction after allergen injection and the possible causative factors associated with immunotherapy in our clinic are similar to other reports from western countries. In order to minimize the number and the severity of systemic reaction, an allergen injection should be performed by physicians and personnel who are well aware of the risks and well trained to recognize and manage the systemic reactions immediately.

Diagnostic significance of intradermal test compared with radiologic findings for clonorchiasis / 대한임상병리학회지

BACKGROUND: Clonorchiasis is a trematodiasis caused by chronic infestation of liver flukes, Clonorchis sinensis(CS). We usually diagnosed clonorchiasis with stool examination. Intradermal(ID) test and radiologic findings have been also used for diagnosis. However, studies associated with ID test were very rare. So, we evaluated the stool examination and ID tests for CS detection associated with radiologic findings. METHODS: We analyzed 69 cases of patients requested stool parasite examination and ID test concurrently. For stool parasite examination, formalin ether precipitation method was used. Abdominal US and/or CT were also reviewed. Eosinophil counts and liver function test(LFT) were evaluated. Clinical diagnosis were reviewed retrospectively. RESULTS: Sensitivity and specificity of ID CS test were 63% and 71.4% respectively. Positive and negative predictive values were 58.6% and 75.0% respectively. US/CT findings showed 10% sensitivity and 52.9% specificity. Positive and negative predictive values of US/CT were 11.1% and 50% respectively. Paragonimiasis westermani ID test showed 17.2% positivity in CS ID test positive cases. No statistical differences were observed among groups in eosinophil and LFT results. Hepatobiliary diseases were the main clinical impression in CS ID test positive groups. CONCLUSION: For the diagnosis of clonorchiasis, stool examination was the most effective method. ID test and radiologic examination still have some limitations in diagnosis because of cured past infestation, small number of parasitic infestation or irreversible anatomical changes etc. However, ID test could have a better supplementary role for diagnosis of clonorchiasis rather than US/CT.

Intradermal test for schistosomiasis japonica (preliminary report)

The results of our preliminary study on intradermal test on 532 subjects, using antigens prepared by us, are here presented and discussed. Thre principle of the test, preparation of the antigens (adult and cercaria), and technique of testing are explainedThis study seems to indicate that intradermal test may augment our methods of diagnosis of schistosomiasis, especially in mass-screening campaigns or mass stool surveys. To be of real significance, however, a potent antigen, freshly prepared, and whose dosage has been standardized with known positive and known negative controls should be used. For routine purposes, a dose of 0.01 to 0.02 of the 1:1000 or 1:2000 dilution of the adult antigen solution may be recommended. In the case of the cercarial antigen, we obtained a fairly good result, with 0.1 cc of the 1:600 dilutionAmong our negative controls, the presence of other parasites, such as ascaris, trichuris, and hookworm, filaria, and paragonimiasis, did not provoke false positive reactions. No false positive reaction was observed in one case of malaria and in one case of infectious hepatitis. (Conclusions)

Analysis of Intradermal Test for Anesthetic Drugs / 대한마취과학회지

BACKGROUND: Intradermal test is a useful diagnostic method for acute anaphylactoid or anaphylactic reactions induced by anesthetic drugs. We analyzed the responses of intradermal test for anesthetic drugs in patients who did not show anaphylactoid or anaphylactic reactions. METHODS: The authors performed intradermal test for anesthetic drugs (thiopental, midazolam, fentanyl, atracurium and vecuronium) in 224 adult patients one hour before induction of anesthesia. The responses were interpreted as measuring the size of wheal and flare. We also did history taking for past allergic history. RESULTS: There were no patient that showed positive reaction. The rate of false positive reaction for atracurium (12.5%) was significantly higher than other anesthetic drugs (p<0.05). And the rate of false positive reaction for atracurium in patients under the age of 40 (20%) was significantly higher than those above the age of 40 (3.8%) (p<0.05). But the difference of the rate of false positive reaction for atracurium between male (8%) and female (15.3%) was not significant statistically. The differences of the rates of false positive reaction for anesthetic drugs between past allergic history group and no past allergic history group were not statistically significant. CONCLUSIONS: In intradermal test for anesthetic drugs, the rate of false positive reaction for atracurium was significantly higher than thiopental, vecuronium, fentanyl and midazolam. Especially, it was significantly higher in patients under the age of 40. So in performing intradermal test to search for causative anesthetic drug, we have to consider the high rate of false positive reaction for atracurium.

On the Intradermal Test of ?-lactam Antibiotics / 中国药房

OBJECTIVE:To discuss the intradermal test of ?-lactam antibiotics.METHODS:The status quo,laws & regulations and mechanism of allergy about intradermal test of ?-lactam antibiotics were expounded.Suggestions on method of performing intradermal test of ?-lactam antibiotics and the judgment criteria were put forward.RESULTS & CONCLUSIONS:The intradermal test must be performed before using penicillins.The intradermal test must be done with active compound before using cephalosporins in patients allergic to pinicillins.

A Case of Granulomatous Reaction to Tattoo Pigment / 대한피부과학회지

A 48-year-old woman, who had had tattoo on her eyebrows, was seen with pruitic erythematous indurated plaques on the tattooing sites. The skin react ion was begun to observe about 4 weeks after getting tattoo. Skin biopsy specimens from the indurated lesions showed granulomatous reactions. Intradermal tests by means of multiple pricks and patch test were done on her low back with the same tattoo dye and also 4 others available in Korea. Serial punch biopsy specimens were obtained from the sites of intradermal test at 2nd, 7th, 28th, and 56th day after intradermal test. Granulomatous reactions were found in the spiecimens taken at the 28th and 56th day.