Síndrome de intolerancia a múltiples medicamentos / Syndrome of intolerance to multiple medicines

El síndrome de intolerancia a múltiples medicamentos (MDIS, por sus siglas en inglés) se caracteriza por la intolerancia a dos o más medicamentos no relacionados. Tiene una prevalencia baja y es común en pacientes con polifarmacia. A pesar de que las reacciones adversas a los medicamentos son muy frecuentes, es raro que los pacientes debuten con este síndrome, el cual tiene implicaciones clínicas de leves a graves que afectan su vida; de acuerdo con esto varían el abordaje y su manejo. La sintomatología presentada varía desde síntomas gastrointestinales como reflujo gastroesofágico, dolores musculares y cefalea, hasta síntomas cutáneos; estos son los más frecuentes, tales como urticaria y erupciones maculopapulares o presentaciones menos comunes como el síndrome de Stevens-Johnson. El MDIS es causado por una amplia variedad de fármacos; por ello el conocimiento del síndrome, así como un adecuado interrogatorio de los antecedentes del paciente, es necesario para realizar un diagnóstico oportuno e instaurar un manejo adecuado y preventivo, evitando reacciones adversas que pongan en riesgo su vida. Con los hallazgos del cuadro clínico en la paciente, y basados en los antecedentes alérgicos presentados anteriormente a diferentes medicamentos no relacionados entre ellos, más la presentación de un rash maculopapular generalizado posterior a la administración de trimetoprim/sulfametoxazol se realiza el diagnóstico de MDIS. Se decide cambiar de medicamento por fosfomicina, con una consecuente evolución favorable. (AU)

Chemical intolerance: involvement of brain function and networks after exposure to extrinsic stimuli perceived as hazardous

BACKGROUND@#Chemical intolerance (CI) is a chronic condition characterized by recurring and severe symptoms triggered by exposure to low levels of odorous or pungent substances. The etiology of CI has been a controversial subject for a long time. The aim of this review is to summarize findings on the neurological processing of sensory information during and after exposure to low levels of odorous or pungent substances in individuals with CI, focusing on the brain function and networks.@*METHODS@#Scientific studies on CI published between 2000 and 2019 in academic peer-reviewed journals were systematically searched using medical and scientific literature databases. Only peer-reviewed articles reporting original research from experimental human studies directly associated with CI, and involving related neurological responses or brain imaging after exposure to odorous or pungent substances (i.e., in chemical provocation tests), were considered.@*RESULTS@#Forty-seven studies were found to be eligible for a full-text review. Twenty-three studies met the selection criteria and were included in this review. Evidence indicated that differences between subjects with CI and healthy controls were observed by brain imaging during and after exposure to odorous or pungent substances. Differences in brain imaging were also observed between initial exposure and after exposure to these substances. Neurological processing of sensory information after exposure to extrinsic stimuli in the limbic system and related cortices were altered in subjects with CI. A previous documentable exposure event was likely to be involved in this alteration.@*CONCLUSIONS@#This review documents consistent evidence for the altered neurological processing of sensory information in individuals with CI. Further neurophysiological research exploring the processing of extrinsic stimuli and cognition of sensation through the limbic system and related cortices in CI, and the appearance of symptoms in individuals with CI, are required.

Expert clinician's perspectives on environmental medicine and toxicant assessment in clinical practice

BACKGROUND@#Most clinicians feel ill-equipped to assess or educate patients about toxicant exposures, and it is unclear how expert environmental medicine clinicians assess these exposures or treat exposure-related conditions. We aimed to explore expert clinicians' perspectives on their practice of environmental medicine to determine the populations and toxicants that receive the most attention, identify how they deal with toxicant exposures and identify the challenges they face and where they obtain their knowledge.@*METHODS@#A qualitative study involving semi-structured interviews with expert environmental clinicians in Australia and New Zealand was conducted. Interviews were recorded and transcribed, and themes were identified and collated until no new themes emerged.@*RESULTS@#Five dominant themes emerged from 16 interviews: (1) environmental medicine is a divided profession based on type of practice, patient cohort seen and attitudes towards nutrition and exposure sources; (2) clinical assessment of toxicant exposures is challenging; (3) the environmental exposure history is the most important clinical tool; (4) patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health; and (5) educational and clinical resources on environmental medicine are lacking.@*CONCLUSIONS@#Environmental medicine is divided between integrative clinicians and occupational and environmental physicians based on their practice dynamics. All clinicians face challenges in assessing toxicant loads, and an exposure history is seen as the most useful tool. Standardised exposure assessment tools have the potential to significantly advance the clinical practice of environmental medicine and expand its reach across other clinical disciplines.

Multiple Chemical Sensitivity in Chemical Laboratory Workers

BACKGROUND: Multiple Chemical Sensitivity (MCS) is an acquired disease which etiology remains unknown. It is characterized by the development of sensitivity to certain chemical products. Most of the hypotheses formulated to explain the syndrome associate it to a previous exposition to some kind of volatile chemical. University researchers in chemical laboratories suffer a phenomenon of multi-exposition to chemical agents at low concentration during long periods of time although in an irregular form. Many of these chemical agents have similar properties to those suspicious of causing MCS. This article studies the prevalence of MCS in laboratory researchers. METHODS: The study group is university researchers in chemical laboratories. The control group was obtained from administrative personnel who work in the same universities and therefore, are not exposed to chemical products from the laboratories, but have the same exposition to the rest of environmental polluting agents from the area and from the buildings of the university. In this study, it is used the Quick Environmental Exposure and Sensitivity Inventory (QEESI) (sensitivity of 92%/specificity of 95%). RESULTS: The results showed that the prevalence of MCS for the university researchers is not related to exposition by inhalation to multiple chemical agents, at low concentration. CONCLUSIONS: The results disagree with one of the main etiological hypotheses of MCS, which is based on the existence of hypersensitive people, who presents a response after prolonged expositions to very low concentrations during a long period of time.

Sensibilidad química múltiple: un desafío para la salud ocupacional / Multiple chemical sensitivity: a challenge for occupational health

La sensibilidad química múltiple (SQM) es una afección adquirida de evolución crónica caracterizada por la presencia de síntomas de variada intensidad que aparecen aun ante la exposición a bajos niveles de sustancias químicas e involucran a varios órganos o sistemas. El desencadenante puede involucrar una simple exposición a altas dosis o la exposición múltiple y repetida a una o más sustancias. En el inicio de la afección las exposiciones que se describen con mayor frecuencia incluyen plaguicidas y solventes orgánicos. Se presentan dos casos clínicos con diagnóstico de SQM vinculada a exposiciones ocupacionales. Se describen las comorbilidades y la evolución crónica con afectación de la calidad de vida que se evidencia con la aplicación del cuestionario QEESI (Quick Environmental Exposure and Sensitivity Inventory). Tal como ocurre en la mayoría de los casos resulta difícil controlar la exposición en los centros de trabajo incluso logrando la reubicación laboral, ya que manifiestan síntomas aun con bajos niveles de contaminación que son tolerados por otros trabajadores. Por último, si la SQM es resultante de una exposición laboral, se cumple la definición de enfermedad profesional establecida en la legislación nacional. Uno de los desafíos actuales es generar ámbitos para difundir el conocimiento de esta afección que facilite su diagnóstico y su reconocimiento como enfermedad profesional...

Allergic Diseases and Multiple Chemical Sensitivity in Korean Adults

PURPOSE: Multiple chemical sensitivity (MCS) is a clinical syndrome representing multi-organ and psychological symptoms caused by chronic exposure to various chemicals in low concentrations. We evaluated the prevalence and related factors of MCS targeting Korean adults using the Quick Environmental Exposure and Sensitivity Inventory (QEESI(c)). METHODS: A total of 446 participants were recruited from Severance Hospital. Participants underwent a questionnaire interview including questions on sociodemographic factors, occupational and environmental factors, allergic diseases, and the QEESI(c). Among them, 379 participants completed the questionnaire and the QEESI(c). According to the QEESI(c) interpretation results, participants were divided into very suggestive (VS) group and less suggestive (LS) group. RESULTS: The estimated prevalence of MCS was higher in allergic patients than non-allergic participants (19.7% and 11.3%, respectively, P=0.04). In the multivariate logistic regression analysis, ages of 30-39 (OR, 2.94; 95% CI, 1.25-6.95) and those of 40-49 (OR, 2.51; 95% CI, 1.02-6.21) were significantly related to MCS compared to those aged less than 30 years. Female sex (OR, 2.16; 95% CI, 1.11-4.18), experience of dwelling in a new house (OR, 2.05; 95% CI, 1.04-4.03), and atopic dermatitis (OR, 1.95; 95% CI, 1.04-3.69) were also significantly related to MCS. However, only age of 30-39 in the allergic group was significant in the stratified analysis. CONCLUSIONS: The estimated prevalence of MCS was higher among allergic patients than non-allergic participants. People with experience of dwelling in a new house and atopic dermatitis were more at risk of being intolerant to chemicals. Further studies to provide the nationally representative prevalence data and clarify risk factors and mechanisms of MCS are required.

Multiple chemical sensitivity caused by exposure to ignition coal fumes: a case report

BACKGROUND: Although multiple chemical sensitivity (MCS) is a well-known disorder caused by environmental exposures, MCS caused by occupational exposure has been reported in Korea. Therefore, we report a MCS case caused by environmental exposure to ignition coal after a differential diagnosis to exclude other diseases. CASE REPORT: Since 2011, a 55-year-old woman had experienced edema, myalgia, and other symptoms when she smelled ignition coal near her workplace. She had been diagnosed with fibromyalgia syndrome(FMS) and was treated, with no improvement of symptoms. Since then, she showed the same symptoms after exposure to city gas, the smell of burning, and exhaust gas. To avoid triggering substances, she moved to a new house and used an air purifier. She quit her job in November 2012. After visiting our hospital, she underwent a differential diagnosis for FMS, chronic fatigue syndrome, and somatization disorder. She was diagnosed with MCS by the Korean version of the Quick Environment Exposure Sensitivity Inventory (QEESI). She was educated about the disease and to avoid triggering substances. She received ongoing treatment for her symptoms. CONCLUSION: This case showed that symptoms began after smelling ignition coal. After that, her triggers was increased such as the smell of city gas, burning, and exhaust gas. This case is the first reported in Korea of MCS due to environmental exposure after ruling out other diseases.

A Validation of the Korean Version of QEESI(c) (The Quick Environmental Exposure and Sensitivity Inventory) / 대한산업의학회지

OBJECTIVES: A standardized questionnaire is not available for use as a screening tool to assess individuals with MCS/IEI in Korea. The QEESI(c), originally developed by Miller & Prihoda in 1998, helps researchers, doctors, and their patients identify individuals with MCS/IEI. Therefore, this study was conducted in order to create a Korean version of the QEESI(c) and evaluate whether this Korean version could be used as an effective MCS/IEI screening tool in Korea. METHODS: The Korean version of the QEESI(c) was developed using a six-step approach: permission, forward translation, the first quality control, backward translation, cognitive debriefing and the second quality control, final proof reading. In order to collect data, we have done a sample survey in certain parts of Korea. A household was used as the sampling unit; we extracted random samples in each survey cluster and then interviewed two adults over 19 years of age living in each sampled household. A total of 300 subjects were recruited from the general population in local community. The factor structure in the Korean version of the QEESI was analyzed with 40 items on four sub-scales except for the 10 items in masking index using principal components analysis with Varimax rotation. A convergent validity test two sub-scales: chemical intolerance and symptom severity. We carefully compared the chemical intolerance with Nordin's chemical sensitivity scale and the symptom severity with Cho's subjective symptom score. RESULTS: The results showed that the 40 items on the four sub-scales,' chemical intolerances',' symptom severity', 'life impact', and 'other intolerances', were consistent with those reported for the US population by Miller and Prihoda. The convergent validity wes very good (r=0.4; p<0.001, r=0.5; p<0.001, respectively). A good internal consistency (Cronbach' alpha=0.86~0.96) and test-retest reliability (r=0.87~0.90) were found in all scales, except for the internal consistency in the masking index. CONCLUSIONS: The Korean version QEESI(c) showed a good reliability and validity. It should be necessary to conduct a MCS/IEI study adopting Korean version QEESI(c).

Multiple Chemical Sensitivity / 대한산업의학회지

This article reviews newly available knowledge on multiple chemical sensitivity (MCS), a chronic medical condition characterized by symptoms in multiple organ and caused by exposure to low levels of common chemicals. Although various pathophysiological models have been proposed (including toxicological, immunological or behavioral models), the causes and underlying mechanisms of MCS are still not fully understood. Most patients with MCS were women between the ages of 30 and 50 years. The most frequently reported trigger was a newly constructed home or job site. The common symptoms are vague, non-specific complaints: fatigue, difficulty concentrating, poor memory, sneezing/runny nose, headache, and muscle pain. There are no laboratory markers or specific investigative findings for MCS. The Quick Environmental Exposure and Sensitivity Inventory (QEESI)(c) has been used as a screening questionnaire. Treatment focuses on assisting patients at the earliest possible opportunity to reduce their exposure to unique symptom triggers and known hazardous chemicals. Early comprehensive assessment, medical management, and social and financial support might avoid the deterioration of functions associated with prolonged illness.

Multiple chemical sensitivity and idiopathic environmental intolerance (part one)

Multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) is a commonly used diagnostic term for a group of symptoms. These symptoms have been described and commented on for more than 15 years in the USA. Recently, it has also been observed in Japan. The main features of this syndrome are multiple symptoms involving in multiple organ systems that are precipitated by a variety of chemical substances with relapses and exacerbation under certain conditions when exposed to very low levels which do not affect the population at large. There are no laboratory markers or specific investigative findings. Although traditional medical organizations have not agreed on a definition for this syndrome due to the lack of obvious evidence to demonstrate the existence of these symptoms, it is being increasingly recognized. It constitutes an increasing percentage of the caseload at occupational/environmental medical clinics.Part one of this review article discusses pathophysiological theories, substances which cause symptoms, prevalence in the general and specific populations, past history and family history, and clinical symptoms of MCS/IEI patients.

Multiple chemical sensitivity and idiopathic environmental intolerance (part two)

Multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) is a commonly used diagnostic term for a group of symptoms without apparent organic basis. The symptoms are characteristic of dysfunction in multiple organ systems. They wax and wane fluctuate according to exposure to low levels of chemical agents in the patient's environment, and sometimes begin after a distinct environmental change or injury such an industrial accident or chemical introduced after remodeling. Although traditional medical organizations have not agreed on a definition for this syndrome, it is being increasingly recognized and makes up an increasing percentage of the caseload at occupational/environmental medical clinics.Part two of this review article discusses diagnosis, clinical examination, long-term follow up of MCS/IEI, and the role of physicians, research on odor and treatment, diseases with similar symptoms, and further research regarding MCS/IEI patients.

Multiple Chemical Sensitivity and Idiopathic Environmental Intolerance (Part Two)

Multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) is a commonly used diagnostic term for a group of symptoms without apparent organic basis. The symptoms are characteristic of dysfunction in multiple organ systems. They wax and wane fluctuate according to exposure to low levels of chemical agents in the patient’s environment, and sometimes begin after a distinct environmental change or injury such an industrial accident or chemical introduced after remodeling. Although traditional medical organizations have not agreed on a definition for this syndrome, it is being increasingly recognized and makes up an increasing percentage of the caseload at occupational/environmental medical clinics. Part two of this review article discusses diagnosis, clinical examination, long-term follow up of MCS/IEI, and the role of physicians, research on odor and treatment, diseases with similar symptoms, and further research regarding MCS/IEI patients.

Multiple Chemical Sensitivity and Idiopathic Environmental Intolerance (Part One)

Multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) is a commonly used diagnostic term for a group of symptoms. These symptoms have been described and commented on for more than 15 years in the USA. Recently, it has also been observed in Japan. The main features of this syndrome are multiple symptoms involving in multiple organ systems that are precipitated by a variety of chemical substances with relapses and exacerbation under certain conditions when exposed to very low levels which do not affect the population at large. There are no laboratory markers or specific investigative findings. Although traditional medical organizations have not agreed on a definition for this syndrome due to the lack of obvious evidence to demonstrate the existence of these symptoms, it is being increasingly recognized. It constitutes an increasing percentage of the caseload at occupational/environmental medical clinics. Part one of this review article discusses pathophysiological theories, substances which cause symptoms, prevalence in the general and specific populations, past history and family history, and clinical symptoms of MCS/IEI patients.