Oral Muscle Relaxant May Induce Immediate Allergic Reactions

Eperisone and afloqualone act by relaxing both skeletal and vascular smooth muscles to improve circulation and suppress pain reflex. These drugs are typically prescribed with non-steroidal anti-inflammatory drugs (NSAIDs) as painkillers. However, there have been no reports on serious adverse reactions to oral muscle relaxants; and this is the first report to describe three allergic reactions caused by eperisone and afloqualone. All three patients had histories of allergic reactions after oral intake of multiple painkillers, including oral muscle relaxants and NSAIDs, for chronic muscle pain. An open-label oral challenge test was performed with each drug to confirm which drugs caused the systemic reactions. All patients experienced the same reactions within one hour after oral intake of eperisone or afloqualone. The severity of these reactions ranged from laryngeal edema to hypotension. To confirm that the systemic reaction was caused by eperisone or afloqualone, skin prick testing and intradermal skin tests were performed with eperisone or afloqualone extract in vivo, and basophil activity tests were performed after stimulation with these drugs in vitro. In one patient with laryngeal edema, the intradermal test with afloqualone extract had a positive result, and CD63 expression levels on basophils increased in a dose-dependent manner by stimulation with afloqualone. We report three allergic reactions caused by oral muscle relaxants that might be mediated by non-immunoglobulin E-mediated responses. Since oral muscle relaxants such as eperisone and afloqualone are commonly prescribed for chronic muscle pain and can induce severe allergic reactions, we should prescribe them carefully.

Four Cases of Drug Allergy Caused by Non-Steroidal Anti-Inflammatory Drugs in Children / 소아알레르기및호흡기학회지

Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), which reduce the production of prostaglandin by inhibiting cyclooxygenase (COX), are widely used in children as antipyretic, analgesic, or anti-inflammatory drugs. They are known to be a major cause of pediatric drug allergies, which are diagnosed by a drug provocation test. The mechanism comprises an immunoglobulin E- or T cell-mediated immune reaction or pseudoallergy caused by the inhibition of COX-1. The diagnosis of NSAIDs drug allergy requires a differential, because there is a high cross-reactivity between NSAIDs. In this study, oral provocation tests with ibuprofen, acetaminophen, diclofenac and celecoxib were carried out, and various types of NSAIDs and acetaminophen allergies were observed. Safe drugs were recommended for each patient according to the test results. We report four cases of NSAIDs and acetaminophen allergy and include the results of oral provocation tests.

Fixed Drug Eruption Due to Allopurinol: Positive Oral Provocation

A fixed drug eruption (FDE) is characterized by the presence of a solitary or multiple, pruritic, well-circumscribed, erythematous plaques. These lesions have tendency to recur at same sites and heal with residual hyperpigmenation. With repeated attacks, the size and/or number of the lesions may increase. So far, more than 100 drugs have been implicated in causing FDEs, including ibuprofen, sulfonamide, naproxen, and tetracylines. FDE caused by allopurinol has been rarely reported in the literature, but there has been no confirmed case based on oral provocation test. Herein, we report a case of FDE in which the lesions recurred whenever allopurinol was administered for the treatment of gout. A 64-year-old male experienced repeated episodes of well-demarcated dusky erythematous patches on the whole body for 2 months. He took allopurinol intermittently for amelioration of his gout symptom, but denied other medication history. Pruritic erythematous edema developed on the previous lesions 12 hours after oral provocation of 200 mg of allopurinol.

A case of acetaminophen induced bronchial asthma without aspirin sensitivity / 천식및알레르기

Acetaminophen is a widely used analgesic-antipyretic. Hypersensitivity reactions to acetaminophen are rare and selective sensitivity to acetaminophen without aspirin or non-steroidal antiinflammatory drug intolerance is even rarer. We experienced a case of acetaminopheninduced bronchial asthma without aspirin sensitivity. An oral challenge test upto 650mg of Tylenol demonstrated urticaria and dyspnea with greater than 20% decrease of FEV1. Both oral provocation test with 500mg of aspirin and lysine-aspirin bronchoprovocation test showed negative results. In conclusion, we report a case of acetaminophen-induced asthma without aspirin sensitivity. Cyclo-oxygenase inhibition may not be a pathogenic mechanism of acetaminophen-induced bronchial asthma. Further studies will be needed to clarify the mechanism of this reaction.

A case of acetaminophen anaphylaxis without aspirin sensitivity / 천식및알레르기

Heterogeneity in clinical features and pathogenesis of non-steroidal anti-inflammatory agent (NSAIDs) hypersensitivity have been reported. NSAIDs can cause bronchial constriction in asthmatics or hives and angioedema in patients with chronic urticaria, in which case causative drugs show cross-reactivity with other NSAIDs. Normal subjects without allergic diseases may develop urticaria angioedema or anaphylaxis after ingestion of a specific NSAID. In this type of reaction, cross-reactivity between causative drugs and other NSAIDs does not occur. We experienced a case of acetaminophen anaphylaxis without aspirin sensitivity in a 38-year-old male, which was confirmed by oral provocation test. An oral challenge with 150mg of acetaminophen induced urticaria in lower legs, and erythema, with febrile sensation in ears. With a dose of 600mg acetaminophen, urticaria developed in trunk and extremities with facial angioedema. An oral provocation test with 650mg of aspirin was well tolerated without any adverse reactions. We report acase of acetaminophen anaphylaxis, which occurred in a normal individual at a small dose(150mg) without cross-reactivity with aspirin. This type of reaction supports heterogenei~ty of NSAIDs hypersensitivity and it may be caused by an other mechanism, not by cyclooxygenase inhibition.

A Clinical Study on Oral Milk Provocation and Elimination Test / 소아알레르기및호흡기학회지

PURPOSE: A Cow's milk allergy (CMA) is one of common problems during first year of life. Though milk caused allergic problems, their parents didn't know it, and gave milk to their children. But the parents don't give milk to their children if they know it. Therefore it may cause problems of growth and development in children. The purpose of this study is to analyze those clinical features of milk allergy confirmed by oral provocation test. METHODS: We carried out the retrospective study on 21 patients who had been performed oral milk provocation test at Yonsei university children's allergic clinic. RESULTS: 9 out of 21cases (43%) showed positive milk oral provocation test. The most common clinical symptom & sign was urticaria, followed by respiratory symptoms and abdominal symptoms. The rate which past history and positive skin test corresponded to oral provocation test was very high (100%). CONCLUSION: The most valuable diagnosis of food allergy is oral provocation test. However, predictive value of allergy skin test and past history was very high in milk allergy.

A Clinical Study on Oral Buckwheat Provocation Test / 소아알레르기및호흡기학회지

PURPOSE: Buckwheat is one of the most common allergen in food allergy, the pathomechanism is IgE-mediated, type I immune reaction. Antigenicity of Buckwheat is extremely strong, and hypersensitivity symptoms included asthmatic attacks, urticaria eruption, gastrointestinal disorders even anaphylactic shock. The purpose of this study is to evaluate diagnostic significance of allergy skin test and allergy history and analyze clinical features of buckwheat allergy confirmed by oral provocation test. METHODS: We carried out the retrospective study on 55 patients who had been performed oral buckwheat provocation test at Yonsei university children's allergic clinic. RESULTS: 1) 40 out of 55 cases(72.7%) showed positive buckwheat oral provocation test. 2) The most common clinical finding after oral provocation test was urticaria. 60% showed severe allergic reactions such as asthma attack or anaphylactic shock. 3) The rate which past history and positive skin test corresponded to oral provocation test was very high(86.1%). CONCLUSIONS: The most valuable diagnosis of food allergy is oral provocation test. However, predictive value of allergy skin test and past history was very high in buckwheat allergy. Our study suggest that the troblesome oral provocation test may be not needed in all cases of suspicious buckwheat allergy patients.

Oral provocation tests with aspirin and food additives in asthmatic patients

Aspirin and food additives are known to induce bronchoconstriction, angioedema or urticaria in susceptible patients. To evaluate the incidence of hypersensitivity to aspirin and food additives, 36 subjects with bronchial asthma, 33 of whom were non-allergic asthmatics and 3 were allergic asthmatics who had a history of aspirin sensitivity, were challenged orally with six compounds: acetylsalicylic acid (ASA), sodium bisulfite, tartrazine, sodium benzoate, 4-hydroxy benzoic acid, and monosodium L-glutamate. Significant bronchoconstrictions were found in 15 (41.7%) of the 36 subjects tested. Eight of the 15 subjects showed positive asthmatic responses to the aspirin, two showed asthmatic responses to the food additives, and five responded to both aspirin and the food additives. It is suggested that ASA and food additives could be causes of clinically significant bronchoconstriction in moderately severe non-allergic asthmatic patients.

Oral provocation tests with aspirin and food additives in asthmatic patients

Aspirin and food additives are known to induce bronchoconstriction, angioedema or urticaria in susceptible patients. To evaluate the incidence of hypersensitivity to aspirin and food additives, 36 subjects with bronchial asthma, 33 of whom were non-allergic asthmatics and 3 were allergic asthmatics who had a history of aspirin sensitivity, were challenged orally with six compounds: acetylsalicylic acid (ASA), sodium bisulfite, tartrazine, sodium benzoate, 4-hydroxy benzoic acid, and monosodium L-glutamate. Significant bronchoconstrictions were found in 15 (41.7%) of the 36 subjects tested. Eight of the 15 subjects showed positive asthmatic responses to the aspirin, two showed asthmatic responses to the food additives, and five responded to both aspirin and the food additives. It is suggested that ASA and food additives could be causes of clinically significant bronchoconstriction in moderately severe non-allergic asthmatic patients.