Alergia e intolerancia a antiinflamatorios no esteroideos en pediatría / Allergy and intolerance to nonsteroidal anti-inflammatory drugs in children

Los antiinflamatorios no esteroideos son ampliamente recetados en niños. Constituyen la segunda causa de reacciones a medicamentos en pediatría después de los antibióticos betalactámicos; sin embargo, solo una parte de estas son reacciones de hipersensibilidad. La prevalencia de dichas reacciones a antiinflamatorios no esteroideos en niños es del 0,3 % y aumenta al 5 % en asmáticos.Los mecanismos fisiopatológicos involucrados (inhibición de la ciclooxigenasa, hipersensibilidad mediada por inmunoglobulina E, linfocitos T reactivos y/o afectación de la inmunidad innata) darán lugar a diferentes entidades clínicas con sintomatología dispar.La confusión con síntomas propios de procesos virales y la variabilidad clínica hacen del diagnóstico de certeza un verdadero desafío. Una historia clínica detallada, análisis de laboratorio, pruebas cutáneas y de provocación controlada permitirán definir estrategias para cada paciente en particular sin etiquetar como alérgico a un niño que no lo es ni exponer a riesgos innecesarios a quien está sensibilizado.

Nonsteroidal anti-inflammatory drugs are widely prescribed in children. They are the second cause of drug ́s reactions in pediatrics after beta-lactam antibiotics, however only a part of them are hypersensitivity reactions. The prevalence of these reactions to nonsteroidal anti-inflammatory drugs in children is 0.3 %, increasing to 5 % in asthmatics.The different physiopathological mechanisms involved (inhibition of cyclooxygenase, immunoglobulin E-mediated hypersensitivity, reactive T lymphocytes and/or disturbance of innate immunity) will cause different clinical entities with diverse symptoms.The confusion between the common symptoms of a viral infection and a hypersensitivity reaction, and the variability of the clinical presentations make diagnosis a real challenge.A detailed clinical history, laboratory, skin and controlled provocation tests will provide strategies for each patient, without labeling a child who is not an allergic one, or taking unnecessary risks with those who are sensitized.

Loss of tolerance 5 days after discontinuing sulphonamide introduced via desensitization in delayed reaction / Perda da tolerância 5 dias após suspensão de sulfonamida introduzida através de dessensibilização por reação tardia

ABSTRACT The fixed drug eruption is a non-immediate hypersensitivity reaction to drug, characterized by recurrent erythematous or violaceous, rounded, well-defined border plaques, which always appear in the same location every time the culprit drug is administered. The usual practice is to avoid the drug involved and to use a structurally different drug. However, there are situations in which there is no safe and effective therapy. In such situations, desensitization is the only option. We describe the case of a patient who presented fixed eruption due to sulfamethoxazole-trimethoprim, who underwent successful desensitization, but required a repeat procedure twice due to relapse after inadvertent full-dose reintroduction. In non-immediate hypersensitivity reaction to drug, the indication is controversial and there is no technical standardization. Furthermore, the time at which such tolerance is lost after discontinuing the drug involved is unknown. In severe non-immediate reactions of types II and III, desensitization is contraindicated. The patient underwent desensitisation to sulfamethoxazole-trimethoprim three times − the first with recurrence of lesions and the second and third without manifestations, all concluded successfully and with no premedication.

RESUMO A erupção fixa por drogas é uma reação de hipersensibilidade a medicamento não imediata, caracterizada por placas eritematosas ou violáceas, arredondadas, recorrentes, de bordas bem definidas e que aparecem sempre na mesma localização cada vez que o medicamento culpado é administrado. A prática habitual é evitar a droga envolvida e utilizar um medicamento estruturalmente diferente. Contudo, há situações em que não há terapêutica segura e eficaz. Em tais situações, a dessensibilização é a única opção. Descrevemos o caso de um paciente que apresentou erupção fixa por drogas por sulfametoxazol-trimetoprim, tendo sido submetido à dessensibilização com sucesso, mas necessitou repetição do procedimento duas vezes, por recidiva da reação após reintrodução inadvertida em dose plena. Em reação de hipersensibilidade a medicamento não imediata, a indicação é controversa e não há padronização técnica. Além disso, não se conhece o tempo durante o qual essa tolerância é perdida após a suspensão da droga envolvida. Nas reações não imediatas graves e dos tipos II e III, a dessensibilização está contraindicada. O paciente foi submetido a dessensibilização ao sulfametoxazol-trimetoprim por três vezes − a primeira com recorrência de lesões, e a segunda e terceira sem manifestações, sendo todas concluídas com sucesso e sem uso de pré-medicação.

Pretreatment with different doses of dexamethasone in the prevention of docetaxel-induced hypersensitivity

This study aimed to evaluate the efficacy and safety of dexamethasone pretreatment regimen with different doses in the prevention of docetaxel-induced hypersensitivity reaction [HSR]. One hundred and sixty-two patients who had malignant tumors as determined by histology and/or cytology and received docetaxel treatments at least 2 cycles, were randomized into two groups. There were 90 patients in the study group and 72 patients in the control group. In the study group, patients received 4.5mg of oral dexamethasone once a day. Patients in the control group received 8 mg of dexamethasone twice a day. All patients received dexamethasone for 3 days, from the day before docetaxel treatment to the day after docetaxel treatment. The endpoints were hypersensitivity reaction [HSR] and other adverse effects, which were determined according to common terminology criteria for adverse event v3.0 [CTCAE 3.0]. In the study group, 10 patients had HSRs [11.1%]. While in the control group, 7 patients had HSRs [9.7%], and the main clinical symptoms of HSR were rash [3.1%], fever/chill [2.5%], angioedema [1.9%], chest discomfort [1.9%] and hypotension [0.6%]. There was no statistically significant difference between these two groups [P=0.774]. There was no significant difference in the incidence rate of adverse effect between patients in the study group and in the control group. Those adverse effects included neutropenia, decreased hemoglobin, nausea, vomiting, fatigue and fluid retention. Since no significant difference in the HSR incidence between these two groups has been found, 4.5mg of dexamethasone [qd] is as efficient and safe as 8mg [bid]

Allergic reaction to patent blue dye in breast surgery - case report / Reação alérgica ao corante azul patente em cirurgia de mama - relato de caso

Abstract We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20 min after the dye injection, the patient developed hypotension (BP = 70 × 30 mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial-like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU 2 h after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye.

Resumo Os autores apresentam um caso de reação alérgica ao azul patente em uma paciente submetida à exérese de linfonodo em sentinela associada a uma ressecção segmentar de mama. Paciente apresentou aproximadamente pós 20 minutos da injeção do corante hipotensão (PA = 70 × 30 mmHg) associada a aumento da frequência cardíaca. Foi tratada satisfatoriamente com diminuição da fração inspirada do anestésico inalatório e reposição volêmica. No fim do procedimento apresentava placas urticariformes azuladas em cabeça, pescoço, membros superiores e tronco e foi usada hidrocortisona. Evoluiu, sem intercorrências, na sala de recuperação pós-anestésica e teve alta duas horas após o término do procedimento cirúrgico sem a presença das alterações cutâneas. Alta hospitalar na manhã seguinte à cirurgia. A incidência de reações alérgicas com o emprego do azul patente é muito superior às reações de hipersensibilidade observadas com drogas anestésicas e adjuvantes. Portanto, o anestesiologista deve ficar atento à instabilidade cardiovascular associada a alterações cutâneas quando do uso do azul patente para o diagnóstico precoce e tratamento adequado dessa reação de hipersensibilidade com o emprego do corante.

Desensibilización con ciprofloxacina en una paciente con infección urinaria parcialmente tratada / Desensitization with ciprofloxacin in a patient with partially treated urinary tract infection

Por más de 30 años se han usado ampliamente las fluoroquinolonas a las cuales ha habidobuena tolerancia; son de amplio espectro contra gérmenes grampositivos y gramnegativos,aunque la actividad de la norfloxacina, la ciprofloxacina y la ofloxacina contra estreptococos yalgunos anaerobios es limitada; tienen, además, buena biodisponibilidad oral y adecuadapenetración en los tejidos. Se presentan reacciones características de hipersensibilidadaproximadamente en 1 por cada 50.000. tratamientos. Se describe un caso de desensibilizaciónoral exitosa con ciprofloxacina en una paciente con infección urinaria crónica parcialmentetratada. Esta es la primera desensibilización con quinolonas reportada en Colombia.

Desensitization with ciprofloxacin in a patient with partially treated urinary tract infectionFluoroquinolones have been widely used for over 30 years and tolerance to them has beengood. They are of broad spectrum against both gram positive and gram negative bacteria, althoughthe activity of norfloxacin, ciprofloxacin and ofloxacin against streptococci and some anaerobicbacteria is rather limited. Their oral bioavailability is good and tissue penetration is adequate.68IATREIA / VOL 23/No. 1/ MARZO/ 2010Hipersensitivity reactions occur in about 1 per 50.000treatments. We report a case of successful oraldesensitization with ciprofloxacin in a patient withchronic partially treated urinary tract infection. This isthe first desensitization with quinolones reported inColombia.

Anaphylaxis: lesson learned from five cases.

Anaphylaxis is a severe hypersensitivity reaction. Its clinical manifestations vary, affecting several organs at once. Skin symptom is the most frequent manifestation; however, diagnosis of anaphylaxis will only be established when involving one or both vital organs, which are cardiovascular and respiratory system. Other symptom, such as that involving central nervous system or gastrointestinal tract, may accompany. We present five cases of anaphylaxis which vary in onset of symptoms, allergen, degree of severity, therapeutic response and clinical manifestation. Anaphylactic reaction to drugs in these cases is mainly manifested as anaphylactic shock and reaction to food allergen causing obstruction of respiratory tract. Four anaphylactic events occurred at home and only one occurred in a hospital, thus education on anaphylaxis to general community is very important, especially for the patients and their families. Prompt medical assistance in patients with anaphylactic symptoms determines their therapeutic response. Skin test prior to administration of cephalosporin does not give negative predictive value toward anaphylactic event.

A randomized, pilot trial comparing full versus escalating dose regimens for the desensitization of AIDS patients allergic to sulfonamides

Sulfonamides are drugs extensively used in the management of AIDS patients. However, the use of sulfonamides is often associated with the development of allergic reactions, provoking the substitution of the drug (by another that may be less effective); alternatively attempts are made to desensitize the patient. OBJECTIVE: Compare two drug regimens (full vs. escalating doses) for the oral desensitization of AIDS patients allergic to sulfonamides. MATERIAL AND METHODS: AIDS patients with previous allergic reactions to sulfonamides and requiring prophylaxis against Pneumocistis carinii, central nervous system toxoplasmosis and diarrhea caused by Isospora belli were randomly assigned to a group receiving a routine dose of cothrimoxazole, or another that received escalating doses of an oral suspension of the same drug, initiating with 75mg/day of sulfamethoxazole that was doubled every 48 hours till the full dose was reached, if no allergic reaction occurred. Patients were monitored for at least 6 months after enrollment in the trial. The major end-point was the ability to maintain prophylactic treatment after that period of time. Plasma viral load (PVL) and CD4/CD8 counts were measured at baseline. Liver enzymes and hematological parameters were measured at baseline and after 1, 3 and 6 months. RESULTS: Eighteen patients were enrolled in the study (15 men and 3 women), with ages ranging from 30 to 57 years (mean 39.9). The mean CD4 counts were slightly higher for patients receiving a full dose; there was also a trend towards higher baseline CD8 counts among patients developing new reactions. The mean PVL was similar among the patients in both desensitization groups. The incidence of new allergic reactions was identical (40 percent) in the two groups. All adverse reactions were mild and no significant increase in liver enzymes were observed. CONCLUSON: Dose regimen is not a predictor of the development of new allergic reactions amongst patients challenged with sulfonamides after an initial allergic reaction.

Reacciones alérgicas por medicamentos: un raro evento durante la internación pediátrica / Drug allergy: a rare complication in pediatric hospitalized

Objetivo: Evaluar la frecuencia y características de Reacciones Alérgicas por Medicamentos (RAM) entre pacientes de sala de Pediatría de Hospital de alta complejidad. Material y Métodos: Se caracterizaron RAM entre los internados desde septiembre de 1996 hasta septiembre de 1998. Resultados: Se internaron 1685 pacientes con una edad promedio de 4,73 (ñ4,79) años. Días de internación promedio: 5,32 (ñ10,23). Antecedentes de RAM: 2,5 por ciento. Promedio de mediciones indicadas: 3,5 RAM presentadas: 6 (vancomicina 2; carbaplatino 2; ceftriazone 1; gammaglobulina antilinfocitaria equina 1). La frecuencia de RAM: 1/280 niños (3,56/1000). 5/6 eran huéspedes inmunocomprometidos (neonato 1; tumores 2; trasplante de médula ósea 2). Conclusiones: los medicamentos causantes han sido de uso exclusivo de internación y de administración intravenosa. Dos casos fueron atribuibles a mecanismos de hipersensibilidad tipo I. El resto obedecieron a causas no bien determinadas. No se registraron episodios relacionados a antibióticos vía oral o antitérmicos, de uso tanto en ambulatorio como en internacioón. Posiblemente, el interrogatorio detallado al momento del ingreso, descarte el uso de drogas potencialmente peligrosas. Las reacciones alérgicas o pseudoalérgicas provocadas por drogas en niños es una rara complicación durante la internación

Desensibilización aguda con cotrimoxazol forte en paciente VIH (+) alérgico a sulfas con neumonía por pneunocistis carinii / Acute desensitization with cotrimoxazol forte in HIV (+) patient with allergy to sulfa and pneunocistis carinii pneumonia

Se presenta el caso de un paciente VIH (+), alérgico a sulfas, hospitalizado en 1998 por una neumopatía de predominio intersticial con insuficiencia respiratoria que no respondía al esquema clásico. Se trata del primer caso en nuestro hospital en el que se aplicó la terapia de desensibilización con cotrimoxazol forte, la cual está ampliamente recomendada en la literatura internacional como alternativa en casos de estas características

Reaçöes alérgicas às drogas / Allergic reactions to drugs

Uma Reaçao Tipo Alérgica (RTA) pode ocorrer após a administraçao de quase todos os medicamentos e o médico deve estar sempre preparado para o atendimento desse paciente. Essa RTA pode cursar com apenas manifestaçoes brandas como as alteraçoes cutâneas ou evoluir para o colapso circulatório e broncoespasmo. Como nao se sabe inicialmente o grau de comprometimento e como a instalaçao é rápida, começa-se imediatamente a terapêutica de maneira coordenada. A primeira medida a ser tomada é suspender a administraçao do agente suspeito e a seguir garantir uma oxigenaçao a 100 por cento. A partir deste momento administrar adrenalina, repor volêmia e usar medicamentos broncodilatadores como a aminofilina, de acordo com a evoluçao do quadro clínico. Nunca se deve esquecer de identificar a populaçao de maior risco e tentar a prevençao. Em suma, na RTA poder-se-á ter um quadro de ocorrência imprevisível, crise grave e com ausência de história prévia de alergia.

Concepto actual sobre las substancias de contraste iodadas, sus reacciones adversas, prevención y tratamiento / Current concepts over contrast media: adverse reactions, prevention and treatment

En este trabajo el autor expone los últimos conceptos sobre sustancias de contraste, reacciones adversas y tratamiento

Reacciones adversas producidas por los antimicrobianos / Adverse reactions to drugs against microorganisms

Las reacciones adversas que los antimicrobianos producen son generalmente por sobre dosificacion real o relativa, a medida que aumenta la concentracion plasmatica de un antimicrobiano aumentan las posibilidades de toxicidad. Reacciones adversas y colaterales: Transtornos gastrointestinales, musculares, venosos. Reacciones Adversas por Sensibilizacion y Reacciones adversas por toxicidad directa. Los antimicrobianos son farmacos de reconocida utilidad frente a las infecciones por germenes sensibles a ellos, siempre y cuando sean correctamente empleados: de lo contrario se convierten en agentes de agresion al propio organismo humano.

Estudio multicéntrico con astemizol en alergias: distribución geográfica de los padecimientos alérgicos y resultados del tratamiento / Multicenter study with astemizole in allergies: geographical distribution of allergic diseases and results of the treatment

Se dividió la República Mexicana en cinco zonas geográficas con objeto de conocer las diferencias existentes tomando como base un estudio en 6.007 pacientes tratados por diferentes padecimientos alérgicos con astemizol. El análisis de los resultados demostró que no existen diferencias entre las características de la población estudiada: sí se encontraron disparidades entre la frecuencia de los padecimientos alérgicos estudiados. La respuesta al tratamiento con astemizol fue buena y consistente. No se presentaron desviaciones inesperadas en la frecuencia de efectos indeseables