Hymenoptera Venom Allergy: Management of Children and Adults in Clinical Practice.

Hymenoptera venom allergy is an epidemiologically underestimated condition and a major cause of morbidity worldwide. Preventing future allergic reactions in patients who experience a systemic reaction is based on the correct management of the emergency followed by an accurate diagnosis, prescription of adrenaline autoinjectors, and, where indicated, specific venom immunotherapy. Some epidemiological studies highlight our poor knowledge of this disease and the frequent inadequacy of its management. Moreover, they emphasize the importance of such a life-saving treatment as specific immunotherapy. The availability of high-quality hymenoptera venom extracts for diagnostic and therapeutic use has dramatically improved the prognosis and quality of life of allergic patients. Subcutaneous venom immunotherapy is currently the most effective form of allergen-based immunotherapy, with a carry-over effect lasting up to several years after its interruption. This report on the management of hymenoptera venom-allergic children and adults was prepared by a panel of Italian experts. The main objective of this consensus document is to review the scientific evidence related to diagnosis, therapy, and management of patients allergic to hymenoptera venom. Thus, we can improve our knowledge of the disease and promote good clinical practices. The present document provides practical suggestions for correct diagnosis, prescription of emergency therapy and immunotherapy, and strategies for patient care.

Hymenoptera venom allergy: management of children and adults in clinical practice

Hymenoptera venom allergy is an epidemiologically underestimated condition and a major cause of morbidity worldwide. Preventing future allergic reactions in patients who experience a systemic reaction is based on the correct management of the emergency followed by an accurate diagnosis, prescription of adrenaline autoinjectors, and, where indicated, specific venom immunotherapy. Some epidemiological studies highlight our poor knowledge of this disease and the frequent inadequacy of its management. Moreover, they emphasize the importance of such a life-saving treatment as specific immunotherapy. The availability of high-quality hymenoptera venom extracts for diagnostic and therapeutic use has dramatically improved the prognosis and quality of life of allergic patients. Subcutaneous venom immunotherapy is currently the most effective form of allergen-based immunotherapy, with a carry-over effect lasting up to several years after its interruption. This report on the management of hymenoptera venom-allergic children and adults was prepared by a panel of Italian experts. The main objective of this consensus document is to review the scientific evidence related to diagnosis, therapy, and management of patients allergic to hymenoptera venom. Thus, we can improve our knowledge of the disease and promote good clinical practices. The present document provides practical suggestions for correct diagnosis, prescription of emergency therapy and immunotherapy, and strategies for patient care

La alergia al veneno de himenópteros es una condición subestimada epidemiológicamente que representa una causa importante de morbilidad en todo el mundo. La prevención de reacciones alérgicas futuras en pacientes que han desarrollado una reacción sistémica se basa en el manejo correcto de la emergencia, seguido de un diagnóstico correcto, la prescripción de autoinyectores de adrenalina y, en el caso de estar indicada, la prescripción de inmunoterapia específica con veneno (VIT). Varios estudios epidemiológicos destacan el escaso conocimiento de esta enfermedad y un frecuente tratamiento insuficiente. Además, enfatizan la importancia de la inmunoterapia específica, un tratamiento que puede salvar la vida del paciente. La disponibilidad de extractos de veneno de himenóptera de alta calidad para uso diagnóstico y terapéutico ha mejorado drásticamente el pronóstico y la calidad de vida de estos enfermos. La VIT subcutánea representa la forma más efectiva de inmunoterapia con alérgeno actualmente disponible, con una eficacia persistente que dura hasta varios años después de su interrupción. Este consenso sobre la evaluación clínica tanto de niños como de adultos alérgicos al veneno de himenópteros ha sido elaborado por un panel de expertos italianos. Su objetivo principal es revisar la evidencia científica disponible en el diagnóstico, la terapia y la evaluación clínica de los pacientes alérgicos al veneno de himenópteros con el propósito de mejorar el conocimiento sobre esta enfermedad y promover buenas prácticas clínicas. Se incluyen sugerencias prácticas para un diagnóstico correcto, la prescripción de terapia de emergencia e inmunoterapia, así como estrategias para el manejo de los pacientes

Acquired C1-inhibitor deficiency: a case report.

Angioedema due to C1--inhibitor deficiency may be hereditary (HAE) or acquired (AAE). AAE is a very rare condition, whose prevalence is possibly underestimated, as it is often unrecognized. AAE usually occurs after the fourth decade of life, and it is commonly associated to an underlying disease, mainly lymphoproliferative disorders. We report a 74-years old woman with recurrent episodes of angioedema involving upper airways in which diagnosis was obtained a long time after symptoms onset. A concomitant B cell leukaemia was also diagnosed This report stresses the importance of the recognition of AAE: a delayed diagnosis is indeed associated to the risk of severe life-threatening episodes, unresponsive to the usual therapy of common form of angioedema. AAE should be considered as a possible diagnosis in subjects with adult onset of angioedema: a careful clinical history is basic, since the clinical features and the time-course are often suggestive of the disease.

[Pseudo-acute abdomen in familial Mediterranean fever. A case report]. / Pseudo addome chirurgico in corso di febbre mediterranea familiare. Osservazioni su di un caso.

The Authors report a case of familial mediterranean fever with pseudo-acute abdomen recently observed and emphasize how a careful anamnesis can avoid unnecessary surgical intervention.

[IgD myeloma. Presentation of a case and review of the literature]. / IgD mieloma. Presentazione di un caso e revisione della letteratura.

A case of IgD myeloma that began with high paraproteinaemia, BJ proteinuria of type and 40% marrow plasmacellular infiltration is reported. These onset data suggested a large tumoral mass and hence a poor prognosis. On the other hand, after subjecting the patient to 4 polychemotherapy cycles (alkeran and prednisone) CM disappeared from serum and urine and bone lesion progression stopped. It is also stressed that this from presents clinical (frequent extra-osseous growth, presence of amyloidosis), laboratory (severe anaemia, renal insufficiency, BJ proteinuria) and particular prognostic features.

[Oxygen therapy via Ventimask. Personal cases]. / Ossigenoterapia con Ventimask. Casistica personale.

Eleven patients suffering from seriously hypoxaemic chronic respiratory insufficiency with slight hypercapnia have been assessed. A comparison between the results obtained with continuous oxygen therapy carried out with a Ventury mask and that done with the Ventimask was made in the case of each patient. Distribution of O2 with the Ventimask made it possible to obtain higher average pO2 levels than with the Ventury mask.

[Morphine combined with marcaine in long-term epidural analgesia in patients with Pancoast's syndrome caused by bronchogenic carcinoma of the apex of the lung]. / Morfina associata a marcaina nell'analgesia epidurale a lungo termine del paziente con sindrome di Pancoast da carcinoma broncogeno dell'apice polmonare.

The long-term, epidural administration of morphine and marcaine (bupivacaine) in 12 patients suffering from bronchogenic carcinoma of the pulmonary apex and consequent Pancoast's syndrome has been examined. In 75% of cases the technique provided satisfactory results and the administration system was well tolerated by the patient.

[Goodpasture's syndrome. Clinical case and diagnostic problems]. / Sindrome di Goodpasture. Caso clinico e problemi diagnostici.

Goodpasture's syndrome is characterised clinically by the association of haemoptysis and haematuria and is therefore the expression of lesions localised in two different apparatus, the respiratory and the renal, with an autoimmune type mechanism (production of circulating antibodies against the glomerular and alveolar basal membrane). A case of Goodpasture's syndrome in a male of 28 is reported in which the two basic clinical signs were not in evidence, making differential diagnosis more complicated.

[An association of acute pancreatitis and intestinal infarct due to superior mesenteric artery occlusion]. / Associazione di pancreatite acuta ed infarto intestinale da occlusione dell'arteria mesenterica superiore.

The clinical case of a 67-year-old woman admitted for abdominal pain whose interpretation created difficulties but which corresponded substantially to the pain encountered in intestinal occlusion associated with diabetes mellitus and increase in amylasemia is reported. After decrease, 48 hours after hospitalization, necropsy revealed extensive acute pancreatitis associated with infarction of the small bowel to occlusion of the superior mesenteric artery.

[Allergic bronchial asthma: an evaluation of immunofluorescence technics on bronchial biopsies]. / Asma bronchiale allergico: valutazione delle tecniche di immunofluorescenza su biopsia bronchiale.

Although the immunofluorescence technique has mostly been applied to renal diseases, it may be of use in the examination of lung tissue. Immunofluorescence tests on bronchial bioptic samples can show: 1) presence of IgE, IgA, IgM, IgG and complement factors; 2) their location on the bronchial mucosa; 3) their relationships with epithelioid cells, mast cells and plasma cells. Patients with atopic asthma were examined. Bioptic samples were taken from the main bronchi and treated by immunofluorescence. Cellular positivity was found for IgE, IgA, IgM and complement components.

[Therapeutic efficacy of the principal antitubercular drugs: an evaluation by antibiogram]. / Efficacia terapeutica dei principali farmaci antitubercolari: valutazione mediante antibiogramma.

Pulmonary and extrapulmonary tuberculosis is still encountered in clinical practice, sometimes in forms that are difficult to categorize nosographically. In this study, the therapeutic efficacy of the 6 main antitubercular drugs (rifampicin, streptomycin, isoniazide, ethambutol, kanamycin, para-aminosalicylic acid) in 20 patients with early TB of the lungs was assessed on the basis of antibiogram findings. Para-aminosalicylic acid was found to be the least effective; isoniazide, rifampicin and streptomycin were reasonably so; both kanamycin and ethambutol were extremely effective.

[Echography in the study of thoracic pathology. II-- Guided biopsy]. / L'ecografia nello studio della patologia toracica. Nota II--Guida alla biopsia.

The usefulness of ultrasonic studies for guiding the needle during biopsy of solid lesions or evacuation of saccate effusions and empyemas. Is a explained possible diagnostic protocol is then proposed which includes the ultrasonic examination in the diagnostic approach to parietal, mediastinic or diaphragmatic lesions.

[Echography in the study of thoracic pathology. I--Indications and limitations]. / L'ecografia nello studio della patologia toracica. Nota I--Indicazioni e limiti.

The role of echography in the study of the thorax is evaluated: after reporting the technical limits due to the peculiar anatomy of this region, personal experience is presented. This method extremely precise to define the solid or liquid nature of tightly adherent to the chest wall lesions, but it is non specific to assess their benign or malignant behaviour. Ultrasounds have their on limits in drawing the extension of such lesions; these limits have been overcome by CT and MR. Finally the usefulness of the method in studying the diaphragm and its pathology is briefly described.

[Percutaneous needle aspiration biopsy in the diagnosis of pulmonary neoplasms]. / L'agobiopsia percutanea aspirativa nella diagnosi delle neoplasie polmonari.

The diagnostic efficacy of percutaneous needle biopsy (PNB) was assessed in 220 lung tumour patients. The results obtained prove this diagnostic technique to be extremely sensitive even though personal experience suggests that slight complications (pneumothorax, homophthoe) may occur.

[Transthoracic needle aspiration in infectious pathology]. / L'agoaspirazione transtoracica nella patologia infettiva.

A study was conducted on 20 patients with isolated or multiple patches of doubtful significance in the framework of neoplastic or infectious pathologies or in the presence of probably infectious diffuse or localised pulmonary infiltrations in immunodepressed patients or those in whom broad spectrum antibiotic treatment had failed. Percutaneous needle aspiration and sterile brushing was performed for the purpose of bacteriological examination in all patients. The result showed the clear superiority of needle aspiration (75% positive) over sterile brushing (25%). The first method is therefore recommended for use in the diagnosis of so-called "difficult" lung pathologies.

[Antibacterial and antifungal activity of isoflurane and common anesthetic gases]. / Attività antibatterica ed antifungina dell'isofluorano e dei comuni vapori anestetici.

An in vitro analysis was conducted to investigate the hypothetical antibacterial and antimycotic activity of the common anesthetic gases (halothane, enflurane, isoflurane, methoxyflurane) in view of the clinical absence of bronchopulmonary pathology after inhalation narcosis despite the many risk factors involved. For this purpose scalar dilutions of the four gases were prepared on cultures of Klebsiella pneumoniae and Candida albicans and the antibacterial action of the gases was tested in vitro. Even with the weaker concentrations used, halothane and methoxyflurane totally inhibited both microorganisms. Enflurane had less effect on Klebsiella p. and almost none on Candida. Isoflurane, a new halogen ether anesthetic was found to have an excellent inhibitory effect. In conclusion it is hypothesised that the anesthetic gases considered might have an in vivo antibacterial activity considering the experimental results obtained in vitro.

[Isolated endobronchial metastases]. / Metastasi endobronchiali isolate.

Endobronchial metastases account for about 5% of autoptic findings in patients with multiple secondary locations. Five cases are reported of patients with malignant neoplasms in various organs with metastases to the trachea and the large bronchi without involvement of the pulmonary parenchyma and therefore with negative radiographic and CT scan findings.