How to Take a Good Clinical History in Cases of Allergic Reactions to Medications.

The clinical history is the cornerstone of the doctor´s work. When assessing patients consulting for a suspected hypersensitivity reaction to a drug, the details collected in the patient´s clinical history are essential when deciding which tests to perform and for making recommendations about which drugs the patient should avoid and which can be taken. This area is especially important today, since many patients are labeled as allergic to drugs, especially penicillins, without this being the case. This article reviews the importance of the clinical history in a patient with a hypersensitivity reaction to a drug and considers which data should be collected. Likewise, a record-based model is proposed to help standardize the clinical history.

How to Take a Good Clinical History in Cases of Allergic Reactions to Medications

The clinical history is the cornerstone of the doctor's work. When assessing patients consulting for a suspected hypersensitivity reactionto a drug, the details collected in the patient's clinical history are essential when deciding which tests to perform and for makingrecommendations about which drugs the patient should avoid and which can be taken. This area is especially important today, since manypatients are labeled as allergic to drugs, especially penicillins, without this being the case. This article reviews the importance of the clinicalhistory in a patient with a hypersensitivity reaction to a drug and considers which data should be collected. Likewise, a record-based modelis proposed to help standardize the clinical history (AU)

La historia clínica es la piedra angular del trabajo del médico. En el estudio de los pacientes que consultan por una supuesta reacción dehipersensibilidad a un fármaco, los detalles recogidos en la historia clínica del paciente son fundamentales para decidir el estudio quehay que realizar y para, al final, dar recomendaciones al paciente sobre los fármacos que debe evitar o que puede tomar. Actualmentecobra especial importancia este tema, dado que hay un elevado porcentaje de la población que, sin serlo, está etiquetada de alergiaa fármacos, sobre todo a las penicilinas. En este artículo se revisa la importancia que tiene la historia clínica ante un paciente con unareacción de hipersensibilidad a un fármaco y qué datos deben ser recogidos. Asimismo, se propone un modelo de ficha que puede ayudara la estandarización de la historia clínica (AU)

Clinical Practice Guidelines for Diagnosis and Management of Hypersensitivity Reactions to Contrast Media.

The objective of these guidelines is to ensure efficient and effective clinical practice. The panel of experts who produced this consensus document developed a research protocol based on a review of the literature. The prevalence of allergic reactions to iodinated contrast media (ICM) is estimated to be 1:170 000, that is, 0.05%-0.1% of patients undergoing radiologic studies with ICM (more than 75 million examinations per year worldwide). Hypersensitivity reactions can appear within the first hour after administration (immediate reactions) or from more than 1 hour to several days after administration (nonimmediate or delayed reactions). The risk factors for immediate reactions include poorly controlled bronchial asthma, concomitant medication (eg, angiotensin-converting enzyme inhibitors, ß-blockers, and proton-pump inhibitors), rapid administration of the ICM, mastocytosis, autoimmune diseases, and viral infections. The most common symptoms of immediate reactions are erythema and urticaria with or without angioedema, which appear in more than 70% of patients. Maculopapular rash is the most common skin feature of nonimmediate reactions (30%-90%). Skin and in vitro tests should be performed for diagnosis of both immediate and nonimmediate reactions. The ICM to be administered will therefore be chosen depending on the results of these tests, the ICM that induced the reaction (when known), the severity of the reaction, the availability of alternative ICM, and the information available on potential ICM cross-reactivity. Another type of contrast media, gadolinium derivatives, is used used for magnetic resonance imaging. Although rare, IgE-mediated reactions to gadolinium derivatives have been reported.

Clinical practice guidelines for diagnosis and management of hypersensitivity reactions to contrast media

The objective of these guidelines is to ensure efficient and effective clinical practice. The panel of experts who produced this consensus document developed a research protocol based on a review of the literature. The prevalence of allergic reactions to iodinated contrast media (ICM) is estimated to be 1:170 000, that is, 0.05%-0.1% of patients undergoing radiologic studies with ICM (more than 75 million examinations per year worldwide). Hypersensitivity reactions can appear within the first hour after administration (immediate reactions) or from more than 1 hour to several days after administration (nonimmediate or delayed reactions). The risk factors for immediate reactions include poorly controlled bronchial asthma, concomitant medication (eg, angiotensin-converting enzyme inhibitors, ß-blockers, and proton-pump inhibitors), rapid administration of the ICM, mastocytosis, autoimmune diseases, and viral infections. The most common symptoms of immediate reactions are erythema and urticaria with or without angioedema, which appear in more than 70% of patients. Maculopapular rash is the most common skin feature of nonimmediate reactions (30%-90%). Skin and in vitro tests should be performed for diagnosis of both immediate and nonimmediate reactions. The ICM to be administered will therefore be chosen depending on the results of these tests, the ICM that induced the reaction (when known), the severity of the reaction, the availability of alternative ICM, and the information available on potential ICM cross-reactivity. Another type of contrast media, gadolinium derivatives, is used used for magnetic resonance imaging. Although rare, IgE-mediated reactions to gadolinium derivatives have been reported (AU)

El contenido y las pautas recomendadas en este documento están dirigidas a lograr una práctica clínica más eficiente y eficaz. El panel de expertos que participó en esta guía de consenso desarrolló un protocolo para revisar lo publicado sobre el tema. La prevalencia de las reacciones alérgicas a medios de contraste iodados (MCI) se estima en 1:170.000, lo que representa un 0,05% -0,1% de los pacientes sometidos a estudios radiológicos con MCI (más de 75 millones de administraciones por año en todo el mundo). Las reacciones alérgicas por hipersensibilidad pueden aparecer dentro de la primera hora tras la administración (reacciones inmediatas) o en un rango de tiempo desde una hora hasta varios días después de la administración (reacciones no inmediatas o tardías). Existen factores de riesgo para las reacciones inmediatas tales como: mal control previo del asma bronquial, uso concomitante de inhibidores de la ECA, beta bloqueantes o inhibidores de la bomba de protones, administración rápida del fármaco, antecedente de mastocitosis, coexistencia de enfermedades autoinmunes o de infecciones virales. Los síntomas más comunes de las reacciones inmediatas son eritema y urticaria con o sin angioedema, apareciendo en más de un 70% de los pacientes que sufrieron reacciones. Las reacciones no inmediatas más comunes son las erupciones maculopapulares (30-90%). Para el diagnóstico de reacciones tanto inmediatas como no inmediatas se deben realizar pruebas cutáneas y pruebas in vitro. Para elegir el MCI que posteriormente puede ser administrado se tendrán en cuenta los resultados de las pruebas cutáneas e in vitro realizadas, el MCI que indujo la reacción (si se conoce), la gravedad de la misma, la disponibilidad de otros MCIs alternativos y la información disponible sobre la potencial reactividad cruzada entre los distintos MCIs. Otro tipo de medios de contraste, son los utilizados en la resonancia magnética (RMN), que son derivados de gadolinio. Aunque infrecuentes, se han descrito reacciones mediadas por IgE a estos medios de contraste (AU)

Antigen specific quantification of sulfidoleukotrienes in patients allergic to Betalactam antibiotics.

BACKGROUND: After in vitro allergen-specific stimulation, basophils become activated and release sulfidoleukotrienes LTC4, LTD4 and LTE4. This can be detected by means of the CAST assay. We assessed the positivity criteria and the reliability of antigen-specific sulfidoleukotriene production (CAST) in the in vitro diagnosis of betalactam (BL) allergic patients. MATERIAL AND METHODS: We studied a sample of 67 patients (age 48.94 +/- 15.76 years) who had presented with anaphylaxis or urticaria-angioedema within the first 60 minutes after administration of Amoxicillin (54/67), Penicillin G (7/67), Cefuroxime (5/67) or Cefazoline (1/67). All of them had a positive skin test to at least one of the antigenic determinants of Penicillin. As control group 30 adults with negative skin tests who tolerated BL were included. All of them underwent skin tests, oral provocation tests, specific IgE (CAP-FEIA, Pharmacia) and CAST. RESULTS: Positivity criteria were established by means of ROC curves: a sLT release induced by Betalactams of at least 100 pg/ml and greater than or equal to 3 times the basal value. The overall sensitivity of CAST is 47.7% and specificity 83.3%. Sensitivity of specific IgE is 37.8% and specificity 83.3%. CONCLUSIONS: We have established validated positivity criteria for the CAST technique in patients allergic to Betalactams. This technique is a useful in vitro diagnostic method in patients with IgE-mediated allergy to Betalactam antibiotics.

Flow cytometric basophil activation test by detection of CD63 expression in patients with immediate-type reactions to betalactam antibiotics.

BACKGROUND: In this study, we used flow cytometry to determine the percentage of activated basophils that expressed the CD63 marker after in vitro stimulation by different betalactam antibiotics. The diagnostic reliability of the technique was assessed, as well as its correlation with specific IgE. METHODS: Fifty-eight patients with clinical allergy to betalactam antibiotics and presenting positive skin tests to at least one of the allergens (minor determinant mixture (MDM), benzylpenicilloyl-polylysine (PPL), penicillin, ampicillin, amoxicillin, cephalosporins) were tested. Thirty subjects non-allergic to betalactams were also studied as controls. The flow assay stimulation test (FAST) uses flow cytometry to determine the percentage of basophils that express CD63 as an activation marker after in vitro stimulation with allergen. Double labelling with monoclonal antibodies anti-CD63-PE and anti-IgE FITC was used. RESULTS: The allergic patients show a statistically greater number of activated basophils than the control subjects, after the incubation of cells with all the betalactams at various concentrations. The sensitivity of the technique is 50%, the specificity 93.3%, the likelihood ratio for a positive value 7.46 and the likelihood ratio for a negative value 0.54. In spite of having a greater sensitivity (37.9%) and specificity (86.7%) than CAP, differences between sensitivity and specificities of both techniques (CAP and FAST) do not reach statistical significance. CONCLUSION: The basophil activation test is a particularly useful technique in the diagnosis of patients with IgE-mediated allergy to betalactams and allows the identification of 50% of patients. Used in conjunction with CAP, it allows the identification of 65.5% of such patients.

Allergic vulvovaginitis in infancy: study of a case.

BACKGROUND: the role of dust mites (Dermatophagoides pt.) in the pathogenesis of allergic vulvovaginitis is still controversial. Association between this mite and atopic dermatitis, conjunctivitis, rhinitis or asthma is already known. Some authors study the possible relationship between some vulvovaginitis and local hypersensitivity. The aim of this study was to corroborate the allergic aetiology due to the mite Dermatophagoides pt. in a girl with vulvovaginitis and perennial rhinitis. METHODS AND RESULTS: we studied a nine year-old patient with symptoms of perennial rhinitis and unspecific vulvovaginitis of torpid evolution. In vivo and in vitro allergologic tests were performed as well as complete analytic tests including immunoglobulins, urine tests, nasal culture, exudative vaginal culture, and parasitic test. Skin test was positive for Dermatophagoides pt. as well as specific IgE (99.5 kU/L). Total IgE was elevated for her age (492 kU/L). In the rest of the complementary tests, no values out of normality or pathological findings were obtained. CONCLUSIONS: considering these results, it was suspected that the nasal symptoms and the vulvovaginitis presented by the patient are of allergic aetiology by hypersensitivity to the mite Dermatophagoides pt. The study did not prove relation with bacteria, parasites, Candida albicans or any inhalant allergens other than mites. After three months of treatment with oral antihistamines and topical chromones, as well as environmental avoiding measures, the symptoms totally yielded.

Allergic vulvovaginitis in infancy: study of a case

Background: the role of dust mites (Dermatophagoides pt.) in the pathogenesis of allergic vulvovaginitis is still controversial. Association between this mite and atopic dermatitis, conjunctivitis, rhinitis or asthma is already known. Some authors study the possible relationship between some vulvovaginitis and local hypersensitivity. The aim of this study was to corroborate the allergic aetiology due to the mite Dermatophagoides pt. in a girl with vulvovaginitis and perennial rhinitis. Methods and results: we studied a nine year-old patient with symptoms of perennial rhinitis and unspecific vulvovaginitis of torpid evolution. In vivo and in vitro allergologic tests were performed as well as complete analytic tests including immunoglobulins, urine tests, nasal culture, exudative vaginal culture, and parasitic test. Skin test was positive for Dermatophagoides pt. as well as specific IgE (99.5 kU/L). Total IgE was elevated for her age (492 kU/L). In the rest of the complementary tests, no values out of normality or pathological findings were obtained. Conclusions: considering these results, it was suspected that the nasal symptoms and the vulvovaginitis presented by the patient are of allergic aetiology by hypersensitivity to the mite Dermatophagoides pt. The study did not prove relation with bacteria, parasites, Candida albicans or any inhalant allergens other than mites. After three months of treatment with oral antihistamines and topical chromones, as well as environmental avoiding measures, the symptoms totally yielded (AU)

Objetivo: el papel del ácaro del polvo de casa ( Dermatophagoides pt.) en la patogenia de la vulvovaginitis alérgica, es un hecho que continúa siendo controvertido. Es ya conocida la asociación entre el ácaro con la dermatitis atópica, la conjuntivitis, la rinitis o el asma bronquial.Algunos autores se preguntan por la posible relación de determinadas vulvovaginitis con la hipersensibilidad local.El objeto de este estudio fue corroborar la etiología alérgica debida al ácaro Dermatophagoides pt. en una niña que presentaba vulvovaginitis y rinitis perennes.Métodos y resultados: estudiamos a una paciente de 9 años, con síntomas de rinitis perenne y vulvovaginitis inespecífica, de evolución tórpida.Se realizaron las pruebas alergológicas tanto in vivo como in vitro y un estudio analítico que incluyó inmunoglobulinas, anormales y sedimento de orina, cultivos de secreción nasal y exudado vaginal y coproparasitario.La prueba cutánea fue positiva frente al Dermatophagoides pt. así como el valor de la IgE específica frente al mismo (99,5 kU/L). El valor de la IgE total se encontraba elevado para su edad (492 kU/L). En el resto de exploraciones complementarias no se encontraron valores anormales ni hallazgos patológicos.Conclusión: a la vista de los resultados obtenidos, se sospechó que los síntomas nasales y vulvovaginales presentados por la paciente eran de etiología alérgica por hipersensibilidad al ácaro Dermatophagoides pt. El estudio no demostró relación con bacterias, parásitos, o con Candida albicans ni con otros neumoalergenos distintos a los ácaros.Tras 3 meses de tratamiento con antihistamínicos vía oral y cromonas vía tópica, así como medidas de desalergenización ambiental los síntomas remitieron en su totalidad (AU)

Variations of serum eosinophil cationic protein and tryptase, measured in serum and saliva, during the course of immediate allergic reactions to foods.

BACKGROUND: Subjective complaints and reactions after placebo administration during food challenges (FC) may make their outcome difficult to interpret. We determined serum ECP and tryptase as tryptase in saliva during FC, looking for markers to support challenge outcomes. METHODS: Twelve patients with systemic reactions after food intake and nine presenting oral allergy syndrome (OAS) underwent skin tests; total and specific IgE determination; double-blind, placebo-controlled FC (DBPCFC); and open challenges. Blood samples were collected before and 1, 2, and 5 h after challenge and saliva before and 5, 30, and 60 min after challenge. ECP and tryptase were quantified by ImmunoCAP (Pharmacia-Upjohn, Sweden). Serum tryptase of > 10 microg/l was considered positive. RESULTS: After positive DBPCFC (n = 8), ECP rose significantly (P < 0.05) at 1-h - 16.03 (12.8) microg/l (mean [standard deviation]) - and 2-h intervals - 17.56 (10.7) microg/l - compared to basal level of 9 (6.4) microg/l. After negative DBPCFC (n = 6), ECP increased from basal 9.63 (3.9) microg/l to 24.84 (14.17) microg/l at the 2-h time point. There were nonsignificant differences in ECP between patients with positive and negative FC. Two patients with positive challenge showed a tryptase level of >10 microg/l and only one patient with OAS showed 5.6 microg/l of tryptase 5 min after FC. CONCLUSIONS: ECP and tryptase in serum and saliva were not useful markers for FC outcomes.

Schnitzler syndrome: a case study.

Schnitzler syndrome is a clinical entity of unknown etiopathogenesis and is an unusual cause of chronic urticaria. It is characterized by the presentation of a monoclonal band, especially IgM, as well as fever, asthenia and arthralgia. We present the case of a 48-year-old man with 5 years of recurrent urticarial lesions, slight itching, as well as lip, face and occasional pharyngeal edema. The patient had also suffered from fever and right hip and left knee arthralgia. The protein electrophoresis and the immunoelectrophoresis presented an IgG band and a slight lambda band, which is suggestive of a monoclonal gammopathy. The bone marrow examination showed a slight increase in the lymphoplasmatic cells. The marrow biopsy was negative. In order to rule out tumorous, infectious and rheumatic processes as well as collagen diseases, other complementary examinations were performed with negative results. The diagnosis of Schnitzler syndrome as a cause of chronic urticaria requires a thorough study in order to rule out other systemic processes provoking the same symptoms.