Allergy to latex and repeated vascular access thrombosis in haemodialysis

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Cyclical hypereosinophilia with skin manifestations and a clonal T cell population.

Hypereosinophilia is a common biological finding in clinical practice, in some cases without an identifiable cause. We describe the case of a 59-year-old woman with recurrent attacks of facial angioedema, fever, pruritic cutaneous nodules, and eosinophilia that reached up to 12.7 x 10(9) cells/L during outbreaks. She had experienced 2 episodes every month for the last 12 years, and the episodes resolved with systemic corticosteroids. Other causes of eosinophilia were ruled out. The patient showed an aberrant T cell population with a CD3-CD4+ TCR- phenotype that accounted for up to 22% of circulating lymphocytes. Analysis of the T-cell receptor (TCR) gene showed evidence of clonal rearrangement. During the episodes, this cell population produced high levels of interleukin-5, which returned to normal levels between the outbreaks. However the aberrant T cell population remained unaffected after the treatment. We suggest that lymphocyte immunophenotyping analysis should be included in the diagnostic workup of patients with hypereosinophilic syndrome, including the variant type of episodic angioedema and eosinophilia (Gleich syndrome).

Cross-reactivity among amide-type local anesthetics in a case of allergy to mepivacaine.

Among the various adverse reactions to local anesthetics, IgE-mediated reactions, particularly to the more commonly used amide group, are extremely rare. We report the case of a 39-year-old man who suffered itching and generalized urticaria with facial angioedema 15 minutes after administration of mepivacaine. Skin tests revealed a strong positive reaction to mepivacaine, lidocaine, and ropivacaine, but negative reactions to bupivacaine and levobupivacaine. Furthermore, double-blind placebo-controlled subcutaneous challenge with bupivacaine and levobupivacaine was well tolerated. We conclude that an extensive allergologic study must be carried out in rare cases of true allergic reaction to amide-type local anesthetics in order to rule out cross reactivity.

Idiopatic angioedema treated with dapsone.

The most commonly identified causes of angioedema are medications, allergens and physical agents, but most cases of angioedema are idiopathic. Treatment depends on identification of the causative agent and, especially when the mechanism is not identified, on the clinicians knowledge and experience with innovative therapeutic regimens. CASE REPORT: A 48-year-old man presented with a 3-month history of recurrent severe episodes of angioedema affecting the lips, tongue and throat. A fiberoptic examination revealed laryngeal edema during some episodes. He did not report abdominal pain, nausea or vomiting. No precipitating factors were identified. The patient was not receiving angiotensin-converting enzyme inhibitors. For the previous 4 years, the patient had been receiving levothyroxine for autoimmune thyroiditis. There was no history of facial palsy or hereditary angioedema. ALLERGY STUDY: Skin prick test with aeroallergens, food, latex, Anisakis and patch test to a standard series (true test) were negative. Laboratory investigations revealed normal complete blood count (CBC), erythrocyte sedimentation rate, urinalysis, blood biochemistry, serum protein electrophoresis and serum immunoglobulins. IgE concentration was 30 UI/ml. Antiperoxidase antibodies were positive (535 UI/ml). Antinuclear antibodies serum immune complexes and rheumatoid factor were negative. Complement study during acute and asymptomatic periods revealed normal values of C1 esterase inhibitor, C1q, C3, C4, functional activity of C1 inhibitor and CH50. No pathologic findings were observed in a lip biopsy. The patient was treated with sedating and nonsedating H1 antihistamines and corticosteroids (prednisone 30 mg/day for 3 months) with no clinical improvement and treatment with 50 mg of dapsone daily was started. Glucose 6 phosphate dehydrogenase deficiency had previously been ruled out. The patient improved and antihistamine and corticoid treatment was withdrawn 1 month after starting the dapsone regimen. No episodes of angioedema appeared during the subsequent year. No reductions in hematologic parameters or adverse events were detected. Dapsone may be an alternative drug in extreme cases of idiopathic angioedema in patients with poor response to conventional therapy.

Idiopatic angioedema treated with dapsone

The most commonly identified causes of angioedema are medications, allergens and physical agents, but most cases of angioedema are idiopathic. Treatment depends on identification of the causative agent and, especially when the mechanism is not identified, on the clinician’s knowledge and experience with innovative therapeutic regimens. Case report: A 48-year-old man presented with a 3-month history of recurrent severe episodes of angioedema affecting the lips, tongue and throat. A fiberoptic examination revealed laryngeal edema during some episodes. He did not report abdominal pain, nausea or vomiting. No precipitating factors were identified. The patient was not receiving angiotensin-converting enzyme inhibitors. For the previous 4 years, the patient had been receiving levothyroxine for autoimmune thyroiditis. There was no history of facial palsy or hereditary angioedema. Allergy study: Skin prick test with aeroallergens, food, latex, Anisakis and patch test to a standard series (true test) were negative. Laboratory investigations revealed normal complete blood count (CBC), erythrocyte sedimentation rate, urinalysis, blood biochemistry, serum protein electrophoresis and serum immunoglobulins. IgE concentration was 30 UI/ml. Antiperoxidase antibodies were positive (535 UI/ml). Antinuclear antibodies serum immune complexes and rheumatoid factor were negative. Complement study during acute and asymptomatic periods revealed normal values of C1 esterase inhibitor, C1q, C3, C4, functional activity of C1 inhibitor and CH50. No pathologic findings were observed in a lip biopsy. The patient was treated with sedating and nonsedating H1 antihistamines and corticosteroids (prednisone 30 mg/day for 3 months) with no clinical improvement and treatment with 50 mg of dapsone daily was started. Glucose 6 phosphate dehydrogenase deficiency had previously been ruled out. The patient improved and antihistamine and corticoid treatment was withdrawn 1 month after starting the dapsone regimen. No episodes of angioedema appeared during the subsequent year. No reductions in hematologic parameters or adverse events were detected. Dapsone may be an alternative drug in extreme cases of idiopathic angioedema in patients with poor response to conventional therapy

Los elementos más frecuentemente implicados en la etiología del angioedema son fármacos, alergenos y agentes físicos, si bien la mayoría de los casos son de carácter idiopático. El tratamiento se basa en la identificación del agente causal y en la experiencia del clínico en el manejo de estos cuadros, siendo preciso en algunas ocasiones recurrir a regímenes terapéuticos novedosos. Caso clínico: Paciente varón de 48 años de edad, que 3 meses antes de acudir a nuestra consulta comienza con episodios de angioedema que afectan labios, lengua y región faringo-laríngea. La laringoscopia reveló edema laringeo durante las crisis. No presentaba síntomas digestivos acompañantes. No identificamos ningún desencadenante. No recibía inhibidores del enzima de conversión de la angiotensina (IECA). Los últimos 4 años seguía tratamiento con levotiroxina por tiroiditis autoinmune. No refería antecedentes de parálisis facial ni angioedema hereditario. Estudio alergológico: prick test con bateria de inhalantes, alimentos, latex, anisakis: negativo. Prueba del parche estándar (true test): negativo. No se detectaron alteraciones en hemograma, velocidad de sedimentación, bioquímica con perfil hepático, electroforesis sérica e inmunoglobulinas. IgE total 30 UI/ml. Anticuerpos antiperoxidasa: positivos (535 UI/ml). Inmunocomplejos séricos, ANA, factor reumatoide: negativos. Estudio de complemento normales (C3, C4, C1 inhibidor, actividad funcional de C1, C1 q, CH50) realizado en fase asintomática y durante las crisis: dentro de los valores normales. No se detectaron alteraciones patológicas en biopsia de labio. Se inicia tratamiento con antihistamínicos y corticoides (prednisona 30 mg/día) durante un periodo de 3 meses persistiendo los brotes de angioedema con la misma intensidad y frecuencia, por lo que decidimos iniciar tratamiento con dapsona 50 mg/día, previamente se descartó déficit de glucosa 6 fosfato deshidrogenasa. El paciente presentó mejoría clínica, pudiendo suspender el tratamiento con corticoides y antihistamínicos al mes de iniciar el régimen terapeútico con dapsona. En los 12 meses posteriores no presentó nuevos episodios de angioedema, tampoco detectamos efectos adversos tras dicho tratamiento, ni reducción en las 3 series hematológicas. La dapsona puede ser un fármaco alternativo en casos de angioedema idiopático que no se controlan adecuadamente con la terapia convencional

Successful desensitization to penicillin after diagnostic reassessment.

Clinical situations for which penicillin is indicated as the sole effective treatment are not infrequent, in these circumstances penicillin allergy complicates their medical management. No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women, it is not possible choosing an alternative non betalactam antibiotic. The management of the patient who has a history of penicillin allergy include skin testing to determine if penicillin-specific IgE antibodies exist, and desensitization if penicillin is the choice treatment. We report a case of successful desensitization to penicillin in a 30 year-old pregnant woman with latent syphilis and penicillin allergy, where the first penicillin study was not positive, but the repetition of diagnosis test (reassessment) with the same betalactam reagents than in the first study two weeks later the initial evaluation was positive, detecting allergic sensitization not detected at the previous examination.

Successful desensitization to penicillin after diagnostic reassessment

Clinical situations for which penicillin is indicated as the sole effective treatment are not infrequent, in these circumstances penicillin allergy complicates their medical management. No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women, it is not possible choosing an alternative non betalactam antibiotic. The management of the patient who has a history of penicillin allergy include skin testing to determine if penicillin-specific IgE antibodies exist, and desensitization if penicillin is the choice treatment. We report a case of successful desensitization to penicillin in a 30 year-old pregnant woman with latent syphilis and penicillin allergy, where the first penicillin study was not positive, but the repetition of diagnosis test (reassessment) with the same betalactam reagents than in the first study two weeks later the initial evaluation was positive, detecting allergic sensitization not detected at the previous examination (AU)

No son infrecuentes los cuadros clínicos en los que la penicilina está indicada como único tratamiento eficaz; en estas circunstancias, la alergia a la penicilina complica su tratamiento médico. No se dispone de alternativas más adecuadas que la penicilina con las que tratar la neurosífilis, la sífilis congénita o la sífilis en mujeres embarazadas, y no es posible elegir un antibiótico no betalactámico alternativo. El diagnóstico integral del paciente con antecedentes de alergia a la penicilina consiste en la realización de pruebas cutáneas para determinar si existen anticuerpos IgE específicos de la penicilina y desensibilización si este antibiótico es el tratamiento de elección. Describimos un caso en el que se logró una desensibilización satisfactoria a la penicilina en una mujer embarazada de 30 años con sífilis latente y alergia a la penicilina. El primer análisis de penicilina no fue positivo, pero la repetición de la prueba diagnóstica (reevaluación) con los mismos reactivos betalactámicos que en el primer estudio, 2 semanas después de la evaluación inicial, fue positiva, pues se detectó sensibilización alérgica no identificada en el examen anterior (AU)

Anaphylaxis to proton pump inhibitors.

Proton pump inhibitors (PPI) are widely used for the treatment of peptic ulcer, but cases of anaphylactic reactions have rarely been described. We present a patient who experienced an episode of urticaria 30 minutes after oral intake of an omeprazole capsule. Skin prick tests to omeprazole, pantoprazole and lansoprazole were positive. Challenge test with lansoprazole was carried out and within 45 minutes the patient developed urticaria, facial edema, vomiting, and hypotension. Oral challenge with other imidazole derivatives (ketoconazole, cimetidine, metronidazole) were carried out with good tolerance. Serum tryptase levels determined 3 hours after the adverse reaction to lansoprazole were elevated. Specific IgE to PPI were not detected by an enzyme-linked immunosorbent assay technique. The clinical findings, positive skin prick test to PPI and elevated serum tryptase levels suggest that an IgE-mediated mechanism was implicated in the reactions to both omeprazole and lansoprazole. Skin prick tests may be a useful tool for detecting patients sensitized to PPI. An experimental protocol was used to detect specific IgE antibodies against PPI, which may explain RAST negativity. The previous findings suggest that cross-reactivity between PPI exists, but not with other imidazoles.

Anaphylaxis to proton pump inhibitors

Proton pump inhibitors (PPI) are widely used for the treatment of peptic ulcer, but cases of anaphylactic reactions have rarely been described. We present a patient who experienced an episode of urticaria 30 minutes after oral intake of an omeprazole capsule. Skin prick tests to omeprazole, pantoprazole and lansoprazole were positive. Challenge test with lansoprazole was carried out and within 45 minutes the patient developed urticaria, facial edema, vomiting, and hypotension. Oral challenge with other imidazole derivatives (ketoconazole, cimetidine, metronidazole) were carried out with good tolerance. Serum tryptase levels determined 3 hours after the adverse reaction to lansoprazole were elevated. Specific IgE to PPI were not detected by an enzyme-linked immunosorbent assay technique. The clinical findings, positive skin prick test to PPI and elevated serum tryptase levels suggest that an IgE-mediated mechanism was implicated in the reactions to both omeprazole and lansoprazole. Skin prick tests may be a useful tool for detecting patients sensitized to PPI. An experimental protocol was used to detect specific IgE antibodies against PPI, which may explain RAST negativity. The previous findings suggest that cross-reactivity between PPI exists, but not with other imidazoles (AU)

Los inhibidores de la bomba de protones (IBP) se utilizan habitualmente para el tratamiento de la úlcera péptica, pero rara vez se han descrito casos de reacciones anafilácticas. Presentamos a una paciente que experimentó un episodio de urticaria 30 min después de la ingestión oral de una cápsula de omeprazol. Las pruebas cutáneas con omeprazol, pantoprazol y lansoprazol fueron positivas. Se realizó una prueba de provocación con lansoprazol y la paciente presentó urticaria, edema facial, vómitos e hipotensión en un plazo de 45 min. Se efectuó una provocación oral con otros derivados imidazólicos (ketoconazol, cimetidina, metronidazol), que fueron bien tolerados. Las concentraciones séricas de triptasa, obtenidas 3 h después de la reacción adversa al lansoprazol, presentaban valores elevados. No se detectó IgE específica frente IBP mediante una técnica de ELISA. Los datos clínicos, la positividad de la prueba cutánea con IBP y la elevación de las concentraciones séricas de triptasa indican que estaba implicado un mecanismo mediado por IgE a las reacciones al omeprazol y lansoprazol. Las pruebas de punción cutánea fueron un instrumento útil para detectar pacientes sensibilizados a los IBP. El hecho de que se utilizase un protocolo experimental para detectar anticuerpos IgE específicos contra la bomba de protones podría explicar la negatividad de RAST. Estos resultados indican que existe reactividad cruzada entre los IBP, pero no con otros imidazoles (AU)

[Study of drug allergies with special reference to skin manifestations]. / Contribución al estudio de la alergia a drogas, con especial referencia a sus manifestaciones cutáneas

One hundred and forty four patients, with dermal reactions to different drugs, were chosen from our clinic. The selection criteria was based on a detailed and careful anamnesis in order to be certain of the specific drug responsible for the reaction. We tried to establish a drug-specific reaction pattern for each of the drugs studied. Intradermal skin tests were performed with all drugs to be studied, except with pyrazolones and aspirin, for which patch tests were applied. The drug concentrations were established prior to the tests in order to avoid unwanted unspecific reactions. In every case, immediate and delayed reaction readings were carried out. A three crosses reaction (+++) was considered positive. The skin tests were positive in 44% of the cases, a value higher than those referred to by most authors. The delayed reactions to skin tests and the chloramphenicol-mediated delayed-type "dermatitis-like" manifestations are compared. It is noteworthy to mention that positive delayed reactions were observed more frequently with chloramphenicol than with any of the other studied drugs. The same applies for those patients with a positive history to chloramphenicol. The most common reaction pattern to penicillin and streptomycin in our series (20%) were urticaria and Quincke's edema. Penicillin, pyrazolones and streptomycin were the most common drugs responsible for urticarial patterns, being the pyrazolones related to fixed erythema in many cases. The age group 25-50 was the most frequently involved. No sex predominance was observed. The value of the classic skin tests is discussed, so are history recording and the in vitro tests.