Síndrome de Lyell asociado a lamotrigina / Lyell's syndrome associated with lamotrigine

Introducción. La lamotrigina (LTG) es un nuevo antiepiléptico de uso habitual en monoterapia tanto en epilepsias parciales como en generalizadas, que presenta entre otros efectos adversos la aparición de erupciones cutáneas leves y, con menos frecuencia, graves como el síndrome de Stevens-Johnson y el síndrome de Lyell o necrólisis epidérmica tóxica, sobre todo en combinación con valproato (VPA). Caso clínico. Mujer de 44 años en tratamiento por epilepsia toxicoalcohólica con VPA. Presenta neutropenia, probablemente secundaria, por lo que se intentó cambiar a LTG, siguiendo una pauta ascendente de LTG y descendente de VPA. En la sexta semana de tratamiento desarrolló una erupción cutánea eritematosa que, tras exposición solar, una semana después, se agravó con fiebre y malestar general, presentando en cabeza, región torácica anterior y posterior, abdomen, extremidades superiores e inferiores lesiones eritematosas con áreas costrosas, áreas de despegamiento de epidermis con signo de Nikolsky positivo y afectación severa de mucosas, siendo diagnosticada de síndrome de Lyell. Las lesiones mejoraron lentamente con sueroterapia, antibioterapia, corticosteroides parenterales y tratamientos tópicos. Conclusiones. Hay una probabilidad de erupción cutánea grave asociada a LTG que se debe tener en cuenta, se aconseja por lo tanto a los pacientes la suspensión de la medicación ante la mínima erupción cutánea (AU)

Eosinophilic gastritis due to Anisakis: a case report.

BACKGROUND: the parasite Anisakis simplex is a helminth included in the nematode class. When man eats raw or rare fish and cephalopods infested by Anisakis larvae, he can acquire the parasitic disease (anisakidosis). The parasite can also originate manifestations of immediate IgE mediated hypersensitivity in patients with sensitisation to it. METHODS AND RESULTS: we present the case of a 14 year old boy diagnosed of eosinophilic gastritis after endoscopic examination and biopsy associated to recurrent abdominal pain. After allergologic study, a type I hypersensitivity mechanism against Anisakis simplex is confirmed by means of prick test, antigen specific IgE determination and antigen specific histamine release test. Sensitisation against fish proteins is ruled out as well as parasitic infestation. CONCLUSIONS: in this case report we demonstrate a type I hypersensitivity mechanism against Anisakis simplex in a patient diagnosed of eosinophilic gastritis. This can be suspected in cases of gastritis or non filiated enteritis with a torpid evolution following the conventional treatment and especially if the onset of the symptoms is related with the intake of fish. The therapeutic success was reached when fish and shellfish were taken out of the diet. After two years without seafood ingestion our patient is asymptomatic and the allergologic study has been normalised.

Adult celiac disease and hypertransaminasemia.

OBJECTIVE: to determine the incidence of hypertransaminasemia in adult patients with celiac disease with or without relevant chronic liver disease, and to evaluate the response after a gluten-free diet. PATIENTS AND METHODS: retrospective study of 20 cases of adult celiac disease (> 14 years old at diagnosis). Patients were included in the study if they fulfilled the revised EPSGAN criteria. If laboratory tests of liver function revealed alterations, hepatitis B and C viral serology, thyroid hormones, and use of alcohol and drugs were investigated, and liver ultrasound scans were done. Liver biopsy and endoscopic retrograde cholangiopancreatography were done only in patients for whom these studies were considered necessary. RESULTS: ten patients had hypertransaminasemia (50%), ascribed to benzodiazepine use in 1 patient, chronic HCV hepatitis in 1, and celiac disease in 8. In all of these last patients except 1 (benzodiazepine use), laboratory values returned to normal after 4-10 months on a gluten-free diet. CONCLUSIONS: celiac disease was frequently associated with hypertransaminasemia. In most patients transaminase levels returned to normal within 1 year after dietary gluten intake was restricted. If alterations in laboratory values persist, other causes that may be related (e.g., autoimmunity or tumors) or unrelated to celiac disease (e.g., virus) must be ruled out.

Actualización en el tratamiento de la pediculosis, sarna y leishmaniasis / Treatment review in pediculosis scabies and leishmaniasis

Realizamos una revisión de los principales agentes utilizados en el tratamiento de la pediculosis, sarna y leishmaniasis.Actualmente constituyen el tratamiento de elección tanto para la pediculosis como para la sarna las piretrinas y sus derivados sintéticos (permetrina tópica) y además para la escabiosis la ivermectina oral (200 µg/kg). Revisamos los principales trabajos que demuestran su eficacia, superioridad y seguridad. Finalmente, hacemos una revisión del tratamiento de las leishmaniasis. El antimonio pentavalente continúa siendo el fármaco de elección. Otros productos empleados son: pentamidina, sulfato de paramomicina, alopurinol, ketoconazol e itraconazol y más recientemente anfotericina liposomal (AU)

Enfermedad celíaca del adulto e hipertransaminasemia / Adult celiac disease and hypertransaminasemia

OBJETIVO: determinar la incidencia de hipertransaminasemia con hepatopatía crónica relevante o no en la celiaquía del adulto y la respuesta a la restricción del gluten. PACIENTES Y MÉTODO: estudio retrospectivo de 20 casos de celiaquía del adulto (> 14 años al diagnóstico). Incluyéndose en el estudio los casos que cumplen los criterios revisados de la ESPGAN. Se realizó analítica hepática y en caso de alteración; serología Vírica B y C, -hormonas tiro¡deas, exclusión de tóxicos (alcohol y fármacos) y ecografía hepática a todos los pacientes. Biopsia hepática y colangiografía retrógrada endoscópica únicamente en los casos que se -cree indicado. RESULTADOS: se detectan diez casos (50 por ciento) de hipertransarninasemia; un caso por benzodiacepinas; otro por hepatitis crónica por el virus C de la hepatitis; ocho casos secundarios a la celiaquía, de los cuales en siete (77,7 por ciento, excluido el caso por benzodiacepinas) se normaliza la analítica en un plazo de 4-10 meses de dieta sin gluten. CONCLUSIONES: 1) La asociación celiaquía e hipertransaminasemia es un fenómeno muy frecuente. 2) En la mayoría de los casos hay normalización tras restricción del gluten de la dieta en un periodo menor de un año. 3) En el caso de persistencia de alteración analítica hay que descartar otras causas independientes de la celiaquía (virus...) o relacionadas con ella (autoinmunidad, tumor..) (AU)

Eosinophilic gastritis due to Anisakis: a case report

Background: the parasite Anisakis simplex is a helminth included in the nematode class. When man eats raw or rare fish and cephalopods infested by Anisakis larvae, he can acquire the parasitic disease (anisakidosis). The parasite can also originate manifestations of immediate IgE mediated hypersensitivity in patients with sensitisation to it. Methods and results: we present the case of a 14 year old boy diagnosed of eosinophilic gastritis after endoscopic examination and biopsy associated to recurrent abdominal pain. After allergologic study, a type I hypersensitivity mechanism against Anisakis simplex is confirmed by means of prick test, antigen specific IgE determination and antigen specific histamine release test. Sensitisation against fish proteins is ruled out as well as parasitic infestation. Conclusions: in this case report we demonstrate a type I hypersensitivity mechanism against Anisakis simplex in a patient diagnosed of eosinophilic gastritis. This can be suspected in cases of gastritis or non filiated enteritis with a torpid evolution following the conventional treatment and especially if the onset of the symptoms is related with the intake of fish. The therapeutic success was reached when fish and shellfish were taken out of the diet. After two years without seafood ingestion our patient is asymptomatic and the allergologic study has been normalised (AU)

Introducción: el parásito Anisakis simplex es un helminto incluido en la clase de los nematodos.Cuando una persona ingiere algún pescado o cefalópodo infestado por larvas de Anisakis puede sufrir anisakidosis. El parásito puede también originar manifestaciones de hipersensibilidad inmediata mediada por IgE en pacientes sensibilizados.Material y métodos: presentamos el caso clínico de un varón de 14 años diagnosticado de gastritis eosinofílica tras examen endoscópico y biopsia, asociado a dolor abdominal. Tras el estudio alergológico, se confirmó un mecanismo de hipersensibilidad tipo I frente Anisakis simplex por medio de prick test, determinación de IgE antígeno específica y test de liberación de histamina antígeno específica. Se descartó sensibilización frente a proteínas de pescado, así como parasitación intestinal. Después de dos años sin ingerir productos marinos nuestro paciente se encuentra asintomático y el estudio alergológico se ha normalizado.Conclusiones: en este caso clínico demostramos un mecanismo de hipersensibilidad tipo I frente a Anisakis simplex en un paciente diagnosticado de gastritis eosinofílica.Podemos sospechar sensibilización frente a este helminto en aquellos casos de gastritis o enteritis no filiadas que evolucionan tórpidamente con los tratamientos habituales, especialmente si la sintomatología se relaciona con la ingesta de pescado o marisco. El éxito terapéutico se consigue con la exclusión de pescado y marisco de la dieta. (AU)

[Lyell syndrome associated with lamotrigine]. / Síndrome de Lyell asociado a lamotrigina.

INTRODUCTION: Lamotrigine (LTG) is a new antiepileptic of habitual use in monotherapy as much in partial epileptic as in generalised, which presents among other adverse effects: slight rashes and less frequently severe rashes such as Stevens-Johnson syndrome and Lyell syndrome or toxic epidermal necrolysis, above all in combination with valproate (VPA). CLINICAL CASE: A 44-yr-old woman in toxico-alcoholic epileptic treatment with VPA, showed a neutropenia possibly of secondary type which it was intended to change to LTG, following an ascending dose of LTG joined to a descending dose of VPA. In the sixth treatment week, the patient developed an erythematous rash which after a week of solar exposure, presented temperature, general discomfort, and in the head, on the front and back part of the thoracic and upper and lower limbs, erythematous lesions with scabbed areas, loosening epidermis areas with a positive Nikolsky sign and severe mucous membrane involvement, being diagnostic of Lyell syndrome. The lesions got slowly better with serum therapy, antibiotherapy, parenteral corticoids and topical treatments. CONCLUSIONS: There is a probability of severe rash associated with lamotrigine which has to be taken into account, and we advise patients to suppress the medication when they present a minimum rash.

Allergic contact blepharoconjunctivitis due to phenylephrine eye drops.

We present two cases of sensitization to phenylephrine hydrochloride with clinical manifestation of blepharoconjunctivitis in the course of an ophthalmologic examination. Patch testing with available commercial preparations containing phenylephrine hydrochloride was positive in both patients. The other eye drops tested during the ophthalmologic examination were negative for both cases.

Atopic dermatitis and food allergy.

In order to determine the importance of food sensitization in the etiopathogenesis of atopic dermatitis, we performed a study on 74 patients who fulfilled a previously suggested diagnosis criteria. Of these patients, 17.5% presented allergic rhinitis and 62.2% had associated bronchial asthma. We found that in 64.9% of the patients there was a food sensitization, with milk (36.5%), egg (35.1%) and fish (21.6%) being the most frequently involved. We also observed that 34% of the patients were sensitized to Dermatophagoides pteronyssinus and 24.3% to pollen. These sensitizations were confirmed by means of skin tests, specific IgE and antigen-specific histamine release test. The patients underwent a 3-year follow-up in order to find out the clinical evolution once the causal food was avoided and/or a symptomatic treatment was prescribed. The group of patients with no food sensitization was significantly different from the group with food sensitization: in the first group only 20% of the patients presented a very good clinical evolution (asymptomatic), while in the second group, in 71.4% of the patients the symptoms completely stopped. Nevertheless, in the first year follow-up, we found no significant differences between the two groups. In conclusion, a diet avoiding the causal food combined with a suitable symptomatic treatment, led to an important remission of the skin manifestations in children diagnosed with atopic dermatitis.

Latex hypersensitivity in only one uniovular twin: a case report.

We present the clinical case of uniovular twins with cerebral palsy, confirming the development of sensitization to latex in one of the twins, due to the fact that he underwent surgery more times (nine) than his brother (four) as well as his different clinical evolution.

Importance of IgG4 determination in in vitro immunotherapy follow-up of inhalant allergens.

Choosing the right parameters to recommend immunotherapy in allergologic diagnosis is very important. Therefore, other parameters which are independent of the improvement of clinical manifestations and which indicate the evolution of asthma are very useful. Although a decrease in skin reactions was observed in 20% to 25% of patients in previous studies, since the in vitro techniques appeared, their evolution has been observed. Total and antigen-specific IgE evolution, as well as histamine release from basophils, in immunotherapy were followed as we had presented in previous studies. In this work, we studied 151 patients with asthma and rhinosinusitis, 70 of whom were sensitive to Lolium perenne and 81 to Dermatophagoides pteronyssinus. The parameters mentioned above were used, and the patients underwent immunotherapy at three different concentrations depending on the degree of sensitization. The standard concentration was used in the first group; those patients with very high values in radioallergosorbent test (RAST) and histamine release test (HRT) were given the concentration 1:2; and lastly, the largest group of patients, who presented the highest sensitization both in vivo and in vitro, were given the concentration 1:10. As a complement to the mentioned in vitro techniques, the antigen-specific IgG4 determination (blocking antibody) was also evaluated. As we observed in previous studies, skin test, total IgE, antigen-specific IgE and HRTs showed no significant modifications in any of the three groups, in spite of the very positive clinical evolution over the 6 years. Regarding IgG4 follow-up in pollinic patients, a very significant increase was observed, reaching its highest value after 6 years, at standard concentration and with an increase of 49.4%. In conclusion, we think that antigen-specific IgG4 is the only easily available and suitable parameter existing for immunotherapy follow-up.

Sensitization to Alternaria and Cladosporium in asthmatic patients and its in vitro diagnostic confirmation.

In order to determine the prevalence of airborne mould sensitization and the reliability of the in vitro diagnostic techniques in daily practice (antigen-specific IgE and histamine release test), we performed a 3-year study in 2,200 patients diagnosed with rhinosinusitis and/or bronchial asthma. We found mould sensitization in 101 patients, 20% of whom presented monosensitization against airborne moulds, and the rest associated other sensitizations as follows: 53.7% against Dermatophagoides pteronyssinus, 45% against grass pollen and 30% against Olea europea. The most frequently involved moulds in our patients were Alternaria and Cladosporium. Seventy-six percent of the patients presented sensitization against Alternaria, 56% of whom were monosensitized, 26% presented cosensitization to Cladosporium and the remainder were sensitive to more than two moulds. Regarding Cladosporium, the percentage of patients was similar (66%), although only 23% were monosensitized and 46% presented an associated sensitization against Alternaria. We also observed a correlation between skin tests and both in vitro diagnostic techniques, with a relative sensitivity of the specific IgE determination compared to the skin test of 98% against Alternaria and 90.4% against Cladosporium, whereas the relative sensitivity of the histamine release test was 97.4% for Alternaria and 85% for Cladosporium. In conclusion, we think that in order to confirm the etiopathogenesis of the airborne moulds and before an immunotherapy treatment is indicated, the positive skin reactions should be confirmed by means of reliable laboratory diagnostic techniques, such as antigen-specific IgE determination and histamine release test.

Cross-reactivity of Olea europaea with other Oleaceae species in allergic rhinitis and bronchial asthma.

Cross-reactivity between pollen extracts of four species of Oleaceae was studied: olive (Olea europaea), ash (Fraxinus excelsior), privet (Ligustrum vulgare), and lilac (Syringa vulgaris). Thus, 51 patients and 13 atopic controls were studied, by means of intracutaneous skin tests, histamine-release tests against the four extracts, and specific IgE to O. europaea. The proteic content of the four extracts was assessed by SDS-PAGE and immunoblotting, and similarity of all the extracts studied was observed after electrophoresis and immunodetection. Six common bands were found to be responsible for the cross-reactivity, with apparent molecular weights of 49.6, 40, 36.7, 19.7, 16.7, and 14 kDa, respectively. The cross-reactivity was also corroborated by immunoblotting inhibition and FEIA inhibition. The patients had a similar response to the four allergenic extracts used, although the response to Olea was greatest. When the patients were compared by their geographic origin (northern or southern Spain, according to the distribution of areas of olive pollen influence), there were no significant differences between the two groups in skin reactivity, but a higher histamine release was observed for the four extracts in the southern group, although it was significant only for Fraxinus and Ligustrum. This work corroborated the practicality of the diagnostic methods used and the cross-reactivity between the four species studied, as demonstrated by the different methods used. Therefore, we suggest that only O. europaea extract be used in diagnosis and immunotherapy in Oleaceae pollen allergy.

Potentiation of histamine release against inhalant allergens (Dermatophagoides pteronyssinus) with bacterial antigens in bronchial asthma.

In the etiopathogenesis of bronchial asthma, the important role of bacterial infection is more evident every day, favoring inflammation and obstruction, that is, triggering an asthmatic response. We gathered 36 patients diagnosed of bronchial asthma with sensitization to Dermatophagoides pteronyssinus and 32 healthy subjects. Histamine release tests against Staphylococcus aureus extract alone or together with D. pteronyssinus were performed, and the results were contrasted with or without the presence of S. aureus in the nasal secretion culture. We found histamine release against S. aureus higher than 10% only at the highest concentration (200 micrograms/ml) and significantly higher in those patients with positive nasal secretion culture. Regarding histamine release against D. pteronyssinus in the presence of S. aureus, we found a release by coincubation significantly higher than the one obtained from the addition of release against S. aureus and release against D. pteronyssinus, both in patients with negative and with positive nasal culture, at concentrations of 20 and 2 micrograms/ml. In conclusion, we observed a potentiation of histamine release against D. pteronyssinus with S. aureus extract in patients with bronchial asthma. These findings support the important role of the bacterial infection in the etiopathogenesis of bronchial asthma and the importance of a treatment against this infection.

Abuse of therapy with corticosteroids in the asthmatic patient and the deficient control of suprarenal function. Indication of therapy with ACTH.

The use of corticosteroids, either oral, parenteral or as aerosol, means a great step forward in bronchial asthma treatment. Nevertheless, given the abuse of their administration, we find more and more frequently, cases of corticodependent bronchial asthma, due to a deficient control in the clinical evolution. For this reason, we performed a study with 39 patients diagnosed with corticodependent intrinsic bronchial asthma. Basal cortisol determination was performed in all, and all of them followed posttreatment with ACTH, antibiotics and mucolytics, as well as follow up of respiratory function parameters and clinical evolution. We found a mean increase in cortisol levels of 488% (basal: 2.49 +/- 0.33 micrograms/dl; posttreatment: 14.59 +/- 2.9 micrograms/dl). Regarding the respiratory function tests, FEV1 improved from 59.38 +/- 4.23% to 68.52% +/- 4.28% (15.4% increase); MEF50 went from 28.62 +/- 3.47% to 35.9 +/- 3.81% (25.4% increase) and MEF25-75 improved from 28.89 +/- 3.47% to 37.05 +/- 3.93% (28.2% increase). Clinical symptomatology and medication improved in general, going from an initial punctuation of 8.5 to a posttreatment score of 7.47. In general, 50% of the patients studied improved from the clinical point of view, only 47.2% had a discrete improvement, and only one patient got worse. Side effects with ACTH treatment appeared in 28.2% of the cases, mainly peripheral edemas, especially in the lower extremities. In conclusion, with patients undergoing lengthy corticosteroid therapy, control of their suprarenal function is absolutely necessary. If a glandular insufficiency appears with low levels of plasmatic cortisol, we advise treatment with ACTH in association with antibiotics.

Serum ECP levels in asthmatic patients: comparison with other follow-up parameters.

In recent years, eosinophil cationic protein (ECP) has been considered as a useful eosinophilic activation marker in asthmatic patients. In this study, serum ECP levels in different stages of bronchial asthma were evaluated. We studied 123 patients suffering from asthma, which was classified as mild (n = 49), moderate (n = 49), severe asthma (n = 25), and also 31 healthy controls. Serum ECP levels were 13.22 +/- 1.11 ng/mL (mean +/- s.e.m.) in controls, and 30.15 +/- 2.38 ng/mL in asthmatic patients. By subgroups, ECP levels were 24.23 +/- 3.37 ng/mL, 31.69 +/- 4.21 ng/mL and 37.61 +/- 4.52 ng/mL, in mild, moderate and severe asthmatic patients, respectively, being the differences among the three groups statistically significant (P < 0.01-P < 0.001). Peripheral blood eosinophil numbers were 157 +/- 20 eos/mm3 in controls, and 334 +/- 35 eos/mm3, 510 +/- 87 eos/mm3, and 658 +/- 72 eos/mm3, in mild, moderate, and severe asthmatic patients, respectively, with significant differences among all groups (P < 0.05-P < 0.001). The serum ECP levels as well as the eosinophil numbers were higher in symptomatic patients than in the asymptomatic ones (P < 0.01). Moderate negative correlations, although highly significant (P < or = 0.001), were found between serum ECP levels and forced vital capacity (FVC) (rs = -0.27), FEV1, MEF25-75 (rs = -031), and MEF50 (rs = -0.32). There was also a good positive correlation between ECP levels and peripheral blood eosinophil numbers (rs = 0.67, P < 0.001).

Reliability of histamine release test in dust mite allergy: influence of the degree of sensitization.

The histamine release test has been proven to be a very useful method for in vitro diagnosis of IgE-mediated allergy to inhalant and food allergens, as well as for the immunotherapy follow-up of the allergic patient. The aim of the present study was to assess the influence of the degree of sensitization in allergic patients sensitive to Dermatophagoides pteronyssinus on their dose-response curves in histamine release tests. To achieve this aim, we studied 109 D. pteronyssinus allergic patients and 25 healthy control subjects. Intracutaneous skin test, D. pteronyssinus-specific and total IgE quantitations, and histamine release tests were carried out in all the patients. In the case of the histamine release test, five D. pteronyssinus extract concentrations were used (2822.5, 282.25, 28.22, 2.82 and 0.28 UBE/ml), and two patterns of histamine release in sensitive patients were found: one with maximal histamine release at the highest antigen concentration (group I) and the other with maximal release attained at lower concentrations (group II). A sensitization score was designed, after the results from specific IgE and intracutaneous skin tests. There were significant differences (p < 0.05) in antigen-specific and total IgE levels, and in papule diameters and sensitization scores, between the control group and groups I and II. Both groups showed significantly higher (p < 0.05) histamine releases than the control group in response to anti-IgE antibodies. When stimulating the cells with anti-IgE antibodies, histamine release in group II was higher than in group I, although this difference was not significant. Finally, the best correlation between sensitization score and antigen-specific histamine release was found at the 2.82 UBE/ml concentration (r = 0.84, p < 0.001).