Sulfasalazine-induced extrinsic allergic alveolitis in a patient with psoriatic arthritis.

We report the first case of a well defined extrinsic allergic alveolitis as a complication of sulfasalazine therapy in a patient treated for psoriatic arthritis. CT of the chest showed small nodular densities over both lungs, BAL demonstrated a highly active lymphocytic alveolitis and transbronchial biopsies revealed lymphoplasmocytic interstitial infiltration. Sulfasalazine as causative agent was proven by an inadvertent rechallenge three years later and a positive lymphocyte transformation test. sulfasalazine; psoriatic arthritis; extrinsic allergic alveolitis

IgG antibodies typical for extrinsic allergic alveolitis--an inter-laboratory quality assessment.

BACKGROUND: Determination of specific IgG antibodies is important for the diagnosis of extrinsic allergic alveolitis (EAA). Various evaluations have however shown, that current methodology lacks sufficient standardization in that the employment of different sources of extracts and techniques makes a comparison of data from one laboratory to another almost impossible. OBJECTIVE: The aim of this study is to establish an external quality control system and to analyse, what the explanations for the different outcomes from various laboratories might be. METHODS: In the past 4 years 5 sera from patients suffering from EAA or healthy controls were sent every 6 months to 11 different allergy laboratories in Austria. The determination of specific IgG antibodies against antigens that are typical for this disease were requested. Results were gained with the method routinely used in the respective laboratory, and then sent back to the reference center for statistical evaluation. Precipitating techniques were used in 8 laboratories during the first mailings, but were gradually exchanged by automated ELISA systems being employed in 8 laboratories in the last mailing. RESULTS: 1127 values were determined in 105 expectedly positive sera and 1003 in 94 negative samples. Of the 562 values obtained with precipitation techniques in positive sera, only 52.0% were reported to be positive, and the results varied considerably among laboratories and antigens. In contrast, 93.3% were positive with commercially available ELISA techniques, with 92.3% for the EnzyDex System and even 95.5% for the UniCAP System. Regarding the specificity however, 93.0% of the expected negative results were correct negative using precipitation methods, whereas merely 75.2% were negative with the EnzyDex System and only 22.5% using the UniCAP System. Moreover 35.8% of the results using this latter method were false-positive. CONCLUSIONS: The traditional precipitation techniques proved not only technically difficult to perform, but also unreliable, difficult to reproduce, insensitive and impractical in daily laboratory work. They suffer from that many draw backs, that their use in daily routine cannot be recommended any more. Automated ELISA systems seem to fulfill the criteria for a routine technique concerning handling, automation, and quality criteria like sensitivity quite well, but not for specificity. Both techniques urgently need external standardization in order to make the results comparable among the different systems and methods; the danger of potentially false-positive results, pretending sensitizations that might be clinically irrelevant in several cases, is high.

Pet-fish food lung- a new form of extrinsic allergic alveolitis.

We report a female patient, who developed extrinsic allergic alveolitis due to pet-fish food inhalation. Some ingredients of pet-fish food are known triggers of type I allergy. To our knowledge, this is the first case in which pet-fish food is reported as causative agent inducing type III allergy.

Anaphylactic shock following peritumoral injection of patent blue in sentinel lymph node biopsy procedure.

Recently, sentinel lymph node dissection has been established for early staging of malignant melanoma. We describe an anaphylactic reaction due to patent blue injection in sentinel lymph node procedure, which was proven by positive results in intradermal testing with patent blue 1:100.

Pinta in Austria (or Cuba?): import of an extinct disease?

BACKGROUND: Pinta, 1 of the 3 nonvenereal treponematoses, is supposed to be extinct in most areas in South and Central America, where it was once endemic. Only scattered foci may still remain in remote areas in the Brazilian rain forest, and the last case from Cuba was reported in 1975. OBSERVATION: A native Austrian woman, who had lived for 7 years in Cuba and was married to a Cuban native, developed a singular psoriasiform plaque on her trunk and several brownish papulosquamous lesions on her palms and soles during a visit to her home in Austria. Positive serological findings for active syphilis and the detection of spirochetes in the trunk lesion indicated early secondary syphilis, but an extensive case history and the clinical appearance fulfilled all criteria for pinta. CONCLUSION: The acquisition of a distinct clinical entity, pinta, in a country where it was formerly endemic but now is believed to be extinct raises the question of whether the disease is in fact extinct or whether syphilis and pinta are so similar that no definite distinction is possible in certain cases.

[Recurrent losses of consciousness in anaphylactic reactions]. / Rezidivierende Bewusstseinsverluste bei anaphylaktischen Reaktionen.

HISTORY: Within one year a 36-year-old man had three episodes of loss of consciousness associated with a fall in blood pressure. No cause was established despite repeated hospital admissions. But an anaphylactic reaction was suspected as the cause after yet another syncope when the administration of antihistamines and steroids had quickly improved the patient's state. In retrospect it became clear that the loss of consciousness had occurred after the eating of bananas. INVESTIGATIONS: Total IgE level was 695 kU/l and there was marked sensitization to bananas (IgE radio-allergosorbent test [RAST] class 2) and latex (IgE RAST class 2), confirmed by marked immediate-type reactions to these substances in the prick test. PREVENTION: Dietary advice was given and the significance of the latex sensitization explained. The patient was given an allergy pass and drugs for emergency use. CONCLUSION: Anaphylactic reaction should be included in the differential diagnosis of loss of consciousness of uncertain cause. The prognosis of such a reaction is excellent only if treated at once. Both diagnosis and treatment are relatively simple.

Clinical and histological features of poor prognosis in cutaneous metastatic melanomas.

Patients with melanoma metastatic to the skin show variable prognosis. Though some may survive for quite a long time, some die of disseminated disease within 1 year of removal of cutaneous metastases. The aim of this study was to find out whether there are any histological criteria indicating particular poor outcome. Clinical and histological features of 344 melanoma lesions metastatic to the skin were assessed and their prognostic relevance was investigated. H&E stained histological slides were scanned for the presence of morphological criteria expressing certain tumor cell-stroma interactions: capsule formation (CAPSULE), formation of intratumoral septa (NEWSEPTA), simple invasion between collagen of reticular dermis (DERM-SIMPLE), or subcutis (SCSIMPLE), preservation of preexistent collagen (PRECOLL) or fatty tissue (PREFAT) and, finally, histological site of metastasis. Additionally, anatomical location of the metastases, time between removal of primary tumor and metastases age and sex of patients were recorded. The metastases were divided into two groups: lesions of patients who died within 1 year after resection (n = 59) and lesions from patients with a longer survival (n = 285). Metastases which were associated with death within one year were significantly more often found in male patients (54.2% versus 34.7%), in younger patients (mean age 51.1 +/- 14.1 years versus 58.8 +/- 15.3 years), had developed earlier after the primary tumor (mean time of 21.7 +/- 19.9 months versus 43.3 +/- 27.4 months) and were more often found at distant sites than in localregional sites (45.7% versus 30.5%), and were more often involved in the subcutis (74.5% versus 56.1%). From a histological point of view, DERMSIMPLE (80% versus 46%; p < 0.001) and PRECOLL (82.8% versus 57.6; p < 0.01) were more frequent in metastases of poor outcome. The same was true for SCSIMPLE (50% versus 25.6%; p < 0.01) and PREFAT (68.1% versus 46.8%; p < 0.05) in lesion with subcutaneous growth, whereas CAPSULE (54.5% versus 75%) was less frequently seen. In conclusion, melanoma deposits metastatic to the skin with particular poor outcome differ clinically and histologically from other cutaneous melanoma metastases. This should be taken into account in the design of therapeutic clinical trials.

Quantitative assessment of fat cells in subcutaneous metastatic melanoma. Correlation with outcome.

The metastatic behavior of tumor cells largely depends on tumor-stroma interactions. In the present study, a particular morphological feature of tumor-stroma interaction was evaluated; hematoxylin-eosin-stained slides of 81 lesions of melanoma metastatic to the skin involving the subcutis were examined by automated image analysis for the presence of preexistent fat cells in the tumor. The area occupied by fat cells, expressed in micrometers squared per slide, was of prognostic significance; lesions with a fat cell area of < 41,000 microns 2 showed a 2-year survival rate of 42%, versus 10% in lesions with a fat cell area of > 41,000 microns 2 (log-rank test, z = 3.24; p < or = 0.01). The adverse effect of fat cell area on prognosis still was seen when age, sex, and site of metastatic spread were concomitantly taken into account in a Cox proportional-hazard model. These data indicate that melanoma deposits involving the subcutis with preservation of preexistent subcutaneous fat cells have high metastatic potential and a high risk for rapid internal dissemination.