J ALLERGY CLIN IMMUNOL JANUARY 2000
(LA) Use Following LA Skin Testing S E Weber Sunnybrook and Women’s College Health Sciences Centre, Toronto, Canada True allergic reactions to LAS are extremely rare. Many individuals labelied as “allergic” often experience vasovagal reactions, toxic reactions, side effects from epinephrine or psychomotor responses and are denied the use of LA agents. At the Drug Safety Clinic, patients presenting with a history of an “allergic” reaction to a LA undergo skin testing to a battery of LAS at various concentrations. If the skin tests are negative, a graded subcutaneous LA challenge is performed. Even though most patients complete testing without any adverse reaction, it is unknown whether patients feel confident enough in the testing results to subsequently receive LAS. 214 patients (mean age=43 yrs; FA4=180/34) completed LA testing between 1992-98. There were 5 positive reactions (2.3%): 2 immediate at the intradermal site, 2 delayed at the intradermal site, and 1 immediate following subcutaneous challenge. A telephone interview was conducted in 79 patients who completed testing. Patients were asked whether they had received a LA since the testing. If not, patients were asked whether they felt “comfortable” receiving a LA in the future. 17 patients (21.5%) stated they were not comfortable to receive a LA and 62 patients either had already received (N=41) or were comfortable to receive (N=21) a LA. Although test results were negative in one patient, the dentist continued to withhold LA. There was no significant difference between patients who would or would not receive a LA except for type of reaction. 42% of patients who would receive a LA reported an allergic-type or skin reaction during the initial exposure. No patient in the group who did not feel comfortable to receive LAS had developed an allergic-type or skin reaction (p
the second dose of AVA, the table below summarizes the frequencies (S) of systemic symptoms (FEV, FLU, SYS) as well as LLR for the Korea survey and the Reservist Unit for total and genderspecific groups (Fem=female).
Systemic M Metrich*,
Symptoms HG Oak+.
1 & 2 Engler*
*Walter Reed Army Medical Center. Washington. DC tSeou1, South Korea Anthrax vaccine for the protection of U.S. military service members from the potentially lethal consequences of inhalation anthrax utilizes an approved vaccine schedule of 6 SQ doses over 18 months (at 0,2.4 weeks; 6, 12, 18 months) with yearly boosters. METHODS: As part of the clinical screening program, AVA recipients completed, prior to the next dose, a questionnaire regarding adverse reactions to prior AVA doses. Soldiers were stationed in Korea or attached to a Walter Reed reserve unit (ResU). The questionnaires included details regarding fever (FEV), malaise or “flu-like” (FLU) illness. and other systemic symptoms (SYS) such as pruritis and fatigue, as well as large local reactions (LLR) exceeding I2 cm in diameter. RESULTS: There were no prolonged reactions resulting in chronic illness. The 1st dose of AVA in women was associated with LLR in >5% and FLU in ~10% for both survey groups. For
2ND AVA KOREA
8.7 7. I
4.8** 4.7 3.0
6.1;’ 10.5 9.0
5.4” 7.0 3.5
5.8** 2.3 1.5
RESU TOTAL RESU MALE RESU FEM
474 86 67 I9
Male-Female differences significant at p < O.Ol(**). Systemic side effects (lasting more than 24 hours) associated with the first 3 doses of AVA in the ResU occurred in 15% of patients (21% Fem. 13.4% Male) for one or more shots. However, not all patients experienced these effects with all doses. CONCLUSION: The first 2 doses of Anthrax vaccination are associated with a high frequency of LLR at the injection site as well as systemic symptoms such as fever, pruritis, fatigue, and generalized “flu-like” illness. Similar reactions have been observed with the adjuvant aluminum hydroxide (also present in AVA), when included in vaccine studies as a component of the placebo. It is noteworthy that no other vaccine with this adjuvant is given by the SQ route. The higher the frequency of LLR and systemic symptoms with anthrax vaccine in women compared to men needs further study and may reflect differences in immune response related to gender.
Recipients D University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh The use of non-specific immunosuppression with either Tacrolimus or Cyclosporine in childhood recipients of solid organ transplantation has been associated with anecdotal reports of allergic hypersensitivity. We propose to describe, in a large cohort of pediatric cardiac transplantation patients, both the risk factors and nature of atopic disease in this population. We used a retrospective review of cardiology, allergy and gastroenterology charts to identify and describe 73 heart transplant recipients less than 16 years old and having survived at least 6 months post transplantation. An allergy questionnaire was performed prospectively by either telephone interview or during follow-up visits in cardiology clinic to determine if, when and how atopy had been diagnosed, the family history of atopy, and the clinical severity of the atopic condition. Our results demonstrate a remarkable incidence of atopic disease in children transplanted in the first year of life. A total of 25 patients were transplanted in the first year of life and 22 have had a physician diagnosis of asthma, eczema or food allergy. Only I3 of the 48 patients who were transplanted after I year of age have been diagnosed with atopic disease. In children less than I year of age eczema was the most common diagnosis 14/22, followed by food allergy 9/22, and S/22 had a diagnosis of either asthma or reactive airway disease. Older transplant recipients were more likely to have nasal disease 6/13, food allergy 5/13, or asthma 5/13. A surprising number of patients 5/73 have been diagnosed with eosinophilic gastroenteritis (EG). A diagnosis of EG did not appear to be related to either patient age or alleric hypersensitivity to foods. Only l/5 patients with EG had either a positive skin test or RAST test to foods. Our data demonstrate a significant risk for the development of
JI; S Kocoshis.
J ALLERGY CLIN IMMUNOL VOLUME 104, NUMBER 1, PART 2
atopic disease in infant recipients of cardiac transplantation. Given that 88% of infant transplant recipients expressed some form of atopic disease, it is reasonable to suggest the use of environmental control measures to minimize the exposure to aeroallergens. A hypoallergenic diet in infant cardiac transplant recipients may also be helpful; however, this should be studied before being widely implemented. The expression of atopic disease implies a shift of lymphocyte T-helper subsets from Thl to Th2. We plan to analyze serum from before and after transplantation to determine if serologic cytokine expression supports the hypothesis of a shift in lymphocyte T-helper cell subsets. 1009
Penicillin Allergy in a Surgical Population J Fernandez*t~ M Blanca$I, A Esreban*tl. MJ Torres§l. H Hernandez*#l. M IbaAez*fl, P Sanros*$l *Elche Hospital tMH University SElche $Malaga ISpain BACKGROUND: Many patients claim to have penicillin allergy but they are rarely documented, and many of them tolerate the penicillin they claimed to be allergic to. OBJECTIVE: The aim of this study was to estimate the incidence of claimed “Penicillin allergy” in a surgical population. MATERIAL AND METHODS: The study was carried out in Elche Hospital, Spain. Patients were interviewed by the anesthetists during the preoperative anaesthetic evaluation over a year ( 1998) and all signs and symptoms of adverse drug reactions were recorded by the allergists. The validity of the claimed allergy was based on the history. RESULTS: Of 3622 subjects who passed the preoperative evaluation for surgery in General surgery, Traumatology and Gynecology in Elche Hospital in 1998. 309 (8.53%) claimed to have drug allergies and only 142 (3.92%) claimed to have penicillin allergy. More women than men claimed to have allergies (64.08% vs 35.92%). Penicillin allergy accounted for 45.95% of all claimed drug allergies. Anafilaxia (8.45%). UrticariaAngioedema (28.87%). Vagal reactions (16.9%). Exanthemas (7.04%). Adverse side effects (23.24%). Others symptoms (6.33%) and No reactions (7.74%) were the clinical symptoms recorded in penicillin allergy patients. Remarkably I9 (13.38%) subjects used and tolerated penicillin well while they were claiming for allergy to penicillin. CONCLUSIONS: In our area nearly 9% of subjects claim drug allergies previous to surgical procedures and only 4% claim penicillin allergy. Most of the clinical symptoms were not true allergies or immunological mediated and 14% used the penicillin they believed to be allergic to.
NSAIDs Reaction Anne Des Roches*, Louis Paradist. Linh Khue Buit, Jean Paradist *H6pital Sainte-Justine. Montrtal, Canada tCentre Hospitalier Universitaire de MontrCal, Montrkal, Canada A 35 year-old woman was known for a past history of severe allergic rhinitis to pollens, house dust mites and molds. She received specific immunotherapy during 3 years in order to obtain a better control of her symptoms. The patient received her shots in both arms, as usually recommended. One year after the end of the immunotherapy, she observed an urticarial rash at the site where the shots were given, each time she was using NSAIDs. She described her reaction as the same local reaction she had when she was receiving her shots. She never had systemic reaction with NSAIDs such as generalized urticaria. angioedema, rhinoconjunctivitis nor bronchospasm. We decided to perform an oral challenge with NSAID to evaluate the symptoms reported. The challenge was done with ibuprofen. One hour after a dose of ibuprofen 200 mg, she developed multiple hives of I to 5 cm of diameter on both arms, without any systemic reaction. We conclude that the NSAID
probably reactivate mast cell localized immunotherapy was injected.
in the skin where
Lymphocyte ‘Ikansformation Test For The Evaluation of Drug Allergic Reactions A Silva, M Meisel, E Tomaz. M Campos, F Indcio Immunoallergology Department, Hospital S. Bemardo, Settibal, Portugal In order to evaluate the role of Lymphocyte Transformation Tests (LIT) in the study of drug related allergic reactions, the authors studied 2.5 patients (M=5; F=20), aged 9-70 years old (average=38,5).Urticaria /angioedema was the most frequent clinical picture (17 patients - 68%); Other presentations included: asthma (2). SLE and chronic urticaria (I), exfoliative dermatitis (I), anaphylactic shock (I), rash (I) and vagal reaction (2). Through clinical history it was possible to identify one drug in fourteen patients: b-lactamic (6). eritromicin (l), NSAID (3). oral contraceptives (2). prednisolone (I), pentoxifinine (I). In eleven patients two or more drugs were identified: b-lactamic+one or more NSAID (7). several NSAID (3). buspirone+ranitidine (I). Six patients were atopic (24%). The probability of a cause-effect was evaluated by using the usual clinical criteria (e.g.: time relation, previous episodes, improvement after suspending, reappearance after reintroduction) and each relation drug-clinical symptoms (46) was classified as “likely”( IO), “possible”(30) or “unlikely”(6). LTT were performed in all. All “unlikely” cases had negative L’IT, 13 “possible” cases were positive (43%) and 6 “likely” cases were positive (60%). From the group of patients that had at least one drug considered “possible” and/or “likely” (22). 13 (59%) had LIT positive to at least one drug. Patients who had all suspected drugs considered “unlikely” (3) had no positive Ln. The authors consider that LTT may have a role in helping to establish the diagnosis of drug allergic reactions specially considering the ethical impossibility, in most cases, to perform DBPC provocation tests.
as an Alternative in Patients with Allergic Reactions to NSAID Jose E Mori, Frances T Guerra Asthma and Allergy Service, Clinica San Borja, Lima, Peru This study was designed to evaluate Nimesulide as an altemative anti-inflammatory drug for patients with adverse reactions to nonsteroidal anti-inflammatory drugs (NSAID). 22 patients were enrolled (mean age 22.9 years + 4.16). All had a history of moderate reactions to NSAID, documented by a physician and consisting of angioedema and bronchial constriction 15 to 60 minutes after ingestion of the drugs (aspirin 82%. metamizole 64%. diclophenac 32%. naproxen 32%. propyphenazone 28%. mefenamic acid 23% and ibuprofen 14%). 32% of the patients were non atopic, 32% had allergic rhinitis, 27% had asthma, and 9% had contact dermatitis. After IO days without antihistamine or steroid therapy, I8 patients were challenged with metamizole via intradermic injection and 4 received aspirin by mouth. The response was positive in all of them (wheal or angioedema). The patients were rechallenged with increasing doses of Nimesulide IO days after the initial test (25.50 And 100 mg in children and 50, 100 and 200 mg in adults) by oral route every 30 minutes and were observed in the offrce for two hours. A follow up visit was scheduled 24 hours later. 86% had no reactions, 14% developed mild angioedema or itching and flushing that reverted with steroids or antihistamines. These results suggest that Nimesulide can be used as an alternative anti-inflammatory drug in patients with allergic adverse reactions to NSAID.