Near-fatal anaphylaxis caused by human serum albumin in fibrinogen and erythrocyte concentrates.

A 40-year-old man developed anaphylactic shock during surgical replacement of a prolapsed mitral valve during general anaesthesia and an attenuated reaction (Grade 2), three days later during a blood transfusion. Human serum albumin, a component of the fibrinogen concentrate used postoperatively with the erythrocyte concentrate, was identified as the trigger, confirmed by positive skin prick and intradermal tests. Any anaphylaxis during the peri-operative period should cause the clinician to perform allergy tests for identification of the culprit drug and, sometimes, culprit additive. Testing of human serum albumin, acting as hidden allergen, should be included, especially where there has been a blood transfusion.

The impact of meteorological conditions on patch test results with 12 standard series allergens (fragrances, biocides, topical ingredients).

BACKGROUND: Fluctuating irritability of the skin induced by low ambient temperature and humidity may compromise the reproducibility of patch testing. OBJECTIVES: To assess the impact of temperature and absolute humidity at the time of patch testing on the occurrence of irritant or doubtful (IR/?), weak positive (+) and (strong) positive (++/+++) reactions, respectively, among 12 allergens included in the German Standard Series. METHODS: Analysis of clinical data collected in the surveillance network IVDK (http://www.ivdk.org) between January 1993 and December 2001 (n = 73 691 patients) combined with meteorological data obtained by the national services in Germany and Austria. Multinomial logistic regression analysis was used to estimate the risk associated with temperature, absolute humidity and vapour pressure, respectively, adjusted for sex, age, atopic dermatitis and duration of patch test application. RESULTS: For low temperature and humidity, a relevant increase of IR/? reaction frequency was observed in the cases of paraben mix and (chloro-) methylisothiazolinone. Both IR/? and + reactions were significantly increased with respect to the allergens fragrance mix, oil of turpentine, methyldibromo glutaronitrile + phenoxyethanol and particularly formaldehyde, while ++/+++ reactions were hardly affected by weather conditions. CONCLUSIONS: The observed increase of IR/? reactions may be due to epidermal barrier function impairment. The impact of dry/cold weather on + reactions in terms of possibly false-positive reactions is restricted to few allergens. In the case of + reactions of unknown relevance, a re-test under warm conditions or verification tests such as the repeated open application test or the provocative use test may be recommendable.

Delayed-type hypersensitivity to low molecular weight heparins and heparinoids: cross-reactivity does not depend on molecular weight.

BACKGROUND: Cross-reactivity is a widespread phenomenon in patients who develop cutaneous delayed-type hypersensitivity (DTH) reactions to low molecular weight heparins (LMWHs). As molecular weight is believed to be a key determinant of sensitization to heparins, the recently developed LMWH bemiparin, with the lowest molecular weight of all LMWHs, appeared to be a significant improvement. OBJECTIVES: To evaluate cross-reactivity between bemiparin and several other LMWHs and heparinoids by means of subcutaneous testing. Methods Test doses of bemiparin and several other LMWHs/heparinoids were given to eight patients with a history of local eczematous reactions after subcutaneous injection of enoxaparin. RESULTS: Seven of eight patients showed cross-reactivity following subcutaneous injection of bemiparin. In addition, nearly all tested substances caused local eczematous reactions in at least some patients, with the exception of fondaparinux, which was well tolerated by all patients. Of all substances tested, bemiparin had the highest cross-reactivity with enoxaparin. Substances with a lower molecular weight did not cross-react less frequently than the others. CONCLUSIONS: No significant correlation was found between the molecular weight of the tested substances and the frequency of DTH reactions. In patients with DTH to enoxaparin, the LMWH bemiparin is not a suitable alternative.

Immunoglobulin E and G antibody profiles to grass pollen allergens during a short course of sublingual immunotherapy.

BACKGROUND: Various studies have shown the clinical efficacy of sublingual immunotherapy in grass pollen-induced rhinoconjunctivitis. However, even short-term treatment with grass extracts might cause sensitizations to formerly unrecognized antigens. OBJECTIVE: To determine whether the antibody profiles are changing in patients receiving a defined grass pollen extract prior to and during the grass pollen season. METHODS: A randomized, double blind, placebo-controlled, multicenter phase I/I111 trial was started prior to the commencement of the grass pollen season. Patients with grass pollen allergy were randomly allocated to four groups, and received daily a standardized tablet at different doses. Treatment was started 8 weeks prior to the beginning of the pollen season and stopped at the end of the season. Blood samples were taken at the beginning of the study, at the beginning and the end of the pollen season, and one year after commencement of the study. RESULTS: At the beginning of the study, all patients tested positive for the major grass pollen allergens, but negative to the minor antigens. In all patients, the degree of antibody reactivity rose considerably after starting active treatment and fell back to the initial values within one year. Immunoglobulin (Ig) E antibodies to the minor antigens remained negative, independent of treatment and seasonal exposure. In contrast to IgE, specific IgG antibodies to all allergens tested revealed no specific trend. CONCLUSIONS: Immunotherapy with grass allergen tablets was accompanied by an increase in grass-specific IgE antibodies, which further increased during pollen exposure, followed by a post-treatment drop in patient- and disease-specific antibodies. During this short course of treatment, no patient developed any additional sensitizations.

Vascular pattern of the palms--a clinical feature of atopic skin diathesis.

BACKGROUND: Atopic skin diathesis is a clinical term to describe skin atopics with previous, present or future atopic eczema/dermatitis syndrome (AEDS). In clinical practice, an unequivocal assessment of atopic skin diathesis in non-eczematous patients may be difficult. The majority of the known clinical features included in diagnostic scores are characteristic, but not specific markers of atopy. Especially, the vasoreactivity of atopic skin is disturbed. This is manifested by white dermographism, an irregular vascular response to thermal stimuli, and paradoxic skin reactions to histamine, cholinergic agents, and nicotinates. OBJECTIVE: The aims of our study were to investigate the clinical morphology of palmar vascular reactions in skin atopic and non-atopic individuals, and to determine whether this abnormal vascular reaction is more pronounced in skin atopic individuals. METHODS: Forty persons, 20 of them skin atopics, assessed by the Erlangen Atopy Score and an elevated serum IgE level (>150 U/ml), were included in a prospective single-centre study. Standardized digital photographs of the palms were presented in a blinded manner to five dermatologists in random order by means of the computerized imaging analysis system KS400 3.0. RESULTS: Evaluation of the original rgb (red, green, blue) color images and modified gray-level images showed that a pronounced reticular pattern of erythema of the palms was significantly (P < 0.0001) more common in skin atopics (72% and 69.6%, respectively). CONCLUSION: The gross vascular pattern of the palm might be an additional diagnostic feature of atopy, and further studies are needed to establish its exact prevalence.

Tryptase as severity marker in drug provocation tests.

BACKGROUND: In the absence of objective symptoms, it is difficult to assess an adverse reaction during drug provocation testing. We evaluated the value of serum tryptase levels to distinguish between positive, negative and, even more important, so-called 'hysterical' reactions (conversion symptoms). The latter are occasionally observed in drug provocation tests when the patient experiences ambiguous subjective symptoms. METHODS: In a prospective single-center study, 303 patients underwent 785 drug provocation tests. Blood was taken for tryptase measurement on each test day before and after drug challenge, and the changes in serum tryptase levels in patients with no reactions were compared with those who experienced immediate reactions to a drug. RESULTS: Thirty-four of 785 drug provocations were clinically judged as being positive. Despite objective symptoms, median serum tryptase values in the afternoon were even lower than baseline levels. However, this decrease was not statistically significant. In the 751 patients suffering no objective reactions, the median values of post-testing tryptase values were statistically significantly decreased as compared with pretesting values. CONCLUSIONS: The measurement of serum tryptase levels does not appear to be helpful to differentiate mild allergic or nonallergic reactions from 'hysterical' ones. The milder decrease in the group with objective drug reactions might indicate slight mast cell activation in some patients. More severe clinical drug reactions led to stronger mast cell degranulation. Mild reactions did not increase the tryptase levels consistently.

[Anal and palmar contact dermatitis caused by iodopropynyl butylcarbamate in moist sanitary wipes]. / Anal- und Palmarekzem durch Iodpropinylbutylcarbamat in feuchtem Toilettenpapier.

A 63-year old man developed severe perianal and palmar contact dermatitis caused by sensitization to iodopropynyl butylcarbamate in moist sanitary wipes. Iodopropynyl butylcarbamate is increasingly employed as preservative in common cosmetic formulations and moist sanitary wipes as substitute for the previously frequently used sensitizers isothiazolinones and methyldibromoglutaronitrile. The allergic potential of diverse preservatives is a serious problem for the cosmetic industry, since truly hypoallergenic preservatives are not available but products such as moist sanitary wipes in large packages definitely require some form of protection.

[Epidemiologic surveillance of contact allergens. The "monitoring series" of IVDK (Information Network ofDermatologic Clinics for Detection and Scientific Evaluation of Contact Allergy]. / Epidemiologische Uberwachung von Kontaktallergenen. Der "Monitorblock" des IVDK.

The selection of the most important contact allergens is subject to a continuous change. Several factors may influence the sensitization rates and thus the decision, which substances to include in the standard series of the most frequent allergens. The Information Network of Departments of Dermatology adds substances of interest for a certain time period to the standard series in order to evaluate parameters such as sensitization rate, grade of reaction, and clinical relevance of positive reactions. In 6 testing periods starting in 1996, 13 test substances were evaluated. Due to the results, propolis, compositae mix, and bufexamac were included in the standard series in 1999, while lyral was added in 2002. Sorbitansesquioleat, dispers blue mix, and iodopropynyl butylcarbamate are under further discussion. Substances such as glutaraldehyde and p-aminoazobenzole should be tested in certain risk groups only, whereas the steroids budesonide and tixocortol should be tested when clinically suspected.

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.