Lessons from peculiar cases of anaphylaxis: why allergists should be prepared for the unexpected.

Summary: Anaphylaxis is the most severe systemic hypersensitivity reaction, it can be caused by a number of well identified triggers such as foods, drugs, stinging insects and facilitated by predisposing clinical conditions. However, sometimes anaphylaxis shows up with uncommon or peculiar characteristics which could delay diagnosis and therapeutic treatment. In this report we aimed to describe less accounted / difficult-to-approach shapes of anaphylaxis to facilitate clinicians to suspect these severe reactions even in uncommon conditions. We choose to present data on anaphylaxis regarding simulation, mode of exposure to sensitizing agents, pregnancy, exposure to animals, intimate behaviour, psychological stress and other situations.

Allergy in adolescent population (14-18 years) living in Campania region (Southern Italy). A multicenter study.

Summary: Adolescents (Ad) constitute a difficult to manage population among individuals suffering from asthma. The aim of our study was to assess the prevalence, clinical characteristics and age of onset of allergic sensitization and clinical symptoms in a sample of atopic Ad living in the Campania region (Southern Italy). Sixteen Allergy units or Centers belonging to the Italian Association of Hospital and Territorial Allergologists (AAIITO, Campania region) participated in this cross-sectional study. A case report form (CRF) was specifically designed for this study and commercial allergen extracts used for screening SPTs were provided by ALK-Abelló Group (Milan, Italy). A total of 443 patients were examined (females, f 220, 49.6 %; males, m 223, 50.3%). Dust mites represent the most common sensitizing agents in allergic Ad living in Campania region (Dermatoph. pteronyssinus 67.4% and Dermatoph. farinae 66.5%), followed by Parietaria (58.9%), grasses (45.8%), Artemisia vulgaris (16.7%), Olea Europaea (32.2%), dog dander (17.1%), cat dander (20.0%), Alternaria alternata (8.1%), Cupressus sempervirens (4.9%), Betula pendula (4.7%), other allergens (19.4%). An interesting comparison has been made between clinical data of our Ad with data of elderly patients (E). The role of allergic sensitization is significantly higher in Ad compared to E. Dermatophagoides pteronyssinus is the first sensitizing allergen in Ad and the last in E. Parietaria constitutes the first sensitizing pollen both in Ad and E, the percentage of sensitization is higher in Ad. Another important difference is the higher prevalence of As, as only symptom, in E compared to Ad (19.7% versus 7.6%). In conclusion, our findings confirm the high prevalence and clinical significance of airway allergic sensitization in the adolescents living in Campania region.

Allergy in urban elderly population living in Campania region (Southern Italy). A multicenter study.

Given the increasing life expectancy observed in Western countries, there is a marked interest to know more about how aging could influence respiratory health. The aim of our study was to assess the prevalence, clinical characteristics and age of onset of allergic sensitization and clinical symptoms in a sample of atopic elders living in Campania region area (Southern Italy). Fourteen Allergy units or Centres examined a total of 462 patients. In this context 215 (46.53%) had positive skin prick tests (SPTs) to at least one allergen and were diagnosed with respiratory allergy. Parietaria represents the most common sensitizing agent in elders living in Campania region, followed by dust mites, grass pollen and Olea europaea. A relatively high percentage of atopic subjects suffered from respiratory symptoms at a fairly advanced age, namely 8.3% at 60-64 years, 10.2% at 65-70 and 5.7% at > 70 years. In conclusion, the prevalence and clinical significance of airway allergic sensitization in the elderly living in Campania region is more significant than expected in latter stages of life. Physicians should not neglect the role of atopy as a risk factor for the onset of allergic respiratory symptoms even in elderly patients.

Sensitization to cockroach allergens in the urban atopic populations living in Campania district (southern Italy). A multicenter study.

BACKGROUND: Although cockroach (CR) is an important cause of allergic sensitization worldwide, only a few data are available in Italy and in a previous study we have observed, in Naples area, a low prevalence of CR sensitization. OBJECTIVES: We sought to perform a prospective study for assessing the prevalence of allergic sensitization to CR in a sample of atopic population living in Campania district area (Southern Italy). METHODS: Ten Allergy Units or Centres of Campania district participated in this cross-sectional study. Each centre was required to collect the results of at least 100 allergy consultations in consecutive outpatients referred for actual or suspected respiratory allergy. We registered demographic data, type and duration of respiratory symptoms, pets ownership, possible exposure to CR allergens, results of the skin prick tests (SPTs). RESULTS: A total of 1477 patients were examined, 985 (66.68%) had a SPTs positivity to at least one allergen. In this context, ninety were sensitized to CR, thus the overall sensitization prevalence in subjects with respiratory allergy was 6.09% ranging between 0-11% and only five patients were mono-sensitized. Thirteen patients reported rhinitis (R) + bronchial asthma (A), twenty-one R + A + conjunctivitis (C), thirty-seven R + C, five only A and eleven individuals only R. Sixty-seven patients exhibited persistent and twenty-three intermittent symptoms. Dust mite constituted the first cause of associated sensitization to CR. CONCLUSIONS: The prevalence of allergic sensitization to CR is not negligible in population living in Campania district and shows a higher trend in comparison to that found recently and some years ago in Naples area. Finally, we suggest atopic individuals and especially those highly sensitized to mite allergens or those living in low-income areas to be tested by SPTs / evaluation of serum specific IgE to CR allergens to exclude the occurrence of CR allergic sensitization.

Perioperative anaphylactic risk score for risk-oriented premedication.

Basing on the current knowledge, this paper is aimed to review the core characteristics of the most relevant therapeutic agents (steroids and antihistamines), administered to prevent perioperative anaphylaxis. Moreover, the Authors propose the validation of a Global Anaphylactic Risk Score, built up by recording the individual scores related to the most relevant anaphylaxis parameters (i.e. medical history, symptoms and medication for asthma, rhinitis and urticaria etc) and by adding them on all together; the score could be used in the preoperative phase to evaluate the global anaphylactic risk and to prescribe risk-oriented premedication protocols.

Sensitization to horse allergens in Italy: a multicentre study in urban atopic subjects without occupational exposure.

BACKGROUND: Horses play a significant role in people's leisure time in Italy and other countries, but few data are available on IgE-mediated sensitization to horse allergens in patients without occupational exposure. We assessed, in a multicentric survey, the prevalence of horse sensitization in atopic subjects and its clinical characteristics. METHODS: Allergists from the whole Italian territory were required to collect the results of skin prick tests from at least 100 consecutive subjects. Those patients with a positive skin test to horse dander underwent a detailed interview concerning clinical history, pet ownership and possible exposure. RESULTS: Data from 3,235 outpatients were collected and 2,097 had at least 1 skin positivity. Among them, 113 (5.38%) were sensitized to horse dander (9 monosensitized). Thirty patients reported direct horse contact (4 owners and 26 for riding or occasional contact), 23 patients were sometimes in contact with horse owners and 60 subjects denied any direct or indirect exposure. Among 9 horse monosensitized patients, 6 had intermittent and mild rhinitis and 3 persistent moderate/severe rhinitis plus asthma. Three of them were horse owners or riders and the remaining had no contact with the animal. CONCLUSIONS: Our data evidence that the rate of sensitization to horse dander is not negligible and probably underestimated. In susceptible, not occupationally exposed individuals, horse contact, but also indirect or no apparent exposure, may induce sensitization. We recommend inclusion of horse allergen in the routine panel for the diagnosis of respiratory allergy.

Amyand's hernia: case report and review of the literature.

The authors report a case of gangrenous acute appendicitis in the sac of an inguinal hernia (Amyand's hernia). After a review of the literature, they emphasise the extreme rarity of the case reported, they underline how the clinical picture is highly similar to that of a strangulated inguinal hernia. They affirm that appendicectomy and hernioplasty may be performed at the same time, since the repair of the hernia should be performed without prosthesis implantation due to the contamination of the operating field.

[Surgery of inguinal hernia in the elderly]. / La chirurgia dell'ernia inguinale nel paziente geriatrico.

The authors report their 14 years experiences with inguinal hernia repair in elderly. The result were compared with young (< 75 years old), and confirmed that there were no significant differences between the 2 groups. The study confirmed the safety and effectiveness of the "tension-free" technique under local anaesthesia, which is proposed as the treatment of choice in elderly.

Long-term absence of sensitization to mepivacaine as assessed by a diagnostic protocol including patch testing.

BACKGROUND: Prospective assessment of non-reactivity to local anaesthetics is a frequent reason for allergy consultation. OBJECTIVES: To investigate the clinical profiles of subjects referred for allergy evaluation; to prospectively reduce the frequency of evaluation by assessing the persistence, during clinical use, of non-reactivity to contaminant/additive-free mepivacaine; and to determine the usefulness of a diagnostic protocol involving patch testing. METHODS: In a prospective study, 198 consecutive patients underwent collection of clinical data, skin prick tests and patch tests using allergens/antigens relevant for the investigation, and an intradermal/subcutaneous challenge procedure using contaminant/additive-free mepivacaine, as appropriate. Patients were followed up for 3 years for assessment of non-reactivity persistence using the same diagnostic protocol. RESULTS: Only one-third of the patients had a history of previous adverse local anaesthetic reactions. Absence of sensitization to contaminant/additive-free mepivacaine persisted in all subjects completing the follow-up. Controlled challenge with mepivacaine was negative in 196 patients with both negative specific skin prick tests and patch tests but it was eventful in two subjects with positive specific patch tests. A few subjects displayed positive skin prick tests and/or patch tests for latex and/or additives. CONCLUSIONS: A few patients had a relevant history for potential local anaesthetic-induced adverse reactions. Upon assessment of absence of sensitization and reactivity, contaminant/additive-free mepivacaine could safely be given for as long as 3 years. The patch testing was shown to be useful and safe for prediction of challenge outcomes. True allergic reactions to contaminant/additive-free mepivacaine were not observed in our patient series.

[Indications for preventive tracheostomy in the surgical treatment of non-neoplastic thyroid disease]. / Indicazioni alla tracheostomia precauzionale nella chirurgia delle tireopatie non neoplastiche.

In thyroid surgery, an emergency tracheostomy is mandatory, as is well known, in acute pre- and postoperative asphyxia due to obstruction of the upper airways, especially in cases of malignant tumours. In particular conditions, in the presence of benign thyroid disease and when there is no reduction in the laryngo-tracheal lumen, tracheostomy has an important precautionary function following total thyroidectomy. The authors describe their experience with 6 patients treated by precautionary tracheostomy after total thyroidectomy for benign thyroid disease, analysing the indications and the advantages of this method.

Hypocalcemia and hypoparathyroidism after total thyroidectomy: a clinical biological study and surgical considerations.

BACKGROUND: Post-operative hypocalcemia is a common and most often transient event afterextensive thyroid surgery. It may be due to iatrogenic injury to the parathyroid glands. AIMS: We carried out a study aimed to evaluate the incidence of hypocalcemia and hypoparathyroidism following extracapsular total thyroidectomy. METHODS: The study was carried out in 312 patients (273 females and 39 males, whose age was between 23 and 76 years, median age 48.61 +/- 14.1) who had undergone total thyroidectomy (TT) in our department from 1995 to 1998 and in 100 patients (72 females and 28 males, whose age was between 24 and 75 years, median age 51.66 +/- 13.4) who had undergone other (non-thyroid) surgery. RESULTS: Post-operative hypocalcemia was observed in 62 patients of the control group (62%) and the decrease of the serum calcium level lasted about 3 days, and went back to normal within the 5th day. In 2 patients undergoing total thyroidectomy, hypocalcemia was considered severe (confirmed for more than 7 days, symptomatic), these had been operated for large multinodular goitre with mediastinal extension. In these patients the symptoms arose acutely about 5 h after the operation. In both cases the clinical and biological aspects went back to normal within 10 days, after a treatment with calcium and vitamin D. Transient asymptomatic hypocalcemia was observed in 234 thyroidectomized patients (75%) and thus did not need any treatment for it. CONCLUSION: The results obtained confirm that transient hypocalcemia can be observed after any operation; and particularly responsible is the decrease of the calcium concerning the proteins. We found that post-operative hypoparathyroidism is due to injury to the parathyroid glands (parathyroid ischaemia or surgical ablation of one or more glands). Here we see the delayed serum calcium level < or = 7.5 mg/dl or the delayed serum phosphorous level > 7.4 mg/dl. The results of our study, with 2 patients presenting transient post-operative hypoparathyroidism, contribute in confirming that the extracapsular total thyroidectomy aimed to reduce any injury to the parathyroid and to the recurrent nerves, represent the better operation also for the extended benignant thyroidopathies.

The recurrent laryngeal nerve related to thyroid surgery.

BACKGROUND: Iatrogenic injury of inferior laryngeal nerve is one of the most serious concerns in thyroid surgery. Paralysis of vocal cords is a common sequela of thyroidectomy. It represents a serious complication inducing, when bilateral, serious functional sequelae such as phonatory, respiratory and psychological problems that limit working capacities and social relationships of patients. We carried out an intraoperative study aimed to define anatomical relationships between the recurrent laryngeal nerve and the adjacent structures (the inferior thyroid artery in particular), intraoperative identification of which may allow prevention of iatrogenic injuries of the laryngeal nerve. METHODS: One hundred ninety-two patients (165 females, 27 males whose age was between 18 and 90 years, median age 55) who had undergone thyroidectomy in our department in the last 3 years. Among them, 179 patients underwent total extracapsular thyroidectomy, and of the 13 remaining, 12 were completions of thyroidectomy in patients who had previously undergone a first thyroid surgical intervention and underwent istmo-lobectomy. RESULTS: Despite a systematic intraoperative search, we identified the recurrent laryngeal nerve in 158 of 192 patients (82.3%), while in the remaining 34 (17.7%), the recurrent laryngeal nerve was not identified. In 122 out of the 158 patients (77.2%) in whom the recurrent laryngeal nerve had been detected, the nerve was identified bilaterally: in 19 of 158 (12%) only on the right side; in 17 of 158 (10.7%) only on the left. Concerning the postoperative results we noticed only one case (0.5%) of recurrent laryngeal nerve injury for neoplastic infiltration of its own branch, one case (0.5%) of monolateral cordal hypomotility, and two cases (1.04%) of bilateral cordal hypomotility with temporary disphonia, which regressed in 6 months of time. CONCLUSION: The results of our study may confirm that iatrogenic injury to the recurrent laryngeal nerve, or to its branches, might be better avoided by searching, identifying, and exposing the nerve itself and by following its course with care. In our view, total extracapsular thyroidectomy, with systematic search for the nerve, is the best approach. We believe that deep knowledge of the thyroid region's surgical anatomy and the awareness of the extremely varying course of the recurrent laryngeal nerve and the inferior thyroid artery and their relations should be taken into account by surgeons.