Clinical Follow-up in Patients With Moderate or Severe Allergic-Like Reactions to Iodinated Contrast Material.

OBJECTIVE: To examine follow-up care in patients with a history of acute allergic-like reaction to iodinated contrast material (ICM), including subsequent imaging management, allergy consultation, and repeat ICM exposure and reactions. METHODS: All patients who had a moderate or severe acute allergic-like reaction to ICM after contrast-enhanced CT (CECT) examination from June 1, 2009, to January 1, 2022, at our institution were included. Chart review was performed to determine (1) whether subsequent imaging was not performed or was altered in these patients, (2) whether the patient underwent a subsequent CECT examination, and (3) whether the patient had an allergist consultation. RESULTS: A total of 251 patients were identified. One-third of patients (90 of 251, 36%) had at least one change to their subsequent imaging management due to their reaction, including performing an unenhanced CT (62 of 251, 25%) or MRI (22 of 251, 8.8%) instead of a CECT or not performing a CECT when otherwise clinically indicated (20 of 251, 8.0%). Patients with a prior severe reaction were more likely to have a change in management than patients with a prior moderate reaction (severe: 22 of 32 [69%] versus moderate: 68 of 219 [31%], P < .0001). Only 17 patients (6.8%) had an allergy consult for their ICM reaction. A total of 90 patients underwent 274 subsequent CECT examinations. Repeat allergic-like reactions were observed in one quarter of patients (24 of 90, 27%) and a tenth of CECT examinations (29 of 274, 11%). DISCUSSION: One-third of patients with a history of a moderate or severe allergic-like reaction to ICM had their subsequent imaging care modified due to their reaction.

Hypersensitivity Reactions and the Respiratory System: Imaging Based Review.

Hypersensitivity reactions are characterized by inappropriate response of the immune system to an inciting antigen, which results in damage to various body tissues. Respiratory system can be involved as a part of hypersensitivity reaction by a myriad of conditions ranging from infective pathologies like tuberculosis to non-infective processes such as asthma, graft- versus host disease, sarcoidosis and vasculitic disorders. Recognition of specific imaging features in appropriate clinical setting helps in diagnosing these conditions. We present a review of mechanism of different types of hypersensitivity reactions; and imaging features of various such pathological conditions affecting the respiratory system.

In vivo non-invasive staining-free visualization of dermal mast cells in healthy, allergy and mastocytosis humans using two-photon fluorescence lifetime imaging.

Mast cells (MCs) are multifunctional cells of the immune system and are found in skin and all major tissues of the body. They contribute to the pathology of several diseases including urticaria, psoriasis, atopic dermatitis and mastocytosis where they are increased at lesional sites. Histomorphometric analysis of skin biopsies serves as a routine method for the assessment of MC numbers and their activation status, which comes with major limitations. As of now, non-invasive techniques to study MCs in vivo are not available. Here, we describe a label-free imaging technique to visualize MCs and their activation status in the human papillary dermis in vivo. This technique uses two-photon excited fluorescence lifetime imaging (TPE-FLIM) signatures, which are different for MCs and other dermal components. TPE-FLIM allows for the visualization and quantification of dermal MCs in healthy subjects and patients with skin diseases. Moreover, TPE-FLIM can differentiate between two MC populations in the papillary dermis in vivo-resting and activated MCs with a sensitivity of 0.81 and 0.87 and a specificity of 0.85 and 0.84, respectively. Results obtained on healthy volunteers and allergy and mastocytosis patients indicate the existence of other MC subpopulations within known resting and activated MC populations. The developed method may become an important tool for non-invasive in vivo diagnostics and therapy control in dermatology and immunology, which will help to better understand pathomechanisms involving MC accumulation, activation and degranulation and to characterize the effects of therapies that target MCs.

Metal Hypersensitivity After Spinal Instrumentation: When to Suspect and How to Treat.

BACKGROUND: Metal hypersensitivity is a rare complication after spinal implant placement but is related to significant clinical challenges including implant failure and poor wound healing. The incidence is likely underreported secondary to challenges with diagnosis and retreatment options. CASE DESCRIPTION: We present the case of a 41-year-old woman with metal hypersensitivity 6 years status post anterior lumbar interbody fusion after a previously failed revision procedure who presented with low back pain and abdominal pain with food intolerance. Diagnostics revealed presacral fluid collection, which was negative for infection. A detailed workup ruled out other possible differential diagnoses and confirmed hypersensitivity to nickel. Intraoperatively, the interbody was loose but difficult to remove secondary to scar tissue. Ultimately, it was successfully replaced with a polyetheretherketone interbody, which did not contain nickel. CONCLUSIONS: Metal hypersensitivity is likely an underreported complication in spine literature that is associated with poor outcomes. Further research to create evidence-based guidelines on diagnosis and retreatment options will facilitate diagnosis, reduce time to revision surgery, and ultimately decrease patient suffering.

Visualizing immune responses of the airway mucosa.

The airway mucosa is the primary tissue site exposed to inhaled particulate matter, which includes pathogens and allergens. While most inhaled particles are eliminated from the airways via mucociliary clearance, some pathogens may penetrate the mucosal epithelial barrier and an effective activation of the mucosal immune system is required to prevent further pathogen spread. Similarly, inhaled environmental allergens may induce an aberrant activation of immune cells in the airway mucosa, causing allergic airway disease. During the last years, several investigators employed advanced microscopic imaging on both intravital and tissue explant preparations to observe the dynamic behavior of various immune cells within their complex tissue environment. In the respiratory tract, most imaging studies focused on immune responses of the alveolar compartment in the lung periphery. However, equally important immunological events occur more proximally in the mucosa of the conducting airways, both during infection and allergic responses, calling for a more detailed imaging analysis also at this site. In this review, I will outline the technical challenges of designing microscopic imaging experiments in the conducting airways and summarize our recent efforts in understanding airway mucosal immune cell dynamics in steady-state conditions, during infection and allergy.

Delayed Allergic Reactions to Jellyfish Stings: Usefulness of Ultrasonographic Evaluation.

Jellyfish stings often cause immediate local skin reactions, and, less frequently, the affected individuals may develop delayed allergic reactions days or months after the sting. Here, we present 4 such cases. In all cases, color Doppler ultrasonography was performed at the time of diagnosis, and in 3 of the cases, clinical follow-ups with ultrasonographic evaluations were performed. Ultrasonography initially showed dermal thickening with decreased echogenicity that progressively normalized during follow-up. Ultrasonography was useful in quantifying inflammation by measuring the thickness of the dermis and was more precise than standard clinical follow-up of cutaneous lesions in these cases.

Allergic tendencies are associated with larger gray matter volumes.

Allergic tendencies are associated with important cognitive and physiological factors, such as intelligence and mathematical abilities. Allergies are widely prevalent, especially in modern life, and the reason for its association with important cognitive variables is an intriguing scientific question. However, despite the unique characteristics of cognitive correlates of allergy, the anatomical correlates of allergy remain unknown. The aim of this study was to identify the associations between regional gray matter volume (rGMV) and allergic tendencies in young adults. In a study cohort of 1,219 healthy, educated young adults, we identified a positive correlation between total allergic tendency and rGMV in large anatomical clusters that mainly encompassed the dorsal part of the cerebral neocortex, right anterior insula, and cerebellum. Furthermore,both mean rGMV of the entire part of these clusters and total allergenic tendency showed a significant positive correlation with spatial ability. These results suggest the link among allergic tendencies, larger rGMV, and the better spatial ability in healthy, educated young adults.

Asiaticoside Mitigates the Allergic Inflammation by Abrogating the Degranulation of Mast Cells.

The effects of asiaticoside (AS) on allergic responses mediated by mast cells were investigated. AS showed no obvious cytotoxicity on RPMCs (rat peritoneal mast cells). AS reduced the intracellular calcium in RPMCs and deprived the histamine release and degranulation. AS also decreased the generation of antigen-induced tumor necrosis factor α, interleukin (IL)-4, IL-8, and IL-1ß in RBL-2H3 cells sensitized by IgE. The suppression of AS on pro-inflammatory cytokines was related with the activation of the intracellular FcεRI and the inhibition of the nuclear factor-κB signaling pathway. In addition, AS disabled the phosphorylation of antigen-induced Syk, Lyn, Gab2, and PLCγ1, thus suppressing the downstream Akt phosphorylation and MAPKs pathways. It also increased HO-1 and Nrf2 expression time dependently. In summary, we demonstrate that AS suppresses the allergic inflammation mediated by mast cells and this effect might be mediated by FcεRI-dependent signaling pathways.

Basophil activation test: Implementation and standardization between systems and between instruments.

The basophil activation test (BAT) is a good ex vivo alternative for measuring hypersensitivity to an allergen in sensitized patients but still lacks standardization. In this present study, we have implemented one of the systems and proposed inter-systems, inter-instrument standardization. Our method for basophil activation and labeling on whole blood: EDTA in one step using BasoflowEx® and FlowCast® . Setup on Navios and fluorescence targets converted to set up FACSCanto™ instrument. Our results: 1) A CD203c/CD63 (BasoflowEx) method was adapted for EDTA samples and simplified. 2) Final washing and concentration and use of time parameter help acquiring as many basophils as possible, spare acquisition time and noise. 3) The modified method was validated according to ISO15189 with a precision at 5.1% RCV, linearity between 1 and 1/8 of anti-IgE stimulation. Results were very close with CCR3/CD63 system (FlowCast). 4) Standardization, between systems and even between instruments. Mean Fluorescence Intensity targets are proposed using standard beads (Cytocal® ) middle peak: FITC = 19.4; PE = 28.8 on Navios® corresponding to FITC = 4,966; PE = 7,373 for FACSCanto. Data analyzed on common software (Kaluza® ) were very closely correlated. 5) Co-labeling of B cells (CD20+) gives the possibility to monitor a significant drop of basophils under stimulation that could explain some underestimation in case of strong hypersensitivity. In conclusion, BAT would strongly benefit from easy implementation [EDTA, one step stimulation/labeling, wash, full sample analysis over time parameter, B cell relative basophil count] and standardization of instrument settings on MFI targets whatever system or instrument is used. © 2017 International Society for Advancement of Cytometry.

Allergic Reaction to Ginkgo Nut on FDG PET/CT.

We report the case of a 36-year-old woman who previously underwent total thyroidectomy for papillary thyroid carcinoma. F FDG PET/CT images demonstrated multiple lymph nodes with increased FDG uptake in the neck, chest, and abdomen and diffusely increased FDG uptake in the spleen, which were highly suspicious findings for malignant lymphoma. However, subsequent biopsy of axillary lymph node presented reactive hyperplasia. Detailed history revealed that the patient had a history of generalized edema and severe arthralgia after contact with ginkgo nut one week ago. This case highlights allergic reaction mimicking lymphoma on FDG PET/CT.

Distinct mucosal immunopathologic profiles in atopic and nonatopic chronic rhinosinusitis without nasal polyps in Central China.

BACKGROUND: The role of atopy to aeroallergens in chronic rhinosinusitis without nasal polyps (CRSsNP) remains unclear. This study aimed to investigate the mucosal immunopathologic characteristics of CRSsNP with and without atopy to inhalant allergens. METHODS: Thirteen nonatopic CRSsNP patients, 9 atopic CRSsNP patients, and 11 nonatopic control subjects were enrolled in this study. The expression of type 1, 2, and 17 cytokines, growth factors, and chemokines for T cell subsets and granulocytes in sinonasal mucosa was detected using Bio-Plex suspension chip technology or enzyme-linked immunosorbent assay (ELISA). Subjective symptoms were scored on a visual analogue scale (VAS), while disease severity on computed tomography (CT) was graded by the Lund-Mackay CT scoring system. RESULTS: There was no significant difference in VAS and CT scores between atopic and nonatopic CRSsNP. Compared with control, both atopic and nonatopic CRSsNP demonstrated increased interferon γ (IFN-γ) levels in sinonasal mucosa. In contrast, although no difference in interleukin 5 (IL-5), IL-13 and eotaxin-1 expression, or mucosal eosinophil infiltration, was found between the control and whole CRSsNP group, atopic CRSsNP manifested an increased expression of IL-5, IL-13 and eotaxin-1, as well as an enhanced infiltration of mucosal eosinophils in comparison with control and nonatopic CRSsNP. Mucosal eosinophil infiltration correlated with IL-5 and eotaxin-1 expression. No difference in IL-12, IL-4, IL-6, IL-17A, IL-8, myeloperoxidase, "regulated upon activation normal T cell expressed and presumably secreted" (RANTES), or chemokine (C-X-C motif) ligand 10 (CXCL10) protein expression was found among control, atopic CRSsNP, and nonatopic CRSsNP. CONCLUSION: Atopic and nonatopic CRSsNP have distinct mucosal immunopathologic profiles. CRSsNP is a heterogeneous disorder consisting of multiple groups of biological subtypes, or "endotypes," which may argue for different therapeutic strategies.

Acute coronary syndrome due to midazolam use: Kounis syndrome during a transurethral prostatectomy.

Developments in the drugs industry are leading to more rare drug side effects being encountered in clinical practice. Of these side effects, allergic reactions and hypersensitivity are seen in the usage of a large group of drugs such as antibiotics, analgesics, antineoplastics, contrast agents, corticosteroids, intravenous anesthetics, nonsteroidal anti-inflammatory drugs, and proton pump inhibitors. One important result of these reactions is acute coronary syndrome, which may have serious life-threatening results. This syndrome was first described in 1991 by Kounis as an 'allergic angina syndrome progressing to acute myocardial infarction', and thereafter called 'allergic myocardial infarction'. This case report presents a 70-year-old male who had angina and dyspnea after administration of midazolam at the beginning of a transurethral prostatectomy operation.

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity.

BACKGROUND: Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity. METHODS: Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG. RESULTS: Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls. CONCLUSIONS: Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.

Sonographic appearance of angioedema in local allergic reactions to insect bites and stings.

Soft tissue infections and angioedema from insect bites and stings may be difficult to differentiate by inspection. We present sonographic findings of 4 cases of soft tissue swelling from insect bites and stings suggestive of angioedema. Sonographic features of soft tissue angioedema consist of thickened subcutaneous tissue layers with multiple linear, horizontal, striated, and hypoechoic lines following the tissue planes between soft tissue layers. In addition to the history and physical examination, sonographic findings may assist in differentiating between local allergic reactions and cellulitis in patients with insect bites and stings. Further study is warranted for clinical application.

Diffuse in-stent restenosis of CYPHER® stent due to hypersensitivity reaction confirmed by pathohistological findings.

The use of drug-eluting stents (DES) reduces the risk of repeat revascularization without increase of death and myocardial infarction compared to standard bare metal stents. However, in-stent restenosis (ISR) after DES implantation still occurs. Here, we report a rare case with a diffuse ISR after CYPHER® stent implantation because of chronic inflammation and hypersensitivity reactions, confirmed by pathohistological findings.

Ultrasound screening of periarticular soft tissue abnormality around metal-on-metal bearings.

Although metal hypersensitivity or pseudotumors are concerns for metal-on-metal (MoM) bearings, detailed pathologies of patterns, severity, and incidence of periprosthetic soft tissue lesions are incompletely understood. We examined the potential of ultrasound for screening of periarticular soft tissue lesions around MoM bearings. Ultrasound examinations were conducted in 88 hips (79 patients) with MoM hip resurfacings or MoM total hip arthroplasties with a large femoral head. Four qualitative ultrasound patterns were shown, including normal pattern in 69 hips, joint-expansion pattern in 11 hips, cystic pattern in 5 hips, and mass pattern in 3 hips. Hips with the latter 3 abnormal patterns showed significantly higher frequency of clinical symptoms, without significant differences of sex, duration of implantation, head sizes, and cup abduction/anteversion angles, compared with hips with normal pattern. Ultrasound examination provides sensitive screening of soft tissue reactions around MoM bearings and may be useful in monitoring progression and defining treatment for periarticular soft tissue abnormalities.

Maxillary sinus infundibulum narrowing influences sinus abnormalities in spite of the presence or absence of allergy.

CONCLUSION: Maxillary sinus abnormalities were demonstrated to be associated with maxillary sinus infundibulum narrowing as well as nasal airflow resistance secondary to nonspecific nasal inflammation. OBJECTIVES: There is no consensus regarding the pathogenetic roles of allergy and anatomic variations in sinus mucosa abnormalities. We investigated the correlation between allergy and anatomic variations in sinus abnormalities in chronic rhinitis patients in the presence or absence of allergy. METHODS: In all, 148 adult patients with allergic rhinitis (AR) and non-allergic rhinitis (NAR) were enrolled. Opacification of sinuses, the size of the maxillary sinus infundibulum, Haller cells, and concha bullosa were evaluated based on computed tomography (CT) images. Simultaneously, nasal airflow resistance was measured. RESULTS: The AR group comprising 105 patients showed maxillary sinus opacification in 45 patients. In the NAR group including 43 patients, soft tissue opacification was observed in 13 patients. There was no significant difference in the incidence of sinus opacification between the AR and NAR groups. Both nasal resistance and the infundibulum size in both the AR and NAR groups with sinus opacification showed significant differences from those without sinus abnormalities. The presence of concha bullosa influenced the sinus opacification in both the AR and NAR groups.

Severe lower limb ischemia after bee stings.

Bee stings entail allergic reactions that can be severe, sometimes even lethal. These reactions can occur immediately or several days after being stung. In this study, we report a case of severe ischemia of the left lower limb observed in a man, with no medical history, who was stung several times by bees.

Elevation of alanine transaminase and gallbladder wall abnormalities as biomarkers of anaphylaxis in canine hypersensitivity patients.

OBJECTIVE: The purpose of the study was to evaluate alanine transaminase (ALT) and gallbladder wall abnormalities as possible biomarkers for anaphylaxis in dogs presented for acute hypersensitivity reactions. DESIGN: Pilot study. SETTING: A private practice, small animal, 24-hour emergency and specialty hospital. ANIMALS: Ninety-six dogs presenting 101 times on an emergency basis for hypersensitivity reactions from March 2007 through March 2009. INTERVENTIONS: Veterinarians acquired a history, physical exam, serum chemistry panel, blood pressure, and ultrasound image of the gallbladder. MEASUREMENTS AND MAIN RESULTS: Dogs were then divided into 2 groups: dogs fulfilling the definition for anaphylaxis (moderate and severe systemic hypersensitivity) and dogs that did not fulfill the definition and were classified as allergic reactions (local hypersensitivity and mild systemic hypersensitivity). Elevated ALT was significantly associated with anaphylaxis (P<0.001). Increased gallbladder wall thickness and a striated wall pattern were significantly associated with anaphylaxis (P<0.001) and these changes were readily apparent to first-responder veterinarians. Decreased body temperature (P<0.001) and hypothermia (P=0.006) were significantly associated with anaphylaxis. There was no significant difference between groups regarding age, heart rate, or presence of respiratory signs. Lower blood pressure was significantly associated with anaphylaxis (P<0.001) but hypotension was not significantly different (P=0.09) between groups. Cutaneous signs were significantly associated with the allergic reactions group (P<0.001) and, when seen with anaphylaxis, were subtle. CONCLUSIONS: This study showed an elevated ALT and an abnormal gallbladder wall to be biomarkers significantly associated with anaphylaxis in dogs with acute hypersensitivity reactions.