Spanish Society of Allergology and Clinical Immunology (SEAIC) Vision of Drug Provocation Tests.

The controlled drug provocation test (DPT) is currently considered the gold standard for the diagnosis of drug allergy. Adverse drug reactions (ADRs) are an increasingly common presenting complaint in both primary and specialized care. In Spain, ADRs are usually assessed via the allergology department, which rules out immunological mechanisms in up to 90% of cases. An adequate approach to ADRs clearly impacts the costs and efficacy of the treatments prescribed by other specialists. Consequently, if we did not use DPTs, patients would require more expensive, more toxic, and less effective treatments in many cases. In recent years, many new drugs have been developed. This document is intended to be a practical guideline for the management of DPTs according to the vision of the Spanish Allergology Society. The diagnostic work-up begins with a detailed clinical history. Skin tests are only useful for some medications, and in most cases the diagnosis can only be confirmed by DPT. Although cross-reactivity is common, DPTs can confirm the diagnosis and help to find an alternative drug. Programmed individualized patient management based on the type of drug to be studied and the patient´s comorbidities usually enables a solution to be found in most cases.

Practical guidelines for diagnosing hypersensitivity reactions to nonsteroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs most frequently involved in hypersensitivity reactions. These reactions include various clinical entities with different mechanisms leading to the release of inflammatory mediators. Characterization of patients based on clinical manifestations and suspected underlying mechanisms is critical for implementation of adequate diagnostic procedures and patient management. Our objectives were to prepare a systematic review of available scientific evidence and to provide general guidelines for the diagnosis and management of patients with hypersensitivity reactions to NSAIDs. We also propose a practical algorithm for the diagnosis of specific types of hypersensitivity to NSAIDs and provide recommendations for the management of hypersensitive patients.

Allergy to quinolones: low cross-reactivity to levofloxacin.

BACKGROUND: Immediate-type hypersensitivity reactions to quinolones are rare. Some reports describe the presence of cross-reactivity among different members of the group, although no predictive pattern has been established. No previous studies confirm or rule out cross-reactivity between levofloxacin and other quinolones.Therefore, a joint study was designed between 2 allergy departments to assess cross-reactivity between levofloxacin and other quinolones. MATERIAL AND METHODS: We studied 12 patients who had experienced an immediate-type reaction (4 anaphylaxis and 8 urticaria/angioedema) after oral administration of quinolones. The culprit drugs were as follows: ciprofloxacin (5), levofloxacin (4), levofloxacin plus moxifloxacin (1), moxifloxacin (1), and norfloxacin (1). Allergy was confirmed by skin tests and controlled oral challenge tests with different quinolones. The basophil activation test (BAT) was applied in 6 patients. RESULTS: The skin tests were positive in 5 patients with levofloxacin (2), moxifloxacin (2), and ofloxacin (2). BAT was negative in all patients (6/6). Most of the ciprofloxacin-reactive patients (4/5) tolerated levofloxacin. Similarly, 3 of 4 levofloxacin-reactive patients tolerated ciprofloxacin. Patients who reacted to moxifloxacin and norfloxacin tolerated ciprofloxacin and levofloxacin. CONCLUSIONS: Our results suggest that skin testing and BAT do not help to identify the culprit drug or predict cross-reactivity. Oral challenge testing is the only way to confirm tolerance to a quinolone before prescribing it as a safe alternative. Levofloxacin could be a safer alternative in cases of reaction to first-, second-, or fourth-generation quinolones.

Allergenicity and cross-reactivity of pine pollen.

BACKGROUND: Pine pollen has long been considered a non-allergenic pollen. The large size of the grain and its low levels of proteins are the main reasons invoked to explain this low allergenicity. The aim of this study was to describe the main allergenic bands of Pinus radiata (PR) and its cross-reactivity with other pine species, other conifers and grass pollen. METHODS: Sixty-five pine-pollen-allergic patients (51% also sensitized to grass pollen) were studied. Skin prick tests (SPT) to a battery of allergens including PR, Pinus pinea, Pinus sylvestris, Pinus nigra and Cupressus sempervirens pollens and specific IgE determination to PR and Pinus strobus were performed. IgE-immunoblotting to a PR extract and other pine pollens was also carried out. UniCAP inhibition and immunoblotting inhibition studies were performed to assess the cross-reactivity between different pollens. RESULTS: The SPTs were positive with all the pine pollen extracts tested in 69% of the patients. Specific IgE was positive to PR or P. strobus in 77% of the patients, and to Lolium perenne in 51%. Nine different allergenic bands were detected. The two main allergens were a 42 kDa band recognized by 85% of the patients and a band of approximately 6-8 kDa recognized by 40%. A high degree of cross-reactivity was observed between different pine pollen species, but not between pines and C. sempervirens pollen. A partial cross-reactivity could be seen between pine and grass pollens only in patients also sensitized to L. perenne. CONCLUSIONS: Pine pollen should be considered as a potential allergenic pollen especially where this pollen is abundant. The detection of a high number of patients that were monosensitized to pine pollen suggests the possibility of treating these patients with specific immunotherapy.

Diagnosis of clavulanic acid allergy using basophil activation and leukotriene release by basophils.

Clavulanic acid is a potent inhibitor of B-lactamase that is increasingly prescribed in association with amoxicillin. We report 2 cases of patients who experienced pruritus, wheals, and angioedema after oral intake of amoxicillin/clavulanic acid. Routine skin tests for B-lactam antibiotics and specific immunoglobulin (Ig) E were negative in both patients. Analysis of CD63 expression by the basophil activation test (BAT) using flow cytometry and of sulphidoleukotriene (sLT) release by basophils using the cellular allergen stimulation test (CAST) revealed significant positive responses with amoxicillin/clavulanic acid and with clavulanic acid, and negative responses with amoxicillin and other beta-lactam antibiotics. In addition, cultured CD3+CD4+ cells showed a significant increase in the expression of CD69, CD25, and HLA-DR in the presence of clavulanic acid. Both patients tolerated therapeutic doses of amoxicillin. BAT and CAST are useful ex vivo procedures for the detection of specific IgE-mediated allergy to clavulanic acid, especially for patients with negative skin test results.

Study of hypersensitivity reactions and anaphylaxis during anesthesia in Spain.

BACKGROUND: Several studies have identified neuromuscular blocking agents as the most common cause of anaphylaxis during general anesthesia. The reported frequencies vary considerably between countries. There are few reports from Spain, probably due to the low prevalence of reactions. METHODS: For 5 years (1998-2002), all the patients who presented perioperative anaphylactic-type reactions, were studied in 2 Spanish allergy departments (Santiago Apostol, Vitoria-Gasteiz and San Pedro, Logroño). The diagnostic protocol consisted of a case history (age, gender, number of previous interventions, characteristics of the reaction, reaction phase, previously administered drugs), serum tryptase measurements, skin tests, and specific immunoassays (immunoglobulin [Ig] E determination against latex, penicillin, and Echinococcus). RESULTS: Forty-eight patients were studied, with ages ranging from 7 to 86 years. The ratio of women to men was 3:2. An IgE-mediated mechanism was confirmed in 27/48 patients (56%). The etiological agents were antibiotics in 12 cases (44%) (10 betalactams, 1 vancomycin, and 1 ciprofloxacin), muscle relaxants in 10 cases (37%), pyrazolones in 2 cases, latex in 2 cases, and Echinococcus in 1 case. CONCLUSIONS: Fifty-six percent of the perianesthetic reactions studied were IgE-mediated. Antibiotics and neuromuscular blocking agents were the most frequent causal agents, as verified by skin tests, and specific IgE and/or challenge tests. It is important to keep appropriate documentation on any of the drugs used during surgery, since our results show that those drugs involved in the reaction as the etiological agent, such as antibiotics and nonsteroidal anti-inflammatory agents, can be used again outside the context of surgery.

Spanish Society of Allergology and Clinical Immunology (SEAIC) Vision of Drug Provocation Tests

The controlled drug provocation test (DPT) is currently considered the gold standard for the diagnosis of drug allergy. Adverse drug reactions (ADRs) are an increasingly common presenting complaint in both primary and specialized care. In Spain, ADRs are usually assessed via the allergology department, which rules out immunological mechanisms in up to 90% of cases. An adequate approach to ADRs clearly impacts the costs and efficacy of the treatments prescribed by other specialists. Consequently, if we did not use DPTs, patients would require more expensive, more toxic, and less effective treatments in many cases. In recent years, many new drugs have been developed. This document is intended to be a practical guideline for the management of DPTs according to the vision of the Spanish Allergology Society. The diagnostic work-up begins with a detailed clinical history. Skin tests are only useful for some medications, and in most cases the diagnosis can only be confirmed by DPT. Although cross-reactivity is common, DPTs can confirm the diagnosis and help to find an alternative drug. Programmed individualized patient management based on the type of drug to be studied and the patient's comorbidities usually enables a solution to be found in most cases (AU)

La prueba de exposición controlada a fármacos (DPT) se considera actualmente el estándar de oro para el diagnóstico de alergia amedicamentos. Las reacciones adversas inducidas por medicamentos (RAM) son un motivo creciente de consulta tanto en atención primariacomo especializada. Las consultas de Alergología en España son las que habitualmente estudian estas RAM y descartan mecanismosinmunológicos implicados hasta en el 90% de los casos consultados. Un abordaje adecuado de estos casos repercute de una maneraevidente en los costes y la eficacia de los tratamientos requeridos por otros especialistas, de modo que, si no empleáramos los DPT, lospacientes requerirían tratamientos más costosos, más tóxicos y menos eficaces en la mayoría de los casos.En los últimos años se han desarrollado un gran número de nuevos fármacos y este documento pretende ser una guía práctica en lagestión de las DPT con la visión de la Sociedad Española de Alergología. El trabajo de diagnóstico comienza con un historial detalladodel paciente. Las pruebas cutáneas solo son útiles en algunos medicamentos y, en la mayoría de los casos, el diagnóstico solo puedeconfirmarse mediante el DPT. Aunque suele haber reactividad cruzada, las DPT pueden confirmar el diagnóstico y también contribuir aencontrar un fármaco alternativo tolerable. El manejo individual de los pacientes de forma programada, teniendo en cuenta tanto eltipo de fármaco a estudiar como las comorbilidades del paciente, suele permitir encontrar una solución para la mayoría de los pacientes (AU)

Rheumatic manifestations in the course of anaphylaxis caused by Anisakis simplex.

Human anisakidosis is a parasitic infection caused by the larvae of Anisakis simplex. Classical clinical manifestations include epigastric pain, occlusion, diffuse abdominal pain, appendicitis, and anaphylactoid reactions. Arthralgias or arthritis have been infrequently reported. We present three patients with proven hypersensitivity to A. simplex together with rheumatologic complaints after ingestion of parasitized fishes. A. simplex must be considered in the differential diagnosis of arthralgias/ arthritis especially if associated with urticaria.

Hereditary angioedema and pneumomediastinum.

Gastrointestinal and respiratory involvement is common in hereditary angioedema, laryngeal edema being the main cause of mortality in these patients. We report the case of an 18 year-old woman with a history of hereditary angioedema, who presented an episode of coughing and vomiting the night before, and who was diagnosed with pneumomediastinum as a complication of an episode of angioedema. We review the causes and pathogenesis of the mediastinic emphysema.

Periodate treatment of Anisakis simplex allergens.

Anaphylactic reactions after parasitized fish consumption are mediated by an IgE response. However, positive skin tests and specific IgE can also be found in many asymptomatic subjects who recognize a single medium-mol.-wt. antigen by IgE immunoblot. The study aimed to find out whether this unspecificity was due to the carbohydrate moieties of parasite antigens. Sixty-two patients with suspected parasite allergy, 51 blood donors, 18 bakers, and 38 atopic patients were studied by blotting. Parasite proteins were treated with periodate. Several selected sera were inhibited with a crude wheat extract and fungal amylase. Twelve patients (19%), eight donors (16%), six bakers (33%), and one atopic patient (3%) recognized a single medium-mol.-wt. band in blotting and should be considered false-positive. This band was periodate-sensitive, but specific IgE to this allergen could not be inhibited by a wheat extract nor by fungal amylase and was clinically irrelevant. Diagnosis of Anisakis simplex hypersensitivity by skin tests and/ or specific IgE values should always be confirmed by specific IgE immunoblotting in order to detect the presence of clinically unrelated antibodies directed to periodate-sensitive allergens. These allergens are probably not a carbohydrate moiety of a parasite glycoprotein.

O-glycans as a source of cross-reactivity in determinations of human serum antibodies to Anisakis simplex antigens.

BACKGROUND: Anisakis simplex is a seafood-borne parasite that may both infect humans and cause allergy. Serodiagnosis of anisakiasis and allergy caused by this nematode is difficult since most Anisakis antigens show cross-reactivity problems. OBJECTIVE: To analyse the possible role of sugar epitopes contained in Anisakis simplex antigens as causes of false-positive results in serodiagnostic assays. METHODS: The antigens UA2R and UA3R recognized by two anti-Anisakis monoclonal antibodies were used in this study. Capture ELISA techniques were used to compare the reactivities with native or O-deglycosylated antigens of sera from Anisakis-free children (most of them infected by several other parasites) and from Anisakis allergy patients. O-deglycosylation was done by mild alkali treatment with NaOH. SDS-PAGE and immunoblotting were used to characterize the effects of NaOH or N-glycanase F treatment on UA3R. RESULTS: Native UA2R was recognized by IgG1 and IgM antibodies in the sera of both Anisakis-free subjects and allergy patients. Native UA3R was recognized by most sera from allergy patients (92% considering immunoglobulin (Ig) G1, 100% considering IgE), but also by a significant proportion of sera from Anisakis-free subjects (36% considering IgG1, 14% considering IgE). O-deglycosylation of UA3R greatly improved specificity: none of the sera from Anisakis-free patients showed either IgG1 or IgE reactivity with O-deglycosylated UA3R, while the proportion of sera from allergy patients showing IgE reactivity with this antigen was practically unaffected. O-deglycosylation of UA2R did not improve the specificity of assays using this antigen. Our results also show that the protein core of glycoproteins may be altered by even very mild alkali treatment, depending on the nature of the protein. CONCLUSION: Native glycoproteins of A. simplex should not be used for diagnostic purposes. O-deglycosylated UA3R seems to be an excellent candidate for use as target antigen in the serodiagnosis of anisakiasis and A. simplex allergy.

Human immunoglobulin isotype profiles produced in response to antigens recognized by monoclonal antibodies specific to Anisakis simplex.

BACKGROUND: Anisakis simplex is a medically important pathogen which not only causes anisakiasis but may provoke allergy reactions, ranging from mild urticaria to anaphylactic shock. OBJECTIVE: To investigate anti-Anisakis isotype profiles in anisakiasis and Anisakis allergy patients. METHODS: Capture ELISA techniques were used to investigate the isotype profiles of antibodies specific for two defined Anisakis simplex antigens, in serum from Japanese patients with confirmed anisakiasis and from Spanish patients with allergy to Anisakis. The antigens were 'UA2R antigens' (two proteins with MW of 48 and 67 kDa, recognized by our monoclonal antibody UA2) and 'UA3R antigens' (two proteins with MW of 139 and 154 kDa, recognized by our monoclonal antibody UA3). RESULTS: Considering IgG, the two most frequent isotypes in the response to the UA2R antigens were IgG1 and IgG2, with IgG4 detected in only one case; in response to the UA3R antigens, by contrast, the two most frequent isotypes were IgG1 and IgG4 (though IgG2 remained reasonably frequent). As regards potential utility for serodiagnosis, 95% of the Japanese anisakiasis patients and 84% of the allergy patients showed detectable IgG1 antibodies to the UA3R antigens. Furthermore, all allergy patients showed IgE antibodies to these antigens. CONCLUSION: Anisakis simplex contains antigens that induce responses which are differentially regulated. Because of their immunogenicity, immunodominance and allergenic nature, we consider that the 139/154-kDa antigens recognized by our MoAb UA3 are good candidates for use in tests for the diagnosis of anisakiasis and of the allergy caused by this parasite.

Laboratory determinations in Anisakis simplex allergy.

BACKGROUND: Anaphylactic reactions caused by the fish nematode, Anisakis simplex, after ingestion of parasitized fish, have been described. OBJECTIVE: This study was undertaken to confirm, by histamine release tests, that A. simplex is able to trigger IgE-mediated reactions and to describe the serologic profiles in this sensitization. METHODS: Twelve patients who had anaphylactic symptoms after ingestion of cooked fish and positive prick test results and determinations of IgE to A. simplex were studied by indirect IgG ELISA and IgG and IgE immunoblotting. Sera from subjects parasitized with other nematodes, patients with fish allergy, and healthy donors were included as controls. A histamine release test was performed in a representative case. RESULTS: IgE immunoblotting was a specific test to detect A. simplex allergy. IgE-reacting bands were found in serum samples from 11 of our patients. Specific IgG antibodies were found by ELISA and immunoblotting, but this response was less specific. Histamine release was positive with A. simplex extract and negative with fish. CONCLUSION: A specific and intense immune response to an A. simplex extract was found in our patients. A. simplex is able to elicit anaphylactic reactions, and A. simplex allergy should be suspected in patients with allergic symptoms after ingestion of fish. A positive prick test response to A. simplex and a negative response to fish is a good indication for a diagnosis of A. simplex allergy.

The use of IgE immunoblotting as a diagnostic tool in Anisakis simplex allergy.

BACKGROUND: The fish parasite Anisakis simplex is the etiologic agent of anisakiasis and induces IgE-mediated reactions. Skin prick tests (SPTs) and the measurement of specific IgE to A. simplex were, in our experience, not valid tools with which to discriminate between allergic and nonallergic patients because many control subjects also had positive results. OBJECTIVE: The study was carried out to assess the usefulness of IgE immunoblotting in the diagnosis of allergy to A. simplex. METHODS: We have studied 61 patients with acute symptoms of urticaria, angioedema, or anaphylaxis and positive specific IgE to A. simplex. According to the anamnesis, time interval between ingestion of fish and clinical onset of symptoms, and exclusion of other causes of allergy, three different groups of patients were established: group A (allergic), group NA (non-allergic), and group D (doubtful). Fifty-one healthy donors were included as control subjects (group C). IgE immunoblotting with A. simplex whole-body extract was performed in all patients and control subjects. RESULTS: Four patterns of immunoblotting were observed: type 1, with a group of several bands of medium molecular weight and others of low molecular weight; type 2, two or more bands of medium molecular weight; type 3, only one band of medium molecular weight; type 4, without any band. There was a significant predominance of blotting type 1 in group A and type 4 in group C. CONCLUSION: These data suggest that IgE immunoblotting is the most useful approach to A. simplex allergy diagnosis.