Successful desensitization in a patient with recurrent anaplastic oligodendroglioma presenting with procarbazine-mediated anaphylaxis.

INTRODUCTION: Procarbazine is an oral chemotherapeutic agent used in the treatment of brain malignancies and is associated with hypersensitivity reactions. In case of grade 4 reactions, rechallenge should be avoided, and the agent should be replaced, unless the treatment is curative, in which case the application of a desensitization protocol should be considered. We present a successful case of desensitization in procarbazine anaphylaxis. CASE REPORT: A 53-year-old male patient was diagnosed with recurrent anaplastic oligodendroglioblastoma. The patient received three cycles of procarbazine, lomustine, and vincristine chemotherapy for malignancy recurrence. In the fourth cycle, on the 12th day of procarbazine treatment, the patient developed anaphylaxis. Procarbazine was given together with premedication as part of the 12-step desensitization process, and the fourth cycle was successfully completed. MANAGEMENT AND OUTCOME: Procarbazine hypersensitivity reactions are observed less frequently than reactions to other chemotherapeutics. We presented a case of procarbazine-associated severe anaphylaxis that was able to continue procarbazine chemotherapy with successful desensitization. This case is important in terms of confirming the procarbazine desensitization protocol. DISCUSSION: In literature there is only one protocol developed was successfully applied in one patient with procarbazine anaphylaxis. In the current case, we took this protocol into consideration in the management of our patient. Following the use of this protocol, the patient was able to continue procarbazine chemotherapy successfully. Procarbazine anaphylaxis is rare, and more cases are needed to be reported to confirm the desensitization protocol and when to continue procarbazine treatment.

Comparison of 300 mg versus 600 mg daily maintenance doses of aspirin treatment after desensitization in N-ERD: A three-year multicentre experience.

Background: Aspirin treatment after desensitization (ATAD) is effective in preventing nasal polyps recurrence as well as respiratory symptoms in patients with nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory diseases (N-ERD). However, there is no consensus on effective daily maintenance doses in ATAD. Therefore, we aimed to compare the effects of two different maintenance doses of aspirin on clinical outcomes for 1-3 years of ATAD. Methods: This was a retrospective, multicenter study that involved four tertiary centers. The maintenance doses of daily aspirin were 300 mg in one center and 600 mg in the remaining three. The data of patients who were on ATAD for 1-3 years were included. Study outcomes (nasal surgeries, sinusitis, asthma attacks, hospitalization, oral corticosteroid use, and medication uses) were assessed in a standardized way and recorded from case files. Results: The study initially included 125 subjects, 38 and 87 were receiving 300 and 600 mg daily aspirin for ATAD, respectively. Number of nasal polyp surgeries decreased after 1 -3 years compared with before ATAD in both groups (group 1, baseline: 0.44 ± 0.07 versus first year: 0.08 ± 0.05; p < 0.001 and baseline: 0.44 ± 0.07 versus 3rd year: 0.01 ± 0.01; p < 0.001; and group 2, baseline 0.42 ± 0.03 versus first year: 0.02 ± 0.02; p < 0.001 and baseline: 0.42 ± 0.03 versus 3rd year: 0.07 ± 0.03; p < 0.001). Conclusion: Given the comparable effects of 300 mg and 600 mg aspirin daily as maintenance treatment of ATAD on both asthma and sinonasal outcomes in N-ERD, our results suggest using 300 mg of aspirin daily in ATAD owing to its better safety profile.

Comparison of the clinical outcomes of patients with NSAID-exacerbated respiratory disease receiving aspirin or biologicals.

OBJECTIVE: NSAID-exacerbated respiratory disease (NERD) is characterized by exacerbation of respiratory symptoms after NSAID intake. While research for specific treatment options continues in patients who cannot tolerate or are unresponsive to aspirin treatment after aspirin desensitization (ATAD), biologicals have emerged as a new therapeutic option in NERD patients. The aim of this study was to compare the quality of life, and the sinonasal and respiratory outcomes of NERD patients treated with ATAD or biologicals. METHODS: Patients who have been followed up at a tertiary care allergy center and who have been receiving at least one of ATAD, mepolizumab or omalizumab for at least six months were included. Evaluations were made using sinonasal outcome test (SNOT-22), asthma control test (ACT), short form-36 (SF-36), blood eosinophil counts, need for recurrent functional endoscopic sinus surgeries (FESS), and asthma or rhinitis exacerbations requiring oral corticosteroids (OCS). RESULTS: A total of 59 patients comprised of 35 (59%) females and 24 (41%) males with a mean age of 46.1 (min-max, 20-70) years were included. The baseline blood eosinophil count was higher, and a significant decrease in blood eosinophil counts was observed in the mepolizumab group compared to ATAD group (p = 0.001, p < 0.001, respectively). At follow-up, the rate of recurrent FESS was lower in the group that received mepolizumab (p = 0.02). CONCLUSIONS: In NERD patients, mepolizumab significantly decreased blood eosinophil counts and recurrent FESS. There was no significant difference between the patients receiving ATAD or mepolizumab regarding other clinical parameters.

Sinonasal and respiratory outcomes of eosinophilic granulomatosis with polyangiitis patients receiving 100 mg mepolizumab in real-life clinical practice: 1-year follow up study.

Background: Mepolizumab 300 mg is an approved treatment option for patients with eosinophilic granulomatosis with polyangiitis (EGPA), yet, the adequacy of 100 mg of mepolizumab in disease control is controversial.Objective: To evaluate the sinonasal and respiratory outcomes of EGPA patients treated with 100 mg mepolizumab for one year.Methods: Evaluations of 11 patients were made of the sinonasal outcome test (SNOT-22) (nasal, otologic, sleep, and emotional domains), asthma control test (ACT), forced expiratory volume in 1 s (FEV1), blood eosinophil counts and oral steroid doses before mepolizumab treatment (T0) and at the 6th (T6) and 12th (T12) months.Results: A significant decrease was observed in the total SNOT-22 scores in the 6th month, after which the scores continued to be stable until the 12th month. (SNOT-22 median (IQR); T0: 70(53-82); T6: 19(4-35); T12: 11(6-40); T0-T6, p = 0.02; T6-T12, p = 0.85). In the subdomains of SNOT-22, nasal and sleep-related domains improved significantly in the first 6 months, and the otologic and emotional domains only improved from baseline in the 12th month. There was a significant decrease in blood eosinophil counts in the 6th month and oral steroid dose in the 12th month (eosinophils, median(IQR), T0: 1000(700-1800), T6: 100(0-200), p = 0.02; OCS dose, median(IQR), T0: 16(8-16); T6: 4(0-4); T12: 0(0-4); T0-T12, p = 0.002). A significant improvement was observed in ACT values in the 6th month (ACT median (IQR); T0:16(8-18); T6: 22(21-25); p = 0.01).Conclusion: Mepolizumab 100 mg provided a significant decrease in SNOT-22 values, especially in nasal and sleep domains, eosinophil counts and OCS dose in the 6th month.

The clinical features and treatment of eosinophilic granulomatosis with polyangiitis (EGPA) in Turkey: one or two distinct diseases?

Eosinophilic granulomatosis with polyangiitis (EGPA) is defined the disease as having two subgroups, ANCA (+) and ANCA (-). We aimed to compare EGPA subgroups in terms of clinical features, outcomes, and treatments. A multidisciplinary team was established under our vasculitis centre since October 2014. Totally 50 EGPA patients were enrolled. Clinical features, treatments, and outcomes (FFS, VDI, relapse) were reviewed. For relapse-free survival analysis, time to first relapse was compared according to ANCA phenotype by Kaplan-Meier survival analysis and log-rank test. 17 (34%) patients were in ANCA (+), 33 (66%) patients were in ANCA (-) group. ANCA (-) patients were significantly younger at the diagnosis time (37.9 ± 14.3 vs 53.8 ± 16.3; p = 0.001) and had more nasal polyposis (45.5% vs 11.8%; p = 0.017). ANCA (+) patients had higher BVAS (17[13] vs 9[4]; p = 0.002), renal involvement and peripheral neuropathy were more common in this group, while cardiac involvement was seen only in ANCA (-) group (n = 3). Biological agents (mepolizumab or rituximab) were prescribed to nine patients in ANCA (-) and two patients in ANCA (+) group. The median duration of follow-up was 47 (IQR 69.9) months. ~ 40% of patients had at least one relapse, but relapse-free survival rate was similar between the groups. However, the predictor of first relapse was elevated Ig E level [OR (95% CI): 6.5 (1.09-38.63) p = 0.04]. Consequently, both clinical features, disease activity, and treatments appear to be significantly different between EGPA subgroups. The relapse risk was similar although clinical features and treatment strategies were different. Also, elevated Ig E levels may be a precursor for the relapse.

Regular Treatment With Aspirin 300 mg/day After Desensitization in Patients With N-ERD: 12-Year Results.

OBJECTIVE: Aspirin desensitization is recommended for patients with nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity, in whom asthma is uncontrolled despite medical treatment, and/or frequent endoscopic sinus surgery (ESS) is required due to nasal polyps. There are few studies in the literature on long-term follow-up of patients undergoing regular aspirin treatment after desensitization. This study aims to evaluate the effect of regular aspirin treatment on respiratory function, symptom control, quality of life, and the number of nasal surgeries required during a period of 12 years. MATERIAL AND METHODS: A total of 18 patients were included in the study in 2006; 11 patients were excluded and 7 patients regularly taking aspirin for 12 years were evaluated. Oral aspirin desensitization was performed at 4-6 weeks following the ESS. Patients receiving 300 mg/day aspirin were followed up in control visits every 3 months. Nasal and respiratory system examinations and pulmonary function test were performed, and all patients responded to the SF-36 Quality of Life scale during each visit. RESULTS: There was no change in respiratory function parameters following the12-year aspirin treatment. There was no statistically significant improvement in the quality of life; however, the need for ESS due to the recurrence of nasal polyps decreased significantly (P = .000). At the 12-year follow-up, all symptom scores improved, but improvement in the postnasal drip score was statistically significant (P = .046). CONCLUSION: Long-term regular treatment with aspirin at a dose of 300 mg/day in patients with N-ERD improved symptom scores, and alleviated the need for ESS due to nasal polyp recurrence.

Is the Perioperative Period No Longer a Problem for Adult Asthmatics under Control?-OPERA Study.

OBJECTIVES: Asthma is a global problem and chronic condition that persists through patient's entire life, during which the possibility of a surgical procedure is common. An accurate clinical and functional evaluation of respiratory functions and asthma control is needed in patients undergoing surgical procedures and requiring general anesthesia. The aim of this study was to disclose any possible relation between postoperative complications and some pre- and postoperative factors. MATERIALS AND METHODS: In this prospective cross-sectional study, randomly selected 111 asthmatic patients who presented to 10 different tertiary centers were included. The patients were evaluated at three different periods; any day between 1-7 days before surgery, and postoperative third and seventh to tenth days. RESULTS: Among the patients included in the study, 86 (77.5%) were women and mean age was 52.2±13.8 years. General anesthesia was the most common anesthesia type (89.2%), and 33.3% of patients had had a thoracoabdominal surgery. There was a statistically significant difference between pre- and postoperative third-day values, including ACT scores (22.2±3.16 and 21.59±3.84, respectively; p<0.001); forced expiratory volume during the first second (84.92±19.12 and 78.26±18.47, respectively; p<0.001); peak flow rate (79.51±21.12 and 70.01±19.72, respectively; p<0.001); and SaO2 (96.95±1.82 and 95.8±3.32, respectively; p<0.001). Bronchospasm and pain were the most common complications during the postoperative period. CONCLUSION: Controlled asthma under treatment steps 1-2-3 does not cause any serious postoperative pulmonary complications (PPCs). Therefore, achieving an optimal control level of asthma during the preoperative period must be considered the "gold standard" to reduce the risk of PPCs in asthmatic patients.

Screening instrument to identify skin prick test-negative patients with asthma and/or rhinitis.

INTRODUCTION: To the best of our knowledge, there is no prediction tool for determining respiratory allergy in patients with asthma and/or rhinitis. OBJECTIVES: As such, this study aimed to develop an instrument for identifying skin prick test (SPT)-negative patients with asthma and/or rhinitis. METHODS: This cross-sectional study screened 510 consecutive patients diagnosed with asthma and/or rhinitis between November 2009 and May 2011 in Ankara, Turkey. A structured questionnaire was the screening tool that was administered during the initial visit by the treating specialist and compared with a SPT result. All 15 variables were analysed using the logistic regression model to obtain ß values (a score) for each variable. Each variable had a score, and scores were summed up to obtain final score for each patient. RESULTS: The study included 363 patients, of which 165 (45.5%) were SPT positive. The final model included 13 variables. The lowest and highest scores were -21 and 26. A total score of 5.5 had sensitivity of 63% and specificity of 80%. The area under the receiver operating characteristic curve was 0.78. The histogram of the total scores for the study population was bimodal. CONCLUSIONS: We designed a highly specific 13-item instrument for identifying SPT-negative patients. It may be used in middle income countries where allergy testing is expensive, not reimbursed or few allergy clinics are available. We think that our idea is interesting, that needs further research.

Non-steroidal anti-inflammatory drug hypersensitivity in adults and the factors associated with asthma.

BACKGROUND: Characteristics of non-steroidal anti-inflammatory drug (NSAID)-hypersensitivity (NH) associated with underlying/accompanying diseases has not been studied in Turkey. In addition, the factors associated with asthma in NH patients are not well known. The present study aimed to investigate the relationship between NH and chronic urticaria, rhinitis/rhinosinusitis, and asthma in an effort to identify NH phenotypes. The study's secondary aim was to identify the factors associated with asthma in NH patients and the NSAID reaction pattern in asthmatics. METHODS: Data for 1137 NH patients in our hospital's allergy clinic database were retrospectively analyzed. Patients were divided into 5 groups based on their accompanying diseases (chronic urticaria, asthma, rhinitis/rhinosinusitis). Asthmatic patients were compared to non-asthmatic patients to identify the factors associated with asthma. RESULTS: Reaction patterns and patient characteristics in each group differed from those in the reference group (NH only group). Asthma in patients with NH was associated with female gender, sinonasal polyposis/polyp surgery, rhinitis/rhinosinusitis, NSAID-induced rhinitis/asthma or a blended reaction pattern, immediate reaction following NSAID intake, self-reported history of food allergy, and family history of asthma; the odds ratios and 95% CIs were 1.35 (1.02-1.78), 13.52 (8.74-20.9)/10.94 (6.73-17.77), 12.06 (9-16.17), 15.28 (10.45-22.36)/2.43 (1.70-3.45), 1.76 (1.31-2.35), 1.49 (1.04-2.14), and 3.1 (2.35-4.08), respectively. The characteristics of the asthmatic patients that had urticaria/angioedema-type reactions to NSAID intake (pseudo Samter's syndrome) differed from those in the asthmatics with rhinitis/asthma-type reactions. CONCLUSIONS: Chronic urticaria, rhinitis, and asthma commonly accompany NH. NSAID response patterns in NH patients may help differentiate groups of patients. The present study identified factors associated with asthma in NH patients and observed that there seems to be different phenotypes of Samter's syndrome, for which a new classification scheme was proposed.

Smooth muscle hyperplasia in an asthmatic patient: do we know it all?

Bronchial smooth muscle hyperplasia is a well-known structural change in asthma. The degree of hyperplasia is related to asthma severity. We report a case of extreme smooth muscle hyperplasia in an asthmatic patient. A 54-year-old female with a diagnosis of analgesic-induced asthma was admitted to our center for nasal polyposis surgery. During her preoperative evaluation, atelectasis of the right middle lobe was detected on chest X-ray. Bronchoscopy revealed the presence of a vegetating polypoid mass obliterating the entrance of the right middle lobe. Histopathological examination of the surgically excised polypoid mass showed benign smooth muscle proliferation with diffuse eosinophilic infiltration. This is a rare case representing an extreme example of benign smooth muscle hyperplasia forming an endobronchial mass in an asthmatic patient.

Asthma and allergic diseases in school children from 1992 to 2007 with incidence data.

BACKGROUND: Information about change in the prevalence of asthma and allergic diseases and factors related with these diseases would be beneficial in decreasing the burden of these diseases. OBJECTIVE: To assess (i) change in prevalence of asthma and allergic diseases; (ii) factors associated with asthma and wheeze; and (iii) incidence of asthma and wheeze. METHODS: A questionnaire was administered to children aged 7-12 years in first five grades in the same primary school in 1992 (n: 1036), 1997 (n: 738), 2002 (n: 621), and 2007 (n: 422) and filled by the parents. A second survey in 2007 (n: 474, in eight grades) was conducted in the same schoolchildren, 6 months apart, to assess the incidence of asthma and wheeze and the associated factors. RESULTS: Comparison of 1992, 1997, 2002, and 2007 surveys revealed that prevalence of asthma (8.3%, 9.8%, 6.4%, 3.3%, respectively), wheeze (11.9%, 13.3%, 6.4%, 3.1%, respectively), hay fever (15.4%, 14.1%, 7.2%, 3.1%, respectively), and eczema (4.0%, 4.3%, 1.8%, 1.2%, respectively) were significantly lower in 2002 and 2007 compared with that in 1992. Percentage of passive smoking decreased after 1992 (74.0%, 64.0%, 64.1%, and 65.5%, respectively). Incidence of asthma and wheeze in 2007 surveys were 0.9/100 and 1.1/100, respectively. After the adjustment for age and gender, infection in the past, family atopy, and presence of atopic disease (eczema or hay fever) were associated with asthma and wheeze. Maternal smoking and lack of breast feeding were associated with asthma. Male gender, pet ownership in the past, lack of health insurance coverage, snoring, and wood or coal used as fuel were associated with wheeze. CONCLUSIONS: Decreased prevalence of asthma and allergic diseases in the last 10 years could be related to decreased rate of passive smoking. Lower socioeconomic status and lack of breast feeding could increase the risk of asthma in children.

Association between asthma, rhinitis and NSAID hypersensitivity in chronic urticaria patients and prevalence rates.

BACKGROUND: The coexistence of allergic diseases and chronic urticaria (CU) is not uncommon. Our aim was to show the prevalence of allergic diseases in chronic urticaria patients and whether possible risk factors precipitate the development of these conditions. METHODS: The data of 953 patients diagnosed with CU in our adult allergy clinic between January 1991 and June 2006 were retrospectively evaluated. RESULTS: The mean ages of the CU patients with and without non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH) were 39.0 +/- 11.8 and 36.7+/- 12.3, respectively (p = 0.014). There was a female predominance in both groups (74.6 and 68.2%, respectively, p = 0.06). Apparently, some conditions occurred significantly more often in CU patients with NSAIDH compared to those without NSAIDH: 16.4 and 8.4% for asthma (p < 0.001), 4.2 and 0.8% for nasal polyps (p < 0.01), 20.8 and 7.3% for antibiotic hypersensitivity (p < 0.001), 21.6 and 12.3% for metal sensitization (p < 0.01), and 8 and 0.6% for familial NSAIDH (p < 0.001), respectively. Dermographism was more common in CU patients without NSAIDH compared to those with NSAIDH (29.4 and 21.2%, respectively; p < 0.05). NSAIDH increased the risk of asthma and rhinitis development [odds ratios: 52.9 (18.1-154.6) and 5.2 (2.0-13.4)]. CONCLUSION: Based on our data, the incidence rates of asthma, nasal polyps, antibiotic hypersensitivity, metal sensitization and familial NSAIDH are increased in patients with CU with NSAIDH compared to those with CU only. Coexistence of NSAIDH and CU increases the risk of developing asthma and rhinitis.

Massive deep venous thrombosis and venous gangrene in a 29-year-old case: metastatic epidermoid carcinoma with an unknown primary.

Cancer-associated venous thromboembolism is a severe form of paraneoplastic syndrome. It rarely leads to venous gangrene. We report a case who presented with multiple deep venous thrombosis and venous gangrene of the lower extremity. During the follow-up period, the patient developed bilateral cervical and right supraclavicular lymphadenopathies. The fine needle aspiration of the lymph nodes revealed metastatic epidermoid carcinoma of an unknown primary. Thrombotic manifestations may complicate the clinicopathological course of malignancies.

Asthma and allergic diseases in schoolchildren: third cross-sectional survey in the same primary school in Ankara, Turkey.

We investigated prevalence and determinants of asthma and allergic diseases in a cross-sectional survey of schoolchildren aged 6-14 in 2002. This was the third of a series of cross-sectional surveys, conducted in 1992 and 1997, in the same school in Ankara, Turkey. Questionnaire including information on house characteristics, dietary habits, past and current exposures and diseases were distributed to 1064 children (523 boys, 541 girls) and filled by the parents at home. Percentage of children having a pet was significantly higher (1992: 7.9, 1997: 22.9, 2002: 21), but that of passive smoking was significantly lower (1992: 74, 1997: 64, 2002: 64.1) in 1997 and 2002 when compared with 1992. Current prevalence percentage of asthma (1992: 8.3, 1997: 9.8, 2002: 6.4), wheeze (1992: 11.9, 1997: 13.3, 2002: 6.4), hay fever (1992: 15.4, 1997: 14.1, 2002: 7.2), and eczema (1992: 4, 1997: 4.3, 2002: 1.8) were significantly lower in 2002 compared with 1992. Multiple logistic regression analysis model for current wheeze included ingestion of cow's milk (no regular ingestion: reference, ORs and 95% CIs, <1 glass/day: 0.5, 0.3-1.0; at least 1 glass/day: 0.3, 0.2-0.7), ingestion of red meat (2.2, 1.2-3.8), and currently holding a dog (6.1, 1.6-23.4). Multiple logistic regression analysis model for current hay fever included ingestion of red meat (1.8, 1.1-2.9) and father's education (none of the parents finished secondary school: reference, secondary school to university: 0.5, 0.2-1.0). Our findings suggested that current prevalence of asthma and allergic diseases decreased among schoolchildren in Ankara, in the last 10 yr, and ingestion of milk and red meat could have a role in the occurrence of asthma and hay fever. Detailed assessment of dietary habits is required to test this hypothesis.

Allergy symptoms and IgE immune response to rose: an occupational and an environmental disease.

BACKGROUND: Turkey is one of the four major producers of rose. Cultivation of rose is the main economic activity of many villagers in the Lakes region. Rose allergy has not been reported before. We investigated the prevalence of allergy symptoms and specific-IgE immune response due to rose in villagers who had been cultivating rose in Güneykent village in the Lakes region. METHODS: A screening questionnaire including respiratory and allergic symptoms was administered to 290 villagers. The investigation team visited and studied 75 randomly selected villagers with an interviewer-administered questionnaire, pulmonary function testing, skin prick testing and serum total IgE. Specific IgE against Rosa rugosa was measured in 41 villagers. RESULTS: Villagers reported asthma/allergy symptoms outside the rose season (17.6%), during the rose season (6.2%), and both during the rose season and outside the rose season (whole the year) (17.6%). Atopy and specific IgE against Rosa rugosa were detected in 12 (19%), and 8 (19.5%) of the villagers tested. Villagers who had symptoms whole the year reported wheeze more frequently than those who reported symptoms only outside the rose season (41.2% vs 11.1%). CONCLUSIONS: IgE-mediated allergy could occur due to rose and/or its pollen. Symptoms mainly affect the upper airways. Further studies in the rose handlers, florists and workers of the rose industry would help elucidate the occurrence of rose allergy.