A case of diacerein-induced DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome with thromboembolic complications

Diacerein is a safe drug for osteoarthritis due to its inhibitory effect on proinflammatory cytokines. Its common side effects, such as diarrhea, abdominal pain and skin rash, are relatively mild. There have been a few cases of drug reactions with eosinophilia and systemic symptoms (DRESS) syndrome accompanied by thromboembolic complications. We report the first case of diacerein-induced DRESS syndrome with thromboembolic complications. A 64-year-old man developed fever, skin rash, increase in liver enzymes, eosinophilia, deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) after taking diacerein. DVT and PTE were improved after anticoagulation therapy; however, fever, skin rash, eosinophilia and increase in liver enzymes were aggravated. A high-dose systemic corticosteroid (methylprednisolone 1 mg/kg/day) was administered, after which his clinical conditions improved.

Efficacy of Allergen Immunotherapy for Allergic Asthma in Real World Practice

PURPOSE: Allergen immunotherapy (AIT) induces immunological tolerance, and there is increasing evidence of the clinical efficacy of AIT in the treatment of allergic asthma. However, the optimal parameters for asthma control in clinical trials are still unclear. We investigated the efficacy of AIT with respect to changes in the inhaled corticosteroid (ICS) dose in patients with allergic asthma. METHODS: A total of 117 adults with allergic asthma who had used ICS for more than 1 year in a single tertiary hospital in Korea were included in this retrospective study. We compared the clinical parameters and outcomes between the AIT group (ICS with AIT, n = 48) and the non-AIT group (ICS without AIT, n = 69) by applying an inverse probability of treatment weighting method. The patients in the AIT group had received subcutaneous AIT monthly as a maintenance treatment for more than 1 year. The changes in the ICS dose from baseline were evaluated in the 2 groups for 3 years. RESULTS: The proportion of responders who discontinued or decreased in the ICS dose with achieving control status of asthma was significantly higher in the AIT group than in the non-AIT group throughout the study period (at 6 months, 52.1% vs. 24.6%; at 1 year, 70.8% vs. 34.7%; at 2 years, 89.5% vs. 35.6%; at 3 years, 96.3% vs. 51.2%). Treatment responses did not differ significantly by type of allergen (single- or multi-allergens or 3 different products) used throughout the study period. CONCLUSIONS: Irrespective of the type of allergen, long-term maintenance AIT helps to spare ICS dose and achieve better control in patients with allergic asthma in real-world clinical practice.

Proper Cut-off Levels of Serum Specific IgE to Cefaclor for Patients with Cefaclor Allergy

PURPOSE: Cefaclor, a second-generation oral cephalosporin, is known to cause IgE-mediated hypersensitivity. Assays of serum-specific IgE (sIgE) to cefaclor are commercially available via the ImmunoCAP system (Thermo Fisher Scientific). While serum levels of sIgE >0.35 kU/L are considered indicative of an allergy, some patients with cefaclor allergy show low serum IgE levels. This study aimed to evaluate the proper cut-off levels of sIgE in the diagnosis of immediate hypersensitivity to cefaclor. MATERIALS AND METHODS: A total of 269 patients with drug allergy history, who underwent assays of sIgE to cefaclor at Ajou University hospital and Dong-A University Hospital, were reviewed retrospectively. Among them, 193 patients exhibited cefaclor-induced immediate hypersensitivity with certain or probable causality of an adverse drug reaction according to the WHO-UMC (the World Health Organization-the Uppsala Monitoring Centre) algorithm, and 76 controls showed delayed hypersensitivity reactions to non-antibiotics. RESULTS: In total, 126 of the 193 patients (65.3%) experienced anaphylaxis; they had higher serum sIgE levels than patients with immediate hypersensitivity who did not experience anaphylaxis (6.36±12.39 kU/L vs. 4.28±13.61 kU/L, p < 0.001). The best cut-off value for cefaclor-induced immediate hypersensitivity was 0.11 kU/L, with sensitivity of 80.2% and specificity of 81.6%. A cut-off value of 0.44 kU/L showed the best sensitivity (75.4%) and specificity (65.7%) for differentiating anaphylaxis from immediate hypersensitivity reactions. CONCLUSION: Patients with cefaclor anaphylaxis exhibit high serum IgE levels. A cut-off value of 0.11 kU/L of sIgE to cefaclor is proper for identifying patients with cefaclor allergy, and 0.44 kU/L may be useful to detect anaphylaxis.

A Rare Cause of Secondary Hypertension in A Young Adult

Reninoma is a rare, renin-secreting, benign renal neoplasm that can cause secondary hypertension. We report a case of a 21-year-old man who suffered from progressively worsening headache for 2 months with a history of hypertension for 7 years. Laboratory studies showed normal potassium level, increased basal plasma renin activity, and normal serum aldosterone level. Abdominal computed tomography and magnetic resonance imaging revealed a small mass in the middle region of the right kidney. Partial nephrectomy was performed; immunohistochemical results demonstrated typical features of reninoma. Postoperatively, blood pressure and potassium level were normal at the 2-month follow-up.

Ventricular Septal Rupture in a Case Suspected as Stress Induced Cardiomyopathy

An 87-year-old woman with continuous chest discomfort was referred to our hospital. ST-segment elevation in lead V1-4 was detected on electrocardiography and ventricular septal rupture (VSR) was observed on echocardiography. Post-acute myocardial infarction (AMI) VSR was suspected and she underwent emergency cardiac catheterization. However, coronary angiography showed normal coronary artery. On the fourth day after admission, the patient died. We suspect that VSR was developed by stress induced cardiomyopathy, not by AMI.

Reversible Atrioventricular Block after Electrical Injury / 대한내과학회지

Here, we report a case of electrical injury-induced reversible advanced second-degree atrioventricular (AV) block. A 28-year-old male visited the emergency department for palpitations 3 days after receiving an electrical injury from 220 volt alternating current. The initial electrocardiogram (ECG) showed sinus rhythm and first-degree AV block with a prolonged PR interval of 400 ms. There was no structural heart disease or electrolyte imbalance. Follow up ECGs acquired 4-6 days after the electrical injury showed intermittent AV block with a prolonged PR interval of 400-460 ms. Exercise treadmill and atropine provocation tests performed 6 days after electrical injury induced advanced second-degree AV block. His bundle electrogram showed intermittent AH block in a Wenckebach pattern with a prolonged AH interval of 220-360 ms and a normal HV interval. Episodes of AV block decreased remarkably 4 weeks after the electrical injury, and the prolonged PR interval returned to 220 ms after 5 months.