Diagnosis and treatment of Hymenoptera venom allergy in adults: A single-center experience in Lithuania.

Background: Venom-specific immunotherapy (VIT) is a major treatment for patients allergic to Hymenoptera venom. Thus, correct diagnosis of sensitization, identification of the risk factors, and choice of venom for the treatment are the key issues. Objective: We aimed to describe diagnostic and treatment experience data of VIT performed in a single center in Lithuania. Methods: In this retrospective study, we analyzed 9 years of clinical data (severity of the allergic reaction, recognition of the culprit insects, diagnostics, VIT protocol safety and efficacy, sting challenge outcomes) of patients treated with cluster VIT. Sting challenge helped to reveal the influence of venom preparation quality and to adjust the dosage of venom. Results: Data from 83 patients were analyzed. Double sensitization confirmed by component diagnosis was found in 39.4% (13/33), and double immunotherapy was initiated in 9.1% (n = 3/33). The cluster immunotherapy protocol was used in 81 patients. Systemic reactions occurred in 7.4% (n = 6/81) patients during the build-up phase. VIT failure was related to bee venom immunotherapy and systemic reactions during a build-up phase. The efficacy in the short term of our approach to cluster VIT was confirmed by the sting challenge in 97% (42/43). Nine patients (10.8%, n = 9/83) voluntarily stopped the treatment due to a lack of motivation. Conclusion: Our protocol regarding the investigation and treatment of patients allergic to Hymenoptera venom has been safe and effective. Patient's motivation to continue VIT is one of the concerns, but the biggest challenge is the patients with bee venom allergy and repeated systemic reactions during VIT.

Two case reports of skin vasculitis following the COVID-19 immunization.

The coronavirus 2019 (COVID-19) disease is now responsible for one of the most challenging and concerning pandemics. Since December 2020, the world has had access to COVID-19 prophylaxis; thus, we encounter adverse events from vaccination more often due to the vast vaccination range. We present two case reports of difficult-to-treat skin vasculitis due to COVID-19 vaccination that were successfully treated in a tertiary-level university hospital. When encountering systemic treatment, resistant skin vasculitis plasmapheresis could be a choice of treatment.

The Penetration of Chromium: An Up-To-Date 0.5% Potassium Dichromate Vehicle Comparison.

BACKGROUND: Chromium (Cr) contact allergy is frequent in many industrialized countries. The knowledge of the factors that can influence percutaneous penetration is very important assessing the risk of human exposure. OBJECTIVE: The aim of the study was to compare the concentration of Cr in various skin layers using 2 different vehicles. METHODS: Full-thickness (approximately 1 mm) porcine ear skin was mounted in Franz-type diffusion cells. Duplicate potassium dichromate preparations in 0.5% petrolatum (pet) and 0.5% in aqua (aq) were applied to the donor compartment facing the epidermis for 24 hours. After the experiment, the porcine skin samples were cut with a microtome. All samples were analyzed for total Cr concentration by inductively coupled plasma sector field mass spectrometry. The limit of detection was 0.001 µg/cm3. RESULTS: Chromium was detected in both recipient phases. The distribution of Cr in the skin is similar for pet and aq preparations, but the concentration of Cr detected in the skin was almost 2 times lower for pet comparing aq preparations. CONCLUSIONS: Both vehicles were suitable for penetrating the skin. Less Cr is found in the skin when pet is used as a vehicle. Acid wipe sampling and finger immersion test results might be false-negative for Cr in occupations involving contact with Cr salts in aq solutions.

Vaccinating with a COVID-19 Vaccine: Experience of the Tertiary Allergology Center.

Background: Allergic reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but detailed descriptions and further actions are not well characterized. Objective: To describe the symptoms of possible allergic reactions after the mRNA COVID-19 vaccine and outcomes of further vaccination. Methods: We descriptively analyzed data of adult (≥18 years of age) patients, who were sent for vaccination to our outpatient center for the Diagnostics and Treatment of Allergic and Immune diseases. All patients were vaccinated with the Pfizer-BioNTech Comirnaty® vaccine. Results: From January 2021 to July 2021 twenty-two patients were vaccinated in our center. Six patients experienced a reaction after the first Comirnaty® dose in different vaccination centers. The majority of them complained of various types of rashes after the first dose, one case was consistent with anaphylaxis. The latter patient was tested with the skin prick using Pfizer-BioNTech Comirnaty® vaccine and the test was negative. Other sixteen patients were vaccinated in our center from the first dose because of past allergic reactions to other medication or due to concomitant mast cell disorder. All patients were vaccinated without any immediate adverse reactions. Conclusions: None of our patients experienced repeated cutaneous reactions after the second dose. Patients with previous anaphylaxis or mastocytosis also were safely vaccinated.

Patch test results to extracts of synthetic garments in textile dye positive patients.

BACKGROUND: Disperse dyes (DDs) are the most prevalent causes of textile-related allergic contact dermatitis and are used for colouring synthetic textile materials based on fibres such as polyester, acrylic, acetate and polyamide. Eight DDs are included in a textile dye mix (TDM) 6.6% petrolatum (pet.) in the European baseline patch test series. OBJECTIVES: The aim of this study was to patch test TDM 6.6% pet. positive individuals with the extracts of synthetic fibre clothes that do not contain any of the pure DDs present in the TDM 6.6% to study the reactivity pattern. METHODS: Seventy-three TDM-positive former patients tested between 2012 and 2017 at the Department of Occupational and Environmental Dermatology in Malmö, Sweden were invited to join the study, 10 participated. Twenty-four textile items (collected in nine countries in Europe, Asia and North America in 2012) were extracted in dichloromethane. The TDM 6.6% was patch tested simultaneously with the 24 textile item preparations in petrolatum made from the extracts. Prior to patch testing the participants filled the 7-question questionnaire regarding possible symptoms from textile exposure. RESULTS: Ten individuals, agreed to join the study. Eight of them reacted to TDM 6.6%. Nine participants reacted to 20 of 24 extracts. One reacted to 19 extracts, another to 14, 3 to 5 extracts, 1 to 4, 1 to 3 extracts and 2 to 2 extracts. One was negative to all tested preparations including TDM 6.6%. The participants mainly reacted to six textile extracts. All controls tested negatively to tested extracts. Four individuals of the 10 TDM-allergic individuals previously had had problems after wearing clothes. Four out of the 10 participants had had atopic eczema in childhood. All women had dyed their hair with permanent hair dyes but none of the males. CONCLUSION: TDM-positive patients react to textile extracts made from synthetic garments, even if they do not contain any of the pure DDs present in TDM 6.6%. More studies are needed to pin-point the culprit haptens in these extracts.

Occupational exposure to nickel, cobalt, and chromium in the Lithuanian hard metal industry.

BACKGROUND: Metalworkers are said to have heavy exposure to metals, but the amount of released metal ions from alloys and deposition on the hands is unknown. OBJECTIVE: To analyze nickel, cobalt, and chromium in vitro release to the artificial sweat from nails and wire made of different alloys, and to test metal deposition on the fingers of metalworkers. MATERIAL AND METHODS: Six different samples of nails and wire were kept in artificial sweat for 24 hours and one week, respectively. The metal release was determined by atomic absorption spectrometry (AAS). Eighty-eight consecutive metal plant workers immersed their index fingers and thumbs in separate laboratory tubes filled with deionized water for 2 minutes. The sample analysis for metals was carried out with an inductively coupled plasma mass spectrometer (ICP-MS). RESULTS: The average released concentration of Ni was 0.0012 µg/cm2 , for Co it was 0.0007 µg/cm2 , and for Cr 0.0037 µg/cm2 after 24 hours and 0.0135, 0.0029, and 0.0042 µg/cm2 , respectively, after 1 week. There was a statistically significant increase in released concentration of Ni during one week: 0.0012 µg/cm2 vs 0.0135 µg/cm2 (P = .04). Medians of the detected Co amount on fingers reflected a statistically significant difference between workplaces: 0.004 µg/cm2 for metalworkers vs 0.001 µg/cm2 for office staff (P = .04). CONCLUSION: Nickel (Ni), cobalt (Co), and chromium (Cr) can be released in different concentrations from nails and wire. Detected Ni and Cr levels can elicit dermatitis in already sensitized patients. Co can be extracted from alloys even if not mentioned on material safety data sheets. The finger immersion technique was used for cobalt and chromium detection on fingers for the first time.

Severe anaphylactic reaction to cisatracurium during anesthesia with cross-reactivity to atracurium.

A case of a severe anaphylactic reaction during general anesthesia was reported. Despite the high suspicion for cefuroxime as a trigger of the anaphylactic reaction, cisatracurium emerged being the culprit drug. This case illustrates the importance of testing all drugs used during procedures/operations, trying to find a culprit of anaphylaxis.

Skin testing with bendamustine: what concentration should be used?

We present a case of the patient, who developed hypersensitivity reaction during the treatment of chronic lymphocytic leukemia. Bendamustine was suspected as a culprit agent. The patient as well as 3 controls underwent skin testing with the concentrations of the bendamustine described in earlier studies. We doubted the testing recommendations as all the controls developed serious local reactions. The clinical meaning of the positive skin test reaction in the patient remained unclear and questioned the safeness of recommended testing concentrations as in certain situations wrong diagnosis could be made or even harm could be done. Future investigations are needed when allergy to bendamustine is suspected.

Heavy metals and the skin: Sensitization patterns in Lithuanian metalworkers.

BACKGROUND: Metalworkers are exposed to many sensitizing and irritant substances. There are no published data on contact allergy in this population in the Baltic countries. OBJECTIVES: To detect skin symptoms related to occupational exposure and to describe the reactivity pattern to the European baseline series in workers from two metal plants in Lithuania. METHODS: In this cross-sectional study 185 metalworkers (154 production workers and 31 office staff) filled an interviewer-administered questionnaire. Patch testing was performed in 135 metalworkers and office staff, as a control group. RESULTS: Metalworkers younger than 40 years complained statistically significantly more often of skin symptoms, especially on the hands and face, than older workers. Physician-diagnosed skin diseases were reported in 1.7% of cases. Metalworkers, working <20 years in the factory, more often had skin symptoms. Contact with chemicals at the workplace was suspected as the main factor provoking skin symptoms. Metalworkers were sensitized mainly to cobalt, and nickel was the most prevalent allergen among office staff. CONCLUSION: Younger metalworkers more often had skin symptoms suspected of being work-related compared to older ones. Sensitization to cobalt was more prevalent in the metalworkers than in the control group.

Solvent Orange 60 is a potent contact sensitizer in occupational and everyday life.

BACKGROUND: Solvent Orange (SO) 60 is a perinone-type dye that is often used in plastic materials such as spectacle frames and has been shown to cause contact allergy. The first case of SO 60 allergic contact dermatitis caused by spectacle frames was reported in 1999, and the second in 2011. We have recently seen 10 patients, of whom 6 developed dermatitis in the retroauricular/temporal area after wearing plastic spectacles. OBJECTIVES: To report the cause of the dermatitis in the 10 patients and to describe our first case with occupational SO 60 contact allergy. METHODS: In this retrospective study, patch test results of 10 patients, tested with the Swedish baseline series and our specific spectacle and/or plastic series, including SO 60 1.0% pet., in 2011-2017 were analysed. RESULTS: Ten patients, 2 males and 8 females, aged 43 to 71 years, reacted positively to SO 60 1.0% pet., namely, 4 pensioners, 2 nurses, 1 office worker, 1 teacher, 1 shop assistant, and 1 unemployed person. Four of the patients had an atopic history. Patch test reactions varied from + to +++; some had spread >20 cm outside the test area in terms of erythematous, infiltrated skin with papules. Retesting of patient no. 1 with serial dilutions of SO 60 in acetone showed positive reactions down to 1 ppm. Three patients reacted to the extracts of their earpieces. Gas chromatography-mass spectrometry was used to confirm the presence of SO 60 in 2 earpieces. CONCLUSIONS: SO 60 should be included in any spectacle patch test series that may be used. If there is a strong suspicion of contact allergy to SO 60 before patch testing, lowering the test concentration from 1.0% to 0.01% should be considered.

Metals Are Important Contact Sensitizers: An Experience from Lithuania.

Background. Metals are very frequent sensitizers causing contact allergy and allergic contact dermatitis worldwide; up-to-date data based on patch test results has proved useful for the identification of a problem. Objectives. In this retrospective study prevalence of contact allergy to metals (nickel, chromium, palladium, gold, cobalt, and titanium) in Lithuania is analysed. Patients/Methods. Clinical and patch test data of 546 patients patch tested in 2014-2016, in Vilnius University Hospital Santariskiu Klinikos, was analysed and compared with previously published data. Results. Almost third of tested patients (29.56%) were sensitized to nickel. Younger women were more often sensitized to nickel than older ones (36% versus 22.8%, p = 0.0011). Women were significantly more often sensitized to nickel than men (33% versus 6.1%, p < 0.0001). Younger patients were more often sensitized to cobalt (11.6% versus 5.7%, p = 0.0183). Sensitization to cobalt was related to sensitization to nickel (p < 0.0001). Face dermatitis and oral discomfort were related to gold allergy (28% versus 6.9% dermatitis of other parts, p < 0.0001). Older patients were patch test positive to gold(I) sodium thiosulfate statistically significantly more often than younger ones (44.44% versus 21.21%, p = 0.0281). Conclusions. Nickel, gold, cobalt, and chromium are leading metal sensitizers in Lithuania. Cobalt sensitization is often accompanied by sensitization to nickel. Sensitivity rate to palladium and nickel indicates possible cross-reactivity. No sensitization to titanium was found.

Time trends of contact allergy to the European baseline series in Lithuania.

BACKGROUND: Monitoring trends of positive patch test reactions is useful for epidemiological surveillance and contact allergy prevention, and has not previously been reported in Lithuania. OBJECTIVES: To examine and compare changes in the prevalence of contact allergy to European baseline series allergens in adults with suspected contact dermatitis during a 9-year period. METHODS: In this retrospective study, patch test results of 297 consecutive patients, tested with the European baseline series in 2014-2015, were analysed and compared with the data published earlier in Lithuania. RESULTS: The most common allergens were nickel sulfate (30.6%), methylisothiazolinone (MI) (13.5%), methylchloroisothiazolinone (MCI)/MI (7.4%), potassium dichromate (6.1%), cobalt chloride (6.1%), Myroxylon pereirae resin (5.4%), p-phenylenediamine (5.4%), fragrance mix I (4.7%), formaldehyde (4.4%), and methyldibromo glutaronitrile (3.7%). Increases in the prevalence of sensitization to MCI/MI (2.3% in 2006-2008 and 7.4% in 2014-2015; p < 0.0001) and nickel sulfate (16.4% in 2006-2008 and 30.6% in 2014-2015; p < 0.0001) and decreases in the prevalence of sensitization to paraben mix (3.2% in 2006-2008 and 0.3% in 2014-2015; p = 0.006) were observed. Prevalences for the other allergens remained stable or showed a decreasing trend (Myroxylon pereirae resin; p = 0.06). CONCLUSION: This study provides current information on the prevalence of contact allergy in Lithuania. Changing trends in sensitivity to some allergens probably reflect changes in exposure.