Persistent type IV hypersensitivity after cyanoacrylate closure of the great saphenous vein.

The VenaSeal (Medtronic, Minneapolis, Minn) cyanoacrylate closure system is a nonthermal technique for ablating saphenous veins using a proprietary n-butyl cyanoacrylate. One possible side effect is an allergic reaction to cyanoacrylate. We report the case of a 49-year-old woman treated with cyanoacrylate closure who developed a persistent type IV hypersensitivity reaction. The patient elected to have the vein excised, and the histologic features were consistent with a type IV hypersensitivity reaction.

Diagnostic Evaluation in Aspirin-Exacerbated Respiratory Disease.

Aspirin-exacerbated respiratory disease (AERD) is a distinct clinical condition characterized by chronic sinusitis with nasal polyps, asthma, and hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). Distinguishing AERD from other forms of chronic sinusitis, asthma, and NSAID reactivity has important clinical implications for management. The clinical history is helpful, but not adequate for confirming the diagnosis of AERD, in most cases. Diagnostic provocation challenge remains the only way to confirm or exclude the diagnosis of AERD. This article discusses the utility of the clinical history and the current evidence regarding measures that optimize the safety of performing diagnostic NSAID provocation challenges.

The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis.

Aspirin-exacerbated respiratory disease (AERD) is a chronic inflammatory disease characterized by chronic rhinosinusitis, nasal polyposis, asthma, and airway reactivity to aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs). For patients who have inadequately controlled rhinosinusitis and/or asthma despite treatment with topical corticosteroids and leukotriene-modifying drugs, aspirin desensitization is an important therapeutic option. This review examines the evidence supporting the effectiveness of aspirin desensitization for the treatment of chronic rhinosinusitis in patients with AERD. Practical aspects of conducting safe aspirin desensitization procedures and optimizing therapeutic benefits are also reviewed. When conducted in accordance with current guidelines, aspirin desensitization is a safe procedure that allows patients with AERD who have an indication for aspirin or other NSAIDs to safely ingest these medications. There is now strong evidence that aspirin desensitization and daily aspirin therapy is effective for treatment of the chronic inflammatory disease of the upper airway and lower airways in AERD.

Sinusitis and chronic progressive exercise-induced cough and dyspnea.

We present the case of a 47-year-old man with exercise-induced dyspnea, cough, chest tightness, and recalcitrant chronic rhinosinusitis. Evaluation revealed IgE sensitization to grass, tree, and weed pollen, no evidence of obstruction on spirometry, and a negative methacholine challenge. Diagnostic considerations included allergic and nonallergic rhinitis, asthma, aspirin-exacerbated respiratory disease, vocal cord dysfunction, extra-esophageal manifestations of acid reflux, and vasculitits. Further evaluation with sinus imaging, laryngoscopy, ambulatory pharyngeal pH testing, upper endoscopy, and bronchoscopy led to a diagnosis. Key issues surrounding the diagnostic and therapeutic approaches to this patient's condition are reviewed.

The relationship between historical aspirin-induced asthma and severity of asthma induced during oral aspirin challenges.

BACKGROUND: Historical aspirin- or nonsteroidal anti-inflammatory drug (NSAID)-induced reactions might provide predictive information about the severity of reactions in patients with aspirin-exacerbated respiratory disease (AERD) undergoing oral aspirin challenge (OAC). OBJECTIVE: We sought to assess the relationship between historical aspirin- or NSAID-induced bronchial reactions and the severity of bronchial reactions during OAC in patients with AERD. METHODS: Data regarding the provoking doses, treatments, and treatment settings of historical aspirin/NSAID-induced reactions were recorded, analyzed, and compared with the provoking doses, maintenance regimens, and observed decreases in FEV(1) that occurred during OAC in 210 consecutive patients referred with suspected AERD. RESULTS: Of 147 patients who reported seeking acute medical care for their historical aspirin/NSAID-induced asthma attacks, 101 (69%) were treated in an emergency department and released, and 46 (31%) required hospitalization. During OAC in these 147 subjects, 23 (16%) had a 20% to 29% decrease and 14 (10%) had a 30% or greater decrease in FEV(1) values from baseline. Of the 46 patients previously hospitalized for aspirin/NSAID-induced asthma attacks, 9 (20%) had a 20% to 29% decrease and 6 (13%) had a 30% or greater decrease in FEV(1) during OAC. By contrast, of the 63 patients who treated their prior aspirin/NSAID-induced reactions at home, 5 (8%) had a 20% to 29% decrease and 5 (8%) had a 30% or greater decrease in FEV(1) during OAC (P = not significant for both). CONCLUSION: The severity of the historical aspirin/NSAID-induced asthma attack was not predictive of asthma severity during OAC. CLINICAL IMPLICATIONS: These data provide further reassurance regarding the safety of outpatient aspirin desensitization.