Different phenotypes of drug-induced anaphylaxis-Data from the European Anaphylaxis Registry.

BACKGROUND: Drugs are a frequent cause of severe anaphylactic reactions. Here, we analyze a large dataset on drug induced anaphylaxis regarding elicitors, risk factors, symptoms, and treatment. METHODS: Data from the European Anaphylaxis Registry (2007-2019) with 1815 reported cases of drug-induced anaphylaxis were studied accordingly. RESULTS: Drugs are the third most frequent cause of anaphylaxis reported in the Anaphylaxis Registry. Among the eliciting groups of drugs analgesics and antibiotics were far most often reported. Female and senior patients were more frequently affected, while the number of children with DIA was low. DIA patients had symptoms affecting the skin and mucous membranes (n = 1525, 84.02%), the respiratory (n = 1300, 71.63%), the cardiovascular (n = 1251, 68.93%) and the gastrointestinal system (n = 549, 30.25%). Drugs caused significant more severe reactions, occurred more often in medical facilities and led to increased hospitalization rates in comparison to food and insect venom induced anaphylaxis. Adrenaline was used more often in patients with DIA than in anaphylaxis due to other causes. Patients with skin symptoms received more antihistamines and corticosteroids in the acute treatment, while gastrointestinal symptoms led to less adrenaline use. CONCLUSION: The study contributes to a better understanding of DIA, with a large number of cases from Europe supporting previous data, e.g., analgesics and antibiotics being the most frequent culprits for DIA. Female gender and higher age are relevant risk factors and despite clear recommendations, the emergency treatment of DIA is not administered according to the guidelines.

Contact dermatitis to hair cosmetics: Current diagnostic recommendations.

Hair cosmetics such as shampoos, hair dyes, bleaching agents or hair straightening creams contain frequent contact allergens. These can lead to allergic contact dermatitis especially in hairdressers, but also in their customers and in others who use hair products at home. While hairdressers suffer mainly from hand dermatitis, in customers and home-users, dermatitis primarily affects the head, neck and face. In this mini-review, we propose a diagnostic algorithm in two steps, based on patch testing, that can be used for the assessment of suspected hair product-induced contact dermatitis. In a first step, we recommend testing the German Contact Allergy Group (DKG) standard series, DKG ointment series, DKG preservative series, DKG hairdresser series, DKG fragrance series as well as (especially in hairdressers) the DKG rubber series. In a second step, if the culprit allergen cannot be identified with the help of the standardized test series and there is a well-founded suspicion, testing the patient's own products, such as shampoos, hair sprays and hair dyes, is recommended.

Structured diagnostic assessment of hand eczema in cleaning workers.

Hand dermatitis is a widespread problem among cleaners. In most cases, it is caused by a combination of wet work and contact with irritants, which can result in irritant (toxic) contact dermatitis. In some cases, the irritant contact eczema then evolves into allergic contact dermatitis, although not all cases of allergic contact dermatitis are preceded by irritant contact dermatitis. This mini-review proposes a two-step diagnostic algorithm based on patch testing, which can be used if allergic contact dermatitis is suspected in cleaning workers. As a first step, we recommend performing the DKG standard series (German Contact allergy research group, DKG), the DKG rubber series, both DKG "further fragrances" series as well as the DKG preservative and disinfectant series. If there are clear hints of an occupational contact dermatitis, the first step can also involve testing patients' own products alongside the standardized tests. In a second step (at the latest), if standardized tests do not suffice to identify the culprit allergen and there is well-founded suspicion, we recommend testing the patients' own products. If necessary, the second step can also include testing the individual contact allergens contained in the screening mixes that are part of the standard series.

Hypersensitivity reaction with multi-organ failure following re-exposure to rifampicin: case report and review of the literature including WHO spontaneous safety reports.

BACKGROUND: True hypersensitivity reactions to rifampicin are relatively rare, nonetheless severe manifestations mostly involving a single organ have been documented. We report a case of acute multi-organ failure occurring after a medication error with re-exposure to rifampicin. CASE PRESENTATION: A 68-year old patient developed acute hypersensitivity pneumonitis, acute renal failure, acute liver failure and haemolytic anemia within hours after a second re-exposure to Rifampicin for the treatment of a hip prosthesis infection with Staphylococcus epidermidis. A recent rifampicin exposure 1 week earlier had resulted in a massive rise of CRP levels without organ manifestations. Nine years previously, the patient had developed a multi-organ hypersensitivity reaction 8 days after commencing treatment with rifampicin for pulmonary tuberculosis; and 23 years previously he had received rifampicin without problems. The organ-specific hypersensitivity reactions were largely reversible after withdrawal of rifampicin and treatment with steroids. A review of the literature and summary of WHO spontaneous safety reports is also given. CONCLUSIONS: Re-exposure to rifampicin in sensitised individuals may cause acute severe hypersensitivity reactions. Due to its indications in the management of mycobacterial and implant-associated infections, rifampicin is a drug which might be given decades apart, which poses a risk that information about previous intolerance is lost.

Urticaria and Angioedema: an Update on Classification and Pathogenesis.

Urticaria is a common, mast cell-driven disease presenting with wheals or angioedema or both. In the last years, urticaria has increasingly attracted notice to clinicians and researchers, last but not least inspired by the approval of omalizumab, an anti-IgE antibody, for urticaria treatment. There is wide consensus on the clinical classification based on duration and elicitation. However, the pathogenesis is incompletely understood. This review summarizes current guidelines for the management and novel insights in the pathogenesis of urticaria with special focus on their impact on clinical praxis. The classification of urticaria subgroups is mainly based on clinical criteria: acute and chronic urticaria (CU). Chronic urticaria comprises both chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU) that includes physical and non-physical urticarias. Recent research focused on characterizing the role of cells and mediators involved in the pathogenesis of urticaria, identifying the mechanisms of mast cell activation, and investigating underlying autoimmune processes in chronic spontaneous urticarial. Currently, non-sedating antihistamines and omalizumab, an antiimmunoglobulin E antibody, are recommended for the therapy of chronic urticaria, as both exhibit a favorable efficacy and safety profile. Novel therapeutic strategies aim at specifically targeting cells and mediators involved in the pathogenesis of urticaria.

Food allergy to the carbohydrate galactose-alpha-1,3-galactose (alpha-gal): four case reports and a review.

Until recently, food allergies to mammalian meats have been considered to be very rare. The observation that patients not previously exposed to the monoclonal chimeric antibody cetuximab suffered from severe anaphylaxis upon first exposure, led to the identification of galactose-alpha-1,3-galactose as a new relevant carbohydrate allergen. These patients later often suffered from anaphylactic reactions to red meat. Epidemiological data indicated that bites by the tick Amblyomma americanum in the USA, later also by Ixodes species in other continents, resulted in sensitisation to alpha-gal. On the other hand, in African patients with parasitic disorders, a high prevalence of anti-alpha-gal IgE, without clinical relevance, has been reported. In our four cases, one patient with a late onset of meat allergy had a history of a tick bite. The other three patients had symptoms from childhood or at a juvenile age. This indicates that in some patients, other ways of sensitisation may also take place. However, in patients without atopy, tick bite-induced IgE to alpha-gal may be more relevant. Diagnosis is based on a history of delayed onset of anaphylaxis. Skin tests with commercially available meat test solutions are often equivocal or negative; skin tests with raw meat and particularly pork kidney are more sensitive. Determination of specific IgE to alpha-gal is commercially available. The highest sensitivity is observed with skin and basophil activation tests with cetuximab which is, however, limited by its high costs.

Hypersensitivity reactions to modern antiplatelet and anticoagulant drugs.

Anticoagulation and antiplatelet drugs are among the most commonly used medical drugs. In addition to the long-established heparins, hirudins, coumarins and antiplatelet drugs such as acetylsalicylic acid, numerous novel and predominantly synthetic pharmacologic agents have come onto the market in recent years. These new agents act at various sites in coagulation and have significantly broadened treatment options. Whilst immunological hypersensitivity reactions are on the whole rare, they have a considerable impact on patient management when they do occur. The present overview discusses the currently known hypersensitivity reactions to anticoagulant and antiplatelet agents, with particular attention to the newer substance classes including P2Y12 inhibitors, glycoprotein IIb/IIIb receptor antagonists, direct factor Xa inhibitors and direct thrombin inhibitors.

Severe anaphylactic shock due to ethylene oxide in a patient with myelomeningocele: successful exposure prevention and pretreatment with omalizumab.

Ethylene oxide (EO) is a highly reactive gas widely used for sterilization of medical devices, for example, plastic materials and ventriculoperitoneal shunts. Allergic reactions to EO are rare and have been observed mainly in patients during hemodialysis and myelomeningocele patients. We describe severe anaphylaxis to EO in a patient with myelomeningocele during general anesthesia. A detailed description is provided about the prevention measures aimed at reducing exposure to EO including a novel approach by resterilization with plasma. Also, pretreatment with omalizumab was implemented for the first time in such a case. With these measures, further surgeries in our patient were uneventful.

Irritant contact dermatitis from a black henna tattoo without sensitization to para-phenylendiamine.

Allergic contact dermatitis from nonpermanent black henna tattoos has been frequently reported, particularly in children. Contamination or adulteration of the dyes with para-phenylendiamine has been identified as major cause of active sensitization and elicitation of severe allergic contact dermatitis. Sequelae include permanent sensitization, hyper- or hypopigmentation, scarring, keloids, and hypertrichosis. We report a rare case of irritant dermatitis to an unknown ingredient in a black henna tattoo with consecutive hypopigmentation. Sensitization to para-phenylendiamine and other para-compounds was excluded by patch test evaluation. This is relevant for future exposure to consumer products such as hair dyes or in occupational settings. Generally, black henna tattoos, particularly if done with dyes of unknown composition, should be strongly discouraged.