A successful desensitization in an adult patient with ARA-C infusion reaction.

INTRODUCTION: Cytarabine (ARA-C) is an antimetabolite agent used especially in the treatment of hematologic malignancies. Infusion reactions have an important place among the side effects that may occur due to treatment. Clinical findings of infusion reactions resemble allergic reactions. CASE REPORT: 47-year-old male patient with a diagnosis of B-cell Acute Lymphoblastic Leukaemia developed infusion reaction during ARA-C treatment. MANAGEMENT & OUTCOME: There was no alternative treatment option for his existing malignant disease, we decided ARA-C desensitization. DISCUSSION: We would like to describe a successful desensitization protocol in an adult patient who experienced a reaction during ARA-C infusion.

Transvaginal natural orifice endoscopic surgery (vNOTES) for elderly patients.

OBJECTIVES: To evaluate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in patients 70 years and over. MATERIAL AND METHODS: The study consisted of eleven patients aged 70 and over who underwent vNOTES for a variety of gynaecological indications at a tertiary referral hospital. The medical and surgical data were noted: age, parity, history of comorbidity, number and type of previous surgeries, body mass index (BMI), operating time, the requirement of intraoperative conversion, the presence of intra- or postoperative complication, estimated blood loss, pre-and postoperative hemoglobin levels, visual analog scale (VAS) pain scores at 6th, 12th and 24th hours, length of hospital stay, and the final pathology results. RESULTS: vNOTES surgery was performed safely and successfully in eleven patients. There were no intra- and postoperative complications or instances of conversions to conventional laparoscopy or laparotomy. The mean age of patients was 75.91 ± 6.47 (range 70-93), and the mean BMI was 42.49 ± 8.77 kg/m2 (range 30.2-56). Seven cases of endometrioid adenocarcinoma, two cases of uterine leiomyoma, one case of complex atypical hyperplasia, and one case of postmenopausal uterine bleeding due to atrophic endometrium were diagnosed. All endometrial carcinomas were early stage; no adjuvant therapy was needed. CONCLUSIONS: vNOTES seems to be a safe and feasible approach for the treatment of gynecologic pathologies in elderly patients. This study suggests that vNOTES become a viable treatment option for existing minimally invasive procedures since it offers better surgical outcomes in various gynecologic surgeries.

Compromised T-cell immunity in patients with spinal cord injury and its relationship with injury characteristics.

Objectives: The aim of this study was to investigate in vivo and in vitro cellular immune responses in patients with chronic (spinal cord injury; SCI), determine the effects of autonomic dysfunction on cellular immune response, and determine the effect of completeness of the injury at different levels on cellular immune response. Patients and methods: Forty-nine patients (42 males, 7 females; mean age: 35.5±13.4 years; range, 18 to 68 years) with chronic (time since injury >6 months) traumatic SCI were included in this cross sectional study between March 2013 and December 2013. Patients were allocated into two groups: Group 1, patients with an injury at T7 or below, and Group 2, patients with an injury at T6 or above. All patients in Group 2 had a history of autonomic dysreflexia and orthostatic hypotension. Intradermal skin tests were applied to the participants to reveal delayed T-cell responses. The percentages of cluster of differentiation (CD)3+ T cells and CD3+ T cells expressing CD69 and CD25 were analyzed by flow cytometry for the detection of activated T cells including all T-cell subsets. Results: When patients with complete injuries were compared, the CD45+ cell percentage was found to be significantly higher in patients in Group 2. Patients with an incomplete SCI had increased skin response to candida antigens compared to complete SCI patients. Incomplete SCI patients also had higher percentages of lymphocytes and CD3+CD25+ and CD3+CD69+ T cells compared to patients with complete SCI. Conclusion: T-cell activity is impaired in chronic SCI patients with higher levels of injury, and the completeness of injury and autonomic dysfunction gain prominence as compromising factors in T-cell immunity.

An atypical urticaria case caused by Giardia intestinalis.

INTRODUCTION: Giardia intestinalis causes diarrhea and malabsorption, especially in developed countries. Although it primarily affects the gastrointestinal system, on rare occasions it causes allergic symptoms such as itching, urticaria, and eczema. Here we describe the case of a 19-year-old man with no past medical history who presented to our hospital with an atypical urticarial rash. DIAGNOSIS: The only abnormal result in laboratory findings of stool parasitology was G. intestinalis. The patient was diagnosed with urticaria due to giardiasis. INTERVENTION AND OUTCOMES: The patient was prescribed Bilastine tablet 20 mg 1 × 1 and referred to the Infectious Diseases Department for treatment. Co-Trimoxazole 400 mg/80 mg tablets 2 × 1 and Metronidazole 500 mg tablets 3 × 1 were prescribed. The urticaria had disappeared at the follow-up visit. The patient confirmed that urticarial symptoms did not recur. CONCLUSIONS: Despite their rarity, Giardia and other parasite infections can cause allergic symptoms. Parasitic factors should be considered in patients, especially those living in the communal areas, who present with treatment-resistant urticaria.

Adverse reactions in venom immunotherapy protocols: conventional versus ultra-rush.

BACKGROUND: Venom immunotherapy (VIT) is an effective treatment in the patients at high risk of anaphylaxis or life-threatening systemic reactions due to Hymenoptera venom allergy. But, systemic and large local reactions can be observed, especially during the build-up phase of VIT. We evaluated the safety of conventional and ultra-rush build-up protocols. MATERIALS AND METHODS: Two protocols in 71 patients (39 conventional and 32 ultra-rush protocols) with honeybee and wasp venom allergy were evaluated retrospectively. Patients were diagnosed and selected for VIT according to the criteria established by the European Academy of Allergy and Clinical Immunology. The severity of systemic reactions was evaluated according to the criteria of Mueller. RESULTS: Build-up phases were tolerated in 66.2% (n = 47) without any reaction. Allergic adverse reactions were observed in 33.8% (n = 24): large local reactions 22.5% (n = 16) and systemic reactions 11.3% (n = 8). There was no significant difference in the number of adverse reactions comparing patients receiving conventional and ultra-rush protocol. In addition, no association was found between allergic adverse reactions and the following factors: sex, previous systemic sting reactions, honeybee and wasp venom extract. CONCLUSION: We found that both protocols were tolerated in patients with honeybee and wasp venom allergy. Ultra-rush protocol will be preferred for patients and clinicians because of its advantages in terms of time and costs.KEY MESSAGESVIT is the only curative treatment method that reduces the risk of severe reactions after a bee sting and improves the quality of life in patients with Hymenoptera venom allergy.Ultra-rush VIT protocol has advantages such as few injection and time savings.Both ultra-rush and conventional VIT are safe treatments to prevent potentially life-threatening reactions in patients with honeybee and wasp venom allergy.

Efficacy of sodium hyaluronate in relieving nasal symptoms of children with intermittent allergic rhinitis: a randomized controlled trial.

PURPOSE: Nasal irrigation is recommended as add-on therapy in patients with intermittent allergic rhinitis (AR). We aimed to evaluate the clinical efficacy of adding hyaluronic acid (HA) or normal saline solution (NSS) to nasal corticosteroid (NC) therapy as add-on therapy in improving quality of life and reducing nasal symptom scores of children with intermittent AR compared to NC therapy. METHOD: In this 28-day long, open-label, randomized controlled trial, one puff of NC was administered once a day through both nostrils of 76 children with SAR (6-12 years old), whose Total Nasal Symptom Score (TNSS) was ≥ 4. Twenty-six patients received NC only (Group 1); 24 patients received NSS (Group 2), and 26 patients received HA (Group 3) twice a day by means of nasal douche device. Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) and TNSS were measured as subjective parameters, and nasal eosinophil count (NEC) in nasal cytology, nasal airflow (NAF), and resistance were measured as objective parameters. RESULTS: No significant difference was found in post-treatment between groups in terms of TNSS, PRQLQ, and NEC values. Mean values of post-treatment left NAF of the groups were significantly different (p = 0.030), and the mean value of Group 3 was the highest (mean ± SD = 247.62 ± 155.8 ccm/sn). In comparing pre- and post-treatment intragroup mean total NAR (TNAR) values, a statistically significant decrease was recorded only in group three (p = 0.025). CONCLUSION: The addition of HA to NC as an adjunct therapy in children with intermittent AR has limited beneficial effects in our study and deserves further investigation. TRIAL REGISTRY: The clinical trial registration number ID:NCT04752956.

Haplotype analysis in a 16-year-old boy with vancomycin-induced DRESS syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but life-threatening multisystem adverse reaction to a medication, with vancomycin being one of the most common cause reported. We present the HLA analysis of a pediatric patient who developed DRESS related to vancomycin and compared the results with the available literature. With further data, the use of pretreatment HLA analysis to prevent vancomycin related DRESS may be a valuable option in the near future.

Adults with common variable immunodeficiency: a single-center experience.

BACKGROUND/AIM: In this study, we aimed to assess the clinical and immunological findings of our patients with common variable immunodeficiency (CVID). MATERIALS AND METHODS: We analyzed the records of 31 adult patients with CVID (12 females, 19 males). The patients were classified into clinical and immunophenotypic subgroups for statistical comparisons. RESULTS: Our patients had some clinical signs in considerable frequencies, such as low body weight (45.2%), urinary tract infections (41.9%), various dermatoses (35.5%), and oral aphthae (32.3%). The histological findings in the biopsy specimens of the gastrointestinal tract (nodular lymphoid hyperplasia, villous atrophy, and lymphocytic infiltrates at mucosa) were significantly associated with splenomegaly, hepatomegaly, or low body weight (P = 0.005, 0.045, and 0.007, respectively). The patients with low CD4/CD8 ratios had lower IgG levels and a lower percentage of CD19+ B cells, but a higher percentage of activated T cells (P = 0.023, 0.011, and 0.028, respectively). CONCLUSION: In adults with CVID, there existed some clinical signs at considerable frequencies, but these are not overemphasized in the literature. The CD4/CD8 ratio is an important factor in antibody production and the clinical presentation of CVID. It seems that the adaptive immune system is on alert and subclinical immune activation insidiously continues in patients with CVID.

Killer-cell immunoglobulin-like receptor and human leukocyte antigen-C genes in common variable immunodeficiency.

BACKGROUND: We aimed herein to investigate the killer-cell immunoglobulin-like receptor (KIR) genes and human leukocyte antigen (HLA)-C alleles in patients with common variable immunodeficiency (CVID), and to reveal their differences from those in healthy population. METHODS: In all, 18 patients who have been diagnosed with CVID and 15 living donors of kidney transplant recipients were enrolled in the study. Polymerase chain reaction-sequence-specific primer (PCR-SSP) typing method was used in molecular genetic analysis. The frequencies of the genes in the study groups were statistically compared with each other using chi-square or Fisher exact tests, whichever were appropriate. RESULTS: Although there was no significant difference between both study groups with respect to distribution of KIR and HLA-C2 group genes, HLA-Cw7 allele frequency in patients with CVID was significantly lower than that in healthy population (P = 0.008). CONCLUSION: This present study results support that HLA-Cw7 allele, an inhibitor of KIR ligand, may play a role in the pathogenesis of CVID.

Safety of subcutaneous immunotherapy with inhalant allergen extracts: a single-center 30-year experience from Turkey.

CONTEXT: Although subcutaneous allergen immunotherapy (SCIT) is effective in allergic rhinitis (AR) and asthma, it carries a risk of local and systemic adverse reactions. OBJECTIVE: The aim of this study was to evaluate the rates and clinical characteristics of local and systemic reactions (LR and SR), and to identify their relation of demographic features, allergen extracts and diagnosis. MATERIALS AND METHODS: This study analyzed the administration of SCIT from 1983 to 2013; involving 1816 patients affected by allergic asthma and/or AR. RESULTS: The rates of SR from SCIT were 0.078% per injection and 9% per patient. According to the World Allergy Organization 2010 grading system, 91 grade 1 reactions (44%), 67 grade 2 reactions (32.3%), 33 grade 3 reactions (16%) and 16 grade 4 reactions (7.7%) were seen. There was no fatal outcome from any of the SRs. Risk factors for a SR included: aluminium-adsorbed extract, pollen-containing vaccines, large LR and recurrent (≥2) LRs. The total LR rates were 0.062% per injection and 5.2% per patient; the small LR rates were 0.027% per injection and 2.3% per patient, and the large LR rate were 0.035% per injection and 2.9% per patient. Female gender, depot extracts, calcium phosphate-adsorbed extract and pollen vaccines were identified as risk factors for LR. CONCLUSION: The analysis of our data over a 30-year period confirmed that SCIT with inhalant allergens conducted strictly according to the standard protocols and when administrated by experienced staff is a safe method of treatment with only a few side-effects.

Desensitization to Adalimumab: An Example of Repeated Desensitization to a Biological Agent.

Biological agents seem to have been more effective than classic immunosuppressive drugs; however, the adverse events including the hypersensitivity reactions are the main drawbacks of these drugs. We report a 35-year-old man who was treated with adalimumab for ankylosing spondylitis, had a local reaction on the injection site, and generalized itching with rash at the 62nd dose and repeated desensitizations to him with adalimumab. One month after the reaction, skin prick test was performed with a commercial preparation of adalimumab. The skin prick test result was determined positive comparing to positive and negative controls. Because of insufficient responses to other drugs, adalimumab desensitization was performed and the whole process was completed without any reaction. Six months later the patient gave up therapy because of a new reaction which was caused by a possible viral infection. Desensitization was repeated successfully 3 months later. Because there are few cases in the literature about adalimumab desensitization process, there is no standard desensitization protocol for the adalimumab allergy yet. Therefore, we suggest that our case report may contribute to the formation of a standardized desensitization protocol in adalimumab hypersensitivity.

A new approach to objective evaluation of the success of nasal septum perforation.

BACKGROUND: Perforations in the nasal septum (NSP) give rise not only to disintegration of the septum anatomy but also impairment in normal nasal physiology. The successes of these surgical techniques are usually equated to anatomical closure of the perforation. The goal of this study is to evaluate the subjective and objective results of our surgical technique for septal perforation surgery. METHODS: All NSPs in the six patients were closed by inferior turbinate flap. The Nasal Obstruction Symptom Evaluation (NOSE) instrument was used to evaluate the preoperative and postoperative subjective sensation of nasal obstruction. Measurement of preoperative and postoperative nasal airway resistance was performed using active anterior rhinomanometry which is an objective test. Wilcoxson signed rank test and Spearman correlation test were used to analyze correlation between NOSE scores and rhinomanometric measurements. RESULTS: The full closure of the septal perforations was noted in 100% of patients. The total NOSE score was 14 preoperatively and one postoperatively. The improvement in NOSE scores was statistically significant (P≤0.002). The mean preoperative total resistance (ResT150) value was 0.13 Pa/cm(3)s(-1), which is below the normal range (0.16-0.31 Pa/cm(3)s(-1)), while the mean postoperative ResT150 value was 0.27 Pa/cm(3)s(-1). The correlation between the improvement in NOSE scores and improvements in ResT150 values was statistically significant. CONCLUSIONS: Surgical approaches should aim to solve both the anatomical and physiological problems of NSP. The application of subjective and objective tests in the postoperative period will help surgeons assess the applied techniques.

IgE-mediated reaction to local anaesthetics.

Local anaesthetics (LAs) are essential agents in daily practices of dentistry, minor surgery and dermatology. Although they have an impressive history of safety and efficacy, LAs also have the potential to produce adverse events, which are mainly of non-immune nature. The true IgE-mediated allergies are quite rare, but are more considerable in terms of ability to cause life-threatening outcomes. In this report, we present a case of IgE-mediated systemic reaction to LAs occurring during epidural anaesthesia for Cesarean section.

Acute urticaria associated with thyroid papillary carcinoma: a case report.

Although there are several studies showing the association between cancer and urticaria, the mechanisms by which these events occur are not yet known. In this report, a case of acute urticaria with a diagnosis of thyroid papillary carcinoma is presented. Disappearance of treatment-resistant urticarial lesions after thyroidectomy suggests that this association was not a coincidence. The fact that urticaria which was nonresponsive to treatment disappeared spontaneously as a result of tumorectomy, strongly suggests that this association is not a coincidence. To our knowledge, this is the first report of the coexistence of acute urticaria and thyroid papillary carcinoma. This case provides further support that detailed history taking and a thorough physical examination are of paramount importance.

Vitamin B12 allergy and successful desensitisation with cyanocobalamin: A case report

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Plasmapheresis in a patient with "refractory" urticarial vasculitis.

Immune complexes are found in the circulation of 30%-75% of patients with urticarial vasculitis and much evidence supports the role of these immune complexes in the pathogenesis of urticarial vasculitis. Plasmapheresis is effective for removing these immune complexes; however, there are few reports on the use of plasmapheresis in the treatment of urticarial vasculitis. We describe a case of "refractory" urticarial vasculitis in which the symptoms improved after plasmapheresis treatment. We suggest that plasmapheresis be considered as an option in patients with severe or treatment-resistant urticarial vasculitis.