The Natural Course of Adult-Onset Food Protein-Induced Enterocolitis Syndrome.

BACKGROUND: Adult-onset food protein-induced enterocolitis syndrome (FPIES) has been increasingly recognized in recent years. Adult FPIES differs from pediatric FPIES in terms of dietary triggers and symptoms, thus further broadening the clinical phenotypes of the disease. The natural history of FPIES in adulthood is poorly characterized. OBJECTIVE: To evaluate the natural course of FPIES in adults. METHODS: We performed an ambispective study of adults diagnosed with acute FPIES during 2016-2021. Data on age, sex, symptoms, implicated food, and oral food challenge (OFC) outcomes at baseline and during follow-up were analyzed. RESULTS: Forty-two adults were included (83.3% female; median age at diagnosis, 40 years). The predominant symptoms were diarrhea (92.9%) and abdominal cramps (71.4%); vomiting was reported by 59% of patients. The most common triggers were shellfish (n = 19, 45.2%) and fish (n = 19, 45.2%). The mean number of reactions before diagnosis was 6.3 (2-15). Twenty-one OFCs were carried out with the offending food in 15 patients. Six patients achieved tolerance (40%) after a mean of 17.8 months (range, 6-36 months). Twelve of all OFCs performed were positive (57.1%). The absolute leukocyte and neutrophil counts measured before and 1 to 2 hours after the positive challenge showed a mean increase of 3045 and 2736 cells/µL, respectively. Serum tryptase, C-reactive protein, and eosinophil and platelet values did not change significantly after the OFC. CONCLUSION: Some patients may outgrow adult-onset FPIES.

Photoallergy to Naproxen.

Reactions caused by photosensitivity, also called photodermatosis, are cutaneous reactions induced or exacerbated by exposure to electromagnetic radiation, including UV radiation, visible light, and infrared radiation. We present the case of a 41-year-old man with no personal history of allergy and who is referred to our Drug Allergy Unit for study. We performed a conventional patch test (non-irradiated) and photopatch (with the application of UVA) with reading at 48 and 96 hours and 24 hours after irradiation with an intensity of 5J/cm2. Drug-induced photosensitivity can manifest itself in two clinically indistinguishable forms: photoallergy and phototoxicity. Photoallergic reactions are due to an immunological response of type IV hypersensitivity (a cell-mediated mechanism). We present a case of photoallergy due to sensitization to naproxen, confirmed by photopatch tests.

Treatment with lipid transfer protein sublingual immunotherapy: slowing down new sensitizations.

Food allergy (FA) is a potentially life-threatening condition, food allergen immunotherapy, targeting the underlying mechanisms, is a potentially curative strategy in FA. A 46-year-old woman had an episode of facial angioedema and urticaria after mandarin ingestion and other episode of urticaria, abdominal pain, and facial angioedema after eating hazelnuts and almonds 4 years ago and contact urticaria (CU) with the manipulation of the peach skin. Three years ago, she suffered a facial and glottis angioedema, generalized urticaria, vomiting, and abdominal pain 10-15 minutes after eating green beans. She was treated with intravenous corticosteroids and antihistamines and intramuscular epinephrine, with complete resolution within a few hours. She no longer consumed nuts, and she avoided vegetables or fruits that caused her symptoms. Prick-prick test were performed, being positive with lettuce, eggplant, and cabbage and negative for cauliflower and broccoli. Total IgE (UniCAP method, kU/L) was 39.3, specific IgE Prup3 lipid transfer protein (LTP), 3.9; specific IgE to peanut, peach, pear, lemon, almond, avocado, walnut, cherry, and green bean were also positive. We decided to try to stop the march of the LTP sensitizations. Sublingual immunotherapy with a peach extract quantified in 12 µg/mL of peach allergen Prup3 was then initiated without any adverse event, and she has good adherence to the treatment. After 1 year, single-blind oral challenge test with peach, mandarin, and aubergine, were performed up to a portion dose (approximately 100 g) with all good tolerances.

Allergic Contact Dermatitis to Fentanyl TTS with Good Tolerance to Systemic Fentanyl.

BACKGROUND: Fentanyl is primarily an opioid agonist. It is frequently used in general anesthesia as a potent analgesic. It can be administered either orally, transdermally or systemically. Adverse effects due to opium alkaloids are usually because of a non-specific histamine release. Only in a few cases, a true allergy mechanism could be involved. Immediate reactions to opioids are most frequent than delayed reactions. In the past years, delayed reactions have increased in frequency because of the wide use of Transdermal Therapeutic System (TTS) with several opioids for its potent analgesic properties. OBJECTIVE: The objective was to study delayed reaction to fentanyl TTS and cross-reactivity with other opioids. METHODS: A 52-year-old man with a diagnosis of pancreatic cancer who began treatment for a bone metastases pain with fentanyl TTS, at a dose of 50 micrograms per hour (mcg/h) is the subject of the study. After 10-15 days of treatment, he developed an itchy papulovesicular rash in the application site of the fentanyl TTS. Afterward, eczema and superficial desquamation just on the application site of the patch were observed. He changed several times the site of application, but always developing the same symptoms in every single application. Later on, he tolerated other opioids such as oral morphine or tramadol. An allergy workout was performed. We performed Patch Tests (PT) with fentanyl at a concentration of 10% in aqua (aq) and with buprenorphine 10% aq., in order to investigate probable crossreactivity among other topical opioids. RESULTS: Readings were recorded at day 2 (D2) and day 4 (D4), with positive PT only with fentanyl at D2 (+++) and D4 (+++). We decided to perform a single-blind challenge test with buprenorphine 35 mcg/h in TTS, with a negative result. At this moment, fentanyl TTS was replaced by buprenorphine TTS, with good tolerance. CONCLUSION: We present the case of Allergic Contact Dermatitis (ACD) due to hypersensitivity to fentanyl with good tolerance to buprenorphine. Positive PT in this patient suggests a type IV hypersensitivity mechanism. Allergic reactions to opioids are frequently immediate, but delayed reactions could appear, especially when the drug is administered topically.

Flare-Up Phenomenon of Intradermal Test with Anaphylactic Reaction to Paracetamol (Acetaminophen).

BACKGROUND: Paracetamol is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that can produce hypersensitive reactions mediated by specific immunological mechanisms (IgE or T celldependent) or by a non-immunological mechanism (inhibition of cyclooxygenase COX-1). OBJECTIVE: An 80-year-old man with a history of allergy to pyrazolones, with good tolerance to other NSAIDs was referred to our allergy department because he presented a generalized urticaria after the administration of Intravenous (IV) paracetamol. METHODS: We performed an Intradermal Test (IDT) with paracetamol (0.02mg/ml) and later a Single Blind Oral Challenge Test (SBOCT) with oral paracetamol. RESULTS: IDT reading at 15min showed negative result so an SBOCT was performed with oral paracetamol. With an accumulative dose of 250mg, after 20min, he developed discomfort, nausea and dizziness, urticarial, hypotension (BP 80/40) as well as flare-up phenomenon was observed in the site of the IDT with paracetamol. Tryptase levels during the reaction and 2hrs later were increased. CONCLUSION: We present an anaphylactic shock due to sensitization to paracetamol because of a type I hypersensitivity mechanism, diagnosed by SBOCT and a positive IDT because of flare-up phenomenon, in a patient with previous pyrazolones allergy and with tolerance to other NSAIDs. Some relevant patents are also summarized in this paper.

Delayed hypersensitivity reaction to lenalidomide: 2 different clinical patterns in the same patient

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Atrial Fibrillation in Anaphylaxis.

BACKGROUND: The relationship between anaphylaxis and cardiovascular events has been reported in the past. While skin and respiratory symptoms are usually the most common and the first to appear, cardiovascular complications play a key role and represent the leading cause of death in anaphylaxis. METHODS: We report 3 episodes of atrial fibrillation triggered by anaphylaxis. Allergy and cardiology studies were performed. In both patients, the etiological agent was identified: Anisakis simplex hypersensitivity and food allergy. RESULTS: The heart is the source and target of chemical mediators released during an allergic reaction. In the heart, there are plenty of mast cells, and they are predominantly located around the coronary adventitia and in close contact with small vessels in the muscle wall. The release of mediators can influence ventricular function, heart rate, and coronary artery tone. Anaphylaxis can trigger any kind of arrhythmia. In these cases, the very interesting point of discussion was: which should be first, treating anaphylaxis or cardiac events? The other controversial point was the use of epinephrine, the first line of treatment for anaphylaxis. Recommendations about epinephrine in cardiac patients during an anaphylactic event are still a major dilemma. CONCLUSIONS: We emphasize the importance of the priority of establishing protocols between cardiologist and allergist in treatment of cardiac complications during anaphylaxis, and we warn about the correct diagnosis of arrhythmias in anaphylaxis in order to treat them as soon as possible, to prevent other consequences and complications.

Fixed Drug Eruption Due to Selective Hypersensitivity to Naproxen with Tolerance to other Propionic Acid NSAIDs.

BACKGROUND: Naproxen is a non-steroidal anti-inflammatory drug (NSAID), belonging to propionic acid group, and its chemical structure is a 6-metoxi-metil-2-naftalenoacetic acid. Fixed drug eruptions (FDE) have been rarely reported. OBJECTIVE: A 38-year-old woman referred that after 2 hours of taking 2 tablets of naproxen for a headache, she developed several edematous and dusky-red macules, one on right forearm and the other two in both thighs and she was diagnosed with FDE probably due to naproxen. METHODS: We performed patch testing (PT) (Nonweven Patch Test Strips Curatest® Lohman & Rauscher International, Rangsdorf, Germany), with ibuprofen (5% Petrolatum), ketoprofen (2.5% Petrolatum), naproxen and nabumetone (both 10% in DMSO) on the residual lesion of the forearm with naproxen and in both thighs with ibuprofen, ketoprofen and nabumetone. RESULTS: Readings at day 1 (D1) and day 2 (D2) showed negative results to ibuprofen, ketoprofen and nabumetone, but were positive to naproxen in D1. A single blind oral challenge test (SBOCT) with other propionic acid derivates were performed in order to check for crossreactivity between them: ibuprofen, ketoprofen and nabumetone were administered and all drugs were well tolerated. CONCLUSION: In our patient PT confirmed the diagnosis and allowed us to study the cross-reactivity between NSAIDs of the same group, and confirmed by SBOCT. Cross-reactivity between propionic acid derivatives was studied. This is a case of hypersensitivity to naproxen with good tolerance to other propionic acids NSAIDs (ibuprofen and ketoprofen) and nabumetone, confirmed by PT and SBOCT. Some relavent patents for fixed drug eruption are discussed.