Serum sickness reaction following multiple insect stings.

BACKGROUND: Anaphylaxis is the most common systemic allergic reaction caused by stinging insects. Serum sickness reactions occur much less frequently. OBJECTIVE: To determine the level of venom-specific IgG and IgE antibodies during and after a serum sickness reaction to vespid venom. METHODS: Case report; ELISA determination of venom-specific IgG and IgE; complement levels and tests for immune complexes were performed. RESULTS: We report the case of a 66-year-old woman who developed a serum sickness reaction nine days after receiving multiple vespid stings. She developed urticaria, angioedema, fever, and arthralgias. She had elevated IgG and IgE venom-specific titers which declined during the recovery phase. Complement levels were normal and tests for immune complexes were negative. She was successfully treated with venom-specific immunotherapy without any serum sickness reaction. CONCLUSIONS: A serum sickness reaction with elevated venom-specific IgG and IgE is reported with successful immunotherapy.

Phenytoin-related immunodeficiency associated with Loeffler's syndrome.

BACKGROUND: Phenytoin is one of the most commonly prescribed drugs in the United States. Its use is associated with a myriad of adverse reactions, including: eosinophilia, selective IgA deficiency and panhypogammaglobulinemia, pseudolymphoma, Stevens-Johnson syndrome, and interstitial pneumonia. OBJECTIVE: To report a case of immunodeficiency manifest by panhypogammaglobulinemia and a low helper-to-suppressor ratio secondary to phenytoin crossreactivity with phenobarbital and carbamazepine complicated by hepatotoxicity, eosinophilia, and fleeting pulmonary infiltrates. METHODS: Case report; immunoglobulin levels, T and B cell studies, and radiologic evaluation of patient. RESULTS: A 37-year-old Oriental female taking phenytoin and phenobarbital for seizure prophylaxis after resection of a grade IV astrocytoma of the left frontal lobe, developed a rash, elevated liver function tests, and cervical lymphadenopathy with parotid gland enlargement. The abnormalities resolved with discontinuation of the drugs and the patient was discharged on carbamazepine. Eight weeks later the patient was readmitted with fever, slowed mentation, elevated liver function tests, and panhypogammaglobulinemia. Clonazepam was substituted for carbamazepine and the patient subsequently developed a rash and further elevation of her liver function tests. The clonazepam was discontinued and the patient was treated with methylprednisolone. She subsequently developed Loeffler's syndrome and a T cell deficiency with a decreased helper-to-suppressor cell ratio. She was treated with increased doses of methylprednisolone and granulocyte stimulating factor with complete resolution of her symptoms. CONCLUSIONS: Phenytoin is associated with a myriad of side effects, including, rash, eosinophilia, panhypogammaglobulinemia, pseudolymphoma, Stevens-Johnson syndrome, immunosuppression in brain tumor patients, and rarely, pulmonary complications such as Loeffler's syndrome. Cross-reactivity with other anticonvulsant agents capable of forming arene oxide intermediates occurs in the cytochrome P-450 system.

Reversible common variable immunodeficiency syndrome induced by phenytoin.

Phenytoin-induced panhypogammaglobulinemia mimicking the common variable immunodeficiency syndrome is rare. We describe a patient who, while being treated with phenytoin and corticosteroids, developed panhypogammaglobulinemia, recurrent pneumonia, eosinophilia, and a transient rash. Immunoglobulin levels, which had been normal prior to phenytoin therapy, returned to normal over a period of several months after the drug therapy was stopped. Levels of IgG subclasses and numbers of B cells, T cells, and T-cell subsets were determined during the recovery period. In a review of the reported cases, eosinophilia and rashes were frequently noted. These findings, along with recurrent infections in a patient receiving phenytoin therapy, should prompt a careful evaluation of the patient's immunologic status.

Hypersensitivity pneumonitis in an orchid grower associated with sensitivity to the fungus Cryptostroma corticale.

Hypersensitivity pneumonitis resulting from sensitivity to the fungus Cryptostroma corticale was last reported 20 years ago in association with the occupation of stripping bark from maple logs. A case of hypersensitivity pneumonitis is presented which was associated with exposure to Cryptostroma corticale from non-maple bark chips used to grow orchids. The exposure history and evidence of immune reactivity to the fungus strongly support its causal role in this case.

Monoclonal hypergammaglobulinemia without malignant transformation in angioimmunoblastic lymphadenopathy with dysproteinemia.

A patient with angioimmunoblastic lymphadenopathy with dysproteinemia had a monoclonal IgG hypergammaglobulinemia. In contrast to previous reports, the development of a monoclonal paraprotein in the setting of angioimmunoblastic lymphadenopathy with dysproteinemia did not herald a transformation to malignancy. The patient improved clinically and the monoclonal gammopathy disappeared when the patient was treated with prednisone. The relationship of these findings to current concepts regarding the cause of angioimmunoblastic lymphadenopathy with dysproteinemia is discussed.

Consecutive lymphoma with monoclonal gammopathy in a married couple.

Mixed cellularity Hodgkin's disease and diffuse non-Hodgkin's lymphoma, mixed cell type, occurred consecutively in a husband and wife. Both patients demonstrated monoclonal IgM gammopathies. The unusual nature and possible significance of these findings are discussed.

Serum immunoglobulin elevations in the acquired immunodeficiency syndrome (AIDS): IgG, IgA, IgM, and IgD.

The exact nature of the immune defect in the acquired immune deficiency syndrome (AIDS) is not known. Most studies have focused on abnormal T-cell functions which occur in AIDS. Although polyclonal elevation of serum immunoglobulins is also consistently reported in AIDS, there have been no statistical studies measuring the isotypes (classes) comprising this hypergammaglobulinemia. Quantitative serum immunoglobulin levels of IgG, IgA, IgM, and IgD in patients with AIDS (n = 33) were compared to healthy homosexual (n = 71) and healthy heterosexual (n = 32) controls. Serum IgD levels are increased tenfold in AIDS compared to healthy heterosexuals, and threefold compared to healthy homosexuals. Serum IgA levels are increased more than twofold that of either control group. In contrast, the elevations of IgG and IgM are relatively small and show much greater overlap compared to controls. We conclude from a statistical analysis of the data that these elevations of IgD and IgA are characteristics of AIDS.

Effect of hypothalamic lesions on immediate hypersensitivity.

Bilateral electrolytic lesions were placed in the anterior basal hypothalamus of male Hartley-strain guinea pigs. The animals with anterior hypothalamic lesions and a group of sham-operated controls were sensitized 5-10 days postoperatively with ovalbumin in modified Freund's adjuvant. At 18-22 days following sensitization both groups were randomly divided into three subgroups and challenged by intrajugular injections of three different antigen doses. Anaphylactic death and the severity of anaphylaxis in the survivors were recorded. Antibody titers were determined prior to challenge with use of the passive cutaneous anaphylaxis technique. Serial sections of each brain were made for lesion localization. Significant protection against anaphylaxis was found in guina pigs with symmetrical lesions in the anterior hypothalamus. No significant differences in antibody titers were observed between the lesion and sham-operated groups. There were no significant differences in the response of isolated muscle strips from anterior-lesioned and sham-operated guinea pigs to exogenous histamine. Anterior hypothalamic lesions of size and location comparable to those that provided protection against lethal anaphylaxis did not modify the anaphylactic response of isolated ileum from actively sensitized animals or following passive sensitization in vitro.