Severe distributive shock, neutrophilic dermatosis, and ST-elevation myocardial infarction in the setting of azathioprine hypersensitivity syndrome.

BACKGROUND: Azathioprine is a purine synthesis inhibitor used as an immunosuppressive therapy for many immune-mediated diseases. Azathioprine hypersensitivity reaction is a rare, life-threatening adverse reaction characterized by a range of multisystem manifestations including fever, abdominal pain, arthralgias, erythematous cutaneous eruption, acute renal failure, neutrophilia, and more rarely, distributive shock. Although acute heart failure has been rarely described in association with azathioprine hypersensitivity syndrome, myocardial infarction has, to our knowledge, never been associated with this entity. CASE PRESENTATION: We describe a case of a 59-year-old male with Crohn's disease who developed severe azathioprine hypersensitivity syndrome that included distributive shock, neutrophilic dermatosis, and acute coronary syndrome with ST-elevation. Clinical improvement was seen after cessation of azathioprine and administration of glucocorticoid therapy. CONCLUSION: Prompt recognition of azathioprine hypersensitivity syndrome, which can manifest as shock and neutrophilic dermatosis, is key to ensure rapid azathioprine cessation.

Revaccination outcomes among adolescents and adults with suspected hypersensitivity reactions following COVID-19 vaccination: A Canadian immunization research network study.

BACKGROUND: COVID-19 vaccination has been associated with anaphylaxis and hypersensitivity reactions. Infectious disease physicians and allergists in the Canadian Special Immunization Clinic (SIC) Network developed guidance for evaluating patients with adverse events following immunization (AEFI) including suspected hypersensitivity. This study evaluated management and adverse event recurrence following subsequent COVID-19 vaccinations. METHODS: Individuals aged 12 years and older enrolled at participating SICs before February 28, 2023 who were referred for suspected or diagnosed hypersensitivity reaction following COVID-19 vaccination, or for prevaccination assessment of suspected allergy to a COVID-19 vaccine component were included. De-identified clinical assessments and revaccination data, captured in a centralized database, were analyzed. The Brighton Collaboration case definition (BCCD) for anaphylaxis (2023 version) was applied. RESULTS: The analysis included 206 participants from 13 sites: 26 participants referred for pre-vaccination assessment and 180 participants referred for adverse events following COVID-19 vaccination (15/180 [8.3%] with BCCD confirmed anaphylaxis, 84 [46.7%] with immediate hypersensitivity symptoms not meeting BCCD, 33 [18.3%] with other diagnosed hypersensitivity reactions, and 48 [26.7%] participants with a final diagnosis of non-hypersensitivity AEFI). Among participants referred for AEFIs following COVID-19 vaccination, 166/180 (92.2%) were recommended for COVID-19 revaccination after risk assessment, of whom 158/166 (95.2%) were revaccinated (all with a COVID-19 mRNA vaccine). After revaccination, 1/15 (6.7%) participants with prior anaphylaxis, 1/77 (1.3%) with immediate hypersensitivity not meeting criteria for anaphylaxis and 1/24 (4.2%) with other physician diagnosed hypersensitivity developed recurrent AEFI symptoms that met the BCCD for anaphylaxis. All 26 participants referred pre-vaccination, including 9 (34.6%) with history of polyethylene glycol-asparaginase reactions, were vaccinated without occurrence of immediate hypersensitivity symptoms. CONCLUSIONS: Most individuals in this national cohort who experienced a hypersensitivity event following COVID-19 vaccination and were referred for specialist review were revaccinated without AEFI recurrence, suggesting that specialist evaluation can facilitate safe revaccination.

Aeroallergen-related Diseases Predate the Diagnosis of Inflammatory Bowel Disease.

OBJECTIVE: This study aimed to determine whether having a diagnosis of asthma or allergic rhinitis (AR) increased the risk of being diagnosed with inflammatory bowel disease (IBD) and whether there was increased incidence of these diseases after a diagnosis of IBD. DESIGN: This is a retrospective, historical cohort-based study. We used the administrative data of Manitoba Health and the population-based University of Manitoba IBD Epidemiology Database. We used numbers of prescriptions for drugs used to treat asthma and to treat AR to identify diagnoses of asthma and AR, respectively.We calculated relative risks (RRs) to assess incidence of IBD compared with matched controls after diagnoses of asthma and AR and hazard ratios to determine the incidence of asthma and AR after IBD diagnosis. RESULTS: Compared with controls, a diagnosis of asthma or AR preceding a diagnosis of IBD was increased in cases (RR, 1.62; 95% confidence interval [CI], 1.50-1.75; and RR, 2.10; 95% CI, 1.97-2.24) with a similar outcome by subtype of IBD (Crohn's disease vs ulcerative colitis) and by sex. On sensitivity analysis, diagnoses of asthma or AR were comparable when considering at least 5, 10, 15 or 20 drug prescriptions. Persons with IBD were more likely to develop asthma or AR than controls after being diagnosed with IBD (hazard ratio for asthma, 1.31, 95% CI, 1.18-1.45; and hazard ratio for AR, 2.62, 95% CI, 2.45-2.80). CONCLUSIONS: The association between asthma, AR, and IBD suggest the possibility that whatever triggers the onset of these atopic diseases may trigger the onset of IBD as well, and aeroallergens are plausible culprits.

This study demonstrates that a preexisting diagnosis of asthma or allergic rhinitis is associated with an increased risk of subsequently developing IBD. These data reinforce the importance of considering that gastrointestinal complaints in patients with asthma and allergic rhinitis may reflect a possible diagnosis of IBD. It also raises the possibility that aeroallergens may be environmental cause(s) of IBD.

Insight into Inflammatory Bowel Disease Pathogenesis: Is the Answer Blowing in the Wind?

Inflammatory bowel diseases (IBD) including Crohn's disease and ulcerative colitis are conditions characterized by immune dysregulation to a trigger in those with a genetic predisposition. Environmental factors are thought to contribute to IBD, but no definite trigger has been identified. Aeroallergens have not been thoroughly investigated in their potential contribution to the pathogenesis to IBD. The geographic distribution of aeroallergens and IBD, the association of atopic disease with IBD, seasonality and IBD, and cross-reactive food allergens require further study with implications for targeted dietary and immunomodulatory therapies.