Investigation of the factors that determine the severity of allergic reactions to Hymenoptera venoms.

Introduction: Many risk factors that facilitate venom allergy and increase systemic reaction severity have been described in various studies, but the data are limited regarding this issue. We aimed to evaluate the impact of total immunoglobulin E (tIgE), specific IgE, and tryptase levels on the severity of systemic reactions in patients with a history of allergic reactions to Hymenoptera stings. Method: Eighty-two patients with a history of allergic reaction to Hymenoptera venom admitted to our outpatient clinic between March 2016 and August 2017 were included. Venom-specific IgE (Apis mellifera and Vespula vulgaris), total IgE, and basal tryptase levels were measured. Skin-prick tests were performed with inhalant allergens. The levels of specific IgE, total IgE, and tryptase were compared between patients with large local reactions and systemic reactions, and the relation of these parameters with the severity of systemic reaction was evaluated. Results: There were no significant differences in the specific IgE, total IgE, and tryptase values in patients with large local reactions and a history of systemic reactions (p > 0.05). The age, basal tryptase, and V. vulgaris-specific IgE levels of patients with a grade IV reaction history were higher than those with grades I-III reaction history (p < 0.05). An important finding was that high basal tryptase levels were a risk factor for grade IV reactions (p = 0.047, χ² = 4.512). There was a strong positive correlation between total IgE levels and V. vulgaris- and A. mellifera-specific IgE values in patients with a grade IV reaction history (r = 0.94, p = 0.005; and r = 0.88, p = 0.021, respectively). Conclusion: Baseline serum tryptase levels were a risk factor for the development of severe systemic reactions in venom allergy. This risk increases with increasing age in these patients. Another notable finding was the correlation between total IgE and venom-specific IgE values in patients with severe systemic reactions.

Magnetic Resonance Imaging May Be a Valuable Radiation-Free Technique for Lung Pathologies in Patients with Primary Immunodeficiency.

PURPOSE: In some primary immunodeficiency (PID) patients, especially in the subgroup with common variable immunodeficiency (CVID), radiosensitivity is a concern and avoidance of repeated radiation exposure has been recommended. To investigate the use of lung Magnetic resonance imaging (MRI) instead of Computed Tomography (CT) for the diagnosis and follow-up of various lesions in the lung parenchyma and airways, especially in PID patients in whom x-ray exposure should be limited. METHODS: The study enrolled 23 patients with PID who underwent thorax CT within the last 3 months and/or who will undergo initial radiological assessment. Lung MRI was performed in all patients to compare the pulmonary findings with CT images. RESULTS: MRI performance was weaker at detecting bronchiectasis extension, and a low concordance was found between MRI and CT in the assessment of the number of bronchial generations. CT better identified peripheral airway abnormalities, while CT and MRI gave similar results for detecting the presence and extension of consolidation, bullae, mucus plugging, bronchial wall thickening, bronchiectasis severity and nodules. CONCLUSIONS: Despite the low spatial resolution, higher cost, and low availability, we suggest MRI as a possible radiation-free alternative to CT in selected patients with PID.

How effective are the 6 European Society of Immunodeficiency warning signs for primary immunodeficiency disease?

BACKGROUND: The European Society of Immunodeficiency (ESID) developed 6 warning signs to promote the awareness of adult primary immunodeficiency disease (PID). OBJECTIVE: To screen adult patients for the presence of PID using these 6 warning signs to determine the effectiveness of this protocol. METHODS: Questions related to the ESID warning signs for adult PID were added to the standard outpatient clinic file system and asked of 3,510 patients who were admitted to our clinic for any reason. Patients with signs and/or suspicion of PID based on their medical history underwent immunologic investigation. RESULTS: In total, 24 patients were diagnosed as having a PID. The most common reason that patients with PID were admitted was frequent infection (n=18 [75%]), and the most common PID subgroup was common variable immunodeficiency (n=12 [50%]). Twenty patients with PID had at least one positive finding according to the ESID warning signs. Two patients with gastrointestinal concerns and 2 with dermatologic symptoms were also diagnosed as having a PID, although they did not have any of the ESID warning signs. CONCLUSION: The ESID warning signs do not specify the need for symptoms to diagnose a PIDs and do not include a comprehensive list of all signs and symptoms of PIDs. As a result, more than infection-centric questions are needed to identify adult patients with immunodeficiencies.

Difficulties encountered in the emergency department by patients with hereditary angioedema experiencing acute attacks.

BACKGROUND: Hereditary angioedema (HAE) is a rare, potentially life-threatening disease characterized by recurrent angioedema attacks. Abdominal symptoms of HAE typically mimic numerous abdominal emergencies, which may result in a delay of correct diagnosis and inappropriate treatments. OBJECTIVE: We aimed to evaluate the difficulties experienced by patients with HAE in Turkish emergency departments (ED). METHODS: We conducted face-to-face interviews with patients with HAE by using a questionnaire regarding the clinical and demographic data of the patients and difficulties encountered during ED admissions. RESULTS: The mean (standard deviation) age of 34 patients with HAE (25 women, 9 men) was 36.2 ± 11.5 years and the mean (standard deviation) delay in diagnosis was 17.2 ± 9.7 years. Inappropriate treatment for HAE attacks was administered to 88.2% (n = 30) of patients in the ED, despite their diagnosis of HAE. The most frequent difficulty was "not knowing how to administer C1 inhibitor concentrate" (n = 11 [32.4%]). Other difficulties encountered were as follows: ED staff being unaware of HAE (n = 6 [17.6%]), lack of C1 inhibitor concentrate in the ED (n = 3 [8.8%]), and kept waiting for the appropriate treatment in triage despite their having angioedema in the head-and-neck region (n = 2 [5.9%]). CONCLUSION: Patients with HAE encounter difficulties in the ED, and the delay in diagnosis could be due to a low level of awareness regarding HAE. Therefore, the management of HAE in EDs requires improvement.

Common variable immunodeficiency and pulmonary amyloidosis: a case report.

Common variable immunodeficiency is the most common symptomatic primary immune deficiency characterized by hypogammaglobulinemia, recurrent infections, and increased risk of autoimmune disease and malignancy. Secondary amyloidosis develops from chronic inflammatory conditions. The co-existence of CVID (especially in patients with bronchiectasis) and secondary amyloidosis has been reported rarely. We describe the first case of pulmonary hypertension secondary to pulmonary amyloidosis in a patient with CVID.

A Cases of Near-fatal Anaphylaxis: Parsley "Over-use" as an Herbal Remedy.

The use of herbal products in patients with allergic diseases is a special problem and still controversial. But, many people often use herbs to maintain good health. The patients use self-prescribed remedies as medications but do not inform their physicians about herbal use. Unfortunately, some herbal self-medications may have unexpected effects and interactions which may lead to fatal complications. In this report, we describe a female patient who suffered near-fatal anaphylaxis to parsley.

IgE-Mediated Reaction to Metamizole: Evaluation of a Patient with Severe Anaphylaxis.

Metamizole, a non-steroidal anti-inflammatory drug with weak anti-inflammatory and spasmolytic effects, is used as an analgesic and antipyretic agent. Many adverse reactions to metamizole, such as early or late-onset systemic reactions and bone marrow suppression, have been identified. In this report, we present a case of systemic reaction after the application of parenteral metamizole (Novalgin(®) ampoule; Sanofi Aventis, Istanbul, Turkey) and discuss the mechanism underlying the reaction.

Common variable immunodeficiency in adults requires reserved protocols for long-term follow-up.

BACKGROUND/AIM: The aim of this study is to establish follow-up protocols for adult patients with common variable immunodeficiency (CVID) in a recently founded adult immunology clinic in the Central Anatolia Region of Turkey, where a clinical immunology center for adults was not available previously. MATERIALS AND METHODS: A total of 25 patients with CVID aged 18 years and older were included in this study. The file format consisted of 13 pages and was developed for the purpose of the study. Separate sections were designated for identity information, medical history, disease course, previous and current laboratory and imaging studies, follow-up plans, detection and management of complications/comorbidities, and treatment results. RESULTS: The mean age of the patients was 36.6 ± 13.4 years. The delay in diagnosis was 107 ± 95.6 months. In 92% of patients, initial symptoms resulting in admission to healthcare facilities were infections. Seventeen of 25 patients (68%) had bronchiectasis at the beginning of follow-up. CONCLUSION: Early identification of complications and comorbidities in patients with CVID will significantly improve quality of life and survival. Close observation and standardized protocols for follow-up are essential components of management.

Accelerated atherosclerosis in patients with common variable immunodeficiency: Is it overlooked or absent?

Common variable immunodeficiency (CVID) is a heterogeneous primary deficiency characterized by hypogammaglobulinemia, recurrent infections, and an increased risk of autoimmune disease and malignancy, and so chronic inflammation. Cardiovascular disease is the leading cause of mortality in the general population. Recent studies have suggested that chronic inflammation is an important player in the pathogenesis of CVID. Accelerated atherosclerosis due to ongoing inflammation from recurrent infections and autoimmunity is an expected clinical entity in patients with CVID. However, cardiovascular mortality as a cause of death in CVID series is either absent or minor. We hypothesized that accelerated atherosclerosis and cardiovascular disease are overlooked by clinicians, or atherosclerosis is really lower than that in the general population that may be prevented by some factors such as life-long immunoglobulin replacement treatment.

Contact dermatitis to cobalt chloride with an unusual mechanism.

BACKGROUND: Contact dermatitis is a frequent inflammatory skin disease. A suspected diagnosis is based on clinical symptoms, a plausible contact to allergens and a suitable history of dermatitis. Therefore, careful diagnosis by patch testing is of great importance because the patch testing is important to find out which allergen/material causes the complaints. Metallic allergens such as cobalt are among the most common causes of allergic contact dermatitis, but frequencies of contact dermatitis to these allergens may vary in different skin areas. Here, we report an unusual case of cobalt allergy on the skin contact with the prosthetic leg of a 30-year-old female patient. CASE DESCRIPTION AND METHODS: The patient developed maculopapular and vesicular lesions on her contact region of residual limb to prosthetic leg. FINDINGS AND OUTCOME: She underwent standard patch testing, which resulted in a strong positive reaction to cobalt chloride. CONCLUSION: This case report may serve to remind doctors to be aware of potential allergic reactions to prostheses and to enable them to recognize a metal allergy if it appears. Prosthetists should also be reminded of potential allergic reactions. CLINICAL RELEVANCE: Cobalt can be used as an accelerator in making a prosthetic socket. Several cases have been reported concerning allergies to components of the prosthetic socket. This is the first report of sensitization to cobalt which is used in making a prosthetic leg.

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.