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Schadow G. Structured product labeling improves detection of drug-intolerance issues. J Am Med Inform Assoc 2008; 16:211-9. [PMID: 18952933 DOI: 10.1197/jamia.m2933] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES This study sought to assess the value of the Health Level 7/U.S. Food and Drug Administration Structured Product Labeling (SPL) drug knowledge representation standard and its associated terminology sources for drug-intolerance (allergy) decision support in computerized provider order entry (CPOE) systems. DESIGN The Regenstrief Institute CPOE drug-intolerance issue detection system and its knowledge base was compared with a method based on existing SPL label content enriched with knowledge sources used with SPL (NDF-RT/MeSH). Both methods were applied to a large set of drug-intolerance (allergy) records, drug orders, and medication dispensing records covering >50,000 patients over 30 years. MEASUREMENTS The number of drug-intolerance issues detected by both methods was counted, as well as the number of patients with issues, number of distinct drugs, and number of distinct intolerances. The difference between drug-intolerance issues detected or missed by either method was qualitatively analyzed. RESULTS Although <70% of terms were mapped to SPL, the new approach detected four times as many drug-intolerance issues on twice as many patients. CONCLUSION The SPL-based approach is more sensitive and suggests that mapping local dictionaries to SPL, and enhancing the depth and breadth of coverage of SPL content are worth accelerating. The study also highlights specificity problems known to trouble drug-intolerance decision support and suggests how terminology and methods of recording drug intolerances could be improved.
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Affiliation(s)
- Gunther Schadow
- Regenstrief Institute, 410 West 10th Street, Suite 2000, Indianapolis, IN 46202, USA.
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Suzuki Y, Miwa S, Shirai M, Ohba H, Murakami M, Fujita K, Suda T, Nakamura H, Hayakawa H, Chida K. Drug lymphocyte stimulation test in the diagnosis of adverse reactions to antituberculosis drugs. Chest 2008; 134:1027-1032. [PMID: 18583516 DOI: 10.1378/chest.07-3088] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) is a worldwide infectious disease. Recently, standard therapy has become very effective for treating patients with TB; however, as a result of this powerful regimen, serious side effects have become an important problem. The aim of this prospective study was to evaluate the usefulness of the drug lymphocyte stimulation test (DLST) to determine anti-TB drugs causing side effects. METHOD Four hundred thirty-six patients with TB were admitted to our hospital for treatment between January 2002 and August 2007. DLST was performed in patients who had certain adverse drug reactions during TB treatment. The causative drug was identified by the drug provocation test (DPT). The tested drugs were mainly isoniazid (INH), rifampin (RIF), ethambutol (EMB) and pyrazinamide (PZA). RESULTS Of 436 patients, 69 patients (15.8%) had certain adverse drug reactions to anti-TB drugs. Of the 261 agents that underwent the DLST and DPT, 28 agents (10.7%) in 20 patients (28.9%) were positive by DLST, and 67 agents (25.7%) in 46 patients (66.6%) were identified as causative drugs by DPT. The sensitivity of DLST was only 14.9% for all drugs (INH, 14.3%; RIF, 13.6%; EMB, 14.3%; PZA, 0%). CONCLUSIONS DLST offers little contribution to the detection of causative agents in patients with adverse anti-TB drug reactions.
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Affiliation(s)
- Yuzo Suzuki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Seiichi Miwa
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan.
| | - Masahiro Shirai
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan
| | - Hisano Ohba
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan
| | - Miho Murakami
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan
| | - Kaoru Fujita
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hirotoshi Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroshi Hayakawa
- Department of Respiratory Medicine, Tenryu Hospital, National Hospital Organization, Hamamatsu, Japan
| | - Kingo Chida
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Syrigou E, Syrigos K, Saif MW. Hypersensitivity reactions to oxaliplatin and other antineoplastic agents. Curr Allergy Asthma Rep 2008; 8:56-62. [PMID: 18377776 DOI: 10.1007/s11882-008-0011-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although the reported incidence of hypersensitivity reactions (HSR) to antineoplastic agents is considered to be uncommon, it is difficult to evaluate their exact prevalence, mainly because their definition is vast and pathogenic mechanisms are vague. HSR include facial flushing, erythema, pruritus, fever, tachycardia, dyspnea, tongue swelling, rash/hives, headache, chills, weakness, vomiting, burning sensations, dizziness, and edema. Treatment and prevention consists of slowing the infusion rate, steroids, and type 1 and 2 histamine receptor antagonists. Desensitization could allow the small number of patients who experience severe HSR to receive effective therapy for their cancer. Reintroductions have only been reported as single case studies or small cohorts. Large-scale validation on desensitization strategies is still missing. With regard to oxaliplatin, knowledge of its rare but eminent toxicity is paramount, because this drug is widely used in treating colorectal cancer, the second-highest cause of cancer mortality in the United States.
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Affiliation(s)
- Ekaterini Syrigou
- Section of Medical Oncology, Yale University School of Medicine, 333 Cedar Street, FMP:116, New Haven, CT 06520, USA
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Cornejo-Garcia JA, Fernandez TD, Torres MJ, Carballo M, Hernan I, Antunez C, Blanca M, Mayorga C. Differential cytokine and transcription factor expression in patients with allergic reactions to drugs. Allergy 2007; 62:1429-38. [PMID: 17983377 DOI: 10.1111/j.1398-9995.2007.01542.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Allergic drug reactions (ADR) can be either immediate reaction (IR) (IgE mediated) or delayed reaction (DR) (T-cell mediated). They follow the Th1/Th2 paradigm, with DR expressing interferon-gamma (IFN-gamma) with down-regulation of interleukin-4 (IL-4) and IR expressing IL-4 with down-regulation of IFN-gamma. We studied the extension of this polarization in DR and IR by examining the cytokine and transcription factor profile in T-cell subpopulations during the acute phase of an ADR. METHODS Expressions of cytokines [IL-4, IFN-gamma and tumor necrosis factor-alpha (TNF-alpha)] and transcription factors (c-maf, GATA-3 and T-bet) were analysed by semi-quantitative real time-polymerase chain reaction in peripheral blood mononuclear cells and in CD4 and CD8 subpopulations from ADR patients. RESULTS In DR, IFN-gamma, TNF-alpha and T-bet increased significantly in both CD4 and CD8 subpopulations, depending on the clinical severity. In IR, IL-4, c-Maf and GATA-3 were increased, but only significantly in CD4. A positive correlation existed between IFN-gamma and T-bet in DR and between IL-4 and c-Maf and GATA-3 in IR. In DR, IFN-gamma, TNF-alpha and T-bet were increased during the acute phase in CD4 and CD8. In IR, IL-4, c-Maf and GATA-3 were all increased in the acute phase, but only in CD4. CONCLUSIONS These results support the Th1/Th2 paradigm in ADR, confirming previous findings that include the expression in both CD4 and CD8 T cells, and extending the observation to the transcription factors involved in the polarization of the immune response. Monitoring the reactions in the cell populations implicated, could be an important tool for assessing the mechanisms involved in ADR.
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Affiliation(s)
- J A Cornejo-Garcia
- Research Laboratory for Allergic Diseases, Carlos Haya Hospital-Fundacion IMABIS, Málaga, Spain
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Park MA, Matesic D, Markus PJ, Li JTC. Female sex as a risk factor for penicillin allergy. Ann Allergy Asthma Immunol 2007; 99:54-8. [PMID: 17650830 DOI: 10.1016/s1081-1206(10)60621-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Identification of risk factors is an integral part of a physician's evaluation of a patient. OBJECTIVE To determine whether female sex is an independent risk factor for penicillin allergy. METHODS Rates of positive penicillin skin test (PST) results, according to sex, were determined in patients with a history of penicillin allergy undergoing penicillin allergy evaluation with major and minor determinants of penicillin between June 1, 2002, and June 30, 2004. Univariate and multivariate logistic regression analyses were used to calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for sex differences in the rates of positive PST results. RESULTS Of the 1,921 patients, 1,759 underwent PST and 157 did not; 5 medical records were not available for review. The mean patient age was 60 years. Sixty-four patients (4%) had a positive PST reaction; of these, 53 (83%) were females and 11 (17%) were males (OR, 3.6; 95% CI, 1.9-7.2; P < .001). In a multivariate logistic regression analysis adjusted for age, history of multiple drug allergies, and elapsed time from the initial penicillin adverse drug reaction to PST, female sex again had a significant risk of a positive PST reaction (OR, 3.2; 95% CI, 1.6-6.7; P = .001). CONCLUSION A greater risk of penicillin allergy exists in association with female sex in patients with a history of penicillin allergy.
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Affiliation(s)
- Miguel A Park
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Matsuno O, Takenaka R, Ando M, Miyazaki E, Kumamoto T. Amoxicillin-Induced Eosinophilic Pneumonia with Granulomatous Reaction: Discrepancy between Drug-Induced Lymphocyte Stimulation Test Findings and the Provocation Drug Test. Allergy Asthma Clin Immunol 2007; 3:70-2. [PMID: 20525146 PMCID: PMC2873625 DOI: 10.1186/1710-1492-3-2-70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 59-year-old man was admitted to the hospital with pulmonary infiltration, fever, erythema, and eosinophilia. Two weeks before admission, he received amoxicillin, acetaminophen, and shoseiryu-to (a Japanese herbal medicine) for a common cold. Bronchoalveolar lavage was performed, and an increased number of eosinophils was recovered. Transbronchial biopsy specimens showed granuloma and interstitial thickening with eosinophils and lymphocytes. Drug-induced eosinophilic pneumonia was suspected, so all drugs were discontinued. The symptoms and infiltration shadow disappeared. A drug-induced lymphocyte stimulation test (DLST) was positive for acetaminophen but not for amoxicillin. In contrast to the DLST, a provocation test revealed that amoxicillin induced the drug allergy. A very striking observation was the coexistence of pulmonary eosinophilia and granulomatous lung infiltrations. In addition, there was a discrepancy between the DLST and provocation test findings. To our knowledge, there is no previous report of drug-induced eosinophilic pneumonia with a granulomatous reaction.
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Affiliation(s)
- Osamu Matsuno
- Division of Respiratory Disease, Department of Brain and Nerve, Oita University Faculty of Medicine, Yufu-city, Oita, Japan.
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Guéant-Rodriguez RM, Guéant JL, Viola M, Tramoy D, Gaeta F, Romano A. Association of tumor necrosis factor-alpha -308G>A polymorphism with IgE-mediated allergy to betalactams in an Italian population. THE PHARMACOGENOMICS JOURNAL 2007; 8:162-8. [PMID: 17471286 DOI: 10.1038/sj.tpj.6500456] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Tumor necrosis factor-alpha (TNF-alpha) is released from mast cells via an immunoglobulin E (IgE)-dependent mechanism. The variant G>A at -308 of TNFA is part of an extended haplotype HLA-A1-B8-DR3-DQ2 and influences the gene expression. We evaluated this variant in relation to IgE-mediated reactions to betalactams, in 427 subjects, including 167 cases and 260 age- and gender-paired controls. TNFA GG genotype was a significant independent predictor of the primary risk of betalactam allergy, concurrently with total IgE level, with an age- and sex-adjusted odds ratio estimated at 2.45 (95% confidence interval: 1.18-5.08, P=0.0163). Cases with -308AA genotype had a higher serum level of specific IgE than those with -308GA/GG genotype, with median levels (relative units) of 4.6 (inter-quartiles: 3.9-10.6) and 2.2 (1.4-4.3), respectively (P=0.0046). In conclusion, our results suggest an ambivalent influence of a genetic determinant of pro-inflammatory pathways on IgE-mediated hypersensitivity to betalactams.
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Affiliation(s)
- R-M Guéant-Rodriguez
- Inserm U-724, Faculté de Médecine, University of Nancy-Henri Poincaré and University Hospital Center (CHU) of Nancy, Nancy, France
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Abstract
PURPOSE OF REVIEW Desensitization for drug allergy is the induction of temporary clinical unresponsiveness to drug antigens. Gradual reintroduction of small doses of drug antigen at fixed time intervals allows for the delivery of full therapeutic doses, protecting patients from anaphylaxis. Rapid desensitizations permit the use of essential antibiotics in severely infected allergic patients or aspirin in aspirin-sensitive cardiac patients undergoing revascularization. We review the indications and outcomes of recent protocols for desensitization to antibiotics and aspirin. RECENT FINDINGS Despite the success of rapid desensitizations, the cellular and molecular inhibitory mechanisms are incompletely understood. In-vitro mast cell and basophil models implicate molecular signaling molecules syk and STAT6. Rapid desensitization protocols treat type I mast cell/IgE dependent reactions, such as anaphylaxis, as seen with sensitization to penicillin, cephalosporins, and other antibiotics. Anaphylactoid reactions induced upon initial drug exposure and with similar clinical presentation as immunoglobulin E-mediated reactions, as seen with aspirin, vancomycin and taxenes, can also be treated with rapid desensitizations. SUMMARY Successful rapid desensitization protocols for treating adverse reactions to antibiotics and aspirin allow for treatment of critically infected patients and aspirin-sensitive cardiac patients. Standardized protocols with high success rates should be implemented as the standard of care.
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Morel E, Bellón T. Amoxicillin conjugates to HLA class I molecules and interferes with signalling through the ILT2/LIR-1/CD85j inhibitory receptor. Allergy 2007; 62:190-6. [PMID: 17298429 DOI: 10.1111/j.1398-9995.2006.01285.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Drugs behave as haptens and are recognized by specific T-cell receptors in the context of major histocompatibility complex (MHC) molecules in allergic subjects. Natural killer cell receptors (NKRs) are MHC class I-specific receptors that modulate the threshold of activation of immunocompetent cells. Amongst them, ILT2/LIR-1/CD85j is an inhibitory NKR widely distributed in several cell lineages and with a broad spectrum of recognition of human leucocyte antigen (HLA) class I ligands. METHODS We have evaluated, at the biochemical and cellular level, the ability of amoxicillin (AX) conjugate to HLA class I molecules and to interfere with the inhibitory signal delivered by the HLA class I receptor ILT2/LIR-1/CD85j. RESULTS We have detected AX bound to cell membrane proteins and in particular to HLA class I molecules. Preincubation with AX rendered target cells susceptible to NK cell-mediated lysis. In conjugation experiments, target cell-bound AX hampered tyrosine phosphorylation of ILT2/LIR-1/CD85j upon ligand recognition and the subsequent recruitment of SHP-1 phosphatase. CONCLUSION Conjugation of AX to HLA class I molecules may mask HLA recognition by inhibitory receptors and attenuate the negative signal delivered by SHP-1 phosphatase, thus lowering the threshold of activation of effector cells.
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Affiliation(s)
- E Morel
- Research Unit, Hospital Universitario La Paz, Madrid, Spain
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Won YJ, Kim OL, Yu ST, Yoon YW, Choi DY. A case of dapsone syndrome. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.5.493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yoo Jong Won
- Department of Pediatrics, School of Medicine, Wonkwang University, Iksan, Korea
| | - Ok Lan Kim
- Department of Pediatrics, School of Medicine, Wonkwang University, Iksan, Korea
| | - Seung Taek Yu
- Department of Pediatrics, School of Medicine, Wonkwang University, Iksan, Korea
| | - Young Wook Yoon
- Department of Pediatrics, School of Medicine, Wonkwang University, Iksan, Korea
| | - Du Young Choi
- Department of Pediatrics, School of Medicine, Wonkwang University, Iksan, Korea
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Abstract
Allergic diseases are common problems affecting 20% to 30% of the US population. Mast cells and basophils are the primary effector cells mediating allergic inflammation through the triggering of membrane immunoglobulin E receptors (FceRI) with antigen. Allergen immunotherapy is used as one treatment for allergic disease and results in the inhibition of mast cell and basophil responses through unknown mechanisms. In this review, we examine potential mechanisms that could result in blunted human mast cell/basophil functional responses, strategies aimed at using these mechanisms to develop new immunologically based therapies, and recent findings that have broad implications toward our understanding of how mast cells/basophils become desensitized.
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Affiliation(s)
- Christopher L Kepley
- Department of Internal Medicine,Virginia Commonwealth University Health Systems,1112 East Clay Street, Richmond, VA 23298, USA.
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MOK KW, GOLDSTEIN D. Hypersensitivity reactions to oxaliplatin: Can patients be rechallenged? Asia Pac J Clin Oncol 2006. [DOI: 10.1111/j.1743-7563.2006.00066.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Most drug reactions are pharmacological reactions rather than hypersensitivity reactions. In assessing drug reactions, a detailed clinical history and careful documentation of reactions are most important. Elucidating the nature and time course (first versus subsequent exposure, immediate versus non-immediate) of a reaction can help to distinguish immune from non-immune hypersensitivity, as well as IgE-mediated from T cell-mediated allergy. Skin testing and in-vitro tests are of predictive value for only a limited group of IgE-mediated drug allergic reactions. Drug provocation challenges can be used to eliminate suspicion of a low-probability drug reaction, find a safe alternative to a proven or probable drug reaction, or as a means of desensitisation. If a patient taking an angiotensin-converting enzyme (ACE) inhibitor develops angioedema, the cause must be assumed to be the ACE inhibitor until proven otherwise.
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Affiliation(s)
- Francis C K Thien
- Department of Allergy Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia. F.ThienATalfred.org.au
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Zingale LC, Beltrami L, Zanichelli A, Maggioni L, Pappalardo E, Cicardi B, Cicardi M. Angioedema without urticaria: a large clinical survey. CMAJ 2006; 175:1065-70. [PMID: 17060655 PMCID: PMC1609157 DOI: 10.1503/cmaj.060535] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Angioedema without major urticarial flares (hives) is poorly understood. Its causes are diverse, and little is known about its pathogenic mechanisms. We report on our 11 years of experience with this condition and propose a classification of patients affected by angioedema unaccompanied by urticaria. METHODS From 1993 through 2003 at our outpatient clinic, 929 consecutive patients were examined for recurrent angioedema unaccompanied by urticaria. A detailed history was taken to identify known causes of angioedema, with special attention to external allergenic agents. Each patient underwent a complete physical examination, routine laboratory tests (blood cell count, protein electrophoresis, erythrosedimentation rate, examination of stool for ova and parasites, pharyngeal and urine cultures, sinus and dental radiography, and measurements of antitissue autoantibodies and rheumatoid factor in plasma), and complement parameters (C1 inhibitor, C4 and C1q). Further testing was done when pertinent, based on clinical findings. When all results were negative, response to H1-antihistamine was considered. RESULTS Angioedema could not be classified in 153 patients who were lost to follow-up (16.4%). Among the 776 cases with adequate data, these types of angioedema were identified: 124 (16%) related to external agents such as a drug, insect bite or foodstuff; 85 (11%) related to treatment with angiotensin-converting enzyme inhibitor; 55 (7%) associated with an autoimmune disease or infection; and 197 (25%) caused by C1 inhibitor deficiency. In the other 315 cases (41%), the etiology was undiscovered: 254 cases (33% of the study sample) were idiopathic histaminergic; 40 (5%) were idiopathic nonhistaminergic; and 21 (3%) had other causes of peripheral or generalyzed edema. INTERPRETATION Our data indicated that angioedema without urticaria could be classified according to specific clinical and pathogenic characteristics, and we have suggested a work-up for patients experiencing this condition.
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Affiliation(s)
- Lorenza C Zingale
- Department of Internal Medicine, San Giuseppe Hospital, University of Milan, Milan, Italy.
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MacPherson RD, Willcox C, Chow C, Wang A. Anaesthetist's responses to patients' self-reported drug allergies. Br J Anaesth 2006; 97:634-9. [PMID: 16950811 DOI: 10.1093/bja/ael237] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with drug allergies are commonplace in anaesthetic practice. We investigated the incidence and nature of drug 'allergies' reported by surgical patients attending a hospital pre-admission clinic, and went on to ascertain to what degree drug allergies recorded in the records influenced drug prescribing during the patients' hospital stay and determine whether any adverse events occurred in relation to drug prescribing in this population. METHODS Patients attending for anaesthetic assessment at a Pre-Admission Clinic over a 30 week period were questioned concerning drug allergies. Medical records of these patients were then examined after their hospitalization to assess medications prescribed during that period. RESULTS Of 1260 patients attending the Pre-admission clinic during the study period 420 (33.4%) claimed to have a total of 644 individual drug 'allergies'. The most common agents implicated were antibiotics (n=272), opioid analgesics (n=118) and NSAIDs (n=62); the most common form of these reactions were dermatological (n=254) and nausea and vomiting (n=124). There were 41 self-reports specifically of anaphylaxis and a further 61 where there was significant respiratory system involvement. CONCLUSIONS The majority of the self-reported allergies were in fact simply accepted adverse effects of the drugs concerned. The patients' reported drug 'allergy' history was generally well respected by anaesthetists and other medical staff. There were 13 incidents, mainly involving morphine, where patients were given a drug to which they had claimed a specific allergy. There were 101 incidents in 89 patients where drugs of the same pharmacological group as that of their allergic drug were used. There were no untoward reactions in 84 patients who had claimed a prior adverse reaction to penicillin who were given cephalosporins. There were no sequelae from any other events. While anaesthetists generally respected patients self-reported 'allergies', more attention needs to be paid to the accurate recording of patients' events and a clear distinction should be made both in medical records and to the patient between true drug allergy and simple adverse drug reactions.
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Affiliation(s)
- R D MacPherson
- Department of Anaesthesia and Pain Management Pacific Highway, St Leonards, NSW 2065, Australia.
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Guéant-Rodriguez RM, Romano A, Béri-Dexheimer M, Viola M, Gaeta F, Guéant JL. Gene–gene interactions of IL13 and IL4RA variants in immediate allergic reactions to betalactam antibiotics. Pharmacogenet Genomics 2006; 16:713-9. [PMID: 17001290 DOI: 10.1097/01.fpc.0000230409.00276.44] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Immediate reactions - particularly anaphylactic ones - to betalactams are the most common adverse reactions to antibiotics mediated by a specific immunologic mechanism. The genetic risk factors influencing these mechanisms are poorly known. We aimed to evaluate the association between immediate allergic reactions to betalactams and the polymorphisms of IL13 (R130Q and -1055C>T variants) and IL4RA (I50V, S478P, and Q551R variants). METHODS We determined these gene variants in 210 patients and 265 age-paired and gender-paired control subjects from Italy. RESULTS The combination of the less frequent allele of the IL13 R130Q polymorphism with any of the predominant homozygous genotypes of the three polymorphisms of IL4RA was more significantly associated with the risk of betalactam allergy (P=0.0006, 0.0077, and 0.0041, respectively) than any polymorphism considered alone (P=0.1745, 0.0268, 0.1812, 0.0152, respectively). The same associations were observed with serum IgE levels (IL13/IL4RA variant combinations: P=0.0009, 0.0007, 0.0020, respectively and each variant: P=0.0201, 0.0021, 0.0531, and 0.0417, respectively). The combination of IL4RA variants with -1055 C>T polymorphism produced similar associations. CONCLUSION Our data suggest that these combinations of IL13 and IL4RA variants are predictors of immediate allergic reactions to betalactams through a mechanism related to IgE production.
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Affiliation(s)
- Rosa-Maria Guéant-Rodriguez
- Inserm U-724, Faculté de Médecine, University of Nancy-Henri Poincaré and Department of Clinical Chemistry, Nutrition and Metabolism, University Hospital, Nancy-Vandoeuvre, France
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Rouveix B. [Clinically significant toxicity and tolerance of the main antibiotics used in lower respiratory tract infections]. Med Mal Infect 2006; 36:697-705. [PMID: 16876974 DOI: 10.1016/j.medmal.2006.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Accepted: 05/19/2006] [Indexed: 11/21/2022]
Abstract
The purpose of this article was not to review all reported adverse reactions of antibiotics used in the treatment of lower respiratory tract infections but rather to focus either on those which might have an impact on observance, efficacy, and resistance, or on rare but life-threatening adverse effects such as torsade de pointe. The latter are mostly predictable and prescribers should adhere to precautions and contraindications. For new antibiotics, the number of patients enrolled in phase I to III clinical trials is far to small to detect such rare adverse effects and large post registration tolerance surveys are mandatory. ss-lactams are well tolerated. The risk of anaphylactic reaction is magnified by patient reports and can be reduced by skin testing. Macrolides are well tolerated as well. The risk of cardiac toxicity should be reduced by assessing individual susceptibility and avoiding drug interactions. The tolerance to telithromycin, a new ketolide, is similar to that of macrolides. Serious toxic reactions such as convulsions, tendon rupture, torsade de pointe, and hypoglycemia are associated with the use of fluoroquinolones. Most of these adverse reactions can be often circumvented by avoiding exposure patients at risk. Quinupristin/dalfopristin can induce arthralgia and myalgia and the major adverse effects of linezolid are IMAO like reactions, reversible myelosuppression, and peripheral neuropathy. Most of the adverse antibiotic reactions are reported when precautions of use in susceptible patients are not taken into account. When they are, the safety/risk ratio is good.
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Affiliation(s)
- B Rouveix
- Service de pharmacologie clinique, CNRS UPRES A 8068, hôpital Cochin-Saint-Vincent-de-Paul, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France.
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Mayorga C, Pena RR, Blanca-López N, López S, Martin E, Torres MJ. Monitoring the acute phase response in non-immediate allergic drug reactions. Curr Opin Allergy Clin Immunol 2006; 6:249-57. [PMID: 16825864 DOI: 10.1097/01.all.0000235897.72429.4a] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The aim of this article is to evaluate the advantages of monitoring the immunological response of non-immediate allergic drug reactions in parallel with the affected tissues, skin and peripheral blood, in order to improve our understanding of the immunological response. RECENT FINDINGS Several studies have shown that in the skin and peripheral blood, the agents that take part in the development of the immunological reaction express a number of markers that parallel the evolution of the disease process. These markers include cytokines, chemokines, and cytotoxic factors, as well as many other markers involved in such mechanisms as drug metabolism and signal transduction. SUMMARY Monitoring the acute phase response to a drug in the skin with parallel studies in the blood provides clues that increase our understanding of the underlying pathological mechanisms in adverse reactions to drugs with an immunological basis. This approach, together with molecular biology techniques such as microarrays and genomic studies may be useful in future, in better characterizing the clinical subtype and prognosis of nonimmediate allergic drug reactions and generating targeted treatment regimens.
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70
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Abstract
T cells are major protagonists of immune-mediated adverse drug eruptions. Immunohistochemical observation as well as isolation and functional characterization of T cells infiltrating the affected tissues provided new insights into the pathomechanisms of the diverse clinical manifestations of drug hypersensitivity, and permitted the recognition of T cell-mediated cytotoxicity against drug-loaded resident cells as a major mechanism of tissue damage.
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Affiliation(s)
- Andrea Cavani
- Laboratory of Immunology and Allergology, Istituto Dermopatico dell'Immacolata, IDI-IRCCS, Rome, Italy.
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71
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Schnabel CA, Fineberg SE, Kim DD. Immunogenicity of xenopeptide hormone therapies. Peptides 2006; 27:1902-10. [PMID: 16517012 DOI: 10.1016/j.peptides.2006.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 01/25/2006] [Accepted: 01/26/2006] [Indexed: 12/25/2022]
Abstract
Peptides are a growing class of agents whose therapeutic use originated with non-human treatments such as animal insulins. Xenopeptides continue to be explored for biotherapeutic development using genetic engineering, and through the rich resource of animal and plant polypeptides. One of the major concerns of therapeutic administration of xenopeptides is the potential for untoward immune responses that may lead to loss of drug efficacy or adverse events in recipients. An increased risk of immunogenicity is perceived with xenopeptides, however, human-derived therapies also induce antibody formation that in some cases has been associated with severe clinical sequelae. In this review, antibody responses to xenopeptides are highlighted looking at current hormone therapies used to treat endocrine disorders. Similar to clinical experiences with peptide-based agents in general, antibody responses against xenopeptide hormone therapies in majority of cases have been benign in nature with minimal clinical impact.
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72
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Komericki P, Arbab E, Grims R, Kränke B, Aberer W. Tryptase as Severity Marker in Drug Provocation Tests. Int Arch Allergy Immunol 2006; 140:164-9. [PMID: 16601354 DOI: 10.1159/000092556] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Accepted: 02/01/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the absence of objective symptoms, it is difficult to assess an adverse reaction during drug provocation testing. We evaluated the value of serum tryptase levels to distinguish between positive, negative and, even more important, so-called 'hysterical' reactions (conversion symptoms). The latter are occasionally observed in drug provocation tests when the patient experiences ambiguous subjective symptoms. METHODS In a prospective single-center study, 303 patients underwent 785 drug provocation tests. Blood was taken for tryptase measurement on each test day before and after drug challenge, and the changes in serum tryptase levels in patients with no reactions were compared with those who experienced immediate reactions to a drug. RESULTS Thirty-four of 785 drug provocations were clinically judged as being positive. Despite objective symptoms, median serum tryptase values in the afternoon were even lower than baseline levels. However, this decrease was not statistically significant. In the 751 patients suffering no objective reactions, the median values of post-testing tryptase values were statistically significantly decreased as compared with pretesting values. CONCLUSIONS The measurement of serum tryptase levels does not appear to be helpful to differentiate mild allergic or nonallergic reactions from 'hysterical' ones. The milder decrease in the group with objective drug reactions might indicate slight mast cell activation in some patients. More severe clinical drug reactions led to stronger mast cell degranulation. Mild reactions did not increase the tryptase levels consistently.
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Affiliation(s)
- P Komericki
- Department of Environmental Dermatology and Venereology, Medical University Graz, Graz, Austria.
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73
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Juang P, Page RL, Zolty R. Probable loop diuretic-induced pancreatitis in a sulfonamide-allergic patient. Ann Pharmacother 2005; 40:128-34. [PMID: 16352777 DOI: 10.1345/aph.1g314] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To report the case of a patient with a prior allergy to a sulfonamide antibiotic who subsequently developed the same reaction when administered various loop diuretics. CASE SUMMARY A 57-year-old female with cardiomyopathy and "sulfa" (trimethoprim/sulfamethoxazole) allergy documented as pancreatitis presented with symptoms consistent with pancreatitis after use of furosemide. She subsequently developed similar symptoms after multiple rechallenges with various loop diuretics including furosemide, bumetanide, and torsemide. The patient was placed on ethacrynic acid until she was desensitized to furosemide. She had been receiving oral furosemide for 5 months at the time of this report, with no complications. According to the Naranjo probability scale, this reaction was probable. DISCUSSION Reactions associated with arylamine sulfonamide-containing antibiotics have been commonly reported; however, cross-reactions with non-arylamine sulfonamide-containing medications have been rare. The time delay by which symptoms of pancreatitis presented following administration of loop diuretics suggests an immunologic pathway. In addition, while cases of loop diuretic-induced pancreatitis, including furosemide, have been published, the allergic manifestations with both sulfonamide antibiotics and non-antibiotics in our patient suggest possible cross-reactivity between these 2 drug classes. CONCLUSIONS The mechanism by which loop diuretics induce pancreatitis appears to be via an immunologic pathway. While the true correlation remains unknown, allergic cross-reactivity may occur between sulfonamide antibiotics and non-antibiotics, such as loop diuretics. Torsemide appears to also be a part of a long list of agents that can cause pancreatitis.
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Affiliation(s)
- Paul Juang
- Department of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO, USA
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74
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Geller M, Wolff PG. Urticária e angiodema associados a fator estimulador das colônias de granulócitos e macrófagos recombinante humano (rhuGM- CSF) em portador de melanoma metastático. An Bras Dermatol 2005. [DOI: 10.1590/s0365-05962005000700010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
É apresentado um caso de melanoma metastático controlado há seis meses com o fator estimulador das colônias de granulócitos e macrófagos recombinante humano (rhuGM-CSF), administrado periodicamente por via subcutânea. Os autores descrevem, pela primeira vez no Brasil, a presença de urticária gigante e angioedema associados a essa bioquimioterapia imunoestimulatória, tendo controlado essas reações adversas com o emprego de um esquema clássico antialérgico preventivo composto de dexclorfeniramina e prednisona. Epinefrina auto-injetora tornou-se disponível durante a administração do rhuGM-CSF.
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Affiliation(s)
- Mario Geller
- American College of Allergy, Asthma and Immunology
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75
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Marié E, Fournier C, Bautin N, Doyen V, Wallaert B. Accoutumance ultrarapide à l'allopurinol. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.allerg.2005.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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76
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Kepley CL. Antigen-Induced Reduction in Mast Cell and Basophil Functional Responses due to Reduced Syk Protein Levels. Int Arch Allergy Immunol 2005; 138:29-39. [PMID: 16088210 DOI: 10.1159/000087355] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Accepted: 04/07/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The high-affinity IgE receptor, FcepsilonRI, is unresponsive on mast cells and basophils from people in several populations through an unknown mechanism. Similarly, FcepsilonRI-positive basophils from 'nonreleasers' are IgE-unresponsive and are deficient in the tyrosine kinase Syk. OBJECTIVE To test the hypothesis that cross-linking FcepsilonRI on mast cells and basophils leads to FcepsilonRI nonresponsiveness through reduction in Syk protein levels. METHODS Human mast cells and basophils were used to determine if FcepsilonRI hyporesponsiveness correlated with reduced Syk levels. RESULTS It is shown that suboptimal antigen challenge, that did not lead to significant mediator release, induced nonresponsiveness and correlated with reduced Syk. Other IgE-associated signaling molecules were unaffected by the same treatment. The ability of IgE-unresponsive mast cells to regain FcepsilonRI responsiveness is paralleled by increased cellular Syk levels in vitro. The reduction of Syk levels with suboptimal antigen concentrations was calcium independent and mediated through a proteasome-dependent mechanism. CONCLUSION These findings confirm and extend our knowledge about a novel regulatory mechanism for maintaining FcepsilonRI in a quiescent state. This mechanism may also explain why low concentrations of allergen given to patients during allergen immunotherapy induce FcepsilonRI nonresponsiveness and therapeutic benefit without inducing systemic anaphylaxis.
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Affiliation(s)
- Christopher L Kepley
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Virginia Commonwealth University Health Systems, Richmond, VA 23298, USA.
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Nierkens S, Aalbers M, Bol M, Bleumink R, van Kooten P, Boon L, Pieters R. Differential Requirement for CD28/CTLA-4-CD80/CD86 Interactions in Drug-Induced Type 1 and Type 2 Immune Responses to Trinitrophenyl-Ovalbumin. THE JOURNAL OF IMMUNOLOGY 2005; 175:3707-14. [PMID: 16148116 DOI: 10.4049/jimmunol.175.6.3707] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The use of mAbs to abrogate costimulatory interactions has attracted much attention with regard to prevention and modulation of adverse (auto)immune-like reactions. However, the role of costimulatory molecules and possible therapeutic use of Ab-treatment in drug-induced immunostimulation is poorly elucidated. In the present studies, we show that CD28/CTLA-4-CD80/CD86 costimulatory interactions differently regulate drug-induced type 1 and type 2 responses to an identical bystander Ag, TNP-OVA, in BALB/c mice using the reporter Ag popliteal lymph node assay. The antirheumatic drug D-Penicillamine, which may induce lupus-like side-effects, stimulated type 2 responses against TNP-OVA, characterized by the production of IL-4 and TNP-specific IgG1 and IgE. These responses were abrogated in CD80/CD86-deficient mice and in wild-type mice that were treated with anti-CD80 and anti-CD86, or CTLA-4-Ig. Anti-CTLA-4 intensively enhanced the D-Penicillamine-induced effects. In contrast, the type 1 response (IFN-gamma, TNF-alpha, IgG2a) to TNP-OVA induced by the diabetogen streptozotocin still developed in the absence of CD80/CD86 costimulatory signaling. In addition, it was demonstrated that coadministration of anti-CD80 and anti-CD86 mAbs slightly enhanced streptozotocin-induced type 1 responses, whereas the CTLA-4-Ig fusion protein completely abrogated this response. In conclusion, different drugs may stimulate distinct types of immune responses against an identical bystander Ag, which are completely dependent on (type 2) or independent of (type 1) the CD28/CTLA-4-CD80/CD86 pathway. Importantly, the effects of treatment with anti-CD80/CD86 mAbs and CTLA-4-Ig may be considerably different in responses induced by distinct drugs.
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Affiliation(s)
- Stefan Nierkens
- Institute for Risk Assessment Sciences, Immunotoxicology, Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
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78
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Kim SH, Choi JH, Park HS. Heterogeneity of the IgE response to allergenic determinants of cefaclor in serum samples from patients with cefaclor-induced anaphylaxis. Ann Allergy Asthma Immunol 2005; 94:700-4. [PMID: 15984605 DOI: 10.1016/s1081-1206(10)61331-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Beta-lactam antibiotics, such as cefaclor, may cause IgE-mediated anaphylactic reactions. However, the clinically available serologic test has not been widely accepted, and the antigenic determinants of these drugs are unclear. OBJECTIVE To describe 4 cases of anaphylaxis caused by cefaclor in which a specific IgE response to cefaclor was demonstrated. METHODS Four patients with anaphylaxis to cefaclor and 35 nonatopic controls never exposed to cefaclor were studied. Skin tests and oral challenges with this drug were performed. The specific IgE response to the antigenic determinant of cefaclor-human serum albumin (HSA) conjugate was compared in each patient. The serum specific IgE to cefaclor-HSA conjugate was detected using enzyme-linked immunosorbent assay (ELISA). Also, ELISA inhibition studies using various concentrations of cefaclor-HSA, HSA alone, and free cefaclor were performed, as were hapten inhibition studies using cefaclor, cephalexin, cefadroxil, ampicillin, ceftriaxone, and cefotaxime. RESULTS Three patients showed high levels of serum specific IgE to cefaclor-HSA and marked inhibition patterns to free cefaclor and cefaclor-HSA conjugate on ELISA inhibition testing. Hapten inhibition testing in 3 individual serum samples showed 2 different patterns. In patient 3, significant dose-dependent inhibitions (up to 92%) were noted with additions of free cefaclor and cefaclor-HSA conjugate, and lesser inhibitions (up to 74%) were noted with cephalexin, which shares the aminobenzyl side chain. In patients 1 and 2, marked dose-dependent inhibitions were noted only with additions of cefaclor-HSA conjugate and free cefaclor, whereas minimal inhibitions were noted with the other 5 compounds. CONCLUSIONS The specific IgE response to cefaclor-HSA conjugate in patients with cefaclor anaphylaxis occurs against the hapten, in which heterogeneity of the antigenic determinant was noted to depend on the individual.
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Affiliation(s)
- Sang-Hoon Kim
- Department of Internal Medicine, Eulji Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
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79
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Lunet N, Falcão H, Sousa M, Bay N, Barros H. Self-reported food and drug allergy in Maputo, Mozambique. Public Health 2005; 119:587-9. [PMID: 15925673 DOI: 10.1016/j.puhe.2004.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2004] [Revised: 07/05/2004] [Accepted: 07/29/2004] [Indexed: 11/17/2022]
Affiliation(s)
- N Lunet
- Department of Hygiene and Epidemiology, University of Porto Medical School, Portugal.
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80
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Abstract
PURPOSE OF REVIEW Drug hypersensitivity reactions are relatively rare but may result in severe morbidity and fatalities. Due to the idiosyncratic nature and multifactorial etiology of these reactions, development of a single animal model to study the immunosensitizing mechanisms of all drugs is impossible. This hampers the development of predictive screening models that are urgently needed to assess the immunostimulating capacity of newly developed drugs. The present review will focus on recent findings on mechanisms of drug hypersensitivity reactions obtained with murine models, and on the use of these models as potential screening tools to assess the immunostimulating capacity of drugs. RECENT FINDINGS Mechanisms of drug-induced sensitization versus tolerance appear dependent on generally accepted immunological paradigms. For instance, co-stimulatory signaling by antigen-presenting cells is decisive in drug-induced immunosensitization and both T cells and antigen-presenting cells are important for the induction of tolerance to orally administered drugs. From recent studies it has been hypothesized that expression of stress-associated transcription factors and the expression of costimulatory molecules or cytokine production within hours or days after the initial exposure may be representative of drug-induced hypersensitivity reactions and may thus be used as predictive parameters to screen for immunosensitizing drugs. SUMMARY The development of animal models to study mechanisms of drug hypersensitivity reactions is still in its infancy. Much effort has been made, however, to search for early indicators of immunostimulation in murine animal models that may eventually appear useful in a tiered strategy to assess drug-induced sensitization.
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Affiliation(s)
- Stefan Nierkens
- Department of Immunotoxicology, Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, The Netherlands.
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81
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Abstract
Mast cell has a long history of being recognized as an important mediator-secreting cell in allergic diseases, and has been discovered to be involved in IBD in last two decades. Histamine is a major mediator in allergic diseases, and has multiple effects that are mediated by specific surface receptors on target cells. Four types of histamine receptors have now been recognized pharmacologically and the first three are located in the gut. The ability of histamine receptor antagonists to inhibit mast cell degranulation suggests that they might be developed as a group of mast cell stabilizers. Recently, a series of experiments with dispersed colon mast cells suggested that there should be at least two pathways in man for mast cells to amplify their own activation-degranulation signals in an autocrine or paracrine manner. In a word, histamine is an important mediator in allergic diseases and IBD, its antagonists may be developed as a group of mast cell stabilizers to treat these diseases.
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Affiliation(s)
- Hua Xie
- Allergy and Inflammation Research Institute, Shantou University Medical College, 22 Xin-Ling Road, Shantou 515031, Guangdong Province, China
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82
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Lelong J, Duburque C, Fournier C, Colombel JF, Desreumaux P, Tonnel AB, Wallaert B. Accoutumance médicamenteuse à l’infliximab dans la maladie de Crohn. Rev Mal Respir 2005; 22:239-46. [PMID: 16092162 DOI: 10.1016/s0761-8425(05)85477-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Infliximab is a chimeric monoclonal antibody directed against tumour necrosis factor-alpha that has been shown to improve chronic refractory and fistulating Crohn's disease. Infliximab infusions have been associated both with immediate and delayed reactions. MATERIAL AND METHODS Desensitisation was performed in four patients who had experienced immediate reactions to infliximab infusions and in one who had developed a delayed reaction. No therapeutic alternatives were available for these patients. Before desensitisation, skin tests were performed. RESULTS Skin-tests were negative for all patients. Desensitisation was performed with serial dilutions of infliximab with monitoring of vital signs before each increment. After parenteral desensitisation, all five patients were able to tolerate infliximab infusion without complications or any requirement for antihistamines or steroids. However, two patients who had initially presented with an immediate reaction to infliximab experienced arthralgia and myalgia similar to a "serum sickness-type" of reaction 6 to 10 days after desensitisation. CONCLUSION Even if there is no evidence of an allergic mechanism in infusion reactions to infliximab, successful desensitization can be achieved for patients experiencing acute reactions. The mechanism of desensitisation remains presently unknown. It is not yet possible to say if desensitization will be effective in preventing delayed reactions.
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Affiliation(s)
- J Lelong
- Service de Pneumo-allergologie, Clinique des Maladies Respiratoires, Hôpital Albert Calmette, CHRU, Lille, France
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83
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Abstract
Among patients with a reported history of penicillin allergy, 80% to 90% have no evidence of IgE antibodies to penicillin on skin testing and thus avoid penicillin unnecessarily. Moreover, 97% to 99% of such patients with a penicillin skin test negative to the major and minor determinants can tolerate penicillin without risk of an immediate-type hypersensitivity reaction. A penicillin skin test is valuable for evaluating penicillin allergy in patients who need penicillin or cephalosporin. Assessment of sensitivities to penicillin is important to reduce the unnecessary use of antimicrobial agents such as vancomycin. We review the role of penicillin skin testing for evaluating penicillin allergy and the use of cephalosporin in patients with a history of penicillin allergy.
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Affiliation(s)
- Miguel A Park
- Department of Internal Medicine and Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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84
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Hegde VL, Venkatesh YP. Anaphylaxis to excipient mannitol: evidence for an immunoglobulin E-mediated mechanism. Clin Exp Allergy 2005; 34:1602-9. [PMID: 15479277 DOI: 10.1111/j.1365-2222.2004.02079.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anaphylaxis to mannitol present naturally in pomegranate and cultivated mushroom in a sensitized subject has been described recently, and an IgE-mediated mechanism to this sugar alcohol has been proposed. The same subject also experienced severe allergic reactions to a chewable pharmaceutical (cisapride drug). OBJECTIVE The purpose of the study was to identify allergenic component in the pharmaceutical preparation, and also, to understand the mechanism of immediate hypersensitivity to mannitol. METHODS Methodology involved skin prick tests (SPTs), high-performance liquid chromatographic (HPLC) analysis of pharmaceutical preparations, separation of mannitol by Ca++-ion-moderated cation-exchange chromatography, preparation of alditol-protein conjugates by reductive amination, SPT using the conjugates, hapten affinity purification of the allergic serum on D-mannitol-keyhole limpet haemocyanin (KLH)-Sepharose CL-6B, and detection of serum mannitol-specific IgE by ELISA. RESULTS Component testing by SPT, and HPLC analysis of various pharmaceuticals indicated that the excipient mannitol is the causative allergen. Mannitol separated from Cisapid MPS showed allergenic activity by SPT. Among the several conjugates tested by SPT, D-mannitol-bovine serum albumin and D-mannitol-KLH showed positive weal/flare reaction, demonstrating the presence of cell-bound mannitol-specific IgE in vivo. Negative results with D-glucitol, D-galactitol, meso-erythritol, and L-mannitol protein conjugates clearly showed that the mannitol-specific human IgE is very specific to the D-isomer of mannitol. ELISA using the hapten affinity-purified allergic serum was positive, demonstrating the presence of mannitol-specific serum IgE in the allergic subject. CONCLUSION Mannitol, which is widely used as a food and drug additive (excipient), can rarely cause IgE-mediated anaphylaxis. This study is the first one to demonstrate the presence of mannitol-specific human IgE in a sensitized allergic subject to validate an IgE-mediated hypersensitivity mechanism for mannitol.
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Affiliation(s)
- V L Hegde
- Department of Biochemistry and Nutrition, Central Food Technological Research Institute (CFTRI), Mysore, India
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85
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Confino-Cohen R, Fishman A, Altaras M, Goldberg A. Successful carboplatin desensitization in patients with proven carboplatin allergy. Cancer 2005; 104:640-3. [PMID: 15977213 DOI: 10.1002/cncr.21168] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Carboplatin is one of the most useful and well tolerated cytotoxic drugs for gynecologic malignancies. Hypersensitivity to carboplatin is not rare among patients receiving multiple recurrent treatments with this drug. The aim of the current study was to offer a safe and convenient carboplatin desensitization strategy to patients with a proven allergic reaction to this drug. METHODS Patients with an immediate objective allergic reaction to carboplatin were skin tested with the drug. A 6-hour carboplatin desensitization protocol was administered to the patients with a carboplatin-positive skin test on each of the following treatment courses. RESULTS Twenty-three patients with an allergic reaction to carboplatin and a positive skin test were included in the current study. Twenty patients (86.9%) were desensitized. One patient developed a mild urticarial rash. Nineteen patients tolerated 80 desensitization courses uneventfully. CONCLUSIONS The data presented a successful desensitization protocol for individuals with a proven allergic reaction to carboplatin. The protocol was safe and convenient and offered an effective therapeutic strategy to patients who required this drug.
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Affiliation(s)
- Ronit Confino-Cohen
- The Allergy and Clinical Immunology Unit, Meir General Hospital, 44281 Kfar Saba, Israel.
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86
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Abstract
AIMS Allergy to recombinant human (rDNA) insulin preparations is a rare complication of insulin therapy. However, insulin preparations contain several allergens, and several disorders can resemble insulin allergy. Studies evaluating the diagnostic procedures on suspected insulin allergy are extremely few. METHODS Since January 1998, we have used a standardized investigative procedure during admittance to the medical ward allowing observation and repeated recording of reactions to intradermal skin test (performed with a commercially available kit containing isolated insulin allergens). Data on all investigated cases until April 2003 were collected retrospectively, and self-reported efficacy of intervention was compared to clinical data. RESULTS Twenty-two patients were included. In nine (41%) cases, non-insulin allergic causes were discovered and successfully treated: poor injection technique (n = 5), skin disease (n = 3) and other systemic allergy (n = 1). Nine other patients were found to be allergic to protamine (n = 3) or rDNA insulin (n = 6), and specific treatment was associated with relief in 8 patients (89%). Four patients had local reactions of unknown causes but symptom relief was obtained in three cases by unspecific therapy. Overall, 20 (91%) reported relief of symptoms. CONCLUSION Our standardized investigative procedure of suspected insulin preparation (IP) allergy was associated with relief of symptoms in > 90% of patients. IP allergy was diagnosed in 41%, and intradermal testing with isolated insulin allergens was a prerequisite in identification of culprit allergen and targeting of treatment.
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Affiliation(s)
- U Bodtger
- Steno Diabetes Centre, Gentofte, Denmark.
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87
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Qiao HL, Yang J, Zhang YW. Specific serum IgE levels and FcepsilonRIbeta genetic polymorphism in patients with penicillins allergy. Allergy 2004; 59:1326-32. [PMID: 15507102 DOI: 10.1111/j.1398-9995.2004.00625.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Numerous studies have suggested that both genetic and environmental influences are involved in the pathogenesis of allergic disease and atopy. The objective of this investigation is to elucidate the underlying mechanism of penicillins allergy and improve the diagnostic methods. METHODS Radioallergosorbent test was used to examine eight kinds of specific IgE antibodies, which included four kinds of major and minor antigenic determinants, respectively, in the sera of 448 patients with penicillins allergy and 101 healthy subjects. A restriction endonuclease fragment length polymorphism of a polymerase chain reaction product was used for analysis of the FcepsilonRIbeta polymorphism. RESULTS The positive rate of specific IgE in 448 patients was 58.26% (261), in which 37.28% (167) patients had positive IgE to major antigenic determinants and 47.09% (211) patients had positive IgE to minor antigenic determinants. Of the 179 patients with allergic history, 70.83% (17/24) patients had positive antibodies within 30 days, while 45.28% (24/53) had positive antibodies after 5 years. The positive reaction degree of skin test was absolutely correlated with specific IgE (P=0.047). Among patients with positive specific IgE, significant differences of E237G genotype were observed between patients with positive benzylpenicillanyl (BPA)-, phenoxomethylpenicilloyl (PVO)- or ampicilloyl (APO)-IgE and control group (P=0.015, 0.015, and 0.008, respectively). There were significant differences in E237G genotype between positive and negative BPA-, PVO- as well as APO-IgE patients (P = 0.014, 0.02, and 0.011, respectively). CONCLUSIONS The patients with penicillins allergy have positive specific IgE not only to major antigenic determinants but also to minor antigenic determinants. The E237G variant of the FcepsilonRIbeta gene is involved in the development of penicillins allergy through the process for the production of specific IgE antibodies.
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Affiliation(s)
- H-L Qiao
- Department of Clinical Pharmacology, School of Medicine, Zhengzhou University, Zhengzhou, China
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88
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Matucci A, Parronchi P, Vultaggio A, Rossi O, Brugnolo F, Maggi E, Romagnani S. Partial safety of the new COX-2 inhibitor rofecoxib in NSAIDs high sensitive patients. Allergy 2004; 59:1133-4. [PMID: 15355480 DOI: 10.1111/j.1398-9995.2004.00532.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Matucci
- Department of Internal Medicine, Section of Immunoallergology and Respiratory Diseases, University of Florence, Policlinico di Careggi Viale Morgagni 85, 50134 Florence, Italy.
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89
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Affiliation(s)
- Stephen P Myers
- Australian Centre for Complementary Medicine Education and Research (ACCMER), a joint venture of the University of Queensland, Brisbane, QLD, and Southern Cross University, Lismore, NSW
| | - Phillip A Cheras
- Australian Centre for Complementary Medicine Education and Research (ACCMER), a joint venture of the University of Queensland, Brisbane, QLD, and Southern Cross University, Lismore, NSW
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90
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Abstract
Pulmonary complications of therapy for RA or other benign conditions are often difficult to diagnose and treat. Clinical presentation of lung disease that is due to noncytotoxic drugs may vary from a mild, nonspecific cough to fulminant respiratory failure. The differential diagnosis of pulmonary disease should include drug toxicity, progression of the primary illness, and opportunistic infection. An objective assessment of the patient's baseline pulmonary status, as well as his treatment history, is crucial to differentiate drug-induced pathology from the primary process. Diagnostic work-up should include chest radiograph, repeat pulmonary function testing, and high-resolution CT of the chest. Bronchoscopy for tissue pathology or specific BAL cytokine markers also may yield useful information; occasionally, open-lung biopsy is required. If pulmonary disease that results from noncytotoxic drug therapy is suspected, the drug should be discontinued until the disease process is understood clearly.
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Affiliation(s)
- Brion J Lock
- Pulmonary Section, Birmingham Veterans Administration Medical Center, AL 35233, USA
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91
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Ravel G, Christ M, Horand F, Descotes J. Cytokine release does not improve the sensitivity and specificity of the direct popliteal lymph node assay. Toxicology 2004; 200:247-54. [PMID: 15212820 DOI: 10.1016/j.tox.2004.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2003] [Accepted: 03/11/2004] [Indexed: 11/26/2022]
Abstract
The popliteal lymph node assay (PLNA) is being considered as a tool to predict the potential of drugs for inducing systemic autoimmune and hypersensitivity reactions. Despite the use of different technical approaches and the evaluation of over 130 compounds, the sensitivity and specificity of the PLNA are still debatable due to many false positive and negative responses. In this study, cytokine production was assessed as a possible endpoint to improve the direct (primary) PLNA. Diclofenac, imipramine, hydralazine, glafenin and minocycline were tested using the classical procedure. TH1 cytokines (IL-2 and IFN-gamma), TH2 cytokines (IL-4 and IL-5) and pro-inflammatory cytokines (IL-6, TNF-alpha, monocyte chemoattractant protein-1 (MCP-1), IL-12p70 and IL-10) were measured in the serum and in suspensions of popliteal lymph node cells of female Balb/c mice by flow cytometry 7 days after drug administration. Only diclofenac and imipramine induced a cellularity index above 5 (considered as a positive response). Of the five tested drugs, only diclofenac induced a slight increase in TH1 cytokines, but there were no effects on TH2 cytokine production whatever the drug tested. Diclofenac increased the production of pro-inflammatory cytokines, whereas the production of MCP-1 was increased by minocycline and decreased by imipramine. No changes in serum cytokine levels were evident. These results suggest that measuring cytokine release is unlikely to improve the sensitivity and specificity of the direct PLNA.
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Affiliation(s)
- Guillaume Ravel
- MDS Pharma Services, Les Oncins, 69210 St. Germain sur L'Arbresle, France.
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92
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Abstract
Adverse drug reactions are a major health problem in the inpatient and outpatient clinical setting. Although all of the immune mechanisms of drug reactions are not well characterized, a detailed medication history, knowledge of the signs and symptoms associated with known immune mechanisms, and knowledge of the types of medications typically associated with distinct immune reactions are helpful in implicating the causative drug. Standardized testing for drug reactions is limited, especially for non-IgE-mediated reactions. Management consists of stopping the offending drug, treating the acute reaction, and making a determination concerning future use of the drug.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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93
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Nuttall TJ, Malham T. Successful intravenous human immunoglobulin treatment of drug-induced Stevens-Johnson syndrome in a dog. J Small Anim Pract 2004; 45:357-61. [PMID: 15266858 DOI: 10.1111/j.1748-5827.2004.tb00248.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A two-year-old, male English springer spaniel developed severe mucocutaneous ulceration following treatment with trimethoprim-potentiated sulphadiazine. The clinical signs were consistent with Stevens-Johnson syndrome (SJS): there were no target or arciform lesions typical of erythema multiforme minor and major; more than one mucosal surface was affected; epidermal detachment affected less than 10 per cent of the body surface area; and there was a clear history of drug exposure. Systemic signs included a severe hepatopathy, dyspnoea, pyrexia and cachexia. Glucocorticoid therapy was associated with secondary infection by Pseudomonas aeruginosa. The clinical signs rapidly resolved following a single intravenous infusion of 0.51 g/kg human immunoglobulin (ivHIG) as a 5 per cent solution. By blocking FAS/FAS ligand (CD95/CD95L) interactions, ivHIG is thought to prevent keratinocyte apoptosis. It also binds to immunoglobulin G Fc receptors, inhibiting cell activation and cytokine synthesis, neutralises autoantibodies and immune complexes, blocks complement activity, is antimicrobial and increases colloid osmotic pressure. To the authors' knowledge, this is the first report of successful treatment of canine SJS using ivHIG, although it has been used to treat erythema multiforme in a cat and toxic epidermal necrolysis in a dog.
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Affiliation(s)
- T J Nuttall
- University of Liverpool Small Animal Hospital, Crown Street, Liverpool L7 7EX
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94
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Abstract
Drug-induced hypersensitivity is an adverse reaction, characterised by damaging immune-mediated responses, initiated by medicine given at therapeutic doses for prevention, diagnosis or treatment. Immune-mediated drug hypersensitivity accounts for 6-10% of the adverse drug reactions, which rank between the fourth and sixth leading causes of death in the US. With <10% of all adverse drug reactions reported, the magnitude of the problem is significant, with estimates of costs >$US30 billion annually in the US (1995 value). In addition, the costs of not determining the potential of a drug to produce hypersensitivity in the pre-clinical phase of drug development can be substantial. It has been estimated that the pre-clinical phase and clinical phase I, phase II and phase III costs are approximately $US6 million, $US12 million, $US12 million and $US100 million per drug, respectively (1999 values). It is important that investigational drugs with the potential to produce hypersensitivity reactions be identified as early in the development process as possible. Some adverse reactions to drugs can be avoided if drug-drug interactions are known or if there is a structure-activity relationship established. However, these methods are inadequate. Appropriate animal models of drug-induced hypersensitivity are needed, especially because hypersensitivity has been cited as the leading reason for taking drugs off the market. It is of critical importance to be able to predict hypersensitivity reactions to drugs. Most anaphylactic reactions occur in atopic individuals. Similarly, patients who have experienced other hypersensitivity reactions are more likely to have recurrent reactions. Therefore, animal models should be considered that predispose the animal to the reaction, such as the use of appropriate adjuvants and species. Using known positive controls of varying strengths, the investigator can rank the reaction against the positive controls as standards. This approach might yield greater results in a shorter period of time than using novel models. For the greatest safety, use of well understood models that have been thoroughly validated is imperative.
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Affiliation(s)
- Helen V Ratajczak
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut, USA.
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