151
|
|
152
|
Romano A, Viola M, Gaeta F, Rumi G, Maggioletti M. Patch testing in non-immediate drug eruptions. Allergy Asthma Clin Immunol 2008; 4:66-74. [PMID: 20525127 PMCID: PMC2868884 DOI: 10.1186/1710-1492-4-2-66] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The present review addresses the literature regarding the sensitivity and specificity of the various diagnostic methods for evaluating non-immediate (ie, occurring more than 1 hour after drug administration) hypersensitivity reactions associated with β-lactams and other antibiotics, anticonvulsants, heparins, iodinated contrast media, etc. Such reactions include several clinical entities, which range from mild reactions, such as maculopapular rash and delayed-appearing urticaria, to severe ones, such as acute generalized exanthematous pustulosis (AGEP), Stevens-Johnson syndrome, and toxic epidermal necrolysis (TEN). Clinical and laboratory studies indicate that a cell-mediated pathogenic mechanism is often involved in maculopapular rashes. However, this mechanism has also been demonstrated in other non-immediate reactions, such as urticarial and/or angioedematous manifestations, TEN, bullous exanthems, and AGEP. Patch tests, together with delayed-reading intradermal tests, lymphocyte transformation tests, and challenges, are useful tools for evaluating non-immediate drug eruptions. Patch tests can be performed with any form of commercial drugs and are safer than intradermal tests. However, patch tests are less sensitive than intradermal tests, and their sensitivity may vary, depending on the vehicle used.
Collapse
Affiliation(s)
- Antonino Romano
- Department of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore (UCSC)-Allergy Unit, C,I, Columbus, Rome, Italy, and Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Oasi Maria S,S, Troina, Italy.
| | | | | | | | | |
Collapse
|
153
|
Demoly P, Pichler W, Pirmohamed M, Romano A. Important questions in Allergy: 1--drug allergy/hypersensitivity. Allergy 2008; 63:616-9. [PMID: 18394136 DOI: 10.1111/j.1398-9995.2008.01693.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- P Demoly
- Exploration des Allergies - Inserm U657, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | | | | | | |
Collapse
|
154
|
Safety aspects of iodinated contrast media related to their physicochemical properties: a pharmacoepidemiology study in two Tuscany hospitals. Eur J Clin Pharmacol 2008; 64:723-37. [PMID: 18401577 DOI: 10.1007/s00228-008-0477-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 02/20/2008] [Indexed: 01/18/2023]
Abstract
BACKGROUND More than 380,000 angiographic procedures are performed every year in Italian hospitals, with an increase rate of 8% per year. Although contrast media (CM) are considered relatively safe, adverse drug reactions (ADRs) remain an important issue. OBJECTIVES The objective of this study was to quantify the incidence of immediate and delayed nonrenal ADRs to iodinated CM in an Italian cohort and to evaluate whether their different physicochemical properties are able to affect the incidence of immediate or delayed ADRs. METHODS A prospective intensive monitoring study was conducted on a cohort of patients undergoing radiodiagnostic procedures with iodinated CM enrolled in two hospitals in Tuscany, Italy. To evaluate both immediate (within 1 h after CM administration) and delayed (>1 h to 1 week after CM administration) ADRs to CM, two questionnaires were administered. Adverse events (AEs) were analyzed to check the causality assessment between CM and ADR. If more than one symptom occurred in the same patient, they were treated as a single event. RESULTS One thousand five hundred and fourteen subjects who were exposed to iodinated CM completed the questionnaires. Mean age [standard deviation (SD)] was 65.4 (13.3) years, and 57.9% were male patients. A total of 178 [11.8%; 95% confidence interval (CI) 10.1-13.4] ADRs were reported. Thirty-four (2.2%; 1.5-3.1) and 144 (9.5%; 8.0-11.1) developed immediate and delayed ADRs, respectively. Both types of ADRs were experienced by six subjects (0.4%; 0.1-0.8). One hundred and seventy-six cases (98.8%; 96.0-99.8) were classified as possible and two (1.1%; 0.1-3.9) as probable ADRs. Monomeric low-osmolal (iopromide, iomeprol, iobitridol) and dimeric iso-osmolal (iodixanol) groups mainly reported delayed allergy-like ADRs of mild severity. Only one immediate reaction was severe. Multivariate analysis confirmed a higher risk of immediate reactions occurring for monomeric CM (OR 4.3; 95% CI 1.2-15.7), whereas the risk of delayed ADRs was significantly higher for the dimeric group (OR 1.8; 1.1-2.5). CONCLUSIONS Monomeric CM were more frequently involved in immediate ADRs, whereas dimeric CM were involved in delayed reactions. Although severe life-threatening ADRs to CM were confirmed to be rare, due to the large use of these drugs, they still retain clinical and epidemiological significance.
Collapse
|
155
|
Torres MJ, Mayorga C, Cornejo-Garcia JA, Lopez S, Chaves P, Rondon C, Fernandez T, Blanca M. Monitoring non-immediate allergic reactions to iodine contrast media. Clin Exp Immunol 2008; 152:233-8. [PMID: 18341616 DOI: 10.1111/j.1365-2249.2008.03627.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Non-immediate reactions to iodine contrast media (ICM) affect 2-5% of patients receiving these agents. We studied the immunological mechanisms involved in patients with a confirmed non-immediate reaction, maculopapular exanthema, after administration of ICM. The diagnosis was carried out by skin testing or drug provocation test. The immunological study was performed in sequential peripheral blood mononuclear cells taken from the onset of the reaction by flow cytometry and in skin biopsy by immunohistochemistry, with specific recognition by the lymphocyte transformation test (LTT) with different ICM. Flow cytometry showed an increase in the different activation markers [CD69, CD25 and human leucocyte antigen D-related (HLA-DR)] and the skin homing receptor [cutaneous lymphocyte-associated antigen (CLA)] in CD4 lymphocytes, whereas perforin was higher in the CD8 lymphocytes. The skin biopsy showed a perivascular mononuclear infiltrate composed of CD4 lymphocytes, expressing CD25, HLA-DR and CLA, with eosinophils. Intradermal skin tests and the LTT were positive to several ICM, including the culprit agent in four and three patients, respectively, with negative results in all 10 tolerant controls. We showed that a specific immunological mechanism was implicated in patients with non-immediate reactions to ICM. Moreover, the positive results in skin tests and lymphocyte proliferation tests indicated that an important cross-reactivity exists.
Collapse
Affiliation(s)
- M J Torres
- Allergy Service, Carlos Haya Hospital, Malaga, Spain
| | | | | | | | | | | | | | | |
Collapse
|
156
|
Bierry G, Kellner F, Barnig C. Management of Patients with History of Adverse Effects to Contrast Media When Pulmonary Artery CT Angiography Is Required. Radiology 2007; 245:919-21; author reply 919-21. [DOI: 10.1148/radiol.2453070428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
157
|
Bousquet PJ, Pipet A, Bousquet-Rouanet L, Demoly P. Oral challenges are needed in the diagnosis of beta-lactam hypersensitivity. Clin Exp Allergy 2007; 38:185-90. [PMID: 17976216 DOI: 10.1111/j.1365-2222.2007.02867.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND beta-lactams continue to remain the most commonly involved drug family in allergic drug reactions. They are often essential and there is a cost-effective and favourable risk-benefit ratio for the exploration of all suspicions of beta-lactam allergy. A firm diagnosis is always based on skin tests and sometimes on provocation tests. Recommendations have been published by allergy societies and distinguished scientists but they are not always concordant and can lead to some confusion for the practicing allergologist. The situation has even worsened since the world wide withdrawal of these penicillin determinants and since the predominance of amoxicillin and cephalosporin prescriptions in most countries. OBJECTIVE - METHOD: In a recent article, it was stated that patients with a penicillin allergy history and negative skin tests to major and minor penicillin determinants are at a low risk of relapse (0-5%) when receiving a beta-lactam. In this paper, our Drug Allergy and Hypersensitivity Database, a cohort database, was used to demonstrate that this statement is false. Standardized European Network for Drug Allergy questionnaires, skin test and challenge procedures were followed. RESULTS One-thousand two-hundred and eighteen subjects, 69.8% of female, 51.7% of atopics, were included. 21.1% had a true beta-lactam allergy confirmed by skin tests (178, 69.3%) or by drug provocation (79, 30.7%). 17.4% of the patients with negative skin tests to major and minor penicillin determinants were positive for a beta-lactam. CONCLUSION In the diagnosis of beta-lactams allergy, if all skin tests are negative, skin tests with other determinants and provocation tests under strict surveillance are mandatory.
Collapse
Affiliation(s)
- P J Bousquet
- Exploration des Allergies, Maladies Respiratoires and INSERM, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier Cedex 5, France
| | | | | | | |
Collapse
|
158
|
Gilgen-Anner Y, Heim M, Ledermann HP, Bircher AJ. Iodide mumps after contrast media imaging: a rare adverse effect to iodine. Ann Allergy Asthma Immunol 2007; 99:93-8. [PMID: 17650837 DOI: 10.1016/s1081-1206(10)60628-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exposure to iodinated contrast media may elicit a variety of adverse reactions. Anaphylactoid and delayed cell-mediated unwanted effects are common; rare adverse reactions include iodine-related sialadenopathy, iododerma, and acneiform eruptions. OBJECTIVES To describe the occurrence of iodide mumps in a patient examined using contrast-enhanced computed tomography and to outline differential diagnoses. METHODS A detailed diagnostic approach, including histologic analysis, skin tests, controlled reexposure, efficacy of premedication, and imaging studies, is presented. The findings unique to this reaction and differential diagnoses are highlighted. RESULTS While undergoing repeated contrast-enhanced computed tomography a patient developed recurrent swellings of the sublingual glands, identified as iodide mumps. These swellings resolved within a few days. Imaging studies and histologic analysis showed distinct patterns without inflammation. The important role of iodine in this adverse reaction is demonstrated. CONCLUSIONS Iodine from iodinated contrast media may rarely elicit noninflammatory edema of the salivary glands. The reaction should be differentiated from other swellings in the head and neck area.
Collapse
|
159
|
Becker C. Radiologisch praxisrelevante Prophylaxe und Therapie von Nebenwirkungen jodhaltiger Kontrastmittel. Radiologe 2007; 47:768-73. [PMID: 17768601 DOI: 10.1007/s00117-007-1550-4] [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] [Indexed: 10/22/2022]
Abstract
Increased utilization of iodinated contrast media may be associated with increased incidence of adverse events. The most important side effects include contrast-induced nephropathy, anaphylactoid reaction, thyrotoxicosis, and extravasation. In patients with moderate renal dysfunction, saline hydration and reduction of contrast media volume are recommended. No regime to prevent anaphylactoid reactions has yet proven to be efficient. If subclinical hyperthyroidism has been determined, prophylaxis with sodium perchlorate is advised. Contrast-induced nephropathy is commonly transient and needs to be followed over time. Mild general anaphylactoid reactions may be treated with antihistaminic drugs and corticosteroids. Furthermore the choice of the X-ray contrast media might influence the risk of any adverse effects.
Collapse
Affiliation(s)
- C Becker
- Institut für Klinische Radiologie, Klinikum Grosshadern der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Deutschland.
| |
Collapse
|
160
|
Abstract
PURPOSE OF REVIEW The present review addresses the most recent literature regarding the diagnosis of drug hypersensitivity reactions, which can be classified as immediate or nonimmediate according to the time interval between the last drug administration and the onset. Immediate reactions occur within 1 h; nonimmediate ones occur after more than 1 h. RECENT FINDINGS Clinical and immunological studies suggest that type-I (IgE-mediated) and type-IV (cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. New diagnostic tools, such as the basophil activation test and the lymphocyte activation test, have been developed and are under validation. SUMMARY In diagnosis, the patient's history is fundamental; the allergologic examination includes in-vivo and in-vitro tests selected on the basis of the clinical features. Prick, patch, and intradermal tests are the most readily available forms of allergy testing. Determination of specific IgE levels is still the most common in-vitro method for diagnosing immediate reactions. The sensitivity of allergologic tests is not 100%; in selected cases, therefore, provocation tests are necessary. The routine use of the basophil activation test and the lymphocyte activation test could increase the sensitivity of diagnostic work-ups, thus reducing the need for drug provocation tests.
Collapse
Affiliation(s)
- Antonino Romano
- Allergy Unit of Integrated Complex Columbus, Catholic University of Sacred Heart, Rome, Italy.
| | | |
Collapse
|
161
|
Kroigaard M, Garvey LH, Gillberg L, Johansson SGO, Mosbech H, Florvaag E, Harboe T, Eriksson LI, Dahlgren G, Seeman-Lodding H, Takala R, Wattwil M, Hirlekar G, Dahlén B, Guttormsen AB. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia. Acta Anaesthesiol Scand 2007; 51:655-70. [PMID: 17567266 DOI: 10.1111/j.1399-6576.2007.01313.x] [Citation(s) in RCA: 195] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The present approach to the diagnosis, management and follow-up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first-line treatment. Recommendations for primary and secondary follow-up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow-up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, Appendix 2 provides an overview of the incidence, mechanisms and possibilities for follow-up for some common drug groups.
Collapse
Affiliation(s)
- M Kroigaard
- Danish Anaesthesia Allergy Centre, Department of Anaesthesia, Section 4231 Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
162
|
Lerch M, Keller M, Britschgi M, Kanny G, Tache V, Schmid DA, Beeler A, Gerber BO, Luethi M, Bircher AJ, Christiansen C, Pichler WJ. Cross-reactivity patterns of T cells specific for iodinated contrast media. J Allergy Clin Immunol 2007; 119:1529-36. [PMID: 17412404 DOI: 10.1016/j.jaci.2007.02.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Revised: 02/09/2007] [Accepted: 02/09/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 3% of patients exposed to iodinated contrast media develop delayed hypersensitivity reactions. OBJECTIVE We wanted to better understand the molecular basis of contrast media cross-reactivity. METHODS Cross-reactivity was assessed by skin testing and measurement of T-cell activation (CD69 upregulation) and proliferation ((3)H-thymidine uptake, 5,6-carboxyfluorescein diacetate succinimidyl ester staining) of PBMCs, T-cell lines, and T-cell clones of 2 patients with delayed hypersensitivity reactions to iohexol and iomeprol, respectively. Thirteen different contrast media and potassium iodide were compared. RESULTS Skin testing and analyses of PBMCs, T-cell lines, and clones showed broad cross-reactivity in both patients. Broad as well as more restricted cross-reactivity patterns were found in iohexol-specific and iomeprol-specific CD4(+) T-cell clones, whereas 1 iomeprol-specific CD8(+) T-cell clone showed no cross-reactivity at all. The reactivity to equimolar concentrations of iohexol and its dimer iodixanol was very similar, suggesting that the dimer was not more stimulatory than its monomer. Consistently low reactivity to iobitridol was found in both patients, but never to iodide. A frequency analysis of contrast medium-specific peripheral T cells gave values between 0.6 % (iomeprol) and 0.05 % (iobitridol). CONCLUSION Clinically observed cross-reactivity between different contrast media is a result of the presence of contrast media-specific T cells, some of which show a broad cross-reactivity pattern. Iodide ions, known to be present at low concentration in contrast media solutions, do not seem to be the causative moiety. CLINICAL IMPLICATIONS Detailed in vitro analysis might help identify noncross-reactive contrast media.
Collapse
Affiliation(s)
- Marianne Lerch
- Clinic for Rheumatology and Clinical Immunology/Allergology, Inselspital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
163
|
Kalogeromitros DC, Makris MP, Aggelides XS, Spanoudaki N, Gregoriou SG, Avgerinou G, Rigopoulos DG. Anaphylaxis to Gadobenate Dimeglumine (Multihance®): A Case Report. Int Arch Allergy Immunol 2007; 144:150-4. [PMID: 17536224 DOI: 10.1159/000103227] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 02/20/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gadolinium chelates are relatively safe contrast media used in MRI. Immediate severe adverse effects are exceptionally rare and mostly concern mild anaphylactoid reactions. We report a case of anaphylaxis to gadobenate dimeglumine (Gd-BOPTA, Multihance), a gadolinium-based contrast agent. METHODS A 32-year-old female patient with a personal history of multiple sclerosis, while undergoing an MRI scan, developed bronchospasm and acute urticaria with diffuse giant pruritic plaques in the first minute of Gd-BOPTA infusion. The procedure was cancelled and acute treatment of the reaction took place. The patient reported 2 additional MRI scans with definite use of unknown contrast media in the past 2 years without any adverse effect. Blood samples were obtained 2 and 48 h after the reaction for measurement of serum tryptase concentration (Pharmacia Diagnostics, Uppsala, Sweden). Skin prick tests and intradermal tests were performed using 1:1,000, 1:100 and 1:10 dilution of the offending agent and alternative gadolinium-based agents [gadodiamide (Omniscan) and gadoteric acid (Dotarem)]. A group of 10 nonatopic individuals who underwent the same skin testing comprised the control group. RESULTS Tryptase concentration was highly elevated 2 h after the reaction (21 microg/l) compared with that at 48 h (3 microg/l). Skin prick tests in our patient were all negative, while intradermal testing with 0.03 ml of 1:100 and 1:10 preparations of Multihance showed a definite positive wheal-and-flare reaction. Skin tests to the alternative agents showed no response. In the control group, all performed tests were negative. CONCLUSION We report the first case of an allergic reaction to gadobenate dimeglumine. Besides, skin testing seems to be a precious diagnostic tool which, if positive, strongly suggests a mast cell-mediated underlying mechanism.
Collapse
|
164
|
Kvedariene V, Martins P, Rouanet L, Demoly P. Diagnosis of iodinated contrast media hypersensitivity: results of a 6-year period. Clin Exp Allergy 2007; 36:1072-7. [PMID: 16911363 DOI: 10.1111/j.1365-2222.2006.02532.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Iodinated contrast media (ICM) hypersensitivity reactions represent a serious problem. Very few clinical data concerning systematic skin testing to ICM are available. OBJECTIVE To evaluate the utility of ICM skin testing in patients with ICM hypersensitivity. MATERIAL AND METHODS All patients referred over a 6-year period for ICM hypersensitivity past reactions were skin tested for (a) the implicated ICM, or (b) a set of ICM if they were positive for the implicated ICM or if its name was unknown. RESULTS Forty-four patients, with a median age of 56 years, were studied (15 males, 29 females). The ICM skin tests were positive in 10 patients (23%): one had a positive skin prick test, seven an immediate positive intradermal test (IDT) and two a delayed positive IDT. Skin tests were more often positive in patients with immediate (9/32) as compared with those with non-immediate reactions (1/11). The time interval between the reaction and skin testing was shorter for those patients with an immediate ICM reaction and a positive skin test result (3 months [2.5-174.0]) as compared with those with an immediate ICM reaction and a negative skin test (48 months [6.8-159.0]), (P<0.05). Respiratory allergy was more frequent in the positive group (6/10 vs. 7/34, P<0.05). CONCLUSIONS Skin tests with ICM are positive in a subgroup of patients with ICM hypersensitivity and may play an important role in the diagnosis of ICM allergy.
Collapse
Affiliation(s)
- V Kvedariene
- Vilnius University Hospital Santariskiu klinikos, Vilnius, Lithiuania
| | | | | | | |
Collapse
|
165
|
Controverse : les tests de provocation médicamenteux assurent toujours le diagnostic d’allergie médicamenteuse. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.allerg.2007.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
166
|
Abstract
PURPOSE OF REVIEW The present review covers the European Society of Urogenital Radiology guidelines for safe use of contrast media of importance for referring urologists. RECENT FINDINGS During the recent years contrast medium-induced nephropathy has become a hot topic. It is of importance to reduce its incidence. First of all, the patients at risk should be identified prior to the administration of a contrast medium, so that appropriate measures can be taken. Before intravenous administration of an iodinated agent but not before gadolinium-based and ultrasound agents, all patients should be questioned about the potential renal dysfunction at the time of referral, and only those who answer affirmative to at least one question should have their serum creatinine level determined. Before intraarterial injection, the serum creatinine should always be measured. In case of an abnormal level, another imaging procedure should be considered. If impossible, hydration should be instituted and administration of nephrotoxic drugs should be stopped. After administration, delayed reactions such as nephrogenic systemic fibrosis, thyreotoxicosis, skin rash, etc. may be seen. Interaction with isotope studies and biochemical analysis occurs too. SUMMARY The awareness regarding the potential adverse reactions due to contrast media and the necessary precautions to be taken are of utmost importance both for radiologists and referring physicians. This is the only way to reduce their incidence.
Collapse
Affiliation(s)
- Henrik S Thomsen
- Department of Diagnostic Radiology, Copenhagen University Hospital at Herlev, Herlev, Denmark.
| |
Collapse
|
167
|
Arnold AW, Hausermann P, Bach S, Bircher AJ. Recurrent Flexural Exanthema (SDRIFE or Baboon Syndrome) after Administration of Two Different Iodinated Radio Contrast Media. Dermatology 2006; 214:89-93. [PMID: 17191055 DOI: 10.1159/000096920] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 03/27/2006] [Indexed: 12/31/2022] Open
Abstract
In 1984, the baboon syndrome was described as a particular form of systemic contact dermatitis that occurred after the administration of a contact allergen in individuals previously sensitized by topical exposure to the same allergen. Its clinical picture presents as an erythema of the buttocks and upper inner thighs resembling the red bottom of baboons. This specific reaction was originally observed with mercury, nickel and ampicillin. Since then over 100 cases have been described, most of them without known prior sensitization to the causative agent. In 2004, our group proposed the acronym SDRIFE specifically for cases associated with systemic drugs; it stands for symmetrical drug-related intertriginous and flexural exanthema, as a distinct reaction pattern related to systemic drugs. Here we describe a case of SDRIFE after administration of the iodinated radio contrast medium (RCM) iomeprol (Iomeron), accidentally reproduced by the RCM iopromide (Ultravist). Positive delayed skin tests with both drugs were observed indicating that the pathomechanism of SDRIFE is likely a cell-mediated type IV allergy. Oral potassium iodide and a skin-test-negative RCM were administered and both tolerated, indicating that the antigen is related to the molecules and not to iodine itself. Therefore, in our case skin tests had a good positive and negative predictive value.
Collapse
Affiliation(s)
- A W Arnold
- Allergy Unit, Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | | | | | | |
Collapse
|
168
|
Delgado-Jimenez Y, Perez-Gala S, Aragüés M, Sanchez-Perez J, Garcia-Diez A. Late skin reaction to iodixanol (Visipaque�): clinical manifestations, patch test study, and histopathological evaluation. Contact Dermatitis 2006; 55:348-53. [PMID: 17101010 DOI: 10.1111/j.1600-0536.2006.00957.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Late reactions to iodinated contrast media are frequent. Cutaneous manifestations are the commonest, in which maculopapular exanthema, a type of cutaneous presentation, is widespread. Controversy exists about the utility of the skin test in the management of these reactions. The aim of this study is to analyse the clinical characteristics, the histopathological findings, and the results of the patch test in patients who developed a late skin reaction (LSR) to the nonionic, dimeric, iodinated contrast media Visipaque. We retrospectively reviewed the patients with LSR to Visipaque, seen in the Dermatology Department between 1999 and 2005. A total of 12 patients participated in this study (7 men and 5 women), ages ranging from 39 to 76 years (mean 56). 11 of the patients had significant medical history. All the patients developed a maculopapular exanthema between 2 hr and 3 days after the radiological examination, involving the trunk and proximal limbs, although some of the patients showed involvement of distal areas. The skin biopsy, performed in 6 patients, showed nonspecific findings consistent with drug reaction. In 3 patients, patch tests to Visipaque and iodixanol were positive. The most frequent manifestation of LSR to iodixanol is a maculopapular exanthema, involving the trunk and the limbs, although distal involvement can be seen. Histopathological findings are nonspecific and cannot be distinguished from other drug reaction. Patch tests have a limited value, and in cases where they were negative, reintroduction of the drug triggered a new LSR.
Collapse
|
169
|
Abstract
The 2nd International Drug Hypersensitivity Meeting was held at Liverpool, UK on 18 - 21 April, 2006. This meeting, attended by almost 200 delegates with expertises in chemistry, pharmacology, toxicology, allergy and immunology, provided an excellent environment to discuss recent advances in the understanding of the chemical, cellular, molecular and genetic basis of drug hypersensitivity. Furthermore, specific symposia addressed clinical, industrial and regulatory perspectives of drug hypersensitivity reactions. The ultimate aim of the meeting was to contribute towards a better understanding and management of this particular form of serious adverse drug reaction. The authors herein provide a synopsis of the main research and clinical findings discussed at the meeting.
Collapse
Affiliation(s)
- Ana Alfirevic
- University of Liverpool, Department of Pharmacology and Therapeutics, The Sherrington Buildings, Ashton Street, Liverpool L69 3GE, UK
| | | |
Collapse
|
170
|
|
171
|
Ebo DG, Hagendorens MM, Bridts CH, Stevens WJ. Immediate-type allergy to drugs and related compounds: evaluation and management. Acta Clin Belg 2005; 60:350-61. [PMID: 16502596 DOI: 10.1179/acb.2005.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Adverse drug reactions (ADR) constitute a major health issue in outpatient and inpatient clinical settings. An allergic drug reaction is an immunologically mediated adverse drug reaction that exhibits specificity and recurrence on re-exposure to the offending and/or cross-reactive compound(s). Diagnosis of drug allergy is difficult, as a broad spectrum of different drugs can elicit various immune-mediated diseases with distinct (sometimes unclear) pathomechanism, the exact structure (epitope) that causes the reaction is frequently unknown, the presence of an in vitro or in vivo test results might not be predictive of a clinical situation, and the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Nevertheless, during the past few years serious attempts have been made to standardise and validate in vitro and in vivo techniques for the diagnosis of drug allergy. New techniques, e.g. flow-assisted analysis of in vitro basophil activation, are replacing older ones like histamine release for immediate-type hypersensitivity reactions. However, additional comprehensive studies are required to further validate the technique and allow its entrance in mainstream diagnostic use, particularly for non-IgE-mediated hypersensitivity. This review attempts to summarize the major causes of immediate hypersensitivity reactions to drugs and related compounds. Special attention is paid to the diagnostic and therapeutic management of this common iatrogenic complication.
Collapse
Affiliation(s)
- D G Ebo
- Dept Immunology, Allergology, Rheumatology, University Antwerp, Belgium
| | | | | | | |
Collapse
|
172
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
173
|
Abstract
Iodinated or gadolinium-based contrast agents are usually well tolerated, but some adverse events can happen due to a direct toxicity of the injected molecule (contrast-induced nephropathy, abnormal thyroid function), or to an indirect effect like in true allergic reactions. Radiologists must be familiar with the possibility of adverse events from contrast agents or injection procedures, and should be able to treat the patient. Also, they should take all necessary actions to minimize the occurrence of possible reactions in the presence of risk factors.
Collapse
Affiliation(s)
- O Clément
- Service de Radiologie, Hôpital Européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris.
| |
Collapse
|
174
|
Abstract
Hypersensitivity reactions to contrast media (CM) are frequent causes of anaphylactically induced fatalities. Adverse events after CM exposure are classified into immediate and non-immediate reactions, with differing pathomechanisms. In the majority of patients with immediate reactions, IgE-mediated allergy can not be demonstrated and the underlying mechanism remains unknown. However, recent data has provided evidence for skin test positivity and/or specific IgE in some patients with severe reactions. Cell-mediated hypersensitivity is the responsible mechanism for the majority of non-immediate skin eruptions. Skin tests have been employed to confirm this hypersensitivity. Previous reactors have an increased risk to develop new reactions upon repeated exposure, however, other risk factors are poorly defined. The use of skin tests for the selection of a "safe" CM is controversially discussed; information on sensitivity and specificity is lacking. New in-vitro assays have to be developed and/or validated. Premedication of previous reactors is common practice among radiologists, however, its precise role in the prevention of severe CM reactions to lower-osmolality CM has not been demonstrated. Thus, the main future tasks are to develop and validate allergic tests procedures, which may identify patients at risk and/or may confirm CM tolerance, and to reassess the value of different premedications in the prevention of hypersensitivity reactions.
Collapse
Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, Division of Environmental, Dermatology and Allergology GSF/TUM, Technical University, Biedersteiner Strasse 29, 80802 Munich, Germany.
| |
Collapse
|