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Tal Y, Maoz Segal R, Langevitz P, Kivity S, Darnizki Z, Agmon-Levin N. Hydroxychloroquine desensitization, an effective method to overcome hypersensitivity—a multicenter experience. Lupus 2017; 27:703-707. [DOI: 10.1177/0961203317735185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Y Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - R Maoz Segal
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - P Langevitz
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Kivity
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine A, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Z Darnizki
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - N Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
CLINICAL FEATURES Acute generalized exanthematous pustulosis (AGEP) is a reaction pattern mostly caused by drugs. It is characterized by the rapid occurrence of dozens to thousands pinhead-sized, non-follicular, sterile pustules on a slightly edematous erythematous base, commonly with accentuation in the major flexures and usually accompanied by a facial edema, fever and leukocytosis. Histology reveals spongiform subcorneal and/or intraepidermal pustules, an inflammatory infiltrate consisting of neutrophils and often eosinophils and frequently a marked edema of the papillary dermis. TRIGGERS Even if in single case reports a large number of drugs has been described as triggers for AGEP, larger studies have revealed a list with an elevated risk to cause the reaction which includes antibacterial agents like ampicillin/amoxicillin, quinolones, pristinamycin, anti-infective sulfonamides, the antimycotic drug terbinafine, (hydroxy)chloroquine, and diltiazem. In some cases infections have been reported as triggers. CLINICAL COURSE, PROGNOSIS AND TREATMENT AGEP is an acute and--especially in patients with concomitant diseases--sometimes severe reaction. Withdrawal of the causative agent usually leads to a rapid and complete resolution--even without further specific therapy.
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Affiliation(s)
- A Sidoroff
- Univ.-Klinik für Dermatologie und Venerologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich,
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Alkhachroum AM, Kazzaz N. A case of acute generalized exanthematous pustulosis associated with polyarteritis nodosa, responding to systemic steroids. J Community Hosp Intern Med Perspect 2015; 5:26645. [PMID: 25846351 PMCID: PMC4387336 DOI: 10.3402/jchimp.v5.26645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/11/2015] [Accepted: 01/19/2015] [Indexed: 11/14/2022] Open
Abstract
A patient with a known biopsy of polyarteritis nodosa diagnosis presented with cyclic fevers, acute kidney injury, and progression of rash from macular to pustular, worsening despite being on antibiotics, without evidence of infection on multiple cultures. The patient had a pathological diagnosis from a skin biopsy of acute generalized exanthematous pustulosis syndrome, with a total resolution of rash, fevers, and acute kidney injury on treatment with pulse steroids.
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Affiliation(s)
- Ayham M. Alkhachroum
- Department of Medicine University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
- Department of Medicine Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Neurology University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nayef Kazzaz
- Department of Medicine University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
- Department of Medicine Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
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Abstract
The potentially life-threatening adverse reactions to Abavacir (ABC), a nucleoside analog reverse transcriptase inhibitor for the treatment of HIV infection, have been known for several years to be limited to individuals expressing the HLA-B57:01 gene. Why the ABC hypersensitivity syndrome is only seen in HLA-B57:01-expressing subjects and what the precise mechanisms underlying this intolerance are remain however controversial. A series of recent studies, particularly a study by Illing et al. recently published in Nature, now answer some of these questions and offer new opportunities to better understand autoimmune disorders and prevent adverse reactions to other drugs.
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Mertes P, Lambert M, Guéant-Rodriguez R, Aimone-Gastin I, Mouton-Faivre C, Moneret-Vautrin D, Guéant J, Malinovsky J, Demoly P. Perioperative Anaphylaxis. Immunol Allergy Clin North Am 2009; 29:429-51. [DOI: 10.1016/j.iac.2009.04.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Interactions between death receptors from the tumor necrosis factor superfamily and their ligands play a crucial role in the development and the integrity of the epidermis. The major consequence resulting from death receptor targeting is apoptosis. Evidence for dysregulation of death receptor signaling associated with the pathogenesis of selected cutaneous diseases, including toxic epidermal necrolysis, graft versus host disease, and skin cancer, are reviewed herein.
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Affiliation(s)
- Emmanuel Contassot
- Department of Dermatology, Zurich University Hospital, Gloriastrasse 31, 8091 Zürich, Switzerland
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Sidoroff A, Dunant A, Viboud C, Halevy S, Bavinck JNB, Naldi L, Mockenhaupt M, Fagot JP, Roujeau JC. Risk factors for acute generalized exanthematous pustulosis (AGEP)-results of a multinational case-control study (EuroSCAR). Br J Dermatol 2007; 157:989-96. [PMID: 17854366 DOI: 10.1111/j.1365-2133.2007.08156.x] [Citation(s) in RCA: 306] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute generalized exanthematous pustulosis (AGEP) is a disease characterized by the rapid occurrence of many sterile, nonfollicular pustules usually arising on an oedematous erythema often accompanied by leucocytosis and fever. It is usually attributed to drugs. OBJECTIVES To evaluate the risk for different drugs of causing AGEP. PATIENTS AND METHODS A multinational case-control study (EuroSCAR) conducted to evaluate the risk for different drugs of causing severe cutaneous adverse reactions; the study included 97 validated community cases of AGEP and 1009 controls. Results Strongly associated drugs, i.e. drugs with a lower bound of the 95% confidence interval (CI) of the odds ratio (OR) > 5 were pristinamycin (CI 26-infinity), ampicillin/amoxicillin (CI 10-infinity), quinolones (CI 8.5-infinity), (hydroxy)chloroquine (CI 8-infinity), anti-infective sulphonamides (CI 7.1-infinity), terbinafine (CI 7.1-infinity) and diltiazem (CI 5.0-infinity). No significant risk was found for infections and a personal or family history of psoriasis (CI 0.7-2.2). CONCLUSIONS Medications associated with AGEP differ from those associated with Stevens-Johnson syndrome or toxic epidermal necrolysis. Different timing patterns from drug intake to reaction onset were observed for different drugs. Infections, although possible triggers, played no prominent role in causing AGEP and there was no evidence that AGEP is a variant of pustular psoriasis.
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Affiliation(s)
- A Sidoroff
- Department of Dermatology and Venereology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Stur K, Karlhofer FM, Stingl G. Soluble FAS ligand: a discriminating feature between drug-induced skin eruptions and viral exanthemas. J Invest Dermatol 2006; 127:802-7. [PMID: 17139262 DOI: 10.1038/sj.jid.5700648] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The clinical spectrum of cutaneous eruptions comprises benign variants like maculopapular rashes (MPRs) and potentially life-threatening events such as toxic epidermal necrolysis (TEN). Apoptosis of keratinocytes is a common histopathological feature of all these drug eruptions. As in skin lesions of TEN and Stevens-Johnson syndrome patients, apoptosis of keratinocytes is often accompanied by an only sparse cellular infiltrate, a soluble fatty acid synthetase ligand (sFASL)-mediated mechanism of keratinocyte cell death is postulated. In MPR patients, evidence for the occurrence of a similar process could not be established so far. We therefore examined sera and lesional skin sections from patients with clinical variants of drug eruptions for FASL expression using a sandwich ELISA and immunohistochemistry, respectively. As controls, healthy persons and patients with other inflammatory skin diseases such as viral exanthema were analyzed. Elevated levels of FASL were detected not only in TEN patients but also in sera and lesional skin of patients with MPR. In contrast, sFASL was repeatedly negative in all viral exanthemas and healthy controls tested. Thus, determination of sFASL serum concentration may represent a discriminating tool between drug rashes and viral exanthemas.
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Affiliation(s)
- Karoline Stur
- Division of Immunology, Allergy and Infectious Diseases (DIAID), Department of Dermatology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
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Roychowdhury S, Svensson CK. Mechanisms of drug-induced delayed-type hypersensitivity reactions in the skin. AAPS JOURNAL 2005; 7:E834-46. [PMID: 16594635 PMCID: PMC2750952 DOI: 10.1208/aapsj070480] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cutaneous drug reactions (CDRs) are the most commonly reported adverse drug reactions. These reactions can range from mildly discomforting to life threatening. CDRs can arise either from immunological or nonimmunological mechanisms, though the preponderance of evidence suggests an important role for immunological responses. Some cutaneous eruptions appear shortly after drug intake, while others are not manifested until 7 to 10 days after initiation of therapy and are consistent with delayed-type hypersensitivity. This review discusses critical steps in the initiation of delayed-type hypersensitivity reactions in the skin, which include protein haptenation, dendritic cell activation/migration and T-cell propagation. Recently, an alternative mechanism of drug presentation has been postulated that does not require bioactivation of the parent drug or antigen processing to elicit a drug-specific T-cell response. This review also discusses the role of various immune-mediators, such as cytokines, nitric oxide, and reactive oxygen species, in the development of delayed-type drug hypersensitivity reactions in skin. As keratinocytes have been shown to play a crucial role in the initiation and propagation of cutaneous immune responses, we also discuss the means by which these cells may initiate or modulate CDRs.
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Affiliation(s)
- Sanjoy Roychowdhury
- Division of Pharmaceutics, College of Pharmacy, The University of Iowa, 115 S Grand Avenue, S213 PHAR Iowa City, IA 52242
| | - Craig K. Svensson
- Division of Pharmaceutics, College of Pharmacy, The University of Iowa, 115 S Grand Avenue, S213 PHAR Iowa City, IA 52242
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Chave TA, Mortimer NJ, Sladden MJ, Hall AP, Hutchinson PE. Toxic epidermal necrolysis: current evidence, practical management and future directions. Br J Dermatol 2005; 153:241-53. [PMID: 16086734 DOI: 10.1111/j.1365-2133.2005.06721.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1-nuclear factor kappaB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance.
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Affiliation(s)
- T A Chave
- Department of Dermatology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK.
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Abstract
Neuromuscular blocking agents (NMBAs) play a predominant role in the incidence of severe adverse reactions occurring during anesthesia. Most hypersensitivity reactions are of immunologic origin (IgE-mediated) or are related to direct stimulation of histamine release. The incidence of IgE-mediated hypersensitivity or anaphylaxis is estimated between 1 in 10,000 and 1 in 20,000 anesthesias, and NMBAs represent the most frequently involved substances, with a range of 50% to 70%. Any suspected anaphylactic reaction must be extensively investigated using combined perioperative and postoperative testing. Because of the frequent cross-reactivity observed with muscle relaxants, every available NMBA should be tested. This should help provide documented advice for future administration of anesthesia. There is no demonstrated evidence for systematic preoperative screening in the general population at this time. Other well-known adverse effects have been described, such as the succinylcholine-triggered cytotoxic effects on muscle cells, but these are responsible for characteristic clinical symptoms, which are usually easy to distinguish from anaphylactic reactions
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Affiliation(s)
- Paul-Michel Mertes
- Département d'Anesthésie-réanimation, CHU de Nancy, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035 Nancy Cedex, France.
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