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Alvarez-Arango S, Kumar M, Chow TG, Sabato V. Non-IgE-Mediated Immediate Drug-Induced Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1109-1119. [PMID: 38423288 PMCID: PMC11081849 DOI: 10.1016/j.jaip.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/04/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
Immediate drug-induced hypersensitivity reactions (IDHSRs) have conventionally been attributed to an immunoglobulin E (IgE)-mediated mechanism. Nevertheless, it has now been acknowledged that IDHSRs can also occur independently of IgE involvement. Non-IgE-mediated IDHSRs encompass the activation of effector cells, both mast cell-dependent and -independent and the initiation of inflammatory pathways through immunogenic and nonimmunogenic mechanisms. The IDHSRs involve inflammatory mediators beyond histamine, including the platelet-activating factor, which activates multiple cell types, including smooth muscle, endothelium, and MC, and evidence supports its importance in IgE-mediated reactions in humans. Clinically, distinguishing IgE from non-IgE mechanisms is crucial for future treatment strategies, including drug(s) restriction, readministration approaches, and pretreatment considerations. However, this presents significant challenges because certain drugs can trigger both mechanisms, and their presentations can appear similarly, ranging from mild to life-threatening symptoms. Thus, history alone is often inadequate for differentiation, and skin tests lack a standardized approach. Moreover, drug-specific IgE immunoassays have favorable specificity but low sensitivity, and the usefulness of the basophil activation test remains debatable. Lastly, no biomarker reliably differentiates between both mechanisms. Whereas non-IgE-mediated mechanisms likely predominate in IDHSRs, reclassifying most drug-related IDHSRs as non-IgE-mediated, with suggested prevention through dose administration adjustments, is premature and risky. Therefore, continued research and validated diagnostic tests are crucial to improving our capacity to distinguish between these mechanisms, ultimately enhancing patient care.
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Affiliation(s)
- Santiago Alvarez-Arango
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Pharmacology and Molecular Science, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Mukesh Kumar
- School of Biological Sciences, University of Hong Kong, Hong Kong, SAR
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vito Sabato
- Department of Immunology, Allergology and Rheumatology, Antwerp University Hospital, University Antwerp, Antwerp, Belgium
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Fernandez-Santamaria R, Ariza A, Bogas G, Salas M, Calvo-Serrano S, Frecha C, Mayorga C, Torres MJ, Fernandez TD. Involvement of autologous myeloid dendritic cells in the evaluation of immediate hypersensitivity reactions to betalactams. Clin Immunol 2024; 262:110166. [PMID: 38432423 DOI: 10.1016/j.clim.2024.110166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/01/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Amoxicillin (AX) and clavulanic acid (CLV) are the betalactam antibiotics (BLs) most used to treat bacterial infections, although they can trigger immediate hypersensitivity reactions (IDHRs). The maturation analysis of monocyte-derived dendritic cells (moDCs) and their capacity to induce proliferative response of lymphocytes are useful to test the sensitisation to a drug, although without optimal sensitivity. Nevertheless, this can be improved using directly isolated DCs such as myeloid DCs (mDCs). METHODS mDCs and moDCs were obtained from 28 allergic patients (AP), 14 to AX, 14 to CLV and from 10 healthy controls (HC). The expression of CCR7, CD40, CD80, CD83, and CD86 was analysed after stimulation with both BLs. We measured the capacity of these pre-primed DCs to induce drug-specific activation of different lymphocyte subpopulations, CD3+, CD4+, CD8+, CD4+Th1, and CD4+Th2, by flow cytometry. RESULTS Higher expression of CCR7, CD40, CD80, CD83, and CD86 was observed on mDCs compared to moDCs from AP after stimulating with the culprit BL. Similarly, mDCs induced higher proliferative response, mainly of CD4+Th2 cells, compared to moDCs, reaching up to 67% of positive results with AX, whereas of only 25% with CLV. CONCLUSIONS mDCs from selective AP efficiently recognise the culprit drug which trigger the IDHR. mDCs also trigger proliferation of lymphocytes, mainly those with a Th2 cytokine pattern, although these responses depend on the nature of the drug, mimicking the patient's reaction.
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Affiliation(s)
- Ruben Fernandez-Santamaria
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain
| | - Adriana Ariza
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain.
| | - Gador Bogas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Maria Salas
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Silvia Calvo-Serrano
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain
| | - Cecilia Frecha
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain
| | - Cristobalina Mayorga
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Maria Jose Torres
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Medicina, Universidad de Málaga-UMA, Málaga, Spain; Allergy Unit, Hospital Regional Universitario de Málaga-ARADyAL, Málaga, Spain
| | - Tahia Diana Fernandez
- Allergy Research Group, IBIMA Plataforma BIONAND, Málaga, Spain; Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga-UMA, Málaga, Spain
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Luo L, Chen N, Li Z, Zhao C, Dong Y, Wang L, Li X, Zhou W, Li Y, Gao C, Guo X. Knowledge mapping and global trends of drug hypersensitivity from 2013 to 2023: A bibliometric analysis. Immun Inflamm Dis 2024; 12:e1245. [PMID: 38629759 PMCID: PMC11022627 DOI: 10.1002/iid3.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/27/2024] [Accepted: 03/31/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Drug hypersensitivity is a major global public health issue with a significant increase in prevalence in populations. Here, we provide a deep insight into the frontier hotspot and future direction in the field of drug hypersensitivity. METHODS A knowledge map is portrayed based on publications related to drug hypersensitivity from Web of Science Core Collection using CiteSpace. Co-occurrence relationships of countries, institutes, authors, journals, references, and keywords are constructed. According to the co-occurrence relationships, hotspots and future trends are overviewed. RESULTS The United States ranked first in the world and China with the second highest publications was the only developing country. Torres, Mayorga, and Blanca were highly productive authors. Harvard University was the institution with the most research publications. Keywords co-occurrence analysis suggested applications in emerging causes, potential mechanisms, and clinical diagnosis as the research hotspots and development frontiers. CONCLUSION Research on drug hypersensitivity is in a rapid development stage and an emerging trend in reports of anaphylaxis to polyethylene glycols is identified. Developing algorithms for understanding the standardization process of culprit drugs, clinical manifestations, and diagnostic methods will be the focus of future direction. In addition, a better understanding of the mechanisms to culprit drugs with immunological precise phenotypic definitions and high-throughput platforms is needed.
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Affiliation(s)
- Li Luo
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Niannian Chen
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Zhanpeng Li
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Chunmei Zhao
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Yiming Dong
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Likai Wang
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Xiaoqian Li
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Wenchao Zhou
- School of Public Health, Academy of Medical ScienceShanxi Medical UniversityTaiyuanChina
| | - Yingna Li
- First Clinical Medical CollegeShanxi Medical UniversityTaiyuanChina
| | - Cairong Gao
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
| | - Xiangjie Guo
- Department of Pathology, School of Forensic MedicineShanxi Medical UniversityTaiyuanChina
- Translational Medicine Research CenterShanxi Medical UniversityTaiyuanChina
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Mayorga C, Çelik GE, Pascal M, Hoffmann HJ, Eberlein B, Torres MJ, Brockow K, Garvey LH, Barbaud A, Madrigal-Burgaleta R, Caubet JC, Ebo DG. Flow-based basophil activation test in immediate drug hypersensitivity. An EAACI task force position paper. Allergy 2024; 79:580-600. [PMID: 38084472 DOI: 10.1111/all.15957] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/06/2023] [Accepted: 11/13/2023] [Indexed: 12/22/2023]
Abstract
Diagnosing immediate drug hypersensitivity reactions (IDHRs) can pose a significant challenge and there is an urgent need for safe and reliable tests. Evidence has emerged that the basophil activation test (BAT), an in vitro assay that mirrors the in vivo response, can be a complementary test for many drugs. In this position paper, members of Task Force (TF) "Basophil activation test in the evaluation of Drug Hypersensitivity Reactions" from the European Academy of Allergy and Clinical Immunology (EAACI) present the data from a survey about the use and utility of BAT in IDHRs in Europe. The survey results indicate that there is a great interest for using BAT especially for diagnosing IDHRs. However, there are still main needs, mainly in the standardization of the protocols. Subsequently consensus-based recommendations were formulated for: (i) Technical aspects of BAT in IDHRs including type of sample, management of drugs, flow cytometry protocols, interpretation of the results; and (ii) Drug-specific aspects that should be taken into account when performing BAT in relation to betalactams, neuromuscular blocking agents, fluoroquinolones, chlorhexidine, opioids, radio contrast media, chemotherapeutics, biological agents, nonsteroidal anti-inflammatory drugs, COVID vaccine, and excipients. Moreover, aspects in the evaluation of pediatric population have also been considered. All this indicates that BAT offers the clinician and laboratory a complementary tool for a safe diagnostic for IDHRs, although its place in the diagnostic algorithm depends on the drug class and patient population (phenotype, geography, and age). The standardization of BAT is important for generalizing this method beyond the individual laboratory.
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Affiliation(s)
- C Mayorga
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
| | - G E Çelik
- Department of chest disease, Division of Allergy & Immunology, Ankara University School of Medicine, Ankara, Turkey
| | - M Pascal
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Immunology Department, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - H J Hoffmann
- Department of Clinical Medicine and Department of Clinical Immunology, Aarhus University and Aarhus University Hospital, Aarhus N, Denmark
| | - B Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - M J Torres
- Allergy Unit, Hospital Regional Universitario de Málaga and Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- RETICS Asma reacciones adversas y alérgicas (ARADYAL) and RICORS Red De Enfermedades Inflamatorias (REI), Madrid, Spain
- Medicine Department, Malaga University, Málaga, Spain
| | - K Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - L H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen and Department of Clinical Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - A Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP.Sorbonne Université, Hôpital Tenon, Département de dermatologie et allergologie, Paris, France
| | - R Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - J C Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - D G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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Nishida Y, Yagami A, Takada S, Muramatsu D, Nobuoka Y, Okayama Y. Clinical investigation for the mechanisms of anaphylactic symptoms in osteoarthritis patients after diclofenac etalhyaluronate administration. Mod Rheumatol 2023:road100. [PMID: 37862589 DOI: 10.1093/mr/road100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/26/2023] [Accepted: 10/11/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE To investigate mechanisms of anaphylaxis in patients with osteoarthritis (OA) of knee and hip after diclofenac etalhyaluronate (product name: JOYCLU® [JCL]) intra-articular injection, and to determine the utility of tests to investigate the mechanism involved. METHODS In this observational study in Japan, patients aged ≥20 years with knee or hip OA who received JCL intra-articular injection, experienced anaphylactic symptoms considered related to JCL ("experienced patients") or did not experience allergic symptoms considered related to JCL ("non-experienced patients"). Basophil activation tests (BAT), specific immunoglobulin E (IgE) antibody testing by enzyme-linked immunosorbent assays (ELISA) or immunochromatographic kit, and genome-wide association studies (GWAS) were conducted using patient blood and saliva. RESULTS Thirteen experienced patients and 14 non-experienced patients were tested. Seven experienced patients tested positive by BAT using diclofenac etalhyaluronate (DEH)-containing test substances. Diclofenac (DF)-specific IgE antibodies were detected in 4 of 7 BAT-positive patients, but not in the non-experienced patients. Specific IgE antibody testing by immunochromatographic kit and GWAS showed no clear results. CONCLUSIONS These findings suggest that anaphylaxis occurs after JCL administration via an IgE-mediated mechanism and that DEH may be involved in this mechanism. BAT and DF-specific IgE ELISA may be useful tests for investigating the mechanisms of anaphylactic reactions after JCL administration.
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Affiliation(s)
- Yoshihiro Nishida
- Department of Rehabilitation Medicine, Rare Cancer Center, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Akiko Yagami
- Department of Allergology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Shuhei Takada
- Research & Development Division, Seikagaku Corporation, Higashiyamato, Tokyo, Japan
| | - Dai Muramatsu
- Research & Development Division, Seikagaku Corporation, Higashiyamato, Tokyo, Japan
| | - Yuji Nobuoka
- Research & Development Division, Seikagaku Corporation, Tokyo, Japan
| | - Yoshimichi Okayama
- Department of Internal Medicine, Division of Allergology, Misato Kenwa Hospital, Misato, Saitama, Japan
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University, Tokyo, Japan
- Department of Internal Medicine, Division of Respiratory Medicine, Nihon University School of Medicine, Tokyo, Japan
- Gunma Paz University Graduate School of Health Sciences, Takasaki, Gunma, Japan
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Rodríguez-Pérez R, de las Vecillas L, Cabañas R, Bellón T. Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions. Int J Mol Sci 2023; 24:12577. [PMID: 37628756 PMCID: PMC10454098 DOI: 10.3390/ijms241612577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Drug hypersensitivity reactions are a serious concern in clinical practice because they can be severe and result in lifelong sequelae. An accurate diagnosis and identification of the culprit drug is essential to prevent future reactions as well as for the identification of safe treatment alternatives. Nonetheless, the diagnosis can be challenging. In vivo and in vitro tests can be helpful, although none are conclusive; therefore, the tests are not usually performed in isolation but as part of a diagnostic algorithm. In addition, some in vitro tests are only available in research laboratories, and standardization has not been fully accomplished. Collaborating research is needed to improve drug hypersensitivity reaction diagnosis. In this review, we update the current available in vivo and in vitro tools with their pros and cons and propose an algorithm to integrate them into clinical practice.
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Affiliation(s)
- Rosa Rodríguez-Pérez
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
| | - Leticia de las Vecillas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
| | - Rosario Cabañas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER U754), 28046 Madrid, Spain
| | - Teresa Bellón
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- PIELenRed Consortium, 28046 Madrid, Spain
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Whitley L, Honsinger R. Drug patch testing for severe cutaneous adverse reactions: Not in the United States? Ann Allergy Asthma Immunol 2023; 130:538-539. [PMID: 37137599 DOI: 10.1016/j.anai.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Lori Whitley
- Los Alamos Medical Care Clinic Ltd, Los Alamos, New Mexico; Department of Clinical Medicine, Burrell College of Osteopathic Medicine, Las Cruces, New Mexico
| | - Richard Honsinger
- Los Alamos Medical Care Clinic Ltd, Los Alamos, New Mexico; Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
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Abuzgaia AM, Elzagallaai AA, Mullowney T, Rieder MJ. Drug Hypersensitivity Reactions in Patients with Cystic Fibrosis: Potential Value of the Lymphocyte Toxicity Assay to Assess Risk. Mol Diagn Ther 2023; 27:395-403. [PMID: 36939981 DOI: 10.1007/s40291-023-00644-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a genetic disease characterized by multi-system dysfunction resulting in recurrent lung infections and progressive pulmonary disease. CF patients are at a higher risk for drug hypersensitivity reactions (DHRs) compared to the general population, which has been attributed to the recurrent need for antibiotics and the inflammation associated with CF disease. In vitro toxicity tests such as the lymphocyte toxicity assay (LTA) offer the potential for risk assessment for DHRs. In the current study, we investigated the utility of the LTA test for diagnosis of DHRs in a cohort of CF patients. METHOD Twenty CF patients with suspected DHRs to sulfamethoxazole, penicillins, cephalosporins, meropenem, vancomycin, rifampicin, and tobramycin were recruited to this study and tested using the LTA test along with 20 healthy control volunteers. Demographic data of the patients, including age, sex, and medical history, were obtained. Blood samples were withdrawn from patients and healthy volunteers, and the LTA test was performed on isolated peripheral blood monocytes (PBMCs) from those individuals. RESULTS Cells from CF patients with DHRs displayed a significant (p < 0.0001) concentration-dependent enhanced cell death upon incubation with the culprit drug compared to cells from healthy volunteers. The positivity rate of the LTA test was over 80% in patients with a medical history and clinical presentation consistent with DHRs. CONCLUSION This study is the first to evaluate the use of the LTA test for diagnosis of DHRs in CF patients. According to our results, the LTA test may be a useful tool for diagnosis and management of DHRs in CF patients. Identifying the culprit drug is essential for optimal healthcare for CF patients in the setting of a suspected DHR. The data also provide evidence that accumulation of toxic reactive metabolites could be an important component in the cascade of events leading to the development of DHRs in CF patients. A larger-scale study is needed to confirm the data.
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Affiliation(s)
- Awatif M Abuzgaia
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St. North, London, ON, N6A 3M7, Canada
| | - Abdelbaset A Elzagallaai
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St. North, London, ON, N6A 3M7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Tara Mullowney
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St. North, London, ON, N6A 3M7, Canada
| | - Michael J Rieder
- Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St. North, London, ON, N6A 3M7, Canada.
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
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Heremans K, Toscano A, Elst J, Van Gasse AL, Mertens C, Beyens M, van der Poorten MLM, Hagendorens MM, Ebo DG, Sabato V. Basophil Activation Test Shows Poor Sensitivity in Immediate Amoxicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:500-505. [PMID: 36402397 DOI: 10.1016/j.jaip.2022.10.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/13/2022] [Accepted: 10/30/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND In light of the pandemic of spurious penicillin allergy, correct diagnosis of amoxicillin (AX) allergy is of great importance. The diagnosis of immediate hypersensitivity reactions relies on skin tests and specific IgE, and although reliable, these are not absolutely predictive. Therefore, drug challenges are needed in some cases, which contain the risk of severe reactions. Safe in vitro diagnostics as an alternative for the drug challenge in the diagnostic workup of AX allergy would be more than welcome to fill this gap. In this respect, the basophil activation test (BAT) has shown potential, but its clinical reliability is doubtful. OBJECTIVE To investigate the reliability of the BAT to AX and determining its exact place in the diagnostic algorithm of AX allergy. METHODS BAT for AX was performed in 70 exposed control individuals and 66 patients diagnosed according to the European Academy of Allergy and Clinical Immunology guidelines for AX allergy. Upregulation of both CD63 and CD203c was flow-cytometrically assessed. RESULTS Analyses revealed that 1370 μmol/L and 685 μmol/L were the most discriminative stimulation concentrations for CD63 and CD203c upregulation, respectively, and a diagnostic threshold of 9% for positivity for both markers was identified. At these concentrations, sensitivity and specificity for CD63 upregulation were 13% and 100%, respectively, and for CD203c upregulation, 23% and 98%. CONCLUSIONS BAT with dual analysis of CD63 and CD203c is of poor performance to document AX allergy. The sensitivity is too low to let it occupy a prominent role in the diagnostic algorithm.
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Affiliation(s)
- Kevin Heremans
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Alessandro Toscano
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium
| | - Michiel Beyens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Margo M Hagendorens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Vito Sabato
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; The Infla-Med Centre of Excellence, Antwerp University, Antwerpen, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
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10
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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11
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Solakoglu Ö, Götz W, von Baehr V, Heydecke G, Pantel K, Schwarzenbach H. Characterization of immunologically detectable T-cell sensitization, Immunohistochemical detection of pro-inflammatory cytokines, and clinical parameters of patients after allogeneic intraoral bone grafting procedures: a prospective randomized controlled clinical trial in humans. BMC Oral Health 2022; 22:592. [PMID: 36496367 PMCID: PMC9741780 DOI: 10.1186/s12903-022-02584-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The null hypotheses were tested that intraoral bone augmentation using two different allogeneic materials has no impact on the patient's blood levels of material-specific lymphocytes and on the immunohistochemical detection of pro-inflammatory cytokines IL-1α, IL1ß and TNF-α and T-cell markers CD4, CD8 in biopsies of the test groups. METHODS In this prospective RCT, 60 systemically healthy participants were randomly assigned to two allogeneic test groups (1: Maxgraft®, freeze-dried, multiple donors, and 2: Puros®, solvent-dehydrated, single donor) and an autologous control group (10 patients). Plasma samples were collected pre-(T1) and postoperatively (2 weeks (T2) and 4 months (T3)). The Lymphocyte Transformation Test (LTT) was used for analyzing levels of transformed lymphocytes for type IV immune reactions by 3H-thymidine activity. Bone biopsies were harvested at T3 and immunohistochemically analyzed for IL-1α, IL1ß, TNF-α, CD4, CD8 and correlated with the immunological and clinical findings. RESULTS A statistically significant difference between the tested materials was observed for LTT measurements at T3 (p = 0.033). Furthermore, three groups were identified: Group A (LTT negative T1-T3, n = 48), group B (LTT positive T1-T3, n = 7), group C (developing positive LTT at T2, n = 5). A highly significant elevation of IL-1α, IL1ß, TNF-α in patients of group C (p = 0.0001) and a significant elevation of CD4+ cells in patients of group B (p = 0.005) was shown. CONCLUSION Our data show that following allogeneic bone grafting, local and systemic immunological reactions can be detected in some patients. These findings were statistically significant for the timepoint T3 between the tested materials as well as for the groups B and C correlated with group A for both tested materials. Therefore, the null hypotheses were rejected. A preoperative compatibility test for allogeneic materials in order to improve patient safety and the predictability of these materials would be desirable. TRIAL REGISTRATION Ethical commission of the Ärztekammer Hamburg, Germany (PV5211) as well as by the German Registry of Clinical Studies (DRKS00013010) on 30/07/2018 ( http://apps.who.int/trialsearch/ ).
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Affiliation(s)
- Önder Solakoglu
- grid.13648.380000 0001 2180 3484The Dental Department of the University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Werner Götz
- grid.10388.320000 0001 2240 3300Department of Orthodontics, Laboratory for Oral Biologic Basic Science, University of Bonn, Bonn, Germany
| | | | - Guido Heydecke
- grid.13648.380000 0001 2180 3484The Dental Department of Prosthodontics of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Pantel
- grid.13648.380000 0001 2180 3484Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heidi Schwarzenbach
- grid.13648.380000 0001 2180 3484Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Roux C, Ben Said B, Milpied B, Bernier C, Staumont-Sallé D, Dezoteux F, Soria A, Barbaud A, Valeyrie-Allanore L, Tétart F, Bellon N, Lebrun-Vignes B, Gener G, Paul M, Ingen-Housz-Oro S, Assier H. Skin Testing and Drug Provocation Tests in Epidermal Necrolysis: A French Experience. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3252-3261.e2. [PMID: 35870724 DOI: 10.1016/j.jaip.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are limited data on the use of skin testing, other than patch testing, and challenges in the evaluation of epidermal necrolysis (EN), including Stevens-Johnson syndrome and toxic epidermal necrolysis. OBJECTIVE To report a French multicenter experience in skin testing and challenges in EN, and investigate the factors associated with tests' positivity. METHODS All patients who were evaluated by patch tests (PTs), skin prick tests, intradermal tests (IDTs), or drug provocation tests (DPTs) for EN between 2010 and 2020 were retrospectively included through 2 French drug reaction networks. RESULTS In total, 113 patients were included from 8 centers. Median (interquartile range) time from EN to hypersensitivity workup was 7.9 months (5.1-15 months). All patients had PTs, 17 (15%) had skin prick tests or IDTs with delayed readings and 32 (28.3%) had DPTs. One mild reaction occurred after a DPT. Overall, 22 patients (19.5%) had positive PTs, and the only factors associated with positivity were Algorithm of Drug Causality for Epidermal Necrolysis (ALDEN) score and drug class. Only 1 IDT was positive but considered irrelevant. The DPTs were never performed to prove responsibility of a highly suspected drug but were used to confirm current tolerance of needed medications. CONCLUSIONS Allergological workup in EN, performed by specialists involved in EN, seems safe. Skin tests, although of limited sensitivity, can be helpful for considering the reintroduction of essential drugs according to a benefit-to-risk decision. We propose an algorithm for approaching hypersensitivity testing in patients with EN, to be adapted to each patient.
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Affiliation(s)
- Camille Roux
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Benoit Ben Said
- Department of Allergy and Clinical Immunology, Edouard Herriot Hospital, HCL, Claude Bernard Lyon 1 University, Lyon, France; Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France
| | - Brigitte Milpied
- Department of Allergy and Clinical Immunology, Edouard Herriot Hospital, HCL, Claude Bernard Lyon 1 University, Lyon, France; Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; Department of Dermatology, National Reference Center for Rare Skin Diseases, University of Bordeaux, Bordeaux, France
| | - Claire Bernier
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology, Nantes University Hospital, Nantes, France
| | - Delphine Staumont-Sallé
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology, Lille University Hospital, Lille, France
| | - Frédéric Dezoteux
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology, Lille University Hospital, Lille, France
| | - Angèle Soria
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology and Allergy, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Annick Barbaud
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology and Allergy, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Laurence Valeyrie-Allanore
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Private Practice, Saint-Mandé, France
| | - Florence Tétart
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology, Rouen University Hospital, Normandie University, Rouen, France
| | - Nathalia Bellon
- Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Dermatology, Necker Hospital, AP-HP, Paris, France
| | - Bénédicte Lebrun-Vignes
- French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Department of Pharmacology, Pharmacovigilance Unit, Pitié-Salpétrière Hospital, AP-HP, Paris, France; Paris Est Créteil University, EpiDermE, Créteil, France
| | - Gwendeline Gener
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Muriel Paul
- Department of Hospital Pharmacy, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Saskia Ingen-Housz-Oro
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France; Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France; French Investigators for Skin Adverse Reactions to Drugs (FISARD) Group, Paris, France; Paris Est Créteil University, EpiDermE, Créteil, France
| | - Haudrey Assier
- Department of Dermatology, Henri Mondor Hospital, AP-HP, Créteil, France; Department of Allergy and Clinical Immunology, Edouard Herriot Hospital, HCL, Claude Bernard Lyon 1 University, Lyon, France; Reference Center for Toxic Bullous Dermatoses and Severe Drug Reactions (TOXIBUL), Créteil, France.
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13
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Mabilat C, Gros MF, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, Timbrook TT. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist 2022; 4:dlac116. [PMID: 36415507 PMCID: PMC9675589 DOI: 10.1093/jacamr/dlac116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. As such, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. Herein, we review the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e. skin test and/or drug challenge. As these tests are labour and resource intensive, there is increased interest in point-of-care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programmes including digital assessment tools. These can be locally parameterized on the basis of characteristics of target populations, incidence of specific allergies and local antibiotic usage to perform clinical risk stratification. Safely ruling out any residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. More research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care. This progress, together with better education of patients and clinicians about the availability, efficacy and safety of penicillin allergy testing, will increase the dissemination of penicillin allergy assessment as an important component of Antimicrobial Stewardship Programmes.
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Affiliation(s)
| | - Marie-Françoise Gros
- bioMérieux, Medical Affairs, 100 Rue Louis Pasteur, F-69280 Marcy l'Etoile, France
| | - Alex Van Belkum
- Current address:BaseClear, Sylviusweg 74, 2333 BE Leiden, The Netherlands
| | - Jason A Trubiano
- Department of Infectious Diseases, Centre for Antibiotic Allergy and Research, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084Australia
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | | | - Tristan T Timbrook
- bioMérieux, BioFire Diagnostics, Global Medical Affairs, 515 Colorow Drive, Salt Lake City, UT 84108, USA
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14
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Han J, Pan C, Tang X, Li Q, Zhu Y, Zhang Y, Liang A. Hypersensitivity reactions to small molecule drugs. Front Immunol 2022; 13:1016730. [PMID: 36439170 PMCID: PMC9684170 DOI: 10.3389/fimmu.2022.1016730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/20/2022] [Indexed: 02/02/2024] Open
Abstract
Drug hypersensitivity reactions induced by small molecule drugs encompass a broad spectrum of adverse drug reactions with heterogeneous clinical presentations and mechanisms. These reactions are classified into allergic drug hypersensitivity reactions and non-allergic drug hypersensitivity reactions. At present, the hapten theory, pharmacological interaction with immune receptors (p-i) concept, altered peptide repertoire model, and altered T-cell receptor (TCR) repertoire model have been proposed to explain how small molecule drugs or their metabolites induce allergic drug hypersensitivity reactions. Meanwhile, direct activation of mast cells, provoking the complement system, stimulating or inhibiting inflammatory reaction-related enzymes, accumulating bradykinin, and/or triggering vascular hyperpermeability are considered as the main factors causing non-allergic drug hypersensitivity reactions. To date, many investigations have been performed to explore the underlying mechanisms involved in drug hypersensitivity reactions and to search for predictive and preventive methods in both clinical and non-clinical trials. However, validated methods for predicting and diagnosing hypersensitivity reactions to small molecule drugs and deeper insight into the relevant underlying mechanisms are still limited.
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Affiliation(s)
- Jiayin Han
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chen Pan
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xuan Tang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qi Li
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Zhu
- Institute of Information on Traditional Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yushi Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Aihua Liang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
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15
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Weir C, Li J, Fulton R, Fernando SL. Development and initial validation of a modified lymphocyte transformation test (LTT) assay in patients with DRESS and AGEP. ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY 2022; 18:90. [PMID: 36210462 PMCID: PMC9548132 DOI: 10.1186/s13223-022-00729-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022]
Abstract
Background The lymphocyte transformation test (LTT) is an in vitro assay used to diagnose drug induced hypersensitivity reactions by detecting the activation and expansion of drug-specific memory T cells to the suspected implicated drug. Traditionally radiolabelled thymidine (3H-thymidine) has been used but requires the handling and disposal of radioactive materials. Objective To examine safe alternatives to 3H-thymidine, test assay modifications for improved assay sensitivity and evaluate the modified LTT in patients with DRESS and AGEP. Methods Four proliferation detection assays (BRDU, CyQUANT™, MTT and XTT) were screened for LTT sensitivity. XTT the most sensitive and practical was selected for further evaluation Modifications like autologous serum (AS) and regulatory T cell depletion (T-REG) were tested for improved assay sensitivity. Finally, an initial evaluation of the XTT–LTT was performed in 8 patients with DRESS and 2 with AGEP including cytokine testing. Results Of the non-radioactive alternatives we tested, XTT a colorimetric assay was the most sensitive and practical to move to evaluation. The addition of AS increased background signal. Depletion of T-REGs improved sensitivity but cell sorting time and risk of contamination limited benefit. Of eight patients diagnosed with DRESS and 2 with AGEP tested with XTT–LTT assay results showed our assay matched clinical findings of implicated drugs in 8/10 patients when using a stimulation index (SI) ≥ 2 and 8/10 with analysis by ANOVA. All ten patients were correctly diagnosed by either analysis. Conclusion XTT appears to be a safe, viable alternative to 3H-thymidine, with high sensitivity and allowing direct cytokine quantification on specific patient cells.
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16
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Fernandez‐Santamaria R, Bogas G, Montañez MI, Ariza A, Salas M, Cespedes JA, Labella M, Paris JL, Perez‐Sanchez N, Perez‐Inestrosa E, Vida Y, Fernandez TD, Mayorga C, Torres MJ. Synthetic antigenic determinants of clavulanic acid induce dendritic cell maturation and specific T cell proliferation in patients with immediate hypersensitivity reactions. Allergy 2022; 77:3070-3083. [PMID: 35611454 PMCID: PMC9796838 DOI: 10.1111/all.15383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/19/2022] [Accepted: 05/04/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Immediate drug hypersensitivity reactions (IDHRs) to clavulanic acid (CLV) have increased in the last decades due to a higher consumption alongside amoxicillin (AX). Due to its chemical instability, diagnostic procedures to evaluate IDHRs to CLV are difficult, and current in vitro assays do not have an optimal sensitivity. The inclusion of the specific metabolites after CLV degradation, which are efficiently recognised by the immune system, could help to improve sensitivity of in vitro tests. METHODS Recognition by dendritic cells (DCs) of CLV and the synthetic analogues of two of its hypothesised antigenic determinants (ADs) was evaluated by flow cytometry in 27 allergic patients (AP) and healthy controls (HC). Their ability to trigger the proliferation of T cells was also analysed by flow cytometry. RESULTS The inclusion of synthetic analogues of CLV ADs, significantly increased the expression of maturation markers on DCs from AP compared to HC. A different recognition pattern could be observed with each AD, and, therefore, the inclusion of both ADs achieves an improved sensitivity. The addition of synthetic ADs analogues increased the proliferative response of CD4+ Th2 compared to the addition of native CLV. The combination of results from both ADs increased the sensitivity of proliferative assays from 19% to 65% with a specificity higher than 90%. CONCLUSIONS Synthetic ADs from CLV are efficiently recognised by DCs with ability to activate CD4+ Th2 cells from AP. The combination of analogues from both ADs, significantly increased the sensitivity of DC maturation and T-cell proliferation compared to native CLV.
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Affiliation(s)
- Ruben Fernandez‐Santamaria
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Departmento de Medicina, Universidad de Málaga‐UMAMálagaSpain
| | - Gador Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain
| | - Maria Isabel Montañez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Departamento de Química Orgánica, Universidad de Málaga‐UMAMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
| | - Adriana Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain
| | - Maria Salas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain
| | - Jose Antonio Cespedes
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Departmento de Medicina, Universidad de Málaga‐UMAMálagaSpain
| | - Marina Labella
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain
| | - Juan Luis Paris
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
| | - Natalia Perez‐Sanchez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain
| | - Ezequiel Perez‐Inestrosa
- Departamento de Química Orgánica, Universidad de Málaga‐UMAMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
| | - Yolanda Vida
- Departamento de Química Orgánica, Universidad de Málaga‐UMAMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
| | - Tahia D. Fernandez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga‐UMAMálagaSpain
| | - Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
| | - Maria Jose Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyALMálagaSpain,Departmento de Medicina, Universidad de Málaga‐UMAMálagaSpain,Allergy Unit, Hospital Regional Universitario de Málaga‐HRUMMálagaSpain,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Centro Andaluz de Nanomedicina y Biotecnología‐BIONANDMálagaSpain
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17
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Sanchez Armengol E, Blanka Kerezsi A, Laffleur F. Allergies caused by textiles: control, research and future perspective in the medical field. Int Immunopharmacol 2022; 110:109043. [PMID: 35843147 DOI: 10.1016/j.intimp.2022.109043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/05/2022]
Abstract
Textile production forms one of the most polluting industries worldwide. However, other than damaging environmental effects, chemical waste products, such as formaldehyde or thiazolinone, are problematic for human health, as allergic potential is present in these compounds. Mostly, contact dermatitis occurs when human skin is exposed to textiles. Moreover, non-eczemous variants are mainly associated to textiles. In order to diagnose the possible allergy of the patient towards these compounds, in vivo and in vitro methods ca be performed, such as patch testing or cytokine detection assays, respectively. Newest research focuses on medical textiles such as garments or sutures to help in diagnosis, therapy and recovery of the patients. Sutures and dressings with antimicrobial properties, with the release of oxygen and growth factors offer greater properties. In this review, state of the art in the field as well as future perspectives will be discussed, which are based on the smart textiles that are going to become more important and probably widespread after the current limits exceeded.
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Affiliation(s)
- Eva Sanchez Armengol
- Department of Pharmaceutical Technology, Institute of Pharmacy, University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria
| | - Aletta Blanka Kerezsi
- Department of Pharmaceutical Technology, Institute of Pharmacy, University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria
| | - Flavia Laffleur
- Department of Pharmaceutical Technology, Institute of Pharmacy, University of Innsbruck, Innrain 80-82, 6020 Innsbruck, Austria.
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18
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Ariza A, Mayorga C, Bogas G, Gaeta F, Salas M, Valluzzi RL, Labella M, Pérez-Sánchez N, Caruso C, Molina A, Fernández TD, Torres MJ, Romano A. Detection of Serum-Specific IgE by Fluoro-Enzyme Immunoassay for Diagnosing Type I Hypersensitivity Reactions to Penicillins. Int J Mol Sci 2022; 23:ijms23136992. [PMID: 35805992 PMCID: PMC9266290 DOI: 10.3390/ijms23136992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 12/15/2022] Open
Abstract
Diagnosis of type I hypersensitivity reactions (IgE-mediated reactions) to penicillins is based on clinical history, skin tests (STs), and drug provocation tests (DPTs). Among in vitro complementary tests, the fluoro-enzyme immunoassay (FEIA) ImmunoCAP® (Thermo-Fisher, Waltham, MA, USA) is the most widely used commercial method for detecting drug-specific IgE (sIgE). In this study, we aimed to analyze the utility of ImmunoCAP® for detecting sIgE to penicillin G (PG) and amoxicillin (AX) in patients with confirmed penicillin allergy. The study includes 139 and 250 patients evaluated in Spain and Italy, respectively. All had experienced type I hypersensitivity reactions to penicillins confirmed by positive STs. Additionally, selective or cross-reactive reactions were confirmed by DPTs in a subgroup of patients for further analysis. Positive ImmunoCAP® results were 39.6% for PG and/or AX in Spanish subjects and 52.4% in Italian subjects. When only PG or AX sIgE where analyzed, the percentages were 15.1% and 30.4%, respectively, in Spanish patients; and 38.9% and 46% in Italian ones. The analysis of positive STs showed a statistically significant higher percentage of positive STs to PG determinants in Italian patients. False-positive results to PG (16%) were detected in selective AX patients with confirmed PG tolerance. Low and variable sensitivity values observed in a well-defined population with confirmed allergy diagnosis, as well as false-positive results to PG, suggest that ImmunoCAP® is a diagnostic tool with relevant limitations in the evaluation of subjects with type I hypersensitivity reactions to penicillins.
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Affiliation(s)
- Adriana Ariza
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
| | - Cristobalina Mayorga
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, 29590 Malaga, Spain
| | - Gádor Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - María Salas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Rocco L. Valluzzi
- Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, 00165 Rome, Italy;
| | - Marina Labella
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Natalia Pérez-Sánchez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Cristiano Caruso
- UOSD DH Gastroenterologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Ana Molina
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
| | - Tahia D. Fernández
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain
| | - María José Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, 29009 Malaga, Spain; (A.A.); (C.M.); (G.B.); (M.S.); (M.L.); (N.P.-S.); (A.M.); (T.D.F.)
- Allergy Unit, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, 29590 Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Malaga, Spain
- Correspondence: ; Tel.: +34-951290224
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19
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Glässner A, Dubrall D, Weinhold L, Schmid M, Sachs B. Lymphocyte Transformation Test for drug allergy detection: when does it work? Ann Allergy Asthma Immunol 2022; 129:497-506.e3. [PMID: 35732204 DOI: 10.1016/j.anai.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The lymphocyte transformation test (LTT) is an in vitro test system for the detection of a sensitization in the context of allergies to drugs. Its reported sensitivity varies largely and seems to be affected by different parameters. In review articles, the average LTT performance was often calculated by combining overall mean sensitivities of various published studies, but without considering different patient characteristics or varying patient numbers per publication. OBJECTIVE This meta-analysis aims to investigate the impact of different patient-specific and methodical parameters on the sensitivity of the LTT based on data on the level of the individual patient extracted from single studies. METHODS We performed an advanced literature search in Pubmed and screened the identified publications according to previously defined inclusion criteria. In total, individual patient data from 721 patients were extracted from 30 studies. Random-effects meta-regression analyses were performed. RESULTS The analysis indicate that the ELISA-based read-out is more sensitive compared to the classical radioactivity method (ELISA: 80% vs. radioactivity: 66%;p=0.084). Interestingly, DRESS/DHISS is associated with a higher probability of a positive LTT test result compared to other investigated clinical phenotypes ("DRESS/DHISS" vs. "bullous reaction"; OR: 2.52;p-value=0.003). Our analysis also revealed an impact of the time to testing period after the occurrence of the allergic event ("<2 weeks" vs. "2 weeks-2 months"; OR: 2.12;p-value=0.034). CONCLUSION The read-out method and relevant clinical parameters affect the sensitivity of the LTT. These findings are based on a meta-analysis providing a higher level of evidence than a single study or previous reviews not considering individual patient data.
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Affiliation(s)
- Andreas Glässner
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany.
| | - Diana Dubrall
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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20
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Teo YX, Haw WY, Vallejo A, McGuire C, Woo J, Friedmann PS, Polak ME, Ardern-Jones MR. Potential Biomarker Identification by RNA-seq analysis in Antibiotic-related Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): a Pilot Study. Toxicol Sci 2022; 189:20-31. [PMID: 35703984 PMCID: PMC9412178 DOI: 10.1093/toxsci/kfac062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
One of the most severe forms of cutaneous adverse drug reactions is 'drug reaction with eosinophilia and systemic symptoms' (DRESS), hence subsequent avoidance of the causal drug is imperative. However, attribution of drug culpability in DRESS is challenging and standard skin allergy tests are not recommended due to patient safety reasons. Whilst incidence of DRESS is relatively low, between 1:1000 to 1:10,000 drug exposures, antibiotics are a commoner cause of DRESS and absence of confirmatory diagnostic test can result in unnecessary avoidance of efficacious treatment. We therefore sought to identify potential biomarkers for development of a diagnostic test in antibiotic-associated DRESS. Peripheral blood mononuclear cells (PBMCs) from a 'discovery' cohort (n = 5) challenged to causative antibiotic or control were analysed for transcriptomic profile. A panel of genes was then tested in a validation cohort (n = 6) and compared to tolerant controls and other inflammatory conditions which can clinically mimic DRESS. A scoring system to identify presence of drug hypersensitivity was developed based on gene expression alterations of this panel. The DRESS transcriptomic panel identified antibiotic-DRESS cases in a validation cohort but was not altered in other inflammatory conditions. Machine learning or differential expression selection of a biomarker panel consisting of six genes (STAC, GPR183, CD40, CISH, CD4, and CCL8) showed high sensitivity and specificity (100% and 85.7-100% respectively) for identification of the culprit drug in these cohorts of antibiotic-associated DRESS. Further work is required to determine whether the same panel can be repeated for larger cohorts, different medications, and other T cell mediated drug hypersensitivity reactions.
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Affiliation(s)
- Ying Xin Teo
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom.,Department of Dermatology, Southampton General Hospital, University Hospitals Southampton NHS Foundation Trust
| | - Wei Yann Haw
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Andreas Vallejo
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Carolann McGuire
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Jeongmin Woo
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Peter Simon Friedmann
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Marta Ewa Polak
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Michael Roger Ardern-Jones
- Clinical Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom.,Department of Dermatology, Southampton General Hospital, University Hospitals Southampton NHS Foundation Trust
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21
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Alvarez-Cuesta E, Madrigal-Burgaleta R, Broyles AD, Cuesta-Herranz J, Guzman-Melendez MA, Maciag MC, Phillips EJ, Trubiano JA, Wong JT, Ansotegui I. Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement. World Allergy Organ J 2022; 15:100640. [PMID: 35694005 PMCID: PMC9163606 DOI: 10.1016/j.waojou.2022.100640] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).
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Affiliation(s)
| | - Ricardo Madrigal-Burgaleta
- Allergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Drug Desensitisation Centre, Catalan Institute of Oncology (ICO), Barcelona, Spain
- Corresponding author. Allergy & Severe Asthma Service, Respiratory Department, 4th Floor, King George V Building, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ana D. Broyles
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Javier Cuesta-Herranz
- Department of Allergy and Immunology, FIIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
- RETIC ARADyAL, Instituto de Salud Carlos III, Spain
| | | | - Michelle C. Maciag
- Division of Allergy & Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth J. Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason A. Trubiano
- Department of Infectious Diseases and Centre for Antibiotic Allergy and Research, Austin Health, Heidelberg, Australia
| | - Johnson T. Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Steering Committee AuthorsAliF. RunaMBBS, PhD, FRCPaxAngel-PereiraDenisseMDlBanerjiAleenaMDayBerges-GimenoMaria PilarMD, PhDmBernal-RubioLorenaMDmBrockowKnutMDnCardona VillaRicardoMDoCastellsMariana C.MD, PhDpCaubetJean-ChristophMDqChangYoon-SeokMD, PhDrEnsinaLuis FelipeMD, MSc, PhDsChikhladzeMananaPhDtChiriacAnca MirelaMD, PhDuChungWeng-HungMD, PhDvEbisawaMotohiroMD, PhDwFernandesBryanMBBS, MRCPaxGarveyLene HeiseMD, PhDxawGomezMaximilianoMD, PhDyGomez VeraJavierMDzGonzalez DiazSandraMD, PhDaaHongDavid I.MDpIvancevichJuan CarlosMDabKangHye-RyunMD, PhDacKhanDavid A.MDadKuruvillaMerinMDaeLarco SousaJose IgnacioMDafLatour-StaffeldPatriciaMDagLiuAnne Y.MDahMacyEricMDaiMallingHans JorgenMDajMasperoJorgeMDakMaySara M.MDalMayorgaCristobalinaPhDamParkMiguel A.MDanPeterJonathanMBChB, PhDaoPicardMatthieuMD, FRCPCapRodriguez-BouzaTitoMD, PhDaq2RomanoAntoninoMDarSanchez-BorgesMarioMDazbaTannoLuciana KaseMD, PhDuTorresMaria JoseMD, PhDamUreña-TaveraAliciaMDasValluzziRocco L.MDatVolcheckGerald W.MDauYamaguchiMasaoMD, PhDavHospital Universitario de Canarias, Tenerife, SpainAllergy Division, Ramon y Cajal University Hospital, Madrid, SpainDepartment of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, GermanyUniversidad de Antioquia, Medellín, ColombiaDivision of Allergy and Clinical Immunology, Department of Medicine, Brigham & Women's Hospital, Boston, MA, USAPediatric Allergy Unit, Geneva University Hospitals, Geneva, SwitzerlandDivision of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of KoreaDivision of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of Sao Paulo, BrazilMedical Faculty at Akaki Tsereteli State University, KuTaisi, Tskaltubo, GeorgiaDivision of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, FranceDepartment of Dermatology, Chang Gung Memorial Hospital, Taipei, Linko and Keelung, TaiwanClinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, JapanAllergy Clinic, Copenhagen University Hospital Gentofte, Copenhagen, DenmarkSchool of Health Sciences, Catholic University of Salta, ArgentinaInstitute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, MexicoRegional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, MexicoServicio de Alergia e Immunologia, Clinica Santa Isabel, Buenos Aires, ArgentinaInstitute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of KoreaDepartment of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USADivision of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USAAllergy Department, Clinica San Felipe, Lima, PeruCentro Avanzado de Alergia y Asma de Santo Domingo, Santo Domingo, Dominican RepublicStanford University School of Medicine, Palo Alto, CA, USASouthern California Permanente Medical Group, Kaiser Permanente Southern California, San Diego Medical Center, San Diego, CA, USADanish Allergy Centre, University of Copenhagen, Copenhagen, DenmarkAllergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, ArgentinaDivision of Pulmonary, Critical Care, Sleep & Allergy, University of Nebraska Medical Center, Omaha, NE, USAAllergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, SpainDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South AfricaDepartment of Medicine, Division of Allergy and Immunology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, CanadaCentro de Patología Alérgica, Hospital Quirón Palmaplanas, Palma, SpainOasi Research Institute – IRCCS, Troina, ItalyClinica Union Medica del Norte, Santiago, Dominican RepublicMultifactorial and Systemic Diseases Research Area, Predictive and Preventive Medicine Research Unit, Division of Allergy, Bambino Gesù Children's Hospital IRCCS, Rome, ItalyDivision of Allergic Diseases, Mayo Clinic, Rochester, MN, USADivision of Respiratory Medicine, Third Department of Medicine, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, JapanDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkAllergy & Severe Asthma Service, St Bartholomew's Hospital, Barts Health NHS Trust, London, UKDivision of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USAAllergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, VenezuelaAllergy and Clinical Immunology Department, Clínica El Avila, Caracas, Venezuela
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22
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Avila-Castano K, Morgenstern-Kaplan D, Carrillo-Martin I, Gonzalez-Estrada A. Bosutinib-Induced Stevens-Johnson Syndrome and Evidence of Tolerance to a Structurally Dissimilar Tyrosine Kinase Inhibitor. Cureus 2022; 14:e23288. [PMID: 35449618 PMCID: PMC9013475 DOI: 10.7759/cureus.23288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/05/2022] Open
Abstract
Bosutinib is a breakpoint cluster region-Abelson gene (BCR-ABL) tyrosine kinase inhibitor (TKI) used for the treatment of chronic myeloid leukemia (CML). Patients on TKIs may develop severe cutaneous adverse reactions (SCARs). A 73-year-old female with CML treated with a second-generation TKI (bosutinib) was evaluated after developing fever and a maculopapular exanthema with skin-peeling affecting her lips, oral mucosa, and genitals 10 days after starting the medication. She required hospitalization, bosutinib discontinuation, and management with intravenous corticosteroids and antibiotics. Patch testing was contraindicated due to the severity of the reaction. The patient was subsequently challenged with first-generation TKI along with careful observation without any adverse reactions. She has not reported any adverse reactions while on therapy in the last two years. In patients who have suffered from SCARs, the suspected triggers must be avoided in all instances. In some cases, the underlying condition limits the use of alternative agents, but low-concentration patch testing may help guide alternative therapies within the same medication group. There appears to be a low cross-reactivity among generational TKIs, and our patient benefited from treatment with a structurally dissimilar alternative TKI for her CML.
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23
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24
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Zgheib O, Trombert V, Jandus P, Serratrice C. Drug-induced hypersensitivity syndrome with lupus manifestations due to mesalazine in a patient with ulcerative colitis. BMJ Case Rep 2022; 15:e248229. [PMID: 35217557 PMCID: PMC8883224 DOI: 10.1136/bcr-2021-248229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 11/04/2022] Open
Abstract
Mesalazine is often used as first-line therapy for ulcerative colitis. Several reports have pointed to systemic adverse reactions associated with this drug. Most have evoked a drug-induced hypersensitivity syndrome, while some have described lupus syndromes but with limited clinical and varied biological features. A 75-year-old man presented with fever, dyspnoea, chest pain, polyarthralgia, and myalgia, following mesalazine introduction. Clinical symptoms and low-titre positive antihistone antibodies disappeared after mesalazine withdrawal without recourse to steroids. Pericardial effusion and 8F-fluorodeoxyglucose uptake on positron emission tomography/CT scan, and glomerular haematuria and proteinuria also disappeared. Cytokine-lymphocyte transformation tests showed a strong sensitisation pattern with interleukin-5 production. This case advances our knowledge of the mechanism of mesalazine-induced adverse effects, namely via drug-induced hypersensitivity with lupus manifestations, which we are the first to report.
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Affiliation(s)
- Omar Zgheib
- Internal Medicine of the Elderly, Geneva University Hospitals, Geneva, Switzerland
| | - Véronique Trombert
- Internal Medicine of the Elderly, Geneva University Hospitals, Geneva, Switzerland
| | - Peter Jandus
- Immunology and Allergology, Geneva University Hospitals, Geneva, Switzerland
| | - Christine Serratrice
- Internal Medicine of the Elderly, Geneva University Hospitals, Geneva, Switzerland
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25
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Gil-Ocaña V, Jimenez IM, Mayorga C, Doña I, Céspedes JA, Montañez MI, Vida Y, Torres MJ, Perez-Inestrosa E. Multiepitope Dendrimeric Antigen-Silica Particle Composites as Nano-Based Platforms for Specific Recognition of IgEs. Front Immunol 2021; 12:750109. [PMID: 34925325 PMCID: PMC8678411 DOI: 10.3389/fimmu.2021.750109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/08/2021] [Indexed: 12/22/2022] Open
Abstract
β-lactam antibiotics (BLs) are the drugs most frequently involved in drug hypersensitivity reactions. However, current in vitro diagnostic tests have limited sensitivity, partly due to a poor understanding of in vivo drug–protein conjugates that both induce the reactions and are immunologically recognized. Dendrimeric Antigen-Silica particle composites (DeAn@SiO2), consisting on nanoparticles decorated with BL-DeAns are promising candidates for improving the in vitro clinical diagnostic practice. In this nano-inspired system biology, the synthetic dendrimer plays the role of the natural carrier protein, emulating its haptenation by drugs and amplifying the multivalence. Herein, we present the design and synthesis of new multivalent mono- and bi-epitope DeAn@SiO2, using amoxicillin and/or benzylpenicillin allergenic determinants as ligands. The homogeneous composition of nanoparticles provides high reproducibility and quality, which is critical for in vitro applications. The suitable functionalization of nanoparticles allows the anchoring of DeAn, minimizing the nonspecific interactions and facilitating the effective exposure to specific IgE; while the larger interaction area increments the likelihood of capturing specific IgE. This achievement is particularly important for improving sensitivity of current immunoassays since IgE levels in BL allergic patients are very low. Our data suggest that these new nano-based platforms provide a suitable tool for testing IgE recognition to more than one BL simultaneously. Immunochemical studies evidence that mono and bi-epitope DeAn@SiO2 composites could potentially allow the diagnosis of patients allergic to any of these drugs with a single test. These organic–inorganic hybrid materials represent the basis for the development of a single screening for BL-allergies.
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Affiliation(s)
- Violeta Gil-Ocaña
- Universidad de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Dpto. Química Orgánica, Campus de Teatinos s/n, Málaga, Spain.,Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
| | - Isabel M Jimenez
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Cristobalina Mayorga
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain.,Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Inmaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Jose Antonio Céspedes
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Maria I Montañez
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain.,Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Yolanda Vida
- Universidad de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Dpto. Química Orgánica, Campus de Teatinos s/n, Málaga, Spain.,Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
| | - Maria J Torres
- Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain.,Allergy Research Group, Instituto de Investigación Biomédica de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain.,Allergy Unit, Hospital Regional Universitario de Málaga, Málaga, Spain.,Universidad de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Dpto. Medicina, Campus de Teatinos s/n, Málaga, Spain
| | - Ezequiel Perez-Inestrosa
- Universidad de Málaga-Instituto de Investigación Biomédica de Málaga (IBIMA), Dpto. Química Orgánica, Campus de Teatinos s/n, Málaga, Spain.,Centro Andaluz de Nanomedicina y Biotecnología-BIONAND, Parque Tecnológico de Andalucía, Málaga, Spain
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Ogulur I, Pat Y, Ardicli O, Barletta E, Cevhertas L, Fernandez‐Santamaria R, Huang M, Bel Imam M, Koch J, Ma S, Maurer DJ, Mitamura Y, Peng Y, Radzikowska U, Rinaldi AO, Rodriguez‐Coira J, Satitsuksanoa P, Schneider SR, Wallimann A, Zhakparov D, Ziadlou R, Brüggen M, Veen W, Sokolowska M, Baerenfaller K, Zhang L, Akdis M, Akdis CA. Advances and highlights in biomarkers of allergic diseases. Allergy 2021; 76:3659-3686. [PMID: 34519063 PMCID: PMC9292545 DOI: 10.1111/all.15089] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 05/19/2021] [Accepted: 09/08/2021] [Indexed: 12/16/2022]
Abstract
During the past years, there has been a global outbreak of allergic diseases, presenting a considerable medical and socioeconomical burden. A large fraction of allergic diseases is characterized by a type 2 immune response involving Th2 cells, type 2 innate lymphoid cells, eosinophils, mast cells, and M2 macrophages. Biomarkers are valuable parameters for precision medicine as they provide information on the disease endotypes, clusters, precision diagnoses, identification of therapeutic targets, and monitoring of treatment efficacies. The availability of powerful omics technologies, together with integrated data analysis and network‐based approaches can help the identification of clinically useful biomarkers. These biomarkers need to be accurately quantified using robust and reproducible methods, such as reliable and point‐of‐care systems. Ideally, samples should be collected using quick, cost‐efficient and noninvasive methods. In recent years, a plethora of research has been directed toward finding novel biomarkers of allergic diseases. Promising biomarkers of type 2 allergic diseases include sputum eosinophils, serum periostin and exhaled nitric oxide. Several other biomarkers, such as pro‐inflammatory mediators, miRNAs, eicosanoid molecules, epithelial barrier integrity, and microbiota changes are useful for diagnosis and monitoring of allergic diseases and can be quantified in serum, body fluids and exhaled air. Herein, we review recent studies on biomarkers for the diagnosis and treatment of asthma, chronic urticaria, atopic dermatitis, allergic rhinitis, chronic rhinosinusitis, food allergies, anaphylaxis, drug hypersensitivity and allergen immunotherapy. In addition, we discuss COVID‐19 and allergic diseases within the perspective of biomarkers and recommendations on the management of allergic and asthmatic patients during the COVID‐19 pandemic.
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Joerg L, Hasler S, Gschwend A, Meincke C, Nordmann TM, Glatz M, Heilig M, Schnyder B, Helbling A, Schmid-Grendelmeier P. 75% negative skin test results in patients with suspected hypersensitivity to beta-lactam antibiotics: Influencing factors and interpretation of test results. World Allergy Organ J 2021; 14:100602. [PMID: 34820050 PMCID: PMC8585645 DOI: 10.1016/j.waojou.2021.100602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/14/2021] [Accepted: 10/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background The diagnostic approach for beta-lactam (BL) drug hypersensitivity reactions (DHR) is based on the history, clinical signs, skin tests (ST), in vitro tests, and drug provocation tests (DPT). The aim of this study was to assess the performance of an allergy workup with ST in a real-world use. Methods In this cross-sectional study the rate of positive ST in subjects with suspected DHR to penicillins and cephalosporins was investigated. Of special interest were correlations of ST positivity: 1) to the time intervals between index reaction and the allergic work-up, 2) time interval from drug exposure to the onset of signs, 3) pattern of manifestation in delayed DHR and involvement of test area in the index reaction, and 4) potential advantage of patch testing in delayed DHR. Results 175 patients were included between January 2018 and April 2019 (63.4% female), 45 (25.7%) with immediate DHR manifestation and 130 with delayed DHR manifestation (74.3%). A total of 44 patients (25.1%) had a positive ST (immediate DHR 37.8% versus 20.0% in delayed DHR). ST positivity decreased in both groups after 3 years from 47.8% [95%CI 29.2-67] to 23.5% [95%CI 9.6-47.3] in immediate DHR and 23.0% [95%CI 15-4-32.9] to 12.9% [95%CI 5.1-28.9] in delayed DHR. The proportion of positive ST was higher in patients with more severe forms of delayed DHR, and in subjects with a shorter latency period of onset of symptoms after drug exposure: 0-3d: 29.5% [95%CI 19.6-41.9] vs. >3d: 11.6% [95%CI 6.0-21.2]). No sensitization was shown in delayed urticaria or angioedema. ST done outside the skin area involved during the index reaction were negative in all cases (0/38 vs. 26/84 in cases with involved area). The combination of patch test and intradermal test (IDT) revealed an additional positive result in 2/77 cases. Additional in vitro testing reduced the proportion of negative test results to 72%. Conclusion In most patients with negative test results, we could not clarify the cause of the BL-associated adverse events even with further investigations (including DPT). How to prevent new drug-induced adverse events in such patients has hardly been investigated yet. Corresponding cohort studies could improve the data situation.
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Affiliation(s)
- Lukas Joerg
- Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susann Hasler
- Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Anna Gschwend
- Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Cordula Meincke
- Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thierry M Nordmann
- Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Martin Glatz
- Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Michelle Heilig
- Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benno Schnyder
- Allergy Unit, Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Arthur Helbling
- Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Atanaskovic-Markovic M, Tsabouri S. Exanthematous reactions to drugs in children. Curr Opin Allergy Clin Immunol 2021; 21:335-339. [PMID: 33993141 DOI: 10.1097/aci.0000000000000749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The true exanthematous reactions to drugs in children are rare and overdiagnosed. Drugs may cause exanthema either due to inducing an immune response or because of their interaction with viruses, if drugs are taken in the course of a viral infection. Also, viral infections are very often in children and they can provoke an exanthema which is difficult to differentiate from exanthematous reactions to drugs. Consequently, the majority of children are incorrectly labeled as 'allergic'. RECENT FINDINGS The correct diagnosis of exanthematous drug reactions in children is still an important and hot topic. Most information about the approach and management of drug hypersensitivity in children is applied from available guidelines and consensus statement for adults. Recently, a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous exanthema while receiving a drug, is proposed. SUMMARY It is important to consider the detailed clinical history of appearing and developing exanthematous drug reaction, as well as physical examination which includes the description and the distribution of exanthema and at the end making the appropriate diagnosis. Thus, it could reduce overdiagnosis and promote appropriate procedures, that will prevent the overlabeling of drug hypersensitivity in children.
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Affiliation(s)
| | - Sophia Tsabouri
- Child Health Department, Medical School, University of Ioannina, Ioannina, Greece
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31
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Fernandez J, Jimenez-Rodriguez TW, Blanca-Lopez N. Classifying cephalosporins: from generation to cross-reactivity. Curr Opin Allergy Clin Immunol 2021; 21:346-354. [PMID: 34074874 DOI: 10.1097/aci.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW To review the most recent literature studying the classifications, immunochemistry, and crossreactivity of allergy reactions to cephalosporins. RECENT FINDINGS Over the last five years, research interest has focused on three areas related to cephalosporin allergy: cross-reactivity among cephalosporins and with other beta-lactams; the incidence of adverse reactions in penicillin allergy patients or in reported penicillin allergy labels; and new cephalosporins structures involved in the immunological recognition. SUMMARY Meta-analysis of a substantial number of studies shows that cephalosporins are safer than previously thought. Evidence supports two main conclusions in that regard. First, there is a relatively low percentage of cross-reactivity between cephalosporins and other beta-lactams with penicillins in penicillin allergy patients. Second, there is a very low incidence of allergy reactions in nonselected as well as in selected penicillin allergy patients when cephalosporins are used prior to surgical intervention.On the other hand, few structures have been discovered related to the immune mechanism of cephalosporin allergy reactions, and these are far from being ready to use in clinical practice.
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Affiliation(s)
- Javier Fernandez
- Allergy Section, Alicante General University Hospital, ISABIAL-UMH, Alicante
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Detection of drug-specific immunoglobulin E (IgE) and acute mediator release for the diagnosis of immediate drug hypersensitivity reactions. J Immunol Methods 2021; 496:113101. [PMID: 34273396 DOI: 10.1016/j.jim.2021.113101] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022]
Abstract
The diagnosis of a drug hypersensitivity reaction (DHR) is complex. The first step after taking the clinical history is to look for a sensitization to confirm or exclude the diagnosis and to identify the culprit drug. Skin tests are the primary means of detecting sensitization in DHR, but are associated with a risk for a severe reaction and may be contraindicated. In vitro tests offer the potential to support or confirm a diagnosis of DHR and influence medical decision making. For immediate-type DHR, a few validated assays for measurement of specific IgE (sIgE) are commercially available to a limited number of drugs. In addition, several home-made sIgE radioimmunoassays have been used in other studies. The sensitivity of the sIgE assay is drug-dependant and generally low (0-85%) for betalactams and reported heterogeneous for other drugs ranging from 26% for chlorhexidine and 44% for suxamethonium to 92% for chlorhexidine. However, as all these studies included patients, in whom DHR was confirmed only by skin tests and not by provocation, the results have to be interpreted carefully and may be unreliable. Determination of mediators during an acute phase of a reaction may indirectly support the diagnosis of a DHR by demonstrating mast cell and basophil mediator release. Negative in vitro tests do not exclude a DHR or imputability of a drug, but a positive result may support causality and eliminate the necessity for a drug provocation test. Unfortunately, evidence is limited with a lack of well-controlled studies in larger numbers of well-phenotyped patients, which results in susceptibility for bias and a need for future multicenter studies.
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Elst J, van der Poorten MLM, Van Gasse AL, De Puysseleyr L, Hagendorens MM, Faber MA, Van Houdt M, Passante E, Bahri R, Walschot M, Mertens C, Bridts CH, Sabato V, Ebo DG. Mast cell activation tests by flow cytometry: A new diagnostic asset? Clin Exp Allergy 2021; 51:1482-1500. [PMID: 34233046 DOI: 10.1111/cea.13984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/04/2021] [Indexed: 12/20/2022]
Abstract
Since the late nineties, evidence has accumulated that flow-assisted basophil activation test (BAT) might be an accessible and reliable method to explore the mechanisms governing basophil degranulation and diagnostic allowing correct prediction of the clinical outcome following exposure to the offending allergen(s) and cross-reactive structures for different IgE-dependent allergies and particular forms of autoimmune urticaria. Although the BAT offers many advantages over mediator release tests, it is left with some weaknesses that hinder a wider application. It is preferable to perform the BAT analysis within 4 h of collection, and the technique does not advance diagnosis in patients with non-responsive cells. Besides, the BAT is difficult to standardize mainly because of the difficulty to perform large batch analyses that might span over several days. This article reviews the status of flow cytometric mast cell activation test (MAT) using passively sensitized mast cells (MCs) with patients' sera or plasma (henceforth indicated as passive MAT; pMAT) using both MC lines and cultured MCs in the diagnosis of IgE-dependent allergies. In addition, this paper provides guidance for generating human MCs from peripheral blood CD34+ progenitor cells (PBCMCs) and correct interpretation of flow cytometric analyses of activated and/or degranulating cells. With the recent recognition of the mas-related G protein-coupled receptor X2 (MRGPRX2) occupation as a putative mechanism of immediate drug hypersensitivity reactions (IDHRs), we also speculate how direct activation of MCs (dMAT)-that is direct activation by MRGPRX2 agonists without prior passive sensitization-could advance paradigms for this novel endotype of IDHRs.
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Affiliation(s)
- Jessy Elst
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Marie-Line M van der Poorten
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.,Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.,Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Leander De Puysseleyr
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Margo M Hagendorens
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.,Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Margaretha A Faber
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | | | - Rajia Bahri
- Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mark Walschot
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Chris H Bridts
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.,Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | - Didier G Ebo
- Department of Immunology - Allergology - Rheumatology, Faculty of Medicine and Health Science and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium.,Department of Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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Fernandez‐Santamaria R, Bogas G, Palomares F, Salas M, Fernandez TD, Jimenez I, Barrionuevo E, Doña I, Torres MJ, Mayorga C. Dendritic cells inclusion and cell-subset assessment improve flow-cytometry-based proliferation test in non-immediate drug hypersensitivity reactions. Allergy 2021; 76:2123-2134. [PMID: 33523478 DOI: 10.1111/all.14755] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/09/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lymphocyte transformation test (LTT) has been widely used to evaluate non-immediate drug hypersensitivity reactions (NIDHRs). However, the lack of standardization and the low sensitivity have limited its routine diagnostic use. The drug presentation by dendritic cells (DCs) and the assessment of proliferation on effector cells have shown promising results. Flow-cytometry-based methods can help apply these improvements. We aimed to assess the added value of using drug-primed-DCs and the determination of the proliferative response of different lymphocyte subpopulations in NIDHRs. METHODS Patients with confirmed NIDHR were evaluated by both conventional (C-LTT) and with drug-primed-DCs LTT (dDC-LTT)analysing the proliferative response in T cells and other effector cell subpopulations by using the fluorescent molecule, carboxyfluorescein diacetate succinimidyl ester (CFSE). RESULTS The C-LTT showed a significantly lower sensitivity (29.4%) compared with dDC-LTT (61.8%), which was confirmed analysing each particular clinical entity: SJS-TEN (62.5% vs 87.5%), MPE (15% vs 47.4%) and AGEP (33% vs 80%). When including the effector cell subpopulations involved in each clinical entity, CD3+ +CD4+ Th 1 or CD3+ +NK cells in SJS-TEN, CD3+ +CD4+ Th 1+NK cells in MPE and CD3+ +NK cells in AGEP, we could significantly increase the sensitivity of the in vitro test to 100%, 68.4% and 100%, respectively, with an overall sensitivity of 87% and 85% of specificity in NIDHR. CONCLUSIONS The use of a flow-cytometry-based test, DCs as drug presenting cells, and focusing on effector cell subpopulations for each clinical entity significantly improved the drug-specific proliferative response in NIDHRs with a unique cellular in vitro test.
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Affiliation(s)
| | - Gador Bogas
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
| | - Francisca Palomares
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Málaga Spain
| | - Maria Salas
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
| | - Isabel Jimenez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Málaga Spain
| | | | - Inmaculada Doña
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
| | - Maria Jose Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Málaga Spain
- Medicine Department Universidad de Málaga‐UMA Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory Centro Andaluz de Nanomedicina y Biotecnología‐BIONAND Málaga Spain
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐HRUM Málaga Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory Centro Andaluz de Nanomedicina y Biotecnología‐BIONAND Málaga Spain
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Tsabouri S, Atanaskovic-Markovic M. Skin eruptions in children: Drug hypersensitivity vs viral exanthema. Pediatr Allergy Immunol 2021; 32:824-834. [PMID: 33621365 DOI: 10.1111/pai.13485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022]
Abstract
Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus-induced and drug-induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta-lactams (BL) and non-steroidal anti-inflammatory drugs (NSAIDs). Viruses, commonly Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.
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Affiliation(s)
- Sophia Tsabouri
- Child Health Department, Medical School, University of Ioannina, Ioannina, Greece
| | - Marina Atanaskovic-Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's Hospital of Belgrade, Belgrade, Serbia
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36
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Srinoulprasert Y. Lymphocyte transformation test and cytokine detection assays: Determination of read out parameters for delayed-type drug hypersensitivity reactions. J Immunol Methods 2021; 496:113098. [PMID: 34216607 DOI: 10.1016/j.jim.2021.113098] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) occur in certain people and are often not predictable. DHRs can be classified as immediate and delayed reactions regarding to onset of clinical manifestations. Both reactions are considered to be an important public health problem because they can lead to life-threatening conditions; however, this review article will focus on delayed DHRs. The most important points for diagnosis of delayed DHRs are the recognition of drug hypersensitivity characteristics and culprit drug identification. While it is usually difficult to identify a culprit drug; clinical evaluation using the causality assessment method, a non-invasive process, can identify the culprit drug without the need for intensive investigation. Delayed DHRs can cause life-threatening conditions; therefore, in vivo skin tests, as well as drug provocation tests, have to be cautiously performed by a drug allergist and have not been recommended in uncontrolled conditions. ENDA/EAACI has recommended that in vitro tests (if available) be performed prior to any in vivo tests. Therefore, in vitro diagnostic tests can be alternative methods to identify a culprit drug for delayed DHR diagnosis as there is no or very low risk for patients under investigation. There are many testing approaches to identify causative agents for delayed DHRs such as: the lymphocyte transformation test (LTT), cytokine/mediator detection assays (i.e. ELISA and flow cytometry-based bead assays), multiplex bead-based immunoassay and ELISpot. The LTT is the most standardized method whereas it has been available in medical schools affiliated with university hospitals. Other in vitro tests, like cytokine detection assays, have also been used, even though they are still being evaluated. They could supplement LTT results that would provide drug allergist's with documentary evidence and prevent risk to patients by avoiding in vivo or drug provocation testing. Hence, the in vitro tests have been promising tests contributing to the management of the delayed DHR work-up process in clinical practice.
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Affiliation(s)
- Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand.
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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Anaphylaxis to nimesulide. Ann Allergy Asthma Immunol 2021; 127:144-145. [PMID: 33845133 DOI: 10.1016/j.anai.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 02/10/2021] [Accepted: 04/06/2021] [Indexed: 12/20/2022]
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Elst J, Sabato V, van der Poorten MLM, Van Gasse AL, Van Houdt M, Bridts CH, Walschot M, Timmermans JP, Pintelon I, Mertens C, Ebo DG. Basophil and mast cell activation tests by flow cytometry in immediate drug hypersensitivity: Diagnosis and beyond. J Immunol Methods 2021; 495:113050. [PMID: 33933471 DOI: 10.1016/j.jim.2021.113050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 01/01/2023]
Abstract
Immediate drug hypersensitivity reactions (IDHRs) constitute a significant health issue with serious consequences of diagnostic error. The primary diagnostics to document IDHRs usually consists of quantification of drug-specific IgE (sIgE) antibodies and skin tests. Unfortunately, the positive predictive value (PPV) and negative predictive value (NPV) of these tests are not absolutely, which leaves room for new tests. Over the last two decades, the basophil activation test (BAT), in which ex vivo activation of individual basophils is quantified by flow cytometry, has emerged as a reliable complementary diagnostic to document IDHRs, to explore allergenic recognition, to study cross-reactivity and to monitor therapy. However, the BAT is technically challenging requiring specialized personnel and equipment, fresh samples and the technique is lost as a diagnostic in patients showing a non-responder status of their cells. By consequence, the BAT has still not entered mainstream application. In contrast, mast cell activation tests (MATs) use serum samples that can be frozen, stored, and shipped to a recognized reference centre experienced in mast cell (MC) lines and/or cultures and capable of offering batch testing with necessary quality controls. This review does not only highlight the use of the BAT and MAT as diagnostics in IDHRs, but also outlines the potential of both techniques in further exploring and unveiling the mechanisms that govern drug-induced basophil and MC activation and degranulation.
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Affiliation(s)
- Jessy Elst
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium
| | - Marie-Line M van der Poorten
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Chris H Bridts
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Mark Walschot
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Jean-Pierre Timmermans
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Isabel Pintelon
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Christel Mertens
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium.
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Unlocking the Non-IgE-Mediated Pseudo-Allergic Reaction Puzzle with Mas-Related G-Protein Coupled Receptor Member X2 (MRGPRX2). Cells 2021; 10:cells10051033. [PMID: 33925682 PMCID: PMC8146469 DOI: 10.3390/cells10051033] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/17/2022] Open
Abstract
Mas-related G-protein coupled receptor member X2 (MRGPRX2) is a class A GPCR expressed on mast cells. Mast cells are granulated tissue-resident cells known for host cell response, allergic response, and vascular homeostasis. Immunoglobulin E receptor (FcεRI)-mediated mast cell activation is a well-studied and recognized mechanism of allergy and hypersensitivity reactions. However, non-IgE-mediated mast cell activation is less explored and is not well recognized. After decades of uncertainty, MRGPRX2 was discovered as the receptor responsible for non-IgE-mediated mast cells activation. The puzzle of non-IgE-mediated pseudo-allergic reaction is unlocked by MRGPRX2, evidenced by a plethora of reported endogenous and exogenous MRGPRX2 agonists. MRGPRX2 is exclusively expressed on mast cells and exhibits varying affinity for many molecules such as antimicrobial host defense peptides, neuropeptides, and even US Food and Drug Administration-approved drugs. The discovery of MRGPRX2 has changed our understanding of mast cell biology and filled the missing link of the underlying mechanism of drug-induced MC degranulation and pseudo-allergic reactions. These non-canonical characteristics render MRGPRX2 an intriguing player in allergic diseases. In the present article, we reviewed the emerging role of MRGPRX2 as a non-IgE-mediated mechanism of mast cell activation in pseudo-allergic reactions. We have presented an overview of mast cells, their receptors, structural insight into MRGPRX2, MRGPRX2 agonists and antagonists, the crucial role of MRGPRX2 in pseudo-allergic reactions, current challenges, and the future research direction.
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Felix MMR, Aun MV, Menezes UPD, Queiroz GRESD, Rodrigues AT, D'Onofrio-Silva AC, Perelló MI, Camelo-Nunes IC, Malaman MF. Allergy to penicillin and betalactam antibiotics. EINSTEIN-SAO PAULO 2021; 19:eMD5703. [PMID: 33909756 PMCID: PMC8054529 DOI: 10.31744/einstein_journal/2021md5703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Betalactams are the most frequent cause of hypersensitivity reactions to drugs mediated by a specific immune mechanism. Immediate reactions occur within 1 to 6 hours after betalactam administration, and are generally IgE-mediated. They clinically translate into urticaria, angioedema and anaphylaxis. Non-immediate or delayed reactions occur after 1 hour of administration. These are the most common reactions and are usually mediated by T cells. The most frequent type is the maculopapular or morbilliform exanthematous eruption. Most individuals who report allergies to penicillin and betalactams can tolerate this group of antibiotics. To make diagnosis, a detailed medical history is essential to verify whether it was an immediate or non-immediate reaction. Thereafter, in vivo and/or in vitro tests for investigation may be performed. The challenging test is considered the gold standard method for diagnosis of betalactam hypersensitivity. The first approach when suspecting a reaction to betalactam is to discontinue exposure to the drug, and the only specific treatment is desensitization, which has very precise indications. The misdiagnosis of penicillin allergy affects the health system, since the "penicillin allergy" label is associated with increased bacterial resistance, higher rate of therapeutic failure, prolonged hospitalizations, readmissions, and increased costs. Thus, it is essential to develop strategies to assist the prescription of antibiotics in patients identified with a label of "betalactam allergy" at hospitals, and to enhance education of patients and their caregivers, as well as of non-specialist physicians.
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Affiliation(s)
- Mara Morelo Rocha Felix
- Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo Vivolo Aun
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Ullissis Pádua de Menezes
- Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Ebo DG, Bridts CH, Mertens CH, Sabato V. Principles, potential, and limitations of ex vivo basophil activation by flow cytometry in allergology: A narrative review. J Allergy Clin Immunol 2021; 147:1143-1153. [DOI: 10.1016/j.jaci.2020.10.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022]
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Mori F, Blanca-Lopez N, Caubet JC, Demoly P, Du Toit G, Gomes ER, Kuyucu S, Romano A, Soyer O, Tsabouri S, Atanaskovic-Markovic M. Delayed hypersensitivity to antiepileptic drugs in children. Pediatr Allergy Immunol 2021; 32:425-436. [PMID: 33205474 DOI: 10.1111/pai.13409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate hypersensitivity reactions (HRs). Although these reactions are usually cutaneous, self-limited, and spontaneously resolve within days after drug discontinuation, sometime HR reactions to AEDs can be severe and life-threatening. AIM This paper seeks to show examples on practical management of AED HRs in children starting from a review of what it is already known in literature. RESULTS Risk factors include age, history of previous AEDs reactions, viral infections, concomitant medications, and genetic factors. The diagnostic workup consists of in vivo (intradermal testing and patch testing) and in vitro tests [serological investigation to exclude the role of viral infection, lymphocyte transformation test (LTT), cytokine detection in ELISpot assays, and granulysin (Grl) in flow cytometry. Treatment is based on a prompt drug discontinuation and mainly on the use of glucocorticoids. CONCLUSION Dealing with AED HRs is challenging. The primary goal in the diagnosis and management of HRs to AEDs should be trying to accurately identify the causal trigger and simultaneously identify a safe and effective alternative anticonvulsant. There is therefore an ongoing need to improve our knowledge of HS reactions due to AED medications and in particular to improve our diagnostic capabilities.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Meyer Children's Hospital, Florence, Italy
| | | | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Hôpital Arnaud de Villeneuve, univ Montpellier, Montpellier, France.,Institut Pierre-Louis D'épidémiologie et de Santé Publique, Équipe EPAR, Sorbonne Université, INSERM, Paris, France
| | - George Du Toit
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St Thomas', London, UK.,Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eva R Gomes
- Allergy Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy.,Fondazione Mediterranea G.B. Morgagni, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Sophia Tsabouri
- Department of Paediatrics, Faculty of Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Wöhrl S, Ostermayer C, Sesztak-Greinecker G, Jarisch R, Hemmer W, Wantke F. Drug-specific history, skin and in vitro tests can reduce the need for drug provocation tests in betalactam-hypersensitivity. Allergol Int 2021; 70:244-251. [PMID: 33191122 DOI: 10.1016/j.alit.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Many patients report questionable drug hypersensitivity reactions (DHR) to betalactam antibiotics. A workup is required for objectivation. Direct drug provocation tests (DPTs) omitting a prior allergy workup are increasingly recommended as the primary diagnostic approach. However, apart from the risk of severe side effects, DPTs often are a scarce resource in overloaded healthcare-systems. We investigated how many cases can be solved by drug-specific history, drug-specific IgE, and skin tests obviating the need for DPT. METHODS We conducted a chart review in a retrospective cohort of 932 patients in an allergy outpatient centre from 2016 to 2017. Patients had been submitted to drug-specific history and specific IgE-, skin prick-, intradermal- and patch-tests with early and late readings with a series of penicillins and cephalosporins but DPTs were no option. RESULTS Overall, positive in vitro and/or skin tests were found in 96/932 (10.3%) patients. Drug-specific IgE was detected in 40/932 (4.3%) patients, 61/787 (7.8%) patients had positive skin tests. In vitro tests to Pencillin V showed the highest rate of positivity 24/479 (5.0%) and early readings of ampicillin the highest amongst the skin tests (3/49, 6.1%). Immediate skin tests were more often positive than delayed ones (75:45). The combination of all parameters including drug-specific history solved 346/932 (37.1%) cases while 586/932 (62.9%) remained unresolved. Self-reported DHR could be less often confirmed in females and young children (p < 0.05). CONCLUSIONS Testing with betalactams applying simple, cheap, and safe skin and blood tests can solve a third of DHR-cases on a high throughput scale.
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Labella M, Castells M. Hypersensitivity reactions and anaphylaxis to checkpoint inhibitor-monoclonal antibodies and desensitization. Ann Allergy Asthma Immunol 2021; 126:623-629. [PMID: 33781937 DOI: 10.1016/j.anai.2021.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To review type 1 hypersensitivity reactions and anaphylaxis to checkpoint inhibitor-monoclonal antibodies and its management with drug desensitization. DATA SOURCES English-language literature on MEDLINE regarding hypersensitivity, anaphylaxis, and checkpoint inhibitor-monoclonal antibodies. STUDY SELECTIONS References were selected based on relevance, novelty, robustness, and applicability. RESULTS There are well-known tissue toxicities associated to checkpoint inhibitors, but hypersensitivity reactions and anaphylaxis have been underreported. The presentation of these reactions is based on clinical phenotypes with underlying endotypes identified by specific biomarkers. Drug desensitizations have been successfully applied to checkpoint inhibitor drugs to allow patients with cancer to receive first-line therapies. This review provides current best practices for the recognition and diagnosis of hypersensitivity reactions and anaphylaxis to checkpoint inhibitors and their management using drug desensitization. CONCLUSION Hypersensitivity reactions and anaphylaxis have been identified as potential adverse effects induced by checkpoint inhibitor-monoclonal antibodies. Drug desensitization is a safe and effective treatment option for patients who experience hypersensitivity reactions in need of these monoclonal antibodies to improve cancer outcomes.
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Affiliation(s)
- Marina Labella
- Allergy Clinical Unit, Hospital Regional Universitario de Málaga, Málaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.
| | - Mariana Castells
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ebo DG, Van Gasse AL, Elst J, Mertens C, Sabato V. Basophil activation test in the diagnosis of hypersensitivity reactions to quinolones by Loli-Ausejo et al. Clin Exp Allergy 2021; 51:980-981. [PMID: 33743551 DOI: 10.1111/cea.13853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium.,Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium
| | - Athina L Van Gasse
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium.,Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium.,Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium
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Sachs B, Fatangare A, Sickmann A, Glässner A. Lymphocyte transformation test: History and current approaches. J Immunol Methods 2021; 493:113036. [PMID: 33745950 DOI: 10.1016/j.jim.2021.113036] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023]
Abstract
Drug-induced hypersensitivity reactions encompass a variety of different clinical phenotypes ranging from harmless rashes to fatal reactions. They can be classified into allergic (i.e. drug allergy) and non-allergic reactions (i.e. non-allergic hypersensitivity). Drug allergies in turn can either be antibody (e.g. IgE) or T cell-mediated. One of the diagnostic tools for the in vitro detection of drug allergy is the lymphocyte transformation test (LTT) which is based on the activation and expansion of the drug-specific memory T cells following co-incubation of the patient's peripheral mononuclear cells (PMBC) with the suspected drug in vitro. The read-out parameter in the classical LTT is T cell proliferation which can be measured as counts per minute following the addition of radiolabeled thymidine to the cell culture. However, in the course of time different modifications of the classical LTT with regard to the read-out parameters and methods have been proposed. Likewise, variations of the LTT platform itself have been described in the literature. This review article describes the development of the classical LTT and its use in the context of drug allergy detection and summarizes the modifications which have been published over time.
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Affiliation(s)
- Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany; Department for Dermatology and Allergology, University Hospital Aachen, Germany.
| | - Amol Fatangare
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany
| | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Bunsen-Kirchhoff-Straße 11, 44139 Dortmund, Germany; Medizinische Fakultät, Medizinisches Proteom-Center (MPC), Ruhr-Universität Bochum, 44801 Bochum, Germany; Department of Chemistry, College of Physical Sciences, University of Aberdeen, Aberdeen AB243FX, UK
| | - Andreas Glässner
- Research Division, Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
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Atanaskovic-Markovic M. What is new in beta-lactam allergy in children? Pediatr Allergy Immunol 2021; 32:219-222. [PMID: 32955758 DOI: 10.1111/pai.13375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 01/13/2023]
Abstract
This review highlights the novelties in understanding the underlying immunologic mechanisms of drug hypersensitivity reactions (DHRs) with special reference to beta-lactams (BLs) in the pediatric population, as well as tiny changes in clinical classification and diagnosis of DHRs, in the last couple of years. BLs are still the most commonly prescribed and used antibiotics in children. Viral infections are very often in children, and they can provoke skin rashes which are difficult to differentiate from DHRs. The majority of children are incorrectly labeled as "allergic." Therefore, allergy to BLs in children is overdiagnosed. These children often receive suboptimal treatment with second-line broad-spectrum antibiotics, which are less effective, more costly, and associated with an increased risk of antibiotic-resistant infections. This prolongs hospitalization and thus more uses health care. The correct diagnosis of BL allergy in children is still an important and hot topic. This review has outlined the need for correct diagnosis of BL allergy in children and all the controversies encountered by pediatricians and pediatric allergists. It is also necessary to change the paradigm.
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Affiliation(s)
- Marina Atanaskovic-Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's hospital of Belgrade, Belgrade, Serbia
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Steveling-Klein EH, Mateluna CM, Meienberg A, Hartmann K, Bircher A, Scherer Hofmeier K. Management of Hypersensitivity Reactions to Nondextran Iron Products: New Insights Into Predisposing Risk Factors. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2406-2414.e2. [PMID: 33486145 DOI: 10.1016/j.jaip.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/14/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) to nondextran iron products (NDIPs) are rare, but can manifest with severe signs and symptoms. Predisposing risk factors are not well understood. OBJECTIVE To characterize patients with HSRs to NDIPs, with a special focus on possible risk factors. METHODS We analyzed clinical characteristics of patients with HSRs to NDIPs referred to our allergy division between 2007 and 2019 compared with tolerant controls, including the type of the eliciting NDIP, severity and characteristics of the HSR, atopy status, history of allergies and urticaria, laboratory and skin test results, and outcome of reexposure with NDIPs. RESULTS We evaluated the data of 59 patients and 21 controls. Sixteen patients and 4 controls received the NDIP iron sucrose and 41 patients and 15 controls received ferric carboxymaltose. In 2 patients and in 2 controls, the culprit NDIP was not known. Twenty-seven patients (46%) experienced an anaphylactic reaction grade I, 15 (25%) a grade II reaction, and 17 (29%) a grade III reaction according to Ring and Messmer. On analyzing the history, we found that 22 patients (37%) and 3 controls (14%) reported previous HSRs to other medications. Interestingly, more than half the patients (n = 35 [59%]) compared with only 7 controls (33%) reported an episode of any type of urticaria in their previous history. Most patients (n = 15 [79%]) tolerated reexposure of an NDIP using a low-reactogenic administration protocol. CONCLUSIONS A history of drug hypersensitivity and urticaria represent potential risk factors for HSRs to NDIPs. On the basis of our findings, we propose an algorithm for practical management of patients receiving NDIPs aiming to prevent HSRs.
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Affiliation(s)
- Esther Helen Steveling-Klein
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland.
| | - Carlos Morales Mateluna
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andrea Meienberg
- Department of Internal Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Bircher
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Kathrin Scherer Hofmeier
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
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Zuo J, Gong R, Liu X, Zhao J. Risk of True Allergy to Local Anesthetics: 10-Year Experience from an Anesthesia Allergy Clinic in China. Ther Clin Risk Manag 2021; 16:1297-1303. [PMID: 33402824 PMCID: PMC7778381 DOI: 10.2147/tcrm.s280259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/30/2020] [Indexed: 01/07/2023] Open
Abstract
Background Local anesthetics (LAs) have been widely used throughout the healthcare settings, especially in local anesthesia and pain management. The incidence of allergic reactions to LAs remains uncertain. The danger of allergic reactions to the use of LAs in every day of clinical practice is a matter of great concern. Therefore, it is necessary to investigate the risk of true allergy to LAs. Methods This study retrospectively evaluated the medical records of patients who were referred to an anesthesia allergy clinic in China and underwent allergy tests with LAs over a 10-year period from 2009 to 2019. The following information was collected from medical records: demographics of the patients, reasons for referral, clinical features of drug hypersensitivity reaction (DHR), and test results with LAs. Skin tests combined with an in vitro method, basophil activation test (BAT), were used to investigate allergic reactions to LAs. Results A group of 109 patients were included in the analysis. The main reason for referral was the presence of a suspected DHR after procedures with LAs (n=68, 62%), the second most common reason for referral was a history of DHR to other drugs and the need to use LAs for upcoming procedures (n=41, 38%). Of the 68 patients with a suspected DHR to LAs, only six cases presented true allergy and showed positive results in skin tests and/or BAT. And all 41 patients who had a history of DHR to other drugs presented negative in all tests. Conclusion Risk of true allergy to LAs may be very low. However, patients with a suspected history of DHR to LAs should be considered for allergy tests. Skin tests and BAT may be useful in the investigation and diagnosis of true allergy to LAs in clinical practice.
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Affiliation(s)
- Jun Zuo
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, People's Republic of China.,Department of Anesthesiology, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Ruisong Gong
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, People's Republic of China.,Department of Anesthesiology, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Xiaowen Liu
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Jing Zhao
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, People's Republic of China.,Department of Anesthesiology, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
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