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Moore A, Blumenthal KG, Chambers C, Namazy J, Nowak-Wegrzyn A, Phillips EJ, Rider NL. Improving Clinical Practice Through Patient Registries in Allergy and Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00470-7. [PMID: 38734373 DOI: 10.1016/j.jaip.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
Patient registries are a mechanism for collecting data on allergic and immunologic diseases that provide important information on epidemiology and outcomes that can ultimately improve patient care. Key criteria for establishing effective registries include the use of a clearly defined purpose, identifying the target population and ensuring consistent data collection. Registries in allergic diseases include those for diseases such as inborn errors of immunity (IEI), food allergy, asthma and anaphylaxis, pharmacological interventions in vulnerable populations, and adverse effects of pharmacologic interventions including hypersensitivity reactions to drugs and vaccines. Important insights gained from patient registries in our field include contributions in phenotype and outcomes in IEI, the risk for adverse reactions in food-allergic patients in multiple settings, the benefits and risk of biologic medications for asthma during pregnancy, vaccine safety, and the categorization and genetic determination of risk for severe cutaneous adverse reactions to medications. Impediments to the development of clinically meaningful patient registries include the lack of funding resources for registry establishment and the quality, quantity, and consistency of available data. Despite these drawbacks, high-quality and successful registries are invaluable in informing clinical practice and improving outcomes in patients with allergic and immunological diseases.
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Affiliation(s)
- Andrew Moore
- ENTAA Care, Johns Hopkins Regional Physicians, Glen Burnie, Md.
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Christina Chambers
- Department of Pediatrics, University of California San Diego, La Jolla, Calif
| | - Jennifer Namazy
- Division of Allergy and Immunology, Scripps Clinic, La Jolla, Calif
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Elizabeth J Phillips
- Department of Medicine, Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Nicholas L Rider
- Department of Health Systems and Implementation Science, Virginia Tech Carilion School of Medicine, Roanoke, Va; Carilion Clinic, Section of Allergy-Immunology, Roanoke, Va
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Alvarez AA, Palka JM, Khan DA. Severe Multiple Drug Intolerance Syndrome in Fibromyalgia and Irritable Bowel Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1192-1201. [PMID: 38278325 DOI: 10.1016/j.jaip.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2024] [Accepted: 01/13/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Multiple drug intolerance syndrome (MDIS) describes patients with multiple nonimmunologically mediated adverse reactions to medications. Patients with more than 10 medication intolerance labels are considered to have severe MDIS. There is overlap in the characteristics of patients with MDIS and fibromyalgia and irritable bowel syndrome (IBS). Severe MDIS can limit treatment options in this already complex patient group. OBJECTIVE This study assessed the prevalence of severe MDIS in patients with fibromyalgia and IBS and its associated risk factors. METHODS A retrospective chart review identified patients diagnosed with fibromyalgia or IBS who had been seen at a large academic center from August 2019 to July 2020. Exact birthdate- and sex-matched controls who had been seen within the same time frame were selected at random. Listed drug intolerance data and patient characteristics were then analyzed with logistic regression and χ2 testing. RESULTS Patients with fibromyalgia and IBS were 12 and 3 times more likely to have severe MDIS compared with controls, respectively. Severe MDIS was associated with polypharmacy in both groups. Opiates were the most frequently reported drug intolerance across all participants. Although patients with IBS more often reported gastrointestinal symptoms as adverse reactions, individuals with fibromyalgia did not more frequently report pain or behavioral changes as adverse reactions. CONCLUSIONS There was an increased rate of severe MDIS in patients diagnosed with fibromyalgia and IBS. Additional studies are needed to better understand the morbidity of MDIS and how it can best be managed in patients with fibromyalgia and IBS.
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Affiliation(s)
- Alicia A Alvarez
- First Physicians Group, Sarasota Memorial Hospital, Sarasota, Fla.
| | - Jayme M Palka
- Department of Internal Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
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Ben Romdhane H, Fadhel NB, Chadli Z, Chaabane A, Benzarti W, Fredj NB, Aouam K. Drug reaction with eosinophilia and systemic symptoms in a paediatric population: Interest of skin tests. Contact Dermatitis 2023; 89:488-495. [PMID: 37731315 DOI: 10.1111/cod.14416] [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: 12/20/2022] [Revised: 08/03/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction. It is uncommon in the paediatric population and can be difficult to diagnose as its initial symptoms may mimic a viral infection. OBJECTIVE To analyse the features of paediatric DRESS and to evaluate the interest of skin tests in identifying the causative drugs. METHODS It is a retrospective analysis (2004-2021) of DRESS cases diagnosed in paediatric patients. The DRESS diagnosis was defined using the RegiSCAR scoring. The skin tests were performed according to the ENDA recommendations. RESULTS We included 19 cases of DRESS occurred in 18 patients. Common clinical symptoms were exanthema and fever in 94.7% of cases each. The most commonly affected organ was the liver (84.2%). Among the implicated drugs, 16 were tested and skin tests were positive in 75%. To assess cross-reactivity and co-sensitization, skin tests with related and/or co-administered drugs were performed in eight patients. Among them, only one child had positive results. CONCLUSION Early diagnosis of DRESS and discontinuation of the incriminated drug might reduce the incidence of mortality in the paediatric population. Skin tests could be a safe and useful tool to identify the causative drug and assess cross-reactivity.
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Affiliation(s)
- Haifa Ben Romdhane
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Najah Ben Fadhel
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Zohra Chadli
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Amel Chaabane
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Wiem Benzarti
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Nadia Ben Fredj
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
| | - Karim Aouam
- Faculty of Medicine, Department of Pharmacology, EPS Fattouma Bourguiba, University of Monastir, Monastir, Tunisia
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van den Berk-Clark C, Grant A, Ferber M. Internalizing disorders as a mediator of the association between adverse childhood experiences and perceived medication intolerance or poly-allergy. Int J Psychiatry Med 2023; 58:591-604. [PMID: 37168017 DOI: 10.1177/00912174231175742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVES There is a well-established link between adverse childhood events, mental health, and physical health conditions. There is also a large literature showing the relationship between medication intolerance or allergies, and poor health outcomes. However, less is understood about the role of medication intolerance and adverse childhood events. Thus, the present study examines the relationship between adverse childhood events, internalizing disorders (depression, anxiety) and medication intolerance. METHOD Three hundred forty-nine participants were recruited from 11 primary care practices and health networks located in a large, Midwestern metropolitan area. Unrelated linear and Poisson regression was used to determine whether internalizing disorders, such as depression and anxiety, mediated the relationship between adverse childhood experiences (ACEs) and allergies to medications, accounting for error terms in regression equations that were correlated. RESULTS Results indicated an association between ACEs and number of allergies to medication, whereby ACEs was associated with depression, anxiety and number of allergies. Sensitivity analysis confirmed these findings. There was a small but significant indirect effect of anxiety on allergies to medication after bootstrapping. CONCLUSION This study found that inflammatory responses occurring because of trauma and depression may be increasing medication allergies. However, given the size of the sample, more research is needed to confirm these results. Implications for healthcare providers are discussed.
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Affiliation(s)
| | - Abigail Grant
- Department of Family and Community Medicine, Saint Louis University, St. Louis, MO, USA
| | - Megan Ferber
- Department of Family and Community Medicine, Saint Louis University, St. Louis, MO, USA
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Palacios Cañas AA, Meneses Sotomayor JV, Clar Castelló M, Gómez Torrijos E, Borja Segade JM, García Rodríguez R. [Reproducibilidad clínica de reacciones de hipersensibilidad a fármacos en pruebas de exposición controlada]. REVISTA ALERGIA MÉXICO 2023; 70:113-120. [PMID: 37933921 DOI: 10.29262/ram.v70i3.1199] [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: 11/30/2022] [Accepted: 05/19/2023] [Indexed: 11/08/2023] Open
Abstract
Objective To assess the reproducibility of symptoms in drug challenge tests. Methods The study included patients with positive cutaneous or challenge test throughout 2019. For each patient, clinical suspicion according to Karch-Lasagna algorithm was registered. Primary outcome was the reproducibility of symptoms in the provocation tests using a paired analysis of data with McNemar test. Results Eighty-nine patients were included, 16 of them presented more than one positive test. Thirty were skin tests positive and 75 reacted to provocation tests. Eighty nine percent of patients who reacted in challenge test were probably or possibly reactors according to Karch-Lasagna scale. Symptoms of initial reaction did not differ from those triggered in challenge tests. Conclusions Karch-Lasagna scale is useful in predicting the response to drug provocation tests. In most of the positive studies, results were suggested by clinical history and no differences were found between symptoms triggered in challenge test and that referred to in the previous reaction.
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Huber B, Joshi S. CNS tuberculoma in an immunocompetent patient: A case report of multi-drug hypersensitivity to RIPE therapy. IDCases 2023; 33:e01886. [PMID: 37674901 PMCID: PMC10477797 DOI: 10.1016/j.idcr.2023.e01886] [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: 06/07/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023] Open
Abstract
Background Tuberculosis (TB) is the second leading cause of death due to an infectious disease worldwide (World Health Organization, 2022 [1]). The first line treatment of TB involves the concurrent use of four drugs: rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE). Given the rising threat of multidrug resistant TB, it is crucial to understand how TB can be treated when first line treatment is not an option. Case presentation We report a rare case of multi-drug hypersensitivity to RIPE therapy in an immunocompetent patient with an unusual presentation of CNS tuberculoma. The patient presented to an outside hospital four months prior with weakness, numbness, imbalance, and speech difficulties. A CT of the head revealed a mass in the left parietal lobe that demonstrated chronic necrotizing granulomatous inflammation with positive cultures for M. tuberculosis. The patient was started on a regimen of rifampin 600 mg daily, isoniazid 300 mg daily, pyrazinamide 2000 mg daily, ethambutol 1200 mg daily, and pyridoxine 50 mg daily. However, the patient developed drug hypersensitivity reactions to both rifampin and ethambutol with subsequent failed desensitization to rifabutin. She was ultimately discharged from the hospital on a regimen of isoniazid, pyridoxine, pyrazinamide, and moxifloxacin with plans for outpatient follow-up. Conclusions This case highlights a rare clinical presentation of multiple drug hypersensitivity in the setting of a CNS tuberculoma and the importance of identifying the offending agents early in the course of treatment and adjusting the drug regimen accordingly. Desensitization should be attempted, but if ineffective, then alternative drug regimens should be formulated on a case-by-case basis.
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Affiliation(s)
- Benjamin Huber
- Department of Infectious Disease, 2799 W Grand Blvd, Henry Ford Health, Detroit, MI 48202, USA
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
| | - Seema Joshi
- Department of Infectious Disease, 2799 W Grand Blvd, Henry Ford Health, Detroit, MI 48202, USA
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Bhathal S, Joseph E, Nailor MD, Goodlet KJ. Adherence and outcomes of a surgical prophylaxis guideline promoting cephalosporin use among patients with penicillin allergy. Surgery 2022; 172:1598-1603. [PMID: 35183368 DOI: 10.1016/j.surg.2022.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The study purpose was to assess adherence to a local surgical prophylaxis guideline in patients with reported penicillin allergies, which recommends cephalosporins as first-line prophylaxis. METHODS Adult patients with penicillin allergies admitted for a surgical procedure from July 2020 to June 2021 were retrospectively screened, and the first surgery per admission was included. The primary outcome was the proportion of surgeries using β-lactam prophylaxis. Additional outcomes included prophylaxis timing, hypersensitivity reactions, acute kidney injury, infectious complications, duration of stay, and 30-day mortality or readmission. RESULTS Among 597 procedures, 504 patients (84.4%) received a β-lactam for surgical prophylaxis, including 494 (82.3%) who received a cephalosporin. Patients in the non-β-lactam group were more likely to have a type I IgE-mediated penicillin allergy (48.4% vs 31.7%, P = .002); however, the majority with type I reactions still received β-lactams (78.0%), including in the setting of anaphylaxis or angioedema to penicillin (67.7%). Zero allergic reactions to prophylaxis antibiotics were reported in either group, and there were no significant differences in the proportion of patients receiving drugs associated with the management of allergic reactions. Receipt of non-β-lactams was associated with inappropriate prophylaxis timing (9.7% vs 3.2%, P = .005) and postprocedural acute kidney injury (7.5% vs 0.6%, P < .001). All other outcomes were nonsignificant between the groups. CONCLUSION Among surgical patients with a documented penicillin allergy, most received cephalosporin prophylaxis as recommended by institutional guidelines, with zero allergic reactions. Receipt of non-β-lactam prophylaxis was associated with worsened outcomes. Cephalosporin prophylaxis should be preferred for surgical patients, including in the setting of true penicillin allergy.
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Affiliation(s)
- Salfee Bhathal
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Eldo Joseph
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ
| | - Michael D Nailor
- Department of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, AZ.
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Süleyman A, Tamay Z, Güler N. Antibiotic allergy in children with cystic fibrosis: A retrospective case-control study. Pediatr Pulmonol 2022; 57:2622-2628. [PMID: 35833362 DOI: 10.1002/ppul.26073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 07/06/2022] [Accepted: 07/09/2022] [Indexed: 11/07/2022]
Abstract
UNLABELLED Antibiotic allergy is a big problem that may affect the treatment and life quality of patients with cystic fibrosis (CF). AIM To evaluate predictive factors for confirmed antibiotic hypersensitivity in children with CF. METHODS In this case-controlled study, we examined 15 patients with CF who had been confirmed with antibiotic allergy. Additionally, we included a control group of age- and gender-matched 45 CF patients with no antibiotic allergy. The diagnosis of antibiotic allergy was confirmed in the presence of a compatible history and a positive response in the drug skin test or provocation test. Multiple drug hypersensitivity was classified according to the temporal relationship of antibiotics: (i) distant, (ii) simultaneous, and (iii) sequential. The data were analyzed by conditional logistic regression. RESULTS β-lactam allergy was confirmed in eight patients (ceftazidime n = 5, piperacillin-tazobactam n = 3) and non-β-lactam allergy was confirmed in two patients (ciprofloxacin n = 1, azithromycin n = 1). Additionally, multiple drug hypersensitivity in five patients (distant n = 4, sequential n = 1), among whom two patients showed hypersensitivity against ceftazidime/piperacillin-tazobactam+ ciprofloxacin/levofloxacin, two patients showed hypersensitivity against ceftazidime+ ciprofloxacin n = 2, and one patient showed hypersensitivity against piperacillin-tazobactam+ amikacin+ trimethoprim-sulfamethoxazole. All patients (n = 13) with confirmed β-lactam allergy were meropenem tolerant. Multivariate analysis indicated that immediate reactions (, p < 0.001) and allergic evaluation in the first six months after the reaction (p = 0.036) were significant risk factors for the prediction of antibiotic hypersensitivity. CONCLUSION Beta-lactam antibiotic allergy is the most commonly confirmed drug allergy in children with CF. However, unlike normal children, ceftazidime and piperacillin-tazobactam account for the majority.
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Affiliation(s)
- Ayşe Süleyman
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep Tamay
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nermin Güler
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Ben Mahmoud L, Ammar M, Bahloul N, Hakim A, Ghozzi H, Lefi N, Sahnoun Z, Zeghal K. Hypersensibilité médicamenteuse multiple chez des patients ayant une allergie aux antibiotiques. Therapie 2022; 77:549-559. [DOI: 10.1016/j.therap.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/06/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022]
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Jagpal PK, Alshareef S, Marriott JF, Thirumala Krishna M. Characterization, epidemiology and risk factors of multiple drug allergy syndrome and multiple drug intolerance syndrome: A systematic review. Clin Transl Allergy 2022; 12:e12190. [PMID: 36017174 PMCID: PMC9395947 DOI: 10.1002/clt2.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Multiple drug allergy and multiple drug intolerance syndrome (MDAS/MDIS) labels are an impediment to clinical care and knowledge regarding these conditions is limited. This systematic review investigated the characterization, epidemiology, risk factors, clinical impact and pharmaco‐economics of MDAS and MDIS. Methods Systematic literature search across 11 databases (01 January 2000–06 November 2020) for MDIS, MDAS and related terminology. Studies were reviewed for quality of evidence and risk of bias by employing Critical Appraisal Skills Programme cohort study checklist. A narrative synthesis approach facilitated by systematic textual descriptions, tabulation and thematic analysis was adopted. Results There was heterogeneity in terminology and methodology. Few studies applied standard drug allergy diagnostic methods. There is some evidence to suggest that multiple drug hypersensitivity syndrome (MDHS; i.e., confirmed allergies in MDAS) is a distinct clinical entity. Prevalence of MDIS and MDAS labels in unselected & selected populations varied between 2.1%–6.4% & 4.9%–90% and 1.2% & 0%–36% respectively. Reported risk factors included female gender, increasing age, body mass index, anxiety, depression, co‐morbidities, concurrent allergies and increased healthcare utilization. Drugs commonly implicated were antibiotics and non‐steroidal anti‐inflammatory drugs. No studies relating to clinical impact and pharmaco‐economics were found. Conclusion There is considerable burden of MDAS and MDIS labels. Data needs cautious interpretation as majority of studies described involved unverified labels. Despite this limitation and heterogeneity of studies, there is some evidence to suggest that MDHS is a distinct clinical entity. Well‐designed multi‐centre studies applying standardized terminology and diagnostic methodology are needed to gain further insight into these conditions.
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Affiliation(s)
- Parbir K Jagpal
- Institute of Clinical Sciences University of Birmingham Birmingham UK
| | - Saad Alshareef
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - John F Marriott
- Institute of Clinical Sciences University of Birmingham Birmingham UK
| | - Mamidipudi Thirumala Krishna
- University Hospitals Birmingham NHS Foundation Trust Birmingham UK.,Institute of Immunology and Immunotherapy University of Birmingham Birmingham UK
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de Groot AC. Patch testing in Drug reaction with eosinophilia and systemic symptoms (DRESS): a literature review. Contact Dermatitis 2022; 86:443-479. [PMID: 35233782 DOI: 10.1111/cod.14090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/15/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
Abstract
The literature on positive patch test results in drug reaction with eosinophilia and systemic symptoms (DRESS) is reviewed. 105 drugs were identified that have together caused 536 positive patch tests in 437 patients suffering from DRESS. By far most reactions (n=145) were caused by carbamazepine, followed by amoxicillin, isoniazid, phenytoin, ethambutol, fluindione, phenobarbital, rifampicin, and ceftriaxone; 43 drugs each caused a single case only. The drug classes causing the highest number of reactions are anticonvulsants (39%), beta-lactam antibiotics (20%), antituberculosis agents (11%), non-beta-lactam antibiotics (6%) and iodinated contrast media (5%). The sensitivity of patch testing (percentage of positive reactions) is high for anticonvulsants (notably carbamazepine), beta-lactam antibiotics (notably amoxicillin) and possibly iodinated contrast media. Allopurinol and sulfasalazine frequently cause DRESS, but never give positive patch tests. Patch testing in DRESS appears to be safe, although mild recurrence of DRESS symptoms, mostly skin reactions, may not be rare. Multiple drug hypersensitivity was found to occur in 16% of all patients, but it is argued that the true frequency is (far) higher. Clinical aspects of DRESS, including diagnosing the disease and identifying culprit drugs (patch tests, intradermal tests, in vitro tests, challenge tests) are also provided, emphasizing the role of patch testing. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anton C de Groot
- dermatologist np Schipslootweg 5, 8351, HV, Wapserveen, The Netherlands
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12
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de Groot AC. Results of patch testing in Acute generalized exanthematous pustulosis (AGEP): a literature review. Contact Dermatitis 2022; 87:119-141. [PMID: 35187690 DOI: 10.1111/cod.14075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
Abstract
The literature on positive patch test results in acute generalized exanthematous pustulosis (AGEP) is reviewed. 93 drugs were identified that have together caused 259 positive patch tests in 248 patients suffering from AGEP. The drug classes causing the highest number of reactions are beta-lactam antibiotics (25.9%), other antibiotics (20.8%), iodinated contrast media (7.3%) and corticosteroids (5.4%), together accounting for nearly 60% of all reactions. The highest number of reactions to individual drugs was to amoxicillin (n=36), followed by pristinamycin (n=25), diltiazem (n=14), amoxicillin-clavulanic acid (n=13), clindamycin (n=11) and iomeprol (n=8); 59 of the 93 drugs each caused a single case only. The "Top-10" drugs together caused over 50% of all reactions. The sensitivity of patch testing (percentage of positive reactions) in patients with AGEP is largely unknown, but may generally be around 50%, which also applies to pristinamycin. Patch testing in AGEP appears to be safe, although mild recurrence of AGEP skin symptoms or other rashes may occur occasionally. Clinical aspects of AGEP, including epidemiology, etiology and pathophysiology, clinical features, histology, treatment, and prognosis are briefly presented, as are diagnosing the disease and identifying the culprit drugs with patch tests, intradermal tests, in vitro tests, and challenge tests. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anton C de Groot
- dermatologist np, Schipslootweg 5, 8351 HV Wapserveen, The Netherlands
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13
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Jeffres MN, Sousa-Pinto B, Blumenthal KG. Dual Allergy to Penicillin and Cefazolin-Does Anaphylaxis Matter?-Reply. JAMA Surg 2021; 156:1184-1185. [PMID: 34431966 DOI: 10.1001/jamasurg.2021.3761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Meghan N Jeffres
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora.,University of Colorado Hospital, Aurora
| | - Bernardo Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Health Technology and Services Research, University of Porto, Porto, Portugal.,Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts.,The Mongan Institute, Massachusetts General Hospital, Boston
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14
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Sim DW, You HS, Yu JE, Koh YI. High occurrence of simultaneous multiple-drug hypersensitivity syndrome induced by first-line anti-tuberculosis drugs. World Allergy Organ J 2021; 14:100562. [PMID: 34386151 PMCID: PMC8339324 DOI: 10.1016/j.waojou.2021.100562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/25/2021] [Accepted: 06/08/2021] [Indexed: 11/22/2022] Open
Abstract
Background Multiple drug hypersensitivity syndrome (MDHS) results in treatment delay or failure and often results in severe drug hypersensitivity reactions. There are few reports of MDHS in response to anti-tuberculosis drugs; however, clinical information is scarce. Understanding the frequency and clinical characteristics of simultaneous MDHS against first-line anti-tuberculosis drugs in patients with non-severe drug hypersensitivity reactions is necessary. Methods We reviewed 27 patients with drug fever or maculopapular exanthem in response to first-line anti-tuberculosis drugs between January 2010 and June 2019. Drug fever or maculopapular exanthem occurred when isoniazid, rifampin, ethambutol, and pyrazinamide were administered simultaneously. Drug provocation tests for the 4 drugs were performed to identify the culprit drugs. Results All patients showed positive reactions to 1 or more drugs. MDHS was diagnosed in 13 (48%) patients, of whom 11 and 2 patients reacted to 2 and 3 drugs, respectively. In comparison to the patients with single-drug hypersensitivity, the patients with MDHS did not exhibit any differences in characteristics. Ethambutol and rifampin were the common drugs that induced a reaction, and the combination of these 2 drugs induced MDHS most frequently. Among the patients with MDHS, there were no differences between the drugs that caused drug fever and maculopapular exanthem. All patients with MDHS were successfully treated with alternative drugs. Conclusions Simultaneous MDHS may occur frequently in patients with drug fever or maculopapular exanthem caused by first-line anti-tuberculosis drugs, indicating the need to evaluate the allergy responses for all 4 drugs, even in patients without severe drug hypersensitivity. The combination of ethambutol and rifampin was the most common trigger that induced MDHS.
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Affiliation(s)
- Da Woon Sim
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hye Su You
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Ji Eun Yu
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Young-Il Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
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Lee EY, Freedman O, Castells M, Vadas P. Delayed hypersensitivity reactions to multiple aromatase inhibitors followed by successful desensitization to letrozole. Ann Allergy Asthma Immunol 2021; 127:378-379. [PMID: 34004279 DOI: 10.1016/j.anai.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Erika Yue Lee
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Orit Freedman
- Department of Medical Oncology, R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health, Oshawa, Ontario, Canada
| | - Mariana Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter Vadas
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Oh JH, Yun J, Yang MS, Kim JH, Kim SH, Kim S, Choi JH, Yim JJ, Kang HR. Reintroduction of Antituberculous Drugs in Patients with Antituberculous Drug-Related Drug Reaction with Eosinophilia and Systemic Symptoms. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3442-3449.e3. [PMID: 33872812 DOI: 10.1016/j.jaip.2021.03.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients who suffered drug reaction with eosinophilia and systemic symptom (DRESS) during the treatment of tuberculosis (TB) commonly experience multidrug hypersensitivity reactions resulting in limited anti-TB drug choices. Therefore, reintroduction based on a desensitization protocol may be an option to resume anti-TB medication. OBJECTIVE To evaluate the outcomes and safety of resuming anti-TB drugs according to reintroduction methods in patients with anti-TB drug-related DRESS. METHODS A retrospective cohort of patients who had experienced anti-TB drug-related severe cutaneous adverse reactions from 2011 to 2017 was established from separate 5 institutions. RESULTS Anti-TB medication was resumed in 27 of 29 patients with anti-TB drug-related DRESS through complete changing regimen (n = 9), reintroduction by a graded challenge (n = 5), or reintroduction using a desensitization protocol (n = 13). Nine patients completely changed their anti-TB regimen to second-line TB drugs, but only 1 (11.1%) succeeded in maintaining new anti-TB drugs. The other 8 failed to take drugs due to the occurrence of hypersensitivity reactions to the newly introduced anti-TB drugs. Two (40.0%) of 5 patients who underwent graded rechallenges successfully completed anti-TB drugs, whereas 3 (60%) failed to resume anti-TB drugs due to the recurrence of hypersensitivity reactions. In 13 patients who resumed anti-TB drugs using a desensitization protocol, no one who underwent desensitization developed recurrence of DRESS; 11 (84.6%) eventually completed anti-TB treatment and 2 eventually failed to complete anti-TB treatment due to late-onset itching and drug-induced liver injury. CONCLUSIONS Resuming anti-TB medication based on desensitization protocols may be a safe and effective option for those with anti-TB drug-related DRESS.
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Affiliation(s)
- Ji Hyun Oh
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea; Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - James Yun
- Department of Immunology and Rheumatology, Nepean Hospital, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung-Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong-Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea.
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17
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Gilissen L, Spriet I, Gilis K, Peetermans WE, Schrijvers R. Prevalence of Antibiotic Allergy Labels in a Tertiary Referral Center in Belgium. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2415-2425.e8. [PMID: 33607341 DOI: 10.1016/j.jaip.2021.01.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/08/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antibiotic (AB) allergies are among the most frequently occurring adverse drug reactions. In US literature, AB allergy labels (AAL) are reported in 10% to 15% of patients' charts; however, large-scale European analyses are scarce. OBJECTIVES To retrospectively assess the prevalence of AAL in a tertiary referral hospital in Belgium between 2010 and 2018. METHODS Patients who consulted and/or were hospitalized during the study period, who had been labeled with an AB allergy, were selected for further analysis. RESULTS Of 1,009,598 unique patients (outpatients, n = 736,469; inpatients, n = 273,129), 28,147 patients (3%) were registered with 1 or more AAL, being 1% of outpatients (n = 9562) and 7% of inpatients (n = 18,585). Women were more likely to carry an AAL (68%) compared with men (32%, P < .001). In patients with an AAL, 9% had multiple labels and 5% had labels for multiple AB classes. Most frequently, beta-lactams were involved (84% of AAL), followed by quinolones (7%) and sulfonamides and macrolides (both 3%). Moreover, 88% of the reactions were self-reported, mostly being an unspecified rash (53%), whereas only 3% were considered confirmed AAL. CONCLUSION With an overall prevalence of 3%, the burden of AAL is less in our Western European center compared with US reports. However, this prevalence most likely still represents an overestimation of genuine AB allergic patients because most labels lack confirmation and/or specifications. Our work indicates that knowledge of the local epidemiology of AAL is necessary to estimate the impact of better allergy labeling and delabeling strategies.
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Affiliation(s)
- Liesbeth Gilissen
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of Dermatology, Contact Allergy Unit, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Karin Gilis
- Information Technology Department, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, Laboratory for Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Infectiology Unit, University Hospitals Leuven, Leuven, Belgium
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium.
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18
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Al-Ahmad M, Edin J, Musa F, Rodriguez-Bouza T. Drug Allergy Profile From a National Drug Allergy Registry. Front Pharmacol 2021; 11:555666. [PMID: 33542684 PMCID: PMC7851708 DOI: 10.3389/fphar.2020.555666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Drug hypersensitivity reactions (DHRs) are among the most frequent reasons for consultation in allergy departments and are becoming more common due to increasing prevalence and case complexity. Objective: To describe the most common drugs associated with clinical reactions, diagnostic methods used, and outcomes of allergic evaluations of a national drug allergy registry over a 12-year period were used. Methods: An observational, prospective, patient’s data registry-based study was conducted to analyze all referrals to the drug allergy outpatient clinics at Al-Rashed Allergy Center, Kuwait, between 2007 and 2019. Demographics, description of DHRs, and results of allergy tests to potential causative medications were reviewed. Diagnostic methods were focused mainly on skin tests (STs) and drug provocation test (DPT), when indicated. Results: We evaluated 1,553 patients with reported DHRs. The mean age of the population was 41.52 ± 16.93 years, and the study population consisted of 63.7% female patients. Hypersensitivity was finally confirmed in 645 (41.5%) of patients, probable in 199 (12.8%), and not confirmed/nonallergic in 709 (45.6%) patients. Anti-inflammatory drugs and analgesics contributed to 39.22% of all confirmed drug allergies, followed by antibiotics 38.1% (β-lactam antibiotics (BLs) constituted 73.98% of all antibiotics and 28.21% of all drugs), anesthetics 1.8%, and radio-contrast media 0.31%. The majority of reactions were non-immediate 51.44%. The most commonly presenting symptoms among confirmed patients were urticaria 57.80%, angioedema 42.50%, respiratory symptoms 47.60%, and erythema 33.60%. Symptoms of anaphylaxis/anaphylactic shock were reported by 284 patients (44.00%) among confirmed cases. The most common method of diagnosis was a positive clinical history (54.4% in BLs and 90.45% in nonsteroidal anti-inflammatory drugs (NSAIDs). Among confirmed allergy to BLs, a positive ST was obtained in 31.9% of patients and positive DPT in 13.7%. Conclusion: NSAIDs and antibiotics, mainly BLs, are the most commonly implicated in confirmed allergy. In both confirmed and not confirmed/nonallergic cases, BLs are the most frequently involved DHRs which are mainly immediate, and the most commonly presenting symptoms were urticaria, angioedema, and respiratory symptoms. Diagnosis was confirmed mainly by a positive clinical history and when indicated, by positive STs or a DPT.
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Affiliation(s)
- Mona Al-Ahmad
- Al Rashed Allergy Centre, Ministry of Health, Kuwait.,Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Jusufovic Edin
- Medical Faculty, University of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Fardous Musa
- Al Rashed Allergy Centre, Ministry of Health, Kuwait
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Jin HJ, Kang DY, Nam YH, Ye YM, Koh YI, Hur GY, Kim SH, Yang MS, Kim S, Jeong YY, Kim MH, Choi JH, Kang HR, Jo EJ, Park HK. Severe Cutaneous Adverse Reactions to Anti-tuberculosis Drugs in Korean Patients. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:245-255. [PMID: 33474859 PMCID: PMC7840880 DOI: 10.4168/aair.2021.13.2.245] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/08/2020] [Accepted: 07/30/2020] [Indexed: 12/18/2022]
Abstract
Purpose Anti-tuberculosis drugs (ATDs) can cause severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS). Underlying tuberculous infection and co-administration of multiple drugs may contribute to the complexity of ATD-related SCARs. This study aimed to investigate the clinical characteristics and outcomes of ATD-related SCARs. Methods We analyzed ATD-related SCAR cases in 2010-2015, selected from a web-based Database of the Korean Registry of SCAR. Results Among 783, 53 patients with ATD-induced SCARs were enrolled, including 12 with SJS/TEN (22.6%) and 41 with DRESS (77.4%). When comparing the ATD and non-ATD groups, the prevalence of DRESS patients was higher in the ATD group than in the non-ATD group (77.4% vs. 45.8%, P < 0.001). Among patients with ATD-related SCARs, those with SJS/TEN were significantly older, had higher intensive care unit admissions, and had higher mortality than those with DRESS (70.5 vs. 50.0 years, P < 0.001; 41.7% vs. 6.1%, P = 0.010; and 33.3% vs. 2.5%, P = 0.003, respectively). ATDs were challenged in 14 cases. The ATD associated most often with SCAR cases was rifampin (81.8%), followed by isoniazid (66.7%), ethambutol (50.0%), pyrazinamide (33.3%). Six patients (42.9%) had hypersensitivity reactions to 2 or more drugs. Conclusions DRESS was more common among the ATD-related SCAR cases. Although treatment with most ATDs carries the risk of SCAR development, the use of rifampin was most frequently involved in the occurrence of SCARs. Multiple hypersensitivity was frequently observed in ATD-related SCARs.
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Affiliation(s)
- Hyun Jung Jin
- Department of Internal Medicine, Medical School of Yeungnam University, Daegu, Korea
| | - Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Young Hee Nam
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young Il Koh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sae Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Suk Yang
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yi Yeong Jeong
- Department of Internal Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Min Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong and Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Hye Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jung Jo
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Hye Kyung Park
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea.
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20
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Ariza A, Mayorga C, Bogas G, Barrionuevo E, Torres MJ, Doña I, Fernandez TD. Advances and novel developments in drug hypersensitivity diagnosis. Allergy 2020; 75:3112-3123. [PMID: 32990987 DOI: 10.1111/all.14603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
A correct diagnosis of drug hypersensitivity reactions (DHRs) is very important for both the patient and health system. However, DHRs diagnosis is complex, time consuming, requires trained personnel, is not standardized for many drugs, involves procedures not exempt of risk, and in most cases lacks standardized in vivo and in vitro tests. Thus, there is an urgent need for improving the different approaches to diagnose patients with suspected DHRs. In this review, we have analyzed the advances performed in immediate and nonimmediate DHRs diagnosis during the last two years and obtained several conclusions: the significant heterogeneity in current practice among centers illustrates the need to re-evaluate, update, and standardize in vivo tests and protocols for the diagnosis and management of patients with suspected drug allergy. Regarding in vitro tests, the latest studies have focused on increasing their sensitivity or on establishing the sensitivity and specificity for the tests performed with new drugs. There seems to be a consensus about combining in vivo and in vitro tests as the best way to increase the diagnostic accuracy.
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Affiliation(s)
- Adriana Ariza
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Gador Bogas
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Esther Barrionuevo
- Asthma and Immunoallergic Diseases Research Group Instituto de Investigación Hospital 12 de Octubre (i+12)‐ARADyAL Madrid Spain
- Allergy Unit Hospital Universitario 12 de Octubre Madrid Spain
| | - Maria J. Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Departamento de Medicina Universidad de Málaga Málaga Spain
| | - Inmaculada Doña
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Departamento de Biología Celular, Genética y Fisiología Universidad de Málaga Málaga Spain
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21
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Drug-related relapses in drug reaction with eosinophilia and systemic symptoms (DRESS). Clin Transl Allergy 2020; 10:52. [PMID: 33292540 PMCID: PMC7682085 DOI: 10.1186/s13601-020-00359-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
Background A drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe T cell mediated hypersensitivity reaction. Relapses of symptoms in the recovery phase are frequent and linked to the reduction of the corticosteroid treatment, to viral reactivations or to the exposure to new drugs. Here, we analyzed, how often the exposure to new drugs leads to new sensitization or drug-related relapses without detectable sensitization. Methods 46 patients with DRESS treated in the allergy division of the Inselspital, Bern University Hospital, were retrospectively assessed. Drug-related relapses were analyzed in terms of frequency and whether a possible sensitization evaluated by skin tests and/or lymphocyte transformation tests (LTT) to the new drugs was detectable. Furthermore, drug tolerance was evaluated in a subset of patients. Results 56 relapses were observed in 27 of 46 patients with DRESS (58.7%). 33 (58.9%) of these relapses were associated with the use of new drugs, 30 drug-related relapses were evaluated by patch test and/or lymphocyte transformation test. In 8/30 (26.7%) drug-related relapses, a sensitization to the new drug was demonstrated, suggesting the emergence of a multiple drug hypersensitivity syndrome (MDH). 14 patients experienced 22 drug-related relapses without any detectable sensitization and only 1/6 patients developed new symptoms upon reexposure. Conclusion Patients with DRESS frequently suffered from drug related relapses. Half of the patients with drug-related relapses developed a MDH with proven sensitizations not only to the DRESS inducing drugs, but also to newly applied drugs. When not sensitized, drugs involved in drug related relapses could be reintroduced, if needed. Here, we propose a procedure for drug testing and future management of drug-related relapses in DRESS.
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Jörg L, Yerly D, Pichler W. Multiple drug hypersensitivity syndrome (MDH) should not be diagnosed by drug provocation tests. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:822-823. [PMID: 32037118 DOI: 10.1016/j.jaip.2019.10.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Lukas Jörg
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Daniel Yerly
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner Pichler
- ADR-AC GmbH, Adverse Drug Reactions, Analysis and Consulting, Bern, Switzerland
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23
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Jörg L, Yerly D, Helbling A, Pichler W. The role of drug, dose, and the tolerance/intolerance of new drugs in multiple drug hypersensitivity syndrome. Allergy 2020; 75:1178-1187. [PMID: 31814130 DOI: 10.1111/all.14146] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiple drug hypersensitivity syndrome (MDH) is used to describe persons with a drug hypersensitivity reaction (DHR) to at least two chemically unrelated drugs, confirmed by skin test or in vitro assay. METHODS Medical records of 25 patients with MDH, tested and confirmed at our allergy division, were retrospectively evaluated in terms of clinical course, involved drugs, daily drug dose, latency periods, test results of skin test and cellular assays, and tolerated drugs in subsequent pharmacological treatments. RESULTS Multiple drug hypersensitivity syndrome almost exclusively appeared as a delayed, often severe DHR and started in 14/25 with a drug reaction with eosinophilia and systemic symptoms (DRESS). Penicillins (13/25, 52.0%) and cephalosporins (6/25, 24.0%), typical high-dose drugs, were most often identified as elicitors of MDH, especially at the first DHR, followed by aromatic antiepileptics (7/25, 28.0%), vancomycin (4/25, 16.0%), and antibiotic sulfonamides (4/25, 16.0%). Cephalosporins, clindamycin, and radio contrast media (RCM) were mainly involved in subsequent DHR. The median daily drug dose of all drug trigger was 1875.0 mg (662.5; 2100.0) at the first DHR and 600.0 mg (300.0; 1300.0) at subsequent DHR, P = .0420. CONCLUSION High-dose drugs, especially beta-lactam antibiotics, RCM and clindamycin, are common elicitors of subsequent DHR in patients with MDH. Macrolides, quinolones, doxycycline, nonaromatic antiepileptics, and paracetamol were often tolerated. As the same drugs elicited both flare-up reactions and real DHR, drug-induced flare-up reactions may be precursors of a possible second DHR and MDH. The administration of highly dosed drugs should be avoided in patients at risk for MDH.
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Affiliation(s)
- Lukas Jörg
- Department of Rheumatology, Immunology and Allergology Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Daniel Yerly
- Department of Rheumatology, Immunology and Allergology Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Arthur Helbling
- Department of Rheumatology, Immunology and Allergology Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Werner Pichler
- ADR‐AC GmbH Adverse Drug Reactions, Analysis and Consulting Bern Switzerland
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Mayorga C, Fernandez TD, Montañez MI, Moreno E, Torres MJ. Recent developments and highlights in drug hypersensitivity. Allergy 2019; 74:2368-2381. [PMID: 31557314 DOI: 10.1111/all.14061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Isabel Montañez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Esther Moreno
- Allergy Unit Hospital Universitario de Salamanca‐ARADyAL IBSAL Salamanca Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Universidad de Málaga Málaga Spain
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