Anaphylaxis to paramethasone with tolerance to other corticosteroids

Association between biphasic reactions and the systems of symptoms and treatment in patients with anaphylaxis hospitalized from the emergency department

AIM

Anaphylaxis is a severe, life-threatening, generated or systemic reaction, and biphasic reaction could occur in some cases. We investigated the clinical course of anaphylaxis in our hospital and studied the relationship between biphasic reactions and the symptoms and treatments for predicting the onset of biphasic reactions.

METHODS

We retrospectively reviewed the medical records of 120 patients with anaphylaxis who were admitted to our hospital from the emergency department during April 2008-October 2015.

RESULTS

The incidence of biphasic reactions of anaphylaxis in our hospital was 10.8% (13 patients) without significant difference when compared with that in previous reports. Regarding the development of biphasic reactions, symptoms, the number of systems of symptoms and severity of the initial reaction, and treatment with adrenaline and corticosteroid were not clearly related with biphasic reaction. Use of adrenaline in the initial treatment was approximately 60%. Of the 13 biphasic reactions, 11 (84.5%) were as equal/mild as the original symptoms.

CONCLUSION

This study could not show the factors predicting the onset of biphasic reactions. Further prospective and nationwide studies are required to research biphasic reactions.

Mass spectrometric method for distinguishing isomers of dexamethasone via fragment mass ratio: An HRMS approach

The major challenge in identifying dexamethasone, betamethasone, and paramethasone from a mixture of these corticosteroids is difficulty in achieving an efficient separation. In this study, we aimed to develop an efficient technique to identify these co-eluting isomers based on the mass spectral patterns of them and their corresponding phase II metabolites after electrospray ionization. Fragmentation pathways in tandem mass spectrometry revealed acceptable specificity within the groups of conjugates. The method was validated using individual isomers and mixtures at various compositions. The effects of concentration and collision energies on fragmentation patterns were also studied extensively. Matrix-fortified equine urine and plasma samples were also included so that matrix effects and interferences on fragmentation ratios could be elucidated. Preliminary results using biological samples demonstrated the suitability of this analytical strategy for direct measurement from their fragmentation patterns. Possible fragmentation pathways for each isomer were proposed.

Tachon Syndrome: Rare Side Effect of Articular Injections of Corticosteroids. A Report of Two Cases

Epidural or intra-articular injections of corticosteroids are an option for the treatment of several pain conditions but are not without adverse effects. Here, we discuss a rare systemic side effect of this therapy: Tachon syndrome. We report two cases, a 64-year-old woman and a 43-year-old man, who presented with Tachon syndrome after receiving, respectively, a shoulder and a lumbar injection of cortivazol 3.75 mg/1.5 ml suspension for injection in pre-filled syringes. The indication for this therapy was, respectively, tendinopathy of the supraspinatus and a mechanical L5 lumbosciatica. A few minutes after receiving the injection, patients experienced acute low back pain, chest tightness, facial erythema and profuse sweating. All vital and biologic parameters were normal. In the first case, improvement was spontaneous and all symptoms resolved in 20 min. The second patient remained under observation and received an intravenous ‘physiological’ infusion. Both patients recovered fully and returned home. A causal relationship between the corticosteroid injections and the patients’ symptoms was very likely because of the acute clinical presentation and the rapid improvement in the patients’ conditions and that no further signs indicating other serious complications developed.

Immediate and Delayed Hypersensitivity Reactions to Corticosteroids: Evaluation and Management

Corticosteroids are anti-inflammatory medications used widely to treat allergic inflammation. Although the endocrine and gastrointestinal side effects of corticosteroids have been described, the occurrence of immediate hypersensitivity reactions and delayed contact dermatitis due to corticosteroids remains under-recognized. Hypersensitivity reactions can occur to a corticosteroid itself, or to the additives and vehicles in corticosteroid preparations. Skin testing and oral graded challenge can help confirm the suspected culprit agent in immediate hypersensitivity reactions and help identify an alternative tolerated corticosteroid. Patch testing can help identify the culprit agents in delayed hypersensitivity contact dermatitis. Cross-reactivity patterns have not been observed for immediate hypersensitivity reactions as they have been for delayed contact dermatitis. Sensitization in contact dermatitis exhibits cross-reactivity patterns based on corticosteroid structure. We review the current understanding regarding the clinical presentation, evaluation, and management of immediate and delayed hypersensitivity reactions to corticosteroids.

Tachon's syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases

OBJECTIVES

To assess the frequency, features, and outcome of excruciating lumbar, dorsal, and/or thoracic pain following injections of local corticosteroids in rare instances.

METHODS

A questionnaire mailed to 500 French rheumatologists.

RESULTS

Three hundred and eighteen cases were reported by 92 rheumatologists (one event per 8000 injections or 6.5 years of practice), following injections into lumbar epidural space (39%), an upper limb (30%), a lower limb (mostly the heel) (24%), or other locations (7%), of cortivazol (67%), hydrocortisone (25%), betamethasone (7%), or paramethasone (1%). Symptoms occurred 1-5 min (78%) or less than 1 min (22%) after injection, and highly acute axial pain usually lasted for less than 5 min (34%) or 5-15 min (51%). In addition to pain in lumbar (84%) and/or dorsal regions (25%) [often preceded or associated with thoracic pain (36%)], other signs were: anxiety (87%), shortness of breath (64%), facial flushing (64%), diffuse sweating (41%), agitation (29%), transient cough (23%), abdominal pain (20%), transient hypertension (15%), paleness (10%), hypotension (8%), diarrhoea (3%) and headache (3%). None of these patients was known to be allergic, and urticaria developed in only 2%. Outcome was favourable in all cases (even though 4/318 patients were transiently hospitalised) with an overall duration of 25 +/- 71 min. Another injection was performed later in 146/318 cases (46%), but Tachon's syndrome recurred in only 20 of these 146 patients (14%).

CONCLUSION

The outcome of this impressive syndrome seems excellent. Tachon's syndrome might be the venous counterpart of Nicolau's syndrome (injection of corticosteroids in an artery).

Validation of the classification of ARIA (allergic rhinitis and its impact on asthma)

BACKGROUND

Allergic rhinitis is commonly divided into seasonal and perennial rhinitis. The recent Allergic Rhinitis and its Impact on Asthma (ARIA) workshop proposes to replace these terms by intermittent vs persistent rhinitis.

METHODS

In order to test the new ARIA classification against the classical one used in medical practice in France, we designed two cross-sectional surveys: (i) a spring survey, where 1321 general practitioners enrolled 3026 patients consulting for seasonal allergic rhinitis and (ii) an autumn-winter survey, where 1346 doctors enrolled 3507 patients for perennial allergic rhinitis. Both doctors and patients filled out a specific questionnaire on allergic rhinitis.

RESULTS

Focusing on the number of days per week and consecutive weeks per year, the patients described the duration of their symptoms (based on an auto-questionnaire). About 43.7% of the patients, classified by their doctor as seasonal, did in fact have persistent rhinitis, whereas 44.6% classified as perennial had intermittent rhinitis.

CONCLUSIONS

The proposal of the ARIA expert panel defining the chronology of allergic rhinitis as number of days per week and consecutive weeks per year is likely to change daily physician practice.