Anaphylaxis from the carboxymethylcellulose component of barium sulfate suspension

Allergic and Infectious complications of Etonogestrel Implant Placements: A Case Series

Patients rarely experience complications at time of Etonogestrel subdermal contraceptive implant placement. Few case reports describe infection or allergy as a complication at time of implant insertion. In this case series, we discuss three infections and one allergic reaction following Etonogestrel implant placement, review 6 previous case reports of 8 cases of infection or allergy and discuss management of these complications. We highlight differential diagnosis when encountering a placement complication, considerations of dermatologic conditions when placing Etonogestrel implants, and discuss when to consider removal of the implant when a complication occurs.

Anaphylaxis to drug excipients

In addition to the therapeutic agent, drugs contain excipients such as stabilizers, preservatives, solubilizers, or dyes, some of which are identical to additives in foods. Anaphylaxis to these excipients is probably an underestimated problem. After the first descriptions of anaphylactic reactions to drug excipients appeared more than 30 years ago, the number of corresponding reports has increased significantly over the years. However, a diagnostic gap exists in the clarification of drug allergic reactions when the index product is not known and/or is not available for testing. In the present work, individual excipients are presented as examples for which publications on anaphylaxis are available. Furthermore, the options of allergological testing both in vivo and in vitro are discussed. The pathogenesis of such reactions is still unresolved in many cases, and current concepts are briefly presented in the conclusion. With increasing knowledge about anaphylaxis to drug excipients, it is assumed that these can then be recognized more often and diagnostically clarified.

Anaphylaxie auf Hilfsstoffe in Arzneimitteln

Neben dem therapeutischen Agens enthalten Arzneimittel Hilfsstoffe als beispielsweise Stabilisatoren, Konservierungsstoffe, Löslichkeitsvermittler oder Farbstoffe, die teilweise identisch mit Zusatzstoffen in Nahrungsmitteln sind. Anaphylaxien auf diese Hilfsstoffe sind ein vermutlich unterschätztes Problem. Nachdem erste Beschreibungen anaphylaktischer Reaktionen auf Arzneimittelhilfsstoffe bereits vor über 30 Jahren auftauchten, hat die Zahl entsprechender Berichte in den letzten Jahren deutlich zugenommen. Eine diagnostische Lücke besteht allerdings in der Abklärung arzneimittelallergischer Reaktionen, wenn das Indexpräparat nicht bekannt ist und/oder nicht als Originalpräparat für Testungen zur Verfügung steht. In der vorliegenden Arbeit werden einzelne Hilfsstoffe exemplarisch vorgestellt, für die Publikationen zu Anaphylaxien vorliegen. Des Weiteren werden die Optionen allergologischer Testungen sowohl in vivo als auch in vitro besprochen. Die Pathogenese derartiger Reaktionen ist vielfach noch unklar, hier werden abschließend aktuelle Konzepte kurz vorgestellt. Mit zunehmendem Wissen über Anaphylaxien auf Arzneimittelhilfsstoffe ist davon auszugehen, dass diese auch vermehrt wahrgenommen und diagnostisch aufgeklärt werden können.

Zitierweise: Pfützner W. Anaphylaxis to drug excipients. Allergo J Int 2022;31:137-40

https://doi.org/10.1007/s40629-022-00214-9

Anaphylaxis to Excipients in Current Clinical Practice: Evaluation and Management

Excipients are the inactive ingredients in a drug or product that help to stabilize, preserve, or enhance the pharmacokinetics and bioavailability of the active ingredients. Excipient allergy is rare and hence often missed or misdiagnosed due to lack of awareness of the need to carefully review all drug ingredients. For the patient, excipient allergy can be frightening and potentially disruptive to health care delivery. This narrative review provides a clinically oriented, international, collaborative perspective on excipient allergy testing, management of future health care safety, limitations in our testing modalities, and barriers to optimal care.

Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions

Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.

Anaphylaxis to Carboxymethylcellulose: Add Food Additives to the List of Elicitors

A 14-year-old girl developed 4 episodes of anaphylaxis of unknown etiology, which required intramuscular adrenaline administration each time. She had eaten pizza and a cheeseburger immediately before the first 2 episodes, respectively, but had not eaten anything for several hours before the last 2 episodes. It turned out that she had eaten the same ice lolly 4 hours before the first 3 episodes and a Café au lait Swirkle (a half-frozen beverage) 4 hours before the last episode. We detected carboxymethylcellulose sodium as the only common ingredient in all anaphylactic episodes. Skin prick tests were positive for carboxymethylcellulose solution and carboxymethylcellulose-containing food products. We obtained a custom-made carboxymethylcellulose sodium-free ice lolly from the manufacturer and confirmed that it did not induce anaphylactic reactions by a challenge test. Carboxymethylcellulose, an anionic water-soluble polymer derived from native cellulose, is considered to be unabsorbable from the human gut and has been widely and increasingly used in pharmaceutical preparations, cosmetics, and food. This article is the first report of anaphylaxis caused by carboxymethylcellulose-containing foods, whereas anaphylaxis to carboxymethylcellulose has been rarely associated with carboxymethylcellulose-containing pharmaceuticals. Although the exact mechanisms underlying the induction of late-onset anaphylaxis by carboxymethylcellulose remain unclear, a small minority of cellulose-digesting microbial flora in the human colon and contamination of food products with carboxymethylcellulose of low molecular weight might be involved. The induction of recurrent anaphylaxis by various products should be a clue that prompts physicians to suspect food additives as a cause for anaphylaxis.

Effects of a Rebamipide Mouthwash on Stomatitis Caused by Cancer Chemotherapy-Evaluation of the Efficacy by Patients Themselves

 Anticancer drug-induced stomatitis develops in 30% to 40% of cancer cases that undergo chemotherapy. However, medications for this condition are not commercially available in Japan. Upon obtaining approval of the ethics committee, a mouthwash containing rebamipide as the active ingredient (rebamipide mouthwash) was administered to one inpatient and four outpatients, who had developed stomatitis caused by cancer chemotherapy. Starting from 14 d after the administration of the rebamipide mouthwash, the patients scored a stomatitis survey on oral state, pain level, and diet and recorded the number of times they gargled, as well as any stomatitis observations, in a stomatitis diary. The total scores for the points for each of the three types of survey sections were classified into Grades 0 to 4 and evaluated as a stomatitis evaluation score (SES). The SES became "0" in three out of the five patients within 14 d of treatment. No change in SES was found in one patient. In the remaining patients, SES became "0" once but increased again later. Using image analysis software (ImageJ), the area at which the stomatitis was observed was measured. When comparing SES and change in the area in patients who agreed to participate, gradual reductions in the extent of stomatitis was observed even during the period when SES did not change. Having patients fill in an observation chart was effective for grasping changes in symptoms in outpatients.

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.

Implant site Nexplanon reaction?

Nexplanon (Schering-Plough Limited/Merck Sharp & Dohme Limited (MSD)) is a long active reversible contraceptive method that provides effective contraception for 3 years. It consists of a single, flexible, rod-shaped implant, containing 68 mg etonogestrel. It is 4 cm long, consists of an ethylene vinyl acetate copolymer, a non-absorbable material, and also contains 15 mg of barium sulfate, which makes it visible by X-ray. We describe a case of a 39-year-old woman who experienced a local reaction to the barium sulfate in Nexplanon. She was given medical treatment, but only the removal of the implant resolved the symptoms. After removal there was gradual improvement and 72 h later the patient was asymptomatic. Allergic reaction to barium sulfate is extremely rare: until now, there have only been two cases associated with Nexplanon described in the literature.

Adverse effects associated with inadvertent intravenous penicillin G procaine-penicillin G benzathine administration in two dogs and a cat

CASE DESCRIPTION

2 dogs and a cat were inadvertently given penicillin G procaine-penicillin G benzathine IV instead of propofol during induction of anesthesia for routine dental prophylaxis. One dog and the cat required hospitalization because of severe neurologic impairment and cardiopulmonary arrest (cat); the remaining dog did not develop any clinical signs.

CLINICAL FINDINGS

In the 2 animals that developed signs consistent with an immediate adverse reaction, clinical signs included muscle tremors, seizures, blindness, vocalization, agitation, and transient loss of vision. Hypothermia, pruritus, hypotension, and cardiac arrest were also documented.

TREATMENT AND OUTCOME

The 2 affected patients responded to treatment with anticonvulsant medications, centrally acting muscle relaxants, sedation, and intensive supportive care including IV fluid administration and oxygen supplementation as needed. Cardiopulmonary cerebral resuscitation was performed successfully in the cat. The dog that did not develop any clinical signs was not treated. The 2 affected patients recovered fully and were discharged from the hospital after 3 to 4 days with no apparent sequelae.

CLINICAL RELEVANCE

Penicillin G procaine-penicillin G benzathine and propofol are common drugs in veterinary practice and may both be administered to patients undergoing elective procedures. Because of their similar milky white appearance, veterinarians should label syringes and take care to avoid this medication error. There is no specific antidote for penicillin orprocaine toxicosis. Aggressive and immediate treatment is required in patients that develop an adverse reaction to ensure a successful outcome.

Anaphylactic reaction to intralesional corticosteroid injection

We report the case of anaphylactic reaction to carboxymethylcellulose, a dispersant in corticosteroid preparation and contrast media. Skin prick testing in this patient revealed a positive response to carboxymethylcellulose at a dilution of 1/1000. Anaphylaxis secondary to carboxymethylcellulose has previously been reported. To avoid further problems, this patient was advised to alert medical staff for the presence of allergy to carboxymethylcellulose in the event of the need for further interventional procedures. Care should be taken when giving intradermal steroids to patients with a history of anaphylaxis after contrast media.

Delayed Hypersensitivity Reaction After Intravenous Glucagon Administered for a Barium Enema: A Case Report

Introduction: Few reports have documented allergic hypersensitivity reactions after barium gastrointestinal studies. Of these, the barium suspension, its additives or intravenous glucagon given for bowel relaxation has been implicated as possible allergens. We report a patient with delayed hypersensitivity reaction after barium enema and discuss the reasons supporting glucagon as the possible allergen. Clinical Picture: A 74-year-old Chinese woman presented with pruritic rashes, 1 day after a barium enema. Intravenous glucagon (GlucaGen®, Novo Nordisk, Denmark) was administered during the barium enema. Physical examination revealed palpable purpuric rashes on the legs with erythematous papules and plaques on the arms and trunk. Skin biopsy demonstrated superficial perivascular infiltrates of lymphocytes and eosinophils, consistent with a drug eruption. Treatment and Outcome: The rashes resolved with antihistamines and topical corticosteroids. Conclusion: This report highlights the potential of glucagon to cause hypersensitivity reactions. Awareness of this entity is important for the prevention and recognition of complications during barium gastrointestinal studies. Key words: Gastrointestinal, Hypersensitivity, Parasympatholytics, Radiology

Contact Urticaria from Carboxymethylcellulose in White Chalk

BACKGROUND

Carboxymethylcellulose (CMC) is widely used in consumer goods, foods, and medicaments as a binder, emulsifier, and viscosity enhancer. Cases of immediate and delayed allergic reactions to this anionic cellulose polymer have been reported.

OBJECTIVE

To report a case of contact urticaria from CMC in chalk, with possible cross-reaction to methyl hydroxyethylcellulose (MHEC).

METHOD

Patch tests with readings at 48 and 96 hours were performed with the North American Contact Dermatitis Group standard series and benzisothiazolinone. Open and prick tests with readings after 30 minutes were performed with two brands of chalk as well as with various petrolatum and aqueous dilutions of CMC, MHEC, oleic acid, and calcium carbonate.

RESULTS

The patient developed strong urticarial reactions during open tests with both powdered chalks and had milder reactions to the open test with CMC 10% aqueous (aq) and to prick testing with CMC 0.1% aq. No reaction to MHEC or any of the other ingredients of the chalks was observed. No relevant delayed reaction was noted.

CONCLUSION

CMC can cause contact urticaria. It remains unclear why our patient reacted more strongly to the chalk than to CMC itself. We speculate that the abrasive nature of the chalk enhances the cutaneous penetration of CMC or that calcium carbonate, the main ingredient of the chalk, acts as an adjuvant. It is also possible that CMC and MHEC cross-react and that our negative results with MHEC may be due to improper testing technique or concentrations.

Prospective evaluation of a jelly-like conducting medium for catheter US probe imaging of esophageal and duodenal lesions

BACKGROUND

The catheter probe EUS(C-EUS) relies on luminal water for acoustic coupling. However, in tubular structures, such as the esophagus and the duodenum, instilled water drains away rapidly. The use of water-filled balloons is limited by air artifact and other problems. This study evaluated the image quality, the penetration depth, the tumor staging accuracy, and the safety of C-EUS by using carboxymethylcellulose, an edible, nontoxic, transparent jelly-like substance (JC-EUS).

METHODS

Forty patients with an esophageal or a duodenal submucosal lesion or an esophageal carcinoma were evaluated prospectively in a crossover study with both C-EUS and JC-EUS when using a 12-MHz US catheter probe. Based on still images, depth of US penetration and image quality (by using a predefined 1 to 5 scale) were assessed by a blinded, independent endosonographer.

OBSERVATIONS

JC-EUS was superior in image quality compared with C-EUS overall (mean score: 4.9 vs. 2.6; p <0.001), as well as in each subgroup (esophageal carcinoma, esophageal submucosal lesion, duodenal submucosal lesion). Penetration depth was not significantly different (2.5 cm). Staging was 100% accurate in 14 patients with esophageal cancer who underwent surgery. There was no procedure-related complication.

CONCLUSIONS

JC-EUS is safe, provides superior image quality to C-EUS, and is accurate for local staging of esophageal cancer.

Anaphylaxis to the carbohydrate carboxymethylcellulose in parenteral corticosteroid preparations

BACKGROUND

Carboxymethylcellulose is a carbohydrate widely used as additive in tablets, cosmetics, some injectable hormone formulations, food (as E466) and as active principle in hydrocolloid dressings. Anaphylaxis to carboxymethylcellulose in parenteral corticosteroid preparations has previously been reported. Typically, skin tests were positive in such cases, occasionally specific IgE or histamine release have been demonstrated.

CASE REPORT

We report on 3 patients who suffered from anaphylactic symptoms after local injection of corticosteroid preparations. Intracutaneous skin tests with carboxymethylcellulose were positive; in 2, sulfidoleukotriene release could be measured in the cellular antigen stimulation test (CAST). Specific IgE could not be identified. Oral provocation tests with typical doses of carboxymethylcellulose as found in food and tablets were negative.

CONCLUSION

In patients with anaphylaxis to parenteral administration of carboxymethylcellulose, small amounts are tolerated by the oral route. Skin tests and CAST are useful diagnostic tools.

Anaphylactic shock reaction to dibutyl-phthalate-containing capsules

We report on a patient who was taking a Gelomyrtol forte capsule, a mucosecretolytic herbal product, to treat an infection of the upper respiratory tract. Itching, urticaria and respiratory distress occurred after 20 min which culminated in anaphylactic shock. Prick tests were carried out with the individual substances from Gelomyrtol forte capsules. Dibutyl phthalate produced a strong positive result. It is used as a plasticizer in films covering tablets, dragées and capsules. As a triggering agent of anaphylactic reactions to drugs, the auxiliary materials, e.g. dibutyl phthalate, should also be taken into consideration.

[Barium sulfate poisoning?]

We report a case with neurologic symptoms which occurred after iterative radiologic examinations of the gastrointestinal tract with barium sulphate, which were related to a barium encephalopathy. Suspected by the presence of barium in the blood, a systematic intoxication was occurred without any evidence for a gut or a vascular leak. This case raises the question about a possible extraluminal diffusion of such a heavy metal, given orally, in normal conditions of use.