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Patch Testing in Drug Eruptions: Practical Aspects and Literature Review of Eruptions and Culprit Drugs. Dermatitis 2022; 33:16-30. [PMID: 35029348 DOI: 10.1097/der.0000000000000839] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT There is overwhelming evidence that many delayed cutaneous adverse drug reactions (beginning >6 hours after drug intake) are mediated by delayed-type (type IV) hypersensitivity, including maculopapular eruptions, erythroderma, symmetrical drug-related intertriginous and flexural exanthema/baboon syndrome, eczematous eruptions, fixed drug eruptions, acute generalized exanthematous pustulosis, and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome. Therefore, after resolution of the reaction, patch tests should be performed as first diagnostic method to identify the culprit drug(s). This article provides tools to perform drug patch tests properly and safely, discussing clinical history, indications, procedure, drug patch test materials, sensitivity, the meaning of negative patch tests, and safety of the procedure. In addition, a literature review of eruptions and culprit drugs is provided in tabular format.
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Cardoso‐Fernandes A, Blumenthal KG, Chiriac AM, Tarrio I, Afonso‐João D, Delgado L, Fonseca JA, Azevedo LF, Sousa‐Pinto B. Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis. Clin Transl Allergy 2021; 11:e12008. [PMID: 34161664 PMCID: PMC8215894 DOI: 10.1002/clt2.12008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold-standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β-lactams. METHODS We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta-analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. RESULTS We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%-0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non-immediate index reactions (OR = 0.05; 95% CrI = 0-0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7-21.5; I2 = 0.3%). Performance of direct DPTs in low-risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. CONCLUSIONS In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life-threatening index reactions or patients with positive skin tests-who were mostly not assessed in this analysis -, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.
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Affiliation(s)
- António Cardoso‐Fernandes
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolHarvard UniversityBostonMassachusettsUSA
| | - Anca Mirela Chiriac
- Department of PulmonologyDivision of Allergy, Hôpital Arnaud de VilleneuveUniversity Hospital of MontpellierMontpellierFrance
- UMR‐S 1136 INSERM‐Sorbonne UniversitéEquipe Epidémiologie des Maladies Allergiques et Respiratoires (EPAR)Institut Pierre Louis d’Epidémiologie et de Santé PubliqueParisFrance
| | - Isabel Tarrio
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - David Afonso‐João
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Delgado
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - João Almeida Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Luís Filipe Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
| | - Bernardo Sousa‐Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS)Faculty of Medicine, University of PortoPortoPortugal
- Center for Health Technology and Services Research (CINTESIS)Faculty of Medicine, University of PortoPortoPortugal
- Basic and Clinical Immunology Unit, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
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Mahler V, Nast A, Bauer A, Becker D, Brasch J, Breuer K, Dickel H, Drexler H, Elsner P, Geier J, John SM, Kreft B, Köllner A, Merk H, Ott H, Pleschka S, Portisch M, Spornraft-Ragaller P, Weisshaar E, Werfel T, Worm M, Schnuch A, Uter W. S3 guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 1. J Dtsch Dermatol Ges 2020; 17:1076-1093. [PMID: 31631537 DOI: 10.1111/ddg.13956] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens. Note: This publication is part 1 of the short version of the S3 guidelines for "Epicutaneous patch testing using contact allergens and drugs" (registry no. 013 - 018; date: March 20, 2019; valid until December 31, 2021). Part 2 of the short version will be published in the next issue. The long version of these guidelines can be accessed at www.awmf.org. The method report is available as online publication (https://www.awmf.org/leitlinien/detail/ll/013-018.html) and contains the evidence tables in its appendix.
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Affiliation(s)
- Vera Mahler
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Paul-Ehrlich-Institut, Langen, Germany
| | - Alexander Nast
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt University of Berlin, and Berlin Institute of Health, Department of Dermatology, Venereology und Allergology, Division of Evidence-based Medicine (dEBM), Berlin, Germany
| | - Andrea Bauer
- Department of Dermatology, University Medical Center, Dresden Technical University, Dresden, Germany
| | - Detlef Becker
- Department of Dermatology, University Medical Center, Mainz, Germany
| | - Jochen Brasch
- Department of Dermatology, Venereology und Allergology, University Medical Center, Kiel, Germany
| | - Kristine Breuer
- Dermatology Practice (Dermatologie Reinbek), Reinbek, Germany
| | - Heinrich Dickel
- Department of Dermatology, Venereology und Allergology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Hans Drexler
- Institute for Occupational, Social and Environmental Medicine, Friedrich--Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Elsner
- Department of Dermatology, University Hospital Jena, Jena, Germany
| | - Johannes Geier
- Information Network of Departments of Dermatology (IVDK), Institute at the University Medical Centre Göttingen, Göttingen, Germany
| | - Swen Malte John
- Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm), University of Osnabrück, Osnabrück, Germany
| | - Burkhard Kreft
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | | | - Hans Merk
- Professor of Dermatology and Allergology, Former Chairman of the Department of Dermatology, RWTH University, Aachen, Germany
| | - Hagen Ott
- Division of Pediatric Dermatology and Allergology, Children's Hospital Auf der Bult, Hannover, Germany
| | - Silvia Pleschka
- German Allergy and Asthma Foundation (Deutscher Allergie- und Asthmabund e.V.), Mönchengladbach, Germany
| | - Maria Portisch
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Petra Spornraft-Ragaller
- Department of Dermatology, University Medical Center, Dresden Technical University, Dresden, Germany
| | - Elke Weisshaar
- Division of Occupational Dermatology, Department of Dermatology, University Medical Center, Heidelberg, Germany
| | - Thomas Werfel
- Department of Dermatology and Allergy, , Hannover Medical School, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology und Allergology, Charité - UniversityMedicine, Berlin, Germany
| | - Axel Schnuch
- Information Network of Departments of Dermatology (IVDK), Institute at the University Medical Centre Göttingen, Göttingen, Germany
| | - Wolfgang Uter
- Institute for Medical Informatics, Biometrics and Epidemiology (IMBE), Medical Faculty, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
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4
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Bergmann MM, Caubet JC. Role of in vivo and in vitro Tests in the Diagnosis of Severe Cutaneous Adverse Reactions (SCAR) to Drug. Curr Pharm Des 2020; 25:3872-3880. [PMID: 31696801 DOI: 10.2174/1381612825666191107104126] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/06/2019] [Indexed: 12/18/2022]
Abstract
Severe cutaneous adverse reactions (SCAR) are life-threatening conditions including acute generalized exanthematous pustulosis (AGEP), Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS). Diagnosis of causative underlying drug hypersensitivity (DH) is mandatory due to the high morbidity and mortality upon re-exposure with the incriminated drug. If an underlying DH is suspected, in vivo test, including patch tests (PTs), delayed-reading intradermal tests (IDTs) and in vitro tests can be performed in selected patients for which the suspected culprit drug is mandatory, or in order to find a safe alternative treatment. Positivity of in vivo and in vitro tests in SCAR to drug varies depending on the type of reaction and the incriminated drugs. Due to the severe nature of these reactions, drug provocation test (DPT) is highly contraindicated in patients who experienced SCAR. Thus, sensitivity is based on positive test results in patients with a suggestive clinical history. Patch tests still remain the first-line diagnostic tests in the majority of patients with SCAR, followed, in case of negative results, by delayed-reading IDTs, with the exception of patients with bullous diseases where IDTs are still contra-indicated. In vitro tests have shown promising results in the diagnosis of SCAR to drug. Positivity is particularly high when the lymphocyte transformation test (LTT) is combined with cytokines and cytotoxic markers measurement (cyto-LTT), but this still has to be confirmed with larger studies. Due to the rarity of SCAR, large multi-center collaborative studies are needed to better study the sensitivity and specificity of in vivo and in vitro tests.
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Affiliation(s)
- Marcel M Bergmann
- Pediatric Allergology Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland.,Centro Pediatrico del Mendrisiotto, Mendrisio, Switzerland
| | - Jean-Christoph Caubet
- Pediatric Allergology Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
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Mahler V, Nast A, Bauer A, Becker D, Brasch J, Breuer K, Dickel H, Drexler H, Elsner P, Geier J, John SM, Kreft B, Köllner A, Merk H, Ott H, Pleschka S, Portisch M, Spornraft‐Ragaller P, Weisshaar E, Werfel T, Worm M, Schnuch A, Uter W. S3‐Leitlinie: Durchführung des Epikutantests mit Kontaktallergenen und Arzneimitteln – Kurzfassung Teil 1. J Dtsch Dermatol Ges 2019; 17:1075-1093. [DOI: 10.1111/ddg.13956_g] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Vera Mahler
- Hautklinik Universitätsklinikum ErlangenFriedrich‐Alexander‐Universität Erlangen‐Nürnberg Erlangen
- Paul‐Ehrlich‐Institut Langen
| | - Alexander Nast
- Division of Evidence‐Based Medicine (dEBM)Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin Berlin Berlin
| | - Andrea Bauer
- Klinik und Poliklinik für Dermatologie Universitätsklinikum Carl Gustav CarusTechnische Universität Dresden Dresden
| | | | - Jochen Brasch
- Klinik für DermatologieVenerologie und AllergologieUniversitätsklinikum Schleswig‐Holstein Kiel
| | | | - Heinrich Dickel
- Klinik für DermatologieVenerologie und AllergologieSt. Josef‐Hospital Ruhr‐Universität Bochum Bochum
| | - Hans Drexler
- Institut für Arbeits‐, Sozial‐ und Umweltmedizin der Friedrich‐Alexander‐Universität Erlangen‐Nürnberg Erlangen
| | - Peter Elsner
- Klinik für HautkrankheitenUniversitätsklinikum Jena Jena
| | - Johannes Geier
- Informationsverbund Dermatologischer Kliniken (IVDK) e.V. an der Universitätsmedizin Göttingen Göttingen
| | - Swen Malte John
- Institut für interdisziplinäre Dermatologische Prävention und Rehabilitation (iDerm) an der Universität Osnabrück Osnabrück
| | - Burkhard Kreft
- Klinik und Poliklinik für Dermatologie und VenerologieUniversitätsklinikum Halle (Saale) Halle
| | | | - Hans Merk
- Univ.‐Professor für Dermatologie & AllergologieDirektor (em.) der Hautklinik – RWTH Aachen University Aachen
| | - Hagen Ott
- Hannoversche Kinderheilanstalt (HKA): Kinder‐ und Jugendkrankenhaus auf der Bult Hannover
| | | | - Maria Portisch
- Hautklinik Universitätsklinikum ErlangenFriedrich‐Alexander‐Universität Erlangen‐Nürnberg Erlangen
| | - Petra Spornraft‐Ragaller
- Klinik und Poliklinik für Dermatologie Universitätsklinikum Carl Gustav CarusTechnische Universität Dresden Dresden
| | - Elke Weisshaar
- Berufsdermatologie, Hautklinik, Universitätsklinikum Heidelberg Heidelberg
| | - Thomas Werfel
- Klinik für Dermatologie, Allergologie und VenerologieMedizinische Hochschule Hannover Hannover
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie Charité ‐ Universitätsmedizin Berlin Berlin
| | - Axel Schnuch
- Informationsverbund Dermatologischer Kliniken (IVDK) e.V. an der Universitätsmedizin Göttingen Göttingen
| | - Wolfgang Uter
- Institut für Medizininformatik, Biometrie und Epidemiologie (IMBE)Medizinische Fakultät der Friedrich‐Alexander‐Universität Erlangen‐Nürnberg Erlangen
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Torres MJ, Celik GE, Whitaker P, Atanaskovic-Markovic M, Barbaud A, Bircher A, Blanca M, Brockow K, Caubet JC, Cernadas JR, Chiriac A, Demoly P, Garvey LH, Merk HF, Mosbech H, Nakonechna A, Romano A. A EAACI drug allergy interest group survey on how European allergy specialists deal with β-lactam allergy. Allergy 2019; 74:1052-1062. [PMID: 30637768 DOI: 10.1111/all.13721] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/09/2018] [Accepted: 08/22/2018] [Indexed: 12/18/2022]
Abstract
An accurate diagnosis of β-lactam (BL) allergy can reduce patient morbidity and mortality. Our aim was to investigate the availability of BL reagents, their use and test procedures in different parts of Europe, as well as any differences in the diagnostic workups for evaluating subjects with BL hypersensitivity. A survey was emailed to all members of the EAACI Drug Allergy Interest Group (DAIG) between February and April 2016, and the questionnaire was meant to study the management of suspected BL hypersensitivity. The questionnaire was emailed to 82 DAIG centres and answered by 57. Amoxicillin alone or combined to clavulanic acid were the most commonly involved BL except in the Danish centre, where penicillin V was the most frequently suspected BL. All centres performed an allergy workup in subjects with histories of hypersensitivity to BL: 53 centres (93%) followed DAIG guidelines, two national guidelines and two local guidelines. However, there were deviations from DAIG recommendations concerning allergy tests, especially drug provocation tests. A significant heterogeneity exists in current practice not only among countries, but also among centres within the same country. This suggests the need to re-evaluate, update and standardize protocols on the management of patients with suspected BL allergy.
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Affiliation(s)
- Maria Jose Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA-UMA; Malaga Spain
| | - Gulfem Elif Celik
- Department of Immunology and Allergy; Ankara University School of Medicine; Ankara Turkey
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | | | - Annick Barbaud
- Dermatology and Allergology Department; Tenon Hospital (AP-HP); Sorbonne Universities; UPMC University Paris 06; Paris France
| | | | - Miguel Blanca
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
| | | | | | - Anca Chiriac
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UMRS 1136; Equipe - EPAR - IPLESP; Sorbonne Universités; UPMC Univ Paris 06; Paris France
| | - Pascal Demoly
- Division of Allergy; Department of Pulmonology; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
| | - Lene Heise Garvey
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Hans F. Merk
- Department of Dermatology and Allergology; RWTH Aachen University; Aachen Germany
| | - Holger Mosbech
- Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - Alla Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospitals; Liverpool UK
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7
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Barnig C, Baron-Thurotte A, Barbaud A, Beaudouin E, de Blay F, Bonniaud P, Demoly P, Deschildre A, Didier A, Drouet M, Just J, Lavaud F, Mailhol C, Metz-Favre C, Neukirch C, Petit N, Perotin JM, Ponvert C, Sauvage C, Magnan A, Birnbaum J. Recommandations de la Société Française d’Allergologie. Indications des actes allergologiques en Hôpital de Jour. REVUE FRANCAISE D ALLERGOLOGIE 2017. [DOI: 10.1016/j.reval.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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8
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Preventing Kounis syndrome by stent implantation: a reciprocal process? Anatol J Cardiol 2017; 18:238. [PMID: 28883309 PMCID: PMC5689058 DOI: 10.14744/anatoljcardiol.2017.7963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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10
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Peter JG, Lehloenya R, Dlamini S, Risma K, White KD, Konvinse KC, Phillips EJ. Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:547-563. [PMID: 28483310 PMCID: PMC5424615 DOI: 10.1016/j.jaip.2017.01.025] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/11/2017] [Accepted: 01/18/2017] [Indexed: 12/17/2022]
Abstract
Most immune-mediated adverse drug reactions (IM-ADRs) involve the skin, and many have additional systemic features. Severe cutaneous adverse drug reactions (SCARs) are an uncommon, potentially life-threatening, and challenging subgroup of IM-ADRs with diverse clinical phenotypes, mechanisms, and offending drugs. T-cell-mediated immunopathology is central to these severe delayed reactions, but effector cells and cytokines differ by clinical phenotype. Strong HLA-gene associations have been elucidated for specific drug-SCAR IM-ADRs such as Stevens-Johnson syndrome/toxic epidermal necrolysis, although the mechanisms by which carriage of a specific HLA allele is necessary but not sufficient for the development of many IM-ADRs is still being defined. SCAR management is complicated by substantial short- and long-term morbidity/mortality and the potential need to treat ongoing comorbid disease with related medications. Multidisciplinary specialist teams at experienced units should care for patients. In the setting of SCAR, patient outcomes as well as preventive, diagnostic, treatment, and management approaches are often not generalizable, but rather context specific, driven by population HLA-genetics, the pharmacology and genetic risk factors of the implicated drug, severity of underlying comorbid disease necessitating ongoing treatments, and cost considerations. In this review, we update the basic and clinical science of SCAR diagnosis and management.
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Affiliation(s)
- Jonathan Grant Peter
- Division of Allergology and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rannakoe Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kimberly Risma
- Division of Allergy, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katie D White
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Katherine C Konvinse
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia.
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11
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Balakirski G, Merk HF. Cutaneous allergic drug reactions: update on pathophysiology, diagnostic procedures and differential diagnosic. Cutan Ocul Toxicol 2017; 36:307-316. [DOI: 10.1080/15569527.2017.1319379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Galina Balakirski
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, Germany
| | - Hans F. Merk
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, Germany
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12
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Weinborn M, Barbaud A, Truchetet F, Beurey P, Germain L, Cribier B. Histopathological study of six types of adverse cutaneous drug reactions using granulysin expression. Int J Dermatol 2016; 55:1225-1233. [DOI: 10.1111/ijd.13350] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 03/07/2016] [Accepted: 03/20/2016] [Indexed: 01/26/2023]
Affiliation(s)
- Marie Weinborn
- Department of Dermatology; Nancy University Hospital; Brabois Hospital; Vandoeuvre-les-Nancy France
| | - Annick Barbaud
- Department of Dermatology; Nancy University Hospital; Brabois Hospital; Vandoeuvre-les-Nancy France
| | - Francois Truchetet
- Department of Dermatology; Metz-Thionville Regional Hospital; Thionville France
| | | | - Lucie Germain
- Department of Clinical Epidemiology and Evaluation; Nancy University Hospital; Nancy France
| | - Bernard Cribier
- Department of Dermatology; Strasbourg University Hospital; Strasbourg France
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13
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Brajon D, Menetre S, Waton J, Poreaux C, Barbaud A. Non-irritant concentrations and amounts of active ingredient in drug patch tests. Contact Dermatitis 2014; 71:170-5. [DOI: 10.1111/cod.12269] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/30/2014] [Accepted: 05/10/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Delphine Brajon
- Dermatology and Allergy Department; Brabois Hospital, Batiment des Specialites Medicales, University Hospital of Nancy; Rue du Morvan 54500 Vandoeuvre les Nancy France
| | - Sophie Menetre
- Pharmacy Department; Brabois Hospital, University Hospital of Nancy; Rue du Morvan 54500 Vandoeuvre les Nancy France
| | - Julie Waton
- Dermatology and Allergy Department; Brabois Hospital, Batiment des Specialites Medicales, University Hospital of Nancy; Rue du Morvan 54500 Vandoeuvre les Nancy France
- Faculte de Medecine, Research Unit EA 72-98 ‘INGRES’, Lorraine University; 54500 Vandoeuvre les Nancy France
| | - Claire Poreaux
- Dermatology and Allergy Department; Brabois Hospital, Batiment des Specialites Medicales, University Hospital of Nancy; Rue du Morvan 54500 Vandoeuvre les Nancy France
| | - Annick Barbaud
- Dermatology and Allergy Department; Brabois Hospital, Batiment des Specialites Medicales, University Hospital of Nancy; Rue du Morvan 54500 Vandoeuvre les Nancy France
- Faculte de Medecine, Research Unit EA 72-98 ‘INGRES’, Lorraine University; 54500 Vandoeuvre les Nancy France
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Abstract
Drug skin tests can reproduce delayed hypersensitivity to drugs and entail a moderate reexposure of patients to offending drugs. Drug patch tests (DPTs) and prick tests can be done with any commercialized form of a drug. In non-severe delayed non-IgE-mediated reactions to drugs, intradermal tests (IDT) with delayed readings have a greater value, but their techniques lack standardization. A negative drug skin test does not exclude the responsibility of a drug, and the drug must be rechallenged in non-severe cases. DPTs are useful in maculopapular rashes, flexural exanthemas, and if done in situ, also in fixed drug eruption. Their best indication is in acute generalized exanthematous pustulosis or drug reaction with eosinophilia and systemic symptoms (DRESS). They should be carried out cautiously, following strict guidelines. Prick tests have a low value but they can sometimes be positive on delayed readings. In non-severe delayed reactions to drugs, intradermal tests with delayed readings are the most sensitive skin tests especially for beta-lactam antibiotics, radiocontrast media, heparins but also some biological agents. The value of patch testing varies according to the implicated drug and the non-immediate adverse drug reaction. In DRESS, DPTs have a good value in testing carbamazepine or proton pump inhibitors but remain negative in testing with allopurinol or salazopyrin. In toxic epidermal necrolysis, DPTs are safe but positive in only 9 to 23 % of the reported cases.
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Rodilla EM, González ID, Yges EL, Bellido FJM, Bara MTG, Toledano FL. Immunological aspects of nonimmediate reactions to β-lactam antibiotics. Expert Rev Clin Immunol 2014; 6:789-800. [DOI: 10.1586/eci.10.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Liippo J, Pummi K, Hohenthal U, Lammintausta K. Patch testing and sensitization to multiple drugs. Contact Dermatitis 2013; 69:296-302. [DOI: 10.1111/cod.12076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/21/2013] [Accepted: 02/09/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Jussi Liippo
- Department of Dermatology; Turku University Hospital; 20521 Turku Finland
| | - Kati Pummi
- Department of Dermatology; Turku University Hospital; 20521 Turku Finland
- Department of Pathology; Turku University Hospital; 20521 Turku Finland
| | - Ulla Hohenthal
- Department of Internal Medicine; Turku University Hospital; 20521 Turku Finland
| | - Kaija Lammintausta
- Department of Dermatology; Turku University Hospital; 20521 Turku Finland
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Ramasamy SN, Korb-Wells CS, Kannangara DRW, Smith MWH, Wang N, Roberts DM, Graham GG, Williams KM, Day RO. Allopurinol Hypersensitivity: A Systematic Review of All Published Cases, 1950–2012. Drug Saf 2013; 36:953-80. [DOI: 10.1007/s40264-013-0084-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Studer M, Waton J, Bursztejn AC, Aimone-Gastin I, Schmutz JL, Barbaud A. [Does hypersensitivity to multiple drugs really exist?]. Ann Dermatol Venereol 2012; 139:375-80. [PMID: 22578342 DOI: 10.1016/j.annder.2012.03.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/06/2011] [Accepted: 03/16/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple-drug hypersensitivity (MDH) in the literature concerns different entities. Our objective was to define its frequency and characteristics in patients examined for cutaneous adverse drug reaction (CADR) before studying genetic predisposition. MATERIALS AND METHODS From a database comprising all patients referred for CADR between 2000 and 2010, we selected those meeting the following criteria: sensitisation to at least two chemically unrelated substances, as confirmed by positive skin tests or challenge tests. The following were excluded: patients with haematological diseases, HIV or chronic wounds and sensitization to the excipients. RESULTS Of the 1925 patients included, 11 (0.6%) were classed as polysensitized: eight women and three men, of mean age 62 years, presenting 2.5 episodes of drug hypersensitivity per patient. Four cases of DRESS were noted. DISCUSSION The strict criteria stipulated for this study enabled us to select patients with MDH, and to affirm that while it does in fact exist, it seems rare. Compared to polysensitized patients described in the literature, we preferred to distinguish between three groups of MDH: one occurring with different substances in separate episodes of CADR, one occurring with different substances during the same episode of CADR, and one occurring during DRESS and correlating with viral replication. CONCLUSION MDH exists and genetic predisposition could be investigated by studying cytokine polymorphism in such patients. However, because of its rarity, it is impossible to rule out fortuitous association of two episodes of CADR in the same patient.
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Affiliation(s)
- M Studer
- Service de Dermatologie, Hôpital de Brabois, CHU de Nancy, Bâtiment Philippe-Canton, 6, Rue du Morvan, 54511 Vandœuvre-lès-Nancy Cedex, France.
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Abstract
Penicillins and cephalosporins are the most widely used antibiotics for the treatment of common infections, and they are the two main classes of β-lactams. On the basis of the time of appearance of the reaction after drug intake and for diagnostic purposes, hypersensitivity reactions to β-lactams have been classified as immediate or non-immediate. The diagnostic evaluation of allergic reactions to β-lactams has changed over the last decade, for several reasons. In many countries, major and minor determinants for skin testing are not available. In immediate allergic reactions, the sensitivity of skin testing is decreasing. For non-immediate reactions, skin testing appears to be less sensitive than previously reported. The drug provocation test is still necessary for diagnosis. In this education review series, we described three cases of β-lactam allergy: first, a child with an IgE-mediated allergy to benzyl-penicillin; second, a child with a non-allergic hypersensitivity to amoxicillin; and in the third patient, we will discuss about cross-reactivity between penicillins and cephalosporins. These cases are correlated with the practical management of evaluating β-lactam allergy.
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Abstract
PURPOSE OF REVIEW Drug provocation test (DPT) is necessary to diagnose most drug hypersensitivity reactions (HSRs) due to decreased sensitivity of skin testing even when combined with in-vitro tests in immunonologic drug HSR and limited availability of these tests in nonimmunologic reaction. We review the principles and controversial issues of DPT, and recent studies using DPT as a diagnostic tool. RECENT FINDINGS DPT is recommended in the diagnosis of HSR to β-lactams, as well as other drug classes [such as acetylsalicylic acid-NSAIDs (ASA-NSAIDs), non-β-lactams antibiotics, heparin, glucocorticoids, and local anesthetic agents]. In view of the decreased sensitivity of skin testing, limited accessibility to new benzylpenicillin polylysine (PPL)/mixture of minor determinant (MDM) test reagents and limited availability of validated sensitive in-vitro tests, individuals who require DPT to β-lactams are increasing. The negative predictive value of allergologic work-up is very high, ranging from 94 to 98% for β-lactams and those reactions after negative tests are mostly nonimmediate and mild. Finally, DPT is recommended to ascertain tolerability of alternative compound when evaluating cross-reactivity among different classes of β-lactams, NSAIDs and glucocorticoids, and possibly iodinated contrast media. SUMMARY DPT is often needed when evaluating patients with suspected drug HSR. More studies regarding standardization of the various protocols are needed in order to increase its acceptance and adoption as a standard practice in the diagnostic algorithm for drug HSR.
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Tang YH, Mockenhaupt M, Henry A, Bounoua M, Naldi L, Le Gouvello S, Bensussan A, Roujeau JC. Poor relevance of a lymphocyte proliferation assay in lamotrigine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis. Clin Exp Allergy 2011; 42:248-54. [PMID: 22092454 DOI: 10.1111/j.1365-2222.2011.03875.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 08/10/2011] [Accepted: 08/23/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND Prior use of 'lymphocyte transformation test' (LTT) in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) provided conflicting results, possibly dependent on sampling dates (acute vs. late). OBJECTIVE Evaluation of LTT in patients with SJS or TEN who reacted to lamotrigine (LTG). In a small subgroup we explored the possible role of regulatory T cells (T-reg). METHODS Acute phase samples (9) and post-recovery samples (14) from cases of SJS or TEN to LTG were provided by the RegiSCAR-study group. Controls were persons never exposed to LTG (12), patients exposed without reaction (6), and patients who developed a mild eruption to LTG (6). LTT was performed by measuring (3) H-thymidine incorporation after 3 days of incubation with phytohemmaglutinin, LTG (10 μg/mL) or medium. Stimulation index ≥ 2 was considered positive. In 16 cases LTT was redone after depletion of T-reg by fluorescence activated cell sorting. RESULTS Positive LTT was observed in 3/6 cases of mild eruptions, 1/9 SJS/TEN-cases tested during the acute phase and 3/14 SJS/TEN-cases tested after recovery. We noted a very mild and nonsignificant trend for an increased response after depletion of T-reg in late samples from SJS or TEN patients. CONCLUSIONS AND CLINICAL RELEVANCE With the largest number of LTT performed in patients with SJS or TEN to a single drug, we confirmed that reactive cells are rarely detected in these reactions. Poor reactivity did not seem related to T-reg. Other in vitro assays than those testing proliferation should be evaluated, before raising the hypothesis that specific cells disappeared by undergoing apoptosis during the reaction.
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Affiliation(s)
- Y H Tang
- Inserm U 841, Université Paris-Est Créteil, Créteil, France
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Waton J, Pouget-Jasson C, Loos-Ayav C, Trechot P, Bursztejn AC, Schmutz JL, Barbaud A. Drug re-challenges in cutaneous adverse drug reactions: information and effectiveness in the long-term management of patients. Allergy 2011; 66:941-7. [PMID: 21303375 DOI: 10.1111/j.1398-9995.2011.02554.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In patients with cutaneous adverse drug reactions (CADR), drug skin tests and re-challenge under hospital surveillance (RCH) are helpful. The aim of this study was to determine if patients with negative drug RCH can tolerate subsequent treatments with the same drugs. PATIENTS AND METHODS Patients with a negative RCH in the last 10 years answered a telephone questionnaire which was delivered by the same investigator in order to determine if subsequently the patients were able to tolerate the drug with which they had a negative RCH and also to study the reasons why the drugs were not taken again. RESULTS Six hundred and thirty-seven RCH were analyzed (349 patients, mean age 47 years), 134 drugs were taken again (group A) and 359 were not (group B). In group A, 12 reactions occurred in 10 patients (9%). In group B, drugs were not taken again because 76% of the patients evaluated for an intolerance to antibiotics or radiocontrast media did not require a new course of these products or because their general practitioner (GP) did not want to prescribe these drugs. DISCUSSION Ninety percent of the RCH (88.5% of the patients) with a CADR followed by investigations and a RCH have a good tolerance to subsequent treatment with the RC drug. The mechanisms involved in this intolerance despite negative RCH are discussed. CONCLUSION The provocation test procedure, considered as useful by 88% of the patients, has a good negative predictive value. Furthermore, these investigations need to be accompanied by clear information on the patient and his GP.
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Affiliation(s)
- J Waton
- Dermatology Department, Medicine University of Nancy, Nancy 54000, France
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Diagnosis and management of drug hypersensitivity reactions. J Allergy Clin Immunol 2011; 127:S67-73. [PMID: 21354502 DOI: 10.1016/j.jaci.2010.11.047] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 11/12/2010] [Indexed: 11/24/2022]
Abstract
The present article addresses the advances in the diagnosis and management of drug hypersensitivity reactions that were discussed in the 4th Drug Hypersensitivity Meeting held in Rome in April 2010. Such reactions can be classified as immediate or nonimmediate according to the time interval between the last drug administration and onset. Immediate reactions occur within 1 hour, and nonimmediate reactions occur after more than 1 hour. Clinical and immunologic studies suggest that type-I (IgE-mediated) and type-IV (T cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. In diagnosis prick, patch, and intradermal tests are the most readily available tools. Determination of specific IgE levels is still the most common in vitro method for diagnosing immediate reactions. New diagnostic tools, such as the basophil activation test, the lymphocyte activation test, and enzyme-linked immunospot assays for analysis of the frequency of antigen-specific, cytokine-producing cells, have been developed for evaluating either immediate or nonimmediate reactions. The sensitivity of allergologic tests is not 100%; therefore in selected cases provocation tests are necessary. In the diagnosis of nonallergic hypersensitivity reactions to nonsteroidal anti-inflammatory drugs, the provocation test with the suspected drug still represents the "gold standard." However, there was no consensus regarding the use of this test in subjects with histories of hypersensitivity reactions to 1 (single reactors) or more (multiple reactors) nonsteroidal anti-inflammatory drugs. With regard to management, desensitization allows patients to be treated with irreplaceable chemotherapy agents, such as taxanes, platinum salts, and mAbs, to which they have presented hypersensitivity reactions. Desensitization also permits the use of aspirin in aspirin-sensitive patients undergoing revascularization and in subjects with aspirin-exacerbated respiratory disease.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Barbaud A. [Drug patch tests in the investigation of cutaneous adverse drug reactions]. Ann Dermatol Venereol 2009; 136:635-44. [PMID: 19686903 DOI: 10.1016/j.annder.2009.06.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cutaneous adverse drug reactions (CADR) are a frequent problem in clinical medicine. Since patients are often on multiple drug regimes, it is often difficult to pinpoint the relevant drug from history alone. Besides clinical and chronological parameters, patch testing with the suspected compound has been reported as helpful in determining the cause of a CADR and in studying the physiopathological mechanisms involved in such reactions. The key advantage of drug patch tests is that they can be performed using any commercialized form of drugs and without hospital surveillance because they only rarely induce adverse reactions, which in any event are mild. The method for performing drug patch tests has been described, and requisite commercialized material is now commercially available, failing which the best approach is to dilute the drug in its commercialized form at 30% in petrolatum or in water. The results of drug patch tests depend on the drug tested and the clinical features of the initial CADR. They appear to be of value in investigating maculopapular rash, eczema at drug injection sites, photosensitivity (photopatch tests with 5J of irradiation), fixed drug eruption (testing at the sequelae site), acute generalized exanthematous pustulosis and symmetrical drug-related intertriginous flexural exanthema. Although less widely used, they are probably also of value in drug reaction with eosinophilia and systemic symptoms (DRESS) but they are of less use in Stevens-Johnson syndrome (SSJ) and Lyell's syndrome. Many drugs have been reported as producing positive patch tests, and most of these are summarized in a summary table of this literature review.
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Affiliation(s)
- A Barbaud
- Service de dermatologie, hôpital Fournier, CHU de Nancy, 36, quai de la Bataille, 54000 Nancy, France.
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Ishibashi N, Abe K, Furuhashi S, Fukushima S, Yoshinobu T, Takahashi M, Matsumoto C, Fukuda K, Kobayashi T, Mochizuki N. Adverse allergic reaction to 131I MIBG. Ann Nucl Med 2009; 23:697-9. [PMID: 19557303 DOI: 10.1007/s12149-009-0282-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 06/07/2009] [Indexed: 10/20/2022]
Abstract
No adverse allergic reactions to iodine-131-metaiodobenzylguanidine ((131)I MIBG) at a diagnostic dose have been reported in the English literature. This report of a skin eruption in a 35-year-old man after an intravenous injection of (131)I MIBG strongly suggests an adverse allergic reaction, and is the first to address such a side effect of (131)I MIBG at a diagnostic dose. Erythematous maculopapular eruptions, some of which were contiguous, were seen in a symmetric disposition on the patient's chest walls, elbows, neck and face 18 h after the (131)I MIBG injection. Antiallergic treatment resolved the lesions completely. There were no possible causes of the exanthema other than the (131)I MIBG injection. Urticaria related to the (131)I MIBG injection and caused by type I allergic reaction was suspected, and these findings point to the possible risk of a hitherto unreported allergic skin reaction to (131)I MIBG. We would like to draw the attention of nuclear physicians to this possible drawback of (131)I MIBG.
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Affiliation(s)
- Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Tokyo 173-8610, Japan
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