Severe anaphylaxis after pelvic examination: a case report of dual latex and chlorhexidine allergies

Revisiting Fruit Allergy: Prevalence across the Globe, Diagnosis, and Current Management

Fruit allergies manifest with a diverse array of clinical presentations, ranging from localized contact allergies and oral allergy syndrome to the potential for severe systemic reactions including anaphylaxis. The scope of population-level prevalence studies remains limited, largely derived from single-center or hospital-based investigations. In this comprehensive review, we conducted a systematic literature search spanning the years 2009 to 2023, with full acknowledgment of potential analytical biases, to provide a global overview of fruit allergy prevalence. The primary mechanistic underpinning of fruit allergies stems from cross-reactivity between aeroallergens and food allergens, a consequence of structurally similar epitopes-a phenomenon recognized as pollen food allergy syndrome (PFAS). In the era of molecular allergology, numerous studies have dissected allergen components with substantial clinical relevance. Within this review, we explore important allergenic molecules found in plant-based foods, scrutinize pertinent cross-reactivity patterns, and offer insights into management recommendations. Additionally, we compare guideline recommendations to enhance clinical understanding and inform decision making.

Successful identification of culprit drugs of perioperative anaphylaxis by repeated skin testing after negative first skin tests in a patient with a long distant history of perioperative anaphylaxis

Background

Perioperative anaphylaxis is a severe immediate hypersensitivity reaction to drugs administered in immediate temporal association to surgical procedures. The European Academy of Allergy and Clinical Immunology recommends allergologic tests be performed within the golden period of between 1 and 4 months after the date of the event to avoid false negatives. Nonetheless, many obstacles prevent patients from receiving diagnostic tests within the recommended time frame.

Case presentation

A 39-year-old male with congenital glaucoma had a history of multiple episodes of perioperative anaphylaxis since the age of 1 year including generalized urticaria, bronchospasm, cyanosis, and hypotension. Because the sequence of events was unclear due to incomplete documentation of operations and the destruction of medical records, the allergists tested different perioperative drugs on the patient. Although the first test results were all negative, repeated tests at 6 weeks were positive for morphine and ketamine. We identified more than one causative drug at the second round of skin tests. Using recommended skin test concentrations, negative skin tests in 5 control subjects could support the validity of the second test. The patient underwent sinus surgery in the next 3 months after the second skin test using propofol, midazolam, sevoflurane, chlorhexidine, and cefazolin without any anaphylactic reactions.

Conclusions

Repeated skin tests after negative results of the first tests may identify the causative drugs, thus providing optimal patient safety, and should be considered under the physician's discretion together with consideration of the severity of the allergic symptoms, time interval from last reactions, and the patient's consent.

Clinical value of in vitro tests for the management of severe drug hypersensitivity reactions

Drug hypersensitivity reactions (DHRs) occasionally present with severe cutaneous adverse reactions (SCARs) which result in a high risk of morbidity and mortality. Although SCARs are rare, the occurrence could lead to a significant increase in healthcare and economic burden, especially when more than one possible culprit drug is implicated. Therefore, the accurate identification of the culprit drug(s) is important for correct labeling and subsequent patient education and avoidance. To date, clinical evaluation using causality assessment has limitations because the assessment may be inaccurate due to the overlapping timelines when multiple drugs are initiated/continued. Moreover, drug provocation tests (DPTs) which is the gold standard in diagnosis, are contraindicated, and in vivo skin tests may also be associated with risks of triggering SCAR. The European Network for Drug Allergy recommended that in vitro tests, if available, should be performed before any in vivo tests. Basophil activation tests and lymphocyte transformation tests, could serve as reliable in vitro tests for both immediate and delayed-type DHR. Many academic medical centers with affiliated laboratory services offer these tests in the diagnostic evaluation of SCARs in clinical practice. This not only complements identification of the culprit drug(s), but may also be used to test for potentially non cross-reactive alternatives, hence avoiding DPTs. In this review, we summarize the roles of in vitro tests in identifying the culprit drug(s) in SCARs, issues with utilization and interpretation of test results, and our experience in clinical practice.

Anaphylaxis to clindamycin following cutaneous exposure

Background

The role and importance of skin barrier as an immunologic organ and as a potent way of sensitization is well known. However, antibiotics anaphylaxis following skin sensitization has not been reported.

Case presentation

We describe the first case of intravenous clindamycin anaphylaxis, with likely sensitization due to previous topical exposure to clindamycin gel for acne in a 14-year-old boy with history of atopy and mild atopic dermatitis.

Conclusion

This case highlights the potential sensitization to drug allergens, including antibiotics, via the skin.

Chlorhexidine Allergy: Current Challenges and Future Prospects

Chlorhexidine is a synthetic bisbiguanide antiseptic and was introduced in healthcare use in 1954. Allergy to chlorhexidine has been increasingly reported particularly in the perioperative and medical procedural settings. The hypersensitivity reactions range from mild cutaneous reactions to anaphylaxis or death. There are many products and medical devices containing chlorhexidine that sometimes lack standardized labeling. With the various routes of chlorhexidine exposure, accidental or recurrent reactions in chlorhexidine-allergic patients have been reported. Therefore, we aim to review the most recent evidence in clinical manifestations, diagnostic methods, management, and preventive measures with a focus on the unique features of chlorhexidine allergy.

Analysis of chlorhexidine gluconate in skin using tape stripping and ultrahigh-performance liquid chromatography-tandem mass spectrometry

BACKGROUND

Topical chlorhexidine gluconate (CHG) is used widely to reduce healthcare-associated infection. The optimal therapeutic dose for maximum efficacy and reduced toxicity is unclear, in part because of the lack of analytical methods to monitor CHG levels in skin. A novel method was developed to accurately measure CHG levels in skin after topical application with the goal of determining its pharmacokinetics in skin.

METHODS

Ultrahigh-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) was used to develop a validated assay for measuring CHG levels in skin cells collected by a non-invasive adhesive tape-stripping method. CHG levels in the skin stratum corneum of healthy adult volunteers were measured at 0.5, 4, 8, and 24 h after its application.

RESULTS

Conditions for extraction of CHG were optimized and the assay was linear in the range 0.1-50 μg/mL (corresponding to 0.2-100 μg chlorhexidine/tape), with an intra-assay precision of 1.74-10.50 % and a relative error of ≤10 %. The inter-assay accuracy was in the range of 5.86-10.96 % with a relative error <9 %. CHG was stable on tapes stored at 4 °C and ambient temperature for 14 and 3 days, respectively. The recovery of CHG from the tape was quantitative and the matrix effect was determined as 2.1-14.8 %. CHG levels in healthy adult volunteer skin following topical application decreased rapidly over a 24 h period.

CONCLUSIONS

A rapid, accurate and specific UHPLC-MS/MS method was developed for the measurement of CHG in the skin obtained by tape stripping that was linear over a large dynamic range. This assay afforded a simple and convenient non-invasive approach to monitor CHG levels in skin after topical application that can be applied to enable the optimal dose to prevent infection and minimize toxicity.

Molecular mechanism of antimicrobial activity of chlorhexidine against carbapenem-resistant Acinetobacter baumannii

Acinetobacter baumannii causes hospital-acquired infections, especially in those with impaired immune function. Biocides or disinfectants are widely used antibacterial agents used to eradicate the effect of A. baumannii on inanimate objects and health care environments. In the current study, the antimicrobial activity of chlorhexidine has been investigated against carbapenem-resistant (RS-307, RS-7434, RS-6694, and RS-122), and sensitive (ATCC-19606 and RS-10953) strains of A. baumannii. We have determined growth kinetics, antimicrobial susceptibility, ROS production, lipid peroxidation, cell viability using flow cytometry assay (FACS), and membrane integrity by scanning electron microscope (SEM). The effect of chlorhexidine on the bacterial membrane has also been investigated using Fourier transform infrared (FTIR) spectroscopy. The present study showed that 32μg/ml chlorhexidine treatment results in the decreased bacterial growth, CFU count and cell viability. The antibacterial activity of chlorhexidine is due to the elevated ROS production and higher lipid peroxidation. These biochemical changes result in the membrane damage and alteration in the membrane proteins, phospholipids, carbohydrates, nucleic acids as evident from the FTIR and SEM data. Therefore, chlorhexidine has the potential to be used in the hospital setups to remove the spread of A. baumannii.