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

Rare causes of pediatric anaphylaxis due to obscure allergens

This review provides a comprehensive overview of rare causes of pediatric anaphylaxis related to obscure allergens. Anaphylaxis, a severe hypersensitivity reaction, can occur without typical symptoms, posing diagnostic challenges, especially in children. Idiopathic anaphylaxis, where no trigger is identified despite thorough evaluation, is notably challenging in this population. This review synthesizes current literature, highlighting obscure triggers such as food additives, spices like fenugreek, and cross-reactive allergens, including lupine and gelatin. These allergens are often overlooked and can lead to misdiagnosis of idiopathic cases. Understanding these uncommon triggers is crucial for clinicians to ensure accurate diagnosis and effective management of pediatric anaphylaxis, emphasizing the need for heightened clinical awareness and further research. This review raises awareness among health care providers about these lesser-known causes, aiming to improve outcomes and quality of life for pediatric patients at risk of anaphylactic reactions.

Gradient Hierarchically Porous Ionic-Junction Fibers of Wet-Spun Carboxymethyl Cellulose Coagulated with Copper Sulfate

Polyelectrolyte-based ionic-junction fibers newly serve as signal transmission and translation media between electronic devices and biological systems, facilitating ion transport within organic matrices. In this work, we fabricated gel filaments of carboxymethyl cellulose (CMC) chelated with Cu(II) ions through wet-spinning, using a saturated coagulant of CuSO4. Interestingly, the as-spun fibers exhibited dramatic 3D porous frameworks that varied with the temperature and precursor concentration. At 20 °C, the Cu(II) chelation networks favored the formation of well-organized cellular chambers or corrugated channels, displaying dense stacking patterns. However, critical transitions from cellular chambers to corrugated channels occurred at precursor dope concentrations of approximately 2 and 7 wt %, with the porous structure diminishing beyond 8 wt %. We have proposed schematic diagrams to mimic the 3D pore structure, dense porous stacking, and formation mechanism, according to electronic micrographs. Our investigations revealed that the distinct ion-junction channels or chambers are under the control of axial drawing extension as well as the outside-inside penetration of Cu(II) ions into the dope and inside-outside diffusion of water into coagulants. Therefore, controlling the metal chelation-water diffusion process at specific temperatures and concentrations will offer valuable insights for tailoring ionic-junction soft filaments with gradient hierarchically porous structures and shape memory properties.

Evidence and hypotheses on adverse effects of the food additives carrageenan (E 407)/processed Eucheuma seaweed (E 407a) and carboxymethylcellulose (E 466) on the intestines: a scoping review

This scoping review provides an overview of publications reporting adverse effects on the intestines of the food additives carrageenan (CGN) (E 407)/processed Eucheuma seaweed (PES) (E 407a) and carboxymethylcellulose (CMC) (E 466). It includes evidence from human, experimental mammal and in vitro research publications, and other evidence. The databases Medline, Embase, Scopus, Web of Science Core Collection, Cochrane Database of Systematic Reviews and Epistemonikos were searched without time limits, in addition to grey literature. The publications retrieved were screened against predefined criteria. From two literature searches, 2572 records were screened, of which 224 records were included, as well as 38 records from grey literature, making a total of 262 included publications, 196 on CGN and 101 on CMC. These publications were coded and analyzed in Eppi-Reviewer and data gaps presented in interactive maps. For CGN, five, 69 and 33 research publications on humans, experimental mammals and in vitro experiments were found, further separated as degraded or native (non-degraded) CGN. For CMC, three human, 20 animal and 14 in vitro research publications were obtained. The most studied adverse effects on the intestines were for both additives inflammation, the gut microbiome, including fermentation, intestinal permeability, and cancer and metabolic effects, and immune effects for CGN. Further studies should focus on native CGN, in the form and molecular weight used as food additive. For both additives, randomized controlled trials of sufficient power and with realistic dietary exposure levels of single additives, performed in persons of all ages, including potentially vulnerable groups, are needed.

Hidden and Rare Food Allergens in Pediatric Age

In food allergy management, the avoidance of the allergen that caused the reaction plays a fundamental role. Nevertheless, that can be thwarted in case of accidental exposure to a rare or hidden allergen, causing the adoption of a monotonous diet and a consequent reduction in the quality of life of the patient and their family. The identification of a rare and hidden allergen is an important diagnostic challenge, taking into account that a significant proportion of all food reactions is in reality due to them. The aim of the present review is to provide the pediatric allergist an overview of the possible sources of rare and hidden food allergens, taking into consideration the routes of exposure to these potential allergens with the main examples published in the scientific literature and the distinction between types of direct or cross-contamination. The identification of the allergen responsible for the reaction and the provision of a dietary advice customized for the specific individual’s dietary habits is essential to improve quality of life of the familiar nucleus and to reduce the risk of further allergic reactions.

Local Reaction Causing Airway Compromise Following Vocal Fold Injection Augmentation with Carboxymethylcellulose

OBJECTIVES

This case report aims to identify local allergic reaction as a rare complication of vocal fold injection augmentation with carboxymethylcellulose and discuss the management of airway swelling following this reaction.

INTRODUCTION

Glottis insufficiency due to true vocal fold immobility is important to manage to reduce risk of aspiration and improve voice function. Vocal fold injection augmentation with carboxymethylcellulose is considered a safe and effective treatment for glottis insufficiency, commonly due to vocal fold immobility.

METHODS

Retrospective medical records review and case report.

RESULTS

We report a unique case of an adult female with vocal fold immobility that was treated with injection laryngoplasty using carboxymethylcellulose and subsequently developed a local reaction requiring intubation and tracheostomy placement.

CONCLUSION

Otolaryngologists should be aware of this rare, but life-threatening complication and counsel patients accordingly when obtaining consent. If there are signs and symptoms of airway edema, the patient should be transferred to the ICU for airway watch, intravenous steroids, and possible intubation.

Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review

The aim of the present study is to describe pharmacological characteristics of drug-related allergies and anaphylaxis leading to the emergency department (ED). An 8-year post hoc analysis on the MEREAFaPS Study database was performed (2012−2019). Subjects who experienced drug-related hypersensitivity leading to an ED visit were selected. Logistic regression analyses were used to estimate the reporting odds ratios (RORs) of drug-related allergies and anaphylaxis adjusting for sex, age classes, and ethnicity. In addition, a systematic review of observational studies evaluating drug-related hypersensitivity reactions leading to ED visits in outpatients was performed. Out of 94,073 ED visits, 14.4% cases were drug-related allergies and 0.6% were anaphylaxis. Females accounted for 56%. Multivariate logistic regression showed a higher risk of drug-related allergy among males and all age classes < 65 years, while a higher risk of anaphylaxis was observed for females (ROR 1.20 [1.01−1.42]) and adults (ROR 2.63 [2.21−3.14]). The systematic review included 37 studies. ED visits related to allergy and anaphylaxis ranged from 0.004% to 88%, and drug-related allergies and anaphylaxis ranged from 0.007% to 88%. Both in our analysis and in primary studies, antibacterials, analgesics, and radiocontrast agents were identified as the most common triggers of hypersensitivity.

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.

Carboxymethylcellulose excipient allergy: a case report

Background

Excipients are widely used in pharmaceuticals, detergents, food, and drink because of their properties of low toxicity and hypoallergenicity. The excipient carboxymethylcellulose is used extensively as a thickener in foods such as baked goods, ice cream, gluten free, and reduced fat products, where it may be labeled as e-number E466. However, excipients can rarely cause type 1 hypersensitivity reactions. Several publications have described systemic allergy following carboxymethylcellulose exposure in pharmaceuticals, particularly systemic corticosteroids. Furthermore, there is one reported case in the literature of anaphylaxis following food containing carboxymethylcellulose.

Case presentation

We identify a case of anaphylaxis in a 45-year-old atopic Caucasian woman on receiving an injectable suspension of the corticosteroid triamcinolone acetonide containing carboxymethylcellulose, and subsequent allergic symptoms on reexposure to carboxymethylcellulose in a commercial drink. Diagnosis of carboxymethylcellulose excipient allergy was confirmed through skin prick testing using Celluvisc carmellose 0.5% eye drops, which contain carboxymethylcellulose as the active ingredient.

Conclusion

This case highlights the importance of identifying excipients such as carboxymethylcellulose as causes of allergy, to reduce burden of further hypersensitivity reactions, not just to drugs but to other consumables.

Facile transformation of carboxymethyl cellulose beads into hollow composites for dye adsorption

Novel millimeter hollow microspheres were fabricated from carboxymethyl cellulose microspheres and polyethyleneimine using glutaraldehyde as a crosslinking agent. The hollow microspheres prepared with different polyethyleneimine usages and different polyethyleneimine treatment time were investigated deeply and characterized via SEM-EDX, FT-IR, and BET surface area analysis. It was shown that polyethyleneimine could break the coordination bonds between the carboxyl and Al (III) in carboxymethyl cellulose microspheres, leading to the formation of hollow structures. Most importantly, the usage and treatment time of polyethyleneimine can distinctly tailor the structure of the carboxymethyl cellulose microspheres, resulting in the formation of different hollow microspheres with varied shell thickness and size. Most importantly, we found that the prepared hollow microspheres have excellent adsorption performance toward targeted methyl blue under testing conditions. By virtue of the large accessible amount of -NH₂ groups and its unique hollow structure, this type of millimeter hollow microspheres have broad application prospects in the treatment of emerging contaminants in wastewater.

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.

World allergy organization anaphylaxis guidance 2020

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.