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Mutlu L, Bermingham WH, Mohamed OE, Melchior C, Samuel L, Heslegrave J, Baretto R, Ekbote A, Huissoon A, Dedicoat M, Krishna MT. Management of suspected hypersensitivity reactions to anti-TB drugs. Int J Tuberc Lung Dis 2023; 27:570-573. [PMID: 37353875 DOI: 10.5588/ijtld.23.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023] Open
Affiliation(s)
- L Mutlu
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - W H Bermingham
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - O E Mohamed
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - C Melchior
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - L Samuel
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Heslegrave
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Baretto
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Ekbote
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Huissoon
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Dedicoat
- Infectious Diseases Department, Birmingham Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - M T Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK, Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
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Sooriyakumar K, Mohamed O, Osborne T, Beck SC, Melchior C, Heslegrave J, Mathew S, Baretto RL, Ekbote A, Huissoon AP, Thirumala Krishna M. Suspected food allergy in adults: mapping 208 open food challenges with allergy tests and risk stratification. J Clin Pathol 2020; 74:133-136. [PMID: 33082161 DOI: 10.1136/jclinpath-2020-206994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/23/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Kavitha Sooriyakumar
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Omar Mohamed
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Toni Osborne
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah C Beck
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cathryn Melchior
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jane Heslegrave
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Silvy Mathew
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard L Baretto
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anjali Ekbote
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aarnoud P Huissoon
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mamidipudi Thirumala Krishna
- Department of Allergy & Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Immunology & Immunotherapy and Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Mohamed OE, Baretto RL, Walker I, Melchior C, Heslegrave J, Mckenzie R, Hullur C, Ekbote A, Krishna MT. Empty mast cell syndrome: fallacy or fact? J Clin Pathol 2019; 73:250-256. [PMID: 31831575 DOI: 10.1136/jclinpath-2019-206157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/06/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
Post-anaphylaxis mast cell anergy (PAMA), commonly referred to as 'empty mast cell (MC) syndrome', is a state of temporary loss of cutaneous MC reactivity in the immediate aftermath of anaphylaxis. Data relating to this condition are sparse and the incidence rate is currently unknown. PAMA has been described only in a few published case reports in the context of hymenoptera venom allergy and perioperative anaphylaxis. Best practice guidelines regarding optimal timing for performing skin tests postanaphylaxis are largely based on expert opinion, and allergy work-up has been recommended after 4-6 weeks postanaphylaxis to avoid false-negative results.This article provides a review of clinical literature surrounding PAMA, critically evaluates intracellular events in MCs from in vitro data and hypothesises regarding plausible immune mechanisms. There are no published data to directly explain molecular mechanisms underlying this phenomenon. Although not evidence based, PAMA has been attributed to depletion of MC granules following anaphylaxis. It is also plausible that exposure to high allergen concentrations in anaphylaxis can induce a temporary shift in MCs towards dominance of inhibitory signalling pathways, thus contributing to a state of transient hyporesponsiveness observed in some patients. Other potential contributory factors for reduced MC reactivity include downregulation of FcεRI expression, cross-linking of FcεRI to the inhibitory, low-affinity IgG receptors and administration of pharmacotherapeutic agents for anaphylaxis treatment. It is likely that this interesting phenomenon can be explained by a combination of these proposed mechanisms in addition to other genetic/host factors that have not yet been identified.
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Affiliation(s)
- Omar E Mohamed
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard L Baretto
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Walker
- Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cathryn Melchior
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jane Heslegrave
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ruth Mckenzie
- Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chidanand Hullur
- Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anjali Ekbote
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mamidipudi Thirumala Krishna
- Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Mohamed OE, Beck S, Huissoon A, Melchior C, Heslegrave J, Baretto R, Ekbote A, Krishna MT. A Retrospective Critical Analysis and Risk Stratification of Penicillin Allergy Delabeling in a UK Specialist Regional Allergy Service. The Journal of Allergy and Clinical Immunology: In Practice 2019; 7:251-258. [DOI: 10.1016/j.jaip.2018.05.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/20/2018] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
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Baretto RL, Beck S, Heslegrave J, Melchior C, Mohamed O, Ekbote A, Huissoon AP, Krishna MT. Validation of international consensus equation for acute serum total tryptase in mast cell activation: A perioperative perspective. Allergy 2017; 72:2031-2034. [PMID: 28609557 DOI: 10.1111/all.13226] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 11/30/2022]
Abstract
There is no standardized method for assessing serum total mast cell tryptase (MCT) in anaphylaxis. The consensus equation (peak MCT should be>1.2× baseline tryptase+2 mg/L) has been proposed to interpret acute MCT in mast cell activation syndrome (MCAS). To validate consensus equation in a perioperative setting analyses of cases of suspected perioperative anaphylaxis during general anaesthesia (GA) were performed. Anaphylaxis was defined as per World Allergy Organisation (WAO) criteria. Timed serial MCT measurements were mapped against the consensus equation and receiver operating characteristic (ROC) curves produced. A total of 82 patients (60 females, mean age 56.5 years±SD17.2) underwent investigation. Sixty (73%) patients fulfilled WAO criteria for anaphylaxis, and 22 patients did not. Aetiology included 59% IgE-mediated anaphylaxis, 2% non-IgE-mediated anaphylaxis, 12% anaphylaxis of unknown cause and 27% deemed non-anaphylaxis. IgE-mediated anaphylaxis included the following: NMBA (35%), antibiotics (46%), chlorhexidine (8%), patent blue dye (8%) and others (8%). An acute MCT with a comparable baseline was available in 71 of 82 (87%) patients (60 anaphylaxis and 11 controls). The median interquartile range (IQR) time from reaction to peak MCT was 1.34 (0.82-2.51) hours. Analyses confirmed that a rise in acute MCT greater than that defined by the equation had a sensitivity, specificity, positive predictive value (PPV) and negative (N) PV of 78%, 91%, 98% and 44%, respectively. The magnitude of increase in acute MCT above the threshold predicted by consensus equation was higher in the anaphylaxis group compared to controls (P=.0001). This equation has a high specificity, PPV with a moderate NPV and sensitivity in perioperative anaphylaxis.
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Affiliation(s)
- R. L. Baretto
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
- Department of Immunology; Kettering General Hospital NHS Foundation Trust; Kettering UK
- Department of Biochemistry & Immunology; University Hospitals of Coventry and Warwickshire; Coventry UK
| | - S. Beck
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
| | - J. Heslegrave
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
| | - C. Melchior
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
| | - O. Mohamed
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
| | - A. Ekbote
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
| | - A. P. Huissoon
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
- Institute of Immunology & Immunotherapy; University of Birmingham; Birmingham UK
| | - M. T. Krishna
- Department of Allergy & Immunology; Heart of England NHS Foundation Trust; Birmingham UK
- Institute of Immunology & Immunotherapy; University of Birmingham; Birmingham UK
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Krishna MT, York M, Chin T, Gnanakumaran G, Heslegrave J, Derbridge C, Huissoon A, Diwakar L, Eren E, Crossman RJ, Khan N, Williams AP. Multi-centre retrospective analysis of anaphylaxis during general anaesthesia in the United Kingdom: aetiology and diagnostic performance of acute serum tryptase. Clin Exp Immunol 2014; 178:399-404. [PMID: 25070464 DOI: 10.1111/cei.12424] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2014] [Indexed: 12/01/2022] Open
Abstract
This is the first multi-centre retrospective survey from the United Kingdom to evaluate the aetiology and diagnostic performance of tryptase in anaphylaxis during general anaesthesia (GA). Data were collected retrospectively (2005-12) from 161 patients [mean ± standard deviation (s.d.), 50 ± 15 years] referred to four regional UK centres. Receiver operating characteristic curves (ROC) were constructed to assess the utility of tryptase measurements in the diagnosis of immunoglobulin (Ig)E-mediated anaphylaxis and the performance of percentage change from baseline [percentage change (PC)] and absolute tryptase (AT) quantitation. An IgE-mediated cause was identified in 103 patients (64%); neuromuscular blocking agents (NMBA) constituted the leading cause (38%) followed by antibiotics (8%), patent blue dye (6%), chlorhexidine (5%) and other agents (7%). In contrast to previous reports, latex-induced anaphylaxis was rare (0·6%). A non-IgE-mediated cause was attributed in 10 patients (6%) and no cause could be established in 48 cases (30%). Three serial tryptase measurements were available in 34% of patients and a ROC analysis of area under the curve (AUC) showed comparable performance for PC and AT. A ≥ 80% PPV for identifying an IgE-mediated anaphylaxis was achieved with a PC of >141% or an AT of >15·7 mg/l. NMBAs were the leading cause of anaphylaxis, followed by antibiotics, with latex allergy being uncommon. Chlorhexidine and patent blue dye are emerging important health-care-associated allergens that may lead to anaphylaxis. An elevated acute serum tryptase (PC >141%, AT >15·7 mg/l) is highly predictive of IgE-mediated anaphylaxis, and both methods of interpretation are comparable.
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Affiliation(s)
- M T Krishna
- Birmingham Heartlands Hospital, Birmingham, UK; University of Birmingham, Birmingham, UK; Warwick Medical School, Warwick, UK
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Richter AG, Wong G, Goddard S, Heslegrave J, Derbridge C, Srivastava S, Diwakar L, Huissoon AP, Krishna MT. Retrospective case series analysis of penicillin allergy testing in a UK specialist regional allergy clinic. J Clin Pathol 2011; 64:1014-8. [PMID: 21742749 DOI: 10.1136/jcp.2010.088203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Penicillin allergy is the most common drug allergy. Skin testing for the major (PPL) and minor determinants (MDMs) of penicillin offers increased sensitivity and specificity over in vitro testing alone. Following a worldwide absence of reagents, a new kit was licensed in the UK in 2008 (Diater, Spain) and this report evaluates its use in a UK specialist allergy clinic. METHODS Prospective data on 50 consecutive patients tested with the new reagents were collected. The departmental protocol is adapted from the 2003 EAACI position paper. RESULTS 14% (7/50) and 12% (6/50) of patients were diagnosed with immediate and non-immediate reactions respectively. The negative predictive value of the PPL and MDM reagents at the neat concentration for an immediate reaction was 93% (true negatives 37, false negatives 3). Two patients experienced systemic reactions to DPT in the absence of demonstrable specific IgE. None of the patients were diagnosed using skin prick testing alone or at lower concentrations of IDT. Five patients were diagnosed at the IDT stage and two at the DPT stage in the absence of demonstrable specific IgE. Six patients were diagnosed with non-immediate reactions, two on IDT alone and four following IDT and DPT. CONCLUSION The new PPL and MDM determinants offer enhanced sensitivity when evaluating β-lactam hypersensitivity; however, there are limitations to the current testing regimens. The UK would benefit from local guidelines, which incorporate the new reagents and acknowledge the high amoxicillin prescription rate and the relatively lower specialist-to-patient ratio in this country.
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Affiliation(s)
- A G Richter
- Department of Clinical Immunology, Birmingham Heartlands Hospital, Birmingham, UK.
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Diwakar L, Heslegrave J, Richter AG, Huissoon AP, Krishna MT. Self-injectable adrenaline devices: is training necessary? J Investig Allergol Clin Immunol 2010; 20:452-453. [PMID: 20945620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Affiliation(s)
- L Diwakar
- Department of Allergy and Immunology, Heartlands Hospital, Birmingham, UK.
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