History Of Anaphylaxis Research Articles

Characteristics and Treatment of Anaphylaxis in Children Visiting a Pediatric Emergency Department in Korea.

Anaphylaxis is a serious life-threatening allergic disease in children. This study is aimed at determining the characteristics of pediatric patients who experienced anaphylaxis along with treatments administered in order to determine the usefulness of tryptase level assessment as a marker of anaphylaxis in Korean children. A total of 107 patients who were diagnosed with anaphylaxis in a single pediatric emergency center over a 3-year period were included in the study. Patient clinical characteristics, symptoms, signs, allergy history, trigger factors, treatments, and laboratory findings, including serum tryptase levels, were included in the analysis. Food allergies (39.3%) were the most commonly reported patient allergic history, and 58 patients (54.2%) were triggered by food. Among this group, nuts and milk exposure were the most common, affecting 15 patients (25.9%). History of anaphylaxis and asthma were more common in severe anaphylaxis compared to mild or moderate anaphylaxis cases. Epinephrine intramuscular injection was administrated to 76 patients (71.0%), and a self-injectable epinephrine was prescribed to 18 patients (16.8%). The median tryptase level was 4.80 ng/mL (range: 2.70–10.40) which was lower than the 11.4 ng/mL value commonly documented for standard evaluation in adults with anaphylaxis. The most common cause of pediatric anaphylaxis was food including nuts and milk. The rate of epinephrine injection was relatively high in our pediatric emergency department. The median tryptase level associated with anaphylaxis reactions in children was lower than 11.4 ng/mL. Further studies are needed to help improve diagnostic times and treatment accuracy in pediatric patients who develop anaphylaxis.

Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study

To assess whether a history of asthma was associated with anaphylaxis severity in children hospitalized for anaphylaxis. Retrospective cohort study of children ≤21years old hospitalized for anaphylaxis from 2009 to 2016. The primary outcome was severe anaphylactic reactions defined by examination findings (stridor, respiratory distress, or hypotension) or administered therapies (≥2 dose of intramuscular epinephrine, continuous albuterol, vasopressors, or positive pressure ventilation). Multivariable analyses were used to assess whether a history of asthma was associated with severe anaphylactic reactions, adjusting for patient age, allergen, and history of atopic dermatitis or anaphylaxis. Among 603 children hospitalized for anaphylaxis, 231 (38.3%) had a history of asthma. Children with a history of asthma were older (median age, 6.6years [IQR, 3.6-12.1] vs 4.0years [IQR, 1.6-9.3]), more likely to have a history of anaphylaxis (38.1% vs 18.0%), and have food as the inciting allergen (68.0% vs 52.2%). Children with a history of asthma were not more likely to have severe anaphylactic reactions (OR, 0.97; 95% CI, 0.67-1.39). Children hospitalized for anaphylaxis with a history of asthma were not more likely to have severe anaphylactic reactions compared with children without asthma. This study supports managing children with anaphylaxis based on the severity of symptomatology, and, if validated, clinicians should not consider asthma comorbidity as a stand-alone criterion for hospitalization.

P583 The prevalence of side effects to immunomodulators and biologics in patients with Crohn’s disease intestinal failure compared with Crohn’s disease without intestinal failure

Abstract Background Treatment of Crohn’s disease (CD) involves medications and surgery but experiencing medication side effects (SE) limits medical options. The aim of this study was to compare SE experienced by patients with CD and intestinal failure (CD-IF) vs. CD without IF as this may contribute to a higher surgical requirement. Methods A single tertiary centre retrospective analysis was performed on CD-IF patients on parenteral nutrition due to short-bowel syndrome vs. small bowel CD without IF. Patients with CD without IF were selected from consecutive clinics who lived in the local catchment area. Results 94 CD-IF and 94 CD patients were included. The proportion of female patients was 56.4% (CD-IF) and 46.8% (CD); mean age was 51.2 (CD-IF) and 41.5 years (CD); mean duration of disease 24 years (CD-IF) and 16 years (CD). Most CD-IF patients had multiple resections. In the CD group, 50 patients never had surgery, 22 had 1 resection, and 9 had 2 or more. From the past medication history for these patients, the proportion in whom a medication was stopped due to SE was similar for CD-IF and CD for azathioprine, mercaptopurine and vedolizumab (Table 1). There were no SE to ustekinumab. Patients in the CD-IF group had a preceding history of significantly more SE to anti-TNF therapy and methotrexate were observed in CD-IF group, of which allergies were most frequent. In the CD group, 2 patients previously had an allergic reaction to infliximab whereas, in the CD-IF group 6 patients had a history of anaphylaxis and 5 an allergy to infliximab, 1 had an allergy to adalimumab and 3 to methotrexate (Table 2). Data on drug levels amongst those with allergy events were limited (due to prior availability of testing); of those tested, 1 had positive antibodies and 1 did not. The frequency of non-response and loss of response was similar between the two groups for each medication. Conclusion The frequency of SE to immunomodulators and biologics was similar between CD and CD-IF, except for anti-TNF therapy and methotrexate due to more allergy/anaphylaxis events in CD-IF. The frequency of these reactions may have caused an earlier shift towards surgical treatment. 92/94 CD-IF patients were diagnosed prior to 2014; it would be useful to review the incidence of CD-IF before 2014 (pre-vedolizumab and ustekinumab) vs. the new biological era.

Effects of Cow's Milk Components, Goat's Milk and Sheep's Milk Sensitivities on Clinical Findings, and Tolerance Development in Cow's Milk Allergy.

Objective:Cow’s milk (CM) contains some proteins capable of causing an allergic reaction in a sensitized individual and one of the most common causes of food allergy in childhood. Most of the patients will develop tolerance by the age of 3. In this study, we aimed to evaluate sensitivity to CM allergen components as well as goat’s milk (GM) and sheep’s milk cross reactions in cow’s milk allergic (CMA) patients and to figure out the risk factors for tolerance non-development.Methods:This is a retrospective cross-sectional study including 66 patients for IgE-mediated CMA with mean age of 38 months. We evaluated the patients in two groups: Group 1 (n=50): Patients who have no tolerance in oral food challenge test; Group 2 (n= 16): Patients who were found tolerant to CM after elimination diet. Cow’s milk-spesific IgE(sIgE), α-lactalbumin(ALA)-sIgE, β-Lactoglobulin(BLG)-sIgE, casein-sIgE, goat’s milk-sIgE, sheep’s milk-sIgE, skin prick tests(SPTs) with CM and GM, eosinophils in peripheral blood were all compared between two groups.Results:In the whole group, goat’s milk-sIgE and sheep’s milk-sIgE were positive in 84.8% and ALA-sIgE, BLG-sIgE, casein-sIgE were positive in 69.7%, 62.7%, 77.3% of the patients, respectively. Two groups were similar in terms of age at onset and diagnosis, gender, median elimination period, total IgE levels, cow’s milk-sIgE and eosinophilia (p>0.05). Mean wheal diameters of CM and GM in SPT (p<0.001), goat’s milk-sIgE (p=0.03), sheep’s milk-sIgE (p=0.01) were significantly higher in Group 1. Cow’s milk-sIgE showed a positive correlation with total IgE (p=0.001), eosinophilia percentage (p=0.04), CM wheal diameter in SPT (p=0.001), casein-sIgE (p<0.001), goat’s milk-sIgE (p<0.001), sheep’s milk-sIgE (p<0.001) in Group 1. Patients with respiratory symptoms and history of anaphylaxis had higher cow’s milk-SPT, cow’s milk-sIgE, casein-sIgE, goat’s milk-sIgE, sheep’s milk-sIgE levels(p<0.05). Gastrointestinal and skin symptoms showed no relation with laboratory findings. Any patient with a history of anaphylaxis did not develop tolerance.Conclusions:As with cow’s milk-sIgE levels and high induration diameters in SPT; high casein-sIgE, sheep’s milk-sIgE and goat’s milk-sIgE levels are also risk factors for persistence of CMA. Anaphylaxis, as a first reaction, may also be a risk factor. High cow’s milk-sIgE, casein-sIgE, sheep’s milk-sIgE, goat’s milk-sIgE levels are associated with respiratory symptoms.

Oleosins: A Short Allergy Review.

In patients having a history of anaphylaxis after consumption of peanuts, sunflower seeds, or soy and skin or blood tests negative for the allergen extracts, oleosins could be the culprit. Oleosins are common and largely underestimated allergy inducers of plant origin, causing severe allergy symptoms, including the anaphylactic shock. They are resistant to high temperatures and digestive enzymes. The consumption of heat-treated oleosins has been associated with a higher risk of a severe anaphylactic reaction. Recent studies have shown that oleosins could be a biomarker of the allergy severity to peanuts. Oleosins have a hydrophobic structure and thus, are poorly soluble in aqueous solutions. The aqueous extraction, separation, and purification procedures do not guarantee their solubility. Oleosins dissolve only in the presence of detergents, which limits their use in both in vivo and in vitro allergy tests. Recently, a multiparameter allergy test that detects the allergen-specific immunoglobulin E (sIgE) against oleosins has become available. This capability may help to unravel the presence of oleosin source during the routine diagnostic of allergy, which is conducive to assessing the risk for severe anaphylaxis and may also help to clarify the ambiguous allergy cases.

Patients with history of anaphylaxis should not receive Pfizer/BioNTech COVID-19 vaccine, says regulator

Patients with history of anaphylaxis should not receive Pfizer/BioNTech COVID-19 vaccine, says regulator

Immunizations in Long-Term Care: Are We Where We Should Be?

Immunizations in Long-Term Care: Are We Where We Should Be?

Tolerability to paracetamol and preferential COX-2 inhibitors in patients with cross-reactive nonsteroidal anti-inflammatory drugs hypersensitivity.

BackgroundAcetylsalicylic acid/aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used drugs that may cause hypersensitivity reactions in a substantial proportion of patients. Physicians ought to be aware of these situations.ObjectiveWe aimed to present the clinical characteristics and rates of tolerability to cyclooxygenase (COX)-2 inhibitor analgesics in patients who had admitted due to multiple cross-reactive type of NSAID hypersensitivity.MethodsThe files of the patients who had admitted with multiple NSAIDs-induced symptoms were investigated retrospectively. Age, sex, underlying diseases, clinical manifestation, skin test results, and drug provocation test results were analyzed.ResultsIn 105 patients with multiple cross-reactive type of NSAID hypersensitivity, we found the rate of cross-reactivity to any of the relatively safe alternatives including paracetamol, meloxicam, and nimesulide to be 16.1%. The rate of cross-reactivity to these relatively safe drugs was significantly higher in patients with a history of anaphylaxis induced by NSAID intake (p = 0.006).ConclusionThe diagnosis of COX-1-mediated multiple NSAID hypersensitivity can be often established with a detailed history. Although rare, severe hypersensitivity reactions may be observed in these patients. Undesired situations for both patients and physicians may be avoided by testing relatively safe paracetamol and COX-2 inhibitors in experienced centers.

Is There an Optimal Training Interval to Improve the Correct Use of Adrenaline Auto-Injectors?

Background: Accurate use of adrenaline auto-injectors (AAIs) for anaphylaxis is critical to decrease mortality and morbidity. Objective: In this study, we aimed to assess user knowledge of AAIs and evaluate the factors that affect their correct use. Methods: The study involved caregivers of pediatric patients diagnosed with anaphylaxis who were trained with trainer injectors up to 24 months ago. The demographics of the caregivers, anaphylaxis history of the patients, usage of AAIs in the case of anaphylaxis, and the reasons for not using AAIs in anaphylaxis were evaluated. Users were asked to demonstrate the use of Penepin® with a trainer injector. Results: Fifty-nine caregivers were enrolled in the study. Forty-seven (79.7%) users stated that they always carry AAIs with them. Forty-one (69.5%) of the users demonstrated all steps of the use of AAIs. The time from the last AAI training was the most significant parameter affecting the ability to use AAIs correctly (OR 0.678, 95% CI 0.546–0.841, p < 0.0001). AAI training every 6 months results in the proper usage of AAIs, with 96% probability. Thirty (50.8%) caregivers stated that anaphylactic reactions occurred in their children after the last AAI training. Of these, 16 (53.3%) users stated that they did not use an AAI for the anaphylactic reaction. The most common reason (50%) was not carrying an AAI on their person. Conclusion: Training users at least every 6 months is associated with the proper application of AAIs. Although regular training increases the frequency of AAI use in anaphylaxis, awareness of carrying AAIs is the most important factor for usage of AAI in anaphylaxis.

Allergological Study of 565 Elderly Patients Previously Labeled as Allergic to Penicillins.

PurposeElderly people thought to have an allergy to beta-lactams (BLs) may tolerate the drugs in subsequent exposures due to initial false labeling of allergies, the spontaneous loss of sensitivity to BLs over time or age-related decline in sensitization. As a result, they may be treated with less appropriate antibiotics, causing more side effects and entailing increased costs for health systems. The aim of this investigation was to assess whether patients in the third and fourth age with previously confirmed allergies to BLs had lost sensitization and could tolerate these antibiotics.Patients and methodsPatients allergic to BLs were divided into group A (aged 60–79 years) and B (aged ≥80 years). Clinical history, skin testing, drug challenge tests (DCT) and evaluation of resensitization were used to classify participants as showing immediate reactions, non-immediate reactions, or tolerance. We compared clinical entities, drugs involved, and final outcome by age group.ResultsOf 1362 cases evaluated, 565 underwent an allergological study. The skin was the most common organ involved. Anaphylaxis and side chain reactions were more frequent in group A (p<0.01), as were positive DCT. Classical benzylpenicillin determinants (benzylpenicilloyl and/or minor determinant mixture) were more frequent triggers in group B (p< 0.01). Resensitization after challenge occurred in very few participants.ConclusionThe risk for allergy to BLs decreases with age and a history of anaphylaxis by BLs is a predictor of positive results in skin tests (ST). Both immunoglobin E (IgE) and T-cell–mediated responses can disappear in elderly people, who can develop tolerance to these antibiotics. These results are of clinical relevance to patients who need to be treated with antibiotics from this family.

Prevention and Management of Daratumumab Mediated Infusion Related Hypersensitivity Reactions Pre-and Post-Implementation of Rapid Infusion Protocol

Background: Multiple Myeloma (MM) is defined as a clonal proliferation of malignant bone marrow plasma cells with high and uniform expression of CD 38 (Kumar et al, J Natl Compr Canc Netw. 2019; 3 and Lin et al, Am J Clin Pathol. 2004; 121:482-488). Daratumumab, a human IgGk monoclonal antibody, targets and binds to CD38, induces antibody dependent cell mediated cytotoxicity, complement activation, and antibody mediated phagocytosis (Prescribing information. Daratumumab; Janssen Biotech, Inc 2016). Daratumumab is associated with infusion related reactions (IRRs), which present with symptoms of rhinitis, cough, dyspnea, bronchospasm, chills and nausea. In two phase 3 trials, CASTOR (Palumbo et al, N Engl J Med. 2016; 375:754-66) and POLLUX (Dimopolous et al, N Engl J Med. 2016; 375(14):1319-31), IRRs occurred in 45% and 48% of patients, respectively. Of these, 98% and 96%, respectively, occurred during the first infusion. Grade 3 IRRs occurred in 5.3% and 8.6% of patients in CASTOR and POLLUX, respectively. No grade 4 IRRs were observed in either trial. Standard of care includes extended infusion times for the first, second, and subsequent infusions with a three-drug pre-infusion prophylaxis strategy including diphenhydramine, dexamethasone or methylprednisolone, and acetaminophen with slow prolonged infusion times is recommended(Bhatnagar et al, Oncologist. 2017; 22:1347-53). A single-arm safety study of accelerated infusion rate indicate that administering daratumumab using a time-saving 90-minute infusion protocol can be safe. Of 28 patients treated with accelerated daratumumab infusion during their third and subsequent infusions, no IRRs were observed, and there was only one mild reaction with no further reactions during subsequent infusions at the 90-minute rate (Barr et al, Leukemia. Mar. 2018). Subsequently, a similar protocol for all daratumumab infusions was implemented at The Johns Hopkins Health System including five premedications and three medications (5+3) during the first two infusions. Premedication can be eliminated for lack of tolerance. The purpose of this study is to evaluate the safety and success of rapid daratumumab administration in clinical practice based on infusion times, IRRs prophylaxis medication administration, IRRs frequency, and management of IRRs in the ambulatory setting of the Johns Hopkins Health System, pre- and post-implementation of the 90-minute infusion protocol using a more robust premedication regimen (5+3) than previously published. Study Design and Methods: This study is approved by the institutional review board at The Johns Hopkins Hospital (IRB 00195519). This is a retrospective, chart review of daratumumab infusions prior to implementing the accelerated infusion rate. The inclusion criterion was adult patients who received daratumumab infusion in the ambulatory infusion clinic July 1, 2016 to May 25, 2018 for pre-implementation and July 1 2018 to June 30 2019 for the post-implementation period. Patients who only received inpatient administration of daratumumab were excluded due to limited infusion related documentation. The primary endpoint is the proportion of patients who experienced IRRs after daratumumab infusion. Secondary endpoints include proportion of patients with grade 1/2 or grade 3/4 IRRs, infusion duration (hours), and the number of pre and post infusion prophylaxis medications given. Other data collected will include but not limited to demographics, prior history of anaphylaxis, eczema, asthma, or other drug allergies to identify risk factors not previously defined. Results: Data collection and analysis are ongoing. The sample size for pre-implementation of rapid infusion is ninety-three patients. Documented IRRs occurred in 18 (19%) patients. The mean infusion time was 7.4 hours for first infusions (n=70), 8 hours for patients with IRRs in the first infusion (n=18) and 7.1 hours for patients without IRRs in the first infusion (n=52). The mean number of IRR prophylaxis medications given was 7.8 (range 2-9) for first or second infusions. All IRRs documented were grade 1 or 2. Additional data analysis will include descriptive statistics as well as comparison of infusion duration, and will use paired t-test within samples and student t-test across different samples. Final results will report safety of daratumumab rapid infusion in largest single center patient population to date. Disclosures Ali: Celgene: Research Funding; Poseida: Research Funding.

M003 SUCCESSFUL DESENSITIZATION TO FLORINEF AFTER ANAPHYLAXIS IN A PATIENT WITH POSTURAL ORTHOSTATIC HYPOTENSION (POTS) DISEASE

Fludrocortisone is a pharmacologic agent used to treat postural orthostatic hypotension (POTS) disease. We describe a case of a patient with reported history of anaphylaxis to fludrocortisone with POTS. Poor quality of life influenced her to undergo the first known reported successful desensitization to fludrocortisone.

1094. Safety of Administering Cefazolin vs. Other Antibiotics in Penicillin Allergic Patients with Anaphylaxis for Surgical Prophylaxis

BackgroundApproximately 10% of patients report a history of penicillin allergy. Recent literature suggests cross-reactivity between cephalosporins and penicillins are due to side-chain similarities. Since cefazolin has a unique side-chain from other β lactams, it can be safely administered in penicillin-allergic patients for surgical prophylaxis. Since October 2018, our hospital updated all surgical prophylaxis preprinted orders to use cefazolin in penicillin-allergic patients, except in those with histories of cefazolin-specific allergy or delayed skin reactions (e.g., Stevens–Johnson syndrome). This study aims to retrospectively determine outcomes and safety of cefazolin as compared with other antibiotics for surgical prophylaxis in penicillin-allergic patients with histories of anaphylaxis prior to implementation of cefazolin preprinted orders.MethodsAll patients with reported anaphylactic reactions to penicillins prescribed surgical prophylaxis from October 9, 2017 to October 9, 2018 were included. Patients were stratified based on antibiotic received (i.e., cefazolin, clindamycin, vancomycin, other antibiotic) and a retrospective chart review was performed to assess for outcomes and safety.ResultsOne-thousand-seventy-three prescriptions for prophylactic antibiotics were identified. Of these, 223 cases met inclusion with histories of anaphylaxis to pencillins: 72 (32%) cefazolin, 70 (31%) clindamycin, 34 (15%) vancomycin, and 47 (21%) other antibiotics. General and orthotrauma surgeries used the most cefazolin in penicillin-allergic patients, while gynecology clindamycin and thoracics vancomycin. Amongst those receiving cefazolin, no critical incidents of allergic reactions were reported and the rates of adverse events, such as pruritus, hives and rash, did not differ between any antibiotic group.ConclusionCefazolin appears to be a safe option for surgical prophylaxis in patients with history of penicillin anaphylaxis. No differences in incidences of allergic reactions, complications or surgical delays were reported, as compared with alternate antibiotics. Further larger studies are needed to confirm our findings and determine rates of adverse events associated with the various antibiotic regimens.Disclosures All authors: No reported disclosures.

Secondary prevention measures in anaphylaxis patients: Data from the anaphylaxis registry.

Patients with a history of anaphylaxis are at risk of future anaphylactic reactions. Thus, secondary prevention measures are recommended for these patients to prevent or attenuate the next reaction. Data from the Anaphylaxis Registry were analyzed to identify secondary prevention measures offered to patients who experienced anaphylaxis. Our analysis included 7788 cases from 10 European countries and Brazil. The secondary prevention measures offered varied across the elicitors. A remarkable discrepancy was observed between prevention measures offered in specialized allergy centers (84% of patients were prescribed adrenaline autoinjectors following EAACI guidelines) and outside the centers: Here, EAACI guideline adherence was only 37%. In the multivariate analysis, the elicitor of the reaction, age of the patient, mastocytosis as comorbidity, severity of the reaction, and reimbursement/availability of the autoinjector influence physician's decision to prescribe one. Based on the low implementation of guidelines concerning secondary prevention measures outside of specialized allergy centers, our findings highlight the importance of these specialized centers and the requirement of better education for primary healthcare and emergency physicians.

Multiple Retained Ocular Bee Stingers

Bee sting injuries, though rare in the eye, can be visually incapacitating for the patient if they occur. They have a wide variety of ocular manifestations ranging from involvement of the ocular surface right up to the optic nerve. This could be due to the venom of the bee itself, the sharp nature of the stinger, the toxic nature of the singer or the induction of the immunological response by the patient. Also, the introduction of the stinger in the eye may sometimes cause infection. These can individually or in part play a role in the clinical manifestations of a patient. We report a case of a 24-year-old female who had history of anaphylaxis due to multiple bee stings all over her body (including severe periorbital edema) one month back. After resolution of her acute symptoms she noticed a foreign body sensation, redness, lacrimation diminution of vision and pain in her left eye for which she came to us. Her Visual Acuity at presentation was 6/12in the left eye. On slit lamp examination two stingers were found embedded in her upper tarsal conjunctiva and one stinger was seen in the anterior chamber. All the three stingers were successfully removed mechanically after which she was prescribed topical antibiotics, steroids and cyclopentolate. This led to resolution of all her symptoms and improvement of her visual acuity to 6/6 within 5 days.

Oral immunotherapy with peach juice in patients allergic to LTPs

IntroductionTo assess the safety and efficacy of an oral immunotherapy regimen in patients with allergy to lipid transfer proteins (LTPs).Materials and methodsProspective study of 24 patients allergic to LTP with positive skin test and a history of anaphylaxis. All patients underwent a desensitization protocol with commercial peach juice. Rising doses of peach juice were administered, starting with an initial dose of seven drops of a 1/1000 dilution and finishing with a dose of 5 ml at visit 17. At visit 18, all patients performed an open challenge with whole juice at a cumulative dose of 200 ml. All adverse reactions occurring during the administration of the different doses were recorded. Levels of rPru p 3 in the juice were quantified.ResultsThere were no severe reactions during the desensitization process in the 24 patients. Seven patients (29%) reported mild oral symptoms, and two patients (8%) had urticaria associated with co-factors (one due to exercise and another due to non-steroidal anti-inflammatory drugs). Nineteen patients were able to swallow 5 ml of juice and five withdrew from the study. In two pregnant patients the final challenge was not performed. In all, 17/24 patients were able to consume 200 ml peach juice without developing symptoms.ConclusionsOral immunotherapy with the regimen used in this study is an effective and safe short-term therapeutic option for patients with allergy to LTPs. Commercial peach juice appears to be suitable for this treatment.

Safety of direct drug provocation testing in adults with penicillin allergy and association with health and economic benefits

BackgroundNonprescription of penicillin-containing antibiotics in patients diagnosed with penicillin allergy is associated with morbidity and mortality. Adverse reactions to penicillins comprise type A and B reactions. ObjectiveTo assess the feasibility of penicillin allergy evaluation without penicillin skin testing (PST) for adult patients with type B reactions and the health and economic benefits of this process. MethodsInpatients at an Australian tertiary hospital between April 1, 2017, and April 30, 2018, with a diagnosis of type B penicillin allergy, requiring a penicillin-containing antibiotic for treatment, were included. All patients underwent clinical history review, PST, and drug provocation testing (DPT). ResultsSeventy-one patients were enrolled. Sixty-three reported a history of type B or unknown adverse reactions. No patients had a history of anaphylaxis requiring intubation or epinephrine within the last 10 years or a history suggesting Gell and Coombs type 2, 3, or 4 (severe) hypersensitivity reaction. Seven did not complete DPT because the treating team used a β-lactam antibiotic other than amoxicillin. Fifty-four of 56 remaining patients (96%) completed 3-day DPT to amoxicillin with no adverse reaction. Two experienced mild cutaneous reactions. Penicillin allergy evaluation was significantly associated with reduced length of stay, reduced hospital expenditure on bed and second-line antibiotics, and reduced readmission rates. ConclusionPenicillin allergy evaluation with DPT without PST may be feasible for all adult patients with a reported history of type B reactions to penicillins who do not have a history of anaphylaxis within the last 10 years or a type 2, 3, or 4 (severe) hypersensitivity reaction.

Beta-lactam allergy in Chinese patients and factors predicting genuine allergy

IntroductionBeta-lactams (BL) are the most frequently reported drug allergy, but the vast majority of patients are found not to be genuinely allergic after evaluation. Few studies have investigated the clinical predictors of genuine BL allergy, and the prevalence in hospitalized Chinese patients is unknown. MethodsPatients admitted to a tertiary hospital in Hong Kong (HK) were analyzed to identify the prevalence and factors associated with the presence of BL allergy labels among hospitalized Chinese patients. A combined cohort of patients having completed allergy investigation for suspected BL allergies in the United Kingdom (UK) and HK were analyzed to identify predictors of genuine allergy. ResultsThe prevalence of BL allergy labels in hospitalized HK Chinese was 5%, which was associated with female gender and concomitant non-BL antibiotic allergy labels. The rate of genuine BL allergy patients referred for suspected allergies in the UK and HK cohort was only 14%. History of anaphylaxis and interval of less than a year since the index reaction were independent clinical predictors of genuine BL allergy. The negative predictive value of penicillin skin testing was 90%, confirming the need for drug provocation testing after negative skin testing. There was a high rate of confirmed piperacillin-tazobactam allergy. DiscussionThe estimated true prevalence of genuine BL allergy in hospitalized HK Chinese is around 0.5%. This high rate of BL mislabeling highlights the need for comprehensive allergy evaluation and screening. History of anaphylaxis and duration since the index reaction are important predictors of genuine allergy. Piperacillin-tazobactam allergy may pose a unique challenge in this population with a high prevalence of suspected allergies, surging antibiotic resistance, and lack of testing available.

Iranian guideline for rituximab therapy in pemphigus patients.

Pemphigus vulgaris (PV) is an autoimmune blistering disease affecting the skin and/or mucosa. Rituximab (RTX) has been approved recently by US FDA as an effective and safe treatment of PV. The high incidence of PV in Iran encouraged our team to prepare a consensus guideline for RTX administration based on literature review and a decade experience of an expert panel. RTX is recommended for the treatment of new cases of PV as well as patients not responding to conventional therapy. Contraindications include history of anaphylaxis or IgE-mediated hypersensitivity to murine proteins of RTX, severe active infections, pregnancy, breastfeeding, severe heart failure, and arrhythmia. Prophylactic antiviral therapy is recommended in patients at risk of reactivation of HBV and isoniazid for those at risk of reactivation of tuberculosis. Concomitant use of systemic corticosteroids is recommended as a rule. Except for methotrexate, the combination with other immunosuppressive drugs is discouraged. Intravenous immunoglobulin is recommended for those at risk of infections or with extensive disease. The recommended dosage of RTX for the first cycle is 2 g either 500 mg weekly or 1 g biweekly. There is no general consensus whether the next doses of RTX be administered upon relapse or as maintenance therapy. We strongly recommend RTX sooner in the course of pemphigus.

Successful intravenous heparin administration during coronary revascularization surgery in a patient with alpha-gal anaphylaxis history

Allergy to galactose-alpha-1,3-galactose (alpha-gal) presents as an immunoglobulin E (IgE)-mediated, yet delayed-onset hypersensitivity reaction to non-primate mammalian meat. 1 Commins S.P. Jerath M.R. Cox K. Erickson L.D. Platts-Mills T. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016; 65: 16-20 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Alpha-gal sensitization develops after tick bite exposure. 1 Commins S.P. Jerath M.R. Cox K. Erickson L.D. Platts-Mills T. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016; 65: 16-20 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar , 2 Commins S.P. James H.R. Kelly L.A. et al. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galacatose. J Allergy Clin Immunol. 2011; 127: 1286-1293 Abstract Full Text Full Text PDF PubMed Scopus (351) Google Scholar , 3 Fischer J. Lupberger E. Hebsaker J. et al. Prevalence of type I sensitization to alpha-gal in forest service employees and hunters. Allergy. 2017; 72: 1540-1547 Crossref PubMed Scopus (59) Google Scholar The lone-star tick (Amblyomma americanum) represents the North American vector, spanning a relatively vast southeast, midwest, and northeast geographic distribution. 4 Approximate Distribution of the Lone Star Tick. Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Disease. Division of Vector-Borne Diseases. https://www.cdc.gov/ticks/maps/lone_star_tick.pdfDate accessed: March 28, 2019 Google Scholar Allergic manifestations include urticaria/angioedema, abdominal pain/diarrhea, or anaphylaxis, occurring approximately 3 to 6 hours after ingestion. 1 Commins S.P. Jerath M.R. Cox K. Erickson L.D. Platts-Mills T. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016; 65: 16-20 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Alpha-gal hypersensitivity is not limited to food-related consumption. Other potential alpha-gal exposures include bioprosthetic heart valves and vaccines or medications (porcine/bovine origin or gelatin-containing), such as heparin. 5 Commins S.P. Invited commentary: Alpha-gal allergy: tip of the iceberg to a pivotal immune response. Curr Allergy Asthma Rep. 2016; 16: 61 Crossref PubMed Scopus (27) Google Scholar , 6 Dunkman W.J. Rycek W. Manning M.W. What does a red meat allergy have to do with anesthesia? Perioperative management of alpha-gal syndrome. Anesth Analg. 2018; https://doi.org/10.1213/ANE.0000000000003460 Crossref PubMed Scopus (8) Google Scholar , 7 Mozzicato S.M. Tripathi A. Posthumus J.B. Platts-Mills T.A.E. Commins S.P. Porcine or bovine valve replacement in 3 patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galactose. J Allergy Clin Immunol Pract. 2014; 2: 637-638 Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar