Immediate-type Hypersensitivity Research Articles

Quoi de neuf en allergologie pédiatrique en 2011 ? Anaphylaxie, allergie alimentaire, médicamenteuse et aux venins d’insectes (une revue de la littérature internationale 2011)

Several studies confirm that, in children with anaphylaxis, the use of epinephrine is not adequate, not only by the patients themselves (self-administration) but also in the emergency rooms, and suggest measures to improve the early use of epinephrine. Prevalence of food allergy, including severe anaphylaxis, is high and constantly increasing. However, 30 to 50% of food sensitizations diagnosed by means of skin and/or biological testing are not associated to allergy and need challenge tests to assess their relevance. In children tolerant to boiled milk or cooked egg, daily consumption of these foods accelerates tolerance acquisition to crude milk and non-cooked egg. Several protocols of desensitization/tolerance induction to egg, milk and peanut are presented, with promising results. Several studies, including two studies in several thousands of children, clearly show that only 10 to 15% of children with suspected drug allergy are really hypersensitive to the drugs. Risk of drug hypersensitivity increases with the earliness and the severity of the reactions. Thus, it is suggested that diagnosis should be primarily based on challenge tests in children reporting non-immediate and non-severe reactions, to avoid unnecessary skin testing. Immediate-type hypersensitivity to toxoid vaccines resolves with time, and this spontaneous recovery may allow booster full-strength injections of the vaccines in most children. Finally, although they are usually tolerated by egg- and milk-allergic children, (injective) drugs and biological substances produced on milk or egg derivatives may be contaminated by proteins and induce anaphylactic reactions.

Hypersensitivity Reactions to Vaccine Constituents

Vaccines are composed of immunogens, preservatives, adjuvants, antibiotics, and manufacturing by-products. Components of vaccines may rarely elicit adverse reactions in susceptible individuals, thus raising concerns regarding vaccine safety. In this report, we add to the medical literature 3 cases of cutaneous delayed-type hypersensitivity to the vaccine preservative aluminum. We provide a review of major constituents in vaccines that have elicited immediate-type or delayed-type hypersensitivity reactions and describe their clinical manifestations. We include a table of the Food and Drug Administration-approved vaccines, which lists the quantities of major components including ovalbumin (egg protein), gelatin, aluminum, neomycin, 2-phenoxyethanol, thimerosal, and formaldehyde. Our goals were to inform physicians on the variety of hypersensitivity reactions to common vaccines and to provide information on the choice of vaccines in patients with suspected hypersensitivity.

International Survey on Evaluation and Management of Eosinophilic Esophagitis

Background Recommendations regarding evaluation and management of eosinophilic esophagitis (EoE) remain incompletely defined. This survey assesses: how providers across the world diagnose, evaluate, and treat EoE and how educational activities affect management.Methods A web-based survey was sent to the members of World Allergy Organization, American College of Allergy, Asthma, and Immunology, and American Academy of Allergy, Asthma, and Immunology. A χ2 analysis compared responses based on personal and practice demographics and participation in educational activities.Results Of the 200 respondents, 68.5% were from the United States. The majority were allergists, who require biopsy to diagnose EoE, perform allergy testing, and obtain follow-up biopsy after treatment. The following variables had significant differences: (1) US practitioners were more likely to test for immediate-type hypersensitivity to foods and obtain follow-up endoscopic biopsies after the initial treatment; (2) Practitioners encountering patients with EoE more frequently were more likely to ask about personal and family history of atopy, test for immediate-type hypersensitivity to aeroallergens and foods, and recommend follow-up biopsy after treatment; and (3) Practitioners who participate more often in EoE workshops were more likely to perform patch testing for foods, while attendance at EoE lectures increased EoE management confidence.Conclusions Diagnostic and management strategies differ based on practice location, EoE patient load, and participation in educational activities. Practitioners who attend more EoE lectures are more confident managing EoE.

An anti-IgE monoclonal antibody that binds to IgE on CD23 but not on high-affinity IgE.Fc receptors

A new monoclonal antibody (mAb), specific for human IgE, the central mediator of immediate-type hypersensitivity reactions, has been shown to possess a unique set of binding specificities. The mAb, 8D6, binds to a conformational epitope on the CH3 domain of human e immunoglobulin and can compete with omalizumab for binding to IgE. Like omalizumab, it does not bind to IgE bound by the high-affinity IgE.Fc receptor (FcɛRI) on basophils and mast cells. It also does not cause activation and degranulation of IgE-pulsed, human FcɛRI-expressing rat basophilic leukemic cells (RBL SX-38). The mAb can inhibit IgE binding to recombinant α chain of human FcɛRI in ELISA and to human FcɛRI-expressing RBL SX38 cells in fluorescence flow cytometric analysis. However, unlike omalizumab, 8D6 can bind to IgE already bound by the low-affinity IgE.Fc receptors (FcɛRII, or CD23), as revealed in ELISA with recombinant CD23 and in flow cytometric analysis with human B cells. Since earlier investigators have shown that anti-CD23 mAbs can inhibit the synthesis of IgE in lymphocyte culture in vitro and can down-regulate IgE production in treated patients, 8D6 may offer pharmacological mechanisms in addition to those mediated by omalizumab, for controlling IgE in patients with allergic diseases.

Immediate and delayed hypersensitivity to corticosteroids

Corticosteroids are therapeutic agents used in cases of allergy and intolerance. Due to the antiinflammatory effects of the corticosteroids, hypersensitivity reactions often are considered to be a paradox. However, delayed-type reaction to corticosteroids is a frequent phenomenon in the daily routine. Non-responding eczema, development of subacute contact eczema, systemic contact dermatitis or maculopapular exanthemas can be a clinical symptom of a delayed-type hypersensitivity reaction to corticosteroids. Immediate-type hypersensitivity reactions to corticosteroids remain uncommon. Nevertheless, they can take a severe clinical course. Patients react with anaphylaxis after systemic administration or with aggravation of an allergic reaction under therapy with corticosteroids. Allergologic testing is necessary for diagnosis and providing alternative corticosteroids in case of an emergency.

Immediate-type hypersensitivity to systemic glucocorticoids: An underrated drug allergy

Immediate-type hypersensitivity to systemic glucocorticoids: An underrated drug allergy

Chrysin suppresses mast cell-mediated allergic inflammation: Involvement of calcium, caspase-1 and nuclear factor-κB

A great number of people are suffering from allergic inflammatory diseases such as asthma, atopic dermatitis, and sinusitis. Therefore discovery of drugs for the treatment of these diseases is an important subject in human health. Chrysin (5,7-dihydroxyflavone) is a natural flavonoid contained in propolis, blue passion flower, and fruits. Several studies reported that chrysin has beneficial effects including anti-tumor and anti-oxidant activities. The aim of the present study was to elucidate whether chrysin modulates the allergic inflammatory reaction and to study its possible mechanisms of action using mast cell-based in vitro and in vivo models. Chrysin inhibited immediate-type systemic hypersensitivity and serum histamine release. Chrysin attenuated immunoglobulin E-mediated local anaphylaxis. These inhibitory effects of chrysin on the systemic and local allergic reaction were more potent than cromolyn, a known anti-allergic drug. Chrysin reduced histamine release from mast cells. The inhibitory effect of chrysin on the histamine release was mediated by the modulation of intracellular calcium. In addition, chrysin decreased gene expression of pro-inflammatory cytokines such as, tumor necrosis factor-α, IL (interleukin)-1β, IL-4, and IL-6 in mast cells. The inhibitory effect of chrysin on the pro-inflammatory cytokine was nuclear factor-κB and caspase-1 dependent. Our findings provide evidence that chrysin inhibits mast cell-derived allergic inflammatory reactions by blocking histamine release and pro-inflammatory cytokine expression, and suggest the mechanisms of action. Furthermore, in vivo and in vitro anti-allergic inflammatory effect of chrysin suggests a possible therapeutic application of this agent in allergic inflammatory diseases.

The hair dyes PPD and PTD fail to induce a TH2 immune response following repeated topical application in BALB/c mice

1,4-Phenylenediamine (PPD) and the structurally-related 1,4-toluenediamine (PTD) are frequently used oxidative hair dye precursors that can induce a delayed-type hypersensitivity reaction known as contact allergy. Very rare cases of Type 1 (IgE-mediated) allergic responses associated with PPD or PTD have been reported among hair dye users. As part of an effort to determine if repeated dermal exposure to the dyes could induce a T-helper-2 (TH2) response, we used a dermal exposure regimen in mice reported to identify a TH2 response. Ear swelling was evident at post-final exposure to PPD and PTD, indicating that an immune response was observed. However, cytokine mRNA after repeated topical exposure to these two chemicals showed no shift in the expression toward the typical TH2 cytokines interleukin (IL)-4 and IL-10 compared to the TH1 cytokine interferon (IFN)-γ. Consistent with these cytokine profiles, no concomitant increase in total serum IgE antibody titer or in B220+IgE+ lymphocytes in lymph nodes and skin application site skin was detected. In contrast, using an identical exposure regimen, animals topically exposed to the known respiratory (Type 1) allergen toluene 2,4-diisocyanate (TDI) showed significant expression of IL-4 and IL-10 mRNA compared to IFNγ as well as an increase in total serum IgE and in B220+IgE+ cells in lymph nodes and skin application site. The data generated are consistent with the pattern of adverse reactions to hair dyes seen clinically, which overwhelmingly is of delayed rather than immediate-type hypersensitivity. Although current animal models have a limited ability to detect rare TH2 responses to contact allergens, the present study results support the view that exposure to hair dyes is not associated with relevant TH2 induction.

Immediate type drug hypersensitivity reactions and associated risk factors in an adult Turkish men population.

The study aimed to assess the prevalence and associated risk factors of immediate-type hypersensitivity reactions (HRs) to drugs in workers. The data consisted of 1152 questionnaires obtained from adult men that consisted of questions on HRs induced by drugs. The prevalence of self-reported drug HRs was 3.6% for all reactions. HRs were most common to beta-lactam antibiotics (51.2%) followed by nonsteroid antiinflammatory drugs (NSAIDs) (41.5%). Multivariate analysis showed that family atopy was associated with drug HRs to both antibiotics (Odds Ratio (OR) 95% Confidence Interval (CI) (3.32 (1.15-9.56)) and NSAIDs (3.70 (1.09-12.51)). Drug HRs of any type were associated with atopic family history (3.23 (1.43-7.24)), ever asthma diagnosis (2.74 (1.07-7.02)), ever allergic rhinitis (2.70 (1.25-5.84)), and ever eczema (3.80 (1.55-9.30)). Drug related skin manifestations were associated with family history of atopic diseases (4.07 (1.76-9.41)), ever allergic rhinitis (2.84 (1.24-6.5)), ever asthma diagnosis (3.16 (1.19-8.39)), and ever eczema diagnosis (4.59 (1.82-11.57)). Systemic manifestations of drug HRs were associated with only asthma diagnosis (4.66 (1.25-17.41)). Risk groups should be followed closely as candidates for immediate type HRs to antibiotics and NSAIDs in also relatively healthy and young aged adult men.

Anaphylaxis to the 23-valent pneumococcal vaccine: A second explored case by means of immediate-reading skin tests with pneumococcal vaccines

Anaphylaxis to pneumococcal vaccines is rare. In the only one child with anaphylaxis to a first injection of the 23-valent pneumococcal vaccine that has been explored, skin tests and specific IgE determination diagnosed immediate-type hypersensitivity to pneumococcal antigens. We report the case of a child who tolerated three injections of the 7-valent pneumococcal vaccine, but experienced anaphylaxis to a fourth injection of the 23-valent vaccine. Immediate responses in skin tests diagnosed immediate-type hypersensitivity to the two vaccines. Immunizations with the 7-valent pneumococcal vaccine may induce IgE-dependent sensitization to pneumococcal antigens, responsible for anaphylaxis to subsequent injections of pneumococcal vaccines.

Bullous Leg Lesions Caused by Culicoides Midges after Travel in the Amazon Basin

A 36-year-old man presented with 1 day of blistering lesions on the lower extremities. Two days before presentation, he had traveled to several rural communities in the Peruvian Amazon. During that trip, he had hiked through several areas of damp soil, decaying plants, and dense grass reaching up to 50 cm in height. He awoke the next morning with numerous confluent, erythematous, pruritic, non-blanching papules that were circumferential around both ankles. Over the next day, multiple bullae up to 4.5 cm in diameter developed with surrounding edema (Figure 1). The patient was treated with prednisone (50 mg daily) by mouth for 3 days, followed by routine wound care with topical antimicrobials, dressings, and topical hydrocortisone for pruritus. The lesions stabilized in size by the third day and had largely resolved by 14 days with minimal scarring. Figure 1. View of the patient's right ankle 1 day after travel, with prominent bullae and numerous confluent papules. Soft-tissue edema is obscuring the medial malleolus. This figure appears in color at www.ajtmh.org. This case was caused by midge bites, likely from the hematophagous species Culicoides paraensis and insinuatus (Figure 2). These small insects are widespread in the Peruvian Amazon, where they favor wet areas, grass, and decaying vegetation such as the remains of banana (platano) trees.1 Approximately 1 mm in size and noiseless, they are difficult to see and may be overlooked in vector-avoidance strategies despite being vectors for Oropouche virus and other pathogens. Bites to humans may manifest as an immediate-type hypersensitivity reaction with urticaria or as presumably delayed-type reactions with papular, ulcerating, or bullous lesions that can require weeks to resolve.2 Travelers to rural regions in the tropics should adhere carefully to vector precautions, including the use of N,N-diethyl-meta-toluamide (DEET), permethrin, and physical barriers such as heavy boots and tucked-in trousers to prevent bites and their potential consequences. Figure 2. Dissecting microscope images (40×) of a female C. paraensis collected near Iquitos, Peru in the vicinity of where the subject traveled. (A) Thorax and legs. (B) Head. (C) Abdomen. (D) Wing. This figure appears in color at www.ajtmh.org.

Immediate-type drug hypersensitivity and associated factors in a general population

Background Our aim was to assess the prevalence and associated risk factors of common hypersensitivity reactions to drugs in the adult population, for which limited data are available. Methods The data consisted of 1052 questionnaires obtained from adults. The questionnaires consisted of questions on immediate-type hypersensitivity reactions induced by drugs (itching, skin rash/hives, angio-oedema, shortness of breath, hypotension, and loss of consciousness). The questionnaire added knowledge on pyhsician’s diagnosis of asthma, allergic rhinitis, eczema, and other chronic systemic diseases. Results The prevalence of self-reported drug hypersensitivity reactions was 11.8% for all reactions. Hypersensitivity reactions to analgesics were the most common (37.2%) followed by antibiotics (24.2%). Multivariate analysis showed that female gender (Odds Ratio (OR) 95% Confidence Interval (CI) (2.00 (1.25–3.21)), pyhsician-diagnosed allergic rhinitis (3.03 (1.64–5.59)), and eczema (3.22 (1.87–5.53)) were associated with any type of drug hypersensitivity reactions. Itching was associated with allergic rhinitis (4.50 (2.06–9.81)) and eczema diagnosis (4.24 (2.14–8.64)). Skin rash/hives were associated with female gender (2.67 (1.24–5.74)), allergic rhinitis (4.57 (1.99–10.05)), and eczema (5.36 (2.65–10.84)). Angio-oedema was higher in females (5.74 (1.69–18.5)). In addition, eczema (2.87 (1.12–7.32)) and systemic hypertension (2.60(1.03–6.10)) were associated with angio-oedema. Shortness of breath was only associated with ever asthma diagnosis (6.59 (2.09–20.83)). Factors associated with loss of consciousness were female gender (5.56 (1.27–24.30)), allergic rhinitis diagnosis (4.76 (1.73–13.14)), and systemic hypertension (2.74 (1.02–7.41)). Conclusion The study showed that females and subjects with allergic diseases and hypertension were more susceptible to drug hypersensitivity reactions.

Diagnosis and treatment of allergy to hymenoptera venoms

This review overviews select advances reported in the literature from mid-2008 to the present in the diagnosis and management of individuals with immediate-type hypersensitivity to hymenoptera venom(s). Skin testing remains the principal confirmatory test for sensitization to hymenoptera venoms. Use of dialyzed extracts in North America could enhance the sensitivity of intradermal skin testing. Hymenoptera venom components are overviewed with focus on their use in IgE antibody microarray assays to distinguish true dual sensitization to yellow jacket venom (YJV) and honeybee venom (HBV) proteins from carbohydrate-related cross-reactivity. Mechanisms on how venom induces vascular permeability in the skin following intradermal testing are elucidated and how tolerance is induced following high-dose venom exposure. For management, venom immunotherapy remains the most effective treatment. Use of immunotherapy in large local reactors to reduce morbidity is discussed. Baseline serum tryptase levels have been identified as one potential marker for severe systemic reactions to a subsequent sting. Minor enhancements involving dialyzed venoms, component allergens, and microarray systems are poised to improve diagnostic confirmatory assays. Use of venom immunotherapy in large local reactors and tryptase as a predictor of a future severe venom-induced systemic reaction may enhance management programs for stinging insect allergic individuals.

Outcomes of premedication for non-ionic radio-contrast media hypersensitivity reactions in Korea

Background Radio-contrast media (CM)-related adverse reactions are important clinical problems that may cause fatal anaphylaxis. Accordingly, it has been common practice to premedicate patients who have had previous reactions to CM with corticosteroids, antihistamines, and H2 blockers to prevent hypersensitive reactions. However, the effectiveness of premedication has not been properly demonstrated, especially in cases related to non-ionic CM. In this study, we evaluated the effectiveness of premedication at preventing of non-ionic CM immediate-type hypersensitivity reactions. Methods A total of 30 patients who had been pretreated with corticosteroid and H1 antihistamines and/or H2 blockers in a 3-year period were enrolled. The results of premedication were evaluated in terms of clinical characteristics and the features of breakthrough reactions. Results Hypersensitivity reactions were not prevented in 5 of the 30 patients who had experienced prior CM reactions (overall recurrence rate after premedication 16.7%; 4/17 patients with mild previous reactions, and 1/13 patients with severe previous reactions). The recurrence rate after premedication was significantly higher in patients with mild previous reactions than in those with severe reactions (23.5% vs. 7.7%; p < 0.001). The breakthrough reactions were similar to the prior reactions in terms of severity and clinical manifestations. Conclusion Premedication with corticosteroid and H1 antihistamines and/or H2 blockers effectively prevent non-ionic CM-related adverse events in most patients who have had severe previous reactions to CM. However, physicians should be aware of the possibility of premedication failing and of breakthrough reactions, even in cases in which the previous reactions were mild.

Anti-IgE monoclonal antibodies that bind to IgE bound by CD23 but not to IgE bound by IgE Fc receptors on basophils (86.10)

Abstract IgE is a central mediator responsible for immediate-type hypersensitivity reactions. The anti-IgE monoclonal antibody (mAb), omalizumab, has been shown in numerous clinical trials to be efficacious in the treatment of severe allergic asthma and other allergic diseases. Omalizumab was designed to bind to free IgE in blood and membrane-bound IgE (mIgE) on B cells, but not to IgE bound by the high-affinity IgE Fc receptors (FcϵRI) on basophils and mast cells and by the low-affinity IgE Fc receptors (CD23) on B cells and many other cell types. Additionally, omalizumab can bind to IgE and prevent it from binding to both FcϵRI and CD23. Studies by other groups have also shown that CD23 is involved in the synthesis of IgE and that interfering CD23 function, such as by cross-linking CD23 on B cell surface, can cause the down-regulation of IgE production. We have developed anti-IgE mAbs that mimic omalizumab in various aspects except their ability to bind to IgE on CD23. These newly developed mAbs bind to linear epitopes on IgE. They do not induce the degranulation of IgE-pulsed rat basophilic leukemic cells (RBL SX-38), which had been transfected with the genes of human FcϵRI. The ability of the mAbs to cross-link IgE-occupied CD23 on the cell surface of B cell lines is being tested. The results suggest that these anti-IgE mAbs may render a set of pharmacological mechanisms, which are somewhat different from that of omalizumab, for controlling IgE in patients with allergic diseases.

Clinical laboratory assessment of immediate-type hypersensitivity

Clinical laboratory analyses aid in the diagnosis and management of human allergic (IgE-dependent) diseases. Diagnosis of immediate-type hypersensitivity begins with a thorough clinical history and physical examination. Once symptoms compatible with an allergic disorder have been identified, a skin test, blood test, or both for allergen-specific IgE antibodies provide confirmation of sensitization, which strengthens the diagnosis. Skin testing provides a biologically relevant immediate-type hypersensitivity response with resultant wheal-and-flare reactions within 15 minutes of allergen application. Allergen-specific IgE antibody in serum is quantified by using 3 laboratory-based autoanalyzers (ImmunoCAP, Immulite, and HYTEC-288) and novel microarray and lateral-flow immunoassays. Technologic advances in serologic allergen-specific IgE measurements have involved increased automation, with enhanced reproducibility, greater quantification, lower analytic sensitivity, and component-supplemented extract-based allergen use. In vivo provocation tests involving inhalation, ingestion, or injection of allergens serve to clarify discordant history and skin- or blood-based measures of sensitization. Other diagnostic allergy laboratory analyses include total and free serum IgE measurement, precipitating IgG antibodies specific for organic dusts, mast cell tryptase, and indicator allergen analyses to assess indoor environments to promote patient-targeted allergen avoidance programs. A critique is provided on the predictive utility of serologic measures of specific IgE for food allergy and asthma. Reasons for the lack of clinical utility for food-specific IgG/IgG4 measurements in allergy diagnosis are examined. When the specific IgE measures are inconsistent with the clinical history, they should be confirmed by means of repeat and alternative method analysis. Ultimately, the patient's clinical history remains the principal arbiter that determines the final diagnosis of allergic disease.

Clinical laboratory assessment of immediate-type hypersensitivity

Clinical laboratory assessment of immediate-type hypersensitivity

Diagnosis of heparin-induced delayed type hypersensitivity

SummaryHeparin is commonly used for prevention and therapy of thromboembolic diseases. Recently, work from a prospective epidemiological investigation has indicated, that heparin-induced skin lesions may be more frequent, than expected. Commonly, delayed-type hypersensitivity reactions can be identified as the cause of heparin-induced skin lesions. Rarely, immediatetype hypersensitivity responses or immune-mediated heparin-induced thrombocytopenia (HIT) are diagnosed. It is of clinical importance to differentiate between those, as patient management is fundamentally different. Patients, methods: We evaluated diagnostic procedures used to identify causes of heparin-induced skin lesions. Based on clinical presentation, histology and/or allergologic testing in 32 patients, heparin-induced delayed-type hypersensitivity (HIHS) was diagnosed. Results: Sensitivity of histology and s.c. provocation was high, amounting to 100% or 78% respectively. All other tests were unspecific or had a low sensitivity: Immediate readings of prick tests were false negative in 81%. Patch, prick and i.c. testing had a sensitivity ranging from 3.1–15.6%. Conclusion: Based on these results and despite the limitations of histology we recommend performing a skin biopsy rather than allergologic testing for diagnosis of HIHS. Compared to allergologic testing, results from histology are sensitive, readily available and may allow a differentiation from other causes of heparin-induced skin lesions.

Dicaffeoylquinic acid ameliorates chronic dermatitis caused by trinitrochlorobenzene

Although the animal models of skin inflammation designed to mimic atopic dermatitis (AD) do not completely reproduce the pathology, they are of importance as research tools to develop new approaches to therapy. Repeated application of 2,4,6-trinitrochlorobenzene (TNCB) at 2-days intervals for 3–4 weeks results in a site-restricted shift in the time course of antigen-specific hypersensitivity responses from a typical delayed-type to an immediate-type hypersensitivity followed by a late reaction, a finding often seen in skin lesions of AD patients [1]. This communication reports the effect of 2-isoprenylhydroquinone-1-glucoside (IHG) and 3,5-dicaffeoylquinic acid (DCA) isolated from Phagnalon rupestre (Asteraceae) [2], on a mouse model of dermatitis induced by repeated application of TNCB. BALB/c mice were sensitized with 0.3% TNCB applied to the both ears on day-7, followed by application to the same site three times a week from day 0 to 21 [3]. IHG and DCA (0.5mg/ear) and the reference drug dexamethasone (0.025mg/ear) were topically applied to both ears 30min after challenge from day 0 to 21. DCA significantly reduced ear thickness at every time point and inhibited the edema over 40% from day 11 onward whereas the effect of IHG was lower (nearly 30% inhibition). DCA significantly inhibited myeloperoxidase (MPO) activity, a quantitative index of neutrophil infiltration into skin, by 44% on day 22. Dexamethasone almost abolished the edema and inhibited MPO activity by 78%. In our previous studies on murine hypersensitivity, DCA was more active than IHG, possibly due to the presence of an ortho-dihydroxycinnamic group which enhanced protection [4]. These results suggest that DCA seems to diminish the development of chronic dermatitis at least partially due to the reduction of ear swelling and cell infiltration at the site of inflammation.

Glucocorticoid hypersensitivity as a rare but potentially fatal side effect of paediatric asthma treatment: a case report

IntroductionImmediate-type hypersensitivity to glucocorticosteroids is rare but well known among allergists. Surprisingly, very few reports of glucocorticosteroid hypersensitivity in children exist although glucocorticosteroid treatment is particularly common in this age group.Case presentationWe report the case of a 2-year-old boy who developed generalized urticaria, facial angio-oedema, nausea and severe dyspnoea after intravenous application of prednisolone-21-hydrogen succinate. Skin prick testing with prednisolone-21-hydrogen succinate elicited a positive result; no reactions were observed to prednisone, betamethasone or dexamethasone. While fluorescence enzyme immunoassay analysis revealed no specific IgE antibodies against prednisolone-21-hydrogen succinate, CD63-based basophil activation testing with the culprit drug prednisolone-21-hydrogen succinate was positive. In contrast, additional incubation of basophils with prednisone, betamethasone and dexamethasone did not elicit any significant response. Hence, we performed an oral provocation test with betamethasone and a titrated intravenous dexamethasone challenge. As both drugs were tolerated without any complications they were recommended for future treatment.ConclusionIn a child with confirmed immediate-type hypersensitivity to glucocorticosteroids, it is still not possible to predict which glucocorticosteroid might be tolerated by solely relying on clinical history or results of skin and in vitro testing. Therefore, incremental glucocorticosteroid challenges under standardized clinical conditions remain necessary in order to facilitate a patient-tailored emergency treatment and to avoid severe reactions to glucocorticosteroids in these patients.