Positive Skin Test Research Articles

Differentiating the endotypes in allergic rhinitis

Aim. The aim of the study was to differentiate the endotypes in allergic rhinitis by key allergy markers in a mixed group of patients.Material and Methods. The study comprised a total of 48 patients, men and women, aged 18-60 years suffering from three endotypes of allergic rhinitis including the classic, local, and dual allergic rhinitis. The standard diagnostics of allergic rhinitis included taking a history of allergies, family history of allergic disease, video rhinoscopy, serum total IgE level assessment, allergy skin tests to house dust mite and pollen allergens, and study of eosinophilic inflammation parameters (eosinophil cationic protein, interleukin-5 (IL5), and eosinophil counts in blood and nasal secretion).Results. Based on total IgE level, the general group of patients was divided to two subgroups: subgroup 1 comprised patients with high IgE level (n = 22); subgroup 2 comprised patients with low IgE level (n = 26). Most of patients in these groups had contradictory results of allergy skin tests i.e. positive allergy skin test results in case of high IgE level (group 1) and vice versa. Cluster analysis-based exminations of general group allowed to categorize three subgroups of patients: patients with classic allergic rhinitis (n = 22), local allergic rhinitis (n = 22), and dual allergic rhinitis (n = 4). Besides, an increased rate of anxiety disorder was found in patients with local allergic rhinitis (p < 0.001).Conclusion. The obtained data showed promise for a new research trend in studying allergic rhinitis endotypes, namely: investigation of neuroimmune relationships in allergic tolerance disruption in the presence of this pathology.

Correlation of clinical features with positive autologous serum skin test in Urticaria

Autologous serum skin test (ASST) is the simplest and the best in vivo clinical test for the detection of basophil histamine- releasing activity. In India, ASST positivity was found to be 26.67% in chronic Urticaria. The details enquired from the patients include duration of disease, duration of individual wheals, frequency of attacks, distribution of wheals, associated systemic symptoms, provoking physical factors, food and drug intolerance, seasonal variation, associated angioedema. Out of total 60 patients, 38 patients gave history of exacerbation of symptoms during evening time. But there was no statistical correlation with ASST positivity. Out of total 60 patients 25 patients were found to have increased serum IgE values, of which 17 (68%) were ASST positive, found to be statistically significant.

First-Dose mRNA COVID-19 Vaccine Allergic Reactions: Limited Role for Excipient Skin Testing

BackgroundThe Centers for Disease Control and Prevention state that a severe or immediate allergic reaction to the first dose of an mRNA COVID-19 vaccine is a contraindication for the second dose.ObjectiveTo assess outcomes associated with excipient skin testing after a reported allergic reaction to the first dose of mRNA COVID-19 vaccine.MethodsWe identified a consecutive sample of patients with reported allergic reactions after the first dose of mRNA COVID-19 vaccine who underwent allergy assessment with skin testing to polyethylene glycol (PEG) and, when appropriate, polysorbate 80. Skin testing results in conjunction with clinical phenotyping of the first-dose mRNA COVID-19 vaccine reaction guided second-dose vaccination recommendation. Second-dose mRNA COVID-19 vaccine reactions were assessed.ResultsEighty patients with reported first-dose mRNA COVID-19 vaccine allergic reactions (n = 65; 81% immediate onset) underwent excipient skin testing. Of those, 14 (18%) had positive skin tests to PEG (n = 5) and/or polysorbate 80 (n = 12). Skin testing result did not affect tolerance of the second dose in patients with immediate or delayed reactions. Of the 70 patients who received the second mRNA COVID-19 vaccine dose (88%), 62 had either no reaction or a mild reaction managed with antihistamines (89%), but 2 patients required epinephrine treatment. Three patients with positive PEG-3350 intradermal (methylprednisolone) testing tolerated second-dose mRNA COVID-19 vaccination. Refresh Tears caused nonspecific skin irritation.ConclusionsMost individuals with a reported allergic reaction to the first dose of mRNA COVID-19 vaccines, regardless of skin test result, received the second dose safely. More data are needed on the value of skin prick testing to PEG (MiraLAX) in evaluating patients with mRNA COVID-19 vaccine anaphylaxis. Refresh Tears should not be used for skin testing.

Association between monocyte-to-lymphocyte ratio and tuberculin skin test positivity in HIV-positive adults.

Association between monocyte-to-lymphocyte ratio and tuberculin skin test positivity in HIV-positive adults.

Serum Human β-Defensin 2 Is Increased in Angioedema Accompanying Chronic Spontaneous Urticaria

Introduction: Chronic spontaneous urticaria (CSU) is a common cutaneous disease caused by mast-cell degranulation. Human β-defensin 2 (HBD2) is a well-known antimicrobial peptide that is also a pruritogen inducing vascular permeability via non-IgE-mediated mast-cell degranulation. Objective: We investigated the associations between serum HBD2 levels and the clinical characteristics of CSU patients. Methods: Serum samples from 124 CSU patients and 56 healthy controls were screened for the levels of HBD2 and translationally controlled tumor protein (TCTP)_ by using ELISA. The urticaria activity score over 7 days (UAS7) was used to measure disease activity in CSU patients. Accompanying angioedema was self-reported. Results: Serum HBD2 levels were higher in the CSU group than in healthy subjects (median [interquartile range], 84.1 [43.5, 142.5] vs. 59.5 [26.7, 121.5], p = 0.034). In CSU patients, serum HBD2 level was negatively correlated with the peripheral basophil percentages (Spearman’s rho = −0.229, p = 0.01) and vitamin D levels (−0.262, p = 0.02), but positively correlated with TCTP levels (0.252, p = 0.006). In CSU patients, HBD2 level was higher in those with than without angioedema (101.7 [50.9, 184.2] vs. 66.7 [37.9, 132.0], p = 0.019). It did not differ by aspirin hypersensitivity or atopy status, or autologous serum skin test positivity. Conclusion: A known mast-cell degranulator, HBD2 was elevated in the sera from CSU patients compared to healthy controls and may be involved in the pathogenesis of accompanying angioedema.

Rheumatoid arthritis-like polyarthralgia after the initiation of omalizumab treatment: A case series

Omalizumab is a monoclonal antibody that binds to free human IgE in the blood and interstitial fluid. The accepted indication of this medication for asthma is moderate-to-severe persistent asthma patients having a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids.1 After omalizumab was approved for commercial use, acute exacerbation of asthma and systemic steroid administration are known to be reduced in asthmatic patients.

Interleukine-22 gene variants are associated with susceptibility to visceral leishmaniasis

Visceral leishmaniasis (VL) is an infectious disease caused by an intracellular protozoan belonging to Leishmania species. Interleukin (IL)-22 plays an important role in inflammatory response, chemotaxis, regulation of cellular proliferation and tissue repair. Considering the role of IL-22 in control of leishmaniasis and the effect of its single nucleotide polymorphisms (SNPs) on respective function and production, this study aimed to investigate the probable association of IL-22 SNPs with VL. The study was carried out on 110 patients with VL, 102 healthy individuals with negative leishmanin skin test (negative control group (NCG)), and 144 healthy individuals with positive leishmanin skin test (LSTPG). Four SNPs in IL-22 including rs2227501, rs2227503, rs2227513 and rs1026786 were analyzed by polymerase chain reaction-restricted fragment length polymorphism (PCR– RFLP) in the study groups. The frequency of A allele and AA genotype at rs1026786 were significantly higher in the LSTPG group than in the patients (P = 0.013 and P = 0.001, respectively). Conversely, the frequency of AG genotype was significantly higher in the patients and the NCG than in the LSTPG group (P = 0.0001 and P = 0.002, respectively). For rs2227503, the frequency of AG genotype was significantly higher in the LSTPG group than in the NCG (P = 0.025). The haplotype TGAA frequency was significantly higher in the NCG, compared to patients and LSTPG group (P = 0.004 and P = 0.023, respectively). The frequencies of haplotypes TAAG and TGAG were significantly higher in the patients than in the LSTPG group (P = 0.046 and P = 0.014, respectively). The TAAA/TAAG frequency was significantly higher in the patients than in the LSTPG group (P = 0.013). Inheritance of rs1026786 A allele and AA genotype of IL-22 could be a possible protective factor against VL, whereas the inheritance of the haplotypes TAAG and TGAG may predispose Iranian population to the disease.

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta-analysis.

BackgroundPatients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold‐standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β‐lactams.MethodsWe performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta‐analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses.ResultsWe included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%–0.13%; I 2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non‐immediate index reactions (OR = 0.05; 95% CrI = 0‐0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7–21.5; I 2 = 0.3%). Performance of direct DPTs in low‐risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions.ConclusionsIn patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life‐threatening index reactions or patients with positive skin tests—who were mostly not assessed in this analysis ‐, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.

Delayed corticosteroid hypersensitivity: a clinical management proposal.

Background. Different clinical pictures are related to corticosteroids (CS) non immediate hypersensitivity and the frequency of these reactions can be underestimated. The classification of CS in 3 groups and the identification of two patient's profiles has been proposed by Baeck to help clinicians in the management of these cases. Methods. Data of 14 patients with clinical history of delayed reactions to various CS and positive skin test and/or oral challenge are retrospectively analyzed. Results. Three different patterns of patients are identified evaluating history, clinical picture and tests results. The first one (6 pts, 43%) is characterized by cutaneous and/or mucosal reaction due to inhaled Budesonide and patch test positive only to topical molecules belonging to the group 1 of CS. The second pattern (4 pts) has clinical history of local and systemic skin reactions to the topic and parenteral administration of the same or other steroid drugs. Patients belonging to the third pattern (4 pts) have a history of systemic reactions to general administration of CS without previous contact reaction. Pattern 2 and 3 show a wide sensitization to molecules belonging to the 3 groups of CS. All the patients show patch test positive to Budesonide. Conclusions. Although the lack of standardization, the allergy workup proves useful to differentiate patients sensitized to one or few molecules from polysensitized and to identify the culprit drugs. Intradermal and challenge test are necessary to complete the diagnostic workup. The results suggest the possibility of a different management of patients. Patients of pattern one can be only patch tested with a limited series of CS belonging to the 3 groups. They don't need an extensive exclusion of steroids use. The pattern 2 and 3 must be submitted instead to a complete allergological individual evaluation to identify alternative tolerated drugs, because of the risk of systemic reactions. The Baeck's classification shows limited usefulness in these cases.

Clinical Characteristics of Clonorchis sinensis-Associated Cholangiocarcinoma: A Large-Scale, Single-Center Study.

Background: Clonorchis sinensis (CS) infection is considered a group 1 carcinogen of cholangiocarcinoma (CCA). There were very few studies regarding clinical characteristics of CS-associated CCA (CACC). This study aimed to investigate clinical characteristics of patients with CCA with or without CS infection.Methods: A total of 367 patients diagnosed with CCA who underwent diagnostic tests for CS infection were enrolled. CS infection was defined as follows: at least one positive serum ELISA test, skin test, stool microscopy, or bile microscopy.Results: There were 95 (26%) patients with CS infections. The median follow-up duration was 14.9 months (range, 6.07–36.17). The following significant differences were noted among patients with CACC compared to non-CACC; diagnosis at younger age (median 62 years vs. 65 years, p = 0.018), higher male to female ratio (83.2 vs. 61.8%, p < 0.001), and residence in CS-endemic area (46.3 vs. 25.4%, p = 0.014). Univariate analysis of prognostic factors indicated that tumor location, curative resection, tumor stage, and laboratory tests including CA 19-9, CEA, and bilirubin were significantly associated with overall survival, but CS infection was not. In multivariate analysis, tumor location, CEA, curative resection and tumor stage were identified as independent prognostic factors. Among patients under age 64, CACC group had lower survival rate than non-CACC group (p = 0.022).Conclusions: CACC had the following significant characteristics compared to non-CACC; diagnosis at younger age, higher male to female ratio, higher prevalence in CS endemic areas and poorer overall survival in patients under age 64.

Basophil reactivity to BNT162b2 is mediated by PEGylated lipid nanoparticles in patients with PEG allergy

The mechanisms underpinning allergic reactions to the BNT162b2 (Pfizer) COVID-19 vaccine remain unknown, with polyethylene glycol (PEG) contained in the lipid nanoparticle suspected as being the cause. Our aim was to evaluate the performance of skin testing and basophil activation testing to PEG, polysorbate 80, and the BNT162b2 (Pfizer) and AZD1222 (AstraZeneca) COVID-19 vaccines in patients with a history of PEG allergy. Three known individuals with PEG allergy and 3 healthy controls were recruited and evaluated for hypersensitivity to the BNT162b2 and AZD1222 vaccines, and to related compounds by skin testing and basophil activation, as measured by CD63 upregulation using flow cytometry. We found that the BNT162b2 vaccine induced positive skin test results in patients with PEG allergy, whereas the result of traditional PEG skin testing was negative in 2 of 3 patients. One patient was found to be cosensitized to both the BNT162b2 and AZD1222 vaccines because of cross-reactive PEG and polysorbate allergy. The BNT162b2 vaccine, but not PEG alone, induced dose-dependent activation of all patients' basophils exvivo. Similar basophil activation could be induced by PEGylated liposomal doxorubicin, suggesting that PEGylated lipids within nanoparticles, but not PEG in its native state, are able to efficiently induce degranulation. Our findings implicate PEG, as covalently modified and arranged on the vaccine lipid nanoparticle, as a potential trigger of anaphylaxis in response to BNT162b2, and highlight shortcomings of current skin testing protocols for allergy to PEGylated liposomal drugs.

Classification Criteria for Tubercular Uveitis

To determine classification criteria for tubercular uveitis. Machine learning of cases with tubercular uveitis and 14 other uveitides. Cases of noninfectious posterior uveitis or panuveitis, and of infectious posterior uveitis or panuveitis, were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were analyzed by anatomic class, and each class was split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the intermediate uveitides. The resulting criteria were evaluated on the validation sets. Two hundred seventy-seven cases of tubercular uveitis were evaluated by machine learning against other uveitides. Key criteria for tubercular uveitis were a compatible uveitic syndrome, including (1) anterior uveitis with iris nodules, (2) serpiginous-like tubercular choroiditis, (3) choroidal nodule (tuberculoma), (4) occlusive retinal vasculitis, and (5) in hosts with evidence of active systemic tuberculosis, multifocal choroiditis; and evidence of tuberculosis, including histologically or microbiologically confirmed infection, positive interferon-γ release assay test, or positive tuberculin skin test. The overall accuracy of the diagnosis of tubercular uveitis vs other uveitides in the validation set was 98.2% (95% confidence interval 96.5, 99.1). The misclassification rates for tubercular uveitis were training set, 3.4%; and validation set, 3.6%. The criteria for tubercular uveitis had a low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.

Interferon-Gamma Release Assays Differentiate between Mycobacterium avium Complex and Tuberculous Lymphadenitis in Children

To assess the performance of interferon-gamma release assays (IGRAs) in the differential diagnosis between Mycobacterium avium complex (MAC) and tuberculosis (TB) in children affected with subacute/chronic submandibular/cervical lymphadenitis. Multicenter observational study comparing children with microbiologically confirmed MAC lymphadenitis from the European NontuberculouS MycoBacterial Lymphadenitis in childrEn study with children with TB lymphadenitis from the Spanish Network for the Study of Pediatric TB database. Overall, 78 patients with MAC and 34 with TB lymphadenitis were included. Among MAC cases, 44 out of 74 (59.5%) had positive tuberculin skin test (TST) results at the 5-mm cut-off, compared with 32 out of 33 (97%) TB cases (P<.001); at the 10-mm cut-off TST results were positive in 23 out of 74 (31.1%) vs 26 out of 31 (83.9%), respectively (P<.001). IGRA results were positive in only 1 out of 32 (3.1%) patients with MAC who had undergone IGRA testing, compared with 21 out of 23 (91.3%) TB cases (P<.001). Agreement between TST and IGRA results was poor in MAC (23.3%; κ=0.017), but good in TB cases (95.6%; κ=0.646). IGRAs had a specificity of 96.9% (95% CI 84.3%-99.8%), positive predictive value of 95.4% (95% CI 78.2%-99.8%), and negative predictive value of 93.9% (95% CI 80.4%-98.9%) for TB lymphadenitis. In contrast to TST, IGRAs have high specificity, negative predictive value, and positive predictive value for TB lymphadenitis in children with subacute/chronic lymphadenopathy, and consequently can help to discriminate between TB and MAC disease. Therefore, IGRAs are useful tools in the diagnostic work-up of children with lymphadenopathy, particularly when culture and polymerase chain reaction results are negative.

Prevalence of hepatitis B surface antigen and hepatitis B core antibody among adults with latent tuberculosis infection.

To evaluate the prevalence of hepatitis B surface antigen (HBsAg) positive or hepatitis B core antibody total (anti-HBc) among adults with latent tuberculosis infection (LTBI) in the USA. Using data from the National Health and Nutrition Examination Survey 1999-2000 and 2011-2012 cycles, US adults with LTBI (identified by positive tuberculin skin test or positive QuantiFERON-TB Gold In-Tube test) were evaluated to determine prevalence HBsAg and anti-HBc. Survey-weighted data was used to determine prevalence estimates of HBsAg or anti-HBc, which were further stratified by sex, race/ethnicity, country of birth and age. Trends were analyzed by regressing the outcome over time. Between-group comparisons used chi-squared testing. Overall prevalence of LTBI was 4.2% [95% confidence interval (CI), 3.5-5.1]. Among individuals with LTBI, HBsAg prevalence was 0.9% (95% CI, 0.4-2.1) and anti-HBc prevalence was 12.9% (95% CI, 9.8-16.8), both of which remained stable between 1999-2000 and 2011-2012. While no significant differences in HBsAg prevalence were observed by sex, race/ethnicity, country of birth, age, anti-HBc prevalence was significantly higher in men vs. women (16.8 vs. 7.9%, P < 0.05), blacks vs. non-Hispanic whites (22.9 vs. 5.9%, P < 0.05), non-US born vs. US-born (15.9 vs. 7.2%, P = 0.01) and highest in the oldest age group (age ≥65 years: 17.5%, 95% CI, 10.5-27.8). Among US adults with LTBI, overall prevalence of HBsAg was 0.9%. One in eight individuals with LTBI had prior HBV exposure. Effective HBV screening among individuals with LTBI may allow changes in clinical practice to prevent drug-induced liver injury from anti-TB therapies.

Value of skin tests for managing allergic hypersensitivity reactions to platinum compounds.

Background Platinum-based therapy continues to be one of the pillars of the treatment of different types of cancer. However, many times the responsible clinician renounces its use after the appearance of a hypersensitivity reaction. Objective To assess the value of skin tests (ST) in clinical practice to address the treatment of patients with suspicion of immediate hypersensitivity reactions (HSRs) to platinum compounds. Method Single-center retrospective study of 3years. Adult patients treated with any platinum compound who experienced HSR symptoms and for whom an oncologist requested ST, were included. ST with cisplatin, carboplatin and oxaliplatin were performed. Results Twenty-two patients were included. ST were positive in 12 patients (54.5%), of which 4 (33%) presented cross-reactivity to another platinum compound. Fifteen patients continued platinum-based chemotherapy: 9 patients with positive ST (4 continued by desensitization and 5 with another platinum compound) and 6 patients with negative ST, of which 1 repeated an HSR. A NPV of 0.91 was calculated. Conclusion ST helped physicians identify patients most susceptible to platinum derivative allergies and resume platinum-based therapy in many patients for whom no suitable therapeutic alternative was clinically acceptable.

Immediate nor Delayed Type Hypersensitivity Plays a Role in Late Inflammatory Reactions After Hyaluronic Acid Filler Injections.

PurposeThe exact etiology of late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers is currently unknown. Some argue that these result from a hypersensitivity reaction, although evidence to support this is very scarce. Most reports on such reactions are not substantiated by positive skin tests. The purpose of our study was to determine whether immediate or delayed type hypersensitivity reaction follows hyaluronic acid (HA) filler injections.Patients and MethodsTwelve patients were referred for general allergic screening (patch tests), as well as specific intradermal testing (injection of 0.1cc boluses) on the medial upper arm with a selection of several currently available hyaluronic acid (HA) fillers on the market. A positive allergic reaction was defined as erythema, firmness or swelling.ResultsDuring the 4 month follow-up, no reactions to any of the tested HA fillers were reported. No correlation was found between results from the general allergic screening and a history with LIRs to HA fillers.ConclusionThe results suggest that neither type I nor type IV hypersensitivity plays a role in late inflammatory reactions (LIRs) to hyaluronic acid (HA) fillers.

Hypersensibilités aux produits de contraste iodés : analyse en cluster

Introduction Cluster analysis refers to a broad set of unsupervised learning techniques used to discover distinct subgroups or clusters within a set of data. This study aimed to distinguish different clinical characteristics among patients with suspicions of drug hypersensitivity reactions (DHRs) to iodinated radiocontrast media (iRCM) based on a cluster analysis. Methodes A retrospective study was performed using data extraction from the Drug Allergy and Hypersensitivity Database (DAHD) at the Allergy Unit, University Hospital of Montpellier, France. All referred patients with suspicions of iRCM DHRs between February 2001 and December 2019 either with confirmed positive skin tests (ST)s or negative STs were included in the analysis. Resultats A total of 1439 patients with suspicion of a DHR to iRCM who underwent a drug allergy work-up were analysed. Positive STs were displayed in 153 patients (10.6 %). The solution proposed by the automatic cluster analysis categorized the 1439 patients into five clusters, with a fair quality of clustering and an optimal ratio (2.3) of the cluster sizes. Cluster 1 contained almost only patients with a non-immediate reaction. Cluster 2 comprised virtually only patients with immediate reactions (IR), all with known culprit iRCM. These were the best defined clusters. Cluster 4 and 5 were virtually identical, with one exception, namely the clinical manifestation. Where they both comprised IRs, with multiple episodes of DHR, induced by unknown culprits, tested two decades after the index reaction, cluster 5 contained virtually only anaphylactic events whereas cluster 4 included various reactions, but no anaphylaxis. Confirmed allergies were more frequent in cluster 1 (16.9 %) and 2 (16.5 %). Conclusion Five clinical phenotypes which make sense clinically were determined by cluster analysis. From a pragmatic point of view, this new knowledge can be integrated in the drug allergy work-up reasoning : patients with well-defined recent reactions are allergic in up to 17 % of cases, but the frequency of allergy is leveled down by two or more in reactions tested more than a decade after their occurrence, despite the clinical manifestation which can resemble anaphylaxis.

Abstract No. 471 Allergy testing for verification of contrast allergy prior to radiology procedures

Allergy to contrast material can limit the diagnostic and therapeutic options for patients, especially if the reaction to contrast media is listed as anaphylaxis (IgE-mediated allergic reactions). Many patients with physiologic response to contrast are labeled as being allergic to contrast because the patient or caregiver do not understand the differences between dose-related responses and allergy. Other patients with a history suggesting only a mild reaction may be at risk for anaphylaxis. Our goal is to provide appropriate documentation for the existences or lack of contrast allergy which facilitate best therapeutic and diagnostic options for the patient. Pre-procedure patients with written documentation of contrast allergy were, at the discretion of a licensed independent practitioner, referred to the Allergy and Immunology department for contrast media testing. Patients were tested using an established protocol. Based on reaction clinical history and skin testing patients were classified into four groups: Nonallergic (Negative skin testing, and negative clinical evaluation), predominantly histamine mediated reaction (Negative skin testing, clinical evaluation consistent with histamine mediated symptoms), allergic- like reaction (Negative skin testing, convincing clinical allergic-like reaction), and IgE- mediated allergic reaction (Positive skin testing and positive clinical history) Ten patients completed contrast allergy testing. Referral to allergy and immunology changed the management as follows: avoided steroids in 8/10 (80%) and avoided premedication completely in 6/10 (60%). The testing also confirmed IgE mediated reaction to contrast (Risk of anaphylactic reaction) in 1 patient (10%). Testing in this preliminary patient population suggests significant clinical benefit from referral to allergy and immunology for contrast media testing in patients with reported contrast allergy. Standardization of patient testing may reduce procedure cancellations, excessive use of steroids and potentially the risk of contrast induced anaphylaxis.

Concurrent positive skin tests to prophylactic antibiotics and rocuronium in two patients with life-threatening anaphylaxis after induction of anesthesia

BackgroundProphylactic antibiotics and neuromuscular blocking agents (NMBA) are two of the major causative agents of anaphylaxis after induction of anesthesia.Case presentationOne female and one male patients (aged 29 and 69 years, respectively) had Ring and Messmer scale grade III anaphylaxis after administration of prophylactic antibiotics following induction of anesthesia. They showed typical hemodynamic and respiratory features of life-threatening anaphylaxis. Postoperative skin tests in these two patients were positive for antibiotics and concurrently positive for rocuronium.ConclusionsOur present report suggests the possibility that both prophylactic antibiotics and NMBA concurrently and synergistically enhance anaphylactic reaction and the necessity to differentiate an immune mechanism from non-immune mechanisms when anesthesiologists encounter concurrent positive skin tests for both antibiotics and NMBA.

The prevalence and characteristics of adults with latent tuberculous infection in the United States and the implications for healthcare in Texas

The Centers for Disease Control and Prevention reported 8,916 cases of tuberculosis in 2019. Reducing the number of cases of active tuberculosis requires identification of patients with latent tuberculous infections (LTBI). Optimal screening for LTBI requires information about the demographics and characteristics of people who are more likely to have had tuberculous infection. Information from the 2011–2012 National Health and Nutrition Examination Survey (NHANES) was used to determine the number and characteristics of adults from a representative sample of the United States who had LTBI. Latent tuberculous infection was identified either by a positive skin test or by a positive QuantiFERON blood test. Information about the number of patients with active tuberculosis in Texas was determined from reports from the Texas State Department of Health Services. The NHANES database for the years 2011-2012 included 5,684 adults. Participants with a positive QuantiFERON blood test were more likely in the age group 45-64, male, foreign born, and have less than a high school education. Participants with a positive skin test had similar characteristics. Participants who had both a positive skin test and positive QuantiFERON test were more likely to be in the age group 45-64, males, foreign born, and Hispanic. In addition, they had diabetes, self-reported fair/poor health, and an educational level less than high school. In the State of Texas tuberculosis occurred more frequently in individuals older than 75 who were male and were not US born Texas residents. Important clinical diagnoses included diabetes, alcohol abuse, correctional facility residence, non-injection drug use, positive HIV status, and homelessness. Information from the NHANES study and from the State Department of Health Services in Texas provides information needed to develop screening programs for latent tuberculosis and active tuberculosis.