Use Of Skin Testing Research Articles

Delayed hypersensitivity reactions caused by iodixanol: An assessment of cross-reactivity in 22 patients

Delayed hypersensitivity reactions caused by iodixanol: An assessment of cross-reactivity in 22 patients

Single-dose influenza vaccination of patients with egg allergy in a multicenter study

Single-dose influenza vaccination of patients with egg allergy in a multicenter study

The very limited usefulness of skin testing with penicilloyl‐polylysine and the minor determinant mixture in evaluating nonimmediate reactions to penicillins

The contribution of skin testing with penicilloyl-polylysine (PPL) and the minor determinant mixture (MDM) to the diagnosis of hypersensitivity reactions to penicillins differs greatly according to the type of reaction: immediate (occurring within 1 h after the last drug administration) or nonimmediate (occurring more than 1 h after the last drug administration). To assess the contribution of skin testing with PPL and MDM to the diagnosis of nonimmediate reactions to penicillins. We evaluated 162 adults who had had 232 nonimmediate reactions to penicillins, mostly aminopenicillins, and presented positive skin and/or patch tests to one or more penicillin reagents: PPL, MDM, benzylpenicillin, ampicillin, and amoxicillin, as well as any responsible penicillins. A total of 157 subjects (96.9%) displayed patch-test and/or delayed-reading intradermal-test positivity to penicillin reagents, which indicates a cell-mediated hypersensitivity; six of them also presented immediate-reading skin-test positivities. All 157 patients with a cell-mediated hypersensitivity were positive to the responsible penicillins (parent drugs); 16 of them also displayed delayed-reading intradermal-test positivity to MDM. Five (3.1%) of the 162 patients displayed only immediate-reading skin-test positivity (four to PPL and one to amoxicillin). Overall, 158 subjects (97.5%) presented positive responses to the responsible penicillins, while only 9 (5.5%) and 17 (10.5%) were positive to PPL and MDM, respectively. The contribution of skin testing with PPL and MDM in diagnosing nonimmediate hypersensitivity reactions to penicillins, especially cell-mediated ones, is very limited. This finding could be useful at a time when PPL and MDM are not available in all countries.

Administration of cisplatin in three patients with carboplatin hypersensitivity: is skin testing useful?

Carboplatin is a chemotherapeutic agent approved in the first-line setting of numerous malignancies. Hypersensitivity to carboplatin has been reported in up to 44% of patients receiving this antineoplastic agent, usually occurring after several courses of treatment. The aim of this study was to determine the usefulness of skin tests in ruling out cross-reaction to cisplatin to continue platinum-based chemotherapy in patients who are responsive to these agents. Prick tests and intradermal tests with a series of dilutions of carboplatin and cisplatin were performed on three patients who had exhibited medium and severe hypersensitivity reactions to carboplatin. Prick tests were negative in both the antineoplastic agents. Intradermal tests with carboplatin were positive in all three patients and negative with cisplatin. In all patients, the administration of cisplatin instead of carboplatin was well tolerated without the need of premedication. In conclusion, intradermal skin tests can be a useful tool for detecting a potential cross-reaction between platinum salts. It allows safe administration of a different platinum agent in patients who seem to benefit from platinum-based therapy. Discontinuation of chemotherapy, desensitization protocols and steroid premedication can be avoided.

Administration of Fluorescein in Atopic Patients, the Use of Skin Tests and Pretreatment

Administration of Fluorescein in Atopic Patients, the Use of Skin Tests and Pretreatment

Administration of Cisplatin in Three Patients with Carboplatin Hypersensitivity: Is Skin Testing Useful?

RATIONALE: Carboplatin is a chemotherapeutic agent approved in the first-line setting of numerous malignancies. Hypersensitivity to carboplatin has been reported in up to 44% of patients receiving this antineoplastic agent, usually occurring after several courses of treatment. The aim of this study was to determine the usefulness of skin tests in ruling out cross-reaction to cisplatin in order to continue platinum-based chemotherapy in patients who are responsive to these agents.

Usefulness of skin testing in cutaneous drug eruptions in routine practice

Cutaneous drug eruptions are common side-effects. The imputation score combining intrinsic (chronology, clinical and paraclinical signs) and extrinsic criteria used in Pharmacovigilance Centres is insufficient alone to identify with certainty a responsible drug. To evaluate the imputation score before and after performing skin testing in patients with cutaneous drug eruptions. A single-centre retrospective study was performed on 339 patients tested between 2001-2006. Imputation scores were calculated before and after skin tests for each cutaneous drug eruption according to the clinical type of skin eruption and the type of drug. Among 121 patients meeting inclusion criteria, 46% showed an increase of the imputation score as shown by 25/41 cases of maculo-papular exanthema, 4/11 cases of acute generalized exanthematous pustulosis and 17/41 cases of urticaria/anaphylaxis. The imputation score increased in 25/70 cases of the tested antibiotic drugs, in 14/56 cases of cardiovascular drugs, and it increased in 19 patients (34%) with I1 or I2 imputation scores before skin testing and in 29 (52%) with an I3 imputation score before skin testing. Drug skin testing appeared useful in investigating cutaneous drug eruptions in routine practice, including not only drugs with a high imputation score (I3) but also those with a lower score (I1, I2). Drug skin testing should lead to oral rechallenge of drugs with negative tests in order to determine which drugs may be used safely.

Diagnosing Hypersensitivity Reactions to Cephalosporins in Children

The goals were to evaluate the usefulness of skin tests, patch tests, serum specific IgE assays, and challenges in diagnosing hypersensitivity reactions to cephalosporins and to clarify the pathogenic mechanism of such reactions. Children with immediate manifestations (within 1 hour) underwent immediate-reading skin tests with penicillin reagents and any suspect cephalosporins, serum specific IgE assays, and challenges; some children underwent reevaluations. Children with nonimmediate manifestations (after >1 hour) were assessed with patch tests, delayed-reading skin tests, and challenges. We evaluated 148 children with hypersensitivity reactions to cephalosporins, mainly cefaclor and ceftriaxone; 105 had experienced nonimmediate manifestations (mostly urticarial eruptions and maculopapular rashes) and 43 immediate manifestations (anaphylactic shock, urticaria and/or angioedema, and erythema). None of the nonimmediate reactors demonstrated positive results in patch tests and/or delayed skin tests; only 1 subject displayed immediate positive responses to penicillin skin-test reagents. Among the 104 patients with negative results, 96 underwent challenges; 95 tolerated the challenges, and 1 reacted to the cefaclor pediatric suspension and tolerated the challenge with a cefaclor capsule. In the first allergologic evaluation, 33 of the 43 children with immediate reactions displayed skin-test positivity. Of the 10 patients with negative results, 7 underwent challenges, followed by therapeutic courses and reevaluations for 4. All challenges and therapeutic courses were tolerated; in the reevaluation, 1 girl demonstrated positive skin-test results for both the responsible cephalosporin and penicillin reagents. Overall, IgE-mediated hypersensitivity was diagnosed for 34 (79%) of 43 subjects. Extremely few nonimmediate manifestations associated with cephalosporin therapy are actually hypersensitivity reactions, whereas most immediate reactions to cephalosporins are IgE-mediated. Cephalosporin skin testing is a useful tool for evaluating such reactions.

Carbamazepine‐induced DRESS and HHV6 primary infection: The importance of skin tests

A 34-year-old male with a 20-year history of epilepsy was treated with valproic acid and phenobarbital. As he had frequent convulsive fits, carbamazepine (CBZ) was added. Thirty-four days later, the patient developed hyperthermia, (39.5 degrees C), cervical lymphadenopathy and generalized cutaneous exfoliated maculae and papulae. Biochemical investigation was characterized by a white cell count of 16.1 x 103/microl (17% eosinophils) and increased levels of aspartate aminotransferase and alanine aminotransferase (50 and 116 IU/L, respectively). HHV6 serological tests performed on day 21, detected anti HHV6 IgM, suggesting a HHV6 primary infection. Hence, CBZ was discontinued. One month later, the skin eruption, fever, lymph node swelling, liver dysfunction, and eosinophilia were progressively relieved. Six weeks after complete recovery, prick and patch skin tests were performed. They were strongly positive at 48-h reading. This report suggests the usefulness of skin tests in diagnosing CBZ-induced-DRESS, as well as s possible association between DRESS and HHV6 primary infection.

The usefulness of skin test in evaluation of immunity to varicella

Purpose : The aim of this study is to assess the usefulness of skin test by an inactivated, 1/50 diluted solution of attenuated varicella vaccine in evaluating the immune status to varicella. Methods : Total 41 subjects (22 males, 19 females, aged 1-32 years) were enrolled from July to August, 2005. Past medical history including varicella infection, varicella vaccination were investigated through questionnaires. The skin test solution was prepared from solution of attenuated varicella vaccine(Oka strain) which was inactivated by exposure to room temperature for 10 days and diluted at 1/50 with normal saline. Skin test was done by injecting 0.1 mL of the solution intradermally into the volar surface of the right forearm and sterile normal saline was used as a control on the left forearm. Positive reaction was defined when the transverse diameter of the induration was 5 mm or more. Serum varicella zoster virus specific IgG antibody test by ELISA (enzyme-linked immunosorbent assay) was done. Results : In adults, the sensitivity of the varicella zoster virus skin test compared to ELISA was 94.7% and the positive predictive value was 100%. In children, both the positive predictive value and specificity were 100% but the sensitivity and the negative predictive value were 50% and 30.7% respectively. Children showed smaller skin test reactivity compared to adults. Conclusion : The varicella zoster virus skin test using inactivated, 1/50 diluted solution of attenuated varicella vaccine was proved as one of the useful tools for evaluating the immunity and susceptibility of the varicella zoster virus.

The Influence of Sensitivity to Fungal Allergens on the Development and Course of Allergic Diseases of the Respiratory Tract

Several epidemiological and diagnostic studies reported increasing prevalence of allergic reactivity to fungi assessed with the use of skin testing or IgE detection. The role of sensitization to fungi in relation to the prevalence and clinical importance in atopic patients remains largely unknown. Although an allergic reaction to fungal allergens is suggested as an important contributing factor in the development of respiratory symptoms, other mechanisms, such as increased exposure to fungal metabolites, mycotoxins and other compounds of immuno-suppressant or irritant properties, may also be important. Sensitivity to fungal allergens has been recognized as a risk factor for the development and persistence of asthma, asthma severity and potentially fatal asthma exacerbations, the increased number of episodes of respiratory arrest and admissions to intensive care unit. Thus far, the role of fungi as the dominant exogenous trigger of asthma has not been completely explored. Some authors suggest, that sensitization to fungal allergens is related with specific phenotype of severe asthma. It remains to be clarified, whether this association is caused by colonization of the airways with fungi or an extreme response to exogenous spores. This review critically discusses the present state of knowledge on the prevalence of IgE-mediated allergy to fungi, as well as the contribution of sensitization to fungi to the allergic manifestations, on the basis of the recent literature. We also try to assess the importance of these connections for the future treatment of allergic disorders of the respiratory tract.

Delayed-type Hypersensitivity Response to Crude and Fractionated Antigens from Fonsecaea pedrosoi CMMI 1 Grown in Different Culture Media

Chromoblastomycosis is a subcutaneous fungal disease caused by dematiaceous fungi, especially by Fonsecaea pedrosoi, regarded as its major causative agent in Brazil. In recent years there has been a decline in the use of skin testing for delayed-type hypersensitivity (DTH) in epidemiological surveys of fungal infections, mainly because of the unpredictability of positive reactions and lack of specificity of the antigens used. The aim of the present study was to assess delayed-type skin tests in guinea pigs experimentally infected with F. pedrosoi using exoantigens prepared from two culture filtrates. Sixteen adult male guinea pigs were inoculated intratesticularly with fungal cells and submitted to sensitivity assays 4 weeks after inoculation. They received an intradermal injection with crude and fractionated antigens from Alviano's and Smith's cultures, and were assessed 24 and 48 h thereafter. Except for one animal, all of them had positive indurations after 48 h. There were no statistical differences between the measurements at 24 and 48 h for each exoantigen used, neither among the induration measurements at 48 h when different preparations were compared. Our results suggest that a delayed-type skin test using antigens produced in synthetic media may be useful for the assessment of primary exposure to chromoblastomycosis.

Skin testing

To provide the reader with a relevant review of the literature regarding skin testing in the allergist's office. A PubMed search for the years 1970 through 2005 was performed using the following keywords: allergy skin testing, skin prick testing, and intradermal skin testing. Articles that highlighted aspects of sentinel to clinical allergists' use of skin testing in the office, such as methods of skin testing, intradermal vs skin prick testing, skin test devices, and methods of expressing skin test results, were selected for further review. Skin testing remains the central test to confirm an allergic response. It is minimally invasive and when performed correctly has good reproducibility. Results are easily quantifiable and correlate well with end organ challenge. It is imperative however that technicians who perform the skin tests and the clinicians who order or interpret these tests understand the characteristics of the specific tests they are administering. It is also important that the clinician express skin test results in a manner that allows easy interpretation by another physician. Allergists must consider controllable variables that affect skin test results and their interpretation. When not considered, they may be responsible for some of the inaccuracies associated with allergy skin testing.

Importance of repeat testing in the diagnosis of penicillin allergy

Conflicts of interest: none declared. Sir, In the May 2005 issue of this Journal Lammintausta and Kortekangas‐Savolainen1 presented an interesting article about the usefulness of skin tests in determining drug hypersensitivity. We have found the results to be very helpful as there are only few reported works about the prevalence of positive skin tests in the context of allergic reactions. However, we have some points of contention. Although both patch tests (PTs) and intradermal tests (IDTs) are used for the diagnosis of nonimmediate reactions to aminopenicillins, and both tests appear to be valuable, delayed‐reading IDTs appear to be somewhat more sensitive2 than PTs, but also less specific.3 In the report by Lammintausta and Kortekangas‐Savolainen, beta‐lactam antibiotics were the drugs more often suspected and tested. However, IDTs with major and minor determinants were carried out only in 31 of 342 patients with suspected penicillin allergy and none of them elicited a positive reaction. The European Network for Drug Allergy (ENDA) recommends testing in most patients in whom penicillin allergy is suspected.4 In fact, most diagnoses of penicillin allergy have recently been reported to be obtained by means of the IDT.5, 6 Between January 2002 and June 2005 we evaluated 604 patients with suspected beta‐lactam allergy. In all of them, after written informed consent, skin prick tests and IDTs were performed with benzylpenicilloyl polylysine (PPL), minor determinants mixture (MDM; including benzylpenicillin, benzylpenicilloic acid and sodium benzylpenicilloate), penicillin G and the suspect drug if it was other than penicillin. PPL and MDM were purchased from two different companies (Allergopen®; Allergopharma, Reinbeck, Germany and Diater SA, Madrid, Spain). If the skin tests were negative, controlled drug challenge was performed under strict supervision. After 15 days the skin tests and drug challenge were repeated, as recommended by ENDA.4 After completing the study, 66 patients were diagnosed with beta‐lactam allergy, 60 by skin testing and 10 of those in the repeat tests. From 1108 challenges with beta‐lactams in 554 patients, there were only six positives following a previously negative skin test.

Diagnosing immediate reactions to cephalosporins

After penicillins, cephalosporins are the betalactams that most often induce IgE-mediated reactions. The development of diagnostic tests has been delayed, however, because the cephalosporin allergenic determinants have not been properly identified. To evaluate the usefulness of skin tests, serum specific IgE assays, and challenges in diagnosing immediate reactions to cephalosporins and to clarify the pathogenic mechanism of such reactions. We studied 76 adults with immediate reactions to cephalosporins, mainly ceftriaxone, cefotaxime, and ceftazidime. Skin tests and serum specific IgE assays were performed for culprit cephalosporins and cefaclor, as well as for penicillin, amoxicillin, and ampicillin. Some subjects with negative results underwent challenges and re-evaluations. Responses to cephalosporins other than the culprit ones were also studied. In the first allergologic work-up, an IgE-mediated hypersensitivity to penicillins and/or cephalosporins was diagnosed in 63 (82.9%) of the 76 patients on the basis of skin-test and/or specific IgE assay positivity. Of the 13 negative patients, eight accepted challenges and underwent re-evaluations. Considering both first- and second-evaluation results, the skin-test-positivity rate increased from 76.3% to 85.5% and that of sepharose-radioimmunoassay positivity from 67.1% to 74.3%. Overall, an IgE-mediated hypersensitivity was diagnosed in 70 patients (in seven after retesting). On the basis of skin-test and CAP-FEIA results, we classified our 76 patients into five groups: group A (three patients), positive only to penicillin reagents; B (17), positive to both cephalosporin and penicillin reagents; C (24), positive to more than one cephalosporin; D (21), positive only to the responsible cephalosporin; E (11) negative to skin tests and CAP-FEIA, including five sepharose-radioimmunoassay positive. Most immediate reactions to cephalosporins appear to be IgE-mediated. Cephalosporin skin testing and sepharose-radioimmunoassay are useful tools for evaluating these reactions. Cephalosporin IgE-mediated hypersensitivity may be a transient condition; therefore, allergologic exams should be repeated in patients with negative initial allergologic work-ups, including challenges.

The usefulness of skin tests to prove drug hypersensitivity

Suspected drug hypersensitivity is common. Only a minority of cutaneous adverse drug reactions (CADRs) are allergic in origin and will reappear after the next exposure. Methods to confirm suspected CADRs are needed and skin testing could serve as one possibility. To analyse the usefulness of skin tests in revealing drug allergy. The relevance of skin test results was evaluated with drug provocation studies. During 1989-2001, 947 patients with a history of suspected CADR were examined with skin tests including patch tests (PTs) (826 patients), skin prick tests (SPTs) (935 patients) and photopatch tests (12 patients). The occurrence of positive and negative test reactions to different drugs was correlated with clinical history. Drug provocation was carried out in 246 patients. Antimicrobial drugs were suspected and tested most often. A positive PT reaction to one or more drug was seen in 89 of 826 (10.8%), most often to beta-lactams, clindamycin and trimethoprim. A positive SPT reaction was seen in 10 of 935 (1.1%) patients. Challenge was carried out in 17 patients with positive skin test results. Thirteen of 16 (81.2%) PT positives developed exanthema, three remained negative and one SPT-positive patient developed urticaria. Among skin test negatives, 207 of 229 (90.4%) challenges were negative and 22 of 229 (9.6%) were positive, 12 with exanthema, three with fixed drug eruptions and seven with urticaria. Skin testing, especially the PT, was a useful screening method to find a cause of CADR if the reaction was exanthema and if antimicrobial, cardiovascular or antiepileptic drugs were suspected. The SPT detected occasional positives with antimicrobials. In cases of fixed drug eruption, PTs performed at the earlier reaction site were useful. When skin tests are negative or dubious, oral challenge should be carried out to confirm the association.

Contrast media hypersensitivity – scope of the problem

Hypersensitivity reactions to contrast media (CM) are frequent causes of anaphylactically induced fatalities. Adverse events after CM exposure are classified into immediate and non-immediate reactions, with differing pathomechanisms. In the majority of patients with immediate reactions, IgE-mediated allergy can not be demonstrated and the underlying mechanism remains unknown. However, recent data has provided evidence for skin test positivity and/or specific IgE in some patients with severe reactions. Cell-mediated hypersensitivity is the responsible mechanism for the majority of non-immediate skin eruptions. Skin tests have been employed to confirm this hypersensitivity. Previous reactors have an increased risk to develop new reactions upon repeated exposure, however, other risk factors are poorly defined. The use of skin tests for the selection of a “safe” CM is controversially discussed; information on sensitivity and specificity is lacking. New in-vitro assays have to be developed and/or validated. Premedication of previous reactors is common practice among radiologists, however, its precise role in the prevention of severe CM reactions to lower-osmolality CM has not been demonstrated. Thus, the main future tasks are to develop and validate allergic tests procedures, which may identify patients at risk and/or may confirm CM tolerance, and to reassess the value of different premedications in the prevention of hypersensitivity reactions.

R�ntgenkontrastmittel�berempfindlichkeit

There has been a remarkable progress in our understanding of the pathophysiology of hypersensitivity to contrast media (CM). Immediate reactions develop within one hour after application of CM under the clinical picture of anaphylaxis. Pruritic exanthems appearing several days afterwards account for the majority of non-immediate reactions. Current evidence indicates an allergic basis of severe immediate as well as of non-immediate reactions involving CM-reactive IgE-antibodies and T-lymphocytes, respectively. Skin tests are helpful to establish the diagnosis of these reactions. The use of skin tests to predict tolerability of CM in patients with previous hypersensitivity reaction to CM is controversial. The value of cellular in-vitro tests is unknown. In patients with previous hypersensitivity to CM, premedication with antihistamins and/or corticosteroids is recommended, but current premedication protocols do not suppress all repeat reactions. European multicenter studies addressing sensitivity, specificity and predictive value of test procedures as well as prophylaxis and risk factors of CM hypersensitivity are currently ongoing.

Determination of immunity to vaccinia virus by using diluted inactivated vaccinia vaccine solution for skin testing

Aims: We evaluated the usefulness of skin test prepared by inactivation of vaccinia vaccine in predicting immunity to vaccinia. Skin test was injected to 77 healthy adults. Twenty had a recent smallpox vaccination (group 1). Thirty-seven were long term vacinees (group 2), while 20 subjects had never been vaccinated for smallpox (group 3). Results: Mean size of induration was 7.9, 5.3 and 0.4 mm for subjects from groups 1, 2 and 3, respectively ( P < 0.03 for difference between groups). Induration ≥5 mm correlated with neutralizing antibody titer >1:32 ( r = 0.73, P < 0.0001). Conclusions: The skin test is a potentially useful tool for the assessment of immunity to vaccinia.

The utility of skin testing in suspected clindamycin allergy

RATIONALE: Skin testing has been validated for lgE-mediated reactions associated with penicillin but little information exists regarding this form of testing for other drugs. We explored the clinical utility of clindamycin prick testing and intradermal testing in patients with immediate or delayed reactions to clindamycin. METHODS: A total of 34 subjects with histories of reactions associated with clindamycin (14 accelerated reactions, 11 delayed, and 8 not documented) underwent prick and intradermal skin testing to clindamycin (0.15 mg/ml to 15 mg/ml) between 1999 and 2001. Subjects with negative skin testing received a single oral dose of clindamycin. RESULTS: Although none of the 34 prick and intradermal tests per- formed were positive, a significant number of patients [11/34 (32%)] had reactions to the oral challenge lie, immediate reactions (n=l) and accelerated reactions (n= 10)]. Sensitivity of the prick and intradermal testing was determined to be 0%, specificity 100%, positive predictive value 0%, and negative predictive value 68%. CONCLUSIONS: Our experience highlights the low clinical utility of prick and intradermal testing for allergic and cutaneous reactions associated with clindamycin. We caution against the use of clindamycin skin testing as a diagnostic tool in this setting. Although a single oral challenge appears to be highly predictive it should be used selectively given the potential for significant morbidity incurred by induced reactions.