Alexei Gonzalez-Estrada

Antibiotics Are an Important Identifiable Cause of Perioperative Anaphylaxis in the United States

BACKGROUNDnThe diagnosis of perioperative anaphylaxis (PA) remains challenging, given its clinical setting, exposure to multiple medications, and rarity. Previous reports have found that PA is most frequently caused by neuromuscular-blocking agents.nnnOBJECTIVEnTo determine characteristics and causes of PA at our center.nnnMETHODSnWe performed a retrospective medical record review to identify patients with anaphylaxis. Cases were further categorized by manifestations of anaphylaxis, age, sex, atopy, timing, tryptase level, and previous PA events. Cases with a cause identified by skin or in vitro tests were classified as IgE-mediated anaphylaxis.nnnRESULTSnThirty cases were identified. Seventeen (57%) had an identifiable cause: antibiotics in 10 (59%)-β-lactams in and metronidazole in 1; latex in 3 (18%); and neuromuscular blockers in 4 (23%). There was no identifiable cause in 13 cases. The most frequent presenting sign of PA was hypotension (97%). Seven patients (23%) presented with cardiac arrest. A minority (17%) exhibited urticaria. Only four had a history of atopy. Most of the reactions occurred during the anesthesia induction phase. Elevated serum tryptase level was found in 10 of 10 (100%) cases of IgE-mediated anaphylaxis compared with 4 of 10 (40%) cases without an identifiable cause.nnnCONCLUSIONSnWe found that antibiotics were the most common identifiable cause of PA. Our findings imply that antibiotic exposure warrants careful attention in the evaluation and management of patients with PA, particularly for those who require repeat and/or future surgeries.

Popular on YouTube: a critical appraisal of the educational quality of information regarding asthma.

BACKGROUNDnAsthma affects >300 million people globally, including 25 million in the United States. Patients with asthma frequently use the Internet as a source of information. YouTube is one of the three most popular Web sites.nnnOBJECTIVEnTo determine the educational quality of YouTube videos for asthma.nnnMETHODSnWe performed a YouTube search by using the keyword asthma. The 200 most frequently viewed relevant videos were included in the study. Asthma videos were analyzed for characteristics, source, and content. Source was further classified as asthma health care provider, other health care provider, patient, pharmaceutical company, and professional society and/or media. A scoring system was created to evaluate quality (-10 to 30 points). Negative points were assigned for misleading information.nnnRESULTSnTwo hundred videos were analyzed, with a median of 18,073.5 views, 31.5 likes, and 2 dislikes, which spanned a median of 172 seconds. More video presenters were male (60.5%). The most common type of video source was other health care providers (34.5%). The most common video content was alternative treatments (38.0%), including live-fish ingestion; reflexology; acupressure and/or acupuncture; Ayurveda; yoga; raw food, vegan, gluten-free diets; marijuana; Buteyko breathing; and salt therapy. Scores for videos supplied by asthma health care providers were statistically significantly different from other sources (p < 0.001) and had the highest average score (9.91).nnnCONCLUSIONnYouTube videos of asthma were frequently viewed but were a poor source of accurate health care information. Videos by asthma health care providers were rated highest in quality. The allergy/immunology community has a clear opportunity to enhance the value of educational material on YouTube.

Penicillin allergy: A practical guide for clinicians.

Penicillin allergy is the most commonly reported drug allergy in the United States. However, after undergoing a complete evaluation by a board-certified allergist, including skin testing, 90% of patients labeled as “penicillin-allergic” are able to tolerate penicillin. Clinical presentation is key in classifying reactions as either mediated by or not mediated by immunoglobulin E (IgE), and in determining which patients may benefit from penicillin skin testing, graded-dose challenge, or desensitization. Cross-reactivity between penicillin and other beta-lactams is less common than previously thought. Clinical presentation is key in classifying reactions as either mediated by immunoglobulin E or not.

Epidemiology of anaphylaxis at a tertiary care center: A report of 730 cases

BACKGROUNDnRecent data reveal that the rate of anaphylaxis is increasing and suggest that idiopathic anaphylaxis may account for most of these cases.nnnOBJECTIVEnTo determine the pattern of anaphylaxis at a tertiary care referral center.nnnMETHODSnA retrospective electronic medical record review spanning 12 years (2002-2013) identified patients with anaphylaxis.nnnRESULTSnOf the 4,777 records reviewed, 730 patients met our anaphylaxis definition. Median age was 34.0 years; 72.7% were adults, 58.6% were female, and 86.8% were white. Median time to evaluation by an allergist was 8.8 months. Foods were the most common cause (29.9%), followed by Hymenoptera venom (24.6%), idiopathic anaphylaxis (13.7%), and medications (13.3%). The most common foods were peanuts (23.9%), tree nuts (21.6%), shellfish (16.1%), and egg and milk (both 10.1%). The most common cause of anaphylaxis in adults was Hymenoptera venom. The most frequent symptoms were urticaria and/or angioedema, reported in 84.7% of cases. Atopy was present in 43.8%. In 15.4% of cases, anaphylaxis was not the chief reason for the office visit.nnnCONCLUSIONnWe found food allergy was the most common overall cause of anaphylaxis, with peanut the most frequent food trigger. Idiopathic anaphylaxis was not the most common cause but accounted for 13.7% of all cases. Approximately 1 in 6 cases of anaphylaxis may be missed if a comprehensive evaluation is not performed.

Diagnostic utility of challenge procedures for physical urticaria/angioedema syndromes: a systematic review.

Purpose of reviewPhysical urticaria/angioedema syndromes (PUAs) are commonly encountered. They are identified by a history of physical factors provoking cutaneous symptoms, and confirmed by provocation testing. Recent guidelines have recommended use of challenge procedures for diagnosis; however, their positive/negative likelihood ratios have not been established. Recent findingsWe conducted a systematic review to determine the diagnostic utility of recommended office procedures for three common PUAs: dermatographia (DERMATO), cholinergic urticaria (CHOL), and delayed pressure urticaria/angioedema (DPUA). In this study, we were unable to identify studies of sufficient methodologic quality to calculate positive/negative likelihood ratios for recommended diagnostic challenges for PUAs. SummaryThe study highlights the need for well designed studies to aid the clinician in interpretation of diagnostic challenges for patients with DERMATO, CHOL, and DPUA. There are limited high-quality data available to support the diagnostic utility of office challenges for PUAs. There is a low sensitivity associated with methacholine intradermal challenge for confirming a diagnosis of CHOL.

Anaphylaxis after home-made quinoa dinner: hold the mustard

Food is the most common cause of anaphylaxis.1 Very few cases of mustard seed-induced anaphylaxis have been reported. We present a case of mustard seed anaphylaxis. A 29-year-old man presented to our department for evaluation of anaphylaxis. He had an episode of facial flushing and angio-oedema (figure 1), lower extremity urticaria (figure 2), chest tightness and vomiting within 30u2005min of eating a …

A rash during surgery: rounding up the usual suspects.

A 72-year-old woman with a medical history of allergic rhinitis, food allergy, non-IgE-mediated reactions to medications, spinal stenosis and previous laminectomy presented to our institution for thoracic decompression laminectomy, facetectomy and foraminotomy. During the procedure, 5u2005min after chlorhexidine application and prior to surgical incision, she developed a blanching urticaria on her back (figure 1). The patient had no associated angio-oedema, hypotension, respiratory failure or anaphylaxis.nnnnFigurexa01 nBlanching urticaria (A) on patient’s back 5u2005min after application of antiseptic agent. Patients back (B) with complete resolution of urticaria within an hour and 45u2005min.nnnnSurgery was cancelled. She was treated with diphenhydramine 50u2005mg intravenously …

Prophylactic IVIG and corticosteroids for severe skin reactions post radio-contrast

### Learning Points for CliniciansnnDelayed skin reactions to radio contrast media (RCM) arise 1 h to 1 week after RCM administration. We describe the first report of successful prophylactic use of low-dose intravenous immunoglobulin (IVIG) in preventing severe late onset skin reaction to RCM despite conventional prophylaxis.nnAn 81-year-old Caucasian male presented with acute coronary syndrome, requiring high-dose radio contrast media (RCM) life-saving catheterization. He had a history of diffuse maculo-papular rash 24 hr after an RCM procedure. The patient had a total of four RCM procedures at outside facility with the use of ionic, hyper osmolar, iodinated RCM and non-ionic, non-iodinated low-osmolar contrast. Despite pretreatment with a conventional prophylactic regimen of antihistamine and corticosteroid medications1 and use of non-iodinated low-osmolar RCM, he developed a delayed skin rash …

A case of cough variant asthma undiagnosed for 16 years

A 64-year-old female patient presented with a 16-year history of persistent dry cough that was undiagnosed after workups at several healthcare facilities. The patient denies wheezing, shortness of breath or sputum production. Previous workups include chest imaging, transthoracic echocardiogram (TTE), laryngoscopy, spirometry and bronchoscopy, all of which were unremarkable. During her current evaluation, spirometry was ordered again for the patient, which showed a post-bronchodilator improvement in the FEV1 by 13%, strongly suggestive of asthma. The patient was started on pharmacological therapy for severe persistent asthma, which led to sustained symptomatic improvement per evaluation at follow-up after 2 months. Spirometric findings, clinical presentation and resolution of symptoms with adequate therapy for asthma suggest that this is a case of cough variant asthma that went undiagnosed for several years. This case report summarizes the workup for chronic cough and how the diagnosis of cough variant asthma can be missed.

PCP: thinking beyond HIV.

A 40-year-old man with a previous AIDS-defining opportunistic infection and five negative HIV tests presented to our outpatient clinic. The laboratory test was relevant for less than 300 total lymphocytes on two separate occasions. He was diagnosed with idiopathic CD4 lymphocytopenia and was started on antibiotic prophylaxis for Pneumocystis carinii pneumonia and Micobacterium avium-intracellulare infection (MAI). This case report summarises the importance of further immunological characterisation in patients presenting with opportunistic infections and decreased cellular immunity.