Alfredo Arias-Cruz

Drug-Induced Anaphylaxis in Latin American Countries

BACKGROUND Information regarding the clinical features and management of drug-induced anaphylaxis (DIA) in Latin America is lacking. OBJECTIVE The objective of this study was to assess implicated medications, demographics, and treatments received for DIA in Latin American patients referred to national specialty centers for evaluation. METHOD A database previously used to compile information on drug-induced allergic reactions in 11 Latin American countries was used to identify and characterize patients presenting specifically with a clinical diagnosis of DIA. Information regarding clinical presentation, causative agent(s), diagnostic studies performed, treatment, and contributing factors associated with increased reaction severity was analyzed. RESULTS There were 1005 patients evaluated for possible drug hypersensitivity reactions during the study interval, and 264 (26.3%) met criteria for DIA. DIA was more frequent in adults and in elderly females (N = 129 [76.6%] and N = 30 [75%], respectively) compared with children and/or adolescents (N = 21 [42.9%], P < .01). Severe DIA was less frequent with underlying asthma (N = 22 vs 35 [38.6% vs 61.4%], P < .05) or atopy (N = 62 vs 71 [43% vs 59% ], P < .01). Nonsteroidal anti-inflammatory drugs (NSAIDs) (N = 178 [57.8%]), beta-lactam antibiotics (N = 44 [14.3%]), and other antibiotics (N = 16 [5.2%]) were the most frequently implicated drug classes. Anaphylaxis was rated as severe in N = 133 (50.4%) and anaphylactic shock (AS) was present in N = 90 (34.1%). Epinephrine was only used in N = 73 (27.6%) overall, but in N = 70 (77.8%) of patients with AS. CONCLUSION In Latin American patients referred for evaluation of DIA, NSAIDs and antibiotics were implicated in approximately 80% of cases. Most of these reactions were treated in the emergency department. Epinephrine was administered in only 27.6% of all cases, although more frequently for anaphylactic shock. Dissemination of anaphylaxis guidelines among emergency department physicians should be encouraged to improve management of DIA.

Allergen sensitization linked to climate and age, not to intermittent-persistent rhinitis in a cross-sectional cohort study in the (sub)tropics

BackgroundAllergen exposure leads to allergen sensitization in susceptible individuals and this might influence allergic rhinitis (AR) phenotype expression. We investigated whether sensitization patterns vary in a country with subtropical and tropical regions and if sensitization patterns relate to AR phenotypes or age.MethodsIn a national, cross-sectional study AR patients (2-70 y) seen by allergists underwent blinded skin prick testing with a panel of 18 allergens and completed a validated questionnaire on AR phenotypes.Results628 patients were recruited. The major sensitizing allergen was house dust mite (HDM) (56%), followed by Bermuda grass (26%), ash (24%), oak (23%) and mesquite (21%) pollen, cat (22%) and cockroach (21%). Patients living in the tropical region were almost exclusively sensitized to HDM (87%). In the central agricultural zones sensitization is primarily to grass and tree pollen. Nationwide, most study subjects had perennial (82.2%), intermittent (56.5%) and moderate-severe (84.7%) AR. Sensitization was not related to the intermittent-persistent AR classification or to AR severity; seasonal AR was associated with tree (p < 0.05) and grass pollen sensitization (p < 0.01). HDM sensitization was more frequent in children (0-11 y) and adolescents (12-17 y) (subtropical region: p < 0.0005; tropical region p < 0.05), but pollen sensitization becomes more important in the adult patients visiting allergists (Adults vs children + adolescents for tree pollen: p < 0.0001, weeds: p < 0.0005).ConclusionsIn a country with (sub)tropical climate zones SPT sensitization patterns varied according to climatological zones; they were different from those found in Europe, HDM sensitization far outweighing pollen allergies and Bermuda grass and Ash pollen being the main grass and tree allergens, respectively. Pollen sensitization was related to SAR, but no relation between sensitization and intermittent-persistent AR or AR severity could be detected. Sensitization patterns vary with age (child HDM, adult pollen). Clinical implications of our findings are dual: only a few allergens –some region specific- cover the majority of sensitizations in (sub)tropical climate zones. This is of major importance for allergen manufacturers and immunotherapy planning. Secondly, patient selection in clinical trials should be based on the intermittent-persistent and severity classifications, rather than on the seasonal-perennial AR subtypes, especially when conducted in (sub)tropical countries.

Multinational experience with hypersensitivity drug reactions in Latin America

BACKGROUND Epidemiologic drug allergy data from Latin America are scarce, and there are no studies on specific procedures focusing on this topic in Latin America. OBJECTIVE To assess the clinical characteristics and management of hypersensitivity drug reactions in different Latin American countries. METHODS An European Network of Drug Allergy questionnaire survey was implemented in 22 allergy units in 11 Latin American countries to report on consecutive patients who presented with a suspected hypersensitivity drug reaction. Each unit used its own protocols to investigate patients. RESULTS Included were 868 hypersensitivity drug reactions in 862 patients (71% of adults and elderly patients were women and 51% of children were girls, P = .0001). Children presented with less severe reactions than adults and elderly patients (P < .0001). Urticaria and angioedema accounted for the most frequent clinical presentations (71%), whereas anaphylaxis was present in 27.3% of cases. There were no deaths reported. Nonsteroidal anti-inflammatory drugs (52.3%), β-lactam antibiotics (13.8%), and other antibiotics (10.1%) were the drugs used most frequently. Skin prick tests (16.7%) and provocation tests (34.2%) were the study procedures most commonly used. A large proportion of patients were treated in the emergency department (62%) with antihistamines (68%) and/or corticosteroids (53%). Only 22.8% of patients presenting with anaphylaxis received epinephrine. CONCLUSION Nonsteroidal anti-inflammatory drugs and antibiotics were the drugs used in at least 75% of patients. More than half the reactions were treated in the emergency department, whereas epinephrine was administered in fewer than 25% of patients with anaphylaxis. Dissemination of guidelines for anaphylaxis among primary and emergency department physicians should be encouraged.

Atmospheric pollen count in Monterrey, Mexico.

There are few reports of pollen count and identification in Mexico; therefore, it is important to generate more information on the subject. This study was designed to describe the prevalence of pollen in the city of Monterrey, Mexico, during the year 2004. Atmospheric pollen was collected with a Hirst air sampler, with an airflow of 10 L/minute during 2004. Pollen was identified with light microscopy; the average monthly pollen count as well as total was calculated from January 2004 to January 2005. The months with the highest concentration of pollen were February and March (289 and 142 grains/m(3) per day, respectively), and July and November had the lowest concentration (20 and 11 grains/m(3) per day, respectively). Most of the pollen recollected corresponded to tree pollen (72%). Fraxinus spp had the highest concentration during the year (19 grains/m(3) per day; 27.5% of the total concentration of pollen). Tree pollen predominated from January through March; with Fraxinus spp, Morus spp, Celtis spp, Cupressus spp, and Pinus spp as the most important. Weed pollen predominated in May, June, and December and the most frequently identified, were Amaranthaceae/Chenopodiaceae, Ambrosia spp, and Parietaria spp. The highest concentration of grass pollen was reported during the months of May, June, September, October, and December with Gramineae/Poaceae predominating. Tree pollen was the most abundant during the year, with the ash tree having the highest concentration. Weed and grass pollen were perennial with peaks during the year.

In the (sub)tropics allergic rhinitis and its impact on asthma classification of allergic rhinitis is more useful than perennial-seasonal classification.

Background Two different allergic rhinitis (AR) symptom phenotype classifications exist. Treatment recommendations are based on intermittent–persistent (INT-PER) cataloging, but clinical trials still use the former seasonal AR–perennial AR (SAR-PAR) classification. This study was designed to describe how INT-PER, mild–moderate/severe and SAR-PAR of patients seen by allergists are distributed over the different climate zones in a (subtropical country and how these phenotypes relate to allergen sensitization patterns. Methods Six climate zones throughout Mexico were determined, based on National Geographic Institute (Instituto Nacional de Estadística y Geografía) data. Subsequent AR patients (2–68 years old) underwent a blinded, standardized skin-prick test and filled out a validated questionnaire phenotyping AR. Results Five hundred twenty-nine subjects participated in this study. In the tropical zone with 87% house-dust mite sensitization, INT (80.9%; p < 0.001) and PAR (91%; p = 0.04) were more frequent than in the subtropics. In the central high-pollen areas, there was less moderate/severe AR (65.5%; p < 0.005). Frequency of comorbid asthma showed a clear no -south gradient, from 25% in the dry north to 59% in the tropics (p < 0.005). No differences exist in AR cataloging among patients with different sensitization patterns, with two minor exceptions (more PER in tree sensitized and more PAR in mold positives; p < 0.05). Conclusion In a (sub)tropical country the SAR-PAR classification seems of limited value and bears poor relation with the INT-PER classification. INT is more frequent in the tropical zone. Because PER has been shown to relate to AR severity, clinical trials should select patients based on INT-PER combined with the severity cataloging because these make for a better treatment guide than SAR-PAR.

Psychoneuroimmunoendocrinology: clinical implications

Psychoneuroimmunoendocrinology, which was first described in 1936, is the study of the interactions between the psyche, neural and endocrine functions and immune responses. The aim of psychoneuroimmunoendocrinology is to apply medical knowledge to the treatment of different allergic, immune, autoimmune, rheumatic, neoplastic, endocrine, cardiovascular and dental pathologies, among other disorders. Epigenetic factors and major stresses from different types of stimuli acting through distinct pathways and neurotransmitters are highly involved in altering the psychoneuroimmunoendocrine axis, resulting in the emergence of disease. The main purpose of this report is to expand the understanding of psychoneuroimmunoendocrinology and to demonstrate the importance of the above-mentioned interactions in the etiology of multiple pathologies. In this review, a search of the medical literature using PubMed (free access search engine for the Medline database of the National Library of Medicine of the United States) over the years 1936 to 2016 was conducted, and descriptive and experimental studies and reviews of the scientific literature were included.

Prevalencia de sensibilización a hongos en pacientes con alergia respiratoria

Como parte de la etiologia de la alergia respiratoria esta la genetica, los factores prenatales y la sensibilidad a diversos aeroalergenos, entre estos los hongos.

Poster 2022: Sublingual immunotherapy in the treatment of allergic rhinitis: series of cases

Background Sublingual immunotherapy (SLIT) has been regarded as a viable alternative to subcutaneous immunotherapy (SCIT) since its introduction in 1986. Several studies have demonstrated the efficacy of SLIT. The safety profile of SLIT is superior to that of SCIT. No fatalities have been reported, and severe systemic reactions are rare. The rate of adverse event (AE) after SLIT is variable in the reported studies, but local AEs are predominant. Systemic side effects such as rhinitis, asthma, urticaria, angioedema, and hypotension make up a minority of the adverse reactions because local reactions (oropharyngeal or gastrointestinal) are most frequently reported.

465 Skeeter Syndrome, a Case Report and Literature Review

Background The worldwide prevalence of allergic reaction to mosquito bites is unknown. Some patients who suffer from local reactions have also systemic symptoms. Methods A 3 year old female who suffered from mosquitoes bites in her left lower extremity, had a large local reaction with erythema, edema, itching, pain and blisters of 5 × 6 cm. It was accompanied by fever of 38.5°C and emesis. She had a positive skin prick test for Aedes aegypti with diagnosis of Skeeter Syndrome. The patient was treated with antihistamine during 10 days and analgesics for 3 days. She was given antihistamine treatment for 10 days and analgesics for 3 days. Results Skeeter syndrome is defined as a large local reaction induced by mosquito bites associated with systemic symptoms (fever and vomiting) with specific IgE for mosquito identified by skin testing. The primary management of Skeeter syndrome is prevention of mosquito bites, the use of repellents and protective clothing. It is also important the symptomatic management control of pruritus with the use of antihistamines or if necessary topical steroids. Overall children with Skeeter syndrome remain healthy, except for the recurrence of large local reactions to mosquito Stings. Conclusions The early recognition of Skeeter syndrome is important to give the right management and to prevent unnecessary diagnostic tests and treatments that can increase the risk of adverse reactions and costs.

371 Cutaneous Response to Patch Tests with Dermatophagoides Farinae and Dermatophagoides Pteronyssinus in Patients with Chronic Rhinitis

Background Rhinitis is characterized clinical by chronic runny nose, sneezing, nasal itching, congestion and postnasal discharge, among other symptoms. It´s classified as allergic and non allergic. Skin prick testing is the principal diagnosis method for allergic rhinits. However, there is a group of patients with chronic rhinopathy that have negative skin tests, the objective of this study was to determine the cutaneous response to patch tests with Dermatophagoides farinae and Dermatophagoides pteronyssinus in patients with chronic rhinitis. Methods It was a cross-sectional, observational and descriptive study. We included patients over 18 years old. They were divided into 3 groups; Group A patients who came for the first time with a history of chronic rhinopathy over 18 months of evolution and positive skin tests for aeroallergens; group B patients with chronic rhinitis with at least one year of evolution and negative skin tests; group C healthy volunteers. Patch test with farinae and pteronisyinnus were done in the subjects of all 3 groups, with readings at 48 and 72 hours. Results A total of 37 patients were studied, mean age 26.1 years. Twenty two were male subjects (60%). The mean lenghtof chronic rhinophaty was 10.8 years. Six patients had positive patch test to any of the mites tested; 2 (33%) in group A, 2 (33%) in group B and 2 (33%) of the control group, but it was not statistically significant (P > 0.05). Conclusions Although the results were not statistically significant, there were patients with chronic rhinitis wich had positive patch test for mites. This sensitization could be clinically significant for those patients.