B. Vos

Predictors of clinical effectiveness of Hymenoptera venom immunotherapy.

Treatment failure during venom immunotherapy (VIT) may be associated with a variety of risk factors, of which the relative importance is unknown.

Diminished reliability of tryptase as risk indicator of mastocytosis in older overweight subjects.

BACKGROUND Currently, measurement of serum tryptase level is the most commonly used test to estimate the need for bone marrow biopsy in patients suspected to have indolent systemic mastocytosis (ISM). Yet tryptase levels do not solely reflect the mast cell load and can be elevated by overweight, older age, and impaired renal function. The influence of these factors on urinary methylhistamine (MH) and methylimidazole acetic acid (MIMA) is still unknown. OBJECTIVE We investigated the impact of age, body mass index (BMI), and kidney function on the diagnostic accuracy of tryptase, MH, and MIMA to select the most optimal test indicating the necessity of a bone marrow biopsy in ISM-suspected patients. METHODS Retrospective data analysis of all adults in whom bone marrow investigations were performed because of high clinical suspicion and/or elevated tryptase, MH, or MIMA. RESULTS 194 subjects were included. ISM was present in 112 and absent in 82 subjects (non-ISM). Tryptase was elevated by age and body weight in non-ISM subjects and by BMI in ISM subjects; however, these factors did not influence MH or MIMA. In the total study population, the diagnostic accuracy of tryptase, MH, and MIMA were comparable (area under the curve 0.80, 0.80, and 0.83). In subjects >50 years with a BMI >25 kg/m(2), the diagnostic accuracy of MIMA was higher compared with that of tryptase (area under the curve 0.93 vs 0.74; P = .011). CONCLUSION In ISM-suspected patients >50 years with a BMI of >25 kg/m(2), MIMA has a greater value compared with tryptase in estimating the need for bone marrow biopsy.

In-vitro diagnostics of Hymenoptera venom allergy

In-vitro diagnostics of Hymenoptera venom allergy Patients with a history of anaphylactic sting reactions require an allergological work-up (history, in-vitro tests, and skin tests) to clarify indications on venom immunotherapy and on the type of venom to be used. To demonstrate a venom sensitisation, measurement of IgE-antibodies (sIgE) specific to the natural composite venom is the standard in-vitro method. In-vitro tests are performed after a field sting reaction. After a sting, an increase of sIgE concentrations, which is followed by a decrease, indicates a previous exposure, and may help to identify the culprit venom. If the eliciting insect is doubtful, it is recommended to do repeated measurements shortly after a sting. In adults measurement of baseline serum tryptase concentration should be included into routine diagnostics of venom allergy. If a sensitisation to the presumably causative composite venom cannot be demonstrated, one may determine sIgE to recombinant COD-free allergen compounds, thereby possibly demonstrating a sensitisation to molecular venom allergens. In addition, one should consider the involvement of in Germany rare elicitors of insect sting anaphylaxis, such as bumble bees, hornets, Dolichovespula, or Polistes. If these rare elicitors could have been involved into allergic reactions, one should test patients for IgE specific to the respective venom. Moreover, several cellular tests (e.g., basophil activation test) are available to confirm venom sensitisation. Herein basophils, which carry cell-bound sIgE, can be used to confirm the involvement of suspected venoms (e.g., by showing a histamine release or up-regulation of cell surface markers upon incubation with venom allergens). Double sensitisation to both honey bee and vespid venom may either indicate true double sensitisation or cross sensitisation. In double-sensitized patients, inhibition tests and tests using molecular allergens may help to clarify the diagnosis. Results of the above mentioned in-vitro tests, however, do not precisely correlate with the clinical relevance of the putative elicitor. Double sensitisation to both honey bee and vespid venom may either indicate true double sensitisation or cross sensitisation. In double-sensitized patients inhibition tests, and tests with molecular allergens may help to specify the diagnosis. None of the mentioned in-vitro tests, however, allows a precise prognosis with respect to clinical relevance.

Stevens Johnson syndrome/toxic epidermal necrolysis-overlap, induced by lacosamide.

A 73-year-old European male with cerebral meningiomas and secondary complex partial seizures was admitted for recurrent status epilepticus. The dose of levetiracetam and valproic acid, both used for months, was increased, and one bolus phenytoin 1000 mg, previously used without cutaneous adverse reaction (cADR), was given. Clobazam, used for 3 weeks, was stopped. For anterior pituitary failure, hydrocortisone 30 mg QD and levothyroxine 75 μg QD had been used for 20 days. Because his condition [...]