Chrystyna Kalicinsky

Prolonged elevation of serum tryptase resulting from intraoperative anaphylaxis to methylene blue

Background Intraoperative anaphylaxis during sentinel lymph node biopsy is a well known phenomenon occurring with administration of patent blue and isosulfan blue dyes, with an incidence of 2.2% and 1.1%, respectively (1,2). Methylene blue has been reported as being a safer alternative with only a few case reports demonstrating anaphylaxis and large studies demonstrating no incidence of anaphylaxis in 224 patients (3,2).

Adjunctive treatment of chronic idiopathic urticaria and angioedema with sulfasalazine

Rationale Urticaria is a common condition that affects as many as 25% of people at some time in their lives. Chronic recurrent urticaria and angioedema can be frustrating and often refractory to conventional treatment. The purpose of this study was to evaluate the efficacy of Sulfasalazine in the treatment of unremitting recurrent urticaria and angioedema. Methods We performed a retrospective chart review of 20 patients with chronic idiopathic urticaria/angioedema (CIU) treated with Sulfasalazine as adjunctive therapy at the Winnipeg Health Science Centre from 2005-2009. We recorded demographic data, response to Sulfasalazine, presence of the IgE receptor antibody, and side effects. Results 20 patients were treated with Sulfasalazine as adjunctive therapy and 1 patient was lost to follow up. The patient’s ages ranged between 27-75 years with a mean of 48 years and 10 (50%) were female. IgE receptor antibody status was determined in 12 patients and 6 patients were positive. Out of the 19 patients who are still being followed, 10(52.6%) failed to respond to the Sulfasalazine, and 9 (47.4%) responded to Sulfasalazine with 2 partial responders and 7 complete responders. Side effects noted included: increased liver function tests, leucopenia, dyspepsia, flatulence nausea, pyrosis and a rash. Conclusions

Resolution of wheat-dependent exercise induced anaphylaxis-case report

BackgroundThe natural history of Wheat Dependent ExerciseInduced Anaphylaxis (WDEIA) is not well defined. InIgE mediated, non exercise dependent, wheat allergy inchildren, the approximate age for resolution is 6.5 yearswith rare persistence into adolescence [1]. We report acase of resolution of WDEIA in an adult.Case reportA 62 year old male was assessed in 2006 with a 3-4 yearhistory of recurrent acute urticaria. A month prior toconsultation he developed anaphylaxis.No consistent trigger was identified, therefore a co-variable with food, such as exercise, was suspected.Skin prick testing (SPT) to foods ingested within 4hours of anaphylaxis was positive to wheat flour andnegative to wheat extract (WE) (Allergy Canada), pea-nut, egg, cow’s milk, cod, pickerel, salmon, whitefish,clam, and potato. Wheat products were tolerated daily,therefore WDEIA was suspected. Strict wheat avoidancewas advised and epinephrine autoinjector prescribed.4-6-12 months later he was asymptomatic with wheatavoidance. SPT was negative to oat, rye, corn flour.In 2008 and 2009 SPT was WE negative and flourpositive.In 2010 he reported eating wheat products, followedby exercise, with no reactions >6 months. SPT wasnegative to WE and flour.ResultsThis patient demonstrates WDEIA which resolved fouryears after diagnosis. The patient is asymptomatic despitewheat ingestion followed by exercise. SPT to wheat flour,which was positive previously, is now negative.ConclusionThis is the first case of WDEIA resolution reported.History plus SPT with wheat flour was used to diagnoseWDEIA, and to confirm its resolution.

A novel combination of an IgE mediated adult onset food allergy and a suspected mast cell activation syndrome presenting as anaphylaxis

BackgroundAdult onset food allergy is a rare, but increasingly recognized phenomenon. Mast cell activation syndromes present an ongoing diagnostic and classification challenge. The combination of the two has been rarely described in the literature.Case presentationWe present a case of a new onset, IgE mediated food allergy in combination with a mast cell activation syndrome in an elderly patient not known to have a history of atopy. He presented to a hospital with a first presentation of anaphylaxis manifesting profound hypotension following consumption of a stew consisting of fish and shellfish. He had a persistently elevated serum tryptase and demonstrated evidence of high titre serum specific IgE to shellfish. He responded well to histaminergic blockade.ConclusionsGiven that mast cell activation syndromes pose an increased risk for recurrent, severe anaphylaxis and that secondary causes of mast cell activation syndromes are more prevalent with aging, this case highlights the importance of considering this entity when evaluating an elderly patient with a first presentation of anaphylaxis.

Penicillin allergies: referral and management practices of anesthesiologists

Rationale Penicillin and other beta-lactams are the most commonly used antibiotics due to their narrow spectrum of activity, low cost and safety profile. However, an “allergy” to Penicillin is also the most commonly reported allergy. Approximately, 5-10% of all patients self-report an allergy to Penicillin and of these 99%) of skin testing to rule out true IgE mediated Penicillin allergy. Less than 10% of patients with a history of penicillin allergy are found to be actually allergic to penicillin on skin testing. Despite this, most physicians forgo further investigations in favor of the usage of alternative antibiotics.

Bloodworm induced Anaphylaxis

Bloodworms are a group of bristle worms found at the bottom of marine waters. They have pale skin, which allows their red body fluid, which contains hemoglobin, to show through, hence the name “bloodworm”. Bloodworms are often used as bait in fishing and are also available commercially as a food-source for aquarium fish [1,2]. This case report describes a patient who experienced repeated allergic reactions after feeding her fish.

Is response to IVIG in Chronic Idiopathic Urticaria related to presense of autoantibodies

Background Treatment of Chronic Idiopathic Urticaria (CIU) may be challenging, as patients can be refractory to various treatments. This may be due to an autoimmune mechanism in its pathogenesis. CIU has been shown to be associated with autoantibodies to IgE or IgE receptor and with thyroid autoimmunity [1,2]. Treatments targeting this autoimmune pathogenesis are now being used, such as intravenous immunoglobulin (IVIG). We reviewed patients with CIU treated with IVIG to see if response to treatment correlated with presence of autoimmunity (antibodies to IgE/IgE receptor or Thyroidperoxidase (TPO) antibodies).

Treatment of angiotensin-converting enzyme inhibitor related angioedema with icatibant

Background The absolute risk of angiotensin-converting enzyme (ACE) inhibitor angioedema is 0.3% [1]. The mechanism is felt to be accumulation of bradykinin. The current treatment is discontinuation of ACE-I inhibitor, and intubation if necessary. Icatibant is a bradykinin receptor antagonist, useful in treating hereditary angioedema [2]. We present a patient from a Canadian center who had ACE-inhibitor induced angioedema requiring intubation who did not respond to epinephrine or C1 esterase inhibitor concen

Diagnosing penicillin allergy in the absence of minor determinant mixture

Background Penicillin allergy is a common presentation in allergy clinic. The diagnosis of immediate hypersensitivity is made using clinical history, skin testing, specific IgE levels and oral challenge. Skin testing is done using benzyl penicilloyl-polylysine (PPL) and a minor determinant mixture (MDM) consisting of penicillin byproducts. Although using PPL and MDM is considered first line for diagnosis [1], our clinic is unable to consistently obtain MDM. We have undertaken a retrospective chart review to assess our current protocol in diagnosing penicillin allergy using Penicillin G (PG) alone instead of MDM.

Resolution of antibody in autoimmune urticaria

Chronic urticaria, defined as widespread daily or nearly daily wheals for at least 6 weeks, with or without angioedema, impacts on patients’ quality of life. Natural course is self-limited, with spontaneous remissions and occasional relapses. Antihistamines, leukotriene inhibitor, immunosuppressive agents are used. 60% are idiopathic and 40% are autoimmune due to presence of anti-IgE antibody or IgG autoantibodies against Fc∑R1. An association exists between chronic urticaria and autoimmune diseases. We report a case of a patient with autoimune urticaria, thyroid disease and vitiligo, who showed resolution of histamine releasing antibody (reflab) on remission. In February 2005, a 44 yr old healthy woman was referred to the Allergy outpatient clinic with two month history of daily hives, moderately controlled with antihistamines, with good response to oral steroid. Lesions were pruritic, raised, erythematous, lasting for < 24 hrs and resolved with purplish discoloration. Screening negative for malignancy, connective tissue disease. TSH normal. Histamine releasing antibody positive, maximum histamine release 27% (<16%). Skin biopsy confirmed chronic urticaria with neutrophils without vasculitis. Sulfasalazine was not tolerated, but control attained with antihistamines and leukotriene inhibitor. By one year, she failed trial of weaning medications. 6 months after presentation she developed vitiligo. 5 years later, she was hypothyroid. By 3 years, the urticaria was in complete remission without medications. Repeat histamine releasing antibody was negative. There is a known association of severe chronic urticaria with auto antibody etiology and other autoimmune disease. Does resolution of antibody correlate with achieving remission? Further prospective studies are required to establish this relationship.