Cristine Radojicic

Utility of routine laboratory testing in management of chronic urticaria/angioedema

BACKGROUND Laboratory tests are routinely ordered to identify or rule out a cause in patients with chronic urticaria/angioedema (CUA). The results of these tests are usually within normal limits or unremarkable. OBJECTIVE To investigate the proportion of abnormal test results in patients with CUA leading to a change in management and in outcomes of care. METHODS Retrospective analysis of a random sample of adult patients with CUA from 2001-2009. RESULTS Cases totaled 356: 166 with urticaria and angioedema (AE), 187 with urticaria, and 3 with only AE. Patients were predominately women (69.1%) and white (75.6%), with a mean age of 48 ± 15 years. Abnormalities were commonly seen in complete blood counts (34%) and in complete metabolic panels (9.4%). Among the 1,872 tests that were ordered, results of 319 (17%) were abnormal. Of 356 patients, 30 underwent further testing because of abnormalities in laboratory work. This represented 30 of 1,872 tests (1.60%). Only 1 patient benefited from a subsequent change in management. CONCLUSIONS Laboratory testing in CUA patients referred for an Allergy and Immunology evaluation rarely lead to changes in management resulting in improved outcomes of care.

Glatiramer acetate: successful desensitization for treatment of multiple sclerosis

BACKGROUND Glatiramer acetate is an immunomodulatory drug that is widely prescribed for the treatment of multiple sclerosis. It is frequently associated with local injection site reactions and generalized urticaria. It is also associated with immediate postinjection systemic reactions in approximately 10% of patients. To our knowledge, no desensitization protocols for glatiramer acetate have been published to date. OBJECTIVES To evaluate the safety and efficacy of glatiramer acetate desensitization in a series of patients with multiple sclerosis. METHODS Six patients with multiple sclerosis and glatiramer acetate-associated local or systemic reactions underwent a 4-hour outpatient desensitization procedure at Cleveland Clinic between 2003 and 2008. Beginning with 20 ng, we administered subcutaneous glatiramer acetate suspension in increasing dosages every 15 minutes. Patient outcomes were monitored by return clinic visit and telephone follow-up. RESULTS No episodes of anaphylaxis or serious adverse reactions occurred during or immediately after desensitization. One patient suspended therapy after 14 months due to persistent local injection site reactions. All other patients successfully continued glatiramer acetate therapy. CONCLUSION Glatiramer acetate offers significant benefit to patients with multiple sclerosis. Our experience suggests that patients who suspend its use owing to local or systemic reactions can be successfully and safely desensitized and can resume medication use. To our knowledge, this is the first report of successful desensitization to glatiramer acetate in patients with multiple sclerosis.

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.

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

### Learning Points for Clinicians Delayed 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. An 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 …