G. Wurpts

Guideline for the diagnosis of drug hypersensitivity reactions

Drug hypersensitivity reactions are unpredictable adverse drug reactions. They manifest either within 1–6 h following drug intake (immediate reactions) with mild to life-threatening symptoms of anaphylaxis, or several hours to days later (delayed reactions), primarily as exanthematous eruptions. It is not always possible to detect involvement of the immune system (allergy). Waiving diagnostic tests can result in severe reactions on renewed exposure on the one hand, and to unjustified treatment restrictions on the other. With this guideline, experts from various specialist societies and institutions have formulated recommendations and an algorithm for the diagnosis of allergies. The key principles of diagnosing allergic/hypersensitivity drug reactions are presented. Where possible, the objective is to perform allergy diagnostics within 4 weeks–6 months following the reaction. A clinical classification of symptoms based on the morphology and time course of the reaction is required in order to plan a diagnostic work-up. In the case of typical symptoms of a drug hypersensitivity reaction and unequivocal findings from validated skin and/or laboratory tests, a reaction can be attributed to a trigger with sufficient confidence. However, skin and laboratory tests are often negative or insufficiently reliable. In such cases, controlled provocation testing is required to clarify drug reactions. This method is reliable and safe when attention is paid to indications and contraindications and performed under appropriate medical supervision. The results of the overall assessment are discussed with the patient and documented in an „allergy passport“ in order to ensure targeted avoidance in the future and allow the use of alternative drugs where possible.

In vitro detection and characterization of drug hypersensitivity using flow cytometry

Background:  The lymphocyte transformation test (LTT) is the only in vitro test for detecting drug sensitization at the cellular level irrespective of the reaction’s phenotype. However, the LTT includes working with radioactive substances and is considered impracticable for routine laboratory investigation.

How to diagnose mould allergy? Comparison of skin prick tests with specific IgE results.

Diagnosis of mould allergy is complicated due to the heterogeneity of the test material and the decrease in the number of commercial mould skin test solutions that are currently available.

Leitlinie Allergologische Diagnostik von Überempfindlichkeitsreaktionen auf Arzneimittel

ZusammenfassungArzneimittelüberempfindlichkeitsreaktionen sind unvorhersehbare, durch Arzneimittel hervorgerufene Reaktionen. Sie manifestieren sich entweder innerhalb von ein bis sechs Stunden nach Arzneimittelzufuhr („Sofortreaktionen“) mit geringgradigen bis lebensbedrohlichen Symptomen der Anaphylaxie oder mehrere Stunden bis Tage später („Spätreaktionen“) vorwiegend als Exantheme. Eine Beteiligung des Immunsystems (Allergie) ist nicht immer nachweisbar. Der Verzicht auf eine Diagnostik kann einerseits schwere Reaktionen bei erneuter Exposition zur Folge haben, andererseits zu ungerechtfertigter Einschränkung der Therapiemöglichkeiten führen. Experten verschiedener Fachgesellschaften und Institutionen haben in dieser Leitlinie Empfehlungen und einen Algorithmus zur Allergiediagnostik erarbeitet. Wesentliche Prinzipien der allergologischen Diagnostik von Überempfindlichkeitsreaktionen auf Arzneimittel werden dargelegt. Die allergologische Klärung möglichst innerhalb von vier Wochen bis sechs Monaten nach der Reaktion ist anzustreben. Eine klinische Zuordnung des Krankheitsbildes anhand von Morphologie und Zeitablauf der Reaktion ist für die Planung der Diagnostik notwendig. Bei typischer Symptomatik einer Arzneimittelüberempfindlichkeitsreaktion und eindeutigen Befunden validierter Haut- und/oder Labortests kann die Zuordnung zu einem Auslöser als ausreichend angesehen werden. Häufig sind jedoch Haut- und Labortests negativ oder nicht sicher aussagekräftig. In diesen Fällen ist eine kontrollierte Provokationstestung zur Aufklärung der Reaktion erforderlich. Bei Beachtung von Indikationen und Kontraindikationen sowie angemessener ärztlicher Überwachung ist sie eine aussagekräftige und sichere Methode. Das Ergebnis der Gesamtbeurteilung wird mit dem Patienten besprochen und in einem Allergiepass dokumentiert, sodass zukünftig eine gezielte Karenz eingehalten werden kann und gegebenenfalls Ausweichmedikamente zur Verfügung stehen.

Perioperative Anaphylaxie aufgrund einer Rocuroniumallergie bei einem Kind

During the induction of anesthesia for strabismus correction, a six-year-old boy suffered anaphylaxis with hypotension. Midazolam, propofol, sufentanil, rocuronium, dexamethasone and ibuprofen had been administered. The boys history failed to reveal any drug allergies. Intracutaneous testings with drugs used for anesthesia and other muscle relaxants verified a positive reaction to rocuronium as well as to cisatracurium, mivacurium, vecuronium and atracurium. There was no reaction to suxamethonium.

Allergie gegen Autositz

ZusammenfassungWir berichten über eine Patientin mit einer Spättypallergie auf Epoxidharz, die sich klinisch als allergisches Kontaktekzem nach Kontakt mit dem Kunstleder ihres Autositzes manifestierte.AbstractThis is a case report of a female patient showing a delayed allergic reaction to epoxy resin. The allergic contact dermatitis occurred after sitting in her new car equipped with artificial leather seats.This is a case report of a female patient showing a delayed allergic reaction to epoxy resin. The allergic contact dermatitis occurred after sitting in her new car equipped with artificial leather seats.

Anaphylaxis in childhood and adolescence

Anaphylaxis represents a severe, systemic and potentially fatal hypersensitivity reaction that severely impairs the life of affected children and their caregivers. With an estimated life time prevalence of 0.05% to 2%, it is not a rare disease. Therefore every physician caring for children at risk for anaphylaxis should be familiar with this disease pattern. Foods are the most frequent triggers in children; less frequent causes include drugs and insect venom. Particularly in case of idiopathic anaphylaxis, systemic mastocytosis should be ruled out as a potential differential diagnosis in this age group as well. First line emergency treatment consists of parenteral epinephrine in a weight-adjusted dosage, and after cardiovascular stabilization systemic antihistamines and corticosteroids as well as inhaled beta-mimetics can be administered. Affected patients, their relatives and other caregivers should receive extensive training in order to guarantee an adequate emergency management of anaphylactic children.

Anaphylaxie im Kindes- und Jugendalter

Anaphylaxis represents a severe, systemic and potentially fatal hypersensitivity reaction that severely impairs the life of affected children and their caregivers. With an estimated life time prevalence of 0.05% to 2%, it is not a rare disease. Therefore every physician caring for children at risk for anaphylaxis should be familiar with this disease pattern. Foods are the most frequent triggers in children; less frequent causes include drugs and insect venom. Particularly in case of idiopathic anaphylaxis, systemic mastocytosis should be ruled out as a potential differential diagnosis in this age group as well. First line emergency treatment consists of parenteral epinephrine in a weight-adjusted dosage, and after cardiovascular stabilization systemic antihistamines and corticosteroids as well as inhaled beta-mimetics can be administered. Affected patients, their relatives and other caregivers should receive extensive training in order to guarantee an adequate emergency management of anaphylactic children.

Impfgranulom bei Spättypallergie gegen Aluminiumsalze

BACKGROUND Aluminium salts are common adjuvants in all established inactivated vaccines. They are necessary to activate the humoral immune system. In the 1990s a Swedish study on an acellular vaccination against pertussis was started. Until 2013, 745 of 760,000 children with pruritic subcutaneous nodules were identified. In 77 % of these children a contact allergy to aluminium could be proven. Contact allergy to aluminium induced by vaccines causes pruritic subcutaneous nodules at the vaccination site. During infections of the upper respiratory tract the pruritus often escalates with inflammatory, erythematous and urticarial plaques. CONCLUSIONS The use of solutions containing aluminium salts for specific immunotherapy is contraindicated in the case of contact allergy to aluminium. Intramuscular injections of inactivated vaccines can be employed to avoid granuloma formation.

[Post-vaccination granulomas caused by delayed-type reaction to aluminum salts].

BACKGROUND Aluminium salts are common adjuvants in all established inactivated vaccines. They are necessary to activate the humoral immune system. In the 1990s a Swedish study on an acellular vaccination against pertussis was started. Until 2013, 745 of 760,000 children with pruritic subcutaneous nodules were identified. In 77 % of these children a contact allergy to aluminium could be proven. Contact allergy to aluminium induced by vaccines causes pruritic subcutaneous nodules at the vaccination site. During infections of the upper respiratory tract the pruritus often escalates with inflammatory, erythematous and urticarial plaques. CONCLUSIONS The use of solutions containing aluminium salts for specific immunotherapy is contraindicated in the case of contact allergy to aluminium. Intramuscular injections of inactivated vaccines can be employed to avoid granuloma formation.