Helmut Gall

Adverse reactions to local anesthetics: Analysis of 197 cases

BACKGROUND Adverse drug reactions to local anesthetics are frequently reported. However, little is known about the underlying mechanisms. Therefore we investigated 177 patients with a history of 197 events after application of these drugs. METHODS The diagnostic approach included prick and intracutaneous tests, provocative challenge tests with causative and unrelated local anesthetics, and in selected cases, radioimmunoassays to detect specific IgE. In addition, tests were performed with preservatives, including sodium metabisulfite and parahydroxybenzoic acid ester. RESULTS Results of prick and intracutaneous tests with local anesthetics were all negative. Only three patients reacted after subcutaneous challenge with the causative drug (local anesthetics of the amide type). Although one patient showed a delayed-type response to mepivacaine, two patients had immediate-type reactions to articaine and lidocaine. However, in both cases no specific IgE could be detected. In five patients with positive skin test reactions to preservatives, challenge test results remained negative. CONCLUSION Two immediate-type reactions were not IgE-mediated. In only one of 197 reported adverse reactions were we able to prove delayed-type allergic response. Therefore true allergic reactions caused by local anesthetics are extremely rare.

Kiwi fruit allergy: A new birch pollen-associated food allergy

BACKGROUND To determine the cross-reacting antigens of kiwi fruit and other foods and pollen, we investigated 22 patients allergic to kiwi fruit: 10 with severe systemic reactions and 12 with localized symptoms confined to oral and pharyngeal mucosa (oral allergy syndrome). Seven patients with birch pollen allergy who tolerated kiwi fruit were included as a control group. METHODS All patients were evaluated by skin testing and RAST; three patients were evaluated by RAST inhibition assays. RESULTS Prick tests showed positive reactions to kiwi fruit in all patients, whereas specific IgE to kiwi fruit could be demonstrated only in patients with generalized severe symptoms. Surprisingly, all 22 patients with clinical kiwi allergy showed positive prick test results and elevated IgE to birch pollen. Clinically, all complained of rhinitis during birch pollen season. Many patients showed sensitization to grass and mugwort pollen. Also, food allergy was found to be associated with kiwi allergy: we found strong reactions to apple and hazelnut; moderate reactions to carrot, potato, and avocado; and weak reactions to wheat and rye flour, pineapple and papaya, and their enzymes bromelain and papain. RAST inhibition studies revealed cross-reacting antigens between birch pollen and kiwi fruit. Interestingly, patients with birch pollen allergy without clinical signs of kiwi allergy had positive prick test reactions to kiwi. Patients with kiwi allergy showed higher concentrations to birch pollen IgE compared with patients with isolated birch pollen allergy. CONCLUSIONS Our results indicate that kiwi allergy is a new manifestation of birch pollen-associated food allergy and is mediated by cross-reacting antigens in the kiwi fruit. Kiwi allergy can be expected in patients with birch pollen allergy exhibiting high levels of IgE to birch pollen.

Arterial anatomy and arteriographic diagnosis of arteriogenic impotence

One hundred twenty-six bilateral selective arteriographic examinations of the iliopudendal vascular tree were performed after comprehensive multidisciplinary evaluation in patients with chronic erectile dysfunction. Best imaging results were obtained by performing the arteriography under epidural anesthesia after intracavernous injection of a vasoactive drug combination. The arteriography is mandatory prior to revascularization procedures. It is further indicated in primary erectile dysfunction and posttraumatic erectile failure. The importance of cavernosography and selective arteriography in primary erectile dysfunction is stressed. Increasing knowledge about the influence of vasoactive drugs on penile hemodynamics has led to its application in diagnosis and therapy of erectile dysfunction. Pharmacocovernosography, Doppler-ultrasound of penile arteries after intracavernous injection of a vasoactive drug combination, and pharmacoarteriography are refined techniques to prove a vascular etiology of erectile dysfunction. The results of the morphologic studies of the vascular system are correlated with functional testing of erectile capacity by intracavernous application of a papaverinephentolamine drug combination.

Functional Evaluation of Penile Hemodynamics

A multidisciplinary study was performed on 200 consecutive patients with erectile dysfunction more than 1 year in duration, which included a standardized intracavernous injection of a vasoactive substance mixture (15 mg. per ml. papaverine plus 0.5 mg. per ml. phentolamine). The multidisciplinary findings correlated well with the intracavernous dose needed for full erection. The group without pathological hemodynamic findings (36 patients) needed an average of 0.67 ml. and the group with pathological inflow (107) needed an average of 1.07 ml. In the venous insufficiency group (57 patients) only 18 achieved full erections with an average of 2.1 ml. (39 achieved tumescence only to 3 ml.). The results show that standardized intracavernous injection of a vasoactive substance mixture is a useful method to evaluate penile hemodynamics. This pharmacological test appears to be effective in the differential diagnosis of nonvascular and vascular erectile dysfunction.

Tolerance to intravenous administration of heparin and heparinoid in a patient with delayed-type hypersensitivity to heparins and heparinoids

Delayed‐type hypersensitivity reactions ot subcutaneously (s.c) injected heparins are common. Since similar reactions usually occur to different heparin preparations, semisynthetic heparinoids might be a therapeutic alternative. We report a patient exhibiting eczematous reactions to heparins as well as heparinoids; delayed‐type hypersensitivity was demonstrated by intracutaneous (i.c.) and patch tests, as well as by s.c. provocation. Remarkably, intravenous (i.v.) administration of heparin as well as heparinoid was well‐tolerated.

Type IV allergy to amide-type local anesthetics

The case of a 45‐year‐old woman is reported, who developed intense erythema and itching 1 day after subcutaneous (S.C) injection of a local anesthetic containing mepivacaine and methylparben. The reaction was attributed to a delayed‐type sensitivity to mepivacaine, since mepivacaine gave a positive patch test response and also elicited a delayed sensitivity reaction after s,c, challenges, whereas prick and patch tests with methylparahen, as well us oral challenges, were negative; Interestingly, the patient also showed sensitization to lidocaine, a compound to which she had previously also been exposed.

Late-type allergy to the X-ray contrast medium Solutrast (iopamidol).

In the past few years, there have been an increasing number of publications on delayed intolerance reactions, including rashes, following the use of X‐ray contrast media. We report a patient in whom infiltrated erythema of the face and generalized maculopapular rashes occurred on 2 occasions, within 1 day, following the use of the X‐ray contrast medium Solutrast® (iopamidol) for coronary angiography. The allergological investigations for clarification included prick tests and patch tests using a series of contrast media, as well as individual intravenous provocation tests. We found the cause to be a late‐type allergy to the active substance iopamidol contained in the contrast medium Solutrast®. We found a concomitant cross‐reactivity to the contrast media iopromid and iomeprol. All 3 contrast media represent the monomeric, non‐ionic type.

Identification of HLA-DR and -DQ alleles conferring susceptibility to pollen allergy and pollen associated food allergy.

Allergenic crossreactivity of pollen and foods due to the antigeneic similarity of oligopeptides is a well established clinical phenomenon.

Clinical and pathophysiological aspects of hydroxyethyl starch-induced pruritus: evaluation of 96 cases.

BACKGROUND It has been recently recognized that long-term infusions of hydroxyethyl starch (HES) as a substitute of human plasma may lead to deposits within the human skin and clinically induces severe pruritus in approximately one-third of the patients treated. OBJECTIVE To analyze the clinical features and pathophysiology of HES-induced itching. METHODS Clinical data of 86 patients were analyzed retrospectively. Furthermore, 10 patients were followed prospectively, in whom we also performed routine laboratory tests, skin biopsies, allergological investigations (skin prick, basophil degranulation test), and substance P measurements in stimulated macrophages. RESULTS Special features of HES-induced pruritus included long latency of onset and persistence. Noteworthy, itching is not always generalized. 30% of patients present with localized pruritus. Symptoms were not relieved by antihistaminics. Accordingly, the basophil degranulation test after HES exposure was negative. Also, substance P release from macrophages was not increased following HES stimulation. Deposits were found mainly in macrophages and endothelial cells. CONCLUSIONS Our findings indicate that pruritus in HES-infused patients is most likely not triggered by pruritogenic mediators. We support data from the recent literature, suggesting a direct stimulation of cutaneous nerves by HES deposits. In patients suffering from long-standing itching it seems important to consider previous HES exposure as a possible cause not only in generalized pruritus but also in localized symptoms.

Ethanol metabolite acetic acid as causative agent for type‐I hypersensitivity‐like reactions to alcohohc beverages

Background Adverse reactions to alcoholic beverages are common and more frequently mediated by immunological mechanisms than previously thought.