Johanna Stoevesandt

Control of large institutional scabies outbreaks

Background: Scabies outbreaks in community facilities may reach large dimensions and take a protracted course. Highly contagious crusted scabies is a major cause of nosocomial outbreaks.

Aminopenicillin‐associated exanthem: lymphocyte transformation testing revisited

The lymphocyte transformation test (LTT) has been promoted as in‐vitro test for diagnosis of drug hypersensitivity. For determination of statistical LTT sensitivity, series of patients with clinically uniform reactions followed by complete drug hypersensitivity work‐up are mandatory. Assessment of LTT specificity requires control patients who tolerated exposure to the drug studied.

Risk stratification of systemic allergic reactions during Hymenoptera venom immunotherapy buildup phase

Comparability of previous studies assessing the incidence of systemic reactions during Hymenoptera venom immunotherapy (VIT) is impaired by methodical differences concerning the definition and classification of VIT‐induced anaphylaxis. Our study aims to systematically evaluate the time course and clinical symptoms of VIT‐related systemic reactions.

Typically atypical: histiocytoid Sweet syndrome, associated with malignancy

Sweet syndrome (acute febrile neutrophilic dermatosis) is characterized by a dramatic onset of high fever, neutrophilia and typical skin lesions. About 20 % of patients have an associated malignancy, most commonly hematologic diseases. Chronic and paucisymptomatic manifestations of Sweet syndrome may be misdiagnosed or misinterpreted as harmless, resulting in delayed diagnosis. “Atypical” manifestations are especially suspicious for associated malignancies. This is demonstrated by a 39‐year old patient with chronic and afebrile disease who was referred to our clinic only after symptoms had persisted for several months. By that point, an underlying nodular lymphocyte predominant Hodgkins lymphoma had already reached an advanced stage. Skin biopsies revealed dermal infiltrates of histiocytoid cells of myelogenous origin, supporting a diagnosis of histiocytoid Sweet syndrome. Specific cutaneous infiltrates associated with myelogenous leukemia were ruled out.

H1-Antihistamine Premedication in NSAID-Associated Urticaria

BACKGROUND Therapeutic options for pain management are restricted in patients with nonsteroidal anti-inflammatory drug (NSAID)-induced or NSAID-exacerbated urticaria because strong cyclooxygenase (COX)-I inhibiting NSAID cannot be used. Alternative NSAID such as weak COX-I inhibitors or selective COX-II inhibitors are sometimes not sufficiently effective or have potentially troublesome adverse effects. OBJECTIVE To date, prophylactic premedication with H1-antihistamines is rarely practiced in patients concurrently suffering from recurrent pain and NSAID-associated urticaria. Our data analysis aims to clarify whether prophylactic premedication before the intake of NSAID is effective, safe, and practicable. METHODS Data of 21 patients with NSAID-induced or NSAID-exacerbated urticaria who underwent single dose NSAID provocation 30 minutes after premedication with 5 mg desloratadine were retrospectively evaluated. RESULTS After H1-antihistamine premedication, 17 patients tolerated 16 single dose provocation tests with strong COX-I inhibitors and 2 tests with weak COX-I inhibitors. Despite H1-antihistamine premedication, 2 patients developed acute urticaria after intake of 400 mg ibuprofen. Another 2 patients with acute urticaria after intake of 800 mg ibuprofen tolerated 400 mg ibuprofen and 1000 mg paracetamol, respectively. CONCLUSIONS AND CLINICAL RELEVANCE In the majority of patients with NSAID-induced or NSAID-exacerbated urticaria concurrently suffering from intermittent pain, a premedication regimen with 5 mg desloratadine 30 minutes before intake of a strong COX-I inhibitor seems to be effective, safe, and practicable.

General anaesthesia‐induced anaphylaxis: impact of allergy testing on subsequent anaesthesia

Immunoglobulin E‐mediated allergy to drugs and substances used during general anaesthesia as well as non‐allergic drug hypersensitivity reactions may account for anaesthesia‐induced anaphylaxis. As IgE‐mediated anaphylaxis is a potentially life‐threatening reaction, identification of the culprit allergen is essential to avoid anaphylaxis recurrence during subsequent general anaesthesia.

S1 guidelines on the diagnosis and treatment of scabies – short version

The goals of this German guideline are the improvement of diagnosis and therapy of scabies, the implementation of a coordinated action in outbreaks of scabies, and the control of this infestation in large migration or refugee flows.Sarcoptes scabiei var. hominis is transmitted by direct skin‐to‐skin contact of sufficient duration. The infectivity of female mites when removed from patients does not exceed 48 hours at room temperature (21°C) and relative humidity of 40‐80%. The risk of infection rises proportionally to the number of mites on the skin and is particularly high in crusted scabies. As elderly persons tend to develop crusted scabies due to disease‐ or medication‐related immunosuppression, there is an increased risk for outbreaks of scabies at nursing homes and extended‐care facilities. The guideline contains detailed recommendations for management of such outbreaks. In refugees the prevalence of scabies is higher than in the general population in Germany, but the risk for outbreaks is not high. Scabies infestation should be considered when a recent onset of itching is associated with eczema and presence of burrows or comma‐like papules at predilection sites. It is confirmed by dermatoscopic detection of mites or by microscopic identification of mites, mite eggs or fecal matter (scybala) from skin scrapings.The treatment of choice for common scabies is topical permethrin 5% cream applied for 8‐12 hours. Permethrin can be considered for off‐label use also in infants of less than 3 months of age and pregnant women. For this group crotamiton is another option, which, besides benzyl benzoate, presents a good second line therapy for the other indications. Indications for oral ivermectin, which has just been licensed in Germany, include patients with immunosuppression, severe dermatitis, and low adherence.Crusted scabies is preferentially treated by a combination of topical permethrin and oral ivermectin. Affected patients should be isolated, and all contact persons should be treated. The guideline contains lists for additional measures, including possible treatment of contact persons, clothes, linen and other possibly infested articles.

Single venom-based immunotherapy effectively protects patients with double positive tests to honey bee and Vespula venom

BackgroundReferring to individuals with reactivity to honey bee and Vespula venom in diagnostic tests, the umbrella terms “double sensitization” or “double positivity” cover patients with true clinical double allergy and those allergic to a single venom with asymptomatic sensitization to the other. There is no international consensus on whether immunotherapy regimens should generally include both venoms in double sensitized patients.ObjectiveWe investigated the long-term outcome of single venom-based immunotherapy with regard to potential risk factors for treatment failure and specifically compared the risk of relapse in mono sensitized and double sensitized patients.MethodsRe-sting data were obtained from 635 patients who had completed at least 3 years of immunotherapy between 1988 and 2008. The adequate venom for immunotherapy was selected using an algorithm based on clinical details and the results of diagnostic tests.ResultsOf 635 patients, 351 (55.3%) were double sensitized to both venoms. The overall re-exposure rate to Hymenoptera stings during and after immunotherapy was 62.4%; the relapse rate was 7.1% (6.0% in mono sensitized, 7.8% in double sensitized patients). Recurring anaphylaxis was statistically less severe than the index sting reaction (P = 0.004). Double sensitization was not significantly related to relapsing anaphylaxis (P = 0.56), but there was a tendency towards an increased risk of relapse in a subgroup of patients with equal reactivity to both venoms in diagnostic tests (P = 0.15).ConclusionsSingle venom-based immunotherapy over 3 to 5 years effectively and long-lastingly protects the vast majority of both mono sensitized and double sensitized Hymenoptera venom allergic patients. Double venom immunotherapy is indicated in clinically double allergic patients reporting systemic reactions to stings of both Hymenoptera and in those with equal reactivity to both venoms in diagnostic tests who have not reliably identified the culprit stinging insect.

Extensive molluscum contagiosum virus infection in a young adult receiving fingolimod

Fingolimod-related viral infections have been described on several occasions since its introduction in 2010. We hereby add a report on an otherwise immunocompetent, 18-year old Caucasian man with relapsing-remitting multiple sclerosis who developed a protracted and extensive molluscum contagiosum (MC) virus infection shortly after being started on fingolimod. Wide-spread cutaneous MC infections in adult patients are considered indicative of underlying immunosuppression. Neurologists prescribing fingolimod ought to be aware of a possibly increased risk of MC, but also need to know about its relative benignity, lack of extra-cutaneous complications, and adequate treatment options.

S1-Leitlinie zur Diagnostik und Therapie der Skabies - Kurzfassung.

(1) Abteilung für Translationale Dermatoinfektiologie und Klinik für Hautkrankheiten, Münster (2) Institut für Mikrobiologie und Hygiene, Charité – Universitätsmedizin Berlin (3) Universitätshautklinik Kiel, Universitätsklinikum Schleswig-Holstein, Kiel (4) Landesgesundheitsamt Baden-Württemberg im Regierungspräsidium Stuttgart (5) Fachbereich Soziales und Gesundheit, Ennepe-Ruhr-Kreis (6) Division of Evidence based Medicine (dEBM), Klinik für Dermatologie, Venerologie und Allergologie, Charité – Universitätsmedizin Berlin (7) Klinik für Dermatologie, Venerologie und Allergologie, Charité – Universitätsmedizin Berlin (8) Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn (9) Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg