Marisa Rosimeire Ribeiro

Nonsteroidal Anti-Inflammatory Drugs are Major Causes of Drug-Induced Anaphylaxis

BACKGROUND Drugs are responsible for 40% to 60% of anaphylactic reactions treated in the emergency department. A global research agenda to address uncertainties in anaphylaxis includes studies that identify factors associated with morbidity and mortality. OBJECTIVE The present study investigated drug-induced anaphylaxis, etiologies, aggravating factors, and treatment. METHODS A total of 806 patients with adverse drug reactions were screened, and those who had a clinical diagnosis of anaphylaxis were included in the study. Clinical and demographic characteristics of anaphylaxis were described, including etiologies, pathophysiologic mechanisms involved in the reactions, and a personal history of atopy and asthma. Factors associated with disease severity also were identified. RESULTS Anaphylaxis was diagnosed in 117 patients (14.5%). The etiologies were defined in 76% of the cases, nonsteroidal anti-inflammatory drugs being the most frequent. Seventy-eight patients (66.7%) reported a previous reaction to the drug involved in the current reaction or to a drug from the same class and/or group. Epinephrine was used to treat 34.2% of patients who presented with anaphylaxis, and 40.8% of those with anaphylactic reactions with cardiovascular involvement. IgE-mediated reactions were associated with greater severity, manifested by the rates of cardiovascular dysfunction, hospitalization, and use of epinephrine. CONCLUSIONS The prevalence of anaphylaxis is high in patients who seek medical assistance for drug reactions, but its diagnosis is missed in emergency services, and adrenaline is underused. Drugs were prescribed to many patients despite a history of previous reaction. Nonsteroidal anti-inflammatory drugs were implicated in most cases of anaphylaxis induced by drugs, and IgE-mediated reactions were less frequent but more severe.

Esophageal Candidiasis—An Adverse Effect of Inhaled Corticosteroids Therapy

Over the last few decades, inhaled corticosteroids (ICs) became the cornerstone in the treatment of persistent asthma. Their use improved asthma control, decreased mortality and also minimized adverse reactions associated with systemic steroid. Esophageal candidiasis is a rare complication resulting from the use of ICs. Although, in recent years, as their prescriptions has increased, more cases have been reported, especially in Japan. Listed are 4 case reports regarding esophageal candidiasis in asthmatic patients associated with inhaled budesonide administration. In the cases reported herein, the use of a different device of dry powder budesonide might have favored esophageal drug deposition and Candida infection. Patients denied using systemic corticosteroids in the previous 6 months. Furthermore, none of the patients presented Diabetes mellitus, malignant disease, HIV infection, or other immunosuppressive conditions. We conclude that patients treated with high doses of ICs are at higher risk of developing esophageal candidiasis. These patients should undergo upper gastrointestinal endoscopy whenever they present symptoms. Nevertheless, we must keep in mind that infection might also be asymptomatic and esophageal candidiasis prevalence may be higher than that reported thus far.

Spirometric values in elderly asthmatic patients are not influenced by obesity

Studies have suggested that asthma in obese individuals differs from the classic asthma phenotype, presenting as a disease that is more difficult to control.

Increase of 10% in the Rate of Adverse Drug Reactions for Each Drug Administered in Hospitalized Patients

OBJECTIVE: To assess the risk factors, incidence and severity of adverse drug reactions in in-patients. METHODS: This prospective study evaluated 472 patients treated at a teaching hospital in Brazil between 2010 and 2013 by five medical specialties: Internal Medicine, General Surgery, Geriatrics, Neurology, and Clinical Immunology and Allergy. The following variables were assessed: patient age, gender, comorbidities, family history of hypersensitivity, personal and family history of atopy, number of prescribed drugs before and during hospitalization, hospital diagnoses, days of hospitalization. The patients were visited every other day, and medical records were reviewed by the investigators to detect adverse drug reactions. RESULTS: There were a total of 94 adverse drug reactions in 75 patients. Most reactions were predictable and of moderate severity. The incidence of adverse drug reactions was 16.2%, and the incidence varied, according to the medical specialty; it was higher in Internal Medicine (30%). Antibiotics were the most commonly involved medication. Chronic renal failure, longer hospital stay, greater number of diagnoses and greater number of medications upon admission were risk factors. For each medication introduced during hospitalization, there was a 10% increase in the rate of adverse drug reaction. In the present study, the probability of observing an adverse drug reaction was 1 in 104 patients per day. CONCLUSIONS: Adverse drug reactions are frequent and potentially serious and should be better monitored in patients with chronic renal failure or prolonged hospitalization and especially in those on ‘polypharmacy’ regimens. The rational use of medications plays an important role in preventing adverse drug reactions.

Specific questionnaire detects a high incidence of intra-operative hypersensitivity reactions

OBJECTIVE: To assess the incidence of intra-operative immediate hypersensitivity reactions and anaphylaxis. METHODS: A cross-sectional observational study was conducted at the Department of Anesthesiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, Brazil, from January to December 2010. We developed a specific questionnaire to be completed by anesthesiologists. This tool included questions about hypersensitivity reactions during anesthesia and provided treatments. We included patients with clinical signs compatible with immediate hypersensitivity reactions. Hhypersensitivity reactions were categorized according to severity (grades I-V). American Society of Anesthesiologists physical status classification (ASA 1-6) was analyzed and associated with the severity of hypersensitivity reactions. RESULTS: In 2010, 21,464 surgeries were performed under general anesthesia. Anesthesiologists answered questionnaires on 5,414 procedures (25.2%). Sixty cases of intra-operative hypersensitivity reactions were reported. The majority patients (45, 75%) had hypersensitivity reactions grade I reactions (incidence of 27.9:10,000). Fifteen patients (25%) had grade II, III or IV reactions (intra-operative anaphylaxis) (incidence of 7:10,000). No patients had grade V reactions. Thirty patients (50%) were classified as ASA 1. The frequency of cardiovascular shock was higher in patients classified as ASA 3 than in patients classified as ASA 1 or ASA 2. Epinephrine was administered in 20% of patients with grade III hypersensitivity reactions and in 50% of patients with grade II hypersensitivity reactions. CONCLUSIONS: The majority of patients had hypersensitivity reactions grade I reactions; however, the incidence of intra-operative anaphylaxis was higher than that previously reported in the literature. Patients with ASA 3 had more severe anaphylaxis; however, the use of epinephrine was not prescribed in all of these cases. Allergists and anesthesiologists should implement preventive measures to reduce the occurrence of anaphylaxis.

NSAIDs-Induced Anaphylaxis

Opinion StatementDrugs are between the main triggers of anaphylaxis. They have been described as major cause of fatal anaphylaxis. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed drugs around the world because of their analgesic, anti-inflammatory, antipyretic, and antithrombotic effects. This class of drug is the first or the second after antibiotics as the cause of drug hypersensitivity reactions, including anaphylaxis. However, frequency of NSAIDs as the drug implicated in anaphylactic reactions is too variable among different countries. We believe there are discrepancies between genetics, frequency of exposure and mainly between classification of hypersensitivity reactions to NSAIDs and definition of anaphylaxis. Actual classification of NSAIDs hypersensitivity considers as anaphylaxis only those severe reactions presented by selective responders, probably IgE-mediated. Blended reactions, when respiratory plus mucocutaneous symptoms are presented after intaking NSAIDs from different groups (cross-intolerant), are not included in this classification. It can lead to underdiagnosis of non-immunological anaphylaxis. International groups of researchers must try to better define phenotypes of hypersensitivity reactions to NSAIDs, in order to include those blended reactions and better manage these cases.

Occupational contact dermatitis due to captopril

Results We assessed a 36 years old female with a history of palpebral and lips oedema, flaking and pruritus, for two months, especially during her work. She worked in pharmaceutical industry and was referred to our outpatient because she had noticed worsening after contact with residues contained in captopril packaging during its manipulation. She had improved when had no contact with the packages. She was treated with topical corticosteroids and oral antihistamines. We performed contact delayed reading test (patch test) with captopril in the concentration of 10%, resulting papules, vesicles and swelling at the application site. In addition, there was a negative reaction standard test series. We told her to avoid new exposures to this drug and others with cross reaction.

Erythema multiforme induced by clindamycin diagnosed by patch test

Results A 17 years of age male was admitted in a University Hospital In Sao Paulo, Brazil, because he had been a victim of a car accident in May 2012. He suffered a tibia open fracture and was submitted to a surgical treatment. Three days after the procedure he developed face rash, cutaneous itching, target lesions in oropharynx and lower limbs peeling. He was being treated with Clindamycin, Ciprofloxacin, Dipyrone, Ketoprofen and Tramadol. The patient evolved with fever and leucocytosis, without eosinophilia. This reaction was diagnosed as EM major by Dermatology Unit and he was successfully treated with antihistamines and corticosteroids, besides suspected drugs substitution. After been discharged the patient was referred to the Allergy Unit to perform a drug hypersensitivity investigation. He was submitted to patch test with all the suspected drugs diluted in petrolatum 10%. Only the clindamycin patch test was positive, which was confirmed with a second patch test. The patient also presented reactivation of previous lesions. Conclusions As far as we know, this is the first patient who had developed erythema multiforme due to clindamycin. The patch test was essential to confirm the diagnosis and the use of all other drugs which were present at the time of the reaction could be released.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE): two atypical case reports

Background The symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a delayed-type hypersensitivity drug reaction (HDR) that causes symmetrical erythematous lesions in flexural areas, including buttocks and groin, which arise following exposure to drugs, especially beta-lactams. The involvement of palms and soles is rare and, until now, it has only been described after exposure of amoxicillin. We hereby report a patient with SDRIFE and involvement of the palms and soles after taking cephalexin and another patient who developed SDRIFE after exposure to doxycyclin.

Persistence of positive skin test 25 years after a penicillin-induced anaphylaxis

Background Skin tests are important in the investigation of hypersensitivity drug reactions (HDR), particularly when betalactams are involved. However, the sensitivity decreases with time. It has been described that skin tests become negative about five years after a betalactam hypersensitivity reaction. We report a patient with persistence of a positive skin test twenty five years after an anaphylactic reaction due to penicillin.