Mercè Corominas

Effect of corticosteroids on the clinical course of community-acquired pneumonia: a randomized controlled trial

IntroductionThe benefit of corticosteroids as adjunctive treatment in patients with severe community-acquired pneumonia (CAP) requiring hospital admission remains unclear. This study aimed to evaluate the impact of corticosteroid treatment on outcomes in patients with CAP.MethodsThis was a prospective, double-blind and randomized study. All patients received treatment with ceftriaxone plus levofloxacin and methyl-prednisolone (MPDN) administered randomly and blindly as an initial bolus, followed by a tapering regimen, or placebo.ResultsOf the 56 patients included in the study, 28 (50%) were treated with concomitant corticosteroids. Patients included in the MPDN group show a more favourable evolution of the pO2/FiO2 ratio and faster decrease of fever, as well as greater radiological improvement at seven days. The time to resolution of morbidity was also significantly shorter in this group. Six patients met the criteria for mechanical ventilation (MV): five in the placebo group (22.7%) and one in the MPDN group (4.3%). The duration of MV was 13 days (interquartile range 7 to 26 days) for the placebo group and three days for the only case in the MPDN group. The differences did not reach statistical significance. Interleukin (IL)-6 and C-reactive protein (CRP) showed a significantly quicker decrease after 24 h of treatment among patients treated with MPDN. No differences in mortality were found among groups.ConclusionsMPDN treatment, in combination with antibiotics, improves respiratory failure and accelerates the timing of clinical resolution of severe CAP needing hospital admission.Trial RegistrationInternational Standard Randomized Controlled Trials Register, ISRCTN22426306.

Rhinosinusitis and atopy in patients infected with HIV

Hypothesis: Rhinosinusitis is common during HIV infection; its prevalence is uncertain and could probably be related to clinical features, immunoallergological status, and diagnostic criteria. Methods: Seventy‐four patients hospitalized with HIV infection were prospectively evaluated for the presence of rhinosinusitis based on clinical findings, nasal endoscopy, or paranasal sinus computed tomography (CT). Immune status, nasal smear, features of atopy (based on the prick test), and its contribution to sinusal inflammatory pathology were also evaluated. Results: Most patients were severely immunosuppressed: CD4+ 155 ± 201 cells/mL and 12 ± 11% (mean ± SD). Thirty‐five percent of the patients presented at least two criteria of rhinosinusitis (clinical findings, nasal endoscopy, and CT: 35%; clinical findings and CT: 50%; nasal endoscopy and CT: 15%). CT scan showed multiple sinus involvement, opacification over 25% of the total volume of the maxillary sinus in 50% of patients, and opacification of the sphenoidal sinus in 40% of cases. Atopy was present in 18% of patients, a figure which reflects the expected prevalence in our geographic area. Two independent predictors were associated with a higher probability of rhinosinusitis: bilateral absence of maxillary infundibular patency (odds ratio, 7.5; 95% CI = 2.03–27.9) and low total count (odds ratio, 0.99; 95% CI = 0.99–1.00) or percentage of CD4+ (odds ratio, 0.93; 95% CI = 0.88–1.00). Conclusions: There is a high prevalence of rhinosinusitis in HIV‐infected individuals. This finding is related to a decreased cellular immunity, but it does not appear to be related to IgE‐related immediate hypersensitivity. Nasal endoscopy should be the first‐step diagnostic test. However, when clinical suspicion exists and endoscopy fails to explain symptoms, CT scan is a valuable adjunct to establish this diagnosis. Key Words: rhinosinusitis, HIV, atopy, endoscopy, computed tomography.

Predictors of atopy in HIV-infected patients

BACKGROUND Some studies have reported an increase of atopy in HIV-infected (HIV+) patients, but the cause still remains unclear. OBJECTIVE To determine the prevalence of atopy in HIV+ patients and to investigate its predictors. METHODS Seventy-four HIV+ hospitalized patients (46 of them with AIDS) were studied prospectively for the presence of atopy, based on immediate hypersensitivity to common allergens by prick test. Serum immunoglobulins, specific IgE, lymphocyte subsets, and the expression of low affinity IgE receptor (CD23) on B cells were determined. RESULTS Thirty-one percent of patients presented IgE values greater than 150 ku/L (39% of patients without AIDS and 26% of AIDS patients; P = .23) and 47% showed an increase (> or = 2%) in the percentage of CD23+ B cells. Non-AIDS patients had higher IgE values than AIDS patients (346 +/- 605 versus 175 +/- 276; P = .16). Atopy prevalence was higher in non-AIDS than in AIDS patients (28% versus 11%; P = .06). Specific IgE agreed with positive prick test in 58% of cases. Multivariate analysis showed that a personal history suggestive of allergic disease and IgE > 150 ku/L were predictors of atopy, while gender, risk group, CD4+ T cells, CD23 expression on B cells, and AIDS were not associated. CONCLUSIONS HIV+ patients present a higher prevalence of atopy in early stages of HIV infection than general population. Since allergic reactions could accelerate HIV-infection by increasing type 2 cytokines, it is important to evaluate the atopic state in HIV+ patients with IgE > 150 ku/L or with suggestive allergic history in order to prevent it.

Association of thromboxane A1 synthase (TBXAS1) gene polymorphism with acute urticaria induced by nonsteroidal anti-inflammatory drugs.

8. Martin L, Raison-Peyron N, N€othen MM, Cichon S, Drouet C. Hereditary angioedema with normal C1 inhibitor gene in a family with affected women and men is associated with the p.Thr328Lys mutation in the F12 gene. J Allergy Clin Immunol 2007;120:975-7. 9. Kluft C. Determination of prekallikrein in human plasma: optimal conditions for activating prekallikrein. J Lab Clin Med 1978;91:83-95. 10. Drouet C, D esormeaux A, Robillard J, Ponard D, Bouillet L, Martin L, et al. Metallopeptidase activities in hereditary angioedema: effect of androgen prophylaxis on plasma aminopeptidase P. J Allergy Clin Immunol 2008;121:429-33. 11. Duan QL, Binkley K, Rouleau GA. Genetic analysis of factor XII and bradykinin catabolic enzymes in a family with estrogen-dependent inherited angioedema. J Allergy Clin Immunol 2009;123:906-10.

IgE-Mediated Allergic Reactions after the First Administration of Glatiramer Acetate in Patients with Multiple Sclerosis

Background: Immediate adverse reactions to glatiramer acetate (GA), a drug used in the treatment of patients with multiple sclerosis (MS), have been poorly investigated. We studied 3 MS patients who presented adverse reactions following GA administration. Two of them experienced severe anaphylactic reactions after the first administration and the other an eyelid edema upon reintroduction 6 months after GA withdrawal. Methods: Skin prick tests (SPT) to GA and mannitol were performed on all 3 patients and in 10 atopic controls. Specific IgE (sIgE) levels to GA, myelin basic protein (MBP) and MBP fragments were assessed in all 3 patients, 6 MS patients treated with GA for more than 6 month and 10 healthy donors. Specific IgG (sIgG) to GA was also quantified in the three study groups. Both sIgE and sIgG were determined by means of the UniCAP 100 assay. Results: SPT and sIgE to GA were positive only in the 3 patients with adverse reactions while sIgE to mannitol was negative in all. sIgE tests against MBP and its fragments were negative in all individuals. Similar levels of sIgG to GA were found in all studied subjects. Conclusion: These results demonstrate the significance of sIgE in allergic reactions to GA presented by these patients and suggest the importance of strict surveillance during administration of the first GA doses.

Hypersensitivity to Cidex OPA: a misdiagnosed condition.

Cidex OPA (ortho-phthalaldehyde solution [0.55%]) is used to disinfect heat-sensitive medical equipment. In the technical leaflet, it is recommended that the product not be used in patients requiring repeated cystocopy, because its use has been associated with hypersensitivity reactions. Nonetheless, Cidex OPA continues to be used for the disinfection of endoscopic equipment in many centers. Here, we describe 4 cases of patients undergoing surveillance fibrolaryngoscopy (FLG) after surgery for neoplasias who experienced hypersensitivity reactions. In all cases, Cidex OPA had been used to disinfect the fibrolaryngoscopes.

Anaphylaxis caused by flaxseed

Methods and results Prick-prick carried out with flaxseed showed a strong positivity. Skin prick test to inhaled allergens were positive to mites, dog and cat danders, plain tree and grasses. Skin prick test to food allergens were positive to almond, hazelnut, peanut, chestnut, walnut, mustard, lentils, soybeans, rice, oat, corn and lupine. Total IgE was: 291 UI/ml. Specific IgE (CAP, ThermoFisher Scientific) to flaxseed was 2.68 kU peach 7.65 kU/L, peanut 2.01 kU / L , lettuce 0.92 kU / L , lupin 3.76 kU / L. Corn IgE 2.71 kU / L , Pru p3 7.62 kU / L , Cor a8 0.68 kU / L. ISAC, ImmunoCAP was positive to Fel d1, Phl p1, Der f1, Der f2, Der p1, Der p2, Pla a3, Ara h9, Cor a8, Jug r3, Pru p3 and Art v3. ISAC performed after inhibit patients’s serum (ISAC inhibition) with a complete flaxseed extract (f233:Linum usitatissium from ImmunoCAP, ThermoFisher Scientific) did not reduced the positivity to non-specific lipid transfer proteins (nsLTP). ISAC inhibition with a complete mite extract (d1: D. pteronyssinus from ImmunoCAP, ThermoFisher Scientific) reduces exclusively the signal of mites (Der f1, Der f2, Der p1, Der p2) in >83%.An immunoblot performed with flaxseed extracts (soluble and liposoluble), showed the presence of an IgE-binding band of about 18 kDa in the liposoluble fraction and a 20 kDa band in the soluble one.

Severe adverse drug reactions induced by hydrochlorothiazide: A persistent old problem.

were performed: (1) basophil activation test6 revealed 0% activated basophils in basal conditions, 89.5% in response to anti-IgE and 86.5% in response to PPC extract; (2) the level of serum specific IgE antibodies to PPC (enzyme allergosorbent test [EAST]; Hytec Specific IgE EIA kit, Hycor Biomedical Ltd, Garden Grove, California) was less than 0.35 kU/L but greater than the value obtained with a pool of sera from nonatopic individuals (negative control); and (3) sodium dodecyl sulfateepolyacrylamide gel electrophoresis immunoblotting assay with and without 2-mercaptoethanol revealed 2 IgE-binding bands of approximately 35and 55-kDa molecular weight in both electrophoretic conditions (Fig 1 and eAppendix). PPC (Thaumetopoea pityocampa) is a Lepidoptera of the Thaumetopoediae family, commonly found in Europe forests, particularly in Mediterranean areas. PPC has urticating hairs that frequently induce local reactions, such as contact dermatitis, urticaria, or keratitis and, more rarely, systemic symptoms, including anaphylaxis, mostly in the context of occupational exposures.7e10 Although an irritant mechanism can be involved in local reactions, IgE-mediated hypersensitivity has been demonstrated, particularly in patients with anaphylaxis, by SPT, enzyme allergosorbent test, and sodiumdodecyl sulfateepolyacrylamide gel electrophoresis immunoblotting.7 Several allergens with different molecular weights have been reported so far,7e9 among which a 15-kDa protein called thaumetopoein (Thau p 1) has been suggested to be one of the most clinically relevant allergens.7,8 Although both IgE-binding bands of approximately 35 and 55 kDa detected with the serum of our patient have been already described,9 these have not been previously reported to be detected within the same patient serum. Noteworthy, our results indicate that basophil activation test might be also a complementary method that supports the hypersensitivity to PPC in this patient. Similarly to other patients with ISMs (eg, ISMs associated with Hymenoptera venom anaphylaxis), the implication of PPC as the culprit trigger of anaphylaxis in our patient is supported by the demonstration of specific IgE to PPC together with the temporal association between the exposure to PPC and the development of symptoms and also by the absence of further anaphylactic episode while the patient has been using adequate protection to avoid new contacts to PPC. To the best of our knowledge, this is the first report on the coexistence of systemic mastocytosis and anaphylaxis attributable to PPC. Moreover, this case highlights the utility of the REMA score as a predicting tool for ISMs ,3,4 even if the culprit elicitor of anaphylaxis has not been previously recognized in patients with mastocytosis.