Ömür Aydın

Hypersensitivity Reactions to Contrast Media: Prevalence, Risk Factors and the Role of Skin Tests in Diagnosis – A Cross-Sectional Survey

Background: Hypersensitivity to contrast media (CMs) may be common and serious. Aim: To evaluate the prevalence of CM hypersensitivity, risk factors associated with it and the role of skin testing in its diagnosis. Methods: A structured questionnaire was administered to patients who underwent computed tomography during a 1-year period. Skin tests with CMs, including skin prick tests (SPTs), intradermal tests (IDTs) and patch tests (PTs), were conducted on CM reactors (n = 24). Volunteers who tolerated CM exposure or had never been exposed to any CMs served as controls (n = 37). Results: A total of 1,131 patients (630 females and 501 males; mean age 55 ± 14.2 years) were enrolled in the study. The prevalence of historical and current CM reactors was 33/1,131 (2.92%) and 8/1,105 (0.72%), respectively. The skin was the most affected site, with mild to moderate reactions. Female gender, a history of doctor-diagnosed asthma, drug allergy, food allergy and psychiatric diseases were significant risk factors. The sensitivities of SPTs and early readings of IDTs in the diagnosis of immediate reactions were 0 and 20%, respectively, and the specificities were 94.6 and 91.4%, respectively. For early readings of IDTs, the positive predictive value (PPV) and negative predictive value (NPV) were 40 and 80%, respectively. For nonimmediate reactions, the sensitivities of delayed readings of IDTs and PTs were 14.3 and 25%, respectively; specificity was 100% for both tests. The PPV was 100% for both of these tests, and the NPVs were 85.4 and 82.4%, respectively. Conclusions: Our findings are comparable with the incidence, profile and risk factors associated with CM hypersensitivity reported previously. Skin testing with CMs has a high specificity, but its role in diagnosis is limited due to low sensitivity.

Immediate-type hypersensitivity reactions to proton pump inhibitors: usefulness of skin tests in the diagnosis and assessment of cross-reactivity.

Data are limited about the value of skin tests in the diagnosis of proton pump inhibitor (PPI)‐induced hypersensitivity reactions and the cross‐reactivity between PPIs. We aimed to assess the role of skin testing in the diagnosis of PPI‐related immediate hypersensitivity reactions and the cross‐reactivity patterns among PPIs.

Prevalence of aspirin-exacerbated respiratory disease in patients with asthma in Turkey: A cross-sectional survey

BACKGROUND There are no country-based data focused on aspirin (ASA)-exacerbated respiratory disease (AERD) in Turkey. OBJECTIVE To assess the prevalence of AERD in adult patients with asthma. METHODS A structured questionnaire was administered via face-to-face interview by a specialist in pulmonology/allergy at seven centres across Turkey. RESULTS A total of 1344 asthma patients (F/M: 1081/263: 80.5%/19.5%, mean age: 45.7 ± 14.2 years) were enrolled. Atopy rate was 47%. Prevalence of allergic rhinitis, chronic rhinosinusitis/rhinitis, and nasal polyposis (NP) were 49%, 69% and 20%, respectively. Of 270 patients with NP, 171 (63.3%) reported previous nasal polypectomy and 40 (25%) had a history of more than three nasal polypectomies. Aspirin hypersensitivity was diagnosed in 180 (13.6%) asthmatic patients, with a reliable history in 145 (80.5%), and oral ASA provocation test in 35 (19.5%) patients. Clinical presentations of ASA hypersensitivity were respiratory in 76% (n=137), respiratory/cutaneous in 15% (n=27), and systemic in 9% (n=16) of the patients. Multivariate analysis indicated that a family history of ASA hypersensitivity (p: 0.001, OR: 3.746, 95% CI: 1.769-7.929), history of chronic rhinosinusitis/rhinitis (p: 0.025, OR: 1.713, 95% CI: 1.069-2.746) and presence of NP (p<0.001, OR: 7.036, 95% CI: 4.831-10.247) were independent predictors for AERD. CONCLUSION This cross-sectional survey showed that AERD is highly prevalent among adult asthmatics and its prevalence seems to be affected by family history of ASA hypersensitivity, history of rhinosinusitis and presence of NP.

Diagnosis of Immediate Hypersensitivity to β-Lactam Antibiotics Can Be Made Safely with Current Approaches

Background: Diagnosing immediate hypersensitivity to β-lactam antibiotics is still a significant problem. Recently, a new penicillin testing reagent was introduced to the market. In this study, the recommendations of the European Network of Drug Allergy (ENDA) for the diagnosis of immediate reactions to β-lactams were followed, and the negative predictive value of this approach with currently available reagents was assessed. Methods: Eighty patients (age range: 6–74 years) with a history of immediate reactions to β-lactams were included. All cases underwent skin testing with benzylpenicilloyl-polylysine (PPL) and minor determinant mixture (MDM), followed by the culprit drug if necessary. If this step was negative, a drug provocation test was offered. If this step also yielded a negative result, then the patients were recommended to use β-lactam antibiotics in future whenever their use was indicated. Results: Overall, 29 patients (36.2%) were diagnosed as β-lactam allergic. The majority of the cases (72.4%) were diagnosed by positive skin tests to either PPL or MDM, whereas 10.3% were diagnosed by skin testing with culprit drugs and 17.2% with drug provocation tests. Regarding the use of the tested drug in the long term, almost half of the contacted patients had had an indication to use the tested drug and the majority had taken the whole course without problems. Conclusions: Although currently available new penicillin tests provide sufficient allergy data, all the steps recommended by ENDA should be followed in the diagnosis of immediate reactions to β-lactams. If these steps are negative, the patients usually tolerate β-lactams and only a few develop mild, non-life-threatening reactions in the long term.

How do patients with asthma and COPD behave during fasting

BACKGROUND-OBJECTIVE Several factors might affect the adherence to treatment in patients with asthma and COPD. Among these factors, the effect of religious beliefs and behaviours has been less studied so far. In this study, the effect of fasting on drug use behaviours of patients with asthma and COPD were comparatively analysed. METHODS A total of 150 adult patients with asthma and 150 adult patients with COPD were consecutively enrolled into this cross-sectional study. The patients were asked whether they fast during Ramadan and if the answer was yes, they were kindly asked to respond to further questions related to use of inhaled medications during that particular time. RESULTS The majority of the cases from both groups [98 (65.3%) of asthma patients and 139 (92.6%) of COPD] were fasting during Ramadan. The majority of the patients with COPD (n=126; 90.6%) reported that they quitted their regular therapy basis during Ramadan. On the other hand, the majority of asthma patients used their controller inhaled medications during Ramadan and preferred to use them on iftar and sahur times (n=81, 82.6%). CONCLUSION Our results showed that in a Muslim population, the patients with asthma and COPD do not feel their diseases to be an inhibitory factor for fasting during Ramadan. However, fasting seems to be an important determining factor in medication compliance by modifying the drug use behaviours in each group in a different way. Therefore, the patients should be informed about the effects of fasting on their disease and the allowed drugs during fasting.

Drug allergy in tertiary care in Turkey: Results of a national survey. The ADAPT study: Adult drug allergy perception in Turkey

BACKGROUND No data are available on the incidence of drug hypersensitivity (DH) reactions in outpatient settings of tertiary allergy/immunology clinics. Our aims were to document the frequency of outpatient hospital admissions due to DH reactions to allergy/immunology clinics in adults and the management of these reactions in real life. We also investigated whether drug allergy affected social and medical behaviours of the patients. METHODS This multi-centre study was performed for one year with the participation of 11 out of 16 tertiary allergy/clinical immunology clinics in Turkey. The study group consisted of the patients with DH reactions. Results of a questionnaire including drug reactions and management were recorded. RESULTS Among 54,863 patients, 1000 patients with DH were enrolled with a median of 2.1% of all admissions. In real life conditions, the majority of approaches were performed for finding safe alternatives (65.5%; 1102 out of 1683) with 11.7% positivity. Diagnostic procedures were positive in 27% (154/581) of the patients. The majority of the patients had higher VAS scores for anxiety. A total of 250 subjects (25%) reported that they delayed some medical procedures because of DH. CONCLUSION Our results documented the frequency of admissions due to DH reactions to allergy/clinical immunology clinics for the first time. Although physicians mostly preferred to perform drug tests in order to find safe alternatives, considering the fact that DH was confirmed in 27% of the patients, use of diagnostic tests should be encouraged, if no contraindication exists in order to avoid mislabelling patients as DH.

Are drug provocation tests still necessary to test the safety of COX-2 inhibitors in patients with cross-reactive NSAID hypersensitivity?

BACKGROUND COX-2 inhibitors are safe alternatives in patients with cross-reactive non-steroidal anti-inflammatory drug (NSAID) hypersensitivity. These drugs are recommended to these patients after negative drug provocation tests (DPTs). However, cumulative data on encouraging results about the safety of COX-2 inhibitors in the majority of these patients bring the idea as to whether a DPT is always mandatory for introducing these drugs in all patients with cross-reactive NSAID hypersensitivity. OBJECTIVE To document the safety of COX-2 inhibitors currently available and to check whether or not any factor predicts a positive response. METHODS This study included the retrospective analysis of cases with cross-reactive NSAID hypersensitivity who underwent DPTs with COX-2 inhibitors in order to find safe alternatives. DPTs were single-blinded and placebo controlled. RESULTS The study group consisted of 309 patients. COX-2 inhibitors were well tolerated in the majority of the patients [nimesulide: 91.9%; meloxicam: 90.2%; rofecoxib: 94.9%; and celecoxib: 94.9%)]. Twenty-five patients (30 provocations) reacted to COX-2 inhibitors. None of the factors were found be associated with positive response. CONCLUSION Our results suggest to follow the traditional DPT method to introduce COX-2 inhibitors for finding safe alternatives in all patients with cross-reactive NSAID hypersensitivity before prescription as uncertainty of any predictive factor for a positive response continues. However, these tests should be performed in hospital settings in which emergency equipment and experienced personnel are available.

Pyrazinamide-Induced Anaphylaxis: Diagnosed by Skin Test and Successful Desensitization

Pyrazinamide (PZA), an antituberculosis drug, may cause hypersensitivity reactions. Here, we report a case of anaphylaxis secondary to a PZA administration for tuberculosis pleuritis. To the best of our knowledge, this is the first reported case of strongly possible IgE-mediated, PZA-induced anaphylaxis proved by skin prick test and oral provocation/desensitization.

Safety of meloxicam in patients with aspirin/non-steroidal anti-inflammatory drug-induced urticaria and angioedema

It has been proposed that aspirin (ASA) and other non‐steroidal anti‐inflammatory drug (NSAID)‐induced urticaria (UR)/angioedema (AE) are mediated through inhibition of cyclooxygenase‐1 (COX‐1) enzymes. Therefore, drugs with COX‐2 selectivity may be well tolerated in such patients. We investigated the safety of preferential COX‐2 inhibitor meloxicam in subjects with UR or AE type intolerance reaction to classical ASA/NSAIDs. Subjects with reliable or documented history of UR/AE due to classical ASA/NSAIDs underwent a single‐blinded, placebo‐controlled oral challenge with a cumulative dose of 7.5 mg meloxicam on 2 separate days. One‐quarter and three‐quarter divided doses of placebo and the active drug were given at 1‐h intervals. A total of 116 patients (86 women and 30 men, mean age 39.6 ± 12.7 years) were enrolled to the study. The rate of atopy was 25.9%. Mean duration of drug reaction was 87.4 ± 110.8 (1–720) months. Almost half of the patients were multi‐reactors. The most comorbid disease was asthma and the two most frequent NSAIDs inducing UR/AE were paracetamol (19. 6%) and ASA (19%). No reaction to placebo was observed. Ten out of 116 patients (8.6%) developed mild UR/AE, or only erythema and pruritus at a one‐quarter or cumulative dose of 7.5 mg of meloxicam. The remaining subjects (91.4%) tolerated perfectly meloxicam challenge. This study indicates that 7.5 mg meloxicam is a safe alternative for ASA/NSAID‐intolerant UR/AE patients. Intolerance reactions to meloxicam are much milder forms of the patients’ historical ASA/NSAID‐induced cutaneous reactions.

Late Onset Anaphylaxis in a Hydatid Cyst Case Presenting with Chronic Urticaria

Hydatid cyst is still endemic in various regions of the world. It is the most frequent cause of liver cysts worldwide. Urticaria is sometimes the first manifestation of the disease. However anaphylactic reaction and urticaria have been very rarely reported in the literature. Traditionally, surgery has been the only accepted mode of treatment; however, percutaneous treatment has recently been proposed as an alternative. Cases of anaphylaxis have been reported after percutaneous drainage of hydatid cyst. However, anaphylaxis usually develops within a few hours. Herein, we describe the case of a patient who presented with hydatid cyst causing chronic urticaria and late anaphylactic reaction following percutaneous aspiration of a liver hydatid cyst. We emphasize that physicians should be aware of hydatid cyst as a possible etiology for seemingly chronic spontaneous urticaria, especially in endemic regions. Patients should be kept under observation for at least one day due to the risk of early and late anaphylaxis after percutaneous aspiration treatment.