Rosario Cabañas

Gastroallergic anisakiasis: borderline between food allergy and parasitic disease-clinical and allergologic evaluation of 20 patients with confirmed acute parasitism by Anisakis simplex.

BACKGROUND Human subjects can be parasitized by Anisakis simplex by eating raw or undercooked fish. Gastric anisakiasis is probably the most frequent clinical entity presenting with severe epigastric pain, vomiting, and diarrhea. In gastroallergic anisakiasis hypersensitivity symptoms predominate. OBJECTIVE We sought to describe clinical features, laboratory data, and gastroscopic findings in gastroallergic anisakiasis. METHODS We selected 40 patients presenting to the emergency department with an acute allergic reaction, and if we suspected acute parasitism by A simplex, a fiberoptic gastroscopy was performed. In 20 patients we could detect one or more nematodes; these patients are referred to as group A. Those in whom no worm could be found are referred to as group B (n = 20). A detailed history, clinical features, gastroscopic findings, laboratory data, and skin prick test responses were compared. RESULTS Long-time intervals of up to 26 hours between fish intake and onset of hypersensitivity symptoms were found (group A, 5.4 +/- 6.3 hours; group B, 5.3 +/- 2.6 hours). Patients in groups A and B did not differ with respect to allergic symptoms (urticaria, angioedema, erythema, bronchospasm, and anaphylaxis) or the mainly light abdominal symptoms (upper abdominal pain, nausea, vomiting, and diarrhea). No significant differences were found with respect to age, time interval between fish intake and onset of symptoms, white cell and eosinophil counts, specific IgE levels against A simplex, or total IgE levels. CONCLUSIONS The peculiar sometimes long-time interval between fish intake and onset of allergic symptoms render the diagnosis difficult. An early gastroscopy can confirm the diagnosis and prevent complications. We suggest that gastroallergic anisakiasis be considered a distinct clinical entity in which the predominant symptoms are hypersensitivity symptoms and in which the correct diagnosis is not only important in the management of the acute reaction but also in the prevention of further allergic episodes.

Gastroallergic anisakiasis: Findings in 22 patients

Background and Aims : Ingestion of Anisakidae larvae in raw seafood may cause anisakiasis. However, despite the high level of consumption of seafood in Spain, only a few cases of anisakiasis have been reported until now. Anisakis simplex can cause allergic reactions in sensitized patients as a result of its parasitism in the gastrointestinal tract. The purpose of this study was to analyse the clinical findings in 22 patients with gastroallergic anisakiasis.

CD94/NKG2C is a killer effector molecule in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe, bullous cutaneous diseases with uncertain pathogenesis, although cytotoxic T cells seem to be involved. Natural killer (NK)-like activity has been found in blister infiltrates. Cytotoxic T lymphocytes (CTLs) with NK-like activity (NK-CTLs) have been shown to express T-cell receptors restricted by the HLA-Ib molecule HLA-E. Alternatively, the HLA-E-specific activating receptor CD94/NKG2C can trigger T-cell receptor-independent cytotoxicity in CTLs. OBJECTIVE Our aim was to test whether HLA-E expression sensitizes keratinocytes to killing by CTLs with NK-like activity and to explore the expression of activating receptors specific for HLA-E in blister cytotoxic lymphocytes. METHODS We used flow cytometry and immunohistochemistry to analyze HLA-E expression in keratinocytes from affected skin in patients with SJS, TEN, and other less severe drug-induced exanthemas. The expression of CD94/NKG2C was analyzed by means of flow cytometry in PBMCs and blister cells from patients. PBMCs and blister cells were analyzed for their ability to kill HLA-E-expressing cells. Involvement of CD94/NKG2C in triggering degranulation of cytolytic cells was explored by means of CD107a mobilization assays and standard cytotoxicity chromium release assays. RESULTS We found that keratinocytes from affected skin expressed HLA-E and that cell-surface HLA-E sensitizes keratinocytes to killing by CD94/NKG2C(+) CTLs. Frequencies of CD94/NKG2C(+) peripheral blood T and NK cells were increased in patients with SJS and TEN during the acute phase. Moreover, activated blister T and NK lymphocytes expressed CD94/NKG2C and were able to degranulate in response to HLA-E(+) cells in an NKG2C-dependent manner. CONCLUSION CD94/NKG2C might be involved in triggering cytotoxic lymphocytes in patients with SJS and TEN.

Clinical characteristics of patients with mustard hypersensitivity

BACKGROUND Although mustard is frequently consumed in Spain and elsewhere, only isolated case reports of mustard allergy have been reported. No large series of case studies have been published. OBJECTIVES We sought to describe demographic, clinical, and immunologic characteristics of patients with mustard hypersensitivity and to determine whether any significant differences exist in age, sex, atopic family history, total immunoglobulin E (IgE) level, and specific IgE to mustard ratio among patients with differing characteristics. METHODS Twenty-nine patients with a history of mustard allergy underwent skin prick tests with mustard, determination of total IgE, and evaluation of specific IgE to mustard. Skin prick tests with Lolium perenne, Olea europaea, and Artemisia vulgaris were done in patients with symptoms of pollinosis. The aforementioned variables were compared between various subgroups of patients for systemic versus local reactions to mustard, association versus no association with allergies to other vegetable foods, and association versus no association with pollinosis. RESULTS The male:female ratio was 10:19. Skin prick tests to mustard were positive in all patients. The total IgE geometric mean was 189.3 kU/L. The specific IgE to mustard was positive in all patients (0.7 to > 100 kU/L). Of the 29 patients, 19 (66%) had a systemic reaction after consumption of mustard, and 10 (34%) had a local reaction; 14 (48%) had anaphylaxis. Fifteen patients (52%) had symptoms after ingestion of other vegetable foods, and 15 also had typical symptoms of pollinosis. No significant differences were found in age, sex, atopic family history, total IgE, and specific IgE to mustard between the various subgroups studied. CONCLUSIONS Most study patients with mustard hypersensitivity had a systemic reaction and had associated pollinosis or allergy to other vegetable foods. Mustard sensitivity should be routinely tested in patients with idiopathic anaphylaxis.

Expression of α‐defensin 1–3 in T cells from severe cutaneous drug‐induced hypersensitivity reactions

To cite this article: Morel E, Álvarez L, Cabañas R, Fiandor A, Díaz R, Escamochero S, Prior N, Blanca M, Bellón T. Expression of α‐defensin 1–3 in T cells from severe cutaneous drug‐induced hypersensitivity reactions. Allergy 2011; 66: 360–367.

Development of a disease-specific quality of life questionnaire for adult patients with hereditary angioedema due to C1 inhibitor deficiency (HAE-QoL): Spanish multi-centre research project

BackgroundThere is a need for a disease-specific instrument for assessing health-related quality of life in adults with hereditary angioedema due to C1 inhibitor deficiency, a rare, disabling and life-threatening disease. In this paper we report the protocol for the development and validation of a specific questionnaire, with details on the results of the process of item generation, domain selection, and the expert and patient rating phase.Methods/DesignSemi-structured interviews were completed by 45 patients with hereditary angioedema and 8 experts from 8 regions in Spain. A qualitative content analysis of the responses was carried out. Issues raised by respondents were grouped into categories. Content analysis identified 240 different responses, which were grouped into 10 conceptual domains. Sixty- four items were generated. A total of 8 experts and 16 patients assessed the items for clarity, relevance to the disease, and correct dimension assignment. The preliminary version of the specific health-related quality of life questionnaire for hereditary angioedema (HAE-QoL v 1.1) contained 44 items grouped into 9 domains.DiscussionTo the best of our knowledge, this is the first multi-centre research project that aims to develop a specific health-related quality of life questionnaire for adult patients with hereditary angioedema due to C1 inhibitor deficiency. A preliminary version of the specific HAE-QoL questionnaire was obtained. The qualitative analysis of interviews together with the expert and patient rating phase helped to ensure content validity. A pilot study will be performed to assess the psychometric properties of the questionnaire and to decide on the final version.

Hypersensitivity to piperacillin

A man was admitted to the hospital for acute gallbladder infection. During the postsurgery period, he had a high digestive hemorrhage and an intra-abdominal infection with much wound drainage, sepsis, and fever. He was treated with Tazocel® (piperacillin 4 g, tazobactam 0.5 g; Lederle, Madrid, Spain), Datracin® (vancomycin), Nolotil® (metamizole), Zantac® (ranitidine), Losec® (omeprazole), and Maalox® (aluminum hydroxide with magnesium). On day 14 of treatment with these drugs, the patient suffered a generalized and diffuse maculopapular itchy skin eruption, and eosinophilia of 47% could be observed in his blood. His physicians replaced Tazocel with tobramycin and clindamycin and started treatment with oral antihistamines. Four days later, as the symptoms and fever remained, the patient was examined by a dermatologist, who diagnosed a toxic reaction. Vancomycin was stopped, but the cutaneous reaction persisted for another 11 days. Treatment with corticosteroids was then started, with progressive improvement of symptoms and development of itchy, scaling dermatitis. The patient was completely asymptomatic within 1 month and eosinophilia had disappeared from his blood by then.

Management of hereditary angioedema in pregnant women: a review

Three types of hereditary angioedema (HAE) have been described: two are due to C1 inhibitor (C1-INH) deficiency (C1-INH-HAE types I and II) and one is characterized by normal C1-INH (nC1-INH-HAE). The management of pregnancy in patients with HAE is often a clinical challenge owing to potential worsening of the disease in relation to the physiological increase in estrogens and the limited treatment options. This review addresses the potential influence of pregnancy on the clinical severity of hereditary angioedema and the management of this disease during pregnancy with currently available treatments.

Allergic Contact Reactions due to Phenylephrine Hydrochloride in Eyedrops

BACKGROUND Dermatitis of and around the eye is common. Allergic contact reactions from phenylephrine are rare despite extensive use by ophthalmologists. Previous reports do not indicate crossreactivity between phenylephrine and other sympathomimetic drugs in patch testing. METHODS We report three cases of allergic contact reactions (dermato-conjunctivitis) after eyedrops. Skin prick tests, epicutaneous testing with the implicated drugs, additives, and a complete patch test battery, TRUE test (Upjohn-Pharmacia, Sweden), were performed in each patient. RESULTS All skin prick tests were negative. The three patients showed positive patch tests to phenylephrine and one of them also to ephedrine. Tolerance of the other eyedrops without phenylephrine was verified by challenge. CONCLUSION Phenylephrine was the responsible agent for the reactions in our patients as confirmed by clinical findings and positive patch tests. Our findings suggest the central structure as the sensitizing part of drug in the second patient. Patch testing is essential for diagnosis of allergic contact reactions of and around the eye.

Management of angioedema without urticaria in the emergency department

Abstract Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.