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Adverse drug reactions (ADRs) are a common problem in children. Health-related quality of life in patients with such conditions has not been well studied. In this study we found that health-related quality of life is adversely affected in children who developed ADRs with cutaneous manifestations.

Abstract Background Changes in emergency department (ED) concordance with guidelines for the management of stinging insect-induced anaphylaxis (SIIA) are not known. Objective To describe temporal changes in ED concordance with guidelines for the management of SIIAs. Methods We analyzed data from 2 multicenter retrospective studies of patients with stinging insect-related acute allergic reactions seen in 1 of 14 North American EDs during 2 periods: 1999 through 2001 and 2013 through 2015. Visits were identified similarly across studies (eg, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 989.5, 995.0, and 995.3). Anaphylaxis was defined as an acute allergic reaction with involvement of at least 2 organ systems or hypotension. We compared concordance between periods with 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for epinephrine auto-injector, (3) referral to an allergist/immunologist, and (4) instructions to avoid the offending allergen. Results We compared 182 patients with SIIA during 1999 to 2001 with 204 during 2013 to 2015. Any treatment with epinephrine (before arrival to the ED or in the ED) increased over time (30% vs 49%; P P P = .002), and instructions to avoid the offending allergen did not change (23% vs 24%; P = .94). Receipt of at least 3 guideline recommendations increased over time; however, the comparison was not statistically significant (10% vs 16%; P = .15). Conclusion During the nearly 15-year study interval, we observed increased ED concordance with epinephrine-related guideline recommendations for the management of SIIA. Reasons for the decrease in allergy/immunology referrals merit further study.

Abstract Background Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but serious delayed hypersensitivity reaction that can be caused by antibiotic exposure. The reaction typically develops in 2 to 6 weeks. The pathophysiology is thought to involve toxic drug metabolites acting as a hapten, triggering a systemic response. The diagnosis is made clinically but can be confirmed using assays such as the lymphocyte toxicity assay (LTA), which correlates cell death upon exposure to drug metabolites with susceptibility to hypersensitivity reactions. Case presentations Case 1 involves a previously healthy 11-month-old male with first exposure to amoxicillin-clavulanate, prescribed for seven days to treat a respiratory infection. The patient developed DRESS fourteen days after starting the drug and was successfully treated with corticosteroids. LTA testing confirmed patient susceptibility to hypersensitivity reactions with amoxicillin-clavulanate. Parental samples were also tested, showing both maternal and paternal susceptibility. Neither parent reported prior hypersensitivity reactions. Lifelong penicillin avoidance for the patient was advised along with the notation in medical records of penicillin allergy. The parents were advised to avoid penicillin class antibiotics and be monitored closely for DRESS if they are exposed. Case 2 involves an 11-year-old female with atopic dermatitis with first exposure to amoxicillin-clavulanate, prescribed for ten days to treat a secondary bacterial skin infection. She developed DRESS eleven days after starting antibiotics and was successfully treated with corticosteroids. LTA testing confirmed patient susceptibility to hypersensitivity reactions with amoxicillin-clavulanate. Maternal samples were also tested and showed sensitivity. The mother reported no prior hypersensitivity reactions. Lifelong penicillin avoidance for the patient was advised along with the notation in medical records of penicillin allergy. Conclusions Amoxicillin-clavulanate is a commonly used antibiotic and the cases we have described suggest that it should be recognized as a potential cause of DRESS in pediatric patients. Furthermore, these cases contribute to current literature supporting that there may be a shorter latent period in DRESS induced by antibiotics. We have also shown that the LTA can be a helpful tool to confirm DRESS reactions, and that testing may have potential implications for family members.

Objectives In epidemiological studies of work-related ill-health only current exposures can, at best, be measured. Previous exposures may be estimated using contemporaneous hygiene records or published data. This study aimed to create a job exposure matrix for exposure in bakers for use in an ongoing cohort study. Methods A systematic review was conducted of English language publications on exposures in bakeries. All publications that appeared to contain quantitative measures of exposure to flour dust, wheat allergen, or fungal α-amylase were read independently by two investigators and relevant data extracted. A third investigator reviewed these data and publications were retained that reported full-shift exposures to inhalable dust, wheat allergen, or α-amylase, and for which geometric means (GMs) were given or could be estimated. For each study, the number of sampling results contributing to each GM was recorded together with information on task, bakery size, product, filter type, sampling head, the country in which the study was conducted, and the estimated year of sampling. Multivariable models were elaborated for each exposure using a linear mixed effects approach. The predictive capacity of the model for inhaled particles was tested against samples collected in eight Alberta bakeries. The capacity of exposure intensity, estimated from each of the three models, to predict sensitization was tested against skin prick testing (SPT) for bakery allergens in bakers currently employed in Alberta. Results One thousand three hundred and ninety-seven publications were identified through the systematic search, of which 27 had data used to create one or more of the predictive models. Weighted GMs were used as outcome variables. For inhalable dust, task, bakery size, type of sampling head, and year of sampling contributed to the final model. For wheat allergen and α-amylase, task, bakery size, sampling head, and year of sampling again contributed. Product (bread rather than confectionary or mixed products) was also important in these two latter measures. The model for inhalable dust was used to predict the concentration in 33 samples from Alberta bakeries. Overall, 91% of observed samples had 95% confidence intervals (CIs) overlapping the 95% CIs of the predicted values. A model including the Alberta samples found no effect attributable to Alberta provenance. Using this model for inhalable dust and the models developed solely from the literature for wheat allergen and α-amylase, a positive SPT for bakery allergens in 57 bakers recruited for this study was significantly related to log cumulative exposure for each of the three outcome variables and to log exposure intensity for wheat allergen and α-amylase. Conclusions The exposure models developed from the literature provide useful estimates of exposure. Calibration of the models against locally collected samples may be useful for countries poorly represented in the modeling dataset.

In their 2018 CMAJ article, Kisilevsky and DeAngelis illustrated the occurrence of ocular vasculopathy in association with the administration of a topical eye decongestant. [1][1] The pathogenesis and clinical manifestations that they reported essentially parallel the complications of use of α-

International audience; BACKGROUND:In 2012, an analysis of the Brazilian mortality database demonstrated undernotification of anaphylaxis deaths due, at least in part, to difficult coding under the International Classification of Diseases (ICD)-10. This work triggered a cascade of strategic international actions supported by the Joint Allergy Academies and the ICD World Health Organization (WHO) representatives to update the classifications of allergic disorders for the ICD-11 revision. These efforts have resulted in the construction of the new 'Allergic and hypersensitivity conditions' section under the 'Disorders of the Immune system' chapter.OBJECTIVE:To analyze the capacity of the new ICD-11 revision to capture anaphylaxis deaths.METHODS:We re-estimated the anaphylaxis deaths that occurred in Brazil during the period 2008 to 2010, utilizing this new framework and the database of the Brazilian mortality information system that had initially been extracted in May 2011. However, in 2016, a manual review of each of the 3638 records was performed.RESULTS:We identified 639 anaphylaxis deaths, of which 95% were classified as 'definitive anaphylaxis deaths'. In contrast to the 2012 published data, we found a higher number of cases; moreover, all 606 definitive anaphylaxis deaths would be considered as underlying causes of death utilizing the ICD-11 revision.CONCLUSION:This study is the first example of how the new 'Allergic and hypersensitivity conditions' section of the forthcoming ICD-11 can improve the quality of official vital statistics data and the visibility of an important public health concern. This research will facilitate comprehensive, comparable population-based epidemiologic data collection on anaphylaxis.

Background Allergen-specific immunotherapy (AIT) still remains the only causal treatment for IgE mediated respiratory diseases (rhinitis/asthma) In addition to the observed clinical decrease in symptoms, AIT can provide a long-lasting and preventive effect. In particular it can modify the progression from rhinitis to asthma.Methods The study was observational, open, non randomized, controlled, prospective and performed in a real-life setting. Patients with pure mite-induced allergic rhinitis were followed-up, receiving adjuvanted SLIT (aSLIT), standard SLIT (sSLIT) or drug treatment alone, according to their preference starting between 2008 and 2009. The possible onset of asthma, changes in pulmonary function and bronchial hyperreactivity (BHR) were assessed over a 5-year horizon. Also the onset of new sensitizations and symptoms-medication score (SMS) were evaluated.Results One hundred forty two patients fulfilling the inclusion criteria were assessed at baseline, and 124 had the 5-year evaluation (age range 8–57, 69 male). After 5 years of treatment, new sensitizations appeared differentially among treatments with 58.1% of new sensitizations in the drug treatment group, 13.2% in the sSLIT patients, and 8.1% in the aSLIT patients. At the end of 5 years, SMS significantly changed (P?

Topical calcineurin inhibitors (TCIs) were approved in the early 2000s for the treatment of atopic dermatitis (AD), and despite the recent introduction of newer topical and systemic therapies for AD, TCIs such as tacrolimus ointment (0.03% and 0.1%) and pimecrolimus cream (1%), remain recommended treatment options in contemporary management guidelines. The goal of this article is to review the evidence supporting the approved indications for TCIs in adults with AD, including short-term treatment of active disease and as intermittent or maintenance treatment for the prevention of flares. Other evidence reviewed in this article includes the treatment of specific body areas (such as the face and eyelids), combination or sequential use of TCIs with topical corticosteroids, and the comparative efficacy of the 2 commercially available TCIs. This review of the evidence confirms that TCIs remain an effective treatment option for the management of adult AD.

Background Insulin allergy is a rare yet severe side effect of exogenous insulin use. Management typically involves use of alternative antihyperglycaemic agents, symptom control with antihistamines, use of different insulin formulations, and induction of tolerance with incremental doses of insulin. This treatment regimen is not always successful, and the use of omalizumab, an anti-IgE monoclonal antibody, has been used to induce tolerance to insulin. Case report G.M. is a 62-year-old man with Type 2 diabetes mellitus. His condition was not optimized on oral agents, and insulin therapy was required. G.M. had anaphylaxis to insulin NPH, and subsequent skin-prick testing was positive to insulin aspart, insulin NPH, insulin glulisine, insulin detemir, regular insulin, insulin glargine 100 units/ml and insulin glargine 300 units/ml. He received incremental doses of several insulin formulations; however, he experienced diffuse urticaria preventing optimal glycaemic control. Three successful cases have been described in the literature of omalizumab inducing tolerance to exogenous insulin; therefore, G.M. was started on omalizumab. He subsequently tolerated treatment doses of insulin glulisine and insulin detemir with no allergic reactions and with improvement in glycaemic control. Conclusion To our knowledge, this is the first described case of allergy to insulin glargine 300 units/ml and reiterates the potential use of omalizumab in insulin allergy. Further research is warranted to determine if omalizumab should be considered standard of care in difficult-to-treat insulin hypersensitivity.