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PubMed2006

Skin testing: a survey of allergists.

BACKGROUND: In the allergist's office, skin testing remains the central way to confirm allergic response. Although anecdotal data suggest widely varying practices in skin testing by allergists, the diversity and relative frequency of these practices have not been documented. OBJECTIVE: To determine the extent of the diversity in skin testing practices among allergists. METHODS: A questionnaire was sent via the Internet to all physician members and fellows of the American College of Allergy, Asthma and Immunology who practice in the United States. This survey explored choice of extract concentrations, skin test device, number and type of tests, method for interpretation and documentation of skin test results, and quality assurance procedures used. RESULTS: Overall, a significant degree of variability was reported with regard to number of skin tests performed, extract concentrations, skin test devices, interpretation and documentation of results, and quality assurance procedures. The average number of skin prick tests performed ranged from 5.09 (grasses) to 10.9 (trees), whereas the average number of intradermal tests performed ranged from 2.03 (grasses) to 5.6 (perennial). The allergen extract concentrations used for intradermal testing varied widely. Expressed as a dilution of the concentrated extracts, 20.8% use 1:100 dilutions, 10.3% use 1:500 dilutions, and 59.4% use 1:1,000 dilutions. Significant variability also occurred regarding devices and the technique with which the devices were used. Most clinicians (92.1%) used the most concentrated extract available for skin prick testing. For reporting the results of skin testing, 53.8% used a 0 to 4+ scale, and only 28.3% measured orthogonal diameters. Of those using a 0 to 4+ scale, two thirds related the results to the size of the histamine control. Quality assurance testing was reportedly performed by 61.2% of responders. However, less than 10% of responders used an objective test protocol for this purpose. CONCLUSIONS: This survey highlights some of the areas that allergists can improve on in the use and reporting of skin tests.

Allergy and Immunology↗
PubMed1987

Delayed-type skin reaction to 2,4-dinitrophenylated epidermal cells in guinea pigs with contact sensitivity to 2,4-dinitrochlorobenzene.

Contact sensitivity (CS) induced by hapten has been thought to be analogous to delayed-type hypersensitivity, such as the Mantoux reaction, because of outstanding similarities between the two phenomena. It can be suggested that animals with CS respond also to intradermal injection of the conjugate of hapten and protein as well as to epicutaneous application of hapten. However, evidence against this has been reported. In the present experiments, delayed-type skin reaction (DSR) was successfully obtained in JY1 strain guinea pigs sensitized by painting the skin with 2,4-dinitrochlorobenzene using in vitro dinitrophenylated epidermal cell suspension (DNP-EC) as antigen for a delayed intradermal test. The experiment using anti-Ia alloantiserum and complement showed that the elicitation of DSR is due to the presence of Ia-positive cells (presumably Langerhans cells) among DNP-ECs. The delayed intradermal test with the conjugates such as haptenated ECs in the animals with CS is considered to be an experimentally useful way of analysing the antigen in the sensitivity.

Administration, Topical↗
PubMed1999

An evaluation of tuberculin skin tests used to diagnose tuberculosis in swamp buffaloes (Bubalus bubalis).

Three types of tuberculin tests were evaluated in swamp buffaloes in two herds of known tuberculosis-positive and tuberculosis-negative status, and the results were compared with postmortem records of 73 tuberculous and 12 non-tuberculous buffaloes from a different herd. Of the 73 tuberculous swamp buffaloes, 30 (41%), 46 (63%) and 56 (77%) animals were detected by the caudal-fold skin test, the cervical skin test and the Stormont test, respectively. Of the 12 non-tuberculous buffaloes, 5 (42%), 4 (34%), and 10 (83%) reacted to the above-mentioned three tuberculin tests, respectively. The reaction was more-pronounced in the cervical skin than in the caudal-fold skin when the single intradermal test was used on the same individual. The Stormont test (a form of the double intradermal test) was the most-sensitive but least-specific test. We concluded that the tuberculin tests described showed poor sensitivity and specificity in swamp buffaloes. Another diagnostic procedure should thus be sought for more-accurate diagnosis.

Animals↗
PubMedDate not supplied

Pathology produced by isocyanates: methods of immunological investigation.

A group of 182 workers exposed to diisocyanates (varnishers, carpenters, producers of polyurethane resins and expanded plastic) were examined to study the immunogenic capacity of these substances. The skin tests, particularly the intradermal tests, revealed reactions of the immediate, accelerated and/or delayed types due to the presence of IgE and IgG, in addition to responses of the cellular type. This was confirmed by passive transfer in guinea-pigs and man and immunohaematological tests such as passive haemagglutination and lymphocyte transformation. In 4 cases it was possible to demonstrate thermoresistant, homocytotropic immunoglobulins, that were not dependent on complement and behaved like reagins (i.e. short-term anaphylactic IgG). Exposure tests were performed on 45 cases; the results are analyzed and compared with those of the skin tests. It is concluded that both these groups of tests are of value in investigating the aetiopathogenesis of the pathology of the isocyanates: the skin tests for initial screening, and then the exposure tests for resolving doubtful diagnoses. Cross-reactions were also demonstrated between toluene-diisocyanate and methylene-diisocyanate. Two phases could be considered in the pathogenesis; in the first phase, signs of inflammation appeared at the primary sites of contact with the irritant, then the ability of the diisocyanates to form a conjugate with organic proteins results in the production of a complete antigen and consequent sensitization of the exposed person. The appearance of symptoms naturally depends on subsequent exposure and the immunogenic capacity of the patient: the response is mainly of the reagin type in atopic patients and of type 3 in non-atopic patients.

Animals↗
PubMed1993

Atopic profile of inner-city asthma with a comparative analysis on the cockroach-sensitive and ragweed-sensitive subgroups.

BACKGROUND: Inner-city asthma is well known for its high risk of mortality. To better understand urban asthma, we examined clinical characteristics and aeroallergen sensitivities of 592 of 680 consecutive urban Chicago residents with asthma. METHODS: A total of 227 male and 453 female subjects who met the criteria for the study were registered. A comprehensive clinical evaluation was followed by allergy skin testing (prick and intradermal testing) with 10 groupings (5 indoor and 5 outdoor) of common aeroallergens. Serum total IgE and selective antigen-specific IgE levels, including cockroach-specific IgE, were routinely measured. A total of 592 (196 male and 396 female) subjects with an average age of 35 years were skin tested. The average duration of asthma was 12.6 years, and 31% of the population was receiving corticosteroids. RESULTS: Aeroallergen sensitivity was noted in 85%, and 94 subjects (15%) were nonallergic. House dust sensitivity (76%) was most prevalent, distantly followed by sensitivity to cockroach (48%), ragweed (45%), other weeds (42%), cat (40%), and dust mite (24%). The average number of aeroallergen sensitivities detected was 4 of 10 groupings of both indoor and outdoor allergens. Twenty percent of subjects were allergic to only indoor allergens, whereas 4% were allergic to outdoor allergens only. Serum IgE was 245 +/- 17.3 IU/ml (geometric mean+SEM), and 74% of 444 serum samples showed IgE antibody levels greater than or equal to 100 IU/ml. A cockroach-sensitive subgroup (283 subjects) had longer duration of asthma (p < 0.0001) and fewer additional aeroallergen sensitivities (p < 0.0001) than the ragweed-sensitive subgroup (264 subjects). CONCLUSION: The results indicate that a great majority (85%) of inner-city Chicago residents with asthma have atopic asthma, as demonstrated by highly elevated IgE levels and multiple aeroallergen sensitivities. Sensitivity to indoor allergens is more prevalent than sensitivity to outdoor allergens. The subjects with cockroach-sensitive asthma appear to be a distinctive subgroup characterized by chronicity and elevated serum IgE antibody levels with fewer aeroallergen skin test sensitivities.

Adolescent↗
PubMed1990

[Anesthetics responsible for anaphylactic shock. A French multicenter study].

Combined allergological and anaesthetic consultations have been started in the last few years in eight French Teaching Hospitals so as to explore peranaesthetic anaphylactoid shocks. A survey was carried out in these centers in order to collect patients investigated with the same protocol, for the assessment of the incidence of anaphylaxis in France, as well as the involved drugs. Investigations were always carried out at least 6 to 8 weeks after the accident. The tests used to diagnose IgE-dependent anaphylaxis were skin tests (prick and intradermal tests, carried out in all eight centers), the radioimmunological assay of specific anti-quaternary ammonium IgE, together with an inhibition test with thiopentone and propofol (six centers), leukocyte histamine release (five centers) and human basophil degranulation tests (three centers) for those drugs for which no specific antibody assay exists. The collected data involved 1,240 patients, investigated within the last four years. Anaphylaxis was diagnosed in 821 patients (66.2%). Muscle relaxants were responsible in 668 cases (80% of cases of anaphylaxis). Suxamethonium was the main cause (54.3% of shocks due to muscle relaxants), followed by vecuronium (15.3%). General anaesthetics (hypnotics and benzodiazepines) were responsible for 9.2% of all cases of anaphylaxis opioids for 2.6%. There were only three cases of shock due to local anaesthetic agents. Latex and ethylene oxide are becoming increasingly involved. It would therefore seem mandatory to carry out after any anaphylactoid accident an assessment with sensitive and specific tests for anaphylaxis. Diagnosing anaphylaxis means that the involved drug should be used never again in that patient. Because muscle relaxants are by far the most involved drugs, anaesthetists should use them only when really required.

Analgesics, Opioid↗
PubMedDate not supplied

Adverse reaction to prednisone in a patient with systemic lupus erythematosus.

Oral corticosteroids are the main therapeutic choice for systemic lupus erythematosus (SLE). Adverse reactions to systemic corticosteroids rarely occur and the etiology is unclear in most cases. A 14-year-old girl with newly diagnosed SLE developed a pruritic bullous eruption while on prednisone. The patient had been treated successfully in the hospital with intravenous methylprednisolone. In preparation for discharge, the steroid preparation was changed to prednisone to which the patient reacted with a development of new crops of bullous lesions. Skin biopsy specimens of lesional areas showed a bullous eruption consistent with erythema multiforme. The patient underwent immediate and delayed hypersensitivity tests. Intradermal and patch tests to liquid prednisone were positive. The patient was discharged on oral methylprednisolone and has not had recurrence of the skin lesions. In conclusion, a case of prednisone sensitivity in a patient with SLE is presented here. An alternative preparation, methylprednisolone, was used to successfully treat her underlying condition.

Adolescent↗
PubMed2000

Vulvitis attributed to hypersensitivity to estrogen. A report of 11 cases.

BACKGROUND: Vulvitis that is refractory to all treatment remains a therapeutic challenge. Hypersensitivity to progesterone and estrogen has been recognized as a rare cause of premenstrual dermatoses. Such hypersensitivity seemed to be the cause of vulvitis in the patients described below. CASES: Nine women had treatment-resistant cyclic vulvitis and two patients had vulvitis develop after commencing hormone replacement therapy (HRT). These patients demonstrated delayed-type hypersensitivity responses by intradermal testing to endogenous estrogens, with two of the patients also reacting to intradermal testing with progesterone. A group of 19 healthy control subjects with no history of vulvar symptoms did not react to any test substance. Ten subjects with other vulvar dermatoses also did not react to any test substance. Of the nine patients with cyclic vulvitis, one recovered at menopause, and three responded to therapy aimed at lowering endogenous estrogen levels. One was able to control symptoms with a potent topical corticosteroid, and four elected not to be treated. Both patients with HRT-related vulvitis recovered when HRT was ceased. CONCLUSION: Hypersensitivity to estrogen appears to be implicated in chronic, cyclic vulvitis and vulvitis related to HRT in these patients. This is the first report of vulvitis due to estrogen hypersensitivity. The problem may not be rare and should be considered in patients with unexplained cyclic vulvitis unresponsive to standard therapy or in those developing noncandidal vulvitis on HRT. Specific therapy aimed at suppressing or antagonizing estrogen may be required in these patients.

Adolescent↗
PubMed2001

[Cutaneous delayed hypersensitivity reactions to heparins and heparinoids].

INTRODUCTION: Due to cross-reactions between unfractionated heparins, low-molecular-weight heparins and sometimes heparinoids, cutaneous delayed hypersensitivity reactions might be a problem for the choice of therapeutic alternative. We report on two cases of sensitization to heparins and heparinoids. OBSERVATIONS: One woman developed localized skin reaction to a low-molecular-weight heparin, then a generalized maculopapular rash when an intravenous injection of unfractionated heparins was performed. The second patient had a localized then extended reaction to a low-molecular-weight heparin and was referred for the choice of a well tolerated method to obtain anticoagulation during a pulmonary surgery. METHODS: Patch tests, prick tests, intradermal and subcutaneous tests were performed with several unfractionated heparins, low-molecular-weight heparins, danaparoid and lepirudin in both cases. RESULTS: In the first case, tests performed with both heparins and heparinoid were positive and the use of lepirudin was proposed if anticoagulation was necessary. In the second case the subcutaneous danaparoid injection induced a localized reaction on the injection site. Danaparoid injections were continued associated with localized applications of dermocorticoids without any side effect. DISCUSSION: Cutaneous delayed hypersensitivity reactions occur on the injection site but can also be generalised. Cross reactions might be unexpected therefore skin-tests are necessary to guide the choice of a therapeutic alternative. In case of intolerance to both heparins and heparinoids various solutions may be proposed such as the application of topical corticosteroids on the injection site or the administration of hirudins. There is no cross sensitization between heparins and hirudins, but the use of hirudins is restricted and requires specific monitoring.

Drug Eruptions↗
PubMed2006

Successful desensitization of a case with desferrioxamine hypersensitivity.

Thalassaemia major is a severe chronic hemolytic disease, resulted with iron overload mainly due to regular blood transfusions. Iron overload may lead to serious organ toxicity and even fatal complications, if no iron excretion is achieved by a chelating agent. First introduced in 1976 as s.c. treatment for thalassaemia major, desferrioxamine (DFO) has substantially improved the life expectancy in the disease. While DFO can cause local allergic reactions including redness, itching, pain and lumps, on rare occasion anaphylactic reactions can occur. The mechanism of anaphylaxis like reactions is not well understood. In this case report, we presented a 10 years-old girl with thalassaemia major who had to stop DFO therapy after appearing of systemic allergic reactions with hypotension, tachycardia, pruritus and urticaria against this drug. Serum IgE level was normal, specific IgE and skin prick tests were negative. Intradermal test was resulted with positive reaction to DFO. The patient was hospitalized and desensitization protocol was initiated with rapid s.c. infusions per 15 min. The protocol was stopped at the 17th cycle because of local reaction reappeared. After that, DFO was further diluted and was restarted with lower dosage and longer infusion period. Then, DFO dosage was increased and the dilutions and infusion times were decreased gradually. By this desensitization programme, the patient would continue to use DFO chelation safely for 10 months.

Child↗
PubMed1988

[Leukocyte histamine liberation tests for the diagnosis of anaphylactic reaction to curare-like agents].

Anaphylaxis to myorelaxants is the main etiology of adverse reactions to anesthetics and adjuvants. The diagnosis relies on skin tests--prick or intradermal tests--radio-immunoassays for series specific IgE, human basophil degranulation tests and leucocyte histamine++ release. 28 patients with an anaphylaxis to myorelaxants have been studied, using the two tests. Skin tests are the more specific and accurate ones. ARIA using a quaternary ammonium hydrated gel, is highly specific and its sensitivity reaches 80%. The leucocyte histamine release may be interest in evaluating anaphylaxis especially when another drug might be involved. The sensitivity of HBDT is low, indicating that HBDT is to be discarded as far as other tests have been developed, for myorelaxants. However, its usefulness for other drugs has to be compared to leucocyte histamine release.

Anaphylaxis↗
PubMed1982

[Cellular reactions of increased delayed sensitivity in human pseudotuberculosis].

A total of 145 patients having Far Eastern scarlatiniform fever, 99 healthy persons and 54 patients with diseases of non-pseudotuberculous etiology have been examined by means of Fradkin's neutrophil damage test, the capillary cell migration inhibition test and the intradermal test. The specific transformation of the cellular immunity system has been shown to occur in scarlatiniform fever. This transformation takes the form of delayed type hypersensitivity reaction. The immunological tests used in this study have been found to be specific, highly sensitive, simple and suitable for diagnosing Far Eastern scarlatiniform fever.

Humans↗
PubMed1993

Skin testing in patients with high risk of anaphylactic reactions to penicillin.

Sequential skin testing including immediate patch test (IPT), skin prick test (SPT), and intradermal test (IT) with sodium benzylpenicillin G (Pen G), and SPT with benzylpenicilloyl human serum albumin (BPO-HSA) was done in 58 subjects with a history of probable anaphylactic reaction or shock of unknown cause. Based on positive skin tests, the diagnosis of penicillin anaphylaxis was confirmed in 30 patients. The average age of onset of penicillin allergy was 42 years ranging from 20-70 years. The sex ratio was 2:28 with marked female predominance. Anaphylactic shock, wheezing and urticaria occurred in 21, 20, 19 patients, respectively. Most symptoms were induced by skin tests and inhalation. The results of skin tests in these patients showed that IPT with 500 U/ml of Pen G was not only reliable but also safe. It is suggested that patients suspected of penicillin anaphylaxis should received IPT with 500 U/ml of Pen G as the initial diagnostic step; if a negative reaction occurred, then SPT and IT should be applied with the same concentration of Pen G, until a positive reaction developed or all the skin testing showed negative results. SPT to BPO-HSA was safe, but its positive rate was only 47.8% in our study; it seems to be less important than skin test to Pen G. As a whole, the skin testing procedure we recommend is relatively reliable, safe and practical even in individuals extremely sensitive to penicillin. In addition, once the patient develops a positive IPT, Pen G residue on the testing site should be wiped away rapidly and washed out with cool water thoroughly to disrupt further violent reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

Quality of life analysis of patients undergoing immunotherapy for allergic rhinitis.

Allergic rhinitis has been conservatively estimated to affect 35 million Americans, with an annual US expenditure of more than $2 billion for treatment. Immunotherapy is generally administered to patients with allergic rhinitis when avoidance is impossible or impractical, when pharmacotherapy provides insufficient relief, and/or symptoms span more than one season. Immunotherapy based on quantified testing (e.g., dilutional intradermal testing [SET] or in vitro methods [RAST, ELISA]) allows administration of antigens in a manner that achieves therapeutic antigen doses more rapidly, yet more safely than immunotherapy administered through a schedule that mixes all antigens at the same concentration and advances on an empirical basis. Sixty patients who received at least one year of quantified testing-based immunotherapy were evaluated using a quality of life questionnaire and individual interviews. Changes in physical, social and emotional well-being were determined. Also investigated were changes in productivity and medication usage. The majority of patients noted significant improvement in all areas within four to six months of initiating immunotherapy, and an overwhelming majority felt that such treatment represented a worthwhile investment of their time and money.

Adult↗