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Allergy to local anaesthetics of the amide group with tolerance to procaine
$170
05
Abstracts
CD69for In Vitro Diagnosis of Delayed Drug Reactions
M. Yazicioglu, K. Cresswell, G. Whalen, J. N. Baraniuk; Georgetown University, Washington, DC. RATIONALE: CD69 is a rapidly up-regulated lymphoid activation antigen. We evaluated flow cytometric detection of CD69 on T cells for the diagnosis of delayed immune-mediated drug reactions. CASE REPORT: A 26 yr Caucasian non-Hispanic male had a 6 month history of facial and neck eczema. He used intranasal dihydroergotamine for 7 yr and oral finasteride for 189 yr. The rash responded to tacrolimus but not to stopping dihydroergotamine for 3 months. METHODS: Liquid dihydroergotamine, chloroform-extracted finasteride tablets, nickel sulfate, positive and negative controls were used for immediate and skin patch tests, and whole blood culture. TrueTest patch tests were also applied. Whole blood was diluted 1/5 with RPMI media, and cultured with dilutions of each substance. CD69+ subsets of CD3+, lymphocyte-gated CD4+ and CD8+ cells were counted by fluorescence assisted cell sorting (FACS) after 4 and 8 days. RESULTS: Puncture and intradermal tests were positive to histamine only. The nickel patch test was positive. Nickel and flnasteride significantly increased the Day 8/Day 4 ratios of CD69+CD8+ cells by 8-fold (p<0.001, X2) and 4.9-fold (p<0.001), respectively. CD69+CD8+ responses were also significantly greater than the RPMI media negative control. There were no changes in CD4+ cells. CONCLUSIONS: Nickel sensitivity was detected by positive patch test and CD69+CD8+ responses. Finasteride was implicated as the cause of his eczema by the CD69+CD8+ proliferative response. These may represent drug-specific CD8+ cells.
Funding: Self-funded Ajr~J~' A Case of Local Anesthetic HypersensitivityCross-Reactiveto "MJlU Both PharmacologicEster and Amide Anesthetic Groups R. S. Botta, B. A. Muller; Internal Medicine, University of Iowa Healthcare, Iowa City, IA. RATIONALE: Bonafide IgE mediated hypersensitivity to a local anesthetic agent is an exceedingly rare occurrence. This case demonstrates sustained sensitivity over time by history, with positive skin testing to both pharmacologic local anesthetic groups, directing future care requirements to include general anesthesia as a sedative preference. METHODS: A 57 year-old Caucasian woman with multiple medical comorbidities requiring a surgically necessary procedure presents with a history of anaphylaxis to Bupivacaine, after a stellate ganglion block performed four years previously. She had experienced acute shortness of breath, stridor and generalized urticaria that subsided within minutes after subcutaneous epinephrine, intravenous diphenhydramine and corticosteroids. Skin testing to local anesthetic agents and RAST to latex was performed. RESULTS: Prick and intradermal testing to positive and negative controls showed appropriate responses. The prick test was positive at 1:1000 dilution of a 2% Procaine (ester) solution with preservative, as a 10 mm wheal response. Incremental intra-dermal testing for Lidocaine (amide) was positive with an 8 mm wheal at 1:10 dilution of a 2% solution without preservative. Latex Cap-RAST was negative. CONCLUSIONS: Patients with true lgE mediated hypersensitivity to local anesthetics are exceedingly rare. Moreover, cross-reactivity between the amide and ester groups defies current dogma in the Allergy literature. This case is the first report to our knowledge of an IgE mediated hypersensitivity, confirmed by skin testing to both pharmacologic local anesthetic groups.
Funding: Self-funded
407 Allergyance to tOprocaineLOCal Anaesthetics of the Amide Group with TolerM. Morais-Almeida, A. Gaspar, J. Rosado-Pinto; Immunoallergy Department, D. Estef~nia Hospital, Lisbon, PORTUGAL. Adverse drug reactions to local anaesthetic (LA) agents are frequently reported but IgE-mediated allergic reactions are rare. We report a case of a 46-year-old woman, nurse, referred to evaluate tolerance to LA before
J ALLERGY CLIN IMMUNOL FEBRUARY 2003
skin biopsies; in briefly, she had had anaphylactic reactions after the administration of an unknown local anaesthetic agent 20 years ago and after lidocaine administration 12 years ago. Five years ago the patient also referred urticaria after topical use of lidocaine (EMLA| After obtaining patient's consent, the diagnostic approach was carried out: we performed skin tests with other amide LA drugs: bupivacaine, positive prick test (6x4mm); mepivacaine, positive prick test (4• ropivacaine, negative prick test but positive intradermal test with 1:100 dilution (12xl0mm). Afterwards, we performed skin tests (prick and ID testing) with procaine (benzoates esters group), that were negative; the patient was admitted in an ICU for challenge procedures. The subcutaneous challenge with lml of procaine (2%) was negative, allowing it use (3 biopsies - lorearm and thigh), with no adverse reaction. Afterwards, to ensure that the positive skin test results were relevant, we carried out placebo-controlled, single blind subcutaneous challenge test with 0.1 ml of ropivacaine (0.2%), and it was positive (severe systemic reaction), confirming the diagnosis of allergy to LA of the amide group. The immunological IgEmediated reaction was proved in this case and, as far as we know, this is the first report of hypersensitivity to ropivacaine. The therapeutic alternative was procaine, ester anaesthetic, not anymore routinely used.
Funding: Self-funded 408
Allergy to Local Anaesthetic
A. Spinola Santos, A. Lopes Pregal, S. Lopes da Silva, A. Vinhas de Sousa, M. Branco Ferreira, E. Pedro, A. G. Palma-Carlos; Immunoallergology, HSM, Lisbon, PORTUGAL. RATIONALE: To evaluate the clinical profile of patients undergoing local anaesthetics (LA) challenge tests. METHODS: Retrospective analysis of the clinical records of 22 patients submitted to LA challenge tests during the last 2 years at our Immunoallergology Unit. After exclusion of latex allergy and CI- inhibitor deficit, challenge tests were perlbrmed, according to the method used by Vervloet et al (skin pricktests first and thereafter subcutaneous administration of 0.1, 0.5, 1, 2 ml of an undiluted LA solution every 15 minutes). The anaesthetic (lidocaine, carbocaine, procaine or bupivacaine) was chosen according to clinical history. RESULTS: The 22 patients (F=I4; M=8; mean age=49.7_+ 13.6 years) were sent to our Unit from Dentistry (77%), Surgery (14%) and Ophthalmology (9%). Urticaria/angioedema was the most frequent complaint (43% of patients) that led to the performance of the challenge, being facial angioedema (28%), bronchospasm (7%), hypotension (7%) and non-specific symptoms (21%) other clinical reasons. No patient had a history of laryngeal obstruction or anaphylaxis. Previous history of other drug allergies was present in 50% of patients and atopy in 27%. We performed 29 challenge tests: lidocaine - 12, carbocaine - 12, procaine - 4 and bupivacaine - 1. Two patients had positive challenge tests to both "ester" and "amide" LA. CONCLUSIONS: Challenge tests are an important diagnostic method in local anaesthetics allergic reactions, we have diagnosed 2 (9%) cases out of 22 in our population. These 2 patients have positive challenge tests in both LA groups, which is an unusual finding.
Funding: Self-funded
409 Aspirin Utility of Topic Application of NSAIDs as Diagnostic Test of Intolerance S. H. Cimbollek j , A. Jimenez 2, C. Lozoya 2, R. Merchan 2, C. Fernandez 2, R. Vives2; ~Allergy, Hospital Doce de Octubre, Madrid, SPAIN, 2Hospital Doce de Octubre, Madrid, SPAIN. BACKGROUND: Three types of provocation are being used for the diagnosis of NSAIDs intolerance (NI). Only few cases of adverse reaction due to topic application have been described. Could topic application be used as a diagnostic test for NI? OBJECTIVE: Validation of a topic cutaneous test as diagnostic alternative. Confirm N1 by transdermal absorption of Ketoprofen in patients with history of cutaneous or mixed reactions with NSAIDs. M A T E R I A L S : Case I reported several episodes after oral NSAIDs ingestion consisting in generalized urticaria, angioedema and bron-
05
Abstracts
CD69for In Vitro Diagnosis of Delayed Drug Reactions
M. Yazicioglu, K. Cresswell, G. Whalen, J. N. Baraniuk; Georgetown University, Washington, DC. RATIONALE: CD69 is a rapidly up-regulated lymphoid activation antigen. We evaluated flow cytometric detection of CD69 on T cells for the diagnosis of delayed immune-mediated drug reactions. CASE REPORT: A 26 yr Caucasian non-Hispanic male had a 6 month history of facial and neck eczema. He used intranasal dihydroergotamine for 7 yr and oral finasteride for 189 yr. The rash responded to tacrolimus but not to stopping dihydroergotamine for 3 months. METHODS: Liquid dihydroergotamine, chloroform-extracted finasteride tablets, nickel sulfate, positive and negative controls were used for immediate and skin patch tests, and whole blood culture. TrueTest patch tests were also applied. Whole blood was diluted 1/5 with RPMI media, and cultured with dilutions of each substance. CD69+ subsets of CD3+, lymphocyte-gated CD4+ and CD8+ cells were counted by fluorescence assisted cell sorting (FACS) after 4 and 8 days. RESULTS: Puncture and intradermal tests were positive to histamine only. The nickel patch test was positive. Nickel and flnasteride significantly increased the Day 8/Day 4 ratios of CD69+CD8+ cells by 8-fold (p<0.001, X2) and 4.9-fold (p<0.001), respectively. CD69+CD8+ responses were also significantly greater than the RPMI media negative control. There were no changes in CD4+ cells. CONCLUSIONS: Nickel sensitivity was detected by positive patch test and CD69+CD8+ responses. Finasteride was implicated as the cause of his eczema by the CD69+CD8+ proliferative response. These may represent drug-specific CD8+ cells.
Funding: Self-funded Ajr~J~' A Case of Local Anesthetic HypersensitivityCross-Reactiveto "MJlU Both PharmacologicEster and Amide Anesthetic Groups R. S. Botta, B. A. Muller; Internal Medicine, University of Iowa Healthcare, Iowa City, IA. RATIONALE: Bonafide IgE mediated hypersensitivity to a local anesthetic agent is an exceedingly rare occurrence. This case demonstrates sustained sensitivity over time by history, with positive skin testing to both pharmacologic local anesthetic groups, directing future care requirements to include general anesthesia as a sedative preference. METHODS: A 57 year-old Caucasian woman with multiple medical comorbidities requiring a surgically necessary procedure presents with a history of anaphylaxis to Bupivacaine, after a stellate ganglion block performed four years previously. She had experienced acute shortness of breath, stridor and generalized urticaria that subsided within minutes after subcutaneous epinephrine, intravenous diphenhydramine and corticosteroids. Skin testing to local anesthetic agents and RAST to latex was performed. RESULTS: Prick and intradermal testing to positive and negative controls showed appropriate responses. The prick test was positive at 1:1000 dilution of a 2% Procaine (ester) solution with preservative, as a 10 mm wheal response. Incremental intra-dermal testing for Lidocaine (amide) was positive with an 8 mm wheal at 1:10 dilution of a 2% solution without preservative. Latex Cap-RAST was negative. CONCLUSIONS: Patients with true lgE mediated hypersensitivity to local anesthetics are exceedingly rare. Moreover, cross-reactivity between the amide and ester groups defies current dogma in the Allergy literature. This case is the first report to our knowledge of an IgE mediated hypersensitivity, confirmed by skin testing to both pharmacologic local anesthetic groups.
Funding: Self-funded
407 Allergyance to tOprocaineLOCal Anaesthetics of the Amide Group with TolerM. Morais-Almeida, A. Gaspar, J. Rosado-Pinto; Immunoallergy Department, D. Estef~nia Hospital, Lisbon, PORTUGAL. Adverse drug reactions to local anaesthetic (LA) agents are frequently reported but IgE-mediated allergic reactions are rare. We report a case of a 46-year-old woman, nurse, referred to evaluate tolerance to LA before
J ALLERGY CLIN IMMUNOL FEBRUARY 2003
skin biopsies; in briefly, she had had anaphylactic reactions after the administration of an unknown local anaesthetic agent 20 years ago and after lidocaine administration 12 years ago. Five years ago the patient also referred urticaria after topical use of lidocaine (EMLA| After obtaining patient's consent, the diagnostic approach was carried out: we performed skin tests with other amide LA drugs: bupivacaine, positive prick test (6x4mm); mepivacaine, positive prick test (4• ropivacaine, negative prick test but positive intradermal test with 1:100 dilution (12xl0mm). Afterwards, we performed skin tests (prick and ID testing) with procaine (benzoates esters group), that were negative; the patient was admitted in an ICU for challenge procedures. The subcutaneous challenge with lml of procaine (2%) was negative, allowing it use (3 biopsies - lorearm and thigh), with no adverse reaction. Afterwards, to ensure that the positive skin test results were relevant, we carried out placebo-controlled, single blind subcutaneous challenge test with 0.1 ml of ropivacaine (0.2%), and it was positive (severe systemic reaction), confirming the diagnosis of allergy to LA of the amide group. The immunological IgEmediated reaction was proved in this case and, as far as we know, this is the first report of hypersensitivity to ropivacaine. The therapeutic alternative was procaine, ester anaesthetic, not anymore routinely used.
Funding: Self-funded 408
Allergy to Local Anaesthetic
A. Spinola Santos, A. Lopes Pregal, S. Lopes da Silva, A. Vinhas de Sousa, M. Branco Ferreira, E. Pedro, A. G. Palma-Carlos; Immunoallergology, HSM, Lisbon, PORTUGAL. RATIONALE: To evaluate the clinical profile of patients undergoing local anaesthetics (LA) challenge tests. METHODS: Retrospective analysis of the clinical records of 22 patients submitted to LA challenge tests during the last 2 years at our Immunoallergology Unit. After exclusion of latex allergy and CI- inhibitor deficit, challenge tests were perlbrmed, according to the method used by Vervloet et al (skin pricktests first and thereafter subcutaneous administration of 0.1, 0.5, 1, 2 ml of an undiluted LA solution every 15 minutes). The anaesthetic (lidocaine, carbocaine, procaine or bupivacaine) was chosen according to clinical history. RESULTS: The 22 patients (F=I4; M=8; mean age=49.7_+ 13.6 years) were sent to our Unit from Dentistry (77%), Surgery (14%) and Ophthalmology (9%). Urticaria/angioedema was the most frequent complaint (43% of patients) that led to the performance of the challenge, being facial angioedema (28%), bronchospasm (7%), hypotension (7%) and non-specific symptoms (21%) other clinical reasons. No patient had a history of laryngeal obstruction or anaphylaxis. Previous history of other drug allergies was present in 50% of patients and atopy in 27%. We performed 29 challenge tests: lidocaine - 12, carbocaine - 12, procaine - 4 and bupivacaine - 1. Two patients had positive challenge tests to both "ester" and "amide" LA. CONCLUSIONS: Challenge tests are an important diagnostic method in local anaesthetics allergic reactions, we have diagnosed 2 (9%) cases out of 22 in our population. These 2 patients have positive challenge tests in both LA groups, which is an unusual finding.
Funding: Self-funded
409 Aspirin Utility of Topic Application of NSAIDs as Diagnostic Test of Intolerance S. H. Cimbollek j , A. Jimenez 2, C. Lozoya 2, R. Merchan 2, C. Fernandez 2, R. Vives2; ~Allergy, Hospital Doce de Octubre, Madrid, SPAIN, 2Hospital Doce de Octubre, Madrid, SPAIN. BACKGROUND: Three types of provocation are being used for the diagnosis of NSAIDs intolerance (NI). Only few cases of adverse reaction due to topic application have been described. Could topic application be used as a diagnostic test for NI? OBJECTIVE: Validation of a topic cutaneous test as diagnostic alternative. Confirm N1 by transdermal absorption of Ketoprofen in patients with history of cutaneous or mixed reactions with NSAIDs. M A T E R I A L S : Case I reported several episodes after oral NSAIDs ingestion consisting in generalized urticaria, angioedema and bron-