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Diagnosis of vaccine hypersensitivity
$146
Abstracts
~
~e)~ The Utility of Skin Testing in Patients With Reactions to a
4 ~---II,il Meningitis Vaccine (MV)
Harold Kim*, June Armstrong§, Fred White*, Bryan Embree§ *Grand River Hospital, Kitchener, ON, Canada §Waterloo Region Public Health, Kitchener, ON, Canada In the United States, there are 2,600 new cases per year of meningococcal (MC) disease. Even with modern anti-microbial and supportive treatment, there is a reported mortality of 7-19% and up to 20% of patients suffer neurologic sequelae. In 1997/98, there was an outbreak of MC disease in Waterloo Region, Canada. There have been outbreaks in Quebec, Alberta, Ontario and Manitoba since then. A mass vaccination was performed during the outbreak in Waterloo. This is an accepted approach during MC outbreaks. Allergic reactions to the MV are uncommon, but it is possible that patients with reactions to the MV may require future MV. We report the utility of skin testing patients who had allergic reactions associated with receiving the MV in Waterloo in 1997/98. We defined an allergic reaction as at least one of the following: urticaria, pruritic rash, bronchospasm, generalized or facial edema, or hypotensive symptoms occurring within twelve hours after the vaccination. Approximately 123,000 persons between the ages of 2 and 22 were vaccinated. There were 17 patients (subjects) with allergic reactions reported. Sixty-one control patients agreed to participate. The controls received the MV previously, but did not have an allergic reaction. Thirteen subjects and 61 control patients were tested. Both groups were prick tested with the full strength of MV. The test was considered positive if there was a 3mm wheal with erythema. If this test was negative, intradermal testing was performed with 1/100 MV then 1/10 MV. The intradermal test was considered positive if the wheal was 5ram larger than the negative control. The relative rates of positive skin tests in these groups were compared. Four of the 13 (30.8%) subjects and 6/61 (9.8%) controls had positive skin tests. Therefore the sensitivity of the skin tests was 30.8%. There was no statistical difference identified between the groups. One subject had a possible allergic reaction with skin testing and received epinephrine. There were very few allergic reactions to the MV in the mass vaccination for MC disease in Waterloo. Our study did not result in a statistically significant difference in positive skin tests between the subjects and controis. It is possible that a larger sample size of subjects would have resulted in a statistical difference between the groups, but the sensitivity of skin testing was still only 30.8%. Based on our study, we cannot recommend skin testing as a reliable method of ruling out allergy in patients with allergic reactions to the MV.
27 Diagnosisof Vaccine Hypersensitivity Hema Prateek Dalal, Lisa Roy Rornard University Hospital at Stony Brook, Stony Brook, NY The current recommended childhood immunization schedule incorporates multiple immunizations given at a visit, making it difficult to ascertain the responsible vaccine in case of a hypersensitivity reaction. We present here a case of a 9 month old female child who developed a generalized urticarial rash after receiving diphtheria-tetanus-acellular pertussis (DTaP), intramuscular polio (IPV), and Hepatitis B-H. Influenzae B (Comvax) vaccines at the primary care physician's office. She was subsequently referred to us for evaluation and further advice regarding the completion of the immunization series. We did skin prick and intradermal testing at 1:100 dilution to HiB and the Hep B vaccines individually with negative results and hence subsequent vaccine administration with success. However, further testing resulted in positive intradermal skin test results to 1:100 dilution of DTaP, DT and Tetanus vaccines. DtaP vaccines of two different pharmaceutical companies were used, both resulting in positive reactions. A blood sample was subsequently drawn from the patient and sent for measurement of Tetanus-specific IgE antibody which resulted in a level of 5.10kU/L (Class 03 or high positive) as measured by ImmunoCAP test from Pharmacia. Considering the clinical history, skin test and the above elevated antibody level, we conclude the presence of tetanus hypersensitiv-
J ALLERGY CLIN IMMUNOL JANUARY 2002
ity in this patient. The patient had a tetanus IgG antibody of 0.88 IU/ml which is greater than 0.10 IU/ml, and hence considered to be above the protective level. It was therefore decided to withhold desensitization and administration of tetanus vaccine at this time and serially follow the tetanus IgG level.
a)~[~ Risk Factors for Angioedema Associated With Angiotensin-
4 /-LIP ConvertingEnzymeInhibitors
Filiz Millik*, Anita T Gewurz§ *RPSLMC-CCH A/I Program, Chicago, 1L §Rush-Presbyterian-St Luke's Medical Center, Chicago, IL INTRODUCTION: Angioedema occurs in _< 0.7% of patients (pts) using angiotensin-converting enzyme inhibitors. Anecdotal reports have indicated risk factors for angiotensin converting enzyme inhibitor-associated angioedema (AAA) include African-American race, deficiency of C1 inhibitor and a recent head or neck injury. We previously reported that AAA was also associated with female gender and reproductive tract abnormalities (Ann Allergy Asthma Immunol 2001; 86:91 Abstract). However, the interpretation of our data was limited by the lack of a reference population. We therefore evaluated a cohort of pts with idiopathic angioedema as case controls and compared the two groups for angioedema risk factors. STUDY DESIGN: All cases of AAA and a similar number of IA pts 39 yrs of age or older, who were seen in our clinic between 1998 and 2000 and who consented to the study, were evaluated for risk factors listed below by chart review and a telephone interview. IA pt charts were randomly selected from the candidate pool. RESULTS: We identified 20 AAA pts, including 15 (75%) women (mean age, 58 yr; range, 39-78) and 5 (25%) men (mean age, 60 yr; range, 46-68). 15 or 75% of the AAA pts were African American and the others, Caucasian. The IA pts included 22 (65%) women (mean age 50 yr; range, 39-70) and 12 men (mean age 61 yr; range 48-73). 14 (41%) IA pts were African-American, 6 (47%) were Caucasian, and 4 (12%) were Hispanic. Head and neck injuries were identified as triggering factors in 2 (10%) AAA pts and no IA pts. Quantitative and functional C1 inhibitor levels were normal in all of the AAA and IA pts tested. Hypertension was present in all of the AAA pts, but only 11 (32%) of the IA pts. Atopic disease was diagnosed in 7 (35%) AAA pts and 17 (50%) IA pts. Adverse reactions to drugs were reported by 38% of AAA and 40% of IA pts; the most commonly implicated drugs were penicillin, sulfonamide antibiotics, nonsteroidal antiinflammatory drugs and radiocontrast media. A history of reproductive tract disease (RTD) was present in 11/15 (73%) of female AAA pts and 10/22 (45%) female IA pts. AAA RTD included uterine fibroids (60%) and hysterectomy for fibroids +- endometriosis (40%); 53% of female AAA pts were on estrogen replacement therapy (ERT). Among the women with IA, 32% had uterine fibroids, 9% had endometriosis and 18% had a hysterectomy, while 22% were on ERT. Among males, 2 (40%) in the AAA group and none in the IA group had a history of prostate cancer. CONCLUSION: In our study population, apparent risk factors for AAA included female gender, RTD (uterine fibroids and possibly prostate cancer), estrogen replacement and hypertension, as well as African-American race. The prevalence of atopy and adverse reactions to drugs was increased in both AAA and IA pts. Other potential risk factors were either not observed or unlikely to be significant.
429 Cross-ReactingHeparins:Study of a Case Repo. Palorna Poza-Guedes, Gabriela Canto, Ruperto Gonzrlez-P~rez, Concepci6n Mero~o, Angdlica Felit~,Arancha Jimenez Hospital Doce de Octubre, Madrid, Spain INTRODUCTION: Heparip. is extensively used in the therapy and prophylaxis of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE). Heparin-induced thrombocytopenia and non-specific skin reactions are among the most common reported side-effects; both immediate and non-immediate hypersensitivity reactions to heparin have also been described, although their incidence is very low.
Abstracts
~
~e)~ The Utility of Skin Testing in Patients With Reactions to a
4 ~---II,il Meningitis Vaccine (MV)
Harold Kim*, June Armstrong§, Fred White*, Bryan Embree§ *Grand River Hospital, Kitchener, ON, Canada §Waterloo Region Public Health, Kitchener, ON, Canada In the United States, there are 2,600 new cases per year of meningococcal (MC) disease. Even with modern anti-microbial and supportive treatment, there is a reported mortality of 7-19% and up to 20% of patients suffer neurologic sequelae. In 1997/98, there was an outbreak of MC disease in Waterloo Region, Canada. There have been outbreaks in Quebec, Alberta, Ontario and Manitoba since then. A mass vaccination was performed during the outbreak in Waterloo. This is an accepted approach during MC outbreaks. Allergic reactions to the MV are uncommon, but it is possible that patients with reactions to the MV may require future MV. We report the utility of skin testing patients who had allergic reactions associated with receiving the MV in Waterloo in 1997/98. We defined an allergic reaction as at least one of the following: urticaria, pruritic rash, bronchospasm, generalized or facial edema, or hypotensive symptoms occurring within twelve hours after the vaccination. Approximately 123,000 persons between the ages of 2 and 22 were vaccinated. There were 17 patients (subjects) with allergic reactions reported. Sixty-one control patients agreed to participate. The controls received the MV previously, but did not have an allergic reaction. Thirteen subjects and 61 control patients were tested. Both groups were prick tested with the full strength of MV. The test was considered positive if there was a 3mm wheal with erythema. If this test was negative, intradermal testing was performed with 1/100 MV then 1/10 MV. The intradermal test was considered positive if the wheal was 5ram larger than the negative control. The relative rates of positive skin tests in these groups were compared. Four of the 13 (30.8%) subjects and 6/61 (9.8%) controls had positive skin tests. Therefore the sensitivity of the skin tests was 30.8%. There was no statistical difference identified between the groups. One subject had a possible allergic reaction with skin testing and received epinephrine. There were very few allergic reactions to the MV in the mass vaccination for MC disease in Waterloo. Our study did not result in a statistically significant difference in positive skin tests between the subjects and controis. It is possible that a larger sample size of subjects would have resulted in a statistical difference between the groups, but the sensitivity of skin testing was still only 30.8%. Based on our study, we cannot recommend skin testing as a reliable method of ruling out allergy in patients with allergic reactions to the MV.
27 Diagnosisof Vaccine Hypersensitivity Hema Prateek Dalal, Lisa Roy Rornard University Hospital at Stony Brook, Stony Brook, NY The current recommended childhood immunization schedule incorporates multiple immunizations given at a visit, making it difficult to ascertain the responsible vaccine in case of a hypersensitivity reaction. We present here a case of a 9 month old female child who developed a generalized urticarial rash after receiving diphtheria-tetanus-acellular pertussis (DTaP), intramuscular polio (IPV), and Hepatitis B-H. Influenzae B (Comvax) vaccines at the primary care physician's office. She was subsequently referred to us for evaluation and further advice regarding the completion of the immunization series. We did skin prick and intradermal testing at 1:100 dilution to HiB and the Hep B vaccines individually with negative results and hence subsequent vaccine administration with success. However, further testing resulted in positive intradermal skin test results to 1:100 dilution of DTaP, DT and Tetanus vaccines. DtaP vaccines of two different pharmaceutical companies were used, both resulting in positive reactions. A blood sample was subsequently drawn from the patient and sent for measurement of Tetanus-specific IgE antibody which resulted in a level of 5.10kU/L (Class 03 or high positive) as measured by ImmunoCAP test from Pharmacia. Considering the clinical history, skin test and the above elevated antibody level, we conclude the presence of tetanus hypersensitiv-
J ALLERGY CLIN IMMUNOL JANUARY 2002
ity in this patient. The patient had a tetanus IgG antibody of 0.88 IU/ml which is greater than 0.10 IU/ml, and hence considered to be above the protective level. It was therefore decided to withhold desensitization and administration of tetanus vaccine at this time and serially follow the tetanus IgG level.
a)~[~ Risk Factors for Angioedema Associated With Angiotensin-
4 /-LIP ConvertingEnzymeInhibitors
Filiz Millik*, Anita T Gewurz§ *RPSLMC-CCH A/I Program, Chicago, 1L §Rush-Presbyterian-St Luke's Medical Center, Chicago, IL INTRODUCTION: Angioedema occurs in _< 0.7% of patients (pts) using angiotensin-converting enzyme inhibitors. Anecdotal reports have indicated risk factors for angiotensin converting enzyme inhibitor-associated angioedema (AAA) include African-American race, deficiency of C1 inhibitor and a recent head or neck injury. We previously reported that AAA was also associated with female gender and reproductive tract abnormalities (Ann Allergy Asthma Immunol 2001; 86:91 Abstract). However, the interpretation of our data was limited by the lack of a reference population. We therefore evaluated a cohort of pts with idiopathic angioedema as case controls and compared the two groups for angioedema risk factors. STUDY DESIGN: All cases of AAA and a similar number of IA pts 39 yrs of age or older, who were seen in our clinic between 1998 and 2000 and who consented to the study, were evaluated for risk factors listed below by chart review and a telephone interview. IA pt charts were randomly selected from the candidate pool. RESULTS: We identified 20 AAA pts, including 15 (75%) women (mean age, 58 yr; range, 39-78) and 5 (25%) men (mean age, 60 yr; range, 46-68). 15 or 75% of the AAA pts were African American and the others, Caucasian. The IA pts included 22 (65%) women (mean age 50 yr; range, 39-70) and 12 men (mean age 61 yr; range 48-73). 14 (41%) IA pts were African-American, 6 (47%) were Caucasian, and 4 (12%) were Hispanic. Head and neck injuries were identified as triggering factors in 2 (10%) AAA pts and no IA pts. Quantitative and functional C1 inhibitor levels were normal in all of the AAA and IA pts tested. Hypertension was present in all of the AAA pts, but only 11 (32%) of the IA pts. Atopic disease was diagnosed in 7 (35%) AAA pts and 17 (50%) IA pts. Adverse reactions to drugs were reported by 38% of AAA and 40% of IA pts; the most commonly implicated drugs were penicillin, sulfonamide antibiotics, nonsteroidal antiinflammatory drugs and radiocontrast media. A history of reproductive tract disease (RTD) was present in 11/15 (73%) of female AAA pts and 10/22 (45%) female IA pts. AAA RTD included uterine fibroids (60%) and hysterectomy for fibroids +- endometriosis (40%); 53% of female AAA pts were on estrogen replacement therapy (ERT). Among the women with IA, 32% had uterine fibroids, 9% had endometriosis and 18% had a hysterectomy, while 22% were on ERT. Among males, 2 (40%) in the AAA group and none in the IA group had a history of prostate cancer. CONCLUSION: In our study population, apparent risk factors for AAA included female gender, RTD (uterine fibroids and possibly prostate cancer), estrogen replacement and hypertension, as well as African-American race. The prevalence of atopy and adverse reactions to drugs was increased in both AAA and IA pts. Other potential risk factors were either not observed or unlikely to be significant.
429 Cross-ReactingHeparins:Study of a Case Repo. Palorna Poza-Guedes, Gabriela Canto, Ruperto Gonzrlez-P~rez, Concepci6n Mero~o, Angdlica Felit~,Arancha Jimenez Hospital Doce de Octubre, Madrid, Spain INTRODUCTION: Heparip. is extensively used in the therapy and prophylaxis of deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE). Heparin-induced thrombocytopenia and non-specific skin reactions are among the most common reported side-effects; both immediate and non-immediate hypersensitivity reactions to heparin have also been described, although their incidence is very low.