- Email: [email protected]
Multiple reasonably tolerated percutaneous coronary interventions in a patient with iodide mumps
Letters / Ann Allergy Asthma Immunol 115 (2015) 244e255 k
Department of Pediatrics Holy Spirit Hospital Nagoya, Japan { Department of Pediatrics Shizuoka Saiseikai General Hospital Shizuoka, Japan # Department of Pediatrics Toyohashi Municipal Hospital Toyohashi, Japan **Department of Pediatrics Miyoshi Municipal Hospital Miyoshi, Japan yy Hibarigaoka Kids Allergy Clinic Nagoya, Japan zz Department of Pediatrics Gifu Prefectural Tajimi Hospital Tajimi, Japan xx Department of Pediatrics Komaki City Hospital Komaki, Japan kk Department of Pediatrics Daido Hospital Nagoya, Japan {{ Terada Kid’s Allergy & Asthma Clinic
253 ## Department of Pediatrics Japanese Red Cross Nagoya Daini Hospital Nagoya, Japan [email protected]
References [1] Urisu A, Ebisawa M, Ito K, et al. Japanese Guideline for Food Allergy 2014. Allergol Int. 2014;63:399e419. [2] Leonard SA, Caubet J-C, Kim JS, et al. Baked milk- and egg-containing diet in the management of milk and egg allergy. J Allergy Clin Immunol Pract. 2015;3:13e23. [3] Sampson HA. Utility of food-specific IgE concentrations in predicting symptomatic food allergy. J Allergy Clin Immunol. 2001;107:891e896. [4] Komata T, Soderstrom L, Borres MP, et al. The predictive relationship of foodspecific serum IgE concentrations to challenge outcomes for egg and milk varies by patient age. J Allergy Clin Immunol. 2007;119:1272e1274. [5] Sicherer SH, Wood RA; American Academy of Pediatrics Section on Allergy And Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2011;129:193e197. [6] Santos AF, Du Toit G, Douiri A, et al. Distinct parameters of the basophil activation test reflect the severity and threshold of allergic reactions to peanut. J Allergy Clin Immunol. 2015;135:179e186. [7] Bird JA, Lack G, Perry TT. Clinical management of food allergy. J Allergy Clin Immunol Pract. 2015;3:1e11. [8] Nomura T, Kanda Y, Kato T, et al. Probability curves focusing on symptom severity during an oral food challenge. Ann Allergy Asthma Immunol. 2014;112: 556e557. [9] Sampson HA. Anaphylaxis and emergency treatment. Pediatrics. 2003;111: 1601e1608.
Multiple reasonably tolerated percutaneous coronary interventions in a patient with iodide mumps Although some adverse reactions to radiocontrast media may be IgE-mediated hypersensitivity, most are due to pharmacologic toxicity or other pseudoallergic causes.1,2 Radiocontrast media agents are all tri-iodinated benzene derivatives,3 and although iodine sensitivity was once believed to be a major cause, adverse reactions to contrast are now thought to be largely unrelated to iodine content.2 An exception is iodide sialadenopathy, or iodide mumps, which is characterized by acute or delayed swelling of the submandibular or parotid glands after exposure to iodinated radiocontrast media.4 The condition was originally described in 1956 in a case series of patients who developed symptoms after intravenous urography.5 Despite its seemingly rare occurrence, iodide sialadenopathy may actually be underdiagnosed; a study performed by McCullough et al6 assessing for the incidence of immediate and delayed reactions to contrast media found symptoms consistent with parotitis in approximately 1% to 2% of the 1,381 patients evaluated. Although most iodine is renally excreted, the remainder is excreted through salivary, sweat, and lacrimal glands.7 The exact mechanism of iodide mumps is unclear, but it has been postulated that iodine accumulation in the salivary secretions leads to mucosal edema, ductal obstruction, and subsequent sialadenitis. Pancreatitis has been reported in rare instances.4 Further supporting the role of iodine in the pathogenesis of iodide sialadenopathy, a study examining the role of iodine in radiocontrast media reactions found 2 patients with histories of likely iodide sialadenopathy to have reproducible submandibular swelling on oral ingestion of potassium iodide.3 Because iodide mumps is not thought to be mast cell or leukocyte mediated, premedication with antihistamines and/or corticosteroids has not been found to be successful.4 Other Disclosures: Authors have nothing to disclose. Funding: This study was funded by the Jeffrey Modell Foundation.
unsuccessful treatments include hyperhydration, given the renal excretion of iodine, and blocking thyroid iodine uptake.4 Kalaria et al8 reported an expedited resolution of swelling in one patient with the use of dialysis, suggesting that this intervention could be considered to hasten improvement of severe cases. With no proven prophylactic treatment available, avoidance of contrast media is the only preventive measure for patients with a history of iodide mumps. However, avoidance may not be possible for patients with significant coronary artery disease who require repeated percutaneous coronary interventions. Although iodide sialadenopathy associated with percutaneous coronary intervention has generally been reported as self-limited, the safety of repeated angioplasty in such patients has not been assessed.9,10 Herein, we describe a woman with a history of iodide mumps and significant coronary artery disease requiring percutaneous coronary intervention on 3 separate occasions. The patient is a 76-year-old woman with a history of coronary artery disease who presented with unstable angina. She additionally reported a history of anaphylaxis, characterized by facial swelling and respiratory distress, to contrast media 50 years ago. She denied exposure to contrast media since her reputed anaphylaxis decades ago. Given the history of anaphylaxis to contrast media, the patient was premedicated with prednisone and diphenhydramine before percutaneous coronary intervention for which she received 150 mL of iopamidol (a nonionic, lowosmolality, iodinated contrast agent). The procedure was uncomplicated; however, approximately 12 hours after completion she developed bilateral submandibular swelling that was nonindurated, nonerythematous, firm, and mildly tender to palpation. The patient was otherwise able to tolerate oral intake and was without respiratory distress or other abnormalities on physical examination. Flexible fiberoptic laryngoscopy revealed a patent airway with no abnormalities seen. She had no history of atopy,
254
Letters / Ann Allergy Asthma Immunol 115 (2015) 244e255
angioedema, or renal disease. Laboratory evaluation revealed a normal complete blood cell count with differential, a basic metabolic panel with a creatinine level of 1.04 mg/dL (which was baseline for the patient), and a normal C-reactive protein level and erythrocyte sedimentation rate. The patient’s submandibular swelling resolved without intervention within 4 days. Two months later the patient underwent a second percutaneous coronary intervention with 100 mL of iopamidol contrast media. The patient was again premedicated with prednisone and diphenhydramine before the procedure, yet similarly developed submandibular swelling the following day, which resolved within 3 days without intervention. The patient then had a third percutaneous coronary intervention 2 months later for which she received 150 mL of iopamidol contrast agent. She was once again premedicated with prednisone and diphenhydramine but subsequently developed submandibular swelling approximately 12 hours after this procedure, which resolved within 2 to 3 days without intervention. Although there is no definitive diagnostic test available, our patient’s case is consistent with iodide mumps based on her history of bilateral submandibular swelling hours after receiving contrast media and absence of response to corticosteroid and antihistamine premedication. This diagnosis was further supported by a recurrence of symptoms on additional exposure to iodinated contrast. Although this patient had a history of contrast anaphylaxis, it is possible that the initial event, which included a description of facial swelling, was actually an episode of iodide sialadenopathy. Regardless, the patient received premedication with antihistamine and corticosteroid in accordance with anaphylaxis history, with sialadenopathy recurring on each subsequent exposure to iopamidol. Thus, this case clearly indicates that premedication with antihistamines and corticosteroid, as used for most other contract reactions, is not effective for iodine mumps. Because significant coronary artery disease may necessitate repeated cardiac catheterization requiring iodinated contrast media, the consulting allergist-immunologist may be asked to weigh the benefits of angioplasty with the risks of iodide sialadenitis. Notably, no fatalities or needs for emergency airway management have been reported in association with iodide mumps.4 Thus, in most cases, the benefits of percutaneous coronary intervention may outweigh the risks of iodide sialadenopathy. This case reveals that repeated percutaneous
coronary intervention can be relatively safe in a patient with a history of iodide mumps. In our patient, only mild self-limited episodes of sialadenitis occurred on repeated iodinated contrast exposure. Importantly, subsequent exposures to iodinated contrast did not result in successively worsened symptoms. Before each iodinated contrast exposure, the patient was noted to have normal renal function, which may have ensured the limited severity of sialadenitis via effective kidney excretion of iodide. In patients with chronic kidney disease or acute kidney injury, dialysis may be required to reduce the severity or duration of iodide mumps. Maureen Egan, MD Paul J. Maglione, MD, PhD Division of Clinical Immunology Icahn School of Medicine at Mount Sinai New York, New York [email protected]
References [1] Brockow K. Immediate and delayed reactions to radiocontrast media: is there an allergic mechanism? Immunol Allergy Clin North Am. 2009;29:453e468. [2] Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105:259e273. [3] Scherer K, Harr T, Bach S, Bircher AJ. The role of iodine in hypersensitivity reactions to radio contrast media. Clin Exp Allergy. 2010;40:468e475. [4] Gilgen-Anner Y, Heim M, Ledermann HP, Bircher AJ. Iodide mumps after contrast media imaging: a rare adverse effect to iodine. Ann Allergy Asthma Immunol. 2007;99:93e98. [5] Miller J, Sussman RM. Iodide mumps after intravenous urography. N Engl J Med. 1956;255:433e434. [6] McCullough M, Davies P, Richardson R. A large trial of intravenous conray 325 and niopam 300 to assess immediate and delayed reactions. Br J Radiol. 1989; 62:260e265. [7] Portulano C, Paroder-Belenitsky M, Carrasco N. The naþ/I- symporter (NIS): mechanism and medical impact. Endocr Rev. 2014;35:106e149. [8] Kalaria VG, Porsche R, Ong LS. Iodide mumps: acute sialadenitis after contrast administration for angioplasty. Circulation. 2001;104:2384. [9] Sajeev CG, Mohanan S, Gopalakrishnapillai A, Muneer K. A rare complication of coronary angiography: ’iodide mumps’. Heart. 2013;99:1222. [10] Dallo ML, Mariottini CJ, Durand P, et al. “Iodide mumps” after coronary angioplasty. Int J Cardiol. 2007;114:396e397.
Boletus dermatitis: a new variant of flagellate erythema A 56-year-old patient presented with itchy skin lesions that had reportedly appeared overnight. She recalled having eaten grilled mushrooms in an Italian restaurant 3 days ago. The patient did not take any medication, had no history of atopic or allergic diseases, and was otherwise in good health. In particular, she did not have fever, lymphadenopathy, muscle weakness, or symptoms that were indicative of systemic autoimmune disease. On inquiry, the restaurant’s cook insisted that exclusively porcini (ie, boletus) mushrooms had been used for the dish in question. Physical examination revealed whiplash-shaped, erythematous plaques arranged in parallel on the trunk and extremities. On therapy with class 3 topical glucocorticosteroids, lesions cleared within a few days. Skin prick testing with standard aeroallergens revealed an immediate type reaction to cat dander only. Prick-to-prick testing with different species of mushrooms elicited late-type reactions
Disclosures: Authors have nothing to disclose.
with crescendo dynamics after 48 hours with shiitake mushrooms, boletus mushrooms, and king oyster mushrooms. A lymphocyte transformation test (LTT) with peripheral blood mononuclear cells from the patient and 2 unaffected controls revealed an antigen-specific stimulation of the lymphocyte proliferation by extracts from all 3 mushroom species. To exclude unspecific mitotic effects of the extracts, serial extract dilutions had been used for stimulation, and subsequently the concentration range with the lowest background mitotic activity was used (Fig 1). Histopathologic analysis revealed orthohyperkeratosis with focal parakeratosis overlying a largely normal epidermis. A predominantly perivascular mixed infiltrate containing lymphocytes, histiocytes, and eosinophils was apparent in the upper and middle dermis. Periodic acideSchiff staining revealed no fungal elements. Laboratory testing revealed slightly elevated eosinophil counts (5.6%; reference range, <4%), C-reactive protein levels (1.41 mg/dL; reference range, <0.05), and normal total IgE level (16 kU/L; reference range, <100 kU/L).
Department of Pediatrics Holy Spirit Hospital Nagoya, Japan { Department of Pediatrics Shizuoka Saiseikai General Hospital Shizuoka, Japan # Department of Pediatrics Toyohashi Municipal Hospital Toyohashi, Japan **Department of Pediatrics Miyoshi Municipal Hospital Miyoshi, Japan yy Hibarigaoka Kids Allergy Clinic Nagoya, Japan zz Department of Pediatrics Gifu Prefectural Tajimi Hospital Tajimi, Japan xx Department of Pediatrics Komaki City Hospital Komaki, Japan kk Department of Pediatrics Daido Hospital Nagoya, Japan {{ Terada Kid’s Allergy & Asthma Clinic
253 ## Department of Pediatrics Japanese Red Cross Nagoya Daini Hospital Nagoya, Japan [email protected]
References [1] Urisu A, Ebisawa M, Ito K, et al. Japanese Guideline for Food Allergy 2014. Allergol Int. 2014;63:399e419. [2] Leonard SA, Caubet J-C, Kim JS, et al. Baked milk- and egg-containing diet in the management of milk and egg allergy. J Allergy Clin Immunol Pract. 2015;3:13e23. [3] Sampson HA. Utility of food-specific IgE concentrations in predicting symptomatic food allergy. J Allergy Clin Immunol. 2001;107:891e896. [4] Komata T, Soderstrom L, Borres MP, et al. The predictive relationship of foodspecific serum IgE concentrations to challenge outcomes for egg and milk varies by patient age. J Allergy Clin Immunol. 2007;119:1272e1274. [5] Sicherer SH, Wood RA; American Academy of Pediatrics Section on Allergy And Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2011;129:193e197. [6] Santos AF, Du Toit G, Douiri A, et al. Distinct parameters of the basophil activation test reflect the severity and threshold of allergic reactions to peanut. J Allergy Clin Immunol. 2015;135:179e186. [7] Bird JA, Lack G, Perry TT. Clinical management of food allergy. J Allergy Clin Immunol Pract. 2015;3:1e11. [8] Nomura T, Kanda Y, Kato T, et al. Probability curves focusing on symptom severity during an oral food challenge. Ann Allergy Asthma Immunol. 2014;112: 556e557. [9] Sampson HA. Anaphylaxis and emergency treatment. Pediatrics. 2003;111: 1601e1608.
Multiple reasonably tolerated percutaneous coronary interventions in a patient with iodide mumps Although some adverse reactions to radiocontrast media may be IgE-mediated hypersensitivity, most are due to pharmacologic toxicity or other pseudoallergic causes.1,2 Radiocontrast media agents are all tri-iodinated benzene derivatives,3 and although iodine sensitivity was once believed to be a major cause, adverse reactions to contrast are now thought to be largely unrelated to iodine content.2 An exception is iodide sialadenopathy, or iodide mumps, which is characterized by acute or delayed swelling of the submandibular or parotid glands after exposure to iodinated radiocontrast media.4 The condition was originally described in 1956 in a case series of patients who developed symptoms after intravenous urography.5 Despite its seemingly rare occurrence, iodide sialadenopathy may actually be underdiagnosed; a study performed by McCullough et al6 assessing for the incidence of immediate and delayed reactions to contrast media found symptoms consistent with parotitis in approximately 1% to 2% of the 1,381 patients evaluated. Although most iodine is renally excreted, the remainder is excreted through salivary, sweat, and lacrimal glands.7 The exact mechanism of iodide mumps is unclear, but it has been postulated that iodine accumulation in the salivary secretions leads to mucosal edema, ductal obstruction, and subsequent sialadenitis. Pancreatitis has been reported in rare instances.4 Further supporting the role of iodine in the pathogenesis of iodide sialadenopathy, a study examining the role of iodine in radiocontrast media reactions found 2 patients with histories of likely iodide sialadenopathy to have reproducible submandibular swelling on oral ingestion of potassium iodide.3 Because iodide mumps is not thought to be mast cell or leukocyte mediated, premedication with antihistamines and/or corticosteroids has not been found to be successful.4 Other Disclosures: Authors have nothing to disclose. Funding: This study was funded by the Jeffrey Modell Foundation.
unsuccessful treatments include hyperhydration, given the renal excretion of iodine, and blocking thyroid iodine uptake.4 Kalaria et al8 reported an expedited resolution of swelling in one patient with the use of dialysis, suggesting that this intervention could be considered to hasten improvement of severe cases. With no proven prophylactic treatment available, avoidance of contrast media is the only preventive measure for patients with a history of iodide mumps. However, avoidance may not be possible for patients with significant coronary artery disease who require repeated percutaneous coronary interventions. Although iodide sialadenopathy associated with percutaneous coronary intervention has generally been reported as self-limited, the safety of repeated angioplasty in such patients has not been assessed.9,10 Herein, we describe a woman with a history of iodide mumps and significant coronary artery disease requiring percutaneous coronary intervention on 3 separate occasions. The patient is a 76-year-old woman with a history of coronary artery disease who presented with unstable angina. She additionally reported a history of anaphylaxis, characterized by facial swelling and respiratory distress, to contrast media 50 years ago. She denied exposure to contrast media since her reputed anaphylaxis decades ago. Given the history of anaphylaxis to contrast media, the patient was premedicated with prednisone and diphenhydramine before percutaneous coronary intervention for which she received 150 mL of iopamidol (a nonionic, lowosmolality, iodinated contrast agent). The procedure was uncomplicated; however, approximately 12 hours after completion she developed bilateral submandibular swelling that was nonindurated, nonerythematous, firm, and mildly tender to palpation. The patient was otherwise able to tolerate oral intake and was without respiratory distress or other abnormalities on physical examination. Flexible fiberoptic laryngoscopy revealed a patent airway with no abnormalities seen. She had no history of atopy,
254
Letters / Ann Allergy Asthma Immunol 115 (2015) 244e255
angioedema, or renal disease. Laboratory evaluation revealed a normal complete blood cell count with differential, a basic metabolic panel with a creatinine level of 1.04 mg/dL (which was baseline for the patient), and a normal C-reactive protein level and erythrocyte sedimentation rate. The patient’s submandibular swelling resolved without intervention within 4 days. Two months later the patient underwent a second percutaneous coronary intervention with 100 mL of iopamidol contrast media. The patient was again premedicated with prednisone and diphenhydramine before the procedure, yet similarly developed submandibular swelling the following day, which resolved within 3 days without intervention. The patient then had a third percutaneous coronary intervention 2 months later for which she received 150 mL of iopamidol contrast agent. She was once again premedicated with prednisone and diphenhydramine but subsequently developed submandibular swelling approximately 12 hours after this procedure, which resolved within 2 to 3 days without intervention. Although there is no definitive diagnostic test available, our patient’s case is consistent with iodide mumps based on her history of bilateral submandibular swelling hours after receiving contrast media and absence of response to corticosteroid and antihistamine premedication. This diagnosis was further supported by a recurrence of symptoms on additional exposure to iodinated contrast. Although this patient had a history of contrast anaphylaxis, it is possible that the initial event, which included a description of facial swelling, was actually an episode of iodide sialadenopathy. Regardless, the patient received premedication with antihistamine and corticosteroid in accordance with anaphylaxis history, with sialadenopathy recurring on each subsequent exposure to iopamidol. Thus, this case clearly indicates that premedication with antihistamines and corticosteroid, as used for most other contract reactions, is not effective for iodine mumps. Because significant coronary artery disease may necessitate repeated cardiac catheterization requiring iodinated contrast media, the consulting allergist-immunologist may be asked to weigh the benefits of angioplasty with the risks of iodide sialadenitis. Notably, no fatalities or needs for emergency airway management have been reported in association with iodide mumps.4 Thus, in most cases, the benefits of percutaneous coronary intervention may outweigh the risks of iodide sialadenopathy. This case reveals that repeated percutaneous
coronary intervention can be relatively safe in a patient with a history of iodide mumps. In our patient, only mild self-limited episodes of sialadenitis occurred on repeated iodinated contrast exposure. Importantly, subsequent exposures to iodinated contrast did not result in successively worsened symptoms. Before each iodinated contrast exposure, the patient was noted to have normal renal function, which may have ensured the limited severity of sialadenitis via effective kidney excretion of iodide. In patients with chronic kidney disease or acute kidney injury, dialysis may be required to reduce the severity or duration of iodide mumps. Maureen Egan, MD Paul J. Maglione, MD, PhD Division of Clinical Immunology Icahn School of Medicine at Mount Sinai New York, New York [email protected]
References [1] Brockow K. Immediate and delayed reactions to radiocontrast media: is there an allergic mechanism? Immunol Allergy Clin North Am. 2009;29:453e468. [2] Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105:259e273. [3] Scherer K, Harr T, Bach S, Bircher AJ. The role of iodine in hypersensitivity reactions to radio contrast media. Clin Exp Allergy. 2010;40:468e475. [4] Gilgen-Anner Y, Heim M, Ledermann HP, Bircher AJ. Iodide mumps after contrast media imaging: a rare adverse effect to iodine. Ann Allergy Asthma Immunol. 2007;99:93e98. [5] Miller J, Sussman RM. Iodide mumps after intravenous urography. N Engl J Med. 1956;255:433e434. [6] McCullough M, Davies P, Richardson R. A large trial of intravenous conray 325 and niopam 300 to assess immediate and delayed reactions. Br J Radiol. 1989; 62:260e265. [7] Portulano C, Paroder-Belenitsky M, Carrasco N. The naþ/I- symporter (NIS): mechanism and medical impact. Endocr Rev. 2014;35:106e149. [8] Kalaria VG, Porsche R, Ong LS. Iodide mumps: acute sialadenitis after contrast administration for angioplasty. Circulation. 2001;104:2384. [9] Sajeev CG, Mohanan S, Gopalakrishnapillai A, Muneer K. A rare complication of coronary angiography: ’iodide mumps’. Heart. 2013;99:1222. [10] Dallo ML, Mariottini CJ, Durand P, et al. “Iodide mumps” after coronary angioplasty. Int J Cardiol. 2007;114:396e397.
Boletus dermatitis: a new variant of flagellate erythema A 56-year-old patient presented with itchy skin lesions that had reportedly appeared overnight. She recalled having eaten grilled mushrooms in an Italian restaurant 3 days ago. The patient did not take any medication, had no history of atopic or allergic diseases, and was otherwise in good health. In particular, she did not have fever, lymphadenopathy, muscle weakness, or symptoms that were indicative of systemic autoimmune disease. On inquiry, the restaurant’s cook insisted that exclusively porcini (ie, boletus) mushrooms had been used for the dish in question. Physical examination revealed whiplash-shaped, erythematous plaques arranged in parallel on the trunk and extremities. On therapy with class 3 topical glucocorticosteroids, lesions cleared within a few days. Skin prick testing with standard aeroallergens revealed an immediate type reaction to cat dander only. Prick-to-prick testing with different species of mushrooms elicited late-type reactions
Disclosures: Authors have nothing to disclose.
with crescendo dynamics after 48 hours with shiitake mushrooms, boletus mushrooms, and king oyster mushrooms. A lymphocyte transformation test (LTT) with peripheral blood mononuclear cells from the patient and 2 unaffected controls revealed an antigen-specific stimulation of the lymphocyte proliferation by extracts from all 3 mushroom species. To exclude unspecific mitotic effects of the extracts, serial extract dilutions had been used for stimulation, and subsequently the concentration range with the lowest background mitotic activity was used (Fig 1). Histopathologic analysis revealed orthohyperkeratosis with focal parakeratosis overlying a largely normal epidermis. A predominantly perivascular mixed infiltrate containing lymphocytes, histiocytes, and eosinophils was apparent in the upper and middle dermis. Periodic acideSchiff staining revealed no fungal elements. Laboratory testing revealed slightly elevated eosinophil counts (5.6%; reference range, <4%), C-reactive protein levels (1.41 mg/dL; reference range, <0.05), and normal total IgE level (16 kU/L; reference range, <100 kU/L).