Hemorrhagic bullous dermatosis: a rare heparin-induced cutaneous manifestation

Heparin is one of the most widely prescribed medications. Cutaneous reactions distant to the injection site are rare and under-reported in the literature. We present an elderly man with history of CNS lymphoma who underwent treatment of a deep venous thrombosis with enoxaparin and subsequently developed well demarcated bullous lesions within days of heparin initiation. The exact pathophysiology is not well understood. Hemorrhagic bullous dermatosis is a rare cutaneous reaction that is temporally associated with the initiation of heparin products. The handful of cases thus far suggest that regression of these seemingly benign lesions may or may not be associated with dose reduction or discontinuation of heparin products and typically occur within a few weeks. Elderly age appears to be one potential risk factor for development of these rare asymptomatic lesions. Malignancy may have some contributing factor and differentiation between this rare cutaneous manifestation from heparin products and other dermatological findings in patients with malignancy is key. Because of the asymptomatic and self-limiting nature of hemorrhagic bullous dermatoses in the setting of heparin product use, we presume that the reported incidence does not reflect true clinical practice.     

Sensitization to bovine serum albumin as a possible cause of allergic reactions to vaccines

BackgroundImmediate type hypersensitivity to vaccines containing bovine/porcine excipients, such as the measles, mumps and rubella (MMR) vaccine is probably due to sensitization to bovine/porcine gelatin. Most patients with such reactions in Sri Lanka have cow's milk (CM) or beef allergy.ObjectivesWe investigated whether those who had beef and CM allergy had a higher incidence of hypersensitivity reactions to vaccines and the possible trigger of such reactions.Material and methodsTwenty patients with immediate type hypersensitivity reactions to vaccines containing bovine/porcine excipients, controls with allergy to beef/pork (n = 11) or CM (n = 11), and 8 non atopic controls were recruited. Total serum IgE, specific IgE to beef, CM, casein, beta lactoglobulin, gelatin and bovine serum albumin (BSA) by Phadia ImmunoCap and IgE to porcine gelatin by Western blot were evaluated.Results11/20, 5/20, 2/20, 2/20, 1/20 and 1/20 patients reported allergic reactions to measles containing, JE, rabies primary chick embryo, pentavalent, diphtheria and tetanus, and adult diphtheria and tetanus vaccines, respectively. Only one patient with allergy to vaccines had gelatin specific IgE, whereas IgE to BSA was seen in 73.3%, 90%, 66.6% and 0 of vaccine, beef or CM allergic and non-atopic controls, respectively. The mean IgE to BSA was higher in patients with allergy to vaccines, although not significant. Specific IgE to BSA was present in 54.7% of children with allergy to CM, of whom 11.8% had high levels (>17.5 kUA/L). In contrast, 66.6% of these children did not have specific IgE to β-lactoglobulin, which is one of the major components of whey protein.Conclusion and clinical relevanceGelatin does not appear to play a major role in Sri Lankan children with allergy to vaccines. In contrast, due to the higher levels of BSA specific IgE, sensitization to BSA is possibly playing a role.     

The role of low-molecular-weight heparins in non-ST-segment elevation acute coronary syndromes

Acute coronary syndromes are believed to be mediated by plaque rupture, initiation of the coagulation cascade, and platelet activation and aggregation. Compared to unfractionated heparin, the low molecular weight heparins possess several important theoretical advantages for the treatment of patients with acute coronary syndromes, including less non-specific binding, resistance to inactivation by platelet factor-4, more reliable anticoagulation effects, and greater factor anti-Xa activity. Four large studies have compared low-molecular-weight heparin therapy with unfractionated heparin therapy in patients with acute coronary syndromes. Two studies involving enoxaparin (Lovenox) have demonstrated that this therapy results in a lower incidence of adverse events compared to treatment with unfractionated heparin. One study of dalteparin (Fragmin) and one of nadroparin (Fraxiparin) have demonstrated comparable results between these low-molecular-weight heparins and unfractionated heparin. Several studies of modest size have demonstrated that low-molecular-weight heparins can be safely combined with platelet glycoprotein IIb/IIIa inhibitors. Ongoing and upcoming studies should add to current knowledge of the utilization of low-molecular-weight heparins.     

临床输血反应调查及其影响因素

目的通过对各类成分血液输血反应发生率及其影响因素的调查和分析,以提高临床医护人员对输血反应的认识,增加针对性的预防措施。方法对阜阳市第五人民医院2011年1月—_2013年1月各科室的输血反应情况进行回顾性统计分析。结果在4303人次输血中,共发生输血反应20次,总输血反应率为0．46％。输血反应表现类型主要为溶血性发热反应最多见,占70．00％;其次是过敏反应,占30．00％。不同性别、年龄段、血液制品、输血史、过敏史的输血反应率差异均有统计学意义（均P〈0．05）。女性、输入全血、有输血史及过敏史是输血反应的危险因素。结论女性患者,有过输血史和过敏史的患者输血时需要医护人员加强观察,尽量少输入全血,根据患者需要采取成分输血,以减少输血反应的发生。     

Utilizing enoxaparin in the management of STEMI

The use of enoxaparin in conjunction with thrombolysis in ST-elevation acute myocardial infarction (STEMI), has been recently investigated in several clinical trials. In 8 published open-label studies including about 10,000 patients, in which enoxaparin was compared to either placebo or unfractionated heparin (UFH), a general superiority of enoxaparin on both reinfarction/recurrent angina and patency of the infarct-related artery, was observed. Overall, bleeding rate with enoxaparin was higher than with placebo and comparable to UFH, with the exception of one study where pre-hospital administration induced a doubled incidence of intracranial bleeding in patients older than 75 years. In a recent double-blind, randomized, mega-trial including over 20,000 patients, the superior efficacy on in-hospital and 30-day adverse cardiac events (namely reinfarction), and comparable safety on intracranial bleedings of enoxaparin compared to UFH, was definitively proven. In conclusion, initial intravenous bolus of enoxaparin followed by twice daily subcutaneous administration for about 1 week should be considered instead of intravenous UFH for the treatment of patients with STEMI receiving thrombolysis. Along with its easiness of use, not requiring laboratory monitoring, the subcutaneous administration of enoxaparin allows extended antithrombotic treatment, while permitting early mobilization (and rehabilitation) of patients.     

Food allergy knowledge,perception of food allergy labeling,and level of dietary practice: A comparison between children with and without food allergy experience

BACKGROUND/OBJECTIVESThe prevalence of food allergies in Korean children aged 6 to 12 years increased from 10.9% in 1995 to 12.6% in 2012 according to nationwide population studies. Treatment for food allergies is avoidance of allergenic-related foods and epinephrine auto-injector (EPI) for accidental allergic reactions. This study compared knowledge and perception of food allergy labeling and dietary practices of students.SUBJECTS/METHODSThe study was conducted with the fourth to sixth grade students from an elementary school in Yongin. A total of 437 response rate (95%) questionnaires were collected and statistically analyzed.RESULTSThe prevalence of food allergy among respondents was 19.7%, and the most common food allergy-related symptoms were urticaria, followed by itching, vomiting and nausea. Food allergens, other than 12 statutory food allergens, included cheese, cucumber, kiwi, melon, clam, green tea, walnut, grape, apricot and pineapple. Children with and without food allergy experience had a similar level of knowledge on food allergies. Children with food allergy experience thought that food allergy-related labeling on school menus was not clear or informative.CONCLUSIONTo understand food allergies and prevent allergic reactions to school foodservice among children, schools must provide more concrete and customized food allergy education.     

Seafood Allergy,Toxicity, and Intolerance: A Review

Seafood allergies have been increasing their presence in the last 2 decades. Allergic reactions to seafood can range from mild urticarial and oral allergy syndrome to life-threatening anaphylactic reactions. Ingestion of seafood infested with Anisakis larvae can cause a disease known as anisakiasis with symptoms similar to true seafood allergy. Furthermore, some adverse reactions to seafood including histamine fish poisoning (HFP), and intolerance to histamine can trigger clinical symptoms, which, although nonallergic in origin, are similar to true immunoglobulin E (IgE)-mediated allergic reactions. Because seafood allergy usually remains a lifelong food allergy, this review focuses on the current knowledge on fish and shellfish allergens and emphasizes the importance of differentiating seafood allergy from other allergy-like reactions (anisakiasis, HFP, and intolerance to histamine).

Key teaching points:

? Fish and shellfish are potent allergens that can provoke serious IgE antibody-mediated adverse reactions in sensitive individuals.

? Sensitization to seafood allergens can be achieved by ingestion, inhalation, or skin contact.

? Shellfish major allergen, tropomyosin, shares significant homology to arthropods (dust mites and cockroaches).

? Accidental exposures to seafood products cross-contaminated with fish or shellfish allergens (hidden allergens) during processing may present a health risk for sensitive individuals.

? Allergens of fish parasite A. simplex present common hidden allergens in seafood, particularly in raw and undercooked home-made fish dishes.

? Symptoms caused by HFP, histamine intolerance, and anisakiasis are similar to true seafood allergy.     

依诺肝素钠治疗急性心肌梗死的临床效果观察

目的观察依诺肝素钠治疗急性心肌梗死的临床效果。方法选取2018年9月至2019年9月我院收治的102例急性心肌梗死患者,依据不同的治疗方法分为对照组和研究组,各51例。对照组采用普通肝素,研究组采用依诺肝素钠。比较两组的血脂参数(LDL-C、 HDL-C、 TC)及不良反应情况。结果给药后,研究组的LDL-C、 HDL-C、 TC水平均明显低于对照组(P <0.05)。研究组的不良反应发生率为2.0%,明显低于对照组的13.7%(P <0.05)。结论采用依诺肝素钠治疗急性心肌梗死的临床疗效显著,安全性高,值得临床推广应用。     

IgE binding to unique hazelnut allergens: Identification of non pollen-related and heat-stable hazelnut allergens eliciting severe allergic reactions

Summary Background: Usually hazelnut allergic patients suffer from the tree pollen associated oral allergy syndrome (OAS) caused by cross-reactive structures. Anaphylactic reactions elicited by hazelnuts happen rarely but are of high clinical significance. Considering that hazelnuts are ingredients in processed foods, hazelnuts may play an important role as hidden allergens for these high risk patients. Therefore, we analyzed the IgE reactivity of a young woman with severe allergic reactions after ingestion of hazelnuts without any association to tree pollen allergy. Aim of the study: The aim of this study was to identify and characterize these potent hazelnut-specific allergens. We compared these allergens to structures displayed by sera from patients with a completely or partially non pollen-related hazelnut allergy and with birch pollen-related hazelnut allergy. None of the sera had a clinical history of anaphylaxis. Special emphasis was placed on the heat stability and cross-activity of these allergens. Methods/Results: Using Western blotting with extract from birch pollen and EAST inhibition techniques we were able to show that the allergens in the serum sample of the young woman were not cross-reactive with birch pollen. Immunoblot experiments with extracts from native and heated hazelnuts and EAST inhibition tests further characterized these allergens to be heat-stable. Unlike the IgE binding pattern of the sera from the patients with pollen-related hazelnut allergy, low molecular weight proteins below 10 kDa were identified by the sera from the patients without pollinosis. Conclusions: Since the binding pattern of the serum sample of the young woman was different from that of the sera from patients without pollen allergy but less severe symptoms, we assume an association between single non pollen-dependent hazelnut allergens in the low molecular range and severe allergic reactions. These results enable us to approach a subgroup of hazelnut allergens which we believe to be responsible for anaphylactic reactions in hazelnut allergic patients after ingestion of heat-stable hazelnut structures in processed food stuff, independent of pollinosis. Received: 14 March 2000, Accepted: 13 July 2000     

COVID-19 Vaccines in Children with Cow’s Milk and Food Allergies

The COVID-19 pandemic is the most challenging global health crisis of our times. Vaccination against COVID-19 plays a key role to control the current pandemic situation. The risk of allergic reactions to new COVID-19 vaccines is low. However, there is a debate on the safety in allergic patients following post marketing findings by different agencies. Our aim is to understand from current experiences whether children with cow’s milk or food allergy are at higher risk than a general population for allergic reactions to COVID-19 vaccines. Current data indicate that patients with a history of allergy to cow’s milk or other foods, even if severe, should receive COVID-19 vaccine in a setting with availability of treatments for anaphylactic reactions and under medical supervision. Recipients should be discharged after a protracted observation period of 30 min if no reaction developed.     

Cross-reactivity between aeroallergens and food allergens

In patients with respiratory allergy, cross-reactivity between aeroallergens and foods may induce food allergy, symptoms ranging from oral allergy syndrome to severe anaphylaxis. Clinical entities due to IgE sensitization to cross-reactive aeroallergen and food allergen components are described for many sources of plant origin (pollen-food syndromes and associations, such as birch-apple, cypress-peach and celery-mugwort-spice syndromes, and mugwort-peach, mugwort-chamomile, mugwort-mustard, ragweed-melon-banana, goosefoot-melon associations), fungal origin (Alternaria-spinach syndrome), and invertebrate, mammalian or avian origin (mite-shrimp, cat-pork, and bird-egg syndromes). Clinical cases of allergic reactions to ingestion of food products containing pollen grains of specific plants, in patients with respiratory allergy to Asteraceae pollen, especially mugwort and ragweed, are also mentioned, for honey, royal jelly and bee polen dietary supplements, along with allergic reactions to foods contaminated with mites or fungi in patients with respiratory allergy to these aeroallergens. Medical history and diagnosis approach may be guided by the knowledge about the diverse cross-reacting allergens involved, and by the understanding of these clinical entities which may vary significantly or may be overlapping. The association between primary IgE sensitization with respiratory symptoms to inhaled allergens and food allergy due to cross-reactive allergen components is important to assess in allergy practice. The use of molecular-based diagnosis improves the understanding of clinically relevant IgE sensitization to cross-reactive allergen components from aeroallergen sources and foods.     

Allergic reactions caused by latex: warning to health workers

In this study, a bibliographic survey is made of all articles, published during the last few years, dealing with allergic reactions to latex. The first article on allergic reactions associated with latex was published in Britain, in 1979. Since then, the number of cases reported have increased (Barton, 1993). Type I allergic reaction (immediate reaction) and Type IV (delayed reaction) are part of the latex allergic process (Steelman, 1995). Contact allergy is due to inadequate washing during manufacture, which results in the retention of water-soluble proteins that cause allergic reactions in susceptible people. A wide variety of allergic reactions that vary from contact dermatitis to anaphylatic shock are described in literature. These finding show that a health team must know the probable implications of latex allergy.     

LTP Allergy Follow-Up Study: Development of Allergy to New Plant Foods 10 Years Later

Introduction: Allergy to nonspecific lipid transfer protein (nsLTP) is the main cause of plant-food allergy in Spain. nsLTPs are widely distributed in the plant kingdom and have high cross-reactivity but extremely variable clinical expression. Little is known about the natural evolution of this allergy, which complicates management. The objective of this study was to assess the development of allergy to new plant foods in nsLTP-sensitized patients 10 years after diagnosis. Methods: One hundred fifty-one patients showing specific IgE to nsLTP determined by ISAC (Thermofisher) were included. After clinical workup (i.e., anamnesis, skin test, and challenge when needed), these patients were divided into two groups: 113 patients allergic to one or more plant food (74.5%) and 38 patients not allergic to any plant food (25.1%). Ten years later, a telephone interview was conducted to check whether patients had developed additional allergic reactions to plant foods. Results: Ten years after diagnosis, 35 of the 113 (31%) plant-food-allergic patients sensitized to nsLTP reported reactions to new, previously tolerated plant foods, mainly Rosaceae/Prunoideae fruits and nuts followed by vegetables, Rosacea/Pomoideae fruits, legumes, and cereals. Five out of 38 (13.2%) patients previously sensitized to nsLTP but without allergy to any plant food had experienced allergic reactions to some plant food: two to Rosaceae/Prunoideae fruits, two to Rosaceae/Prunoideae fruit and nuts, and one to legumes. Conclusion: Patients sensitized to nsLTP developed allergic reactions to other plant foods, mainly Rosaceae-Prunoideae fruits and nuts. This was more frequent among plant-food-allergic patients than among those who had never had plant-food allergy.     

Nasal and bronchial responses to flour-inhalation in subjects with occupationally induced allergy affecting the airway

Objectives: The aim of the study was to follow the similarities and differences, of cellular and mediator changes and mucosal/vascular permeability in the upper and lower airway after specific and nonspecific bronchial provocation, in bakers with diagnosed occupationally induced allergy affecting the airway. In addition, the authors try to find whether there is a relationship between cellular changes in nasal and bronchoalveolar lavage, and bronchial hyperreactivity. Methods: The study participants were 10 bakers with occupational bronchial asthma and allergic rhinitis. All patients were sensitized to investigated allergen-flour. Nasal- and bronchoalveolar lavage techniques were used to evaluate the changes of the cellular and mediator response (tryptase, eosinophil cationic protein, ECP) and albumin level after specific (flour) and placebo provocation. In addition, bronchial hyperreactivity for histamine, and forced expiratory volume in 1 s (FEV₁) were measured after the challenge. Results: There was a significant increase in the percentage of eosinophils, basophils and albumin in nasal and bronchoalveolar lavage of occupationally sensitized bakers. A statistically significant increase in the percentage of neutrophils in bronchoalveolar lavage was observed only 24 h after the allergen challenge. The level of tryptase in nasal lavage was significantly higher during the early allergic response. The levels of ECP in both nasal and bronchoalveolar lavage were significantly increased during the late allergic response. There were also severe bronchial reactions and increase of bronchial hyperreactivity for histamine in occupationally sensitized bakers in the late phase of allergic reaction. Conclusion: Eosinophils and basophils proved to be the predominant cells in nasal and bronchoalveolar lavage of patients with occupationally induced bronchial asthma and rhinitis. The prolonged increase of albumin level seems also to be a good predictor of protracted nasal and bronchial inflammation. The results obtained confirmed that tryptase and ECP are good markers for monitoring mast cell and eosinophil degranulation during the allergic reaction. Increase of airway responsiveness reflects an eosinophil and basophil contribution to airway allergic response. Received: 24 June 1999 / Accepted: 25 April 2000     

Problematik ?versteckter Allergene“ in Lebensmitteln aus Sicht des allergischen Verbrauchers

Despite improved allergen-labeling and careful avoidance strategies, hidden allergens in food are a substantial risk for unintended reactions in food allergy sufferers. Unpublished data from a survey of the German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund, DAAB) show that 85% of 738 questioned food allergic patients have experienced at least one allergic reaction from each prepacked products as well as food sold loose. Almost half of the participants said to have not received information of a food allergen as an ingredient or possible trace on the label. Different possibilities are discussed under which food allergens can be hidden in processed products, like incomprehensible labeling, labeling gaps, unexpected occurrence of allergens as well as cross contaminations or allergens in loose products. To each of the seven highlighted sources of hidden allergens in food, practical examples are given as well as proposals for the improvement of the situation from consumer view. The aim is to indicate possibilities and measures for politics and industry by which allergic consumers and their social circle are able to make an informed choice concerning the safe consumption of a certain product and to protect themselves from unintentional reactions.     

Food allergy: nuts and tree nuts

Nuts are a well-defined cause of food allergy, which affect approximately 1 % of the general population in the UK and the USA. There do appear to be differences in the frequency of nut allergy between different countries because of different dietary habits and cooking procedures. For example, in the USA and France, peanuts are one of the most frequent causes of food allergy, but in other countries, it seems to be less common. Genetic factors, in particular, appear to play a role in the development of peanut allergy. While the majority of nut allergens are seed storage proteins, other nut allergens are profilins and pathogenesis-related protein homologues, considered as panallergens because of their widespread distribution in plants. The presence of specific IgE antibodies to several nuts is a common clinical finding, but the clinical relevance of this cross-reactivity is usually limited. Allergic reactions to nuts appear to be particularly severe, sometimes even life-threatening, and fatal reactions following their ingestion have been documented. Food allergy is diagnosed by identifying an underlying immunological mechanism (i.e. allergic testing), and establishing a causal relationship between food ingestion and symptoms (i.e. oral challenges). In natural history investigations carried out in peanut-allergic children, approximately 20 % of the cases outgrew their allergy or developed oral tolerance. The treatment of nut allergies should include patient and family education about avoiding all presentations of the food and the potential for a severe reaction caused by accidental ingestion. Patients and families should be instructed how to recognise early symptoms of an allergic reaction and how to treat severe anaphylaxis promptly.     

Latex allergy. Clinical manifestations in the general population and reactivity crossed with foodstuffs

Because of widespread latex manufacturing in the last decades, latex allergy has become an important clinical problem, not only in high-risk groups (health-workers) but also among the general population. Latex is used to produce a large variety of natural rubber products (medical equipment, household gloves, condoms, balls and balloons, footwear, baby pacifiers...) employed in the ordinary life, with high risk for patients allergic to latex. Among general population, children affected by myelomeningocele or spina bifida, have a higher risk to develop latex allergy. Clinical manifestations range from local reactions(contact dermatitis, urticaria), rhino-conjunctivitis, asthma, pharyngeal edema to severe systemic reactions such anaphylactic shock. Furthermore, latex can crossreact with some plant foods, and patients suffering from latex allergy often associate food allergy.     

输血患者不良反应的临床特点及其相关影响因素分析

目的分析输血患者发生不良反应的临床特点,并对可能引起输血不良反应发生的相关因素进行探讨。方法2015年1月—2015年12月,安康市中心医院各临床科室3 127例输血患者为研究对象,对出现输血不良反应患者的输血类型、临床特点以及可能导致发生输血不良反应的相关因素进行分析。结果 3 127例输血患者输血不良反应发生率0.512%(16/3 127),其中过敏反应发生率0.352%(11/3 127)、发热反应发生率0.160%(5/3 127),无溶血反应发生,无其他不良反应发生;前三位发生输血不良反应的血液成分依次为机采血小板、红细胞悬液以及血浆,发生率分别为0.288%、0.160%和0.064%;且机采血小板输血不良反应发生率显著高于红细胞悬液和血浆输血不良反应发生率(P0.05);年龄小于18岁的患者、有输血史患者以及有过敏史患者输血不良反应发生率明显高于年龄18岁以上的患者、无输血史患者以及无过敏史患者,差异有统计学意义(P0.05);血液病组患者输血不良反应发生率显著高于非血液病组,差异有统计学意义(P0.05);儿童血液病区患者输血不良反应发生率显著高于输血科患者,差异有统计学意义(P0.05)。结论临床输血对年龄18岁、有输血史、有过敏史的患者进行输血治疗时应严密监视以防止输血不良反应的发生。积极使用白细胞过滤器有利于减少输血不良反应的发生。