Conjonctivite allergique : un mécanisme inhabituel

A case of chronic conjunctivitis in an infant in Provence, symptoms being present in the first three months of the year, allowed us to observe both a positive delayed (48 h) contact skin test and a positive delayed (24 h) conjunctival provocation test (CPT) to cypress; immediate skin tests were negative or doubtful. Specific sublingual desensitization resulted in regression of the symptoms, but the young patient could not swallow the extract without triggering painful pharyngeal symptoms. Delayed sensitization is unusual in this sort of condition and shows the importance of delayed reading of CPTs as well as the utility of patch tests with aeroallerens.     

The necessity of culture for the diagnosis of tinea pedis

BACKGROUND: This study examined the consistency between the clinical diagnosis of tinea pedis and the results of direct fungal examination, prepared with 10% potassium hydroxide, and culture. METHODS: 2,427 patients clinically diagnosed with tinea pedis who presented to the mycology laboratory were reviewed retrospectively for the outcomes of direct fungal examination and culture. RESULTS: Direct examination was positive in 54.3% and culture was positive in 36.6% of the cases. The sensitivity and specificity of direct microscopy were 95.7% and 69.6%, respectively CONCLUSIONS: The clinical diagnosis of tinea pedis can be misleading, since it features lesions that can also be present in some other skin diseases and direct microscopy may be insufficient to confirm the diagnosis. Therefore, we suggest using culture for a definitive diagnosis.     

Frequency of culture-proven dermatophyte infection in patients with suspected tinea pedis

BACKGROUND: This study examined the incidence of culture-proven tinea pedis in patients who presented with a foot rash clinically suspected to be tinea pedis. METHODS: Cultures were taken from 874 patients in 4 dermatology clinics across the country. The incidence of patients with positively cultured tinea pedis was compared with the total number of patients in the study. RESULTS: The surprisingly low percentage of patients correctly diagnosed with tinea pedis was determined to be 32%. The remaining 68% of patients either had a nonfungal foot dermatitis or tinea pedis with false-negative cultures. CONCLUSIONS: This study demonstrates the need for fungal cultures when patients present with scaling feet as well as the importance of a broad differential diagnosis to ensure timely and appropriate therapy.     

Mycotic infections. Effective management of conditions involving the skin, hair, and nails

Superficial mycotic infections of the skin, hair, or nails are recurring presentations in the geriatric primary care setting. The most common infections are those caused by dermatophytes. The genus Trichophyton gives rise to most of the tinea dermatophytoses, including tinea capitis, tinea pedis, and tinea unguium (onychomycosis). Part of the diagnostic challenge lies in distinguishing the mycotic lesions from those caused by cutaneous diseases such as psoriasis, eczema, dyshidrosis, and contact dermatitis. Because environmental conditions play a major role in fungal infection onset, clinical management should include patient education about conditions conducive to fungal propagation. Oral agents are the primary mode of treatment for fungal infections of the scalp and nails, whereas topical treatments are frontline agents for other superficial skin conditions.     

The reaction to trichophytin in dermatophytoses]

The authors investigated the specific immunological competence of 31 patients with dermatophytosis using tricophytin antigen. Among them, 54.8% showed reaction to the delay phase (48 h) in the following proportions: tinea inguinale, 75%; tinea pedis, 61.5%; tinea unguium, 50% and tinea corporis, 20%. Other 62.5% showed positive result to the early phase (30 m). The association between these reactions revealed that, although the majority of cases with early positive reaction showed negativity to the delayed reaction, 20.8% presented positively to both phases of the reaction. Out of the non-reactive patients to the delayed phase, 8 were submitted to the other cutaneous tests such as PPD, streptokinase, candidin, vaccinia and DNCB and showed preserved cellular immunity in 75%. These results suggest that, while using this reaction for immunological evaluation of patients with dermatophytosis, one should consider the overall immune status of the patient, the presence of early hypersensibility and the localization of the infection.     

Allergic contact sensitivity in elderly patients

BACKGROUND AND AIMS: Aging has been shown to be correlated with the rate and type of contact sensitization, but only a few studies have evaluated patch test reactivity in elderly subjects with an adequately large population. METHODS: The response patterns to patch testing in 1444 elderly subjects (>65 years) with suspected allergic contact dermatitis were studied, and the results compared with a control group of individuals with suspected allergic contact dermatitis, aged between 20 and 40 years. RESULTS: The prevalence of the positive patch test to at least one hapten was significantly lower in the group of elderly patients compared with adult patients (40.7 vs 47.8%, p<0.0001). However, some allergens, i.e., primin, diaminodiphenylmethane, neomycin, lanolin alcohols, paraben mix, Euxyl K400 and quinoline mix, showed an increased sensitization rate in elderly patients compared with adult patients. These allergens are now less frequently employed in the workplace, or are substances particularly used in the formulation of topical treatment of age-related diseases, i.e., leg ulcer and xerosis. It was also found that the intensity of positive patch test reactions was significantly lower in elderly patients compared with younger subjects, with higher proportions of weak (+) positive reactions. Moreover, elderly patients showed a dynamic pattern of increasing intensity of patch test reactions at the second reading after 3 days compared with the first reading after 2 days more frequently than younger patients (60 vs 53%, p<0.0001). CONCLUSIONS: These findings suggest an age-dependent decline of overall positive patch test reactions, but a higher sensitization rate to some allergens frequently used in the composition of topical treatments. The development of an allergic response in elderly patients was found to be delayed, and this may require an additional reading after 7 days and the interpretation of even weak reactions as valid positive patch test reactions.     

The prevalence of skin eruptions and mycoses of the buttocks and feet in aged care facility residents: A cross-sectional study

The prevalence of skin mycoses in the elderly remains unclear. The proportion of people with skin eruptions who are positive for mycoses using direct microscopy is not known. The purpose of this study is to identify the prevalence of skin eruptions and skin mycoses (e.g. candidiasis and tinea) in the buttocks and feet, which are common sites of skin mycoses in residents of long-term care facilities. This multi-site cross-sectional study used visual inspection and direct microscopy to diagnose the type of skin eruption. Subjects were residents of facilities covered by long-term care insurance schemes in Japan. Of the 171 residents enrolled in this study, 72.5% had a skin eruption. Only 4.8% of participants had tinea in the buttocks; 2.4% had buttock candidiasis. In those with a nail abnormality, 58.3% of residents had tinea unguium. For tinea pedis, residents who had any form of interdigital or plantar region skin eruption, 22.5% and 31.4% of residents were positive, respectively. The prevalence of observed skin mycoses was: buttock candidiasis 1.8%; buttock tinea 3.5%; tinea unguium 56.2%; interdigital tinea pedis 20.5%; and plantar tinea pedis 22.5%. The very low proportion of residents with mycoses in the buttocks suggests that anti-inflammatory agents, such as steroids, should be used as first choice. Our observation that not all residents with skin eruptions on the feet had tinea, should remind clinicians to perform direct microscopy before initiating antifungal treatments.     

Quoi de neuf en allergologie pédiatrique en 2005 ? Partie 1 : épidémiologie,diagnostic précoce et prévention (une revue de la littérature internationale d'octobre 2004 à octobre 2005)

The most important notions published in 2004–2005 concern a positive relationship between the risk of in utero sensitization and allergen levels in maternal blood, a neonatal deficiency of immune responses to microbial components in atopy-prone children, varying patterns of sensitization to aeroallergens, with frequent remittance of early sensitizations to seasonal allergens, in contrast with persistence of sensitizations to perennial allergens, an increased risk of sensitization to aeroallergens in children exposed to long-term background ambient air pollutants, an increased risk of polysensitization in siblings of polysensitized children, and a low efficacy of rigorous dietary egg exclusion during gestation and breastfeeding. The relations between the risk of childhood atopy and maternal parity, neonatal and perinatal conditions, vaccinations and infectious diseases in infancy, and early exposure to pets remain controversial. The predictive value of biological tests in newborns (total serum IgE determination and eosinophil count) is still disputed. Finally, several studies confirm the end of the allergy « epidemics » in Europe, although the prevalence of childhood allergic diseases is still increasing in Eastern European countries.     

Choc anaphylactique à l'Augmentin chez une patiente présentant des tests cutanés et un test de provocation négatifs à l'amoxicilline

Mme M. was seen in consultation with a history of possible allergy to penicillin. The patient reported that three months earlier she had experienced the sudden onset of a generalized but not very severe urticarial reaction, which included swelling of the face, beginning four days after taking amoxicillin, but not any other medication. She was not aware of any previous reaction associated with taking any drug, including penicillin. Skin tests with major and minor penicillin determinants, and then with amoxicillin, up to a concentration of 20 mg/ml intradermally were negative. It was then elected to do an oral provocation test with amoxicillin. She tolerated a single 1 g oral dose perfectly well. Eighteen months later, she was seen again following an episode of anaphylactic shock that had begun immediately after taking 1 g of amoxicillin associated with clavulanic acid (Augmentin^®). Between the two consultations, the patient had received no betalactamines, whereas she had tolerated two courses of treatment with macrolides. At the second consultation, skin tests with penicilloyl-polylysine and amoxicillin were definitely positive. This observation suggests two hypotheses, which are not however mutually exclusive: 1) The low predictive value of skin and provocation tests in patients weakly sensitized (Could such patients continue treatment with amoxicillin for several more days?); 2) the possibility that an initially weak sensitization was potentiated by the skin and provocation tests (Is it advisable to systematically do a second allergy workup several weeks after the first one to exclude the possibility of sensitization in this type of patient?).     

Les réactions allergiques et pseudoallergiques aux antalgiques,antipyrétiques et anti-inflammatoires non stéroïdiens

Antalgics, antipyretics and non-steroidal anti-inflammatory drugs (NSAIDs) are widely used, but suspected allergic reactions to these drugs are rare, especially in children. Most frequent reactions are cutaneous (urticaria, angioedema) and respiratory (rhinitis, asthma). Other reactions (anaphylaxis or anaphylactoid reactions, potentially harmful toxidermias) are rare. In a few patients, reactions may result from a specific (allergic) hypersensitivity (HS), with positive responses in prick and intradermal tests (anaphylaxis, immediate urticaria and/or angioedema) and in intradermal and patch tests (non-immediate reactions). However, most reactions result from a non-specific (non-allergic) HS (intolerance), with a frequent cross-reactivity between the various families of antalgics, antipyretics and NSAIDs, including acetaminophen (paracetamol). Based on a convincing clinical history and/or positive responses in challenge tests, intolerance to antalgics, antipyretics and NSAIDs has been diagnosed in 13 to 50% of the patients with allergic-like reactions to these drugs. Risk factors for HS to antalgics, antipyretics and NSAIDs are a personal atopy and age. In our experience, 50% of the children with allergic-like reactions to antipyretics, antalgics and NSAIDs were diagnosed intolerant to these drugs. Risk was high in children reporting reactions to NSAIDs (aspirin, ibuprofen) and lower in children reporting reactions to paracetamol. All the children intolerant to paracetamol were also intolerant to NSAIDs. In contrast, most children with NSAID intolerance were tolerant to paracetamol. A personal history of atopy and a mean age ≥ 8 years were significant risk factors for intolerance to antalgics, antipyretics and NSAIDs.     

Aspects cliniques et étiologiques des uvéites : étude rétrospective de 121 patients adressés à un centre tertiaire d’ophtalmologie

Purpose

Uveitis consists of a large group of diseases characterized by intraocular inflammation involving the uveal tract. This heterogeneity makes the diagnosis and the treatment of uveitis frequently challenging. The purpose of this study was to describe the various clinical and etiologic aspects of uveitis, through the new standardized uveitis classification and the use of modern investigations for its diagnostic work-up.

Methods

The medical records of 121 new patients with uveitis referred to our tertiary ophthalmologic centre between January 2002 and December 2006 were retrospectively reviewed. Uveitis associated to human immunodeficience virus and secondary to exogenous endophthalmitis were excluded. All patients had a complete ophthalmological examination and appropriate clinical and paraclinical examination. The diagnosis was established according to the recent international criteria.

Results

One hundred and twenty-one patients were included. The four main etiologies were: toxoplasmosis (14%), sarcoidosis (11.6%), spondylarthritis or HLA B27-associated uveitis (13.2%) and Herpes virus infections (9.1%) that represented almost half of the uveitis causes (47.9%). Various diseases constituted the remaining causes of the uveitis (20.9%). Uveitis remained unexplained in the remaining 36 patients (29.7%). Overall, associated systemic diseases were diagnosed in 35.5% of our uveitis patients (34 patients), associated infectious conditions in 26.4% (32 patients) and specific ocular diseases in 8.3% (12 patients).

Conclusion

Despite a limited number of patients, our study showed an etiologic distribution similar to that of the main series reported in the literature. Nevertheless, we observed an elevated frequency of sarcoidosis and systemic diseases, which emphasizes a management that takes into account standardized clinical and paraclinical criteria and the usefulness of a collaboration with the internist.     

Role of aeroallergens in the etiopathogenesis of atopic dermatitis

Atopic dermatitis is a chronic relapsing inflammatory skin disease. It is most frequent in childhood and its clinical manifestations vary with age. The etiopathogenic mechanisms that explain this process are still poorly understood; several studies performed in adults speculate on the possible role of aeroallergens through direct contact with the skin but, because the etiology of this disease varies with age, studies in children of different ages are required.Aims: (i) To determine whether children with atopic dermatitis are sensitized to inhalant allergens. (ii) To determine whether these inhalant allergens cause dermatitis or whether they provoke allergic respiratory disease (asthma, rhinitis) concomitant with atopic dermatitis. (iii) To evaluate whether sensitization to a particular allergen takes place at any age or whether there are differences according to age.Material and methods: This study was performed in the following groups: (i) 64 children with atopic dermatitis, divided into two subgroups, one consisting of 37 children who also presented allergic respiratory disease (asthma, rhinitis) (AR) and another subgroup of 27 patients who presented atopic dermatitis only. (ii) Control group: eight children who presented AR only, to determine whether this group reacted to patch testing with inhalant allergens. (iii) Control group: seven healthy children to rule out non-specific positive tests in the non-atopic population. All groups were divided by age according to the phases of atopic dermatitis: early childhood phase (< 2 years): 21, childhood phase (2-10 years): 37, adolescent phase (> 10 years): 21. In all children total serum IgE determination (RIA), allergen-specific IgE determination (RAST), prick- and patch test were performed. In the three tests the same allergens were used, consisting of the usual components of standardized inhalant and food allergens. When the results of patch testing were positive, biopsy and histopathological analysis were performed and monoclonal antibodies were used to determine reproducibility of the eczematous lesion.Results: Sensitization was found to differ among patients with atopic dermatitis according to whether they presented respiratory symptoms and according to age with a clear predominance of food sensitization in the group aged less than 2 years. In the group aged 2-10 years, mixed sensitization predominated, mainly because of simultaneous respiratory involvement, but it is highly probably that inhalant allergens participate in the etiopathogenesis of atopic dermatitis. In children aged more than 10 years sensitization to inhalant allergens predominated as most presented respiratory symptoms. Patch testing was positive in 34.3 % of patients with atopic dermatitis and approximately half were positive to dust mites. The patch test is of great diagnostic value in atopic dermatitis and none of the tests were positive in the control group. All the biopsies of patch tests with inhalant allergens reproduced the lesions typical of eczema, demonstrating their involvement in the etiopathogenesis of dermatitis.     

Epidemiological study of periocular dermatitis in a specialised hospital department

Contact dermatitis is frequent skin pathology and eyelids are one of the more frequent locations of this pathology. The objective of the present work was to study the population distribution of periocular dermatitis, determine the allergens which most frequently indicate positive in patch tests and in provocative use tests, and analyse the clinical relevance of the positive tests.Patients with periocular dermatitis (N=93) underwent a thorough physical examination and a patch test with standard series. According to clinical suspicions, 76 patients underwent a patch test with specific series. Finally a provocative use test was done for 36 patients with suspected products that the patients brought. The tests were classified according their relevance.The most frequently observed allergen in the patch tests (with standard and specific series) was nickel followed by mercury, and anti-glaucoma drops in the provocative use tests with patients products.Patients' sex, age, occupation, clinical status, presence of associated periocular symptoms, and presence of atopic or seborrheic dermatitis and/or rosacea did not relate with relevance.We conclude that a clinical diagnosis may not always be made with patch tests with standard and specific series due to lack of relevance. It is important to do provocative use tests with the products suspected as allergens in those cases where patch tests with standard and specific series indicated positive for more than one allergen.     

Allergie aux protéines du lait et aux hydrolysats de protéines de lait : à propos d'une observation au diagnostic retardé

The authors report the case of an infant with a history of eczema due to cow milk and who later had two bouts of urticaria after drinking milk protein hydrolysate. The particular interest in this case is the disconnection between the onset of the eczema (when an allergy workup was not predictive) and the subsequent finding, one year later, of positive IgE-dependant sensitization tests.     

Thrombopénie immunoallergique à la rifampicine : à propos d'un cas

Rifampicin can induce toxic and hypersensitivity reactions. However, immediate hypersensitivity (IgE-mediated) reactions are rare. In contrast, other types of reactions, among which are the immunoallergic thrombocytopenias, are not exceptional. We report the case of a 73 year-old man with pleural tuberculosis who reported having hemorrhagic and purpuric symptoms five hours after beginning treatment with rifampicin, isoniazid and pyrazinamide. A diagnosis of rifampicin-induced immunoallergic thrombocytopenia was made, based on extrinsic and intrinsic etiological criteria, despite a negative specific serum antibody assay and a borderline positive rifampicin skin prick test. No previous treatment with rifampicin was reported by the patient, except for prior prolonged self-administration of eye drops that may have contained rifampicin. This adverse effect cannot be explained by an immediate type hypersensitivity reaction, but probably resulted from a type II or III hypersensitivity reaction, as suggested in the literature. The short interval between the beginning of treatment and the onset of symptoms may have been a consequence of earlier sensitization to rifampicin-containing ophthalmic drops. In conclusion, we report a case of rifampicin-induced immunoallergic thrombocytopenia. This case illustrates the limits of diagnostic tests for drug allergy, especially for type II and III hypersensitivity reactions. It also raises the question of the sensitizing potential of drugs administered locally, as well as the question of the necessity of informing physicians and patients of this possibility.     

Réflexes autonomiques cardiovasculaires dans le syndrome de tachycardie orthostatique idiopathique

Postural orthostatic tachycardia syndrome (POTS) is a badly known pathology because its diagnosis is not based on the conventional methods of investigation. The orthostatic test allows to make the diagnosis easily. The objective of this study is to determine cardiovascular autonomic reflexes of 70 patients having POTS. The tests of exploration of the autonomic nervous system practised are: deep breathing, hand grip, mental stress and orthostatic test. The analysis of orthostatic test showed that the increase of the cardiac frequency, relative to the state of “β” peripheral sympathetic hyperactivity occurred before the 2nd minute in 80% of patients. The POTS was considered “florid” in 43% of patients and had complicated of a rough and severe fall of systolic blood pressure inferior to 70 mmHg in four patients, after the fifth minute of the test. The analysis of the different tests had shown vagale hyperactivity in 63% of patients on deep breathing, in 93% of patients on hand grip and in 100% on orthostatic test. The “α” central sympathetic activity was increased in 76% of the cases and “β” central sympathetic activity was high in 83% of cases. The “α” peripheral hyperactivity was observed in 63% of patients on hand grip, and in 44% on orthostatic test. The analysis of cardiovascular autonomic reflexes on patients affected by POTS allowing the determination of their autonomic profile, will contribute probably to a better understanding of this pathology and to a better orientation of its care.     

洗涤剂椰油酰胺丙基甜菜碱过敏

目的观察洗涤剂椰油酰胺丙基甜菜碱（CAPB）在北京协和医院变态反应科接触性皮炎患者中的斑贴试验阳性率。方法对本科门诊湿疹患者进行常见的10种接触性过敏原的斑贴试验：香料混合物、柳硫汞、咪唑烷基脲、甲醛、凯松CG、对苯二胺、硫酸镍、重铬酸钾、氯化钴和CAPB，观察CAPB的阳性率。结果在进行斑贴试验的562例湿疹患者中。CAPB阳性5例，其中4例为全身皮炎，1例为面部皮炎。5例进行相关化妆品或洗涤用品的斑贴试验均有阳性反应。结论本院接触性皮炎患者中的CAPB阳性率低于其他报道，但考虑到洗涤剂的广泛应用,应在怀疑化妆品过敏引起的湿疹皮炎患者中常规进行CAPB斑贴试验。     

Is There a Need for Repetition of Skin Test in Childhood Allergic Diseases? Repetition of Skin Test and Allergic Diseases

Background: Skin prick tests are widely used to determine sensitivity in allergic diseases. There is limited information about the natural history of skin sensitization tests and factors that affect them. It was aimed to determine the changes in skin test results and the factors affecting the reactivity of skin tests after a period of approximately four years in children with allergic disease.Methods: SPT of 170 patients among 2485 children with asthma and/or allergic rhinitis and/or atopic dermatitis, who underwent SPT between 2005 and 2007, were repeated after an interval of at least 3 years.Results: The mean age was 10.7 ± 3.1 (5-18) years and 70% of the patients were male. In total 66 (39.0% of the study population) had a different skin tests result in follow-up. Alterations: loss of sensitivity in 18 (11%) patients, the formation of a new sensitivity in 37 (22%) patients, and 11 (6%) both gained and lost sensitization. The presence of atopy in the family, the presence of allergic rhinitis and IgE elevation significantly predicted the incidence of new sensitization. The presence of sensitization to multiple allergens significantly predicted the incidence of loss of sensitization.Conclusions: It is found that there was an alteration of sensitization in 4/10 children at the end of the average 4-year period. The presence of family atopy, the presence of allergic rhinitis and serum total IgE elevation were risk factors for the development of new sensitization. On the other hand sensitization to multiple allergens was risk factors for the loss of sensitization.     

Orientation des patients par leur médecin généraliste vers les secteurs hospitaliers publics ou privés en France : étude épidémiologique prospective du réseau Sentinelles

Purpose

In-patients characteristics generate cost differences between hospitals. In France, there are few data on the characteristics on the patients referred to hospitals by their general practitioners (GPs) and none on the predictors of referral to the public or for-profit hospitals. The aim of this study was to analyze those characteristics and the predictors of referral to the public or for-profit hospitals.

Methods

We collected, prospectively, the request for hospitalizations made by the GPs of the Sentinelles network in France, from 2007 to 2009. Patients’ characteristics and also the reasons for that request were analyzed. A logistic regression was used to compare the population between local hospitals.

Results

Ten thousand seven hundred and eighteen statements were collected. The median age was 73 years. Patients were women in 51% of the cases, and only 14% of the hospitalizations had been planned. Hospitalization in the public sector was preferred for young children and the elderly (P < 0.001). When compared to the patients referred to the private sector, patients addressed to the public sector were more often seen for emergencies (OR: 2.3 [2.0–2.8]), by a doctor different from their referring GP (OR: 1.7 [1.4–2.1]) and out of the GP's office. The reasons for hospital admission were different depending on the sector of hospitalization (P < 0.001), patients addressed to the public sector hospitals presented with greater comorbidity or more complex diagnosis (for example: feeling ill, fainting or syncope and fever) or a greater disability (for example: stroke, neurological and psychiatric diseases).

Conclusion

This study suggests that GPs send their patients to the public or for-profit hospitals according to criteria of severity, comorbidity and disability.