Allergien und pseudoallergische Reaktionen auf Narkosemittel Klinische Symptomatik, Risikofaktoren und Nachweismöglichkeiten

Zusammenfassung Nahezu alle im Rahmen einer An?sthesie eingesetzten Medikamente k?nnen überempfindlichkeitsreaktionen ausl?sen, die einer akuten Typ-I-Allergie bzw. einer mehr oder minder schweren Intoleranzreaktion entsprechen k?nnen, in seltenen F?llen mit letalem Ausgang. Ein pr?operatives „screening” hat trotz der erh?hten H?ufigkeit der m?glichen Risikofaktoren (Atopie, Allergien anderer Art etc.) im Kollektiv der Kranken mit überempfindlichkeitsreaktionen auf Narkosemittel einen geringen pr?diktiven Aussagewert. Eine sorgf?ltige allergologische Diagnostik ist 4–6 Wochen nach einem Narkosezwischenfall mit Verdacht auf überempfindlichkeitsreaktionen auf Medikamente notwendig. In erster Linie kommen die Hautteste für die Muskelrelaxanzien und Injektionsnarkotika in Frage, weniger für die volatilen Narkotika und die Opioide. Die Diagnose kann je nach Verfügbarkeit durch RAST- bzw. RIA-Teste bzw. durch Testversuche, die die Freisetzung von Mediatoren erfassen, erweitert werden. Neben den im konkreten Fall applizierten Pr?paraten sollten auch alle bekannten Muskelrelaxanzien (Suxamethonium, Vecuronium, Pancuronium, Alcuronium, Atracurium, Mivacurium) getestet werden, die oft Ursache derartiger Reaktionen sind. Unsicher erscheint die Relevanz der Hautteste im Hinblick auf einige Substanzklassen, z.B. Inhalationsnarkotika und Opioide. Für leichtere, nicht lebensbedrohliche Zwischenf?lle, die mit Pruritus und Arzneimittelexanthemen einhergehen, erscheint die Hauttestung nicht immer aussagef?hig. Eingegangen am 13. Juni 1996 Angenommen am 16. April 1997     

Immunologische Grundlagen des atopischen Ekzems

Atopic eczema is considered as the cutaneous manifestation of atopy. Atopic dermatitis is most likely a T-cell mediated inflammatory skin disease resulting first in acute dermatitis, which then leads to eczema. The diagnosis of atopic eczema is based on a score system that includes four clinical major criteria and large series of conditional minor criteria, including elevated serum IgE levels . The definite diagnosis of atopic dermatitis requires three major and three minor criteria (Table 1). Despite the close association of atopic dermatitis with the other manifestations of atopy and the established role of T cells in the induction of atopic eczema, the immune mechanisms underlying atopic eczema are far from being resolved. It is currently believed that the high sensitivity to toxic stimuli and a hypersensitive immune system, reacting to normally harmless protein antigens, the allergens, initiate an inflammatory cascade that ultimately leads to the eczema.     

Diagnostik des Asthma bronchiale

Zum Thema Das Asthma bronchiale ist eine Erkrankung, die mit einer chronischen, charakteristischen Entzündung der Atemwege einhergeht. Der Entzündungsproze? führt zu Symptomen, einer überempfindlichkeit der Atemwege sowie einer obstruktiven Ventilationsst?rung mit reversibler Komponente. Die Methoden zur Diagnostik des Asthma bronchiale erlauben eine frühzeitige Diagnostik. Die Einleitung einer angemessenen Therapie ist die Voraussetzung für eine regelrechte Prognose der Erkrankung bei uneingeschr?nkter Lebensqualit?t. Das Ausma? der Entzündung der Atemwege kann heute mit nicht-invasiven Verfahren (induziertes Sputum, Messung der NO-Konzentration in der Ausatemluft) bestimmt werden. Diese Techniken sind hilfreich zur Therapieoptimierung.

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Le formaldéhyde inhalé et la réponse bronchique

Formaldehyde is a chemical pollutant that is ubiquitous in indoor environments. Exposure to high concentrations in occupational environments has revealed its irritant and allergenic character. However, low levels of exposure in households can likewise have an effect on respiratory health in a non-specific manner, as is equally the case with other pollutants. Augmentation of the response to allergen by formaldehyde has been demonstrated in animals and in children. An effect has also been observed on respiratory symptoms, with the risk of asthma being increased by 39% with domestic exposure to more than 60 μg m⁻³. We have recently been able to show in a study involving mite-sensitized asthmatics that bronchial provocation tests with an allergen are augmented after exposure to 100 μg m⁻³ of formaldehyde for 30 min. All data show that exposure in households to a low concentration of formaldehyde is sufficient to induce sensitization but it can also aggravate symptoms of patients with allergic asthma. Considering the published evidence, it is agreed that the concentrations of formaldehyde in products used in households should be known in order to allow improvement in the quality of indoor air.     

Histoire de l'allergie alimentaire : des précurseurs à l'histoire contemporaine

Food allergies are an important public health problem. Relatively unheard of during the 1970–1980 s, they had almost always been associated with the same allergens (cow milk, chicken eggs, and fish). Since then, they have become more frequent and more varied, involving about 4% of the general population of all ages; the prevalence may even be 5–6% or more among children. They are also becoming more and more severe, and interfering more in daily living. Beginning in the 1980 s, the story of food allergy has been marked by the explosion of the occurrence of peanut allergy, the prevalence of which has at least doubled over the past five years. Another important tendency has been an increase in the frequency of allergy to shelled fruits (e.g. exotic nuts) and to certain plant allergens (e.g. sesame, buckwheat and wheat). There has also been an increase in the number of near-fatal and fatal cases of food-related anaphylaxis, justifying the establishment of a monitoring network. The workup of food allergies has become more standardized, allowing a definitive diagnosis to be more easily established, thus justifying avoidance of the responsible substance. Indeed, until recently, in the absence of effective preventive measures and a good risk-benefit ratio, the prevention of food allergies depended on avoidance of the responsible food(s), which recommendation is nevertheless often not followed as prescribed. Other preventive measures (antihistamines, corticosteroids, adrenalin auto-injectors) are then adopted to avoid recurrences, which can be considered as evidence of treatment failure. Recent years have been marked by standardization of preventive measures based on the Project of Individual Care and by the establishment of educational protocols. The future may see the development of specific immunotherapy (until now, difficult and dangerous), modification of food allergens, and treatments that block IgE-dependant allergic reactions. For example, the preliminary results of a clinical trial of sublingual immunotherapy with hazelnut appear to be promising. Considering the difficulty of diagnosis and prevention, the social and psychological repercussions of food allergies are considerable for both children and their families.     

Un cas de syndrome de Hoigné lors d’une injection intraveineuse de ceftriaxone

Introduction

Hoigne's syndrome is characterized by the development of acute clinical manifestations which are mainly psycho-sensorial. Classically, these features immediately follow the injection of procaine penicillin G.

Case report

We report a 59-year-old man who presented with psycho-organic manifestations that occurred just after the intravenous injection of ceftriaxone; to our knowledge, this is the first case of Hoigne's syndrome reported after an injection of this antibiotic.

Conclusion

The pathophysiologic basis of this syndrome is still unknown. It is important to keep in mind its clinical characteristics, which may mimic immuno-allergic symptoms. It should be differentiated from anaphylactic manifestations because Hoigne's syndrome allows the continuation of the treatment.     

Dermatite atopique et allergie alimentaire chez l'enfant

Food allergy is known to provoke flares of atopic dermatitis (AD). The prevalence of food allergy in infants with atopic dermatis has been estimated to be 40%. Atopy patch testing is a novel approach to diagnose food-induced AD, but standardization of atopy patch test extracts needs addional studies. Oral food challenge is the gold standard for diagnose of food allergy. Nevertheless, the method used for oral food challenges in cases of late eczematous reactions remains to be defined. Food appears to aggrevate eczematous lesions in young children, and it is recognized that allergy testing needs to be standardized in order to prove that relationship.