Cyclical Hypersensitivity, Anaphylaxis and Related Hormonal Reaction

Case Report

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Title: Where does worsening asthma end and an asthma exacerbation begin?

When does worsening asthma end, and an asthma exacerbation begin?

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EARLY BIRD CATCHES THE SPOT: ACUTE FIXED DRUG ERUPTION

Fixed drug eruption (FDE) is a recurring cutaneous reaction that characteristically occurs in the same location(s) upon re-exposure to the same drug. Lesions normally appear 8 hours and up to 2 weeks after drug administration.

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Prevalence, Characterization, and Impact of Voice Disorders in Fado Singers

Fado is a genre of urban folk music from Portugal characterized by some particularities. Some indictions in the study point this population of singers to be at higher risk of developing voice disorders.

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How Much Loading Does Water Resistance Voice Therapy Impose on the Vocal Folds? An Experimental Human Study

Water resistance voice therapy applies phonation into water through a tube. This study investigates how strenuous this therapy can be for the vocal folds in terms of impact stress (IS). It further examines whether it is possible to estimate the IS using the contact quotient (CQ) and maximum derivative from an electroglottogram (EGG).

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Mitchell–Hoole–Kanatas (MHK) questionnaire: the first to measure patient-reported outcomes relating to problems with intimacy after diagnosis and treatment of head and neck cancer

Patient-reported outcomes are increasingly used by clinical teams as indicators of quality when assessing treatment after a diagnosis of head and neck cancer. About a third of patients report reduced sexual interest or enjoyment after such treatment but, despite that, there is no questionnaire about intimacy that has been developed specifically for them. The aim of this study was to develop such a questionnaire, to gain an indication of the relative incidence of individual items, and to compare characteristics such as age, stage, treatment, time since treatment for an established head and neck cancer, and a health-related quality of life (QoL) measure (European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-C30 with the Head and Neck 35 module).

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Deep neck infection in patients with and without human immunodeficiency virus: a comparison of clinical features, complications, and outcomes

We retrospectively studied the clinical features, complications, and outcomes of deep neck infections in 31 adult patients with the human immunodeficiency virus (HIV) (HIV group) and 192 patients without (non-HIV group). In the HIV group, the cause was more likely to be odontogenic (21 (68%) compared with 90 (47%); odds ratio (OR) 2.38; 95% CI 1.06 to 5.32). In both groups, the parapharyngeal, submandibular, and masticator spaces, were those most often involved. However, in the HIV group, Ludwig's angina was common, and was the main cause of airway obstruction.

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GuttaFlow Bioseal promotes spontaneous differentiation of human periodontal ligament stem cells into cementoblast-like cells

Publication date: Available online 19 November 2018

Source: Dental Materials

Author(s): F.J. Rodríguez-Lozano, M. Collado-González, C.J. Tomás-Catalá, D. García-Bernal, S. López, R.E. Oñate-Sánchez, J.M. Moraleda, L. Murcia

Abstract

Objectives

To evaluate in vitro the cementogenic potential and the biological effects of GuttaFlow Bioseal, GuttaFlow 2, MTA Fillapex and AH Plus on human periodontal ligament stem cells (hPDLSCs).

Methods

Cell viability, cell migration and cell morphology assays were performed using eluates of each material. To evaluate cell attachment, hPDLSCs were directly seeded onto the material surfaces and analyzed by scanning electron microscopy (SEM). The effects of endodontic sealers on cementum protein 1 (CEMP1), cementum-derived attachment protein (CAP), bone sialoprotein (BSP), ameloblastin (AMBN), amelogenin (AMELX) and alkaline phosphatase (ALP) gene expression on hPDLSCs were investigated by qPCR and immunofluorescence (IF). Statistical analysis was performed with analysis of variance and Bonferroni or Tukey post-test (α < 0.05).

Results

More than 90% of viable cells were obtained using extracts of GuttaFlow Bioseal and GuttaFlow2 after 72 h of culture. By contrast, AH Plus and MTA Fillapex induced significantly lower levels of cell viability. GuttaFlow2 and GuttaFlow Bioseal promoted wound closure in a concentration-dependent manner, comparable to that observed with control extracts (*p < 0.05). However, with AH Plus and MTA Fillapex, cell migration was significantly lower than in the control (***p < 0.0001). SEM analysis pointed to an organized stress fiber assembly and high degree of cell adhesion on GuttaFlow Bioseal disks but low rates on GuttaFlow2, MTA Fillapex and AH Plus. When hPDLSCs were cultured with GuttaFlow Bioseal-conditioned media, qPCR assays and IF showed a higher level of AMELX, AMBN, CEMP1 and CAP expression than the control (*p < 0.05)), whereas no such expression was observed in the other sealers.

Significance

Our results showed that GuttaFlow sealers were more cytocompatible than AH Plus and MTA Fillapex, while GuttaFlow Bioseal favored cementoblast differentiation of hPDLSCs in the absence of any growth factors.

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GAS: a Genetic Atlas Selection Strategy in Multi-Atlas Segmentation Framework

Publication date: Available online 19 November 2018

Source: Medical Image Analysis

Author(s): Michela Antonelli, M. Jorge Cardoso, Edward W. Johnston, Mrishta Brizmohun Appayya, Benoit Presles, Marc Modat, Shonit Punwani, Sebastien Ourselin

Abstract

Multi-Atlas based Segmentation (MAS) algorithms have been successfully applied to many medical image segmentation tasks, but their success relies on a large number of atlases and good image registration performance. Choosing well-registered atlases for label fusion is vital for an accurate segmentation. This choice becomes even more crucial when the segmentation involves organs characterized by a high anatomical and pathological variability. In this paper, we propose a new genetic atlas selection strategy (GAS) that automatically chooses the best subset of atlases to be used for segmenting the target image, on the basis of both image similarity and segmentation overlap. More precisely, the key idea of GAS is that if two images are similar, the performances of an atlas for segmenting each image are similar. Since the ground truth of each atlas is known, GAS first selects a predefined number of similar images to the target, then, for each one of them, finds a near-optimal subset of atlases by means of a genetic algorithm. All these near-optimal subsets are then combined and used to segment the target image. GAS was tested on single-label and multi-label segmentation problems. In the first case, we considered the segmentation of both the whole prostate and of the left ventricle of the heart from magnetic resonance images. Regarding multi-label problems, the zonal segmentation of the prostate into peripheral and transition zone was considered. The results showed that the performance of MAS algorithms statistically improved when GAS is used.

Graphical abstract

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Determinants of Myocardial Strain in Experimental Chronic Myocardial Infarction

Publication date: Available online 19 November 2018

Source: Ultrasound in Medicine & Biology

Author(s): Haitham Ballo, Miikka Tarkia, Matti Haavisto, Christoffer Stark, Marjatta Strandberg, Tommi Vähäsilta, Virva Saunavaara, Tuula Tolvanen, Mika Teräs, Ville-Veikko Hynninen, Timo Savunen, Anne Roivainen, Juhani Knuuti, Antti Saraste

Abstract

We evaluated the relationships between regional myocardial strain measured by speckle tracking echocardiography and viability, fibrosis, hypertrophy and oxygen consumption in the infarcted or remote myocardium in a pig model of chronic myocardial infarction (MI). Thirteen farm pigs with surgical occlusion of the left anterior descending coronary artery and five sham-operated pigs were studied 3 mo post-MI. Computed tomography revealed significant left ventricle remodeling. Reduced radial or circumferential strain identified areas of transmural infarction (area under the curve: 0.82 and 0.79, respectively). In the remote non-infarcted area, radial strain correlated inversely with the amount of fibrosis (r = –0.66, p = 0.04) and myocyte hypertrophy (r = –0.68, p = 0.03). Radial strain rate inversely correlated with myocardial resting oxygen consumption assessed with ¹¹C-labeled acetate positron emission tomography (r = –0.71, p = 0.006). In conclusion, myocardial strain and strain rate reflect fibrosis, hypertrophy and oxygen consumption of the remote areas after MI.

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Transvaginal Ultrasound Vibro-elastography for Measuring Uterine Viscoelasticity: A Phantom Study

Publication date: Available online 19 November 2018

Source: Ultrasound in Medicine & Biology

Author(s): Xiaoming Zhang, Boran Zhou, Wendaline M. VanBuren, Tatnai L. Burnett, John M. Knudsen

Abstract

The purpose of this research was to determine the feasibility of a transvaginal ultrasound vibro-elastography (TUVE) technique for generating and measuring shear wave propagation in the uterus. In TUVE, a 0.1-s harmonic vibration at a low frequency is generated on the abdomen of a subject via a handheld vibrator. A transvaginal ultrasound probe is used to measure the resulting shear wave propagation in the uterus. TUVE was evaluated on a female ultrasound phantom. The shear wave speeds in the region of interest of the uterus of the female ultrasound phantom were measured in the frequency range of 100–300 Hz. The viscoelasticity was analyzed based on the wave speed dispersion with frequency. The measurement of shear wave speed suggests that the uterus of this female ultrasound phantom is much stiffer than the human uterus. This research illustrates the feasibility of TUVE for generating and measuring shear wave propagation in the uterus of a female ultrasound phantom. We will further evaluate TUVE in patients, both normal controls and those with uterine diseases such as adenomyosis.

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The role of dopamine in the brain - Lessons learned from Parkinson's disease

Publication date: Available online 20 November 2018

Source: NeuroImage

Author(s): David Meder, Damian Marc Herz, James Benedict Rowe, Stéphane Lehéricy, Hartwig Roman Siebner

Abstract

Parkinson's disease causes a characteristic combination of motor symptoms due to progressive neurodegeneration of dopaminergic neurons in the substantia nigra pars compacta. The core impairment of dopaminergic neurotransmission has motivated the use of functional magnetic resonance imaging (fMRI) in patients with Parkinson's disease to elucidate the role of dopamine in motor control and cognition in humans. Here we review the main insights from functional brain imaging in Parkinson's disease. Task-related fMRI revealed many disease-related alterations in brain activation patterns. However, the interpretation of these findings is complicated by the fact that task-dependent activity is influenced by complex interactions between the amount of dopaminergic neurodegeneration in the task-relevant nuclei, the state of medication, genetic factors and performance. Despite these ambiguities, fMRI studies in Parkinson's disease demonstrated a central role of dopamine in the generation of movement vigour (bradykinesia) and the control of excessive movements (dyskinesia), involving changes of both activity and connectivity of the putamen, premotor and motor regions, and right inferior frontal gyrus (rIFG). The fMRI studies addressing cognitive flexibility provided convergent evidence for a non-linear, U-shaped, relationship between dopamine levels and performance. The amount of neurodegeneration in the task-relevant dopaminergic nuclei and pharmacological dopamine replacement can therefore move performance either away or towards the task-specific optimum. Dopamine levels also strongly affect processing of reward and punishment for optimal learning. However, further studies are needed for a detailed understanding of the mechanisms underlying these effects.

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Corrigendum to “Spatial analysis and high resolution mapping of the human whole-brain transcriptome for integrative analysis in neuroimaging”

Publication date: Available online 19 November 2018

Source: NeuroImage

Author(s): Gregor Gryglewski, René Seiger, Gregory Miles James, Godber Mathis Godbersen, Arkadiusz Komorowski, Jakob Unterholzner, Paul Michenthaler, Andreas Hahn, Wolfgang Wadsak, Markus Mitterhauser, Siegfried Kasper, Rupert Lanzenberger

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Flexible proton density (PD) mapping using multi-contrast variable flip angle (VFA) data

Publication date: Available online 19 November 2018

Source: NeuroImage

Author(s): Sara Lorio, Tim M. Tierney, Amy McDowell, Owen J. Arthurs, Antoine Lutti, Nikolaus Weiskopf, David W. Carmichael

Abstract

Quantitative proton density (PD) maps measure the amount of free water, which is important for non-invasive tissue characterization in pathology and across lifespan. PD mapping requires the estimation and subsequent removal of factors influencing the signal intensity other than PD. These factors include the T1, T2* relaxation effects, transmit field inhomogeneities, receiver coil sensitivity profile (RP) and the spatially invariant factor that is required to scale the data. While the transmit field can be reliably measured, the RP estimation is usually based on image post-processing techniques due to limitations of its measurement at magnetic fields higher than 1.5 T. The post-processing methods are based on unified bias-field/tissue segmentation, fitting the sensitivity profile from images obtained with different coils, or on the linear relationship between T1 and PD. The scaling factor is derived from the signal within a specific tissue compartment or reference object. However, these approaches for calculating the RP and scaling factor have limitations particularly in severe pathology or over a wide age range, restricting their application.

We propose a new approach for PD mapping based on a multi-contrast variable flip angle acquisition protocol and a data-driven estimation method for the RP correction and map scaling. By combining all the multi-contrast data acquired at different echo times, we are able to fully correct the MRI signal for T2* relaxation effects and to decrease the variance and the entropy of PD values within tissue class of the final map. The RP is determined from the corrected data applying a non-parametric bias estimation, and the scaling factor is based on the median intensity of an external calibration object. Finally, we compare the signal intensity and homogeneity of the multi-contrast PD map with the well-established effective PD (PD*) mapping, for which the RP is based on concurrent bias field estimation and tissue classification, and the scaling factor is estimated from the mean white matter signal. The multi-contrast PD values homogeneity and accuracy within the cerebrospinal fluid (CSF) and deep brain structures are increased beyond that obtained using PD* maps. We demonstrate that the multi-contrast RP approach is insensitive to anatomical or a priori tissue information by applying it in a patient with extensive brain abnormalities and for whole body PD mapping in post-mortem foetal imaging.

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AN EVOLVING DIAGNOSIS OF A DIFFUSE ERYTHRODERMIC RASH

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): M. Kuder, F. Hsieh

Introduction

Lymphocytic variant hypereosinophilic syndrome (L-HES) is a rare condition that can be challenging to diagnose. In patients presenting with an erythrodermic skin rash and eosinophilia, it is imperative to review the L-HES diagnostic criteria and periodically reassess for alternative etiologies, particularly with disease progression.

Case Description

A 39-year-old female presented with a 4-year history of an erythematous, confluent plaque-like rash. Initially, her skin biopsy demonstrated granulomatous dermatitis with necrobiosis but no eosinophils. She had a peripheral absolute eosinophil count of 1100/uL. Her bone marrow biopsy demonstrated a CD4+, CD3-T-cell population with small, non-necrotizing granulomas and no clonal eosinophilia. She was diagnosed with L-HES and started on high-dose glucocorticoids with initial skin improvement; however, skin symptoms subsequently progressed, covering 90% of her body surface area. She was then managed as cutaneous sarcoidosis, but treatment with methotrexate and leflunomide did not improve symptoms. Given her persistent symptoms, she underwent repeat skin biopsy, which demonstrated cutaneous T-cell lymphoma. Symptoms improved with romidepsin.

Discussion

This patient had initial findings suggestive of L-HES but did not meet L-HES diagnostic criteria. She never had an absolute eosinophil count >1500/uL, nor tissue biopsy demonstrating eosinophil-mediated organ damage. Her disease progression led to re-evaluation and a malignancy diagnosis. Although patients with L-HES can progress to cutaneous T-cell lymphoma, clonal CD4+, CD3- T cells can be found in primary cutaneous T-cell lymphoma without prior HES diagnosis. This case illustrates the importance of continued diagnostic inquiry when the diagnosis is unclear and symptoms progress despite therapy.

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DRESS TO TEN: IS THIS A CONTINUUM?

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): F. Khan, J. Simonaire, N. Klaiber, S. Kumar

Introduction

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potentially life-threatening severe cutaneous adverse drug reaction (SCAR) that can be triggered by medications. Toxic Epidermal Necrolysis (TEN) is also a type of SCAR. To the best of our knowledge, we present a first known clear case of DRESS which progressed to clinical TEN and was successfully treated.

Case Description

A 17-year old female was started on Lamotrigine and Escitalopram for a mood disorder. One week later, she developed tender cervical lymphadenopathy, fevers, and abdominal discomfort. About 2.5 weeks after starting these two medications, she developed a raised, pruritic, erythematous rash on her arms. Although the medication was discontinued, she failed to improve and developed facial angioedema, hepatic failure, eosinophilia and atypical lymphocytosis - all concerning signs for DRESS. Skin biopsy confirmed perivascular lymphocytic infiltrate with scattered eosinophils supporting DRESS. She was treated with intravenous immunoglobulin and eventually discharged home with a resolving rash. As Prednisone was tapered, the patient was readmitted with concerns for relapsing DRESS. She went on to develop TEN with mucosal involvement as well as greater than 30 percent skin involvement. She was successfully treated with a combination of Cyclosporine and high dose Prednisone.

Discussion

There is paucity of literature on SCAR overlap syndromes and we acknowledge the ambiguity and difficulty with this diagnosis given the overlapping presentation with SCAR syndromes. Although the mortality rate tends to be quite high for SCAR overlap syndromes, our patient was successfully treated with a combination of IVIG, steroids and Cyclosporine.

Progression towards TEN.

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AllergyWatch - Feb-19

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): John J. Oppenheimer, Vivian Hernandez-Trujillio, Stanley M. Fineman

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"Drug Allergy in children and adults: is it the double X chromosome?"

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Allison Norton, Ana Dioun Broyles

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Racial differences in Atopic Dermatitis

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Patrick M. Brunner, Emma Guttman-Yassky

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The Glycerin Associated Pain (GAP) Study

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Christopher A. Coop, Karen Barker, Scott Dickson, Troy Baker, Kirk Waibel

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Immediate-hypersensitivity reactions to proton pump inhibitors – experience in a medical department

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Joana Sofia Pita, João Azevedo, Rosa-Anita Fernandes, Carlos Loureiro, Ana Todo Bom

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Asthma in the Melting Pot

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Margee Louisias, Lakiea Wright, Wanda Phipatanakul

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Inpatient Beta-lactam test-dose Protocol promotes Antimicrobial Stewardship in Patients with History of Penicillin Allergy

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Keith A. Sacco, Benjamin P. Cochran, Kevin Epps, Mark Parkulo, Alexei Gonzalez-Estrada

Abstract

Background

Penicillin allergy is the most commonly reported drug allergy in hospitalized patients, resulting in increased second-line antibiotic use, nosocomial infections, and healthcare utilization. Given that the vast majority of patients are not truly allergic, a safe strategy that empowers the admitting physician is needed.

Objective

To assess the impact on antibiotic prescribing practices for hospitalized patients with penicillin allergy using a validated intervention.

Methods

An intervention was implemented to educate providers on management of patients with penicillin allergy using a validated risk-stratification algorithm to guide testing and antibiotic use. 30 days of control data using current standard of care was compared with 60 days of post-intervention data measuring documentation of penicillin allergy history and antibiotic selection.

Results

The relative use of cephalosporin and penicillin antibiotics increased by 121.2% (p=0.027) and 256% (p=0.043) respectively without an increase in adverse drug reactions. There was a decrease in the use of broad-spectrum antibiotics; vancomycin 67.2% (p=0.036), quinolones 33.3% (p=0.31), carbapenems 81.9% (p=0.080), and aztreonam 73.8% (p=0.180).

Conclusion

The antibiotic choice in patients admitted to the hospital with a reported penicillin allergy can be improved by better evaluation of the allergy history and the use of a risk stratification guideline.

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Implementation of the NIAID Peanut Allergy Guidelines: Outcomes and Experience

Publication date: Available online 20 November 2018

Source: Annals of Allergy, Asthma & Immunology

Author(s): Amanda L. Pratt, Jonathan A. Hemler

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A CASE OF CARRAGEENAN ALLERGY IN A PEDIATRIC PATIENT

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): H. Kular, J. Dean, V. Cook

Introduction

Carrageenan is a common food additive obtained from Eucheuma, Chrondrus, and Gigartina species of seaweed. It is used in dairy, processed meat, sauces, pharmaceuticals and other food products as a thickener and stabilizer. It's soluble fiber properties are used to alter the consistency, appearance, and nutritional properties of food. Although it has been reported to cause adverse gastrointestinal effects, reports of IgE-mediated allergy appear limited to a case of anaphylaxis to carrageenan-containing barium enema. We present a unique case of carrageenan allergy in a pediatric patient.

Case Description

A 10-month-old male presented for assessment after developing lip angioedema immediately following ingestion of icing from a fruit cake. He had no associated urticaria, respiratory distress, hypotension, or gastrointestinal symptoms. He had a history of eczema, and was known to tolerate milk, egg, soy, peanuts, hazelnuts, and other cake icing without adverse reactions. Skin prick testing to the cake icing produced a positive wheal measuring 11 by 5 mm. Skin prick testing to cow's milk and melon contained in the cake was negative. A detailed ingredient list revealed carrageenan as an ingredient. Skin prick testing to carrageenan produced a positive wheal measuring 10 by 8 mm. Instructions regarding carrageenan avoidance were provided along with an epinephrine-auto-injector and anaphylaxis action plan.

Discussion

To our knowledge, this is the first reported case describing IgE-mediated reaction following carrageenan ingestion. Carrageenan continues to be a common food additive. This case highlights the importance of recognizing carrageenan as a potential cause of IgE-mediated reactions in unexplained food allergy presentations.

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INDEX OF ORAL AND POSTER ABSTRACT AUTHORS: * = Presenting Author

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s):

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Author disclosures

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s):

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THE DIFFICULT MANAGEMENT OF THREE PATIENTS WITH NETHERTON SYNDROME

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): R. Saenz, M. Chen, A. Ahmed, Y. Gernez

Introduction

Netherton Syndrome (NS) is a rare congenital ichthyosis characterized by generalized scaling, erythema, and epidermal barrier defects due to homozygous defects in the SPINK5 gene that encodes for the serine protease inhibitor LEKT1. When mutated, the SPINK5 gene results in the breakdown and thinning of the stratum corneum. The ichthyosis of NS is difficult to manage, and we discuss the result of several systemic treatments attempted, including IVIG and dupilumab.

Case description

We describe three patients with NS, ranging in age from 9 months to 31 years. Infections among these three patients are common and range from recurrent skin infections and upper respiratory infections, to multi-organism bacteremia and sepsis complicated by metabolic acidosis, requiring ICU admission. Additionally, multiple food allergies were noted in one patient. Labs demonstrate a variety of immune abnormalities including mixed T and B cell lymphopenias, impaired cytotoxicity, intermittent eosinophilia, and significant elevations in IgE. Our genetic studies reveal several previously unidentified variants in SPINK5 that appear to cause clinical disease. Our three patients were started on IVIG. While prior studies demonstrated significant clinical improvement in patients on IVIG, only minimal to moderate subjective skin improvement was noted in two of the patients. In one patient, dupilumab was used in the context of increased IgE and eosinophilia, but to date has not proven useful.

Discussion

These cases provide insight into complexity of NS and challenge the existing theory that IVIG provides favorable outcomes. We suggest that new systemic/targeted therapeutics should be attempted for treatment of NS.

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RECURRENT ERYTHEMA MULTIFORME, RESOLVED AFTER IMMULOGLOBULIN REPLACEMENT THERAPY IN A PATIENT WITH NORMAL IMMUNOGLOBULIN LEVELS

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): A. McInerney, S. Siegel

Introduction

While immunoglobulin has been used for Stevens-Johnson syndrome (SJS), its use in erythema multiforme (EM) is limited. Our case describes recurrent EM after SJS with antibiotic exposure and Mycoplasma pneumoniae infection, with normal immunoglobulin levels, which failed standard treatment but resolved following immunoglobulin replacement therapy (IRT).

Case Description

A 13-year-old boy developed fever, cough, and rash progressing to generalized sloughing bullae, with dyspnea that deteriorated to emphysematous lung changes. The lesions were targetoid with erythematous base, dusky center, including mucosa. Symptoms developed after treatment for presumed pneumonia with amoxicillin-clavulanate. He was admitted with SJS and Mycoplasma pneumoniae. Steroids, azithromycin, and acyclovir were given. Biopsy was consistent with EM. He was discharged on azithromycin, doxycycline, and valacyclovir for persistent lesions, although HSV titers and cultures were negative. Immune work-up was unremarkable. He lacked immunity to multiple pathogens, despite vaccination, but responded to re-immunization. Immunoglobulins remained normal. Lesions recurred frequently, with minimal response to steroids, and flares with weaning. IRT was administered during re-admission with near resolution. He was then started on IRT therapy. Steroids were weaned without recurrence.

Discussion

Traditionally described secondary to HSV, Mycoplasma and medications are implicated frequently in pediatric EM. Standard treatment includes prolonged antivirals, antibiotics, and steroids. With treatment failure, immunosuppressants, anti-malarials, and IRT are used. However, controlled trials and consistent data are lacking. As our patient demonstrates, IVIG's immunomodulatory effect can facilitate resolution of recurrent EM. Furthermore, prophylactic use for infections may prevent recurrence. Finally, IVIG represents an alternative to immunosuppressants in pediatric patients with recalcitrant EM despite normal immunoglobulins.

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A MYSTERIOUS RASH AROUND SURGICAL WOUNDS

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): W. Jithpratuck, D. Kays, P. Sriaroon

Introduction

Contact dermatitis (CD) that occurs shortly after a surgery is often caused by a direct irritant effect of medical products or, infrequently, a delayed type hypersensitivity. Various agents have been reported to cause CD including topical medications, surgical instruments, and surgical glue. We present a patient who developed rash around surgical wounds. Skin patch testing identified the causative agent of his CD.

Case Description

A 15-year-old male presented with new onset of pruritic papulovesicular rash three weeks following Nuss procedure, a minimally invasive pectus excavatum repair using a metal bar. The rash initially appeared on upper extremities and chest wall around surgical wounds (Figure 1A). Later, new erythematous lesions occurred on foreskin of penis. Patient denied other systemic symptoms or prior history of metal or medication allergy. A delayed hypersensitivity to nickel or other components of stainless steel used in the pectus bar was suspected. Surgical removal of the bar was contemplated. A trial of oral prednisone 30mg BID led to resolution of the rashes (Figure 1B). Blood test for metal-lymphocyte proliferation assay was unremarkable. Skin patch test was negative to nickel and metal disc, and confirmed a reaction to 2-octyl cyanoacylate (surgical glue) (Figure 1C).

Discussion

Delayed-type hypersensitivity to surgical glue should be considered in patients who develop rash around surgical wounds. Evaluation of surgery-related CD requires a thorough understanding of procedure steps and potential exposures to medical products. Patch test can aid in identification of the offending agent and allow a recommendation of alternative products to avoid recurrence.

Figure. A. Rash around surgical wounds Figure 1B. Improvement of rash after a 5-day course of prednisone 30 mg BID treatment Figure 1C. Positive patch test to 2-octyl cyanoacrylate (Dermabond® surgical glue)

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HAND DERMATITIS IN A SURGEON: A DIFFICULT PROBLEM AND A THREE-PRONGED SOLUTION

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): S. Mahapatra, L. Caraballo, V. Dimov, F. Eidelman

Introduction

Hand dermatitis is a common problem affecting up to 25% of health workers, it can be caused by contact dermatitis (CD). CD is categorized as irritant in 80% of patients and allergic in 20%.

Case Description

A 42-year old male surgeon with a history of recurrent eczematous lesions on hands and trunk presented with a recurrence of pruritic rash. The rash had persisted despite using OTC hydrocortisone, triamcinolone and OTC moisturizers. Hand dermatitis interfered with his work as a surgeon. Patch testing for allergic contact dermatitis was positive for 1, 3-diphenylguanidine, ammonium persulfate, carba mix, cinnamic aldehyde, cocamidopropyl betaine, coconut diethanolamide (cocamide DEA), colophony, formaldehyde, fragrance mix, hydrocortisone-17-butyrate, Iodopropynyl butylcarbamate, lidocaine-HCl and propylene glycol. The glove materials (1, 3-diphenylguanidine, carba mix), fragrances, preservatives (propylene glycol) and topical steroids were correlated with the patient's symptoms. After contact dermatitis was confirmed with patch testing, a targeted avoidance was recommended. Treatment modalities were adjusted. Triamcinolone and hydrocortisone were eliminated based on patch test results (triamcinolone 0.1% cream contained propylene glycol). Symptoms improved with: 1. topical calcineurin inhibitor (tacrolimus); 2. avoidance of irritants and allergens based on skin patch test; 3. use of barrier protection such as cotton undergloves.

Discussion

Hand dermatitis can have a potentially devastating effect on a surgeon's career based on the limitations it imposes on the ability to practice. The three-pronged approach described above can offer a clinical solution to a difficult problem.

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IMPROVEMENT OF SYSTEMIC SCLEROSIS-LIKE SYMPTOMS AFTER THERAPY FOR MULTIPLE MYELOMA

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): S. Davuluri, A. Tieng, G. Franchin, M. Niazi

Introduction

Systemic sclerosis is known to carry an increased risk of malignancy. In this report we describe a rare case of systemic sclerosis as the presenting sign of amyloidosis associated with multiple myeloma.

Case Description

A 59-year-old woman presented to the clinic with a 6-month history of bilateral hand pain and puffiness. Physical examination revealed melasma, multiple enlarged right supraclavicular lymph nodes, and sclerodactyly. Laboratory tests were positive for antinuclear antibodies (1:160) in a nucleolar pattern and nephrotic range proteinuria (>8g/day). The initial impression was systemic sclerosis associated arthritis and patient was treated with hydroxychloroquine, resulting in slight improvement in her range of motion. Computed tomography of the neck showed mildly enlarged right supraclavicular lymph nodes measuring up to 1.6 centimeters in diameter. Biopsy of a cervical lymph node revealed malignant lymphoma. Bone marrow biopsy showed plasma cell myeloma (>80%); serum immunoelectrophoresis revealed elevated levels of free kappa lambda light chains (8447 mg per liter; reference range, 3.3-19.4). Initial management included cyclophosphamide, bortezomib, and dexamethasone, resulting in significant improvement in joint pain. Furthermore, she developed multiple periorbital papules. A biopsy of her left upper eyelid lesion demonstrated apple-green birefringence after Congo red staining, compatible with a diagnosis of amyloidosis.

Discussion

This patient initially presenting with a picture suggestive of systemic sclerosis was subsequently diagnosed with multiple myeloma and amyloidosis. She developed significant improvement in the range of motion of her finger joints as well as the skin tautness after initiating chemotherapy.

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IATROGENIC SYSTEMIC ALLERGIC CONTACT DERMATITIS FROM CETIRIZINE AND LEVOCETIRIZINE

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): D. Lei, C. Guo, P. Greenberger

Introduction

H1 antihistamines are frequently utilized in the management of dermatitis-associated pruritus; they may be overlooked and are rarely considered as an etiology for dermatitis.

Case Description

A 76-year-old woman with a history of allergic rhinitis and hypertension was referred for one year of pruritic, erythematous papules/plaques scattered throughout the body, worse over sun-exposed areas. Prior dermatologic evaluation and biopsy were suggestive of allergic contact dermatitis. Patch testing was positive for fragrance mix, ethylenediamine, and balsam of peru. The patient discontinued all products containing these substances without improvement. She continued to develop new lesions. There were no new medications except cetirizine and then levocetirizine, which she continued for the management of pruritus. She was treated with multiple courses of systemic and topical corticosteroids, and hydroxychloroquine, without resolution. The patient was advised to discontinue levocetirizine, avoid cetirizine, and initiate fexofenadine. At follow up at two weeks and one year later, she reported complete resolution of the rash after discontinuation of levocetirizine.

Discussion

Piperazine derivative antihistamines, such as hydroxyzine, cetirizine, and levocetirizine, share a similar structure with ethylenediamine, which is a common etiology of contact dermatitis. Hypersensitivity to H1 antihistamines is rare. Continued use of H1antihistamines, despite lack of improvement or worsening of symptoms, may be incorrectly interpreted as a failure of response to treatment. Development of generalized dermatitis induced by cetirizine or levocetirizine is rarely reported. This case illustrates the importance of re-evaluation in patients who fail to respond to treatment with consideration of piperazine derivative H1 antihistamines as a possible trigger.

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ATYPICAL PRESENTATION OF SCABIETIC URTICARIAL VASCULITIS

Publication date: November 2018

Source: Annals of Allergy, Asthma & Immunology, Volume 121, Issue 5, Supplement

Author(s): J. Hanna, T. Bingemann

Introduction

Pruritic rash with burrows is pathognomonic for scabies. Classic lesions are seen less frequently as the incidence has increased. Our patient presented with none of the classic findings of scabies and biopsy features consistent with urticarial vasculitis.

Case Description

75-year old male presented with a generalized urticarial eruption for 1 month that burned and itched, and was accompanied by post-inflammatory hyperpigmentation. No new medications had been started. No family members had similar symptoms. Multiple urticarial plaques were noted with post-inflammatory changes without burrows. Dermatographism was present. Skin biopsy showed dense perivascular and superficial interstitial infiltrate, leukocytoclasis, and smudged small vessel walls. No mites or eggs were identified. No eosinophilia was present. Autoimmune work up and complement were normal. Treatment with Colchicine, Dapsone, Prednisone, and Hydroxychloroquine led to initial improvement but then relapse. When he was not improving, we sent him to dermatology again and they did not recommend any changes. As medications were changed, lesions again improved and then worsened. He called complaining of persistent lesions. When he was seen at that point, he had developed typical features of scabies and was treated with topical Permethrin and oral Ivermectin and rash completely subsided. After he improved, he was tapered off Dapsone without recurrence of his symptoms.

Discussion

Urticarial vasculitis is an uncommon presentation of scabies with frequently delayed diagnosis. This case serves as a reminder to reassess the diagnosis if the patient does not respond as expected to treatment and adds to the cases of scabies with atypical presentations.

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Oral & Maxillofacial surgery is ready for patient-centred eHealth interventions − the outcomes of a scoping review

Publication date: Available online 19 November 2018

Source: International Journal of Oral and Maxillofacial Surgery

Author(s): S.C. van den Bosch, N.E.M. van de Voort, T. Xi, R.B. Kool, S.J. Bergé, M.J. Faber

Abstract

Within the field of oral and maxillofacial (OMF) surgery, eHealth is expected to be a tool to improve quality of care. The aim of this study is to map the research of patient-centred eHealth interventions within OMF surgery by means of a scoping review.

After a systematic literature search, relevant studies on patient-centred eHealth interventions for OMF-surgery patients were selected. The interventions were mapped based on their key components, target population and outcome measures. To gain insight in the research phase of evaluation, the framework of the Medical Research Council (MRC) was used.

Forty-one papers were included, comprising 34 unique interventions. Nineteen interventions were designed for head and neck cancer patients, 11 interventions concernd video-teleconsultation. According to the MRC framework, 26 papers fitted into the feasibility and piloting phase of research, 8 into the evaluation phase, 7 were in the development phase. No implementation studies were found.

This scoping review can be a starting point for those who are interested in applying and evaluating eHealth in their practice. Since many feasibility and pilot studies were found on similar interventions, a more extensive collaboration with and connecting to each other is recommended to catalyze the implementation of eHealth in daily practice. Profound involvement of patients in developing and evaluating eHealth interventions is essential to achieve true patient-centred OMF surgery.

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Macrophage Response and Surface Analysis of Dental Cementum after Treatment with High Intensity Focused Ultrasound

Publication date: Available online 19 November 2018

Source: Archives of Oral Biology

Author(s): U. Daood, A.S. Fawzy

Abstract

Objective

To investigate effects of HIFU on macrophage phenotype, surface micro-topography and nano-scale surface mechanical properties of dental cementum.

Materials and Methods

Root discs (2 mm thickness) were cut apical to CEJ and sectioned into quadrants. HIFU setup with bowl-shaped piezo ceramic transducer submerged in a water tank was used for exposure on each specimen for 15 s, 30 s or 60 s. The specimens of the control group were left without any HIFU exposure. HIFU was generated with a continuous sinusoidal wave of 120Vpp amplitude, 250 KHZ resonance-frequency and highest ultrasonic pressure of ~10 bar at the focus. Specimens for SEM were viewed, and micro-topography characterization performed, using AFM and Ra parameter and surface area (SA) calculated by specialized SPM surface analysis software. For nano-indentation testing, experiments were carried out using AFM. Macrophage cell isolation and culturing was performed on cementum to receive the HIFU treatment at different time periods. Raman spectroscopy were scanned to create spectra perpendicular to the cementum substrate to analyze generation of standard spectra for Raman intensity ratio of hydroxyapatite normalized to the peaks ν₁ 960 cm^-1. Data was expressed as means ± standard deviations and analyzed by one-way ANOVA in term of Ra, SA, H and E_r. Different points for fluorescence intensity ratio were analyzed by Raman using Wilcoxon rank sum test.

Results

HIFU exposure at 60 s removed the smear layer and most of cementum appeared smoothened. AFM characterisation, showed a slight decrease in the irregularity of the surface as exposure time increased. Intact macrophages can be identified in control and all experimental HIFU groups. The level of fluorescence for the control and HIFU 15 and 30 s were low as compared to HIFU 60 s.

Conclusion

If HIFU can be successfully implemented, it may be a possible alternative to current methods used in periodontal therapy to achieve smooth root surfaces.

Graphical abstract

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Selection of Fitting Model and Arterial Input Function for Repeatability in Dynamic Contrast-Enhanced Prostate MRI

Publication date: Available online 20 November 2018

Source: Academic Radiology

Author(s): Sharon Peled, Mark Vangel, Ron Kikinis, Clare M. Tempany, Fiona M. Fennessy, Andrey Fedorov

Rationale and Objectives

Analysis of dynamic contrast-enhanced (DCE) magnetic resonance imaging is notable for the variability of calculated parameters. The purpose of this study was to evaluate the level of measurement variability and error/variability due to modeling in DCE magnetic resonance imaging parameters.

Materials and Methods

Two prostate DCE scans were performed on 11 treatment-naïve patients with suspected or confirmed prostate peripheral zone cancer within an interval of less than two weeks. Tumor-suspicious and normal-appearing regions of interest (ROI) in the prostate peripheral zone were segmented. Different Tofts-Kety based models and different arterial input functions, with and without bolus arrival time (BAT) correction, were used to extract pharmacokinetic parameters. The percent repeatability coefficient (%RC) of fitted model parameters K_trans, v_e, and k_ep was calculated. Paired t-tests comparing parameters in tumor-suspicious ROIs and in normal-appearing tissue evaluated each parameter's sensitivity to pathology.

Results

Although goodness-of-fit criteria favored the four-parameter extended Tofts-Kety model with the BAT correction included, the simplest two-parameter Tofts-Kety model overall yielded the best repeatability scores. The best %RC in the tumor-suspicious ROI was 63% for k_ep, 28% for v_e, and 83% for K_trans . The best p values for discrimination between tissues were p <10⁻⁵ for k_ep and K_trans, and p = 0.11 for v_e. Addition of the BAT correction to the models did not improve repeatability.

Conclusion

The parameter k_ep, using an arterial input functions directly measured from blood signals, was more repeatable than K_trans. Both K_trans and k_ep values were highly discriminatory between healthy and diseased tissues in all cases. The parameter v_e had high repeatability but could not distinguish the two tissue types.

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Usefulness of MR Arthrography of the Hip with and without leg Traction in Detection of Intra-articular Bodies

Publication date: Available online 19 November 2018

Source: Academic Radiology

Author(s): F. Schmaranzer, T.D. Lerch, U. Strasser, P. Vavron, E. Schmaranzer, M. Tannast

Rationale and Objective

Although intra-articular bodies are a classic indication for MR arthrography and surgical removal, diagnostic studies are currently sparse. To assess the diagnostic performance of MR arthrography with and without leg traction in detection of intra-articular bodies in the hip joint.

Material and Methods

The institutional hip arthroscopy data base (2009–2016: 631 hips) was retrospectively reviewed. Inclusion criteria were hips with and without intra-articular bodies and direct MR arthrography performed with and without leg traction. Twenty-one hips with intra-articular bodies constituted the "disease-positive" group. Seventy-nine randomly selected hips without intra-articular bodies constituted the "disease-negative" group. Images were reviewed independently for presence of intra-articular bodies by two blinded readers. Overall diagnosis and location of intra-articular bodies was recorded (peripheral or central). Arthroscopy served as goldstandard for diagnosis and location of intra-articular bodies. Diagnostic performance and kappa statistics of traction MR arthrography with and without traction were calculated.

Results

For both readers sensitivity/specificity of traction MR arthrography was 86%–95% respectively 90%–91% for overall diagnosis of intra-articular bodies and was 81%–86% respectively 90%–92%for MR arthrogrpahy without traction. For central intra-articular bodies sensitivity was higher for both readers with traction (79%–89%) than without traction (74% each).

Conclusion

MR arthrography with and without traction of the hip is highly accurate in identifying central and peripheral intra-articular bodies. Application of traction was further useful for visualization of centrally located intra-articular bodies.

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CHRONIC ULCERATIVE STOMATITIS: a comprehensive review and proposal for diagnostic criteria

Abstract

Chronic ulcerative stomatitis (CUS) is an immune‐mediated disorder characterized by oral erosions and ulcers usually refractory to conventional treatments.

The disease often involves middle‐aged and older women with painful lesions sometimes resembling those of erosive oral lichen planus (OLP).

The most affected sites are the buccal mucosa, the gingiva and the tongue, but the skin is involved in 22.5% of cases.

Histopathologic features in CUS are non‐specific and indistinguishable from those of OLP, with the exception of the presence of a mixed infiltrate composed of lymphocytes and plasma cells.

Direct immunofluorescence (DIF) analysis reveals the presence of stratified epithelium‐specific antinuclear antibodies (SES‐ANA) in the lower third of the epithelium. The IgG antibodies detected on DIF are directed against the ∆Np63α isoform of p63 expressed in the nuclei of the epithelial basal cells.

A distinguishing feature of CUS is the low response to conventional corticosteroid therapy and the good outcome with hydroxychloroquine at the dosage of 200 mg/day or higher dosages.

This paper presents a comprehensive review of CUS and is accompanied by a new case report (the 73^rd case) and a proposal for updated diagnostic criteria.

This article is protected by copyright. All rights reserved.

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Adherence to instructions and fluctuation of force magnitude in cervical headgear therapy.

Adherence to instructions and fluctuation of force magnitude in cervical headgear therapy.

Angle Orthod. 2018 Nov 19;:

Authors: Talvitie T, Helminen M, Karsila S, Varho R, Signorelli L, Peltomäki T

Abstract
OBJECTIVES:: To investigate how patients adhere to instructions and how force magnitude fluctuates and influences the use of cervical headgear (CHG) therapy.
MATERIALS AND METHODS:: In this controlled clinical trial, subjects (n = 40) were treated with CHG with light (L, 300 g) or heavy (H, 500 g) force. Patients were asked to wear CHG for 10 hours per day for 10 months (ie, during sleep), but the importance for treatment of wearing CHG also in the evening hours was emphasized. Adherence to instructions and force magnitude in CHG use were monitored by electronic module (Smartgear, Swissorthodontics, Switzerland).
RESULTS:: Force magnitude can be set at a certain level, L or H, even if great individual variability is seen in all subjects (0-900 g). Children in the L group used CHG longer per day than those in the H group (9.3 hours ±1.5 hours and 7.8 hours ± 2.1 hours, respectively, P = .002). During evening hours, CHG was used more ( P = .02) in the L group than in the H group. In both groups, CHG was used less in the evening hours during school breaks than in the evening hours during school ( P < .001).
CONCLUSIONS:: Children with lower force in CHG seem to adhere better to the instructions for CHG use. Daily rhythm also influences the time of appliance use regardless of force magnitude. The force can be set to a certain magnitude level, even though there is substantial individual variability.

PMID: 30451531 [PubMed - as supplied by publisher]

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