Dhm12 programm v7

ABSTRACTS

Programme & Abstract Book

www.eaaci-dhm2012.com Programme & Abstract Book DHM5 2012 | 3

CONTENTWelcome ...............................................................................................................................................................4

Organising Committee .....................................................................................................................................6

History of DHM ...................................................................................................................................................7

EAACI Executive Committee ..........................................................................................................................8

General Information A-Z ..................................................................................................................................9

Sponsors ...........................................................................................................................................................14

Map of the Venue „Klinikum rechts der Isar“ .........................................................................................15

Programme Overview ....................................................................................................................................18

Scientific Programme ....................................................................................................................................20

Poster Exhibition.............................................................................................................................................28

Abstracts ...........................................................................................................................................................30

Welcome Reception “Little Oktoberfest”..............................................................................................152

Exhibition Plan ..............................................................................................................................................153

List of Exhibitors ..........................................................................................................................................154

Imprint.............................................................................................................................................................155

www.eaaci-dhm2012.comProgramme & Abstract Book DHM5 20124 |

Dear Friends and Colleagues,

I warmly welcome you to the 5th edition of the Drug Hypersensitivity Meeting (DHM5), which is

taking place for the first time in Munich, Germany.

Our Academy is aware of the growing interest on Drug Hypersensitivity, and is therefore proud

of supporting the development of active tools for the scientific and research community working

in this field. EAACI has a Drug Allergy Interest Group and diverse Task Forces related to this topic,

which reflects the high profile of this field for our members and our speciality.

The EAACI Drug Allergy Interest Group involves many different groups from all over Europe. The

core group of this Interest Group is called ENDA (European Network of Drug Allergy), and com-

prises active participants with a common area of research e.g. in the epidemiological, clinical, or

fundamental aspects of drug hypersensitivity.

Allergic drug reactions are a continuing challenge for healthcare professionals. There is a lot to

learn and discuss. More and more different types of reactions and mixed types are expected to

occur due to new biologicals that are going to be used in our area. This meeting will give you the

opportunity to learn about new techniques and discuss with other experts about the different

aspects of diagnosis and management of your patients.

With six plenary sessions and twelve parallel symposia, DHM5 2012 will give you up to date

information about basic, translational and clinical aspects of mechanisms and management of

drug hypersensitivity. These scientific sessions will be complemented with practical seminars

and case reports.

The Local Organisers worked tirelessly to make your time in Munich a wonderful scientific experience.

I wish you a very fruitful DHM5 2012 Meeting.

Best regards,

Prof. Cezmi Akdis

EAACI President

WELCOME FROM EAACI


Dear Friends and Colleagues,

As Congress Chairs, we are delighted to welcome you to the Drug Hypersensitivity Meeting 5 (DHM5 2012) and to the beautiful city of Munich. The success of the previous DHM Meetings as well as the rapidly growing interest in drug hypersensitivity encouraged EAACI to promote DHM as one of its thematic “Focused Meetings”.In the light of the increasing knowledge in the field, DHM 2012 will provide you with an excellent opportunity to learn about and to share major developments, novel ideas and unprecedented progress in this area. We can all look forward to four intense days of talks, seminars and case reports and more than 200 posters, but we hope there will also be plenty of time to meet old and new friends, engage in discussions of science, and experience the amenities of the town. Thank you for joining us. We are sure that this will be a most enjoyable experience.The capital of Bavaria is located at the Isar River, north of the Bavarian Alps. Munich is a modern and cultural city with a rich historic background. We welcome you in the recently renovated lecture hall buildings of the Faculty of Medicine/Klinikum rechts der Isar, the clinical campus of the Technische Universität München (TUM) – near to the city center offering rich socio-cultural, historic and modern-life aspects of Munich hospitality. Don’t miss the welcome reception on Wednesday, 11 April in the evening, where a “Little Oktoberfest” will be given right on the campus, hopefully outside (weather permitting).We would like to thank our corporate sponsors for supporting the meeting and the continued growth of our specialty. We encourage you to visit them at the exhibition area, located on the Hörsaal A Foyer.On behalf of the organising committee and the local and EAACI organisers we cordially welcome you to Munich wishing you an interesting and stimulating meeting and a chance to meet old and

make new friends!

Knut Brockow Dean Naisbitt

DHM5 2012 Chair DHM5 2012 Vice-Chair


WELCOME TO MUNICH


ORGANISING COMMITTEE• K. Brockow (DHM5 Chair), Germany

• D. Naisbitt (DHM5 Co-Chair), United Kingdom

• W. Pichler (Past DHM Chair), Switzerland

• B.K. Park (Past DHM Chair), United Kingdom

• J.C. Roujeau (Past DHM Chair), France

• P. Demoly (Past DHM Chair), France

• A. Romano (Past DHM Chair), Italy

• A. Bircher, Switzerland

• M. Blanca, Spain

• M. Castells, USA

• Y.T. Chen, Taiwan

• H.J. Hoffmann, Denmark

• M. Kammüller, Switzerland

• T. Kawabata, USA

• S.H. Kim, South Korea

• S. Mallal, Australia

• S.F. Martin, Germany

• H. Merk, Germany

• M. Mockenhaupt, Germany

• J.F. Nicolas, France

• R. Pieters, The Netherlands

• M. Pirmohamed, United Kingdom

• J. Ring, Germany

• N. Shear, Canada

• T. Shiohara, Japan

• A. Trautmann, Germany

• J. Uetrecht, Canada

• C. Yu , USA

Are you an EAACI Member?

Here are just a few of the benefits Members receive: Discount on registration fees to EAACI annual

congresses. Subscription to ALLERGY Journal and the Pediatric

Allergy and Immunology Journal including supplements. Online access to the offi cial EAACI journals. The EAACI Newsletter.

For more information contact: [email protected] | www.eaaci.net

Ad EAACI Membership_180x100.indd 1 21.04.2011 14:49:21


HISTORY OF DHMIn comparison to other hypersensitivity reactions in allergology and immunology, diagnosis and therapy of drug hypersensitivity is more complicated, as multiple drugs are able to elicit a heterogeneous array of symptoms ranging from mild to severe and from exanthematous skin eruptions to anaphylaxis. Thus, drug hypersensitivity still has to be regarded as a developing area. In order to combine existing knowledge and share new experiences in drug hypersensitivity, the Drug Hypersensitivity Meeting (DHM) was created by W. J. Pichler, Bern, which became an unofficial world congress on drug hypersensitivity.

The 1st Drug Hypersensitivity Meeting was hosted in Bern, Switzerland, 5 – 8 May 2004. The programme encompassed all aspects of drug hypersensitivity, and was aimed at scientists in the fields of Pharmacology, Toxicology, Chemistry, Allergy and Immunology. It should foster the exchange of knowledge between representatives from academia, industry and the regulatory agencies interested in drug hypersensitivity and aimed to create a better understanding and management of adverse drug reactions. The first meeting developed to be a success with more than 250 delegates and it was decided to continue the meeting every second year.

The 2nd Drug Hypersensitivity Meeting was organised by Dean J. Naisbitt, Munir Pirmohamed, and B. Kevin Park in Liverpool, United Kingdom, from 18 – 21 April 2006. It was attended by about 200 delegates and provided an excellent environment to discuss recent advances in the understanding of the chemical, cellular, molecular and genetic basis of drug hypersensitivity.

The 3rd Drug Hypersensitivity Meeting was hosted by Jean-Claude Roujeau and Pascal Demoly in Paris, 11 – 13 April 2008, and successfully continued the interaction between basic scientists and clinicial researchers. Like the previous Drug Hypersensitivity Meetings, it brought together international experts with the aim of fostering the exchanges of knowledge in drug hypersensitivity and improving the management of a constantly evolving problem.

From 22 – 25 April 2010, Antonino Romano organised the 4th Drug Hypersensitivity Meeting, now with increasing recognition and support of the European Academy of Allergy and Clinical Immunology (EAACI). In addition to basic research, it intensified practical clinical approaches in part by presenting updates on pathogenic mechanisms, diagnosis and prevention provided by the European Network for Drug Allergy (ENDA), the EAACI Interest Group on Drug Hypersensitivity.

The 5th Drug Hypersensitivity Meeting, which will be held in Munich 11 – 14 April 2012, will be the first DHM organised and promoted by the EAACI. The EAACI provides logistic and financial support and the intense participation by Asian, Australian and American colleagues underline that it will continue as an international meeting. As in previous meetings, experimental scientists as well as clinicians will find a platform to discuss their results and hopefully exchange their approach to drug hypersensitivity research. To enhance the attractiveness of DHM for clinicians, clinical case reports and practically oriented breakfast seminars will be provided. Let’s hope that the 5th DHM will become as successful as the previous ones – the high number of already registered participants and poster presenters seems to be a big promise for a successful meeting.

Werner Pichler Dean Naisbitt Knut Brockow


EAACI EXECUTIVE COMMITTEEEAACI Executive CommitteeC. Akdis, President

N. Papadopoulos, Secretary General

A. Muraro, Treasurer

J. Lötvall, Past President

P. Demoly, Vice-President Education & Specialty

C. Virchow, Vice-President Congresses

V. Cardona, Vice-President Communications & Membership

Section ChairsA. Custovic, Asthma Section Chairperson

C. Grattan, Dermatology Section Chairperson

P. W. Hellings, ENT Section Chairperson

E. Knol, Immunology Section Chairperson

G. Roberts, Pediatric Section Chairperson

E. Heffler, JMA Chairperson

Interest Group RepresentativesB. Bilo, IG Representative

T. Werfel, IG Representative

Members at LargeI. Agache

M. Jutel

M. Triggiani

P. Eigenmann

R. van Ree

S. Bavbek

Adjunct MembersF. Braido, CME Committee Chair

J. De Monchy, Specialty Committee Chair

J. Gayraud, Ethics Committee

P. Schmid-Grendelmeier, Exam Committee Chair

L. K. Poulsen, SPC Chairperson

C. Skevaki, EAACI Web Editor

M. Walker, Executive Director


GENERAL INFORMATION A-ZBank, Cash machineCash machines can be found at various bank institutions around the Max-Weber-Platz.

Certificate of AttendanceParticipating delegates will receive a Certificate of Attendance at the registration desk on-site.

Climate and Dress CodeIn April the average temperature in Munich is approx. 12,6 °C. For weather forecasts please visit www.weathercity.com/de/munich/The dress code will be informal throughout the Meeting.

CloakroomThere will be a supervised cloakroom located on the right side of the entrance to the plenary hall, Hörsaal A.

CME CreditsWe are pleased to inform you that EAACI will offer Continuing Medical Education (CME) Credits for the Drug Hypersensitivity Meeting 5. The aim of the CME system is to assure a high level of theoretical and clinical competences through medical specialists’ working life. The EAACI CME Accreditation Committee guarantees that CME programmes are of a high scientific and educational standard in agreement with the European and American CME systems. The EAACI CME Committee has applied to the European Accreditation Council for CME (EACCME) for European credits recognition.EACCME Credits will be available to US Doctors attending DHM5, due to a reciprocal agreement signed by the American Medical Association (AMA) and the European Union of Medical Specialists (UEMS).Each medical specialist should claim the recognition of the EAACI/EACCME Credits to his/her own CME National Authority.The DHM5 Meeting is certified with 21 CME credit points.The number of the credits per day will be : Wednesday: 6Thursday: 6Friday: 6Saturady: 3

CurrencyThe unit of currency is the Euro (€). The national currency in Germany is Euro (€).

DisclaimerThe Organisers cannot accept liability for injuries or losses of whatever nature incurred by participants, nor for loss of or damage to their luggage and/or personal belongings.


GENERAL INFORMATION A-ZEAACI BoothWe invite you to visit the EAACI Booth in the exhibition area just outside the Main Auditorium. If you have any questions regarding EAACI membership or if you want to settle your membership fee, the staff from the EAACI Headquarters will be happy to help you.Samples of EAACI publications will be displayed for your perusal as well as information about future EAACI events.We hope to see you at the EAACI Booth. Remember that after the DHM5 2012 you can always visit the website www.eaaci.net and read the latest news about EAACI activities and publications.

Opening Hours of the EAACI Booth:Wednesday, 11 April 2012 12:00 – 18:00 Thursday, 12 April 2012 08:00 – 18:00Friday, 13 April 2012 08:00 – 18:00 Saturday, 14 April 2012 08:00 – 14:00

EAACI HeadquartersGenferstrasse 21CH-8002 ZurichSwitzerlandTel: +41 44 205 55 33Fax: +41 44 205 55 39E-mail: [email protected]: www.eaaci.net

EAACI MembershipEAACI membership gives its members priority status at EAACI Congresses and Focused Meetings.Members over 36 years of age receive a discount of EUR 100 on the Registration fee of this Meeting and Junior members are entitled to register to the Meeting at the low “Student” fee. EAACI offers free Junior membership to individuals up to 36 years of age (with online access to the Journals ALLERGY and Pediatric Allergy Immunology). In addition, EAACI also offers a 50 % reduction on membership fees to members from countries with a GNP of less than USD 10’000, with full membership benefits. As an EAACI member you will be kept informed on the latest research and developments through our official journals ALLERGY and Pediatric Allergy Immunology (available in printed or electronic version) and Clinical and Translational Allergy (e-journal). These journals contain editorials, review articles, original articles, educational series and more. Experience and be part of the advancement of the knowledge and practice of allergy, asthma and immunology for optimal patient care! For more information and to apply for membership visit our website: www.eaaci.net

Electricity220 volts, 50Hz. European-style two-pin plugs are standard.


GENERAL INFORMATION A-ZExhibitionThe Drug Hypersensitivity Meeting 5 includes an exhibition that starts 11 April 2012 and will be open during the Meeting hours. Opening hours:

Wednesday, 11 April 2012 12:00 – 18:00 Thursday, 12 April 2012 08:00 – 18:00Friday, 13 April 2012 08:00 – 18:00 Saturday, 14 April 2012 08:00 – 14:00

General Information – MunichThe city of dreams in Southern Germany is situated in the midst of a beautiful pre-alpine countryside and offers a spectacular variety of culinary, artistic and cultural highlights.Munich combines the splendour of an old royal seat with the vitality of a modern high-tech location.

The city owes its generous architecture to the reign of the Bavarian King Ludwig I (1786-1868). The townscape is marked by broad avenues and the contrast between Classicist restraint and Baroque profusion. Daring creativity and innovation have placed new architectural accents all over the city.

The downtown area presents a clear, delightful and charming image marked by the distinctive feature of the Frauenkirche cathedral whose two towers rise above the roofs of the city.

Munich is the largest city in the south of Germany and is about an hour and a half drive from the Alps. It is located very close to Austria, Switzerland and after a short hop through Austria, also Italy.

Information for Speakers / Oral PresentationPlease bring your oral presentation on a memory stick and hand it in, in good time before your session starts. Only PowerPoint projections will be available in the session halls and only computers provided on-site can be used. Only PowerPoint version 2007 or previous running on PC’s will be available. The maximum resolution for the computers and projectors will be set at 1024x768. We recommend that you only use standard fonts and symbols to avoid formatting issues for your presentation. We also recommend you to include your fonts when you save your presentation. The standard set-up does not allow audio in your presentation. If you use clips or attachments, make sure to create a presentation folder where these are included. Only standard codecs are supported.

InternetWLAN is available for free for all participants at their own risk in most areas of the lecture hall building. The name of the SIID-network is “con”, password is not needed.


GENERAL INFORMATION A-ZLanguageThe official language of the meeting is English.Simultaneous translation will not be provided.

Media / PressPress registration is available at the registration desk.

Name BadgesEvery participant will receive a name badge at the registration desk. For security reasons all participants are requested to wear their badges during the DHM5 Meeting. Entrance will not be permitted to those delegates not wearing their badge.

Badge colours:Transparent DelegatesRed FacultyGreen ExhibitorsWhite PressBlue Staff

Programme ChangesThe Organisers cannot assume liability for any changes in the programme due to external unforeseen circumstances.

Public TransportMunich has an extensive public transport system consisting of S-Bahn (a mainly above ground urban railway system), U-Bahn (mainly underground rail system), buses and trams.

All of these can be accessed with the same ticket available from counters or ticket machines at the S- and U-Bahn stations or on the bus or tram. Different kinds of day passes and group tickets are also available. The main airport and all train stations are easily accessible by public transport. More information at: www.mvv-muenchen.de

Registration DeskThe registration desk at the Klinikum rechts der Isar, which can be found opposite to the main entrance of the lecture hall building, will be open as follows:

Wednesday, 11 April 2012 08:00 – 18:30Thursday, 12 April 2012 06:30 – 18:30Friday, 13 April 2012 06:30 – 18:30Saturday, 14 April 2012 07:00 – 14:00

Phone: +49 (0) 172 58 01 346


GENERAL INFORMATION A-ZSafetyThe area around the Lecture Hall Building of Klinikum rechts der Isar is known to be a very safe zone of Munich. However, please be aware of thieves and pick-pockets like in any major European city and take respective precautions.

Smoking PolicyIn accordance with the policy of EAACI, this is a non-smoking event.

Welcome ReceptionYou can purchase tickets for the Welcome Reception at the registration desk.

TelephoneThe international access code for Germany is + 49. The outgoing code is 00 followed by the relevant country code (e. g. 0044 for the United Kingdom). Note that telephone numbers in Germany can range from four to nine digits.

Local emergency telephone numbers are 112 (fire and ambulance) and 110 (police).

Tourist InformationThe staff at the registration desk and at the reception of your hotel will be glad to answer any questions.

Travel GrantsCosts will be refunded after the Meeting, upon presentation of your original tickets and travel receipts. You will get the reimbursement form at the registration desk.

VenueThe Drug Hypersensitivity Meeting 5 is held at:

Klinikum rechts der IsarTechnische Universität München (TUM)Faculty of MedicineLecture Hall BuildingIsmaninger Straße 2281675 Munich, Germany

Websitewww.eaaci-dhm2012.com


SPONSORSPlatinum SponsorResearch Laboratories Maruho Co., Ltd.

Silver SponsorDiater Laboratorios S.A.

Bronze SponsorDeutsche Gesellschaft für Allergologie und klinische Immunologie e.V. (DGAKI)

Other ContributorsPhadia GmbHNovartis


KLINIKUM RECHTS DER ISAR

How to get there?

From the Main Central Station• Take the underground train “U4” in direction to “Arabellapark” or “U5” in direction to “Neuperlach Süd”

• The stop is “Max-Weber Platz”

• Take the exit “Einsteinstraße” (approx. 4 minutes walk to Klinikum rechts der Isar)

• Take the tram (street train) “18” in direction to “Effnerplatz”

• The stop is “Max-Weber Platz” (approx. 2 minutes walk to Klinikum rechts der Isar)

From Marienplatz• Take the underground train “U6” in direction to “Garching Forschungszentrum” or “U3” in direction to “Olympiaeinkaufszentrum OEZ”

• Change at “Odeonsplatz” (1 stop after Marienplatz)

• Take the underground train “U4” in direction to “Arabellapark” or “U5” in direction to “Neuperlach Süd”

• The stop is “Max-Weber Platz”

• Take the exit “Einsteinstraße” and follow the signs “DHM5” (approx. 4 minutes walk to Klinikum rechts der Isar)

Klinikumrechts der Isar

Hörsäle Lecture Halls


ABSTRACTS

For more information please contact: [email protected]

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PROGRAMME OVERVIEW

Wednesday, 11 April 2012

08:15 - 11:30 Pavillon Pre-congress clinical course and workshop: Basophil activation test

12:45 - 13:15 Welcome

13:15 - 14:00 Introductory lecture Drug hypersensitivity research: past, present and future?

14:15 - 16:00 Plenary Drug anaphylaxis

16:00 - 16:30 Coffee break

16:30 - 18:00 Parallel symposia – Approach to drug exanthems – Drug hypersensitivity and viral disease: a dynamic interaction?

18:00 Welcome Reception “Little Oktoberfest”

Thursday, 12 April 2012

07:30 - 08:15 Practical seminars – How to manage NSAID hypersensitivity– Drug desensitization

08:15 - 08:45 Teaching case reports Case report presentations

09:00 - 10:45 Plenary Fundamental immunological principles relevant to drug hypersensitivity


11:15 - 12:45 Parallel symposia – Diagnostic tools: options and controversies of in vivo tests – Relevant models to understand new and emerging drug hypersensitivity issues

12:45 - 13:15 Snack lunch

13:15 - 14:00 Poster viewing

14:15 - 16:00 Plenary Side effects of biologicals: clinical issues


16:30 - 18:00 Parallel symposia – In vitro diagnostic tools: research instruments or fit for practice? – Risk assessment of side effects to biologicals


PROGRAMME OVERVIEW

Friday, 13 April 2012

07:30 - 08:15 Practical seminars – How to manage adverse reactions to chemotherapy and biologicals

– Drug provocation test


09:00 - 10:45 Plenary Drug-induced liver injury


11:15 - 12:45 Parallel symposia – Clinical hypersensitivity reactions to important drugs – What have we learned from genetic studies on drug hypersensitivity?


13:15 - 14:00 Poster viewing

14:15 - 16:00 Plenary Severe adverse drug reactions


16:30 - 18:00 Parallel symposia – Contact hypersensitivity meets drug hypersensitivity – Progression of allergen recognition to delayed hypersensitivity

Saturday, 14 April 2012

07:30 - 08:15 Practical seminars – How to manage radiocontrast media hypersensitivity– How to manage betalactam hypersensitivity


09:00 - 10:45 Plenary Understanding the structural basis of HLA associations for drug hypersensitivity


11:15 - 12:45 Parallel symposia – Update on ENDA activities – Pathomechanisms of SJS/TEN

12:45 - 13:15 Highlights of the meeting: experimentalHighlights of the meeting: clinical



SCIENTIFIC PROGRAMMEWednesday, 11 April 2012

Pavillon Pre-congress clinical course and workshop: Basophil activation test in drug hypersensitivity08:15 – 09:15 Research tool or diagnostic test?

Drug allergens with BATClinical case reports

09:30 – 11:00 Hands-on BAT (provided by Bühlmann Laboratories)11:00 – 11:30 Discussion of case reports with BAT results

12:45 - 13:15 Welcome13:15 - 14:00 Lecture Hall A Chair: K. Brockow, D. Naisbitt Introductory lecture

13:15 – 14:00 W. Pichler Drug hypersensitivity research: past, present and future14:15 -16:00 Plenary

Lecture Hall AChair: J. Ring, P. Demoly Drug anaphylaxis14:15 – 14:45 R. Pumphrey Lessons from fatal anaphylaxis to drugs14:45 – 15:15 P. M. Mertes Blood derivative-induced anaphylaxis15:15 – 15:45 L. Heise Garvey Hidden allergens in perioperative anaphylaxis15:45 – 16:00 F. Gomez PV 30 Diagnosing immediate hypersensitivity reactions to radio contrast media

16:00 - 16:30 Coffee break16:30 - 18:00 Parallel symposia

Lecture Hall A

Lecture Hall B

Chair: A. Romano, P. Whitacker Approach to drug exanthems16:30 – 16:52 F. Rueff Morphology and dermatological differential diagnoses16:52 – 17:14 N. Shear Use of chronology and literature to conclude to the culprit drug 17:14 – 17:36 A. Trautmann Management: Treating through, cessation or desensitisation?17:36 – 18:00 A. Bircher Non-immediate urticaria and angioedema – does it exist?Chair: J. C. Roujeau, P. Musette Drug hypersensitivity and viral disease: a dynamic interaction?

16:30 – 16:55 T. Shiohara Characterisation of viral responses in patients with severe drug eruptions16:55 – 17:20 H. Hashizume Drug- and virus-specific T-cells as mediators of DRESS17:20 – 17:45 P. Musette EBV-specific T-cells in DRESS 17:45 – 18:00 Y.-C. Chen PV 124: Reactivation of human herpes viruses in various forms of cutaneous adverse drug

reactions: a comparative study in Taiwan18:00 Welcome Reception “Little Oktoberfest” at the Mensa / Rechts der Isar


SCIENTIFIC PROGRAMMEWednesday, 11 April 2012

Pavillon Pre-congress clinical course and workshop: Basophil activation test in drug hypersensitivity08:15 – 09:15 Research tool or diagnostic test?

Drug allergens with BATClinical case reports

09:30 – 11:00 Hands-on BAT (provided by Bühlmann Laboratories)11:00 – 11:30 Discussion of case reports with BAT results

12:45 - 13:15 Welcome13:15 - 14:00 Lecture Hall A Chair: K. Brockow, D. Naisbitt Introductory lecture

13:15 – 14:00 W. Pichler Drug hypersensitivity research: past, present and future14:15 -16:00 Plenary

Lecture Hall AChair: J. Ring, P. Demoly Drug anaphylaxis14:15 – 14:45 R. Pumphrey Lessons from fatal anaphylaxis to drugs14:45 – 15:15 P. M. Mertes Blood derivative-induced anaphylaxis15:15 – 15:45 L. Heise Garvey Hidden allergens in perioperative anaphylaxis15:45 – 16:00 F. Gomez PV 30 Diagnosing immediate hypersensitivity reactions to radio contrast media


Lecture Hall A

Lecture Hall B

Chair: A. Romano, P. Whitacker Approach to drug exanthems16:30 – 16:52 F. Rueff Morphology and dermatological differential diagnoses16:52 – 17:14 N. Shear Use of chronology and literature to conclude to the culprit drug 17:14 – 17:36 A. Trautmann Management: Treating through, cessation or desensitisation?17:36 – 18:00 A. Bircher Non-immediate urticaria and angioedema – does it exist?Chair: J. C. Roujeau, P. Musette Drug hypersensitivity and viral disease: a dynamic interaction?

16:30 – 16:55 T. Shiohara Characterisation of viral responses in patients with severe drug eruptions16:55 – 17:20 H. Hashizume Drug- and virus-specific T-cells as mediators of DRESS17:20 – 17:45 P. Musette EBV-specific T-cells in DRESS 17:45 – 18:00 Y.-C. Chen PV 124: Reactivation of human herpes viruses in various forms of cutaneous adverse drug

reactions: a comparative study in Taiwan18:00 Welcome Reception “Little Oktoberfest” at the Mensa / Rechts der Isar


SCIENTIFIC PROGRAMMEThursday, 12 April 201207:30 - 08:15 Practical seminars Lecture Hall A A. Bircher How to manage NSAID hypersensitivity

Lecture Hall B M. Castells Drug desensitisation08:15 - 08:45 Teaching case reports Case report presentations (immediate drug hypersensitivity)09:00 - 10:45 Plenary

Lecture Hall A

Chair: T. Shiohara, H. Merk Fundamental immunological principles relevant to drug hypersensitivity09:00 – 09:26 O. Rötzschke The role of HLA in presentation of peptide and chemical antigens09:26 – 09:52 W. Schamel T-cell activation and signaling 09:52 – 10:18 S. Martin Immune regulation: stimulation of innate immunity by drugs/chemicals10:18 – 10:45 K. Eyerich Immune regulation: Th17 cells and Tregs


Lecture Hall A

Lecture Hall B

Chair: A. Bircher, M. Blanca Diagnostic tools: options and controversies of in vivo tests11:15 – 11:40 A. Romano What do we know about cross-reactivity in betalactams?11:40 – 12:05 A. Barbaud Approach to standardised skin test techniques12:05 – 12:30 P. Demoly Value and limitations of the drug provocation test12:30 – 12:45 J. Hjortlund PV 74 Prospective study on the diagnosis of penicillin allergy (PEDAL 2)Chair: K. Park, S. Martin Relevant models to understand new and emerging drug hypersensitivity issues11:15 – 11:37 L. Kwast Animal models for screening drug hypersensitivity issues 11:37 – 11:59 R. Abe Production of SJS/TEN model mice using patients’ samples 11:59 – 12:21 L. Faulkner Risk assessment for drugs using genotyped drug naïve volunteers: Liverpool experience12:21 – 12:45 Y. Yerly Risk assessment for drugs using genotyped drug naïve volunteers: Bern experience

12:45 - 13:15 Snack lunch13:15 - 14:00 Poster viewing14:15 - 16:00 Plenary

Lecture Hall A

Chair: W. Pichler, M. Castells Side effects of biologicals: clinical approaches14:15 – 14:45 A. Wollenberg Unusual cutaneous side effects of biologicals 14:45 – 15:15 A. Vultaggio Adverse effects due to antibody formation and test possibilities15:15 – 15:45 L. Macchia PV 58 Rapid desensitisation to rituximab15:45 – 16:00 A. Barbaud PV 56 Evaluation of a practice og managing drug eruptions due to pegylated Interferon and

effectiviness of tolerance induction16:00 - 16:30 Coffee break16:30 - 18:00 Parallel symposia

Lecture Hall B

Lecture Hall A

Chair: C. Mayorga, J. Nicolas In vitro diagnostic tools: research instruments or fit for practice?16:30 – 16:55 A. Rozieres LTT and ELIspot 16:55 – 17:20 J. Leysen Flow cytometry based assays including histoflow 17:20 – 17:45 J.-L. Guéant How to develop new specific IgE assays to drugs? 17:45 – 18:00 T. Hanafusa PV 189 Evaluation of drug-specific T-cell population by flow cytometric drug-induced

lymphocyte stimulation testChair: A. Vultaggio, Guest: M. Kammueller Risk assessment of side effects to biologicals16:30 - 16:34 M. Kammüller Introductory Lecture16:34 - 16:55 T. Manigold Cytokine release syndromes: in vitro risk assessment16:55 - 17:16 S. Spindeldreher Investigating assessment of the immunogenicity risk for biotherapeutics – Available methods

and their predictive value17:16 - 17:37 T. Ishida Cytokine imbalance after biological treatment is responsible for paradoxical deterioration 17:37 – 18:00 O. Hausmann Acute infusion reactions including anaphylaxis


SCIENTIFIC PROGRAMMEThursday, 12 April 201207:30 - 08:15 Practical seminars Lecture Hall A A. Bircher How to manage NSAID hypersensitivity

Lecture Hall B M. Castells Drug desensitisation08:15 - 08:45 Teaching case reports Case report presentations (immediate drug hypersensitivity)09:00 - 10:45 Plenary

Lecture Hall A

Chair: T. Shiohara, H. Merk Fundamental immunological principles relevant to drug hypersensitivity09:00 – 09:26 O. Rötzschke The role of HLA in presentation of peptide and chemical antigens09:26 – 09:52 W. Schamel T-cell activation and signaling 09:52 – 10:18 S. Martin Immune regulation: stimulation of innate immunity by drugs/chemicals10:18 – 10:45 K. Eyerich Immune regulation: Th17 cells and Tregs


Lecture Hall A

Lecture Hall B

Chair: A. Bircher, M. Blanca Diagnostic tools: options and controversies of in vivo tests11:15 – 11:40 A. Romano What do we know about cross-reactivity in betalactams?11:40 – 12:05 A. Barbaud Approach to standardised skin test techniques12:05 – 12:30 P. Demoly Value and limitations of the drug provocation test12:30 – 12:45 J. Hjortlund PV 74 Prospective study on the diagnosis of penicillin allergy (PEDAL 2)Chair: K. Park, S. Martin Relevant models to understand new and emerging drug hypersensitivity issues11:15 – 11:37 L. Kwast Animal models for screening drug hypersensitivity issues 11:37 – 11:59 R. Abe Production of SJS/TEN model mice using patients’ samples 11:59 – 12:21 L. Faulkner Risk assessment for drugs using genotyped drug naïve volunteers: Liverpool experience12:21 – 12:45 Y. Yerly Risk assessment for drugs using genotyped drug naïve volunteers: Bern experience


Lecture Hall A

Chair: W. Pichler, M. Castells Side effects of biologicals: clinical approaches14:15 – 14:45 A. Wollenberg Unusual cutaneous side effects of biologicals 14:45 – 15:15 A. Vultaggio Adverse effects due to antibody formation and test possibilities15:15 – 15:45 L. Macchia PV 58 Rapid desensitisation to rituximab15:45 – 16:00 A. Barbaud PV 56 Evaluation of a practice og managing drug eruptions due to pegylated Interferon and

effectiviness of tolerance induction16:00 - 16:30 Coffee break16:30 - 18:00 Parallel symposia

Lecture Hall B

Lecture Hall A

Chair: C. Mayorga, J. Nicolas In vitro diagnostic tools: research instruments or fit for practice?16:30 – 16:55 A. Rozieres LTT and ELIspot 16:55 – 17:20 J. Leysen Flow cytometry based assays including histoflow 17:20 – 17:45 J.-L. Guéant How to develop new specific IgE assays to drugs? 17:45 – 18:00 T. Hanafusa PV 189 Evaluation of drug-specific T-cell population by flow cytometric drug-induced

lymphocyte stimulation testChair: A. Vultaggio, Guest: M. Kammueller Risk assessment of side effects to biologicals16:30 - 16:34 M. Kammüller Introductory Lecture16:34 - 16:55 T. Manigold Cytokine release syndromes: in vitro risk assessment16:55 - 17:16 S. Spindeldreher Investigating assessment of the immunogenicity risk for biotherapeutics – Available methods

and their predictive value17:16 - 17:37 T. Ishida Cytokine imbalance after biological treatment is responsible for paradoxical deterioration 17:37 – 18:00 O. Hausmann Acute infusion reactions including anaphylaxis


SCIENTIFIC PROGRAMMEFriday, 13 April 201207:30 - 08:15 Practical seminars Lecture Hall A A. Barbaud How to manage adverse reactions to chemotherapy and biologicals

Lecture Hall B P. Demoly Drug provocation test08:15 - 08:45 Teaching case reports Lecture Hall A Case report presentations (immediate drug hypersensitivity)09:00 - 10:45 Plenary

Lecture Hall AChair: E. Phillips, M. Pirmohamed Drug induced liver injury09:00 – 09:30 A. K. Daly Genome studies and HLA associations in drug-induced liver injury (DILI)09:30 – 10:00 C. Ju Immunological mechanism of DILI: Lessons from animal models 10:00 – 10:30 D. Naisbitt Immunological mechanism of DILI: Lessons from patients and human volunteers expressing HLA risk alleles 10:30 – 10:45 N. Wuillemin PV 163 Mechanisms of T cell stimulation by flucloxacillin in HLA-B*5701

+ flucloxacillin-naïve individuals10:45 - 11:15 Coffee break11:15 - 12:45 Parallel symposia

Lecture Hall B

Lecture Hall A

Chair: A. Trautmann, H. Merk Clinical hypersensitivity reactions to important drugs11:15 – 11:40 C. Mayorga Quinolones11:40 – 12:05 M. Castells Targeted and traditional chemotherapy 12:05 – 12:30 K. Scherer Anticoagulants 12:30 – 12:45 B. Y. Thong PV 60 A Retrospective Study on Sequential Desensitisation-Rechallenge for Anti-Tuberculous Drug AllergyChair: A. Daly, S. Hung What have we learned from genetic studies on drug hypersensitivity?11:15 – 11:37 M. Mockenhaupt Lessons to be learned from epidemiology 11:37 – 11:59 Y.-T. Chen Carbamacepine-induced hypersensitivity: HLA, T-cell receptors and pharmacogenetics 11:59 – 12:21 T. Mushiroda HLA-A*3101 allele is a risk factor for different carbamazepine-induced cutaneous adverse drug reactions12:21 – 12:45 M. Pirmohamed Pharmacogenetic screening for drug hypersensitivity: lessons from the ITCH project


Lecture Hall A

Chair: M. Mockenhaupt, H. Hashizume Severe cutaneous adverse reactions14:15 – 14:45 Y. Kano Complications and sequelae of severe drug reactions 14:45 – 15:15 J.-F. Nicolas Are SCADRs allergic? Value of immunobiological tests 15:15 – 15:45 J.-C. Roujeau Treatment recommendations 15:45 – 16:00 E. Genin PV 130 HLA-A*3101 is more strongly associated with carbamazepine-induced drug reac-

tion with eosinophilia and systemic symptoms than with carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis


Lecture Hall B

Lecture Hall A

Chair: I. Kimber, A. Barbaud Contact hypersensitivity meets drug hypersensitivity16:30 – 16:55 A. Schnuch Contact allergy to drugs 16:55 – 17:20 W. Aberer Hematogeneous contact allergy 17:20 – 17:45 T. Rustemeyer Contact allergy and drug exanthema to drugs: differences and similarities 17:45 – 18:00 P. R. Esser PV 109 Innate immune responses to contact sensitisers are mediated via ROS production

and HA degradation Chair: A. Rozières, C. Ju Progression of allergen recognition to delayed hypersensitivity16:30 – 16:52 I. Kimber From antigen recognition to dendritic cell migration 16:52 – 17:14 E. Maggi From dendritic cell migration to a polarised immune response 17:14 – 17:36 S. Lloyd Watkins T-cell receptor interactions with drugs 17:36 – 18:00 E. Perez-Inestrosa Nanostructures mimicking hapten protein


SCIENTIFIC PROGRAMMESaturday, 14 April 201207:30 - 08:15 Practical seminars Lecture Hall A M. Grosber How to manage radiocontrast media hypersensitivity

Lecture Hall B M. J. Torres How to manage betalactam hypersensitivity08:15 - 08:45 Teaching case reports Case report presentations (miscellaneous)09:00 - 10:45 Plenary

Lecture Hall AChair: Y.-T. Chen, D. Yerly Understanding the structural basis of HLA associations for drug hypersensitivity09:00 – 09:26 E. Phillips Abacavir and Nevirapine as two distinct models for HLA-binding09:26 – 09:52 J. Adam T-cell receptor affinity determines reactivity 09:52 – 10:18 C. Bell Chemical restriction of abacavir-responsive T-cells10:18 – 10:45 S.-I. Hung T-cell receptor use is critical for carbamazepine-induced SJS


Lecture Hall B

Lecture Hall A

Chair: W. Aberer, P. Bonadonna Update on ENDA activities11:15 – 11:40 I. Terreehorst Do we need separate protocols for children with drug hypersensitivity?11:40 – 12:05 M. Blanca Practical workup of patients with NSAID hypersensitivity 12:05 – 12:30 P. Whitaker Desensitisation in proven non-immediate reactions12:30 – 12:45 E. Gomez PV 169 Accelerated allergic reactions to amoxicillinChair: Y. Kano, N. Shear Pathomechanisms of Stevens-Johnson-Syndrome / Toxic epidermal necrolysis11:15 – 11:37 K. Kabashima Live imaging of T-cells attacking keratinocytes expressing non-self antigens in SJS/TEN11:37 – 11:59 T. Bellón CD94/NKG2C is a killer effector molecule in patients with SJS/TEN11:59 – 12:21 K. Nagao A novel model of interface dermatitis caused by autoreactive CD4+ T-cells

12:21 – 12:45 Y. Aoyama SJS/TEN as the drug-induced variant of paraneoplastic autoimmune multiorgan syndrome (PAMS)

12:45 - 13:15 K. ParkK. Brockow

Highlights of the meeting: experimentalHighlights of the meeting: clinical

13:15 - 14:00 Snack Lunch

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SCIENTIFIC PROGRAMMESaturday, 14 April 201207:30 - 08:15 Practical seminars Lecture Hall A M. Grosber How to manage radiocontrast media hypersensitivity

Lecture Hall B M. J. Torres How to manage betalactam hypersensitivity08:15 - 08:45 Teaching case reports Case report presentations (miscellaneous)09:00 - 10:45 Plenary

Lecture Hall AChair: Y.-T. Chen, D. Yerly Understanding the structural basis of HLA associations for drug hypersensitivity09:00 – 09:26 E. Phillips Abacavir and Nevirapine as two distinct models for HLA-binding09:26 – 09:52 J. Adam T-cell receptor affinity determines reactivity 09:52 – 10:18 C. Bell Chemical restriction of abacavir-responsive T-cells10:18 – 10:45 S.-I. Hung T-cell receptor use is critical for carbamazepine-induced SJS


Lecture Hall B

Lecture Hall A

Chair: W. Aberer, P. Bonadonna Update on ENDA activities11:15 – 11:40 I. Terreehorst Do we need separate protocols for children with drug hypersensitivity?11:40 – 12:05 M. Blanca Practical workup of patients with NSAID hypersensitivity 12:05 – 12:30 P. Whitaker Desensitisation in proven non-immediate reactions12:30 – 12:45 E. Gomez PV 169 Accelerated allergic reactions to amoxicillinChair: Y. Kano, N. Shear Pathomechanisms of Stevens-Johnson-Syndrome / Toxic epidermal necrolysis11:15 – 11:37 K. Kabashima Live imaging of T-cells attacking keratinocytes expressing non-self antigens in SJS/TEN11:37 – 11:59 T. Bellón CD94/NKG2C is a killer effector molecule in patients with SJS/TEN11:59 – 12:21 K. Nagao A novel model of interface dermatitis caused by autoreactive CD4+ T-cells

12:21 – 12:45 Y. Aoyama SJS/TEN as the drug-induced variant of paraneoplastic autoimmune multiorgan syndrome (PAMS)

12:45 - 13:15 K. ParkK. Brockow

Highlights of the meeting: experimentalHighlights of the meeting: clinical

13:15 - 14:00 Snack Lunch

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POSTER EXHIBITIONThe poster exhibition will take place in the Pavillon as well as in the left foyer of the lecture hall building of Klinikum rechts der Isar.

Hang-up and take down time for posters:Hang-up: from Wednesday, 11 April 2012, 15:00 Take down: until Saturday, 14 April 2012, 10:00 (after guided walk on Friday)

Poster viewingExperts will review and discuss selected posters in their field and will select the best presentations to receive poster prices (2 for clinical and experimental each). Thus, representers are required to attend to and discuss their posters on Thursday, 12 April 2012, 13:15 – 14:00,Poster P1 – P110

Poster viewingFriday, 13 April 2012, 13:15 – 14:00P 111 – P 231

In addition, poster discussions are encouraged from 18:00 - 19:00 on Thursday and Friday by some pretzels, water and beer. At 19:00 the meeting location closes.

The poster prizes will be awarded during the closing session on Saturday, 14 April 2012, 12:45 - 13:15, Lecture Hall A


ABSTRACTSPosters with Oral Presentations

Drug anaphylaxis

PV30

Diagnosing immediate hypersensitivity reactions to radio contrast media Gómez F.1, Torres M.J.1, Doña I.1, Gracía Nuñez I.1, Aranda A.2, Cañamero D.1, García Campos J.1, Mayorga C.2, Blanca M.11HRU Carlos Haya, Málaga, Spain, 2IMABIS Foundation-Carlos Haya Hospital, Málaga, Spain Introduction: The incidence of immediate hypersensitivity reactions to radio contrast media (RCM) is low, ranging from 0.7-1,3%. Although usually mild, severe reactions and sometimes fatal, have been reported. This type of reactions has been classically considered as non-allergic in nature and therefore skin tests not useful for diagnosis. Actually, there is not a consensus on the diagnostic approach in patients with immediate hypersensiti-vity reactions to RCM. Objectives: The aim of the study was to analyse in detail the clinical symptoms as well as the diagnosis value of skin test, drug provocation test (DPT) and basophil activation test (BAT), in a group of patients with symptom compatible with immediate hypersensitivity reactions to RCM. Methods: We studied patients referred over 5 years period (2006-2011) with suspicion of immediate hypersen-sitivity to RCM. Prick and intradermal skin tests with a panel of RCM were done. In mild reactions with skin test negative pre-medication was recommended and in moderate-severe reactions DPT was done for searching an alternative. BAT was done in those confirmed as allergic by positive skin tests or DPT. Results: We studied 146 patients (108 females), with a mean age of 52,6 years. Six (4,11%) patients were confirmed as allergic, 3 by positive skin tests and 3 by positive DPT. Regarding skin testing: one were prick test positive (Iodixanol) and two intradermal test positive (Iodixanol, Iohexol and Meglumine Ioxaglate). DPT was positive to Iodixanol in 2 cases and to Iomeprol, Iohexol and Iobitridol in one case. BAT was positive to Iodixanol, Iomeprol, Meglumnine Ioxaglate and Iohexol, being in all controls cases (N=10). Patients confirmed as allergic were those developing anaphilaxis or urticaria while cases with skin test negative had mild symptoms. In this last group the recommendation was to use premedication. Conclusions: Only 4,11% of the patients evaluated were confirmed as allergic to RCM, by skin testing or DPT. These patients were those with moderate or severe reactions. BAT was useful for confirming the diagnosis. Most patients had mild symptoms, being all skin test negative and having good tolerance to subsequent exposures when administered with premedication. These results reinforce the need of evaluating patients with immediate hypersensitivity reactions to RCM, specially dose with more severe reactions.

Drug hypersensitivity and viral disease: a dynamic interaction?

PV124 Reactivation of human herpes viruses in various forms of cutaneous adverse drug reactions - a compara-tive study in TaiwanChen Y.-C.1, Chang C.-Y.2, Cho Y.-T.2, Chiu H.-C.2,3, Chu C.-Y.2,3

1Cathay General Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 2National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 3National Taiwan University College of Medicine, Department of Dermatology, Taipei, Taiwan, Republic of China Purpose: The association of human herpesvirus (HHV) reactivations with DRESS has been reported, but their roles in the pathogenesis are debating. Viral reactivation might be a secondary event after drug-induced immunological reactions or the consequence of therapy. The purpose of this study is to investigate the reactivation rates of HHV in various forms of cutaneous adverse drug reactions (cADRs) by using uniform laboratory methods in a single medical center in Taiwan. Materials and methods: From September 2010 to August 2011, we prospectively enrolled patients who were hospitalized due to drug eruptions. After informed consent, venous blood samples of each patient were obtained within three days of admission and then every week till they were discharged or resolution of all symptoms. DNA from serum and peripheral blood mononuclear cells (PBMC) of each sample was extracted and tested by quantitative polymerase chain reaction (q-PCR) for Epstein-Barr virus (EBV), HHV-6 and cytomegalovirus (CMV) reactivations. Serological tests were performed to detect changes in antibody titers for the three viruses.


ABSTRACTSEBV reactivation was defined as a fourfold elevation of IgG antibody titer against EBV early antigen (EA) or viral capsid antigen (VCA) but without IgM antibodies against VCA, viral DNA loads in sera more than 50 copies/ ml, or viral loads in PBMC over 103 copies/µg DNA. Reactivation of HHV-6 was defined as a fourfold increase of anti-HHV-6 IgG antibody titer or positive q-PCR results from serum samples. CMV infection/reactivation was defined as detection of viral DNA in serum samples or PBMC by q-PCR. Results: There are 24 cases enrolled in this study: 9 SJS/TEN, 9 DRESS, 1 GBFDE and 5 with generalized maculopapular eruption (MPE). EBV reactivation was detected in 11 patients, including 6 DRESS (66.7%), 2 SJS/TEN (22.2%), 2 MPE (40%) and 1 GBFDE patient. Reactivations of HHV-6 and CMV were observed in 4 (44.4%) and 2 (22.2%) DRESS patients respectively. Those two patients with CMV reactivation also had HHV-6 and EBV reactivations. Both of them had HHV-6 reactivation first, and then followed by sequential or simultaneous CMV and EBV reactivations, as well as fluctuating clinical courses. Conclusions: EBV reactivation, which was detected in various forms of cADRs, is not specific to DRESS, while HHV-6 and CMV reactivations seem to be more specific to DRESS Diagnostic Tools: options and controversies of in vivo tests

PV74 Prospective study on the diagnosis of penicillin allergy (PEDAL 2) Hjortlund J.1, Mortz C.G.1, Skov P.S.1, Bindslev-Jensen C.1

1Odense University Hospital, Department of Dermatology and Allergy Centre, Odense C, Denmark Background: The purpose of PEDAL is to improve diagnostic tools in penicillin allergy.Methods: A total of 334 patients suspected of having penicillin allergy were prospectively investigated at the Allergy Centre, Odense University Hospital, Denmark in the period Sep. 2010 to Sep. 2011 according to ENDA guidelines.We used the ENDA questionnaire, specific IgE from Termo Fisher, skin testing in dublicate with penicillin G and V, amoxicillin, ampicillin, dicloxacillin, mecillinam, PPL and MDM and patch testing with all mentioned except PPL and MDM. Challenge were performed in consecutive steps: first an intravenous (i.v) titrated challenge with benzylpenicillin and if negative, an oral challenge (single dose) with phenoxymethylpenicillin, followed by (when negative) a prolonged oral treatment (p.o.7) for 7 days. Results: Nineteen of the 334 patients were IgE sensitized to penicillin. None reacted in prick test (SPT). Intra-cutaneous testing (ICT) was subsequently performed in all patients; including the patients with positive IgE. 22 patients were positive in ICT, 15 cases with late reading positive reactions and 7 with immediate reactions. Only 3 patients had positive ICT to PPL and/or MDM. All was also positive to penicillin G in ICT. Only 4 patients with positive IgE also showed a positive immediate reaction in ICT. Patch testing was positive in 9 patients; all of them also had a positive late reaction in ICT. The remaining patients (n=297) were challenged with penicillin.Four patients were positive in the i.v challenge; the remaining 293 received oral provocation (single dose), where 5 had positive reactions. The remaining 288 patients received p.o.7 and here 23 patients responded with positive outcome; 15 with urticaria +/- angioedema, 5 with maculopapulous exanthema and 3 with other signs. Patients with a case history of anaphylaxis, urticaria or angioedema were statistically more likely to be positive in the tests (IgE, SPT/ICT, patch test or penicillin challenge) than patients reporting unspecific cutaneous rash or those not remembering the nature of their initial reaction. Conclusion: We have demonstrated that approximately 25% of all the patients with positive outcome in the peni-cillin investigation are found by adding a prolonged oral (one week) treatment with penicillin. Skin testing seems of little value in our region. Side effects of biologicals: clincal approaches

PV56

Evaluation of a practice of managing drug eruptions due to pegylated interferon and effectivness of tolerance induction Poreaux C.1, Studer M.1, Waton J.1, Schmutz J.-L.1, Bronowicki J.-P.2, Barbaud A.1

1CHU, Dermatology, Nancy, France, 2CHU, Hepatology, Nancy, France Introduction: Interferons (IFN) are glycoproteins belonging to three major classes (α,b,g) sometimes responsible for skin manifestations. The main objective is to provide a standardized course of action in the treatment of cutaneous


ABSTRACTSadverse drug reactions to IFN. Secondary objectives are to assess the effectiveness of treatment when the local and general pursuit of IFN is essential and the efficiency of a protocol to induce tolerance to IFN when there is no other alternative therapy. Patients and methods: This is a cross-sectional clinical study, prospectively conducted from 2009 to 2011. All patients with drug eruption due to IFN were examined in thrust, and were followed by allergy testing. In absence of alternative, a tolerance induction has been proposed. Results: 12 patients (6W, 6M), average aged 54.2 years with a debilitating drug eruption to IFN may have had allergy testing. The IDT were positive in 9/12 cases with an average time of 48 hours. A cross-reactivity between PegIFNα2a and PegIFNα2b was observed in 5/10 cases. In 8/12 cases, treatment with IFN was stopped. In 4/12 cases, treatment could be continued. The DC and anti-H1 were sufficient in 2/4 cases. In two other cases, topical tacrolimus was highly effective. In 8 cases when treatment was stopped, 2 patients had an indication for early resumption of the anti-viral by pegIFNα. These two patients had positive tests for pegIFNα2a and pegIFNα2b and received the protocol for inducing tolerance pegIFNα2b successfully. In these two cases, tolerance induction performed weekly dose has gradually increased the recovery of an anti-viral C. Discussion: Our study demonstrates the benefit of allergy testing in generalize drug reactions to IFN, the exist-ence of cross reactions in the same class of IFN and the importance of delayed IDT reading . In case of failure of DC and anti-H1, we report for the first time in eczema rashes to IFN, UV TL01 or topical tacrolimus may be effective. On the pegIFNα in patients with active hepatitis C, the tests can, in addition to diagnostic confirmation, guide the choice of therapeutic alternative or suggest an induction of tolerance to a pegIFN for patients in therapeutic failure. From this unique series of patients treated with IFN for drug reaction we offer support and if that fails an allergy tests (IDT) to the choice of alternative IFN. It might be interesting to evaluate the role of induction of tolerance which we report the effectiveness in 2 patients.

PV58

Rapid desensitization to Rituximab Macchia L.1, Lotti A.1, Kourtis G.1, Rossi M.P.1, Giliberti L.A.1, Loconte F.1, Perrone T.2, Gaudio F.2, Guarini A.3, Iacobazzi A.3, Caiaffa M.F.4, Ferrara L.5, Pavone V.5

1University of Bari - Aldo Moro, Allergology and Clinical Immunology, Bari, Italy, 2University of Bari - Aldo Moro, Hematology, Bari, Italy, 3IRCCS Istituto Tumori ‘Giovanni Paolo II’, Hematology, Bari, Italy, 4University of Foggia, Allergology and Clinical Immunology, Foggia, Italy, 5Hospital ‘Cardinal Panico’, Hematology, Tricase, Italy Rituximab (Mabthera™) is a chimeric human-mouse anti-CD20 monoclonal antibody with human constant regions and mouse variable regions, which is currently used in the treatment of B cell malignancies, particularly non-Hodgkin lymphomas, and other B cell-associated conditions. However, severe adverse reactions preclude rituximab administration in a number of patients, who would otherwise benefit from this therapy.Thirty-one patients, with non-Hodgkin B cell lymphoma, who had previously experienced severe side effects following rituximab infusion, were subjected to a protocol of rapid desensitization, allowing resumption of the infusion therapy with rituximab in the great majority of cases.The series included 11 male and 20 female patients (mean age 64 years, s.d. 12). All were also receiving standard chemoterapy (various regimens).Sensitization to rituximab was investigated in vivo by intradermal tests with rituximab at concentrations from 10 µg/ml to 40 mg/ml, respectively. The procedure proved positive in 25 of the 31 patients.Carefully designed experiments aimed at detecting rituximab-specific IgE in serum, by using an anti-IgE Mab-based ELISA and biotinylated rituximab, have been so far unsuccessful.The desensitization protocol consisted of 11 sessions, over 3 weeks. Rituximab was given subcutaneously every second day, staring with 40 µg at day 1. The desensitizing dose was rapidly raised and, at session 8, 100 mg were administered (2,500-fold increase). The latter dosage was then repeated 3 times. In 26 out of the 31 patients, the desensitization course allowed full resumption of the infusion therapy. In 3 other patients the intravenous therapy was resumed but non tolerated. Nevertheless, these patients could be treated by compact courses of subcutaneous 100 mg rituximab administrations (which were tolerated). In the other 2 cases, desensitization could not be finalized, due to circumstantial reasons. Approx. 2050 desensitizing injections have been so far administered. Immediate systemic reactions were never observed. Local reactions were frequent but mild. Rituximab should be already regarded as a crucial therapeutic option in a number of B cell-associated conditions and its employment will probably increase in the future. Accordingly, severe adverse reactions are likely to become more frequent. In these cases, the rapid desensitization procedure we developed can help make the rituximab approach feasible.


ABSTRACTSIn vitro diagnostic tools: research instruments or fit for practice?

PV189 Evaluation of drug-specific T-cell population by flow cytometric drug-induced lymphocyte stimulation test Hanafusa T.1, Azukizawa H.1, Matsumura S.1, Katayama I.1

1Osaka University Graduate School of Medicine, Department of Dermatology, Osaka, Japan Background: Delayed hypersensitivity is responsible for severe cutaneous adverse drug reactions (cADRs), especially in Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis, and drug-induced hypersensitivity syndrome (DIHS) (also known as drug rash with eosinophilia and systemic symptoms [DRESS] syndrome). The drug-induced lymphocyte stimulation test (DLST), or lymphocyte transformation test (LTT), is used to identify the culprit drug in severe cADR cases. Purpose: The aim of this study was to examine the immune reactions in cADR patients through the identification of the drug-specific proliferating cells by flow cytometric DLST (FCM-DLST). Materials and methods: The peripheral blood mononuclear cells (PBMCs) of 16 anticonvulsant-induced cADR patients were investigated by conventional DLST and a FCM-DLST protocol in which CFSE dilution and BrdU incorporation were combined. FCM-DLST allowed for the identification of the drug-specific proliferating cells in six cases. Three of these cases were DIHS cases, whereas there was one case of SJS, one case of maculopapular rash (MP), and one case of erythema multiforme (EM) among the six cases. Results: In FCM-DLST, drug-specific proliferating T cells were detected as CFSElow BrdUhigh cells. The drug-specific lymphocytes divided approximately five or six times in the 7 days in DLST-culture medium. The average ratio of drug-specific T cells to PBMCs was estimated to be 0.024 %. These cells corresponded to the cells incorporating 3H-thymidine in conventional DLST. Although CD4+ T-cell proliferation dominated the observed proliferation in most of the cases (in the recovery stage of the three DIHS cases, the MP case, and the EM case), drug-specific CD8+ cytotoxic T lymphocytes (CTLs) were detected, especially in the acute stages of the SJS case and one of the DIHS cases. There was a dramatic switch in the predominant drug-specific proliferating T-cell po-pulation in the course of one of the cases of DIHS in which CD8+ CTLs were predominant initially, whereas CD4+ T cells were predominant later. Moreover, drug-specific CD4+ CD25+ Foxp3+ regulatory T cells (Tregs) proliferated during the recovery stage in one DIHS case. Conclusions: FCM-DLST revealed that the cell proliferation detected by conventional DLST is a heterogeneous proliferation of both CD8+ CTLs and CD4+ T cells that likely includes Tregs. However, the number of cADR cases in this study was limited, which limits the conclusions that can be drawn from it.

Drug-induced liver injury

PV163 Mechanisms of T cell stimulation by flucloxacillin in HLA-B*5701+ flucloxacillin-naïve individualsWuillemin N.1, Adam J.1, Fontana S.2, Krähenbühl S.3, Pichler W.J.1, Yerly D.1

1University Hospital of Bern, Clinic for Rheumatology and Clinical Immunology/Allergology, Bern, Switzerland, 2Regional Blood Transfusion Service of the Swiss Red Cross, Bern, Switzerland, 3University Hospital of Basel, Division of Clinical Pharmacology and Toxicology, Basel, Switzerland Purpose: Drug induced liver injury (DILI) is a main cause of drug withdrawal. A particularly interesting example is flucloxacillin (FLUX)-DILI, which is associated with the HLA-B*5701 allele. Despite the strong association with HLA-B*5701, only 1 in every 500 to 1000 individuals with this genotype will develop a FLUX-DILI. To better under-stand this side effect, we established an in vitro model for FLUX induced T cell activation. Materials and methods: Peripheral blood mononuclear cells from FLUX-naïve, HLA-B*5701+ healthy donors were cultured by iterative in vitro restimulations with FLUX. FLUX-specific T cells (FLUX-Tc) were enriched by positive selection of CD107a expressing cells and characterized by flow cytometry (IFNγ and CD107a) and cytotoxicity assay. Results: FLUX-specific T cells could be generated in 7/7 healthy HLA-B*5701+ donors and are mainly CD8+. They react by IFNγ secretion and CD107a upregulation upon drug stimulation and are cytotoxic against autologous antigen presenting cells (APC). In most T cell lines (TCL), FLUX-pulsed APC were not able to activate FLUX-Tc if FLUX was not additionally added. The direct addition of FLUX to FLUX-Tc was actually sufficient to fully activate FLUX-Tc even in the absence of autologous APC. Moreover, proteasome inhibition by lactacystin and bortezomib did not affect the Tc reactivity. Calcium influx measurement in T cell clones revealed an immediate activation after


ABSTRACTSthe addition of FLUX in solution, reaching a maximum signal after 5 minutes. In a few FLUX-TCL, the reactivity upon FLUX stimulation was decreased if APC were not pulsed with FLUX in advance or if APC were not present at all. Conclusions: The non-involvement of the proteasome and the APC independent T cell reactivity do not support the classical hapten theory. In contrast FLUX-Tc reactivity is best explained by a direct interaction of FLUX with the restricting HLA-B*5701 molecule.

Clinical hypersensitivity reactions to important drugs

PV60 A retrospective study on sequential desensitization-rechallenge for anti-tuberculous drug allergy Thong B.Y.1, Chia F.L.1, Tan S.C.1, Tan T.C.1, Leong K.P.1, Tan J.W.1, Tang C.Y.1, Hou J.F.1, Chan G.Y.1, Chng H.H.1

1Tan Tock Seng Hospital, Rheumatology, Allergy and Immunology, Singapore, Singapore Purpose: To describe the results of sequential desensitization-rechallenge (D-R) for anti-tuberculous (TB) drug allergy. Materials and methods: Consecutive patients who had undergone D-R to anti-TB drugs between 1 Sep 1997 and 31 Jan 2012 were recruited for study. Following resolution of the acute reaction, anti-TB drug was restarted at 1:100 to 1:3 of the final daily dose (FDD), with gradual dose escalation daily to the FDD. Subsequent drugs were sequentially added ≥ 3 days later when the preceding drug was tolerated. Full blood count and liver function tests were monitored prior to addition of each new drug. Results: There were 11 patients of whom 10 were male, predominantly Chinese (8). Six patients received treatment for pulmonary, 2 extrapulmonary, and 3 for both pulmonary and extrapulmonary TB. The most common regimen causing TB drug allergy comprised rifampicin (RIF), ethambutol (EMB), isoniazid (INH) and pyrazina-mide (PZA) (REHZ) in 5 patients. REH was used in 4, RHZ in 1, and REHS containing streptomycin (S) in 1. All patients had non-immediate reactions. All had cutaneous eruptions, where maculopapular exanthema (MPE) was most common (8). Drug induced hypersensitivity syndrome (DIHS) occurred in 54.5% (6 patients) of whom all had fever, 83.3% hepatitis, and 83.3% eosinophilia. Two patients had Stevens Johnson syndrome (SJS). D-R to INH was successful in 7/9 (77.8%) patients starting at 100 mg/d and achieving 300 mg/d within a mean of 4.3 ± 2.3 days; RIF in 7/7 (100%) starting at 3.6-150 mg/d and achieving 450-600 mg/d in 4.4 ± 1.7 days; EMB in 3/3 (100%) patients starting at 100-200 mg/d and achieving 800-1200 mg/d in 5.0 ± 1.0 days; PZA in 2/2 (100%) pati-ents starting at 5-100 mg/d and achieving 1000-1250 mg/d in 7 days; S in 1/1 (100%) patient starting at 100 mg/d and achieving 700 mg/d in 5 days. Of the 2 patients who failed INH D-R, 1 developed fever and MPE on day 3, the other MPE on day 8. D-R with INH and RIF respectively in the 2 SJS patients was successful in both. Among DIHS patients, 1 failed D-R with INH (fever and MPE on day 3). There were 23/25 (92%) successful D-R among the 11 patients. All patients completed TB treatment of ≥ 5 months’ duration with no cases of drug-resistant TB. Conclusions: Sequential TB drug D-R is successful with careful dose escalation and close monitoring, even in DIHS and SJS.

Severe cutaneous adverse reactions

PV130 HLA-A*3101 is more strongly associated with carbamazepine-induced drug reaction with eosinophilia and systemic symptoms than with carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis Genin E.1, Chen D.-P.2, Hung S.-I.3, Sekula P.4, Schumacher M.4, Chang P.-Y.2, Tsai S.-H.2, Wu T.-L.2, Bellon-Heredia T.5, Tamouza R.6, Fortier C.6, Toubert A.6, Charron D.6, Hovnanian A.7, Wolkenstein P.8, Chung W.-H.9, Mockenhaupt M.10, Roujeau J.-C.8

1Inserm, UMR-S946, Paris, France, 2Chang-Gung Memorial Hospital, Chang Gung University, Department of Laboratory Medicine; Department of Medical Biotechnology and Laboratory Science, Taoyuan, Taiwan, Republic of China, 3Institute of Pharmacology; School of Medicine; National Yang-Ming University, Taipei, Taiwan, Republic of China, 4Institute of Medical Biometry and Medical Informatics, University Medical Center, Freiburg, Germany, 5Hospital Universitario La Paz, IdiPAZ, Madrid, Spain, 6Institut Universitaire d’Hématologie; Saint-Louis Hospital; University Paris Diderot, Inserm UMR-S940, Paris, France, 7Inserm UMR-S 781; Institute of Genetic Diseases


ABSTRACTSImagine; University Paris Descartes; Centre Hospitalier Universitaire Necker-Enfants Malades, Department of Genetics and Dermatology, Paris, France, 8Hôpital Henri Mondor; Université Paris-Est; Inserm UMR-S 448; Service de Dermatologie, Créteil, France, 9Chang Gung Memorial Hospital; Chang Gung University College of Medicine; Linko, Department of Dermatology, Keelung, Taiwan, Republic of China, 10Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Freiburg, Germany Purpose: Recently, HLA-A*3101 was reported to be strongly associated with different phenotypes of carbamazepine (CBZ)- induced hypersensitivity reactions, including mild maculopapular eruption (MPE), drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in Europeans. We aim to verify the HLA-A*3101 association with two clinically different CBZ-induced severe phenotypes, DRESS and SJS/TEN, by conducting an international collaborative study with a standardized phenotype definition. Method: 162 cases of CBZ-induced DRESS or SJS/TEN (132 Han Chinese from Taiwan and 30 Europeans from RegiSCAR) and 144 controls were enrolled in this study. HLA-A genotyping was performed for all cases and controls. Result: HLA-A*3101 was strongly associated with CBZ-induced DRESS in Chinese (PFisher=9x10-7, OR:16.15 (95%CI 4.04-64.65)) as well as in Europeans (PFisher=3.98x10-10, OR:100.54 (95%CI 25.81-391.62)). However, HLA-A*3101 was not associated with CBZ-SJS/TEN in Chinese (PFisher=0.69) and was only weakly associated with this condition in Europeans (PFisher=0.01, OR:7.6 (95%CI 1.76-27.72)). This latter OR was significantly smaller than the one associated with DRESS in Europeans (test of homogeneity of OR: P=0.003). Conclusion: HLA-A*3101 is strongly associated with CBZ-induced DRESS in Chinese and European patients, but the association is much weaker with CBZ-induced SJS/TEN.

Contact hypersensitivity meets drug hypersensitivity

PV109 Innate immune responses to contact sensitizers are mediated via ROS production and HA degradation Esser P.R.1, Wölfle U.2, Dürr C.3, von Loewenich F.D.4, Schempp C.M.2, Freudenberg M.A.5, Jakob T.1, Martin S.F.1

1University Freiburg Medical Center, Dermatology, Allergy Research Group, Freiburg im Breisgau, Germany, 2University Freiburg Medical Center, Dermatology, Skintegral, Freiburg im Breisgau, Germany, 3University Frei-burg Medical Center, Haematology and Oncology, Freiburg im Breisgau, Germany, 4University Freiburg Medical Center, Medical Microbiology and Hygiene, Freiburg im Breisgau, Germany, 5Max Planck Institute, Immunobiolo-gy and Epigenetics, Freiburg im Breisgau, Germany Allergic contact dermatitis (ACD) represents a severe health problem with increasing prevalence. Contact sensiti-zers induce a proinflammatory micro-milieu within the skin that results in the activation of DCs and, subsequently, the priming and activation of T cells. Recent evidence indicates for a crucial role of endogenous activators of pattern recognition receptors like the Ttoll like receptors (TLR). One candidate is the extracellular matrix (ECM) component hyaluronic acid (HA), acting as TLR2/4 agonist when degraded to low MW HA fragments. Aim: We focus in our study on the initial events resulting in the activation of innate immune responses triggered by contact sensitizers. Therefore, we aimed at unraveling the role of sensitizer induced production of reactive oxygen species (ROS), the activation of hyaluronidase activity and their contribution to the degradation of HA. Method: To this end, we detected ROS production by oxidation of fluorescent dyes in vivo and in vitro after sensitizer treatment. In vivo HA degradation was visualized by staining with a HA binding protein and by gel elec-trophoresis. The potential role of p38 MAPK activation in the enhancement of sensitizer induced hyaluronidase activity was adressed by analysis of the effects of a p38 MAPK inhibitor in the contact hypersensitivity (CHS) model in vivo. In addition, we investigated the influence of antioxidants or a hyaluronidase inhibitor blocking HA degradation on the CHS response. Results: We observed that contact sensitizers readily induce ROS production both in vitro and vivo and enhance the activity of hyaluronidase in vivo. ROS and hyaluronidase both degrade high MW HA into low MW HA frag-ments as observed both in human and murine skin. Blocking p38MAPK activity, ROS production or hyaluronidase activity abrogates CHS responses. These effects are reverted by addition of exogenous active hyaluronidase. Time kinetics indicate the necessity of HA degradation for CHS responses both in the sensitization and elicitation phase. In summary, we provide a novel mechanism for the early innate immune response triggered by contact sensitizers resulting in the generation of pro-inflammatory endogenous PRR ligands by ECM breakdown induced by contact sensitizers.


ABSTRACTSConclusions: These findings have implications for the development of in vitro based assays for the identification of contact sensitizers and for the development of a causative treatment for ACD.

Update on ENDA activities

PV169 Accelerated allergic reactions to amoxicillin Gomez E.1, Torres M.J.1, Chaves P.1, Doña I.1, Rodriguez-Bada J.L.1, Gomez A.I.1, Blanca M.1, Mayorga C.1

1Carlos Haya Hospital, Malaga, Spain Purpose: Hypersensitivity reactions to betalactams are the most frequent cause of reactions mediated by specific immunological mechanisms. Levine classified the reactions in three types: immediate, accelerated and delayed, according to the time between the drug intake and the symptoms appearance. With different immunological me-chanism involved being IgE-mediated in immediate reactions and T cell mediated in delayed reactions; however the mechanism involved in accelerated reactions are not sufficiently addressed. Thus we wanted to study the underlying immunological mechanism in patients with accelerated reaction to amoxicillin (AX). Materials and methods: Three patients with urticarial/exanthematic reactions appearing between 1-6 hours after AX or AX-clavulanic acid (AX-CLV) administration were included. The allergological study consisted on skin te-sting and drug provocation test (DPT) at increases doses. Specific IgE and tryptase determinations were carried out by immunoCAP system. The immunological study included cellular markers of lymphocyte subsets, skin homing and chemokines, as well as their chemokine receptors in peripheral blood (acute phase (T1) and basal) by flow cytometry, and in skin biopsy (T1) by immunohistochemistry. Results: Prick and intradermal skin tests with major and minor betalactam determinants including AX and CLV were negatives in both immediate and delayed lecture. After DPT with AX patients presented generalised erithema accompanied with angioedema beginning at least 2h after the administration and increasing during the next 10h. The monitorization of the phenotypical analysis at T1 and basal show an increase in the percentage of CD8 and NK cells (CD56+) producing perforin and granzyme B, indicating an effector response. Moreover, NK cells showed also a production of IFN-g and TNF-a with no changes in IL4 production Regarding to skin homing and chemokine we observed an increase in CLA and CCR4 expression in both CD4 and CD8 T cells. The Th1 chemokine receptor CXCR3 was also increase in the two T cell subsets. These results were confirmed in the immunohistochemical studies. We could not find either specific IgE (< 0.35 kU/ml) nor tryptase (< 10 µg/ml) in any patients. Conclusions: The data provided support that accelerated reactions to AX are T-cell mediated with skin homing and a Th1 pattern with cytotoxic characteristics. Further studies are in progress to characterise in more detail these allergic responses.


ABSTRACTSPoster Presentation – Walk of Experts P1

Clinical analysis of cutaneous adverse drug reactions in Yokohama City University Hospital Watanabe Y.1, Sano S.1, Okada R.1, Murata N.1, Nagashima M.1, Hakuta A.1, Yamane Y.1, Ikezawa Z.1, Aihara M.1

1Yokohama City University School of Medicine, Department of Dermatology, Yokohama, Japan Purpose: To evaluate the trends of drug eruptions in university hospitals. Materials and methods: A retrospective study was performed at Yokohama City University Hospital using medical records of patients with cutaneous adverse drug reactions (CADR) from April 2003 to March 2009. Totally, 341 patients were analyzed for clinical features and causative drugs. Result: The two major causative drugs were antibiotics (29%) and anti-cancer drugs (18%). Among causative antibiotics, glycopeptide and carbapenem were increased to 13% and 10% with the increase of resistant bacterias to penicillin and cephem. Among causative anti-cancer drugs, we recorded a greater number of molecular target drugs compared with previous studies. Although macropapular rash was the most common reaction, as reported previously, patterns of clinical manifestation were different to those previously recorded. Notably, in patients treated with anti-cancer drugs, localized macropapular rash, hand-foot syndrome, and severe acneciform eruption were seen. Regarding the severe types of CADR, Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DIHS) accounted for 6% and 2%, respectively, of CADR types. The eosinophilia was observed in 17% of patients, and it showed the highest-frequency in the patients with erythrodermia. Positive reactions with causative drugs were observed in 34%, 68%, and 60% of patients as determined by patch, intradermal, and drug-induced lymphocyte stimulation tests, respectively. The positive rate of patch test was over 50% in SJS / TEN and eczema type, which were damaged mainly epidermis. Patients with macropapular and erythema multifome showed high positive rate of intradermal tests account for over 60% compared with others. Almost 80% of patients were cured after discontinuing the causative drugs without any general treatments, including steroids, or could continue the drugs with just topical therapies. Conclusion: Clinical manifestations of CADR are changing with changing drug therapies. It is therefore important to continue clinical analysis of CADR. P2

The perspective and management of penicillin allergy among Thai physicians Klaewsongkram J.1, Suetrong N.1

1Chulalongkorn University, Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Bangkok, Thailand Purpose: This study was to assess the perspective and management of patients with a history of acute immediate reactions to penicillin in Thailand Materials and methods: The online questionnaire was emailed to Thai physicians about several aspects of penicillin allergy management. Results: The answers from 205 Thai physicians (males: females=89: 116, mean age= 31.2±7.4 years old,) were analyzed. Most physicians asked for penicillin allergy history before penicillin administration but only 41.8% of them explored whether they were immediate or non-immediate reactions. Although 44.0% of Thai physicians know that intradermal test after negative skin prick test is the standard penicillin testing procedure to diagnose an immediate reaction; only 10.7% of them interpret the result properly. 68.0% of them predicted that ≤ 40% of patients with a history of penicillin allergy would develop allergic reactions if penicillin is readministered and 62.2% of them believed that ≤ 40% of suspected patients would have positive penicillin skin test. Only 22.7% of Thai physicians have ever requested or performed penicillin skin test in suspected patients. The lack of penicillin skin test reagents was the main reason (56.4%) for not performing the test whereas 31.1% of them were not convinced with skin test diagnostic accuracy. Aminopenicillins, first-generation cephalosporins, third-generation cephalosporins, and carbapenems were also avoided by 67.6%, 22.2%, 12.0%, and 9.8% of Thai physicians in patients with a history of penicillin allergy with unknown penicillin skin test result. 44.9% of Thai physicians agreed that patients with a history of penicillin allergy should undergo skin testing while 35.6% of them suggested avoiding the use of penicillin in these patients without skin testing. The main reasons of this suggestion were the availability of alternative drugs (38.7%) and medico-


ABSTRACTSlegal issues (24.4%). Cephalosporins were completedly avoided in patients with penicillin-induced urticarial/angioedema, maculopapular exanthems, anaphylaxis, and Stevens-Johnson syndrome by 8.9%, 25.3%, 75.1%, and 86.2% of Thai physicians, respectively. Conclusions: Thai physicians have certain awareness on the problem of penicillin allergy. However, the lack of skin test reagents, the availability of alternative drugs, and the medico-legal issues, were the main reasons for not performing penicillin skin testing in suspected patients and leading to the avoidance of several beta-lactams.

P3 Drug hypersensitivity reactions in children: Comparison of causality assessment results obtained with 2 different methods Amaral R.1, Herdeiro T.1,2, Faria E.3, Rebelo Gomes E.4

1Faculty of Medicine - University of Porto, CINTESIS, Porto, Portugal, 2Faculty of Medicine - University of Porto, Northern Pharmacovigilance Centre, Porto, Portugal, 3Hospital Universitario Coimbra, Allergy, Coimbra, Portugal, 4Hospital Pediatrico Maria Pia, Drug Hypersensitivity Clinic-Allergy, Porto, Portugal Purpose: To compare causality assessment after clinical workup of drug hypersensitivity (DH) with the results obtained from the World Health Organization (WHO) global introspection (GI) method. Materials and methods: Retrospective analysis of a case series of suspected pediatric DH reactions (n=84), reported to the database of the Northern Portuguese Pharmacovigilance Unit. Patients underwent a standardized allergy diagnostic workup (including anamnesis, in vitro and in vivo tests), at the Oporto children’s hospital by an allergist unaware of the pharmacovigilance causality assessment score. This score was based on the WHO scale of imputability (“Definitive”, “Probable”, “Possible”, “Unlikely”, “Conditional” and “Unclassifiable”) and were established by a pharmacovigilance expert, unaware of drug testing results, using the GI method. The gold-standard was considered to be the clinical diagnosis of DH. Multi-level likelihood ratio (LR) and post-test probability were calculated to assess the diagnostic impact of the GI method on the DH reactions. Post-test probabilities were calculated using a Fagan monogram. Results: From the initial 84 reports/patients 53 were excluded (31 because their reports were not accessible in the database, 17 refused diagnostic investigation, 4 did not have the results by the time of this study and 1 provocation was contra-indicated). 31 reports/patients were finally left for analysis (20 male-64.5%; median age, 8 years). Most of the reactions were non-immediate (>1 hour) (77.4%), cutaneous reactions (88.7%) and were caused by betalactam antibiotics (40%), followed by non-steroid-anti-inflammatory drugs. After a complete clinical evaluation, DHs was confirmed in only 5/31 patients (16.1%). DH reactions were classified into “Definitive” in 1/5 of the positive patients and in 1/26 of the negative patients (LR 5.0; post-test probability 0.5); 4/5 of the positive patients were classified as “Probable” as 23/26 of the negative ones (LR 0.9; post-test probability 0.15) and 2/26 of the negative patients were classified as “Possible”. Conclusions: Only the causality score “Definitive” had a moderate impact on the likelihood of DH reactions. Therefore, although being a good hypothesis generator, GI method is not accurate to do definitive decisions in DH reactions. This method, by itself, cannot replace the standard diagnostic allergy tests.

P4 Drug-induced acute pancreatitis following positive drug rechallenge: A review Fathallah N.1, Slim R.1, Ben Salem C.1, Bouraoui K.1

1Faculty of Medicine of Sousse, Department of Clinical Pharmacology, Sousse, Tunisia Drug-induced pancreatitis is rare with an estimated incidence of 0.1-2%. Over 500 medications have been associated with this disease. Recrudescence of the pancreatotoxicity upon re-exposure to the suspicious drug is considered the more reliable evidence of drug-induced pancreatitis. A retrospective review of MEDLINE was conducted to assess clinical outcomes of positive drug rechallenge following possible drug-induced pancreatitis. A total number of 250 cases of drug-induced pancreatitis with positive rechallenge were identified, among which, 183 met inclusion criteria for analysis in our review. A broad spectrum of suspect drugs was identified. Analgesics and anti-inflammatory drugs were incriminated in 28.4% of all cases, antimicrobials in 19.4 %, cardiovascular agents in 11.4% of cases, immunomodulator drugs in 10.28 % of cases and gastro-intestinal drugs in 4.9 % of cases. Improved identification and communication of possible drug-induced pancreatitis is needed to avoid potentially serious and/or fatal drug rechallenges.


ABSTRACTSP5 Avoidance of NSAIDs despite a negative oral provocation test: what does really happen? Bommarito L.1, Zisa G.1, Riccobono F.1, D’Antonio C.1, Calamari M.2, Poppa M.2, Moschella A.2, Di Pietrantonj C.3, Galimberti M.1

1Novara Hospital - Experimental Program Piemonte Allergy Network, Allergology and Immunology Unit, Novara, Italy, 2Domodossola Hospital, Allergology and Immunology Unit, Domodossola, Italy, 3Servizio Regionale di Epidemiologia SeREMI ASL AL, Alessandria, Italy Background: Drug provocation tests (DPTs) are the gold standard in diagnosis of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity and they have to be performed in hospital setting. Aim of this study was to assess patient behaviour towards NSAID re-assumption at home and to evaluate the subsequent NSAID tolerability after negative allergological work-up. Materials and methods: This is a follow-up study including patients evaluated in the allergy centers of Novara and Domodossola Hospitals between July 2004 and June 2010 for cutaneous reactions (urticaria and/or angioedema) following NSAID intake. All the patients who tested negative to the suspected NSAID DPT were asked by a phone interview (performed not less than 11 months after DPTs) about home NSAID assumption, tolerance and reasons for avoidance. The negative predictive value (NPV) of DPT was calculated. Results: 111/142 patients were contacted, 46/111 (41.44%) took the same NSAID as the one tested with 2 reactions reported (4.3%); 65/111 (58.56%) did not take the same NSAID but 34 of them took another as strong COX-1 inhibitor with 1 reaction. The three reactions reported consisted in mild urticaria, but none of the patients accepted allergological re-evaluation. NPV overall was 96.25%. 12/65 patients (18.46%) did not take any NSAID, 2 only using non pharmacological therapies as homeopathy or acupuncture. Reasons for avoidance were no need (29.2%) and fear of reactions (70.8%). A statistical association between re-assumption and type of the drug tested, being lower for strong COX-1 inhibitors (28/85) than for weak COX-1 inhibitors (28/46), was observed (OR 0.31 CI 95% 0.14-0.66). Conclusions: Even after ruling out NSAID hypersensitivity diagnosis the majority of patients with a history of urticaria and/or angioedema continued to avoid NSAID intake at home for fear of new reactions, particularly when strong COX-1 inhibitor NSAIDs are involved. Nevertheless NSAID DPT showed a good NPV.

P6 ACE induce angioedema according the data of Vilnius university hospital Santariškiu Klinikos Kozlovska A.1, Aleksoniene R.1,2, Kvedariene V.1,2

1Vilnius University, Faculty of Medicine, Vilnius, Lithuania, 2Vilnius University Hospital Santariskiu Klinikos, Center of Pulmonology and Allergology, Vilnius, Lithuania Angioedema (AE) frequently is rapid and life-threatening reaction. To find the cause is difficult even in the case when patient takes many drugs at the same time. Diagnostic of ACE and ARB induce angioedema haven’t good investigated time delay between last drug intake and manifestation of clinical reaction. Aim of study was to explore frequency of AE induced by ACE and evaluate the role of time delay between last drug intake and clinical reaction. Methods: 566 patients with adverse drug reactions were hospitalized in Pulmonology and Allergology center between 2008 and 2011. ENDA questionnaires were completed for all of them. We chose 46 (8.12%) patients, who at the moment of AE or urticaria take of ACE or ARB. Solely AE induced by this type of drugs had 36(6.4%) patients. Results: Median age of patients was 59[50.3 - 75.5] with min. 34 and max. 87years, it were 19(52.8%) men and 17(47.2%) women. ACE related AE for 31(86.1%) reactions and ARB only in 2(5.6%). In our study ramipril and enalapril were the most frequently implicated drugs and induce AE in 7(19.4%) of cases for each drug; losartan, valsartan and traolapril - rarely. Median time delay between last drug intake and clinical reaction was 12[0.8 - 42.0] month. The latest reaction was induced by losartan and appeared after 96months; the earliest AE was induced by captopril after one week of treatment. All reactions were of non- immediate type. Conclusion: ACE and ARB induced AE was rare among our patients. Ramipril and enalapril were often implicated. Only captopril was induced clinical reaction in one week, all other drugs - after one year or late after start the treatment


ABSTRACTSP7 Allergic reactions to drugs in Slovenian children Vesel T.1, Accetto M.1, Berce V.2, Bizjak R.3, Homšak M.2, Ihan A.4, Koren-Jeverica A.1, Korošec P.5, Košnik M.5, Lužnik Z.6, Nahtigal M.6, Obermayer-Temlin A.7, Posega-Devetak S.8, Šilar M.5, Tomšič-Matic M.9, Toplak N.1, Zupančič M.10, Avčin T.1

1University Children’s Hospital, University Medical Center, Department of Allergology, Rheumatology and Clinical Immunology, Ljubljana, Slovenia, 2University Clinic Maribor, Department of Pediatrics, Maribor, Slovenia, 3General Hospital in Šempeter, Nova Gorica, Slovenia, 4Institute of Microbiology and Immunology, Faculty of Medicine, Ljubljana, Slovenia, 5University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia, 6General Hospital in Slovenj Gradec, Slovenj Gradec, Slovenia, 7General Hospital in Celje, Celje, Slovenia, 8General Hospital in Izola, Izola, Slovenia, 9General Hospital in Trbovlje, Trbovlje, Slovenia, 10University Children’s Hospital, University Medical Center, Ljubljana, Slovenia Purpose: Few national epidemiological studies have been performed in children with suspected allergy to drugs. The incidence of drug allergies and the quantity/quality of their diagnosing procedures have not been systematically evaluated in pediatric population in Slovenia. Materials and methods: We analyzed the allergological work-up of children who were referred for investigation of suspected drug allergy to the allergy clinic at the University Children’s Hospital Ljubljana and to 6 pediatric departments in the regional hospitals in Slovenia from January 2011 to December 2011. Results: In 2011, 639 children were referred for investigation of suspected drug allergy. β- lactams (89%) and non-steroidal anti-inflammatory drugs (NSAIDs) (5,5 %) were most frequently incriminated. Diagnosis of β-lactam allergy was confirmed in 36 children, 5 children were allergic to corticosteroids, two to opiods, two to neuromuscular blocking agents (NMBAs), two to benzodiazepines and in one child allergy to NSAID, gentamicin and growth hormone was confirmed, respectively. Cross-sensitization within the same group of drug showed 19 children allergic to β-lactams, 2 children allergic to NMBAs, 4 children allergic to corticosteroids, 2 children allergic to opiods and one child allergic to benzodiazepines. Drug allergy was confirmed with skin testing in 29 children, more than one diagnosing method in 12 children, reaction during challenge test in 5 children and basophil activation testing or specific IgE antibodies only in 2 children, respectively. Three hundred seventy one children completed allergological work-up with drug challenge. Five out of 7 children who reacted during drug challenge had negative previous testing result including skin testing and two children went directly to provocation testing with suspected drug. Positive outcome on penicillin challenge was found after prolongation of provocation test to three days in one child. The median time between suspected drug reaction and provocation test was 2.3 years. Conclusions: The results of the allergological work-up were often negative and positive outcomes in challenge testing were less than 2 %. The most frequently involved drugs were β- lactams followed by corticosteroids. A continuing education program for pediatricians and nurses is needed in order to improve the ability of diagnosing drug allergies in childhood population in Slovenia.

P8 The peculiarities of side effects during cancer patients treatment in oncological dispensary Kazangapova A.1, Rozenson R.2

1Astana Medical University JSC, Children disease #1, Astana, Kazakhstan, 2Astana Medical University JSC, Astana, Kazakhstan There is a gap in knowledge of incidence of the side effects of cancer drug treatment, which may be important both for study of treatment outcomes and for allergic reactions preparedness in Oncological Dispensary (special hospital in former Soviet Union for cancer treatment). Materials and methods: We provided a cohort retrospective study of archival patients in Astana city Oncology Municipal Dispensary. In total, 463 patients aged 21-67 years in 2011 were studied. Side effects of drug therapy during treatment in Oncological Dispensary were registered in 96 patients, and after treatment - in 67 patients. Results and discussion: An average incidence of drug treatment side effects was 20%, from them 38% were men, and 62% were women. The spectrum of cancer was: 44% - breast cancer, 12% - ovary cancer, 6% - lung cancer, 6% - gastric cancer, 6% - thyroid cancer, 5% - colon and rectum cancers, 5% - cervical cancer, 5% - non-Hodgkin’s lymphoma, 4% - myoma, 3% - cancer of pancreas, 2% - lymphosarcoma, 2% - melanoma. The following medicines were reasons of drug side effects: antibiotics - 36%, analgesic - 13%, salt solutions -


ABSTRACTS10%, vitamins - 9%, iodine - 6%, gemodez - 3%, antihistamines - 3%, cytostatics - 3%, anti-inflammatory - 3%, antianemic - 2%, glucose - 1% , other drugs reactions - 10%. After discharge from oncological dispensary every 2 months we provided the telephone inquiry about possible side effects of drug therapy in outpatient’s step of treatment. In this step side effects were evident in 67 from 367 patients (18,3%). Among them 48% were patients with urticaria, 27% with atopic dermatitis exacerbations, 11% with contact dermatitis, and 7% with rhinoconjunctivitis. The results of retrospective cohort studies showed that side effects were most common among patients with breast cancer (44%). Mortality rate among breast cancer patients with side effects was significantly higher (p< 0,05), than among breast cancer patients without side effects of treatment. We concluded that the presence of side effects of treatment was higher among cancer patients with unfavorable prognosis.

P9 Breakthrough of kids drug allergy reactions in Bosnia Bajraktarevic A.1, Miokovic M.1, Kumasin L.1, Selimic E.1, Niksic H.2, Selimovic A.3, Mujicic Selimovic E.3, Musabegovic J.4, Sporisevic L.5

1Public Health Institution of Sarajevo Canton, Pediatrics Department, Sarajevo, Bosnia and Herzegovina, 2Clinical Medical Center Sarajevo, Department for Clinical Pharmacology, Sarajevo, Bosnia and Herzegovina, 3Pediatrics Clinic Sarajevo, Department for Allergology and Pulmonology, Sarajevo, Bosnia and Herzegovina, 4Pharmacy Faculty Sarajevo, Department for Clinical Pharmacology, Sarajevo, Bosnia and Herzegovina, 5First Medical Aid, Pediatrics Departrment, Sarajevo, Bosnia and Herzegovina Background: A drug allergy is an allergic reaction to a medication. Adverse drug reactions as an unpredictable reaction is related to immunological response and hypersensitivity reactions or nonimmunological response opposite a predictable drug reaction is related to the pharmacological actions of the drug. Common symptoms such as rash, hives, and itching can often be controlled with antihistamines and occasionally corticosteroids. Methods: A retrospective cohort study of pediatric patients who experienced an allergic drug reaction between January 1, 2009, and December 31, 2010, was conducted at a pediatric primary, secondary and tertiary care, children´s offices and hospitals in Sarajevo. The first phase included a cross-sectional survey that assessed the life occurrence of adverse drug reactions and self-reported drug allergy in the outpatient clinic of a pediatric hospital. The second phase involved a diagnostic workup in children with parent-reported drug allergy, including detailed clinical history and in vitro and in vivo investigations. Results: For many, medication allergies go undetected until they take a drug and have an allergic reaction. Some adverse reactions to drugs are side effects. Among the most common side effects are upset stomach, diarrhea, vomiting, fever and a skin reaction to sunlight called photosensitivity. Dermatologic signs and symptoms were the most common 66% (462). Conclusions: The symptoms of drug allergy may happen immediately or after taking the drug for a week or more. Disappear on cessation of therapy and reappear after readministration of a small dose. Symptoms of non-allergic drug reactions vary depending on the type of medication.

P10 Adverse drug reactions notified by an Immunoallergology Department and causality assessment systems agreement Costa M.J.1, Herdeiro M.T.2,3, Botelho C.4, Castro E.4, Cernadas J.R.4

1Faculty of Medicine, University of Oporto, Department of Biostatistics & Medical Informatics, Oporto, Portugal, 2Faculty of Medicine, University of Oporto, Northern Pharmacovigilance Centre, Oporto, Portugal, 3University of Oporto, Centre for Research in Health Technologies and Information Systems (CINTESIS), Oporto, Portugal, 4H. S. João, EPE, Immunoallergology Department, Oporto, Portugal Background: Adverse drugs reactions (ADRs) are an important public health problem, a major cause of morbidity and mortality. Purpose: The main objective was the characterization of ADRs notified from January 2006 to December 2010, by the Drug Allergy Unit of Immunoallergology Department (ID) of Hospital São João (Oporto), to the North Pharmacovigilance Unit (NPU) of the Medical Oporto School. The secondary objective was to compare the results obtained by two causality assessment systems (CAS), the one applied by the NPU and the other applied by the ID.


ABSTRACTSMaterial and methods: An observational retrospective descriptive study was conducted. Participants were all the patients from the ID, with notified suspected ADRs. The exclusion criteria were the insufficient information in the notification reports. The ADRs and patient characterization was made. The two CAS, the World Health Organization (WHO) CAS applied by the NPU and the ID diagnostic work up based in the European Network for Drug Allergy (ENDA) guidelines, were compared with coefficient kappa weighted determination. Results: The studied population presented a median age of 41 years (range 8 months to 78 years), with a higher proportion of the female gender (73.2%). Allergic rhinitis and asthma were the most frequent co morbidities. All the studied ADRs were type B, for their allergic nature; 89.6% serious; 86.4% not referred in the summary of the drug characteristics and 97.4% associated with drugs that presented more than two years in the market. The most represented drug classes were non steroidal anti-inflammatory (56.8%) and antibiotics (27.2%). Skin complaints represented 61.2% of the total notified signs. The ADRs occurring in less than one hour after intake represented 52.9%. Following ADRs the most frequent treatment orientation was drug withdraw (80%), followed by the prescription of anti-histamines (42.2%). The comparison of the two CAS obtained a coefficient kappa weighted of 0.08 (95% confidence interval: 0-0.21). Conclusions: From 2006 to 2010, the ADRs notified by the ID to the NPU were predominantly serious and unexpected. The most frequent drugs were the non steroidal anti-inflammatory and antibiotics, with more than two years of commercialization. The two main limitations of this study were the incomplete information, and for the agreement of the CAS, the two systems were different.

P11 Drug anaphylaxis in Portugal: National Survey 2007-2010 Faria E.1, Cernadas J.2, Gaspar A.3, Botelho C.2, Castro E.2, Lopes A.4, Gomes E.5, Malheiro D.6, Cadinha S.6, Campina-Costa S.7, Neto M.8, Sousa N.1, Rodrigues-Alves R.9, Romeira A.10, Caiado J.4, Morais-Almeida M.3, Interest Group on Drug Allergy of Portuguese Society of Allergology and Clinical Immunology (SPAIC) 1Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2Centro Hospitalar São João, EPE, Porto, Portugal, 3Hospital CUF Descobertas, Lisboa, Portugal, 4Hospital Santa Maria, Lisboa, Portugal, 5Hospital Maria Pia, Porto, Portugal, 6Centro Hospitalar Vila Nova Gaia/Espinho, Vila Nova Gaia, Portugal, 7Hospital Egas Moniz, Lisboa, Portugal, 8Hospital Pulido Valente, Lisboa, Portugal, 9Hospital Divino Espirito Santo, Ponta Delgada, Açores, Portugal, 10Hospital Dona Estefânia, Lisboa, Portugal Purpose: To contribute to a better understanding of the epidemiology of drug-induced anaphylaxis in immunoallergology outpatient consultations in Portugal. Materials and methods: A national notification system for anaphylaxis was implemented, focused on voluntary reporting by physicians with allergy differentiation since 2007. From January 2007 to December 2010 data from 313 patients with drug-induced anaphylaxis have been received and analyzed.Results: The mean age was 43.8 ± 17.4 years, 8% having less than 18 years old. The ratio female / male was 2:1. The mean age at first episode was 39 ± 18.2 years. Nine patients had more than one cause of drug anaphylaxis, corresponding to a total of 322 reports. The main culprit drugs were non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anesthetic agents in 48%, 36% and 6% respectively. Other drugs involved were: cytostatics, corticosteroids, proton pump inhibitors, iodinated contrast media. There was a predominance of mucocutaneous symptoms (92%), followed by respiratory (81%) and cardiovascular (49%) symptoms. Patients with NSAIDs anaphylaxis to showed a higher propensity to have co-respiratory and mucocutaneous manifestations. Reactions occurred in 53% of cases within 15 minutes after drug administration, in 45% were in hospitalized patients and in 35% hospitalization were needed. The recurrence of anaphylaxis occurred in 26% of cases and the risk was significantly higher when NSAIDs were involved. Only 48% of patients were treated with adrenaline and in 9% of cases a self-injectable adrenaline kit was prescribed. Conclusions: In this study the most frequent culprit drugs were NSAIDs and they were associated with a higher rate of anaphylaxis recurrence. We stress the under-treatment with adrenaline and the need to achieve a better therapeutic management and prevention of recurrence of anaphylaxis to drugs in Portugal.


ABSTRACTSP12 Drug induced anaphylaxis in Korean: data from the adverse drug reaction reporting system to the Korea food and drug administration Jung J.W.1, Kang H.R.2, Sohn S.W.3, Song W.J.2, Park H.W.2, Cho S.H.2, Min K.U.2, Choi B.W.1

1Chung-Ang University College of Medicine, Seoul, Korea, Republic of, 2Seoul National University College of Medicine, Seoul, Korea, Republic of, 3Dongguk University Ilsan Hospital, Goyang, Korea, Republic of Introduction: Adverse drug reactions occur in 10-20% of hospitalized patients, 2% to 3% experience allergic drug reactions and 1 in every 2,700 suffers drug-induced anaphylaxis. Incidences of drug-induced anaphylaxis from all drug types are reportedly rising. Objectives: We investigate causal drug and clinical manifestation of the drug induced anaphylaxis in Korean by using data from the adverse drug reaction (ADR) reporting system to the Korea Food and Drug Administration(KFDA). Methods: Data were extracted from spontaneous ADR reporting system to KFDA from July, 2009 to December, 2010. The data were established by a pharmacovigilance research network (PVNet) including 15 regional pharmacovigilance centers. The data included reported date, patient’s age, gender, and initials, as well as suspected drugs, concomitant drugs, and adverse event. We extracted and analyzed data about drug induced anaphylaxis. Results: A total of 1,303 cases of drug induced anaphylaxis were identified. Male was 630 (49.0%) and mean age was 52.09±21.50 years. 318 cases (13.1%) had grade 2 anaphylaxis, 503 (20.7%) had grade 3, and 1,613 (66.3%) had grade 4. Hypotension was presented in 790 patients (60.6%) and dyspnea was in 419 (32.2%). Most common causal drug was antibiotics (422, 17.3%), 2nd was aspirin and NSAIDs (330, 13.6%) and 3rd was contrast media (261, 10.7%) and 4th was anticancer drug (131, 5.4%). Intravenous injection was most common administration rout (59.9%) and next was oral administration (37.0%). The rate of grade 4 anaphylaxis was significantly higher in males than in female (71%, vs. 64%, P=0.001), in patients ≥ 60 years (P< 0.001) and in intravenous injection than in oral administration (72% vs. 57%, P< 0.001). Acetaminophen had high risk (OR=1.725, 95% CI: 1.046-2.935) and coxibs had low risk for grade 4 anaphylaxis (OR=0.253, 95% CI: 0.063-1.015). Discussion: More than half of drug induced anaphylaxis was grade 4. Male and old age was risk for severe anaphylactic reaction. Drug induced anaphylaxis is allergic disease which can be prevented through avoidance of exposure to causal drug. Therefore, education and management for these patients will be needed.

P13 The burden of alleged allergy to betalactam antibiotics in a tertiary care hospital and the role of the allergist: A pilot study Calderón O.1, Bobolea I.1, Cabañas R.1, Fiandor A.1, Uriarte S.2, López-Serrano M.1, Quirce S.1

1La Paz University Hospital, Allergy Department, Madrid, Spain, 2Fundación Jiménez Díaz Hospital, Allergy Department, Madrid, Spain Purpose: Up to 17% of the population reports a history of allergy to betalactams (BL), which leads to treatments with alternate broad-spectrum, more toxic and expensive antibiotics (with consequent microbial resistances and higher costs), although most of them never undergo an allergological work-up.Method: Retrospective study using the clinical charts. Inclusion criteria: patients labeled as “BL allergy”, admitted throughout 2010 in the Pulmonology unit (chosen randomly) for any respiratory infection, requiring treatment with BL as a first-choice drug, according to current guidelines (e.g. community-acquired pneumonia in patient with severe COPD and/or with P. aeruginosa suspected/confirmed). We recorded demographics and clinical information on: confirmed BL allergy; days of antibiotics treatment/antibiotic type; number of hospitalizations for the same process the same year. The economic burden was evaluated comparing the costs of the antibiotic treatment received by the patients with the costs of the first or even second-choice BL (depending on the diagnosis of each patient), disregarding other factors as readmission for complications, drug resistance etc. A descriptive analysis was performed using SPSS v11. T-student test for paired samples was used to compare the costs.Result: 74 patients (41 F; mean age 67 years [25-90]) were included.15 of them (20%) had confirmed BL allergy (group I), while 59 (80%) reported old reactions, never studied, many of them not suggestive of an allergic mechanism (group II). Most patients, 57 (77%) received levofloxacin, alone or in combination with macrolides and/or aminoglycosides. Group I: we were asked to perform desensitization. Group II: 10 (16%) were referred


ABSTRACTSto our department (follow-up until end of 2011), confirming the allergy in 6 of them (10% of group II). 15 patients were hospitalized more than once, 11 of them (73.3%) belonged to group II. Days of antibiotic therapy: mean 12.09 (7-27 days). Costs/ patient (group II only): mean + SEM (CI 95% min,max); First-choice drug vs received treatment: -56.6 €+20.9 (-14.8,-98.3), p=0.009. Second-choice drug vs received treatment: -118 € + 22.8 (-72.6,-163.9), p< 0.001.Conclusion: Evaluation by an allergist or desensitization procedures are rarely demanded, although they may lead to reduction in patient complications and also in costs. The results of this pilot study should be confirmed in larger studies with similar inclusion criteria in other medical or surgical units

P14 Prospective study of drug hypersensitivity reaction in a large teaching hospital, Thailand Rerkpattanapipat T.1, Tragulpiankit P.2, Wannathong P.2, Kerdklang S.2

1Mahidol University, Allergy Immunology and Rheumatology Division, Department of Medicine, Bangkok, Thailand, 2Mahidol University, Department of Pharmacy, Faculty of Pharmacy, Bangkok, Thailand Purpose: To determine the frequency and characteristics of drug hypersensitivity reaction (DHR) occurring in hospitalized patients between August 2008 and February 2009 at Ramathibodi Hospital. Materials and methods: All adverse drug reactions (ADRs) in hospitalized patients were notified to ADR team. Those reactions with suspected DHR were consulted and verified by allergist and dermatologist. Clinical information according to validated ENDA questionnaire was recorded. DHRs were finally classified into 5 types, that are anaphylaxis, severe cutaneous adverse reaction (SCAR), other severe exanthema, mild rash (immediate or non-immediate), and nonspecific histamine release. Culprit drug was identified according to expert opinion based on epidemiological data and chronological relevance. Results: Total of 108 patients was recruited with 61 (62%) female. Average age was 53.5 ± 1.6 years old. Total number of suspected DHR occurring was 126 events. Twenty-four events (19%) were non-drug reaction, and 7 events (5.6%) were ADR type A. Ninety-five events (75.4%) of DHR were classified into immediate reaction 26 events (27.4%) and non-immediate reaction 69 events (72.6%). Anaphylaxis accounted for 5 events (19%) of 26 immediate reactions. Nine events (13%) of non-immediate reaction were SCAR (8 with drug reaction with eosinophilia and systemic symptoms [DRESS] and 1 acute generalized exanthematous pustulosis [AGEP]), 1 event (1.4%) was fixed drug eruption [FDE], and 4 events (5.8%) were other severe exanthema (1 vasculitis, 1 erythema multiforme major and 1 MPE with fever). The rest of 76 events (80%) were mild rash, which 7 events (9.3%) were nonspecific histamine release. Conclusions: Evaluation of DHR required multidisciplinary team, as 25 % of all suspected event were non-DHR. Of all DHR occurring in hospitalized patients, high probability event (anaphylaxis, SCAR, severe exanthema and FDE) accounted for only 20%, while most of reaction (80%) was mild rash with low probability of being allergic reaction.

P15 The value of diagnostic studies for drug allergy: Patient characteristics and drugs involved Corominas M.1, Andrés B.1, Lleonart R.1, Lazaro A.1, Fabregas E.1, Martin C.1, Pedrós C.2, Vallano A.2

1Hospital Universitari de Bellvitge, Allergology, L’Hospitalet de Llobregat, Spain, 2Hospital Universitari de Bellvitge, Clinical Pharmacology, L’Hospitalet de Llobregat, Spain Purpose: To evaluate patients referred to the Allergy Department in order to study drug allergy and to assess the usefulness of these diagnostic studies. Material and methods: We conducted a prospective observational study in patients referred both from primary health centres and patients admitted in the hospital who had experienced a suspected allergic drug reaction. Clinical and epidemiological data, implicated drugs and the results of diagnostic tests were recorded in a specific database for subsequent statistical analysis and evaluation. Drug allergy definition included those patients with a clinical positive history and/or positive diagnostic tests. Results: We studied 443 patients (144 male and 299 female) with mean age 49.21 years old (range: 15-89 years). Only 7% of them were hospitalized patients and 8% had experienced previous drug allergic reactions. 82% of the patients had reported cutaneous manifestations, 2% had suffered an anaphylactic shock and 6.5% had exhibited non-organic symptoms. Serum specific IgE antibodies to betalactams were positive in 4% of 117 patients with suspected penicillin allergy. In 268 patients we carried out cutaneous tests that were positive in


ABSTRACTS13% of the patients. 22 (10%) had a positive challenge test with the suspicious drug. 180 patients (40.6%) were diagnosed with drug allergy (including 48 patients with non-steroidal anti-inflamatory drug [NSAID] idiosyncrasy). The drugs more frequently implicated were NSAID (64.8%) and betalactam antibiotics (23%). In the remaining subjects: 155 (58%) were diagnosed with non-immune adverse drug reaction, 77 patients (29%) with adverse drug effect and 12% (31 patients) with non-organic symptoms. One year after the study, 121 patients were asked about tolerability of the drug indicated at the end of study. 35 of 37 patients had tolerated the recommended drug and in 84 patients the drug was not administered: 48 patients because it was not necessary; 30 patients due to fear and 6 patients still considered themselves allergic despite their negative results (29.7% of surveyed patients). Conclusion: In our area, less than half of the patients referred to study for drug reactions were diagnosed as having allergy, and a high percentage of the patients surveyed did not accept the results. A better knowledge among family doctors could both reduce the number of patients unnecessarily referred to the allergy services and also reduce the cost of the studies.

P16 Drug hypersensitivity reactions: patterns of responses, drug involved and temporal variation in a large series of patients evaluated Doña I.1, Gómez F.1, Torres M.J.1, Garcia-Nuñez I.1, Salas M.1, García J.1, De Leyva C.1, Blanca M.1

1Carlos Haya Hospital, Allergy Department, Málaga, Spain Background: Drug hypersensitivity reactions (DHR) are one of the most frequent reasons for consultations in allergy services, with an increasing prevalence. Objective: To study the clinical characteristics, drugs involved, diagnostic methods used and temporal variation in a large series of patients with a history of DHR over a six-year period. Methods: All patients attending our department between 2005 and 2010 were included. The diagnosis was performed by in vivo and/or in vitro test (basophil activation test and specific IgE in serum) and drug provocation test (DPT) when indicated. Results: We evaluated 4460 patients who reported 4994 episodes (mean of 1.13±0.36 episodes per patient). Based on clinical history, 37% of the episodes were attributed to NSAIDs, 29.4% to BLs, 15% to non-BL antibiotics and 18.4% to other drugs. Analysis of the 1683 (37.45%) patients finally confirmed as allergic showed that the most frequent diagnosis was hypersensitivity to multiple NSAIDs (47.29%), followed by immediate reactions to BLs (18.12%). There was an increase in the reactions in the group of non-BL antibiotics (from 21.2% to 31.9%; p< 0.03), mainly due to quinolones (from 0.5% to 6.8%; p< 0.02) and radiocontrast media (from 1.08% to 5.91%; p< 0.001). Considering diagnosis 44% were done by clinical history, 14.6% by skin test, 10.4% by in vitro test and 30.8% by DPT. Conclusion: NSAIDs were the drugs most frequently involved, being urticaria/angioedema with cross intolerance the most usual diagnosis. Emerging drugs showing increasing relevance were quinolone derivatives and radiocontrast media.

P17 Positive predictive value of skin testing with beta-lactams: Literature review Chiriac A.M.1, Demoly P.1,2

1University Hospital of Montpellier, Allergy Department, Montpellier, France, 2INSERM U 657, Montpellier, France Aim: The negative predictive value of skin testing with beta-lactam antibiotics has been measured by several studies. However, little data is known about the positive predictive value of such tests. Patients with a positive skin test usually undergo desensitization, if the culprit drug is mandatory, otherwise, an alternative antibiotic is considered. Performing challenge tests in such patients may pose ethical concerns. The aim of the present paper is to review the available data on the positive predictive value of skin testing with beta-lactam antibiotics. Methods: A PubMed search was undertaken using the keywords “beta-lactam”, “penicillin” and “cephalosporin” “allergy” and “skin test”. There were no date restrictions. Articles in the English and French language were reviewed. References of selected articles were reviewed for additional sources. A total of 76 articles are included in this review. We considered four situations to provide information on the positive predictive value of skin tests with beta-lactam antibiotics: systemic reactions occurring during skin testing, reactions occurring during a desensitization process in patients with positive skin tests, reactions following re-administration (either accidental or under certain circumstances by challenge test) of the culprit drug in patients with positive skin tests and finally, positive challenges with a cross-reactive drug.


ABSTRACTSResults and conclusions: Available data are heterogenous, and results vary greatly, according to the type of clinical situation described above. A somewhat comforting finding comes from accidental re-exposure or intentional drug challenge performed in skin positive patients with a clinical history of non severe delayed type reaction, in whom a positive predictive value of up to 36 percent was found in larger series.

P18 Comparison and predictors of cutaneous hypersensitivity reactions associated with antiepileptic drugs Porebski G.1, Bosak M.2, Szczygiel E.2, Szczudlik A.2

1Jagiellonian University Medical College, Department of Clinical and Environmental Allergology, Krakow, Poland, 2Jagiellonian University Medical College, Department of Neurology, Krakow, Poland Purpose: Cutaneous drug hypersensitivity reactions (cDHRs) from antiepileptic drugs (AEDs) are common, but their optimal management still can be improved. This study investigated the predictors and incidence of serious and benign cDHRs due to current AEDs and determined rates of cross-sensitivity among commonly used AEDs in patients with epilepsy. Materials and methods: We applied a standard questionnaire to all 430 consecutive adult outpatients with epilepsy seen at our Epilepsy Center between May 1, 2011, and December 31, 2011. A detailed analysis of obtained medical records comprising 1123 exposures to AEDs was performed. Gender, age, history of atopic diseases and hypersensitivity reactions to drugs other than AED were checked as potential predictors of cDHR. The incidence of AED-related cDHR was determined for all taken drugs: valproic acid (VPA), carbamazepine (CBZ), phenobarbital (PB), primidone (PRM), phenytoin (PHT), lamotrigine (LTG), topiramate (TPM), vigabatrin (VGB), levetiracetam (LEV), tiagabine (TGB), gabapentin (GBP), oxcarbazepine (OXC), clonazepam (CLZ), ethosuximide (ESX). Results: A total of 5,8% (25/430) of patients had a cDHR attributed to AED (21 to one AED; 2 to two AEDs: LTG/OXC, CBZ/OXC and 2 to three AEDs: PHT/OXC/VPA, LTG/OXC/VPA). It corresponds to 2,7% of the exposures. No patients experienced toxic epidermal necrolysis. There were four cases of Stevens-Johnson syndrome involving three AEDs, 19 cases of maculopapular exanthema and 2 cases of DRESS. The highest AED-related cDHR rates were seen with CBZ (36%) and LTG (28%), lower rates were seen with LEV (8%) and PHT (8%). The only significant predictor in analysis was occurrence of another AED-related cDHR. There was no interaction effect from gender, age, atopy or non-AED drug allergy. Conclusions: Though cDHR to AED are usually mild, the relatively rare occurrence of severe reactions indicates that the AED should be ceased. History of AED-related cDHR is the greatest risk factor for developing cDHR to another AED. Clinicians should be aware of the cross-reactivity between AEDs.

P19 Predictive factors on severity of serum sickness like reaction in Iranian patients Ghobadidana V.1, Ziaee V.2, Moradinejad M.-H.2, Mehrdad N.3, Zaker Z.1

1Academic Center for Education Culture and Research (ACECR), Iranian Center for Immunology and Allergy (ICIA), Tehran, Iran, Islamic Republic of, 2Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran, Islamic Republic of, 3Breast Cancer Research Center, Tehran, Iran, Islamic Republic of Background: Serum sickness-like reactions (SSLR), although rare in clinical practice, most commonly occurs in children following drug consumption specially following antibiotic therapy. The aim of this study was evaluation of predictive factors on severity of serum sickness like reaction. Method: All patients with SSLR diagnosis who admitted in a tertiary children hospital in Tehran (Children’s Medical Centre) during 2009-2010 enrolled in this study. In addition to demographic data, fever, cutaneous eruptions and arthralgias/arthritis, other organ involvement and the name of drugs which used during 2-3 past weeks, were registered. Laboratory findings, including: complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum immunoglubin , circulatory immune complex (CIC), blood urea nitrogen(BUN), creatinin and urine analysis were assessed in all patients . Severity of SSLR was defined based on the duration of admission and end organ involvement. Findings: Overall, 70 patients (47.1% male and 52.9% female), with mean age 4± years old were enrolled in this study. just 4.3% had previous history of SSLR. Skin rash was generalized in 94.3% patients (and in others was localized).Joint involvement and fever were observed in 85.7% and 64.3%, respectively. History of recent upper respiratory tract infection was found in 48.6%. Fifty patients (71.4%) had history of recent antibiotics therapy, 2


ABSTRACTSpatients anticonvulsants therapy, 3 patient NSAIDS, 3 patients recent immunization and 1 patient contact with chemical agents. Stimulant agents was not found in patients. Cefixim and furazolidon were the most common antibiotic agents (25.7% and 20%, respectively). In laboratory evaluation, 91.8% had positive CRP and 53% had high ESR. 53.6% had leukocytosis and eosinophilia were found in 53.6% and 1.6% patients. serum IgE in 61.8% of patient was higher than normal range, while high level of serum IgA, IgM and IgG were seen in 9.1%, 22.7 and 15.9%, respectively. Sever SSLR was seen in 34.4%of patient.ESR rate and peripheral leukocyte (WBC) count were significantly higher in patient with sever disease (P=0.004 and P= 0.032 , respectively).. Conclusion: Based our findings, high ESR rate and WBC count can be as predictive factors of severity in SSLR. Keywords: serum sickness like reaction, Erythrocyte sedimentation rate(ESR, leukocytosis, CRP, Drug reaction.

P20 Recurrent anaphylaxis to macrogol (polyethylene glycol) Wagner N.1, Podda M.1

1Hautklinik, Klinikum Darmstadt GmbH, Darmstadt, Germany A 49-year old patient repeatedly experienced episodes of anaphylaxis: after taking laxatives, a penicillin-preparation, acetylcysteine and during coloscopy. Furthermore she suffered from pruritus when using a certain type of shampoo. Active ingredients of suspected medication showed no chemical similarities. Comparison of the excipients revealed polyethylene glycol (pharm. macrogol) as shared component. Positive prick testing of macrogol and anaphylactic reaction after oral provocation verified macrogol being the culprit ingredient. Polyethylene glycol has hygroscopic properties and is widely used in medication, cosmetics, paint, polish and for conservation of archeological objects. Immediate-type reaction to polyethylene glycol is very rare, but should always be taken into account, when there seems to be no obvious link between different reports of anaphylaxis.

P21 Immediate hypersensitivity to chlorhexidine following urological procedures: Report of two cases Khan S.1,2, Griffiths H.1,2, Deacock S.1,2

1Frimley Park Hospital NHS Foundation Trust, Department of Immunology & Allergy, Frimley, United Kingdom, 2Royal Surrey County Hospital NHS Foundation Trust, Department of Immunology, Guildford, United Kingdom Purpose: To report 2 cases of immediate hypersensitivity to chlorhexidine following urological procedures confirmed on skin prick and specific IgE tests. Materials and methods: Patient 1: 73-year-old male underwent an operation for resection of bladder tumour and prostate biopsy. Anaesthesia was induced with fentanyl and propofol. Two hours later, a catheter was inserted using Instillagel (chlorhexidine gluconate 0.25%, lidocaine 2%). 10 minutes later in the recovery unit, he felt hot and itchy with difficulty in breathing. Observations: BP 54/34 mmHg, oxygen saturation 92% and widespread urticaria that required 0.5mg 1:1000 adrenaline (Mϋller Grade IV reaction). A month previously, he had a catheter inserted with Instillagel and had felt unwell and light-headed. Past surgical history: 3 uneventful herniorrhaphies. Patient 2: 60-year-old male developed generalised urticaria (Mϋller Grade I reaction) following two urological procedures with Cathejell with lidocaine (chlorhexidine 0.05% and lidocaine 2%). He had contact urticaria to Savlon antiseptic wipe (chlorhexidine and cetrimonium) to clean a cut 4 years earlier. 15 years ago, he had generalised urticaria and angioedema 48 hours after receiving contrast medium (IVP procedure). Results: Patient 1: (73/Male): Mast cell tryptase (at 4h) raised at 35.8 mcg/L (0-16) that normalised (6.95 mcg/L) at 24h in intensive care. Skin prick tests: Histamine control 5x5mm; Chlorhexidine gluconate handwash, dilutions 1:1000, 1:100, 1:10 were 4x4mm at 15 minutes; neat (Chlorhexidine 4%) 15x7mm wheal with significant flare at 35 minutes. Chlorhexidine digluconate 0.2% (w/v) mouthwash, dilutions 1:1000, 1:100, 1:10 and neat were negative at 15 minutes. 1:10 produced 3x3mm and neat 15x8mm wheal at 30 minutes. Specific IgE to Chlorhexidine (Phadia) was Grade 3 positive, 11.8kUA/L. Patient 2: (60/Male): Skin test: Chlorhexidine 0.2% dilutions 1:100 and 1:10 produced 4x4mm weal and flare that was delayed until 30 minutes and skin response to 1:10 dilution lasted 18 hours. Skin tests to lignocaine,


ABSTRACTSarticaine, bupivacaine, mepivacaine, prilocaine, ropivacaine dilutions 1:100, 1:10 and neat were negative. Specific IgE to Chlorhexidine: Grade 1 positive. Conclusions: Chlorhexidine allergy is potentially life-threatening that was proven on skin tests and allergen specific IgE available from Phadia. Clinicians should consider this as an important allergen as sensitization can be achieved by numerous methods.

P22 A case of anaphylaxis to macrogol 3350 after injection of a corticosteroid Lapeere H.1, Borderé A.1, Stockman A.2, Franki A.-S.3, Coppens M.4, Lambert J.1

1University Hospital Ghent, Department of Dermatology, Gent, Belgium, 2Sint-Rembert Ziekenhuis, Department of Dermatology, Torhout, Belgium, 3University Hospital Ghent, Department of Pharmacy, Gent, Belgium, 4University Hospital Ghent, Department of Anesthesiology, Gent, Belgium We report a case of an anaphylactic reaction to macrogol 3350, after injection with Depo-Medrol Lidocaine® (methylprednisolonacetate, macrogol 3350, benzylalcohol 8,7 mg/ml, lidocaine 10 mg, myristyl-gamma-picolinium chloride, sodium chloride, water for injection). A 54-year old woman contacted us because of respiratory distress, generalized erythema, itch and hypotension, a few minutes after an intra-articular injection with Depo-Medrol Lidocaine® in her shoulder. Her general practitioner immediately treated her with an intra-muscular injection with Solu-Medrol® (methylprednisolon natriumsuccinate), with relief of the symptoms. No epinephrine was injected. She has a history of atopy and urticaria. Skin prick tests with a panel of inhalation allergens, Depo-Medrol and wheat flour were positive for tree pollen, dermatophagoïdes farinae, cat, wheat flour and Depo-Medrol. Components of Depo-Medrol that were commercially available were ordered and prepared for skin testing by the pharmacy of our hospital. Skin prick tests with macrogol 3350 diluted at 0,01%, 0,1%, 1%, 10% and pure were slightly positive for 10% and the pure solution (wheal diameter respectively 3 and 5 mm, histamine wheal 7 mm). The patient was admitted to perform intradermal testing with macrogol 3350. Thirty minutes after the intradermal injection of the 10% solution of macrogol 3350, the patient developed rhinitis, and itch in her mouth and throat. Ten minutes later she developed an anaphylactic shock with a general itch with urticae on her legs, hypotension and lower consciousness. She was treated with adrenaline 1/1000 0,5 ml IM and levocetirizine 2 tablets with complete recuperation. She was seen the next day at the consultation because she had developed an erythematous swelling were the 1% and 10% solution was injected the day before (diameter respectively 10 and 20 mm). The lesions disappeared after taking ebastine but reappeared several hours later. Treatment with 2 tablets ebastine a day was continued during one week. Additional tests (skin prick test, intradermal tests and provocation tests) with lidocaine and methyprednisolon were performed to rule out additional allergies. These tests were negative. A basophil activation test (BAT) for macrogol 3350 was negative. Macrogol 3350 is an additive widely used in medication which can cause severe anafylaxis. It should not be overlooked in the work-up of anaphylactic reactions following use of medication. P23 A case history of drug hypersensitivity to H1-antihistamines Chloropyramine (suprastine) Myasnikova T.N.1, Latysheva T.V.1, Latysheva E.A.1

1Institute of Immunology, Immunopathology, Moscow, Russian Federation Background: The case of anaphylaxis developed due to the treatment of Chloropyramine, which is H1-antihistamines and derivatives of ethylenediamine. Case report: The simultaneous intake of metamizole and chloropyramine for fever for the first time by 50-year old woman caused swollen of lips and tongue. The same reaction happened in a year after the next intake of this combination of medications accompanied with a hypotension. Previously there were no reactions for medications. After that she didn’t take any medications because of fear. She visited our clinic to select safe NSAID. In allergy examination no atopy was found. The complex examination was performed. Acute pathology of gastrointestinal tract was not found. Obviously, the most possible causative agent of drug hypersensitivity metamizole was suspected. We used test of inhibition of leucocyte’s migration (TILM), sublingual and oral drug provocation


ABSTRACTStests (DPT) in therapeutic doses, started with placebo, following testing using different groups of NSAID. The results were negative in all groups of NSAID. After all, we performed the same testing with metamizole - the results were negative too. Due to the TILM with chloropyramine isn’t used. So, we were to start with sublingual test with chloropyramine (1/8 tab, 3,12 mg). During 1-2 minutes patient complained on itching in the sublingual area: we revealed the beginning of swollen in the sublingual area, which was stopped with using the injection of glucocorticosteroides. Test was considered as positive. The intake of chloropyramine and another derivatives of ethylenediamine, such as ranitidine, piperazine and it’s derivatives (cetirizine, hydroxyzine) and other were prohibited for the patient. Discussion: We should remember that H1-antihistamines also can cause drug hypersensitivity. The DPT is the gold standard for the diagnosis of drug hypersensitivity. Key words: drug hypersensitivity, swollen lips and tongue, hypotension, Chloropyramine (suprastine)

P24 Is Gadolinium a safe alternative to iodinated contrast agent allergy? A case report Yesillik S.1, Kartal O.1, Demirel F.1, Gulec M.1, Sener O.1

1Gulhane Military Medical Academy and Medical School, Division of Immunology and Allergic Diseases, Ankara, Turkey Introduction: Gadolinium based contrast agents are used for MRI (magnetic resonance imaging) and considered to be safe, with few reports of severe allergic reactions and deaths. They can be alternative agents in patients with prior history of severe adverse reactions to iodinated contrast agents. Case History: We present a 36 year old female who had reactions to iodinated and gadolinium based contrast agents. She had also history of allergic reactions to vitamin C, ampicillin and corticosteroids. Prior to abdomino-pelvic MRI scan, she was referred to our clinic because of adverse reaction histories to both iodinated and gadolinium contrast agents (generalized rash, hives, itching, difficulty breathing, and swelling of tongue, hypothermia and hypotension). Skin tests were performed with Gadobenat Dimeglumin and Gadodiamid. Skin prick test results were negative, but intradermal tests were positive to 1:10 dilution of two agents. We suggested her that MRI procedure should be done without contrast agent or underwent another radiologic procedure. Twenty days later, she was consulted to our clinic from cardiology department before elective coronary angiography. Skin tests were performed with Iodixanol and Iomeprol. Skin prick test was positive to Iodixanol and intradermal test was positive to 1:100 dilution of Iomeprol. Conclusion: Gadolinium based contrast agents are concluded to be an acceptable alternative for patients who had allergic reactions to iodinated contrast agents. However, there are few case reports regarding severe allergic reactions against to gadolinium based contrast agents. As in our patient, who has an allergy to iodinated contrast agents and history of multiple drug allergy, gadolinium allergy should be excluded before the procedure. P25 Systemic urticaria-and-angioedema reaction after treatment with topical menthol- and NSAID-containing cream Kolkhir P.V.1

1Andrey`s Hospital, Allergy, Moscow, Russian Federation Purpose: This is the report of a case of severe contact urticaria with systemic involvement resembling an anaphylactic reaction, following the application of a topical combined cream containing nonsteroidal anti-inflammatory drug (NSAID) ibuprofen, menthol and some other plant-derived components (eucalyptus, cinnamomi, peppermint) in a 29-year old female with no previous history of allergies to NSAID or any other allergies. Symptoms resolved after intensive antihistamine and steroid therapy. The patient also told that her mother suffers from pollinosis. Menthol is an organic compound made synthetically or obtained from peppermint or other mint oils. Menthol is widely used in cosmetics, perfumery and topical drugs as antipruritic, analgesic, antispasmodic agent and well known for its local irritant effect. Menthol also enhances the efficacy of ibuprofen in topical applications via vasodilation, which reduces skin barrier function. Method: A single-blind, placebo-controlled oral challenge (SBPCOC) with ibuprofen was carried out. Skin prick and patch tests were performed with ibuprofen, menthol and pollen of different plants.


ABSTRACTSResult: SBPCOC with ibuprofen was performed, with good tolerance as well as skin tests. Skin prick and patch tests with menthol and weeds were highly positive, confirming the causal association. The patient was diagnosed with menthol, peppermint and weeds hypersensitivity, and was instructed to avoid drugs containing these plants. Conclusion: Despite the fact that the reactions after administration of NSAIDs occur very often there is always a risk of reaction to the other components of the topical drug such as menthol. Menthol and other plant-derived components are present in many topical drugs used by dermatologists and allergologists. To our knowledge, this is one of the first cases in the literature of a potentially life-threatening immediate-type reaction in the context of a contact urticaria syndrome due to menthol. Physicians should be aware of the contact urticaria syndrome and of the increasing use of menthol in topical drug formulation in order to identify possible adverse reactions. The diagnosis can be confirmed by skin testing, in vitro evidence of specific IgE, oral or parenteral challenge, or an allergic patch test.

P26 Angioedema by losartan: A case report Montoro A.1, Garcia A.2, Tavakov A.2, Mateos J.M.1, Burgos A.1, Fernandez M.1

1Hospital Central de la Defensa, Alergia, Madrid, Spain, 2Hospital Central de la Defensa, Farmacologia Clínica, Madrid, Spain Aim: Angioedema is a serious, infrequent and well-known Adverse Drug Reaction (ADR) to antihypertensive drugs: Innibitors of Angiotensin Converting Enzyme (ACEI) and Angiotensin II Receptor Blocker (ARB). AECI/ARB is largely used worlwide, with approximately 40 millon patiens exposed to them; therefore, the morbidity and mortality from ADR could be considerable. Method: A woman, 88 years old, with a history of hypertension in treatment with losartan, was admitted to the hospital with a diagnosis of recurrent episodes of face, tongue and lips angioedema. She had no airway compromise, but she had speech impairment and hoarseness and poor response to antihistamines and corticosteroids. Three months before, treatment with ACEI enalapril was stopped, as it induced cough and oropharyngeal angioedema. The patient had not seasonal, drug or food allergies. The causal relationship between losartan and angioedema was established according to the modified Karch Lasagna algorithm, used by the Spanish Postmarketing Surveillence System. Result: Blood count, biochemistry and standard skin test were normal. Total IgE was 12,4kU/l and eosinophil cationic protein was elevated (36,8 ug/l). Complement (C3 and C4) and C1 esterase inhibitor (C1IHN) and other immunoglobulins levels were normal. Angioedema episodes disappered after losartan was withdrawn. Causal relatoinship between losartan and angioedema was defined. Conclusion: Angioedema associated to ACEI and ARB is a serious ADR, it is rare but not unusual due to the widespread use of this class of drugs. When an ADR related with the use of ACEI was noted, it was thought that the best alternative treatment was ARB, but this treatment caused the reapperance of the ADR. ARB should not be used as substitutes for ACEI.

P27 Anaphylaxis to Chlorhexidine during surgery: Case reports Nakonechna A.1, Dore P.1, Holding S.1, Dixon T.2, Abuzakouk M.1

1Hull and East Yorkshire Hospitals NHS Trust, Allergy and Immunology, Hull, United Kingdom, 2Royal Liverpool and Broadgreen University Hospitals NHS Trust, Allergy, Liverpool, United Kingdom Background: Chlorhexidine is widely used and being a potentially immunogenic substance it can cause hypersensitivity reactions, however anaphylaxis to chlorhexidine is rare. Purpose: We describe four cases of IgE mediated anaphylactic reaction attributed to chlorhexidine during surgery. These patients were exposed to chlorhexidine in different ways: as cleansing swabs, as a lubricant on urinary catheters and using chlorhexidine-impregnated catheters. Material and methods: Four patients with clinical history suggestive of anaphylaxis during surgery were included. Cause of the collapse was not obvious. Detailed history, review of case notes, total and specific IgE, skin prick and intradermal tests with drugs used during anaesthesia and mast cell tryptase (MCT) measurements were performed. Results: In three out of four cases re-exposure to chlorhexidine triggered more severe reactions. Two out of four patients demonstrated increased MCT levels in serum in 1-4 hours after event, while in one it was normal and in


ABSTRACTSone blood samples for MCT were not taken. All four patients had elevated specific IgE to chlorhexidine and skin prick test to chlorhexidine was positive in two patients tested. Conclusion: We suggest that in any unexplained cardiovascular collapse during surgery anaphylaxis must be considered. Investigation of suspected anaphylactic reactions during surgery is essencial to identify a potential trigger to prevent further exposure and potential harm. We recommend centres investigating patients with allergic reactions during anaesthesia should routinely include testing for chlorhexidine allergy. Clinical history, mast cell tryptase level, skin tests and specific IgE to chlorhexidine - in combination help in the diagnosis of allergy to chlorhexidine.

P28 IgE-mediated hypersensitivity to mannitol as a cause of anaphylaxis to intravenous paracetamol Fernando S.L.1,2, Anderson J.1, Fulton R.B.1, Green S.3, Rose M.3

1Royal North Shore Hospital, Department of Immunology, St. Leonards, Australia, 2Sydney University, Sydney, Australia, 3Royal North Shore Hospital, Department of Anaesthesia, St. Leonards, Australia Aim: A 39-year-old woman with a history of breast cancer had 3 anaphylactic episodes following breast reconstructive surgery. The common agent administered prior to each of these episodes was intravenous paracetamol. She was able to subsequently take oral paracetamol without adverse reaction. She was subsequently investigated to determine the whether mannitol, an excipient found in intravenous but not oral preparations of paracetamol was the inciting agent of her anaphylaxis Method: The patient was tested intradermally to intravenous paracetamol and mannitol. Twenty-five volunteers were also tested to establish a baseline non-reactive concentration for intradermal testing. Specific IgE testing was also performed on serum collected from the patient and 25 volunteers. Result: The patient was skin test positive to both intravenous paracetamol and mannitol 20% at a dilution of 1:1000 but negative at a 1:10000 dilution. In contrast, no volunteers were positive to intravenous paracetamol beyond a 1:10 dilution. One of the 25 volunteers had an equivocal result to mannitol at 1: 10 and 1:100 dilutions with the rest negative at all dilutions. The patient also demonstrated a positive specific IgE response to 1-amino-1-deoxy-d-mannitol using the Phadia ImmunoCap 250 as compared to the negative responses observed in 25 volunteers using a cut-off value of 0.35 kUA/L. Conclusion: Mannitol is an excipient found in a wide range of drugs and a potential cause of IgE-mediated anaphylaxis. The patient and the relevant clinicians were subsequently provided with a list mannitol-containing drugs that were to be avoided in the future.

P29 Type I hypersensitivity to Polyethylene Glycols (PEGs) Wenande E.C.1, Skov P.S.1, Mosbech H.1, Poulsen L.K.1, Garvey L.H.1

1Copenhagen University Hospital Gentofte, Allergy Clinic, Hellerup, Denmark Purpose: Polyethylene glycols (PEGs) or macrogols are hydrophilic polyethers commonly used in pharmaceutical, cosmetic, industrial, food and household products. Primarily known as active ingredients in colonoscopy lavages, PEGs of varying molecular weights also serve as solvents, excipients, bulking and dispersing agents. Over the past two decades, sporadic cases of mild to severe hypersensitivity to PEGs have been reported. We present a 27-year-old atopic patient with severe hypersensitivity reactions to an intramuscular injection of Depo-medrol and a Balancid Novum tablet, one week apart. A week prior to the first episode, she experienced an acute urticarial reaction during tattooing of her forearm. The purpose of the study was to confirm an underlying type I hypersensitivity to PEGs, found to be the common factor between the hypersensitivity reactions. Materials and methods: Histamine release test (HR-test), Skin Prick Test (SPT) and provocation using PEG-containing products, non-PEG-containing products and the molecular monomer (ethylene glycol) and dimer (diethylene glycol) were performed. Also, basophile histamine release inhibition studies were conducted using ethylene glycol and diethylene glycol. Results: SPT and HR-test with the steroid Depo-medrol (containing PEG 3350) were positive, whereas other steroid-based products tested negative in a combination of SPT, HR-test and provocation. SPT and HR-tests with Balancid (containing PEG 6000) and with PEG-containing creams as well as pure solutions of high molecular


ABSTRACTSweight PEG were all positive. Conversely, SPT and HR-tests with ethylene glycol and diethylene glycol were negative. In subsequent PEG inhibition studies, separate pre-incubation with the monomer and the dimer abolished PEG-induced histamine release. Conclusions: History, clinical symptoms and positive test results point to hypersensitivity to PEGs. Clinical symptoms appeared indiscriminate of exposure route. Furthermore, chain length and dose may play a role in eliciting allergic responses. Successful inhibition of PEG-induced basophile histamine release by the PEG monomer and dimer haptens supports an IgE-mediated mechanism. It is to our knowledge the first time inhibition by monovalent haptens has been demonstrated using basophile histamine release. Hypersensitivity to PEGs is rare, but probably often overlooked and may thus be the underlying cause behind some cases labeled idiopathic anaphylaxis.

P31 Malignant Hyperthermia simulating perioperative anaphylaxis Gastaminza G.1, Javaloyes G.1, Berroa F.1, Urbain C.M.1, Goikoetxea M.J.1, Sanz M.L.1, Moncada R.2, Lafuente A.2

1Clinica Universidad de Navarra, Alergologia, Pamplona, Spain, 2Clinica Universidad de Navarra, Anaesthesia, Pamplona, Spain Aim: Anaphylactic reactions to anaesthetic drugs are difficult cases for allergists, because there are several underlying mechanisms and allergenic tests can result negative. Moreover, other kind of non-immunologic reactions can occur. We present a case of probable malignant hyperthermia (MH). Method: A thirteen year old female diagnosed of Noonan syndrome and well controlled bronchial asthma, presented in July 2010 during anaesthesia induction for a facial nerve paralysis surgery, mild bronchoconstriction with hypercapnia. In December 2010 she suffered during anaesthesia induction a more severe reaction with wheezing, hypercapnia without hypoxemia, hypertension and tachycardia. The surgery was suspended and serum tryptase was 4.12 µg/L. Allergenic study performed in other Hospital in March 2011 with the drugs used resulted negative. An unspecific histamine release was suspected and the use of less histamine- releasing drugs was recommended. On a second attempt to operate the patient in April 2011, a similar reaction occurred, the body temperature reached 38ºC and the surgery was suspended again; serum tryptase was 3.51 µg/L. The patient was referred to our Hospital. Allergenic study was performed applying prick, intradermal test (IDT) and basophil activation test (BAT) with the drugs used in the three episodes. Result: IDT resulted positive to cisatracurium, that was administered in the second anaesthesia (atracurium in the first, rocuronium in third) and that had resulted negative in the first allergologic study. Other drugs resulted negative. BAT resulted negative to the drugs used. The surgery was never performed. Conclusion: Noonan syndrome has been associated to MH, a potentially fatal pharmacogenetic disorder of skeletal muscle calcium regulation, triggered by some anaesthetic drugs, specially suxamethonium and volatile anaesthetics. It is associated with an increase in free ionised myoplasmic calcium that results in symptoms like tachycardia, muscle stiffness, hypercapnia, tachypnea, fever and other symptoms. The mortality rate is high and the management include the use of dantrolene sodium and the avoidance of the anaesthetic triggers. The diagnostic gold standard procedure is the in vitro contracture test, too expensive and confined to specialized testing centers, that requires a surgical procedure and can yield equivocal results. Despite our suspicion, diagnosis of MH in our patient could not be confirmed because we had not access to this test.

P32 Mebeverine hypersensitivity Uriarte S.A.1, De las Heras M.1, Calderón O.M.2, Zafra M.3, Del Pozo V.3, Sastre J.1

1Fundación Jiménez Díaz Hospital, Allergy Department, Madrid, Spain, 2La Paz University Hospital, Allergy Department, Madrid, Spain, 3Fundación Jiménez Díaz Hospital, Immunology, Madrid, Spain Introduction: Mebeverine, a opium alkaloid Papaverine synthetic derivate, is a musculotropic antispasmodic drug widely use in the treatment of irritable bowel syndrome (IBS). Case report: A 46-year old woman with IBS developed an immediate generalized urticaria reaction after taking the first 135 mg dose of DUSPATALIN® (Mebeverine) to relieve an abdominal pain, which disappeared within a few hours in the absence of treatment. This drug had been previously well tolerated and the patient had no history of previos urticaria, food or drug allergy.


ABSTRACTSMethods: Skin prick tests were performed with a set of pneumo and food allergens; Histamine Phosphate and saline were used as positive and negative controls. Skin prick test was performed with DUSPATALIN® tablets, arabic gum (used as Duspatalin® tablet excipient), anticholinergic antispasmodics drugs (Atropine, Butylscopolamine, Otilonium bromide), as well as other natural opium alkaloids and synthetic opioids (Codeine, Fentanyl, Tramadol and Meperidine). Every test was assayed in duplicate. Single blind, placebo-controlled oral challenges were performed with DUSPATALIN® tablets (Mebeverine), Butylscopolamine, Otilonium bromide, Codeine and Tramadol. Basophil activation test (Basotest) was performed with different concentrations of DUSPATALIN® (Mebeverine), Butylscopolamine and Meperidine. Results: Skin tests were negative to inhalants, food allergens and arabic gum. Skin prick test was positive to Mebeverine (5x5 mm) and negative in five control subjects. Skin tests to atropine, butylscopolamine, otilonium bromide, codeine, fentanyl, tramadol and meperidine were negative. Within 20 minutes after oral challenge with Mebeverine (7.5 mg), the patient developed itchy hives in her face and abdomen which disappeared with dexchlorpheniramine. Oral challenges with butylscopolamine, otilonium bromide, codeine and tramadol did not elicited adverse reactions. Basotest was positivo to the 1250 mcg/ml Mebeverine dilution (3.45 SI), whereas no positive results were found in two healthy controls. Basotest results were negative to Butylscopolamine and Meperidine. Conclusions: The positive prick test result, as well as the oral challenge and the basophil activation test, strongly suggest an IgE-hypersensitivity mechanism to Mebeverine in this patient. Allergic reactions to Mebeverine are extremely rare. A cross reaction to other antispasmodics and opioid derivates was not found in this case.

P33 Immediate hypersensitivity to corticosteroids - two clinical cases Sousa F.1, Oliveira S.1, Câmara R.1

1Hospital Dr. Nélio Mendonça, Immunoallergology Unit, Funchal, Portugal Background: Corticosteroids are drugs frequently used in different diseases. Taking into account their extensive use, hypersensitivity reactions are very rare. The most commonly reported symptoms are urticaria, angioedema, bronchospasm and hypotension. The drugs most often involved are methylprednisolone and hydrocortisone. The reactions may be or not immunologically mediated. The diagnostic approach is not yet well established. Case reports: Case 1 - 47 years old woman with chronic urticaria, partially controlled with antihistamine. The first episode occurred at 37 years old: 15 minutes after intravenous (iv) administration of prednisolone (50 mg) for an exuberant insect sting reaction presenting generalized itching, erythema and angioedema. Second reaction, occurred 30 minutes after oral administration of prednisolone (20 mg) for the same situation, resulting in generalized itching, erythema, angioedema, accompanied by dyspnea, which resolved spontaneously within 2 weeks after drug withdrawal. Seven years ago, the third reaction: 15 minutes after oral administration of deflazacort (30 mg), a generalized itching morbiliform rash appeared, associated with angioedema, dyspnea and wheezing, positive Nikolsky´s sign, with partial resolution after two administrations of epinephrine (0.5 mg) intramuscular (im) and antihistamine (iv), requiring hospital admission. Case 2 - 8 years old male child with cow’s milk allergy and extensively hydrolyzed whey protein formula allergy (anaphylaxis and multiple accidental ingestions), egg allergy, atopic rhinitis and mild persistent asthma since early years. At the age of 8, 10 minutes after iv methylprednisolone (40 mg) for migraine, he developed lips angioedema and upper dyspnea. Epinephrine (0.3 mg) im, was administered with symptoms resolution. He underwent oral deflazacort provocation test, which was negative. Conclusions: The authors present two clinical cases of immediate hypersensitivity (anaphylaxis) to systemic corticosteroids. In the first case, given the increasing severity of the reactions the authors decided not to move forward in diagnostic evaluation and the avoidance of corticosteroids. In the second case we chose to test an alternative corticosteroid. Although it is not clear, we can’t exclude immune system involvement, since they are patients requiring systemic corticosteroids due to their underlying disease exacerbations. An IgE-mediated mechanism is also possible since they are immediate reactions.

P34 Patent blue anaphylaxis Viegas L.P.1, Lopes A.1, Ferreira M.B.2, Barbosa M.P.2

1Hospital Santa Maria - CHLN, Immunoallergology Department, Lisbon, Portugal, 2Hospital Santa Maria - CHLN; Faculdade de Medicina - Universidade de Lisboa, Immunoallergology Department, Lisbon, Portugal


ABSTRACTS Background: Patent blue V belongs to the triarylmethane family of the synthetic dyes. Its use in mapping of the sentinel node for biopsy purposes in oncologic surgery has been increasing. There have been descriptions of anaphylactic reactions associated with it, in patients who have undergone sentinel node biopsy. Clinical case: 46-year-old woman with history of 3 episodes of generalized macular, pruriginous erythema: 30 to 40 minutes after beta-lactams administration, 2 episodes after IM penicillin (12 and 30 years old) and 1 after amoxicillin administration (36 years old).At the age 46, upon diagnosis of breast cancer, she was mastectomized with lymphatic mapping and sentinel node biopsy. Drugs used in anesthetic induction included: midazolam, fentanyl, propofol, rocuronium, cefazolin, dexamethasone and esomeprazole. Five minutes after orotraqueal intubation, patent blue V was injected and 10 minutes later there was an anaphylactic reaction with generalized urticaria and severe hypotension. Reversal of the clinical features was achieved after immediate administration of adrenalin, and fluids. Hydrocortisone, methylprednisolone, hydroxyzine and ranitidine were also administrated. Immunoallergologic study yielded skin tests (ST) negative to aeroallergens, latex and beta-lactams, including cefazolin. Provocation tests with amoxicillin and penicillin were negative. ST with muscle relaxants (rocuronium), general anesthetics (propofol and fentanyl), midazolam, dexamethazone and esomeprazole were negative. Skin prick test and intradermal test (IDT) with patent blue V 2.5% were positive for concentrations of 1:1 (after 30 minutes) and 1: 10 000, respectively. Irritative effect was excluded by using the same concentration in negative controls. Although an eventual alternative with methylene blue was studied, SPT and IDT were also positive, the former in the concentration of 1:1 and the latter of 1:10 000. Conclusion: Given the growing use of patent blue V for sentinel node mapping, as well as the possibility of anaphylactic reactions associated with this dye, as demonstrated by this clinical case, the authors suggest including patent blue V in the immunoallergologic study of all the peri-operatory reactions that have included its administration.

P35 No cross-reactivity with other benzodiazepines in patient with tetrazepam anaphylaxis Martínez Tadeo J.A.1, Perez Rodriguez E.1, Hernandez Santana G.1, Rodriguez Plata E.1, De La Torre Morin F.1, Garcia Robaina J.C.1

1Hospital Universitario Ntra. Sra. De Candelaria, Santa Cruz de Tenerife, Spain Background: Benzodiazepines are sedative hypnotic agents that have been in clinical use since the 1960s for sedation and to treat anxiety, seizures, withdrawal states, insomnia and drug associated agitation. Adverse reactions are mostly related with overdosing. Allergic reactions are rare, with only a few cases reported in the literature. Patients, methods and results: A 33 year old male patient presented systemic urticaria after the intake of 50 mg of tetrazepam. He received treatment in the Emergency Unit with steroids and antihistamines and was referred to our unit for study. Skin prick test with tetrazepam showed a negative result. Then, we proceeded to a single blind placebo controlled challenge (SBPCC) oral test with tetrazepam.. Fifty minutes after the intake of 25 mg of tetrazepam, our patient presented generalized pruritus, urticaria, dyspnea and tachycardia. We administrated treatment with adrenaline, methylprednisolone and dexchlorpheniramine with resolution “ad integrum”. Basal tryptase levels were 6.5 ug/L, reaching a peak of 17.5 ug/L at ninety minutes, descending until 4 ug/L four hours later. A hive appeared on the area of the forearm where cutaneous test were carried out. We performed prick and intradermal tests (1/100) with midazolam, flunitrazepam, diazepam and clorazepate with negative result. SBPCC oral challenge with diazepam and clorazepate until therapeutic doses were negative. Benzodiazepines are a rare cause of immediate allergic reactions, more of them in the context of general anesthesia. Our patient presented an immediate reaction with anaphylactic clinic, which was reproduced after oral challenge. Skin prick test was negative at the first moment, but turned positive after the development of a systemic reaction. This could be due to local release of mediators from skin mast cells or to the action of drug metabolites. Serum tryptase levels showed a progressive elevation and later decrease, consistent with mast cell activation. All these data strongly suggest a type I -Ig E mediated- mechanism. Previous reports of type I reactions to benzodiazepines do not have study cross reactivity. Tetrazepam is very similar chemically to diazepam. The selective pattern of sensitization found could be due to very different metabolites. Conclusion: In summary, we present a case of anaphylaxis to tetrazepam supported by serological data. No cross reactivity was found with other benzodiazepines, suggesting a selective IgE mediated mechanism.


ABSTRACTSP36 Three more case studies corroborate suspected lack of specific IgE in diclofenac hypersensitivity Steiner M.1, Wedi B.2, Harrer A.1, Schneider M.3, Ferreira F.1, Himly M.1

1University of Salzburg, Christian Doppler Laboratory for Allergy Diagnosis and Therapy, Salzburg, Austria, 2Hannover Medical School, Dept. of Dermatology and Allergy, Hannover, Germany, 3Bühlmann Laboratories AG, Schönenbuch, Switzerland Purpose: Hypersensitivity to diclofenac (DF), a representative of non-steroidal anti-inflammatory drugs, is considered non-immune-mediated (Harrer, et al., PLoS One, 2010). However, certain severe adverse reactions to DF resemble immediate IgE-mediated hypersensitivity. Results of skin tests with DF are not reliable, the diagnostic gold standard is the oral provocation test (OPT). The objective of this work was to determine whether selective severe confirmed DF hypersensitivity is associated with IgE-mediated hypersensitivity mechanisms. Materials and methods: Three patients with clinical evidence for IgE-mediated reactions were delivered to the hospital. All had suffered from severe grade III systemic reactions including loss of consciousness within 10 min after intake of DF. Intradermal tests (IDT; all patients) and OPT (patient 2 and 3) were performed. DF and DF-5-hydroxy (DF5OH) metabolite were covalently conjugated to human serum albumin (HSA) and characterized by high performance size-exclusion chromatography. Using sera of DF-KLH-sensitized mice, both conjugates were tested in ELISA for DF-specific mouse-IgG binding. The two conjugates were used for analysis of serum IgE in all patients. In addition, basophils of patient 1 were investigated in BAT for activation marker expression after stimulating either with DF-HSA or DF5OH-HSA. Results: All patients demonstrated positive IDT. Patient 1 developed systemic grade II reaction 15 min after IDT. Patient 2 and 3 demonstrated positive OPT. Analysis of conjugation degree showed that 10.7 molecules DF and 16.1 molecules DF5OH were bound per HSA. In the mouse immuno-assay both conjugates were able to bind DF-specific IgG. In the sera of the DF-hypersensitive patients IgE was below the detection limit using DF-HSA as well as DF5OH-HSA. No upregulation of CD63 surface expression on basophils of patient 1 was observed. Conclusion: No IgE was detected in sera of the hypersensitive patients using conjugates with approved functionality and immunogenicity. This finding was confirmed by negative BAT of patient 1. Hence, no proof for IgE-mediated mechanisms was found, even though positive reactions in the skin tests and provocation tests were observed and even one patient demonstrated a rare systemic reaction during the skin test. This confirms previous findings of our group and leaves the pathomechanism of diclofenac hypersensitivity unresolved. Acknowledgments: This work was supported by FWF, CDG, and Biomay, AT

P37 Does mast cell activation syndrome favours hypersensitivity reactions to β-lactams antibiotics? Stafylaraki C.1, Losappio L.1, Preziosi D.1, Mascheri A.1, Mirone C.1, Farioli L.1, Ortolani V.1, Pastorello E.A.1

1Ospedale Ca Granda Niguarda, Milano, Italy Aim: The aim of the present study was to evaluate the role of the newly recognised entity named “mast cell activation syndrome” (MCAS) in favouring hypersensitivity reactions to amoxicillin. Methods: We selected all the patients recently visited at our Unit for suspected reactions to amoxicillin. The specific IgE anti-amoxicillin levels, the results of skin tests for amoxicillin (performed as suggested by Blanca guidelines) and the existence of the recently accepted diagnostic criteria for MCAS (tryptase, cutaneous symptoms, response to anti-histamines, ecc) were evaluated in each patient between 1 to 6 months after the reaction. Results: Two hundred patients were recruited: 31 pts with documented anaphylactic reactions, 112 patients with cutaneous symptoms alone or plus gastrointestinal reactions. IgE levels were significantly higher in the 31 anaphylactic patients than in the cutaneous one (p< 0,003); while symptoms and signs related to MACS were significantly more frequently found in patients with skin reactions only. Conclusions: MACS can play a role in favouring drug cutaneous reactions, especially to amoxicillin in non specific-IgE presented patients. A brief questionnaire and tryptase levels and specific IgE values were enough to identify these patients that in many cases presented various risk factors favouring mast-cell mediator release.


ABSTRACTSP38 Hypersensitivity reaction to human papillomavirus vaccine due to polysorbate 80 Badiu I.1, Geuna M.2, Nebiolo F.3, Heffler E.M.3, Bussolino C.3, Rolla G.3

1University of Turin, Allergology - Mauriziano Hospital, Turin, Italy, 2Mauriziano Hospital, Pathology Department, Torino, Italy, 3Mauriziano Hospital, Allergology Department, Turin, Italy Background: True hypersensitivity to papillomavirus (HPV) vaccine is uncommon, being estimated at 1/190000 injections. Hypersensitivity reactions may occur not only toward active ingredients, but also to excipients, commonly considered inert molecules not believed to be potential causes of adverse reactions, as it occurred in the case we describe. Case report: A 17-year-old girl reported generalized urticaria, eyelid angioedema, rhino-conjunctivitis, dyspnea and wheezing 1 hour after third i.m.. administration of quadrivalent HPV vaccine (Gardasil®). She was treated with anti-histamine, and corticosteroids with prompt relief of rhinitis and dyspnea, while urticaria and angioedema lasted 24 h. Medical history was significant for seasonal rhinitis due to grass sensitization, autoimmune thyroiditis on substitutive therapy, and type 1 diabetes mellitus on 4 daily insulin injections. Diagnostic work-up: Skin prick and intradermal (id) tests were carried out respectively with 1:1 and with 1:1000 and 1:100 dilutions of both the quadrivalent (contains polysorbate 80, PS80, and Saccharomyces cerevisiae) and the bivalent HPV vaccines. Id test with 1:1000 dilution of the quadrivalent vaccine resulted positive (wheal diam. 10 mm), while the skin tests with the bivalent vaccine gave negative results. Prick test with Saccharomyces cerevisiae was negative, while prick test performed with PS80 (Tween 80; Merck, Germany) at 1:1000 dilution resulted positive (wheal diam. 8 mm). Ten healthy controls, prick and i.d. tested with PS80, showed negative responses. The CD203 basophil activation test result was negative for PS80 at all the tested dilutions. As flu vaccine was recommended, we skin tested two flu vaccine, one containing PS80 (Fluarix®, GSK), which resulted positive after 1:1000 i.d. test (wheal diam. 10 mm), and another flu vaccine with no adjuvant or preservative (Vaxigrip®, Sanofi Pasteur MSD ), which was negative. The patient then received Vaxigrip® without adverse reactions. Conclusion: PS80 is used in a wide variety of topical, oral and parenteral drugs. It has been involved in the development of severe nonimmunological reactions similar to those of our patient in two patients being treated with omalizumab. Urticaria has been reported in one patient with severe psoriasis treated with different biologic drugs containing PS80. The case we report here is the first case of vaccine adverse reaction due to PS80 hypersensitivity, with mechanisms which remain elusive.

P39 Tolperisone severe anaphylaxis - case series report Zamfirescu M.1, Guran C.T.2

1Medlife Medical Center, Allergy and Clinical Immunology, Bucharest, Romania, 2MAI Hospital ‘Prof. Dr. D. Gerota’, Anesthesia and Intensive Care, Bucharest, Romania Tolperisone is widely used in some countries as a prescription myorelaxant. It has a central mechanism of action - presynaptic inhibition by voltage-gated sodium and calcium channels blocking. Individual case reports of allergy have been rarely described, with little data and experience on clinical features and appropriate tests to approach such drug hypersensitivity. A series of 6 adult females, diagnosed in one private setting Allergy practice during the last 18 months, is presented. Clinical details, immunological and biohumoral tests were collected. In all cases, severe to very severe (grade III or mostly IV) anaphylaxis motivated admission to the emergency room, at least two patients receiving adrenaline. 5 out of 6 patients developed these symptomes at the first re-exposure dose (after frequently receiving Tolperisone on a chronic base), while one had received first time treatment three days before the acute episode. While one patient describes the symptomes three hours after ingestion, the five remanining reported immediate reaction - within ten minutes. The clinical presentation has several common elements: severe abdominal and pelvic pain, rectal tenesmae, nausea, palmo-plantar pruritus, rapid progressing facial angioedema and dysphonia during the acute episode, persistence of fatigue and pruritus for 2 to 5 days. Clinically, recurrent urticaria (spontaneouos, dermographic, pressure, cold, or contact induced) in three patients, contact dermatitis in two, chronic hand eczema and high total IgE in another one are noted.


ABSTRACTSPersonal history also revealed autoimmune thyroiditis in two cases, associated to mixed crioglobulinemia and cold urticaria in one of them. Cutaneous tests were not performed mainly due to extreme anxiety of these patients after such severe symptoms. A basophil degranulation test for sulphidoleucotriens to Tolperisone done for the first two cases returned negative. This and also the high costs did not encouraged continuing it in the rest of patients. The mechanisms responsible for these reactions remain unclear. Clinical literature describes exclusive reactions to oral forms of Tolperisone (both accidental reactions and provocation tests), which may lead to a susspicion of possible reaction to a either a metabolyte or an excipient (eg. Macrogol 6000). Negative cutaneous tests from other clinical reports and negative basophil degranulation tests in this case series could sustain this hypothesis.

P40 Immediate and delayed type hypersensitivity to tolperisone Scherer K.1, Bircher A.J.1

1University Hospital Basel, Department of Dermatology, Allergy Unit, Basel, Switzerland Purpose: Tolperison hydrochloride (Mydocalm ®, 2,4’-dimethyl-3-piperidinpropiophenone) is a centrally acting muscle relaxant with arterial vasodilatative effect and inhibitory potential on the voltage-gated sodium channels in the brain stem. Only few cases of hypersensitivity to tolperisone have been reported to date. Material and methods: We report on 14 patients with a history of probable immediate type reactions (ITR) under treatment with tolperisone and on 6 patients with a history of probable delayed type reactions (DTR). Patients were investigated using prick/scratch tests, patch tests and LTT as needed or available. Other potential elicitators were excluded as far as possible by skin tests, lab tests and provocation tests. Results: Patients with ITR (4 male, 10 female, mean age 42+/-6 years) suffered from urticaria w/o angioedema (n=8) or anaphylaxis grade III to IV (n=6) after repeated intake of tolperisone. The delay between intake of the drug and first clinical symptoms was between approximately 30 min to several hours. Potential co-factors of anaphylaxis were present in 5 cases. Prick/scratch tests were negative in all patients tested (13/14). LTT was clearly positive in 3/3 patients and negative in 3 controls. In 6 cases tolperisone was definitely considered to be the causative agent, in 6 patients it was the probable cause. 2 cases were decided to be unrelated to tolperisone. Patients with DTR (3 male, 3 female, mean age 60+/-11 years) suffered from maculo-papular exanthems after intake of tolperisone. Prick/Scratch tests were negative in 3 patients. In one of 4 patients the patchtest was positive. LTT was negative in two patients. One case was definitely decided to be due to tolperisone, 2 were probably due to tolperisone, 2 cases were probably unrelated and one case was definitely unrelated to tolperisone. Oral provocation tests were not performed, but 4 patients (ITR) reexposed themselves accidentally and reacted again with an ITR. Conclusions: We report a large patient series with hypersensitivity reactions to tolperisone. Skin tests were only helpful in one patient in confirming the diagnosis. Interestingly, the LTT demonstrated T-cell reactivity in 3 patients with clear immediate type reactions. So far the allergenic determinant of tolperisone and the pathomechanism in both ITR and DTR have not been elucidated.

P41 Chronic urticaria secondary to nebulised colistin Shah A.1, Whitaker P.1, Gooi J.2, Venemalm L.3, Naisbitt D.4, Peckham D.1

1St James’s Hospital, Regional Adult Cystic Fibrosis Unit, Leeds, United Kingdom, 2St James’s Hospital, Department of Immunology, Leeds, United Kingdom, 3Phadia AB, Uppsala, Sweden, 4University of Liverpool, MRC Centre for Drug Safety Science, Liverpool, United Kingdom Colistin is a polypeptide antibiotic produced by Bacillus polymyxa var. colistinus. It is bactericidal against gram negative bacteria including Pseudomonas aeruginosa (PA). In patients with chronic PA infection of the respiratory tract colistin is used in nebulised form to control bacterial load. Whilst hypersensitivity to intravenous antibiotics is common it is rare to see systemic reactions to nebulised antibiotics. We report two cases of chronic urticaria, both of whom had prolonged symptoms for over a year before the diagnosis was made.


ABSTRACTSPatient 1: A 31 year old female with cystic fibrosis (CF) and chronic PA infection. She was maintained on nebulised colistin for 18 months when she developed urticaria. She also had a history of allergic bronchopulmonary aspergillosis and was on long term steroids. Patient 2: A 36 year old female with CF. As with Patient 1 she had chronic PA and on nebulised colistin for 2 years when urticaria developed. In addition she had heart failure and CF related arthritis. The urticaria persisted for 12 months and there was no improvement when her ACE inhibitor and tramadol were discontinued. Autoimmune screens and complement levels were normal in both cases. No cause was identified by the dermatology team and patients were maintained on high doses of anti-histamines to control the pruritis. The diagnosis was made when Patient 1 developed a pulmonary exacerbation and was treated with intravenous colistin. After the second dose she developed a widespread urticarial reaction and both her intravenous and nebulised colistin was discontinued. Within days the urticarial resolved and when rechallenged with nebulised colistin 6 weeks later urticaria recurred which resolved on stopping colistin. It was decided to stop Patient 2’s nebulised colistin stopped and this resulted in rapid resolution of her urticaria. Both patients were skin prick negative to colistin. However Patient 2 developed a positive intradermal response at 48 hours to 2,000 units/ml colistin. Patient 2 was also LTT positive with a stimulation index of 3. Patient 1 remained on long term steroids and this may explain the negativity of skin tests and LTT. Assays to measure colistin specific IgE and IgG showed elevated specific IgG in both patients (Patient 1 33.6 mgA/l and Patient 2 25.5mgA/l). Specific IgE to colistin was negative. In conclusion, we report two cases of chronic urticaria secondary to nebulised colistin and this appears to be immune mediated.

P42 Drug hypersensitivity as an important worsening factor in a patient with multiple comorbidities and multiple drug use Jurakic Toncic R.1, Lipozencic J.1, Turcic P.2

1University Hospital Center Zagreb, School of Medicine, Department of Dermatology and Venereology, Zagreb, Croatia, 2School of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia Introduction: We present a case of coexistence of psoriasis and severe psoriatic arthritis, prurigo and drug hypersensitivity. Male patient aged 65 presented to our Allergy outpatient clinic due to suspition of having drug hypersensitivity. Case report: Worsening of psoriasis accompanied with severe pruritus was observed in a patient with psoriasis and severe arthritis. Major concern was development of hypersensivity to etanercept with excellent therapeutic effects on psoriatic arthritis. Etanercept was stopped during a period of few weeks, without any improvement of pruritus and skin changes, but with severe deterioration of arthritis. With reintroduction of etanercept, no changes were observed, and therefore we excluded etanercept as a possible cause of drug hypersensitivity. Material and methods: Routine biochemistry revealed minor liver and kidney damage and weakly controlled diabetes type II. Histopathological analysis showed typical changes for prurigo chronica. Also, exclusion of internal malignancies was made. Shelley’s test(ITDBG) and test of lymphblastic transformation of lymphocytes(TTL) were performed with all the drugs that the patient was taking. TTL revealed positive result for acetylsalicilic acid. Patient was adviced to stop the offending drug, as a one of the worsening factors. Conclusions: Beside the drug hypersensitivity, we concluded that chronic liver and kidney damage, along with diabetes mellitus were responsible for prurigo. Experience with this patient pointed us to keep in mind drug hypersensitivity as a cause of worsening in patients with multiple comorbidites and multiple drug use. Also, we point out value of TTL in detection of late type of drug hypersensitivity, especially in the patients with disseminated skin changes and no possibility for patch testing.

P43 Cephalosporin allergy: Cross-reactivity and tolerability to penicillin Park M.A.1, Frigas E.1

1Mayo Clinic, Division of Allergic Diseases, Rochester, United States Aim: We studied the results of penicillin skin tests (PST) and tolerance to treatment with a penicillin (PCN), administered after the PST, in subjects with history of cephalosporin allergy in order to determine whether subjects with a history of cephalosporin allergy are at increased risk for adverse drug reactions to PCN.


ABSTRACTSMethod: A retrospective study of the medical records of 47 consecutive subjects (16 children and 31 adults), who had reported a history of allergy to cephalosporins (mostly immediate skin reactions) were included in the study. In the evaluation for allergy to beta-lactam antibiotics, their physicians had included PST. We reviewed the medical records for basic demographics, PST results and tolerance to the antibiotic administered after PST. The IRB approved the study and all subjects had signed a written informed consent. Results: The mean ages of the children were 8 ± 5 years and 63 ± 16 years for adults. Among the children, 9 (56%) were female and 7 (44%) male compared to 22 (71%) female and 9 (29%) male among adults. All 31 adults had a negative PST. Of the 16 children, 1 (6%) had a positive PST (penicilloate only). Five (16%) of the adults and 10 (63%) of the children received a PCN. None had an adverse drug reaction to the PCN they received. Conclusion: In this study of 47 patients with allergy to cephalosporin, only one had a positive PST. Fifteen of them tolerated treatment with a PCN without any adverse effect effects. Hence, in our patients with a history of cephalosporin allergy, they were unlikely to have a positive PST and adverse reaction to PCN.

P44 Tygecycline: A new alternative antibiotic molecule in patient with antibiotics allergy Calogiuri G.1, Nettis E.2, Di Leo E.2, Ferrannini A.2, Vacca A.3

1Hospital N Melli, Pneumology, San Pietro Vernotico, Italy, 2Bari University, Allergy and Clinical Immunology, Bari, Italy, 3Bari University, Internal Medicine, Bari, Italy We described 4 patients with various antibiotic allergy, in whom their critical condition, the presence of fever or a previous recent course of glucocorticoids did not allow to perform correctly skin tests for beta-lactams antibiotics according to EAACI Position Paper for betalactams hypersensitivity. Furthermore, 3 of them referred other side effects, different of hypersensitivity reactions, following the use of other antibiotics, e.g. a worsening of renal function after aminoglycosides administration or a fluorquinolone induced tendinitis. Two of them showed the presence of specific IgE to G-Penicillin and V-Penicillin (Phadia ImmunoCap System). A patient referred an history of multiple antibiotic allergy. All the patients were treated with Tigecycline, a new antibiotic, belonging to the class of glycylcycilines, an improvement of the old tetracyclines. Tigecycline possesses a wide spectrum of action towards Gram-positive and Gram negative bacteria, except Pseudomonas Aeruginosa. The particular formula of Tigecycline allow this antibiotic to be easily tolerated in patients with betalactams allergy in whom an alternative betalactam cannot be investigated adequately and in patients with an history of hypersensitivity to multiple antibiotics. Tigecygline is derived from minocycline where a t-buthyl-glycylamic group has been added at 9 position to overcome bacteria resistance. Actually in literature there is no case report of tigecycline hypersensitivity reaction.

P45 ASA challenge confirms cross-reactivity in patients with multiple NSAID induced urticaria/angioedema Blanca-López N.1, Doña I.2, Torres M.J.2, Seoane E.1, Campo P.2, Blanca M.2, Canto M.G.1

1Infanta Leonor Hospital, Madrid, Spain, 2Carlos Haya Hospital, Málaga, Spain Purpose: Multiple NSAID-induced urticaria/angioedema (MNSAID-UA) is the most common manifestation of hypersensitivity reactions to NSAIDs. Diagnostic evaluation is based on the clinical history and a drug provocation test (DPT). The objective of this work is to evaluate the role of ASA DPT and the clinical history in the diagnosis of MNSAID-UA. Methods: We studied a group of patients with an unequivocal history of urticaria and/or angioedema after NSAID intake. Subjects had to have had at least two episodes of cutaneous symptoms with two different COX-1 inhibitors. The diagnosis was confirmed in all cases by a DPT with ASA. Multivariate analysis was done by analyzing different variables, including number of drugs involved, episodes and time elapsed between drug intake and symptom onset. Results: Out of the total group with MNSAID-UA diagnosed according to the clinical history, 80% developed a positive DPT with ASA. The risk for being allergic was 17 times higher in patients who developed symptoms within the first 60 minutes after drug intake, 13 times higher in those who experienced reactions with more than two non chemically related NSAIDs, and 10 times higher in women. Conclusions: ASA DPT confirms the diagnosis of MNSAID-UA in up to 92% of cases with an unequivocal clinical history when reactions occur within one hour and more than two different NSAID are involved.


ABSTRACTSP46 Hypersensitivity to drug formulations. Interference with additives, dyes and preservatives in medical products and food - a diagnostic challenge Baló-Banga J.M.1, Schweitzer K.2, Vajda A.1

1Military Hospital, Dept. of Dermatology and Venerology, Budapest, Hungary, 2Military Hospital, Dept. of Toxicology and Immunology, Budapest, Hungary Purpose: to find examples in which differentiation among drug or additive hypersensitivity/intolerance against any other causative agent, i.e. food ingredients, preservatives, plants, grains or derived products that might have affected the therapy or indicated later restriction in the diet or habits of our patients. Patients: In a retrospective study mostly adult out patients advised for consultation to the allergy section of the Dermatology Department between 2005-2011 in the central metropolitan area of Hungary were involved .Those patients admitted with active skin and general symptoms were diagnosed, treated until full recovery and ordered back later. Fifty well documented cases with controversial histories and outcome, observed because of suspected drug hypersensitivity were studied. Materials and methods: In vitro and in vivo tests including provocation were carried out insymptomless stage according to EAACI and ENDA guidelines. Results: The “problem patients” comprised 3.8-8% in our material. Clinically, 10 different phenotypes were encountered; anaphylaxis, urticaria (contact urticaria), angioneurotic edema, dermatitis (atopic, protein contact), generalized pruritus, rhinitis+asthma+facial rash, intertriginous rash, erythema multiforme, Stevens Johnson syndrome, Crohn’s disease with extraintestinal manifestations. The following substances could be verified as elicitors of multiple triggering: patent blue, (E131) ferrous oxides and hydroxides (E172), benzoic acid and benzoates (E210-213), silver (E174) salicylates, sorbic acid (E200-203), camphor, sodium laurylsulfate, nickel, mercury and amalgam, menthol, hyaluronidase, propylene glycol. Out of 100 tests carried out to verify various drugs as causative agents 75 were negative and only 25 positive. We confirmed in 1/3 of the cases various ingredients of medications different from the active substance; in ¼ of patients food proteins and in 7% pollen-food cross reactions. In the remaining cases food preservatives E 210-213 and E200-203 together with balm of Peru and cynnamate aldehyde marked contact urticaria due to early (20-90 min.) positive readings of patch tests. Conclusions: The incidence of these reactions, risk factors, mechanisms, clinical manifestations, diagnostic methods and management may differ from patient to patient. There is one general rule, i.e., there are no general rules. Some cases may need a prolonged observation period with occasional flare-ups lasting sometimes for months.

P47 Multiple drug hypersensitivity (MDH) - no defect of Treg cells but enhanced T-cell reactivity Daubner B.1,2, Hausmann O.V.2, Kawabata T.3, Naisbitt D.J.4, Park K.4, Wendland T.5, Lerch M.6, Pichler W.J.2

1ADR-AC GmbH, Bern, Switzerland, 2Inselspital, University Bern, Division of Allergology, Clinic for Rheumatology and Clinical Immunology/Allergology, Bern, Switzerland, 3Pfizer, Inc., Drug Safety Research and Development, Groton, United States, 4University of Liverpool, Department of Pharmacology and Therapeutics, Liverpool, United Kingdom, 5Inselspital, University Bern, Division of Internal Medicine, Bern, Switzerland, 6Kantonsspital St. Gallen, Division of Dermatology/Allergology, St. Gallen, Switzerland Background: Multiple drug hypersensitivity (MDH) is considered to be a syndrome manifesting with allergic symptoms after the intake of chemically distinct drugs. The pathomechanism of this syndrome is unclear. It is defined by history and clinical observation, and different allergic and non-allergic reactions have been summarized as MDH syndrome, contributing to certain confusion. In our study we defined MDH in patients if they had a documented clinical reaction to at least two structurally distinct drugs, which could be associated with a sensitization by in vivo and/or in vitro tests. Hypothesis: We reasoned that the enhanced reactivity to chemicals is either due to a loss of Treg cell function and/or enhanced reactivity to chemicals/drugs. Materials and methods: We analyzed eight patients with reactions to two ore more chemically distinct drugs in vivo (clinic and skin tests) and in vitro (lymphocyte transformation test & analysis of activation markers). We compared the in vitro analysis to patients with hypersensitivity to a single drug (n=8) and healthy controls (HC) (n=6). The role of Treg cells (Foxp3+CD25high) was analyzed functionally in Treg depletion assays. The phenotype of reacting T-cells was determined by staining of surface markers (CD38 and PD-1).


ABSTRACTSResults: Treg cells from MDH patients are functionally highly active and suppress T-cell proliferation similar to the Treg cells from monoallergic patients and HC. Removal of Treg cells enhanced the reactivity to involved drugs, but does not facilitate an immune response to irrelevant drugs in vitro. Drug-reactive T-cells from monoallergic patients reside in the resting CD4+CD25neg T-cell fraction, while in MDH patients they reside in an in vivo activated cell fraction (CD4+CD25dim), which show an enhanced reactivity to drug allergens as well. Conclusions: MDH is not related to a quantitative or functional Treg cell loss. However, patients with MDH carry a permanently activated T cell fraction, which shows an enhanced T-cell mediated reactivity to various drugs. The reason for the in vivo pre-activation is still unclear.

P48 Allergic immediate hypersensitivity to quinolones associates with neuromuscular blocking agent sensitization Rouzaire P.1, Nosbaum A.2, Mullet C.3, Dubost R.3, Bienvenu F.1, Guilloux L.4, Piriou V.3, Bienvenu J.1, Bérard F.2

1Hospices Civils de Lyon, Immunology Laboratory, Pierre-Bénite, France, 2Hospices Civils de Lyon, Allergy and Clinical Immunology Department, Pierre-Bénite, France, 3Hospices Civils de Lyon, Anesthesia Department, Pierre-Bénite, France, 4Biomnis Laboratory, Lyon, France Purpose: Positive quaternary ammonium (QA) specific IgE (sIgE) were fortuitously detected in a patient who presented an immediate allergic hypersensitivity (IAHS) to ofloxacin. This biological sensitization was confirmed by positive skin tests to several neuromuscular blocking agents (NMBAs). This case leads us to hypothesize a potential association between IAHS to quinolone and NMBA sensitization. We thus evaluated the prevalence of NMBA sensitization in our patients with quinolone IAHS. Methods: 17 patients who developed a quinolone IAHS were included in our study. They were diagnosed upon the positivity of skin tests (ST) and/or basophil activation tests (BAT) and/or challenge tests. Two control populations were also studied: i) 9 patients who underwent a quinolone immediate non-allergic hypersensitivity reaction; all these patients well tolerated a challenge test with the culprit drug; ii) 88 outpatients without history of quinolone and NMBA hypersensitivity. NMBA skin and biological tests: Total IgE and QA sIgE were determined using the ImmunoCAPTM FEIA technique (Thermo Fisher, Uppsala, Sweden). Patients with positive QA sIgE (≥0.10 kU/L) had skin tests and BAT with 7 NMBAs. QA sIgE inhibition tests with ofloxacin were performed in 4 patients with positive QA sIgE. Inhibitions with vecuronium and amoxicillin were used as positive and negative controls respectively. Results: Prevalence of positive QA sIgE was significantly higher in patients with quinolone IAHS (9/17, 53%) compared to patients with quinolone immediate non-allergic hypersensitivity (1/9, 11%) and to outpatients (3/88, 3.4%) (p< 0,05 and p< 0,0001 respectively). Ofloxacin elicited inhibition of the 4 tested positive QA sIgE sera, in a dose response manner, as vecuronium. The inhibition tests were negative with amoxicillin. Among the 9 patients with positive QA sIgE, 7 benefited of ST and BAT to NMBAs. The biological QA sensitization, based on specific IgE detection, was confirmed by positive ST and/or BAT to at least one NMBA in 5 of the 7 tested patients. Conclusion: This study points out a significant higher QA sensitization in patients with quinolone IAHS compared to those with quinolone immediate non-allergic hypersensitivity reactions and to general population. These results suggest a new route for NMBA sensitization in addition to the well described pholcodine involvement. Thus, it seems justified to evaluate NMBA sensitization in patients with quinolone IAHS.

P49 Case-control study of a series of multiple drug hypersensitivity patients Chiriac A.M.1, Bousquet P.J.1, Demoly P.1,2

1University Hospital of Montpellier, Allergy Department, Montpellier, France, 2INSERM U 657, Montpellier, France Aim: Multiple drug hypersensitivity syndrome is defined as well-documented reactions to chemically- and pharmacologically-unrelated drugs. Reports of multiple drug hypersensitivity are scarce and mostly based upon positive clinical history alone. The aim of the present study was to evaluate retrospectively a group of patients with multiple drug hypersensitivity in the large drug allergy and hypersensitivity database (DAHD®).


ABSTRACTSMethods: Patients having been tested positive for at least 2 different drugs between September 1996 and May 2011 were retrieved from the database and their charts reviewed. Those confirmed as having multiple drug hypersensitivities were analysed with respect to demographic characteristics, associated comorbidities, presence of atopy or asthma, clinical features of the drug hypersensitivity reaction, type and results of the allergy work-up. We then performed a case control-study (four to five controls having one proven drug hypersensitivity per case). Controls were matched on sex and age (considering the age at the last reaction confirmed as drug hypersensitivity in the multiple drug hypersensitivity group +/- 2 years). Results: 19 female and 7 male patients with 54 drug-related reactions were confirmed as having multiple drug hypersensitivity. An immunological mechanism (as demonstrated by positive skin testing) accounted for 26 episodes (48.1%, with 30.8% type I and 69.2% type IV reactions). Drug provocation tests were performed in order to confirm the diagnosis in the remaining patients. In one patient, type I and IV hypersensitivity coexisted. The most frequent drug associations included beta-lactams, either with nonsteroidal anti-inflammatory drugs (8 patients, 30.7%), quinolones (5 patients, 19.2%) or corticosteroids (3 patients, 11.5%). When compared to the control group, odd ratios for atopy and asthma were 1.03 [0.44 - 2.40] (p = 0.95) and 2.22 [0.77 - 6.41] (p = 0.13) respectively. Conclusion: Our data support the concept of multiple drug hypersensitivity syndrome (to antibiotics mostly). Skin testing and drug provocation tests are mandatory for confirming the diagnosis. Neither atopy nor asthma are risk factors for multiple drug hypersensitivity syndrome.

P50 A case of hypersensitivity to multiple corticosteroids Bruno Soares J.1, Viegas L.1, Lopes A.1, Silva R.2, Branco Ferreira M.1, Pereira Barbosa M.1

1Hospital Santa Maria, Immunoallergology, Lisbon, Portugal, 2Hospital Santa Maria, Dermatology, Lisbon, Portugal Background: Corticosteroids(CS) are used in the treatment of various conditions, due to its immunosuppressive, antiproliferative, antiallergic and anti-inflammatory effects. Coopman et al, classified CS by chemical structure into 4 reactivity groups and two subgroups from A through D2, with various cross-reactions. Topical and systemic treatments can induce sensitization and elicit immediate or delayed-type hypersensitivity reactions with subsequent administrations. Some authors estimate the prevalence of allergic reactions for topical CS between 0.2% and 5%, and 0.1% to 0.3% for systemic CS administration. Case report: 30 year-old woman with an exuberant local reaction to a non-specified insect sting on the eyelid, was treated with IV hydrocortisone in the emergency department, and later with oral deflazacort, hydroxizine and ebastine, and topical hydrocortisone. 24 hours after treatment was started the local symptoms worsened, she discontinued all CS and continued treatment only with anti-histamines. Since there was no improvement, deflazacort was added again, which led to a new exacerbation with appearance of disseminated pruritic and erythematous papules and vesicules . She was admitted to a Dermatology ward and treated only with antihistamines, with rapid improvement. In her medical past history she refers allergic reaction to various products, with patch tests positive for Tixocortol pivalatum, kathon, neomycin, nickel, cobalt, thimerosal and benzac. She hadn’t taken any medication before the reaction. Laboratory tests were all within normal range values. Skin prick and intradermal tests with prednisolone, methylprednisolone, dexamethasone, bethametasone, hydrocortisone and deflazacort were all negative for immediate reactions. There was a delayed reaction to hydrocortisone, deflazacort, methylprednisolone and prednisolone (readings at 48 and 96h). Skin patch tests with the previous mentioned drugs and a standard battery as defined by the Portuguese Contact Dermatitis Study Group were positive for Tixocortol pivalatum, deflazacort, hydrocortisone, nickel and cobalt (at 24, 48, 96 hours and 1 week). She was instructed not to take any group A CS to which she reacted, as well as to avoid groups B and D2 CS, due to possible cross-reactions. Discussion: This case report aims to remind that, although rare, allergic hypersensitivity to CS can lead to both immediate and delayed-type reactions and that crossreactivity is frequent between CS the same group.


ABSTRACTSP52 Tolerance to cyclooxygenase 2 selective inhibitors in patients with non steroidal anti-inflammatory drug sensitivity: Experience in a Colombian center Echeverry E.J.1, Serrano C.D.2

1Fundación Valle del Lili, Internal Medicine, Cali, Colombia, 2Fundación Valle del Lili, Internal Medicine and Allergy, Cali, Colombia Purpose: Patients with non-steroidal anti-inflammatory drugs (NSAIDs) sensitivity have a low prevalence of cross-reaction to COX-2 selective inhibitors. Oral drug challenge with these agents can be done in a clinical setting with a good safety profile. Our aim was to evaluate the tolerance to COX-2 selective inhibitors in patients with history of NSAIDs sensitivity using a shortened oral drug challenge. Methods: Patients with NSAIDs sensitivity were included. A shortened oral drug challenge (placebo and two dose-progressive steps) with a COX-2 selective inhibitor (meloxicam or etoricoxib) was performed. The challenge was considered positive if any of these following symptoms appeared in the first 24 hours: urticaria, rhinoconjunctivitis, angioedema, anaphylaxis or bronchospasm, the latter defined as a fall in FEV1 equal or greater than 20%. Results: Fifty-four patients (78% were women) with a mean age of 39,6 years (range from 13 to 70 years) were enrolled. 43 patients were challenged with meloxicam (79,6%) and 11 with etoricoxib (20,4%). 49 patients tolerated the drug challenge (90,7%), and only five patients (all challenged with meloxicam) developed a reaction (9,3%): urticaria in two, urticaria plus angioedema in one, and broncospasm in other two. From those, three were re-challenged with etoricoxib and all of them tolerated it. Conclusion: Most of subjects with NSAIDs sensitivity tolerated a COX-2 selective inhibitor by mean of a shortened oral drug challenge. This is the first cohort of patients with NSAIDs sensitivity and its tolerance to COX-2 selective inhibitors reported in our country.

P53 Meloxicam and etoricoxib tolerance in patients with urticaria/angioedema induced by multiple Nonsteroidal Anti-Inflammatory Drugs (NSAID) Ferreira A.R.1, Santos N.1, Botelho C.1, Castro E.D.1, Cernadas J.R.1

1Centro Hospitalar São João, EPE, Serviço de Imunoalergologia, Porto, Portugal Purpose: The mechanism underlying NSAID-induced skin symptoms is not fully understood. Nevertheless, the choice of an alternative NSAID in cross-reactive patients is sometimes influenced by the degree of COX-1 inhibition of a particular drug. The authors aimed to evaluate the results of drug challenges (DC) with meloxicam (MDC) and etoricoxib (EDC) in patients with skin symptoms induced by multiple NSAIDs, with or without complaints with paracetamol. Materials and methods: Retrospective analysis of the DC results of patients referring urticaria and/or angioedema to more than 1 NSAID. Patients with other symptoms related to NSAID intake and those who reported skin symptoms only to 1 NSAID were excluded. Patients were divided in 2 groups, paracetamol-intolerant (PI) and paracetamol-tolerant (PT). Fisher’s test was used to compare groups (p< 0.05 significant). Results: Inclusion criteria were met by 89 patients, aged 20 to 75 (43.8±11.6 years-old), 58 (65.2%) female. Thirty-six patients (40.4%) reported reaction to 2 NSAIDs, 34 (38.2%) to 3 NSAIDs, 14 patients (15.7%) to 4 of these drugs, 4 (4.5%) to 5 NSAIDs, and 1 to 6. The most implicated drugs were acetylsalycilic acid in 71 patients (79.8%), paracetamol in 45 (50.6%) patients, and ibuprofen and nimesulide both in 42 (47.2%). DC was performed in 85 patients; in 8 patients it was necessary to perform more than 1 DC. In the PI group (n=45), 27 underwent MDC, of which 8 (29.6%) were positive, and 15 underwent EDC, of which 1 was positive (6.7%).In those with positive MDC, 4 underwent subsequent EDC, which was positive in 2 (50%). In the PT group (n=44), 26 underwent MDC, of which 3 (11.5%) were positive, and 15 underwent the EDC, which were all negative. In those with positive MDC, all 3 had positive subsequent EDC. The difference of tolerance to meloxicam in both groups was not significant (p =0.18), as it was not for the difference of tolerance to etoricoxib (p=1.0). In the PI and PT groups, the difference of tolerance to meloxicam and etoricoxib were not significant (p=0.13 and p=0.29, respectively). Conclusions: In this sample, there is no significant difference between tolerance to meloxicam and etoricoxib between both groups and within the groups. Further and larger studies are needed to confirm these findings. These data may be particularly relevant considering the cost and cardiovascular risks of selective COX-2 inhibitors.


ABSTRACTSP54 Lichen planus occurring during Etanercept therapy for Rheumatoid Arthritis Chiriac A.1, Solovan C.2, Ancuta C.3

1Nicolina Medical Center, Dermatology, Iasi, Romania, 2University of Medicine V Babes, Dermatology, Timisoara, Romania, 3University of Medicine Gr T Popa, Rheumatology, Iasi, Romania Clinical report: A 59-year-old woman, with a long history of Rheumatoid Arthritis, under imunosupressive therapy with Etanercept and Methotrexate, presented to our Department for evaluation of a pruritic erythematous, infected plaque on the pretibial areas. She reported having had different lesions (fig 2) on the same location for approximately 25 years, that had flared over the past three years; she was diagnosed at that time with lichen planus and she continued self medication with topical steroids.Since she has started the new therapy for Rheumatoid Arthritis with Etanercept and Methotrexat (one year before admission to our Department) the lesions have changed and transformed into violaceous, pruritic, infected plaques A wound culture from the plaque grew methicillin-sensitive Staphylococcus aureus and we started Ciprofloxacinum 500 mg twice daily for 2 weeks with wonderful results along with topical steroids that allevated the pruritus and with the interrupt of the biologic. We performed 4 mm punch-biopsy and we concluded : lichen planus, but which type? Is the infection secondary to the scratch marks or is it related to the imunsupressive therapy? As far as we know, there are few reports of lichen planus ( verrucuous) with secondary infection in a female patient with a long history of Rheumatoid Arthritis, under imunosupressive therapy with Etanercept and Methotrexate. Musumeci3 presented in 2010 a case of a 24-year-old Caucasian man with psoriasis vulgaris who developed lichen planus during treatment with Etanercept after 8 months´ therapy. Lichen planus is considered to be a T-cell mediated autoimmune skin disease, in which autoreactive CD8+ cytotoxic T lymphocytes are key effectors through the induction of keratinocyte lesions 4. There are several reports with oral and cutaneous lichen planus with significant improvement after therapy with Efalizumab5, Alefacept6, Etanercept 7

Battistella in 2008 reported a case of lichen planus occurring during Etanercept therapy for Rheumatoid arthritis indicating that anti-TNF-a therapy may also be associated with the paradoxical induction of inflammatory disease.

P55 Hypersensitivity reactions to monoclonal antibodies in patients with Rheumatoid diseases and desensitization results Abadoglu O.1, Kaptanoglu E.2

1Cumhuriyet University Faculty of Medicine, Immunology and Allergy Diseases Department, Sivas, Turkey, 2Cumhuriyet University Faculty of Medicine, Rheumatology Department, Sivas, Turkey Background: The use of biological agents in rheumatologic diseases is increasing The infusion of this mAb may cause hypersensitivity reactions. Aim: In this study, we aimed to evaluate retrospectively the characteristics of hypersensitivity reactions to biological agents and desensitization results of referred patients to our clinic by Rheumatology Department. Method: We retrospectively assessed 16 patients with rheumatologic disease in the study. Twelve patients were diagnosed with rheumatoid arthritis (RA), 1 with Crohn’s disease and 3 with ankylosing spondilitis between October 2003 and January 2012 Results: A total of 9 patients referred for diagnosis of drug hypersensitivity were treated with adalimumab, 5 with infliximab, 3 with rituximab, 3 with etanercept. Skin prick and intradermal tests with adalimumab were positive 2 of 7 patients, one of 6 patients with infliximab, all of 2 patients with etanercept. In all of 4 patients skin prick and intradermal tests with rituximab were negative. Seven patients were desensitized 1 with rituximab, who had positive and 3 patients had negative skin tests, and 2 with infliximab and 1 with adalimumab who had negative skin test. In total of 5 patients (31.3%) treated with biological agents skin prick and/or intradermal test were positive. Conclusion: Hypersensitivity reactions to biological agents are not rare. Although an IgE-mediated mechanism was not confirmed by skin tests, rapid desensitization can be used for both IgE-mediated and non-IgE-mediated hypersensitivity reactions.


ABSTRACTSP57 Adverse cutaneous reactions to new second generation tyrosine kinase inhibitors in chronic myeloid leukemia Valeyrie-Allanore L.1, Giraudier S.2, Ortonne N.3, Delgado L.1, Cordonnier C.2, Chosidow O.1, Tulliez M.2

1Department of Dermatology, Referral Center for Auto-immune and Toxic Diseases, Henri Mondor Hospital, UPEC, Créteil Cedex, France, 2Department of Hematology, Henri Mondor Hospital, UPEC, Creteil Cedex, France, 3Department of Pathology, Henri Mondor Hospital, UPEC, Creteil Cedex, France Purpose: Nilotinib and dasatinib corresponds to new selective and potent inhibitors of BCR-ABL, which had a significant antileukemic activity in the treatment of chronic myeloid leukemia. The purpose of this study was to evaluate their prevalence rates and to describe their clinical and pathological features. Patients and methods: All consecutive in and outpatients with chronic myeloid leukemia, treated by dasatinib or nilotinib were included between September, 1st 2010 and June, 30th 2011. All patients were interviewed with a structured form and examined by a single investigator. Results: Among the 39 patients included, 31 received nilotinib. The prevalence rate of adverse cutaneous reactions was 71%, consisting in follicular keratosis, hair loss, alopecia, rash, and pigmentation disturbances. The mean delay between drug intake and onset of the disease was 9.63 ± 7.7 weeks. There was no difference between the two groups considering age (52.8±13.3 vs 56.6±17.9; p=0.85), more often women (57%; p=0.83). Adverse cutaneous reactions were not dose related (581mg/d±162 vs 600mg/d±151; p=0.93). Thirteen patients (33%) had oedema , mainly localized on the face, associated to rash in 11 cases. Pruritus was observed in 14 patients, (35.9%) with a mean delay of 6±8.6 weeks. The withdrawal of ITK was necessary for 2 patients, according to the severity of the rash. Histologies, performed in more severe cases (n=4) showed follicular atrophy and fibrosis. Conclusions: We conducted the first prospective study focused on cutaneous adverse reactions due to second-generation tyrosine-kinase inhibitors. Skin manifestations induced by nilotinib and dasatinb were frequent, mostly begnin, not dose related but associated in most of cases with alteration of quality of life. They are characterised by an original clinical presentation with follicular involvement. These results could suggest that these skin reactions are not related to a pharmacological effect. Inhibition of specific metabolic pathways mediated by tyrosine kinases should be involved in the pathophysiology of these adverse skin reactions.

P59 Prophylactic desensitisation with ertapenem and clarithromycin in a patient with multiple drug reactions in whom a novel form of C1 inhibitor deficiency co-exists van Nunen S.A.1,2, Coatsworth N.3, Baumgart K.1,4,5

1Royal North Shore Hospital, Department of Allergy, Sydney, Australia, 2University of Sydney, Sydney Medical School-Northern, Sydney, Australia, 3Royal North Shore Hospital, Department of Microbiology, Sydney, Australia, 4Sonic Clinical Institute, Sydney, Australia, 5Douglass Hanly Moir Pathology, Sydney, Australia Aim: To safely introduce ertapenem and clarithromycin for treatment of atypical tuberculosis (M.chelonae) in a patient with multiple drug reactions to 53 drugs across all known drug classes with reaction types, excluding SJS/TENs/DRESS, including IgE mediated, contact and less well defined reaction types, including IgE-mediated reactions to cephalosporins, and pharyngeal and possibly laryngeal oedema after roxithromycin; a patient in whom a novel form of C1 inhibitor deficiency co-exists. Method: Ertapenem and clarithromycin were selected as the drugs most likely to successfully treat the M.chelonae infection,whilst bearing in mind the plethora of drugs which were known to provoke serious reactions in this patient. C1 inhibitor concentrate, 1000U Berinert® monthly, had been commenced 4 months prior, to control the C1 inhibitor deficiency (a novel variant g.1410A>G in the non-coding region linking intron 6 and exon 7) documented by C1 inhibitor gene (Serping 1) mutation screening (Sonic Clinical Institute, Sydney, Australia). Cephalosporin-specific IgE, to cephalolithin, cephalexin and cefaclor had been detected after previous reaction to cephalosporins. Prescott et al 2004 have shown an 11% incidence of an allergy type reaction to carbapenems in known penicillin allergic patients. The past reaction to roxithromycin was most likely IgE mediated in type, although no in vitro confirmation was possible. Accurate skin testing was precluded by the C1 inhibitor deficiency. Deeming the risk of serious reaction in this particular patient to be unacceptable, desensitisation regimens for ertapenem (adapted from Wilson et al 2003 for meropenem) and clarithromycin (Holmes et al 2008) were commenced on successive days.


ABSTRACTSResult: The introduction of both drugs via desensitisation regimens was tolerated without side-effect, as was long term use. Review two months later confirmed the tuberculous lesions had healed substantially. Conclusion: Desensitisation with clarithromycin is likely to have been prophylactic for this particular patient, whilst desensitisation with ertapenem may have been merely prudent. The development and use of a desensitisation regimen to ertapenem appears to be novel. The prior commencement of monthly C1 inhibitor concentrate could conceivably have contributed to the success of the safe introduction of clarithromycin, as the symptoms experienced by the patient with roxithromycin overlap with those attributed to the C1 inhibitor deficiency.

P61 The first anticonvulsant hypersensitivity overlap syndrome treated successfully in Vietnam using intravenous gammaglobulin therapy Hieu C.C.1, Dinh N.V.2, Hang V.M.1, Doan N.V.1, van Nunen S.A.3,4, Craig T.5

1Bach mai Hospital, Center Allergology and Clinical Immunology, Hanoi, Viet Nam, 2Hanoi Medical University, Center Allergology and Clinical Immunology, Hanoi, Viet Nam, 3Royal North Shore Hospital, Department of Allergy, Sydney, Australia, 4University of Sydney, Sydney Medical School-Northern, Sydney, Australia, 5Pennsylvania State University, Section of Allergy Asthma and Immunology, Philadelphia, United States Rationale: The mortality and morbidity associated with TENS, DRESS and Overlap Syndrome can be exceedingly high. Therapeutic options include supportive care, early use of corticosteroids and other immunosuppressive agents. In Vietnam, available treatment is usually limited to corticosteroid therapy and supportive care. The following is a description of the first known use of intravenous gammaglobulin in Vietnam for DRESS/TENS, presented as a carefully monitored and illustrated case including a literature review. Methods: A carefully monitored patient is described with serial clinical assessments, prognostic factor assessments, illustrations of skin lesion progression and mucosal involvement changes and the response to therapy documented. Due to the clinical severity of the patient´s condition at the time of presentation, corticosteroids were initiated on day 4. Despite corticosteroids, the patient deteriorated and re-assessment demonstrated worsening prognostic factors. After reviewing the literature, the decision was made to institute therapy with high dose intravenous immunoglobulin (IVIG) and 2g/Kg of IVIG was initiated on day 7. Results: Use of IVIG in severe DRESS/TENS is supported by minimal, but favorable literature. Because of the limited prognosis in our patient and the lack of evidence-based literature supporting other therapeutic interventions, IVIG was started. Two days after initiation of IVIG the patient´s fever abated. Within 5 days the skin and mucosal involvement stabilized, and coagulation indices and liver function tests returned toward normal. Conclusion: This is the first known case of the use of IVIG in DRESS/TENS Syndrome in Vietnam. Our poster illustrates the progression of the case, the patient´s response to IVIG therapy and presents a summary of the literature that supports the use of IVIG.

P62 Successful introduction in Vietnam of aspirin desensitisation in aspirin sensitive patients requiring aspirin for management of their coronary artery disease Dinh N.V.1,2, Hieu C.C.1, Doan N.V.1,2, van Nunen S.A.3,4, Craig T.5

1Bach mai Hospital, Center of Allergology and Clinical Immunology, Hanoi, Viet Nam, 2Hanoi Medical University, Allergy Department, Hanoi, Viet Nam, 3Royal North Shore Hospital, Department of Allergy, Sydney, Australia, 4University of Sydney, Sydney Medical School-Northern, Sydney, Australia, 5Pennsylvania State University, Section of Allergy, Asthma and Immunology, Philadelphia, United StatesAim: To introduce aspirin desensitisation in Vietnam in aspirin sensitive patients requiring aspirin for management of coronary artery disease. Method: Three aspirin sensitive patients requiring aspirin (ASA) desensitisation for management of coronary artery disease were referred to the Center of Allergology and Clinical Immunology, Bach mai Hospital, Hanoi. Their ASA hypersensitivity was characterised as either COX-1 or IgE mediated and an ASA desensitisation protocol, modified to account for the type of hypersensitivity reaction, was introduced and further modified, as clinically indicated, according to their progress during the desensitisation procedure.


ABSTRACTSResults: Case1: Male, aged 43, asthma since childhood, angioedema previously after minor analgesics and sneezing, periorbital angioedema and pharyngeal discomfort 30 minutes after 300mg ASA prior to insertion of cardiac stents. Skin prick testing positive to ASA at 1mg/mL. Total serum IgE 106U/L (NR < 100U/L). Nasal/sinus CT scans and spirometry normal. ASA desensitisation began with 0.0001mg ASA, with doubling doses each 30 minutes. Breakthrough symptoms occurred after a dose of 50mg, necessitating protocol modification with 100mg daily tolerated since day 10. Case 2: Male, aged 76, with recurrent episodes of urticaria after ASA, requiring an urgent stent for coronary artery disease. Total serum IgE 1337U/L. Ascaris lumbricoides ova and parasites in faeces. Toxocara and liver fluke ELISAs positive (1/3200 dilution). ASA desensitisation (modified protocol, Wong JT 2000) was ceased after urticaria occurred at a dose of 100mg. Albendazole 400mg/day was given for 3 days, ASA desensitisation protocol modified and now 100mg ASA is tolerated daily. Case 3: Male, aged 66, childhood asthma history, recurrent ASA-induced urticaria and recent myocardial infarction, needing ASA prophylaxis. Spirometry and nasal examination normal. Total serum IgE 570U/L. No parasites detected. Urticaria occurred at the first dose of 100mg during desensitisation. After protocol modification, 100mg daily was tolerated. Conclusion: ASA desensitisation has been successfully introduced in Vietnam in 3 aspirin sensitive patients requiring ASA for management of their coronary artery disease. Their clinical course demonstrates the importance of tailoring desensitisation regimens to both hypersensitivity type and tolerance to ASA during the progress of desensitisation and, possibly, the importance of prior parasite eradication as well.

P63 Successful intravenous Acyclovir desensitization in pediatric patient with HIV and cutaneous Herpes zoster reactivation Sandoval-Ramirez E.1, Diaz-Barba C.1, Del Rio-Navarro B.E.1, Rosas-Vargas M.A.1

1Hospital Infantil de Mexico ‘Federico Gomez’, Pediatric Allergy and Clinical Immunology, Mexico City, Mexico Aim: To describe a desensitization protocol to intravenous acyclovir in a pediatric patient who developed an adverse drug reaction (ADR), since Foscarnet and cidofovir are the known safe treatment alternatives, however these drugs are not commercially available in Mexico. Method: Hispanic seven year-old male with HIV B2 and herpes zoster reactivation presented with a maculopapular exanthema and angioedema after intravenous acyclovir administration. To desensitize our patient, we used a twelve steps protocol initially designed for female patients with cancer. We made three drug dilutions and administrated in incremental doses with 15 minutes intervals. Result: No adverse reactions occurred during the procedure, and the patient received the full antiviral course with no complications Conclusion: This methodology has emerged as a powerful tool for safely reintroducing medications that are beneficial for the management of patients with drug allergies in a clinical scenario where no other therapeutic alternative is available.

P64 Successful adalimumab desensitization after generalized Pruritic Rash Kartal O.1, Yesillik S.1, Demirel F.1, Gulec M.1, Baysan A.1, Tezel K.2, Sener O.1, Musabak U.1

1Gulhane Military Medical Academy and Medical School, Division of Immunology and Allergic Diseases, Ankara, Turkey, 2Gulhane Military Medical Academy and Medical School, Department of Physical Medicine and Rehabilitation, Ankara, Turkey Introduction: Biological agents have been seem to be more effective than classic immunosuppressive drugs, however the adverse events including the hypersensitivity reactions are the main drawbacks of these drugs. Here we describe a case of an immediate systemic hypersensitivity reaction to adalimumab with a positive skin test and subsequent successful desensitization. Case history: We report a 35-year old man, who was treated with adalimumab for ankylosing spondylitis, emerged a local reaction on the injection site, and generalized itching with rash at the 62th dose. One month after the reaction, skin prick test was performed with a commercial preparation of adalimummab (Humira, Abbott


ABSTRACTSLaboratories, USA). The skin prick test result was determined positive comparing to positive and negative controls. Because of insufficient responses to other drugs, adalimumab desensitization was performed and the whole process was completed without any reaction. Conclusion: Because there are few cases in the literature about adalimumab desensitization process, there is no standard desensitization protocol for the adalimumab allergy yet. Therefore, we suggest that our case report may contribute to the formation of a standardized desensitization protocol in adalimumab hypersensitivity.

P65 Safety of rapid desensitization in hypersensitivity reactions to chemotherapy agents: our experience after 111 treatments Rubio-Perez M.1, Casado Herraez A.2, Lucendo Abarca P.1, Robledo Echarren T.1, Rodriguez-Alvarez M.1, Cimarra Alvarez- Lowell M.1, Gonzalez Gutierrez M.L.1, Diaz Rubio E.2, Fernandez-Rivas M.1

1Hospital Clinico San Carlos, Allergy Department, Madrid, Spain, 2Hospital Clinico San Carlos, Oncology Department, Madrid, Spain Purpose: Hipersensitivity reactions (HSRs) to chemotherapy agents are increasing due to multiple exposure in cancer survivors. Drug desensitization is the induction of a temporary stateof tolerance to a compound responsible for a HSR. The need to offer first line therapy has lead to the development of rapid desensitization protocols to deliver the target medications and protect against anaphylaxis.The use of rapid desensitization protocols for cancer patients with HSRs to chemotherapy depends on their demonstrated tolerability and efficacy in selected populations, so the aim of this study is to prove the safety of the Brigham and Women Hospital (BWH) 12-step protocol in a Spanish population. Matherial and methods: 25 patients (mean age 59.4 years), with cancer of different origin as ovarian (80%), cervix (8%), endometrial (4%) or cancer of unknown primary origin (8%) with HRS to platins (84%), taxenes (12%) and doxorubicin (8%) were desensitized with the BWH protocol. In addition to premedication prescribed by oncologists (corticosteroids, anti-H1 and anti H2) we added Acetylsalicylic acid (300 mg) and Montelukast (10 mg) to protect from cutaneous and respiratory reactions. Results: 100 rapid desensitizations (88 to platins, 19 to taxenes and 4 to doxorubicin) were performed and 96 % presented mild or no reactions. 85.7% of reactions ocurred at the last step of the protocol and were milder than the initial reactions. In subsequent infusions the protocol was modified and no reactions appeared. Full target dose was completed in 99% of the cases. Conclusions: In our experience, the BWH 12-step protocol is useful, safe and allows patients with HRS to continue on first line chemotherapy treatments and likely increased their survival. This protocol has been incorporated in our standard clinical practice with excellent results.

P66 How to test insulins? Waton J.1, Barbaud A.1

1University Hospital, Dermatology, Vandoeuvre les Nancy, France Introduction: The dilutions used during insulins intradermal tests are disparate from one publication to another. We thus try to determine them. Patients and method: A retrospective analysis of the tests carried out in case of suspicion of allergy to insulin was done. The patients had patch (P) and prick (p) tests with 14 different insulins (6 analog insulins : glargine, lispro, aspartate, detemir, glulisine, aspartate protamine, 3 not mixed insulin with intermediate action, 2 mixed insulin with intermediate action, 3 human recombinant insulin with rapid action ) pure and with their additives (protamine sulfate 1000U/ml, Glycérol 10% water out of P and 0,5mg/ml out of p, Zinc 2% water out of P and 0,1mg out of p, Nickel sulfate 5% water, Metacresol 1mg/ml, saccharomyces, Phenol 0.8mg/ml). The intradermal tests (I) were then carried out with insulins with 1/10ème (10 UI/ml) and pure (100UI/ml) like with the additives (Protamine 100U/ml, Protamine 1000U/ml, Zinc 0.1mg/ml, Metacresol 1mg/ml, Phenol 0.8mg/ml) by the injection of 0.03ml on the external face of the arm. Positive test was the doubling of the papule of injection at 20 minutes and appearance of erythematous papule at 1 day (criteria of European Society off Dermatitis Contact). Results: 8 patients (7 localised reactions of type I and 1 urticaria generalized with angioedème) had tests. 19 P and 23 p tests with the additives were all negative (-). On 10 I with the additives, only 1 with the protamine was positive (+), non relevant clinically. The 39 P and 41 p with insulins were -. 9/43 I with 10UI/ml and 17/33 with 100UI/ml were +.


ABSTRACTSDiscussion: No P was + what is usual in type I reactions. The p do not have a good sensitivity because all were -. In fact for 5 patients all I were - in reading at 20 minutes and 1day (21 with the 1/10ème and 15 pure). I with insulin pure thus do not seem irritating. On the other hand among 3 patients 9/23 I with the concentration 1/10ème were + (2 /23 in reading immediate and 7/23 in delayed reading) and 17/18 I with pure insulin (5 to 20 min and 12 to 24h). Conclusion: Without I pure nor late readings, 19 sensitizations with insulins would not have been diagnosed. With our technique of realization of I and our criterion of reading, I with pure insulin are not irritating and the delayed reading is essential.

P67 First year experience in drug hypersensitivity testing Sedlackova L.1, Cap P.1

1Hospital Na Homolce, Prague, Czech Republic Purpose: The aim of this study was to analyse preliminary data from our first year experience with drug hypersensitivity testing. It is not frequently used in daily practice because it is a time consuming activity and it carries the risk of complications for patients. However, for future management it is very useful to distinguish real drug allergy from other adverse events. Materials and methods: During the reported period we examined 1 patient with immediate systemic reaction after penicillin injection (skin and challenge test), 1 patient with immediate skin reaction after oral methylprednisolone (skin and challenge test) and a group of 5 patients with either delayed maculo-papular exanthema or a not well described reaction in the past after beta-lactam (skin tests). The first step was to take a detailed individual history. Then we carried out laboratory tests (specific IgE and basophil activation test). The third step, when laboratory results were negative, was skin testing. Prick and intradermal tests were performed with standardised Penicillin allergenic determinants (Diater) and/or diluted native drugs. The oral challenge tests were performed with penicillin (Ospen) and methylprednisolone (Medrol). Results: The skin and challenge tests were performed in an outpatient setting. No complications were recorded. In both patients with immediate reaction allergy to penicillin or methylprednisolone respectively was ruled out by laboratory, skin and challenge tests. In the group of patients with a less definite history or delayed exanthema to beta-lactam all laboratory and skin tests were also negative. This means at least that severe immediate reaction (e.g. anaphylaxis) is very unlikely now and beta-lactam treatment would be possible if needed. Conclusions: We rule out allergy to penicillin and methylprednisolone respectively in 2 patients by complex diagnostics including challenge tests. We have confirmed by laboratory and skin tests that at least severe immediate reaction to beta-lactam was very unlikely in all patients. Despite the low number of tested subjects these tests can be very useful for individuals where the use of beta-lactam would be necessery in the case of in life-threatening infections.

P68 Diagnosis and cross-reactivity patterns in delayed type hypersensitivty reactions to parenteral anticoagulants Syre K.1, Wöhrl S.1, Stingl G.1, Jensen-Jarolim E.2,3, Kinaciyan T.1

1Medical University of Vienna, Div. of Immunology, Allergy & Infect. Diseases, DIAID, Department of Dermatology, Vienna, Austria, 2University of Veterinary Medicine Vienna, Medical University of Vienna and the University of Vienna, Messerli Research Institute, Vienna, Austria, 3Medical University of Vienna, Department of Pathophysiology and Allergy Research, Vienna, Austria Background: Heparins, low molecular weight heparins (=LMWH), heparinoids and hirudin are frequently used anticoagualtives. Especially LMWH are known to often cause localized delayed type hypersensitivity reactions (DTHR) at the injection site and to frequently cross-react among each other. Methods: In this study, we retrospectively analysed data of 52 patients introduced to our outpatient clinic in the past 11 years for diagnostic evaluation of current or past hypersensitivty reactions after using LMWH. Data was evaluated regarding the culprit drug/s, type of reaction, age, gender, atopy and other risk factors. Further, the skin and provocation test results were reviewed for their clinical relevance and reliability. Results: Enoxaparin was the most common causative LMWH for localized DTHR, followed by Dalteparin. Intradermal tests with late reading were twice as much sensitive as patch testing and resulted positive in 41% for


ABSTRACTSEnoxaparin and 32% for Deltaparin. The most common cross-sensitivity pattern was between Enoxaparin and Dalteparin. Those two participated together at different patterns of cross-reactivity in 61,54%. In 34,62% each the following triple-combinations also appeared in different patterns of cross-reactivity: Enoxaparin, Dalteparin and Danaparoid and Enoxaparin, Dalteparin and Nadroparin. In 2 patients a cross-reactivity between 6 tested praparations were found, in 3 cases cross-reactivity extended over 5, in 9 over 4 in 5 over 3 and in another 5 cases over 2 LMWH. Monosensitivity was found only in 3 cases. 84,6% of the patients were women, there was a significant difference in gender regarding DTHR or cross-reactivity in LMWH. In men only in 25% a cross-reactivity against two or more LMWH has been detected whereas in women in 50%. No patients suffered from an atopic dermatitis, 38,5% showed another atopic disease or had an atopic predisposition, pregnancy may be a risk factor in 2 of our patients, in one of those an allergy could be excluded. Conclusions: Our data suggest that female gender, advanced age are not only risk factors for localized DTHR to LMWH but also for higher frequency and amount of cross-reactivity. Enoxaparin was the most common LMWH and cross-reacted most frequently with Deltaparin followed by Danaparoid, a heparinoid, that was used as an alternative earlier. The very extensive cross-reactivity in some patients makes it difficult to find an individual safe alternative.

P69 Retrospective review of skin testing and drug provocation test in the evaluation of beta-lactam allergy Chan G.Y.1, Chng H.H.1, Thong B.Y.1, Chia F.L.1, Tan J.1, Tan T.C.1, Tan S.C.1, Tang C.Y.1, Hou J.F.1, Leong K.P.1

1Tan Tock Seng Hospital, Rheumatology, Allergy and Immunology, Singapore, Singapore Purpose: The aim of this study is to describe the outcomes of skin testing and drug provocation test (DPT) in the assessment of patients suspected to have beta-lactam allergy. Materials and methods: A retrospective review of all consecutive skin testing results from 2006 to 2010 was performed on all patient referred to our department for evaluation of beta-lactam allergy. Results: A total of 77 patients (mean age 43.8 years; SD 16.5 years; 53% female) were enrolled.All the patients were assessed by allergists or allergists-in-training. Fourteen patients (18.2%) were found to have positive skin test. Most of the patients (89.1%) were tested with the major determinant benzylpenicilloyl (53 Diater® and 16 Prepen®) except when it was not available in 2006. Other skin test reagents are penicillin G, and the implicated beta-lactam. All patients tested with Prepen® were negative whereas 24.5% tested with Diater® were positive. Of the patients who tested positive, 12 had suspected penicillin and 2 cefazolin allergy. Positive skin test rates for history of anaphylaxis, angioedema, urticaria and non-specific rash were 45%, 21%, 20% and 18% respectively(p=0.24). All patients who reported maculopapular rash, erythema or itchiness tested negative. The frequency of positive skin test was lower in patients with longer interval between clinical reaction and skin testing (< 2 years: 24.3% vs >10 years: 19%, p=0.43). Positive skin test rate corresponded with the clinician’s assessment (probable: 31%, possible: 23.8%, indeterminate: 17.4%, unlikely: 0%, p=0.11). Drug provocation tests (DPT) were performed in all patients with negative skin tests. Six tested positive and 2 equivocal. The specificity of skin testing was 90.2% with exclusion of equivocal cases and 88.9% when the equivocal cases were considered as positive. Among patients with positive DPT, 2 patients developed urticaria during ceftriaxone DPT, 1 patient had maculopapular rash with cefazolin DPT, 1 patient developed erythema and itchiness during cloxacillin DPT, 1 patient developed maculopapular rash after 1 week of amoxicillin and 1 patient had serum sickness after 2 doses of augmentin. All reactions were mild. Conclusions: Specificity of skin test is 90.2%. Allergists´ pretest clinical assessments correlated with skin test outcomes. Skin testing and drug provocation tests are safe in the evaluation of beta-lactam allergy.

P70 Patch test with antiepileptics: Positivity and cross-sensitivity Tanno L.K.1,2, Dracoulakis M.2, Ensina L.3, Motta A.A.1, Wilson A.2, Mello J.F.2, Kalil J.1

1University of Sao Paulo, Allergy and Clinical Immunology, Sao Paulo, Brazil, 2Hospital Servidor Público Estadual of Sao Paulo, Allergy and Clinical Immunology, Sao Paulo, Brazil, 3UNIFESP, Rheumatology, Sao Paulo, BrazilPurpose: Antiepileptics drugs are used worldwide and have been related to non- immediate hypersensitivity reactions (NIHR), some of that, life-threatening. Our aim was to analyze drug patch test (PT) as an in vivo complementary method of investigation to assess the culpability of antiepileptics in NIHR, as well as evaluate the cross-sensitivity among aromatic antiepileptics. Methods: A prospective study was developed in Allergy Clinics of two Services in São Paulo, Brazil, from March 2009 to December 2011. The patients were studied based on history of NIHR to antiepileptics using an adapted


ABSTRACTSENDA (European Network of Drug Allergy) questionnaire. PTs were performed with the culprit drug and with structure-related aromatic antiepileptics at least 6 weeks after recovery. The tests were evaluated in 48 and 72h according to the European Environmental Contact Dermatitis Research Group. The concentrations and dilutions were those suggested by literature. Results: We performed 39 PT, all with antiepileptics with aromatic ring. Sixteen patients had history of Drug Hypersensitivity Syndrome (HSS), 16 of Stevens-Jonhson Syndrome (SJS), 3 of maculo-papular exanthema (MPE), 2 of macular exanthema and 2 of multiform erithema. The mean age of the studied population was 46 years, 27 (69%) were women. Eleven patients reported the intake of more than one drug at the same time of the reaction. Of all PT, 22 (56,4%) were positive, 11/16 (69%) in HSS, 9/16 (56,3%) in SJS. Six (27%) patients presented cross-sensistivity, in both HSS and SJS. No adverse reactions were observed during the tests and none of the 10 healthy controls had positive reaction to tested agents. Conclusion: PT with antiepileptics may be an useful and safe diagnostic method in assessing the drug involved in NIHR, particularly in severe cutaneous adverse reactions. Tests with structure-related aromatic antiepileptics can provide us data about cross-sensitivity among this drugs but more studies are needed in this field.

P71 Is there an economic impact on the number of provocation tests performed in dermatological university departments in Germany? Treudler R.1, Simon J.C.1

1Universität Leipzig, Klinik für Dermatologie, Venerologie und Allergologie, Leipzig, Germany Background: According to several position papers, provocation tests are the gold standard in drug allergies as well as in food or insect allergy. In Germany, Diagnosis related groups (DRG) have been introduced in 2003. We aimed at investigating a possible impact of the DRG system on patient-centered allergological care, namely on provocation tests, in Germany. Methods: DRG classification was recorded for the diagnostic skin- and sensitization testing (ICD Z01.5) over the years since 2003. Benchmarking was performed by comparing quality records of 35 Germany University Medical Centres for Dermatology for 2008 and 2010. We recorded total number of patients as well as position order and (when given) number of patients who were treated under the diagnosis of Z01.5. Results: DRG: Since 2003, the diagnosis Z01.5 correlated to a case weight (CW) between 0,211 and 0,449. In 2012, it is assigned to the DRG Z64C with a CW of 0,381 (decreasing tendency).Benchmarking: 33/35 hospitals gave full data for both years including the ten most frequent diagnoses under which patients were treated, for 2008 data were available for 34/35 hospitals. Between 2008 and 2010, total number of patients treated increased in 23/33 (70%) hospitals. Exact number of patients treated were only available for the top ten diagnoses. In 2008, the Z01.5 was on the top of the list in 30/34 (88%; patient numbers between 26 and 559) hospitals, in 2010 in 25/33 (76%, patient numbers between 26 and 250). Data did not allow to differentiate, which type of allergen was tested. Only in 11/24 (46%) hospitals with available data for both years, patient numbers with diagnosis of Z01.5 increased. Overall, position order of diagnosis Z01.5 decreased in 15/33 (45%) with position order data for both years, it seemed to be stable in 9/33 (23%; in n=3 position order >10, thus also decrease/increase possible but no exact data) and increased in 8/30 (24%). In 2010, in 8/33 (24%) hospitals - compared to only 4/34 (12%) in 2008 - ten diagnoses were treated more frequently than the diagnosis Z01.5. Conclusion: Along with a decreasing case weight, data from quality records seem to point out a tendency for decreasing numbers of provocation tests being performed in dermatological university departments in Germany. As numbers of patients suffering from allergies rather increase, one may speculate about any economic impact

P72 Investigation of Penicillin allergy using skin testing and oral challenge at Auckland City Hospital, New Zealand Fitzharris P.1, Verryt C.2, Jordan A.1, The R.3, Thompson J.2

1Auckland City Hospital, Immunology, Auckland, New Zealand, 2University of Auckland, Auckland, New Zealand, 3LabPlus, Auckland, New Zealand Aim: Our previous audit (2007/8) confirmed PPL and MDM reagents as valuable in penicillin skin testing, but identified concerns of systemic reactions to skin testing and low completion rate of oral challenge after negative skin tests. New protocols were initiated in April 2009 and their use and effectiveness has been retrospectively


ABSTRACTSaudited here. Predictors of positive skin test and challenge were also sought. Method: The records of all adult immunology patients undergoing penicillin skin testing at Auckland Hospital from April 2009 to July 2011 were examined and relevant history, skin test and challenge results recorded. Skin testing with benzylpenicillin, major(PPL) and minor(MDM) determinants (Diater), amoxicillin, Augmentin and/or flucloxacillin was undertaken using either a three or five-step protocol, both including prick and intradermal steps, dependant on physician-assessed risk of systemic reaction. If skin tests were negative an appointment was made for subsequent incremental oral challenge with the suspected penicillin. Result: The mean age of the 231 patients was 45y (15-95y), 72% female. Immediate positive skin tests (STpos) occurred in 16(6.9%); 3 to MDM and/or PPL only; 4 to amoxicillin/Augmentin only, with 5 positive only to flucloxacillin. Skin tests were positive in 27.8% of those with a history of anaphylaxis compared with 3.1% of those without (p< .0001,ChiSq). Also significant were reaction recency of < 1year 13.7% v >1y 4.0% (p< 0.027) and immediacy of reaction after dosing < 1 hour 15.4% v > 1 h 4.5% (p< 0.013). Logistic regression identified a history of prior anaphylaxis to a penicillin as the dominant predictor of positive skin tests. The 5-step protocol had been chosen for 50% of STpos and 26% of STneg patients. No patient experienced anaphylaxis related to skin testing; two had mild reactions. Thirteen of 132 (9.8%) skin test negative (STneg) patients gave positive responses to incremental oral challenge, 12 of these to amoxicillin/Augmentin, with 2 patients requiring treatment with adrenaline for challenge-induced anaphylaxis. No significant predictors of positive challenge response were identified from the clinical history. Conclusion: Immediate positive skin tests occurred in only 6.9% of all referred patients. Oral challenge was positive in 9.8% of the 132 STneg patients. Challenge is thus an essential part of the investigation process. It remains difficult to assess risk and allergy status based on clinical history alone.

P73 Intradermal tests for diagnosis of drug allergy are not affected by the use of a topical anaesthetic patch Couto M.1,2, Silva D.1, Ferreira A.1, Botelho C.3, Castro E.1,3, Cernadas J.R.1,3

1Centro Hospitalar São João, EPE, Serviço de Imunoalergologia, Porto, Portugal, 2Faculty of Medicine, University of Porto, Immunology Department, Porto, Portugal, 3Hospital Privado Boavista, Unidade de Imunoalergologia, Porto, PortugalPurpose: The use of a topical anaesthetic cream containing prilocaine and lidocaine has proven to significantly reduce pain associated with diagnostic allergy skin tests. However, its utilization in intradermal tests (IDT) for drug allergy diagnosis was never investigated. We aimed to determine the effects of a topical anaesthetic patch containing prilocaine and lidocaine on wheal response to IDT injection of drugs. Methods: Patients who performed IDT as part of their investigation process of suspected drug hypersensitivity were selected. IDT were performed according to EAACI’s guidelines. Anesthetic patch was placed according to manufacturer’s recommendations on the volar surface of the forearm, and the same prior positive IDT, as well as positive (histamine SPT) and negative (saline IDT) controls, were performed in the anesthetized area. Eight patients with negative IDT with drugs were also included to explore the possible occurrence of false positives. D+d/2 mm of initial and final wheals were measured; size´s increase after 20minutes both with and without the patch was recorded and compared using t-student or Wilcoxon tests (p< 0.05). Results: 47 IDT were performed in 38 patients (29 females, mean age 46±18 y), with 27 different drugs (20 antibiotics, 10 general anaesthetics, 6 non-steroidal anti-inflammatory, 3 iodinated contrasts, 3 anti-histamines, 2 local anaesthetics, 1 antitubercular agent, 1 vitamin and 1 with ranitidine). Mean histamine SPT size without the anaesthetic patch was 4.9mm (SD 0.9), and 4.7mm (SD 0.9) with the anaesthetic patch. Mean wheal increase in IDT for drugs without the anaesthetic patch was 4.8mm (SD 2.9) and with the anaesthetic patch was 4.8mm (SD 3.4). No statistical significant differences were observed between skin tests with or without the anaesthetic patch for: histamine SPT (p=0.103), IDT with saline (p=0.796), and IDT with drugs (p=0.933). None of the patients with negative IDT showed positivity with the anaesthetic patch. Conclusions: This is the first study using the topical anaesthetic patch containing prilocaine and lidocaine in drug allergy IDT. We show that it does not interfere with IDT to diagnose drug allergy, and no false positive tests were found. It is therefore suitable for implementation and will improve comfort of patients. It enables to perform this diagnostic procedure in young children in the work up diagnosis of drug allergy. The use of a patch allows better standardization than the cream.


ABSTRACTSP75 Patch testing and cross-sensitivity study of antiepileptic-induced cutaneous adverse reactions Lin Y.-T.1, Chang Y.-C.1, Chung W.-H.1, RegiSCAR, Asian SCAR1Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China Purpose: To evaluate the usefulness of patch tests for patients with carbamazepine- (CBZ) and phenytoin (PHT)-induced cutaneous adverse drug reactions (cADR) and the cross-reactivity in patch tests among the aromatic antiepileptic drugs. Methods: We measured the frequency of positive patch test reactions and cross-sensitivity to structure-related aromatic anti-epileptic drugs (AEDs) for patients after Stevens-Johnson syndrome (SJS) ⁄ toxic epidermal necrolysis (TEN) or drug reaction with eosinophilia and systemic symptoms (DRESS) episodes caused by CBZ or PHT. CBZ, PHT and other structure-related AEDs used for patch testing were prepared in 10% and 30% petrolatum. Secondary measures included the association of HLA-B genotyping and frequency of possible side effects from the patch tests. Results: Positive patch test reactions to CBZ in 30% petrolatum in patients with CBZ-induced SJS ⁄ TEN were seen in 62.5% (10 ⁄ 16), in 70% (7 ⁄ 10) of patients with CBZ-induced DRESS and 85.7% (6/7) in patients with PHT-induced cADR ( including 1 DRESS, 2 SJS, 4 MPE) . None of the 10 healthy controls displayed a positive reaction to tested agents. Cross-reactivity to other aromatic AEDs was observed in both, patients with CBZ- and PHT-induced SJS ⁄ TEN and in patients with CBZ- and PHT-induced DRESS. Conclusions: Drug patch testing is a safe and may help to identify CBZ or PHT as the culprit drug of SJS ⁄ TEN as well as DRESS/ MPE. Testing of chemically or pharmacologically related AEDs may provide information on cross-reactivity for these patients.

P76 Multicenter prospective study in order to standardize European intradermal drug tests (ENDA group) Weinborn M.1, Kvedariene V.2, Testi S.3, Gomes E.4, Brockow K.5, Ponvert C.6, Bavbek S.7, Aberer W.8, Garvey L.H.9, Barbaud A.1

1University Hospital of Nancy,P. Canton Building of Medical Specialties, Department of Dermatology, Vandoeuvre les Nancy, France, 2Vilnius University Hospital Santariskiu klinikos, Vilnius, Lithuania, 3Azienda Sanitaria di Firenze, Allergy and Clinical Immunology Unit, Florence, Italy, 4Hospital Maria Pia, Allergy and Clinical Immunology Unit, Porto, Portugal, 5Technische Universität München, Department of Dermatology and Allergy Biederstein, München, Germany, 6Necker Hospital Paris, Department of Pneumology and Paediatric Allergology, Paris, France, 7School of Medicine Ankara, Department of Allergy, Ankara, Turkey, 8University of Graz, Department of Dermatology, Graz, Austria, 9Copenhagen University Hospital, Danish Anaesthesia Allergy Centre, Copenhagen, Denmark Introduction: A previous study demonstrated that each centre has its own method in performing and reading the results of intradermal tests (IDT). Therefore in order to compare the results and thresholds of specificity it is absolutely necessary to standardize the method. Considering our previous results we have demonstrated that injecting 0.03 mL induces a too large wheal (mean diameter of the Pi from 318 IDT was 4.8 mm), therefore we have decided to determine the mean injection wheal or papule (Pi) in administering 0.02 mL. Objectives: From a European multicenter study of the ENDA group, in order to standardize the methods used to perform IDT drug by determining the mean diameter of Pi with 0.9% saline (S) or amoxicillin at 20 mg/ml and to compare the diameter of Pi according to the injection sites. Materials and methods: 3 steps were done in a multicenter study. First step: each centre did IDT with S according to their usual practice, in injecting what they supposed to be 0.02 ml, 2nd step, during a training meeting and after measuring the real injected volume in using different methods to fill the seringue a standardized methode was defined ; 3rd step with the standardized method the diameter of the Pi was measured in injecting 0.02 mL of 0.9% saline (S) or amoxicillin at 20 mg/ml on the forearm (F), the arm (A) or the back (B). The results were analyzed according to the injection site and the centre. Results: 1st step: after injecting what they supposed to be 0.02 ml, the mean diameter of Pi was 3.9 mm. With the 2nd step, the standardized method was proposed as follows: with a tuberculin syringe of 1 mL contents, with a needle having a gauge of 0.50 mm X 16 mm, just take 0.02 mL, in putting the top first ring of the piston on the 0.02 mL graduation, then to inject the whole volume contained in the syringe and needle with the hole of the needle at the top. 3rd step: with this method, the mean diameter of Pi in injecting 0.02 ml, obtained from 242


ABSTRACTSIDT with S was 4.9 mm. There was no difference according to the injection site as the mean diameter of the Pi was 4.8 mm on the A, 5 mm on the F and 4.9 mm on the B (p=0.1415). With 73 IDT with amoxicillin the mean diameter of the Pi was 4.8 mms. Conclusion: We reports the first results of a standardized method used for IDT that seems reproducible and will permit in the future to really compare results from one centre to another and published data on drug IDT.

P77 A Prospective Study: the negative predictive value of skin testing for cephalosporins Jo E.J.1, Yang M.S.2, Kim M.Y.2, Lee S.E.1, Lee S.Y.2, Kwon J.W.3, Song W.J.2, Kim S.H.1, Cho S.H.2, Min K.U.2, Chang Y.S.1

1Seoul National University Bundang Hospital, Internal Medicine, Seongnam-si, Korea, Republic of, 2Seoul National University College of Medicine, Internal Medicine, Seoul, Korea, Republic of, 3Kangwon National University Hospital, Internal Medicine, Chuncheon-Si, Korea, Republic of Purpose: To evaluate the negative predictive value of intradermal skin testing with cephalosporin antibiotics using electronic medical recording (EMR) system Material and methods: All patients who admitted to Seoul National University Bundang Hospital from October 1st 2011 and planned to use cephalosporin antibiotics via parenteral route underwent intradermal skin testing with cephalosporin. The antibiotics included for intradermal skin testing in this study were cefazolin, cefoxitin, cefotetan, cefuroxime, cefotaxime, ceftazidime, ceftriaxone, ceftizoxime, cefepime. The results of intradermal skin testing were reported in nursing chart of EMR system which automatically produced ‘a signal’ to enable to collect the data. Additionally, we made a automatic consultation system which was activated when the patients had past medical history of any kind of drug adverse reaction, when the results of intradermal skin testing were positive or when the patients actually had drug adverse reaction. Results: Total of 8095 who underwent intradermal skin testing with cephalosporin antibiotics were enrolled so far. Male were 3837 (47.4%). Mean age was 50 (±22) years old. Among them 139 patients showed positive intradermal test results to cephalosporin antibiotics (1.7%). Cefazolin was the most frequently prescribed cephalosporin (5447 cases, 67.3%) followed by ceftriaxone (764, 9.4%), cefotaxime (667, 8.2%) and cefotetan (647, 8.0%). Negative predictive value of IDT for cefotaxime was 99.85% (95% confidential interval 99.55%-100%) till now. Conclusion: This is the first prospective study for the evaluation of the negative predictive value of skin testing in cephalosporins.

P78 Hypersensitivity reactions to proton pump inhibitors - First step in diagnosis Silva D.1, Castro E.1, Cernadas J.R.1

1Serviço de Imunoalergologia Hospital São João, Porto, Portugal Purpose: Proton pump inhibitors (PPI) are widely used in clinical practice for treatment of acid-peptic diseases and gastric symptoms prevention. Despite being well tolerated, case reports of hypersensitivity reactions and cross-reactivity between PPI exist. The aim of this study was to describe a group of patients with suspicion of hypersensitivity reactions to PPI and evaluate cross reactivity in skin prick test (SPT) and intradermal tests (IDT). Methods: Patients referred to the drug allergy unit in the last 4 years were selected. To evaluate cross-reactivity, SPT were performed with all commercially available endovenous PPI formulations (omeprazol 4mg/ml, esomeprazol 20mg/ml, pantoprazol 4mg/ml) and crushed tablets in saline (lanzoprazole 15mg/ml, rabeprazol 10mg/ml). IDT were also done with omeprazol 4mg/ml, esomeprazol 20mg/ml and pantoprazol 4mg/ml (dilutions from 1/1000 to 1/1). Due to safety and accuracy issues, IDT were not performed with tablet formulations. Results: The authors describe a series of 8 patients (4 female, mean age 55 years) with hypersensitivity reactions to PPI. PPI were needed for stomach ache, gastric protection or helicobacter pylori eradication. Four patients had symptoms while taking omeprazol (2 anaphylaxis and 2 urticaria), 2 to esomeprazol (urticaria), 1 to lanzoprazol (anaphylaxis) and 1 to lanzoprazol and omeprazol (urticaria). Time until reaction varied between 3min to 24h. One patient had an accidental exposure to oral esomeprazol with reproducible urticaria reaction. Three patients with urticaria and 1 with anaphylaxis had positive IDT only to omeprazol(IDT 1/1). Three patients showed cutaneous cross reactivity: 1 with urticaria had positive IDT(1/10 dilutions) with esomeprazol and omeprazol; 1 with anaphylactic reaction had positive tests to esomeprazol (IDT 1/10) and omeprazol (IDT 1/1000) and the third


ABSTRACTSwith anaphylaxis had positive tests for esomeprazol (SPT), omeprazol(IDT 1/100) and pantoprazol (IDT 1/100). Two non atopic controls performed IDT for the highest omeprazol concentration (1/1) without reaction. Conclusions: Hypersentivity to omeprazol was most frequently reported, probably due to its more widespread use. Cross reactivity was seen in 3 patients which could be possibly explained by the chemical structure similarity of PPI. More studies are needed with standardized skin diagnostic tests with all PPI, supported by oral challenges to increase diagnostic accuracy and cross reactivity knowledge.

P79 Oral drug provocation tests in children and adolescents with suspected betalactam hypersensitivity - a systematic review Hengst M.1, Lange L.2, Ott H.1, Task Force on Drug Allergy of the German Society of Paediatric Allergology1Cath. Children’s Hospital, Dpt. of Paediatric Dermatology and Allergology, Hamburg, Germany, 2St.-Marien-Hospital, Dpt. of Paediatrics, Bonn, Germany Purpose: To provide a comprehensive overview of published studies on oral drug provocation tests (DPT) in children and adolescents with suspected betalactam hypersensitivity and to compare the respective test protocols. Materials and methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE, EMBASE and the Cochrane controlled trials register until January 2012 and bibliographies of previous review articles. Relevant publications were identified independently by two reviewers screening titles, abstracts and finally full text articles. Results: Of the 979 identified studies 20 were eligible and mainly consisted of retrospective analyses, whereas no randomized controlled trials could be retrieved. The evaluated publications included a highly variable number of patients (n = 39 to 1865) recruited in distinct clinical settings (emergency department, allergy clinic, private practice) and subjected to different sets of pre-DPT in vitro and in vivo diagnostic procedures. DPT protocols proved to be markedly heterogeneous with regard to DPT setting, administration route, culprit drugs, incremental test doses, application intervals and total duration of drug challenge. Accordingly, positivity rates ranged from 0 to 13 % largely depending on whether patients with previously positive skin and/or in vitro test results had been excluded from oral challenges. Conclusions: The current study suggests that evidence-based recommendations for the performance of DPT in children and adolescents cannot be deduced from currently available data. Hence, thoughtfully designed, prospective, controlled trials are urgently needed to provide allergologists with a reliable diagnostic tool for definitive drug allergy workup in paediatric patients.

P81 Outcomes of drug provocation tests: three-year retrospective analysis Chatzipetrou A.1, Tsilochristou O.1, Kogkas S.1, Chytiroglou E.1, Koulias C.1, Aggelides X.1, Chliva C.1, Makris M.1

1University General Hospital Attikon, Drug allergy Unit 2nd Dpt of Dermatology and Venereology, Athens, Greece Aim: Drug Provocation Tests (DPTs) are considered the gold standard for the diagnosis of Drug Hypersensitivity Reactions (HRs). The aim of this study was to present our experience in DPTs on a population with well-documented HRs. Method: Six hundred ninety-one patients (M: 199, F: 492, mean age 45) with adverse drug reactions that referred to Drug Allergy Outpatient Clinic between 2009 and 2011 were retrospectively evaluated. Specific drug allergy medical history, skin, intradermal and/or patch testing as well as laboratory exams were performed where needed, in all patients. DPTs were not performed in the culprit drug in case of severe anaphylaxis and or positive testing. Three hundred seven single blind, placebo-controlled DPTs were carried out in 232 patients according to the European Network for Drug Allergy recommendations with b-lactams, non-steroidal anti-inflammatory drugs, local anesthetics, as well as with other drugs. The DPTs according to drug class and the clinical outcomes were analyzed. HRs to chemotherapeutics, monoclonal abs and radiocontrast media were excluded from study analysis. Result: Three hundred seven DPTs were performed with: b-lactams (n=143), aspirin (n=23), COX-2 inhibitors (n = 55), acetaminophen (n=12), local anesthetics (n = 28), quinolones (n=9), macrolides (n=21) or other drugs (n=16). One hundred twenty nine DPTs were carried out to the culprit drug and 178 DPTs to alternative for safety reasons. We registered 13 positive reactions (11/129, 8,5% to culprit drug): b-lactams (3/143), COX-2 inhibitors


ABSTRACTS(2/55), acetaminophen (3/12), local anesthetics (1/28) quinolones (1/9), macrolides (1/21), PPIs (1/6), and ranitidine (1/3). Two severe reactions were observed: anaphylaxis to lidocaine on a patient affected by systemic mastocytosis and acute bronchospasm to celecoxib in a patient with AERD; both reactions were managed without complications. Fourteen patients (4,6%) reacted to the placebo before administration of the drug. Thirty-two patients reported non-specific symptoms. Conclusion: DPTs, in a well-selected population, even to culprit drug, are safe for use in clinical practice but they should be placebo-controlled and should be performed in a hospital setting of an allergy unit. Special attention should be reserved to patients with underlying disease.

P82 Safety and outcomes of drug allergy testing Makatsori M.1, Scadding G.1, Cappella A.1, Durham S.R.1

1Royal Brompton Hospital, Allergy, London, United Kingdom Background: Identification of the responsible medication in possible drug-hypersensitivity reactions is important in order to advise patients about the need for future avoidance and identification of safe alternatives. Methods: We carried out a retrospective review of 206 consecutive adults who attended our Day Unit for drug allergy testing during the period of January 2010 to January 2012. All patients were initially assessed in clinic and a detailed history of the suspected hypersensitivity reaction(s) was taken. Demographics, skin-prick and intra-dermal test and provocation test outcomes were analysed. Results: 388 different drugs were skin tested and 192 provocation tests were performed including oral, intravenous, subcutaneous and inhalation challenges. 75.7% of patients were female. Patients’ ages ranged from 16-80 years with a mean of 49±16 years. The majority of patients (55.8%) were tested for reactions to antibiotics (n=115), in particular beta-lactams (n=104). The rest were tested to local anaesthetics (n=25), general anaesthetics (n=13), non-steroidal anti-inflammatory drugs (n=9), vaccines (n=12), COX-2 inhibitors (n=10), other analgesics (n=11), corticosteroids (n=6), chlorhexidine (n=8), gelofusine (n=4) and others (n=15). 11.1% of the drugs tested were positive on skin prick testing (n=11), intra-dermal (n=17) or provocation testing (n=15). The reactions included anaphylaxis (n=1), urticaria and angio-oedema (n=4), asthma exacerbation (n=2), and delayed rash (n=1). The remaining patients had a variety of other symptoms (n=7). Of note, two patients developed systemic reactions following intradermal skin testing. Conclusion: The majority of patients referred for investigation of suspected drug allergy prove negative on sequential skin and provocation testing, meaning they may use the drug again in future. We test a greater number of female than male patients for suspected drug allergy. Whether this may be explained simply by greater medication use, particularly of antibiotics, is unclear. Provocation testing is needed to conclusively exclude allergy, as some patients with negative skin tests will react to drug challenge, including severe reactions. Both drug allergy skin testing and provocation testing carry a small but non-negligible risk of adverse events, such that testing should only be performed in specialised allergy centres.

P83 Allergy to drugs in children Pichkhadze G.M.1, Kosherbekov E.1, Davletgildeeva Z.1, Stabaeva E.M.1, Akanova A.1

1Kazakh National Medical University named after S. Asfendiyarov, Pharmacology, Almaty, Kazakhstan Aim: The aim of our investigation was to study a frequency, an etiology and a pattern of clinical presentations of allergy to drugs (DA) in children. Methods: A retrospective analysis of 195 medical reports of DA experiencing children and treated at the allergic department was carried out (16,5% of total cases).The majority of DA (57%) happened to very young children. Results and discussion: The comparative statistics of DA from Jan. to Dec. 2007 showed that most of cases appeared in Jan. and March-12,8% and 10,8% resp. This might be explained by high sickness rate and/or by lowering host defenses. DA associated with viral infections and bronchitis-44%, pneumonia-10%. The main disease course was not severe but all children received 1- 3 courses of antibiotic therapy mainly per orally in the form of penicillin syrups and cephalosporin’s, 4-6 drugs were taken additionally. Antibacterials were leaders in drugs causing DA-42%:antibiotics of penicillin family 35,4%, cephalosporin’s 15,9%,others 48,8%. Temperature lowering drugs accounted for 20%; vitamins 19 %: ascorbic acid-29,3%. 10,3% of DA to mucolytics, 5,1 % to


ABSTRACTSsulfonamides, to others in 3,6 %. Clinical presentations of DA were various: shallowly edematous, small/large spotted exanthema-57%, urticaria-18%, Quincke’s edema-15,6%. 38% of DA cases were associated with high temperature (up to 39º) on the second day of the treatment. The state of health of the children experienced DA was averagely severe 91,8%, 8,2% had severe forms and complications such as toxic dermatitis; 1 child suffered from Stevens- Johnson’s Syndrome after chloramphenicol parenteral injections; no lethal cases were detected. The health state improved after the therapy cancellation followed by disappearance of symptoms in 2-5 days. The main therapy included cancellation of drugs intake, intake of sensitivity lowering medicines (2 at least) and in most severe cases use of prednisolone or dexamethazone. In cases of antibiotics requirement less allergenic antibiotics were applied. The diet was also hypoallergenic especially if food allergy/atopical dermatitis had taken place. Conclusions: 1. The frequency of DA children hospitalized to the allergy department was 16,5%. 2. Predominantly only very young children experienced DA especially in wintery-spring season (57%). 3. DA etiology mainly accounted for by antibiotics-42%, followed by temperature lowering means -20% and vitamins-19%. 4. DA was associated with complications in 8,2% cases.

P84 Hypersensitivity reactions to systemically administered corticosteroids Salas M.1, Doña I.1, Torres M.J.1, Gómez F.1, Ruiz M.D.1, Campos G.1, Blanca M.1

1Carlos Haya Hospital, Allergy Department, Málaga, Spain Background: Corticosteroids are widely used and sensitization to these compounds can occur. Allergic reactions to systemically administered corticosteroids seem to be infrequent considering their extensive use, being most reactions described after topical administration. Objective: The aim of this study was to describe the clinical characteristics and the methods used for diagnosis in a group of patients attended our allergy department because of development of reactions after systemically administration of corticosteroids. Methods: All patients with a clinical history of hypersensitivity reaction to corticosteroid attending our department between 2005 and 2010 were evaluated. The diagnosis was performed by skin testing, basophil activation test (BAT) and drug provocation test (DPT) when indicated. Results: A total of 183 patients attended our department because of adverse reaction to corticosteroids in a 6 years period. After the allergological work-up 27 (14,75%) cases were confirmed as allergic to these drugs. A total of 24 (88,88%) were female with a mean age of 53,5±19,36 (21-77) years. Two patients had also intolerance to different NSAIDs and 4 were atopic. In 37,5% of cases the corticosteroid involved could not be identified, 18,8% was betamethasone, 18,8% dexamethasone, 15,6% metilprednisolone, 3,1% deflazacort, 3,1% prednisone and 3,1% triamcinolone. In 65,63% reactions occurred more than 1 hour after corticosteroid administration. The most frequent clinical manifestations were facial erythema (37,5%) followed by generalized urticaria (21,87%), anaphylaxis (15,62%), facial angioedema (9,37%), facial erythema with dyspnea (6,25%), generalized erythema (6,25%) and generalized angioedema (3,12%). Regarding diagnosis, in those with immediate reactions 1 subject was diagnosed by BAT, 3 by skin tests and BAT and 5 by DPT; and in those with non-immediate reactions, all of them were diagnosed by DPT. A total of 19 cases (70,37%) had cross reactivity to a different corticosteroid in DPT. Conclusion: Most of allergic reactions due to systemically administered corticosteroids appears more than 1 hour after drug administration being facial erythema the most frequent clinical manifestation. DPT is necessary to achieve the diagnosis in most of cases, especially in non-immediate reactions, with a high degree of cross-reactivity.

P85 Profile of skin prick test and challenge test in lung tuberculosis patients allergic to anti tuberculosis drugs at Allergy Immunology Polyclinic of Prof. Dr.r.d. Kandou Hospital Manado from January - December 2011 Surachmanto E.E.1

1Sam Ratulangi University, Internal Medicine, Manado, Indonesia Background: Increased prevalence of drug allergy required more appropriate and practical of diagnotic tests. Tuberculosis is one of infection diseases causing morbidity and mortality in the world. Currently, Fix Drug


ABSTRACTSCombination (FDC) is used to treat tuberculosis. There are several cases of allergic to FDC, therefore prompt and appropriate strategy is needed to determine drugs that caused allergy. Previously, there were only few reports of skin prick test (SPT) of non-standardized drugs, and it could be used to prove type-I reaction. Objective: Non-standardized skin prick test early and late phase reaction could demonstrate type-1 reaction that played a role in majority of drug allergy patients. Methods: This was an observational-retropective study in patient with history of drug allergy to FDC at polyclinic Allergy-Immunology Prof.Dr.R.D.Kandou Manado, January-December 2011. Skin prick test was performed in all patients based on modified Peppy’s procedure (1mg/ml aquous solution), interpreted in early and late phase, continued with challenge test to anti tuberculosisi drugs. Results: There were 15 patients allergic to FDC, 9 males (60 %) and 6 females (40 %). There were 4 patients allergic to rifampisin(R) (26,7%), 2 patients allergic to isoniazid(H) (13,3 %), 2 patients allergic to rifampisin, isoniazid, pirazynamid(Z) (13,3%), allergic to ethambutol; pirazynamid; rifampisin and pirazynamid; rifampisin and ethambutol; isoniazid and pirazinamid; rifampisin,isoniazid and pirazynamid 1 patient respectively (6,7%), One patient allergic with FDC but negatif respons to RHEZ both by SPT or challenge test (6,7%). There were 7 patients performed skin prick test and challenge test and 6 patients were demonstrated to have correlation between these two techniques (85,7%). Conclusions: Skin prick test with non-standardized drug allergen may demonstrate type-1 drug allergy and had correlation with challenge test.

P86 Allergy to local anesthetics - two years analysis Kosnik M.1

1University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia Aim: Local anesthetics (LA) are one of most frequently prescribed medications worldwide. Adverse reactions to LA are common, while different type of allergic reactions are rare. In our analysis we tried to evaluate the frequency of allergic reactions to LA in our population. Method: The study is retrospective. We included the patients admitted to our hospital with suspected allergy to LA in a period from January 2008 till June 2010. All patients were tested according to in-house protocol for patients with allergy to LA. Results: 233 tests were performed in 187 patients, 155 (83%) were women.In189 patients one LA was tested, in 43 patients two LA and in one patient 3 LA were tested. Lidocaine was tested in 110 patients (47.2%) with one positive reaction, mepivacaine was tested in 68 patients (29.2%) - none positive, bupivacaine in 18 patients (7.8%) - none positive and articaine in 37 patients (15.8%) - one positive reaction. 92 patients (49.2%) in their history stated symptoms suspected to anaphylaxis. In 91 patients (48.7%) pre-test probability of anaphylaxis was low. The most frequent symptoms in patients history were: urticaria (7 pts), angioedema (5 pts), dyspnea (21 pts), rash (20 pts), hypotension (2 pts), paresthesia (46 pts), loss of consciousness (29pts), erythema (15pts), large local reaction (15 pts). In a patient with positive reaction to lidocaine skin tests were negative. After application of 0.1 ml of 2% lidocaine she felt flush in her head and sensation of heat in her limbs. Vital signs were normal. We evaluated the reaction suspected of pseudoanaphylaxis. In the other patient with positive raction we tested articaine with adrenaline. Skin tests were negative. After application of 2 ml of LA she felt sensation of heat in her head, epigastric pain and had difficulty with swallowing saliva. An angioedema of eyebrow appeared. The reaction was evaluated as anaphylaxis, also some pharmacological effects of adrenaline was observed. The test with lidocaine was negative. Conclusion: Our results confirmed that allergic reaction to LA are extremely rare. Allergy to other ingredients or pharmacological effects of other ingredients of LA preparation should be considered. Allergy testing of LA is important also to rule out psychosomatic involvement.

P87 Sinus bradycardia induced by intravenous methylprednisolone during the treatment of Stevens Johnson-toxic epidermal necrolysis overlap syndrome: A case report Zarate-Correa L.C.1, Carrillo-Gomez D.C.1, Ramírez-Escobar A.F.2, Perafan-Bautista P.E.3, Serrano-Reyes C.D.4

1Fundación Valle del Lili, Internal Medicine, Cali, Colombia, 2Fundación Valle del Lili, Dermatology, Cali, Colombia, 3Fundación Valle del Lili, Cardiology-Electrophysiology, Cali, Colombia, 4Fundación Valle del Lili, Internal Medicine and Allergy, Cali, Colombia


ABSTRACTSPurpose: The Stevens Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap syndrome has the characteristics of both SJS and TEN with epidermal detachment of 10%-30% of the body surface area. This disease occurs most commonly as a drug reaction and intravenous glucocorticoid therapy is an important therapeutic modality in the treatment. Adverse effects of steroids include hypertension, hyperglycemia and behavioral changes. The most serious and uncommon adverse effect is cardiac rhythm disturbance, both tachyarrhythmias and bradyarrhythmias5-16. Here, we report a patient with SJS-TEN overlap due to allopurinol use who developed sinus bradycardia after intravenous methylprednisolone. Case report: A 41-year-old female with a past history of hypertension and diabetes mellitus was started on allopurinol by the general practitioner based on her uric acid levels (7,6 mg/dl). Four weeks later, the patient developed mucocutaneous manifestations of SJS-TEN overlap with erythematous maculopapular lesions over the neck and face spreading to other parts of the body involving ocular, oral and genital mucosa with detachment of the skin of 30% of the body surface area. IV methylprednisolone (125 mg) was administered every 6 hours. Twenty four hours after the first dose, the patient developed persistent resting bradycardia with heart rate of 40 beats per minute, asymptomatic and with normal blood pressure. ECG revealed severe sinus bradycardia. No specific therapy was given; however, the doses of methylprednisolone were reduced to 60 mg every 6 hours. Two days later, due to further progression of the disease and persistence of sinus bradycardia, methylprednisolone was stopped and a single dose of 300 mg of infliximab (Remicade®, Schering-Plough) was administered with stoppage of new blisters and gradual improvement on general condition. Her resting bradycardia resolved 24 hours after the last dose of IV methylprednisolone. Conclusion: Serious cardiovascular adverse effects of glucocorticoid pulse therapy have been described previously. Severe sinus bradycardia may occur after intravenous methylprednisolone and electrocardiographic monitoring and careful observation should be used in patients who receive this therapy not only during high-dose. A study of a larger number of patients is needed to establish the frequency and severity of these cardiac rhythm disturbances.

P88 Severe cutaneous adverse reaction due to pseudo-ephedrine. What about other sympaticomimetics? Lapeere H.1, Lanssens S.1, De Munter S.1, Stockman A.2, Lambert J.1

1University Hospital Ghent, Department of Dermatology, Gent, Belgium, 2Sint-Rembert Ziekenhuis, Department of Dermatology, Torhout, Belgium Purpose: We report a case of Acute Generalized Exanthematous Pustulosis (= AGEP) to pseudo-ephedrin and discuss possible cross reactions. Materials and methods: A 29 year patient was refered to our department to know which local anesthetic could be used. As a seventeen year old, she developed a painful erythemateus skin eruption with pustules and high fever, two days after starting a treatment with Actifed ® tablets (triprolidine HCl + pseudo-ephedrin HCl), Merced ® tablets (miocamycin) and Cirrus ® tablets (pseudo-ephedrin HCl + cetirizine 2HCl). AGEP induced by pseudo-ephedrine was suspected, but no thorough work-up was done. Avoidance of pseudo-ephedrine and products containing epinephrine (such as local anesthetics) was advised. Later on, this was generalized to allergy to all local anesthetics. Minor surgery (excision of naevi) was done under general anesthesia. Patch test ware performed with the Belgian standard series, cosmetic, farmaceutical, antibiotic series, Cirrus ® 30% in petrolatum (= pet), Actifed ® 30% pet, Merced ® 30% pet and Zyrtec ® 30% pet. A second batch of patch tests was performed with the local anesthetics series, phenylephrine hydrochloride 10% in aqua, epinephrine 1% in aqua, epinephrine 1% pet, ephedrin 1% in olive oil, pseudo-ephedrin 1% pet, ephedrin 1% pet and ephedrin 5% in aqua. To rule out allergy for local anesthetics an intradermal test with serial dilutions of Xylocaïne ® (lidocaïn) and a provocation test with 2 ml of Xylocaïne ® with epinephrine were performed. Results: - The patch tests were read after 48 and 96 hours and were positive test for Cirrus ® (+) and Actifed® (+) and pseudo-ephedrine 1% pet (+). - The intradermal tests with Xylocaïne ® (lidocaïn) and provocation test with 2 ml of Xylocaïne® with epinephrine were read at 20 min, 48, 96 hrs and 7 days and were negative. Discussion: Pseudo-ephedrin is a common used, sympathicomimetic and decongestive drug, often prescribed for relief of symptoms of common cold and hayfever.


ABSTRACTSTo our knowledge, only six cases of pseudo-ephedrin induced AGEP have been described in literature. When reviewing the literature, we found that in 20 out of 28 reported patients, cross-reactivity between pseudo-ephedrine, ephedrine or phenylefrine occured. However no cross-reactivity to epinefrine was reported. This case illustrates the importance of a thorough work-up and allergy testing. False assumptions made shortly after the acute event led to unnecessary drug avoidance.

P89 Appearance of ANCA associated vasculitis under TNF-alpha inhibitors treatment Reitblat T.1, Reitblat O.1

1Barzilai Medical Center, Ashkelon, Israel Purpose: To describe two patients who developed ANCA associated Vasculitis during Tumor Necrosis Factor Alpha inhibitor (TNF-i) treatment. Materials and methods: Patient 1: A 58 years old woman has suffered from RF positive Rheumatoid Arthritis (RA) 13 years. During the last 7 years she has been treated with Methotrexate 15 mg/week and Etanercept 25mg twice a week. She has been in remission during the last 4 years. One year ago she presented with high C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR), without clinical sign of active synovitis. One month later she was hospitalized with acute renal failure, with creatinine level of 7.3 mg/dl. Blood serology revealed positive C-ANCA with high titer of proteinase 3 antibody, negative ANA and complement. Kidney biopsy showed vasculitic changes. The diagnosis of C-ANCA associated vasculitis was made. Etancercept treatment discontinued and high dose prednisone therapy was initiated. Patient 2: A 52 years old man has suffered from Psoriatic Arthritis (PsA) for 10 years. He was treated with Infliximab 5mg/kg during the last 5 years. Three years ago he developed Bronchial asthma with nasal polyposis following later. Nine months ago he was hospitalized with clinical picture of pneumonia with vasculitic rash on his lower extremities. Blood tests showed hypereosonophilia, positive P-ANCA with high titer of myeloperoxidase antibody. Chest CT revealed infiltrates in both lungs. Churg Strauss vasculitis diagnosis was made. Infliximab therapy was stopped and high dose Prednisolone treatment was introduced. Discussion: We report here of 2 patients who developed ANCA associated vasculitis on anti-TNF therapy. TNF-i is the treatment of choice in patients with moderate to severe RA and PsA. The literature on the side effects of etanercept and infliximab has focused on infective complications and the development of autoantibodies and cases of drug-induced systemic lupus erythematosus and episodes of demyelination. Reports concerning vasculitis have been contradictory, and rare. Conclusions: Awareness of the possibility that TNF-i could trigger systemic necrotizing vasculitis should be kept in mind when applied in treatment.

P90 Sensitization and delayed manifestation of allergic exanthemas to contrast media upon first exposure Bircher A.J.1, Brockow K.2, Grosber M.2, Scherer Hofmeier K.1

1University Hospital of Basel, Allergology/Dermatology, Basel, Switzerland, 2TU Munich, Dermatology Clinic, Munich, Germany Aim: Contrast media are known to elicit immediate and delayed type hypersensitivity reactions. In a previously sensitized individual, the latter typically manifests with a time period of 1 to 2 days, Except in the situation of a cross-reactive molecule, a naïve patient usually does not react upon first exposure. We report five patients reacting with exanthemas upon first exposure to a contrast medium. Patients and methods: Five patients were observed (3 female, age range 55 to 81 years). All received for the first time the culprit contrast media (Iomeprol 4 x, Iodixanol 1 x). In one patient only previous exposure to contrast media was documented. One patient suffered from acute pre-renal insufficiency during the reaction. A typical maculopapular exanthema started at day 5 (1 x), day 8 (3 x) and day 10 (1 x), respectively. In all patients, an extensive allergological workup within the time frame of 1 to 5 months was performed. This included prick, intradermal, and in some patients patch tests with series of contrast media and other concomitant drugs. Results: Sensitization was confirmed in 3 patients mono-sensitization, in 2 a cross-reactive pattern with positive skin tests to contrast media. All other concomitant drugs were negative and were later tolerated by the patients.


ABSTRACTS1 patient was accidentally re-exposed with the culprit contrast medium and reacted within 2 days with a similar clinical manifestation. Conclusions: Five patients who received for the first time a particular contrast medium reacted with a delay of 5 to 10 days (mean = 8 days) with a typical T-cell mediated manifestation. In 1 patient, a similar manifestation developed within 2 days upon re-exposure. This implies that single-dose contrast media even in patients without known risk factors, such as renal insufficiency, may induce sensitization in the typical time period of 5 to 10 days and then still elicit a hypersensitivity reaction. Although it is thought that these contrast media are excreted within 1 to 2 days mostly by the renal route, it has been observed that by biliary excretion traces of vascular contrast media may remain for several days to weeks within the gastrointestinal tract. This observation is of clinical relevance because typically a single dose of a drug does not lead to sensitization and thereafter within 5-10 days, elicitation of a delayed hypersensitivity reaction.

P91 Positive patch tests to sulfites in patients with exanthemas to metamizole: culprit or innocent bystander? Bircher A.J.1, Michel S.1, Gimenez-Arnau E.2, Lepoittevin J.-P.2, Scherer Hofmeier K.3

1University Hospital of Basel, Allergology/Dermatology, Basel, Switzerland, 2University of Strasbourg, Laboratory of Dermatochemistry, Strasbourg, France, 3University Hospital, Basel, Switzerland Aims: Metamizole (novaminsulfone, dipyrone) may elicit various hypersensitivity reactions including agranulocytosis, anaphylaxis, as well as delayed exanthemas. It is a pro-drug, which is rapidly metabolized into the active principle 4-methyl-amino-antipyrine (4-MAA) and a sulfite moiety which represents up to 25% of the total administered dose. We report on 15 patients (age range 28 to 71 years; 5 males, 10 females) who were suspected to have either suffered from a delayed (n = 11) or an immediate (n = 5) type hypersensitivity manifestation from metamizole. Patients and methods: In all patients (age range 28 to 71 years; 5 males, 10 females), metamizole was the culprit or among the primarily suspected drugs. Skin prick tests, intradermal tests with immediate and late readings, and patch tests were performed with metamizole and sulfites. Oral provocation tests were performed with sodium metabisulfite. Results: In 7 patients delayed hypersensitivity to metamizole was confirmed by patch or intradermal tests, 5 patients were also positive to sulfites. Manifestations included severe maculopapular exanthemas (n=4), drug hypersensitivity syndrome (n= 2), and bullous exanthema in one. In 5, oral provocation tests with sulfites were performed; 4 were negative, 1 was positive, 2 declined. In another 3 patients with delayed exanthems, skin tests with metamizole and sodium metabisulfite were negative but in 2 with a flexural exanthema (SDRIFE) nickel, a known elicitor of this manifestation, was positive. Among 5 patients with immediate hypersensitivity reactions skin tests were positive in 2 only. In 5 metamizole-exposed patients without proof of sensitization to this compounds and identification of another cause (“exposed controls”), oral provocation tests with sulfites were negative. Conclusions: Metamizole is a pro-drug which releases a considerable amount of sulfites upon metabolization. In a high number of patients with delayed exanthems, delayed type tests with metamizole and sulfites were positive, indicating a potential role of this latter moiety. However, oral re-exposure with representative sulfite doses elicited symptoms in one patient only. Therefor it is suggestive that the active principle of metamizole 4-MAA is the sensitizing and eliciting principle in this drug. Patients with delayed sensitization to metamizole and sulfites and immediate reactions to metamizole mostly tolerate oral sulfite re-exposure

P92 Fixed drug eruption caused by ornidazole and fluconazole but not isoconazole itraconazole, ketoconazole and metranidazole Bavbek S.1, Yilmaz I.1, Çelebi Sözener Z.1, Aydin Ö.1

1Ankara University, School of Medicine, Department of Chest Diseases, Division of Immunology and Allergy, Ankara, Turkey Fixed drug eruption (FDE) is an uncommon side effect of drug ingestion, accounting for approximately 0.5% of all drug-related rashes. The drugs mostly reported to cause FDE are antibiotics, acetylsalicylic acid and other NSAIDS, cotrimoxazole, allopurinol, dapsone, phenolphthalein, phenobarbitone, and oral contraceptives. We present here a fourth case of FDE induced by antiprotozoal nitroimidazoles, ornidazole, along with cross reactivity to antifungal triazole, fluconazole, but not isoconazole, itraconazole, ketoconazole and metranidazole.


ABSTRACTSA 42 year-old woman with a recent history of hypersensitivity reaction to nitroimidazoles was admitted to the department of Clinical Immunology and Allergy. She had suffered four episodes of a similar eruption at the same sites. First and last episodes induced by fluconazole, the remaining two episodes due to ornidazole. Occlusive patch tests at previously affected sites and in the unaffected skin of the with 30% and 50% ornidazole (500 mg), 10% fluconazole (200 mg), and 10% isoconazol (600 mg) vaginal ovule, in petrolatum were carried out and found strongly positive with % 30% and 50% ornidazole on affected sites, but were negative with 10% fluconazole and 10% isoconazol. She reported that she consumed itraconazole and ketoconazole, metronidazole without developing any episodes of FDE. Our data support that fluconazole, ornidazole should be added in the list of the drugs inducing PDE, and cross sensitivity among azole compounds is not always necessarily an all.

P94 Erythema multiforme induced by sorafenib Azukizawa H.1, Hanafusa T.1, Arase N.1, Katayama I.1

1Osaka University, Dermatology, Suita, Japan Purpose: Sorafenib (Nexavar) is a multikinase inhibitor used for treating hepatocellular or renal cell carcinoma. Although sorafenib often causes hand-foot skin reactions in a dose-dependent manner, delayed-drug hypersensitivity reactions are rare and idiosyncratic. Here, we report six cases of delayed-hypersensitivity reactions induced by sorafenib. Since sorafenib targets tumor cells and endothelial cells by inhibiting Raf kinase and receptor tyrosine kinases of proangiogenic factors, respectively, hematologic adverse events are rarely induced. Therefore, utility of lymphocyte simulation test (LST) was additionally evaluated for sorafenib-induced erythema multiforme or maculopapular rash. Materials and methods: Six cases were involved in this report. Five patients were treated with sorafenib for renal cell carcinoma, and one patient was for hepatocellular carcinoma. Four patients presented erythema multiforme and other two patients developed maculopapular rash. Skin biopsy was taken from four out of six patients, and CD4 and CD8 staining were performed. Lymphocyte simulation test (LST) induced by sorafenib was examined for all cases. Results: Two out of four erythema multifome patients were treated with systemic steroids, since they presented fever and oral erosion without skin blister formation comparable with erythema multifome major. Histologically, most of the skin biopsies showed interface dermatitis with apoptotic keratinocytes and eosinophil-infiltration consistent with erythema multifome. Moreover, CD8 positive cells were massively infiltrated into the upper dermis and epidermis. LST induced by sorafenib showed positive results four out of six patients. Conclusions: These findings indicated that immunological reaction induced by sorafenib may be cytotoxic, and is a potential severe cutaneous adverse reactions such as Stevens-Johnson syndrome. LST may be useful for diagnosis of erythema multiforme induced by sorafenib to determine culprit drugs.

P95 Fixed drug eruption: A case series Chadly Z.1, Chaabane A.1, Ben Fredj N.1, Ben Fadhel N.1, Mrad S.1, Boughattas N.1, Aouam K.1

1Faculty of Medicine / University of Monastir, Pharmacology, Monastir, Tunisia Aim: To evaluate the epidemiological, clinical and chronological fixed drug eruption (FDE) characteristics and to identify the implicated drugs. Method: We carried out a retrospective study including all cases of FDE notified to the Pharmacovigilance Unit of Monastir during 7 years (2004 - 2011). Imputability was established according to Begaud’s method. Patch tests were performed according ENDA (European Network for Drug Allergy) recommendations. Result: Twelve cases of FDE were notified to our unit: 7 men and 5 women, with a mean age of 41 years ± 18 (10 to 66 years). Clinical examination revealed erythematous pruritic eruption in all cases. The lesion was solitary for 3 patients and multiple for the 9 remainder (2 to 7 plaques). The diameters of the plaques have varied between 1 and 15 cm. The affected sites were limbs (9 cases), face and trunk (3 cases each) and neck (2 cases). One patient had oral mucosal lesions. Four patients had presented a bullous eruption. The incubation period has varied from 2 hours to 13 months. In all cases, the lesions disappeared spontaneously in few days leaving residual hyperpigmentation after drug withdrawal. The most characteristic finding was recurrence of similar lesions at the same sites after every intake of the causative drug. Patch tests on pigmented lesions (intra lesional patch tests) and on normal skin of the back (extra lesional patch test) were done in 10 cases. On 48-hour reading, intra lesional patch tests were positive in 6 patients. All extra lesional patch tests were negative.


ABSTRACTSIn 11 cases the diagnosis was confirmed by accidental rechallenge with the suspected drug. No steroidal anti-inflammatory drugs (NSAIDs) and antibiotics were the most frequent responsible drugs in our series (5 cases each) followed by paracetamol and phenobarbital (1 case each). There have been no further episodes of inflammation since the patients avoided incriminated drugs. Conclusion: Throughout this study, we point out the predominance of NSAIDs and antibiotics in inducing FDE in one hand, and the usefulness of skin tests in identifying elicitor drugs in the other hand.

P96 Photodistributed Lichenoid eruption induced by Glibenclamide Chadly Z.1, Chaabane A.1, Ben Fredj N.1, Mrad S.1, Ben Fadhel N.1, Boughattas N.1, Aouam K.1

1Faculty of Medicine / University of Monastir, Pharmacology, Monastir, Tunisia Aim: To report a case of photodistributed lichenoid drug eruption induced by glibenclamide.Case report: A 75-year-old woman, without personal history of atopy or other allergic diseases, presented during the summer with a 2-month history of a photodistributed hyperpigmentation. The patient had been treated for primary biliary cirrhosis with ursodesoxycholic acid 600 mg/day, since 2007. On 2008, for diabetes, she started glibenclamide 15 mg/day and insulin. About 3 years later, she presented a pruritic purplish maculo-papular eruption on the face. The eruption has spread within few weeks to the neck and hands. Physical examination revealed circumscribed oval and round hyperpigmented macules and papules on the face, neck and dorsae of the hands. Their diameters varied between 1 and 8 cm. No lesions were found on the mucous membranes. This clinical picture suggested a lichenoid eruption. Histopathological examination of skin lesions confirmed the diagnosis and showed: hyperorthokeratosis and acanthosis of the epidermis, basal cell attack and perivascular lymphocytic infiltrate in the superficial dermis. A diagnosis of glibenclamide-induced photodistributed lichenoid eruption was suspected and glibenclamide was switched to acarbose. Gradual resolution of the hyperpigmentation was observed over the following two months. Conclusion: To the best of our knowledge, this is the first reported case of photodistributed lichenoid drug eruption induced by glibenclamide.

P97 Phenobarbital-induced fixed drug eruption: A pediatric case Chadly Z.1, Chaabane A.1, Ben Fredj N.1, Ben Fadhel N.1, Mrad S.1, Boughattas N.1, Aouam K.1

1Faculty of Medicine / University of Monastir, Pharmacology, Monastir, Tunisia Aim: To report a rare case of fixed drug eruption (FDE) induced by phenobarbital in a -10-year-old child confirmed by a positive intra-lesional patch test. Case report: A-10-year-old girl, with a history of recurrent urinary tract infections treated with sulfametoxazole-trimethoprim was referred to our department for multiple hyperpigmented plaques. One week previously, she had been given one suppository of acetylsalicylic acid - phenobarbital for fever. Twelve hours after the drug intake the child developed pruritic red oedematous plaques on the left thigh. Sulfametoxazole-trimethoprim was not discontinued and the lesions improved within five days. The physical examination revealed four circumscribed oval and round hyperpigmented plaques on the left thigh. Their diameters varied between 10 and 15 cm. No lesions were found on the mucous membranes. After a detailed questioning, the mother reported three other former episodes that had occurred in the same sites with the same morphological features of eruption. The lesions disappeared spontaneously in 5 to 10 days leaving residual hyperpigmentation. Just before each episode, the child had received acetylsalicylic acid-phenobarbital and paracetamol for fever. The mother reported that few weeks before the last episode, the child had received paracetamol for three days, without any recurrence of skin lesions. Six weeks after complete resolution, patch tests were performed separately, with phenobarbital and acetylsalicylic acidboth prepared at 10% in water and in petrolatum according to the European Network for Drug Allergy (ENDA) recommendations. The patch test was applied on pigmented sequellae (intra lesional patch test) and on normal skin of the back (extra lesional patch test). On 48-hour reading, only the phenobarbital intra lesional patch test was positive. Because of possible cross-reactions between aromatic anticonvulsants, subsequent intra lesional patch tests to carbamazepine and phenytoin were performed. They were all negative at 48-hour reading. The child carried on taking sulfametoxazole-trimethoprim and paracetamol. There was no relapse during a six-month follow-up period. Conclusion: We report a rare case Phenobarbital-induced FDE in a child and point out the usefulness and safety of intra lesional patch tests in establishing the diagnosis.


ABSTRACTSP98 Biologicals, Mycobacteria and drug allergy - is there a link?Ferreira A.R.1, Castro E.D.1, Coelho R.2, Ribeiro N.2, Sarmento A.2, Cernadas J.R.1

1Centro Hospitalar São João, EPE, Serviço de Imunoalergologia, Porto, Portugal, 2Centro Hospitalar São João, EPE, Serviço de Doenças Infecciosas, Porto, Portugal Background: It is uncertain if biologicals increase the risk of drug hypersensitivity reactions (DHR). Case description: A 54 year-old woman presented at the Emergency Room with facial angioedema and pruritic, scaling erythroderma for 3 days. She was on isoniazid (H), rifampicin(R), levofloxacin, ethambutol (E), levetiracetam, mirtazapine, sertraline and ranitidine. Blood tests showed 16% eosinophils (1240/mm3). Considering probable DHR to antituberculosis drugs (ATBD), these were withdrawn and antihistamine and oral steroid prescribed, with resolution after 3 days and a decrease in eosinophil count. She had Crohn’s Disease diagnosed 10 years before (treated with oral steroids until 2010, then replaced by adalimumab) and admission in the Neurosurgery Department 3 months before for cerebral abcess; 15 days after starting vancomicine, meropenem and phenytoin she presented a generalized maculopapular rash; vancomicine was suspended and phenytoin substituted by levetiracetam. Presuming that the abcess could be of mycobacterial origin, she was transferred to the Infecciology Department on the 40th day of admission and started ATBD and dexamethasone, with reduction of the abcess size. Four days later the eosinophil count started to rise, peaking at 1800/mm3 and then slowly decreasing to 700/mm3.H was reintroduced 20 days after ATBD suspension; 4 hours after 1/5 of the prescribed dose, she developed facial angioedema and erythroderma and the eosinophil increased. It was assumed that H was the culprit drug and 1 week later she started E (1/4 of the prescribed dose); she presented a reproducible reaction 6 hours later. The case was again discussed with Infecciology staff and the records of the Neurosurgery admission were reviewed, revealing a slow increase in eosinophil count before the introduction of ATBD, together with the maculopapular rash and an increase of AST and ALT (10 times). During the time the ATBD were stopped, the cerebral abcess increased and it was decided to reinitiate the ATBD one at a time, with the patient in the hospital. Pyrazinamide, R, and E were introduced without problems. Hours after the 1st dose of isoniazid, she developed angioedema and erythroderma. Tolerance induction to isoniazid was achieved in 3 days and she was discharged and remains symptom-free. Comments: In this patient it is difficult to establish the correct diagnosis. Did the patient have DRESS to phenytoin and a toxidermia to ATBD? Do biologicals play a role in these DHR?

P99 Metamizole induced multiple bullous fixed drug eruption proven by in vivo and in vitro testing Lukacs A.1, Harsing J.1, Hidvegi B.1, Banvolgyi A.1, Karpati S.1, Temesvari E.1

1Semmelweis University, Department of Dermatology, Venerology and Dermatooncology, Budapest, Hungary Purpose: A 76-year-old woman developed multiple livid- erythematous, itchy patches followed by topical blistering. Skin biopsy confirmed the diagnosis of bullous fixed drug eruption. The patient´s ad hoc new medication included diclofenac a day before and metamizole 3 times within a two weeks’ period before the skin symptoms occured. Discontinuation of metamizole and diclofenac therapy and the application of local corticosteroid controlled the symptoms. To determine which drug induced the fixed eruptions, both in vivo and in vitro testing were planned. Materials and methods: 2 months after the episode a patch testing was performed by standard drug series. The suspected drugs (diclofenac, metamizole) were directly applied on the already healed lesions. Lymphocyte transformation test was carried out for both diclofenac and metamizole. Results: A bullous reaction was experienced in 24 hours on site of metamizole testing within the pigmented lesion. Skin biopsy from the positive test showed a fixed bullous skin reaction. The lymphocyte transformation test was also positive in different concentrations for this drug. Conclusions: The diagnosis of fixed drug eruption is usually based on the classical clinical symptoms. In our case the prominent bullous lesions led to an early diagnosis during the first episode and was confirmed by histology. It was important to verify which drug was responsible for the adverse event, because the bulla formation and the mucosal involvement indicated severe reaction. The detailed medical history, the selected patch test and lymphocyte transformation test verified the etiology within 2 months after the clinical symptoms.


ABSTRACTSP100 Drug neosensitization during sulfasalazine-induced hypersensitivity syndrome in an adolescent with juvenile idiopathic arthritis Arikoglu T.1, Kuyucu S.1, Tufekci S.B.1, Delibas A.2

1Mersin University Hospital, Pediatric Allergy Immunology Department, Mersin, Turkey, 2Mersin University Hospital, Pediatric Nephrology Department, Mersin, Turkey Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug induced hypersensitivity syndrome (DIHS). The diagnosis requires the presence of the following criteria: 1. Maculopapular rash developing >3 weeks after starting drug therapy 2. Prolonged clinical symptoms after discontinuation of the causative drug 3. Fever (>38°C) 4. Hepatitis or renal involvement 5. Leukocyte abnormalities 6. Lymphadenopathy 7. HHV-6 reactivation.It is well described in treatment with aromatic-antiepileptic drugs, sulphonamides and NSAI drugs.Case report: We report on an 17-years-old boy on sulphasalazine therapy for juvenile idiopathic arthritis (JIA).Two weeks after sulphasalazine is stopped, he developed a pruriginous maculopapular erythema and fever of 39.5°C,which led to treatment with amoxicillin, and then ampicilin-sulbactam for a presumptive infectious process.During ampicillin sulbactam therapy, the skin eruptions propagated and facial edema developed.Enlargement of neck and axillary lymph nodes, jaundice with acute cholestatic hepatitis and coagulation abnormalities appeared.Peripheric smear showed no eosinophilia and atypical lymphocytosis. Bone marrow aspiration showed scarce hemophagocytosis but no cytopenia in complete blood count. All test results for viral and autoimmune hepatitis were negative. Serum anti-HHV-6 titer was moderately elevated.Serum vitamin D3 level was found to be low. He was given pulse steroid therapy and then, prednisone 2 mg⁄kg daily and a H1 antihistamine.Drug patch tests with sulphasalazine, amoxicilline and ampicilllin sulbactam were negative.Six months later, he developed a maculopapular erythema during clarithromycin and amoxicillin treatment.Skin prick, intradermal,patch tests with clarithromycin and amoxicillin were negative.A systemic and itchy rash appeared during oral amoxicillin provocation test.No reaction was seen with macrolide provocation test. Discussion: Defective detoxification of reactive oxidative metabolites have been implicated in the pathophysiology of this syndrome.Viral replication acts as a necessary cofactor for activation of immune system, leading to the development of drug-specific T cells and drug neosensitization.Amoxicillin may induce a flare of DRESS, possibly by acting directly on herpesvirus replication. Conclusion: This report highlights the possibility of neosensitization to chemically or antigenically unrelated drugs during sulphasalazine induced-DIHS in children.

P101 Gemifloxacin-associated fever, maculopapular rash and elevated liver enzymes: A case report Sezgin G.G.1

1Maltepe University, Medical School, Internal Medicine, Istanbul, Turkey Introduction: Fluoroquinolones are wide spectrum bactericidal antibiotics being used for over 25 years. Increasing number of generations increased spectrum of efficacy, but caution is needed for side effects and these medications should not be used without true indication. We report here a case a gemifloxacin toxicity to underline the wide spectrum of medication-related adverse effects and to draw attention to rational use of antibiotics. Case presentation: We report here a 33-year-old man presented with high fever, photosensitivity, maculopapular rash and elevated liver enzymes after prophylactic use of gemifloxacine 320 mg tablet, in the course of preparation for surgery for nasal polyp. A thorough diagnostic investigation did not reveal any other metabolic or infectious etiology. His clinical findings resolved completely after cessation of the medication without any definitive treatment. Conclusion: This case highlights the need for clinicians to be cautious when using antibiotics. Continued care and caution is recommended as gemifloxacin and other fluoroquinolone usage is increasing for various infectious diseases, since these medications may increase likelihood of adverse effects, which are reported infrequently.


ABSTRACTSP102 Insulin Allergy: Case report Gasiuniene E.1, Slomskis T.M.1, Bajoriuniene I.1, Sitkauskiene B.1

1Hospital of Lithuanian University of Health Sciences, Department of Pulmonology and Allergology Kaunas Clinics, Kaunas, Lithuania Background: Insulin allergy is not very common form of drug allergy, but it’s differentiation may be problematic: very often the cause of allergy is not insulin itself, but such additives as zinc, protamine, cresol, trometamol and fenol. Introduction of recombinant human insulin resulted in decrease of allergy rate, which now is between 0.3% and 3%. According to the literature the most common forms are: urticaria, angioedema, general malaise with palpitations, paresthesia (hands and mouth), induration at injection site, macular exanthema, insulin resistance and other. Insulin allergy may be diagnosed using skin prick test and intracutaneus test with insulin preparations, insulin additives, and clinical laboratory methods for the assessment of specific IgG, IgE antibodies to insulin and protamine. Case report: 73 old female was diagnosed with 2nd type of diabetes, which was treated with hypoglycaemic therapy: gliclazide - 120mg per day, metformine - 500mg 3 times per day. However, sufficient control of glycaemia was not achieved therefore insulin therapy was started with ins. lisprum (Humalog®) and ins. lispro and ins. lispro protamine (Humalog Mix®). After 24 hours redness a positive reaction developed in the prick place: the patient suffered from urticaria, pruritus, diplopic images, general malaise with palpations, confusion, induration at injection site, maculous macular exanthema. Skin prick and intracutaneous tests demonstrated positive reactions for the following drugs: ins. glarginum (Lantus®), ins. humanum solubile (Apidra®), ins. lispro (Humalog-Basal®), ins. detemirum (Levemir®), ins. aspartum (NovoMix 30®), ins. aspartum (Novorapid®), ins. lispro mix (Humalog Mix 25®), ins. lisprum (Humalog®), ins. isophan (Protaphan®). Delayed allergy developed after injection of mentioned drugs with the following symptoms: induration at injection site, macular exanthema, urticaria, pruritus, diplopic images. Insuling therapy was not possible because of allergy, therefore it was changed to therapy using repaglinide, which resulted in both good glicaemia control and treatment tolerance. Conclusion: Insulin allergy still remains a problem in diabetes treatment. It is not always possible to identify insulin additives, which may cause allergy. In the presented case, patient was allergic to many insulin preparations. Fortunately, glycaemia control and resolution of symptoms was achieved using another therapy (metformin and repaglinide).

P103 Diagnostic evaluation of patients with non-immediate reactions to iodinated contrast media with skin involvement Torres M.J.1, Gómez F.1, Doña I.1, Rosado A.2, Mayorga C.3, Garcia-Nuñez I.1, Blanca-Lopez N.4, Huertas J.A.1, Guerrero M.A.1, Canto G.4, Blanca M.1

1Carlos Haya Hospital, Allergy Department, Málaga, Spain, 2Alcorcón Hospital, Allergy Department, Madrid, Spain, 3Research Laboratory Carlos Haya Hospital-IMABIS Foundation, Málaga, Spain, 4Infanta Leonor Hospital, Allergy Department, Madrid, Spain Background: The frequency of non-immediate reactions to iodinated contrast media (CM) seems to have increased. Skin testing is currently used for diagnosis. Objective: The aim of the study was to establish the role of skin testing and drug provocation test (DPT) in the diagnosis of non-immediate reactions to CM. Methods: Skin intradermal test with delayed readings and patch testing were done with different CM (Iobitridol, Iomeprol, Iodixanol, Iohexol, Ioversol, Iopramide and Ioxaglate). DPT was done for searching an alternative. Skin biopsy was obtained from positive skin tests and positive DPT. Results: From the 161 subjects evaluated 34 (21,1%) were skin tests positive, 21(50%) to Iomeprol, 7(16,7%) to Iodixanol, 5 (11,9%) to Iobitridol, 4 (9,5%) to Ioxaglate, 3 (7,1%) to Iohexol and 1 (2,4%) to Iopramide. DPT was positive in 44 cases (34,6%) with skin test negative, 38 (76%) to Iodixanol, 8 (16%) to Iomeprol and 4 (8%) to Iohexol. We finally confirmed as allergic 78 cases (48,4%), 34 (43,6%) by skin testing and 44 (56,4%) by DPT. Skin biopsies showed a perivascular mononuclear cell infiltrate, mainly in the dermis, with higher levels of CD4 lymphocytes than CD8 T lymphocytes, with expression of activation markers and skin homing receptors. Conclusion: Using skin testing we diagnosed 43,6% of the patients with non-immediate reactions to CM, being necessary the performance of DPT in the other 56,4% of the cases. The method confirming the diagnosis differs depending on the CM involved.


ABSTRACTSP104 Cellular-mediated reaсtion to thiomersal in a patient with drug intolerance Sidorovich O.1, Luss L.1, Vaschenko E.1

1RNC Institute of Immunology, Moscow, Russian Federation Aim: We studied a 30-year-old female patient has been suffered from different reactions (mostly nonspecific) of drug (only liquid forms, vaccines, intravenous antibiotics, but not pills) and food intolerance for a 4 years, cough, nasal burning, respiratory affection by sharp smells, feeling of legs and face numbness, ringing in the head, urticaria, heartburn, food eructation, liquid stool tendency, abdominal pains, menstrual irregularities. The symptoms were cut off repeatedly by intravenous injections of glucocorticoids and antihistamines. According to medical documentation a gastrointestinal pathology was found. There was no gaematological pathology. The patient does not use drugs for fear of side effects. She had no clear evidence of drug allergies and atopic deseases before 2007. Method: We analysed skin-prick tests (Allergopharma, Germany), total serum IgE (Elecsis, Hitachi, Japan) and levels of specific IgE (UniCAP, Phadia, Sweden), the patch test system for cellular-mediated reactions on chemical agents detection (Nycomed/Mekos Laboratories AS). Result: Skin-prick tests with main atopic and food allergens were negative. The levels of total IgE 35,5 ME/ml (N 0,1 - 100). The specific IgE to D. рteronyssinus, D. farinae, Penicillium notatum, Cladosporium herbarum, Aspergillus fumigatus, Candida albicans, Alternaria alternate, Helminthosporium halodes were not found. Phadiatop Infant (Pharmacia) was negative.The patch test was positive with thiomersal. There were negative results with other 23 components. Conclusion: We have described a cellular-mediated type hypersensitivity to thiomersal proven by positive patch-test. No immunological changes were demonstrated. Nonspecific reactions of drug and food intolerance were reduced by taking neuroleptics and anxiolytics. This case shows the necessity of focusing attention not only on active ingredients, but on drug admixtures and additives.

P105 Petechiae adverse reactions to Ciprofloxacin Chiriac A.E.1, Foia L.2

1University of Medicine Gr T Popa, Iasi, Romania, 2University of Medicine Gr T Popa, Biochemistry, Iasi, Romania There are many dermatological adverse reactions to Ciprofloxacin reported in the literature : allergic reaction, pruritus, urticaria, photosensitivity/phototoxicity reaction, flushing, fever, chills, angioedema, edema of the face, neck, lips, conjunctivae or hands, cutaneous candidiasis, hyperpigmentation, erythema nodosum, sweating. We report a case of petechiae appeared 24 hours after the initiation of Ciprofloxacin treatment for urinary infection, with long lasting evolution, despite the immediate withdrawn of the medication.The petechiae were present on the lower limbs, with intense pruritus, no systemic reactions.

P106 Non allergic rhinitis associated with Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Antagonists Montoro de Francisco A.M.1, Garcia Luque A.2, Burgos Pimentel A.M.1, Tabakov A.2, Fonseca Avendaño J.A.1, Puerro Vicente M.2

1Hospital Central de La Defensa, Allergy, Madrid, Spain, 2Hospital Central de La Defensa, Clinic Pharmacology, Madrid, Spain Aim: Angiotensin-Converting Enzyme Inhibitors (ACEI) and Angiotensin II Receptor Antagonists (ARAII) are widely used. Although there are few references in the literature of rhinitis associated to these drugs, it is not a well known adverse drug reaction (ADR) and it is not included in the summary of product characteristics. Design: A case series of 24 patients with rhinitis associated with ACEI/ARAII. Scope: Allergy service, Hospital Central de la Defensa. Period: March 2009 to February 2012. Main Variables Assessed: demographic and clinical varialbles, diagnostic test, treatment, evolution, casual relationship between drugs and rhinitis according to modified Karch Lasagna algorithm.


ABSTRACTSResults: Twenty four patients with persistent rhinitis. Four severe rhinitis with anosmia and twenty moderate all of them associated with ACEI/ARAII. In addition to rhinitis, the patients showed cough, conjunctivitis and angioedema. Age 67,1 years (37-85), 13 females and 11 males. Seven drugs involved (enalapril, valsartan, losartan,candesartan, captopril, telmisartan and lisinopril). More frequently involved drugs were enalapril and valsartan. Re-exposure to drug (n=7 patients 29%). Treatment was drug withdrawal, achieving complete remission in all cases, in an average time of 6,2 weeks (3-12 weeks). The casual relatoinship between drugs and rhinitis were defined as 7/24 and probable as 17/24. Conclusion: Antihypertensive drugs are widely used and they should be taken into account in moderate/severe persistent rhinitis. ADR caused by these drugs is resource-consuming and has a direct effect in the patient´s quality of life. Postmarketing Surveillance Systems should inform health professionals of this ADR.

P107 The role of the transcriptional factor Nrf2 in contact hypersensitivity El Ali Z.1, Gerbeix C.2, Esser P.3, Robert P.4, Legrand J.-J.2, Martin S.3, Pallardy M.1, Kerdine-Römer S.1

1Faculté de Pharmacie Paris Sud, INSERM UMR-996, Châtenay-Malabry, France, 2CIT-Safety and Health Research Laboratories, Evreux, France, 3University Medical Center Freiburg, Allergy Research Group, Department of Dermatology, Freiburg, Germany, 4University Paris Sud, IPSIT, Châtenay-Malabry, France Chemical sensitizers, inducing contact hypersensitivity (CHS), are known to induce reactive oxygen species (ROS). The Nrf2/Keap1 pathway is central for detoxification. Nrf2 is a redox-sensitive basic leucine zipper transcription factor involved in the transcriptional regulation of many antioxidant genes. Nrf2 plays a central role in protecting cells from ROS and electrophiles. We have demonstrated that contact sensitizers induce, in vitro, the accumulation of Nrf2 in human dendritic cells. In order to elucidate the role of Nrf2 in CHS, we used the Local Lymph Node Assay (LLNA) for studying the sensitization phase and the Mouse Ear Swelling Test (MEST) for studying the elicitation phase during the CHS. These studies were performed, in nrf2 knock out (nrf2-/-) and in wild type (nrf2+/+) mice, in response to dinitrochlorobenzene (DNCB). The MEST results showed that (DNCB) (1%) induced a higher increase of ear thickness in nrf2-/- mice than in nrf2+/+. Furthermore, the swelling increase was time dependent after challenge. Sensitization of mice with DNCB (0.5%) induced a high significant response in nrf2-/- mice compared to nrf2+/+ mice where no swelling was observed after challenge. On the other hand, results obtained in LLNA showed that DNCB induced an increase of lymphocyte proliferation in nrf2-/- and nrf2+/+ mice. However, the stimulation index (SI) for a same concentration was higher in nrf2-/- mice than in WT nrf2+/+ mice. These results underlie the crucial role of Nrf2 in CHS. Nrf2 seems to control the inflammation response and the lymphocyte proliferation, involved in allergic response to chemical sensitizers.

P108 Cotrimoxazole allergy due to hidden para-phenylenediamine sensitization Calogiuri G.1,2, DiLeo E.2, Nettis E.2, Ferrannini A.2

1Ospedale Ninetto Melli, Pneumology, San Pietro Vernotico, Italy, 2Bari University, Allergy and Clinical Immunology, Bari, Italy We observed a 21 years-old male patient with an itching maculopapular rash on the trunk, upper limbs and face, appeared on the third day following an antibiotic treatment with Bactrim Forte® (cotrimoxazole: sulfamethoxazole/trimethoprim 800mg/160mg) tablets for an acute febrile dysenteriae. Physical examination showed no bullous skin lesions or mucosal involvement. Medical history showed a seasonal allergic rhinitis to ragweed pollen and two previous episodes of drugs hypersensitivity reactions with anaphylactic shock after oral assumption of amoxicillin/clavulanic acid and urticarial episode with an unspecified oral cephalosporin. Because of the previous adverse reactions, patient had always taken macrolides if necessary. Patient referred that he had never taken before Bactrim Forte® tablets. We suspended Bactrim Forte® administering Rifaximin as alternative treatment, systemic antihistamines and corticosteroids. 45 days far from lesions resolution, the patient underwent to patch tests with SIDAPA (Italian Society of Dermatology and Allergology Environmental Professional) series and Cotrimoxazole 10% in petrolatum (F.I.R.M.A. Inc -Florence-Italy). Patch tests gave a positive result with reading at D2 and D3 to paraphenylenediamine (PPD) 1% in petrolatum (+++), to nickel sulfate 5% in petrolatum (+) and cotrimoxazole


ABSTRACTS10% (++) according to the European Contact Dermatitis Society criteria. Apparently, these positive results seemed without a clinical relevance. Patient reported that he had never dyed his hair previously. Nevertheless, he reported two years ago, during a Greek vacation, he had been tattooed with a temporary henna dye on his left arm. Few days after the tattoo, a painful bullous itching lesion had appeared at the same site of the tattoo. Skin lesion faded with a course of oral and topical corticosteroids and macrolides therapy, but an area of hyper-pigmentation persisted for some months. We reputed p-phenylenediamine containing henna tattoo was responsible of cotrimoxazole allergy because of their cross-reactivity.It is known PPD is added to henna dye used for temporary tattoos to make the tattoo brighter and more definite, but PPD shows cross-reactivity with several amino compound and azo-dyes derivatives.Other Authors reported the development of generalized dermatitis in PPD-sensitized patients after intake of systemic drugs cross-reacting with PPD, such as mesalazine and thiazide diuretics.

P110 A case of photoallergic contact dermatitis Milito C.1

1Dapienza University of Rome, Dpt of Molecular Medicine, Rome, Italy The nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in topical form for the relief of musculoskeletal pain. The application of topical drugs with occlusive bandage often used in general practise may induce allergic or photoallergic contact dermatitis. Different studies underline the role of NSAIDs and excipients in the development of photoallergic dermatitis and the increase of photoallergic contact dermatitis NSAID-induced. A 35 year old man get to our attention because of the onset of vesicular itching lesions associated with erythema, tenderness and swelling, at his left wrist. He referred us the use of an ointment containing ketoprofen for a week, twice a day, with an occlusive bandage. The topical application was due to a painful wrist resulting from a protract use of mouse. He reported indirect exposure to UV during the topical therapy. We decided to stop the topical application of ketoprofen and start therapy with antihistaminic. After a short period of relief we observed a worsening of the reaction that obliged us to treat the patient with systemic corticosteroids and antihistaminic. He improved after 10 days. We decided to perform dermoallergological investigation e.g. patch tests for NSAID and other ingredients containing in the ointment. After 72 hours patch tests were negative. So we went on with photopatch testing. On photopatch testing, ketoprofen eliciter erythema and vescicoles 48 hours after UVA irradiation. Our case underlines the need of use both patch and photopatch testing with all ingredients to verify the actual allergen and photoallergen.

P111 Severe adverse cutaneous drug reactions: The 5-year Hospital Kuala Lumpur experience Tang M.M.1, Gill P.1, Chang C.C.1, Johar A.1

1Hospital Kuala Lumpur, Dermatology, Kuala Lumpur, Malaysia Purpose: Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), SJS-TEN overlap syndrome, and drug-induced hypersensitivity syndrome (DHS) are well known severe adverse cutaneous drug reactions (SACDRs). These conditions are potentially life threatening and have medico-legal implication. Materials and methods: We retrospectively review the clinical patterns, management strategies and outcome of 134 patients with severe adverse cutaneous drug reactions managed at the Department of Dermatology Hospital Kuala Lumpur between 2006 and 2010. Results: The median age of presentation was 44.8 years (13-83). The male:female ratio was 1:1.03. There were 68 cases (50.7%) of SJS, 32 (23.9%) TEN, 10 (7.5%) SJS-TEN overlap syndrome, and 24 (17.9%) DHS. The top five drugs causing SCADRs were allopurinol (26.9%), carbamazepine (13.4%), phenytoin (9.7%), co-trimoxazole (7.5%) and mefenamic acid (4.4%). The median intervals of drug exposure before the onset of reaction were 1.5-2.5 weeks for SJS, TEN and SJS-TEN overlap but slightly longer for DHS (3.0 weeks). A hundred and thirty patients (97%) were managed as in-patient. The median duration of hospitalization were 8, 11, 15 and 13 days for SJS, SJS-TEN overlap, TEN and DHS respectively. Systemic corticosteroids was given to 96% cases of DHS for a median duration of 10 weeks; 52.9% of SJS and 60% of SJS-TEN overlap syndrome for 2 weeks; and 62.5% of TEN for 2.3 weeks. Thirteen patients (42%) with TEN were treated with intravenous immunoglobulin. The


ABSTRACTSuse of systemic corticosteroids significantly reduced the mortality in TEN. Intravenous immunoglobbulin was not associated with survival advantage in TEN. Eight patients (6%) died, of which 7 were TEN and one DHS. Conclusion: SACDRs are life-threatening emergencies which not only results in significant morbidity and mortality; but potentially increases the health care cost and burden. Clinicians should recognize “high risk” medications and prescribe them with great caution.

P112 Dress sindrom from sulphasalazine Qirko E.1, Qerimi D.1, Priftanji A.1

1University of Medicine, Immunology - Alergology Clinic, Tirana, Albania Sulphasalazine is an antiinflamatory and antimicrobial drug used ind bowel inflamatory disease etc. Dress sindrom from sulphasalazine is not very common. It is a serious immunological hiperreaction characterized by generalized cutan rush, fever, involvement of internal organs. Methods and material: Case report Results: Patient A.L male 48 years old came in our clinic with the diagnoze of ulcero-hemorrhagic kolitis. He was on sulphasalazine for more than 3 weeks. He had generalized cutan rush, fever, disphagia, dyspnea, gastrointestinal discomfort, fascial edema. Patient had hyperglicemia, because he was diabetic. He had encrease of basophils, eosinophils, high level of SGOT SGPT, and hiperglicemia. We stopped the administration of sulphasalazine and pacient was administered metilprednisolon 1mg/kg weight which was tapered very slowly and treatment for diabetis. Conclusion: The discontinuing of the drug involved and tapering of intravenous steroids is recommended and this cases. The tapering should be done very slowly in order to prevent recurrence. Key words: Sulphasalazine, derss sindrom, cutan rush, antiinflamator drug

P113 Drug induced hypersensitivity syndrome/DRESS in pediatric allergy practice: A single center experience Ozmen S.1, Ilknur B.1, Duman H.1, Dogru M.1, Ginis T.1, Dibek Misirlioglu E.1

1Dr. Sami Ulus Research and Training Hospital of Women’s and Children’s Health and Diseases, Pediatric Allergy, Ankara, Turkey Purpose: DRESS (drug rash with eosinophilia and systemic symptoms) is a rare but life threatening syndrome. Although it is seen more commonly with anticonvulsants, its’ association with other kinds of drugs has recently been reported. Case series in children have not been reported in English literature. The aim of our study was to show the clinical characteristics of patients with DRESS. Methods: Five patients with DRESS, aged between 5-15 years old, were enrolled and followed by our Pediatric Allergy Clinic. Results: All patients had maculopapular eruptions, fever and eosinophilia. The suspected drugs in two of the patients were anticonvulsants (phenobarbital and lamotrigine) whereas a variety of antibiotics were suspected in the remaining patients. Patients were treated with steroids and/or IVIG. Patch tests with suspected antibiotics were applied on two patients. One of the patients was diagnosed with hemophagocytic syndrome from which she subsequently died. Conclusion: As DRESS is a life threatening syndrome, early diagnosis and immediate cessation of the suspected drug is essential. We should like to remind all physicians that when a child with multiple drug use develops a rash, DRESS should be considered during differential diagnosis.

P114 Toxic epidermal necrolysis successfully treated with Infliximab: Report of four cases Zarate-Correa L.C.1, Carrillo-Gomez D.C.1, Ramírez-Escobar A.F.2, Serrano-Reyes C.D.3

1Fundación Valle del Lili, Internal Medicine, Cali, Colombia, 2Fundación Valle del Lili, Dermatology, Cali, Colombia, 3Fundación Valle del Lili, Internal Medicine and Allergy, Cali, Colombia


ABSTRACTSPurpose: Toxic epidermal necrolysis (TEN) is a life-threatening dermatosis characterized by widespread detachment of the epidermis and mucosal erosions that is most commonly caused by drug intake. Mortality rates depend on the area of skin affected and vary from 30% to 60%. Massive keratinocyte apoptosis is the hallmark of TEN and the release of tumor necrosis factor alpha (TNF-α) by activated keratinocytes and macrophages seem to play a role in the pathogenesis of this disease. Therefore, the selective TNF-α blockade is a promising treatment. Infliximab is a chimeric monoclonal antibody with human and mouse components that binds specifically to both soluble and membrane-bound TNF-α. Methods: We administred a single dose (300mg) of infliximab (Remicade®, Schering-Plough) to four patients with TEN admited to the intensive care unit between 2009 and 2011 and referred from outside institutions. Patients were followed according to their history of pre-existing diseases, suspected culprit drug, total body surface area, mucosal involvement, therapy, SCORTEN score, complications and outcome. Results: Three patients were women (75%). The mean age was 41 years (17-76 years). All the cases had a large body surface area affected with a mean of 87.5% (50-100%). The suspected causal agent was carbamazepine in one case, ceftriaxone in one case, furosemide in one case and nevirapine in one case. It was medical prescription in all cases. The mean time delay between the onset of drug intake and the onset of symptoms was 6.5 days (1-14 days). Mucosal involvement was observed in all patients with ocular involvement in 80% of cases. All patients had comorbidities such as diabetes mellitus, epilepsy, hypertension, human immunodeficiency virus and systemic erythematosus lupus. The most common complication was sepsis in three cases (75%). The mean duration of hospitalization was 22 days (16-30 days). The calculated SCORTEN score was 2 in two patients (50%), 3 in one patient and 4 in one patient and the overall mortality rate was 0%. In all four patients, infliximab showed the reduction of blister formation, as well as stoppage of progression of erythema. Complete resolution took a mean of 9.75 days (7-16 days). Conclusion: The rapid recovery in our four patients suggests a beneficial effect of infliximab. However, large-scale studies are needed before infliximab may be considered as a new ‘gold standard’ in treating TEN.

P115 Long-term sequelae of drug reaction with eosinophilia and systemic symptoms - A retrospective cohort study from a medical center in northern Taiwan Chu C.-Y.1,2, Chen Y.-C.3, Chang C.-Y.1, Cho Y.-T.1, Chiu H.-C.1,2

1National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 2National Taiwan University College of Medicine, Department of Dermatology, Taipei, Taiwan, Republic of China, 3Cathay General Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China Purpose: To investigate the incidence of sequelae, including less well known sequelae, in patients with drug reaction with eosinophilia and systemic symptoms (DRESS) among a group of patients treated at a medical center in Taiwan. Materials and methods: Using the diagnostic criteria proposed by the International Registry of Severe Cutaneous Adverse Reactions (RegiSCAR), we establishd a database of DRESS patients treated at National Taiwan University Hospital since 1998 by retrospective chart review and prospective case enrollment. After excluding cases of patients who died during the acute stage of the disease, we collected all cases during 1998-2009, and then attempted to survey these patients’ medical status after resolution of previous drug hypersensitivity. In our study design, “long-term sequelae” was defined as onset of symptoms after drug hypersensitivity, or onset of disease during acute stages that was not resolved after DRESS. Other criteria included autoimmune diseases, observed end-organ failure, and clearly diagnosed diseases. We designed an interview questionnaire focusing on patients’ reasons for seeking medical care. Then we conducted a non-concurrent cohort study, using telephone contact and medical chart review to evaluate patients who were followed at least one year after the diagnosis of DRESS. For those patients who died before being interviewed by telephone, we charted the cause of death and health status before death, using medical records and interviews with family members. Results: Nine patients died before our telephone interview, and the remaining 43 patients completed a specially designed questionnaire. The overall incidence of long-term sequelae was 13.5% (7 of 52 patients). Four patients developed autoimmune diseases, two with Graves’ disease, and other two with type 1 diabetes mellitus and autoimmune hemolytic anemia, respectively. Alopecia areata was also noted in one of the two patients with Graves’ disease. The other three patients developed end organ failure after visceral involvement. Two needed lifetime hemodialysis and one died of cardiac failure.


ABSTRACTSConclusions: This is the first study to survey the incidence of sequelae and long-term outcome of DRESS. These sequelae can be divided into two major spectra in different patients: young patients tend to develop autoimmune diseases and elderly patients are more vulnerable to end organ failure.

P116 Thymus and activation-regulated chemokine (TARC/CCL17) in drug-induced hypersensitivity syndrome (DIHS): Identification of TARC as potential marker for early indication of the disease and prediction of the disease activity. Ogawa K.1, Hasegawa A.1, Daikoku N.1, Miyagawa F.1, Okazaki A.1, Fukumoto T.1, Kobayashi N.1, Kasai T.2, Asada H.1

1Nara Medical University, Department of Dermatology, Kashihara, Japan, 2Nara Medical University, Department of Diagnositic Pathology, Kashihara, Japan Purpose: DIHS is a serious acute drug reaction that is characterized by fever, cutaneous eruption, lymphadenopathy, and involvement of several visceral dysfunctions. TARC is a family of CC chemokine known to play an important role in Th2-mediated immune-inflammatory processes. In this study, we evaluated a role of TARC in patients with DIHS. Methods: The sera were obtained from 8 patients with DIHS and 14 patients with drug-induced maculopapular exanthema and serum TARC levels were measured by ELISA. We studied the correlation of serum TARC levels and various hematological parameters. Results: The initial TARC levels before treatments were significantly higher in patients with DIHS than those in patients with MPE. There are significant correlations of serum TARC levels with serum sIL-2R levels and with blood eosinophil counts in patients with DIHS. Conclusions: Serum TARC levels might be associated with initial presentation of DIHS as well as disease activity during the course. Thus, they can be possibly used as indicators for early diagnosis and for determination of response to treatments in DIHS.

P117 Saliva Polymerase-Chain-Reaction assay for detection and follow-up of Herpesviruses reactivation in DRESS Descamps V.1, Avenel-Audran M.2, Valeyrie-Allanore L.3, Bensaid B.4, Barbaud A.5, Ranger-Rogez S.6

1Bichat Hospital, Paris Diderot University, Dermatology, Paris, France, 2Anger Hospital, Dermatology, Anger, France, 3Henri Mondor Hospital, Créteil, France, 4Pierre Benite Hospital, Dermatology, Lyon, France, 5Nancy Hospital, Dermatology, Nancy, France, 6Limoges University, Virology, Limoges, France Purpose: Human Herpesviruses (HHV) are shed in saliva. The first manifestations of DRESS occur in oropharynx. We evaluated the interest of quantitative real-time PCR analysis on saliva in DRESS for the detection and follow-up of HHV reactivations. Material and methods: We prospectively recruited ten consecutive patients with DRESS in several departments of Dermatology in France in 2010-2011. Reactivations of HHV, including HHV-6, HHV-7, cytomegalovirus (CMV), and Epstein-Barr virus (EBV), were studied by quantitative real-time PCR analysis. Analyses were done in blood (at the beginning) and in the saliva (three times a week during two weeks). Patients with definite criteria for DRESS were included by members the French Group of Cutaneous Drug Adverse Reactions. Characteristics of the patients, previous and ongoing treatments, manifestations of the DRES, and course of the disease were analysed.We compared results of quantitative real-time PCR analysis done on saliva and on blood samples. We analysed the course of Human Herpesvirus shedding in saliva during the first two weeks of DRESS. Results: Seven out of 10 cases were analysed for Human Herpesvirus reactivation in both blood and saliva. In three patients either blood or saliva sampling were lacking. The average age of the seven analysed patients was 42 years. Severe visceral manifestations (hepatitis, nephritis, encephalitis, hemophagocytic syndrome, and pneumonitis) prompted systemic corticosteroids in 6 cases or superpotent topical corticosteroids in one case. Antivirals (ganciclovir or acyclovir) were given in two cases and intravenous gammaglobulins in one case. HHV reactivation was confirmed in the seven cases. By order of magnitude reactivations of HHV-7 first, then EBV, HHV-6, and CMV were demonstrated. DNA viral load (DNA copies/DNA microgram) value was closed in both blood and saliva. Concomitant and sequential reactivations of human herpesviruses were observed in the seven cases. We observed that in some patients treated with corticosteroids with clinical good response viral loads


ABSTRACTSof viruses increased with a CMV disease in one case (colitis). This may explain why rapid discontinuation of corticosteroids in some patients may induce a flare of DRESS. Conclusion: HHV reactivation and antiviral immune response are responsible for the severity of DRESS. Saliva DNA sampling device and DNA PCR with titration of HHV load could be helpful for the long-term management of patients in severe DRESS.

P118 Prolonged elevation of serum granulysin in drug-induced hypersensitivity syndrome(DIHS) / Drug reaction with eosinophilia and systemic symptoms (DRESS) Saito N.1, Abe R.1, Yoshioka N.1, Murata J.1, Fujita Y.1, Shimizu H.1

1Hokkaido University Graduate School of Medicine, Sapporo, Japan Purpose: Drug-induced hypersensitivity syndrome (DIHS) / drug reaction with eosinophilia and systemic symptoms (DRESS) is characterized by a limited number of causative drugs, late onset, dysfunction of the liver and prolonged clinical course due to relapse. Granulysin is a cytotoxic molecule produced against virus-infected cells, tumor cells and transplant cells. A recent paper reported that granulysin is highly expressed in blisters of Stevens-Johnson syndrome and toxic epidermal necrolysis. In addition, we found that serum granulysin is more elevated in patients with early-stage SJS/TEN. In this study, we assembled serum samples of patients with DIHS/DRESS and analyzed the correlation between granulysin concentrations with clinical manifestations and disease courses. Materials and methods: Sera of 15 patients with DIHS/DRESS (10 men and 5 women; average age: 55.4 ±19.9 years) were obtained from multiple Japanese institutions. The disease onset (day 1) was defined as when the skin eruption appeared. Sera of patients with ordinary drug skin reactions (ODSRs) (n=24) and healthy controls (n=31) were also obtained. The granulysin concentrations of the serum samples were measured with an ELISA. Results: In serum samples taken from day 1 to day 10 (n=9), 8 samples showed elevated serum granulysin levels over 10 ng/ml (88.9%, 21.9 ±12 ng/ml). From day 11 to day 20 (n=11), we detected prolonged high serum granulysin levels (63.6%, 16.1±14.8ng/ml). Serum granulysin levels decreased gradually after day 21 (n=20) (30%, 7.6 ± 3.4). By day 20, the skin eruptions of all patients had disappeared. In 31 healthy control subjects, no increase of granulysin level was detected (0%, 1.6±0.6 ng/ml) and in 24 patients with ODSRs, elevated granulysin was detected in only one patient (4.16%,3.5±3.4 ng/ml). Conclusions: We showed that serum granulysin levels of DIHS/DRESS were elevated significantly compared to those of ODSRs, and elevated granulusin level was prolonged until day 20 after disease onset. Serum granulysin levels tended to return to normal after the skin lesion cleared. These data indicate that serum granulysin levels are useful for diagnosing DIHS/DRESS and determining its prognosis. Recently we developed a rapid immunochromatographic test to detect high serum granulysin level in 10 minutes. We expect that monitoring of serum granulysin by the rapid test might contribute to the early diagnosis of DIHS/DRESS and predict disease prognosis.

P119 Drug reaction with Eosinophilia and Systemic Symptoms (DRESS): What still have to be learned? Tanno L.K.1,2, Dracoulakis M.2, Motta A.1, Aun W.2, Mello J.F.2, Kalil J.1

1University of Sao Paulo, Allergy and Clinical Immunology, Sao Paulo, Brazil, 2Hospital Servidor Público Estadual of Sao Paulo, Allergy and Clinical Immunology, Sao Paulo, Brazil Purpose: The diagnosis of Drug induced hypersensitivity syndrome is challenging due to the variety of clinical patterns and to the irregular application of case definition for this reaction. Our aim was to analyze series of cases of Drug Reaction with Eosinophilic Hypersensitivity Syndrome (DRESS) and their clinical and demographic data. Methods: A prospective study was developed in Allergy Clinics of two Services in São Paulo, Brazil, from November 2008 to December 2011. The patients were studied based on history of DRESS based on standardized scoring systems and using an adapted ENDA (European Network of Drug Allergy) questionnaire. Clinical and demographic data were analysed. Results: Thirty-one cases were validated as probable or definitive DRESS, 21 females (68%) and the mean age was 45. The reactions generally started with fever and exanthema. All cases had exanthema, mucosal involvement was found in 4 patients (13%). Fever >38oC was present in 87% and lymphadenopathy in 55%. Involvement of a single internal organ (68%) or variable combination of 2 or more internal organs (19%) was


ABSTRACTScommon, particularly liver (80%), kidney (19%) and lung (6,5%) commitment. Fifty percent of patients with renal involvement required dialysis. Eosinophilia was present in 90% and atypical lymphocytes in 6,5%. Sixty-eigth percent were related with antiepileptics, 9,6% with sulfonamides, 9,6% with β-lactams antibiotics, 6,5% with allopurinol and 6,5% with non-steroidal anti-inflammatory drugs. The mean interval between the intake of the suspected drug and the reaction was 27,6. Twenty-six patients reported the intake of more than 2 drugs at the same time of the reaction, but 66,6% (14/21) of patch tests with the culprit drug were positive. No fatalities occurred. Conclusion: This series confirmed the clinical variability of DRESS, highlighting skin, fever, lymphadenopathy, internal organs involvement and eosinophilia. There was severe internal organ involvement, but no fatalities occurred. Antiepileptics were the main pharmacological group involved. Clinical characters and time of onset of the reactions differs from others non-immediate hypersensitivity reactions and supports that DRESS is a particular phenotype. Prospective long-term multicentric epidemiological studies may be important for the better understanding of this syndrome.

P120 Drug reaction with eosinophilia and systemic symptoms (DRESS) to piperacillin/tazobactam (PT) diagnosed with delayed-reading intradermal tests Rutkowski C.1, Nasser S.M.1, Ewan P.W.1

1Cambridge University Hospitals NHS Foundation Trust, Allergy Department, Cambridge, United Kingdom Aim: PT is a wide-spectrum antibiotic used in severe polymicrobial/Gram (-) infections. Despite its common use adverse reactions are rare. Anaphylaxis, urticaria, angioedema, maculopapular rash (MPR), AGEP, occupational asthma and haematological abnormalities have been reported. DRESS is a delayed onset, multi-organ drug reaction caused by an expanding list of drugs with a mortality of 10-40%. Pathogenesis is heterogeneous and poorly understood. European (RegiSCAR; Kardaun 2007) and Japanese (Shiohara 2007) diagnostic criteria are in use. DRESS is usually diagnosed clinically but patch tests have also been used. Drug challenge is contraindicated. There are few case reports of PT-induced reactions with some DRESS features, often with no or only limited allergological work-up. We present the first 3 cases of PT-induced DRESS, fulfilling RegiSCAR criteria, diagnosed by delayed-reading IDT. Methods and results: Patient 1: 61 female; perforated sigmoid; day 1-13: PT 4g/0.5g iv tds; day 14-17: oral ciprofloxacin, metronidazole added; day 17: widespread MPR, pruritus, fever; antibiotics (Abx) stopped, topical steroids started; day 19: thrombocytopenia; day 23: eosinophilia, hypoalbuminaemia; negative SPT to penicillins (PPL, MDM, amoxicillin, flucloxacillin, benzylpenicilllin, co-amoxiclav, PT) and other Abx; IDT positive only to PT 2mg/ml at 24 hrs. She later tolerated co-amoxiclav. Patiend 2: 29 male; chronic femoral osteomyelitis; multiple Abx: PT, vancomycin, ciprofloxacin, rifampicin, meropenem; day 21 of PT: pyrexia/rigors, headaches, widespread MPR, eosinophilia, raised ALT; PT stopped, topical steroids started; rash resolved gradually; Negative SPT to penicillins and other Abx; IDT positive only to PT 2mg/ml at 24 hrs. Patient 3: 27 male; skin necrosis due to complex leg fracture; multiple Abx: co-amoxiclav, ciprofloxacin, vancomycin, meropenem, PT (21 days); day 25: extensive MPR with severe pruritus, fever, mild eosinophilia, deranged LFT; SPT negative to penicillins and other Abx; IDT positive only to PT 2mg/ml at 48 hrs. Conclusion: IDT with PT 2mg/ml were safe in 3 patients with no recurrence of DRESS. In 50 controls this concentration was non-irritant. IDT are more sensitive and easier to perform than patch testing, although slightly less specific. We propose that they should be included in the diagnostic algorithm for PT (β-lactam)-induced DRESS. DRESS moreover appears to be drug- but not class-specific (patient 1 tolerated co-amoxiclav).

P121 Anti-inflammatory treatment in adults with Stevens Johnson Syndrome and toxic epidermal necrolysis: A systematic review Carrillo-Gomez D.C.1, Zarate-Correa L.C.1, Ramírez-Escobar A.F.2, Serrano-Reyes C.D.3

1Fundación Valle del Lili, Internal Medicine, Cali, Colombia, 2Fundación Valle del Lili, Dermatology, Cali, Colombia, 3Fundación Valle del Lili, Internal Medicine and Allergy, Cali, Colombia


ABSTRACTSPurpose: Toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome (SJS) are severe mucocutaneous reactions that differ among them in the percentage of the detachment of the skin, being less than 10% for SJS and more than 30% for TEN. Mortality varies from 1-35%, although it may exceed 90% depending on the severity of the disease. There is not approved specific treatment and patients must be treated mainly by eliminating the trigger and general support. Our aim was to perform a systematic review to evaluate the effect of anti-inflammatory treatment in adults with SJS or TEN. Methods: Systematic, objective, exhaustive and reproducible search of original research was conducted in electronic databases (Cochrane Skin Group Specialized Register, the Cochrane Controlled Trials and CDSR, Trip database, MEDLINE, EMBASE, CINAHL, Biomed, NCBI, HINARI and LILACS using “Stevens-Johnson Syndrome / drug therapy” or “Stevens-Johnson Syndrome / therapy” or “Toxic epidermal necrolysis / drug therapy” or “Toxic epidermal necrolysis / therapy” as key words with restriction to open trials and phase III clinical trials from 1998 to December 30, 2011 in Spanish or English languages. Grey literature was not included. Title or abstract were reviewed to identify clinical trials. Results: From 240 results, 231 were discarded by title, abstract, article, duplication or availability. Only one randomized placebo-controlled double-blind trial using thalidomide was identified, and 7 open trials without control group or historical control were included. The drug therapy used in those were immunoglobulin in four studies, cyclosporine in two and methylprednisolone in one. Mortality was 0% in two studies with cyclosporine, one with methylprednisolona and one with immunoglobulin, despite of the skin compromise greater than 50%, and was 83% in the trial with thalidomide. In other study with high-dose of immunoglobulin the observed mortality was 32% vs 21% of predicted mortality and in other with low-dose, predicted mortality was 32% and 10% was observed. Conclusion: There seems to be some benefit from therapy with methylprednisolone, immunoglobulin and cyclosporine but randomized controlled clinical trials are needed to determine the efficacy of these therapies available. Thalidomide increased mortality in toxic epidermal necrolysis.

P122 Expression of CD80, CD86, and CD137 ligand on CD14+ CD16+ monocyte lineage cells infiltrating in the lesional skin of Stevens-Johnson syndrome and toxic epidermal necrolysis Tohyama M.1, Watanabe H.2, Iijima M.2, Hashimoto K.1

1Ehime University Graduate School of Medicine, Department of Dermatology, Ehime, Japan, 2Showa University School of Medicine, Department of Dermatology, Tokyo, Japan Purpose: We previously demonstrated that CD14+ CD16+ monocyte lineage cells infiltrate not only in the lesional skin of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), but also in the normal appearance skin of SJS/TEN before developing epidermal damage (DHM4, in Roma). Since CD14+ CD16+ monocytes are known as dendritic cell precursors, we examined whether these cells express co-stimulatory factors such as CD80, CD86, and CD137 ligand in the lesion skin of SJS/TEN. Materials and methods: Skin biopsies were taken from 12 patients with SJS/TEN. Immunofluorescence double staining were performed in cryo-sections of these samples. Results: CD80 was expressed on CD16+ cells in nine of the 12 SJS/TEN skin samples, and CD86 on CD16+ cells in all samples. CD80 and CD86 expression by CD16+ cells tended to be stronger in the early phase of SJS/TEN. In addition, strong CD80 and CD86 co-expression was observed in the skin of patients in whom the area of epidermal detachment progressed after the biopsy. CD137L was also expressed on CD16+ cells in all skin samples. The CD137L-expressing CD16+ cells were seen bound to CD8 T cells expressing CD137 in the dermis.Conclusion: Co-stimulation with CD80/CD86 and CD137L has been reported to promote the proliferation and cytotoxicity of CD8 T cells. CD16+ monocyte lineage cells may participate in the epidermal damage via enhancement of cytotoxicity of CD8 T cells.

P123 Intravenous Immunoglobulins does not improve survival in toxic epidermal necrolysis: A retrospective cohort analysis of 63 patients Lee H.Y.1, Lim Y.L.2, Tay L.K.1, Thirumoorthy T.1, Pang S.M.1

1Singapore General Hospital, Singapore, Singapore, 2National Skin Centre, Singapore, Singapore


ABSTRACTSPurpose: Toxic epidermal necrolysis(TEN) and Stevens-Johnson syndrome (SJS) are life-threatening, severe cutaneous adverse reactions that differ only in the amount of skin detachment. They are immune-mediated and various specific interventions such as intravenous immunoglobulins (IVIG) have been proposed. Although widely used, the survival benefit of IVIG remains unclear. The aim of our study is to evaluate the effectiveness of IVIG in reducing mortality in patients with SJS/TEN. Material and methods: A retrospective analysis of 63 consecutive patients with TEN or SJS/TEN-overlap who were treated with IVIG was perfomed. Primary outcome is in-hospital mortality. 7 independent risk factors (SCORTEN) were documented. This score was used to predict mortality and derive the standardized mortality ratio. Results: The mean age of patients was 56 years with a male: female ratio of 1:1.5. These patients were classified as SJS/TEN-overlap cases n=27 (48%) and TEN cases n=36 (52%). The mean SCORTEN value was 2.6. The mean dosage of IVIG given was 2.4 g/kg. The mean delay from the onset of epidermal detachment to administration of IVIG was 3.0 days. There were a total of 21 deaths (33.3%) in our cohort of patients. The number of predicted deaths based on the SCORTEN was 17 and the standardized mortality rate was 1.21 (CI : 0.77-1.82) . Subgroup analysis was made comparing the survivors and non-survivors. Non survivors were older (64 versus 52 years; p=0.02 and had higher SCORTEN values (3.3 vs 2.2); p< 0.01. There was no difference in terms of daily dosage, cumulative dosage of IVIG, and duration of administration between the 2 groups. Conclusions: Based on the comparison between the observed mortality and that predicted by SCORTEN, the use of IVIG did not improve survival in patients with TEN and should not be recommended as standard of care.

P125 Fluctuation of serum cytokine levels in subjects with severe adverse drug reactions Fujita H.1, Matsukura S.2, Kambara T.2, Ikezawa Z.3, Aihara M.1

1Yokohama City University Graduate School of Medicine, Environmental Immuno-Dermatology, Yokohama, Japan, 2Yokohama City University Medical Center, Department of Dermatology, Yokohama, Japan, 3International University of Health and Welfare, Department of Dermatology, Atami, Japan Purpose: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions (ADRs) characterized by widespread epidermal damage due to keratinocyte apoptosis. Drug-induced hypersensitivity syndrome (DIHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is ADRS characterized by high fever, multiple organ involvement and sequential reactivation of latent herpes virus. To clarify immunological pathogenesis of SJS/TEN and DIHS/DRESS, fluctuation of serum cytokine levels in subjects with these diseases was investigated. Materials and methods: Peripheral blood was taken from 9 Japanese subjects with SJS/TEN (4 men and 5women; mean age 59.2 years, range 4-80) and 9 Japanese subjects with DIHS/DRESS (4 men and 5 women; mean age 54.5 years, range 39-69) at the time of onset, peak and recovery. Serum was stored at -80 degrees and cytokine level was measured by luminometric bead array and enzyme-linked immunosorbent assay. Results: Most cytokine levels were high at onset and peak, and they gradually decreased in the process of recovery. IL-5 was significantly high in DIHS/DRESS compared with that in SJS/TEN. Conclusions: Cytokine storm occurs and plays a critical role in severe ADRs. Type 1 helper T cells, cytotoxic T lymphocytes and sequential innate immune reaction may be involved in SJS/TEN, whereas type 2 helper T cells caused by drug allergy may induce DIHS/DRESS. These findings may shed light on the treatment of severe ADRs.

P126 Histopathologic characteristics of drug rash with eosinophilia and systemic symptoms (DRESS) Chi M.-H.1, Lin J.-W.1, Hui R.C.-Y.1, Chung W.-H.1, RegiSCAR, Asian SCAR1Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China Aim: To analyze the histopathologic features of patients with DRESS Method: We conducted a retrospective study of patients with probable or definite DRESS diagnosed by the RegiSCAR scoring system at Chang Gung Memorial Hospital in Taiwan. Clinical and histopathologic features of all patients were reviewed.


ABSTRACTSResult: A total of 32 patients diagnosed as definite or probable DRESS by RegiSCAR scoring system were enrolled and their histopathologic features were reviewed. Pathological changes observed were basket-weave hyperkeratotis (94%), dyskeratosis (97%), lymphocytic exocytosis (91%), perivascular lymphocytic infiltration (97%), interstitial eosinophilic infiltration (69%) and extravasation of erythrocytes (53%). The dermoepidermal junction revealed interface vacuolization with or without melanin incontinence (97%). Among dyskeratosis, mild dyskeratosis (1-10 dyskeratotic cells per field at 200x magnification ) was found in 72% (23/32), moderate dyskeratosis (11-20 dyskeratotic cells per field at 200x magnification) in 19% (6/32), and severe dyskeratosis is (> 20 dyskeratotic cells per field at 200x magnification) in 6% (2/32). In 22 cases with eosinophils in the skin, 19 had elevated peripheral eosinophilia, but 3 had normal peripheral eosinophil count. Other findings included epidermal spongiosis (47%), papillary edema (50%), and vasculitis (6%). According to the histopathologic features, the pathologic diagnoses were frequently made as lichenoid dermatitis, erythema multiforme, leukocytoclastic vasculitis and pseudolymphoma. Conclusion: The histopathologic feature of DRESS is a spectrum which can be similar to maculopapular drug eruption. Some cases with marked dyskeratosis may have histopathologic features mimicking erythema multiforme. Although peripheral eosinophilia is crucial as one of diagnostic criteria for DRESS, some cases without peripheral eosinophilia may still be observed to have interstitial eosinophilic infiltration in histopathology.

P127 Generalized bullous fixed drug eruption versus Stevens-Johnson syndrome/Toxic epidermal necrolysis - A comparison study of clinical and histopathological features Cho Y.-T.1, Lin J.-W.2, Chen Y.-C.1,3, Chang C.-Y.1, Hsiao C.-H.4, Chung W.-H.2,5, Chu C.-Y.1,6

1National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 2Chang Gung Memorial Hospital, Department of Dermatology, Taoyuan, Taiwan, Republic of China, 3Cathay General Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 4National Taiwan University Hospital, Department of Pathology, Taipei, Taiwan, Republic of China, 5Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China, 6National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China Purpose: Generalized bullous fixed drug eruption (GBFDE) is a particular form of fixed drug eruption. It characterizes as widespread blisters and erosions, which would be difficult to differentiate from Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Therefore, we tempt to analyze clinical and histopathological features of GBFDE and try to differentiate it from SJS/TEN. Materials and methods: We retrospectively enrolled GBFDE patients in two referral centers in Taiwan during a period of 10 years. SJS/TEN patients with available skin pathology were recruited as the comparison group. GBFDE was defined as typical FDE lesions with bulla formation involving at least 10% body surface area on three of different anatomical sites. Clinical data and pathological slides of these patients were reviewed. Immunohistochemical studies of CD3, CD4, CD8, CD56, Fas, FasL, granzyme B, and perforin were performed. We also compared serum levels of granulysin, sFasL, TNF-α and INF-γ in both groups. Results: Twenty-three cases of GBFDE were collected, including 15 men and 8 women. The average age was 73.1±15.5. The average time to disease onset was 3.2±2.3 days after drug intake. Ten patients (43.5%) had at least one site of mucosal involvement. The most common culprit drugs were antibiotics (8 cases, 34.8%), including cephalosporin (4), penicillin (2), and co-trimoxazole (2), followed by non-steroidal anti-inflammatory drugs (7 cases, 30.4%). Pathology slides were available in 16 cases. All cases revealed basal vacuolization with apoptotic cells. Superficial perivascular mononuclear cell infiltrates were identified in all cases, while deep perivascular infiltrations were found in 2 cases (12.5%). Eosinophils were identified with various intensities in 14 cases (87.5%). All cases had melanophages in the upper dermis. In the comparison group of 6 SJS/TEN cases, eosinophils and melanophages were found in 50% and 33.3%, respectively. No obvious differences of infiltrating CD4 and CD8 T-cells were observed between the two groups. The most significant difference was the number of intra-epidermal CD56-positive cells, which were prominent in SJS/TEN but only few cells identified in GBFDE. The granulysin level in serum or blister fluids of GBFDE was significantly lower than in SJS/TEN. Conclusions: GBFDE could be distinguished from SJS/TEN by shorter latent periods, more eosinophils and melanophages, less intra-epidermal CD56-positive cells and lower granulysin level.


ABSTRACTSP128 The role of prior corticosteroids on the clinical course of Stevens-Johnson syndrome and toxic epidermal necrolysis: A case-control analysis of patients selected from the multi-national EuroSCAR and RegiSCAR studies Lee H.Y.1, Dunant A.2,3, Sekula P.4, Mockenhaupt M.5, Wolkenstein P.2, Valeyrie-Allanore L.2, Naldi L.6, Halevy S.7, Roujeau J.-C.2

1Singapore General Hospital, Dermatology, Singapore, Singapore, 2Henri Mondor Hospital, Reference Centre for Toxic and Autoimmune Diseases, Department of Dermatology, Creteil, France, 3Institute Gustave-Roussy, Biostatistics and Epidemiology Unit, Villejuif, France, 4University Medical Center Freiburg, Biostatistics and Epidemiology Unit, Freiburg, Germany, 5University Medical Center Freiburg, Dokumentationszentrum schwerer Hautreaktionen (DZH), Dermatology, Freiburg, Germany, 6Azienda Ospedaliero Ospedali Riuniti di Bergamo, GISED study center, Department of dermatology, Bergamo, Italy, 7Ben-Gurion University of the Negev, Department of Dermatology, University Medical Center, Beer Sheva, Israel Aim: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immunologically-mediated, severe cutaneous adverse reactions. Since up to 15% of SJS/TEN occur in patients with chronic corticosteroid use, the aim of our study is to evaluate if systemic corticosteroids prior to the onset of SJS/ TEN modified the clinical course and outcome. If a disease-modifying effect is present, information from such an analysis may have implications on the therapeutic use of corticosteroids in SJS/TEN. Method: From the EuroSCAR and RegiSCAR studies, 92 cases of SJS/TEN with exposure to corticosteroids prior to the onset of disease and 321 randomly selected SJS/TEN patients without prior exposure were selected. Primary outcomes included progression of disease, disease severity and mortality. A secondary analysis evaluating the latency between exposure to high-risk drugs and the index day of skin reaction was also performed. Result: On multivariate analysis, cases with prior exposure to corticosteroids had a longer progression of disease of 2.2 days. (95% confidence interval (CI): 1.1-3.2). The disease severity and mortality outcome was unaffected. From the latency analysis, there is evidence that corticosteroids delayed the onset of SJS/TEN in patients with exposure to high risk drugs by 7.1 days (CI: -0.2-14.5). Conclusion: The prior use of corticosteroids modified the latency and progression of SJS/TEN Mortality appears unaffected. Altogether, the results suggest that there is no major preventive effect, which does not exclude a therapeutic benefit.

P129 Phenobarbital causing drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a definite case according to registry of severe cutaneous adverse reaction (SCAR)’s scoring system criteria Tavassoli M.1, Ghavami M.1, Movahedi M.1, Gharegouzloo M.1, Dabbaghzadeh A.1

1Immunology and Allergy, Children’s Medical Center, Tehran, Iran, Islamic Republic of Drug Reaction with Eosinophilia and Systemic Symptoms is a rare potentially fatal syndrome that clinically recognized by fever, rash and internal multi-organ involvement. Exposure to aromatic anticonvulsant drugs usually causes this syndrome 2-6 weeks after initiation of therapy. We report a case of a male infant (6 month old) suffered from febrile seizure attacks (resulted by pneumonia accompanied by fever) treated with phenobarbital that showed a diffuse maculopapular rash two weeks after culprit drug initiation. Laboratory testing included leukocytosis with eosinophilia elevated liver enzymes. Other differential diagnoses (such as idiopathic hypereosinophilic syndrome and eosinophilic leukemia) must be excluded in the absence of immature esinophils in peripheral blood smear, presence of classic clinical features of DRESS and recent phenobarbital exposition. According to registry of severe cutaneous adverse reaction (SCAR)’s scoring system, this case is fourth definite (final score:6) phenobarbital induced DRESS syndrome.

P131 Systemic involvement in acute generalized exanthematous pustulosis: a retrospective study of 58 cases Hotz C.1, Valeyrie-Allanore L.1, Bouvresse S.1, Ortonne N.2, Oro S.1, Duong T.-A.1, Wolkenstein P.1, Chosidow O.1

1Henri-Mondor Hospital, Dermatology, UPEC, Créteil, France, 2Henri-Mondor Hospital, Pathology, UPEC, Créteil, France


ABSTRACTS Introduction: Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction characterized by rash with overlying sterile pustules, high fever and elevated blood neutrophils count (PMN). We investigated prevalence and clinical features of systemic involvement (SI) occuring in AGEP. Materials and methods: We conducted a retrospective study including all patients hospitalized in our department between 2000 and 2010 with a discharge diagnosis of AGEP. Patients had to fulfill the following criteria: i) a specific EuroSCAR score higher than 4 ii) biological and radiological check-up available. Photographs and histology were rated by 3 dermatologists blinded to the clinical data. Mann Withney test was used to compare the median of PMN count between groups of patients with or without SI. Results: Among 78 patients with a discharge diagnosis of AGEP, 58 patients, included in RegiSCAR, were enrolled. Ten patients had SI (17.2%). At least two visceral involvements were observed in six cases. Liver involvement included cytolysis (n=2), cholestasis (n=3) and both (n=2). Mild functionnal renal failure was observed in six cases. Two patients developped a respiratory distress. CT scan showed pleural effusion and the bronchoalveolar lavage revealed infiltrate with 38% of neutrophils without germs (n=1). In the other case, the etiology was unknown. Agranulocytosis was observed in one case. Any concomitant disease that would have explained these SI had been excluded. The median of PMN was significantly increased (p=0.048) in patients with SI. In all cases, evolution was rapidly favourable after drug withdrawal, symptomatic and topical steroids treatments. Discussion: SI is rare but may occur in AGEP. In general pustular psoriasis (GPP), another PMN rich disease, systemic manifestations were described. The hypothesis that abnormalities in GPP could be related to neutrophilic infiltration has been raised. In our study, agranulocytosis was linked to drug toxicity and acute functional renal failures to inflammatory status. However, the PMN infiltration documented in one case of acute respiratory distress, the correlation between the blood neutrophil count and SI, and the analogy with the neutrophilic infiltration in some organs in GPP strongly suggest the role of PMN in SI in AGEP. Conclusion: We describe here SI-related AGEP which should increase physician awareness. Better knowledge of the potential SI of AGEP should help in medical decisions makings.

P132 Allopurinol-induced hypersensitivity syndrome in hungarian patients Kinyó Á.1, Lakatos A.2, Varga A.1, Gyulai R.1, Varga E.1, Bata-Csörgő Z.1, Kemény L.1

1University of Szeged, Department of Dermatology and Allergology, Szeged, Hungary, 2University of Szeged, Szeged, Hungary Allopurinol is an effective urate lowering drug, which is usually well-tolerated with no adverse effects in most cases, but about 2% of treated patients develop a skin rash and may experience severe allopurinol-induced hypersensitivity syndrome (AHS). Our aim was to summarize and present the clinical manifestations of allopurinol-induced hypersensitivity cases treated at our clinic and to identify potential associations with this syndrome. Retrospective review was done for all patients who were referred to the Department of Dermatology and Allergology, University of Szeged with allopurinol-induced hypersensitivity syndrome in the last four years. Over four years 11 patients were treated with allopurinol-induced hypersensitivity syndrome at our clinic. The average age was 70.3 years. Before initiation of allopurinol therapy, 36% of patients already had various degrees of renal impairment, and 72% of them had been taking thiazide diuretics. Cutaneous manifestations were mainly generalized, erythematous, maculopapulous exanthems (9 patients, 82%), and two patients showed erythema multiforme (18%). Asymptomatic hyperuricaemia was the indication for allopurinol therapy in all patients. Allopurinol-induced hypersensitivity syndrome is a severe, life-threatening disease. Allopurinol should be initiated with clear indications at appropriate dosages. Old age, underlying renal impairment and concomitant thiazide diuretic intake should be considered as potential risk factors for developing hypersensitivity syndrome.

P133 Retrospective comparison of the detection of herpesvirus in maculopapular exanthem and longitudinal monitoring of DRESS and viral PCR in 16 DRESS Bollaert M.1, Jeulin H.2, Waton J.3, Gastin I.4, Trechot P.5, Rabaud C.6, Schmutz J.-L.3, Barbaud A.3

1University Hospital of Nancy, P. Canton Building of Medical Specialties, Dermatology, Vandoeuvre les Nancy, France, 2Brabois Hospitals, CHU Nancy, Virology, Vandoeuvre les Nancy, France, 3University Hospital of Nancy, P. Canton Building of Medical Specialties, Brabois Hospitals, Department of Dermatology, Vandoeuvre les


ABSTRACTSNancy, France, 4Brabois Hospitals, CHU Nancy, Virology, INSERM Unit 954, Vandoeuvre les Nancy, France, 5Central Hospital, University Hospital of Nancy, Department of Drug Monitoring, Vandoeuvre les Nancy, France, 6University Hospital of Nancy, P. Canton Building of Medical Specialties, Brabois Hospitals, Department of Infectious and Tropical Diseases, Vandoeuvre les Nancy, France Purpose: The association between drug reaction with eosinophilia and systemic symptoms (DRESS) and herpesvirus reactivation is clear. However, does reactivation exist in maculopapular exanthems (MPE)? Here, we report the results of a retrospective study of EBV, HHV-6, HHV-7 and CMV detection in peripheral blood mononuclear cells (PBMC) of patients with MPE and DRESS, and a study of the evolution of reactivations in patients with DRESS. Patients and methods: Herpesvirus detection in PBMC was done by PCR for nine DRESS and 15 MPE during the acute phase, and 14 MPE time after the acute phase. Both qualitative and quantitative comparisons were performed for EBV, CMV and HHV-6, and qualitative comparisons were performed for HHV-7 replication in MPE and DRESS during the acute phase, and in MPE time after the acute phase. Fourteen DRESS were included in the retrospective longitudinal monitoring of viral reactivations. Results: The number of detected EBV and HHV-6 was similar, or even higher for HHV-6, between MPE and DRESS during the acute phase and lower during the chronic phase. Reactivations in DRESS occurred mainly during the first month, but could also occur later and last for a prolonged time. Conclusion: Some drugs lead to increased replication of herpesviruses and to antiviral CD8+ T-cells activation. Replication was increased in the acute phase of MPE rashes caused by classic “DRESS inducer drugs”, in comparison to time after eruption. The same reactivation of herpesviruses in DRESS and MPE seems to exist, although this should be confirmed in a large, prospective, comparative study. This raises the hypothesis of the existence of a pre-existing abnormal antiviral immunity, perhaps genetically predisposed, which would favor the occurrence of DRESS rather than MPE.

P134 Stevens Johnson, toxic epidermal necrolysis: follow-up pulmonary function test after remission Duong T.A.1, Oro S.1, De Prost N.2, Carrié A.S.3, Valeyrie-Allanore L.1, Roujeau J.C.1, Wolkenstein P.1, Maitre B.3

1Hôpital Henri Mondor, Dermatology, Creteil, France, 2Hôpital Henri Mondor, Intensive Care Unit, Creteil, France, 3Hôpital Henri Mondor, Pneumology, Creteil, France Purpose: At the acute phase, specific bronchial epithelium detachment is associated to Stevens Jonson syndrome and toxic epidermal necrolysis (SJS /TEN). In a prospective study performed on 41 patients, ten patients had sloughing bronchial epithelium at bronchoscopy, with complete detachment on histology. After remission, SJS/TEN are associated to several mucous membrane sequelae. Our aim was to evaluate the pulmonary function after SJS/TEN remission. Material and methods: Patients with SJS/TEN from April 2007 to January 2010 prospectively underwent pulmonary function test (PFT). All patients were included and validated cases in the RegiSCAR study. PFT measured obstructive pulmonary syndrome (OPS, FEV/FVC < 75% T), restrictive syndrome (RS, TLC < 80%T) and diffusion impairment with diffusion capacity of carbon monoxide for alveolar volume (DI, DLCO/VA< 80%T). For each patient, following variables were recorded at acute stage: SCORTEN, specific pulmonary dysfunction or infections, intensive care unit transfer, ciclosporin treatment, after remission pulmonary symptoms and dyspnea. Statistics analysis used Student or Chi 2 test. All tests were two-tailed. Results: 32 patients were included, 17 males, 15 females. Mean age was 38 years [20-79] with a median length of stay of 16.5 days [3-46]. At the acute stage, 25% of the patients were admitted in intensive care unit, 9% had specific bronchial epithelium detachment, 31% had pulmonary infection and 81 % were treated with ciclosporin. The median time from the acute stage to PFT was 3 months [1-18]. Eighteen patients had abnormal PFT, 13 DI (median DLCO/VA : 70% [45-79]), 5 RS (median TLC median 76% [58-79]). Three patients had dyspnea. Patients with DI had significantly increase skin surface detachment compare to patients without DI (30% vs 10%, p=0,0056), and no significant pressure of oxygen (PaO2) (93 vs 88 mmHg; p=0.24). La DLCO/VA was conversely and significantly associated to initial skin surface detachment (r=-0.41 ; P=0.026). DI was still impaired after a second PFT for eight patients (DLCO/VA=67,5% (62-74%). Conclusions: Despite specific proximal bronchial involvement in SJS/TEN, no OPS was evidenced after remission. Systematic PFT displayed asymptomatic DI which was significantly associated to skin surface detachment.


ABSTRACTSP135 Mortality in Stevens-Johnson and toxic epidermal necrolysis: experience of a referral center over the past five years Duong T.A.1, Valeyrie-Allanore L.1, Dunant A.2, Chosidow O.1, Wolkenstein P.1, Roujeau J.C.1

1Hôpital Henri Mondor, Dermatology, Creteil, France, 2Institut Gustave-Roussy, Biostatistics, Villejuif, France Purpose: Stevens Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are rare and severe cutaneous adverse reaction with a 20-40% mortality at the acute stage. Their appropriate diagnosis and management may considerably improve their outcome. To predict individual mortality, a severity score SCORTEN was built on seven independent factors: age, cancer or hematology disorders, skin detachment surface (>10%), heart rate, bicarbonates, glycemia and urea serum level. In 2004, referral center were organized to identify and connect all the specialists involved SJS/TEN management and to set up protocols and medical education. Our aim was to analyze their impact on SJS/TEN acute stage mortality. Material and methods: All patients hospitalized for SJS/TEN from 2005 to August 2009 were retrospectively included. All patients were included in the RegiSCAR study. For each patient, SCORTEN, specific treatments, intensive care unit transfer, mortality within the first six weeks, cause of deaths, were collected. Observed mortality was compared to the predicted mortality with SCORTEN using binomial distribution. All tests were two-tailed. Results: 93 patients were managed, including SJS 43% (n=39), overlap syndrome 36% (n=33), toxic epidermal necrolysis 21% (n=19) with a mean age of 40 years, sex ratio 1. The median delay between onset and admission was 5 days [0.5-72]. Patients were transferred in intensive care unit in 18% (n=16), with cancer in 17% (n=15) and treated by ciclosporin in 61% (n=56). Their median SCORTEN was 1 [0-4]. Eight patients deceased in acute phase with a mean age of 64 years [17-89], SCORTEN at 4 [2-5]. Main cause of death was sepsis. The observed mortality of 9% (8/93) was lower than the predicted mortality of 14% using SCORTEN, without significant difference p =0.14. Discussion: the acute stage mortality reported in our study is lower than reported, 21% in the European EuroSCAR study. In this study of 379 patients, 29% of the patients had TEN in comparison with 21% in our study. To add, from 1987 to 1997, mortality in our department was 24% (n=48) of 203 SJS/TEN. Referral center, continuous medical education as well as specific therapeutics trials may have influenced the acute stage mortality. But the lack of possible comparison between these two series leads a cautious analysis of this difference. Conclusions: SJS/TEN are rare, referral center may improve their management and outcome.

P136 Drug patch tests in investigating severe cutaneous adverse drug reactions: a multicenter study of the French group “Toxidermies” Barbaud A.1, Collet E.2, Milpied B.3, Assier H.4, Staumont D.5, Truchetet F.6, Avenel Audran M.7, Grange A.8, Waton J.9, Toxidermies of the French Society of Dermatology1University Hospital of Nancy, P. Canton Building of Medical Specialties, Dermatology, Vandoeuvre les Nancy, France, 2University Hospital of Dijon, Dijon, France, 3University Hospital of Bordeaux, Bordeaux, France, 4University Hospital of Creteil, Creteil, France, 5University Hospital of Lille, Lille, France, 6Thionville Hospital, Dermatology, Thionville, France, 7University Hospital of Angers, Dermatology, Angers, France, 8University Hospital of Reims, Dermatology, Reims, France, 9University Hospital of Nancy, P. Canton Building of Medical Specialties, Dermatology, Nancy, France Objective: To determine the value and safety of drug patch tests in severe cutaneaous adverse drug reactions (CADR). Methods: A multicenter study was conducted with all patients referred for a plausible DRESS class 4 or 5 according to Regiscar criteria, an AGEP or a SJS/TEN. In the 12 months following the disappearance of the CADR, drug patch tests were done with the commercialized form of the drug diluted at 30 % in petrolatum (pet., 60% of the cases) or at 10% in 40% of the cases, and with the pure drug diluted at 10% in petrolatum Chemotechnique laboratory, Malmo, Sweden). Drug patch tests were done with all the drugs introduced within the 10 days for AGEP or within the 6 weeks for the DRESS or SJS/TEN preceding the onset and in the week following the onset of the CADR.


ABSTRACTSResults: Among 133 included patients (74 F et 45 M, mean age: 53 y.o, 72 DRESS, 44 AGEP, 17 SSJ/TEN), 77 (58%) had positive drug patch tests, 47/72 (65.3%) in DRESS, 26/44 (59%) in AGEP and 4/17 (23.5%) in SSJ/TEN. There was no difference in testing with drug patch test products commercialized by Chemotechnique laboratory and patient’s personal drugs diluted at 30% in pet. In AGEP drug patch tests were positive with 28 different drug classes (8 betalactams, 8 pristinamycin, 2 fluindione, 4 radiocontrast media (RCM), 1 pseudoephedrin, 3 corticosteroids, 2 tetrazepam) with 1 multi-sensitization with 2 drug classes. In DRESS positive patch tests were observed with antibiotics (betalactams: 12 +/20, Glycopeptides: 4+/7, 0+/2 minocycline), 1/9 allopurinol, 11+/13 carbamazepine, 0/5 salazopyrine, 4 Proton pump inhibitors (PPI) and 2/3 fluindione and 12 other drugs. In 7 cases a multiple sensitization was observed with positive patch tests to at least two different chemical classes. Only 4/17 SSJ/TEN had positive patch tests (ramipril, lamotrigine, tetrazepam and multisensitization to glycopeptides and PPI). Discussion: From this large series of patients with severe CADR due to different drugs having been reported as frequent inducers of severe CADR, drug patch tests diluted at 30% in pet. seems to be safe and useful in investigating AGEP and DRESS. We also demonstrate that multisensitization (that can be persistent more than 10 years later) seems frequent in DRESS. All the drugs, even with a low imputability in literature have to be tested as we demonstrated the involvement of corticosteroids in AGEP or PPI in DRESS.

P137 DRESS syndrome in a patient with anticonvulsivant treatment Sanchez V.1, Sola J.1, Berges P.1, Madrigal R.1

1Ramón y Cajal Hospital, Madrid, Spain Aim: The acronym DRESS, which stands for Drug Rash with Eosinophilia and Systemic Symptoms, has been frequently related to the administration of aromatic anticonvulsants and sulphonamides. It has been estimated to occur in about one in 10,000 cases of exposure to these drugs. However, few cases of DRESS syndrome by lamotrigine have been reported in the literature recently. Early clinic diagnosis and the suspected drug discontinuation could prevent its high morbidity and mortality rate (mortality of around 10%). Material and methods: A 31-year-old white male who had been on treatment with olanzapine (7,5mg/ day) for psychosis induced by drug addiction, started lamotrigine (25mg-0-50mg) in the last month. He was not taking any other medications. Department of gastroenterology contacts us for allergy study. Results: The patient had been on treatment with lamotrigine for the past 4 weeks when he was seen as an emergency with persistent fever of 39.5°C, pruritus and generalized maculopapular rash. Diffuse myalgia, asthenia and anorexia were associated, without cough or sibilance. The clinical examination showed jaundice, skin rash with exfoliative dermatitis and facial edema, cervical and occipital lymphadenopathies.

• Laboratory tests: bilirubin level: 4.76 UI/l; ALT: 120 U/l (NR:7-35); AST: 187 U/l (NR:13-35); GGT: 399 IU/l (NR:8-41); LDH: 1.089 IU/l, FA: 255 IU/l. • The total white cell count was 25,400 (NR: 4,000-11,000), eosinophil count 2,300/ mm3 (NR: 0-500/mm3). • The peripheral blood contained few atypical lymphocytes. • Tests for autoinmune antibodies (antinuclear and rheumatoid factor): negative. • Viral serological tests positive for CMV, EBV, HHV6.

Lamotrigine was immediately discontinued and olanzapine was maintained with good results. He was treated with antihistamines and corticosteroids. Recovery and normal laboratory tests had been achieved in following weeks. Allergy study: patch tests negative to carbamazepine, phenytoin (5% and 10% pet.) and positive for lamotrigine and valproic (5% and 10% pet.) on days 2-4. Conclusion: We report a case of DRESS syndrome by Lamotrigine, a second-line treatment, used in monotherapy for epilepsy. The initial diagnosis is based on clinical features and laboratory tests. Patch tests positive to Lamotrigine and Valproic showed cross-reactivity between these antiepileptic drugs.

P138 Oxacillin induced toxic epidermal necrolysis: clinical case Gasiuniene E.1, Pileckyte M.2, Pilipaitytė L.3, Sitkauskiene B.1

1Lithuanian University of Health Sciences, Pulmonology and Immunology Department, Kaunas, Lithuania, 2Lithuanian University of Health Sciences, Rheumatology Department, Kaunas, Lithuania, 3Lithuanian University of Health Sciences, Plastic and Reconstructive Surgery Department, Kaunas, Lithuania


ABSTRACTSToxic epidermal necrolysis (TEN) is a rare but potentially fatal delayed hypersensitivity reaction to numerous medications. Antibacterial, anticonvulsants and nonsteroidal anti-inflammatory drugs are the most common etiologic factors. The approved and controversial management strategies are still under consideration, including the administration of intravenous immunoglobulin (IVIG). We describe a patient who developed TEN while using oxacillin for the treatment of acute uric arthritis. Patient suffered from podagra, type II diabetes mellitus for several years. Four days after starting oxacillin in addition to diclophenac and antihypertensive drugs (nebivolol and fosinopril) the patient experienced systemic hypersensitivity reaction with diffuse pruritic maculopapular eruption, which became vesicular and bullous, involved oral and genitalia mucosa. Diagnosis of TEN was considered, skin biopsy was performed and previously used drugs were discontinued. Skin biopsy histology revealed dermal infiltration of monomorphonuclear and polymorphonuclear cells, background of ulcer was coated with necrotic detrit and neutrophils, desquamated epidermis. In addition to standard treatment (discontinued all suspected drugs, adequate maintenance of skin lesions), IVIG was administered of 0.4 g/kg (30 g) a day for a 5-day-course. The treatment led to prevention of new blister formation and improvement of skin lesions. This case-report suggests that IVIG might be beneficial in the treatment of patients with TEN.

P139 A case with dress and macrophage activating syndrome Ozmen S.1, Duman H.1, Bostanci I.1, Dogru M.1, Keles S.1

1Dr. Sami Ulus Research and Training Hospital of Women’s and Children’s Health and Diseases, Pediatric Allergy, Ankara, Turkey Introduction: DRESS is a life-threatening hypersensitivity syndrome characterized by skin rash, fever, leukocytosis, eosinophilia and / or atypical lymphocytosis, lymph node enlargement, liver and / or renal disfunction. It usually occurs 2-6 weeks after the exposure of specific drugs especially anticonvulsants. Herein we report a case of DRESS induced by multiple antibiotics and who developed hemophagocytic syndrome (HPS). Case: A five year-old girl was admitted to hospital with angio-odema and hematuria. The medical history revealed insulin-dependent diabetes mellitus and nonatopic asthma. Amoxicilline-clavulonate for 15 days and cephalexin for three days was used for pneumonia 18 days prior to admission. She was diagnosed as hemolytic-uremic syndrome and pneumonia and ceftriaxone treatment was begun. On the fallowing days multiple antibiotics like ciprofloxasin, vancomycine was begun and clinical manifestations included fever, lymphadenopathy, rash, hypereosinophilia, and visceral involvement (hepatitis) occured. She was diagnosed as DRESS. Although IVIG and steroid treatment, she developed hemophagocytic syndrome (HPS) which was fetal Conclusion: In conclusion, since DRESS is a life threatening syndrome it should be minded at patients who developed eruption, fever and internal organ involvement under any kind of treatment.

P140 Stevens-Johnson syndrome and toxic epidermal necrolysis: Are they more frequent in certain age groups? Mockenhaupt M.1, Sekula P.2, Liss Y.3, Schumacher M.2

1University Freiburg Medical Center, Department of Dermatology, Freiburg, Germany, 2University Freiburg Medical Center, Institute of Medical Biometry and Medical Informatics, Freiburg, Germany, 3University Freiburg Medical Center, Department of Dermatology, Dokumentationszentrum schwerer Hautreaktionen (dZh), Freiburg, Germany Based on published case reports, it seems that severe cutaneous adverse reactions (SCAR) such as Stevens-Johnson-syndrome (SJS) and toxic epidermal necrolysis (TEN) are more frequent in children and young adults compared to elderly people. The purpose of this study was to determine whether frequency and incidence of SJS/TEN differ among certain age groups. All potential cases of SJS/TEN treated in hospitals throughout Germany are ascertained by a population-based registry for severe skin reaction (dZh). The registry started in 1990 and since 2003 all cases have been included into the international RegiSCAR-project. A high coverage rate of the registry is ensured by active surveillance and regular contact with approx. 1,800 hospitals and departments likely to treat patients with SJS/TEN. For this analysis, all cases occurring between 2003 and 2009 which were validated by an independent expert committee as “probable” or “definite” were included. They were compared with the population data from the German Federal Statistical Office for the same years. Age groups were defined for comparison of the two data sets as follows: < 11 years, 12-18 years, 19-64 years, 65-79 years, ≥ 80 years.


ABSTRACTSIn total, 483 validated cases of SJS/TEN were identified between 2003 and 2009, of which 254 were SJS, 161 were SJS/TEN-overlap and 68 TEN. Based on the population data the incidence was estimated being 0.46 in the age group < 11 year, 0.23 for 12-18 year old, 0.66 for 19-64 year old, 1.76 for 65-79 year old and 2.32 for patients of 80 years and older. The frequency of SJS/TEN was up to 10 times higher in the elderly population, although there was some variability due to small numbers in some age groups over the years. The rather conservative approach to only include probable and definite cases of SJS/TEN leads to an overall lower incidence than previously reported by the German Registry. Earlier incidence calculations included possible cases of SJS/TEN and varied between 1.53 and 1.89. There may be various reasons for a higher frequency of SJS/TEN in older patients: One could be an increased use of medication in general but also the use of specific medications with a high risk to induce SJS/TEN, such as allopurinol. Furthermore, underlying conditions including impaired renal function and hepatic metabolism may contribute to the risk of SJS/TEN. Of course, the higher age among patients with SJS/TEN may also reflect the overall aging population in Germany.

P141 Acute generalized exanthematous pustulosis: analysis of 59 cases Schalk V.1, Kardenbach A.1, Sekula P.2, Mockenhaupt M.1

1University Freiburg Medical Center, Department of Dermatology, Dokumentationszentrum schwerer Hautreaktionen (dZh), Freiburg, Germany, 2University Freiburg Medical Center, Institute of Medical Biometry and Medical Informatics, Freiburg, Germany Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction (SCAR) usually induced by drugs. It is a rare disease occurring at any age. The clinical course shows a rapid onset with erythema followed by dozens to hundreds of sterile, non-follicular pinhead-sized pustules, located mainly in the folds. Beside the skin eruption the patients have fever (>38°C), neutrophilia (>7000/ul) and malaise. Even mild mucosal involvement and facial edema may occur. The resolution comes within a few days in a characteristic postpustular desquamation. The population-based registry on severe skin reactions in Germany (dZh) ascertains different types of SCAR including AGEP. All cases are reviewed by an independent expert committee separating definite, probable, possible and no cases of each reaction type. Since 2003 all cases are included into the International RegiSCAR-project. Between 2003 and 2010 106 AGEP-cases were collected in Germany and reviewed by the experts. 59 cases were validated as definite or probable cases, whose median age was 59 years (range 20-83 years). 32 (57%) patients were female. 73% of the patients developed AGEP before, 27% during hospital stay. Clinically, erythema (90% widespread, 71% >30% BSA) and pustules were seen in all cases. Duration of pustules was a median of 6 days, duration of desquamation 7.5 days and time of resolution took < 15 days in 88%. Mucosal involvement was described in 19%, especially oral (12%) and lip involvement (9%), fever in 46% of the cases. Neutrophilia was shown in 71% cases with a median of 17,288/ul. Infections within 4 weeks before the onset were seen in 59% of the patients and, in addition, 6% of the patients had a herpes simplex infection Compared to published data on AGEP, e.g. in the EuroSCAR-study (no German AGEP-cases included) or a case series from North Africa, patients from Germany are older. This may reflect the aging population in Germany, but could also mean that AGEP is rarely identified as a SCAR in children and adolescents. A pre-described female predominance could be confirmed. The role of infections, especially bacterial ones, are frequently found in AGEP and may indicate the risk due to antibiotic treatment, which has been shown to be a risk factor. Mucosal involvement seems to be more frequent than suggested. It should, therefore, be accepted as a sign of AGEP and should not lead to downgrading in the score system.

P142 Comparative proteomic approach identifies serine protease inhibitors as potential prognostic and therapeutic applications for Stevens-Johnson Syndrome and toxic epidermal necrolysis Chen T.-J.1,2, Chung W.-H.3, Hung S.-I.2, RegiSCAR, Asian SCAR1Taipei Medical University-Wan Fang Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China, 2National Yang-Ming University, Institute of Pharmacology, School of Medicine, Taipei, Taiwan, Republic of China, 3Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China


ABSTRACTSPurpose: To Identify biomarkers in SJS/TEN blister fluids or plasma by proteomic analysis Method: We collected blister fluids from the skin lesions of SJS (n=3) and TEN (n=3) for the initial proteomic profiling analysis, and blister fluids from burn patients (n=3) for the control comparison. The proteins in the blister fluids were first resolved into 30 fractions by SDS-PAGE, and then the protein IDs were identified by LC-MS/MS mass spectrometry and MASCOT techniques. We identified proteomics profiling which were up-regulated in the blisters of TEN or SJS, yet low levels or absence in burn blisters. We further validated the expression of these proteins in an extended sample size of the blister fluids or plasma sample in acute stage of SJS/TEN, or health controls by ELISA and western blotting analysis. Result: The serine protease inhibitors (SPIs) were found to be highly expressed in blister fluids of TEN or SJS, including alpha-1-antichymotrypsin (ACT) and kallistatin (KS). ACT is known to be involved in immune modulation and KS is also reported to be involved in vascular inflammation. Our study further showed plasma level of ACT and KS were significantly lower in acute stage of non-survival TEN patients, comparing to survival SJS or TEN patients. Conclusion: SPIs were significantly increased in blistering lesions of SJS/TEN and decreased plasma level of SPIs was associated with poor prognosis for patients with SJS or TEN, suggesting a functional role of SPIs in SJS/TEN.

P143 Toxic epidermal necrolysis- carbamazepime Pitsas V.1, Savatianos S.1, Manousakis M.1, Papadopoulos N.1

1National & Kapodistrian University of Athens, Allergy & Clinical Immunology, Athens, Greece Background: The prevalence of adverse drug reactions (ADR) in patients receiving some drugs in a chronic base is estimated at 10-20% and can be potentially life-threatening. Toxic epidermal necrolysis (TEN) is one of the most severe forms of ADRs, with low incidence but high mortality. The most frequently incriminated drugs are antibiotics, non-steroidal anti-inflammatory drugs and anti-convulsants. Other drugs, such as vancomycin, although less frequent, can also be involved. Case-Report: The authors present a case of a 12-year-old boy with a history of afebrile seizures. From the age of 4 and up to the age of 8 years, he was suffering from seizures treated them with valproic acid. At the age of 12, a new episode of seizures reappeared. The patient was administered carbamazepine and 5 days later he developed a truncular micropapular rash with good initial response to hydroxylzine hydrochloride taking it for a couple of days. A month later, the patient presented with fever, skin lesions on the trunk, face and upper extremities, erythema and erosions of the buccal, ocular and genital mucosa. His clinical condition progressed to blister formation and epidermal detachment of more than 40% of total body surface. The suspected drug was immediately discontinued and supportive care measures as well as IV immunoglobulin were adopted, with complete clinical resolution within 3.5 weeks. In the course of the TEN treatment, the patient was given azithromycin, cefotaxim, vancomycin, nystamycin, tobramycin, carbomer with no direct adverse reactions. Atopy patch tests to the anti-convulsants that were performed one month later were positive to carbamazepine. Discussion: In our case there was a strong evidence and clear temporal correlation between the intake of anti-convulsant drug (carbamazepime ) and TEN. Anticonvulsant administration should be done with caution since some of them, such as carbamazepine, could prove dangerous especially in children. Our patient was advised to refused taking carbamazepine again and was given valproic acid with excellent results

P144 DRESS syndrome induced by Piperacillin-Tazobactam in six patients Calderón O.1, Cabañas R.1, Prior N.1, Fiandor A.1, Caballero M.1, Quirce S.1, López-Serrano M.1, Bellón T.1

1La Paz University Hospital, Allergy Department, Madrid, Spain Purpose: Drug reaction rash with eosinophilia and systemic symptoms (DRESS) syndrome, also known as drug-induced hypersensitivity syndrome (DIHS), is a life-threatening multiorganic systemic reaction characterized by rash, fever, lymphadenopathy, hepatitis, and leukocytosis with eosinophilia. Our objective is to describe the


ABSTRACTSclinical and laboratory findings of six DRESS syndrome cases induced by Piperacillin-Tazobactam. They were studied in our allergy clinic from 2006 to 2010. Methods: A descriptive study using the patients´ clinical charts was perfomed. The DRESS syndrome diagnosis was established according to Kardaun diagnosis scale criteria and Japanese consensus group. An allergological workup including prick test, intradermal test, patch test and Lymphocyte Transformation Test (LTT) according to Pichler et. al. was carried out in order to identify the culprit drug. Results: Six out of the 23 patients diagnosed with DRESS syndrome in our allergy clinic were induced by Piperacillin-Tazobactam. Our cohort of two women and four men had a median age of 64 years (range 43-83). All of them had been treated with an intravenous dose of Piperacillin-Tazobactam (4g-500 mg /tid) for prolonged infectious diseases. Skin rash had a mean latency time of 19.3 days (range 14-28), maculopapular pruriginous generalized exanthema was detected in all cases and facial edema in 50%. Fever was present in five patients and lymphadenopathies in two. The mean time for skin clinical recovery was 17.8 days (range 2-35). All six patients had eosinophilia greater than 1000/mm³, two had leukocytosis, one had atypical lymphocytes. Further analyses revealed hepatic cytolysis in four patients. HHV-6 reactivation was detected between the first to third week following the onset of symptoms in two out of six patients. LTT was positive in all the patients with SI > 4. All of them had a full recovery. Conclusions: Piperacillin-Tazobactam was shown to be the most frequent culprit drug in our group of patients with DRESS and it should be included on the list of drugs that cause DRESS syndrome. Skin rash, facial angioedema, fever, eosinophilia, and liver abnormalities are features of Piperacilin-Tazobactam DRESS syndrome. Full recovery was observed after the withdrawal of the culprit drug in all our cases. An allergological study including LTT was proved useful in identifying the drug involved in the reaction.

P145 DRESS syndrome induced by vitamin B1 and B12 contained in a Polyvitaminic complex Calderón O.1, Cabañas R.1, Fiandor A.1, Prior N.1, Quirce S.1, López-Serrano M.1, Bellón T.1

1La Paz University Hospital, Allergy Department, Madrid, Spain Purpose: Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse drug reaction. Aromatic anticonvulsants and allopurinol are reported as main responsible drugs. To our knowledge there is only 1 reported case of DRESS induced by vit B1 and none by B12 in literature. Methods: A 38-year-old female was admitted with fever (39 º C), malaise and bullous lesions with progressive deterioration despite treatment with corticoids and anti-H1. She had generalized erythroderma excluding face and soles. Blisters were present on her wrists, inguinal areas and lower limbs. Nikolsky sign was negative. She had facial and cervical edema, occipital and cervical lymphadenopathies. Blood tests revealed leukocytosis (24,000) on admission, eosinophilia later on, maximum 10%, (1010) in the 3rd week and elevated liver enzymes (AST:147, ALT:212, GGT:389). A diagnosis of exfoliative erythroderma secondary to infection vs drugs was established. She had taken zolmitriptan during the last 5 years when needed, the last dose 2 months before. Polyvitaminic complex (PC), (Folic acid, Vit B1, B2, B3, B6, B12, Iron and others) 1 tablet oid, during the last 5 months. These drugs were stopped. She was treated with anti-H1, intravenous human IgG, and antibiotics with favourable outcome in ten days with desquamation. Different serologies including herpes viruses and skin biopsy were ordered.Allergological study carried out with PC and its components. Lymphocyte Transformation Test (LTT) was performed according to Pichler et al; an stimulation index (SI) was calculated. Prick, intradermal (ID) and patch tests were also performed. Results: Serologies: HHV-6 IFI:1/80 and 1/160 in the 2nd and 3rd week respectively. Histology was DRESS suggestive. Allergological study: LTT was positive to PC (SI>7) in 2 different determinations and with vit B1 (SI>2). ID tests were positive with vit B1 at immediate reading and with vit B12 at 24h reading. Patch tests were negative. Conclusions: We report a DRESS syndrome induced by a Polyvitaminic Complex. A definite diagnosis according to Kardaun scale criteria and typical DRESS according to Japanese consensus group was established. Patient´s outcome was good with treatment and withdrawal of the responsible drug. PC, especially its components Vitamin B1 and B12 were identified as the responsible drugs. LTT and ID tests have been useful in the diagnosis. We report the first case of DRESS by vit B1 with performed allergological study.


ABSTRACTSP146 DRESS syndrome by Metamizole magnesium associated a fulminant hepatic failure by Acetaminophen Calderón O.1, Cabañas R.1, Fiandor A.1, López-Serrano M.1, Jiménez A.2, Prior N.1, Quirce S.1, Bellón T.3

1La Paz University Hospital, Allergy Department, Madrid, Spain, 212 de Octubre Hospital, Allergy Department, Madrid, Spain, 3La Paz University Hospital, Madrid, Spain Purpose: Drug reaction with eosinophilia and systemic symptoms (DRESS), is a life-threatening multiorganic systemic reaction. Fulminant hepatic failure (FHF) is defined by the sudden onset of hepatic encephalopathy in an otherwise healthy individual, often in association with coagulopathy, jaundice and multisystem organ failure. Methods: A 21 yr old male (RegiSCAR interview number 5010033) was studied in Allergy department after receiving a hepatic transplant for FHF, suspecting DRESS by NSAIDs vs Acetaminophen (AC). Eleven days before he had taken Metamizole magnesium (MZ) 1 cp/tid for dental pain (3cps). Five days later he started with fever (39ºC), malaise, myalgias, and arthralgias. He was treated with ibuprofen 600 mg 1 cp/tid (6cps) and acetaminophen (AC) 1g (2cps) without improvement and appearance of abdominal rash. Ibuprofen was stopped and he continued taking 3 more doses of AC 650mg. Despite treatment with corticoids and antiH1, he had a progressive deterioration with high fever and maculopapular generalized exanthema. Blood tests revealed liver disfunction, leucocytosis, thrombopenia and elevated levels of AC at admission. Hepatic encephalopathy, coagulopathy and multisystem organ failure was developed 48 hrs later as well as sharp worsening of hepatic function tests and leucocytosis with 16.9% Eos 4060. He needed an urgent liver transplant despite treatment with N-acetyl-cistein and high doses of corticoids. NSAIDs and AC were forbidden. Allergological study was carried out 7 months later. Patch tests and Lymphocyte Transformation Test (LTT) according to Pichler et al. were performed. Results: Negative serologies to hepatic and herpes viruses. Hepatic histology: Centrolobulillar necrosis with infiltrate of activated lymphocytes and eosinophils. LTT was positive to MZ (SI>2) and negative to AC and ibuprofen. Patch test was positive to MZ at 72 h reading, with persistence of positivity 1 week later. ASA was administered orally under clinical surveillance with good tolerance. Conclusions: We report a DRESS case induced by MZ with associated FHF by AC. A definite diagnosis (score 6) according to RegiSCAR criteria (Kardaun et al 2007) was established. We think that liver inflammation due to DRESS by MZ has decreased the threshold for liver toxicity by AC, and FHF has developed even without very high doses of AC. LTT and patch tests have been useful in identifying MZ as the culprit drug of this DRESS syndrome. Good tolerance to ASA has been proved.

P147 Exploration of biomarkers in Stevens-Johnson syndrome and toxic epidermal necrolysis using a newly developed mouse model Nakajima S.1, Egawa G.1, Miyachi Y.1, Kabashima K.1

1Kyoto University Graduate School of Medicine, Dermatology, Kyoto, Japan Purpose: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but potentially life-threatening adverse drug reactions. Since the early diagnosis is beneficial for treatment, it is important to explore biomarkers of SJS/TEN. Others and we have reported that granulysin, Fas ligand, and high mobility group box 1 protein (HMGB1) are possible candidates as biomarkers for early diagnosis, but their precise kinetics remains unclear. To this end, we sought to establish a new animal model to analyze the kinetics of biomarkers for SJS/TEN. Material and method: We newly generated transgenic mice that express a membrane-bound form of OVA under the control of the involucrin promoter (inv-mOVA). To induce epidermal necrolysis, we adoptively transferred naive OVA-specific CD8+ T cells from the OT-I transgenic mice into inv-mOVA transgenic mice. We collected serum with time and analyzed serum levels of several cytokines and alarmins by means of ELISA. Result: OT-I T cell transferred inv-mOVA mice exhibited severe dermatitis in accord with epidermal necrolysis, which were reminiscent of SJS/TEN. In addition, consistent with the human analysis, Fas ligand and HMGB1 were elevated before the development of epidermal necrolytic skin lesions. Conclusions: Inv-mOVA transgenic mice can be a useful tool for analyzing the mechanism and exploration of biomarkers of SJS/TEN.


ABSTRACTSP148 TNF-α as a potentially useful marker in the disease process of DIHS Uno H.1,2, Watanabe H.1, Sueki H.1, Kabashima K.3, Tohyama M.4, Hashimoto K.4, Iijima M.1

1Showa University School of Medicine, Department of Dermatology, Tokyo, Japan, 2Showa General Hospital, Dermatology, Kodaira, Japan, 3Kyoto University Graduate School of Medicine, Dermatology, Kyoto, Japan, 4Ehime University Graduate School of Medicine, Dermatology, Toon-city, Japan Purpose: Many studies have been reported on drug-induced hypersensitivity syndrome (DIHS)/drug rash with eosinophilia and systemic symptoms (DRESS) since its identification in the 1990s, but the pathogenesis of this life-threatening syndrome is not fully understood. Patients and methods: We conducted comparative assessments of 21 cases of DIHS at the Department of Dermatology, Showa University Hospital, between August 2001 and March 2011 with respect to causative drugs and timing of human herpesvirus (HHV)-6 reactivation. In addition, we measured serum levels of CRP, LDH, IL-6, TNF-α and IL-13, and compared them with serum levels in patients with erythema multiforme (EM)-like drug eruption (n=7), Stevens-Johnson syndrome/toxic epidermal necrolysis (n=4), and normal controls (n=9), before and after treatment. Moreover, these protein levels were measured when HHV-6 reactivation was observed in patients with DIHS. Results: The DIHS group comprised 17 men and 4 women (mean age 49±15.4 years). Causative drugs were anticonvulsants (14 patients), allopurinol (4), mexiletine (1), salazosulfapyridine (1) and trichloroethylene (1). Anti-HHV-6 IgG titers were significantly increased in 14 patients. HHV-6 DNA was detected in the serum in 10 patients (mean 24.4±7.0 days for 9 patients; HHV-6 DNA was detected during the whole disease course in the remaining patient because of chromosomal integration). Interestingly, the TNF-α level decreased significantly in parallel in response to treatment in the DIHS group only (P< 0.05). Their levels were not increased at HHV-6 reactivation. Pre-treatment serum IL-6 levels were significantly higher in the DIHS group than in the EM-like drug eruption group (P=0.0439) and normal controls (P=0.012). Moreover, in the DIHS group, serum levels of TNF-α, CRP and LDH before treatment were significantly higher in the HHV-6 reactivated group than the non-HHV-6 reactivated group (P< 0.05). Serum IL-13 levels were undetectably low in all subjects. Conclusions: These results indicate that TNF-α reflects therapeutic responses and may be a useful marker of the disease process. Moreover, TNF-α may be a predictive tool of HHV-6 reactivation in DIHS.

P149 Stevens Johnson Syndrome to toxic epidermal necrolysis. A rapid progression. Case report Herrera A.G.1, Hernández V.M.1, Durán C.2

1INP, Immunology and Allergy, Mexico City, Mexico, 2INP, Dermatology, Mexico City, Mexico Aim: To remind the rapid progression from SJS to NETMethod: Case reportResult: A 3 year-old boy, was transfer by plane from a small state in Mexico, as an emergency to receive medical care and treatment on January 2012. He was previously healthy without relevant background. On january 12th, he presented low grade fever, a doctor prescribed acetaminophen but the fever persisted, so the doctor added ibuprofen and then metamizole (a third NSAID)without control. The day after he presented red eyes and odynophagia. He also received “homotoxicology” the parents reported as homeopathy. The next day a pediatrician prescribed a second generation cephalosporin for “upper airways infection” and continued NSAID with partial control of fever. The next day he presented maculo-papular skin lesions on neck and posterior thorax, the pediatrician added an antiviral because he suspected chickenpox. The next day the skin lesions spread to the rest of the body forming painful and confluent blisters that covered about 80% of the total body surface. His parents and doctors decided transfer him to Mexico City. We received at the ER, with regular hydration, heart and respiratory rate increased, complaining of severe pain and the lesions previously described. A central catheter and urinary catheter were placed and he was orotracheal intubated. He received a 2gr per kg dose of IVIG, broad-spectrum antibiotics and antifungal agent, analgesia and sedation, intravenous fluids, vaseline, topical antibiotic and Epifast (keratinocytes) on lesions. Initially his laboratory studies reported CRP and ESR elevated, hypoalbuminemia and discrete leukopenia and neutropenia, the rest was normal. In the following days he needed an increase in IV fluids and norepinephrine until his vital signs returned to normal. He started parenteral feeding by transpyloric tube. He presented dysthermias, considering normal at first, but the next 3days he presented fever, we decided a new IVIG dose (1grkg) and extend the antimicrobial treatment. Then he was extubated, afebrile and the rest


ABSTRACTSof vital signs such as laboratory studies returned to normal. After 22 days he was discharged from the intensive care unit with skin lesions healing, oral mucosa and lips remains affected, covered by crusts but he accepts oral feeding. He moves and walks normally and he is without antimicrobial agents. Conclusion: These kind of patients must be treated quickly to prevent the progression and the treatment must be intesive.

P150 Dress long term sequelae: A prospective study of 43 patients Ben Said B.1, Berard F.2, Rozieres A.3, Nosbaum A.2, Nicolas J.-F.1

1Hospices civils Lyon/CHU Lyon Sud, Severe Cutaneous Drug Reaction Regional Center / Allergology and Immunology Department, Lyon, France, 2Hospices civils Lyon/CHU Lyon Sud, Severe Cutaneous Drug Reaction Regional Center, Lyon, France, 3Inserm U 851, Hospices Civils Lyon,Universite Claude Bernard Lyon, Allergolgoy and Immunology Department, Lyon, France DRESS syndrome is one of the most severe cutaneous drug reaction with an estimated mortality of 10%. The prognosis of DRESS at the acute phase depends on visceral involvement which may affect all organs among which kidney and liver failure are the most severe. However, patients recovering from DRESS may develop short-term (1-6 months) and long-term (>6months) sequelae which frequency and severity are not known precisely. Here we report on a prospective study evaluating the long term sequelae after DRESS syndrome. Materials and methods: Between June 2009 and October 2011, 43 patients with the diagnosis of DRESS (KARDAUN score >5) were included in this study and consulted a panel of medical specialists 6 month after the onset of the disease. Results: Visceral involvment in acute phase were dominated by liver and kidney failure (27 and 16 cases respecitively). Other diseases included heart (4 cases), hemophagocytosis (2 cases), polyneuropathy (2 cases), lung (3 cases) and GI tract (1 case). All patients had a skin rash. At 6 month, chronic visceral alteration were found in 18/43 patients(41%). The sequelae involved the skin [18 cases (xerosis, chronic eczema, erythroderma)], liver [3 cases : chronic hepatitis with cytolysis (2 cases) and cholestasis (1 case)], kidney (4 cases with 2 cases confirmed by kidney biopsy), heart (2 cases with chronic cardiac insufficiency), nerves (2 cases including one case of chronic polyradiculonveritis), autoimmune diseases (4 cases included 1 GVH, 1 thyroiditis, 2 alopecia aerata) and lung (2 cases of interstitial pneumopathy). Among the patients with sequelae, 13 patients have been treated with systemic corticosteroids at acute phase and 5 patients with topical corticosteroids. Discussion - conclusion: DRESS is very often complicated by long term organ involvement. The frequency of persisting skin symptoms and the emergence of autoimmune diseases following DRESS was unexpected. Therefore, a systematic and careful follow-up of all DRESS patients needs to be implemented in the guidelines of the clinical management of DRESS. Bibliography: Cacoub P, Musette P, Descamps V, Meyer O, Speirs C, Finzi L, Roujeau JC .The DRESS syndrome: a literature review. Am J Med. 2011;124:588-97. Kano Y, Ishida T, Hirahara K, Shiohara T.Visceral involvements and long-term sequelae in drug-induced hypersensitivity syndrome.Med Clin North Am. 2010 ;94:743-59.

P151 A network of regional medical centers to improve the management of severe cutaneous adverse drug reactions (SCADR). The 2 year experience of the Lyon regional center CCR2A.Ben Said B.1, Berard F.1, Rozieres A.1, Nosbaum A.1, Nicolas J.-F.1

1Hospices civils Lyon/CHU Lyon Sud, University Lyon1, Lyon-Sud Medical School; INSERM, U851; Drug Allergy Unit, Allergy and Clinical Immunology Department and CH Lyon-Sud, Lyon, France In January 2009, the French ministry of health created a network of regional medical centers involved in the management of SCADR, under the responsibility of the National reference center based in Creteil. The Lyon regional center is referred to as CCR2A (Centre de Competence Rhone-Alpes-Auvergne). Seven different diseases are under the scope of the network: 1) toxic epidermal necrolysis (TEN), including Lyell and Stevens-Johnson syndroma, 2) drug-induced reaction with eosinophilia and systemic symptoms (DRESS), 3) acute generalized exanthematous pustulosis (AGEP), 4) Bullous fixed drug eruption (BFDE, 5), major erythema


ABSTRACTSmultiforme (EM), 6) linear IgA dermatosis (DIgA), 7) other severe erythematous drug eruptions (EDE). The aim of the network is to improve the management of SCADR: i) acceleration of the diagnosis and standardization of the treatment at the acute phase; ii) follow-up of patients to detect and treat sequelae; iii) development of clinical and fundamental research programs. During the period 01/2009-04/2011, 122 patients have been included in the CCR2A program: 66 DRESS, 21 TEN ,8 AGEP, 6 EDE, 4 BFDE, 2 EM, 0 DIgA but also 15 non-drug induced dermatosis (DNM), including 7 Staphylococcal Scaled Skin Syndrome. 86 patients were seen at the acute phase (45 DRESS and 12 TEN). 74 patients have received allergological work-up (immunobiological assays and patch tests) after resolution of the symptoms and 74 were evaluated at 6 month for diagnosis of sequelae (43 DRESS, 14 TEN, AGEP 7, 5 EDE, 3 BFDE, 2 major EM). Sequelae were found in TEN (100%) and DRESS (42% ). The immuno-allergological assessment allowed the identification of the offending drug in 56% of DRESS, 33% of TEN, 33% of AGEP, 66% of EDE, 0% of BFDE and 50% of EM. The reintroduction of alternate drugs was performed in 18 DRESS, 2 TEN, AGEP 1 and TM 2 without incident. Conclusion: The 2 year experience of CCR2A confirms the usefulness of a network organization in the managment of SCADR at both the acute and chronic phase.

P152 Aseptic meningitis associated with lamotrigine: Case report and review of the literature Knowles S.1, Shear N.H.1

1Sunnybrook Health Sciences Centre, Toronto, Canada Purpose: Drug-induced aseptic meningitis (DIAM) most frequently presents with headache, fever, meningismus and changes in mental state. The drugs most frequently associated with this adverse reaction include NSAIDs, antibiotics (in particular trimethoprim-sulfamethoxazole) and intravenous immunoglobulin. We report a case of DIAM following lamotrigine. Case report: A 63-year-old woman with a history of bipolar disorder, presented to the emergency with a 5-day history of headache, neck pain, erythematous macular rash on trunk and legs, and fever (39ºC). She had been started on lamotrigine 25 mg daily 2 weeks before the onset of her symptoms. She was on no other medication. Routine blood tests were normal except for WBC 3.8x109/L with lymphocytes 0.3x109/L, elevated AST (402 IU/L) and ALT (149 IU/L), and serum sodium 134 mmol/L. Her cerebrospinal fluid (CSF) values were: protein 422 mg/L (N: 150-450), glucose 4 mmol/L (N: 2.8-4.2), WBC 28x106/L (N: 0-10). CSF and blood cultures for bacteria, mycobacteria, and viruses were negative. Her brain CT scan was normal. On admission, the lamotrigine was discontinued and she was empirically started on antibiotics. Her course in hospital was uneventful and she was discharged after 4 days. Results: A diagnosis of aseptic meningitis due to lamotrigine was made, although a broader diagnosis of DRESS (Drug Rash Eosinophilia Systemic Symptoms) is perhaps more accurate since the patient had a triad of fever, rash and internal organ involvement. Use of the Naranjo adverse drug reaction probability scale indicates a probable relationship (score 6) between the patient’s reaction and exposure to lamotrigine. There have been 7 cases of lamotrigine-induced aseptic meningitis reported (including our case) (6 F, 1 M; mean age 50.3 years). Fever was present in all patients, and rash was reported in 3 patients. The mean time to onset of symptoms was 12.4 days, with a range of 3-20 days. Resolution occurred within 2-3 days of discontinuing lamotrigine. Four patients were rechallenged, with symptoms occurring with a mean of one hour after ingestion of the lamotrigine. Conclusions: Lamotrigine should be considered in the differential of drugs causing DIAM. Rash and fever were prominent in lamotrigine-associated cases (42 and 100%, respectively), suggesting a broader diagnosis of DRESS may be more appropriate.

P153 Delayed recognition of DRESS: A case series demonstrating frequent misdiagnosis Walsh S.A.1, Lee H.Y.1, Creamer D.1

1King’s College Hospital, Department of Dermatology, London, United Kingdom Aim: Early recognition of DRESS, withdrawal of the suspected drug and the institution of supportive/specific measures are vital if the complications of multi-organ failure and death (mortality being estimated at 10%) are to be avoided. The failure on the part of non-dermatologists to recognize and manage DRESS as an adverse drug reaction has been recently reported, with a high rate of misattribution to other diagnoses. The aim of our study


ABSTRACTSwas to review the presentation and initial diagnosis of 27 cases ultimately fulfilling the criteria for DRESS at our institution. Methods: data were taken from a UK severe drug reactions database, supplemented by information from review of clinical notes. Results: There were 11 males and 16 females, with a mean age of 40 years. Besides the cutaneous eruption, symptoms of fever and malaise were most common (75%). 18 patients initially presented to medical departments (internal medicine: 8, dermatology: 3, rheumatology: 2, hepatology: 2, pediatrics: 1, haematology: 1, chest medicine: 1). 4 patients presented to neurosurgery, 2 patients were on the intensive care ward and 3 patients were initially seen in the emergency department. In 13/27 (48%) cases, infection was the presumed initial diagnosis. In a further 7/27 (26%) patients, infection plus another diagnosis (such as an inflammatory or autoimmune condition) was initially applied. This led to the inappropriate prescribing of antibiotics in 15/27 (56%) patients. Drug hypersensitivity was only suspected in 7/27 patients at presentation, meaning that almost three-quarters of patients with DRESS were misdiagnosed at presentation. There was a mean delay of 1.7 days in the correct diagnosis being reached. The definitive diagnosis of DRESS was made in all cases by the consulting dermatologist. Over time in our institution, the proportion of cases of DRESS initially diagnosed as infection has fallen, from 0.6 in 2005 - 2007, to 0.5 in 2007 - 2009, to 0.38 in 2010 - 2011. Conclusions: We infer from these results that awareness of DRESS is increasing, possibly attributable to improved dissemination of information on this severe adverse drug reaction. This condition represents a further example of the importance of the dermatologist both in the acute hospital setting and in out of hours care

P154 Clinical trial and mechanism of anti-TNF alpha as a therapeutic agent for Stevens-Johnson syndrome/ toxic epidermal necrolysis Chung W.-H.1, Hui R.C.-Y.1, Yang C.-H.1, Hung S.-I.2, RegiSCAR, Asian SCAR1Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China, 2National Yang-Ming University, Institute of Pharmacology, School of Medicine, Taipei, Taiwan, Republic of China Purpose: Previously we have found that granulysin released from CTL and NK cells is key mediator for epidermal necrolysis in SJS/TEN. However, currently, an ideal treatment for SJS/TEN is still unavailable. A previous clinical trial for TEN by using thalidomide (an anti-TNF alpha mechanism) showed increased mortality. We aim to evaluate the potential therapeutic effect of the biologic anti-TNF alpha and its therapeutic mechanism related to granulysin in SJS/TEN. Method: A prospective randomized open-label trial of etanercept vs. systemic corticosteroids is conducted for patients with SJS or TEN in Taiwan. Patients are included within 7 days after disease onset (date of the first cutaneous sign). In addition to evaluation of the survival rate, the end points include duration between onset and maximum of skin detachment, beginning of re-epithelization, and complete healing of skin or mucosal erosions since disease onset. Result: There are 44 SJS/TEN-patients (26 etanercept, 18 systemic corticosteroids ) enrolled in this study. 4 patients with TEN deceased (2 /13 (15.4%) in the etanercept group, 2/8 (25%) with TEN in the corticosteroids group, (p=0.6). The average duration to reach maximal skin detachment in SJS/TEN was 6.8 days in the etanercept group and 8.6 days in the corticosteroids group (p=0.05). The average duration to complete skin healing in SJS/TEN was 14 days in the etanercept group and 18.5 days in the corticosteroids group (p=0.026). Further in vitro investigations showed that etanercept as well as steroids or thalidomide significantly decreased granulysin expression of blister cells in SJS/TEN. However, thalidomide increased the cytotoxic effect of SJS blister fluids to keratinocytes, but etanercept has no additional cytotoxic effect on keratinocytes. In addition, etanercept up-regulated Treg and decreased granulysin expression in patients with SJS/TEN. Conclusion: Anti-TNF alpha is effective for the treatment of SJS/TEN. There was no increased mortality as observed in thalidomide trial by using biologic anti-TNF alpha agent. Compared to systemic corticosteroids, a shorter mucocutaneous healing time was observed in the group with anti-TNF alpha therapy. The therapeutic mechanism of biologic anti-TNF alpha further shows an ability to attenuate granulysin expression of CTL and NK cells and up-regulates Treg in patients with SJS/TEN.


ABSTRACTSP155 Clinical prognostic factors related to toxic epidermal necrolysis Lin J.-W.1, Ho H.-C.1, Yang C.-H.1, Chung W.-H.1, RegiSCAR, Asian SCAR1Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China Purpose: To evaluate variables that may be associated with prognosis and severity of patients with TEN. Method: A retrospective review of 35 consecutive patients with TEN (13 men and 22 women; age range: from 13 to 91 years, mean age= 54.33 years) over a period of 7 years(from July 2002 to July 2009) was undertaken in Chung Gung Memorial Hospital, Taiwan. They were classified into two groups on the basis of the ultimate survival outcome (20 and 15 for surviving and non-surviving, respectively). Clinical data and laboratory data were analyzed. Differences between groups were evaluated by the chi-square test with p< 0.05 considered as statistically significant. Result: Several factors showed significant differences between the two groups. The main factors associated with mortality in TEN are leukopenia with bandemia, concurrent malignancy, septicemia, hypoalbuminemia, and serum level of bicarbonate, blood urea nitrogen, creatinine, and lactate. Conclusion: The clinical prognosis factors related to TEN from Taiwan were consistent with the prognostic factors of SCORTEN. Other poor prognostic factors other than SCORTEN need to be further investigated.

P156 HHV6 integration into human chromosomes as a cause of misleading diagnosis of HHV6 reactivation in DRESS Ben Said B.1, Rogez S.2, Descamps V.3, Berard F.1, Nicolas J.-F.1

1Hospices civils Lyon/CHU Lyon Sud, Severe Cutaneous Drug Reaction Regional Center, Lyon, France, 2CHU Dupuytren, Laboratoire de Virologie, Limoges, France, 3Hopital Bichat, APHP, Service de Dermatologie, Paris, France During the last 5 years a close relation between DRESS (Drug reaction with eosinophila and systemic symptom) and human herpes virus (HHV) reactivation has been suggested. Different teams actually considered DRESS as a manifestation of uncontrolled antiviral immunity against these re-activated viruses. HHV6 is a latent herpes which DNA could be integrated into the host germline genome and transmitted thereafter in a Mendelian way. This integration is found in about 1% of the human population. We report a case of HHV6 integration in a DRESS patient responsible for a positive blood HHV6 PCR which may have been interpreted as an HHV6 infection/reactivation. Case report: In July 2011, a 79 year old man developed a DRESS 4 weeks after the introduction of antibiotics (teicoplanine and ofloxacine) for severe sepsis. The symptoms included a pancytopenia (neutrophils < 700/mm3, platelets 60000/mm3 and anemia), hepatic cytolysis associated to blood eosinophilia (2900/mm3) and skin rash (generalized morbilliform rash and purpuric lesions). The Kardaun score was 6. HHV6 blood PCR was strongly positive (1,5x107 copies/ml). The evolution of DRESS was favorable within one month under systemic corticosteroids. Four months later HHV6 PCR was still positive (7.2x 105 copies/ml) without any sign for ongoing viral infection. Because of this discrepancy, we tested for HHV6 DNA integration in patient’s chromosomes. HHV6 DNA was found in patient’s hair follicle and cytogenetic FISH analysis found the integration site in chromosome X. The medical history of the patient and his family (especially women) did not find any sign of HHV6 infection or herpes virus-associated diseases. We concluded that the positive HHV6 blood PCR reflected the presence of the integrated HHV6 gene rather than the existence of HHV6 reactivation and consequently we did not treat the patient with antiviral drugs. Conclusion: We recommend checking for integration of HHV6 DNA into human chromosomes in DRESS patients with extremely high loads of HHV6 PCR DNA copies before concluding to an HHV6 infection and starting an antiviral treatment. Reference: Pellett PE, Ablashi DV, Ambros PF et al. Chromosomally integrated human herpesvirus 6: questions and answers Rev Med Virol. 2011 in press.


ABSTRACTSP157 Cytomegalovirus (CMV) infection of the gastrointestinal tract during DRESS: Usefulness of CMV blood PCR Ben Said B.1, Wallet F.2, Durupt F.3, Berard F.1, Nicolas J.-F.1

1Hospices civils Lyon/CHU Lyon Sud, Severe Cutaneous Drug Reaction Regional Center, Lyon, France, 2Hospices civils Lyon/CHU Lyon Sud, Intensive Care Unit, Lyon, France, 3CH Valence, Service de Dermatologie, Valence, France DRESS syndrome is a rare but lethal hypersensitivity syndrome which pathophysiology involves several immune abnormalities including i) herpes virus infections, ii) immune restoration syndrome and iii) drug hypersensitivity. Gastrointestinal (GI) involvement during DRESS remains rare. Here, we report three DRESS patients who developed a late cytomegalovirus (CMV) infection of the GI tract with favourable evolution under gancyclovir therapy Results: The characteristics of the patients are summarized in Table 1. Briefly, the 3 patients developed DRESS (Kardaun score of 6, 6 and 7) under treatment for tuberculosis (1 patient) and leukemia (2 p). At time of DRESS diagnosis, blood PCR for HHV6 was positive but negative for CMV. GI symptoms [oesophagitis (2p) and colitis (1p)] started 6 weeks after the onset of DRESS only. At that time the CMV PCR was positive in the blood of the 3 patients. Anti-viral treatment (gancyclovir) yielded to rapid improvement in 4 (p3), 10 (p1) and 15 days (p2). Discussion: Severe digestive involvement during DRESS, mostly due to CMV infection, remains rare with only few cases reported. Our report: i) confirms that CMV infection may occur lately in DRESS patients and emphasize the need to check for GI symptoms (abdominal pain, diarrhea, bleding) suggestive of GI CMV infection ; ii) supports that HHV6 reactivation represents an early risk factor for later CMV reactivation and GI infection; iii) suggests that the specific PCR on blood has a diagnostic value for CMV infection/reactivation which may be as good as the CMV PCR performed on GI lesions; iv) shows that antiviral treatment is highly effective and should be started as early as possible after proof of CMV infection. Bibliography:Do-Pham G, Charachon A, Duong TA et al.Drug reaction with eosinophilia and systemic symptoms and severe involvement of digestive tract: description of two cases. Br J Dermatol. 2011 ;165:207-9. Asano Y, Kagawa H, Kano Y, Shiohara T.Cytomegalovirus disease during severe drug eruptions: report of 2 cases and retrospective study of 18 patients with drug-induced hypersensitivity syndrome. Arch Dermatol. 2009 Sep;145(9):1030-6.

P158 Delayed elimination of oxypurinol contributes to the poor prognosis of allopurinol-induced severe cutaneous adverse reactions Chang W.-C.1, Lee M.-H.H.2, Stocker S.L.2, Graham G.G.2, Williams K.M.2, Day R.O.2, Chung W.-H.3, Hung S.-I.1

1National Yang-Ming University, Institution of Pharmacology, Taipei, Taiwan, Republic of China, 2University of New South Wales, Department of Clinical Pharmacology and Toxicology, Sydney, Australia, 3Chang Gung Memorial Hospital, Department of Dermatology, Taipei, Taiwan, Republic of China Purpose: Allopurinol is one of the notorious drugs causing severe cutaneous adverse reactions (SCAR). The renal clearance of allopurinol active metabolite, oxypurinol, is known to be related to renal function and patients with renal impairment are usually suggested to take lower dose of allopurinol. We previously reported that HLA-B*5801 is strongly associated with allopurinol-SCAR in Han Chinese, and this genetic predisposition has been later validated in different populations. In this study, we aim to evaluate the relationship between allopurinol pharmacokinetics (plasma oxypurinol level) and prognosis of allopurinol-SCAR. Materials and methods: We enrolled 65 patients of allopurinol-induced cutaneous adverse drug reactions (cADRs) from Chang Gung Memorial Hospital in Taiwan. We also recruited 82 allopurinol-tolerance who had received allopurinol for more than 6 months without adverse reactions as the control. We detected the levels of oxypurinol in the plasma of different time-points (from the beginning of allopurinol withdrawal to the disease maximal stage) by HPLC. We used the NONMEM model to estimate the oxypurinol plasma levels in the steady-state before the discontinuation of allopurinol. We analyzed the renal function by detecting creatinine clearance. Results: HLA-B*5801 is present in 92.3% (60/65) of allopurinol-cADRs patients, yet detected in only 26.8% (22/82) of tolerant controls (p=1.8E-16). Poor renal function (eGFR< 30mL/min/1.73m2) is more frequently detected in allopurinol-cADRs patients (60%, 39/65) than in the tolerance (22%, 18/82) (p= 3.3E-6). In 39 patients


ABSTRACTSwith renal impairment, 29 cases showed delayed elimination of plasma oxypurinol, and maintained abnormal high levels of oxypurinol after allopurinol withdrawal. By comparison, 5 of 26 patients with normal renal function had delayed elimination (p=1.5E-5; OR=12.2). Among the 39 patients with renal impairment, 9 patients expired, and 5 of them showed higher oxypurinol plasma levels (>1.6mg/L) lasting for longer than 10 days after withdrawing allopurinol. Conclusion: This study revealed that allopurinol-cADRs patients frequently showed poor renal function, delayed elimination of oxypurinol, and kept higher levels of oxypurinol, leading the worse of the clinic outcomes. Our results suggested that a rapid clearance of oxypurinol from plasma, such as hemodialysis approach, may attenuate the hypersensitivity reactions caused by allopurinol and improve the prognosis of SCAR patients.

P159 Immunosensitizing drugs are capable of inducing various early immune effects Kwast L.M.1,2, Fiechter D.1, Kruijssen L.J.W.1, Ludwig I.S.1, Pieters R.H.H.1

1Institute for Risk Assessment Sciences - Utrecht University, Research Group Immunotoxicology, Utrecht, Netherlands, 2TIPharma, Leiden, Netherlands Aetiology of drug-induced adverse immune reactions is not completely understood, but known risk factors include e.g. genetic background, age, immune status and metabolism. This complexity emphasises the need for models to examine (early) mechanisms contributing to the development of adverse reactions. The liver is a key organ in the metabolism of orally taken drugs, generating reactive metabolites and possibly haptens. Furthermore, the liver is an immunological active organ with a distinct leukocyte population. Previously, we have shown that acetaminophen (APAP) increases the influx of neutrophils in the liver and stimulates T cell responses to a bystander antigen (TNP-OVA). In addition, we have shown that depletion of neutrophils in APAP-treated mice partly prevented the adjuvant effect of APAP, confirming the importance of neutrophils in the immune-adjuvant effect of APAP, but also indicating that other immune processes are involved in induction of APAP-induced hypersensitivity. Therefore, we measured several immune parameters shortly after oral exposure to APAP and other drugs with known immune-adjuvant capacity. Mice were orally exposed to vehicle or drugs (APAP, diclofenac (DF), carbamazepine (CMZ) or ofloxacin (OFLX)). Sixteen hours after either a single or the last of seven consecutive doses of the drugs blood was drawn and the mice were sacrificed. Liver and spleen were removed for analysis of e.g. drug-related immune responses. DF and APAP were able to induce changes in spleen weight after oral exposure. Liver weight was increased following DF or CMZ exposure, and decreased after OFLX administration. Also all chemicals were able to modify the levels of liver enzymes in plasma. Oral exposure to APAP and DF resulted in an increase of neutrophils and in increased expression of the neutrophil chemo-attractant MIP-2 in the spleen and increased serum MIP-2 levels. Furthermore, DF exposure resulted in decreased percentages of naïve CD4+ T cells and increased percentages of memory CD4+ T cells. CMZ exposure increased the percentage of naïve CD8+ T cells and decreased the percentages of effector and memory CD8+ T cells. APAP and OFLX did not induce changes in CD4+ or CD8+ T cell phenotypes. In conclusion the observed adjuvant activity of immunosensitizing drugs appears to be linked to early innate immune effects in the liver.

P160 Direct interaction between HLA-B and carbamazepine activates T cells in Stevens-Johnson syndrome Wei C.-Y.1,2, Chen Y.-T.3, Hung S.-I.3,4

1Molecular Medicine Program, Taiwan-International Graduate Program, Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Republic of China, 2Institute of Biochemistry and Molecular Biology, School of Life Sciences,National Yang-Ming University, Taipei, Taiwan, Republic of China, 3Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan, Republic of China, 4Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China Aims: Increasing studies revealed that HLA alleles are the major genetic determinants of drug hypersensitivity; however, the underlying molecular mechanism remains unclear. Here, we adopt the HLA-B*1502 genetic predisposition to carbamazepine (CBZ)-induced Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) as a model to study the pathological role of HLA in delayed-type drug hypersensitivity.


ABSTRACTSMethod: We in vitro expanded CBZ-specific cytotoxic T lymphocytes (CTLs) from CBZ-SJS/TEN patients and analyzed the interaction between HLA-B and CBZ/analogs by CTLs response, surface plasmon resonance, peptide binding assay, site-direct mutagenesis, and computer modeling. Results: The endogenous peptides-loaded HLA-B*1502 molecule presented CBZ to CTLs without the involvement of intracellular drug metabolism or antigen processing. The HLA-B*1502 /peptide/β2m protein complex showed binding affinity toward chemicals sharing 5-carboxamide on the tricyclic ring as CBZ. However, modifications of the ring structure of CBZ altered HLA-B*1502 binding and CTLs response. In addition to HLA-B*1502, other HLA-B75 members could also present CBZ to activate CTLs, whereas members of HLA-B62 and B72 could not. Three residues (Asn63, Ile95, and Leu156) in the peptide-binding groove of HLA-B*1502 were involved in CBZ presentation and CTLs activation. In particular, Asn63 shared by members of B75 was the key residue. Computer simulations revealed a preferred molecular conformation of 5-carboxamide group of CBZ and the side chain of Arg62 on the B pocket of HLA-B*1502. Conclusions: This study demonstrates a direct interaction of HLA with drugs, provides a detailed molecular mechanism of HLA-associated drug hypersensitivity, and has clinical correlations for CBZ-related drugs induced SJS/TEN.

P161 Quantification of the frequency of human T-cells specific to penicillin G in healthy donors Nhim C.1, Delluc S.2, Delarue-Cochin S.3, Weaver R.J.4, Claude N.4, Joseph D.3, Maillère B.5, Pallardy M.1

1INSERM UMR-S 996, Université Paris-Sud, UFR Pharmacie, Châtenay-Malabry, France, 2Indicia, Lyon, France, 3UMR CNRS 8076, Université Paris-Sud, UFR Pharmacie, Châtenay-Malabry, France, 4Institut de Recherches Internationales Servier, Suresnes, France, 5Commissariat à l’Energie Atomique et aux Energies Alternatives, Service d’Ingénierie Moléculaire des Protéines, Gif-sur-Yvette, France Penicillins are known to provoke hypersensitivity reactions in treated patients. Initiation of allergic reactions needs the presentation of peptides associated to the drug, by dendritic cells (DC) to T lymphocytes (LT). According to the hapten hypothesis, penicillins, due to their low molecular weight, have to bind to a protein, to be recognized by the immune system. Penicillins can bind covalently to proteins, like Human Serum Albumin (HSA), especially to the nucleophilic primary amine function of lysine residue, through opening of their β-lactam ring. The aim of this work was to evaluate the frequency of T cells, able to specifically recognize HSA-Penicillin G adducts. HSA-Penicillin G bio-conjugates were produced using physiological and basic pH conditions, and characterized by mass spectrometry. One to seventeen penicillin G molecules were found to be bound to HSA depending on the coupling conditions. Co-cultures of human CD4+ LT or naïve CD4+ LT from healthy donors, with human DC loaded with bio-conjugates was performed. These CD4+ T cells were stimulated three times with fresh autologous DC. Stimulated T-cell lines were then detected using an ELISpot Interferon γ assay. Frequencies of T-cell precursors specific to HSA-Penicillin G adducts were calculated. Six donors, harbouring the most frequent HLA-DR allotypes in the Caucasian population, have been tested. T-cell lines specific to HSA-Penicillin G adducts were detected for each donor, and the frequency ranges from 0,08 to 0,7 specific LT per million of peripheral LT. This study demonstrates and quantifies for the first time the existence of LT specific to HSA-Penicillin G adducts, in the circulating blood from healthy donors. Preliminary data, using CD45RA+ T cells shows that recognition was mediated by naïve T-cells.

P162 Expression of IL-17 and IL-22 in severe cutaneous drug-induced hypersensitivity reactions: Differential expression of IL-22 in SJS/TEN Hermoso A.1, Escamochero S.1, Cabañas R.2, Fiandor A.2, Moreno R.3, Buitrago A.1, Bellón T.1, PIELenRed, RegiSCAR 1Hospital La Paz Health Research Institute-IdiPaz, Madrid, Spain, 2Hospital La Paz Health Research Institute-IdiPaz, Allergy, Madrid, Spain, 3Hospital Universitario La Paz, Dermatology, Madrid, Spain Purpose: Previous transcriptomic microarray analysis of peripheral blood mononuclear cells from patients with cutaneous adverse drug reactions (cADR) revealed increased expression of IL17A during the acute disease. IL-17 is a proinflammatory cytokine involved in several autoimmune and autoinflammatory diseases. Some


ABSTRACTScell subpopulations producing IL-17 also secrete IL-22 which has a relevant role in the regulation of epithelium homeostasis. We studied the expression of IL-17 and IL-22 in PBMCs from patients with various cADR (SJS/TEN, DRESS, and MPE) and analyzed differences in gene expression levels in different clinical entities. Methods: Quantitative PCR analysis of IL17A and IL22 gene expression was performed in peripheral blood mononuclear cells (PBMCs) from patients with SJS/TEN (N= 13), DRESS (N=7), and mild exanthematic reactions (N=10). PBMCs from 13 control donors with no history of drug hypersensitivity were also analyzed for comparative purposes. Results: In PBMCs from SJS/TEN patients IL-17 mRNA levels were increased as compared to control donors. However, no differences were found in mRNA levels between acute and resolution samples. IL-22 gene expression was also increased in SJS/TEN patients. Moreover, when blister fluid cells were analyzed we found increased IL-17 and IL-22 mRNA levels as compared to PBMCs drawn simultaneously from the donors. On the contrary, in DRESS patients only IL-17 was overexpressed, while no differences were found in IL-22 mRNA levels between DRESS samples and healthy individuals. IL-17 and IL-22 mRNA levels in patients with mild reactions were similar to those in healthy donors. Conclusions: The proinflammatory cytokine IL-17 is overexpressed in severe reactions like SJS/TEN and DRESS and may participate in the cutaneous or systemic inflammatory response. On the contrary, high expression of IL-22 was found specifically in SJS/TEN. This differential expression may lie behind differences in the pathogenesis of both clinical entities. Whereas IL-22 alone has protective and regenerative effects, it synergizes with proinflammatory agentes such as IFN-γ, TNF-α, or IL-17 and stimulates the production of several cytokines, chemokines and antimicrobial peptides by keratinocytes, amplifying the inflammatory reaction. Such functional synergism is also observed for IL-17. Thus, overexpression of IL17A and IL-22 together with high levels of TNF-α and/or IFN-γ may have great impact in cutaneous blistering diseases.

P164 Chemical restriction of abacavir-responsive T-cells Bell C.C.1, Yang E.2, Santoyo Castelazo A.1, Martinsson K.1, Maggs J.L.1, Alfirevic A.1, Jenkins R.1, Tugwood J.3, Powell H.3, Schuppe-Koistinen I.4, Cederbrant K.4, O’Neill P.M.2, Pirmohamed M.1, Naisbitt D.J.1, Park K.B.1

1University of Liverpool, Department of Pharmacology, Liverpool, United Kingdom, 2University of Liverpool, Department of Chemistry, Liverpool, United Kingdom, 3AstraZeneca, Macclesfield, United Kingdom, 4AstraZeneca, Södertälje, Sweden Purpose: The incidence of hypersensitivity reactions to abacavir has been effectively reduced by the introduction of genetic screening for HLA-B*5701. The isolation of drug-specific CD8+ T-cells from both hypersensitive patients and healthy volunteers provides evidence of an immune pathogenesis. The mechanisms of T-cell activation are currently unclear. The hepatic formation of a protein-reactive aldehyde metabolite has been suggested in vitro, however this is yet to be confirmed in patients. We sought to evaluate the immunogenicity of abacavir utilising lymphocytes from genotyped volunteers. Methods: Abacavir-specific T-cell clones were generated by serial dilution from volunteers expressing HLA B*5701 and other HLA molecules. Clones were then characterised in terms of their phenotype and functionality. Analogues of abacavir were synthesised and used to probe the chemical restriction of the MHC-TCR interaction. The hepatic metabolism of each of the compounds was assessed in human liver cytosol via mass spectrometry. Alcohol dehydrogenase expression and activity in antigen presenting cells was also measured. Results: Abacavir-specific clones were generated from all volunteers expressing HLA-B*5701. These clones proliferated and secreted cytokines (IFN-g, IL-13) and effector molecules (FasL, GrzB and perforin). Antigen presenting cells (APCs) pulsed with abacavir for 16h stimulated 10/19 T-cell clones. This response was blocked by fixation of the APCs with glutaraldehyde prior to adding the drug. Pulsing the APCs with abacavir for 1h did not stimulate T-cells. An alternative enantiomer of abacavir (1R,4S conformation) did not stimulate any of the clones tested. Both enantiomers were however metabolised to three isomeric carboxylic acids in human liver cytosol. This metabolism was 4-methylpyrazole sensitive. Metabolic investigations in APCs were unable to detect any turnover via mass spectrometry (LOD = 2nM). Low levels of mRNA for ADH1, 6 and 7 were however detected via PCR array. Higher levels of ADH 5 mRNA were detected and the protein for this isotype was also identified by protein mass spectrometry. Conclusion: Chemical restriction exists at the HLA-TCR interface and is key to the activation of abacavir-specific T-cell clones.


ABSTRACTSP165 Multiple drug hypersensitivity in patients with cystic fibrosis: Characterization of highly drug-specific T-cell clones Yaseen F.S.1, Monshi M.1, Farrell J.1, Whitaker P.2, Peckham D.2, Park K.B.1, Naisbitt D.J.1

1University of Liverpool, Pharmacology, Liverpool, United Kingdom, 2St James’s Hospital, Regional Adult Cystic Fibrosis Unit, Leeds, United Kingdom Aim: Β-lactam antibiotics provide the cornerstone of treatment for lung infections in patients with cystic fibrosis. However, up to 20% of patients develop multiple hypersensitivity reactions. Reactions are usually non-immediate and consist of maculopapular rash, fixed drug eruption, arthralgia and fevers. We have recently characterized multiple haptenic structures on albumin in patients exposed to piperacillin and shown that albumin conjugates constitute functional antigenic determinants for T-cells. In this study we have looked at three commonly prescribed β-lactam antibiotics; piperacillin, aztreonam and meropenem, in order to determine (1) if it is possible to detect drug-responsive T-cell in vitro and (2) the reason why certain individuals develop multiple hypersensitivity reactions. Methods: PBMC were isolated from 5 patients with a history of hypersensitivity to at least 2 of the drugs and 5 tolerant controls. PBMC responses to piperacillin, aztreonam and meropenem were characterized using the lymphocyte transformation test and enzyme-linked immunosorbent spot (ELISpot; IFN-γ, IL-13). T-cell clones were generated from drug-stimulated T-cell lines and characterized in terms of phenotype and function. Results: PBMC proliferative responses were detected with cells from the hypersensitive patients following exposure to piperacillin, aztreonam and meropenem. ELISpot showed increased IFN-γ and IL-13 secretion in drug-treated cultures. PBMC from tolerant controls did not proliferate or secrete cytokines when stimulated with the drugs. Aztreonam and piperacillin-responsive CD4+ T-cell clones were generated from the hypersensitive patients. A panel of thirty clones were shown to proliferate and secrete cytokines in a concentration-dependent fashion. Activation of clones was highly drug specific. Proliferation and cytokine secretion was detected with piperacillin or aztreonam, but not the alternative drug. Conclusion: Piperacillin-, aztreonam- and meropenem-specific proliferative responses and cytokine secretion are detectable with PBMC from hypersensitive patients with cystic fibrosis. In patients with a history of multiple hypersensitivity reactions, separate T-cell clones exist that are stimulated with a single drug.

P166 Developing in vitro culture methods to characterize primary T cell responses to drugsFaulkner L.1, Martinsson K.2, Santoyo Castelazo A.1, Alfirevic A.1, Pirmohamed M.1, Schuppe-Koistinen I.2, Cederbrant K.2, Powell H.3, Tugwood J.3, Naisbitt D.1, Park K.1

1University of Liverpool, MRC Centre for Drug Safety Science, Liverpool, United Kingdom, 2AstraZeneca, Molecular Toxicology, Sodertalje, Sweden, 3AstraZenca, Molecular Toxicology, Alderley Park, United Kingdom Purpose: Adverse drug reactions represent a major stumbling block to drug development and those with an immune aetiology are the most difficult to predict. Thus, we have developed an in vitro T cell priming assay using peripheral blood from healthy volunteers to assess the allergenic potential of drugs. The drug metabolite nitroso-sulfamethoxazole (SMX-NO) was used as a model drug allergen to establish optimum assay conditions. Methods: Naive CD4 T cells were co-cultured with monocyte-derived dendritic cells at a ratio of 25:1 in the presence of the drug for a period of 8 days, to expand the number of drug-responsive T cells. The T-cells were then incubated with fresh dendritic cells and drug and their antigen-specificity analyzed using readouts for proliferation, cytokine secretion and cell phenotype. Results: All 4 volunteers showed dose-dependent proliferation as measured by CFSE content and by 3H-thymidine uptake. CD4 T cells that had divided in the presence of SMX-NO had changed from a naive phenotype (CD45RA+) to a memory phenotype (CD45RO+). These memory T cells expressed the chemokine receptors CCR2, CCR4 and CXCR3 suggesting a mixture of TH1 and TH2 cells in the responding population; with a propensity for homing to the skin. Drug stimulation was also associated with the secretion of a mixture of TH1 cytokines (IFNγ and TH2 cytokines (IL-5 and IL-13) as detected by ELISpot.Conclusion: Our findings clearly demonstrate that a model drug allergen stimulates naive CD4+ T cells from healthy volunteers to proliferate, secrete cytokines and change their phenotype. The assay is flexible in that the phenotype and function of T cells can be measured using a battery of readouts. We are currently developing this approach to investigate the allergenic potential of other drugs, including those where an association between specific HLA alleles and susceptibility to an immunological reaction has been established.


ABSTRACTSP167 Characterization of the antigen specificity of T-cell clones from piperacillin hypersensitive patients with cystic fibrosis El-Ghaiesh S.1, Monshi M.1, Whitaker P.2, Jenkins R.1, Meng X.1, Farrell J.1, Peckham D.2, French N.1, Pirmohamed M.1, Park K.1, Naisbitt D.1

1University of Liverpool, MRC Centre for Drug Safety Science, Liverpool, United Kingdom, 2St James’s Hospital, Cystic Fibrosis Unit, Leeds, United Kingdom Purpose: β-lactam antibiotics provide the cornerstone of treatment for patients with cystic fibrosis. They reduce the rate of decline of lung function in these patients but their use is limited by a high frequency of delayed-type allergic reactions. The objective of this study was to utilize cloned T-cells from five piperacillin hypersensitive patients to characterize both the cellular pathophysiology of the reaction and its antigen specificity; in order to define the mechanism of activation of T-cells by piperacillin. Methods: T-cell clones were generated from 5 piperacillin lymphocyte transformation test positive hypersensitive patients and characterized in terms of phenotype and function. ELISA, Western blot and mass spectrometry were used to (1) identify piperacillin binding proteins, (2) define the kinetics of adduct formation and (3) define the specific lysine residues targeted by the drug. A fully-characterized synthetic piperacillin albumin conjugate was generated for T-cell studies to explore mechanisms of antigen presentation. Results: Over 400 piperacillin-responsive CD4+, CD4+CD8+ or CD8+ T-cell clones were generated. The T-cell response (proliferation, cytokine secretion and cytotoxicity) to piperacillin was concentration-dependent and highly specific. Piperacillin was found to bind exclusively to albumin in the T-cell cultures. Haptenic epitopes were detected at Lysine 190, 195, 199, 432 and 541 on albumin. A synthetic piperacillin albumin conjugate stimulated T-cell receptors via a MHC-restricted and processing-dependent pathway. Flucloxacillin competes for the same Lysine residues on albumin as piperacillin but the resulting conjugate does not stimulate T-cells. This shows that the hapten is responsible for antigen specificity. Thus, binding of the piperacillin hapten in peptide conjugates confers structural specificity on the activation of the T-cell receptors expressed on drug-specific clones. Conclusion: Collectively, these data describe the cellular processes which underlie the structural specificity of piperacillin antigen binding in hypersensitive patients with cystic fibrosis.

P168 Development of cell culture methods to study drug antigen-specific memory B-cell antibody production Sullivan A.1, Faulkner L.1, Amali M.1, Monshi M.1, Park K.1, Naisbitt D.1

1University of Liverpool, MRC Centre for Drug Safety Science, Liverpool, United Kingdom Purpose: Antigen-specific memory B-cells have an important role in the presentation of soluble antigen to T cells. They influence the T-cell response by enhancing antigen capture and delivery and by modulating processing pathways. We and others have used β-lactam albumin conjugates to detect anti-drug antibodies in certain β-lactam tolerant and allergic patients. However, the dynamics of the drug-specific humoral response, the kinetics of antibody production and the profile of β-lactam albumin binding associated with a B-cell response have not been defined. Thus, the purpose of this study was to develop integrated cell culture methods to characterize antigen-specific memory B-cell antibody production using PBMC isolated from drug tolerant and hypersensitive patients. Methods: Anti-IgG ELISpot and flow cytometry staining (CD3, CD19, CD27) methods were used to characterize the activation of memory B-cells. Unstimulated and CpG DNA stimulated PBMC were cultured for 5 days, prior to transfer to IgG coated ELISpot plates and antibody staining for flow cytometry. An aliquot of cell culture supernatant was collected and stored for measurement of total IgG and IgG subtypes by ELISA. In certain experiments, cell cultures were supplemented with a combination of BAFF, IL-10, IL-15 and IL-21. Results: The assay used relies on the ability of memory B-cells, but not naive B-cells, to differentiate into antibody secreting plasma cells in response to CpG DNA. The number of CD19+ cells was increased 2-3 fold in the presence of CpG DNA and IgG secreting cells were readily detectable by ELISpot. Addition of IL-15, IL-21 and BAFF resulted in small changes in cell expansion, differentiation and IgG secretion. The greatest effect was found with IL-10 which reduced B cell expansion compared to CpG DNA alone but significantly enhanced the proportion of CD19 cells expressing high levels of CD27. Conclusion: We have developed methods to characterize memory B-cell activation and the array of IgG


ABSTRACTSsubtypes secreted from activated B-cells. These techniques can be applied directly to drug allergic and tolerant patients. Culture conditions have been optimized to allow the use of soluble drugs that form protein adducts in situ. Of note, IgG subtypes are measured directly from culture supernatant; thus, fully characterized protein conjugates are not required to define the profile of the humoral response.

P170 Tregs in carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis Ko T.-M.1,2, Chen Y.-T.1,2,3, Hung S.-I.1,4,5

1Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan, Republic of China, 2National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China, 3Duke University Medical Center, Durham, United States, 4Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China, 5Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan, Republic of China Specific human leukocyte antigens (HLAs), correlate with the trigger of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Previous reports also demonstrated that the drug-specific T-cell receptors (TCRs) of cytotoxic T lymphocyte cells (CTLs) are critical for recognizing the complex of drug/peptide-HLA as well as the development of SJS and TEN. However, the role of peripheral tolerance for maintaining immune homeostasis and suppressing the cytotoxicity of these drug-specific CTLs remains unclear. Using carbamazepine (CBZ) induced-SJS/TEN as a model, we aim to investigate whether regulatory T cells (Tregs) are involved in the immune reaction of SJS and TEN. We enrolled patients with CBZ-SJS/TEN and subjects who are tolerant to CBZ. We determined the frequency of regulatory CD4+CD25highCD127low/- Treg cells and evaluated Treg cell-related cytokines, including interleukin-35 (heterodimer of EBI3 and IL-12A), transforming growth factor beta (TGF-beta), and interleukin-10 (IL-10), as well as transcription factors (FoxP3) in the CBZ-stimulated T cells from patients with SJS and TEN. After 4 cycles of CBZ incubation with PBMCs from CBZ-SJS/TEN patients, an enrichment of CD8+ T cell subsets was nearly 80 %, but the quantity of CD4+CD25highCD127low/- Treg cells was not detectable. When comparing the frequency of CD4+CD25highCD127low/- Treg cells in the in vitro enriched cells obtained at the same time-point (the 2nd cycle), there was no significant difference between the cells obtained from CBZ-SJS/TEN patients or from tolerant subjects. Similarly, there was no significant up-regulation of the expression of Treg cell-related cytokines. Furthermore, no specific TCR subfamily from the PBMCs cultures of tolerant subjects could be selected for suppressing drug-specific T cells. Depletion of CD4+CD25highCD127low/- Treg in the PBMCs of CBZ-tolerant subjects did not enhance the capacity of CBZ-reactivity. This study implies that the control of the development of SJS and TEN involves peripheral tolerance other than CD4+CD25highCD127low/- Tregs.

P171 In silico analysis of HLA associations with drug-induced liver injury: use of a HLA-genotyped cell archive from healthy volunteers Alfirevic A.1, Gonzalez-Galarza F.2, Bell C.C.1, Martinsson K.1, Platt V.1, Bretland G.1, Evely J.1, Lichtenfels M.1, Cederbrant K.3, French N.1, Naisbitt D.J.1, Park K.B.1, Jones A.R.2, Pirmohamed M.1

1University of Liverpool, Department of Pharmacology, Liverpool, United Kingdom, 2University of Liverpool, Department of Functional and Comparative Genomics, Liverpool, United Kingdom, 3AstraZeneca, Södertälje, Sweden Purpose: Drug-induced liver injury (DILI) is one of the most common adverse drug reactions leading to drug withdrawal post-marketing. Recently, genome-wide association studies have identified a number of human leukocyte antigen (HLA) alleles associated with ADRs to low molecular weight (LMW) drugs; however, the cellular and chemical mechanisms are not fully understood. Methods: To study these mechanisms of DILI, we established an HLA-typed cell archive from 400 healthy volunteers. In addition, we utilised HLA genotype data from publically accessible repositories on more than four million individuals such as Allele Frequency Net Database, Major Histocompatibility Complex Database and Immune Epitope Database to study HLA alleles which have been associated with DILI. Results: We utilised novel in silico strategies to examine HLA haplotype relationships among DILI alleles using information from the data repositories by implementing bioinformatics tools such as NetMHCpan, PyPop, GraphViz, Phylip and TreeView. We demonstrated that many of the alleles that have been associated with liver


ABSTRACTSinjury induced by structurally diverse drugs (flucloxacillin, co-amoxiclav, ximelagatran, lapatinib, lumiracoxib) reside on the same common HLA haplotypes, which were present in populations of diverse ethnicity. Conclusion: Our bioinformatic analysis indicates that there may be a connection between the different HLA alleles that have been associated with the therapeutically different drugs causing liver injury, possibly through the presence of causal variant(s) that are in linkage disequilibrium with the defined HLA alleles. Further functional work, together with next generation sequencing techniques, will be needed to define the causal alleles associated with DILI.

P172 Characterization of flucloxacillin-responsive T-cell clones from patients with liver injury. Monshi M.1, Gibson A.1, Faulkner L.1, Farrell J.1, Alfirevic A.1, Pirmohamed M.1, Park K.B.1, Naisbitt D.1

1University of Liverpool, Department of Molecular and Clinical Pharmacology, Liverpool, United Kingdom Purpose: The role of T-cells in drug reactions targeting the liver is not well defined. The discovery of HLA alleles as risk factors for DILI (e.g., flucloxacillin [B*5701]1, ximelagatran [DRB1*0701], lumiracoxib [DRB1*1501]) support an immune mechanism; however, biological data showing that cytotoxic T-cells are involved is lacking. The strength of the association described for flucloxacillin - approximately 85% of cases carry at least one copy of HLA-B*5701 - prompted us to investigate the cellular response in patients with flucloxacillin-mediated DILI. Methods: PBMC were isolated from 6 patients with a history of flucloxacillin-induced liver injury (5 of the patients express HLA-B*5701) and 5 tolerant controls. PBMC responses to flucloxacillin were characterized using enzyme-linked immunosorbent spot (ELISpot; IFN-γ, IL-5, IL-13, granzyme B, perforin, FASL). T-cell clones were generated from drug-responsive T-cell lines and characterized in terms of phenotype, function and cross reactivity with related drug structures. Results: PBMC activation with flucloxacillin was detected with five patients including the HLA-B*5701 negative blood donor. Thirty five flucloxacillin-responsive CD8+ clones expressing a range of different Vβ receptors were generated from the 4 HLA-B*5701 ELIspot positive patients. Flucloxacillin-responsive CD4+ clones were also generated, albeit in low numbers. Flucloxacillin-responsive CD4+, but not CD8+ clones, were generated from the HLA-B*4402/5501 ELIspot positive patient. Clones secreted Th1 and Th2 cytokines, and the cytolytic molecules granzyme B, FasL and perforin, following flucloxacillin stimulation. Activation of the clones with flucloxacillin was time- and processing-dependent. Interestingly, piperacillin, amoxicillin and penicillin G, which form similar antigenic structures on albumin lysine residues, also stimulated flucloxacillin-responsive clones. Conclusion: These data show that flucloxacillin is highly immunogenic and that drug-responsive cytotoxic T-cells circulate in most patients with liver injury. Protein binding is critical for the formation of β-lactam antigens and the stimulation of T-cells.

P173 HLA-B*5701-restriced activation of drug-responsive CD8+ T-cells provides the immunological basis for flucloxacillin-induced liver injury Monshi M.1, Faulkner L.1, Farrell J.1, Alfirevic A.1, Pirmohamed M.1, Park K.B.1, Naisbitt D.1

1University of Liverpool, Department of Molecular and Clinical Pharmacology, Liverpool, United Kingdom Purpose: The discovery of HLA-B*5701 as a risk factor for flucloxacillin-induced liver injury supports an immune mechanism. Moreover, we have recently characterized flucloxacillin-responsive T-cells in patients with liver injury. However, if the HLA-B*5701 genotype is a functional determinant of liver injury, it should be possible to activate T-cells from HLA-B*5701 positive volunteers, who have never been exposed to the drug. Thus, the aim of the current study was to explore whether flucloxacillin activates naive T-cells from volunteers expressing HLA-B*5701 and define the role of HLA-B*5701 in antigen presentation. Methods: We utilized our recently established in vitro T-cell priming assay that recapitulates key elements of events that occur in vivo during elicitation of an immunological drug reaction by combining naive CD3+ T-cells from 3 HLA-B*5701 positive volunteers with flucloxacillin and dendritic cells in culture. Drug-responsive T-cells were expanded for 8 days prior to analysis of IFN-γ secreting cells and T-cell cloning. Proliferation and cytokine secretion were measured by [3H]thymidine incorporation and ELIspot, respectively. The mechanism of flucloxacillin presentation to T-cells and the basis for the association with HLA-B*5701 was investigated using anti-class I/II blocking antibodies and antigen presenting cells expressing different HLA-B alleles.


ABSTRACTSResults: Flucloxacillin-enriched T-cells were found to secrete IFN-γ when re-stimulated with the drug, while the cells that had divided were shown to be CD8+ by T-cell cloning. Over 40 flucloxacillin-specific CD8+ clones generated from the 3 drug-naive volunteers were found to proliferate, and secrete cytokines and cytolytic molecules following drug stimulation. Activation of the clones with flucloxacillin was blocked using an anti-HLA class I antibody. Furthermore, T-cell activation was only detected when clones were stimulated with flucloxacillin and antigen presenting cells expressing either HLA-B*5701 or B*5801. Conclusion: These data represent an important breakthrough in our understanding of the role of the adaptive immune system in liver injury and effectively link the genetic association to the disease pathogenesis.

P174 Towards development of novel tools for the diagnosis of Beta-lactam hypersensitivity Earnshaw C.J.1, Jenkins R.E.1, Meng X.1, Naisbitt D.J.1, Pirmohamed M.1, Park B.K.1

1University of Liverpool, Molecular and Clinical Pharmacology, Liverpool, United Kingdom Purpose: Beta-lactam antibiotics are a major cause of drug-induced adverse reactions. The hapten hypothesis of drug hypersensitivity states that low molecular weight compounds must first bind covalently to a macromolecular carrier, such as a protein, in order to stimulate an immune response. Methods: Conjugates were generated in vitro by incubating a variety of beta-lactams with human serum albumin (HSA). Analysis of these synthetic conjugates by liquid chromatography tandem mass spectrometry (LC-MS/MS) was used to define the chemistry of hapten formation in vitro. These mass spectrometric methods were then used to analyse patient samples for the detection of hapten(s) in order to confirm the physiological relevance of the synthetic conjugate(s). Semi-quantitative epitope profiling by multiple reaction monitoring mass spectrometry (MRM-MS) of conjugates formed in vitro and in vivo was performed to validate the synthetic conjugate(s) as a tool for investigating beta-lactam induced immune responses. Results: Mass spectrometric analysis revealed that beta-lactams modify lysine residues in HSA (K12, K137, K162, K190, K195, K199, K212, K351, K432, K436, K475, K525, K541) in a concentration and time dependent manner, revealed by semi-quantitative epitope profiling. The epitope profiles seen in vitro were mirrored by those observed in vivo for albumin isolated from patient blood. In parallel studies, it was demonstrated that the conjugates are antigenic in T-cell assays with samples from hypersensitive patients. As the same drug-protein adducts were seen in both the hypersensitive and non-hypersensitive patient samples, absolute quantification of the hapten is required to determine whether there is a threshold at which the immune system is activated. Synthesis of drug-modified peptides for this purpose is problematic because of the lability of the adducts. Conclusion: These conjugates will be evaluated as fully-defined reagents for diagnosis and direction of therapeutic strategy in clinical practice.

P175 Influence of abacavir on the peptide binding properties of HLA-B*5701 molecules Yerly D.1, Jamin H.1, Adam J.1, Fontana S.2, Villiger P.3, Pichler W.J.3

1Clinic for Rheumatology, Allergology and Immunologie, Division of Allergology, Bern, Switzerland, 2Regional Blood Transfusion Service of the Swiss Red Cross, Bern, Switzerland, 3Clinic for Rheumatology, Allergology and Immunologie, Bern, Switzerland Aim of the study: The function of MHC class I molecules is to present antigenic peptides to CD8+ T cells. Since abacavir (abc) hypersensitivity reaction have been associated with the HLA-B*5701 allele, we hypothesize that abc may modify the peptide binding capacity of the of HLA-B*5701 molecules. Material and methods: HLA-B*5701 binding peptides were synthesized with a fluorochrome (FITC) on position 3 (FluoP). The binding of these peptides was measured by flow cytometry as a function of fluorescence of HLA-B*5701+ cells incubated with the FluoP, in presence or absence of abc. In addition, we generated peptide specific T cell lines (TCL) and analysed their peptide specific reactivity (CD107a upregulation and IFNg secretion) in the presence or absence of abc. Results: a) Incubation of HLA-B*5701+ cells with the FluoP resulted in a FluoP-concentration dependent fluorescence. Short-term co-incubation (30min - 4hours) with abc (50µM - 2mM) reduced the affinity for FluoP, which could only partly be balanced by increasing the FluoP concentration.


ABSTRACTSb) However, if pulsing with FluoP was done for 12hrs, addition of abc even enhanced the binding of FluoP. c) In order to verify these contradictory results, we performed functional assays with peptide specific TCL. Peptide titrations on antigen presenting cells (APC) were performed for 12hrs in presence or absence of abc and then used to stimulate specific TCL, so that the EC50 of the TCL for the peptide could be calculated. In presence of abc, a reduction of EC50 by a factor of 100 to 1000 could be detected, confirming the drastic increase in the peptide binding in presence of abc. d) Competition experiments of FluoP with a second unlabelled peptide were also undertaken, in absence or presence of abc. The competing effect of the second peptide was increased in the presence of abc. Conclusion: These data confirm that abc modifies the peptide binding properties of the HLA-B*5701 molecule. The shorter incubation time with abc limits the binding of peptides to HLA-B*5701 molecules, showing a typical competition kinetic. Long term incubation assays, functional data and competition assays with 2 peptides revealed that abc can actually facilitate the exchange of peptide on HLA-B*5701+ APC.

P176 Interleukin (IL) 17 expression by allergen-activated lymph node cells : innate and adaptive contributions Dearman R.J.1, Hayes M.D.1, Kimber I.1

1University of Manchester, Manchester, United Kingdom T helper (Th)17 cells and innate immune cells, including γδ T cells, express IL-17 cytokines and play important roles in inflammation and the pathogenesis of autoimmunity. However, little is known of their involvement in immune responses to low molecular weight drug allergens. Drug hypersensitivity reactions can be classified as delayed or immediate, with type 1 and type 2 T lymphocyte activation, respectively, implicated in the mechanism of action. Reference chemical allergens 2,4-dinitrochlorobenzene (DNCB) and trimellitic anhydride (TMA) have been shown previously to stimulate selective type 1 or type 2 immune responses, respectively, following prolonged (13 day) exposure of BALB/c strain mice. Using these haptens as chemical probes to polarise the immune system, we have investigated the kinetics of IL-17 expression in the skin draining lymph nodes (LN). At selected time points auricular LN were excised, single cell suspensions prepared, cultured for 120h and supernatants analysed by cytokine enzyme linked immunosorbant assay. A single topical (acute) exposure to both allergens resulted in transient up-regulation of IL-17 cytokines. Maximal levels were observed at 6h and 48h following DNCB and TMA treatment, respectively. A 13 day priming (day 0 and 5) and challenge (days 10, 11 and 12) (chronic) protocol which results in stimulation of preferential type 1 (interferon-g and IL-12) and type 2 (IL-4, IL-5 and IL-13) responses by DNCB and TMA, respectively, was examined. Under these conditions, only DNCB provoked IL-17 expression. Interestingly, priming of the mice followed by a single challenge completely abrogated TMA-induced IL-17 expression whereas DNCB treatment provoked a similar pattern of IL-17 production (transient peak at 6h) to that observed in the absence of priming, albeit at much lower levels. The pattern and kinetics of IL-17 production are consistent with a single acute exposure to both allergens stimulating IL-17 production by γδ T cells. During the development of the adaptive immune response, however, exposure to TMA down-regulates γδ T cell IL-17 production. Whereas not only is the γδ T cell response maintained following DNCB priming, but there is also evidence of Th17 cell activation.

P177 Genotype-phenotype association of HLA-B*1502 and carbamazepine induced cutaneous adverse drug reactions Hui R.C.-Y.1, Chung W.-H.1, Hsiao Y.-H.1, Hung S.-I.2, RegiSCAR, Asian SCAR1Chang Gung Memorial Hospital, Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Taipei, Taiwan, Republic of China, 2National Yang-Ming University, Institute of Pharmacology, School of Medicine, Taipei, Taiwan, Republic of China Purpose: To understand the genotype-phenotype association of HLA-B*1502 with various cutaneous adverse drug reactions (cADRs) induced by carbamazepine (CBZ) in Chinese. Method: We followed up the HLA-B genotypes of 195 patients in Taiwan with CBZ-induced cADRs and analyzed the possible correlation between prognosis and gene or drug dosage effect. Result: Of the 195 CBZ-induced cADRs, 112 were Stevens-Johnson syndrome/ toxic epidermal necrolysis (SJS/TEN), 53 maculopapular exanthema (MPE), 23 drug reaction with eosinophilia and systemic symptoms (DRESS)


ABSTRACTSand 7 other less common presentations. HLA-B*1502 was present in 100 of 112 cases (89.29%) of CBZ-induced SJS/TEN. A further stratification of clinical severity showed HLA-B*1502 was present in all patients of CBZ induced SJS or TEN with more extensive epidermal necrolysis (100% in cases with >5% body surface area (BSA)), but lost its 100% association in SJS with less BSA involved (< 5% BSA). In contrast, HLA-B*1502 was not associated with CBZ-induced MPE and DRESS. Further analysis on the severity or prognosis of SJS/TEN revealed no correlation with homozygosity for HLA-B*1502 or cumulative CBZ dosage effect. Conclusion: HLA-B*1502 was present in most CBZ-induced case of SJS/TEN with extensive epidermal necrolysis, but not associated with other types of CBZ- induced cADRs. In addition, few cases of CBZ-induced SJS without HLA-B*1502 were observed, especially in cases with limited blistering lesions, suggesting a possible correlation between the presence of HLA-B*1502 and extent of epidermal necrolysis. However, no gene dosage or drug dosage effect was found on severity or prognosis of CBZ-induced SJS/TEN.

P178 Investigation of hypersensitivity reactions to nevirapine in a Malawian cohort Cornejo Castro E.M.1, Carr D.F.1, Chaponda M.1, Rainbow L.2, Lane B.3, Jorgensen A.L.4, Alfirevic A.1, Pirmohamed M.1

1University of Liverpool, Department of Molecular and Clinical Pharmacology, Liverpool, United Kingdom, 2University of Liverpool, Centre for Genomic Research, Liverpool, United Kingdom, 3University of Liverpool, Department of Molecular and Clinical Cancer Medicine, Liverpool, United Kingdom, 4University of Liverpool, Department of Biostatistics, Liverpool, United Kingdom Purpose: Highly active antiretroviral therapy (HAART) is used for the treatment of human immune deficiency virus 1 (HIV-1) infections. Nevirapine (NVP) is a highly effective non-nucleoside reverse transcriptase inhibitor (NNRTI) used in combination therapies and is one of the most prescribed antiretrovirals in developing countries. However, approximately 5 % of patients receiving NVP-containing regimens develop drug-induced hypersensitivity reactions (HSR), which include drug rash with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and isolated drug-induced liver injury (DILI). Materials and methods: Over 1000 HIV-positive patients in Malawi treated with a NVP-containing regimen were recruited prospectively. Of these, 57 patients were diagnosed with NVP-induced HSRs. Another group of NVP-hypersensitive patients were also recruited retrospectively, giving a total of 237 patients with HSR. Depending on the time of sampling patients were subdivided into 3 groups: acute, tolerant and recovered. Expression levels in 36 mRNA samples were analysed by microarray analysis using the Agilent Human Genome Array. Genes that were differentially expressed during NVP-induced HSRs were identified and the results were validated using TaqMan qRT-PCR. Data analysis was performed using a multilevel model. Results: A transcript encoding CD177, a neutrophil-specific antigen implicated in transendothelial migration and proteinase 3 induced activation of neutrophils, was one of the most significantly up-regulated genes in NVP-treated patients in our cohort. CD177 showed higher expression in the tolerant patients when compared to the recovered group (at least 7.2 -fold increase; p < 0.005). The microarray data on CD177 was validated by qRT-PCR. Conclusions: Our study has identified gene transcripts, in particular CD177, which was significantly up-regulated in NVP-hypersensitive patients in a Malawian cohort. Further, functional investigation is necessary to elucidate the implications of the gene expression changes observed.

P179 Investigating the functional role of the HLA-A*3101 allele in Carbamazepine-induced hypersensitivity reactions Lichtenfels M.1, Alfirevic A.1, Park K.B.1, Naisbitt D.J.1, Pirmohamed M.1

1University of Liverpool, Department of Molecular and Clinical Pharmacology, Liverpool, United Kingdom Background: Carbamazepine (CBZ) is known to cause hypersensitivity reactions (HSR) in a small proportion of patients. There is strong evidence that specific human leukocyte antigen (HLA) alleles are associated with a higher risk of developing CBZ-induced HSR - HLA-A*3101 represents the latest example, and is associated with the major clinical phenotypes of CBZ-induced HSR in Caucasian and Japanese patients. The functional role of HLA-A*3101 however remains unclear.


ABSTRACTSAim: To determine whether HLA-A*3101 is functionally involved in the development of HSR to CBZ.Methods: Peripheral blood mononuclear cells (PBMCs) from 8 healthy volunteers, 4 positive and 4 negative for HLA-A*3101, were studied using a range of immune-based assays, such as the lymphocyte transformation test (LTT) and interferon-γ enzyme-linked immunospot assay (INF-γ ELISpot). PBMCs were stimulated with CBZ for 4 weeks to induce a primary immune response and subsequently tested for their reactivity to the drug. Additionally we looked at PBMCs isolated from patients with a reported HSR to CBZ. The generation of drug-specific T-cell clones was attempted from both healthy volunteers and patients. Results: None of the eight healthy volunteers showed a positive LTT and no difference in INF-γ secretion upon CBZ stimulation could be observed between lymphocytes from HLA-A*3101 positive and negative donors. After the 4-week induction culture, one out of four HLA-A*3101 positive samples showed a positive response in a 48-hr proliferation assay, but this could not be replicated in the INF-γ ELISpot. In contrast PBMCs from a HLA-A*3101 positive patient responded in both the 48-hr proliferation assay and INF-γ ELISpot, and T-cell cloning was performed successfully. Conclusions: Primary stimulation with CBZ using lymphocytes from HLA-A*3101 positive donors using the current methodology was not sufficiently sensitive in inducing a proliferative response, in contrast to the secondary stimulation observed in donors known to be hypersensitive. Further refinement of the assay is required.

P180 Association of MHC SNPs with delayed onset maculopapular exanthema after aminopenicillin use Swale A.1, Alfirevic A.1, Steen K.2, Gaeta F.3, Valluzzi R.L.3, Pirmohamed M.1, Romano A.3

1University of Liverpool, Molecular and Clinical Pharmacology, Liverpool, United Kingdom, 2University of Liverpool, Liverpool School of Tropical Medicine, Liverpool, United Kingdom, 3Complesso Integrato Columbus, Allergy Unit, Rome, Italy Purpose: Penicillins are the most widely prescribed antibiotics worldwide. Approximately 2% of total penicillin treatments result in hypersensitivity reactions, which can be classified as ‘immediate’ or ‘nonimmediate’. The latter reactions occur more than hour after the last drug administration and are characterised by a wide range of clinical manifestations, most commonly, maculopapular and urticarial rashes. Susceptibility factors have not been adequately characterised. The aim of our study was to investigate whether genetic variation across the MHC region on chromosome 6 predisposes to the occurrence of delayed onset maculopapular exanthema following aminopenicillin use Methods: We studied 142 patients with delayed onset maculopapular exanthema caused by aminopenicillins. All patients had positive responses to either immunological testing or oral provocation with at least one penicillin reagent. An initial cohort of 91 cases was genotyped for 1300 SNPs using the Illumina MHC mapping panel. Ethnicity-matched healthy controls comprised 159 individuals from the POPRES and HapMap TSI populations. The top 10 SNPs with the lowest p-values from the case-control analysis underwent further genotyping in our full cohort of 142 patients and 256 tolerant penicillin-exposed controls Results: In an initial analysis we identified ten SNPs associated with penicillin-induced delayed onset reaction. They were located in a number of HLA Class I and II genes such as RNF39, HLA-C, HLA-DQA1 and HLA-DRA. The top 10 SNPs were then genotyped in all of our cases (n=142) and controls (n=256). One SNP was found to be associated with delayed onset maculopapular exanthema arising after aminopenicillin use: rs707918 in the BAT5 gene (p=0.006; OR=1.60, 95% CI 1.13, 2.28). After correction for multiple testing this remained significant (p=0.048). Conclusion: Our findings support the involvement of the MHC in delayed onset penicillin-induced maculopapular exanthema. Further work is required to validate and extend these findings.

P181 Cytokine gene polymorphisms in cutaneous adverse drug reactions: a peculiar profile for drug reaction with eosinophilia and systemic symptoms (DRESS) Barbaud A.1, Waton J.1, Herberth B.2, Bursztejn A.-C.1, Bollaert M.1, Cuny J.-F.1, Schmutz J.L.1, Gueant-Rodriguez R.2, Namour F.2, Guéant J.L.2, Gastin I.2

1University Hospital of Nancy, Dermatology, Vandoeuvre les Nancy, France, 2University Hospital of Nancy, INSERM UMR 954, Vandoeuvre les Nancy, France


ABSTRACTSBackground: Some genes could be involved in the genetic susceptibility to cutaneous adverse drug reactions (CADR). Polymorphisms of genes controlling cytokine production have not been studied in CADR. Our objectives were to determine whether cytokine gene polymorphisms that predict the risk of immediate type drug allergy also contribute to the occurrence of other types of CADR. Methods: Results from 118 patients with a well-defined CADR were compared to 236 controls without drug intolerance living in the same area of France. We assessed nine polymorphisms: interleukin (IL)1-alpha-889C>T (rs 1800587), IL1-beta-511C>T (rs 16944), IL1-RN intron-2-VNTR (rs2234663), IL2-330T>G (rs 2069762), IL4-33C>T (rs 2070874), IL5-745C>T (rs 2069812), IL10-592C>A (rs 1800872), IL16-295T>C (rs 4778889), and tumour necrosis factor-alpha-308G>A (rs 1800629). Results: Three polymorphisms exhibited a significant association with CADR (p < 0.05). The combination of the IL1-RN-A2 and IL1-beta-511C alleles was statistically different between cases and controls (p = 0.007) and the A2C haplotype was associated with susceptibility to CADR, particularly in drug reaction with eosinophilia and systemic symptoms (DRESS) patients (odds ratio = 3.22; 95% confidence interval = 1.23-8.41; p = 0.016). The frequency of the IL10-592A allele was higher in DRESS patients than in controls (dominant model CC vs. CA+AA: p = 0.035). These abnormalities were not evident in maculopapular rashes or urticaria. Conclusions: This is the first study showing that IL1-cluster polymorphisms and haplotypes and the IL10-592A allele (a low IL10 producer) are predictors of DRESS. These gene variants may decrease drug tolerance and promote herpes virus reactivation.

P182 The pathogenic role of HLA-B*5801 in allopurinol-induced severe cutaneous adverse reactions Lin C.-H.1,2, Chen Y.-T.1,2, Hung S.-I.1,3

1Institute of Biomedical Science, Academia Sinica, Taipei, Taiwan, Republic of China, 2Graduate Institute of Microbiology, College of Medicine, National Taiwan University, Taipei, Taiwan, Republic of China, 3Institute of Pharmacology, School of Medicine, Genome Research Center, National Yang-Ming University, Taipei, Taiwan, Republic of China Allopurinol is a commonly prescribed drug used primarily to treat hyperuricemia and its complication, gout. The major limitation for allopurinol is that it is a frequent cause of severe cutaneous adverse reactions (SCAR), which include hypersensitivity syndrome (HSS), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). Our previous study showed that the susceptibility of these life-threatening reactions induced by allopurinol is genetically determined and is strongly associated with the HLA-B*5801. However, the underlying mechanism remains unclear. To investigate the role of HLA-B*5801 in allopurinol-SCAR, we enrolled 12 patients with allopurinol-SCAR and cultured PBMCs in response to allopurinol or oxypurinol (the active metabolite of allopurinol). The in vitro expanded T lymphocytes from the peripheral blood of patients were evaluated for the cell phenotypes, proliferation ability and cytotoxicity. In all of 12 allopurinol-SCAR patients, the CD4+ or CD8+ T cells showed in vitro proliferation upon 3-cycles of co-culture. By comparison, no cell proliferation was detected from the PBMCs of allopurinol-tolerant control subjects. The number of CD8+ T cells was predominately than that of CD4+ T cells in 67% (8/12) of the allopurinol-SCAR patients. These T cells expressed cytotoxic proteins, including granzyme B and granulysin in the culture medium. In 71% (5/7) of the cultures of patients, T cells showed strong cytotoxicity against autologous antigen presenting cells (APCs) carrying HLA-B*5801 allele. However, there was only 28% (2/7) of the T cell expansions of patients showed drug-specific cytotoxicity or T cell proliferation. The proliferation ability could be blocked by anti-HLA class I monoclonal anitbody but not anti-HLA class II antibody. The proliferation of T cells was not altered by the fixation procedure on APCs, suggesting the involvement of antigen processing-independent pathway. Our data revealed the pathogenesis role of HLA-B*5801 in allopurinol-SCAR.

P183 The role of genetic polymorphism of CYP P450 2B6 gene in nevirapine-induced skin rash among Malaysian HIV-1 patients: A multi-centre study Al-Dulaimy S.N.Y.1, Sulaiman S.A.S.1, Ismail R.B.2, Tan S.C.2

1University Sains Malaysia, Clinical Pharmacy, Penang, Malaysia, 2University Sains Malaysia, Institute for Research in Molecular Medicine (INFORMM), Penang, Malaysia


ABSTRACTSPurpose: This study aims to investigate the association between two CYP P450 2B6 Single Nucleotide Polymorphisms (SNPs) and the skin rash incidence in Malaysian HIV-1 patients receiving Nevirapine as a component of their Antiretroviral Therapy (ART). Materials and methods: This multi-centre study was conducted among Malaysian HIV-1 diagnosed patients in three hospitals in three different states. Whole blood samples were taken from patients after group them into two groups, as Nevirapine-tolerant group and Nevirapine-Induced skin rash. DNA was extracted by (QIAmp DNA Mini Kit, Qiagene, Germany). Polymorphism detection was carried out by Polymerase Chain Reaction (PCR) to investigate two SNPs, they are: CYP2B6 516G>T and CYP2B6 785A>G. Results: Out of one hundred and seventeen patients, 28 (24%) of them needed to switch to other regimens after being diagnosed with nevirapine-induced skin rash. For CYP 2B6 516 G>T polymorphism it was presented in sixty percent of the entire study sample. And for CYP 2B6 785A>G, 40% represent the heterozygote while the mutant homozygous represent 15.4%. There was no significance correlation between nevirapine-induced skin rash and either SNPs of (CYP2B6 516G>T and CYP2B6 785A>G) with P-value of 0.092 and 0.795, respectively.Conclusion: Both of these SNPs (CYP2B6 516G>T and CYP2B6 785A>G) can not be used as markers to predict nevirapine-induced skin rash. Further investigations of other SNPs in CYP 2B6 and other genes are required to understand the mechanism of occurrence of this side effect and the ways to prevent it.

P184 Synthesis of an amodiaquine-specific antibody as a tool for studying amodiaquine-induced agranulocytosis Lobach A.R.M.1, Uetrecht J.P.1

1University of Toronto, Leslie Dan Faculty of Pharmacy, Toronto, Canada Introduction: Amodiaquine (AQ) is an antimalarial agent associated with idiosyncratic agranulocytosis, a reaction that is suspected to involve both toxic and immune components. AQ is metabolized by activated neutrophils to a reactive quinone imine, which is capable of covalently binding protein in vitro. It is suspected that hapten formation in vivo could stimulate an immune response, and in some cases lead to agranulocytosis. In order to characterize the covalent binding of AQ in vivo, an AQ-specific antibody was synthesized for use in various immunochemical applications. Methods and results: AQ-specific immunogens were synthesized by conjugating AQ to bovine serum albumin (BSA) and blue carrier protein (BCP). In the first step, AQ was oxidized to its reactive quinone imine by manganese (IV) dioxide, as confirmed by mass spectrometry analysis. Secondly, BSA and BCP were thiolated with 2-iminothiolane and levels of thiolation were quantified using Ellman’s assay. The thiolated proteins were reacted with the quinone imine and the resulting protein-AQ conjugates, BSA-AQ and BCP-AQ, were purified by dialysis. The BSA-AQ conjugate was further characterized by SDS-PAGE and mass spectrometry. The hapten density on BSA appeared to be about 100-fold higher than on BCP, so both conjugates were employed as immunogens. Two female New Zealand White rabbits (2.5 kg) were immunized with 400 µg of either BSA-AQ or BCP-AQ, followed by booster injections of 250 µg after 3 and 6 weeks. Titer checks were carried out two weeks after each boost to probe the serum for the presence of AQ-specific antibodies by ELISA, and the final titer was collected one week after the second titer check. Antiserum from both rabbits specifically recognized AQ, as determined by inhibition ELISA assays with the opposite antigen and AQ alone. Conclusions: The synthesized protein-AQ conjugates appear to have acted as effective immunogens in rabbits to produce AQ-specific antibodies. The antibodies will be used in applications such as western blot, immunohistochemistry and flow cytometry, to further investigate the in vivo covalent binding of amodiaquine to proteins in rats and mice. Funding: Canadian Institutes of Health Research

P185 Generation of Allopurinol/Oxypurinol-specific T cells in vitroYun J.1, Yerly D.1, Fontana S.2, Pichler W.J.1

1University of Bern, Department of Rheumatology, Clinical Immunology and Allergy, Inselspital, Bern, Switzerland, 2Regional Blood Transfusion Service of the Swiss Red Cross, Bern, Switzerland Purpose: Allopurinol hypersensitivity is a major cause of severe cutaneous adverse reactions (SCAR). A recent Taiwanese study had identified its strong association with HLA-B*58:01 allele and this finding was confirmed in


ABSTRACTSa European study for Stevens-Johnson syndrome/Toxic epidermal necrolysis (SJS/TEN). But approximately one third of the patients with allopurinol-induced SJS/TEN did not have this allele, implying that other factors might be involved. We took advantage this association to investigate the immune mechanism of allopurinol-induced SCAR. Materials and methods: Allopurinol or oxypurinol-specific T cell lines (ALP/OXP-TCL) were generated from PBMC isolated from allopurinol allergic individuals, allopurinol-naïve HLA-B*58:01 positive donors and allopurinol-naïve HLA-B*58:01 negative donors. Autologous PBMC and Epstein-Barr virus-transformed lymphoblastoid B cell lines (EBV-BLCL) were used as antigen presenting cells (APC). The specificity of TCL was assessed by FACS analysis. Results: In patients with a history of allopurinol hypersensitivity (2), ALP/OXP-TCL could be generated within 4 weeks but this was not possible in allopurinol-naïve individuals (6). However, in all allopurinol-naïve HLA-B*58:01 positive individuals (5), ALP/OXP-TCL could be generated after 4 weeks with multiple restimulations. In allopurinol-naïve HLA-B*58:01 negative individuals (3), ALP-TCL could not be generated at all but OXP-TCL were able to be generated in 2 out of 3 individuals. There were no obvious phenotypic differences between these groups when assessed by FACS. Conclusions: Our in vitro data suggest that HLA-B*58:01 molecule is likely involved in the pathogenesis of allopurinol hypersensitivity as it facilitates reactivity to allopurinol or oxypurinol in allopurinol naïve individuals. However, consistent with the findings of European cohort, this allele is not an absolute requirement for the development of allopurinol hypersensitivity as in vitro induction can also occur when PBMC were repeatedly restimulated with oxypurinol.

P186 Comparative omics approaches in deciphering bioefficacy and side effects of chemotherapeutic drug and phytoagent against mouse melanoma Shyur L.-F.1

1Academia Sinica, Agricultural Biotechnology Research Center, Taipei, Taiwan, Republic of China Purpose: This study aims to investigate the bioefficacy and potential renal and hematologic toxicities of a phytoagent deoxyelephantopin (DET) and chemotherapeutic drug cisplatin (CP) against mouse B16 melanoma. Materials and methods: DET, a natural sesquiterpene lactone was isolated from a traditional medicinal plant Elephantopus scaber L. Various in vitro and in vivo gene- and cell-based assays were used to characterize the bioactivity and underlying mechanisms of DET and CP against B16 melanoma cell activities. The B16-COX/Luc melanoma cell growth and metastasis in syngeneic C57BL/6J mice with drug treatment were monitored using in vivo bioluminescence imaging system. The potential renal and hematological toxicity induced by CP or DET were evaluated using comparative metabolomics approach, by coupling UPLC/QTOF mass spectrometry and PCA and PLS-DA analysis. Results: DET and CP inhibited B16 cell proliferation with IC50 value at 4.5 mM and 45 mM, respectively; both chemicals showed synergism on inhibiting B16 cell activity based on isobologram analysis. A series of drug treatment protocol were designed, i.e., DET or CP treatment alone, DET co-treated with CP (DET+CP), and sequential treatment with CP and DET (CP→DET). Our results showed that Pre-DET10 and CP2 have similar profound effect against lung metastasis of B16 melanoma and increase of median survival rate in tested mice. However, cisplatin resulted in renal damages and hematological toxicity in mice that were not seen in DET10 or DET+CP treatments. Comparative metabolomic study urther delineated the cisplatin-induced, but not DET, side effect, e.g., nephrotoxicity in test mice. DET was observed to suppress B16 melanoma cell proliferation, migration and invasion through modulating cell cycle machinery and inducing apoptosis in B16 melanoma cells. Conclusions: This study demonstrates that little or no toxicity was found by DET treatment; notably, DET cotreatment with CP can not only reduce the use of CP concentration to reach a similar drug efficacy, but also much reduce side effect caused by CP in mice. Our findings may prove useful in further exploration of the combinational approaches in treatment of metastatic melanoma.

P187 Development of a predictive mouse model for allergic drug reactions Whritenour J.E.1, Cole S.1, Hudson A.1, Kawabata T.T.1

1Pfizer Inc, Drug Safety Research and Development, Groton, United States Animal models that can be used to predict the allergenic potential of drug candidates have not been adequately optimized, validated or characterized. While initial validation data from an inter-laboratory study of the mouse


ABSTRACTSlymph node proliferation assay (LNPA) appeared promising, no additional investigations in this model have been reported. The objectives of this study were to further optimize and validate the LNPA utilizing a non-radioactive endpoint and additional positive and negative control drugs. Compounds associated with hypersensitivity reactions in the literature (positive controls) were chosen to be tested in the model in addition to compounds with few or no reports (negative controls) of hypersensitivity. For each compound, the highest dose achievable based on solubility and clinical side effects, including irritation, was used. Mice received a subcutaneous injection of drug or vehicle into the scruff of the neck once daily for a period of three days (days 1-3). On day 6, draining lymph nodes were harvested, single cell suspensions prepared, and total and large lymphocyte cell numbers were determined by flow cytometry for each animal. A stimulation index was calculated by dividing the mean number of large lymphocytes (proliferating and/or reactive cells) for the treated group by that of the vehicle treated animals. Based on statistical analysis of the data, animals with a total large lymphocyte number >5X the mean of the vehicle group were classified as a “responder”. Based on the data generated to date with 12 positive control and 7 negative control compounds, the model has a sensitivity of 70% and specificity of 71% and a relatively good predictive value as measured by the Receiver Operating Characteristic AUC of 0.79. These data suggest that this model may be a useful tool for identifying drug candidates with the potential to produce allergic responses in the clinic. Future studies will investigate the mechanism(s) for the lymph node responses in order to develop additional endpoints that may increase the sensitivity and specificity of the model.

P188 Preliminary assessment of modified specific tryptase assay in diagnosing drug hypersensitivity Refaat M.1, Attia M.1

1Ain Shams University, Faculty of Medicine, Medicine Department, Allergy and Clinical Immunology Division, Cairo, Egypt Background: Mast cells are key effectors cells of the allergic response. When stimulated by specific allergen through the high-affinity IgE receptors or through other stimuli, these cells release a number of potent mediators of inflammation as the serine proteases tryptase and chymase. Diagnosis of the etiology of drug hypersensitivity is a vital step in therapy, which is mainly done through patient history, as skin testing is not always reliable and oral provocation testing is life-threatening. Hence, evidence for an underlying IgE-mediated mechanism is difficult to obtain. Aim of the work: To assess a new test, the specific tryptase test, which depends on libration of tryptase as a result of mast cell degranulation when it contact with drug to which the patient is sensitive to, it will be carried out as an in vitro test. It’s a modification of classic tryptase test which is used in diagnosing anaphylaxis but it is an antigen-specific cellular test. Methods: Heparinized Blood (about 4ml) from 15 patients with known history of drug hypersensitivity were obtained, retrospectively, 7 to penicillins,one to cefotaxime, 3 to lidocaine and 4 to diclofenac. . Skin prick tests (SPT), Specific IgE and specific tryptase test were performed. Tryptase substrate was used with standard known its concentration and spectrophotometer for colorimetric or kinetic assay of tryptase.Normal control was up to 10 µmol/ml. Results: On determining specific tryptase assay, 12 out of the 15 samples were positive to tryptase (except 2 for penicillin and one for lidocaine) compared with specific IgE (80%), while10 cases only gave positive SPT to particular drug (67%). Accuracy of SPT as compared by specific tryptase test was 83%. Conclusion: These preliminary results revealed that, the Specific tryptase assay can be used for diagnosis a number of hypersensitivity reactions against drugs including antibiotics, NSAIDs, and anesthetics, etc for an involvement of an IgE-mediated mechanism. It is a commercial and cheap method that sees the cell itself. Its technical simplicity allows its routine use by a non-specialized laboratory; also we can rely on this test in children or in the patients who can’t perform the skin test. P190 Validation of the in vitro platelet Toxicity Assay (iPTA) for the diagnosis of suspected hypersensitivity reactions to sulfonamides Elzagallaai A.A.1, Rieder M.J.1, Bend J.R.2, Koren G.3

1Western University, Paediatrics, London, Canada, 2Western University, Pathology, London, Canada, 3Western University, Physiology and Pharmacology, London, Canada


ABSTRACTSBackground / purpose: Drug hypersensitivity syndrome (DHS) is a rare but potentially fatal type of adverse drug reaction (ADR) that develops in susceptible patients following exposure to certain drugs including sulfonamides, β-lactam antibiotics, antiretrovirals, aromatic anticonvulsants and NSAIDs. The diagnosis of this type of ADR is challenging and currently depends on clinical evaluation. A valid and reliable laboratory test to diagnose DHS would be a major advance in the clinical care of patients and in the evaluation of possible ADRs during drug development and clinical studies. Current in vitro tests including the lymphocyte toxicity assay (LTA) and the lymphocyte transformation test (LTT) have been used but are cumbersome. We have recently developed a novel simple in vitro diagnostic test for DHS called the in vitro platelets toxicity assay (iPTA) using peripheral bllod platelets as a surrogate cell model to test patient susceptibility to DHS. This work was to validate the use of the iPTA for the diagnosis of DHS using clinical criteria and the LTA to identify DHS cases. Materials and methods: Forty-seven (47) individuals (25 DHS-sulfa patients and 22 healthy controls) were recruited to participate in this research. The DHS cases were referred and diagnosed with DHS based on rigorous internationally accepted criteria. Blood samples were obtained and both LTA and iPTA were performed independently. Results were then compared to determine the degree of agreement between the two diagnostic approaches. Results: There was concentration-dependent toxicity in the cells of patients when incubated with the reactive hydroxylamine metabolite of sulfamethoxazole in both the LTA (lymphocytes) and iPTA (platelets) (p< 0.05) and toxicity was significantly greater in the cells from patients versus cells from controls (p< 0.05) at all concentrations used. The two tests had a high degree of agreement (correlation coefficient: R2 = 0.97). The iPTA, however; was significantly more sensitive than the conventional LTA test in detecting the susceptibility of patient cells to in vitro toxicity (p< 0.05). Conclusion: The novel iPTA has considerable potential to be used as an investigative tool for DHS. Being an inexpensive and requiring no special reagents makes it a good candidate for wider clinical use.

P191 Enhancing the sensitivity of lymphocyte transformaton test (LTT) using CD25high depleted effector T cellsSrinoulprasert Y.1,2,3, Hausmann O.2, Pichler W.J.2,3

1Mahidol University, Department of Immunology, Bangkok, Thailand, 2University Hospital of Bern, Clinic for Rheumatology and Clinical Immunology / Allergology, Bern, Switzerland, 3ADR-AC GmbH, Bern, Switzerland Background: The lymphocyte transformation test (LTT) is widely used as a diagnostic tool for various T cell mediated drug hypersensitivity reactions (DHR). Although specificity of the test is more than 90%, the sensitivity of the test is depends on many factors such as type of DHR, type of drug, time interval since clinical reaction, etc. We addressed the question, whether the removal of CD25high T-regulatory cells (Treg) may increase the sensitivity of the test. Purpose: To enhance the sensitivity of LTT in patients with previous negative or borderline LTT and in controls by removal of CD25high Treg cells. Materials and methods: 9 patients diagnosed with drug hypersensitivity reactions with clear history and positive skin tests but negative or berderline LTT results were recruited. One part of PBMCs was utilized for regular LTT, the other part was subjected to FACSorting. CD3+/CD25high cells were sorted out and the remaining CD3+ CD25neg

or low cells were used as effector cells. The CD3- cells were irradiated at 4500 cGy and then used as APC. Regular and modified LTTs were performed with similar protocol and incubated for 6 days. The cells were stimulated with relevant (history and skin test positive) and irrelevant drugs in order to evaluating the effect of Treg removal on proliferation to non involved drugs as well. Proliferation was measured by 3H thymidine incorporation and results expressed as stimulation index (SI). Results: Only 2/9 of the regular LTT was positive, but if the Treg depleted cells were stimulated, 6/9 patients were positive to the incriminated drug. No reaction occurred to the irrelevant drug in normal or Treg depleted LTT. Conclusions: The drug reactivity in LTT could be modified by removing CD25+ Treg cells. This procedure seems to increase the sensitivity of LTT but did not affect the specificity, as no unspecific reacivity could be observed. The procedure seems to be useful in particular situations, but is expensive and time consuming, which limits its use for routine analysis.


ABSTRACTS P192 The use of ROC analysis in the evaluation of testing for specific IgE to morphine, pholcodine and chlorhexidine in cases of perioperative anaphylaxis Fernando S.L.1,2, Fulton R.B.1, Anderson J.1, Green S.3, Rose M.3

1Royal North Shore Hospital, Department of Immunology, St. Leonards, Australia, 2Sydney University, Sydney, Australia, 3Royal North Shore Hospital, Department of Anaesthesia, St. Leonards, Australia Background: Neuromuscular blocking agents (NMBAs) are the most frequently reported causative agents in cases of anaesthetic related anaphylaxis. Assays for specific IgE (sIgE) to morphine and pholcodine are available as indicators of sIgE to the substituted ammonium groups on NMBAs. Chlorhexidine is an antiseptic also implicated in perioperative anaphylaxis. Aim: To evaluate laboratory tests for sIgE to morphine, pholcodine and chlorhexidine in the investigation of perioperative anaphylaxis. Method: This study included 140 patients referred to the Anaesthesia Allergy and Adverse Events clinic at Royal North Shore Hospital, Sydney, Australia. Standardized skin tests were performed with all suspected agents to which patients had been exposed. Testing for sIgE to morphine, pholcodine and chlorhexidine was performed via the Phadia ImmunoCAP system. Results: Using the recommended cut-off value sIgE tests for morphine, pholcodine and chlorhexidine all showed good sensitivity (67%, 57%, 86% respectively) and specificity (95%, 95%, 96% respectively) with reference to skin test results. ROC analysis suggested an alternative positive cut-off. Application of this lower threshold allowed for increased sensitivity for morphine, pholcodine and chlorhexidine (71%, 67%, 100% respectively) without adversely affecting specificity. Conclusion: Specific IgE testing to morphine, pholcodine and chlorhexidine is a reliable adjunct to skin testing in determining diagnosis of allergy to NMBAs and/or chlorhexidine. Additionally, adjustment of cut-off thresholds is able to increase test sensitivity.

P193 Flow cytometric basophil activation test by detection of CD63 expression in patients with NSAIDs-induced hypersensitivity without underlying bronchial asthma and chronic urticaria Piotrowicz-Wójcik K.1, Porębski G.1, Dyga W.1, Obtułowicz K.1, Czarnobilska E.1

1Jagiellonian University, Clinical and Environmental Allergology, Cracow, Poland Purpose: Flow cytometric basophil activation test (BAT) has been evaluated as a new diagnostic tool for in vitro diagnosis of NSAID hypersensitivity. Most of the studies were performed on heterogeneous populations covering patients with different clinical manifestations of NSAID syndrome. The aim of the study was to estimate accuracy of BAT in the well-defined group limited to rare cases - patients with multiple NSAIDs-induced urticaria/angioedema and single NSAID-induced reactions. Materials and methods: We enrolled 19 patients with a history of NSAIDs-induced urticaria/angioedema or anaphylactic-like symptoms confirmed by positive oral provocation tests or suggestive anamnesis (mean age 46,6 years). 17 healthy subjects who tolerated aspirin were examined as controls (mean age 43.9 years). BATs using CD63 expression (Flow2CAST provided by Bühlmann Laboratories) were done following the manufacturer’s instructions after stimulation with suspected drug in two concentrations and two alternative drugs, also in two concentrations (Sigma-Aldrich). We tested: aspirin (0,6 mg/ml; 0,06 mg/ml), ibuprofen (0,2 mg/ml; 0,02 mg/ml), diclofenac (0,06 mg/ml; 0,006 mg/ml) and metamizole (0,5 mg/ml; 0,0125 mg/ml). BATs were performed at FACS Canto flow cytometer and results were analyzed using a Diva software program (BD Biosciences). Results: Stimulation index (SI) above 2 was considered as a positive result. The highest value of two tested concentrations was used to analysis. In patients group we observed 11 positive BATs, 3 patients were identified as non-responders. In the controls 15 BATs were negative. It corresponds to sensitivity 69% and specificity 88%. Conclusions: We observed higher percentage of positive BATs in patients group than it is usually reported in studies on mixed types of NSAIDs hypersensitive populations. It suggests that underlying disease is important factor influencing the results.


ABSTRACTSP194 Monitoring of IgE and IgG-antibodies in dental allergy Lazarenko L.1

1Pirogov National Medical Surgery Centre, Saint-Petersburg, Russian Federation Background: Evaluation of allergic reactions to local anaesthetics and dental materials is difficult, because of poor sensitivity of in vivo testing, which controlled administration provocative tests in order to confirm the diagnosis. Contrary, in vitro testing is a high sensitive and reliable diagnostic procedure, which avoid risks of an in vivo testing. It is apparently clear, that IgE - monitoring is a reliable method for testing in cases of dental allergy, but it is unclear the role of IgG-antibodies. The aim of our study: determine the diagnostic value of IgG-testing in cases of allergy to local anaesthetics and dental materials. Method: 54 outpatients with symptoms of hypersensitivity (HS) to local anaesthetics (LA) - Group A and 264 outpatients with hypersensitivity to dental materials (DM) - Group B, were investigated for specific IgG-antibodies in serum. Assays were arranged by ELISA method. We studied patients with controversial result of patient´s case history and prick (Group A) or patch (Group B) skin tests. No drug provocation tests were done because of risk of immediate allergic reactions with a positive history of multi hypersensitivity. In parallel we determine IgE-antibodies by ELISA method. Group A (n=54) consist of 40 females, 14 males, mean age 39.1 years (6-80), group B (n=264) - of 201 females and 63 males, mean age 57 years (31-82). For in vitro specific IgG EAST we used such local anaesthetics allergens as - articaine, mepivacain, prilocain, lidocain; and dental materials allergens - gold, platinum, palladium, cuprum, cobalt, nickel, and chromium. Result: We found positive IgG levels to LA (Group A) to: articaine - 2.4%; mepivacain - 1.84%; prilocain - 1%; lidocain - 4%. In the second group, sensitive to dental materials (Group B), IgG-specific antibodies were positive for: cuprum - 13.4 %, cobalt - 21.7%, nickel - 21.8%, palladium - 4.9%, chromium - 20.3%, gold - 33.1%, platinum - 20.7% of patients. Conclusion: The result of IgG and IgE-testing is not the same. When it was similar, we decided that it was really allergic reactions (confirmed by patient case history). Most cases of positive results are correlated with previous history of using those dental materials. We propose the parallel testing of IgE and IgG antibodies in cases of allergy to local anaesthetics and dental materials in order to elevate diagnostic value of those in vitro methods. Detail analysis of patient history is too useful.

P195 In vitro diagnosis of aspirin-sensitive asthma Evsyukova H.V.1

1St.Petersburg State University,Medical Faculty, Hospital Therapy, St.Petersburg, Russian Federation It is known that melatonin (MT) is the unique hormone of the diffuse neuroimmunoendocrine system (DNIES). Platelets are the one of the extrapineal sources of melatonin production and involved in the pathogenesis of bronchial asthma, including aspirin-sensitive asthma (ASA). As one of the MT metabolites is the substance (N-acetyl-5-methoxy-kynurenamine) with a chemical structure similar to that of acetylsalicylic acid we studied melatonin production by enzymimmunoassay and platelets’ MT expression by means of indirect immunofluorescence in 21patients with ASA, 12 patients with aspirin-tolerant asthma (ATA) and 26 control subjects. The results of the study have revealed a lower of daytime 6-sulphatoxymelatonin (αMT6s) excretion in ASA patients (12.7±2.7 ng mL-1) than in ATA patients (32.7±9.9 ng mL-1, P< 0.05) and control subjects (19.9±5.8 ng mL-1, P< 0.05). The low MT production depended on the condition of extrapineal MT sources because NAT activity was unchanged. The results of the study have revealed that only 13.1±1.3% of platelets in ASA patients have shown melatonin -specific luminescence, as compared to 97.7±0.6% of platelets in healthy subjects (P< 0.001). No melatonin expression has been observed in the rest of platelets in ASA patients. We conclude that the study of the urinary excretion of αMT6s, the major metabolite of melatonin, and platelets‘ MT expression are the new ASA diagnostic tests.


ABSTRACTSP196 Approach to synthetic antigenic determinants of cephalosporins: In vitro studies of chemical structure - IgE molecular recognition relationships Montanez M.I.1, Mayorga C.1, Ariza A.1, Perez-Inestrosa E.2, Blanca M.3, Torres M.J.3

1IMABIS Foundation-Carlos Haya Hospital, Research Laboratory, Malaga, Spain, 2University of Malaga, Organic Chemistry Department, Malaga, Spain, 3Carlos Haya Hospital, Allergy Service, Malaga, Spain Purpose: Structural studies of cephalosporin protein adducts have never been addressed successfully and are difficult to investigate. Understanding the way in which the drug metabolizes after protein conjugation, is important if we are to make advances in the diagnosis of clinical allergy. Our approach to determine the requirements involved in antigenic determinant structures consisted of designing and synthesizing a proposed skeleton that remains linked to the carrier protein after chemical degradation in cephalosporin conjugated to carrier proteins. Methods: A series of proposed epitopes were efficiently synthesized following a versatile methodology, involving the condensation of the R1 acyl side chains of native cephalosporins, with the nuclear fragment structures (derived from amino acids or other aminofunctionalized molecules). The determinants display the same basic structure but with variations in both the substituent R1 and different functional groups at C-3 (carbon derived from C-6 in the native cephalosporin), including hydroxyl, thiol and acetal derived. These compounds were immunologically tested by RAST (RadioAllergoSorbentTest) inhibition using sera from controls and 7 patients allergic to cephalosporins. Results: The final well-defined structures, representing a fragment from the proposed cephalosporin Lys(protein) adduct intermediate, consist of closely related low-molecular-weight molecules, differing only in the functional group at C-3 and the R1 side chains. As a rule, evaluated sera had optimal recognition with structures containing the same R1 side chain as the cephalosporin inducing the allergic reaction and, in cross-reactivity cases, structures including a similar R1 structure. The functional groups tested in C-3, hydroxymethyl and acetal groups showed the same pattern with improved inhibition compared to the methyl group. However, the change of the oxygen atom by a sulfur atom in C-3, drastically decreased the inhibition and showed no inhibition in most cases. Conclusions: Fine structural selective recognition was detected between IgE from patients allergic to cephalosporins and our proposed skeleton epitopes involving the appropriate functionality and R1 side chain. Thus, we have been able to refine the earlier design of model antigenic determinants which fulfill the structural implications needed for recognition by IgE antibodies to cephalosporin and which are consequently responsible for the adverse reactions.

P197 Histamine release induced by medical devices in a patient with IgE mediated hypersensitivity to ethylene oxide Garvey L.H.1, Krøigaard M.1, Bjerremann L.1, Mosbech H.1, Skov P.S.1

1Copenhagen University Hospital Gentofte, Danish Anaesthesia Allergy Centre, Allergy Clinic, Hellerup, Denmark Purpose: Ethylene oxide (EO) is a gas widely used to sterilize medical devices. During sterilization gas is diffused through packaging into devices and subsequent aeration ensures that residual EO levels are not toxic. EO binds to plastic in devices and diffusion time varies with plastic type and thickness. IgE mediated hypersensitivity to EO has been described and IgE antibodies against EO can be measured in serum. We report a case of anaphylaxis during anaesthesia for removal of a ventriculoperitoneal shunt (VPshunt) in a patient with spina bifida, attributed to EO. The patient required surgery to reinsert a VPshunt and the purpose of this study was to show 1) if EO sterilized devices needed for subsequent surgery would induce histamine release in the patient’s blood and 2) whether such a response could be blocked by anti-IgE (omalizumab) pretreatment. Materials and methods: Histamine release was induced in the patient’s blood by 10 mm pieces of EO sterilized devices (tubing from VPshunt, hard plastic packaging around shunt, urinary catheter used for self-catheterization (in plastic/paper wrapping)). Released histamine was determined fluorometrically (RefLab, Copenhagen, Denmark). The devices did not induce unspecific histamine release in blood from a healthy non-allergic individual. A positive result was defined as histamine release ≥ response induced by the positive control. All testing was performed in duplicate. Sensitivity of histamine detection is 5 ng/ml washed blood. Results: Spontaneous histamine release in the patient’s blood was 45 ±3.7 ng/ml and response to positive control was 74 ±7.9 ng/ml. Highest histamine release in response to VPshunt was 110 ng/ml, to hard plastic


ABSTRACTSpackaging from shunt 102 ng/ml and to urinary catheter 62 ng/ml. Omalizumab pretreatment of the patient reduced histamine release to 35, 37 and 44 ng/ml, respectively. Subsequently, a non EO sterilized VPshunt was inserted during uneventful surgery in an EO minimized environment with additional antihistamine and steroid pretreatment. Conclusion: Residual EO levels in medical devices are difficult to measure. This study shows a novel way to indirectly show reactivity to EO, by inducing histamine release in response to pieces of EO sterilized devices. The response was blocked by pretreating the patient with omalizumab. Residual EO diffuses slowly from medical devices over time and this may contribute to allergic sensitization and reactions in patients with implanted devices.

P199 NSAID-triggered hypersensitivity: correlation of clinical symptoms and in vitro results using a functional cell-based approach Schäfer D.1, Meier H.2, Mühlmeier G.2

1Friedrich-Alexander-Universität Erlangen-Nürnberg, Mediziniksch Klinik III, Erlangen, Germany, 2Bundeswehrkrankenhaus Ulm, HNO-Klinik, Ulm, Germany Purpose: Non-steroidal anti-inflammatory drug (NSAID)-triggered hypersensitivity is known longer than 110 years. Provocation tests may confirm NSAID-triggered respiratory diseases, but this procedure is contraindicated as well as unsuitable for diagnoses in other cases of NSAID-triggered hypersensitivity. Therefore, in vitro diagnosis is a major challenge for diagnosis of outpatients and those without respiratory hypersensitivity. Materials and methods: Twentyeight outpatients (16 female, 12 male, 20-68 years) and 30 controls were investigated. All individuals were characterised clinically (i.e. medical history: severity and duration of symptoms, number of polypectomy, intravenous provocation) and in vitro (functional analysis of peripheral blood leucocytes (PBLs): determining the balance of eicosanoids using the functional eicosanoid test (FET)). Results: 36 % of the patients revealed negative and 64% positive provocation test results. No provocation was performed in 3 patients with unstable asthma. Controls revealed significantly lower FET-values (mean 0.45) than patients suffering from NSAID-triggered hypersensitivity (mean 1.0 to 2.3). The FET-value correlated with the dose of provocation. Conclusions: In approximately 1/3 of our patients the provocation test could not confirm the clinically known NSAID-triggered hypersensitivity, whereas less than 1/10 revealed a borderline FET-result. The FET-values correlated with the severity of the patients’ symptoms. The preliminary results of our study suggest a confirmative value as well as some predictive relevance of the FET for clinically reaction to NSAIDs. In such cases where in vivo provocation is not suitable, the FET might be an alternative approach for supporting further therapeutic decisions.

P200 Basophil activation test at the cutting site between serology and cellular diagnostics Gentinetta T.1,2, Pecaric-Petkovic T.1, Hausmann O.V.2, Jörg L.2, Pichler W.1,2

1ADR-AC GmbH, Bern, Switzerland, 2Inselspital, University Bern, Department of Rheumatology, Immunology and Allergology, Bern, Switzerland Aim of the project: The basophil activation test (BAT) in its direct form (with patient basophils) has already found wide application in the diagnostic management of immediate allergic reactions. The measurement of the activation of basophils, as a sign of an immediate-type allergic response, brought a new functional dimension into in vitro diagnostic tests. Of particular value might be the use of an indirect BAT, namely the use of third party basophils sensitized with donor serum to detect drug specific IgE: This would open novel diagnostic possibilities and would prove the existence of drug specific IgE. Materials and methods: We established a blood donor bank of potential basophil donors: these basophils were characterized by reactivity to IL-3 under various stimulatory conditions and its responsiveness to serum containing bet v 1- specific IgE. The optimal sensitizing conditions were taken over from Gitte-Lund and adapted to our needs. Results: The donor basophils came from atopic and non-atopic donors and were stable over time with regard to fMLP, anti-IgE, C5a and IL-3 co-stimulatory requirements. We observed no seasonal variations in basophile reactivity. The passive sensitization with anti-bet v1 specific IgE containing serum was reproducible with a low CV.


ABSTRACTSSensitization with drug specific IgE proved to be more difficult: while IgE to carboxymethylcellulose (CMC) was easily demonstrable in direct and optimized passive BAT, the demonstration of quinolone specific and amoxicillin specific IgE was mostly negative using sera of well documented patients with anaphylaxis/urticaria. Interestingly, sera of skin-test positive patients with cephalosporin induced anaphylaxis had often a positive direct BAT, but remained negative in indirect BAT. Conclusion: So far. we were successful in improving and standardizing the conditions for basophils in indirect BAT. The assay is reproducible using a standard protein allergen or drugs or drug constituents with larger size (e.g. CMC). However, the same conditions do not allow a demonstration of drug specific IgE to amoxicillin, cephalsosporin and quinolone: Apparently, drug preparations and ability to crosslink drug specific IgE molecules needs a better understanding of drug - protein interactions and conditions for cross-linking IgE - which we are presently pursuing.

P201 Evaluation of new reagents for the detection of platin specific IgE Rouzaire P.1, Ranchon F.2, Nosbaum A.3, Cabut A.1, Renosi F.1, Venemalm L.4, Rioufol C.2, Bienvenu J.1, Bérard F.3, Bienvenu F.1

1Hospices Civils de Lyon, Immunology Laboratory, Pierre-Bénite, France, 2Hospices Civils de Lyon, Clinical Oncology Pharmacy Department, Pierre-Bénite, France, 3Hospices Civils de Lyon, Allergy and Clinical Immunology Department, Pierre-Bénite, France, 4ThermoFisher Scientific, Uppsala, Sweden Purpose: Hypersensitivity reactions occur in 10-40% of patients treated by platinium agents. In our center, the management of patients who experienced such reactions consists in the careful documentation of the clinical history, the realization of skin tests and basophil activation tests. The purpose of this study was to evaluate the sensitivity of new reagents for the detection of platin specific IgE. Material and methods: Populations: 8 patients who developed immediate hypersensitivity reactions after oxaliplatin administration were included in our study. Five of them had skin tests: they were positive in 2 cases. Basophil activation tests were positive in 5 of the 7 patients tested. Two control populations were included: 5 patients with total IgE lower than 100 kU/L, and 5 patients with total IgE higher than 5000 kU/L. Total IgE and specific IgE determination: Total IgE and specific IgE to oxaliplatin, carboplatin and cisplatin were determined using the ImmunoCAPTM FEIA technique (Thermo Fisher, Uppsala, Sweden). For specific IgE, results ≥0.10 kU/L were considered positive. Results: Among the 8 patients, 6 had detectable specific IgE to oxaliplatin (sensitivity: 75%), generally with quite low levels. No oxaliplatin specific IgE were detected in the control population with normal IgE level. Interestingly, specific IgE to carboplatin and cisplatin were negative in patients with immediate hypersensitivity to oxaliplatin, except in 2 patients who displayed total IgE higher than 5000 kU/L. This suggests an interference of high levels of IgE. This point was confirmed in the second control population: all controls with total IgE higher than 5000kU/L presented false positive results of specific IgE for the three platins (range: 0.10-0.43kU/L). Finally, we focused our attention on the kinetics of the decay of oxaliplatin specific IgE. One patient was tested 3 times (3, 5 and 8 months after the allergic reaction). These preliminary data show a quick decrease (0.29 / 0.19 and < 0.10 kU/L respectively). Conclusion: Our study highlights the good characteristics of new tools available for the detection of platin specific IgE, even if specific IgE levels remain low. This detection brings precious elements in the management of patients who experienced immediate reaction upon platin administration. It could also constitute a valuable tool to monitor the sensitization of the patients during the successive administrations of platins.

P202 How to determine in vitro the causative drug of Stevens-Johnson syndrome - alternatives for lymphocyte proliferation assay Porebski G.1,2,3, Pecaric-Petkovic T.1,2, Groux-Keller M.1,2, Bosak M.4, Kawabata T.5, Pichler W.J.1,2

1Inselspital, University of Bern, Division of Allergology, Department of Rheumatology, Clinical Immunology and Allergology, Bern, Switzerland, 2ADR-AC GmbH, Bern, Switzerland, 3Jagiellonian University Medical College, Department of Clinical and Environmental Allergology, Krakow, Poland, 4Jagiellonian University Medical College, Department of Neurology, Krakow, Switzerland, 5Pfizer, Drug Safety Research and Development, Groton, United States


ABSTRACTS Purpose: Patients with SJS/TEN are often exposed simultaneously to a few potentially culprit drugs. There is an urgent need to identify the relevant drug particularly in such severe, life threatening reactions, where provocation tests are not recommended. However, both lymphocyte transformation tests (LTT) as well as skin tests, if done, are mostly negative.. Since various studies underlined the importance of activated cytotoxic CD8+ and NK cells in the pathomechanism of SJS/TEN, we aimed to improve the in vitro assays able to identify the eliciting drug in patients with SJS/TEN. Materials and methods: Patients with SJS/TEN underwent individual assessment of drug causality according to algorithm of drug causality for epidermal necrolysis (ALDEN). 15 patients with an ALDEN score >6 (“very probable”) were included in the study. They served as a “gold diagnostic” standard and were compared to 18 drug-exposed healthy controls. Peripheral blood mononuclear cells from patients in remission were isolated from heparinized blood and cultured under defined conditions alone, with tetanus toxoid or drugs at previously optimized concentrations. All cultures were performed with and without preincubation with IL-7 and IL-15. The response was measured by either routine LTT, granzyme B-ELISPOT, flow cytometry (intracytoplasmic cytokine detection of granulysin and IFNg in NKp46+, CD8+, CD4+ cells) and cytokines beads assay (IL-2, IL-5, IFNg in supernatants). Results: LTTs with culpirit drugs were positive in 4 of 15 patients (sensitivity 26,7%). Similarly, in 4/15 patients culprit drug elicited granzyme B release (sensitivity 26,7%). Granulysin, but not IFNg was expressed at significant levels by NKp46+, CD8+, CD4+ cells in 5, 2, 8 of 15 patients, respectively (sensitivity 33,3%; 13%; 53,3%). Drug-specific cytokine production could be demonstrated in 57% of patients for IL-2 and IL-5 and in 50% for IFNg. Specificities of tested in vitro assays was in the range 92-100%. Combining selected assays increased the sensitivity up to 84,1%. Above parameters of diagnostic testes were reached at the cut-off: mean+2SD, but ROC-curve analysis allows to select the optimal cut-offs for particular tests. Preincubation with IL-7/IL-15 enhanced drug-specific response only in selected patients. Conclusions: The evaluated in vitro assays can successfully substitute LTT in diagnosis of SJS/TEN. The combined approach substantially increased the sensitivity of the assays.

P203 Characterisation and evaluation of Aspirin and Aspirin metabolites conjugated and unconjugated to HSA for diagnostic use in Basophil Activation Test Schneider M.J.1, Radlinska A.2, Wolanczyk-Medrala A.2, Jermann T.1, Medrala W.2

1Bühlmann Laboratories AG, R&D, Schönenbuch, Switzerland, 2Wroclaw University of Medicine, Department of Internal Diseases, Geriatrics and Allergology, Wroclaw, Poland Introduction: Reports and studies about the sensitivity of Basophil Activation Test (BAT) with NSAIDs (Non-steroidal anti- inflammatory drugs) show heterogeneous and often unsatisfying results. Beside optimization in the BAT procedure one possibility is to improve the quality of the data with the allergen itself. Coupling to a carrier protein can be used for a better presentation of the allergen especially with small molecules. Metabolites of a drug may also be responsible for an adverse reaction. The following metabolites of Acetylsalicylic acid (ASA) are known: 2,3-Dihydroxbenzoic acid (2,3-DHBA), 2,5-Dihydroxybenzoic acid (2,5-DHBA), Salicylic acid (SA) and 2-Methoxybenzoic acid (2-MBA). Methods: We coupled ASA and the four metabolites 2,3-DHBA, 2,5-DHBA, SA and 2-MBA via their carboxyl group and the use of NHS-ester covalently to Human Serum Albumin (HSA). We synthesized conjugates with and without a C-5 spacer, and varied the degree of conjugation from 5-10 to 20-40 molecules per albumin molecule. The conjugates where analysed with GFC-HPLC to determine the purity and the labelling degree. Dose finding was performed with BAT and control subjects to reduce unspecific stimulation of the antigens. We compared ASA and its metabolites with their corresponding HSA conjugates in BAT with 8 allergic patients to Aspirin and 12 controls. Results: Only unconjugated ASA and SA showed a significant and similar effect on basophil activation within the patient population. None of the other metabolites and none of the conjugates (with or without spacer or different labeling degree) showed a patient specific response in BAT. Conclusion: In our study improvement of the sensitivity of BAT could not be observed by coupling Aspirin or Aspirin metabolites to a carrier (HSA) molecule. We speculate immunogenic reactivity of Aspirin gets lost after conjugation over the carboxyl group.


ABSTRACTSP204 Clinical evaluation of a new Basophil Activation Test (Flow CAST® highsens) combining the activation markers CD63 and CD203c for the use in diagnosis of patients with Aspirin hypersensitivity Schneider M.J.1, Radlinska A.2, Wolanczyk-Medrala A.2, Jermann T.1, Medrala W.2

1Bühlmann Laboratories AG, R&D, Schönenbuch, Switzerland, 2Wroclaw University of Medicine, Department of Internal Diseases, Geriatrics and Allergology, Wroclaw, Poland Introduction: Reports and studies about the sensitivity of Basophil Activation Test (BAT) with NSAIDs (Non-steroidal anti- inflammatory drugs) show heterogeneous and often unsatisfying results. Common BAT protocols use either CD63 or CD203c as activation marker getting sensitivities around 15-30%. We tested the combination of CD63 and CD203c within the same test system for possible improvements in the sensitivity of BAT with Aspirin sensitized patients. Methods: Healthy controls (n=11) and patients (n= 18) with Aspirin hypersensitivity with urticarial and/or angioedema were tested with Flow CAST® highsens Basophil Activation Test. Patients and controls were tested with Acetylsalicylic acid (ASA) the ASA metabolites 2,3-Dihydroxbenzoic acid (2,3-DHBA), 2,5-Dihydroxybenzoic acid (2,5-DHBA), Salicylic acid (SA) and 2-Methoxybenzoic acid (2-MBA). The influence of time after blood drawing was tested by performing the BAT directly after blood drawing and 24 hours later stored at 2-8°C. Two to four allergen concentrations for each allergen were used for dose finding. Results: With ASA and SA significant differences in Basophil activation were measured between patients and controls respectively (Mann-Whitney Test p=0.017 and 0.014). Both ROC curves have an area under curve of 0.74 resulting in a sensitivity/specificity of 44.4% / 90.9% for ASA and of 61.1% / 90.9% for SA. Best concentrations in stimulation for ASA was 0.41 mg/ml and for SA 0.11 mg/ml Blood storage influences the response to ASA and SA. With fresh blood also control persons show elevated activation leading to higher cut-off values and an inferior differentiation between patients and controls. Conclusion: The combination of the two Basophil activation markers CD63 and CD203c in BAT increase the sensitivity in the testing of aspirin hypersensitive patients compared with other studies using CD63 or CD203c alone. Aspirin and its metabolite Salicylic acid show a promising sensitivity by using it in the Flow CAST® highsens.

P205 Immediate reactions to NSAIDs: usefulness of Basophil Activation Test Maietta G.1, Ardito S.2, Iaia M.L.2, Giuliano G.2, De Donno M.1

1Pignatelli Institute, Immunology, Lecce, Italy, 2Perrino Hospital, Allergy, Brindisi, Italy Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs that may promote an anaphylactoid response (1). In vitro demonstration of human basophils activation has been proposed as a surrogate marker of in vivo hypersensitivity.Over the past 10 years a number of studies on basophil activation tests (BAT) have been published which focused on their use as a diagnostic tool in IgE-mediated hypersensitivity reactions to various allergens and drugs (2). In this work, we tested the usefulness of BAT in the diagnosis of immediate reactions to NSAIDs. Methods: Fourteen patients with typical clinical features of an immediate adverse reaction to NSAIDs underwent clinical evaluation in our Allergy Unit in the period between January to Dicember 2011. Clinical data were recorded using an adaptation of the ENDA drug allergy questionnaire. In all patients BAT were performed at least six weeks after the adverse reaction. BAT was performed by flow cytometry and the percentage of activated basophils was evaluated as CCR3 positive cells which expressed CD63 on their surface. The cut off was fixed at 5% and a stimulation index (SI) (positive control/negative control ratio) greater than 2 was considered positive (3). Results: Nine of the fourteen patients evidenced SI greater than 2 (ranging from 2,1 to 5,4), showing a positive correlation of BAT with clinical history. Conclusions: In our experience 64,3% of patients with history of immediate reactions to NSAIDs showed a correlation with BAT results. For these reasons BAT seems to be a useful tool for the diagnosis of immediate reactions to NSAIDs. The selection of the patient rappresents an important requisite for the signification of the test.


ABSTRACTSReferences: 1. Szczklik A, Stevenson DD. Aspirin induced asthma:advances in pathogenesis, diagnosis and management. J Allergy Clin Immunol 2003; 111:913-21. 2. Boumiza R, Debard AL, Monneret G. The basophil activation test by flow cytometry: recent developments in clinical studies, standardization and emerging prospectives. Clin Mol Allergy 2005; 3:9. 3. De Weck AL, Sanz ML, Gamboa PM, Abrer W, Bienvenu J, Blanca M, Demoly P, Ebo DG, Mayorga L, Monneret G, Sainte Laudy J. Diagnostic tests based on human basophils:more potentials and perspectives than pitfalls. J Investig Allergol Clin Immunol 2008; 18: 143-155.

P206 Evaluation of the IFN- gamma ELISPOT for the prediction of penicillin allergy Moritz K.1, Pickl W.2, Stingl G.1, Wöhrl S.1

1Medical University of Vienna, Department of Dermatology, Division of Immunology, Allergy and Infectious Diseases, Vienna, Austria, 2Medical University of Vienna, Department of Pathophysiology, Infection and Immunology; Division of Immunology, Vienna, Austria Background: Betalactam antibiotics are frequently responsible for drug allergy. Cutaneous reactions such as maculo-papular exanthema (MPE) are considered as delayed type of hypersensitivity (DTH) reactions involving drug specific T-cells. Skin patch tests in penicillin allergy in clinical practice have a good specificity with an at the same time big drawback: a very low sensitivity. Drug provocation test remains the gold standard for the identification of the eliciting culprit drug. There is a great need for sensitive and at the same time specific in vitro tests. Several studies have shown that the LTT assay is useful for the diagnosis of drug DTH allergy with a sensitivity ranging from 60% to 75%. Aim: The aim of this study was to analyze the frequency of circulating drug specific T cells by IFN-gamma- enzyme linked immunospot essay (ELISPOT) in betalactam allergic patients. Methods: 12 patients were enrolled in this study. 6 Patients with a history of DTH allergy to betalactam antibiotics underwent skin PRICK-, intradermal and PATCH testing for amoxicillin, amoxicillin/clavulanic acid, penicillin G, penicillin V, PPD and MDM (Laboratorios Diater, Madrid, Spain). Drug provocation tests were performed in 2 patients with negative skin tests. 4 healthy people without a history DTH served as controls. ELISPOT assays were performed according to the manufacturers protocol. LTTs were done as described previously. Results: Drug specific T cells were detected in 4 out of 6 amoxicillin allergic patients by ELISPOT. No reactivity was observed in 4 healthy controls and 2 patients with a history of drug induced MPE but tolerant in the oral provocation test. Conclusion: The IFN gamma ELISPOT assay is able to detect drug specific T cells in betalactam antibiotic allergic patients and appears to be a sensitive in vitro test in the diagnosis of drug allergy.

P207 Diagnosis of drug allergy in DRESS: Excellent correlation between in vitro immunological tests and skin patch-tests Rozieres A.1, Ben Said B.2, Vocanson M.1, Bricard G.1, Rodet K.1, Berard F.2, Nicolas J.-F.1,2

1University Lyon1, Lyon-Sud Medical School, INSERM U851, Pierre-Benite, France, 2Department and CH Lyon-Sud, Hospices Civils de Lyon, Lyon, France Background: DRESS (drug rash with eosinophilia and systemic symptoms) is a severe drug-induced reaction. Identification of the drug involved in the development of the disease relies on skin tests and immunobiological assays. Aim of the study: To test for the presence of drug-specific T cells in DRESS by using both in vivo skin patch-test and ex-vivo immunobiological assay. Methods: IFN-g enzyme-linked immunosorbent spot-forming (ELISPOT) assay and skin patch-test were evaluated in 40 patients who developed a DRESS (drug rash with eosinophilia and systemic symptoms) reaction. All patients have been tested in remission phase. Results: 13/40 (32.5%) patients had negative results for both skin patch-test and IFNg elispot assay. 20/40 (50%) patients had both positive skin patch and IFNg elispot assay. 1 /40 (2.5%) patients had positive skin patch-test only and 6/40 (15%) patients had positive IFNg elispot assay only.


ABSTRACTSConculsion - discussion: The results show that: i) the diagnosis of delayed drug allergy, i.e. the presence of drug-specific T cells by patch-test and/or Elispot, is confirmed in the majority of patients (67.5%, 27/40 patients); ii) the correlation between the results of skin patch-test and those of ELISPOT assay is excellent since it is observed in 33/40 patients (82.5%) (Chi square (χ2) test: p=0.0006, α< 0.05). Therefore the Elispot assay appears as an alternative to the use of patch test for the diagnosis of drug allergy in DRESS patients. P208 Lymphocyte transformation test in TEN after antiepileptic treatment: highly positive response to culprit phenytoin but vexing findings to valproic acid Petrausch U.1, Schmid-Grendelmeier P.2

1University Hospital Zurich, Immunology, Zurich, Switzerland, 2University Hospital Zurich, Allergy Unit, Dermatology, Zurich, Switzerland Purpose: The lymphocyte transformation test (LTT) is a well standardized test method to evaluate drug hypersensitivity in vitro. Herein we describe the case of a patient with a drug hypersensitivity reaction after intake of an anticonvulsant and the following LTTs intended to screen different anticonvulsants. Patient and methods: In 2006 a 34 years old female patient was diagnosed with a meningioma because of repetitive symptomatic epilepsy (SGE). The meningioma was surgically removed and anticonvulsant therapy with phenytoin was initiated. 28 days after start of phenytoin the patient developed Toxic Epidermal Necrolysis (TEN, SCORTEN 4pts). She was treated with intravenous human immune globulins G (IgG) 1g/kg BW for 3 days and treated at intensive care unit for 12 days. After resolution of the skin lesions the patients was discharged and no further anticonvulsant therapy was initiated. In April 2011 due to new onset of SGE anticonvulsant therapy was started with Levetiracetam; this had to be stopped because of fatigue and Clobazam was started (10 mg q.d.). In November 2011 ECG showed continued epileptic activity. The patient was now referred to our allergy unit for the risk assessment of other anticonvulsants - mainly valproic acid. Results: Due to the risk of potential relapse no skin tests were performed with the potential culprit drug phenytoin. However a LTT was performed in December 2011 showing a highly increased proliferation in response to phenytoin (SI of max 22.8, no < 2.5). Unexpected there was also increased proliferation after incubation with valproic acid (SI of max 6.7) that was never given to the patient before. Thanks to the scientific accuracy of the performing laboratory, the LTT could be repeated in February 2012. Again the increased proliferation in response to phenytoin was observed (SI of max. 33.8), but this was not anymore the case with valproate acid now (SI 0.8). Conclusions: LTT is a valid and standardized in vitro test to assess the risk of patients for drug hypersensitivity and can be very useful in the diagnosis also of TEN with a potentially life-threating reactions in re-exposure to the culprit drug. However the presented case points out the needed careful and critical evaluation of LTTs in the situation of unexpected results. Re-testing can be a useful and appropriate method of choice to confirm or disconfirm the previous results. In the current case unspecific hyperactivation might be the cause of the “false positive “LTT.

P209 Referral to the laboratory testing: how do we understand drug allergy? Borushko A.1, Baranovskaya T.1

1BelMAPGE, Minsk, Belarus Aim: The increase of pharmaceutical consumption and awareness of allergic pathology lead to growth of the number of patients, who worry about drug allergy. Nowadays in Belarus patients can undergo laboratory testing either by themselves or by the doctor’s referral. The objective of this study was to analyse how the available drug allergy laboratory testing is used. Methods: The survey was conducted on the base of immunolaboratory of the 10th Minsk clinic. Over the 10th-week period the patients (n=147) were questioned concerning their referral to the laboratory and their drug allergies. Also all performed during 3 months laboratory tests for drug allergy (two available tests for immediate reactions: reaction of the mast cell degranulation and specific IgE detection, n=5152) were analysed. Results: The mean age of evaluated patients was 54.16±13.91 years (121 females, 26 males). Mostly patients were referred to the laboratory by doctors (91.2%), specifically by dentists (59.6%) and allergists (19.2%). The majority of their self-reported allergies were adverse effects of the culprit drugs. As for medications prescribed for laboratory testing, in 32.31% cases patients didn’t use this drug before (or couldn’t remember that fact) or


ABSTRACTSthey had no previous reaction; 44.1% of those who had a reaction had a non-immediate one. None of patients underwent other type of allergy testing (skin or provocation tests) before referral to the laboratory. The mean number of performed laboratory tests was 4.65 per person (min 1- max 14). In the structure of tested drugs prevailed local anaesthetics (see the table 1).

Agent N %Local anaesthetics 1182 22.51Antibacterial 840 15.99For dental prosthetics (metals, acrylate) 690 13.14Cardiovascular 686 13.06NSAIDs 562 10.70Antidiabetic 345 6.57Others 847 16.10

[Table 1. The structure of the performed laboratory] Conclusions: Specific laboratory testing could be useful in differential diagnosis for allergic drug hypersensitivity reactions, but usually it becomes the only used method. An accurate evaluation of patients’ events needs to be done prior to the reference to laboratory. An erroneous assessment of local anaesthetics and agents for dental prosthetics (metals, acrylate) as causing immediate allergic reactions in most cases leads to misuse and overuse of the laboratory testing. It indicates that continuing education and informing about the modern concepts of drug-related reactions (particularly drug hypersensitivity) are essential. P210 Acetylsalicylic acid-triggered 15-HETE generation is not useful for identifying ASA sensitivity Adamic K.1, Tisler U.2, Bajrovic N.1, Silar M.1, Mrhar A.2, Kosnik M.1, Korosec P.1

1Hospital Golnik, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia, 2University of Ljubljana, Faculty of Pharmacy, Ljubljana, Slovenia Background: Exposure to acetylsalicylic acid (ASA) may exacerbate respiratory or skin diseases or induce anaphylactoid reactions in apparently healthy individuals. We wanted to evaluate the clinical and diagnostic usefulness of measuring ASA-induced 15-hydroxyeicosateraenoic acid (15-HETE) generation. Methods: We performed a prospective single-blind study with 26 subjects undergoing clinical evaluation and/or ASA provocation testing. We also included 12 control subjects. Peripheral blood leucocytes were incubated with 500 µM ASA and 15-HETE release was measured by competitive ELISA. Results: We found that 18 subjects were ASA-tolerant and eight were ASA-intolerant. The mean increase in 15-HETE in intolerant subjects was 34% and this was comparable to the mean increase of 30% observed in ASA-tolerant subjects. A similar mean increase was also observed in control subjects. The ROC calculation showed that the optimal diagnostic threshold would be an increase of greater than 33%. However, the sensitivity of this increase was only 63% and the specificity was 50%; the area under the ROC curve was 0.57 (p = 0.58). Conclusions: Our data demonstrate that ASA-induced 15-HETE generation is not useful for identifying ASA-intolerant patients. Abbreviations used: ASA: acetylsalicylic acid; NSAIDs: nonsteroidal anti-inflammatory drugs; 15-HETE: 15-hydroxyeicosateraenoic acid P211 The in vivo and in vitro diagnosis of β-Lactams hypersensitivity in Thai patientsSitcharungsi R.1,2, Vilaiyuk S.2, Rerkpattanapipat T.2, Kamchaisatian W.2, Ngamjanyaporn P.2, Khupulsup K.2, Srisala S.2, Sasisakulporn C.2, Teawsomboonkit W.2, Benjaponpitak S.2

1Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand


ABSTRACTSAim: To evaluate and confirm the diagnosis of true drug allergy in patients with self-reported β-Lactams (BLs) hypersensitivity, using skin test and drug provocation test (DPT), and also to evaluate the sensitivity and the specificity of CFSE-based T cell proliferation assay. Method: This was a diagnostic study done in children (3-18 years old) and young adults (19-40 years old) who had histories of amoxicillin, amoxicillin-clavulanate, ampicillin, or ceftriaxone hypersentitivity at Ramathibodi Hospital during a period from 1st December, 2009 to 31st December, 2010. At the enrollment, baseline characteristics of the subjects were recorded, including causative drug, age, sex, and hypersensitivity symptoms. Skin tests for BLs, CFSE-based T cell proliferation assay, drug-specific secretion of IFN-γ, IL-5 by ELISA, specific IgE to amoxicillin, and DPT were performed in the subjects. Result: A total of 62 patients were enrolled, of which 7 were excluded due to incompleted study protocols and 55 were included with completed protocols. Skin tests were positive in 15 patients (27%), of which 4 were positive to the skin prick test and 11 to the intradermal test. DPTs were positive in 7 (17.5%) of 40 patients. The BLs allergy was confirmed in 22 cases (40%), composed of 18 immediate reaction cases and 4 non-immediate reaction cases. Specific IgE to amoxicillin tests were negative in all patients with confirmed BLs allergy, but positive in 2 cases with negative DPTs. Concerning clinical histories, positive tests were found in 9 of 31 patients (29%) with histories of urticaria, 10 of 21 cases (48%) with histories of maculopapular eruption and 3 of 3 (100%) patients with histories of anaphylaxis. One patient had anaphylaxis during the DPT, but the reaction was easily controlled with standard treatment. There was no statistically significant difference of ratios of drug specific CD4 T cells/media reacted CD4 T cells between confirmed β-lactams hypersensitivity and non-hypersensitivity cases. (p = 0.39). Sensitivity of drug-specific secretion of IFN-γ and IL-5 was 47% and 60%, respectively. Conclusion: Drug allergy testing should be done in all suspected cases if no contraindication is presented and DPT should be performed when others tests have yielded inconclusive results. CFSE-based T cell proliferation assay needs further studies. P212 Pancreatic cancer: incidence, clinical profile, and frequency of associated factors in Kuwait Almajed H.T.1, El-Basmi A.A.2, Al-Mohannadi S.H.3, Govindan R.4,5, Rajakumari G.B.5

1Public Authority of applied Education and Training- College of Health Sciences, Applied Medical Sciences Department, Kuwait, Kuwait, 2Kuwait Cancer Control Center, KCCC Registry, Kuwait, Kuwait, 3Kuwait Cancer Control Center, Nuclear Medicine KCCC, Kuwait, Kuwait, 4Kuwait Cancer Control Center, Cancer Registrar, Kuwait, Kuwait, 5Kuwait Cancer Control Center, Registrar Department, Kuwait, Kuwait Purpose: The purposes of this study were to investigate the incidence, clinical profile, and the frequency of associated factors of pancreatic cancer in Kuwait. Materials and methods: The study design was retrospective hospital-based record study in which cases were retrospectively ascertained. A total of 251 pancreatic cancer patients were recruited from the population of patients who were registered, evaluated and treated at Kuwait cancer control center (KCCC). From January 2004 through December 2010. The socio-demographic features and medical histories of patients were retrieved from their medical records and data recorded in database of KCCC. Results: KCCC reported 276 new cases from 2000 to 2010, with 0.9/100000 population as an overall incidence of pancreatic cancer. The overall ratio of men to women was 1.5:1. Kuwaiti subjects constituted 52.6%. The mean age of patients were 60.6 ± 7.7 years, the majority of cases were fifty years or older, 19.9% had positive family history of pancreatic cancer, 44.6% had family history of diabetes mellitus. Overweight and obesity were the majority, 38.2% gave history of smoking. patients with diabetes mellitus constituted 61.4%, 52.6% of them were type 2. Moreover, 62.3% of patients reported that diabetes came first and 37.7% reported that pancreatic cancer came first. Among 76.1% of cases the site of cancer was head of pancreas. The majority of patients complained from abdominal pain (91.2%), jaundice (87.6%), anorexia. Less than half of cases were diagnosed clinically and 90% radiologically; the majority of them (75.3%) by Computed tomography (CT). Metastasis were diagnosed in 67.7% of patients at diagnosis of pancreatic cancer. Conclusions: Pancreatic cancer in Kuwait is diagnosed in late stages. Screening for this disease in indicated specially in diabetic patients. A comprehensive comparative study is required for determination of risk factors that could be associated with the disease.


ABSTRACTSP213 Clinical efficacy of desloratadine therapy in children with persistent form of allergic rhinitis and its impact on asthma symptoms Shishimorov I.N.1, Petrov V.I.1, Gorbunov V.A.1

1Volgograd State Medical University, Department of Clinical Pharmacology and Intensive Therapy, Volgograd, Russian Federation Purpose: To evaluate the clinical efficacy of therapy with desloratadine in children with persistent form of allergic rhinitis and to evaluate its impact on asthma symptoms. Materials and methods: A prospective, randomized, parallel-group, open-label study of desloratadine effectiveness in children with persistent allergic rhinitis in age from 2 to 16 years in 4 weeks. The effectiveness of therapy is monitored by clinical symptoms and rhinomanometry. Results: The study showed that desloratadine is an effective treatment for persistent allergic rhinitis in children of different age groups, well-controlled nasal and other symptoms of allergic rhinitis, nasal congestion helps to reduce and restore nasal breathing. The best effect is seen with regard to histamine-induced symptoms (itching, sneezing, rhinorrhea). In children with allergic rhinitis and asthma therapy desloratadine additionally contributes to the positive dynamics of symptoms of asthma. Conclusion: The effectiveness of desloratadine therapy in children with isolated allergic rhinitis is higher than in patients with concomitant asthma. Keywords: Allergic rhinitis, bronchial asthma, treatment, desloratadine, and children.

P215 Novel molecular strategies against sulfur mustard toxicity Kunak I.Z.1, Toygar M.2, Yaren H.1

1Gulhane Military Medical Academy, Department of Medical CBRN Defence, Ankara, Turkey, 2Gulhane Military Medical Academy, Department of Forensic Medicine, Ankara, Turkey Objective: Among the available chemical warfare agents, sulfur mustard (SM), also known as mustard gas, has been widely used chemical weapon. In our laboratory, we have shown that, acute toxicity of SM is related to reactive oxygen and nitrogen species, DNA damage, poly(ADP-ribose) polymerase activation and energy depletion within the affected cell. Materials and method: In spite of the knowledge about acute SM-induced cellular toxicity, unfortunately, it is not clear how mustard gas causes severe multi-organ damage years after even a single exposure. A variety of treatment modalities including antioxidants, anti-inflammatory drugs and others have resulted no promising results. We, therefore, made an attempt whether epigenetic aberrations may contribute to pathogenesis of mustard poisoning. Results: The term epigenetic describes the study of inheritable alterations in gene expression that occur in the absence of changes in genome sequence. Therefore, epigenetic gene regulation requires molecular mechanisms that encode information in addition to the DNA base sequence and can be propagated through mitosis and meiosis. Conclusion: Our current understanding of epigenetic regulation of gene expression involves basically two classes of molecular mechanisms: histone modifications and DNA methylation. Preliminary evidence obtained from our laboratory reveals that exposure to mustards may not only cause nitro-oxidative stress and DNA (genetic) damage, but epigenetic perturbations as well. Epigenetic therapy is a new and rapidly developing field in pharmacology. Epigenetic drugs alone or in combination with conventional drugs may prove to be a significant advance over the conventional drugs used to treat both acute and delayed SM toxicity. Future studies are urgently needed to clarify the mechanism of delayed SM-induced toxicity and novel treatment modalities.


ABSTRACTSP216 Solated Scrotal & Penile edema after anti-fungal treatment Kotb A.1

1National Research Center, Dermatology, Cairo, Egypt 45 years old male came complaining of Tinea versicolor covering his back, he was given fluconazole 300 mg once & topical terbenafine. After 48 hours, he came back with severe Scrotal & penile edema with the complete embedding of the glans penis inside the edematous shaft. He shows no other signs of Urticaria or angioedema in other parts of the body. he gave no history of other drug intake for the last 10 days prior to the antifungal treatment. he also stated that food intake was the regular he used to eat. he was given short acting systemic steroids injection for 2 successive days along with oral anti-histaminics & the edema was relieved 12 hours after the first injection. P217 Prognostic significance of Glypican-3 in liver diseases Hashish M.1

1Mansoura University, Mansoura, Egypt Hepatocellular carcinoma (HCC) is the fifth most com mon cancer and the third most common cause of cancer-relat ed death worldwide. Treatment and prognosis are still problematic in management of HCC.Glypican-3 (GPC3) is a member of the glypican family of heparan-sulfate proteoglycans, which are linked to the cell surface through a glycosylphosphatidylinositol anchor. The aim of this work is to use the enzyme-linked immunosorbent assay (ELISA), to identify and quantify the GPC3 concentrations in serum of patients with liver cancer. GPC3 was assessed in 78 serum samples from selected liver patients with cirrhosis and hepatocellular carcinoma (HCC) using ELISA based on monoclonal antibody (GPC3 - mAb). A significant difference in GPC3 between healthy individuals group and HCC patients (p < 0.0001). Also, we found that the sensitivity of serum GPC3 in patients with HCC was 82.5%. A significant difference in GPC3 between HCC patients (malignant) and cirrhotic patients without cancer (nonmalignant) (p < 0.05) and the specificity of GPC3 which calculated according to healthy individuals was 100%. This specificity indicates that GPC3 is more specific tumor marker for HCC. In conclusion, the GPC3 protein is overexpressed in patients with HCC and this accumulated GPC3 protein may be released into blood circulation that can be assayed using a noninvasive technique.

P218 Amioderone lung toxicity Bazarbashi M.1

1kfsh & RC, Riyadh, Saudi Arabia Two cases of amiodarone lung toxcity will be presented, with different presentation and response to therapy, acute amiodarone toxicty can happen after 10 days of starting therapy, and is most likely hypersensivity type since responce to therapy is much better than the accute lung toxicity that happen to patients on Amiodarone for more than 3 months, will discuss risk factors and meesure we recomend to prevent the toxicity. 2 cases will show the radiological features of amiodarone acute lung toxicity .

P219 Rabies infection and its treatments in Bangladesh Rahman M.1

1Institute of Public Health, Public Health Laboratory, Dhaka, Bangladesh A cross-sectional survey research has been undertaken to address the question whether or not the Anti-Rabies vaccine users are aware of the necessity of using such vaccine in all cases following animal bite.


ABSTRACTSData were collected from 493 individuals by a pre-designed study instrument to collect personal information, knowledge about vaccine, prior familiarity with any victims of animal bites, use and reaction of use of vaccine. The mean age of the vaccine users was 25 years, and little above two thirds of the users had primary level education or was illiterate. About 93 percent of the victims had dog bite and the rest were affected by cat, fox and monkey bite. 90 percent cases, the victims came to collect vaccine within 10 days of animal bite incident, which was a premature phenomenon indicating a lack of proper knowledge about when to take vaccine. A majority of the victims came for vaccine with the popular information about ARV, and others had suggestion from local physician or health workers. Although 90 percent of the vaccine collectors had earlier seen persons who had taken vaccine from IPH, only a very small proportion (2.6%) had seen minor reaction after the vaccine intake. Among the respondents, only 4.3% had seen some hydrophobic patients during the last year. About the use of vaccine, 50 percent of the collectors had knowledge of the imported cell-cultured vaccine; but 89 percent of them did not choose this because of its high price. . The reality, according to the study finding, 65 %of the victims is from lower income group and tends to choose the local and cheaper ARV. out of the total of 38 victims belonging to higher income group, as many as 34 (89%) have chosen the local vaccine. Among the rural victims, 32 percent initially took traditional medicines (such as Milum, Babla, Sonapata), while several herbal plants were identified to have treatment value, but its effectiveness as ARV is yet to be established. The study concludes with the suggestions that so far the demand for local vaccine is high and as such its availability is to be sustained; and any side effects of the vaccine should be systematically studied. About the management of the supply of the vaccine, a system should be instituted to make the local level heath worker responsible for identifying the animal bite cases and suggest to get proper advice from the nearest qualified doctor to ascertain who would actually need ARV.

P220 Role of ursolic acid in oxidative stress induced by haloperidol in rats Pemminati S.1, Shenoy A.K.2, Herur G.2

1Manipal University, Pharmacology, Mangalore, India, 2Manipal University, Mangalore, India Purpose: Neuroleptic drugs used in the treatment of schizophrenia and other affective disorders are known to produce extra pyramidal side effects. Oxidative stress induced by these drugs in animals has been used as a model for the extra pyramidal side effects associated with antipsychotic agents in human beings. In the present study, we have attempted to evaluate the anti-oxidative effect of the ursolic acid (UA) on haloperidol (1.0 mg/kg, intraperitoneal administration)-induced catalepsy (HIC) in mice by employing the standard bar test. Materials and methods: Mice were allocated to five groups, each group containing six animals. The effects of the test drug UA (at 0.05, 0.1 & 0.2 mg/kg doses) and the standard drug, scopolamine (1.0 mg/kg) was assessed after repeated dose administration for seven days, 30 minutes prior to the haloperidol and total free radicals were estimated. Results: The results suggest that UA has a protective effect against haloperidol-induced oxidative stress, which is comparable to the standard drugs used for the same purpose. Conclusions: Our study indicates that UA could be used to prevent neuroleptic drug-induced oxidative stress.

P221 Phenomenon of ihnibition of natural leucocyte emigration for diagnosing drug allergy Bondareva G.1

1Institute of Immunology, Moscow, Russian Federation Purpose: To examine how drugs influence on natural leucocyte emigration in patients with drug allergy.Materials and methods: In our previous research we determined that allergens at dose 10 PNU/ml decrease the natural leucocyte emigration from vassals of oral cavity in patients with pollinosis. Before the test the pollinosis was proved by anamnesis, positive skin tests, specific IgE and provocation tests. Only allergens to which patients are sensitized decrease the emigration, other allergens don’t influence on emigration. We also determined that it is a dose-depended inhibition. The test was performed in vivo. Using the results of this research we examined the influence of drugs (penicillin) on natural leucocyte emigration in patients with drug allergy. The study enrolled 21 patients aged 19-45 years divided into 3 groups: the 1st group - patients with drug allergy to penicillin (n=8), the 2nd group - patients with drug allergy to local anesthetic (novocain) (n=7), the 3rd group - control (n=6).


ABSTRACTSAll patients underwent specific tests for sustaining the diagnose drug allergy. Patients with drug allergy had an allergic reaction to drug in anamnesis, positive specific IgE and positive sublingual provocation test. In preliminary test with peniccillin at dose 1,0-100 µg/ml didn´t influence on natural leucocyte emigration of oral cavity in patients without drug allergy or atopy. Results: Penicillin at doses 1,0-100 µg/ml decreases the leucocyte emigration for more than 30% in patients with drug allergy to penicillin. No decrease of leucocyte emigration to penicillin was determined in the 2nd group and 3rd group. The negative results of this test were proved by provocation test, when patients received the drug at dose ½ of therapeutic. Conclusion: Drug allergens at low doses decrease the rate of the natural leucocyte emigration in patients that are sensitized to this drug. This test can be used at early stage of drug allergy diagnostics in vivo.

P222 Penicillin allergy Masood A.1

1Al-Junaid Hospital, Allergy/Pulmonary, Nowsehra, Pakistan Rationale: The penicillin allergy is an exaggerated reaction by your immune system to penicillin that is related antibiotics. The antibiotics are extensively prescribed for bacterial infections, such as strep throat. Nevertheless, not all unfavorable reactions to penicillin are a true penicillin allergy. Methods: Numerous people who documented having a penicillin allergy, but don´t have a true allergy. Rather they may have had a reaction to penicillin, such as certain types of pimples, however not all reactions are allergies. A good number of serious allergic reactions to penicillin are anaphylactic responses, which can be life-threatening. Such reactions develop instantly after penicillin exposure in highly sensitive people. Results: The penicillin allergy is due to the response the drug as if it were a harmful substance instead of a helpful remedy. The human immune system triggers certain cells to produce immunoglobulin E (IgE) antibodies to fight the component of penicillin to which one may be allergic (allergen). Conclusions: Desensitization to penicillin has a significant impact on the later on diagnosis of hypersensitivity reaction.

P223 eNOS Polymorphism in asthmatic patientes Cortez e Castro M.M.T.C.1, Ferreira J.2, José A.2, Bicho M.2, Marinho C.2

1CHLN-HSM, ImmunoAllergy Department, Lisbon, Portugal, 2Lisbon Medical School, Genetic Department, Lisbon, Portugal Background: It is known that NO has a relevant role in inflammation, vascular and muscular tonus in asthma. Endothelial nitric oxide synthase (eNOS) modulates the amount of NO that could be related with eNOS polymorphisms. The purpose of this study is to analyze the association between endothelial nitric oxide synthase (eNOS) gene polymorphism eNOS intron 4 Ins/del (eNOS 4 a/b-27 bp-base pairs) with asthma severity. Methods: Asthmatic patients : n=31; were compared with a control group of n=174 healthy blood donors. The Ins/del polymorphism (eNos 4 a/b) was determined by PCRPolymerase chain reaction. Control of asthma assessed by validated instrument (ACQ7 and PAQLQ) .Statistical analysis was performed with PASW version 18 and Primer of biostatistics, establishing a significance level of p< 0.05. Results: The mean age of the 31 asthmatics was 40 ± 19.5 years; minimum 12 and maximum 86 ; 15 females and 16 males; all caucasians; 28 atopics and 3 nonatopics; 20 with controlled and 11 with uncontrolled asthma.In asthmatics the frequencies of the Ins/del polymorphism (eNos 4 b) is 87% and of the Ins/del polymorphism (eNos 4 a) is 13%; in controls: 80% and 20% respectively. There is no statistical difference between these groups (p>0.05).Genotypes in the asthmatics- bb: 77.4%; aa: 3.2%; ab: 19.4%; in control group-bb: 67.82%;aa: 8.6%; ab: 23.56%. There is no statistical difference between these groups(p>0.05).In asthmatics, there is no statistical difference (p>0.05): atopics and non atopics; controlled and uncontrolled asthma; males and females; and in the different age-groups. Conclusions: The role of eNOS gene intron 4 a/b Ins/del polymorphism in asthmatics is a controversial risk factor to the severity of asthma, but we think that we need a larger sample to infer about its role in inflammation and in vascular and muscular tonus homeostasis in asthmatic disease.


ABSTRACTSP224 Bronchopulmonary disease induced by snuff or ”Neffa” Khadhraoui M.M.1,2, Moatamri Z.2, Aichaouia S.2, Dabbouss S.2, Meddeb G.2, Cheikh R.2

1Faculty of Medicine Tunis, Respiratory Diseases and Allergology, Tunis, Tunisia, 2Faculty of Medicine Tunis Al Manar, Respiratory Diseases and Allergology, Tunis, Tunisia Aim: In Tunisia, the habit of consuming snuff is common among Tunisian low economic status and affects both men and women primarily if not exclusively in rural areas. The respiratory effects were noted through communication of clinical cases more or less documented. We will try, through this retrospective study, present a clinical profile, radiological, functional and alveolar citology for this condition little known in the European Literature. Methods: The authors have selected fifty cases including 31 men (75 ± 9 years) and 19 women (68 ± 8 years), the selection criteria are based primarily on the exclusive consumption of snuff powder legally marketed in Tunisia and exclusive use with nasal inhalation. The average consumption is 32 years. All patients have been sent are for various reasons (respiratory insufficiency, lung infection, lung tumoral process..) All patients underwent imaging, functional exoploration and bnchiolo-alveolar lavage. Result: Chronic intoxication by snuff appears to seems to be evolving similarly but more slowly in in the way of COPD, however, with addition of a nonspecific interstitial atteine especially at the alveolar cellular level. we found an increased tendency to fibrosis Cystic lesions. This condition is favorable to exacerbations (4-7 times per year) is twice that of COPD same profile. The consumers of Neffa would bebexacerbateurs frequents . Aspects of imaging and respiratory function are clearly distinguishable from COPD smokers of cigarettes. Conclusion: The sniffers of neffa have a risk for some thirty years after a chronic respiratory disease combining symptoms of COPD, cystic fibrosis and others lesions with progression to respiratory failure.

P225 Comparative efficacy of montelukast with sodium cromoglycate in the treatment of mild bronchial asthma in children of preschool age Gorbunov V.1, Petrov V.1, Shishimorov I.1, Polyakova O.1

1The Volgograd State Medical University, Clinical Pharmacology and Intensive Care, Volgograd, Russian Federation Purpose: To examine the comparative effectiveness of course treatment of asthma in children 3 - 6 years with sodium cromoglycate and montelukast, including the assessment of clinical symptoms and pulmonary function parameters using the methodology for determining the resistance of airway (Rint). Material: Single-arm open, randomized study in parallel groups are parallel comparative efficacy mild persistent forms of asthma in children with sodium cromoglycate and montelukast for 12 weeks. The effectiveness of therapy was evaluated on the following criteria: severity of daytime symptoms, the severity of nighttime symptoms, the number of days without asthma symptoms, need for bronchodilators (mean number of doses), the number of exacerbations of asthma, airway resistance indices (RINTexp and Δ RINTexp). Results: Significant decrease in severity of daytime and nighttime asthma symptoms, reduced need for β2-agonists and short-acting improvement in lung function observed in the group of children treated with montelukast. In 83% of patients achieved control of symptoms, while for the entire period of observation were noted of adverse reactions. Therapy with Kromoglycate was less effective, 12-week course which does not result in a significant reduction of the disease. Control of asthma symptoms was achieved in 22% of patients. In the group of children who received Kromogeksal in 7 children (20%) noted the development of adverse reactions did not require discontinuation. Conclusion: Thus, the results showed that the 12-week course of therapy, leukotriene receptor antagonist Montelukast for children 3 - 6 years with mild persistent form of asthma therapy is superior to Cromones- Kromoglycate sodium on the most significant clinical effects and safety profile. Keywords: Children, bronchial asthma, medication, montelukast, sodium cromoglycate.


ABSTRACTSP226 Skewing of SAG mediated therapy for a predominant Th1 during Visceral Leishmaniasis on triggering CD2 epitope Sinha S.1, Bimal S.2, Sundaram S.1

1University of Allahabad, Centre for Biotechnology, Allahabad, India, 2Rajendra Memorial Research Institute of Medical Sciences, Division of Immunology, Patna, India Background: Visceral leishmaniasis is a macrophage associated disorder which is linked with a profound decrease in the immunotherapeutic potential of the infected subjects leading to a marked reduction in the CD4 linked Th1 protective immune response. Simultaneously the patients in Bihar are showing unresponsiveness towards SAG which is still a first line of drug in many countries around the world against Visceral Leishmaniasis. We have previously reported down regulation of CD2 co receptor on the surface of CD4 cells in patients suffering from Visceral Leishmaniasis. Stimulation of CD2 epitope with antiCD2 antibody has led to a remarkable increase in the Protein kinase C alpha mediated phosphorylation on CD2 co receptor on CD4 T cells, induction of IFN-γ led Th1 dominated immune response, a substantial increase in the lymphoblast population and this response remained Th1 dominated even in the presence of Th2 predominant conditions signified with rIL4. Studies in the 1980s showed that biological immunomodulators such as interferon (IFN)-γ can provide a missing signal and enhance the activity of antimonials in the treatment of VL and CL. Methodology/Principal Findings: In the present part of the study we have tried to evaluate the use of CD2 antibody as an immunotherapeutic agent along with SAG in ensuring treatment of BALB/c mice induced with experimental Visceral leishmaniasis. It has been found in the present set of studies that stimulation of CD2 co receptor along with along with therapeutic dose of SAG has led to the enhancement in the release of IFN-gamma which leads to the release of TNF-alpha and activates the macrophages. An increase in the NO mediated killing further observed by the activated macrophages leading to the reduction in the parasitic load. Conclusions/Significance: The results indicate that enhancing the immune potential of a VL patient will help in the better response of Sodium Antimony Gluconate which is the first line of drug against VL in many countries.

P227 Treatment of atopic dermatitis patients Turcic P.1, Jurakic-Toncic R.2, Marinovic B.2, Lipozencic J.2

1Faculty of Pharmacy and Biochemistry, University of Zagreb, Department of Pharmacology, Zagreb, Croatia, 2University Hospital Center Zagreb, School of Medicine, University of Zagreb, Department of Dermatology and Venereology, Zagreb, Croatia Aim: Management of atopic dermatitis (AD) is clinical challenge. Optimal skin care and hydratation, identification of specific and non-specific trigger factors is needed. The goal of this study was to point out therapeutic agents for use according to disease severity. Method: According clinical diagnosis after Hanifin and Rajka and SCORAD index we treated 50 patients (aged 2-30). Included patients had basic therapy for solely dry skin; low to mid potency topical corticosteroids and/or topical calcineurin inhibitors for mild to moderate AD, mid/high potency (corticosteroid/calcineurin inhibitors) for moderate to severe and systemic therapy (antihistamines, cyclosporine A, cephalosporin...) Result: In 45 out of 50 patients was beneficial therapeutic respond. In 5 children a wet layer of cotton dressing in combination with antiseptics or corticosteroids has been used for cases of exacerbated AD skin lesions. For Staphylococcal secondary infection we ordered cephalosporin for 7 to 10 days in 6 patients. Cetirizin and loratadin were ordered in 36 patients. Cyclosporine A or phototherapy (narrow-band UVB) was used in 10 patients each for recalcitrant severe AD. A combination of different topical agents was used too. Maintained therapy to prevent disease progression with topical immunomodulators was in 12 patients. Psychological intervention with anxyolitics was in 3 severe adult patients. Conclusion: In 45 out of 50 AD patients was beneficial effect. SCORAD Index decreased for 50% in each group of patients especially in severe AD forms. Although there has been an enormous progress in understanding of the molecular biology of AD, it seems as well as in our study, that management is currently focusing on avoidance of triggers, use of skin hydratation and reduction of skin inflammation. There is no disease modifying drugs. Use of emollients in remissions of AD is demand. Phototherapy in disseminated skin lesions of AD patients is useful, too.


ABSTRACTSP228 Effect of Benzo(α)Pyrene on the pollen allergenicity in sunflower (Helianthus annuus L.)Baghaei-Far Z.1, Majd A.2, Chehregani A.3, Pourpak Z.4, Chehregani A1Payame Noor University, Department of Biology, Tehran, Iran, Islamic Republic of, 2Islamic Azad University, North Branch of Tehran, Department of Biology, Tehran, Iran, Islamic Republic of, 3Faculty of Science, Bu-ali Sina University, Department of Biology, Hamedan, Iran, Islamic Republic of, 4Immunology, Asthma, & Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran, Islamic Republic of Background: Allergy occurrence was increased in recent years dramatically. The reason of this phenomenon was not clear but there is a scientific attention to air pollution. Diesel exhaust particles (DEP) are a major part of air pollutants that express both adjuvant activity for sensitization against common allergens and enhancing effects on allergic symptoms. Benzo(α)Pyrene (BaP) is considered as the most important part of DEP. The aim of this research was study of the effect of BaP on pollen allergenicity in Helianthus annuus L. Method: Helianthus annuus L. var Record plants were grown from seed in greenhouse controlled condition and shoots treated by different concentration of BaP solutions in phosphate buffer saline (PBS) (0.002, 0.02, 0.04 gL-1) daily. Allergenicity of collected pollens was studied by means of skin prick test, determination of blood cells and evaluation of total IgE in different studied groups using of sensitized guinea pigs as an experimental model. Pollen proteins were also studied by SDS-PAGE and Immuno-blotting method for BaP-induced changes in protein profile and detection of allergen bands. Result: Comparing of allergy potency showed that allergic skin reactions in animals treated by polluted pollen was 2-3 times more than the groups treated by normal pollen extract and 5-6 times more than BaP treated group. Eosinophil number and IgE level, as allergy indicators, were also increased considerably in the blood of the groups treated by BaP exposed pollen than control ones. Results of SDS-PAGE showed that there are additional two bands in the BaP treated pollens. Immuno-blotting study of pollen proteins showed that new bands act as allergens that are reacted with IgE strongly. Conclusion: Results of this research work concluded that BaP could increase the allergy potency of H. annuus pollen and also cause to formation of new protein bands that act as new allergens. Key words: Air pollution, Diesel exhaust particles, Benzo (α) pyrene, Pollen allergy, Helianthus annuus

P229 Cytotoxic effect of extracts from Q. grandiflora Mart. (Vochysiacea)Quilles M.1,2, Bernardes de Andrade Carli C.1, Lira M.2, Wagner V.2, Iracilda Zeppone C.1

1School of Pharmaceutical Sciences, UNESP, Araraquara, Brazil, 2Institute of Chemistry, UNESP, Araraquara, Brazil The use of plants for the treatment of diseases is one of the oldest and most traditional therapeutic forms. This century’s first years, marked by strong ecologic preservation movements and increased search for alternative therapies, saw the revival of the search for cure in plants. One major concern, thought, is the immunological response triggered by phytoterapic. The Qualea gender is found in the brazilian cerrado and is used by the population to treat ulcers and inflammation. However, few studies on its toxicity and pharmacological activity have been conducted. As a part of the Biota-FAPESP project, the objective of this work was to evaluate the immunological activity of the hexane extracts of Qualea grandiflora Mart (Vochysiacea), contributing to a greater understanding of this plant’s biological effects. The cytotoxic effect of the extract on macrophages an on Erhlich tumor was evaluated using the MTT assay. Peritoneal macrophages and the tumor cell are sensitive to the extracts toxicity when cultured in their presence (viability over 90% from macrophage and 24% from tumor cells, using 1,0 mg/mL solution). Since, the results support the excellent selective activity of the cytotoxic of Ehrlich tumor without affecting the immune cells. Financial support: CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), FAPESP (Fundação de Amparo á Pesquisa do Estado de São Paulo).


ABSTRACTSP230 Cytotoxicity in vitro of Qualea multiflora against breast and pulmonary cancerCarli C.B.A.1, Quilles M.B.1, Carlos I.Z.1

1UNESP, Araraquara, Brazil The Qualea genus occurs throughout the whole tropical America, where it is used by population local as natural anti-inflammatory and antitumor. Based on this evidence, we evaluated the citotoxic effect of fractions obtained from the plant Qualea multiflora upon peritoneal macrophages and mammary and pulmonary tumoral cell lineages in vitro. The samples tested showed exceptional selective citotoxic effect upon tumoral cell lineages with 100% of death having killed 100% of cells for both tumour lineages and 0% of death macrophages. Considering that the samples herein studied presented exceptional selective tumoral citotoxicity, we can suggest that the fraction obtained from Q. multiflora possesses a promising therapeutical potential.

P231 Validity and reliability of anamnestic questions for allergic rhinitis and asthma Losappio L.1, Preziosi D.1, Pedotti R.2, Farinotti M.2, Filippini G.2, Tramacere I.2, Balossi L.1, Pastorello E.1

1Niguarda Ca’ Granda Hospital, Milano, Italy, 2Carlo Besta Hospital, Milano, Italy Introduction: Rhinitis and allergic asthma are different clinical aspects of a single inflammatory disease of the lower and upper respiratory tract. Therefore, the diagnosis of respiratory allergy should provide an integrated and easily implemented approach with diagnostic questions to assess the presence of rhinitis and asthma symptoms and to seek the potential presence of asthma in people with rhinitis. Objective: This study evaluated the validity and reliability of diagnostic questions for allergic rhinitis and asthma in the population. The questions investigated the presence of respiratory symptoms of rhinitis and asthma, previous physician diagnoses, laboratory tests performed, age at onset of symptoms and at the last attack, presence or absence of specific drugs and treatments. Materials and methods: The study population was selected from the population in Milan and the diagnostic questions were asked at the Department of Allergy and Immunology, Niguarda Ca´ Granda Hospital. Seven questions were administered to investigate allergic asthma and 7 to investigate questions on allergic rhinitis. In case of positive responses to questions about symptoms, presence of physician diagnosis, allergic tests performed, positivity to skin prick tests or respiratory function tests, the subject was considered as having a physician diagnosis of asthma or rhynitis. For negative answers to these questions, or positive but a lower number than that indicated as diagnostic of respiratory allergy, the person was regarded as negative for respiratory allergy. The validation of the diagnostic questions was performed by subjecting each person to skin prick test with a standard panel of inhalant, to baseline spirometry and for those subjects who were borderline at spirometry to bronchial provocation test with methacholine. Results: We analyzed complete questions from hundred aged between 15 and 75 years, 31 men and 69 women. Sixty four people of the study were cases and 36 controls.The questions were validated with prick tests with inhalant and spirometry which gave results indicative of 100% diagnostic reliability. Bronchial provocation testing with methacholine was not required for diagnosis. Conclusion: The anamnestic questions for respiratory allergy that we elaborated may be used as a valid and reliable diagnostic tool to identify patients with diagnosed allergic asthma and rhinitis.


ABSTRACTS

ISAF 2012 International Severe Asthma Forum

11 - 13 October 2012

Gothenburg, Sweden

www.goteborg.com/Jorma Valkonen

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ABSTRACTS

ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVEN-TION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLER-GENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARN-ING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER SON ASTHMA RHINITIS COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA RE-ACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY CLINICAL SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POI-SON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL FEVER MOLD ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS IMMUNOLOGY IN ALLERGYWHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT TRANSLATIONAL POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRON-CHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOTHERAPY/ALLERGENS IMMUNOLOGY SKIN FOOD DRUGS SYMP-TONS PREVENTION ALLERGY WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT SKIN FOOD & DRUG POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIA-

Clinicaland

Translational Allergy

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COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION

POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRON-ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT

POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION

FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL

IMMUNOTHERAPY/ALLERGENS IMMUNOLOGY SKIN FOOD DRUGS SYMP-WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-

TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION

AllergyCOUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH

AllergyCOUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-TION BRONCHIAL ALLERGENS ACUTE BREATH ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION

PREVENTION WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL IMMUNOTHERAPY/ALLERGENS IMMUNOLOGY SKIN FOOD DRUGS SYMP-

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POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRON-ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT

POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REACTION BRONCHIAL ALLERGENS ACUTE ASTHMA IMMUNOLOGY SKIN FOOD DRUGS SYMPTONS PREVENTION WHEAT POISON WARNING INFECTION

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IMMUNOTHERAPY/ALLERGENS IMMUNOLOGY SKIN FOOD DRUGS SYMP-WHEAT POISON WARNING INFECTION FEVER MOLD COUGH POLLEN ECZEMA REAC-

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ABSTRACTSABSTRACTSHEADLINE

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Save the date!

7 - 9 February 2013

Food Allergy and Anaphylaxis Meeting

FAAM 20137 - 9 February 2013

Nice, France

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WELCOME RECEPTION “Little Oktoberfest”

Date: Wednesday, 11 April 2012

Start: 18:00

Venue: Mensa at the Klinikum rechts der Isar (one floor beneath the lecture halls)

Rate: EUR 20,00 per person incl. 19% German VAT

Come and join us after the lectures on Wednesday at the Welcome Reception themed “Little Oktoberfest”. In an atmosphere of Bavarian cosiness you will have time to chat with your friends and colleagues. A buffet with traditional dishes and drinks including a typical beer barrel await you. Carnival attractions as you can find them at the real Oktoberfest promise an enjoyable evening. Challenge your colleagues at the High Striker or the Tin Can Alley Toss.Wheather permitting, the beergarden will be open.


EXHIBITION PLAN

© INTERPLAN AG

Entrance

Subject to alterations!Print: 26.03.2012

Lecturebuilding

Einsteinstraße

Registration

Delivery Accessvia Gate(see road map)

Posters

Wardrobe

PavillonPoster

PlenaryLecture Hall A

ExhibitionCatering

LectureHall B


LIST OF EXHIBITORS

Company detailsin printed media

Country Stand No.

EAACI Switzerland 1

BÜHLMANN Laboratories AG Switzerland 2

Laboratorios Diater SA Spain 3


IMPRINT

Chair of the Organising CommitteeProf. Dr. Knut BrockowDepartment of Dermatology and Allergy BiedersteinTechnische Universität MünchenBiedersteiner Straße 2980802 MunichGermanyPhone: +49 89 4140 31 82Fax: +49 89 4140 31 27E-mail: [email protected]

EAACI Headquarters

Genferstrasse 218002 ZurichSwitzerlandPhone: +41 44 205 55 33Fax: +41 44 205 55 39E-mail: [email protected]: www.eaaci.net

DHM5 2012 Organiser

INTERPLANCongress, Meeting & Event Management AGLandsberger Str. 15580687 MunichGermanyPhone: +49 89 54 82 34 62Fax: +49 89 54 82 34 43E-mail: [email protected]

Final Programme Layout

Juliane Stahr / networkSchmargendorfer Str. 612159 Berlin Germany

ABSTRACTSEuropean Academy of Allergy and Clinical Immunology

16 – 20 June 2012 Geneva, Switzerland

www.eaaci2012.com

©G

enèv

e To

uris

me

EAACI Congress 2012

At the Crossroads of Research, Practice and Education

Ad_2012_111108:A4 2011-11-08 13.54 Sida 1

Dhm12 programm v7

Health & Medicine

Transcript of Dhm12 programm v7