ABSTRACTS Peter Rosen, MD - - editor

Director of the Division of Emergency Medicine, Denver General Hospital

Frank J. Baker, II, MD- -ass is tant editor Associate Professor and Director, Department of Emergency Medicine,

University of Chicago Hospitals and Clinics

Diagnosis and treatment of anaphylactic reactions to Hymenoptera stings in children, J Pediatr 97:177-184, (Aug) 1980.

A prospective study was done to test the safety and efficacy of insect venom immunothe rapy in decreasing Hymenoptera sensit ivity in children. Forty-four children (mean age 9.6 years) with a history of allergic reaction(s) to a bee sting and at least one positive insect venom skin test were studied. Allergic reactions consisted of cutaneous manifestat ions in 43/44 (98%), respiratory embar rassment in 21/44 (48%), and hypotension in only 4/44 (9%). Skin tests were to honeybee venom, honeybee phospholipase-A, vespid (hornet and yel- lowjacket) venom, and wasp venom. Also done was RAST testing to measure IgE antibodies to yellow jacket venom (present in 78%) and honeybee PL-A (present in 77%) as well as venom-specific IgG levels. There were no correlations be- tween skin test reactivi ty and specific IgE antibody t i ters for the two tested insect venom extracts. Immunotherapy was carried out with the venom specific for the pat ients ' sensitiv- ity as determined by skin test results. The immunotherapy was performed for 15 weeks, at which t ime the pat ients were challenged with a bee sting in 37/44 cases with a resul tant 3% reaction rate. Twenty out of 44 pat ients were re-stung o n e year la ter and there was one mild, delayed reaction. IgG- blocking antibodies to yellow jacket venom and honeybee PL- A were followed throughout therapy, and there was a sub- stantial increase of these in the first 15 weeks of therapy in the majority of the patients, wi th a fivefold increase in anti- venom IgG thought to provide clinical protection. Five of 44 failed to develop a significant increase in ant ivenom IgG and were t r e a t e d m o r e vigorously. Specific IgE antibodies against yellow jacket venom were measured during immunotherapy and were found to have increased 3.7-fold by week 8 with a slow decline to 40% greater than baseline at one year. In terms of reactions to therapy, there were three (7%) systemic reactions and 12/44 (27%) experienced at least o n e l a r g e local react ion during immunotherapy. The authors conclude tha t venom immunotherapy in children is safe and effective. How- ever, they also point out t ha t the significant increase in IgE during the first eight weeks of therapy may, theoretically, make the pat ient more sensit ive to stings during tha t period. Also, they concede t ha t most children will probably lose the i r sensitivity to bee venom natura l ly , and proceeding wi th venom immuno the rapy may prevent th is na tu ra l cure by maintaining IgE levels. Other d i sadvan tages include the monetary and t ime expenditure. The ul t imate conclusion is that al though venom immunotherapy is both safe and effica- cious in desensitizing children at r isk of a fatal anaphylactic reaction, the indications for ini t ia t ion of immunotherapy and its proper durat ion are not clearly defined. Therefore, more work must be done to determine which pat ients are most likely to benefit from this type of immunotherapy.

Timothy L. Turnbull, MD stings, Hymenoptera

Culture-proved Fitz-Hugh-Curtis syndrome. Kornfeld SJ, Worthington MG, Am J Obstet Gyneco/139:106-107, (Jan) 1980. The Fitz-Hugh-Curtis syndrome, consisting of the acute onset of severe pleuritic r ight upper quadran t pain, with radiat ion to the r ight shoulder and back, in a pat ient with genitouri- nary gonorrhea, was first described in 1919. However, the proposed agent, Neisseria gonorrhaeae, has never been iso- lated in peritoneal cultures. Whether the gonococcus actually t r ave r ses the per i tonea l cavi ty en route to the liver, o r whether other organisms may be responsible for this syn- drome has not been answered. The authors report a case study of a 24-year-old woman who presented with Fitz-Hugh- Curt is syndrome following abdominal t r auma . Per i toneal lavage revealed 1,230 polymorphonuclear leukocytes and en- docervical and peritoneal cultures were positive for N gonor- rhaeae. They offer this as evidence t ha t the Fitz-Hugh-Curtis syndrome is caused solely by an ascending gonococcal infec- tion in female patients, and suggest tha t this substant ia tes the fact t h a t the gonococcus reaches the l iver capsule by direct peritoneal spread. They also point out the danger of this condition mimicking an acute abdomen, and the fact tha t physicians must be aware of the similari ty if they wish to avoid unnecessary surgery. (Edi tor ' s note: One case does not a series make.) Sandra Greco, MD

syndrome , Fitz-Hugh-Curt is

Reversible ischaemic colitis in young adults. Duffy J, Br J Surg 68:34-37, 1981. The authors present four cases of ischemic colitis in young adults and discuss the clinical presentat ion and course of this infrequent problem. In young adults, this disease is usually preceded by profound hypotension often produced by drug overdose and hemorrhage. However, it has been noted to oc- cur with oral contraceptives, collagen vascular disease (ie, vasculitis), as well as with no identifiable etiology. The syn- drome consists of a clinical t r iad of lower abdominal pain, d iar rhea , and rectal b leeding of sudden onset with rapid clearance of symptoms on a non-specific management regi- men. A bar ium enema can help confirm the diagnosis, and the characteristic finding is a s tr icture of the colon showing ~ t h u m b - p r i n t i n g " and/or "saw-tooth" i r regular i ty . There appears to be a predominance of right-sided lesions in young adults; however, there is also a predilection for the splenic flexure area. The majority of pat ients become asymptomatic within four days without specific t rea tment , but a colonic re- section may be required if gangrene of the bowel occurs. (Edi tor ' s note: I t is hard to know whether this syndrome is recognizable in the emergency department. Probably most pa- tients with this presentation would be admitted with a diagno- sis of ulcerative colitis and a barium enema would not be ordered as an emergency procedure.) John Tucker, MD colitis, i s c h e m i c

10:7 (July) 1981 Ann Emerg Med 400/87