Severe Persistent Eczema in a Recipient of the Gam-COVID-Vac vaccine

Since the beginning of the COVID-19 pandemic, efforts have been made to design safe and effective vaccines against SARS-CoV-2. Numerous vaccines have been designed and tested in limited clinical trials in various countries. Among them, the Sputnik V vaccine has shown a relatively safe profile and, to our knowledge, has no associated major side effects. We describe the case of a 40-year-old female healthcare worker who developed severe persistent eczematous lesions on the second day after she received the first dose of the Sputnik vaccine. The eczematous lesions were refractory to an antihistamine and persisted at the 1 month follow-up. Severe persistent eczematous lesions should be viewed as a potential side effect of vaccination with the Sputnik V vaccine. Moreover, a severe allergic reaction to a COVID-2019 vaccine may indicate the vaccine is ineffective in the recipient.

Monitored COVID-19 mRNA vaccine second doses for people with adverse reactions after the first dose

Background: After Emergency Use Authorization of the coronavirus disease 2019 (COVID-19) vaccines, guidance was provided by the Centers for Disease Control and Prevention that persons with an immediate allergic reaction to a messenger RNA (mRNA) COVID-19 vaccine should be evaluated by an allergist/immunologist before receipt of the second dose. Methods: In vaccinating health-care personnel, we referred those with significant reactions to allergy/immunology specialists so that they could safely receive the second dose. Results: We found that many reactions after the first dose were nonallergic but could be debilitating and a barrier to the second dose. We created a protocol of premedications to allow health-care personnel to safely receive their second mRNA COVID-19 vaccine dose. Conclusion: This protocol is adaptable and can be used in settings where allergy/immunology referral is not immediately available.

Cercarial Dermatitis in Schleswig-Holstein Distribution of Cercariae in Public Swimming Lakes

Cercarial dermatitis is a neglected zoonotic disease with distribution all over the world’s temperate zones. It is caused by cercariae, a larval stage of parasitic blood flukes of the genus Trichobilharzia that is a parasite of waterfowl. When cercariae burry into human skin, they trigger an allergic reaction that leads to severely itching papules. Goal of this research was to get an overview over the distribution of cercariae in the bathing places of Schleswig-Holstein, the most northern state of Germany. Therefore, all public bathing places were visited and searched for fresh water snails that are the potential intermediate hosts of cercariae. Water snails of different families and genera were collected and examined for the presence of cercariae. Water samples were taken and examined for cercariae via a microscope. Additionally slime samples of the water snails were taken to test a new, time saving method of detection. In total 8 different kinds of water snails were collected and examined, of which the families of Lymnaeidae and Planorbidae proved to be the most common hosts of cercariae. In total, the results indicate a spatial distribution of cercariae shedding snails all over Schleswig-Holstein.

A rare case of spontaneous expulsive suprachoroidal haemorrhage in a glaucomatous eye treated with topical alpha-adrenergic agonist

Spontaneous expulsive suprachoroidal hemorrhage is a rare ocular condition, which usually occurs after sudden decompression of the eyewall. Most of the cases of expulsive hemorrhage reported had a predisposing glaucoma with the combination of corneal pathology. We are reporting a case of spontaneous expulsive suprachoroidal hemorrhage in a glaucoma patient probably due to perpetuated inflammatory reaction and frequent eye rubbing induced by allergic reaction to topical alpha adrenergic agonist in a compromised cornea.

Spontaneous Drainage of Lower Lip Abscess by Insect Sting in the Prediabetic Male: A Case Report

Most insects have a stinging apparatus at the tail end of their abdominal segment and can deliver venom. The venom can usually result in pain, erythema, abscess, or allergic reaction in human tissues such as the skin and even the lips. The presentation of lip abscess, especially in the vermilion, is rare and needs to be appropriately managed. A 39-year-old prediabetic male presented with a swollen right lower lip stung by an insect six days before the consult. The swelling started as a vesicle which became bigger, then burst, exuding a yellowish fluid and blood. The swollen area became more significant, and pain was felt. The clinical presentation was that of a lower lip abscess. Adequate antibiotics were prescribed along with a corticosteroid and a topical antiseptic. The treatment was essential to prevent the dissemination of infection and the likelihood of tissue necrosis. This case report is presented as a rare clinical case of a lower lip abscess due to an insect sting with spontaneous drainage after treatment in a prediabetic male. The dentist and clinician needed to identify this condition and to manage the case properly.

Agreement between Prehospital and Final Diagnosis in Patients with Acute Allergic Reactions: A Cross-Sectional Study

Introduction: Acute allergic reactions are usually first encountered in the prehospital setting and account for about 0.3% to 0.8% of prehospital runs in different countries. Right, and rapid recognition and treatment are necessary to decrease mortality and morbidity, especially in severe critical cases. This study evaluates the accuracy of prehospital care providers’ diagnosis in patients with acute allergic reactions in comparison with final (discharge) diagnosis as the gold standard. Methods: Patients who were transported to 2 urban referral hospitals between 2008 and 2014 under the dispatch code of “acute allergic reaction” were included in the study, retrospectively. Demographic data, etiology of an allergic reaction, clinical presentations, vital signs stability, and need for epinephrine injection were evaluated. The prehospital care providers’ diagnosis (documented on-call report) was compared with the final diagnosis (documented on discharge summary form). Results: A total of 300 patients were included in the study. In 55 (18.3%) cases the prehospital care providers’ and final diagnoses were different. Diagnoses were similar in 245 (81.6%) patients. Kappa coefficient was calculated as 0.621which shows a moderate-to-substantial agreement between prehospital and final diagnoses. Fifteen patients (5%) were discharged from the hospital with a diagnosis of anaphylaxis and only 4 cases (26.6%) were diagnosed in the prehospital setting. Conclusion: Although the overall agreement between prehospital and final diagnosis of acute allergic reactions calculated in this study was good, the accuracy of diagnosing the anaphylaxis (as the most critical allergic reaction with a potential fatality) was less than optimal.

Allergic Reaction of the Body to Drugs Used in Dental Practice

The article examines allergic reactions of the body to drugs used in dental practice. The authors note that adverse or allergic reactions of medicines to the human body are possible with any medications that are prescribed or administered in a dental office. Although most of the pharmacological agents used today have a favorable profile and they are relatively safe, a modern specialist should be aware of potential adverse reactions that may occur and one should be ready to cope with any complications. Adverse or allergic reactions are possible when working with drugs such as local anesthetics, sedatives, analgesics and antibiotics, for this reason, it is necessary to study the possible reactions of the patient's body to them when administering such drugs to reduce the negative impact on the body. In general, the pharmacological arsenal of a practicing dentist is relatively safe today. However, a prudent clinician should be aware of potential adverse reactions that may occur as a result of taking medications, and be confident in the treatment of such complications.

The Monocyte Monolayer Assay to Build a Personalized Pipeline of Transfusion Support in Highly Sensitized Sickle Cell Disease

BACKGROUND: RBC transfusions play a role in organ- and life-preservation for patients with sickle cell disease (SCD). These in turn are subject to higher-fidelity matches to offset the particularly high condition-specific odds of seroconversion events. Adverse outcomes may be as severe as hyperhemolysis, and/or undertransfusion from the scarcity of suitable antigen profiles. In a woman with HbSS SCD and multiple alloantibodies (-K, -E, Jkb-, -Fya, -S), correspondingly antigen-negative units had nevertheless become invariably crossmatch-incompatible (iXM) owing to the development of an antibody to -Kna, a high-prevalence (but clinically insignificant) target antigen on CR1/CD35. Genotyping ruled out the absence of other rare antigen-negative states at risk of high-frequency antibodies (hrB, hrS, Joa, U). Due to uncertainties on the in-vivo effects of iXM RBC in this patient, the infeasibility of sourcing of complete antigen matches, and challenges ruling out other emerging (and potentially more harmful) antibodies, a prolonged period of transfusion-avoidance ensued. This deferral correlated with progression of SCD-associated dilated non-ischemic cardiomyopathy and restrictive interstitial pulmonary fibrosis. In order to qualify Kna-unselected iXM that were otherwise target-negative for her clinically significant antibodies, a monocyte monolayer assay (MMA) approach was taken to identify, transfuse, and maintain a personalized roster of RBCs for monthly top-up transfusions. METHODS: Selected donors (group O, ±D, ±C, E- K- Jkb- Fya-) were assessed at least once in the MMA by a 4:1 (patient serum) to (candidate unit RBC) ratio, incubated at 37°C for 1 hour. The total number of RBCs phagocytosed in 100 patient monocytes was reported as a phagocytic index (PI), with a significance cut-off of 5 (or lower, if rosettes were noted, and/or a noticeably more incompatible [≥3+] crossmatch was observed compared with other prepared units). Antibody screens (automated solid phase) and manual serologic crossmatches (by both conventional tube- and gel microtube- technique) were performed at each RBC sitting. Interval/pre-RBC tests incorporated hemolytic markers and hemoglobin electrophoresis (HbS%). RESULTS: Of 26 donors examined in 8 MMA arrays over 3 years, 10 were excluded due to high PI (median 6 [range 3.3-54]) and/or differential iXM. Of the remaining 16 (PI 0.9 [0.2-4.5]), RBCs have been transfused from 13, with 56 units [u] (51 fresh/5 frozen-deglycerolized) given in 27 sittings over 113 weeks. Most have donated >1u (7/13 with ≥1u transfused to this recipient, median 4u [range 1-8]). The HbS% fell from 91% to 45% [39-48] (median [IQR], pre-3rd-to-27th sitting) with improved hemolytic markers and freedom from overt incompatibility reactions. A minor allergic reaction on the 1 st sitting (with 2u from the same donor) led to a default mitigation strategy of supernatant reduction and antihistamine-premedication thereafter. All sittings (including 5u from the index donor) were reaction-free until a 2 nd minor allergic reaction 2 years later (associated with 2 other donors). Improvements occurred in cardiac function, performance status, pain, and quality of life over the 1 st 20 months of transfusions, though an acute pulmonary embolism and progressive iron overload have reversed the initial gains. Of 11 donors re-examined in 3 repeat MMA (29-112 weeks later), 10 were re-qualified; the 1 st donor was excluded due to an unexplained PI surge (2.5 to 5.6). Host tolerance otherwise increased to most re-qualified donors in a PI downtrend over time (in 8/10, median 1 st PI 2.1, vs median 2 nd PI 1.0, P=0.006 [paired, 2-sided t-test]). A new sensitization (anti-Cob) was noted before the 14 th sitting, with donor genotypes imputing and disqualifying donor 9. CONCLUSIONS: An MMA-vetted pipeline of RBCs in a once-prohibitively alloimmunized patient with SCD has re-enabled transfusion care by the coordinated efforts of the national blood collector with its donors, its MMA laboratory, and the supervising hospital transfusion service. An unexpected finding in repeated exposures to a limited number of donors was increased tolerance. When the viability of transfusions is restored in SCD, so too are opportunities in disease control and in transfusion-requiring curative treatment options. The number of similarly constrained patients, and the scalability of this innovation, remain to be determined. Disclosures No relevant conflicts of interest to declare.

Post-Transfusion Takotsubo Cardiomyopathy

In three recent cases an initial transfusion-related adverse event (TRAE) occurred that had a significant respiratory component, and other features suggesting a severe allergic reaction. All were treated as such. Shortly after treatment the nature of the event changed to something resembling transfusion-associated circulatory overload (TACO). These cases suggest the possibility that a severe TRAE that is not TACO may precipitate TACO. In other words, some transfusions, sometimes, may deliver a 'double whammy'. A possible mechanism might be through the development of Takotsubo, or stress, cardiomyopathy - a cause of acute, reversible, heart failure. Takotsubo cardiomyopathy typically presents with chest pain or shortness of breath. Ventricular wall dysfunction occurs, and characteristic echocardiographic abnormalities are seen. ECG and biochemical features suggest cardiac ischaemia. It is commoner in post-menopausal women. A range of 'stressors' - hypotension, asthma attacks, accidents, medical procedures, pain, bad news, etc. - may precipitate it. 1 Catecholamines such as adrenaline are believed to play a central role. They cause direct toxicity to the myocardium, and also coronary artery spasm, and increased cardiac workload. 2 One other such case is reported. There, a 48 years old post-menopausal woman developed acute reversible heart failure with the features of Takotsubo cardiomyopathy, following urticaria and pruritus, whilst having a platelet transfusion. No adrenaline was given, but the authors postulate that adrenergic and histaminergic elements may have combined to produce the effect on the heart. 3 Thus, in some patients the 'perfect storm' compounded of borderline cardiac function,catecholamine release (secondary to the stress of the underlying disorder, the transfusion, and the TRAE),histamine release (in allergic TRAE),the treatment of the allergic reaction with adrenalinerecent or ongoing volume overload may be sufficient to precipitate or exacerbate TACO. Careful consideration of cases with similar features is needed. Potential precipitating factors are modifiable or preventable. References: 1. https://www.health.harvard.edu/heart-health/takotsubo-cardiomyopathy-broken-heart-syndrome 2. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.116.027121 3. Zhou JQ, Choe E, Ang L, et al. Stress-induced cardiomyopathy associated with a transfusion reaction: A case of potential crosstalk between the histaminic and adrenergic systems. Exp Clin Cardiol.2011; 16: 30-32 Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Prevalence of Stroke and Cognitive Impairment in Patients with Hereditary Thrombotic Thrombocytopenic Purpura

Hereditary thrombotic thrombocytopenic purpura (HTTP) is a rare autosomal recessive disorder caused by biallelic mutations in the ADAMTS13 gene. From 3 large case series reported in 2019 (UK Registry, Blood 2019; 133(15):1644; International Registry, Haematologica 2019 104(10);2107-2115; Borogovac, et al. Blood Advances 2019; 3(23):2973-6), we know that the clinical presentation of HTTP can range from asymptomatic disease to significant morbidity and early mortality. Stroke is the most common and most severe morbidity reported in 25-31% of patients (pts) with HTTP. However, due to a short duration of follow-up (median age of last follow up of 24-26 years (yrs) old) in these 3 case series, the morbidities in older pts are unknown. We conducted a descriptive study with adult and pediatric pts within the US who have a diagnosis of HTTP by ADAMTS13 activity level of <10% and biallelic ADAMTS13 mutations and are enrolled in the International HTTP Registry. Previously reported studies have had limited long-term follow up. Our objective was to characterize the clinical features of the disease and its impact on patients over multiple decades. We determined the frequency and age of onset of stroke and other neurologic and neuropsychiatric symptoms. Each pt and/or their parents (if children) completed a 30-60 minute phone interview with the first author to learn about their daily lives, their medical history and their limitations or disabilities. The interviews used a semi-structured discussion guide tailored to their age group. Chi-square analysis or Fisher's exact test were performed to assess the difference in frequency of symptoms in pts with or without history of stroke. To assess the incidence rate of stroke depending on prophylaxis use, a rate ratio was performed using stokes as events and person-time yrs on or off prophylaxis as the denominator. A total of 26 pts (or their parents) were interviewed from April 2020 to July 2021. The median age was 37 with 24 adults (ages 19-63) and 2 children (ages 1, 12). Our sample was predominantly female (73%), white (88%), and with a college or higher education (75%). Stroke was reported in 16 pts (62%) with a median age for first stroke of 26 yrs (newborn-53 yrs). Residual symptoms were reported in 10 (63%) stroke pts. Six (23%) pts have been on stroke-related disability, beginning at a median age of 40 yrs (18-53 yrs). Twenty-four of 25 (96%) pts reported recurrent neuropsychiatric symptoms (the one infant was excluded, Table). The most common symptoms were recurrent headaches (22 pts), migraine with aura (14 pts), poor concentration (16 pts), and forgetfulness (11 pts). There was no difference in the frequency of these symptoms in pts with or without history of stroke except dysarthria was more common in pts with a history of stroke (Table). Twenty of 24 (83%) pts who have received plasma within their lives have had an allergic reaction, most commonly rash or itching in 70%, followed by shortness of breath or chest pain in 20%, and 2 pts (10%) had anaphylaxis. Two pts reported no allergic reaction to plasma. Sixteen pts (62%) are currently on prophylaxis. Prophylaxis was not shown to be protective of stroke with a calculated rate ratio of 0.76 (95% CI 0.26-2.18). A total of 4 pts had a stroke while on prophylaxis, of whom 2 had reported not missing any doses. The other 2 pts had missed a dose at the time of stroke or had been receiving prophylaxis at a prolonged interval of every 3 weeks, indicating inadequate administration. In conclusion, HTTP pts suffer from significant neurologic morbidity with an overall occurrence of stroke in 62%, more than twice the rate from prior reports. Our median age of follow-up (37 yrs) is older than in previous reports (24-26 yrs). Here, 56% of first strokes occurred at age 25 yrs or older. Importantly, the penetrance of stroke as a life event increases with age at follow-up and is 100% in pts over 50 yrs (Figure). Our observational study did not demonstrate that the use of prophylaxis significantly decreases the risk of stroke. Limitations include small sample size and non-randomized trial design. Neuropsychiatric symptoms occurred in 96% of pts independent of a history of stroke, possibly related to recurrent microvascular thrombosis. Future prophylaxis with recombinant ADAMTS13 (currently completing its phase 3 trial) will be make self-administration more convenient, and may be more effective than plasma. Figure 1 Figure 1. Disclosures Kremer Hovinga Strebel: Baxalta US Inc: Other: grant; Shire: Consultancy, Speakers Bureau; Ablynx: Consultancy, Speakers Bureau; Federal Office of Public Health: Consultancy; Insel Gruppe AG: Current Employment. Friedman: Bayer: Consultancy; Alexion: Speakers Bureau; Siemens: Consultancy; Genentech: Consultancy; Sanofi: Consultancy; Instrumentation Laboratories: Consultancy.