Unusual, non-anaphylactic transfusion reactions associated with severe IgA and IgM deficiencies and anti-IgA

A few individuals with undetectable IgA develop anti-IgA, which is theorized to promote anaphylactic or anaphylactoid reactions to blood products. Here, we describe a recurrent, unusual reaction in a patient with no IgA or IgM, and anti-IgA present. The patient is a 49-year-old male with cirrhosis secondary to hepatitis C, who presented to the emergency department in January of 2014 with abdominal distension, leg swelling and dyspnea. He was severely anemic with a hemoglobin of 4.5 g/dL. Several minutes into a transfusion, he complained of chills, dyspnea and back pain. The transfusion was discontinued after <10mL, and his symptoms resolved rapidly without further intervention. The patient’s blood pressure, heart rate and temperature before and after the reaction were 134/63 mmHg and 180/64 mmHg, 98 beats/minute (bpm) and 102 bpm, and 98.6⁰ F and 98.7⁰ F, respectively. A laboratory workup for hemolysis was negative pre- and post-transfusion and an “OK to transfuse” order was given if future blood products were indicated. The following day, another transfusion of PRBCs was stopped after <75 mL due to similar symptoms, which again resolved rapidly; no vital signs changes or signs of hemolysis were noted. Because he was receiving other fluids concurrently with the PRBCs, it was recommended to transfuse future products slowly and to premedicate with furosemide. Although he tolerated three subsequent PRBC transfusions during the same admission, he developed the same clinical picture as soon as <75mL of a platelet unit was started. At that time, unbeknownst to Transfusion Medicine, the primary care team ordered immunoglobulin levels and anti-IgA, and the results of these tests were entered into his electronic medical record (EMR) after discharge. Approximately six years later, the patient was readmitted following a fall and was found to be thrombocytopenic. After receiving <30 mL of platelets, he developed back pain and headache and the transfusion was aborted. His wife informed the primary provider that her husband was IgA-deficient. When Transfusion Medicine was notified, a review of his EMR showed undetectable IgA (<6 mg/dL: reference: 46-236 mg/dL) and IgM (<25 mg/dL; reference 43-279 mg/dL) and mildly increased IgG (1787 mg/dL; reference 650-1643 mg/dL) from 2014. Additionally, a high-titer IgG anti-IgA (>1000 U/mL; reference <99 U/mL), had been reported. In lieu of these findings, we changed his transfusion requirements to issue only washed PRBCs and IgA-deficient platelets and plasma, but he has not required any blood products since the last reaction. While a definitive cause and effect has not been established, this case suggests that severe IgA- and IgM-deficiency with IgG anti-IgA may be associated with nonspecific symptoms even with the transfusion of small volumes (<75 mL). To our knowledge, similar reactions have not been previously reported.

Kounis syndrome after almonds ingestion: From the diagnostic approach to new therapeutic options

Acute coronary syndromes can develop with an unusual and challenging presentation. Kounis syndrome is a mostly overlooked Acute Coronary Syndrome (ACS) in the setting of anaphylactic or anaphylactoid reactions in response to an allergic insult that can lead to severe complications including cardiac arrest. A 52-yearold- man presented to the emergency department of our hospital because of acute transient loss of consciousness that developed some minutes after almonds ingestion. The complex diagnostic workup led to the diagnosis of vasospastic Kounis syndrome, an infrequent type of acute coronary syndrome, mostly overlooked, with challenging diagnostic and therapeutic features. Peculiarities on clinical presentation, the approach adopted by the emergency physician and the consultant cardiologist to achieve the correct diagnosis and our proposed management with a brief revision of the literature will be reported. Unusual clinical presentations of acute coronary syndromes represent part of the pitfalls that an emergency physician can face during the everyday practice. Prompt identification of these conditions is always struggling but of crucial importance to improve patient prognosis with a correct diagnostic work-up and therapeutic management.

An unusual case of concurrent Kounis syndrome and prolonged QT in a young patient

Allergic reactions related to drug use is a common entity presenting often from minor urticaria to life-threatening anaphylactoid reactions. A common but easily overlooked diagnosis, Kounis syndrome, is an established hypersensitivity coronary disorder induced by drugs, foods, environmental factors, and coronary stents that can present in the same way as non-allergy-induced acute coronary syndrome. Here within, we present a unique case of dual presentation of Kounis syndrome and prolonged QTc in a young patient after a single dose of Domperidone and Lansoprazole.

Comparison of Two Muscle Relaxants for Tracheal Intubation in Patients Undergoing Surgery at Goa Medical College and Hospital

BACKGROUND Cisatracurium and atracurium are intermediate acting muscle relaxants which do not depend on renal or hepatic metabolism for elimination since they undergo Hofmann elimination. Despite the advantages of cisatracurium such as minimal effects on the cardiovascular system, no accumulative effects, no metabolite toxicity, and metabolic product has no neuromuscular blocking effects, due to slow onset and unsatisfactory intubating conditions, the use of cisatracurium is limited compared with those seen with equipotent doses of other neuromuscular blocking agents. This study was undertaken to find onset time and intubating conditions with 3 × ED95 doses of atracurium versus cisatracurium. METHODS ASA grade 1 or 2 patients, (N = 220) were randomly allocated into 2 groups to receive equipotent doses of either atracurium or cisatracurium. Intubating conditions were assessed using Cooper et al scale and neuromuscular monitoring done using TOF Watch SX. Haemodynamic responses and any adverse effects were noted. RESULTS The onset time was 167.36 ± 75.41 seconds (2.78 ± 1.25 minutes) in atracurium group whereas in cisatracurium group, onset time was 249.26 ± 75.90 seconds (4.15 ± 1.26) and the difference was statistically significant with p value of < 0.001. The difference in intubating conditions between the groups was statistically insignificant. However, atracurium produced a higher incidence of clinically acceptable conditions (excellent in 94.4 %) than cisatracurium (excellent in 87.3 %). The incidence of adverse effects such as erythema, flushing and bronchospasm was greater in Atracurium group though hypotension was observed in both groups. CONCLUSIONS Onset time and intubating conditions are significantly better with equipotent doses of atracurium compared to cisatracurium. But atracurium is associated with higher incidence of adverse effects such as erythema, flushing and bronchospasm, though the potential of cisatracurium to cause anaphylactoid reactions cannot be ignored. KEYWORDS Cisatracurium, Atracurium, Muscle Relaxants, Neuromuscular Blocking Agents, Erythema, Flushing, Bronchospasm, Hypotension, Anaphylactoid Reactions

Anaphylactic events in mRNA vaccines: a reporting case-control study

Background: mRNA vaccines are a novel method of eliciting immunity, and play a significant role in the global fight against COVID-19. Anaphylactic reactions are a widespread concern driving vaccine hesitancy due to the serious and potentially fatal nature of anaphylaxis. A quantitative estimation of the risk of anaphylactic and anaphylactoid reactions deriving from mRNA vaccines is of a significant public health importance. Objective: To estimate the relative Reporting Odds Ratio of anaphylactic and anaphylactoid reactions following mRNA vaccination vis-a-vis other vaccinations. Design: Reporting case-control study. Setting: Persons reporting adverse events following vaccination to VAERS whose reports were received between 01 January 2000 and 02 July 2021, inclusive. Patients: Each case of anaphylaxis or anaphylactoid reaction was matched with 2.7 unique controls on average, by gender and age rounded to the nearest integer. Measurements: Overall and stratified Reporting Odds Ratios (ROR) were calculated. Stratified contingency tables were tested for homogeneity using the Breslow-Day procedure, and Cochran-Mantel-Haenszel statistics were calculated to test the hypothesis of a ROR of unity. Results: 2,665 cases of anaphylaxis or anaphylactoid reactions and 7,125 controls of non-anaphylactic/anaphylactoid reports were compared. The ROR of an anaphylactic or anaphylactoid reaction was 1.325 (95% CI: 1.212 - 1.448, p < 0.001). The matched set of cases and controls did not reveal inhomogeneity by gender or age band strata, suggesting that these factors have no impact on the likelihood to report an anaphylactic event as opposed to a non-anaphylactic event following mRNA vaccination. A slightly elevated ROR was observed with patients who reported a history of allergic reactions to NSAIDs and/or fluoroquinolone antibiotics. The precise meaning and relevance of this finding remains to be elucidated. Previous reactions to vaccines do not appear to correlate statistically significantly with a higher risk of reporting an anaphylactic adverse effect after mRNA vaccination. Limitations: As a reporting study using data from VAERS, our analysis is subject to under- and overreporting, the extent of each of which is not known with any degree of precision. Since the Emergency Use Authorizations for both mRNA vaccines mandate reporting of all serious adverse events, reporting bias is likely in favour of non- mRNA vaccines, where such reporting is not mandatory in adults. Consequently, this analysis may exaggerate the ROR of anaphylactic and anaphylactoid events associated with mRNA vaccines, which may in reality be significantly lower. Conclusions: mRNA vaccination is not associated with a statistically significant higher risk of reporting an anaphylactic adverse event to VAERS. Anaphylaxis is a serious but very rare complication of all immunisations. No significant increase in reporting odds was found in any age group or gender, nor in most cases of previously known allergic adverse events in relation to vaccines. This study contributes to the growing body of evidence proving the safety and tolerability of mRNA vaccines.

Intravenous ondansetron induced hypersensitivity reaction: a case report

Ondansetron a selective 5-HT3 receptor antagonist has been widely used as a prophylactic antiemetic for chemotherapy induced and anaesthesia related nausea and vomiting. Anaphylaxis and anaphylactoid reaction rarely occur in less than 1% of the patients and may lead to potentially life-threatening events. This study is one such rare case report of hypersensitivity reaction to intravenous ondansetron in a perioperative setting. Familiarity about anaphylactoid reactions to intravenous ondansetron among the health practitioners would help them to bring about a rational approach to decrease its incidence.

Real-world patterns of pegloticase use for treatment of gout: descriptive multidatabase cohort study

ObjectivePegloticase is used in severe refractory gout or in cases of intolerance to other urate-lowering therapies. We sought to evaluate the patterns of pegloticase use in the USA and the incidence of safety outcomes.MethodsWe conducted a retrospective descriptive study using data from two US commercial insurance claims databases (2010–2018). We identified new initiators of pegloticase with ≥1 gout diagnosis code in the 365-day baseline period prior to pegloticase initiation. We measured the number and duration of pegloticase infusions. We assessed the risk of anaphylaxis or anaphylactoid reactions, cardiovascular events, including myocardial infarction or stroke, and hospitalisation for heart failure (new onset or exacerbations) while undergoing pegloticase therapy.ResultsAmong 2.9 million patients with ≥1 diagnosis of gout, we identified only 483 (179 in Optum and 304 in MarketScan) pegloticase initiators. The mean age and % female was 55.6 years, 10.9% for MarketScan and 60.6 years and 17.3% for Optum. Hypertension was present in up to 85%, diabetes mellitus in 38%, chronic kidney disease in 46% and heart failure in 21% of the patients. The median number of infusions was four and the duration of therapy was 3 months. During the mean 0.5-year follow-up time on pegloticase, there were 3 (0.6%) anaphylaxis, 7 (1.4%) composite cardiovascular, 31 (6.4%) heart failure hospitalisations and 3 (0.6%) deaths.ConclusionPegloticase is rarely used in gout, and the median duration of pegloticase therapy was 3 months. There were few anaphylaxis events captured in this claims-based study, while heart failure hospitalisations were common.