Anaphylaxis and Biphasic Phase in Thailand: 4-year Observation

BackgroundAnaphylaxis, a severe systemic allergic reaction, can be fatal. However, its prevalence has been underestimated especially in biphasic phase, due to a lack of case awareness. This study aimed to determine the rate of anaphylaxis, describe clinical manifestations and management, and identify the causative agents and risk factors of biphasic anaphylactic reaction.MethodsAn observational study was conducted at the Emergency Department of Thammasat University Hospital, Thailand, during the period 2004–2008.ResultsOf total 208 cases of anaphylaxis identified, the median age was 20.67 years; 52.9% were male. The anaphylaxis rate was 49 per 100,000 patient-years. No fatal case was found; 58.7% had a history of atopy, and 38.5% had experienced a previous allergic reaction, of whom 8.8% had had a previous anaphylactic reaction. The causative allergens were identified in 82.2% of cases; food allergy was most common. Urticaria was the most common presentation (87%). Among 6.3% of the patients who developed biphasic reaction, a significantly longer time from onset of symptoms to administration of epinephrine was detected, with a median of 240 minutes for those with biphasic anaphylaxis, versus 70 minutes for those without (p = 0.002). The median times from onset to hospital arrival and the arrival to administration of epinephrine were also significantly longer in the biphasic group than the non-biphasic patients (p = 0.002 and p = 0.001, respectively). In multivariable regression models, the time intervals from onset and hospital arrival to administration of epinephrine continued to predict biphasic phase occurrence (p < 0.01).ConclusionsAnaphylaxis predominantly occurs among children and young adults. Delayed administration of epinephrine was associated with the occurrence of biphasic anaphylaxis.     

Laparoscopic enucleation of an endometriotic cyst in a renal transplant patient. A case report

BACKGROUND: Laparoscopic enucleation of an endometriotic cyst in a renal transplant patient has not been reported before. CASE: An endometriotic cyst was found in the same side as a transplanted kidney. Laparoscopic enucleation of the cyst was performed. CONCLUSION: A renal transplant patient with an endometriotic cyst can be treated successfully with laparoscopic enucleation.     

Effects of H1 antihistamine addition to intranasal corticosteroid for allergic rhinitis: a systematic review and meta‐analysis

Background

A combination of H1 antihistamine (AH) with intranasal corticosteroid (INCS) is commonly prescribed to patients with allergic rhinitis (AR) who have an inadequate response to monotherapy. In this systematic review we aimed to determine the effects of AH combined with INCS (AH‐INCS) for treating AR.

Methods

Literature searches were performed using Medline and Embase. Randomized, controlled trials that studied the effects of AH‐INCS vs INCS monotherapy for treating patients with AR were included. The primary outcomes were total nasal symptom scores, total ocular symptom scores, and disease‐specific quality of life. The secondary outcomes were objective tests for nasal patency and adverse events.

Results

Sixteen studies (4026 patients) met the inclusion criteria. Compared with INCS, AH‐INCS decreased total nasal symptom scores (standardized mean difference [SMD], ?0.13; 95% confidence interval [CI], ?0.19 to ?0.06; p < 0.001; 10 trials, 3348 patients) and total ocular symptom scores (SMD, ?0.12, 95% CI, ?0.20 to ?0.04; p = 0.003; 6 trials, 2378 patients). Subgroup analysis indicated no benefit with the oral AH‐INCS combination but did show benefit with intranasal AH‐INCS (SMD, ?0.18; 95% CI, ?0.27 to ?0.09; p < 0.001). There were no significant differences with regard to disease‐specific quality of life (SMD, ?0.07; 95% CI, ?0.16 to 0.02; p = 0.12; 6 trials, 1981 patients), nasal inspiratory flow (MD, ?0.03 L/min; 95% CI, ?0.57 to 0.50; p = 0.91; 1 trial, 54 patients), or adverse events.

Conclusion

Intranasal AH‐INCS has benefit over INCS on nasal and ocular symptom improvement for treating AR. Oral AH‐INCS is not recommended.

     

Disseminated gonococcal infection during pregnancy

Background: Disseminated gonococcal infection in pregnancy is rare with the incidence of 0.04–0.09% in pregnant women. Its most common manifestation is arthritis. Case: A 38-year-old woman, G₁P₀, 36⁺ weeks pregnancy came to hospital with decreased fetal movement. She had purulent vaginal discharge and history of self treatment 1 month earlier. She had a fever with arthritis for 3 days. Purulent joint fluid from arthrocentesis of her right wrist demonstrated intracellular Gram negative diplococcal bacteria. The diagnosis was disseminated gonococcal infection. She was successfully treated with parenteral ceftriaxone followed by oral cefixime. Cesarean section was performed due to preterm premature rupture of the membranes. The maternal and neonatal outcomes were uneventful. Conclusion: Disseminated gonococcal infections are not rare, however, disseminated gonococcal infection in pregnancy is a rare condition. Clinicians should be suspicious of the disease when a pregnant patient presents with arthritic symptoms.     

Multinucleate giant cells in neurofibromas: a clue to the diagnosis of neurofibromatosis

Background: A 54-year-old African-American male patient underwent removal of several cutaneous neurofibromas. Histopathologic examination revealed a nonencapsulated, haphazardly arranged proliferation of slender spindle cells in a myxoid stroma consistent with neurofibroma. Interestingly, each specimen exhibited numerous, large, multinucleate giant cells with nuclei arranged in a wreath-like or linear pattern. Immunoperoxidase staining revealed these cells to be negative with S-100 and CD-34. It was subsequently learned that this patient has neurofibromatosis type 1 (NF1).
Methods: A retrospective review of all lesions coded as neurofibroma from our institution between 1 June 2006 and 28 August 2006 was performed.
Results: Biopsies of 53 cutaneous neurofibromas from 51 patients were reviewed. In these, multinucleate giant cells were present in only three (5.7%), all in patients with single lesions.
Conclusions: Although the incidence of floret-like giant cells in neurofibromas of patients with NF1 is unknown, our findings suggest that the presence of these cells might be a clue to the presence of NF1.     

N-acetylcysteine in severe falciparum malaria in Thailand

One hundred and eight patients with severe falciparum malaria underwent a placebo controlled trial with the antioxidant, N-acetylcysteine (NAC), as an adjunctive therapy along with standard intravenous artesunate therapy. Three NAC dosage regimens were used: an intravenous loading dose of 140 mg/kg followed by 70 mg/kg every four hours intravenously for up to 18 doses (Group 1); a single intravenous loading dose followed by oral NAC in the same amount as for Group 1 (Group 2); a regimen identical to Group 1 except that oral NAC was administered after the first 24 hours (Group 3). Fifty-four patients received placebo plus artesunate. Two critically ill patients died in Group 1. No patient sustained an adverse reaction to the NAC other than vomiting, and the deaths were attributed to severe disease with multiple organ involvement. The excellent results with NAC, the lack of adverse effects, and the rationale for NAC benefit supports the need for a large, double blind trial of NAC as an adjunctive therapy for severe malaria.     

6-month evaluation of JinHuang Chinese herbal medicine study in asymptomatic HIV infected Thais

Good results of in vitro study of anti-HIV effects of JinHuang, a Chinese herbal medicine led to in vivo study of safety and efficacy among asymptomatic HIV infected individuals. It was a prospective open study of 21 asymptomatic HIV infected Thai volunteers. Twelve and 9 were female and male, respectively, with mean age of 29.24 +/- 3.94 years. JinHuang preparation, 6 capsules and 2 bottles of liquid formula orally three times a day, was given on an outpatient basis initially for 6 months. Regular close monitoring and follow-up were done. The side effects reported included : increased bowel movements (81%), vague taste, and smell of drug after initiation (52%). No serious adverse event related to JinHuang was detected during study. No significant changes in terms of log viral load and CD4 count were observed after 6-months' duration. Most of the patients felt that the quality of life was better in terms of better appetite, good sleep and healthy during study participation, however, these were subjective.