ALLERGY Net ALLERGY 2005: 60: 1087–1093 • • • COPYRIGHT ª 2005 BLACKWELL MUNKSGAARD ALL RIGHTS RESERVED • C O N T R I B U T I O N S T O T H I S S E C T I O N W I L L N O T U N D E R G O P E E R R E V I E W, B U T W I L L B E R E V I E W E D B Y T H E A S S O C I AT E E D I T O R S Table 1. Allergologic study with proton-pump inhibitors Allergy to lansoprazole: study of cross-reactivity among proton-pump inhibitors S. Porcel*, A. Rodríguez, S. JimØnez, M Alvarado, J. Hernµndez Keywords: allergy; lansoprazole; proton-pump inhibitors. Lansoprazole is a substituted benzimidazole used in the treatment of peptic ulcer disease and gastroesophaSlight cross-reactivity geal reflux disamong proton pump ease. The capsules contain inhibitors in a case of the active ingre- IgE mediated dient in the form lansoprazole allergy. of enteric-coated granules. A few cases of hypersensitivity to lansoprazole have been reported (1, 2). We report a 42-year-old female referred to our allergy department with an adverse drug reaction to lansoprazole. The patient suffered from dyspepsia and her family physician prescribed continuous treatment with lansoprazole. Thirty minutes after taking the first capsule, she developed generalized cutaneous rash, oedema of the eyelids, sick feeling and abdominal pain. She was treated with intramuscular methylprednisolone and antihistamines. The reaction was completely resolved in 48 h. Skin tests with lansoprazole and the whole proton-pump inhibitors (PPI) group were performed according to general considerations for drug allergy diagnosis (3, 4). Skin-prick test (SPT) and intradermal tests with ten-fold dilutions of lansoprazole at 30 mg/ml were carried out. We observed an immediate positive reaction to SPT (4 · 3 mm wheal). Intradermal tests at 1/1000 and 1/100 w/v also gave immediate positive reactions IDT SPT 1/1000 w/v 1/100 w/v 1/10 w/v 1/1 w/v SBPCDC Lansoprazole caps (30 mg/ml) 4·3 Omeprazole i.v. (40 mg/ml) ()) Omeprazole caps 20 mg NP Pantoprazole i.v. (40 mg/ml) ()) Pantoprazole caps 20 mg NP Rabeprazole tablet (20 mg/ml) ()) Esomeprazole tablet (20 mg/ml) ()) 12 · 9 ()) NP ()) NP ()) ()) 10 · 9 ()) NP ()) NP ()) ()) NP ()) NP ()) NP 10 · 8 ()) NP ()) NP ()) NP NP ()) NP NP ()) NP ()) NP ()) SPT, skin-prick test; IDT, intradermal test; SBPCDC, single-blind placebo-controlled drug challenge; ()), negative; NP, not performed. Results expressed in millimetre of wheal. (12 · 9 and 10 · 9 mm wheal, respectively). Allergologic study with the rest of commercially available PPI are shown in Table 1. Only rabeprazole (20 mg/ml) gave positive results after intradermal test at 1/10 w/v (10 · 8 mm wheal). Skin tests with lansoprazole and rabeprazole were negative in five control subjects. If a negative response in skin tests was observed, a single-blind placebo-contolled drug challenge would follow. Drug provocation test with omeprazole, pantoprazole and esomeprazole showed no adverse reactions. Only two cases with suspicion of allergy to lansoprazole have been reported (1, 2). No immunologic studies were performed and no specific causal mechanism has yet been identified. Perez Roldan et al. (1) described a case of glottis oedema after taking lansoprazole. Natch et al. (2) described two anaphylactic reactions with omeprazole and lansoprazole in the same patient, suggesting cross-reactivity. Previously, Galindo et al. (5) demonstrated crossreactivity between omeprazole and lansoprazole by means of skin testing in a case of anaphylaxis to omeprazol. We report the first case of IgE mediated allergy to lansoprazole based on a close association between the time course of the reaction and the ingestion of lansoprazole, as well as the positive immediate response in skin tests. Negative responses in control subjects confirm the specificity of these findings. Evidence of cross-reactivity between lansoprazole and rabeprazole was provided by intradermal tests. Cross-reactivity with omeprazole, pantoprazole and esomeprazole were not observed. Previous reports suggest cross-reactivity between lansoprazole and omeprazole (not confirmed by our group), but a complete study with the whole group have not been yet performed. We also describe the first documented sensitization to rabeprazole which suggests, hypersensitivity reactions will probably be observed in the future. In spite of their chemical near-related structures, we have not found great cross-reactivity among PPI. In patients with hypersensitivity reactions to one of the PPI, the cross-reactivity of the whole group should not be assumed and a complete study should be carried out. *Allergy Department Complejo Hospitalario Cáceres Pablo Naranjo street s/n. 10002 Cáceres Spain E-mail: seporcel@yahoo.es 1087 ALLERGY Net Accepted for publication 6 May 2004 Allergy 2005: 60:1087–1088 Copyright
Blackwell Munksgaard 2005 DOI: 10.1111/j.1398-9995.2005.00765.x References 1. Perez Roldan F, de los Rios IL, Rodrı́guez E. Lansoprazole and glottis edema. Am J Gastroenterol 1999;94:1995. 2. Natsch S, Vinks MH, Voogt AK, Mees EB, Meyboom HB. Anaphylactic reactions to proton-pump inhibitors. Ann Pharmacother 2000;34:474–476. 3. Demoly P, Bousquet J. Drug allergy diagnosis work up. Allergy 2002;57(Suppl 72): 37–40. 4. Brockow K, Romano A, Blanca M, Ring J, Pichler W, Demoly P. General considerations for skin test procedures in the diagnosis of drug hypersensitivity. Allergy 2002;57:45–51. 5. Galindo PA, Borja J, Feo F, Gómez E, Garcı́a R, Cabrera M, Martı́nez C. Anaphylaxis to omeprazole. Ann Allergy Asthma Immunol 1999;82:52–54. Anaphylaxis after a horse bite G. Guida, F. Nebiolo, E. Heffler, R. Bergia, G. Rolla* Key words: anaphylaxis; bite; horse; lipocalin. Animal bites, insect bites excluded, are a rare cause of anaphylaxis. Most case reports concern reactions occurring after bites A case of anaphylaxis of rodents (1). after a horse bite in a The case we re- patient sensitized to port here is the lipocalins. first occurring after a horse bite. A few minutes after a horse bite over her forearm, a 42-year-old woman developed large local erythema and edema, soon followed by urticaria, rhinitis and wheezing. The wound was superficial and mildly bleeding. After promptly administered epinephrine, chlorpheniramine and methylprednisolone, her clinical conditions improved and she full recovered in 3 h. The patient had a history of seasonal rhinitis 1088 Figure 1. Immunoblotting with rabbit anti-human IgE-HRP of horse dander extract incubated with: (A) serum of the patient with anaphylaxis after a horse bite: three immunoreactive bands are evident at 65, 25 and 18 kD, respectively; (B) serum of a control patient sensitized to horse dander: one immunoreactive band is evident at 65 kD. and mild intermittent rhinitis when she entered horse-boxes. Skin prick tests confirmed sensitization to horse dander, dog and cat hair, and to grass pollen. Class 3 specific IgE to horse dander (Immulite, DPC, CA, USA) were detected. Sixteen percent acrylamide/bisacrylamide (37,5:1) SDS/PAGE was prepared by a commercial lyophilized horse dander extract (30 000 NTU/ml, 0.5% w/v, ALK Abellò, Hørsholm, Denmark) and performed under reducing condition (2). Separated proteins were transferred onto nitrocellulose membrane and then incubated with the patient’s serum (diluted 1:4) overnight at 4C. Immunoreaction with rabbit anti-human IgE HRP-conjugated (DakoCytomation, Carpinteria, CA, USA) identified three reactive bands at 65 kDa (horse serum albumin), 25 kDa (Ecu c1) and 18 kDa (Ecu c2), respectively (Fig. 1A) (2–5). A control serum of a patient with allergic rhinitis in relationship to exposure to horse dander (specific IgE Class 2, Immulite, DPC, CA, USA) revealed only one immunoreactive band at 65 kDa. (Fig. 1B). Equ c1 and Equ c2 are both lipocalins (6), proteins known to be highly concentrated in the saliva of mammals. Lipocalins may be injected directly into the blood stream of a patient trough a bite causing severe generalized reactions. Allergy to horse is mainly occu- pational and is characterized by rhinitis, asthma, and occasionally, by urticaria. Horse dander, horse hair and skin scraping are the usual sources of inhalant allergens causing symptoms in sensitized persons. The case reported here shows that patients with allergy to horse, even if characterized by mild clinical manifestations, are at risk of anaphylaxis after a horse bite, probably due to lipocalin sensitization. Supported by a grant (ex 60%) of Ministero Italiano dell’Università e della Ricerca. Prof. Giovanni Rolla, MD Allergologia e Immunologia Clinica Ospedale Mauriziano Umberto I Largo Turati 62 10128 Torino, Italy Tel: +39 011 5082 083 Fax: +39 011 5682 588 Accepted for publication 24 January 2005 Allergy 2005: 60:1088–1089 Copyright
Blackwell Munksgaard 2005 DOI: 10.1111/j.1398-9995.2005.00837.x References 1. Lim DL, Chan RME, Wen H, van Bever HPS, Chua KY. Anaphylaxis after hamster bites-identification of a novel allergen. Clin Exp Allergy 2004;34:1122– 1123.