Cases reported "Hypersensitivity, Delayed"

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1/29. Polymorphic light eruption occurring in common variable hypogammaglobulinaemia, and resolving with intravenous immunoglobulin therapy.

    A 55-year-old woman with a past history of lower respiratory tract infections presented with a photosensitive eruption. Polymorphic light eruption (PLE) was diagnosed on the basis of the temporal relationship to sun exposure and the diagnosis was supported by positive monochromator irradiation tests in the ultraviolet A wavelength spectrum. Investigation of the patient's immune status identified low levels of all immunoglobulin (Ig) subtypes consistent with common variable hypogammaglobulinaemia. Intravenous Ig replacement therapy, instituted to minimize risks from bacterial infections, was commenced and over the ensuing months resulted in a complete resolution of the PLE. PLE is considered to represent a type IV hypersensitivity reaction directed against a cutaneous autoantigen induced by exposure to ultraviolet light. In PLE, nonspecific immunomodulatory mechanisms of intravenous Ig may be active, such as a reduction in the synthesis of cytokines and a blockage of the IgG Fc receptors on macrophages.
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2/29. Delayed cutaneous reaction to jellyfish.

    A 57-year-old woman presented with a widespread papulonodular eruption. The dermatitis had appeared about 1 week after her return from a trip to the Red Sea, where she had come into contact with a shoal of unidentified jellyfish; however, that contact had not been followed by cutaneous lesions and/or symptoms. The patient also stated that she had had previous contacts with jellyfish during other trips to exotic seaside resorts. The dermatitis was characterized by papulonodular lesions, round or oval in shape, of a few millimeters in diameter, with a color ranging from pink to red to brown, and with a smooth and regular surface. The lesions were grouped in an apparently random fashion (Fig. 1) or arranged linearly (Fig. 2). The patient complained of pruritus and burning. Histopathologic examination showed the presence of some necrotic keratinocytes; in the upper and mid dermis, edema and a predominantly perivascular and periadnexal lymphohistiocytic infiltrate, with numerous neutrophils and eosinophils, were observed (Fig. 3). The patient was treated with hydroxyzine (37.5 mg/day) and hydrocortisone butyrate, which resulted in the rapid disappearance of the symptoms; however, the cutaneous lesions persisted for about 3 weeks.
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3/29. Possible role of cellular immunity: a case of cellulitis.

    On the basis of the observation that there was a "skip" area in an otherwise diffuse drug eruption where cellulitis had previously occurred, it is theorized that both delayed hypersensitivity type of dermatologic drug reaction and cellulitis share pathogenic mechanisms.
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4/29. Granulomatous folliculitis as a manifestation of post-herpetic isotopic response.

    We report a case of postherpetic granulomatous folliculitis in a 52-year-old female. The several cutaneous granulomatous eruptions following herpes zoster reported in the literature include annular, sarcoid and tuberculoid granuloma, granulomatous vasculitis and granulomatous folliculitis. The mechanism of granuloma formation is probably triggered by a delayed hypersensitivity response to the virus.
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5/29. Generalized lichen nitidus successfully treated with an antituberculous agent.

    We describe a Japanese girl with generalized lichen nitidus. She had been exposed to mycobacterium tuberculosis at 6 years of age via her teacher. At 8 years of age, she developed severe contact dermatitis on sun-exposed areas after contact with Japanese lacquer trees. Shortly after, numerous tiny, shiny, flesh-coloured papules developed over the upper part of her body. At 10 years of age, she was exposed to a school outbreak of M. tuberculosis. Her eruption showed no response to topical corticosteroids or oral tranilast, but most of the papules completely disappeared after she had received oral isoniazid for 6 months.
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6/29. chlorpromazine photoallergy. Coexistence of immediate and delayed type.

    A 54-year-old woman had a recurrent pruritic eruption in light-exposed areas. She had a combination of three types of hypersensitivity to chlorpromazine, ie, allergic contact dermatitis, photocontact dermatitis, and immediate allergic photosensitivity. Immediate wheal reactions were found after long-wave ultraviolet light irradiation at photopatch test and intradermal injection sites with chlorpromazine. These responses were differentiated from phototoxic reactions. A positive passive transfer reaction was also observed. To my knowledge, chlorpromazine photosensitivity of the immediate type has not been previously described.
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7/29. Occupational dermatitis from Lactuca sativa (lettuce) and Cichorium (endive). Simultaneous occurrence of immediate and delayed allergy as a cause of contact dermatitis.

    Four patients with occupational contact dermatitis to Lactuca sativa had cross-sensitivity to Cichorium endivia. One of the patients also had contact urticaria to Lactuca and Cichorium, and another reacted positively to scratch tests with these plants as a sign of immediate allergy. In two cases such immediate allergy was considered the cause of a vesicular, intense itching eruption within a few minutes of contact with fresh leaves of Lactuca on previously eczematous skin. The severe chronic dermatitis of the hands of these patients is ascribed to combined delayed and immediate allergy.
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8/29. Delayed hypersensitivity to 6-methyl-prednisolone in Henoch Schoenlein syndrome.

    We report a case of allergic reaction to oral 6-methyl-prednisolone in a patient with Henoch Schoenlein syndrome. When this syndrome was first diagnosed the patient was started on 6-methyl-prednisolone orally and after 4 days he developed a pruriginous generalized maculo-papular eruption. The rash disappeared 1 week after withdrawal of 6-methyl-prednisolone. The skin tests performed 1 month after with main food allergens were negative. Patch test with 0.10 ml of solution containing 6-methyl-prednisolone 40 mg/ml was positive after 48 and 72 h. The cutaneous biopsy on the patch tested skin revealed a perivascular infiltrate of lymphocytes, histiocytes and eosinophils.
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9/29. Enhancing effects of fluorescein on beta-lactam rash. I: High incidence of cefclidin rashes in an ophthalmological volunteer trial.

    Disseminated maculopapular eruptions were frequently observed in a volunteer trial of cefclidin's use in ophthalmological and neurological examinations (8/12; 67%) It appeared at 8-12 days (mean /- SD, 9.6 /- 1.1 days) from the initiation of the trial and subsided within 1-2 days (mean /- SD, 1.8 /- 0.4 days). Patch testing with cefclidin produced a /- reaction in 1 of 8 cases, and the drug-induced lymphocyte stimulation test (DLST) elicited a positive response (SI: 2.8) in 1 of 8 and a weakly positive response (1.8 < or = SI < 2) in 2 of 8. From these findings, it seems likely that the eruptions may be partially mediated by delayed type hypersensitivity (DTH) reactions to cefclidin. No such eruption was observed in the phase II trial of cefclidin where only 2.8% of 1.122 volunteers developed the eruption. The volunteers were given both fluorescein and oxybuprocain in their eyes to measure ocular tension on days -1, 0, 1, 3, 5, 7, 9, 11, 13 and weeks 3, 5, 7 after the initiation of cefclidin. fluorescein and/or oxybuprocain may affect cefclidin to induce these abnormal reactions in the volunteers.
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10/29. Delayed cutaneous reactions to heparin in antiphospholipid syndrome during pregnancy.

    BACKGROUND: Clinical symptoms related to antiphospholipid antibodies often first occur during pregnancy with the diagnosis of antiphospholipid syndrome (APS). Unfractionated heparin (UFH) and low-dose aspirin are considered as first-line treatments for pregnant women with APS and recurrent fetal loss. However, in addition to an increased incidence of hemorrhagic side-effects and thrombocytopenia there are a number of drug eruptions with cutaneous components secondary to the use of UFH. One of these eruptions has been classified as a delayed type I.V. hypersensitivity reactions at the sites of UFH injections. The majority of these reactions occur in pregnant women. METHOD: We present three pregnant patients who developed delayed hypersensitivity reactions at the sites of UFH injections. Two patients had documented APS and the other patient had two previous spontaneous abortions. RESULTS: The histopathologic and immunohistochemical findings in the biopsy specimens from the sites of the delayed reactions were distinctive. The inflammatory infiltrate contained CD3 and CD4 lymphoid cells with plasma cells, and eosinophils. There was a marked increased in mast cells with increased stromal cells within the dermis and increased vascular proliferation. CONCLUSIONS: The distinctive histopathologic and immunohistochemical features seen in the delayed hypersensitivity reactions at the sites of UFH injections may be modulated by the immunomodulatory effects of UFH as well as the hormonal levels and cytokine patterns during pregnancy. Alternative therapies may not always be successful in resolving the reactions.
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