Download 中部風濕病醫學會月會

中華民國免疫學會暨風濕病醫學會
臨床病例討論會
時
間：98 年 12 月 26 日 (星期六) 14:00~16:00
地
點：台北馬偕紀念醫院福音樓九樓(舊)第二講堂
主辦單位：台北馬偕紀念醫院 過敏免疫風濕科
主 持 人：馬偕紀念醫院 過敏免疫風濕科 陳天令主任
馬偕紀念醫院 小兒過敏免疫科 徐世達主任
演講者及題目：
Ⅰ.
Early RA present as monoarticular synovitis with
marked pannus formation
黃章喜 醫師
Ⅱ. Buckwheat anaphylaxis
程潔菡 醫師
Ⅲ. Storage mite Anaphylaxis
羅佳怡 醫師
Ⅳ. Anaphylaxis – New concept
雷偉德 醫師
Early RA present as monoarticular synovitis with marked
pannus formation
黃章喜醫師
馬偕醫院 內科部 風濕免疫過敏科
30 year old female had left knee swelling for 4 years. There was no other joint
symptoms complained. MRI was done, and revealed strong enhancement of
synovium, Radiologist’s report suggested synovial chondromatosis or focal PVNS.
Patient hesitate tissue biopsy and she lost follow-up. When she came back on 30th,
September 2009 for the same problem, blood test revealed low titer rheumatoid factor
in serum, and elevated C-reactive protein and Erythrocyte Sedimentation Rate.
Anti-CCP level was high. MRI was done again, and revealed synovial thickening
with periarticular bony erosions of medial tibial plateau seen. Rheumatoid Arthritis
is impressed.
Buckwheat anaphylaxis
程潔菡 醫師
台北馬偕紀念醫院小兒過敏免疫科
IgE-mediated hypersensitivity to buckwheat is common in Korea, Japan, and
some other Asian countries. However, buckwheat is not a common allergen in
Taiwan. We report a woman with asthma who had anaphylactic shock, generalized
urticaria, and an acute exacerbation of asthma five minutes after ingesting buckwheat.
The patient underwent skin prick and Pharmacia CAP testing (Uppsala, Sweden) for
specific IgE to buckwheat, white sesame and soybean as well as other common
allergens in Taiwan including Dermatophagoides pteronyssinus (Dp), D. farinae (Df),
cat and dog dander, cockroach, egg white, cow milk and codfish. The patient had a
strongly positive skin prick test response to buckwheat and positive reactions to Dp
and latex. Specific IgE results were class 6 for buckwheat, class 4 for Dp and Df, and
class 2 for dog dander, wheat, sesame and soybean. Results of an open food challenge
with white sesame and soybean were negative. Although buckwheat is a rare allergen
in Taiwan, it can cause extremely serious reactions and should be considered in
patients presenting with anaphylaxis after exposure to buckwheat.
Skin prick test of the patient
Erythema (mm)
Wheal
Positive control
18
11
Negative control
2
0
D.p
15
8
White sesame (1gm/ml)
4
2
Soybean (1gm/ml)
3
2
Buckwheat (1gm/ml)
21
14
Latex
6
4
Specific IgE of the patient
Level(KU/l)
Class
Sesame
2.97ku/L
2
Soybean
1.85ku/L
2
Buckwheat
>100ku/L
6
(mm)
Storage mite anaphylaxis
羅佳怡醫師
台北馬偕紀念醫院小兒過敏免疫科
All mites can broadly be categorized as pyroglyphid mites,referred to as house
dust mites, or nonpyroglyphid mites, referred to as storage mites. Allergy to storage
mites was first report by Cuthbert et al1 in Scottish farmworkers exposed to hay and
grain used for feeding cattle wintered indoors. Spieksma and Spieksma-Boezeman2
indicated that sensitivity to storage mites is an occupational hazard in farming
environments and for people living in damp houses. Systemic anaphylaxis after eating
storage mite– contaminated food has been reported. In this report, we describe
systemic anaphylaxis in a 8-year-old child after eating pancake flour contaminated by
a species of storage mite, Blomia freemani, in Taiwan.
An 8-year-old boy visited the emergency department complaining of dyspnea, a
generalized pruritic rash, and a swollen face. Physical examination revealed
expiratory wheezing with subcostal retractions, diffuse erythema, and facial
angioedema. Five minutes after an epinephrine injection, his blood pressure was
106/60 mm Hg, his heart rate was 131/min, and his arterial oxygen saturation was
85% as measured using a pulse oximeter. Treatment included epinephrine,
methylprednisolone, diphenhydramine, and inhaled fenoterol by nebulizer. The
patient’s symptoms gradually subsided in more than 4 hours. On questioning, the
patient stated that the reaction had started approximately 30 minutes after eating
pancakes made by his grandfather. The commercial pancake flour used had been
purchased 1 year earlier and opened once, the remainder being left in a plastic box
until being used on the day of the child’s reaction. After a serial examinations, we
confirm that the boy had anaphylactic reaction to storage mite which contaminated
pancake flour.
Anaphylaxis – New concept
雷偉德醫師
台北馬偕紀念醫院小兒過敏免疫科
Anaphylaxis is a systemic, type I hypersensitivity reaction that occurs in
sensitized individuals resulting in mucocutaneous, cardiovascular, and respiratory
manifestations and can often be life threatening. Anaphylaxis was first described in
1902 by Portier and Richet when they were attempting to produce tolerance in dogs to
sea anemone venom. Richet coined the term aphylaxis (from the Greek a , against,
-phylaxis protection) to differentiate it from the expected "prophylaxis" they hoped to
achieve. The term aphylaxis was replaced with the term anaphylaxis shortly thereafter.
Richet won the Nobel Prize in medicine or physiology in 1913 for his pioneering
work.
Anaphylaxis occurs in persons of all ages and has many diverse causes, the most
common of which are foods, drugs, latex, hymenoptera stings, and reactions to
immunotherapy. Of note, a cause cannot be determined in up to one third of cases.
Anaphylactoid reactions are identical to anaphylaxis in every way except the former
are not mediated by immunoglobulin E (IgE). Common causes of anaphylactoid
reactions include radiocontrast media, narcotic analgesics, and nonsteroidal
antiinflammatory drugs.
Signs and symptoms can be divided into four categories: mucocutaneous,
respiratory, cardiovascular, and gastrointestinal. Reactions that surpass
mucocutaneous signs and symptoms are considered to be severe, and, unfortunately,
mucocutaneous manifestations do not always occur prior to more serious
manifestations. Mucocutaneous symptoms commonly consist of urticaria,
angioedema, pruritis, and flushing. Common respiratory manifestations are dyspnea,
throat tightness, stridor, wheezing, rhinorrhea, hoarseness, and cough. Cardiovascular
signs and symptoms include hypotension, tachycardia, and syncope. Gastrointestinal
manifestations include nausea, vomiting, abdominal cramps, and diarrhea.
First-line treatment of anaphylactic shock is epinephrine. Other adjuvant
treatments are often also used; however, there is no substitute for prompt
administration of epinephrine.
In this report, we will review the literatures and discuss about the new concepts
in management of anaphylaxis.