Palabras clave: Inmunoterapia frente a veneno. Veneno de avispa. Trastornos autoinmunológicos.Venom immunotherapy (VIT) is the only highly effective way of treating patients with hymenoptera venom allergy (HVA). The most serious anaphylactic symptoms of HVA (HVA-SYS IVo) are life-threatening, thus making their occurrence an unconditional recommendation for VIT. Yet, VIT is contraindicated in immune-mediated inflammatory diseases.We present the case of a 55-year-old woman with autoinflammatory neurological disease (initially diagnosed with relapsing remitting multiple sclerosis) who received VIT following an anaphylactic reaction (SYS-IVo) to wasp sting (Vespula germanica). Allergy tests showed the presence of specific IgE antibodies to wasp venom (intradermal test at 0.001 µg/mL, 12×12 mm; sIgE class 2). The basal serum tryptase concentration was normal. Her past medical history included gastrointestinal reflux, mild gastritis, allergy to ketoprofen and metamizole sodium, and seronegative spondyloarthropathy. At the age of 50, she was diagnosed with remitting-relapsing multiple sclerosis. Her first symptoms of neurological damage were mild facial weakness, mild instability with the eyes closed in the Romberg test, and clumsy movements of the left hand. Magnetic resonance imaging (MRI) was performed twice and revealed multiple hyperintense areas that were considered demyelinating lesions. The cerebrospinal fluid study showed intrathecal production of immunoglobulins 1.75 [normal range,). Visual evoked potentials were normal. Lyme disease was excluded. The patient was treated with intravenous methylprednisolone (Solu-Medrol, 1000 mg/d over 5 days) during 3 exacerbations of the disease. Progression in her disability was measured using the Kurtzke Expanded Disability Status Scale (EDSS). Her initial EDSS was 1.5, which rose to 4.0 after the last exacerbation of the disease.The patient met the clinical and immunological criteria for VIT. Another reason in support of the decision to administer VIT was the patient's physical disability, which might have hindered attempts to avoid a sting, especially given that she lives in an area with high exposure to stinging insects. The decision to start VIT was made despite the hitherto accepted belief that autoimmunological diseases constitute a contraindication to immunotherapy. At the time the patient qualified for VIT, her condition was stable, with no new active neurological symptoms.No complications were recorded during the induction phase (ultrarush; Pharmalgen, ALK-Abelló) and a complete 5-year course of VIT. There were no local or systemic allergic reactions. Neurological symptoms did not intensify, and no new symptoms appeared. The patient did not experience exacerbation of her neurological disease; the EDSS score remained unchanged. The findings in subsequent MRI examinations of the brain were stable, with no new lesions. The MRI revealed no lesions in the temporal lobes or posterior fossa structures and no juxtacortical lesions (Figure, A). However, numerous, small,...

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A 77-year-old male with trigeminal neuralgia was initially treated with carbamazepine (CBZ). Three weeks later pregabalin (PG) was added to his treatment regimen as the pain persisted. However, 1 week after initiating the combination therapy (CBZ + PG), the patient developed a generalized maculopapular rash, facial edema, and fever. On physical examination a skin rash was observed and hepatomegaly and lymphadenopathy detected. Laboratory tests revealed the following measurements: leukocytes 13 100/ mm 3 , lymphocytes 3800/mm 3 , eosinophils 2900/mm 3 , aspartate aminotransferase 62 IU/L, alanine aminotransferase 101 IU/L, urea 80 mg/dL, and creatinine 1.5 mg/dL. A skin biopsy was performed which showed moderate spongiosis with few eosinophils and signs of vasculitis. GÓMEZ TORRIJOS ET AL. 405 The patient was eventually diagnosed with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome and therapy with CBZ and PG was stopped. The patient recovered within 1 month, following treatment with only levocetirizine. Allergy tests were performed 1 month after his recovery. Patch tests were performed with PG (Lyrica) 5% and CBZ (Tegretol) 5% in both water and pet., with both drugs initially placed at the dorsal region of the left arm, and readings obtained on day (D) 2 and D4 ( Figure 1). Test results were positive with both drugs in aq. and pet. for readings obtained on D2 and D4 ( Figure 1A). The same tests were then repeated with these two drugs but on different arms and after a 2-week interval: PG 5% (Lyrica) at the dorsal region of the right arm and, 2 weeks later, CBZ 5% (Tegretol) at the dorsal region of the left arm. These patch tests were negative with PG ( Figure 1B) but positive with CBZ. The patient then underwent an oral challenge with PG (75 mg/d/4 d) which did not trigger a reaction. DISCUSSION Mitchell emphasized that skin hyperirritability is a serious problem in patch testing and demonstrated that, in the presence of a strong positive patch test reaction, other concomitant weak positive reactions may be false positive. 1,2 Skin hyperirritability affects the entire skin; for this reason, Bruynzeel and Maibach proposed the name EES instead of ABS. 2 Our patient has had a rash 1-2 months earlier, so he could still have some degree of skin hyperirritability. In the initial patch test, both drugs were placed very close to each other and the positive response of PG was not reproducible when re-examined separately 3,4 ; therefore, the proximity of the patch tests has likely caused this syndrome. 1,2 However, it was important to identify the drug that had triggered DRESS syndrome in our patient because PG could have been effective in treating pain; therefore, we decided to repeat the patch test with PG alone and on the contralateral arm, and demonstrated that the previous result had indeed been false-positive due to EES. 1,4 Most allergens that give false-positive results are "marginal irritants," such as nickel (1) but are usually not drugs. EES may have many causes depending on both the contac...

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