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The contribution of major and minor determinants from benzylpenicillin to the diagnosis of immediate allergy to β-lactams

2005; Elsevier BV; Volume: 117; Issue: 1 Linguagem: Inglês

10.1016/j.jaci.2005.08.012

1097-6825

Marı́a José Torres, M. Blanca,

Allergic Rhinitis and Sensitization

To the Editor:We would like to comment on the recent letter published by Bousquet et al,1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar which emphasizes the role of major and minor determinants of benzylpenicillin (benzylpenicilloyl polylysine [PPL] and minor determinants mixture [MDM]; Allergopen, Allergopharma, Reinbeck, Germany) for skin testing in patients with allergy to β-lactams. The withdrawal from the market of these reagents has set us back many years, and an approach based only on the clinical history might classify as false-positive many patients who are suspected of being allergic to β-lactams but who in fact have good tolerance after an appropriate allergologic workup.2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar According to the letter, 14.7% of the cases would have been missed if these reagents had not been used. Moreover, if we include those patients who had positive results to different penicillin determinants (and which, in some countries, are not always available) and who also had positive results to PPL, MDM, or both (32%), the number of nondiagnosed cases would have increased to 46.7%. Thus almost half of all the patients would not have received proper diagnoses if PPL and MDM had not been used.1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google ScholarStudies have shown that of patients with allergic reactions to penicillin confirmed by means of skin testing, 75% had positive results to PPL, 10% to MDM, and 14.8% to PPL and MDM.3Gadde J. Spence M. Wheeler B. Adkinson Jr., N.F. Clinical experience with penicillin skin testing in a large inner-city STD clinic.JAMA. 1993; 270: 2456-2463Crossref PubMed Scopus (275) Google Scholar In our experience the contribution of PPL, MDM, or both to total skin test positivity was 42.1%,2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar which is similar to the results reported by Bousquet (46.7%).The disagreement seen between groups1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar reflects different patterns of β-lactam prescription and consumption that vary from country to country and even within the same country over the years. To this extent, we have shown that differences exist when analyzing populations in one country at different times,2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar such that the contribution of PPL, MDM, or both to skin test positivity in the 1990s was 77.7%, in 2000 was 42.1%, and in 2005 is 22.1%, as suggested by current information from our database.In conclusion, although differences exist between countries and over time, skin testing with PPL and MDM is more necessary for the diagnosis of β-lactam allergy than suggested in the letter. An international coordinated effort under the direction of experts is necessary to provide industry with the support required to continue producing these valuable reagents. To the Editor: We would like to comment on the recent letter published by Bousquet et al,1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar which emphasizes the role of major and minor determinants of benzylpenicillin (benzylpenicilloyl polylysine [PPL] and minor determinants mixture [MDM]; Allergopen, Allergopharma, Reinbeck, Germany) for skin testing in patients with allergy to β-lactams. The withdrawal from the market of these reagents has set us back many years, and an approach based only on the clinical history might classify as false-positive many patients who are suspected of being allergic to β-lactams but who in fact have good tolerance after an appropriate allergologic workup.2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar According to the letter, 14.7% of the cases would have been missed if these reagents had not been used. Moreover, if we include those patients who had positive results to different penicillin determinants (and which, in some countries, are not always available) and who also had positive results to PPL, MDM, or both (32%), the number of nondiagnosed cases would have increased to 46.7%. Thus almost half of all the patients would not have received proper diagnoses if PPL and MDM had not been used.1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar Studies have shown that of patients with allergic reactions to penicillin confirmed by means of skin testing, 75% had positive results to PPL, 10% to MDM, and 14.8% to PPL and MDM.3Gadde J. Spence M. Wheeler B. Adkinson Jr., N.F. Clinical experience with penicillin skin testing in a large inner-city STD clinic.JAMA. 1993; 270: 2456-2463Crossref PubMed Scopus (275) Google Scholar In our experience the contribution of PPL, MDM, or both to total skin test positivity was 42.1%,2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar which is similar to the results reported by Bousquet (46.7%). The disagreement seen between groups1Bousquet P.J. Co-Minh H.B. Arnoux B. Daures J.P. Demoly P. Importance of mixture of minor determinants and benzylpenicilloyl poly-L-lysine skin testing in the diagnosis of beta-lactam allergy.J Allergy Clin Immunol. 2005; 115: 1314-1316Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar reflects different patterns of β-lactam prescription and consumption that vary from country to country and even within the same country over the years. To this extent, we have shown that differences exist when analyzing populations in one country at different times,2Torres M.J. Blanca M. de Weck A. Fernandez J. Demoly P. Romano A. et al.Diagnosis of immediate allergic reactions to betalactam antibiotics.Allergy. 2003; 58: 961-972Crossref PubMed Scopus (504) Google Scholar such that the contribution of PPL, MDM, or both to skin test positivity in the 1990s was 77.7%, in 2000 was 42.1%, and in 2005 is 22.1%, as suggested by current information from our database. In conclusion, although differences exist between countries and over time, skin testing with PPL and MDM is more necessary for the diagnosis of β-lactam allergy than suggested in the letter. An international coordinated effort under the direction of experts is necessary to provide industry with the support required to continue producing these valuable reagents.