Polyethylene glycol (PEG), also known as macrogol, is an excipient in numerous medications, health care products, cosmetics, and foods. It acts as an inert bulking, or stabilizing, agent. Despite its ubiquity, including in 2 of the newly launched vaccines against SARS-CoV-2, awareness of PEG allergy remains low. We present 6 cases of acute hypersensitivity to PEG. Accurate diagnoses in these cases posed a challenge, and although the triggering agents differed, PEG was demonstrated as the common culprit. All cases were female, with a mean age of 36.4 years. Four patients were originally suspected to have nonsteroid anti-inflammatory drug allergy, and 2 had a history of chronic spontaneous urticaria and angioedema. Biphasic allergic reactions featured prominently in this case series. Diagnosis relies on a high index of suspicion leading to a focused clinical history, supported by skin tests with PEG solutions to demonstrate sensitization. This case series highlights important clinical features of this rare, potentially serious, and increasingly recognized excipient allergy.
It is often quoted that while short-term graft survival in kidney transplantation has improved in recent years, it has not translated into a commensurate improvement in long-term graft survival. We considered whether this was true of the entire experience of the national kidney transplant program in Ireland. A retrospective analysis of the National Kidney Transplant Service (NKTS) database was undertaken to investigate patient and graft survival for all adult first deceased donor kidney transplant recipients in Ireland, 1971-2015. Three thousand two hundred and sixty recipients were included in this study. Kaplan-Meier methods were used to estimate survival at each time period post transplant for the various eras of transplantation. Uncensored graft survival has improved over the course of the program in Ireland at various time points despite risk factors for graft failure progressively increasing over successive eras. For example the graft survival at 15 years post transplant has increased from 10% in 1971-1975 to 45% by 1996-2000. Ireland has experienced a progressive improvement in long-term graft survival following kidney transplantation. Whether these trends are attributable to biological or nonbiological factors is unclear but likely involves a combination of both. Transplant International 2019; 32: 974-984
Anaphylaxis is a rare side-effect of Covid-19 vaccines. In order to (a) provide direct advice and reassurance to certain persons with a history of anaphylaxis/complex allergy, in addition to that available in national guidelines, and (b) to provide a medically supervised vaccination, a specialist regional vaccine allergy clinic was established. The main objective was to determine if risk stratification through history can lead to safe COVID-19 vaccination for maximum population coverage. A focused history was taken to establish contraindications to giving COVID-19 vaccines. People who reported a high-risk allergy history were given a vaccine not containing the excipient thought to have directly caused previous anaphylaxis. All vaccinees were monitored for 30 minutes after administration. 206 people were vaccinated between 6 July 2021 and 31 August 2021; Comirnaty (Pfizer-BioNTech) (n=34), and Janssen (n=172). 78% were women. Ninety-two people (45%) reported a high-risk allergy history. There were no cases of anaphylaxis. Three people developed urticaria and one of these also developed transient tachycardia. One vaccinee developed a pseudoseizure. Two of 208 people (<1%) referred during this time declined vaccination based on personal preference, despite assessment of low clinical risk. In our experience, all vaccinees with high-risk allergy histories were administered Pfizer BioNTech or Janssen Covid-19 vaccines uneventfully following screening based on allergy-focussed history. Our data support that drug allergy is not associated with a higher risk of vaccine-related anaphylaxis but may act to guide administration of alternate vaccines to people with polyethylene glycol/polysorbate 80/trometamol allergies or anaphylaxis after first dose.
We read with interest the report by Rimawi et al. 1 They showed convincing evidence that with a negative penicillin skin test, a course of b-lactam is safe 2 hours after a negative challenge. However, we advise caution in generalizing these data to the outpatient setting where resensitization is a possibility. One study showed that 4.9% of patients who had negative skin tests and drug challenges reacted on rechallenges 3 weeks later. 2 In our center, b-lactam allergy assessment is carried out according to European Academy of Allergy and Clinical Immunology guidelines. 3 We encountered a patient who had life-threatening anaphylaxis with coamoxiclav 1 month after negative allergy investigations.A 43-year-old woman was referred with a history of non-drug related urticarial episodes and urticaria and angioedema of face, neck, and arms 30 minutes after a first dose of oral co-amoxiclav 2 years previously.Specific immunoglobulin E tests to penicillin and amoxicillin, skin tests, and oral co-amoxiclav challenge were negative. A month later, she developed anaphylaxis (intraoral angioedema, wheeze, hypotension [70/30 mm Hg], oxygen desaturation to 60% on room air, becoming unresponsive) within minutes of an intravenous dose of co-amoxiclav for acute cholecystitis.Our case illustrates that despite a detailed negative allergy assessment, severe anaphylaxis can occur requiring prompt identification and appropriate treatment.
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