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The tuberculin skin test is widely used in the diagnosis of latent tuberculosis infection Blistering skin lesion from the test is rarely observed. In this manuscript, I report a patient who develops a bullous lesion from the test and I review the related literature.

Résumé Nous rapportons l’observation d’un érythème pigmenté fixe bulleux à l’hydroxyzine et réactivité croisée avec les dérivés de la pipérazine chez une femme de 72 ans. La patiente présentait une apparition récente de bulles flasques sur fonds érythémateux des mains, des pieds et du flanc. Des macules pigmentées arrondies de grande taille étaient notées. Le diagnostic d’érythème pigmenté fixe bulleux était évoqué. Le seul médicament introduit récemment était l’hydroxyzine. À l’interrogatoire, il y avait plusieurs épisodes similaires après la prise de fluoroquinolones et d’antihistaminiques (levocétirizine et cétirizine) ; la loratadine et la desloratadine étaient bien tolérées. L’histologie montrait des nécroses kératinocytaires compatibles avec un érythème pigmenté fixe bulleux. Les tests épicutanés réalisés avec l’hydroxyzine, la cétirizine, la levocétirizine et les fluoroquinolones (concentration à 30 % dans l’eau et dans la vaseline) étaient négatifs aux lectures successives à 48, 72 et 96 heures tant au niveau des séquelles pigmentées qu’au niveau de la peau saine. Le diagnostic d’un érythème pigmenté fixe bulleux à ces différentes molécules était tout de même retenu et une carte contre-indiquant ces molécules était remise à la patiente. Quelques mois plus tard, une prise accidentelle de levocétirizine avant la réalisation d’un scanner avec injection provoquait une nouvelle poussée bulleuse de toutes les lésions séquellaires de l’érythème pigmenté fixe. We report a case of hydroxyzine-induced fixed drug eruption and cross-reactivity with piperazine derivatives. A 72-year-old woman presented with a recent onset of flaccid bullae over erythematous patches on her hands, feet and back; large rounded pigmented patches were noted. A diagnosis of bullous fixed drug eruption was raised. The only drug she began taking recently was hydroxyzine. Her past medical history included similar episodes after taking fluoroquinolones and antihistamines (levocetirizine and cetirizine); desloratadine and loratadine had been well tolerated. A histological examination of her skin showed keratinocyte necrosis compatible with a bullous fixed drug eruption. Patch-tests performed with hydroxyzine, cetirizine, levocetirizine and fluoroquinolones (concentration at 30% in water and in vaseline) were negative in successive readings at 48, 72 and 96 hours, both in pigmented scars and in healthy skin. These diverse molecules were nevertheless held responsible for the bullous fixed drug eruptions. For this reason, a document listing these drugs as contraindicated was given to the patient. A few months later, the fortuitous injection of levocetirizine before having a CT scan caused a new bullous eruption, with all the typical lesions of a fixed drug eruption. [ABSTRACT FROM AUTHOR]

Abstract: The diagnosis of drug allergy is important because most suspected cases are not confirmed. Diagnosis is based on immediate or delayed skin test reactions, done in the absence of contraindications. In vitro laboratory tests have not yet replaced skin testing. Skin tests are not without risk, which accentuates the very important place of the clinical history, and also the need for precaution in skin testing, but in the large majority of cases they are the only means of confirming or rejecting the diagnosis of drug allergy. [Copyright &y& Elsevier]

Abstract: Comment: Today in France, except some contra-indications BCG remains a compulsory vaccination. However a modification of BCG vaccine policy is in progress. Primo-vaccination remains but revaccination was recently abandoned, then totally abandon of BCG is the challenge. This article states the art of the BCG and of the tuberculin skin test. Key points: This approach is incorporated in a globally thought of necessary adaptations for organising fight against tuberculosis and more treatment of latent tuberculosis infections is urged on. These measures set back again tuberculin skin test in the tuberculosis infection screening process. Perspectives: New diagnosis blood tests would bring more reliability. Their place and their spread should be confirmed. [Copyright &y& Elsevier]

Abstract: Immediate-reading skin tests (pricks and intradermal tests) are indicated in patients reporting symtoms suggesting immediate-type hypersensitivity reactions. The diagnostic and/or predictive value of these tests is good with betalactams, latex and myorelaxants, and several other substances such as corticosteroids, dyes, antiseptics, vaccines, etc. Non irritant concentrations have been determined for several substances (betalactams, myorelaxants, etc.), but are unknown for numerous other substances. For other substances, non irritant concentrations in skin tests should be evaluated in control patients, in parralel with skin tests performed in patients. The diagnostic value of nonimmediate-reading skin tests is highly variable, and depends on the drug and the nature of the symptoms. Although the sensitivity and the specificity of nonimmediate-reading skin tests are not perfect, these tests are useful in the diagnosis of mild to moderately severe toxidermias, such as nonimmediate urticarias and angio-oedemas, fixed drug eruptions, maculopapular rashes, and acute generalized exanthematic pustulosis. In contrast, their diagnostic value is low in potentially severe toxidermias. The diagnostic value of responses in intradermal tests is usually higher than in patch-tests. However, patch-tests may be positive in few patients with negative intradermal tests. Ideally, skin tests should be performed between 6 weeks and 1 to 2 years after the clinical reaction. However, most nonimmediate drug sensitizations can be diagnosed several years later. [Copyright &y& Elsevier]

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Allergy to penicillin is reported to occur in up to 8% of the patients who receive this class of drugs. 80 to 85% of the patients with a positive clinical history to penicillin will nevertheless tolerate penicillin with no adverse effect. Of the remaining 15 to 20%, only a few will develop a severe adverse reaction, and these patients can be identified by skin tests with derivatives of penicillin used at optimal concentrations according to a protocol that is effective and safe. Skin tests to penicillin are positive in 25% of patients with a history of an immediate reaction to penicillin; they are more frequently positive in those who have had a severe reaction. In addition to being able to identify patients who are at risk for a severe reaction when they take penicillin, skin tests can also provide immunological evidence of the origin of delayed clinical reactions such as maculopapular rashes. Such rashes, a frequent and benign manifestation of penicillin allergy, are usually caused by the widely used aminopenicillins. Intradermal skin tests (IDR) and late phase (patch) tests can demonstrate allergy to betalactamines in 5 to 45% of patients with negative skin tests to major and minor determinants of penicillin. When skin tests are positive, provocation tests are not recommended. On the other hand, when the skin tests are negative, an oral provocation test should be done, but such tests can result in an immediate clinical reaction, which may be severe in 3 to 10% of cases. [Copyright &y& Elsevier]

Vaccination is the most efficient way to fight the Covid epidemic. However, suspicion of severe hypersensitivity to PEG (PolyEthylen Glycol) usually constitutes a vaccine contraindication. We report the case of a patient with a proven allergy to PEG and skin sensitization to the COMIRNATY vaccine (PEG in its composition). He was able to benefit from the vaccine under the 5-step desensitization protocol. Conclusions: Specific allergological management should be offered to patients suspected of severe hypersensitivity to PEG and other vaccine excipients. We propose a solution for Comirnaty administration for patients with a proven severe allergy to PEG., (© 2021 Elsevier Masson SAS. All rights reserved.)

Copyright of Revue Francaise d'Allergologie is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)