Ivan Marković

Penicillin allergy is the most commonly reported drug allergy, often leading to unnecessary avoidance of beta-lactam antibiotics, increased use of alternative broad-spectrum antibiotics, and higher healthcare costs. However, studies indicate that over 90% of penicillin allergy labels are erroneous. This study presents real-world data from a penicillin allergy delabeling program conducted at the Special Hospital for Pulmonary Diseases in Zagreb, Croatia. A total of 132 adult patients with a reported beta-lactam allergy were evaluated with a stepwise diagnostic protocol, including medical history review, skin tests, specific IgE, and drug provocation tests. Five patients were delabeled directly, while 127 underwent diagnostic testing. Among 121 participants who completed the protocol, penicillin allergy was confirmed in 13 (10.74%) patients, and the label was retained in an additional 3 patients because of high-risk history, resulting in an overall confirmed allergy rate of 13.2%. The negative predictive values for STs were 99.07% and 94.39% for immediate and delayed reactions, respectively, while the NPV of sIgE for immediate reactions was 100%. No severe reactions occurred during the diagnostic process. Hundred and five out of one hundred and thirty two (79.5%) patients were safely delabeled. These findings confirm the safety and effectiveness of PAD programs in out-patient settings and highlight the potential for improving antibiotic stewardship by reducing unnecessary beta-lactam avoidance.

Introduction: As a widespread malignancy in women throughout the world, breast cancer has an extremely high incidence and mortality rate and therefore poses a serious public health concern. Metastasis of breast carcinoma in the urinary bladder wall poses a challenge in diagnosis because it is a rare and sometimes asymptomatic disease. This paper aims to present a rare case of urinary bladder metastasis originating from invasive lobular breast carcinoma and to emphasize the importance of recognizing atypical metastatic sites. Case Report: A 58-year-old woman with a three-year history of lobular carcinoma of the right breast presented with urinary symptoms and bilateral hydronephrosis. The initial tumor was triple-negative, staged T4bN3M0. Following neoadjuvant chemotherapy (anthracyclines and taxanes), radiotherapy, and modified radical mastectomy. The histopathological assessment of tumor response to therapy: almost complete response (pNCR), and two of ten lymph nodes were positive for metastases. The treatment was continued with Capecitabine in an adjuvant approach (8 cycles), and the patient remained asymptomatic for two years. Subsequently, she developed urosepsis and was hospitalized for bilateral hydronephrosis and renal calculi. Imaging (CT) revealed retroperitoneal lymphadenopathy, and cystoscopy showed bullous edema of the bladder wall. The histopathological examination after TUR showed infiltratory carcinoma of the urinary bladder wall, and immunohistochemical staining was positive for GATA3, GCDFP-15, CDX2, and Mamaglobin. It was concluded that it was a metastasis of breast carcinoma in the urinary bladder wall. Conclusion: Despite therapeutic advances, prognosis remains poor. Awareness of this unusual metastatic pattern is crucial for timely recognition, accurate diagnosis, and multidisciplinary management.

We present a case report of a new-onset seropositive rheumatoid arthritis in a 60-year-old patient, occurring six weeks after SARS-CoV-2 infection. The patient had pain and swelling of several joints with positive rheumatoid factor and anti-citrullinated protein antibodies.

Objectives: COVID-19 in it is more severe form is characterized by a hyperinflammatory condition, hypercoagulation state and the appearance of pulmonary microembolism. In this study we wanted to correlate levels of D-Dimer, protein C, protein S and antithrombin 3 with severity of disease and clinical outcome. Methods: We included 134 of patients who were divided in 3 groups regarding oxygen support (high flow oxygen therapy, mechanical ventilation and oxygen supplementation with nasal cannula or mask). Results: Concentration of D-Dimer, and activity of protein C and antithrombin 3 are presented as mean±SD and differed significantly between patients on mechanical ventilation (3.26 ± 1.15 mg/L, 86 ± 22.55 %, 81.21 ± 17.61 %)/HFNO (2.35 ± 1.68 mg/L, 109.6 ± 26.96 %, 94.67 ± 17.49 %)/BNC (1.37 ± 1.17 mg/L, 116.92 ± 28.16 %, 103.29 ± 15.63 %) with p<0.001 for all parameters. Mortality in oxygen group was 10.9 %, in HFNC group 40.7 % and in mechanical ventilated group 80 %. Conclusions: determination of anticoagulant factors in COVID-19 patients may indicate which of them are at increased risk of developing severe disease, venous thromboembolism and fatal clinical outcome.

Key Clinical Message: Alpha‐gal syndrome is an immunoglobulin E‐mediated hypersensitivity characterized by delayed allergic reactions to ingested products containing alpha‐gal carbohydrate. We present a patient with recurrent urticaria and suspected repaglinide hypersensitivity, who was eventually diagnosed with alpha‐gal syndrome, wanting to emphasize possible drug allergy misdiagnosis and required caution with the medication choice.

A document by Marina Božan. Click on the document to view its contents.

Concerns have been raised about allergic reactions to messenger ribonucleic acid (mRNA) coronavirus disease 2019 (COVID-19) vaccines. A history of allergic reactions, including anaphylaxis to drugs, has been frequently reported in individuals with anaphylaxis to mRNA vaccines. To estimate the rate of immediate allergic reactions in patients with a history of drug allergy or other allergic disorders. We included adult patients who had received at least 1 dose of an mRNA COVID-19 vaccine at the Special Hospital for Pulmonary Diseases between March 1, 2021, and October 1, 2021, and who reported a history of drug allergy or other allergic diseases (asthma, allergic rhinitis, atopic dermatitis, food or insect venom allergy, mastocytosis, idiopathic anaphylaxis, acute or chronic urticaria, and/or angioedema). Immediate allergic reactions, including anaphylaxis, occurring within 4 hours of vaccination were recorded. Six immediate allergic reactions were noted in the cohort of 1679 patients (0.36%). One patient experienced anaphylaxis (0.06%), which resolved after epinephrine administration, and the other reactions were mild and easily treatable. Most patients with a history of allergies can safely receive an mRNA COVID-19 vaccine, providing adequate observation periods and preparedness to recognize and treat anaphylaxis.

Granulomatosis with polyangiitis (Wegener's granulomatosis) is one of the anti-neutrophil cytoplasmic anti-body-associated small vessel vasculitides. Upper and lower respiratory system and kidneys are most commonly affected. The disease is characterized by granulomatous inflammation of the respiratory tract and necrotizing vasculitis of small to medium-sized blood vessels. Most patients show involvement of more than one organ systems at the time of diagnosis, and constitutional symptoms may be present. In around a quarter of patients the disease is initially localised, with involvement of upper respiratory tract or lungs. We report a 21-year-old female patient with chronic rhinitis, saddle nose deformity and subglottic stenosis who presented with inspiratory stridor and impending respiratory failure. Initially, urgent tracheotomy was performed. The patient was diagnosed with granulomatosis with polyangiitis limited to upper respiratory tract. Treatment with glucocorticoids and methotrexate was followed by clinical improvement.

Rheumatoid arthritis is a chronic systemic inflammatory disease characterized by synovitis, erosions, and destruction of affected joints. If untreated, it leads to severe disability and premature mortality. Tumor necrosis factor alpha (TNF-α) inhibitors are biological drugs used in treatment of rheumatoid arthritis. Possible side effects include skin allergic reactions, which, if generalized, are the reason for discontinuation of the drug. We report the case of a 46-year-old female patient with rheumatoid arthritis who presented with pruritus and erythematous papular exanthema after administration of the second dose of adalimumab. At first, we suspected a drug hypersensitivity reaction. As the signs and symptoms persisted for 2 months after discontinuation of adalimumab and despite continuous administration of antihistamines and glucocorticoids, further work-up was performed, and scabies was diagnosed. The patient was treated with topical 10% crotamiton. The symptoms were persistent and additional applications of the preparation were needed. After clinical remission of scabies, treatment of active rheumatoid arthritis with adalimumab was restarted without any complications.

Patients with systemic lupus erythematosus (SLE) are at an increased risk of developing low bone mass (LBM) or osteoporosis, either because of the disease itself or due to its treatment. Osteoporosis and osteoporotic fractures significantly contribute to morbidity and mortality. We aimed to determine the associations of bone mineral density (BMD) changes with the duration of SLE, age, gender, and glucocorticoid treatment in SLE patients treated at our Department. BMD measurements of the lumbar spine and total hip were performed by dual-energy X-ray absorptiometry (DXA). Osteoporosis and LBM were determined according to the 1994 World Health Organization definition. In the statistical analysis, the independent Mann-Whitney U test and Tukey post-hoc testing were used. The study included 48 SLE patients (44 female and 4 male), with a mean age of 45.8 years and an average SLE duration of 9.8 years. Osteoporosis was diagnosed in 21%, and LBM in 15% of the patients. The mean ages of the subgroups with normal BMD, LBM, and osteoporosis were 41.1, 47.6, and 59.0 years, respectively. Variant analysis showed a statistically significant correlation between age and BMD (p < 0.05). The duration of SLE was significantly shorter in patients with normal BMD (7.3 years), compared to patients with LBM (16.1 years) and osteoporosis (12.9 years) (p < 0.05). Nearly all patients (47 of 48) were on long-term treatment with glucocorticoids. One third (33.3 %) of patients did not take vitamin D3, and 56.3 % did not take calcium supplements. The etiopathogenesis of decreased BMD in SLE patients is multifactorial and includes both traditional and SLE-related risk factors. In our group of SLE patients age and glucocorticoid treatment were the major risk factors for LBM. Timely prevention and treatment of LBM and osteoporosis in SLE patients, according to current knowledge, are essential for reducing morbidity and mortality.