Intradermal Testing

Mertes PM, Moneret-Vautrin DA Skin reactions to intradermal neuromuscular blocking agent injections a randomized multicenter trial in healthy volunteers. Anesthesiology 2007 107 245. Moneret-Vautrin DA, Gueant JL, Kamel L, Laxenaire MC, el Kholty S, Nicolas JP Anaphylaxis to muscle relaxants cross-sensitivity studied by radioimmunoassays compared to intradermal tests in 34 cases. J Allergy Clin Immunol 1988 82 745. 

In a study performed by Ruzicka et al. [23], 104 patients with positive patch tests to LAs and a history of contact dermatitis were tested with LA in a prick test and in an intradermal setting. All prick tests remained negative. There were 9 persons positive for procaine in the intradermal test and 3 positive for butanilicaine. There was no correlation to history in the patients with skin tests and no correlation between patch test results and results of the intradermal test [23]. 

Skin Test. Usually a battery of LAs is tested in the skin-prick test which is almost always negative. Then the intradermal test is performed with a 1 10 dilution of the substances. Undiluted LA preparations may commonly lead to false-positive reactions [30-32] in a rather high percentage of patients. 

Subcutaneous Provocation Testing. When prick and intradermal tests are negative, subcutaneous provocation testing is started using 0.1 ml of the undiluted LA solution followed by 0.2, 0.5, 1.0 and 2.0 ml into the extensor side of the patients upper arm at 30-min intervals. For most of the patients it is possible to find a tolerable LA which is recommended for future applications [33] (table 3). In a long-term followup, Wasserfallen and Frei [32] found in 28 patients undergoing skin and subcutaneous provocative testing that over 3 years in 19 cases re-exposure to a tolerated LA was well tolerated without untoward reaction. 

Ruzicka T, Gerstmeier M, PrzybiUa B, Ring J Allergy to local anesthetics comparison patch test with prick and intradermal test results. J Am Acad Dermatol 1987 16 1202-1208. 

If the prick test is non-reactive, proceed to the intradermal test. 

In addition to the patch test for nickel sulphate, intradermal nickel tests have been used [407, 408]. The intradermal testing was recommended for confirmation of doubtful patch-test reactions, particularly to disclose false positive reactions. 

Respiratory Effects. Scratch tests and intradermal tests were performed on a patient diagnosed with nickel-related asthma (McCoimell et al. 1973). Nonasthmatic controls were also tested. Testing resulted in respiratory distress in the patient but not in the controls, with a more severe response resulting from the scratch test. 

A 58-year-old woman, who had been involved in the manufacturing of glucocorticoid creams and ointments for over 10 years, developed occupational contact sensitization to topical glucocorticoids (472). Patch tests were positive to hydrocortisone, hydrocortisone butyrate, and tixocortol pivalate. Intradermal tests were positive to hydrocortisone succinate, methylpredniso-lone, and prednisolone. An oral challenge with betamethasone 0.75 mg, 2.5 mg, and 8 mg on three consecutive days resulted in no adverse reactions. 

A 5-year-old child with diabetes, Pierre Robin syndrome, cleft palate, allergic rhinitis, recurrent sinusitis, and obstructive sleep apnea, who had previously had skin rashes after penicillin, sulfonamides, and clindamycin, was given soluble and isophane human insulins (131). Three years later she developed local reactions, 2-5 cm areas, 30-120 minutes after injection. Skin-prick tests were negative for the diluent, isophane, and soluble insulin, but intradermal testing was positive with both insulins. Cetirizine and dexamethasone added to the insulin gave temporary relief. She was... 

Morris DL Intradermal testing and sublingual desensitization fornickel. Cutis 1998 6/3 129—132. Ewan P, Alexander M, Snape C Effective hyposensitization in allergic rhinitis using a potent partially purified extract of house dust mite. Clin Allergy 1988 18 501-508. 

A 28-year-old nurse had generalized urticaria and collapsed while she was undergoing a gastroscopy for suspected Helicobacter pylori infection (24). Before the start of the procedure she was given lidocaine oral spray and intravenous diazepam 10 mg, and at the end intravenous flumazenil 1 mg. Skin prick tests and intradermal tests with diazepam 5 mg/ml produced a weal-and-flare reaction flumazenil 0.1 mg/ml and lidocaine 2% had no effect. 

Both SPT (concentration range 0.1-100 rg/ml) and intradermal tests (concentration range 1 ng/ml-1 rg/ml) were performed. Positive and negative control solutions were the same as in the routine SPT (physiological saline and 0.1% histamine, respectively). After 15 min the weal size was measured and photographs were taken. The two commercial A. altemata extracts used in the study were Pangramin from ALK (Horsholm, Denmark) and an A. altemata extract from Stallergenes (Fresnes, France). 

Therefore we can say that SPT and intradermal testing showed that the two recombinant allergens, Alt a 1 and A. altemata enolase were superior to the commercial A. altemata extracts used with respect to positive and negative predictability in the diagnosis of A. altemata allergy. 

Intradermal tests introduce all the problems of allergy to drugs, e.g. metabolism, combination with protein, fatal anaphylaxis (see p. 143). 

GaUetly DC, Treuren BC. Anaphylactoid reactions during anaesthesia. Seven years experience of intradermal testing. Anaesthesia 1985 40(4) 329-33. 

A 71-year-old man received intrathecal anesthesia using 0.3% cinchocaine 2 ml for a transurethral prostatectomy (8). He had a history of allergic rhinitis, and 2 months before had had an uneventful prostate biopsy and cystoscopy, also under spinal anesthesia with iso-baric bupivacaine. Within 45 minutes of the spinal injection he complained of periorbital itching, started to shake, and developed muscle rigidity. He rapidly became unconscious, with a systolic blood pressure of 40 mmHg and widespread erythema. He was treated with hydrocortisone and antihistamines and required an infusion of adrenaline. Intradermal testing after full recovery was positive with cinchocaine. 

A 30-year-old woman developed a generalized urticarial reaction immediately after the intravenous administration of aminophylline (4). Skin intradermal testing was positive to ethylenediamine. Rechallenge was positive with intravenous aminophylline but negative with diprophylline, which does not contain ethylenediamine. 

Immunological investigations combined with positive intradermal tests have been used to confirm fazadinium as the causative agent in a severe reaction (9). 

Sanchez-Perez J, Bartolome B, del Rio MJ, Garcia-Diez A. Allergic contact dermatitis from 5-fluorouracil with positive intradermal test and doubtful patch test reactions. Contact Dermatitis 1999 41(2) 106-7. 

Urticaria developed after 9 months of treatment with interferon beta-lb in a 32-year-old woman with a previous history of penicillin allergy (64). She also had an exacerbation of asthma shortly after starting treatment. A positive intradermal test to interferon beta-lb, but not to interferon beta-la or the diluents, suggested a specific IgE allergic reaction. 

This report documents a rare chnical reaction to ioxaglate, with a combination of a maculopapular rash, fever, hepatic and muscle involvement, eosinophiha, and a very high serum IgE concentration. The intradermal tests confirmed a delayed hypersensitivity reaction to ioxaglate. Histological examination of a skin biopsy identified the predominantly T lymphocyte nature of the infiltrate. A contributing role of the beta-blocker atenolol to the seriousness of the clinical syndrome must also be considered. 

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