new england journal
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amounts of several enzymes, including cytochromeP-450 (CYP) 1A1, CYP1B1, CYP2B6, CYP2E1, andCYP3A5, as well as members of the glutathioneS-transferase family. These enzymes may gener-ate allergenic metabolites of various drugs, includ-ing azathioprine.
We have demonstrated, by patch testing andenzyme-linked immunosorbent spot assay, a caseof indirect conjugal azathioprine-induced allergiccontact dermatitis. The mechanistic basis for thehusband’s idiosyncratic drug hypersensitivity hasnot yet been determined, but there may be an aber-rant pathway of detoxification within his skin,resulting in the production of an immunogeniccompound.
Hywel L. Cooper, B.Med.Sci.Fethi Louafi, Ph.D.Peter S. Friedmann, F.Med.Sci.
University of SouthamptonSouthampton SO16 6YD, United Kingdomhlc1@soton.ac.uk
Barbaud A, Gonçalo M, Bruynzeel D, Bircher A. Guidelines for
performing skin tests with drugs in the investigation of cutane-ous adverse drug reactions. Contact Dermatitis 2001;45:321-8.Pichler WJ, Tilch J. The lymphocyte transformation test in
the diagnosis of drug hypersensitivity. Allergy 2004;59:809-20.Czerkinsky C, Nilsson L, Nygren H, Ouchterlony O, Tarkow-
ski A. A solid-phase enzyme-linked immunospot (ELISPOT) assay for enumeration of specific antibody-secreting cells. J ImmunolMethods 1983;65:109-21.Bergström MA, Ott H, Carlsson A, et al. A skin-like cyto-
chrome P450 cocktail activates prohaptens to contact allergenicmetabolites. J Invest Dermatol 2007;127:1145-53.
Dengue Hemorrhagic Fever Transmitted by Blood Transfusion
To the Editor:
Dengue, the most common vec-torborne viral infection worldwide,
is predomi-nantly transmitted by the
mosquito.We describe a well-documented cluster of bloodtransfusion–associated dengue infections in Singa-pore, a country in which the disease is endemic.A 52-year-old, asymptomatic, repeat blood do-nor gave blood on July 15, 2007. An investigationof all recipients of his blood products was initi-ated after he informed the blood bank that he hadhad a fever the day after donation. The stored se-rum sample was positive for dengue virus type 2,as ascertained by means of a polymerase-chain-reaction (PCR) assay.
The recipient of the donor’s red cells had feverand myalgia 2 days after transfusion. The recip-
Table 1.Characteristics of the Donor and Recipients.PatientAgeSexCoexistingConditionsSymptomsof Dengue FeverSigns of Capillary LeakResults of Serologic TestingFindings onPCR Assay*Outcome
Donor52MNoneFever and myalgiaafter donation(not hospital-ized)NoneNot doneDengue virustype 2Full recoveryRecipientof fresh-frozenplasma64MDiabetes mellitus,hypertension,ischemic heartdisease, recentcoronary-arterybypass graft,chronic renalimpairmentDay 2 after trans-fusion (hospi-tal day 12): fe-ver, jaundice,malaise, andworseningthrombocy-topeniaWorsening of bilateral pleu-ral effusionsSeroconversion(on July 19,negative forIgG and IgM;on July 31,positive forboth)Dengue virustype 2Discharged ingood healthRecipient of packedred cells72MDiabetes mellitus,hypertension,ischemic heartdisease, pepticulcer diseaseDay 2 after trans-fusion (hospi-tal day 6):fever, myalgia,malaiseSmall right pleu-ral effusionIgG-positive onfollow-upDengue virustype 2Discharged ingood healthRecipient of platelets74MHepatocellularcarcinomaNoneNonePositive for bothIgG and IgMon follow-upNot doneDischarged ingood health* PCR denotes polymerase chain reaction.
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