Sugammadex is widely used for rapid and predictable reversal of aminosteroid neuromuscular blockade and has a favorable safety profile. However, rare cardiovascular adverse events, including severe hypotension, bradycardia, and asystole, have been reported. We describe a case of a 39-year-old healthy male who developed profound hypotension without bradycardia approximately six minutes after receiving sugammadex for reversal of moderate neuromuscular blockade following uncomplicated orthopedic surgery. His blood pressure decreased from 95/51 mmHg at baseline to 68/33 mmHg six minutes after sugammadex administration, reaching a nadir of 50/29 mmHg at 17 min, with a heart rate of 117 beats/min. The patient had stable intraoperative hemodynamics and no evidence of bronchospasm, cutaneous manifestations, or airway compromise at the time of the event. Hypotension was refractory to repeated boluses of phenylephrine and ephedrine, with subsequent improvement following norepinephrine administration. The patient recovered without further complications and was discharged the same day. Although causality cannot be definitively established, the temporal relationship raises concern for sugammadex-associated hypotension without bradycardia, possibly related to an atypical hypersensitivity reaction. This case highlights that severe hypotension may occur even in low-risk patients in the absence of bradycardia or other classic features of anaphylaxis, requiring prompt recognition and early potent vasopressor support.

Spasticity affects a significant portion of individuals with cerebral palsy, often progressing to contractures and neuro-orthopedic deformities if left untreated. Cryoneurolysis is an emerging, mini-invasive ultrasound-guided technique that induces secondary axonotmesis of peripheral nerves through the formation of an ice ball, shown to result in months of improved range of motion. However, cold urticaria is listed as a contraindication for this procedure because of the risk of localized or systemic anaphylaxis. We present a case of a 10-year-old girl with ataxic cerebral palsy who successfully underwent multisite cryoneurolysis. She had test-confirmed cold urticaria, requiring an epinephrine autoinjector to be kept on hand. By employing skin warming techniques and guided nerve branch targeting to attempt to keep the dermis above her critical temperature threshold, the procedure was completed without adverse events, achieving significant improvements in tone and gait. This case suggests that cryoneurolysis can be performed safely and is an effective spasticity treatment for patients with cold urticaria when appropriate thermal prophylactic measures are taken.

Pediatric adverse drug reactions are difficult to evaluate after approval because pediatric trial evidence is limited and spontaneous-report systems differ in product naming, event coding, seriousness fields, and duplicate submissions.

This review summarizes major advances in mast cell (MC) research published between January 2024 and December 2025. Recent discoveries have reshaped our understanding of MC biology, revealing previously unrecognized roles in brain development, mucosal immunity, neuroimmune communication, and cancer. High-resolution structural studies have provided new insights into high affinity receptor for immunoglobulin (Ig)E (FcεRI) signaling, while emerging evidence has expanded the functional repertoire of inflammasome components and established Mas-related G-protein coupled receptor member (MRGPRX)2 as a central receptor mediating IgE-independent MC activation. Single-cell transcriptomic and spatial profiling studies have uncovered remarkable MC heterogeneity, identifying specialized populations with distinct homeostatic and pathogenic functions across tissues. These findings have also redefined the contribution of MCs to early-life allergic disease, anaphylaxis, pain, infection, and tumor immunity, highlighting their context-dependent functions. In parallel, major therapeutic advances-including antibodies targeting the KIT-stem cell factor (SCF) axis, next-generation anti-IgE therapies, Bruton's tyrosine kinase (BTK) inhibitors, and strategies targeting type 2 inflammatory pathways-are accelerating the development of more selective treatments for MC-driven disorders. Advances in experimental platforms, including human skin MC cultures, receptor-humanized and humanized mouse models, and computational pathology, are further expanding the tools available to investigate MC biology and accelerate translational research. Together, these conceptual, technological, and therapeutic advances are shaping the next generation of MC-targeted therapies.

Dialyzer reactions can cause significant morbidity and even mortality. The current convention using time- and symptom-based classification has limited practical utility because of considerable overlap and diverse presentations. Several biomarkers have been described as diagnostic adjuncts, but clinical application remains sparse and inconsistent. There is also little guidance on subsequent management after diagnosis. In this paper, we highlighted the diagnostic complexities and current limitations through 2 clinical cases. We hence proposed a novel, pragmatic clinical and biomarker-guided algorithm using serum tryptase levels to address these. We adopted an acute increase from baseline levels of ≥ 20% + 2 ng/mL (20 + 2 rule) as the diagnostic threshold, demonstrated in one of the cases. Following this, ethylene oxide exposure should first be eradicated, as it remains one of the most common precipitants. If symptoms persist, decisions on dialyzer change should then be guided by clinical severity. In conclusion, there is a dire need for better diagnostic precision and individualized management of dialyzer reactions. Our proposed algorithm can potentially fill this gap but requires validation in larger prospective studies. Future research could further refine the optimal diagnostic threshold and explore risk stratification using a similar clinical-biomarker approach for more precise management.

Hydatid disease (cystic echinococcosis), caused by Echinococcus granulosus, is a zoonotic infection that can involve the lungs, particularly in endemic regions. We report an 11-year-old boy with a 4-month history of chronic cough following an upper respiratory infection. He presented acutely with recurrent vomiting, hemoptysis, severe respiratory distress, and hypoxemia (SpO2 82% on oxygen). Blood pressure was preserved and there were no clinical features of anaphylaxis or sepsis at arrival. Imaging confirmed a ruptured left pulmonary hydatid cyst with bronchial fistula; right-sided radiographic opacities were also present and likely reflected aspiration of cyst contents contributing to the initial severity. Emergency thoracotomy, cyst resection, and chest-tube drainage of an associated pneumothorax (reflecting bronchopleural fistula) were performed Imaging revealed a ruptured pulmonary hydatid cyst. He underwent emergency left thoracotomy with cyst resection and chest tube placement. Postoperatively, he developed acute kidney injury with oliguria, managed conservatively, along with ongoing respiratory complications. Albendazole therapy was initiated. This case highlights the diagnostic delays, airway management challenges, and high morbidity of complicated pulmonary hydatid disease in children.

Johannes Ring has shaped allergology for more than five decades. His scientific work ranges from early studies on anaphylaxis and drug hypersensitivity to atopic dermatitis, the atopy patch test and the role of environmental factors in allergic disease. But this is only one part of his legacy. As a clinician, the patient was always at the centre of his thinking, and many of his research questions came directly from clinical observation. As a mentor, he encouraged young physicians and scientists to be curious, critical of their own results and, most importantly, to find their own scientific path. Many of his former trainees today hold leading positions in allergology and dermatology across Europe. For me, Johannes Ring has been a mentor for more than two decades-and still is. At 80, he has taken on a new role in Davos. He is clearly not finished yet.

Among bacteria that are associated with the development and/or exacerbation of allergic/atopic diseases, several have been described to produce IgE-binding components. However, only one bacterial protein, Bac s 1, is currently listed in the official database of the World Health Organization/International Union of Immunological Societies (WHO/IUIS) Allergen Nomenclature Sub-Committee. The aim of this position paper was to identify potential bacterial allergens and their reported clinical relevance in the published literature and consider candidates for the Allergen Nomenclature database. PubMed and the WHO/IUIS Allergen Nomenclature database were searched up to October 2025. Consensus was obtained during task force meetings and by a written commentary process. Sixty-six IgE-binding components in 20 different species of bacteria were found, most associated with clinical symptoms. Allergen candidates include staphylococcal superantigens, bacterial enzymes, and components from two Chlamydia species, some of which are potential marker allergens for disease severity. The results point to long-neglected evidence of "bacterial allergy" that in certain cases may be induced by unconventional mechanisms. Diseases that are currently considered non-allergic might be re-classified as allergic if these IgE-binding components are recognized as allergens and used for diagnosis in the future.

This article reports two pediatric cases of anaphylaxis to the M-M-RVaxPro® vaccine, attributable to porcine gelatin used as a stabilizer (14.5 mg/dose). Both patients developed severe reactions after the booster dose, with positive skin and blood tests for gelatin. The first case had hereditary alpha-tryptasemia as an aggravating factor. Investigations ruled out the responsibility of neomycin, latex, and chlorhexidine. Key recommendations include avoidance of gelatin-containing vaccines and medications, substitution with gelatin-free alternatives (Priorix®), evaluation of food tolerance through an oral challenge test, and provision of an emergency kit with epinephrine. Hospital monitoring is recommended for future vaccinations in patients with mast cell disorders. The study highlights gelatin as the primary culprit in vaccine anaphylaxis, emphasizing the importance of systematic testing for vaccine components and proper management of sensitized patients.