Alessandro Buonomo

Oral Specific Desensitization in Food-Allergic Children

The possibility of obtaining oral desensitization in patients with food allergy is still a matter of debate. We decided to evaluate the safety and efficacy of standardized protocols for oral desensitization with the most common food allergens. Forty-two children (ages up to 16 years) diagnosed as affected by food allergy (on the basis of clinical history, skin prick tests, measurement of specific IgE, and double-blind, placebo-controlled food challenge) underwent a sublingual-oral desensitizing treatment according to new standardized protocols. The control group consisted of 10 patients who followed an elimination diet. The treatment was successfully completed by 85.7% of the patients. Specific IgE showed a significant decrease, while specific IgG4 showed a significant increase, in all treated patients. The immunological modifications observed in our patients lead us to hypothesize that oral tolerance may be mediated by the same mechanisms as those involved in traditional desensitizing treatments for respiratory and insect sting allergy.

Oral Rush Desensitization in Peanut Allergy: A Case Report

Allergy to peanuts represents one of the most severe food allergies, rarely remitting compared with milk and egg allergy and frequently associated with life-threatening allergic reactions (1, 2). Its prevalence in the United States is 1.1% (3). Clinical manifestations range from vomiting, diarrhea, and local or generalized urticaria–angioedema to dyspnea, hypotension, collapse, and anaphylactic shock (4). Ara h1, Ara h2, and Ara h3 have been identified as the major peanut allergens (5). Currently prolonged strict avoidance represents the only effective means to prevent allergic symptoms, but this is hardly feasible. Peanut-allergic patients are particularly vulnerable to accidental exposure because small traces (doses as low as 100 μg of protein) may provoke severe symptoms (6, 7). Results of peanut allergen monitoring showed a remarkable quantity of products (such as snacks, cereal bars, and potato snacks) with hidden allergen (8). Another study has shown how simple tasks such as shopping and eating in restaurants can be extremely frightening, even perceived as life-threatening (9). We report the case of a woman with peanut allergy who successfully underwent specific rush desensitization by the oral route (10–14).

Sublingual desensitization: a new approach to latex allergy problem

The prevalence of latex allergy has rapidly increased. Clinical manifestations range from contact urticaria-angioedema and rhinoconjunctivitis to more severe bronchial asthma and anaphylactic shock. The only effective therapy is desensitization. We studied 24 patients allergic to latex: 12 of them underwent a rush (4-day) sublingual desensitization to latex, performed by putting increasing doses of latex extract under the patients’ tongues for 3 min every 20 min, followed by a maintenance therapy. The other 12 patients were considered controls. The sublingual rush desensitization protocol was successfully completed in all patients with no side effects. After 3 mo, all patients underwent an allergological evaluation, which showed a significant improvement of symptoms scores after challenges in the treated group as compared with the controls. All the desensitized patients can now wear latex gloves and undergo medical procedures without any symptoms.

Effects of lysine-acetylsalicylate (LAS) treatment in nasal polyposis: two controlled long term prospective follow up studies

Nasal polyposis is a multifactorial disease with a complex and still not completely understood pathogenesis. In more than one third of cases it is associated with intolerance to acetylsalicylic acid (aspirin, ASA) or to other non-steroidal anti-inflammatory drugs (NSAIDs).1 In as many as 20% of cases nasal polyposis is also associated with the presence of bronchial asthma and/or rhinitis, configuring the so-called ASA triad or aspirin disease.2 Nasal polyps may benefit from medical treatment (corticosteroids) and surgery,3 but they frequently relapse soon after surgery4-9 with significant morbidity and high social and medical costs. Unfortunately, the effect of treatment with steroids is also often temporary.3 10-16 In the last two decades it has been observed that, in aspirin sensitive patients, oral aspirin desensitisation (followed by long term aspirin treatment) often results in an improvement in the clinical course of nasal polyposis.17-21 We have shown that aspirin sensitive patients with nasal polyposis have a higher rate of positive nasal provocation tests (rhinomanometric measure of nasal airflow reduction after exposure to the drug) with lysine-acetylsalicylate (LAS) than aspirin sensitive patients without nasal polyps.22-24 Moreover, LAS has been found to have an in vitro non-specific antiproliferative, dose dependent effect on the growth of fibroblasts of both nasal polyps and normal skin.23 We have shown that long term topical (endonasal) treatment with LAS prevents the recurrence of nasal polyps after polypectomy with satisfactory results.24 In this paper we present and discuss the definitive results obtained in two controlled long term prospective follow up studies dealing with the evaluation of relapse rates in nasal polyposis. The first is a six year follow up study of patients with nasal polyps who underwent long term intranasal LAS treatment after surgical polypectomy in comparison with matched controls (patients who underwent …

Oral desensitisation in cow milk allergy: immunological findings.

In the literature there are several reports dealing with the possibility of a desensitising treatment in food allergy, but there are very few studies concerning the immunological mechanisms of or al desensitisation. We studied the immunological modifications in four children who underwent oral desensitisation with cow milk. Four children with cow milk allergy underwent oral desensitisation according to a standardized protocol. Total IgE, eosinophilic cationic protein in serum, and specific IgE and IgG4 to α-lactalbumin, to β-lactoglobulin and to casein were determined at the beginning of the treatment and after 6, 12 and 18 months in the 4 children treated. All the 4 treated patients successfully completed the treatment. Specific IgE to casein showed a significant reduction (p<0.01), while specific IgG4 to α-lactalbumin (p<0.02), to β-lactoglobulin (p<0.01) and to casein (p<0.01) showed a significant increase. Total IgE, eosinophilic cationic protein, and specific IgE to a-lactalbumin and to β-Iactoglobulin did not show any significant modification. Control patients did not show any immunological modification and still had a positive double-blind, placebo-controlled food challenge. These results make us think that oral desensitisation in food allergy occurs with the same mechanisms of traditional desensitising treatments for respiratory and insect sting allergies.

Tolerability of aztreonam in patients with IgE-mediated hypersensitivity to beta-lactams

Cross-reactivity between aztreonam and penicillins is poor, but clinical tolerance of aztreonam has been assessed, by means of tolerance challenge tests, only in a few groups of penicillin-allergic patients. The aim of this study is to evaluate the tolerability of aztreonam in a large group of betalactam-allergic patients. We studied all patients (> 14 years of age), with a clinical history of immediate reactions to any betalactam and with positive immediate-type skin tests and/or positive specific IgE to any of the studied betalactam; they were studied by means of: skin prick and intradermal tests with penicilloyl polysine, minor determinant mixture, semisynthetic penicillins, cephalosporins, aztreonam and imipenem; detection of specific IgE to penicillin G, penicillin V, ampicillin, amoxicillin, cefaclor and ceftriaxone. Patients with negative immediate-type skin tests with aztreonam then underwent a graded intramuscular challenge. Forty-five patients (mean age 46.1 ± 15.2 years), 27 females and 18 males, had positive skin tests and/or specific IgE to at least one of the studied betalactams. The most involved drugs were amoxicillin (23 cases), ampicillin (9 cases), penicillin G (8 cases) and other betalactams in the remaining cases. The most frequent reactions were anaphylaxis (27 cases) and urticaria (15 cases). All patients had negative intradermal tests with aztreonam and all patients tolerated the intramuscular graded challenge. Our data confirm the lack of cross-reactivity between betalactams and aztreonam. Immediate-type skin tests with aztreonam represent a simple and rapid diagnostic tool to establish tolerability in betalactam-allergic patients who urgently need this drug.

A Clinical Trial of Oral Hyposensitization in Systemic Allergy to Nickel

Nickel allergy is the most common contact allergy. Some nickel-sensitive patients present systemic (cutaneous and/or digestive) symptoms related to the ingestion of high nickel-content foods, which significantly improve after a specific low nickel-content diet. The etiopathogenetic role of nickel in the genesis of systemic disorders is, furthermore, demonstrated by the relapse of previous contact lesions, appearance of widespread eczema and generalized urticaria-like lesions after oral nickel challenge test. The aim of this study is to investigate the safety and efficacy of a specific oral hyposensitization to nickel in patients with both local contact disorders and systemic symptoms after the ingestion of nickel-containing foods. Inclusion criteria for the recruitment of these patients were (other than a positive patch test) a benefit higher than 80% from a low nickel-content diet and a positive oral challenge with nickel. Based on the previous experiences, our group adopted a therapeutic protocol by using increasing oral doses of nickel sulfate associated to an elimination diet. Results have been excellent: this treatment has been effective in inducing clinical tolerance to nickel-containing foods, with a low incidence of side effects (gastric pyrosis, itching erythema).

Multiple-drug intolerance syndrome: clinical findings and usefulness of challenge tests.

BACKGROUND Multiple-drug intolerance syndrome (MDIS) is characterized by adverse reactions to several classes of chemically unrelated drugs. OBJECTIVE To analyze all patients with a history of adverse reactions to at least 3 drugs at the Allergy Unit of Policlinico Gemelli in a 6-year period to better characterize patients with MDIS and to find safe alternative drugs. METHODS We studied 480 patients (aged >16 years) with a history of adverse reactions to at least 3 unrelated drugs and with negative allergy test results. Patients who had experienced mild adverse reactions that remitted spontaneously underwent challenge tests without any premedication (group A). Patients with a clinical history of moderate reactions received sodium cromolyn, 500 mg, before the challenge (group B). Patients with a clinical history of severe reactions or undergoing parenteral challenges were given an antihistamine 30 minutes before the challenge (group C). RESULTS In group A, 491 tolerance challenge tests were performed: 414 had negative results and 77 had positive results. In group B, 1,077 tolerance challenge tests were performed: 956 had negative results and 121 had positive results. In group C, 240 tolerance challenge tests were performed: 214 had negative results and 26 had positive results. Comparing the tolerance of alternative drugs in groups A and B, groups A and C, and groups B and C, no significant results were observed (P = .24, .14, and .44, respectively). CONCLUSIONS Patients with MDIS can tolerate alternative drugs. Premedication with sodium cromolyn or oral H1-antihistamines may be useful in preventing adverse reactions.

Latex allergy desensitization by exposure protocol: Five case reports

Two clinical reports dealing with subcutaneous desensitization to latex are available, but these treatments were reported to have significant side effects. To investigate an alternative method for latex desensitization, we present five cases of immunoglobulin E-mediated latex allergy in which a specific desensitization was successfully performed by means of an original exposure protocol. Five female patients with proven latex allergy underwent an original contact desensitization by wearing latex gloves daily, progressively increasing exposure to latex. All patients reached a final latex exposure time of 60 min in both hands. The desensitization protocol was completely successful in all patients. Twelve months after the beginning of the desensitization program, all the treated subjects were able to wear latex gloves daily without any clinical manifestations. This study provides evidence that a successful contact desensitization to latex is possible with no side effects. The adopted exposure protocol seems to be completely safe and effective. However, further studies in larger groups of subjects are necessary to fully confirm these preliminary results.

The aspirin disease

Aspirin or acetylsalicylic acid (ASA) is still one of the most widely sold drugs in the world and its side effects are well known. Among these, hypersensitivity reactions represent one of the most frequently described since the first report of urticaria and angio-oedema by Hirshberg in 1902.1 The hypersensitivity reactions to aspirin may be divided into two major categories2: type A characterised by respiratory symptoms (bronchial asthma, rhinitis) which account for about 15% of cases, and type B with urticaria and angio-oedema which occur in more than 75% of cases.3 A third category (type C) which includes any other peculiar clinical presentation (such as multiform erythema, fixed exanthema, Stevens-Johnsons syndrome, Lyells syndrome) occurs in a small number of cases. Females are more affected than males, except in childhood in which the asthmatic type A reactions are rare. A familial (and sometimes a personal) history of allergic disease is reported in about one third of cases.3 An extra-immunological (“pseudo-allergic”) mechanism is involved in the pathogenesis of nearly all aspirin hypersensitivity reactions. The most accepted pathogenetic theory4 5 postulates that the cyclo-oxygenase (COX) block (COX-1 and COX-2) induced by aspirin leads to an increase in arachidonic acid metabolism by an alternative pathway represented by lipoxygenase. This in turn increases the synthesis of leukotrienes C4, D4, and E4 which are able to exert a powerful bronchospastic action.6 7 An increasing number of reports concerning the existence of a relationship between bronchial asthma and the presence of nasal polyposis in the clinical picture of hypersensitivity reactions to aspirin has been accumulating in the literature since the late 1920s. The association of bronchial asthma and nasal polyposis in aspirin intolerant patients was first described by Widal in 19228and confirmed by several …