Anne-Marie Kochuyt

Prevalence and clinical relevance of specific immunoglobulin E to pollen caused by sting- induced specific immunoglobulin E to cross-reacting carbohydrate determinants in Hymenoptera venoms.

Background Hymenoptera stings can induce specific IgE (sIgE) to carbohydrate determinants (CD) on venom glycoproteins that cross‐react with CD in pollen. sIgE to such cross‐reacting CD (CCD) are believed to have little or no biological activity and thus may cause misdiagnosis of pollen sensitization after a sting.

Occupational allergy to bumble bee venom

The clinical profile of anaphylactic reactions to bumble bees is described and successful immunotherapy with honey bee venom in seven bumble bee allergic patients is reported. The cause of the high frequency of sensitization to pollen in these patients is discussed.Sirs, I read with great interest the article published by A. S. Kochuyt et al. [1], concerning occupational allergy to bumble bee venom. We have recently treated a 37-year-old woman who developed a severe generalized allergic reaction to bumble bee (BB) sting (grade III Mueller classification) while working on a bumble bee farm. Skin tests on two different occasions with honey bee venom, wasp venom and yellow jacket venom, 005 ml each until a maximum concentration of 1 ;Ug/ml was reached were negative. Specific serum IgE antibodies measured with the commercially available ELISA system (Pharmacia, Sweden) gave a class 2 reaction for honey been venom and a class 0 reaction to yellow jacket venom. Confronted with these conflicting results and considering our lack of experience with BB stings, we searched the literature for advice and found an abstract presented at the XVth Congress ofthe European Academy of Allergology and Clinical Immunology, Paris (10-15 May 1992) [2]. In this abstract the authors present six patients with reactions to BB stings ranging from grade I to grade IV according to the Mueller classification. The specific IgE was positive in five ofthe six patients but the material for intracutaneous testing was proven to be unreliable. One of the six patients was chosen for specific immunotherapy. This patient, with a grade IV reaction, was challenged after hyposensitization with honey been venom and this resulted once more in a grade IV reaction. Based on this, we decided not to perform immunotherapy and advised the patient to stop her occupational exposure to BB.

Perioperative allergic reactions: experience in a Flemish referral centre.

BACKGROUND The incidence of perioperative anaphylactic reactions is overall estimated to be 1 per 10,000-20,000 anaesthetic procedures. We performed a retrospective analysis of patients referred to a University Allergy Centre in Belgium with the suspicion of an allergic reaction during or shortly after general anaesthesia. OBJECTIVES Our aim was to assess the causes of perioperative allergic reactions, to evaluate cross-reactivity among neuromuscular blocking agents (NMBA) and to analyze the diagnostic relevance of tryptase levels in the discrimination between IgE and non-IgE-mediated reactions. METHODS A total of 119 patients, referred from 2007 to 2011 were included. The diagnostic protocol consisted in case history, serum tryptase measurements, immunoassays and skin tests. RESULTS A diagnosis of IgE-mediated reaction was established in 76 cases (63.9%). The most common agents were NMBA (61.8%), antibiotics (14.5%), latex (9.2%) and chlorhexidine (5.2%). Rocuronium was the most frequently causative NMBA (48.9%). Vecuronium cross-reactivity was established by skin testing in 47.6% of cases. Cisatracurium was the NMBA most frequently tolerated (cross-reaction in 13.9%). In 23.4% of NMBA allergic patients, the reaction occurred on the first exposure. Most IgE-mediated reactions occurred during the induction phase (72.4%). Latex-induced reactions occurred mainly during maintenance and recovery phases (71.4%; p<0.02). Mean tryptase values were significantly higher in patients with IgE-mediated reactions (p=0.0001), than in those with no identified cause. CONCLUSIONS NMBA, antibiotics, latex and chlorhexidine were the main culprits of IgE-mediated perioperative reactions. Uncertainties remain concerning the specificity and sensitivity of skin testing. Tryptase assays can be useful in the discrimination of IgE and non-IgE-mediated reactions.

Inhalative occupational and ingestive immediate‐type allergy caused by chicory (Cichorium intybus)

We report a first case of occupational allergy to chicory (Cichorium intybus) in a vegetable wholesaler. Symptoms occurred after oral, cutaneous or inhalatory exposure. The patient also reported reactions after ingestion of botanically related endive (Cichorium endivia) and lettuce (Lactuca sativa.) We identified the responsible allergen by SDS‐PAGE and immunoblot to be a 48‐kDa protein, confined to the non‐illuminated parts of the plants. No cross‐reactivity was found with mugwort (Artemisia vulgaris) ryegrass (Lolium perenne) and birch (Betula verrucosa) pollen, which suggests that the vegetable is the primary allergenic material.

Safety and efficacy of a 12-week maintenance interval in patients treated with Hymenoptera venom immunotherapy

It is currently recommended to administer a maintenance dose of 100 μg of venom at 4–6 week intervals for Hymenoptera venom immunotherapy (VIT), Because the optimal duration of therapy is not known, we decided to progressively prolong the interval between maintenance injections instead of accepting the risk of anaphylactic reactions when VIT is discontinued after a predetermined period. We report here on the results of a first phase of this interval extension programme, covering the gradual increase of the interval from 1‐12 weeks over 19 months in 178 patients. A 12‐week interval maintenance VIT could be achieved in 117/128 (91%) of yellow jacket venom (YJV) and in 35/50(70%) of honeybee venom (HBV) allergic patients. At the lime of the interview these 152 patients had been treated with 12‐weekly 100 μg venom injections for an average period of 2 years without any untoward reaction to VIT. During this period of 48 YJV allergy sufferers experienced 77 field re‐stings without systemic reaction (SR), and 17 HBV allergic subjects were restung at least 213 times in total, with one patient developing a very large local reaction and one a mild systemic reaction. In 26 of the 17S patients the interval of 12 weeks was not reached for various reasons, with a higher failure rate among the HBV allergic patients. Most Hymenoptera venom allergic patients can thus be safely and effectively treated with 12‐weekly injections of 100 μg venom.

Drug intolerance reaction to insulin therapy caused by metacresol.

A 13-year-old boy with type II hereditary sensory autonomic neuropathy had been using Eusol soaks for recurrent trophic ulcers since the age of 4 years. He presented with itchy papulovesicular lesions on the dorsa of both feet for 1month. He had applied neomycin cream on and off for the ulcers and wore cotton socks and rubber footwear with leather straps throughout the day. He was patch tested with a standard series of allergens obtained from Systopic Laboratories, New Delhi, India (Indian standard series), selected allergens of a rubber additives series (mercaptobenzothiazole, thiuram mix, carba mix, mercapto mix and diphenylguanidine), and selected allergens of a textiles series (dimethylol dihydroxyethylene urea, Disperse Blue 106/124, ureaformaldehyde resin and melamineformaldehyde resin), along with leather and foam of footwear, samples of coloured socks, and Eusol (containing 12 5 g each of boric acid and calcium hypochloritc in 100mL of water). The following were positive on day (D) 2 and D3: * diphenylguanidine –/þ;

Ethylene Oxide Allergy in Patients on Hemodialysis Waiting for Kidney Transplantation: Logistical Nightmare or Challenge? A Case Report

Ethylene oxide (EO) is widely used as a sterilization gas for heat-sensitive devices. In EO-sensitized patients, this type of sterilization can cause rare but major allergic reactions such as hives, rash, asthma, or anaphylactic shock. Hemodialysis patients in particular are at risk of developing hypersensitivity to EO. In these patients, surgical interventions should be planned far in advance allowing a thorough EO-free preparation of all equipment needed for the surgery as well as for the pre-, peri-, and postoperative care. In contrast to elective surgery, kidney transplantation with allografts from deceased donors cannot be planned; exact timing is unpredictable. Furthermore, transplantation may take place years after patients have been put on the waiting list. Listing of patients sensitive for EO is therefore a logistical and medical challenge for all health care professionals involved in the patients care (eg, surgeons, nephrologists, anesthetists, nurses, pharmacists, and sterilization specialists). This case report describes a patient with chronic kidney disease stage V who developed EO allergy during hemodialysis while waiting for a kidney transplantation. Diagnosis was made based on clinical signs and confirmed biochemically (including a positive radioallergosorbent test). Because the only treatment is avoidance of contact with EO-sterilized materials, a strict EO-free protocol was developed to allow an uneventful transplantation thereafter. Subsequently, 4 newly diagnosed EO-sensitive patients on the active kidney transplantation waiting list were diagnosed, and 1 of these patients has been transplanted successfully. EO allergy in patients on the waiting list for kidney transplantation is a unique challenging situation which, to the best of our knowledge, has not been reported yet for kidney transplantation. This report further highlights the logistical preparation of a renal transplantation, including anesthesiologic, surgical, and postoperative care.

Highly sensitive assays are mandatory for the differential diagnosis of patients presenting with symptoms of mast cell activation: diagnostic work-up of 38 patients

Mastocytosis is a heterogeneous disease caused by excessive mast cell (MC) proliferation. Diagnosis of systemic mastocytosis (SM) is based on the presence of major and minor criteria defined by the World Health Organization. Symptoms of MC activation can also occur in patients without SM or without allergic or inflammatory disease. These MC activation syndromes (MCAS) can be divided into primary (monoclonal) MCAS (MMAS) vs. secondary and idiopathic MCAS. In this single center study, the diagnostic work-up of 38 patients with a clinical suspicion of SM and/or with elevated basic tryptase levels is presented. Clinical symptoms, biochemical parameters, results of bone marrow investigation, flow cytometric immunophenotyping, and molecular analysis were retrospectively reviewed. Twenty-three patients were found to have a monoclonal MC disorder of which 19 were diagnosed with SM and 4 with MMAS. In 13/19 SM patients, multifocal MC infiltrates in the bone marrow were found (major criterion), while in 6 the diagnosis was based on the presence of ≥3 minor criteria. Flow cytometric analysis of bone marrow showed CD25 expression of MCs in all patients with SM and MMAS (range: 0.002–0.3% of cells). In bone marrow, the KIT D816V mutation was detected in all SM patients but in only 2 patients with MMAS (range: 0.007–9% mutated cells). Basic tryptase elevation was demonstrated in 16/19 patients with SM but also in 9/19 patients without SM. Our study reveals the heterogeneity of primary MC disorders and the importance of sensitive assays in patients suspected of having SM.