Arnon Goldberg

Chronic urticaria and autoimmunity: Associations found in a large population study

BACKGROUND Chronic urticaria (CU) is a common disease in which most cases were considered to be idiopathic. Recent evidence indicates that at least a subset of cases of chronic idiopathic urticaria are autoimmune in origin. OBJECTIVE We aimed to characterize the association between CU, autoimmune diseases, and autoimmune/inflammatory serologic markers in a large unselected population. METHODS Data on 12,778 patients given a diagnosis of CU by either allergy or dermatology specialists during 17 years in a large health maintenance organization in Israel were collected. For each patient, we collected information on diagnosis of major, well-defined autoimmune diseases and autoimmunity- and inflammatory-related serologic markers. Similar data were collected for a control group comprised of 10,714 patients who visited dermatologists, family physicians, or allergy specialists and had no indication of CU. RESULTS Having CU was associated with an increased odds ratio for hypothyroidism, hyperthyroidism, and antithyroid antibodies. Female patients with CU had a significantly higher incidence of rheumatoid arthritis, Sjögren syndrome, celiac disease, type I diabetes mellitus, and systemic lupus erythematosus, mostly diagnosed during the 10 years after the diagnosis of CU. High mean platelet volume, positive rheumatoid factor, and antinuclear antibodies were all significantly more prevalent in patients with CU. CONCLUSIONS A strong association was found between CU and major autoimmune diseases. A common pathogenic mechanism is implied by the high prevalence of autoantibodies and the existence of a chronic inflammatory process expressed by the high mean platelet volume. These findings have implications for the diagnosis, management, and prognosis of patients with CU.

A modified, prolonged desensitization protocol in carboplatin allergy

Carboplatin (CP) is the mainstay therapy in ovarian and testicular carcinoma. Several cases of allergic reactions to CP have been descr ibed? -3 Pre t rea tment with steroids and antihistamines did not prevent recurrent reactions. 1,3 A successful 4-hour desensitization protocol was documen ted in a single pa t i en t? We describe two patients allergic to CP who had recurrent reactions while undergoing the 4-hour desensit ization protocol . One of the patients had an allergic react ion on receiving a diluted solution of CP (1/100 of the total dose). In an a t tempt to overcome these reactions, we designed a modified protocol , which was pro longed to more than 3 days, for one of the patients. This modificat ion enabled both patients to receive the p lanned CP dose without adverse effects for numerous t rea tment courses.

Timing of venom skin tests and IgE determinations after insect sting anaphylaxis

Determinat ion of venom-specific IgE either by skin testing or by RAST is a prerequisite for the correct diagnosis and t reatment of patients who have had a systemic reaction (SR) caused by an insect sting. Over the past 30 years the routine recommendat ion has been to postpone tests for specific IgE determinat ion for varying periods of time after the SR. TM Initially, delay in testing was recommended because of the expectation of false-negative results from testing with whole-body insect extract soon after anaphylaxis. This recommendation has not been revised, since testing with venoms became available. To assess whether venom skin tests (STs) and serum venom-specific (SVS)-IgE determinations have any value when performed shortly after the insect sting and to determine possible kinetics of these tests in other clinical situations of venom hypersensitivity, we investigated patients with insect sting-induced SR or large local reaction (LLR). Patients were evaluated twice: within i week of and 4 to 6 weeks after the sting.

Allergic responses to pollen of ornamental plants: High incidence in the general atopic population and especially among flower growers

BACKGROUND The incidence of allergy to pollen of ornamental plants has not been deeply investigated, and its extent has remained obscure. Most of such studies have concentrated only on pollen of ornamental plants from the Asteraceae family (Compositae). In this study an attempt was made to clarify whether various other ornamental plants may also cause skin responses and allergic symptoms among allergic urban dwellers and among rural flower growers. METHODS Two hundred ninety-two patients were referred for allergic evaluation by their primary physicians; 75 flower growers and 44 university students were evaluated. For all participants, a detailed health record was obtained, and skin prick tests (SPTs) were performed. Extracts for SPTs included commercial common airborne allergens and autochthonous pollen extracts of 11 species of plants belonging to the Asteraceae, Ranunculaceae, Liliaceae, Scrophulariaceae, and Genetianaceae families. RESULTS Fifty-one of the 292 patients (17%) referred for allergic evaluation had positive SPT responses to pollen of various ornamental plants. A similar incidence was found among the students (23%). However, the incidence among flower growers was significantly higher, reaching 52%. Higher incidence (83%) of positive SPT responses to ornamental plants was found among flower growers also sensitive to the common allergens. All the tested plants, not only those belonging to the Asteraceae family, provoked positive SPT responses in all 3 groups of participants. None of the participants from the general population or the group of students reported exacerbation of allergic symptoms on exposure to the tested plants. In contrast, almost half of the flower growers (45%) described nasal, ocular, or respiratory symptoms associated with occupational exposure to the tested plants. Some 15% of the growers were eventually compelled to change their profession. CONCLUSIONS The incidence of positive SPT responses to ornamental plants was 17% to 23% among the general public but 52% among flower growers. Thus the effects of ornamental plant pollen on atopic patients should be seriously contemplated.

The inferior turbinate mast cell population of patients with perennial allergic and nonallergic rhinitis.

The number of mast cells in the inferior turbinates of patients with perennial allergic rhinitis and perennial nonallergic rhinitis was compared with normal controls. Mast cell counts expressed as the mean number in 100 high-power fields, assessed after Carnoys fixation and toluidine blue staining were 1.84 in normal controls (n = 11), 4.39 in patients with perennial allergic rhinitis (n = 13), and 4.00 in those with perennial nonallergic rhinitis (n = 26). Statistical analysis confirmed that the density of mast cells in allergic as well as in nonallergic patients was significantly higher than in normal controls, whereas no significant difference was found between the number of mast cells in allergic and nonallergic patients. It is concluded that the number of mast cells in the inferior turbinate mucosa of patients with perennial rhinitis is increased compared with normal controls, and the increased number is not necessarily allergy-dependent.

Allergen immunotherapy-induced biphasic systemic reactions: incidence, characteristics, and outcome: a prospective study

BACKGROUND An anaphylactic reaction is one of the alarming adverse effects of allergen immunotherapy. Although a systemic reaction can follow a biphasic course, its incidence, its outcome, and the risk factors for its development are unknown in patients treated with immunotherapy. OBJECTIVE To record the incidence, characteristics, and outcome of immunotherapy-inflicted biphasic reactions (BRs). METHODS All patients attending large in-hospital allergy clinics for immunotherapy were followed up prospectively. Recorded patient data included the following: demographics, diagnosis, type and phase of immunotherapy, and peak expiratory flow (PEF) before each administration of the injections. If an anaphylactic reaction occurred, medical treatment was recorded and the patient was asked to complete a 3-day diary that included symptoms and periodic measurements of PEF. A BR was defined as a late decrease in PEF of more than 20%, with or without accompanying symptoms. RESULTS During 10,040 visits, 453 patients received 21,022 immunotherapy injections and 131 anaphylactic reactions occurred. Of these reactions, 11 (10%) were biphasic. Most uniphasic reactions (URs) and all BRs occurred in patients who were being treated for allergic rhinitis. A low baseline PEF or concomitant asthma was more common in patients with BRs. Other parameters were comparable between patients with URs and BRs. All BRs were mild and resolved either spontaneously or with oral antihistamines. CONCLUSIONS Immunotherapy-induced BRs are uncommon. They tend to be mild and might be more common in patients with a low baseline PEF or concomitant asthma. Therefore, a long observation after the initial reaction is not required.

Vitamin D, asthma prevalence and asthma exacerbations: a large adult population-based study

The impact of low vitamin D status on asthma, asthma morbidity and control is unclear. We aimed to investigate in adults the associations between serum 25‐hydroxyvitamin D level and prevalent asthma as well as asthma exacerbations.

Bee venom immunotherapy – how early is it effective?

To cite this article: Goldberg A, Confino‐Cohen R. Bee venom immunotherapy – how early is it effective? Allergy 2010; 65: 391–395.

Rush venom immunotherapy in patients experiencing recurrent systemic reactions to conventional venom immunotherapy

BACKGROUND An unknown number of venom-allergic patients fail to reach the maintenance dose (MD) during the build-up period of conventional venom immunotherapy (VIT) due to recurrent systemic reactions (SRs). OBJECTIVE To establish an alternative VIT protocol that will enable these patients to reach a full protective MD. METHODS Venom-allergic patients who had experienced recurrent SRs during the build-up period of conventional VIT underwent rush VIT. RESULTS Of the 9 patients who participated in this study, the 6 who underwent 8 treatment courses tolerated the rush VIT well and reached the MD within 3 days. In 3 of these patients, mild cutaneous SRs were overcome with loratadine. In 2 patients who experienced recurrent and more severe SRs, the original 3-day rush VIT had to be modified and extended to 5 days until the MD was reached. In a single patient who experienced an anaphylactic reaction, VIT was discontinued. CONCLUSIONS Rush VIT is an appropriate therapeutic alternative that enables most patients with recurrent SRs throughout the build-up period of conventional VIT to reach a full protective MD.

Debilitating beliefs, emotional distress and quality of life in patients given immunotherapy for insect sting allergy.

Patients who receive immunotherapy for systemic reaction to insect stings are told that once they reach maintenance dose they are almost 100% protected against future systemic reactions. However, we have observed that some patients continued to perceive themselves as highly debilitated by the allergy, and this perception had a significant impact on their quality of life.