Christopher A. Coop

Patient perceptions regarding local reactions from allergen immunotherapy injections

BACKGROUND Although most allergists agree that local reactions to immunotherapy are not predictive of future systemic reactions, the 2 main reasons for dose adjustments are the concern that local reactions cause discomfort that may lead to patient noncompliance and the concern that local reactions are predictive of future local reactions. OBJECTIVES To determine patient perceptions regarding local reactions from immunotherapy. METHODS A survey on allergen immunotherapy was provided to patients. Participants were asked about the presence of local reactions, the size of their local reactions, and how bothersome these local reactions were. Patients were also asked if they had considered stopping immunotherapy because of these local reactions. RESULTS All 249 patients undergoing immunotherapy completed the survey. Seventy-one percent of the patients reported that they had experienced a local reaction during allergen immunotherapy. Of those patients who reported local reactions, 84.7% reported local reactions smaller than the palm of the hand and 81.9% deemed local reactions not to be bothersome at all or only slightly bothersome. Of those who experienced local reactions, 96.0% stated they would not stop immunotherapy because of these local reactions. CONCLUSIONS Although most patients reported local reactions, these local reactions were usually small and not very bothersome. Most patients would not stop allergen immunotherapy because of local reactions.

The LOCAL Study: local reactions do not predict local reactions in allergen immunotherapy.

BACKGROUND Although previous immunotherapy studies have demonstrated that a local reaction does not predict a systemic reaction, no study has investigated whether a local reaction predicts a local reaction. OBJECTIVE To determine whether a local reaction predicts a local reaction at the next immunotherapy injection. METHODS A retrospective analysis of an electronic immunotherapy database over a 12-month period was performed at a single site that did not dose-adjust for local reactions. Total injections, small local reactions (less than or equal to the size of patients palm), large local reactions (LLRs; larger than the patients palm), systemic reactions, and whether a local reaction was followed by a local reaction were recorded. RESULTS Between August 2005 and July 2006, 360 patients received a total of 9678 injections. Of all patients, 78.3% had at least 1 local reaction, and 7.5% had an LLR. The total local reaction rate was 16.3% (1574/9678), the small local reaction rate was 15.9% (1536/9678), and the LLR rate was 0.4% (38/9678). Of all local reactions followed by another injection, 27.2% were followed by a local reaction. The sensitivity and positive predictive value for a local reaction predicting a local reaction at the next injection were 26.2% and 27.2%, respectively. In contrast, the specificity for the absence of a local reaction predicting the absence of a subsequent local reaction was 85.5%. For LLRs, only 6.0% were followed by another LLR; the sensitivity, positive predictive value, and specificity were 5.2%, 6.0%, and 99.6%, respectively. CONCLUSION In a clinic that does not dose-adjust for local reactions, local reactions do not predict local reactions at the next immunotherapy injection.

Anaphylaxis from the Influenza Virus Vaccine

Background: Allergic reactions to the influenza vaccine are uncommon and usually associated with sensitivity to egg or gelatin. The aim of this study was to report the case of anaphylaxis to the influenza vaccine. Methods: Allergy percutaneous skin testing, serum specific IgE testing and IgE immunoblotting were performed to the influenza vaccine, egg, and gelatin. Results: Percutaneous skin testing to the influenza vaccine and gelatin were positive and egg (white, whole, and yolk) was negative. Immunocap® serum-specific IgE testing to egg (white, whole, and yolk) and gelatin were negative (<0.35 kU/l). IgE immunoblots were performed with 2 cord blood serums and the patient’s serum at a 1:20 dilution against 10 µg of the Fluzone influenza vaccine. The patient’s IgE immunoblot showed a protein band at 100 kDa which is similar to the molecular weight of gelatin protein, a 68-kDa protein which is similar to the molecular weight of hemagglutinin protein from the influenza vaccine, and a 45-kDa protein band that is similar to the molecular weight of ovalbumin protein from chicken embryo/egg. Conclusion: Based on clinical symptoms, skin testing, Immunocap testing and immunoblot evaluation, we feel that our patient is allergic to the infectious agent in the influenza vaccine as well as gelatin and ovalbumin in egg.

Trimethoprim-sulfamethoxazole–induced aseptic meningitis—not just another sulfa allergy

OBJECTIVE To review the literature on trimethoprim-sulfamethoxazole (TMP-SMX)-induced aseptic meningitis (TSIAM) and discuss the features, possible mechanisms, evaluation, and treatment options relevant for the allergist. DATA SOURCES A MEDLINE search was performed using the terms aseptic meningitis, trimethoprim-sulfamethoxazole, trimethoprim, and sulfamethoxazole. STUDY SELECTIONS Cases were included that fit the case definition of headache, neck pain, or change in mental status with elevated cerebrospinal fluid white blood cell count or protein attributable to TMP-SMX or either medication alone. RESULTS Forty-one patient cases were reviewed. There was a predominance of female patients and patients with autoimmune disease reported. Fever, headache, neck pain, and altered mental status were the most common findings reported in TSIAM reactions. Severe reactions ranged from hypotension to seizure and unconsciousness or coma. Typical cerebrospinal fluid findings included elevated white blood cell count with neutrophil predominance, elevated protein, and normal glucose. Symptoms quickly remitted with withdrawal of TMP-SMX, typically over 48 to 72 hours. Full recovery was typically experienced, although permanent paraplegia was reported in 1 case. The mechanism of reaction is unknown, although an IgE-mediated reaction is unlikely. Many patients experienced multiple TSIAM reactions before the diagnosis was made. Diagnosis can be confirmed with drug challenge or graded test dosing when necessary. Patients with TSIAM subsequently reacted to TMP and SMX alone and therefore should be advised to avoid these 2 classes of medication after diagnosis. CONCLUSION TMP-SMX is the most common antibiotic to cause drug-induced aseptic meningitis. By being aware of this reaction, allergists are well poised to diagnose TSIAM and prevent future reoccurrences for the patient.

Dog allergen immunotherapy: past, present, and future.

OBJECTIVE To review the published medical literature on dog allergy immunotherapy and discuss prior clinical trials, important allergens, extract specifics, and potential future treatment options for dog allergy relevant to the clinical allergist. DATA SOURCES MEDLINE search was performed using the terms dog, immunotherapy, and allergy limited to human studies from any period. Articles cited in selected studies also were reviewed for appropriateness of inclusion into this review. STUDY SELECTIONS Publications were included that were original research and fit the topic of dog allergen immunotherapy, specifically articles that investigated prior effectiveness and safety of dog allergen immunotherapy, dog extracts, identification of dog allergens, and current prescribing trends among allergists. RESULTS Two hundred fifteen articles were initially identified and 60 were reviewed in complete detail for inclusion in this review. The primary focus was placed on the 17 clinical trials that investigated the safety and efficacy of dog immunotherapy and the 19 studies that explored and defined the complex allergenic profile of dog extracts. CONCLUSION The medical literature on the use of dog extract immunotherapy in patients with hypersensitivity to dog shows poor and conflicting results of clinical efficacy, which has been attributed to poor-quality extracts and the inherent complex allergenic profile of dogs that remains without a clearly dominant allergen.

Immunotherapy for Mold Allergy

The objective of this article is to review the available studies regarding mold immunotherapy. A literature search was conducted in MEDLINE to identify peer-reviewed articles related to mold immunotherapy using the following keywords: mold, allergy, asthma, and immunotherapy. In addition, references cited within these articles were also reviewed. Articles were selected based on their relevance to the topic. Allergic responses to inhaled mold antigens are a recognized factor in allergic rhinitis and asthma. There are significant problems with respect to the production of relevant allergen material for the diagnosis and treatment of mold allergy with immunotherapy. Mold allergens contain proteases and should not be mixed with other allergens for immunotherapy. Most of the immunotherapy studies focus on two molds, Alternaria and Cladosporium. There is a lack of randomized placebo-controlled trials when evaluating the efficacy of mold immunotherapy with trials only focusing on immunotherapy to Alternaria and Cladosporium. Additional studies are needed regarding mold allergy and immunotherapy focusing on which molds are important for causing allergic disease.

Perceptions regarding injection number and technique

Local cutaneous reactions are a common occurrence during allergen immunotherapy.1e4 Patients can experience pain and discomfort from the immunotherapy injections. Because of this pain and discomfort, physicians may attempt to limit the number of injections per visit. Published data are lacking to support the practice of minimizing the number of immunotherapy injections for patient comfort or therapy adherence. The goals of this study were to survey patients and learn their perceptions with regard to the number of immunotherapy injections received per visit. A survey was provided to all patients on allergen immunotherapy at the Wilford Hall Ambulatory Surgical Center Allergy Clinic. The parents of patients younger than 18 years were asked to complete the survey for their child. The survey was approved by the Wilford Hall Ambulatory Surgical Center Institutional Review Board. The survey consisted of 12 questions (Table 1). A total of 344 of 363 immunotherapy patients (94.8%) completed surveys (363 was the total number of patients receiving immunotherapy). The age range of the patients of the study population was 4 to 80 years, which is the age range of our immunotherapy population. Of the 338 patients (6 of the 344 patients did not respond), 276 (81.7%) were receiving aeroallergen immunotherapy, 51 (15.1%) were receiving venom immunotherapy, and 11 (3.2%) were receiving both. Patients were receiving 1 (135/341 [39.6%]), 2 (143/341 [41.9%]), 3 (57/341 [16.7%]), or more than 3 (6/ 341 [1.8%]) injections at each visit (3 of the 344 patients did not respond). Of the 343 patients who answered the question regarding length of immunotherapy, 103 (30.0%) had been receiving immunotherapy for less than 12 months, 76 (22.2%) for 12 to 23 months, 52 (15.2%) for 24 to 35 months, 40 (11.7%) for 36 to 47 months, 19 (5.5%) for 48 to 59 months, and 53 (15.5%) for more than 59 months. Of the 323 patients who responded to the question regarding improvement of symptoms since starting immunotherapy, 36 (11.1%) believed that their symptoms had not improved at all, 40 (12.4%) had slightly improved symptoms, 71 (22.0%) had moderately improved symptoms, 113 (35.0%) had mostly improved symptoms, and 63 (19.5%) reported completely improved symptoms with immunotherapy. Most patients (218/312 [70.0%]) surveyed were receiving immunotherapy in the red 1:1 vol/vol (maintenance) vial.

The dry needle technique

Abbreviation: MOAHLFA, Male, Occupational dermatitis, Atopic dermatitis, Hand dermatitis, Leg ulcers, Facial dermatitis, and Age older than 40 years. For this data analysis, patch test reactions at day 3 were selected. Statistical analyses were performed using SAS statistical software, version 9.3 (SAS Institute Inc, Cary, North Carolina). Letters / Ann Allergy Asthma Immunol 113 (2014) 114e121 120