Demetrios S. Theodoropoulos

Systemic reactions and fatalities associated with allergen immunotherapy

OBJECTIVE The primary objective of this review is to discuss systemic allergic reactions and risk factors associated with the injection of allergen vaccines. DATA SOURCES A review of the literature on anaphylactic reaction, adverse effects, and fatalities associated with allergen immunotherapy (IT) was conducted. STUDY SELECTION The expert opinion of the author was used to select relevant data. RESULTS Systemic allergic reactions associated with the injection of allergen vaccines usually begin within 20 minutes. However, on occasion, they begin 20 to 30 minutes or longer after an injection. Such reactions can also occur after allergen skin testing. Most reactions associated with skin testing and allergen IT are mild and readily respond to appropriate treatment. However, severe and even fatal reactions have been reported with both skin testing and IT. CONCLUSIONS Risk factors for skin testing and allergen IT include: 1) patients, particularly asthmatic patients, suffering with seasonal exacerbation of their symptoms; 2) patients who demonstrate exquisite sensitivity to particular allergen(s); 3) patients on beta-blockers; 4) patients with asthma, especially if their asthma is unstable; 5) patients in whom rush IT is used; and 6) patients in whom high doses of potent standardized allergen vaccines are used. It is essential that strict attention be paid to the risk factors for systemic reactions, and that techniques and management be initiated both before and after skin testing or IT to minimize these risks. Done properly, the risk of skin testing and IT is minimal.

Allergen immunotherapy: guidelines, update, and recommendations of the World Health Organization.

Allergen immunotherapy (AIT) is the administration of increasing doses of an allergen vaccine to an allergic subject in order to reach a dose effective to improve symptoms associated with subsequent exposure to the causative allergen. This form of therapy is effective in the treatment of allergic rhinitis/conjunctivitis, allergic reactions to stinging insects, and allergic asthma. It is the only therapeutic modality that can affect the natural course of allergic diseases, and may prevent the development of asthma in patients with allergic rhinitis. AIT is indicated for patients with demonstrated specific IgE antibodies against clinically relevant allergens. The mixture of allergens to be utilized is based on the patients history and skin and laboratory tests. The major risk of AIT is anaphylaxis. Such therapy is continued for three to five years, but the decision to discontinue it should be individualized. Interpretation of the history, physical findings, and skin and laboratory tests, the prescription and administration of allergen immunotherapy, its integration into the patients treatment plan, and the decision to discontinue it require qualifying experience provided by specialist training in allergy and immunology.

Gastroesophageal reflux and asthma: a review of pathogenesis, diagnosis, and therapy

Gastroesophageal reflux disease (GERD) occurs in up to one‐third of the adult US population. Most affected individuals are either unaware of their condition or do not seek medical help, relying on nonprescription acid suppressants and antacids for relief. GERD, a common disorder of infancy, old age, and pregnancy, is particularly prevalent in patients with asthma. A causal relationship between the two diseases has been postulated by many investigators. The physiologic changes of asthma exacerbations and the actions of some of the medications used to treat asthma both aggravate GERD. The adverse effect of GERD on asthma and the pathophysiology of this relationship are still under debate. Some studies showed no objective improvement by spirometry of asthmatics treated for GERD, but recognized improvement in asthma symptoms and decreased use of asthma medication. Other studies, supporting GERD induction of asthma, have been performed to test two hypotheses: that asthma is exacerbated by endotracheal aspiration of gastric contents or by a reflex response to stimulation of esophageal receptors. Clinical experience has shown that early diagnosis and treatment of GERD often leads to better control of asthma.

Visceral Sensitivity in Gastroesophageal Reflux

Symptomatic gastroesophageal reflux disease (GERD) is characterized by a wide spectrum of symptoms. The variance of GERD symptoms may be due to a decreased threshold for symptom elicitation/perception described as “visceral sensitivity.” In this study GERD symptoms were scored for presence/frequency. The symptom score was weighted for the presence/frequency of typical reflux symptoms: heartburn, retrosternal pain, and regurgitation. The weighted GERD symptom score was used to assess symptom expansion and the hypothesis of GERD visceral sensitivity. One hundred five subjects with heartburn/retrosternal pain underwent esophageal pH studies. Subjects with abnormal esophageal pH studies reported more GERD-related symptoms, occurring more frequently, compared to subjects with normal esophageal pH studies. Symptom scores correlated with the number of reflux episodes but not with the length of time of mucosal exposure to acid. Therefore, aggregation of symptoms in gastroesophageal reflux is associated with frequent alternation between low and normal pH values in the distal esophagus.

Sandifer’s syndrome and gastro- oesophageal reflux disease

Perkin and Murray-Lyon’s Neurology and the gastrointestinal system reviews gastrointestinal disorders with neurological features.1 The authors do not mention Sandifer’s syndrome, a disorder of the upper gastrointestinal tract with neurological manifestations occurring in children and adolescents. Sandifer’s syndrome is the association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements. Nodding and rotation …