Eleonora Nucera

Beneficial Effects of Helicobacter pylori Eradication on Idiopathic Chronic Urticaria

Helicobacter pylori, the most important cause ofgastritis and peptic ulcer, recently has been associatedwith several extradigestive diseases. The aim of thisstudy was to assess the prevalence of Helicobacter pylori infection and the effects of bacteriumeradication in 42 consecutive patients affected byidiopathic chronic urticaria. Helicobacter pylori wasassessed by [13C]urea breath test.Amoxicillin, clarithromycin, and lansoprazole were given to infectedpatients for seven days. Urticaria and gastrointestinalsymptoms were assessed on enrollment and aftereradication. Fifty-five percent of patients proved to beinfected by Helicobacter pylori. Prevalence ofgastrointestinal symptoms did not differ betweeninfected and uninfected patients. Eighty-eight percentof infected patients in whom the bacterium waseradicated after therapy showed a total or partial remission ofurticaria symptoms. Conversely, symptoms remainedunchanged in all uninfected patients. In conclusion,Helicobacter pylori affects a high percentage ofpatients with idiopathic chronic urticaria; however,typical gastrointestinal symptoms do not identifyinfection status. Bacterium eradication is associatedwith a remission of urticaria symptoms, suggesting apossible role of Helicobacter pylori in the pathogenesisof this skin disorder.

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.

Clinical usefulness of patch and challenge tests in the diagnosis of cell-mediated allergy to betalactams

BACKGROUND Literature reports dealing with cell-mediated allergy to betalactams have appeared with increasing frequency in the last years. OBJECTIVE To evaluate patients with such reactions and to identify cross-reactivities among betalactams in order to provide safe guidelines for their further clinical management. METHODS Thirty consecutive subjects with cell-mediated allergy to betalactams (history of adverse reactions to these antibiotics; serum total IgE within the normal range; absence of serum specific IgE antibodies to penicillin G and V, amoxicillin, and ampicillin; negative skin tests with a wide pattern of betalactam preparations; and positive patch-test to at least one betalactam antigenic determinant) were investigated. The subjects admitted to the study were patch tested with a wide variety of betalactam preparations in order to identify alternative molecules tolerated by the patient. To better evaluate the cross-reactivity pattern, tolerance challenges with patch-negative betalactams were also performed in each subject. RESULTS Both specific IgE and skin tests were negative in all patients. The skin biopsies performed on the positive patch-tested area in four patients showed a clear T-lymphocyte, CD4+-type infiltrate, thus definitely proving the occurrence of a cell-mediated response. A total of 44 adverse reactions (mean: 1.47 episodes for each patient) were reported in history, with a mean interval of 15 hours after betalactam administration. The reported symptoms were mainly cutaneous (maculo-papular rash and urticaria) and the responsible drugs were chiefly aminopenicillins (86.4% of cases) and penicillin G (9.1%). We were able to identify three separate groups of patients on the basis of clinical history, patch-test, and tolerance challenge pattern: allergy to the side chain of aminopenicillins in 16 patients (53.3%); allergy to the thiazolidine ring in 3 patients (10.0%); undetermined specificity in the remainder 11 patients (36.7%). Cross-reactivity among different betalactam molecules (revealed by positive tolerance tests performed with patch-negative betalactams) was found in 4.8% of cases only (23.3% of all investigated patients). This fact demonstrates a very high (95.2%) predictive value of a negative patch-test in excluding the occurrence of a cross-reactivity. The mis-match between patch and tolerance tests was observed in 3 out of 178 cases only (1.7% of cases, 10.5% of patients) in groups A and B, and in as much as 12.2% of cases (45.5% of subjects) in group C (P < .05). CONCLUSIONS Delayed allergy to betalactams (mainly to aminopenicillins) may be exerted by a cell-mediated response. Patch tests and tolerance challenges are extremely useful and safe for diagnosis and further clinical treatment of these patients, helping to identify safe alternative betalactam molecules that could be successfully tolerated by the allergic subjects.

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 …

Carnitine Deficiency: Primary and Secondary Syndromes

Emerging literature has shown that carnitine deficiency may be frequently recognized in human and the list of disorders associated with carnitine deficiency is growing.

Oral Hyposensitization to Nickel Allergy: Preliminary Clinical Results

Fifty-one patients presenting a dermatological allergy (erythema, urticaria, angioedema, contact dermatitis) to nickel were treated over 3 years with oral doses of 0.1 ng nickel sulfate per day, following a low-nickel diet. Diagnostic tests comprised patch and oral provocation tests. In 7 cases, the treatment was interrupted because of symptom reactivation, and in 14 cases for other reasons. Among the 30 cases who went through the whole follow-up, symptomatology totally disappeared in 29 cases, and a partial alleviation was achieved in 1 case after 1 year of treatment. Oral provocation tests with these 30 patients showed an overall increase of tolerance. Patch tests showed no variation in 20 cases, a diminution in 5, and were negative in 5. Although the study was not conducted double blind, the results of this attempt to cure nickel allergy are statistically significant.

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.