G. Barberio

Clinical and immunologic effects of long‐term sublingual immunotherapy in asthmatic children sensitized to mites:a double‐blind, placebo‐controlled study

Background: Immunotherapy through local routes is thought to be a valuable therapeutic option for respiratory allergy. We investigated the clinical efficacy and immunologic effects of sublingual immunotherapy (SLIT) in asthmatic children with mite‐induced respiratory allergy.

Impact of sublingual immunotherapy on seasonal asthma and skin reactivity in children allergic to Parietaria pollen treated with inhaled fluticasone propionate.

Background Immunotherapy is a recognized treatment for allergic respiratory diseases.

Sublingual immunotherapy abrogates seasonal bronchial hyperresponsiveness in children with Parietaria-induced respiratory allergy: a randomized controlled trial†

Background:  The use of immunotherapy in asthmatic children is still controversial. Sublingual immunotherapy (SLIT) may represent an advance, due to the good safety profile, but little is known about its effects on lung function and nonspecific bronchial responsiveness.

A new protocol for specific oral tolerance induction in children with IgE-mediated cow's milk allergy.

IgE-mediated cows milk allergy (CMA) is a heavy burden for patients, particularly for children and their families. Allergen avoidance represents the only therapeutic option, but oral desensitization protocols have been suggested. Because of the long duration and complexity of these protocols we examined the feasibility of an oral tolerance induction protocol using a weekly up-dosing schedule. Children with IgE-mediated food allergy to milk, confirmed by a double-blind placebo-controlled food challenge, were recruited. Six of them were randomized to double-blind desensitization with milk or soy formula as placebo. Seven patients underwent the protocol in open fashion. The desensitization schedule started with one drop of whole CM diluted 1:25 every week. The dose was doubled weekly until the 18th week to achieve an intake of 200 mL in approximately 4 months. Of the 13 children enrolled, 10 children received CM and 3 control children received soy formula. Full tolerance (200 mL of milk) was achieved in 7 children; in 2 children this therapeutic approach failed, because severe reactions occurred during the procedure. One patient achieved a partial tolerance (64 mL of milk). The three control children receiving placebo still showed a positive food challenge at the end of the study. A weekly up-dosing oral tolerance induction could be a viable alternative to traditional protocols for children with IgE-mediated CMA.

Chronic urticaria and associated coeliac disease in children: A case–control study

Celiac disease (CD) and chronic urticaria (CU) are both sustained by immune mechanisms, but there are so far few data on their clinical association. We performed a case–control study to determine the occurrence of CD in urticaria and matched control children, and to assess the clinical relevance of this association. Children and adolescents were diagnosed to have severe chronic idiopathic urticaria in the presence of hives for more than 6 wk poorly or not responsive to oral antihistamines. Other known causes of urticaria had to be excluded. A matched control group without urticaria was enrolled. In both groups, the presence of CD was searched by assaying antitransglutaminase and antiedomysial antibodies, and confirmed with endoscopic intestinal biopsy. Results. CD was diagnosed and confirmed in 4/79 (5.0%) of children with CU and in 17/2545 (0.67%) of the controls (p = 0.0003). In the four children with urticaria and CD the gluten free diet (GFD) lead to complete remission of urticaria within 5–10 wk, whereas the disappearance of serological markers occurred in longer times (5–9 months). Conclusions. The presence of CD in children with CU was significantly more frequent than in controls. GFD resulted in urticaria remission. CD may be regarded in such subjects as a cause of CU.

Food-exercise-induced anaphylaxis in a boy successfully desensitized to cow milk.

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Predictive features for persistence of atopic dermatitis in children

Allergen exposure plays an important role in atopic dermatitis (AD). Because immunological mechanisms underlying asthma and AD have great similarities, we evaluated whether features such as allergen sensitization, immune response, disease severity and duration or allergen exposure could be considered predictive for AD persistence. Seventy‐one AD children (age range 14–158 months) were enrolled and followed for 3 consecutive years for AD severity using the SCORAD index (SI). At enrollment, reactivity to inhalant and food allergens using the skin prick test (SPT) and house dust mite (HDM) atopy patch test (APT), and HDM allergens in house dust were evaluated. After 3 years, 38 children outgrew their AD (AD– group), while in 33 AD persisted (AD+ group). At enrollment, AD+ children had a higher SI, higher rate of positivity to SPT and APT for mites (p = 0.001), and higher environmental exposure to HDM allergens (p = 0.035). The AD+ children developed more respiratory symptoms in comparison to AD– children (p < 0.001). None of the AD– children presented APT positivity. In our study population, positivity of SPT and APT for HDM, environmental allergen exposure levels and severity of the disease at enrollment presented a significant predictive power towards AD persistence. Subjects with positive skin reactivity to HDM should be considered at risk of AD persistence and of possible development of allergic respiratory disorders.

Anaphylaxis to sesame

We report a case of contact urticaria due to cyclopentolate hydrochloride eye-drops, with tolerance to other mydriatic eyedrops. A 72-year-old man, with a clinical history of adverse drug reactions to sulfonamides, was referred for allergologic investigation because of an adverse reaction after local application of several eye-drops. He was treated with Colircusõ Â Tropicamida (1% tropicamide) eye-drops for ophthalmologic examination and then with Tobrex (0.3% tobramycin) eye-drops for 2 days, before undergoing cataract surgery. During the immediate preparations for surgery, several drugs were instilled into his right eye: Colircusõ Â Tropicamida, Colircusõ Â Cicloplejico (1% cyclopentolate hydrochloride), and Colircusõ Â Fenilefrina (10% phenylephrine hydrochloride) one drop every 15 min up to four drops of each drug, and Voltaren Colirio (0.1% diclofenac sodium) one drop every 20 min. During the course of this procedure, the patient developed erythema, edema, itching, and burning in his right eye, and an urticarial rash on his right cheek, following the path of drug-containing tears. There were no other symptoms. The rash began to subside a few minutes later, and the symptoms disappeared without treatment. Patch testing was carried out with the eyedrops (as is) used in our patient, and with Colircusõ Â Atropina (1% atropine sulfate). They were applied to the skin of the patients back by the AL-Test method with Scanpor tape. Readings were performed every 15 min during the ®rst hour. If negative, patch tests remained applied, and further readings were done at 48 and 96 h. At the 15-min reading, mild erythema appeared at the site of the patch test with Colircusõ Â CiclopleÂjico; at the 30-min reading, the patient developed an itching wheal at the same site. All of the other eyedrops tested were negative for both immediate and delayed reactions. By the same procedure, eight healthy individuals were tested as controls for immediate reactions with Colircusõ Â ciclopleÂjico, and all were negative. Afterward, our patient underwent cataract surgery successfully, using other mydriatic eye-drops (Colircusõ Â Atropina, Colircusõ Â Fenilefrina) without adverse reactions. Mydriatics are continually used by ophthalmologists for both diagnostic and therapeutic procedures. Allergic reactions to the topically applied cycloplegics are unexpected responses, and are very rare with cyclopentolate (2±4). To our knowledge, one case of contact urticaria (2) and another one of generalized urticaria due to cyclopentolate hydrochloride have been reported (4). Nevertheless, in these cases, patch tests were not performed, and the patients were not rechallenged with cyclopentolate. In the case reported here, clinical features led us to suspect a contact urticaria syndrome. The positive result at 15and 30min readings of patch testing with Colircusõ Â CiclopleÂjico con®rmed the diagnosis of contact urticaria. In our patient, preservatives were not suspected to be responsible for the adverse reaction because Colircusõ Â Atropina shares with Colircusõ Â CiclopleÂjico the same substances (methylparahydroxybenzoate, propylparahydroxybenzoate, sodium chloride, and distilled water), and patch testing with Colircusõ Â Atropina was negative. Furthermore, Colircusõ Â Atropina was used later in cataract surgery in our patient without adverse reactions. The negative results elicited in all the subjects from the control group (atopic and nonatopic) challenge the concept of direct histamine release. For con®rmation of an immunologic mechanism, the presence of speci®c IgE against cyclopentolate hydrochloride may be dif®cult to prove, and tests are not available. All these data led us to diagnose this case as contact urticaria due to cyclopentolate hydrochloride, caused by an uncertain (although probably immunologic) mechanism.

Does a ‘reverse’ atopic march exist?

The classical description of the atopic march usually refers to the progression from atopic dermatitis towards asthma, but this pathway has been questioned. We assessed in a prospective observation the possible onset of atopic dermatitis in children with asthma alone at baseline, and evaluated retrospectively their characteristics. Seven hundred and forty‐five children (360 male, 6–9 years of age) with asthma alone, without food allergy or atopic dermatitis, were followed‐up with regular visits for 9 years. 692 children completed the 9‐year observation, and 20% of them were found to have developed atopic dermatitis at 9 years. Comparing retrospectively the children who developed AD with the remaining, no significant difference existed at baseline concerning the demographic characteristics and family history. There was a significantly higher proportion ( χ2 = 0.01) of subjects with single sensitization to mites and a significantly lower proportion of polysensitized subjects ( χ2 = 0.01) within the children who developed AD. Sensitization to foods appeared in 9% of children who developed AD and in 3.8% in the other children (NS). According to these observations, the development of a particular allergic disease does not necessarily follow the classical paradigm of the atopic march.

Double-blind multicenter study on the efficacy and tolerability of cetirizine compared with oxatomide in chronic idiopathic urticaria in preschool children

BACKGROUND There are no studies on the use of cetirizine in children under the age of 6. OBJECTIVE We compared the efficacy and tolerability of cetirizine in patients with idiopathic chronic urticaria to the more widely used antihistamine, oxatomide. METHODS This double-blind study was performed on 62 patients (38 male and 24 female) with idiopathic chronic urticaria, recruited from four different medical centers of the national territory (Ancona, Cagliari, Catania, and Messina). The childrens ages ranged from 2 to 6 years (mean 3.85). The patients were randomly assigned to two treatment groups: one group treated 31 children with cetirizine at a dosage of 5 mg q.d., and a second group treated 31 children for the same amount of time with oxatomide, at a dosage of 25 mg q.d. Sixty-two children began the treatment, but five did not finish the study (three in the cetirizine and two in the oxatomide group). Thus, the clinical study and the statistical evaluation were conducted on 57 children (28 cetirizine and 29 oxatomide). The Students t test was used to compare severity of the illness and changes in the hematochemical tests. RESULTS Overall, the effectiveness of the two medications in treating erythema, papules, edema, and itching showed comparable therapeutic activity (P < 0.001). Neither medication produced significant side effects. CONCLUSIONS The results of the present study suggest that cetirizine may represent an effective and safe pharmacologic therapy for chronic urticaria in preschool children. There was no evidence for changes in hematochemical and urinary values, demonstrating the safety and the tolerability of the two antihistamines, even when given to young children.