Gisoo Ghaffari

Effects of poor sleep in allergic rhinitis.

Purpose of reviewAllergic rhinitis affects a large portion of the population. These patients often suffer from daytime fatigue, both as a result of the mechanics of the nasal airway in patients with allergic rhinitis as well as through central effects on sleep by immune mediators. By understanding these mechanisms and by becoming familiar with effective treatments for allergic rhinitis that are beneficial in alleviating rather than worsening daytime somnolence, physicians may improve patient quality of life. Recent findingsChildren with rhinitis and snoring have poorer school performance compared with controls. The role of rhinitis in chronic fatigue remains controversial despite an increase in literature on this subject. The role of immune mediators on rhinitis and sleep is evolving as well. Nasal steroids effectively treat rhinitis and improve daytime fatigue. Second-generation antihistamines are preferred to first-generation antihistamines based on efficacy and safety studies. SummaryUnderstanding the relationship between rhinitis in sleep abnormalities and subsequent daytime fatigue is still developing. Nasal steroids are the mainstay of treatment, but the role of future agents is promising although undefined. Abbreviation REM: rapid eye movement.

Biomarkers for eosinophilic esophagitis: a review

BACKGROUND The complex pathophysiology of eosinophilic esophagitis (EoE) provides several candidate biomarkers that could be used to establish diagnosis, assess response to therapy, and document disease recurrence. OBJECTIVE To review the literature on various biomarkers of EoE, with respect to their correlation to disease activity and response to treatment. DATA SOURCES A literature search was performed using PubMed and OVID with keyword combinations of EoE and various potential biomarkers. STUDY SELECTIONS Between 2006 and 2012, 26 studies that investigated the correlation of various tissue and serum biomarkers with EoE were identified. RESULTS The markers investigated included eotaxins-1,-2, and -3, interleukin-5 (IL-5), interleukin-13 (IL-13), eosinophil-derived neurotoxin, mast cell markers, absolute eosinophil count, and micro-RNAs. Several studies have shown a positive correlation between eotaxin-3, IL-5, and IL-13 messenger RNA (mRNA) expression in esophageal tissue and disease activity. Eotaxin-3 mRNA staining was found to have 89% sensitivity for diagnosing EoE. Staining for mast cells and their products has also shown promise. More recently, a microRNA signature that can potentially distinguish EoE from non-EoE esophagitis has been identified. CONCLUSION The studies are quite heterogeneous with respect to their methodology and the biomarker(s) studied, but most have investigated tissue biomarkers. Eotaxin-3 and IL-13 have emerged as the most promising ones with respect to sensitivity and degree of positive correlation to disease process. Future research on biomarkers for EoE should include longitudinal studies, establishment of normal values, effects of concomitant atopic diseases, age and gender, and validation of methodology of the tests.

A review of the evidence linking eosinophilic esophagitis and food allergy.

Eosinophilic esophagitis (EoE) is a chronic inflammation of the esophagus that has been considered an allergic phenomenon based on its similarities to other allergic conditions. More specifically, EoE has been considered a form of food allergy because of patient sensitizations to foods and improvements in symptoms and inflammation after food eliminations. This article presents the currently available evidence regarding the classification of EoE as an allergic condition, the involvement of foods in disease pathogenesis, and the value of different types of allergy testing and elimination diets in management of EoE. Using the search engines PubMed and Ovid, English literature in the past 10 years was reviewed with the use of the following key words: eosinophilic esophagitis, EoE epidemiology, EoE pathophysiology, food allergy, eosinophils, skin-prick testing, atopy patch testing, elemental diet, test directed elimination diet, six food elimination diet. Studies of EoE epidemiology and pathophysiology support the link between EoE and allergy in general, and studies of food allergy testing and elimination diets have supported a link between EoE and food allergy. Although food elimination diets cause resolution of symptoms and pathology in pediatric EoE, the results of testing and diet elimination studies are not as clear in adults, and aeroallergen sensitizations may play a larger role in adult EoE pathophysiology. Although several studies in children and adults support considering EoE a form of food allergy, the usefulness of skin-prick testing and atopy patch testing for food allergies and the optimal elimination diet for disease management are still uncertain.

Comparison of atopic features between children and adults with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a clinicopathological diagnosis seen in children as well as adults. Growing evidence suggests that EoE is strongly associated with atopic disorders. Presenting symptoms differ in children and adults and it is not known whether atopic features vary by age. This study was designed to compare atopic features and allergic sensitization between children and adults with EoE. We conducted a retrospective analysis of demographic and clinical data from 50 children (aged 2-18 years) and 50 adults (aged 21-75 years) with a biopsy-proven diagnosis of EoE referred to our allergy clinic. Data regarding patient characteristics, history of atopic diseases, and allergy test results were collected for analysis. The majority of children and adults were white and male patients. When compared with adults, a higher percentage of children had a history of asthma (52% versus 24%; p < 0.05). There was no statistically significant difference between adults and children regarding history of allergic rhinitis, atopic dermatitis, immunoglobulin E-mediated food allergy, and family history of atopy. There was no statistically significant difference between children and adults regarding immediate-type sensitization to foods and aeroallergens. Compared with adults, a higher percentage of children showed a positive reaction to one or more foods on patch testing (62% versus 31%; p = 0.01). A high prevalence of comorbid atopic diseases and sensitizations to food and environmental allergens was seen in both children and adults. Children had a significantly higher rate of asthma and positive patch test to foods compared with adults.

A sixty-five-year-old man with rash, fever, and generalized weakness.

Diffuse erythematous rash accompanied by high-grade fever, eosinophilia, and facial edema can be caused by a variety of infective, allergic, or systemic etiologies. We present a case of 65-year-old man with septic arthritis, who had a vancomycin antibiotic spacer placed in his infected knee and was also started on intravenous (i.v.) vancomycin. After 2 weeks he presented with sudden onset of fever and generalized weakness. Physical examination was significant for tachycardia and hypotension, facial edema, diffuse erythematous rash, and bilateral wheezing. Laboratory values indicated acute renal insufficiency associated with eosinophiluria and significant peripheral eosinophilia. Septic shock was highly suspected and he was treated with i.v. fluids and broad-spectrum antibiotics. Despite aggressive management his condition rapidly deteriorated with persistent of shock state, increase in facial edema, and rash. Other suspected etiologies included hypersensitivity reactions to i.v. antibiotics (piperacillin/tazobactam) or vancomycin, systemic vasculitis, or idiosyncratic reactions to medications such as Stevens-Johnson syndrome. The patient was started on high-dose i.v. steroids, which led to improvement of his clinical condition. Clinical presentation of adverse drug reactions is highly variable and may present as potentially life-threatening multiorgan failure. Early recognition of the etiology and removing the offending agent is important to improve the outcome.

Adverse events associated with intranasal influenza vaccine in the United States.

Methods: The goal of this review was to analyze the post-vaccination adverse effects associated with Live Attenuated Influenza Vaccine (LAIV) compared to those of the Injectable Trivalent Inactivated Vaccine (TIV) in patients with egg allergy and asthma. PubMed, Ovid, and Google searches were conducted. Searched articles relating to allergic reactions, asthma or food allergy, and LAIV were reviewed. Results: Similar or superior efficacy of LAIV compared to TIV was reported by various studies. Respiratory symptoms were the most common adverse events following both vaccinations. Although no evidence was found of a direct causal relationship between intranasal influenza vaccine and anaphylaxis due to egg allergy, a number of cases of anaphylaxis were reported. To date, there are no studies directly comparing the frequency of anaphylactic reactions between the two vaccines. Conclusions: The safety of LAIV in individuals with unstable asthma and egg allergy has not been established and it should be avoided in these populations. For patients with unstable asthma, TIV should remain the therapy of choice.

Anaphylaxis to polymyxin B-trimethoprim eye drops.

Figure 1. Skin prick testing to polymyxin (left side) and trimethoprim (right side) in duplicate, with a histamine control (þ) and saline ( ) in the center. The inner columns are in a 1/10 concentration, and the outer columns are full strength. bacterial conjunctivitis in the pediatric population. Although allergic reactions to polymyxin, such as contact dermatitis, from topical antimicrobial applications have been reported, to our knowledge no prior literature has documented a case of anaphylaxis after the administration of eye drops that contain polymyxin.1e3 In this letter, we describe a case of a systemic anaphylactic response to polymyxin Betrimethoprim eye drops. A 2-year-old boy presented to the emergency department with severe eye swelling and erythema of the cheeks, which soon progressed to lip swelling and stridor at rest. The symptoms started immediately after the first administration of the second course of polymyxin Betrimethoprim eye drops prescribed to treat bacterial conjunctivitis. Approximately 5 months before this incident, the patient had used polymyxin Betrimethoprim eye drops for the first time to treat a previous episode of bacterial conjunctivitis, which resolved with no sequelae. On presenting to the emergency department with signs of anaphylaxis, he was given 0.15 mg of intramuscular epinephrine, nebulized racemic epinephrine, and 30 mg of methylprednisolone. The patient was admitted to the hospital overnight to monitor for a rebound reaction; however, his symptoms slowly resolved after 24 hours with continued corticosteroid and antihistamine treatment. Before this acute reaction, the patient had no history of allergic reactions or atopic dermatitis. Three months after his anaphylactic reaction, a skin prick test was performed on the patient at the allergy and immunology clinic. He was tested for sensitization to trimethoprim and polymyxin because the eye drops contained both substances. The skin test result was negative for a reaction to trimethoprim at a concentration of 1/10 as well as when given at full strength (Fig 1). The patient tested negative to polymyxin in a concentration of 1/10, but the results of a full-strength skin test were positive with a wheal and flare size of 5/20 and 5/15, respectively. All tests were run in duplicate, with an unremarkable saline control and a histamine control that measured 5/15. The test was performed again as a control on the physician, who did not have a known allergic response to polymyxin, and it did not result in any skin irritation with the administration of diluted or full-strength polymyxin. On the basis of these findings, the patient’s reaction was consistent with an IgE-mediated hypersensitivity to polymyxin. A literature review revealed few data on testing for systemic reactions to topical antimicrobial treatments and ocular medications. When the patient was administered the drops previously, he was likely sensitized to polymyxin, a multivalent polymer large enough to bind to an IgE antibody. Although we are unaware of other cases of anaphylaxis to polymyxin eye drops in humans, other antibiotics have been found to cause fatal reactions in a study of felines after ocular exposure.4 Although the eye is considered an immune

Tongue Necrosis as an Initial Manifestation of Giant Cell Arteritis: Case Report and Review of the Literature

Giant cell arteritis (GCA) is a systemic vasculitis of medium and large arteries that mainly affects the external carotid artery. It is a diagnosis of the elderly that typically presents as low-grade fever, temporal tenderness, claudication of the jaw, and in some patients vision loss. In cases where GCA presents with atypical manifestations, the diagnosis may be more difficult, causing a delay in both diagnosis and treatment and ultimately leading to irreversible complications. In this paper, we present an atypical presentation of GCA with symptoms of neck swelling and lingual pain in an elderly female. These symptoms progressed to bilateral necrosis and eventual dislodgement of the tongue. Lingual necrosis is a severe potential complication in GCA. In patients presenting with lingual swelling, pain, and discoloration, GCA should be suspected and prompt therapy should be initiated to avoid irreversible complications.

Esophageal Rupture as a Primary Manifestation in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory process characterized by symptoms of esophageal dysfunction and, histologically, by eosinophilic infiltration of the esophagus. In adults, it commonly presents with dysphagia, food impaction, and chest or abdominal pain. Chronic inflammation can lead to diffuse narrowing of the esophageal lumen which may cause food impaction. Endoscopic procedures to relieve food impaction may lead to complications such as esophageal perforation due to the friability of the esophageal mucosa. Spontaneous transmural esophageal rupture, also known as Boerhaaves syndrome, as a primary manifestation of EoE is rare. In this paper, we present two adult patients who presented with esophageal perforation as the initial manifestation of EoE. This rare complication of EoE has been documented in 13 other reports (11 adults, 2 children) and only 1 of the patients had been previously diagnosed with EoE. A history of dysphagia was present in 1 of our patients and in the majority of previously documented patients. Esophageal perforation is a potentially severe complication of EoE. Patients with a history of dysphagia and patients with spontaneous esophageal perforation should warrant an evaluation for EoE.

Aseptic Splenic Abscess as Precursory Extraintestinal Manifestation of Inflammatory Bowel Disease

Splenic abscesses are most often secondary to aerobic bacterial infections due to Streptococcus, Staphylococcus, and Enterococcus species of organisms. Sterile splenic abscesses rarely occur and diagnosis and treatment of those are challenging. We report a case of a previously healthy young female presenting with aseptic splenic abscesses as the initial manifestation of Crohns disease along with a review of the literature on aseptic splenic abscess as an extraintestinal manifestation of Crohns disease.