J. Barbarroja-Escudero

Component-resolved diagnosis in hymenoptera allergy

Component-resolved diagnosis based on the use of well-defined, properly characterised and purified natural and recombinant allergens constitutes a new approach in the diagnosis of venom allergy. Prospective readers may benefit from an up-to-date review on the allergens. The best characterised venom is that of Apis mellifera, whose main allergens are phospholipase A2 (Api m1), hyaluronidase (Api m2) and melittin (Api m4). Additionally, in recent years, new allergens of Vespula vulgaris have been identified and include phospholipase A1 (Ves v1), hyaluronidase (Ves v2) and antigen 5 (Ves v5). Polistes species are becoming an increasing cause of allergy in Europe, although only few allergens have been identified in this venom. In this review, we evaluate the current knowledge about molecular diagnosis in hymenoptera venom allergy.

Kounis syndrome induced by cefditoren pivoxil

Article history: Received 8 December 2015 Received in revised form 3 January 2016 Accepted 4 January 2016 Available online 11 January 2016 mal b5) and the peak level of troponin I reached 1.32 ng/mL (normal b0.06). Serum tryptase was 4.5 μg/L (normal b11.4). This tryptase value was the only one determined and it was obtained 8 h after the episode had begun. All in vitro tests were measured by the ThermoFisher Laboratories (ThermoFisher, Massachusetts, USA). Echocardiography revealed a normal mechanical prosthesis and normal left ventricular systolic function. Chest X-ray revealed a left lobar pneumonia without

Allergic reaction to polyethylene glycol in a painter

We report a case of a male painter who visited our outpatient clinic after developing a distinct skin reaction 15 min after the ingestion of a laxative solution containing polyethylene glycol (PEG) prior to colonoscopy. He described suffering from the same skin reaction when he was previously exposed to paints that contained PEG-4000. An exposure challenge test with pure PEG-4000, simulating his workplace conditions, elicited a generalized urticarial reaction. Allergy to PEG should be considered in painters who develop urticarial or other systemic symptoms after handling PEG-containing products.

Fixed drug urticaria: a report of two patients.

Fixed drug eruptions (FDE) represent a skin syndrome expressed clinically as a round, erythematous and edematous plaque, involving occasionally mucous membranes, that often recur in the same location, developing hyperpygmentation.1 This type of cutaneous hypersensitivity reaction is mediated by cytotoxic CD4þ, CD8þ, and CD56þ Tcells (type IVc reaction), and its progression is believed to be limited by regulatory T cells.1e3 Nevertheless, other clinical variants have been described, including dermatographic4 or papular eruptions.5 Either local anesthetics (LA)6 or non-steroidal anti-inflammatory drugs (NSAIDS)7 represent two major families of drugs causing FDE. We present two patients who suffered from atypical FDE types. Patient 1: A 30-year-old woman with a personal history of rhinoconjunctivitis due to pollen sensitivity, and diagnosed with congenital multiple nevus syndrome. She denied having any allergic symptoms to latex exposure. This patient developed, in two different occasions after nevus exeresis (on the back and the neck, respectively), one itching and erythematous urticarial wheal on the outer face of her right arm. In both cases, the lesion appeared 20 min after the administration of ScandinibsaTM (mepivacaine 2% [20 mg/ml], Inibsa, Barcelona, Spain) and spontaneously disappeared 15 min later without leaving neither desquamation nor hyperpigmentation. One month later, an allergological workup was undergone after granting her informed consent. Patient 2: A 50-year-old womanwithout a personal or familial history of atopy. Eight years ago, she had sufferedmore than 10 episodes of an itching and erythematous isolated urticarial wheal always located over the upper abdomen (epigastrium). It appeared after taking metamizole or acetaminophen for different pains or upper respiratory infections. All the episodes started 15e20 min after the drug intake and disappeared within 30 min spontaneously with no residual skin lesions. After the last episode, she has tolerated ibuprofen, dexketoprofen, and other NSAIDS. Two months later, an allergy study was undergone after receiving her informed consent. We performed an allergological study for both cases. Patient 1: Skin prick testing (SPT) and intradermal tests (with inmediate and late readings at 48 and 72 h) with commercial MepivacainaTM 1% (Braun, Barcelona, Spain) (10 ml of aqueous solution of mepivacaine 1% [10 mg/ml], sulphites-, and parabens-free) were carried out. The SPT was made with an undiluted solution of the commercial drug. For intradermal tests, 0.02 ml from two different concentrations were injected sequentially: 0.02 mg (1:10 dilution in

Abnormal Chemokine Receptor Profile on Circulating T Lymphocytes from Nonallergic Asthma Patients

Background: T lymphocytes are involved in the pathogenesis of nonallergic asthma. The objective of this study was to characterize the subset distribution and pattern of chemokine receptor expression in circulating T lymphocyte subsets from nonallergic asthma patients. Methods: Forty stable nonallergic asthma patients and 16 sex- and age-matched healthy donors were studied. Twelve patients did not receive inhaled steroids (untreated patients), 16 received 50-500 μg b.i.d. of inhaled fluticasone propionate (FP) (standard-dose patients), and 12 received over 500 μg b.i.d. of inhaled FP (high-dose patients) for at least 12 months prior to the beginning of this study and were clinically well controlled. Flow cytometry was performed using a panel of monoclonal antibodies (4 colors). Results: Nonallergic asthma patients treated with high doses of inhaled FP showed a significant reduction in the percentages of CD3+ T lymphocytes compared to healthy controls. Untreated patients showed a significant increase in CCR6 expression in CD8+CD25+ and CD8+CD25+bright T cells compared to healthy controls. The results were similar for CXCR3 and CCR5 expression. In patients treated with standard doses of FP, CCR5 expression was significantly increased in CD3+ T lymphocytes relative to healthy controls. Conclusions: The different groups of clinically stable nonallergic asthmatic patients showed distinct patterns of alterations in subset distribution as well as CCR6, CXCR3, and CCR5 expression on circulating T lymphocytes.

Flare-up reaction in the inoculation drug sites by glatiramer acetate: First case described

Glatiramer acetate (GA) (CopaxoneTM) is an immunomodulatory drug used in multiple sclerosis (MS) to reduce the frequency of relapses.1,2 It represents a safe treatment option with mild side effects. The pre-filled syringe contains 20 mg of GA and mannitol as excipient. GA is composed of the acetate salts of synthetic polypeptides containing L-glutamic acid, L-alanine, L-tyrosine and Llysine, and may work as a decoy for the immune system.1,2 There are described cases of hypersensitivity to GA as contact dermatitis, immediate and delayed exanthema and anaphylaxis, with positive skin tests in some of the cases.2e4 Flare-up reactions are characterized by the reactivation of previously positive intradermal tests (IDT) or skin-prick-tests (SPT) elicited by patch testing or after systemic provocationwith an allergen.5 A case of flare-up reaction during provocation test with GA has been described in the skin test sites.1 To our knowledge, we illustrate the first case of a patient with a flare-up reaction with GA in the inoculation drug sites. A 37-year-old woman, diagnosed with remittenterecurrent MS and no history of atopic diseases is presented. She started treatment with subcutaneous injections of CopaxoneTM 20 mg/day. From the first dose she immediately had a local erythema and inflammation of 2e3 cm along with pruritus in the injection site, disappearing spontaneously within 2e3 h. The eleventh day of treatment, 12 h after the GA administration, she displayed erythema, inflammation and pruritus in the gluteal area, arms, abdomen and legs, with no high fever detected, matching with the places where the patient had been administering herself the drug the preceding days. She took dexchlorpheniramine for two days and was referred to our outpatient clinic. We observed persistent hot and erythematous plaques with painful subcutaneous nodules of 2e3 cm in each point of GA inoculation (Fig. 1A, B), we prescribed a treatment with oral antihistamines, topical corticosteroids and we recommended her to discontinue GA. Besides, a biopsy was obtained from the abdomen (Fig. 1A). One month later, the lesions disappeared without any residual lipoatrophy. We performed SPT and IDT on the volar side of the forearm with immediate, late and delayed lectures 12, 24 and 72 h later, either with GA and mannitol. The SPT with GA was made at a concentration of 20 mg/ml (1:1) and with mannitol at 200 mg/ml (1:1). The IDTs were carried out at 0.02 mg/ml (1/ 1000) and 0.2 mg/ml (1/100) with GA and at 2 mg/ml (1/100) and 20 mg/ml (1/10) with mannitol. We obtained negative results for mannitol and a negative SPT and IDT of 0.02 mg/ml for GA.

Pine nut anaphylaxis: a proteomic study.

Pine nuts are the edible seeds derived from several varieties of pine trees. They are able to induce severe allergic reactions, usually anaphylaxis, in sensitized patients. Commonly, other nuts also induce this clinical picture in the same patient. There have been identified several allergens related with pine nut-induced anaphylaxis by SDS-PAGE and Immunoblotting. 1-3 Nevertheless, to the best of our knowledge, a proteomic study on this entity has not been performed so far. We studied a 19-year-old woman who presented two anaphylactic reactions after eating small amounts of pine nuts when she was 4 and 14 years old, respectively. Up to date, she completely tolerates all foods including peanut, and the rest of tree nuts. She had never suffered from atopic symptoms. Skin-pricktesting (SPT) was performed using a subset of both indoor and outdoor aeroallergens, including pollens from Pinus pinea and Olea europea, as well as, against the panallergens profilin and lipid transfer protein (LTP) (ALK-Abelló, Madrid, Spain) . Skin prick-byprick (SPP) tests were also performed against both fresh and roasted nuts, including peanut, hazelnut, chestnut, sunflower seed, pistachio, cashewnut, almond and pine nut, plus negative (50% glycerinated saline) and positive (histamine, 10 mg mL) controls. The results were measured 15 minutes after application. Both SPT and SPP tests were considered positive if the mean weal diameter was 3 mm than the saline control. Data were excluded if the saline control was 3 mm, the histamine control was <3 mm, or the difference of histamine minus saline was <3 mm. A serum total IgE and a serum specific IgE against those allergens used in SPT and SPP, were measured by ImmunoCAPTM (Phadia, Uppsala, Sweden) , following the manufacter’s instructions. The calibration range for serum total IgE was from 2.0-5,000 kU L, while for serum specific IgE it was 0.1-100 kUA L. A serum total IgE was considered normal if the data was up to 100 kU L, and a serum specific IgE was considered negative if its value was < 0.35 kUA L. Pine nuts were extracted (1 : 10 [wt vol], 4°C) during 90 minutes with PBS by magnetic sterring. Subsequently, extract was centrifuged and supernatants were filtered in a 0.2 μm membrane and frozen at -20 °C until used. Samples were separated by means of SDS-PAGE (10-20% polyacrylamide) according to the method of Laemmli and electrotransferred onto nitrocellulose membranes as described by Towbin et al..4 After blocking with 1% casein in PBS buffer during 1 hour at room temperature, membranes were incubated during about 18 hours with the serum of the patient (1 : 5 dilution). Nitrocellulose membranes containing the same extract were incubated with 1% casein in PBS, and alternatively with a serum from a non-atopic individual, as negative controls. After washing by means of 0.1% Tween-20 in PBS, nitrocellulose membranes were incubated during 2 hours at room temperature with the monoclonal antibody antihuman IgE HE-2 at 1 : 3,000 dilution.5 Washing of the membranes was performed subsequently and then, an anti-mouse IgG peroxidase-conjugate antibody (RAMHRP, DAKO, Barcelona, Spain) (1 : 5,000 dilution) was added during 1 hour at room temperature. Detection of reactive bands was performed using enhanced chemiluminescence, following the manufacter’s instructions (ECL, GE Healthcare, Buckinghamshire, UK ) . IgE-Immunoblotting against pollen extracts was performed to rule out evidence for crossreactivity of pine nut with a series of pollens (Olea europea, 6 Pinus pinea, 7 Artemisia vulgaris, 8 and Lolium perenne)9 as previously proved. SDS-PAGE associated with a MALDI-TOF (Matrix-Assisted Laser Desorption Ionization, Time-Of-Flight ) Mass Spectrometry (MS) analysis was carried out to identify new allergen molecules. The main IgE-binding bands revealed by Immunoblotting were excised from gels, alkylated and digested with trypsin for identification by MALDI-TOF-MS and MALDI-TOF-MS MS. MALDI-MS and MS MS data were combined through the BioTools programme (Bruker Daltonics, Billerica, MA, USA) to search a non-redundant protein database (NCBInr; National Centre for Biotechnology Information, Bethesda, MD, USA) using the Mascot software ( Matrix Science, London, UK ) . MALDI-MS (MS) spectra and database search results were manually inspected in detail using the above programmes. SPT against commercial common aeroallergens, profilin and LTP were performed with positive result exclusively against Olea europaea. SPP testing to raw and cooked pine nuts were all positive, unlike the rest of the nuts tested. Serum total IgE was 73 UI mL, specific IgE to pine nut of 16.20 kU L, and specific IgE to nOle e 1 of 0.73 kU L. The rest of specific IgE to nuts was negative. A Coomassie blue staining of the pine nut extract, and a SDS-PAGE followed by IgE-Immunoblotting assays were performed revealing IgE-reactivity at 30 and 33 kDa (Fig. 1) . Additional weaker bands were observed at 15, 20 and 60 kDa. No signal was obtained for the negative controls. We did not find cross-reactivity with Olea europaea, Pinus pinea, Artemisia vulgaris, and Lolium perenne pollens after performing IgE-Immunoblotting assays. Mass Spectrometry and database searching demonstrated that the sequence of the two bands of 30 and 33 kDa matched with a short-chain dehydrogenase (where the following sequences were obtained: Allergology International. 2014;63:125-126

Reacciones alérgicas a fármacos

Resumen Las reacciones adversas a farmacos se consideran, segun la Organizacion Mundial de la Salud, “un efecto perjudicial o indeseado que ocurre tras la administracion de un farmaco en dosis normalmente usadas en el hombre para la profilaxis, el diagnostico o el tratamiento de sus enfermedades”. Los farmacos mas comunmente implicados son los antiinflamatorios no esteroideos y los antibioticos, sobre todo betalactamicos. Hablariamos de una reaccion alergica a farmacos cuando se demuestra una base inmunologica, esto es, si existe produccion de anticuerpos especificos, celulas T sensibilizadas o ambos; aqui estarian englobadas el 6–10% de las reacciones. El diagnostico se basa en la historia clinica, las pruebas in vivo (cutaneas y exposicion controlada) y las pruebas in vitro. Como tratamiento principal esta la evitacion del farmaco y su grupo farmacologico, pero tambien se puede recurrir a la desensibilizacion.

Alergia de las vías respiratorias

Resumen La via respiratoria debe ser considerada como una via aerea unica, siendo el asma y la rinitis manifestaciones clinicas asociadas o comorbilidades que deben abordarse conjuntamente. Para realizar el estudio etiologico es imprescindible conocer los alergenos del entorno del paciente, que permitan, con una anamnesis detallada, establecer un diagnostico de sospecha. Este diagnostico se confirmara en la mayor parte de los casos mediante pruebas cutaneas (prick-test), dejando las pruebas in vitro (IgE especifica) como segunda linea diagnostica. El diagnostico alergologico ofrece la posibilidad de curacion si el alergeno puede ser retirado del entorno o, al menos, facilita medidas encaminadas a disminuir la exposicion, pudiendo en muchos casos ofrecer un tratamiento etiologico, la inmunoterapia, que puede modificar y controlar la respuesta alergica.

Protocolo diagnóstico del asma

Nowadays asthma shall be considered not a disease but a syndrome which encompasses similar clinical manifestations. Due to the similitude of its symptoms which may resemble other entities, it is mandatory a diagnostic confirmation, fulfilled by functional lung tests showing either a reversible obstructive pattern or bronchial hyperreactivity. When the results of the functional tests are not conclusive, the inflammatory component shall be assessed by means of the evaluation of the fractional exhaled nitric oxide o even by using the corticosteroid therapeutic response. As regards the diagnosis of allergic asthma, the key role relies on directed anamnesis confirmed by skin prick testing, so as to leave as a second line-diagnostic tool the assessment of the specific Immunoglobulin E, and performing the allergen-specific bronchial challenge exceptionally.