James L. Baldwin

Autoimmune progesterone dermatitis in a patient with endometriosis: case report and review of the literature.

Autoimmune progesterone dermatitis (APD) is a condition in which the menstrual cycle is associated with a number of skin findings such as urticaria, eczema, angioedema, and others. In affected women, it occurs 3–10 days prior to the onset of menstrual flow, and resolves 2 days into menses. Women with irregular menses may not have this clear correlation, and therefore may be missed. We present a case of APD in a woman with irregular menses and urticaria/angioedema for over 20 years, who had not been diagnosed or correctly treated due to the variable timing of skin manifestations and menses. In addition, we review the medical literature in regards to clinical features, pathogenesis, diagnosis, and treatment options.

Physician attitudes, opinions, and referral patterns: comparisons of those who have and have not taken an allergy/immunology rotation.

BACKGROUND Interest in the field of allergy/immunology (A/I) is increasing, yet resident training programs are under pressure to shorten elective rotations such as A/I. It is unclear if there are differences between those who have and have not taken an A/I rotation. OBJECTIVE To evaluate differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. METHODS An anonymous questionnaire was sent to 375 primary care physicians at one academic medical center. Subjects were separated into 5 cohorts based on specialty and level of training (internal medicine faculty, internal medicine resident, pediatric faculty, pediatric resident, and internal medicine-pediatric resident). RESULTS Of the participants, 227 (61.0%) completed the survey. Compared with those who had not taken an A/I rotation, those who had taken an A/I rotation were more likely to feel they knew the types of cases seen by an allergist (75.9% vs 33.3%), to feel they knew an adequate amount about A/I (59.3% vs 19.5%), to feel they were exposed to an adequate amount of A/I during residency (64.8% vs 9.8%), to view immunotherapy as effective (70.0% vs 52.3%), and to have referred a patient to an allergist (77.8% vs 46.0%). CONCLUSIONS There are significant differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. Allergic diseases are increasing, yet residency training programs are under pressure to shorten rotations such as A/I to accommodate federally mandated work hour restrictions. The potential for inadequate care of allergic diseases may be an important issue if these trends continue.

Carmine hypersensitivity masquerading as azithromycin hypersensitivity

Macrolide hypersensitivity is a rarely reported event. However, carmine dye has become increasingly important as a provocative agent. We present a case of a woman with documented carmine hypersensitivity, who reported anaphylaxis 90 minutes after ingestion of a generic azithromycin. Our investigations revealed that this was an allergy to the carmine dye in the tablets coating rather than to the antibiotic. Seven extracts were prepared including carmine dye, crushed dried female cochineal insects, crushed tablets of Zithromax (Pfizer Inc.) and generic azithromycin (Teva Pharmaceuticals), and the crushed colored coatings from both tablets. These were suspended in preservative-free normal saline, and then applied as a skin-prick test and read at 30 minutes. The skin-prick skin test results were 4+ to histamine and carmine dye, but negative to cochineal insect extract, Pfizer crushed tablets, and negative control. The patient was 1+ to the Teva crushed tablet, but was 4+ to the Teva brand coating and negative to the Pfizer brand coating, which did not contain carmine. The patient subsequently ingested Pfizer Zithromax without any sequelae. To our knowledge, this is the first reported case of carmine anaphylaxis attributed to carmine-containing medication. Careful history and skin-prick testing to the appropriate agents allowed elucidation of the subtlety of the true offending agent without unnecessary avoidance of the medication class. Patients with a carmine hypersensitivity should actively check with their pharmacy or prescribing physician to verify their medications are free of this offending agent.

Carmine dye and cochineal extract: hidden allergens no more

Carmine dye and cochineal extract are red colorants derived from the dried, gravid bodies of the Dactylopius cocus costa insect that grows on the prickly pear cactus. They are widely used commercially to color foods, drugs, cosmetics, and textiles.1–5 The colors are classified by the Food and Drug Administration (FDA) as “exempt from certification” and, until recently, not required to be listed on labels of foods to which they are added.2,6 In contradistinction to FDA-certified synthetic colors (eg, Federal Food, Drug, and Cosmetic Act [FDC † Division of Allergy and Clinical Immunology, The University of Michigan Health Systems, Ann Arbor, Michigan. Disclosures: Authors have nothing to disclose. Received for publication January 27, 2009; Received in revised form February 17, 2009; Accepted for publication February 18, 2009.

Systemic reactions to inhalant immunotherapy using 1:1 target dosing

BACKGROUND The 2007 immunotherapy practice parameters advocate maintenance dosing at 1:1 (1:20 maintenance concentrate). There is limited literature exploring the effect of 1:1 dosing on the rate of systemic reactions to subcutaneous immunotherapy (SRITs). OBJECTIVE To investigate the effects of 1:1 dosing on SRITs in a large, academic practice. METHODS We conducted a retrospective cohort study of all nonvenom and noncluster SRITs that occurred between 2005 and 2011. SRITs that occurred from August 2008 through December 2011, postparameter dosing (post-PD) was initiated, were compared to SRITs that occurred from January 2005 to July 2008 with preparameter dosing (pre-PD) using 1:50 as a maintenance concentrate. RESULTS A total of 269 SRITs occurred in a 7-year period. Significantly more post-PD SRITs (131 of 38,548 injections) occurred than pre-PD SRITs (132 of 52,833 injections) (0.34% vs 0.25%, P = .01). However, when excluding 44 SRITs that occurred in established pre-PD patients transitioned to post-PD, there was no significant difference in SRIT rate (0.25% vs 0.22%), World Allergy Organization (WAO) grade, or SRIT time to onset. Nonred (non-1:1) vials accounted for a significantly larger proportion of all post-PD SRITs compared with all pre-PD SRITs (50.7% vs 31.1%, adjusted P = .009). Prior SRITs were reported less frequently among persons with post-PD SRITs (29.2% vs 70.8%, adjusted P = .009). In an adjusted logistic regression model, male sex (odds ratio, 7.9; 95% CI, 2.4-26) and longer time to reaction onset (odds ratio, 0.94; 95% CI, 0.89-0.99) were associated with higher WAO severity grade reactions. CONCLUSION Pre-PD vs post-PD SRIT rates were not significantly different, adjusting for patients transitioned from established pre-PD to post-PD. This finding suggests that post-PD is as safe as pre-PD. Male sex and faster time to reaction onset were associated with higher WAO grade reactions.

Flushing and syncopal episode in a 47-year-old female

Introduction A 47-year-old white female was referred for further evaluation of flushing and a syncopal episode. About 2 weeks before presentation, while eating her lunch of a bagel and soda, she developed a feeling of pressure in her head, followed by warmth in her head and neck along with a sensation of a racing heart. She then passed out, vomited, and experienced incontinence of her urine and stool. She denied having hives, lip swelling, tongue swelling, throat closing, wheezing, or shortness of breath. She had no recollection of any sting. She recalls mosquitoes being present. She denied using any diet pills, powders, lotions, laxatives, herbal remedies, new cosmetics, or ingestants. The patient was initially evaluated in a local emergency room where she had the following vital signs: blood pressure 92/52, pulse 77 beats/minute, temperature 97.3° F. A review of her system at that time was negative for headache, blurred vision, ringing in the ear, focal weakness, sore throat, earache, difficulty in swallowing, chest pain, or abdominal pain. There was no fever, chill, arthralgia, or skin rash. She was treated with intravenous normal saline, intravenous methylprednisolone, and diphenhydramine. She was discharged home on hydroxyzine (Atarax; Pfizer, New York, NY), 100 mg daily, cimetidine (Tagamet; SmithKline Beecham, Pittsburgh, PA), 800 mg daily, and nafzodone hydrochloride (Serzone; Bristol-Myers Squibb, New York, NY).

Recurrent perioperative anaphylaxis in a 54-year-old man

Reports suggest that perioperative anaphylaxis in patients undergoing general anesthesia range from 1 in 5000 to 1 in 20,000 with mortality rates as high as 9%. Because of the variety of medications that are used for general anesthesia and the rapid succession in which they are administered, it is often difficult to determine the etiology of a severe allergic episode in this setting. Antibiotics and anesthetics are notorious for precipitating allergic reactions and are often implicated. Other perioperative exposures and patient risk factors must also be considered. In this article, we describe the case of a patient who exhibited recurrent anaphylaxis episodes while trying to undergo a vital cardiac surgery.

Factors correlated with repeated aspirin dosing during aspirin desensitization

BACKGROUND Aspirin desensitization is an appropriate procedure for many patients with aspirin-exacerbated respiratory disease (AERD). Patients can require aspirin re-dosing, which prolongs the desensitization process. The frequency of this is not widely reported, nor is it known which patients will require multiple re-dosing. OBJECTIVE To determine the frequency of and factors associated with repeat aspirin re-dosing during desensitization. METHODS Charts of aspirin desensitization procedures from 2011 to 2016 at the University of Michigan Allergy/Immunology Clinic were reviewed. Reactions with provoking doses and number of dose repetitions were characterized. Previous AERD history, medical history, medications, and baseline spirometry were also recorded. Bivariate correlation and multivariate logistic regression were used to analyze associations between patient characteristics and need for repeated dosing of aspirin. RESULTS A total of 84 positive-reacting patients during desensitization were identified. Of these patients, 33% required 2 or more aspirin dose repetitions during desensitization. Requiring 2 or more repeat doses during desensitization was associated with male gender (odds ratio = 6.194, P = .008), forced expiratory volume in 1 second (FEV1) decrease during desensitization (odds ratio = 1.075 per percent point drop, P = .021), and initial aspirin provoking dose during desensitization of 81 mg or lower (odds ratio = 11.111, P = .003). No association was found with pre-desensitization medications, asthma severity, AERD duration, or number/character of reported previous aspirin reactions. CONCLUSION During aspirin desensitization for AERD, approximately one third of our patients require multiple repeat doses. Risk factors for multiple repeated doses include male gender, drop in FEV1, and lower aspirin provoking doses during desensitization. This information can help inform which patients may require multiple re-dosing for desensitization.

A 60-year-old woman with recurrent episodes of flushing, urticaria, and angioedema

Recurrent episodes of flushing, urticaria, and angioedema raise suspicion for many conditions with a wide differential diagnosis. The diagnostic approach involves consideration of allergic, cardiovascular, gastrointestinal, endocrine, infectious, neurologic, dermatologic, and drug-related causes. We describe a unique case of recurrent episodes of flushing, urticaria, and angioedema that has gone into remission after a novel therapeutic intervention.

Anosmia and an uncommon nonsteroidal anti-inflammatory drug reaction in a 38-year-old man.

Anosmia with asthma and nasal polyposis raises suspicion for aspirin-exacerbated respiratory disease (AERD). Guidelines for desensitization of patients with AERD to prevent recurrent nasal polyposis and improve upper and lower respiratory symptoms are well established. We present a patient with an uncommon reaction to acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drugs who required deviation from the standard ASA desensitization approach.