Jittima Veskitkul

The development of allergic rhinitis in children previously diagnosed as nonallergic rhinitis.

Background Nonallergic rhinitis (NAR) is characterized by nasal symptoms similar to allergic rhinitis (AR) without an IgE-mediated immune response. Limited data are available on the natural history of NAR in its progression toward AR, particularly in children. This study evaluates the development of AR in children who were previously diagnosed with NAR. Methods Children with the diagnosis of NAR during the period of 2005–2007 were reevaluated in 2010. Nasal symptoms, disease severity, comorbidities, rescue medication scores (RMSs), and skin-prick test to aeroallergens were assessed. Results We recruited 175 children with an early diagnosis of NAR. The median age was 5.7 years, 62.9% were boys and 45.7% had family history of atopy. At reevaluation, 41% of children with previously diagnosed NAR developed sensitization to aeroallergens and were reclassified as having AR. The most frequent aeroallergen sensitization was Dermatophagoides pteronyssinus (59.7%), followed by Dermatophagoides farinae (54.2%) and American cockroach (38.9%). Children who developed AR had more nasal/eye symptoms, higher severity, and RMSs than children who did not develop AR. The predictors of developing AR were persistent nasal symptoms (adjusted odds ratio [OR], 8.9; 95% CI, 3.2–24.6), nasal itching (adjusted OR, 3.4; 95% CI, 1.2–9.5), triggered by house dust (adjusted OR, 4.3; 95% CI, 1.6 –11.9) and animal danders (adjusted OR, 15.8; 95% CI, 3.3–76.1), and family history of atopy (adjusted OR, 6.0; 95% CI, 2.3–15.9). Conclusion Children with NAR who had family history of atopy, persistent nasal symptoms, and symptoms triggered by aeroallergens should be reevaluated periodically for the development of AR. This study was part of the clinical trial NCT01068808 registered in www.clinicaltrials.gov.

The proportion of local allergic rhinitis to Dermatophagoides pteronyssinus in children

Local allergic rhinitis (LAR) is diagnosed by the positive response to nasal allergen provocation test (NAPT) to aeroallergen and/or local synthesis of specific IgE (sIgE). This entity is found in half of the adults with non‐allergic rhinitis (NAR). In children, very few data of the prevalence and characteristics of LAR were reported.

Successful wheat-specific oral immunotherapy in highly sensitive individuals with a novel multirush/maintenance regimen.

We reported a successful oral immunotherapy (OIT) in 2 children with high wheat sensitivity (4 and 14 years old boys). Oral challenges indicated eliciting doses of 300 mg, and wheat flour of 30 mg. The OIT protocol includes 5 days of build-up phase in the hospital, intervening with 2 to 5 months of home maintenance phase. Patients could tolerate 45 g, and 60 g of wheat flour per day, respectively. We have demonstrated that OIT to a large amount of wheat in extremely sensitized patients could be achieved with a stepwise multi oral/maintenance regimen.

Provocation proven drug allergy in Thai children with adverse drug reactions.

BACKGROUND Adverse drug reactions (ADRs) are a common healthcare problem. The drug provocation test (DPT) is a gold standard for ADR diagnosis. OBJECTIVES To evaluate a correlation between history of ADRs, skin prick test (SPT), intradermal test (ID) and DPT in Thai children. METHODS This was a retrospective review of 211 children under 16 years of age who had a history of ADRs and underwent DPT from January 2006 to December 2012. RESULTS Two hundred and thirty six (236) DPTs were performed in 211 children with a history of ADRs. The median age at which DPTs were performed was 4 years. Thirty-four children (14.4%) had positive DPT. The positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, likelihood ratio (LR) + and LR- of SPT were 50, 85.7, 6.9, 98.8%, 5.8 and 0.9, respectively. The PPV, NPV, sensitivity, specificity, LR+ and LR- of ID were 33.3, 84.6, 20, 91.7%, 2.4 and 0.9, respectively. Different presentation of symptoms (maculopapular rashes, urticaria, angioedema and anaphylaxis) did not predict SPT, ID and DPT results. Positive human immunodeficiency virus (HIV), but not atopy, was a risk in the present scope of evaluation for drug allergy (odds ratio 11.44, 95% confidence interval 2.60-50.41). CONCLUSION Drug allergy, denoted by positive DPT, was present in 14.4% of Thai children with a history of ADRs. Antibiotics were the most common cause of ADRs. Both SPT and ID had high NPV and specificity but did not predict DPT results. HIV positivity is a risk factor of drug allergy in Thai children.

Recurrent Acute Rhinosinusitis Prevention by Azithromycin in Children with Nonallergic Rhinitis

BACKGROUND Recurrent acute rhinosinusitis (RARS) is characterized by multiple episodes of acute rhinosinusitis between which symptoms and signs resolve completely. The role of antibiotic prophylaxis to prevent RARS in children with nonallergic rhinitis (NAR) has not been investigated. OBJECTIVE To evaluate the effect of azithromycin to prevent RARS in children with NAR. METHODS A randomized, double-blind, placebo-controlled study was conducted in NAR children (5-15 years) with RARS. Azithromycin (5 mg/kg/d) 3 d/wk for 12 months or placebo was assigned to the study group and the control group, respectively. Patients with allergic rhinitis were excluded. Number of rhinosinusitis episodes in 12 months, visual analog scale score of nasal symptoms, and adjunctive medication score were recorded. RESULTS Forty patients were enrolled and 20 patients were assigned randomly to the azithromycin and placebo groups. IgG subclass and specific antibody deficiencies were found in 83% and 2.5% of patients, respectively. After 12 months, the number of rhinosinusitis episodes/y in the azithromycin group reduced significantly from 5 to 0.5 (P < .001) in contrast to the placebo group. Number needed to treat using azithromycin prophylaxis to prevent 1 patient from having RARS was 2. The average visual analog scale score and the average adjunctive medication score in the azithromycin (but not in the placebo) group reduced significantly compared with baseline (2.2 ± 1.4 vs 5.4 ± 1.8) and (3.9 ± 1.7 vs 5.4 ± 1.1), respectively (P < .001). CONCLUSIONS Azithromycin prophylaxis can reduce the number of rhinosinusitis episodes and medication score, and improve nasal symptoms in NAR children with RARS.

Age of resolution from IgE-mediated wheat allergy

BACKGROUND The natural history of wheat allergy varies among different countries. OBJECTIVE To study the age of resolution from IgE-mediated wheat allergy and to define the predictors of wheat tolerance. METHODS Patients with a history of immediate reactions after wheat ingestion were enrolled. Skin prick test (SPT) and measurement of serum specific IgE (sIgE) to wheat and ω-5 gliadin were performed. Oral challenge to wheat was performed to determine wheat tolerance. RESULTS Fifty-five patients, aged 6 months to 12 years, were studied. The median age of wheat tolerance was 76 months (range 37-114 months). The percentage of children with wheat tolerance was 14.7% at age 2 years, 27% by age 4, 45.7% by age 5 and 69% by age 9. Predictors for wheat tolerance were SPT for wheat less than 3 mm of wheal diameter (hazard ratio 8.9), sIgE levels of wheat and ?-5 gliadin less than 0.35 (HR 4.3) and 0.35 kAU/L (HR 44), respectively, duration of onset of symptoms to time of physician diagnosis less than 36 months (HR 7.6) and no history of allergic rhinitis (HR 4.8). CONCLUSIONS Forty percent of children with IgE-mediated wheat allergy develop tolerance by the age of 5 years. Size of SPT, IgE level of wheat and ω-5 gliadin, time from onset of symptoms to physician diagnosis and history of allergic rhinitis are helpful for predicting wheat tolerance.

Clinical characteristics of recurrent acute rhinosinusitis in children.

OBJECTIVE Recurrent acute rhinosinusitis (RARS) is defined as multiple episodes of acute rhinosinusitis in which the symptoms and signs of infection resolve completely between episodes. Limited data are available on the characteristics and preventive therapy of RARS. This study evaluated the clinical characteristics and predisposing factors of RARS in children as well as the preventive therapy. METHODS Medical records of children with RARS diagnosed between January 2010 and December 2012 were obtained. Demographic data, presenting symptoms, predisposing factors and preventive therapy were reviewed. RESULTS Ninety-four children with RARS were recruited. The mean age was 7.7±2.6 years, with a mean age of onset of 4.0±1.4 years. Sixty-one patients (64.9%) were boys and 56 patients (59.6%) had family history of atopy. The most common presenting symptom of RARS was purulent nasal discharge (100.0%), followed by nasal congestion (68.1%) and postnasal drainage (31.9%). The most common predisposing factor for RARS was immunoglobulin G subclass deficiency (78.7%), followed by non-allergic rhinitis (64.9%) and allergic rhinitis (35.1%). Sixty-five children (69.1%) received preventive therapy for RARS. The responses to preventive measures were: 80.0% (32/40 patients) to oral antibiotic prophylaxis, 50.0% (11/22 patients) to adenotonsillectomy, 91.7% (11/12 patients) to specific allergen immunotherapy, 27.3% (3/11 patients) to gentamicin nasal irrigation, and 66.7% (4/6 patients) to intravenous immunoglobulin. CONCLUSION The most common presenting symptoms of RARS in children were purulent nasal discharge, nasal congestion and postnasal drainage. Children with RARS should be evaluated for the presence of underlying conditions such as immunodeficiency and allergic disease, which led to the appropriate management for these children.