John M. Kelso

Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gelatin

BACKGROUNDnAllergic reactions to measles, mumps, and rubella (MMR) vaccine are rare; some have been attributed to allergy to trace quantities of egg proteins. We report a 17-year-old female who had an anaphylactic reaction to MMR vaccine. A primary vaccination with MMR at age 15 months had been uneventful. She is not allergic to eggs; however, ear and throat pruritus and tongue swelling develop after she eats gelatin. MMR vaccine contains gelatin as a stabilizer.nnnMETHODS AND RESULTSnPrick skin tests were positive to 1:10 wt/vol dilutions of MMR vaccine and gelatin but negative to egg. By immunoassay, her serum IgE antibodies were elevated to both MMR vaccine and gelatin, but not to isolated MMR antigens. IgE binding to the gelatin carrier could be inhibited in a dose-dependent fashion by addition of not only MMR vaccine but also gelatin from a variety of animal sources. Immunoblotting confirmed the presence of IgE antibodies to multiple gelatin components as well as to MMR vaccine components.nnnCONCLUSIONSnWe conclude that the patient has an anaphylactic sensitivity to gelatin, and that her anaphylaxis to MMR vaccine was caused by the gelatin component. This sensitivity may explain other cases of MMR anaphylaxis.

Extractable latex allergens and proteins in disposable medical gloves and other rubber products

BACKGROUNDnIgE-mediated sensitization to rubber proteins is being reported with increasing frequency in health care workers. To explore the relative importance of various sources of allergen exposure, we measured the total rubber allergen and protein levels in extracts of disposable rubber gloves and compared the allergen levels with those in extracts of other medical and consumer rubber products.nnnMETHODSnRubber allergens were measured by inhibition immunoassay with a rubber glove extract as the solid-phase allergen and pooled plasma from five rubber-sensitized health care workers as the IgE antibody source. Proteins were measured by Ninhydrin assay.nnnRESULTSnAmong 71 lots of gloves tested, the extractable allergen and protein levels were significantly correlated and were appreciably higher in powdered gloves than in powder-free gloves. Allergen levels varied 3000-fold among gloves from different manufacturers and were higher in examination gloves than in surgical or chemotherapy gloves. Measurable allergen was found in 11 of 24 lots of hypoallergenic gloves tested. Allergen levels in toy balloons were comparable to those in powdered gloves; much lower allergen levels were measured in condoms and anesthesia rebreathing bags.nnnCONCLUSIONSnThe allergen content of disposable rubber gloves varies widely and is higher in powdered gloves than in powder-free gloves and higher in examination gloves than in surgical gloves. Hypoallergenic gloves may contain substantial amounts of IgE-binding proteins. Gloves and toy balloons appear to be more important sources of rubber allergens than the other rubber products tested.

The rate of systemic reactions to immunotherapy injections is the same whether or not the dose is reduced after a local reaction

BACKGROUNDnEven though no studies have shown that local reactions to immunotherapy injections predict subsequent systemic reactions, many protocols continue to call for dose adjustments after local reactions.nnnOBJECTIVEnTo determine whether the rate of systemic reactions to immunotherapy injections is affected by dose adjustment after local reactions.nnnMETHODSnIn our clinic before March 1999, if a patient had a local reaction to an immunotherapy injection, an adjustment was made to repeat or reduce the next dose. From March 1999 on, no such adjustments were made. At our outlying clinics, the adjustment protocol continued. A retrospective review was conducted for shots given from March 1997 to February 2001, recording whether an immunotherapy visit resulted in a systemic reaction.nnnRESULTSnIn our clinic, there were 3,250 shot visits from March 1997 to February 1999 (adjustment protocol) and 4,692 visits from March 1999 to February 2001 (no adjustment protocol). The systemic reaction rate during the 2 periods was not different (1.11% vs 0.85%, P = .29). In the outlying clinics, there were 1,138 shot visits from March 1999 to February 2001 (adjustment protocol), and the systemic reaction rate was not different than in our clinic (no adjustment protocol) (0.88% vs 0.85%, P = .86).nnnCONCLUSIONSnThe rate of systemic reactions to immunotherapy injections is the same whether or not the dose is adjusted after a local reaction. These dose adjustments are thus unnecessary, and eliminating them lessens chances for errors and decreases the number of shots required to reach a therapeutic dose.

Immunization of egg-allergic individuals with egg- or chicken-derived vaccines

Viruses used in several vaccines are propagated in embryonated eggs. These vaccines contain variable quantities of residual egg or chicken proteins and pose risks when administered to egg- or chicken-sensitive persons. This article highlights differences in how vaccines are prepared, with emphasis on the quantitation of residual egg-derived protein in each vaccine. Published reports on the frequency and severity of these vaccine-induced allergic reactions are reviewed, and an algorithm is provided for the preimmunization evaluation of egg-sensitive persons.

Pulmonary function studies in healthy Filipino adults residing in the United States

BACKGROUNDnDifferences in lung volumes among various ethnic groups are known to occur; however, this has not been studied in Filipinos.nnnOBJECTIVEnWe sought to assess pulmonary function in healthy, nonsmoking Filipinos residing in the United States compared with standards for white subjects.nnnMETHODSnHealthy adult Filipinos, age 18 years or greater, were recruited. All subjects were screened with health questionnaires to exclude those with cardiopulmonary disease. Pulmonary function tests were performed by using forced expiratory maneuvers. Values for FEV(1 ), forced vital capacity (FVC), FEV(1 )/FVC, forced expiratory flow from 25% to 75% of FVC, and peak expiratory flow rate were compared with predicted values for white subjects (ie, without a racial adjustment).nnnRESULTSnTwo hundred twenty-four healthy subjects (121 men and 103 women) completed the study. The group means (as a percentage of the predicted standard for white subjects) were as follows: FEV(1 ), 86%; FVC, 84%; FEV(1 )/FVC, 103%; forced expiratory flow from 25% to 75% of FVC, 96%; and peak expiratory flow rate, 107%. These findings are very similar to those for African Americans and other Asians.nnnCONCLUSIONnWe conclude that it is appropriate to use an 85% racial adjustment for FEV(1 ) and FVC when interpreting pulmonary function test results in Filipinos.

Recurrence of allergic rhinitis, previously alleviated with allergen immunotherapy, after autologous bone marrow transplant.

BACKGROUNDnSeveral associations between immunoglobulin E and bone marrow transplantation (BMT) have been reported.nnnOBJECTIVEnA patient whose allergic rhinitis (AR) resolved after allergen immunotherapy (AIT) but recurred after the patient received an autologous BMT is reported.nnnMETHODSnAllergy skin tests were performed before AIT began and after 4 years of therapy. Skin tests were repeated after a recurrence of symptoms 6 years later after an autologous BMT for breast cancer.nnnRESULTSnSix years of AIT led to a near complete resolution of AR symptoms. Skin tests showed a marked reduction in reactivity to allergens in the AIT. After an additional 6-year symptom-free interval off AIT, symptoms returned after the BMT. Repeat skin tests showed a marked increase in reactivity.nnnCONCLUSIONSnPatients reconstituting their immune systems after autologous BMT may have a recurrence of AR previously suppressed with AIT.

Skin test results in related and unrelated persons with allergic rhinitis.

BACKGROUNDnFirst degree relatives of patients with allergic rhinitis are at increased risk of having the disorder. It is not yet clear whether or not two such related persons with allergic rhinitis are more likely to be skin test positive to the same specific allergic extracts than unrelated persons with allergic rhinitis.nnnOBJECTIVEnTo determine whether or not first degree relatives (parent and child or full siblings) with allergic rhinitis are more likely to be skin test positive to the same allergen extracts than unrelated persons with the disease.nnnMETHODSnA retrospective chart review of Allergy Clinic patients was performed. Skin test results for 12 common aeroallergen extracts were compared in 32 pairs of genetically related subjects and 32 pairs of age-matched and sex-matched unrelated subjects, all with allergic rhinitis. The percent of concordant results (both members of a pair skin test positive or both negative) and discordant results (one member of a pair positive and the other negative) were calculated and compared for related and unrelated groups. Also, the expected rates of positive concordance (both skin tests positive) based on the prevalence of skin test positively in the two groups were calculated and compared with the corresponding observed rates.nnnRESULTSnResults were concordant in 242 of 384 skin tests (63%) in related pairs versus 233 of 384 skin tests (61%) in unrelated pairs (P = .28, not significant). The expected and observed rates of positive concordance were not significantly different in the related (P = .38) or unrelated (P = .49) groups. When the groups were subdivided into parent-child pairs and sibling pairs, a similar lack of significant differences between the groups was found.nnnCONCLUSIONSnIt is concluded that first degree relatives, both with allergic rhinitis, are no more likely to be skin test positive to the same allergen extracts than unrelated persons with this disease. Further, it seems appropriate to advise patients with allergic rhinitis that their first degree relatives who also have the disorder will not necessarily have the same specific allergies.

Application of topical corticosteroids to sites of positive immediate-type allergy skin tests to relieve itching : results of a double-blind, placebo-controlled trial

BACKGROUNDnIn many allergy clinics topical corticosteroid cream is applied to sites of positive skin tests in an attempt to alleviate itching.nnnOBJECTIVESnTo determine whether or not this practice is effective.nnnMETHODSnPatients with 5 or more positive skin test results were randomly assigned to 1 of 3 groups after skin test result reading: application of 2.5% hydrocortisone in moisturizing cream, moisturizing cream alone, or no topical application. Immediately after the skin test results were read (baseline) and at 5, 15, and 30 minutes, patients rated their itching on a 100-mm visual analog scale.nnnRESULTSnAverage itch scores for all groups combined were 44, 33, 22, and 12 at 0, 5, 15, and 30 minutes, respectively. No differences were found among the groups at any time point. No correlation was found between the baseline itch scores and age, sex, number of positive skin test results (> or = 3-mm wheals), or number of large positive skin test results (> or = 15-mm wheals).nnnCONCLUSIONSnThe application of corticosteroid cream to sites of positive immediate-type allergy skin tests does not provide relief of itching; therefore, this practice should be abandoned. Instead, patients should be informed that any itching they may be experiencing will substantially resolve during the next 30 minutes and that application of such topical treatment will not hasten the relief of itching.