Jordan N. Fink

Food-dependent exercise-induced anaphylaxis

This article describes four cases of exercise-induced anaphylaxis occurring only in temporal relationship to the ingestion of food. One individual developed anaphylaxis if exercise followed the ingestion of any food within 2 hr. Three other individuals had symptoms only if celery was ingested in relation to exercise. Skin reactivity to fresh celery extracts was demonstrated in all three individuals. The episodes were prevented by avoidance of food ingestion in relation to exercise. This syndrome appears to be a variant of exercised-induced anaphylaxis.

Allergic bronchopulmonary aspergillosis in cystic fibrosis

One hundred patients with CF were screened for ABPA. Forty-eight male patients and 52 female patients with age range of 2 to 34 yr (mean 14.2) were studied. Patients were evaluated for skin reactivity and serum precipitating antibodies to Af, predominant sputum organisms, total blood eosinophil levels, total serum IgE, and Af-specific IgE and IgG, as well as abnormalities of pulmonary function and chest x-ray films. Careful evaluation of all patients with CF demonstrated that 10% had features indicative of ABPA, which is another potentially destructive pulmonary disorder. Thus careful evaluation of patients with CF, especially those with asthma, may be rewarding in uncovering a disorder that may slow progression of CF when it is appropriately treated.

Hypersensitivity Pneumonitis Due to Contamination of an Air Conditioner

In four of 27 office workers, symptoms of intermittent chills, fever and dyspnea, or progressive dyspnea alone developed. Pulmonary-function studies indicated restrictive and diffusion defects, and x-ray examination demonstrated diffuse nodular infiltrates in all four patients. Examination of their environment revealed contamination of the air-conditioning system with a thermophilic actinomycete known to cause a hypersensitivity pneumonitis such as farmers lung. Serum specimens of all patients contained high titers of rheumatoid factor and precipitating antibodies against the offending organism. Inhalation of the antigen by one of the ill workers during an asymptomatic period reproduced all clinical features of the disorder. Treatment with steroids and subsequent avoidance of exposure resulted in complete recovery. Hypersensitivity pneumonitis should be suspected in cases of interstitial pneumonitis, even in the absence of clear-cut contact with organic dusts.

Skin and serologic testing in the diagnosis of latex allergy

BACKGROUND Latex hypersensitivity is associated with occupational allergy, contact urticaria, rhinitis, asthma, and anaphylaxis. However, standardized sensitive and specific latex extract for skin prick or serologic testing is not available in the United States. METHODS We investigated the reliability of two latex extracts in 118 consecutive skin tests in patients with spina bifida, health care workers, and other patients with symptoms of latex allergy, and 10 control subjects. RESULTS Forty-two of 86 patients with spina bifida, 11 of 15 health care workers with symptoms of latex allergy, 6 of 7 patients with symptoms of latex allergy, and 0 of 10 control subjects had demonstrable immediate wheal and flare responses to latex prick testing. In addition, 95 patients and 10 control subjects were tested concurrently for latex-specific IgE by ELISA. Of 55 patients with positive skin prick test results, 48 were reactive as determined by ELISA for IgE-specific latex antibody (sensitivity = 87%). Latex ELISA titers were significantly higher in patients with positive skin prick test results with a history of anaphylaxis to latex and in individuals without symptoms of latex allergy who had positive skin prick test results when compared with patients with negative skin prick test results. During the skin test procedure, nine patients had adverse reactions, including anaphylactic reactions in four. CONCLUSIONS Skin prick and serum testing are reliable methods of diagnosing latex allergy. Serologic evaluation may be more desirable until allergen standardization is available.

A cluster of anaphylactic reactions in children with spina bifida during general anesthesia: Epidemiologic features, risk factors, and latex hypersensitivity

BACKGROUND Anaphylactic reactions (ARs) in high-risk pediatric patients undergoing general anesthesia, especially those with spina bifida, have been attributed to anesthetics, muscle relaxants, antimicrobials, ethylene oxide, and latex. METHODS To identify risk factors for AR during general anesthesia and to investigate the role of latex allergy, we studied epidemiologic and immunologic characteristics of patients with ARs during general anesthesia during a 13-month cluster of such reactions at Childrens Hospital of Wisconsin (case patients). Patients with AR were compared with patients with spina bifida undergoing uneventful general anesthesia during the same period (control patients). For each case patient and control patient, we conducted a chart review; a parental interview; skin prick testing with latex, anesthetics, aeroallergens, and banana extract; ELISA and RAST for latex-specific IgE; a total serum IgE; and an ELISA for IgE antibody to ethylene oxide. RESULTS Anaphylactic reactions occurred exclusively in patients with spina bifida (n = 10) or patients with a congenital urinary tract anomaly (n = 1). Case-patients were more likely than control patients to have a history of asthma (p = 0.002), rubber contact allergy (p = 0.001), food allergy (p = 0.001), rash caused by adhesive tape (p = 0.05), daily rectal disimpaction (p < 0.001), nine or more prior surgical procedures (p < 0.002), latex-specific IgE (p = 0.027), or elevated total serum IgE levels (p = 0.002). Multivariate analysis identified non-white race, rubber contact allergy, history of food allergy, and nine or more surgical procedures as significant independent risk factors. Logistic model equation identified the predicted probability of AR with a sensitivity, specificity, and positive predictive value of 82%, 97%, and 82%, respectively. CONCLUSIONS These findings demonstrate that atopy, especially symptomatic latex allergy, is associated with AR during anesthesia in patients with spina bifida. Until a standardized latex test is available, a medical history of immediate rubber contact allergy, non-white race, food allergy, or nine or more prior surgical procedures can identify patients with spina bifida at highest risk for ARs. A complete history, including rubber contact and food allergy, should be compiled on all patients with spina bifida before surgery.

Immunopathogenesis of hypersensitivity pneumonitis

This review describes antigenic and host factors of possible significance in the immunopathogenesis of hypersensitivity pneumonitis (HP). Although certain immunologic studies suggest immune complex mechanisms in HP, recent experimental and clinical data accumulated support a role for cell-mediated immunity. In addition, some data support roles for anaphylactic and cytotoxic antibody-mediated reactivity as well. One type of reactivity alone may not be sufficient for production of HP, and local pulmonary immune responses may be most relevant to the pathogensis. Whether immune damage will be produced in an exposed individual or not may depend on the characteristics of the antigenic exposure as well as inherited and acquired individual differences in immunologic reactivity and possibly target organ sensitivity.

Comparison of latex hypersensitivity among patients with neurologic defects

BACKGROUND Latex hypersensitivity has been described in discrete populations including health care workers and children with spina bifida (SB). OBJECTIVE This study was designed to determine whether the SB population is a unique neuroimmunologic group manifesting this sensitivity. METHODS Four groups of subjects were studied. These included: 36 patients with SB with or without clinical evidence of latex hypersensitivity, 50 patients with spinal cord injury (SCI), and 10 patients with cerebrovascular accidents (CVAs), all of whom were questioned regarding contact with and possible clinical allergic reactions to latex. Ten healthy control subjects were also studied. We used a latex sap extract, previously shown to react with latex-specific IgE in a biotin-avidin ELISA, to determine latex-specific IgE antibody titers and to compare the groups. RESULTS Responses to questionnaires indicated that neither the patients with SCI nor the patients with CVA had histories suggestive of latex hypersensitivity. In contrast, 72% of the SB population had histories of clinical latex allergy. Comparisons of latex contact among the SB, SCI, CVA, and control groups revealed that the SB and SCI groups had similar latex exposure, whereas the other groups had less exposure. Both the SB and SCI groups had an average of two surgical procedures per year, which was greater than the average for the other groups. Comparisons of IgE latex antibody titers among the groups indicated that only the SB group had significant levels. The mean optical density values for each group were: 0.299 +/- 0.177 for patients with SB and positive skin prick test results, 0.072 +/- 0.066 for patients with SB and negative skin prick test results, 0.098 +/- 0.005 in patients with SCI, 0.073 +/- 0.038 in patients with CVA, and 0.053 +/- 0.034 in control subjects. The percentages of positive latex IgE antibody detection were 72% for SB, 4% for SCI, 0% for CVA, and 0% for control groups. CONCLUSIONS The results suggest that the SB population is unique in demonstrating IgE responses to latex contact, which may be due to increased latex exposure or altered neuroimmunologic interactions.

Immunologic lung disease.

IN 1972, McCombs published an elegant review of diseases due to immunologic reactions in the lungs.1 Since then, intense interest in pulmonary immunology has provided new insights into the role of ...

The diagnosis of natural rubber latex allergy

Allergy to latex is a rapidly emerging public health problem. Because our knowledge of the major allergens involved is incomplete, standardized in vivo and in vitro tests have not been available. Because of systemic reactions to skin prick testing, this method should be used only after results of other tests have been inconclusive. Risks and benefits of the test need to be explained to the patient, and until standard extracts of latex are available, skin tests should be performed under a research protocol. We anticipate that with greater knowledge of the relevant allergens, purification of these allergens with affinity chromatography, high-performance liquid chromatography, and monoclonal antibodies, a safe and reliable extract will be available in the near future for skin testing. Until then, the above guidelines can serve clinicians in their daily practice in the diagnosis of latex allergy.

A study of lung lavage materials in patients with hypersensitivity pneumonitis: in vitro response to mitogen and antigen in pigeon breeders' disease.

Abstract BAL fluids and cells were evaluated for cellular content and PHA- and antigen-induced proliferation in patients with the HP, PBD. Peripheral blood cells from these patients were also evaluated for mitogen- and antigen-induced proliferation as a comparison with lung lavage cells. The results indicate that BAL from patients with HP contained large proportions of lymphocytes which responded to PHA. However, several pigeon breeders without typical symptoms of PBD also had high proportions of lymphocytes in BAL and all lung lavage cells from these individuals responded to PHA as did peripheral blood cells from both patients with PBD and their asymptomatic cohorts. When BAL cells were stimulated with pigeon antigens, seven of eight patients with PBD displayed significant proliferation, whereas only two of nine asymptomatic pigeon breeders responded to antigen. Most patients with PBD (five of eight) had circulating lymphocytes which responded to pigeon antigens; however, five of nine asymptomatic pigeon breeders also had circulating lymphocytes which were stimulated by pigeon antigens. This study substantiates the fact that patients with PBD have high proportions of lymphocytes in their bronchoalveolar cells and shows that they respond to PHA, a predominantly T cell mitogen. However, some asymptomatic pigeon breeders also have large proportions of lymphocytes in their BAL fluid which react with PHA; the significance of this finding is not known at the present time. The key finding of lymphocytes in BAL which react with pigeon antigens, usually not found in BAL of asymptomatic pigeon breeders, indicates that specifically activated T lymphocytes are present in the lung parenchyma and suggests that they participate in the pathogenesis of the disease.