Kirk H. Waibel

Incidence and characteristics of biphasic reactions after allergen immunotherapy.

BACKGROUND The reported incidence of biphasic anaphylactic reactions varies from 1% to 20%. Reported risk factors for biphasic reactions include a delay in epinephrine administration and a longer interval to initial improvement. To date, only 4 cases of biphasic reactions after allergen immunotherapy have been reported. OBJECTIVE We sought to determine the incidence, clinical characteristics, and risk factors for biphasic reactions after allergen-specific immunotherapy. METHODS Patients who were treated with epinephrine for systemic reactions after allergen immunotherapy were prospectively enrolled. Patients were assessed initially and at 24 hours by using a 31-symptom scoring system. RESULTS Sixty systemic reactions occurred in 55 patients; 14 (23%) biphasic reactions were reported. Patients experiencing biphasic reactions were more likely to be female (P = .03) and older (P = .01) and require greater than 1 dose of epinephrine (P = .001). There was no difference between groups (biphasic vs no biphasic reaction) regarding the type of immunotherapy, current asthma, initial symptom scores, or time to symptoms, initial epinephrine, or improvement. No specific symptom predicted biphasic reactions. Biphasic reactions were significantly less severe compared with the initial reaction (P < .001), did not occur in children, and did not require additional epinephrine. CONCLUSIONS Twenty-three percent of patients requiring epinephrine for systemic reactions caused by allergen immunotherapy experienced biphasic symptoms. Patients treated promptly with epinephrine for systemic reactions should be cautioned regarding biphasic reactions; however, biphasic reactions after allergen immunotherapy were mild and did not require additional epinephrine.

Safety of chitosan bandages in shellfish allergic patients.

BACKGROUND In 2005, the Office of the Surgeon General mandated that every soldier carry a HemCon bandage. Made from chitosan, a polysaccharide derived from shrimp shells, this bandage effectively stops bleeding. There are no studies reporting the safety of this bandage in shellfish allergic patients. METHODS Patients who reported shellfish allergy were recruited. Initial assessment included a detailed history, IgE skin prick testing (SPT), and serum testing to shellfish allergens. Participants who demonstrated specific shellfish IgE underwent a bandage challenge. RESULTS Nineteen participants were enrolled; 10 completed the study. Seven (70%) were male and the average age was 44.8 + 10 years. Nine (90%) reported a shrimp allergy history and five (50%) reported multiple shellfish allergies. All participants completing the study had positive SPT and serum IgE testing to at least one shellfish; eight (80%) had shrimp positive SPT and ten (100%) demonstrated shrimp-specific IgE. No participant had a positive SPT to chitosan powder or experienced an adverse reaction during bandage challenges. No protein bands were visualized during gel electrophoresis analysis of chitosan powder. CONCLUSION All participants tolerated the HemCon bandage without reaction. This is the first study demonstrating the safety of this bandage in shellfish allergic subjects.

Ovalbumin content in 2009 to 2010 seasonal and H1N1 monovalent influenza vaccines

In summary, we demonstrate that UV-B irradiation of human keratinocytes supplemented with 7-DHC triggers the synthesis of hormonally active calcitriol, which then differentially affects expression of AMPs cathelicidin and HBD2. Furthermore, we propose an explanation for the differences observed in AMP regulation in vitro and in vivo on UV-B treatment. Mark Peric, PhD Bodo Lehmann, PhD Gabriela Vashina, MD Yvonne Dombrowski, PhD Sarah Koglin Michael Meurer, MD Thomas Ruzicka, MD J€urgen Schauber, MD From the Department of Dermatology and Allergology, Ludwig-Maximilians-Universität Munich; and the Department of Dermatology, Carl Gustav Carus Medical School, Dresden University of Technology, Germany. E-mail: juergen.schauber@ med.uni-muenchen.de. J.S. has received grants from the Deutsche Forschungsgemeinschaft (Emmy Noether Programm; Scha 979/3-1; http://www.dfg.de) and the Fritz Thyssen Stiftung (http:// www.fritz-thyssen-stiftung.de). B.L. has received a grant from the Gesellschaft der Freunde und Förderer des Universitätsklinikums Dresden. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article. Disclosure of potential conflict of interest: M. Meurer is on the speakers’ bureau for Novartis Pharma and is an advisor for Basilea Pharma. The rest of the authors have declared that they have no conflict of interest.

Fever and leg pain in a 42-month-old.

Introduction A 42-month-old female child presented with a 3-month history of left lower leg pain and 3 weeks of fevers to 38.9° C. The leg pain was a constant dull ache that had increased gradually. Her pain localized over the anterior left lower leg, but there was no swelling or erythema. She had a noticeable limp and avoided walking. There was no improvement with nonsteroidal anti-inflammatory drugs. There was no history of previous leg pain, trauma, lymph node swelling, rash, insect bite, viral infection, or joint swelling.

Prevalence and food avoidance behaviors for gustatory rhinitis.

BACKGROUND Gustatory rhinitis is a type of nonallergic rhinitis that is usually associated with ingestion of hot or spicy foods. Characteristics of this condition and its impact on food choices have not been studied. OBJECTIVE To survey individuals regarding causative foods, association with atopic conditions, and food avoidance behaviors for gustatory rhinitis. METHODS An original, self-administered questionnaire was distributed to children and adults who were seen in a busy outpatient dermatology clinic. Atopic history, frequency of rhinorrhea after food ingestion, intake of foods associated with gustatory rhinitis, symptom severity, and food avoidance were evaluated. RESULTS Of the 571 participants who completed the survey, 396 (69%) indicated at least 1 food resulted in gustatory rhinitis symptoms. Patients with allergic rhinitis (P < .001) and a history of smoking (P = .049) were more likely to have experienced gustatory rhinitis. Bread (6%) and hot chili peppers (49%) represented the least and most common foods identified, respectively. A total of 65% of patients who experienced gustatory rhinitis never avoided the causative food, whereas 46% were never bothered by their symptoms. Patients who reported more causative foods were also more likely to use medications before eating to lessen their symptoms (P = .03). CONCLUSION The results presented herein suggest that almost all foods can be implicated, both children and adults develop this condition, and patients with a history of allergic rhinitis or smoking are more likely to report gustatory rhinitis symptoms. Most patients though do not avoid the causative food(s) and are not significantly bothered by symptoms.

Effect of topical vapocoolant spray on skin test wheal, flare, and pain responses

BACKGROUND Skin puncture and intradermal tests are commonly used to evaluate allergic rhinitis. Ethyl chloride, a topical vapocoolant spray, provides skin analgesia before venipuncture, but it has not been studied with allergy skin testing. OBJECTIVE To determine the effects of ethyl chloride vs placebo on skin puncture testing (SPT) and intradermal allergy testing. METHODS We enrolled 20 healthy adults with a history of positive aeroallergen skin test results in a randomized, double-masked, placebo-controlled study. Ethyl chloride and placebo sprays were randomly placed on the upper back. Paired SPT was performed with saline, histamine, and standardized aeroallergens, including Bermuda grass, Kentucky blue grass, timothy grass, cat, Dermatophagoides pteronyssinus, and Dermatophagoides farinae. Serial dilutional end-point intradermal tests were then performed using 1 standardized aeroallergen. Wheal and flare areas were outlined, scanned, and digitally measured. Participants used a 10-cm visual analog scale to record pain during skin testing. RESULTS Eighteen individuals completed the study. Compared with placebo, ethyl chloride had no significant effect on histamine wheal (P = .53), histamine flare (P = .39), aeroallergen wheal (P = .10), or aeroallergen flare (P = .71) area for SPT. Serial dilutional end-point intradermal testing was similar after ethyl chloride and placebo application (P = .75). Mean pain scores for SPT were improved with ethyl chloride compared with paired placebo skin tests, although pain scores did not reach significance for SPT (P = .21) or intradermal testing (P = .87). CONCLUSIONS Ethyl chloride does not significantly reduce histamine and aeroallergen wheal and flare areas during SPT and intradermal allergy skin testing. Ethyl chloride, vs placebo, reduced pain in some individuals during skin testing, although this did not attain statistical significance.

Inhalant Horse Allergens and Allergies: A Review of the Literature

A wealth of literature exists regarding common allergies to household pets such as cat or dog. Allergy to horse, however, is infrequently discussed in the medical literature despite significant sensitization rates among urban-dwelling subjects without direct exposure to horses. A literature search was conducted in PubMed and additional references were collected from surveying the references of the pulled articles. This review summarizes aspects of IgE-mediated horse allergy including the prevalence and mechanisms for sensitization, clinical presentation, molecular characterization of the major and minor horse allergens, and the role of allergen immunotherapy. There is currently only one horse immunotherapy study showing significant improvement in clinically sensitive patients. The 1997 World Health Organization Position Paper on Immunotherapy lists horse immunotherapy among the areas needing further clinical research. Inclusion of horse into the standard allergen panel for children and adults has been supported by several authors, although further identification and characterization of horse antigens is needed to provide the most efficacious extract. As clinicians, we need to be aware of the potential cross-reactivity among the common mammalian allergens and consider the possibility of known or occult exposure to horse as a possible source of symptom exacerbation in susceptible individuals.

Periorbital swelling and nasal congestion in a 31-year-old man

HISTORY OF PRESENT ILLNESS A 31-year-old previously healthy man was first seen with a 10-week history of increasing bilateral upper and lower eyelid edema and nasal congestion. The patient reported that these symptoms gradually worsened despite trials of nasal corticosteroids, nasal decongestants, and oral antihistamines. He also complained of intermittent headaches, postnasal drip, eye pressure, anosmia, and yellowish rhinorrhea. There was no history of atopy or sinusitis. He denied lip, tongue, throat, or extremity swelling. There was no recent foreign travel, sick contact exposure, trauma, nonsteroidal anti-inflammatory drug (NSAID) use, or herbal medication use.