Larry L. Hagan

Immediate cutaneous hypersensitivity after treatment of tattoo with Nd:YAG laser: a case report and review of the literature.

BACKGROUND To our knowledge this is the first reported case of an immediate cutaneous reaction to Q-switched neodymium:yttrium-aluminum-garnet (Nd:YAG) laser tattoo removal. A 26-year-old female presented with two 6-year-old tattoos placed at different times. These were of different colors and had remained entirely asymptomatic since placement. There was a Mardi Gras mask on her thigh and a Tasmanian devil on her chest. With laser treatment of the Tasmanian devil, she experienced no untoward effects. However, with treatment of the Mardi Gras mask tattoo, she developed an extensive urticarial and indurated reaction 30 minutes posttreatment. The identical reaction occurred twice with subsequent laser treatments. Dermatology consulted allergy to provide prophylaxis against possible systemic reaction with subsequent Nd:YAG laser therapy. The patient was treated with 3 days of prednisone, cetirizine, and ranitidine before subsequent laser treatments. Prophylactic treatment suppressed all subsequent reactions to laser therapy. RESULTS Delayed hypersensitivity to tattoo pigments occurring days to weeks after placement is well documented. There are no previous reports of immediate hypersensitivity during placement or laser removal. However, there are two previous reports of local and systemic delayed reactions after laser therapy. CONCLUSIONS As far as we know, this is the first case report of immediate hypersensitivity after Nd:YAG laser treatment of a tattoo. Prophylactic treatment with steroids and antihistamines prevented reactions with subsequent laser treatments. Reactions after laser removal are rare, but may increase as popularity of skin art increases with the need for subsequent removal.

Plasma Resistin Levels in Asthmatics as a Marker of Disease State

Background. Resistin is a protein produced by adipoctyes and circulating macrophages that has been found to be associated with inflammatory states. Objective. To determine the levels of resistin in relation to asthma disease state and severity, we investigated a cohort of adult patients with asthma. Methods. A cohort of moderate to severe persistent asthma patients and control patients were recruited and underwent fasting labs to evaluate levels of serum glucose, C-reactive protein (CRP), and resistin. Results. No significant differences were found between the control and asthma group with respect to serum CRP at 0.78 ± 0.60 mg/dL and 0.48 ± 0.60 mg/dL, (p < 0.36) or glucose at 92.2 ± 11.9 mg/dL and 89.5 ± 7.2 mg/dL, (p < 0.084), respectively (mean ± SD). However, plasma resistin levels were found to be significantly elevated in asthma patients, 186 ng/mL (95%CI 169-202) compared with control patients 121 ng/mL (95%CI 90.4-151), (p < 0.005). Conclusions. Patients with asthma were found to have higher levels of resistin, and resistin levels were increased with disease severity in the asthma cohort.

Cross-reactivity between coconut and hazelnut proteins in a patient with coconut anaphylaxis

BACKGROUND The medical literature reports few cases of severe allergic reactions to coconut. We encountered a patient with anaphylaxis to coconut and oral symptoms to tree nuts. OBJECTIVE To identify cross-reactive antibodies between coconut and other tree nuts. METHODS We performed commercial radioallergosorbent tests to coconut and various tree nuts using the patients serum. Skin prick testing was performed to fresh coconut and commercial extracts of coconut, almond, Brazil nut, cashew, pecan, walnut, and hazelnut. Proteins from fresh coconut, commercial coconut extract, and tree nuts were extracted. Immunoblot and inhibition assays were performed to evaluate for cross-reacting IgE antibodies between similar-sized allergens in coconut and hazelnut. RESULTS Positive skin test results occurred to the coconut and multiple tree nut extracts. In vitro serum specific IgE was present for coconut, hazelnut, Brazil nut, and cashew. Immunoblots demonstrated IgE binding to 35- and 50-kDa protein bands in the coconut and hazelnut extracts. Inhibition assays using coconut demonstrated complete inhibition of hazelnut specific IgE, but inhibition assays using hazelnut showed only partial inhibition of coconut specific IgE. CONCLUSIONS Our study demonstrates the presence of cross-reactive allergens between hazelnut (a tree nut) and coconut (a distantly related palm family member). Because there are many potentially cross-reactive allergens among the tree nuts, we recommend patients with coconut hypersensitivity be investigated for further tree nut allergies.

Intraoperative anaphylaxis to bacitracin during pacemaker change and laser lead extraction

BACKGROUND Bacitracin is widely used in operating rooms to soak implants, irrigate compound fractures, and apply to surgical incisions. However, bacitracin is a known sensitizer and causes not only allergic contact dermatitis but also anaphylaxis. OBJECTIVE To describe a 72-year-old woman with anaphylaxis after irrigation and packing of an infected pacemaker pocket with a bacitracin solution. METHODS Skin prick testing to bacitracin and latex; serum tryptase, serum histamine, serum IgE to latex, and serial cardiac enzyme measurements; blood cultures, transthoracic echocardiograms, and venograms were performed to characterize the reaction. RESULTS Six hours after the anaphylactic event, the patient had an elevated serum tryptase level of 49 ng/mL (reference range, 2-10 ng/mL), which normalized the next morning. She had immediate-type skin prick test reactions to full-strength bacitracin ointment (500 U/g) and bacitracin solution (150 U/mL). Serum IgE level to latex was undetectable, and results of skin testing to latex were negative. CONCLUSIONS To our knowledge, this is the first case report of anaphylaxis to bacitracin during pacemaker surgery. This case illustrates that intraoperative anaphylaxis to bacitracin can be life-threatening.

The role of intradermal skin testing in inhalant allergy

OBJECTIVE To provide an overview of the role of intradermal skin testing (IDST) in inhalant allergy. DATA SOURCES A literature search was conducted in MEDLINE to identify peer-reviewed articles related to IDST using the following keywords: skin testing, intradermal, intracutaneous, aeroallergen, and inhalant allergen. In addition, references cited within these articles were also reviewed. STUDY SELECTION Articles were selected based on their relevance to the topic. RESULTS The use of IDST for inhalant allergy varies widely among allergists. When performed, it is necessary to use a 100- to 1,000-fold dilution from the stock allergen extract. IDST is used routinely in the standardization of extracts in the United States. With a negative skin prick test result, a positive IDST result has low agreement with in vitro and challenge results and generally adds little to the diagnostic evaluation. In contrast, a negative IDST result generally has a high negative predictive value. Only a few inhalant allergens have been evaluated with challenge models for IDST. A summary of the data is also presented in tabular form. CONCLUSIONS Most of the literature suggests that with a negative skin prick test result, a positive IDST result adds little to the diagnostic evaluation of inhalant allergy. However, additional studies are necessary using challenge models for less potent and nonstandardized inhalant allergens (molds, trees, dog, weeds).

Sudden Infant Death Syndrome: a Search for Allergen Hypersensitivity

BACKGROUND Sudden infant death syndrome (SIDS) remains a diagnosis by exclusion which leaves few if any pathologic clues to its etiology. Previous evaluations for anaphylaxis in SIDS have been few and limited. OBJECTIVE To analyze forensic blood specimens for evidence of anaphylaxis in 51 (43 boys and 8 girls) children dying of SIDS and 13 (9 boys and 4 girls) age-matched controls who died from defined, nonanaphylactic causes. METHODS Specimens collected over a 5-year period were assayed for (1) total IgE (IU/mL) by immunoenzymatic assay; (2) latex, cat, dust mite (Dermatophagoides farinae and Dermatophagoides pteronyssinus), milk, soy, wheat, peanuts, egg, and tomato specific-IgE by RAST; and (3) serum tryptase levels (U/L) by radioimmunoassay. RESULTS The 51 SIDS cases (median age 3 months; range 1 to 9 months) and 13 control cases (median age 4 months; range 1 to 11 months) demonstrated similar total IgE of 9.8 +/- 1.1 IU/mL (mean +/- SEM) and 10.9 +/- 2.8 IU/mL (P = .59). The frequency of detectable (> 0.5 U/L) serum tryptase levels among SIDS cases (10/51) was similar to controls (3/13, P = .72). The frequency of positive RAST tests was 39% (20/51) in SIDS and 38% (5/13) in control subjects (P = .99). Differences in frequencies of positive RAST tests in SIDS and control cases were not statistically significant for any allergen tested. The most frequently detected allergen-specific IgE, to milk, was similar in SIDS (22%) and controls (31%, P = .48). CONCLUSIONS Elevated tryptase levels and allergen-specific IgE (milk, soy, wheat, peanuts, egg, tomato, dust mites, cat, and latex) were demonstrated in some infant SIDS deaths but were no more common than in controls. We conclude that anaphylaxis is probably an uncommon etiology for SIDS.

IMPORTED FIRE ANT HYPERSENSITIVITY: A 1-DAY RUSH IMMUNOTHERAPY SCHEDULE WITHOUT PREMEDICATION

Imported fire ants (IFAs), which now reside in much of the southern part of the United States, are a frequent cause of hypersensitivity reactions, being the reason for 42% to 54% 1,2 of insect hypersensitivity evaluations performed in these endemic areas. Conventional IFA immunotherapy (IT) schedules, given in the insect hypersensitivity practice parameter, comprise 25 to 28 injections to reach the maintenance dose, which could take more than 3 to 6 months. 3 Unique to IFAs is the difficulty with practicing effective avoidance measures, 4 with annual sting rates up to 58% in people residing in endemic areas. 5 Patients sensitive to IFAs are, therefore, at considerable risk of continued systemic reactions to stings during the months of IT buildup by conventional schedules. We believe these issues, which are unique to IFAs, make rush IT schedules an important option to consider for those patients allergic to IFA stings. In the only published trial of IFA rush IT, Tankersley et al 6 reported on a highly successful and safe 2-day IFA rush IT regimen. After continuing to experience ongoing success with this 2-day regimen, we attempted to shorten the rush period to a single day. We believed this could lessen patient inconvenience and time away from work, reduce costs, and make it a more attractive option for more patients. Because a significant benefit to medication pretreatment was not found using the prior 2-day IFA rush protocol, it was not used in the current protocol. The inclusion criteria for enrollment into the study were patients aged 18 to 65 years, those with a history consistent with a systemic reaction to an IFA sting, and either a positive result to an IFA skin test or an IFA ImmunoCAP (Phadia AB, Uppsala, Sweden) specific IgE test. The protocol was approved by the Wilford Hall Medical Center (San Antonio, Texas) institutional review board. The rush protocol consisted of 10 injections being given during the

Cross-reactivity between raw mushroom and molds in a patient with oral allergy syndrome

BACKGROUND Oral allergy syndrome, resulting from a cross-reactivity between raw fruits and vegetables and a number of pollens, is well described. However, it has never been associated with mold spore sensitivity and mushrooms. We evaluated a patient with oral allergy symptoms to raw, but not cooked, mushrooms, who also had positive skin testing to molds. OBJECTIVE To identify and characterize antigenic cross-reactivity between mushroom and mold spores. METHODS The patient underwent skin prick testing to molds and mushroom. Proteins from raw and cooked mushrooms were extracted and immunoblot/inhibition assays were performed to evaluate for cross-reacting immunoglobulin E antibodies between mushroom and mold extracts to which the patient was sensitive. RESULTS The patient had a positive skin prick test result to raw mushroom and four types of molds. The immunoblot assay revealed immunoglobulin E antibodies directed against similar molecular weight proteins in the raw mushroom and 3 of the 4 molds: Alternaria tenuis, Fusarium vasinfectum, and Hormodendrum cladosporioides. These protein bands on protein electrophoresis were absent in the cooked mushrooms. Inhibition immunoblot of the raw mushroom with the three molds indicated total inhibition of the 43- and 67-kD protein bands. CONCLUSIONS We report the first case of cross-reactivity between mushroom and molds in a patient with oral allergy syndrome to raw mushroom and allergic rhinitis secondary to molds.

Tobacco hypersensitivity and environmental tobacco smoke exposure in a pediatric population

BACKGROUND Skin testing and RAST have verified the existence of tobacco-specific IgE. However, published studies report conflicting results concerning the clinical significance of tobacco IgE. Previous studies have not focused on the role of environmental tobacco smoke (ETS) as it relates to tobacco hypersensitivity (TH) in nonsmoking children. OBJECTIVE We used nonsmoking pediatric patients to investigate the relationship between ETS and TH. METHODS Children, ages 4 to 10 years, were prospectively enrolled. ETS exposure and smoke-triggered symptoms were recorded by questionnaire and physician history. Patients were given a skin test (ST) with a panel of aeroallergens plus tobacco extract. A ST reaction to at least one aeroallergen classified a patient as atopic; a ST reaction to tobacco classified a patient as TH. RESULTS We enrolled 170 patients, mean age 7.2 years. We found 58 (34%) patients reported routine exposure to ETS and 78 (46%) patients reported ETS-induced symptoms. We found 121 (71%) atopic patients and 61 (36%) TH patients. TH was more common in atopic patients (P < .0001) and those routinely exposed to ETS (P < .05). However, TH failed to predict ETS-induced symptoms in either atopic or non-atopic patients (PPV = 0.40, NPV = 0.69). CONCLUSIONS We evaluated the clinical significance of TH in a nonsmoking patient population related to ETS exposure. We concluded that although TH is statistically related to atopy and ETS exposure, the low predictive values of skin testing for TH limit its clinical usefulness.

Exhaled breath condensate pH in the evaluation of asthma

As a marker of inflammation, exhaled breath condensate (EBC) pH may be a useful screening tool in the evaluation of asthma, especially in a military recruit population. To evaluate the utility of EBC pH in the diagnosis of asthma, EBC pH levels were determined in basic military trainees prior to an evaluation for asthma that included a history, physical exam, baseline spirometry, and a methacholine or exercise challenge. Of 86 basic trainees who had symptoms suggestive of asthma and underwent methacholine or exercise challenges, 51 (59.3%) had a positive methacholine or exercise challenge and were diagnosed with asthma. The mean EBC pH of the trainees who were diagnosed with asthma (6.39, range 5.91-6.82), was significantly (p < 0.001) lower than those trainees without asthma (6.64, range 6.34-7.18). There was, however, some overlap of the EBC pH values between the two groups. The measurement of EBC pH did show a significant mean difference between asthmatic and nonasthmatic patients in a military recruit population.