Mariangiola Crivellaro

Causes of food-induced anaphylaxis in Italian adults: a multi-centre study.

Background: Data about food-induced anaphylaxis in Italy are missing. Objective: It was the aim of this study to detect the main foods/food allergens causing anaphylaxis in Italy. Methods: The frequency of anaphylaxis and the relative importance of many offending foods were assessed in 1,110 adult patients with food allergy diagnosed by common criteria at 19 allergy centres scattered throughout Italy from 1 January to 31 December 2007. Results: Fifty-eight of 1,110 (5%) food-allergic patients experienced at least 1 episode of anaphylaxis. On average, they were older than other food-allergic patients (34 vs. 31 years; p < 0.05). The majority of anaphylactic episodes occurred in patients sensitized to lipid transfer protein (LTP; n = 19), followed by shrimp (n = 10), tree nuts (n = 9), legumes other than peanut (n = 4), and seeds (n = 2); peanut, spinach, celery, buckwheat, wheat, avocado, tomato, fish, meat, and Anisakis caused an anaphylactic reaction in single patients. Among LTP-hypersensitive patients, peach caused 13/19 anaphylactic episodes. Shrimp-allergic patients were significantly older than other patients with food-induced anaphylaxis (p < 0.05), whereas patients allergic to LTP experienced their anaphylactic episodes at a younger age (p < 0.001). The frequency of anaphylaxis among patients sensitized to LTP, shrimp or tree nuts did not differ between northern and central/southern Italy. Conclusion: LTP is the most important allergen causing food-induced anaphylaxis in Italy, peach being the most frequently offending food. Peanut-induced anaphylaxis seems very uncommon. Geographic and environmental differences both between Italy and other countries and within Italy seem to play a relevant role in the pattern of sensitization to foods.

EpidemAAITO: features of food allergy in Italian adults attending allergy clinics: a multi-centre study.

Background Studies of the prevalence of different types of food allergy in adults are lacking.

The role of patient training in the management of seasonal rhinitis and asthma: clinical implications

Background: Allergic rhinitis is an inflammatory disease often associated with bronchial asthma. Intranasal corticosteroids and oral antihistamines are the first‐choice drugs. Patient training is relevant to asthma management, but little is known about its impact on rhinitis. We evaluated the role of patient training in the treatment of allergic rhinitis and its effects on nasal and bronchial symptoms.

A prospective Italian survey on the safety of subcutaneous immunotherapy for respiratory allergy

Background Subcutaneous immunotherapy is effective for the treatment of respiratory allergy, and it is largely used in Italy, but no systematic safety assessment has been carried out so far.

Asthma control in elderly asthmatics. An Italian observational study

BACKGROUND The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it. METHODS A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project. FINDINGS A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n = 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV(1)/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV(1)% of predicted and the coexistence of COPD were the only variables to enter the model. INTERPRETATION Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control.

A double-blind placebo-controlled study on the diagnostic accuracy of an electrodermal test in allergic subjects

Background Many unconventional diagnostic procedures based on bioelectrical skin responses are presently widely used for allergic diseases, but rigorous experimental evaluations of their accuracy are still lacking.

Shrimp Allergy in Italian Adults: A Multicenter Study Showing a High Prevalence of Sensitivity to Novel High Molecular Weight Allergens

Background: Shrimp is a frequent cause of food allergy worldwide. Besides tropomyosin, several allergens have been described recently. Objective: We investigated which allergens are involved in Italian shrimp-allergic adults. Methods: Sera from 116 shrimp-allergic patients selected in 14 Italian allergy centers were studied. Skin prick tests with house dust mite (HDM) as well as measurements of IgE to Pen a 1 (shrimp tropomyosin) and whole shrimp extract were performed. All sera underwent shrimp immunoblot analysis, and inhibition experiments using HDM extract as inhibitor were carried out on some Pen a 1-negative sera. Results: Immunoblots showed much variability. IgE reactivity at about 30 kDa (tropomyosin) was found in <50% of cases, and reactivity at about 67 kDa and >90 kDa was frequent. Further reactivities at 14–18, 25, 43–50, about 60 and about 80 kDa were detected. Most subjects had a history of shrimp-induced systemic symptoms irrespective of the relevant allergen protein. IgE to Pen a 1 were detected in sera from 46 (41%) patients. Skin reactivity to HDM was found in 43/61 (70%) Pen 1-negative subjects and inhibition studies showed that pre-adsorption of sera with HDM extract induced a marked weakening of the signal at >67 kDa. Conclusions: Several allergens other than tropomyosin are involved in shrimp allergy in adult Italian patients. Some hitherto not described high molecular weight allergens seem particularly relevant in this population and their cross-reactivity with HDM allergens makes them novel potential panallergens of invertebrates.

Exercise-induced anaphylaxis to grape†

. EXERCISE-induced anaphylaxis (EIA) is characterized by airways obstruction urticaria, and hypotension following physical exercise, and it can be associated with food allergy (1, 2). We describe one case of EIA due to ingestion of grape, which rarely causes allergic reactions. A 33-year-old woman, with allergic rhinoconjunctivitis due to Parietaria and mugwort, reported in the past year facial flushing, edema of the lips, and dyspnea after drinking white or red wine, although she could eat fresh grapes without problem. The symptoms were reproducible and clearly related to wine; therefore, she was advised to avoid it. One month before, after eating white grapes, she had gone jogging. After the exercise, urticaria, facial/ pharyngeal edema, abdominal pain, and dyspnea appeared and rapidly worsened. At the emergency department, profound hypotension was found: her blood pressure was 70/52 mmHg, heart rate 130 bpm, and respiratory frequency 24/min. She received epinephrine, plasma expanders, and corticosteroids/antihistamines, and recovered within 3 h. We suspected EIA associated with grape allergy, and performed a detailed diagnostic procedure. The skin prick tests with commercial extracts (Stallergènes, Antony Cedex, France) with inhalants and foods were negative except for Parietaria and mugwort. Molds (Aspergillus fumigatus, Cladosporium herbarum, Alternaria alternata, Penicillium notatum, and Botrytis), which can be present on grape surfaces, were negative as well. The prick-to-prick tests with juice from white and red grapes were positive. The arithmetic means of wheal diameters were as follows: 8 mm for white grape, 5 mm for red grape, and 4 mm for histamine HCl 0.1%. The oral single-blind challenge with metabisulfite using increasing doses up to 75 mg (Test Dose, Lofarma, Milan, Italy) was negative. An in vivo challenge (food plus exercise) was not performed for ethical reasons. Serum tryptase (Tryptase UniCAP, Pharmacia, Uppsala, Sweden) in a blood sample obtained within 1 h after the onset of EIA was increased (18.2 ng/ml, normal value ,15 ng/ml). A grape extract was prepared for immunologic studies. Grape was homogenized and extracted at 10% w/v in 0.1 M potassium phosphate buffer, pH 7, for 1 h. After removing the particulate by centrifugation, the supernatant was dialyzed against 5 mM ammonium bicarbonate, lyophilized, and resuspended in 1/10 of the initial volume. Electrophoresis of the extract (12 mg/lane) was performed in a 10% polyacrylamide gel (Nupage Sis-Tris, Prodotti Gianni, Milan, Italy) at 180 mA for 1 h. The resolved proteins were stained with 0.1% Coomassie brilliant blue and transferred to a nitrocellulose membrane (Protann BA, 85, Scheicher and Schuell, Milan, Italy). The membrane was saturated with 5% defatted dried milk before incubation with patient’s serum or control sera diluted 1:2. Bound specific IgE was then detected by peroxidase-conjugated antihuman IgE serum. No grape-specific IgE could be demonstrated in the patient’s serum by the CAP-RAST technique. However, the assessment of IgE reactivity of serum against grape extract provided a positive result. The SDS–PAGE profile of grape extract showed the presence of a well-resolved band at about 67 kDa and a diffuse stain between 25 and 35 kDa. Immunoblotting showed that the patient’s serum had IgE antibodies against one specific component of the extract (approximate molecular mass 30 kDa), whereas control sera also reacted to the 67kDa band. IgE-mediated reactions to grape have been rarely reported (2, 3–6). The case herein described was a true food-associated EIA, since the patient remained asymptomatic when eating at rest great amounts of the sensitizing food. The prick-to-prick positivity and the increase of serum tryptase confirmed the mast-cell activation. Moreover, the immunoblot analysis suggested that the patient had specific IgE reacting to one component of the grape extract, despite the negativity of the CAPRAST assay.

Prevalence of latex-specific IgE in blood donors : an Italian survey

available on the ward. On arrival, the childs weight and vital signs (blood pressure, pulse, and respiratory rate) are recorded, the emergency drug chart is completed, and an intravenous cannula is inserted. The child is examined for any evidence of allergy by the day-care nurse before progressing to the challenge. Any abnormal respiratory ®ndings such as wheeze or breathlessness preclude the test from being performed until the child is well. Evidence of and distribution of eczema are clearly marked out, as this is a common coexisting condition in food allergy which may also be the only sign of a reaction. Throughout the challenge procedure, vital signs are recorded, and the child is examined for any reaction before each subsequent dose is ingested. The nut challenge involves the childs ingesting visually measured doses of nut at 15±30-min intervals. It starts with a nut touching the oral mucosa and progresses to the ingestion of a portion the size of a pinhead, which is then doubled until a minimum of 5 g of nut has been ingested. The challenge procedure is speci®c to each individual, using the principle of starting with a quantity smaller than that which caused the presenting reaction, and given at time intervals longer than the time to the reaction. The challenge also considers the childs age, as children over 7 years are given whole nuts while younger children receive peanut butter or ground tree nuts. In those children where dif®culties in ingesting the nut are encountered, the measured dose is given in or with a familiar food that the child has eaten before (e.g., peanut butter on chocolate buttons). Children complete a 60±120-min (no reaction) or 4-h (mild reaction) observation period after the end of the challenge before discharge home. Fifteen of the 17 children showed no symptoms after open challenge (Table 1). All these children continued to ingest foods containing nut without incident. Two children reacted, one with hives on the left cheek and abdomen after 45 min, and the other with mild urticaria under the left eye 2 h after the start of the challenge. Neither experienced a major or life-threatening reaction. With the increase in public awareness of nut allergy, coincidental allergy-like symptoms may be attributed to nuts, labelling children as having a lifelong, potentially fatal allergic condition and subjecting them to many lifestyle restrictions. As the skin and blood tests are highly predictive of the absence of IgE-mediated allergy (2, 4), we have found that the parents of our patients welcome our supervised challenge procedure in an informal but safe setting where a negative test places the diagnosis of nut allergy in doubt. Hourihane et al. (5) recently suggested that some children may show resolution of their nut allergy. The 15 children in our study with negative nut challenges may fall into this category or may coincidentally have reacted to another food or other factor which we have not identi®ed. The two patients who reacted when challenged are important, as they demonstrate the possibility of persistence of symptoms despite a negative test, a phenomenon not described by Hourihane et al. (5), and the need to conduct all nut challenges in a setting where any allergic reaction can be safely managed. These children may need a repeat blinded, placebo-controlled nut challenge in future to avoid any bias. In conclusion, we propose an easy, economical, yet effective and safe dietary challenge for nuts. Our study also con®rms that history alone, that is, in the absence of con®rmatory allergy tests, is not adequate to make the diagnosis of nut allergy. We recommend that all hospital-based allergy clinics should offer these challenges as an integral part of the treatment and management of food allergy.

Efficacy of venom immunotherapy given every 3 or 4 months: a prospective comparison with the conventional regimen

BACKGROUND Standard venom immunotherapy involves the administration of the maintenance dose every 4 to 6 weeks. This regimen may have adherence problems, especially in the long term; thus, extended intervals have been proposed. OBJECTIVE We prospectively compared the efficacy of 3- or 4-month extended maintenance dose vs the conventional regimen. METHODS Patients receiving immunotherapy with a single venom were offered the extended maintenance dose (EMD) and were then followed up for field re-stings. Only the re-stings by the insect for which the patients received immunotherapy were considered. A comparable group of patients receiving the conventional maintenance dose (CMD) was used for comparison by logistic regression analysis. RESULTS Seventy-six patients (60 male; mean age, 48 years) receiving the EMD were re-stung on 247 occasions by the insect for which they were receiving immunotherapy. The group receiving CMD included 110 patients (82 male; mean age, 44 years) certainly re-stung on 167 occasions by the specific insect. The percentage of re-sting without reaction was 93.5% in the EMD group and 81.5% in the CMD group, with a significant difference in favor of the former (P=.001). At logistic regression analysis, only age, but not maintenance dose protocol, was predictive of subsequent systemic reactions. CONCLUSION The EMD is as effective and safe as the CMD. An increased maintenance seems to be the best option in term of convenience and economic savings.