Nualanong Visitsunthorn

Features of patients with anaphylaxis admitted to a university hospital

BACKGROUND Anaphylaxis in hospitalized patients has been infrequently reviewed. There are few studies of anaphylaxis from Asian countries. OBJECTIVE To describe the clinical characteristics of patients with anaphylaxis admitted to Siriraj Hospital. METHODS The medical records of 101 patients admitted with clinical anaphylaxis between January 1, 1999, and December 31, 2004, were reviewed. Data were analyzed using the chi2 test. RESULTS The annual occurrence of anaphylaxis increased from 9.16 per 100,000 admitted persons in 1999 to 55.45 per 100,000 admitted persons in 2004. The case fatality rate was 0.19 per 100,000 admitted persons. The mean +/- SD age was 23.73 +/- 21.84 years. Males experienced more anaphylaxis than females in pediatric patients and vice versa in adult patients. Biphasic anaphylaxis was found in 7% of pediatric and 2% of adult patients. Anaphylaxis occurred in the hospital in 37% of patients. Involved systems were cutaneous (86%), respiratory (80%), cardiovascular (52%), and oral and gastrointestinal (36%). Identifiable causes were drugs (50%), foods (24%), idiopathic (15%), and insect stings/bites (11%). Epinephrine was given to 77% of the patients. CONCLUSIONS We report the clinical characteristics of patients with anaphylaxis admitted to a university hospital. Knowing the clinical features will raise physician awareness of this condition.

IgE antibodies to omega-5 gliadin in children with wheat-induced anaphylaxis.

Background:  Wheat can cause severe immunoglobulin E (IgE)‐mediated systemic reactions including anaphylaxis but knowledge on relevant wheat allergens at the molecular level is scanty.

Identification of the etiologies of chronic urticaria in children: A prospective study of 94 patients

Jirapongsananuruk O, Pongpreuksa S, Sangacharoenkit P, Visitsunthorn N, Vichyanond P. Identification of the etiologies of chronic urticaria in children: A prospective study of 94 patients.
Pediatr Allergy Immunol 2010: 21: 508–514.
© 2009 John Wiley & Sons A/S

Specific allergy to Penaeus monodon (seawater shrimp) or Macrobrachium rosenbergii (freshwater shrimp) in shrimp-allergic children

Background Allergy to specific shrimp species has not been studied systematically by oral challenges. A comparison of allergy to different shrimp species, especially seawater or freshwater varieties treatment, would be useful in testing shrimp‐allergic subjects.

How do Thai children and adolescents describe asthma symptoms

Prevalence of childhood asthma appears to be increasing worldwide. In Thailand, the prevalence of childhood asthma increased from 4.2% to 13% within the past decade. The last epidemiologic survey in Thailand utilized the International Study of Asthma and Allergies in Childhood (ISAAC) phase I questionnaire translated into Thai language. Language in the questionnaire can affect the reliability and validity of results of the survey. The purpose of this study is to determine common Thai wordings actually used by Thai children and adolescents to describe wheeze, chest tightness, shortness of breath and dyspnea. Sixty asthmatic Thai children, aged 9.2–18 years with asthmatic attacks less than 1 yr prior to the study, and 178 age‐matched controls were recruited into the study. Asthmatic children spontaneously expressed their terms describing their asthma symptoms (in Thai) and then answered a preoutlined questionnaire regarding asthma terminology during an interview session after viewing the severe attack scene of the International ISAAC video questionnaire. Controls responded only to the preoutlined questionnaire after viewing the video scene. Of the 60 asthmatic children (38 males and 22 females, mean age 11.9 yr), 75% had their last asthmatic attacks within 2 months prior to the study. Wheeze was referred to as ‘’ and ‘/wi:d/’ in 50% and 33% of patients, respectively, and ‘’ in 93.8% among controls. Using only the word ‘/wi:d/’ in our previous ISAAC‐I survey, as it sounded like the English word ‘wheeze’, it appears that up to 67% of the cases could have been missed. Dyspnea was referred to as rapid breathing and feeling tired in 78.2% of cases and as rapid and difficult breathing in 76.3% of controls. Chest tightness was referred to as chest discomfort in 65.7%. Shortness of breath was referred to as not being able to catch a breath, too short a breath, not enough breath and feeling suffocated in 88.8%. Local terms for asthma symptoms should be established and validated into each language to obtain reliable epidemiologic data.

Pediatric asthma quality of life questionnaire (PAQLQ) : Validation among asthmatic children in thailand

Quality of life (QoL) is an important consideration among asthma sufferers. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) is one of the most widely used instruments for measuring health‐related QoL in children with asthma. The standardized version of PAQLQ contains 23 questions in three domains, i.e., activity limitation, symptoms and emotional function. The objective of this study was to validate the Thai‐translated version of the PAQLQ. The study design consisted of a five‐week single cohort study. Patients recorded symptoms, and peak expiratory flow rate (PEFR) each morning and evening during the first and fifth week of the study in asthma diary. At each clinic visit, a trained‐interviewer administered the PAQLQ and performed spirometric measurements. Fifty‐one children, ages between 7 and 17 yr participated in the study. Scores from the asthma diary were used to classify patients into stable vs. unstable groups. The construct validity of the questionnaire was confirmed in both cross‐sectional and longitudinal studies by demonstrating correlations between various PAQLQ domains with clinical asthma parameters (asthma diary, β‐agonist use and PEFR). There was high internal consistency for scores of the three domains (Cronbachs α‐coefficient = 0.83–0.95). For those with stable asthma, the reliability of PAQLQ was good for the rating scale (intra‐class correlation coefficient – ICC = 0.84) and for total score (α = 0.97) indicating high reproducibility of the PAQLQ. The significant difference of changes QoL scores between stable and unstable groups was observed in all domains. We conclude that the Thai version of PAQLQ is valid and reliable for implementing in Thai children with asthma.

The Effect of Vitamin D Status on Pediatric Asthma at a University Hospital, Thailand

Purpose In the USA and Europe, hypovitaminosis D is associated with increased asthma severity, emergency department (ED) visit, and impaired pulmonary function in asthmatic patients. However, in tropical countries, data on the effect of vitamin D status on asthma is limited. This study evaluates the relationship between vitamin D status and the level of asthma control as well as other asthmatic parameters. Methods Asthmatic children were evaluated for serum 25-hydroxyvitamin D, pulmonary function tests, a skin prick test, and the level of asthma control. Results A total of 125 asthmatic children were recruited (boys, 66.4%). Their mean age±SD was 10.8±3.0 years. Vitamin D statuses were: deficiency (<20 ng/mL) in 19.2% of the patients, insufficiency (20-30 ng/mL) in 44.8%, and sufficiency (>30 ng/mL) in 36%. The vitamin D levels were 25.9±9.4 ng/mL in uncontrolled patients, 29.2±8.6 ng/mL in partly controlled patients, and 27.9±8.0 ng/mL in controlled patients (P>0.05). There were no significant differences in pulmonary function, asthma exacerbation, inhaled-corticosteroid (ICS) dose, anti-inflammatory drugs, or ED visit or hospitalization between different vitamin D statuses. Vitamin D deficiency patients were older and had a delayed onset of asthma than insufficiency or sufficiency patients. There was no significant correlation between serum vitamin D and pulmonary function/doses of ICS. Conclusions High prevalences of vitamin D deficiency and insufficiency were found in asthmatic children in Thailand; however, there was no significant relationship between vitamin D status and the level of asthma control or other asthma parameters.

Proteome and allergenome of Asian wasp, Vespa affinis, venom and IgE reactivity of the venom components.

Vespa affinis (Asian wasp, Thai banded tiger wasp, or local name: Tor Hua Seua) causes the most frequent incidence of medically important Hymenoptera sting in South and Southeast Asia. However, data on the venom components attributable to the sting derived-clinical manifestations (local reactions, IgE mediated-anaphylaxis, or systemic envenomation) are lacking. This study provides the first set information on V. affinis venom proteome, allergenome, and IgE reactivity of individual venom components. From 2DE-gel based-proteomics, the venom revealed 93 protein spots, of which proteins in 51 spots could be identified and classified into three groups: typical venom components and structural and housekeeping proteins. Venom proteins in 32 spots reacted with serum IgE of wasp allergic patients. Major allergenic proteins that reacted to IgE of >50% of the wasp allergic patients included PLA1 (100%), arginine kinase (73%), heat shock 70 kDa protein (73.3%), venom allergen-5 (66.7%), enolase (66.7%), PLA1 magnifin (60%), glyceraldehyde-3-phosphate dehydrogenase (60%), hyaluronidase (53.3%), and fructose-bisphosphate aldolase (53.3%). The venom minor allergens were GB17876 transcript (40%), GB17291 transcript (20%), malic enzyme (13.3%), aconitate hydratase (6.7%), and phosphoglucomutase (6.7%). The information has diagnostic and clinical implications for future improvement of case diagnostic sensitivity and specificity, component-resolve diagnosis, and design of specific Hymenoptera venom immunotherapy.

The utility of serum tryptase in the diagnosis of food-induced anaphylaxis.

Purpose This study investigates the utility of serum tryptase for the confirmation of shrimp-induced anaphylaxis. Methods Patients with a history of shrimp allergy and positive skin prick tests (SPT) to commercial shrimp extract were recruited for shrimp challenges. Serum total tryptase was obtained at baseline and 60 min (peak) after the onset of symptoms. Results Thirty-nine patients were challenged. There were 12 patients with anaphylaxis, 20 with mild reactions and 7 without symptoms (control group). Characteristic features and baseline tryptase were not different among the 3 groups. The peak tryptase levels were higher than the baseline in anaphylaxis and mild reaction groups (P<0.05). The delta-tryptase (peak minus baseline) and the tryptase ratio (peak divided by baseline) in the anaphylaxis group were higher than the mild reaction and control groups (P<0.01). The optimum cut-off for peak tryptase to confirm anaphylaxis was 2.99 µg/L with 50% sensitivity, 85% specificity, 3.33 positive likelihood ratio (LR) and 0.59 negative LR. The manufacturers cut-off for peak tryptase was >11.4 µg/L with 17% sensitivity, 100% specificity, infinity positive LR and 0.83 negative LR. The best cut-off for delta-tryptase was ≥0.8 µg/L with 83% sensitivity, 93% specificity, 11.86 positive LR and 0.18 negative LR. The best cut-off for tryptase ratio was ≥1.5 with 92% sensitivity, 96% specificity, 23 positive LR and 0.08 negative LR. Conclusions The peak tryptase level should be compared with the baseline value to confirm anaphylaxis. The tryptase ratio provide the best sensitivity, specificity, positive and negative LR than a single peak serum tryptase for the confirmation of shrimp-induced anaphylaxis.

Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis

Introduction: The safety and efficacy of fluticasone furoate nasal spray (FFNS) for the symptoms of seasonal and perennial allergic rhinitis have been previously demonstrated in several clinical studies. The objective of this pilot study was to compare the efficacy and safety of FFNS 110 mcg once daily with placebo in patients with irritant (non-allergic) rhinitis triggered predominantly by air pollution. Methods: This was a randomized, double-blind, placebo-controlled, 4-week study of subjects in Thailand with irritant rhinitis who received either FFNS 110 mcg (N=53) or placebo (N=49) once-daily. Subjects with a ≥2 year history of air pollution as their predominant rhinitis trigger, negative skin test to local seasonal/perennial allergens, positive histamine skin test, and normal sinus radiograph were enrolled if they met minimum reflective total nasal symptom score (rTNSS) ≥4.5 (maximum=9) and a nasal congestion score of ≥2 (maximum =3). All were assessed for nasal eosinophilia at study entry and completion. Air quality was monitored throughout the study. The primary efficacy endpoint was the mean change from baseline over the treatment period in daily rTNSS, the average of the morning and evening rTNSS. The key secondary measure was the mean change from baseline over the entire treatment period in morning pre-dose instantaneous total nasal symptom score (iTNSS). Results: The Air Quality Index (AQI) during the study generally did not reach unhealthy levels. Baseline daily rTNSS scores were similar between treatment groups (FFNS=6.7; placebo=6.4). The least square mean change from baseline in rTNSS was -2.17 and -2.10 for FFNS and placebo, respectively, with a difference of -0.065 (p=0.845). Gradual improvements were seen in both treatment groups for iTNSS; however, the treatment difference (-0.075) was not statistically significant (p=0.827). Additionally, there were no statistically significant differences between treatment groups for AM and PM rTNSS, individual nasal symptoms, daily reflective, AM and PM reflective and AM pre-dose instantaneous total ocular symptom scores (TOSS) or individual ocular symptom scores. Nasal cytology at baseline found more than two-thirds of subjects had <20% eosinophils. Adverse events were few and similar between groups and noted as mild in intensity. Conclusion: Subjects receiving FFNS had similar improvement to placebo in their rhinitis symptoms. The lack of a treatment effect may be in part due to the overall good air quality present throughout the study or an insufficient dose or duration of FFNS. The safety findings showed FFNS 110 mcg once daily to be well tolerated.