Theodore M. Freeman

Imported fire ant immunotherapy: Effectiveness of whole body extracts☆

The purpose of this study was to determine if whole body extract (WBE) immunotherapy for imported fire ant (IFA) hypersensitivity is effective. This evaluation was carried out by retrospectively interviewing 76 patients with a history of generalized allergic reactions to IFA stings and positive skin tests to IFA-WBE. The study groups consisted of 65 patients on immunotherapy and 11 similar patients who were not treated for various reasons. In addition, an IFA sting challenge was performed in 30 volunteers of the 65 patients on immunotherapy. The retrospective review showed that of the 65 patients on immunotherapy there had been 112 subsequent field-sting episodes in 47 patients. Only one sting episode in this group (2.1%) produced an anaphylactic reaction. Six of the 11 patients not on immunotherapy have had subsequent field re-sting episodes, and each has had a systemic reaction. Repeat skin testing on 31 of the 65 patients in the immunotherapy group showed persistent positive responses in five (16%), but each was at a lower dilution than initially. Responses of the other 26 of the 31 patients who had skin testing had become negative. The four untreated patients who were available for skin testing continued to have positive responses at comparable dilutions on skin testing. Sting challenges carried out on 30 volunteers from the 65 patients (all from the 31 who had repeat skin tests) on immunotherapy resulted in only local reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

The natural history of exposure to the imported fire ant (Solenopsis invicta).

BACKGROUND Imported fire ants (IFA) are a common cause of insect venom hypersensitivity in the southeastern United States. The purpose of this study was to determine the sting attack rate and development of specific IgE in an unsensitized population. METHODS Study participants consisted of 137 medical students with limited exposure to IFA-endemic areas who were temporarily training in San Antonio, Tex. Subjects were surveyed for prior IFA exposure with a questionnaire, and IFA-specific IgE was evaluated with RAST and intradermal skin testing. Evaluations were performed on arrival and reported at departure from the endemic area 3 weeks later. RESULTS One hundred seven subjects completed the study. Field stings were reported in 55 subjects, resulting in a sting attack rate of 51%. In these 55 subjects 53 (96%) reported a pustule or a small local reaction at the sting site, one (2%) reported an isolated large local reaction, and none reported a systemic reaction. At the 3-week follow-up skin test and RAST conversions occurred in seven subjects (13%) and in one subject (1.8%), respectively. CONCLUSIONS Even brief exposures to IFA-endemic areas result in significant sting rates and concurrent rapid development of IFA-specific IgE in 16% of stung subjects.

HLA-DR4-associated nonresponsiveness to mountain-cedar allergen

We did human lymphocyte antigen (HLA)-DR and DQ typing on 37 subjects with mountain-cedar (MC) pollinosis as defined by history and a positive skin test. Of these 37 subjects, 31 were subdivided into 18 subjects with a single positive skin test (SPST) and 13 subjects with multiple positive skin tests (MPSTs). We also typed 51 subjects without MC sensitivity or atopy as defined by history and negative skin tests to a battery of aeroallergens. We also typed 116 subjects in whom MC sensitivity had not been determined. Total IgE, Mc-specific immunoglobulin E (sIgE), and MC-sIgE binding bands by immunoblot were also determined on the subjects with SPSTs and MPSTs. No significant differences were found between the subjects with SPSTs and MPSTs for HLA type, total IgE, MC sIgE, or bands bound by MC sIgE by immunoblot. There was a strong negative relationship between HLA-DR4 and subjects with MC pollinosis; chi-square, 14.857; p = 0.0096; and odds ratio, 0.139. These findings suggest that there is no difference in genetic immunoregulation between subjects with SPSTs and MPSTs but that the presence of the DR4 gene product is associated with a decreased risk of an IgE response to MC and protection from MC pollenosis.

Hymenoptera Hypersensitivity in an Imported Fire Ant Endemic Area

BACKGROUND Imported fire ants are a common cause of insect venom hypersensitivity in the Southeastern United States. OBJECTIVE The purpose of this study was to determine the most frequent insect cause for evaluation in a Hymenoptera hypersensitivity clinic in an area endemic for the imported fire ants. METHODS This was a retrospective study reviewing all patients seen in a venom clinic at a large teaching hospital. RESULTS Of the 703 patients evaluated, between 1985 and 1995, 515 (73%) had reactions consistent with systemic anaphylaxis for which a determination of specific IgE was appropriate. Of the 703 patients seen, 315 (45%) had a positive history and skin test positivity and were offered specific immunotherapy. This was 61% of those individuals skin tested. Of the total patients seen, imported fire ants were responsible for 42% of the visits to the clinic and accounted for 59% of the total immunotherapy that was begun in this endemic area. CONCLUSION In areas endemic for the imported fire ants, the most frequent cause of Hymenoptera hypersensitivity is the imported fire ant.

Allergy to β-lactams: A survey of current practices

Abstract Many issues related to the diagnosis and management of β-lactam drug allergy still await definitive recommendations. To determine how practicing allergists deal with some of these dilemmas, a questionnaire was mailed to 3500 physician members and fellows of the American Academy of Allergy and Immunology. It was also sent to each of the allergy training program directors in the United States to determine what is currently taught to fellows in training. Benzylpenicilloyl-polylysine (Pre-Pen) and fresh penicillin G are used for skin testing by more than 86% of both respondent groups, whereas minor determinant mixtures are used by only 40%. Epicutaneous followed by intradermal injection was the skin test technique used by 86% of these allergists. More than 90% said they would skin test in cases of reaction history of urticaria, whereas only 1.5% would test in cases of family history of penicillin allergy. Practicing allergists and program directors differed slightly when queried about cephalosporin cross-reactivity. Program directors were more cautious in their use of cephalosporins with patients allergic to penicillin. Program directors were also more likely to repeat skin testing before future penicillin courses than were practicing allergists. Clearly, some individual approaches to the diagnosis and management of β-lactam allergy are practiced. Development of practice guidelines by our professional organizations may be useful.

Stinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

Practice ParameterStinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

Successful rush immunotherapy for anaphylaxis to imported fire ants

Imported fire ants (IFAs) infest most of the southern United States.] Life-threatening anaphylaxis occurs in 1% to 2% of patients treated by physicians for IFA stings. 1 In endemic areas the annual attack rate is high, ranging from 13% to 58%,2 and IFAs may comprise the majority of insect hypersensitivity.3 Immunotherapy with IFA whole body extract prevents recurrent anaphylaxis after subsequent IFA stings. Although successful rush immunotherapy (RIT) has been reported for anaphylaxis caused by winged Hymenoptera,S no published reports of RIT for IFA anaphylaxis exist. We report the successful use of RIT with IFA extract.

Identification of allergens in the venom of the common striped scorpion

BACKGROUND The common striped scorpion, Centruroides vittatus, is endemic to the southwestern United States and causes thousands of human stings annually. Immediate hypersensitivity reactions to C. vittatus venom have been reported. OBJECTIVES To identify specific IgE in 11 patients with immediate hypersensitivity to C. vittatus and to characterize the allergens present in the venom. METHODS Skin testing to dialyzed, filtered venom was performed in 5 patients. Immunoglobulin E immunoblots to whole milked venom was accomplished with serum samples from 8 patients. Enzymatic properties of whole venom were also determined. RESULTS C. vittatus venom was found to contain 150 microg/microL of protein. Four of 5 patients tested had positive skin test reactions to the purified venom extract, with no late reactions. In all 8 patients, sodium dodecyl sulfate-polyacrylamide gel electrophoresis demonstrated multiple proteins, 9 of which were identified as allergens on IgE immunoblots, ranging in size from 30 to 170 kD. Enzymatic activity was found to include phospholipase A, alkaline phosphatase, esterase, esterase lipase, and acid phosphatase. CONCLUSIONS C. vittatus envenomation may result in immediate hypersensitivity reactions in susceptible individuals. Venom specific IgE can be identified by using skin tests and IgE immunoblots. The allergens identified in these patients had molecular weights distinct from those of known scorpion neurotoxins. A safe and effective skin testing extract can be prepared from dialyzed pure venom and may lead to the widespread ability to diagnose C. vittatus venom allergy.

Are ACE Inhibitors and Beta-blockers Dangerous in Patients at Risk for Anaphylaxis?

The objective of this article is to review the available studies regarding angiotensin converting enzyme (ACE) inhibitors and beta-blockers and their effect on patients at risk for anaphylaxis. A literature search was conducted in PUBMED to identify peer-reviewed articles using the following keywords: anaphylaxis, ACE inhibitor, beta-blocker, food allergy, radiocontrast media, venom allergy, skin testing, and immunotherapy. Some studies show an increased risk of anaphylaxis in patients who are taking ACE inhibitors and beta-blockers, whereas others studies do not show an increased risk. For venom immunotherapy, there are more data supporting the concomitant use of beta-blockers and ACE inhibitors in the build-up and maintenance phases. Most of the medical literature is limited to case reports and retrospective data. Prospective controlled trials are needed on this important topic. For those patients at risk of anaphylaxis who lack cardiovascular disease, it is recommended to avoid beta-blockers and possibly ACE inhibitors. However, for those patients with cardiovascular disease, beta-blockers and ACE inhibitors have been shown to increase life expectancy. Consideration should be given for the concomitant use of these medications while patients are receiving venom immunotherapy.