allergy
Clinical usefulness of patch and challenge tests in the diagnosis of cell-mediated allergy to betalactams.

Patriarca G, D'Ambrosio C, Schiavino D, Larocca LM, Nucera E, Milani A.

Department of Internal Medicine and Allergology, Universita Cattolica S.Cuore, Rome, Italy.

BACKGROUND: Literature reports dealing with cell-mediated allergy to betalactams have appeared with increasing frequency in the last years. OBJECTIVE: To evaluate patients with such reactions and to identify cross-reactivities among betalactams in order to provide safe guidelines for their further clinical management. METHODS: Thirty consecutive subjects with cell-mediated allergy to betalactams (history of adverse reactions to these antibiotics; serum total IgE within the normal range; absence of serum specific IgE antibodies to penicillin G and V, amoxicillin, and ampicillin; negative skin tests with a wide pattern of betalactam preparations; and positive patch-test to at least one betalactam antigenic determinant) were investigated. The subjects admitted to the study were patch tested with a wide variety of betalactam preparations in order to identify alternative molecules tolerated by the patient. To better evaluate the cross-reactivity pattern, tolerance challenges with patch-negative betalactams were also performed in each subject. RESULTS: Both specific IgE and skin tests were negative in all patients. The skin biopsies performed on the positive patch-tested area in four patients showed a clear T-lymphocyte, CD4+-type infiltrate, thus definitely proving the occurrence of a cell-mediated response. A total of 44 adverse reactions (mean: 1.47 episodes for each patient) were reported in history, with a mean interval of 15 hours after betalactam administration. The reported symptoms were mainly cutaneous (maculo-papular rash and urticaria) and the responsible drugs were chiefly aminopenicillins (86.4% of cases) and penicillin G (9.1%). We were able to identify three separate groups of patients on the basis of clinical history, patch-test, and tolerance challenge pattern: allergy to the side chain of aminopenicillins in 16 patients (53.3%); allergy to the thiazolidine ring in 3 patients (10.0%); undetermined specificity in the remainder 11 patients (36.7%). Cross-reactivity among different betalactam molecules (revealed by positive tolerance tests performed with patch-negative betalactams) was found in 4.8% of cases only (23.3% of all investigated patients). This fact demonstrates a very high (95.2%) predictive value of a negative patch-test in excluding the occurrence of a cross-reactivity. The mis-match between patch and tolerance tests was observed in 3 out of 178 cases only (1.7% of cases, 10.5% of patients) in groups A and B, and in as much as 12.2% of cases (45.5% of subjects) in group C (P < .05). CONCLUSIONS: Delayed allergy to betalactams (mainly to aminopenicillins) may be exerted by a cell-mediated response. Patch tests and tolerance challenges are extremely useful and safe for diagnosis and further clinical treatment of these patients, helping to identify safe alternative betalactam molecules that could be successfully tolerated by the allergic subjects.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10507273&dopt=Abstract allergy medicine



allergy
Human immunoglobulin isotype profiles produced in response to antigens recognized by monoclonal antibodies specific to Anisakis simplex.

Lorenzo S, Iglesias R, Audicana MT, Garcia-Villaescusa R, Pardo F, Sanmartin ML, Ubeira FM.

Laboratorio de Parasitologia, Facultad de Farmacia, Universidad de Santiago de Compostela.

BACKGROUND: Anisakis simplex is a medically important pathogen which not only causes anisakiasis but may provoke allergy reactions, ranging from mild urticaria to anaphylactic shock. OBJECTIVE: To investigate anti-Anisakis isotype profiles in anisakiasis and Anisakis allergy patients. METHODS: Capture ELISA techniques were used to investigate the isotype profiles of antibodies specific for two defined Anisakis simplex antigens, in serum from Japanese patients with confirmed anisakiasis and from Spanish patients with allergy to Anisakis. The antigens were 'UA2R antigens' (two proteins with MW of 48 and 67 kDa, recognized by our monoclonal antibody UA2) and 'UA3R antigens' (two proteins with MW of 139 and 154 kDa, recognized by our monoclonal antibody UA3). RESULTS: Considering IgG, the two most frequent isotypes in the response to the UA2R antigens were IgG1 and IgG2, with IgG4 detected in only one case; in response to the UA3R antigens, by contrast, the two most frequent isotypes were IgG1 and IgG4 (though IgG2 remained reasonably frequent). As regards potential utility for serodiagnosis, 95% of the Japanese anisakiasis patients and 84% of the allergy patients showed detectable IgG1 antibodies to the UA3R antigens. Furthermore, all allergy patients showed IgE antibodies to these antigens. CONCLUSION: Anisakis simplex contains antigens that induce responses which are differentially regulated. Because of their immunogenicity, immunodominance and allergenic nature, we consider that the 139/154-kDa antigens recognized by our MoAb UA3 are good candidates for use in tests for the diagnosis of anisakiasis and of the allergy caused by this parasite.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10457114&dopt=Abstract allergy medicine



allergy
Association of allergy with Tourette's syndrome.

Ho CS, Shen EY, Shyur SD, Chiu NC.

Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan.

In our clinical practice, we often encounter signs and symptoms of allergy, such as rhinitis and asthma, in patients with Tourette's syndrome (TS). Some of the allergic manifestations are similar to the oral tics or motor tics found in TS patients. To clarify the association between TS and allergy, we evaluated 72 consecutive patients with TS from 1 September 1996 through 31 August 1997. The diagnosis of TS was based on the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria. Sixty-five boys and 7 girls, 4 to 17 years old (9.4 +/- 3.1 yr) were evaluated using the Multiple Allergens Simultaneous Tests (MAST) for the detection of total and specific immunoglobulin. Forty-five patients had positive results, of whom 41 (56.9%) had clinical evidence of allergy. The prevalence of allergy in the local population as reported by The International Study of Asthma and Allergy in Childhood Taiwan Group (1994) was 44.3% (33.5% with allergic rhinitis and 10.8% with asthma). These subjects served as controls. Comparing the number of patients with clinical evidence of allergy in the MAST positive group (56.9%) of TS patients with the control group (44.3%), the difference was significant++ (p < 0.05). The prevalence of allergy in TS patients in our study was significantly higher than in the general population. TS had an association with allergy.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10462998&dopt=Abstract allergy medicine



allergy
Specific immunoglobulin E to peanut, hazelnut and brazil nut in 731 patients: similar patterns found at all ages.

Pumphrey RS, Wilson PB, Faragher EB, Edwards SR.

Immunology Unit, Central Manchester Healthcare NHS Trust Hospitals, St Mary's Hospital, UK.

BACKGROUND: Previous studies have reported reactions to an increasing range of nuts as patients with nut allergy grow older. Most patients with symptoms suggesting nut allergy have specific IgE to more than one nut. Furthermore, fatal reactions have followed eating nuts different from any causing the deceased's previous reactions. OBJECTIVE: To explore the pattern of specific IgE to three distantly related nuts in patients of all ages with nut allergy. METHODS: This study includes all patients referred to our laboratory for nut allergy testing from January 1994 to August 1998 who were tested for peanut, hazelnut and brazil nut, and had specific IgE to at least one of these nuts. All tests were performed using the Pharmacia Unicap system. RESULTS: Seven hundred and thirty-one patients (age 7 months to 65 years, median 6.6 years) had specific IgE >0.35 kU(A)/L to at least one of these three nuts: 282 had IgE to one nut, 130 to two nuts, and 319 to all three nuts. When analysed by gender and age quartile, very similar patterns were found in all subgroups though significant age trends and age interactions were found for IgE to individual nuts and combinations of nuts. CONCLUSIONS: The probability of a patient with nut allergy having specific IgE to a particular combination of peanut, hazelnut and brazil nut is similar, whatever their age or sex. The apparent increase in multiple nut reactivity with increasing age may therefore be due to exposure of previously unchallenged sensitivity. The frequency of multiple-nut specificity is sufficiently high that patients should always be tested for allergy to a range on nuts if they have a history of reacting to any nut.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10469035&dopt=Abstract allergy medicine



allergy
Self-administration of epinephrine in children: a survey of current prescription practice and recommendations for improvement.

Hughes JL, Stewart M.

Department of Child Health, Institute of Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BJ. jlhughes doctors.org.uk

The prevalence of peanut allergy is increasing rapidly and many children are now prescribed self-injectable epinephrine as part of their management. We aimed to examine the current extent of self-injectable epinephrine dispensing to children in the Eastern Health and Social Services Board (EHSSB), Northern Ireland, including indications for prescription, investigations performed, information and training provided and actual usage. Dispensing records held by the EHSSB were examined for the period May to August 1998. All general practitioners prescribing 'Epipens' during this period were contacted and asked to identify the patient and provide contact details. Information was gathered using postal questionnaires sent to General Practitioners and parents. A total of 104 'Epipen' prescriptions were dispensed. Thirty-seven (36%) general practitioners responded to the initial questionnaire; of these 36 (35%) were suitable for analysis. Thirty-four parents were then contacted; 28 (82%) returned questionnaires were reviewed. The commonest indication for 'Epipen' prescription was peanut allergy (32 of 36 (89%) general practitioner responses; 25 of 28 (89%) parent responses). Twenty-six (72%) children had been seen by a specialist; all except one had either blood or skin tests. Six of the remaining eight children had no investigations. General practitioners reported 14 (39%) parents to have basic life support training, compared with six (21%) parents. Eighteen (64%) parents had been given written information regarding their child's allergy, nine (32%) had been referred to a dietician and seven (25%) children wore a medical warning bracelet. The Epipen had been used by three children; all three had multiple food allergies. This study has identified a great variability in the management of children with allergy including the need for specialist referral, further investigation, written allergy advice, referral to a dietician and formalised training in basic life support and administration of epinephrine. It suggests a lack of consensus amongst health care professionals as to the best practice in the management of potentially life threatening food allergy and indicates, at least, a need for better multidisciplinary communication.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14696817&dopt=Abstract allergy medicine



allergy
Idiopathic maxillary pain: prevalence of maxillary sinus hyperreactivity in relation to allergy, chronic mucosal inflammation, and eosinophilia.

Emshoff R, Bertram S, Kreczy A.

Department of Oral and Maxillo-Facial Surgery, University of Innsbruck, Austria.

OBJECTIVE: In patients with chronic orofacial pain, an underlying sinus hyperreactivity may contribute to the clinical symptoms of a diagnosis of atypical odontalgia, trigeminal neuralgia, or temporomandibular disorders. The purpose of this study was to assess the prevalence of histamine-related maxillary sinus hyperreactivity in patients manifesting signs and symptoms of idiopathic maxillary pain and to correlate the respective findings with the presence or absence of chronic maxillary sinusitis-related diagnoses such as allergy, chronic mucosal inflammation, and eosinophilia. STUDY DESIGN: Fifty patients who had been assigned a diagnosis of idiopathic maxillary pain underwent skin allergy tests, maxillary sinus histamine provocation tests, and maxillary sinus mucosa biopsy. Histamine challenge to a selected area was performed during transoral sinuscopy of the maxillary sinus; a positive test result was defined as the development of a significant local mucosa response such as reddening and swelling. RESULTS: Comparison of the data showed most patients (38%) to have an absence of chronic maxillary sinusitis-related diagnoses, whereas the most common multiple diagnosis was found to be chronic mucosal inflammation in combination with eosinophilia (22%). Regarding the prevalence rates of positive histamine provocation test outcomes, a significant difference was found between the diagnostic subgroup "absence of chronic maxillary sinusitis-related diagnoses" (36.9%) and the diagnostic subgroups "chronic mucosal inflammation" (20%; P< .05), "chronic mucosal inflammation in combination with eosinophilia" (18.2%; P< .05), and "chronic mucosal inflammation in combination with eosinophilia and allergy" (14.3%; P < .01). An analysis of the distribution of chronic maxillary sinusitis-related diagnoses revealed absence of chronic mucosal inflammation-related diagnoses to be significantly more frequently associated with positive histamine provocation test outcomes than with negative histamine provocation test outcomes (41.2% vs 19.7%; P< .01), whereas chronic maxillary sinusitis (41.0% vs 29.4%), eosinophilia (26.2% vs 17.6%), and allergy (13.1% vs 11.8%) were found to be more prevalent in patients with negative histamine provocation test outcomes. CONCLUSIONS: The findings of this study suggest patients with idiopathic maxillary pain to be associated with a low rate of sinus hyperreactivity, whereas a positive test outcome with histamine provocation may not be linked to the presence of chronic maxillary sinusitis-related diagnoses such as allergy, chronic mucosal inflammation, and eosinophilia. Further investigations using a larger sample size of patients with idiopathic maxillary pain and nonidiopathic maxillary pain are necessary to demonstrate the presence or absence of an idiopathic maxillary pain-specific prevalence of maxillary sinus hyperreactivity.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10397658&dopt=Abstract allergy medicine



allergy
Lymphonodular hyperplasia as a sign of food allergy in children.

Kokkonen J, Karttunen TJ, Niinimaki A.

Department of Pediatrics, University Hospital, Oulu, Finland.

BACKGROUND: Lymphonodular hyperplasia of the gastrointestinal tract in children is a rare endoscopic finding of uncertain clinical significance. In this study, 12 children with lymphonodular hyperplasia of the duodenum from a series of 63 children were studied for recurrent abdominal pain. Four additional children with lymphonodular hyperplasia of the colon are described. All the patients with lymphonodular hyperplasia were also evaluated for food allergy. METHODS: A gastroduodenoscopy was performed in the patients with recurrent abdominal pain and in the four in whom lymphonodular hyperplasia of the colon had been diagnosed by colonoscopy. An open oral elimination and challenge test to diagnose food allergies was scheduled for all subjects with lymphonodular hyperplasia or any suspicion of food allergy. The study design also included skin prick tests with common allergens and determination of serum immunoglobulin A and immunoglobulin E concentrations. RESULTS: Lymphonodular hyperplasia of the duodenal bulb was the main finding in 12 (19%) of the 63 children. The condition was found to be associated with food allergy in nine subjects (75%), which was significantly more often than among the remaining 51, 12 (24%) of whom had food allergy by the same criteria. In an oral challenge, food allergy first manifested gastrointestinal symptoms in the subjects of both groups and, in all except one, on days 2 through 5 after the foodstuffs were administered in minimal doses. In a histologic study, the duodenal specimens revealed significantly more eosinophilic cells in the children with food allergy and lymphonodular hyperplasia than in the children with food allergy but no lymphonodular hyperplasia. The major symptoms in the four patients with lymphonodular hyperplasia of the colon had been anemia and blood in stool in two and abdominal pains with mucous loose stools in the remaining two. Colonoscopic examination showed one to have diffuse and the other three patchy lymphonodular hyperplasia of the colon. In an oral challenge, three reacted to milk and two to cereals. CONCLUSIONS: Preliminary observations showed that lymphonodular hyperplasia of the duodenum or the colon is related to the gastrointestinal type of food allergy to basic foodstuffs. Further research is needed to define this finding as a separate entity.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10400105&dopt=Abstract allergy medicine