[Update on the latex allergy topic]

Type I allergies to latex have become an increasing problem in occupational dermatology during the past few years, especially since at least 10% of health care workers are affected. In the Department of Dermatology, University Erlangen-Nuremberg, a 12-fold increase in latex-allergic patients has been documented between 1989 and 1995 with a clear trend to more severe systemic manifestations (from 10.7% in 1989/ 1990 to 44% in 1994/1995). Among the water soluble proteins (molecular weights 2 to 200 kD) which may induce latex allergy, at least 5 are considered as main proteins with known primary structure. In addition some "marker' proteins seem to induce specific IgE antibodies in special risk groups (e.g. 46 kD-protein in medical professions, 14.6 kD- and 27 kD-proteins in children with spina bifida). Cross reactions between latex and several fruits (especially avocado, kiwi, banana and chestnut) in 60 to 70% of latex-allergic patients have to be taken into account when evaluating and counselling affected patients. Most important in prophylaxis is the complete change to powder-free latex gloves in medical institutions, since these gloves usually have a low protein content. Our listing of surgical and examination gloves according to their protein content (as measured by the modified Lowry- and High Pressure Liquid Chromatography method) should be a useful guideline for the choice of suitable gloves.

[Latex: an allergological emergency? An update and outlook]

Allergy to latex has become an increasing and clinically important problem during last years. Natural rubber latex (NRL) allergy has been acknowledged as a major occupation problem among health-care workers. More recently, NRL allergy also occurs in children with spina bifida and in atopic children. Even patients allergic to various fruits, such as banana and avocado may experience allergic reaction from NRL and vice versa. Different latex allergens have been characterized at the molecular level using varied techniques and heterogeneous latex materials. Little is known about prevalence and clinical relevance of latex sensitization and allergy in the general population although the incidence is increasing in children. The wide spectrum of symptoms of NRL allergy range from mild contact urticaria to asthma and anaphylactic reactions. History is an integral part to identify latex allergy. Different tests (skin prick tests, RAST, Pricking, Use test) have been used to objectively supplement the history. Latex allergy must be prevented by the standardization of medical gloves including the labeling of latex content and allergenicity; furthermore the industrial strategies may also develop new methods of less allergenic gloves and other NRL products.

Natural rubber latex skin testing reagents: safety and diagnostic accuracy of nonammoniated latex, ammoniated latex, and latex rubber glove extracts

BACKGROUND

Nonammoniated latex, ammoniated latex, and rubber glove extracts are the only sources of natural rubber (Hevea brasiliensis) latex that have potential for use as skin testing reagents in the diagnosis of latex allergy. Their diagnostic sensitivity and specificity as skin test reagents are unknown.

OBJECTIVE

We conducted a phase 1/2 clinical study to examine the safety and diagnostic accuracy (sensitivity and specificity) of nonammoniated latex, ammoniated latex, and rubber glove extracts as skin test extracts to identify the most efficacious source material for future skin test reagent development.

METHODS

Twenty-four adults not allergic to latex, 19 adults with hand dermatitis or pruritus, and 59 adults with a latex allergy were identified by clinical history. All provided blood and then received puncture skin tests and intradermal skin tests with nonammoniated latex, ammoniated latex, and rubber glove extracts from Malaysian H. brasiliensis latex by use of sequential titration. A glove provocation test and IgE anti-latex RAST were used to clarify positive history-negative skin test response and negative history-positive skin test response mismatches.

RESULTS

All three extracts were biologically safe and sterile. After normalization to 1 mg/ml of total protein, all three extracts produced equivalent diagnostic sensitivity and specificity in puncture skin tests and intradermal skin tests at various extract concentrations. Optimal diagnostic accuracy was safely achieved at 100 micrograms/ml for intradermal skin tests (e.g., nonammoniated latex: puncture skin test sensitivity 96%, specificity 100%; intradermal skin test sensitivity 93%, specificity 96%). The presence of IgE antibody in skin was highly correlated with IgE anti-latex in serum (nonammoniated latex: r = 0.98, p < 0.001; ammoniated latex: r = 0.94, p < 0.001; rubber glove extract: r = 0.96, p < 0.001). All five available subjects with a positive history, negative skin test response, and absence of IgE antibody in serum had a negative glove provocation test response, indicating no clinical evidence of latex allergy. No systemic or large local allergic reactions were observed with puncture skin tests or intradermal skin tests.

CONCLUSIONS

Equivalent diagnostic sensitivity and specificity were observed with the nonammoniated latex, ammoniated latex, and rubber glove extract skin test reagents after normalization for total protein; nonammoniated latex may be considered the reagent of choice on the basis of practical quality control and reproducibility considerations.

A novel acidic allergen, Hev b 5, in latex. Purification, cloning and characterization

Latex allergy is recognized as a serious health problem among health care workers and children with spina bifida. A number of IgE-reactive proteins have been identified in natural and processed latex products. One of the most acidic proteins in the cytoplasm of lacticifer cells of rubber trees (Hevea brasiliensis) is demonstrated to be a potent allergen in eliciting allergic reactions in humans. This protein, with pI = 3.5, has a molecular mass of 16 kDa with a blocked N terminus and an unusual amino acid composition. This acidic protein was found in extracts prepared from latex gloves, which were shown to be allergenic. The purified protein elicits histamine release from human basophils passively sensitized with serum from latex-allergic individuals in a dose-dependent manner. From a latex cDNA library, the cDNA coding for this protein was isolated and sequenced. The deduced amino acid sequence shows a high degree of homology to another acidic protein identified in kiwifruit (Actinidia deliciosa var. deliciosa). The sequence homology (47% sequence identity) between these two acidic proteins suggests a molecular explanation for the high frequency of fruit hypersensitivity in latex-allergic patients.

Latex elastic-induced periodontal damage: a case report on the subsequent orthodontic management

Proper management of a malocclusion relies on a basic understanding of the development of the dentition and the craniofacial complex. Diagnosis should only be formulated after all the relevant diagnostic records, including clinical examination and history, are reviewed. Armed with this information, the dentist forms the treatment plan. The mere occurrence of a malocclusion does not constitute a need for treatment. Injudicious intervention can be counterproductive or destructive. Through a case report, the deleterious effects of improper case management and questionable treatment mechanics are highlighted. The subsequent orthodontic management emphasizes the principles and techniques for the successful treatment of the patient in question.

Latex allergy and the student with spina bifida

This article discusses the potential problem of latex allergy in the school, particularly among students with spina bifida. The origin of the problem, its symptoms, and prevention and management of latex allergy in the school environment are described. The individual roles of school administrator, school nurse, parent, student and other service providers are listed within an Individual Healthcare Plan (IHP). The IHP is proposed as a guide to schools to assist with identification of latex allergy reactions as well as response procedures if an allergic reaction is identified.

Latex-induced asthma in a dental assistant

In this case report, latex-induced asthma is described in a dental assistant with an associated history of contact dermatitis, contact urticaria, and rhinitis. She switched to vinyl gloves, which eliminated her cutaneous symptoms, but her respiratory symptoms continued. Skin-testing to latex was strongly positive. Methacholine challenge and peak expiratory flow rates (PEFR) were abnormal during the workweek but normalized after a two-week vacation. Nebulized latex was implicated in the development of occupational asthma, and personal latex-avoidance measures did not prevent the condition.

[Latex allergy in 16 children]

BACKGROUND

Latex allergy is now well-known in adults and children. It represents the first cause of anaphylactic operating shock in pediatrics.

POPULATION

A diagnosis of latex allergy was made in 16 children (five girls and 11 boys), aged 2 to 15 years, because of evoking signs and symptoms, from simple urticaria to Quincke edema in presence of latex. The revealing factor was wheezing in balloons in 13 out of the 16 patients. An atopic past history was frequent. Previous eventually sensitizing surgical operations were present in five patients; associated food allergy existed in four. Skin tests were positive in nine out of 12 patients, as well as latex specific IgE (13 out of 16). The diagnosis was made with a labial provocation test in one patient.

CONCLUSION

Latex allergy can be severe and requires that patients avoid any contact with rubber objects, especially gloves. A detailed medical certificate should be given to the family in view of any medical, surgical or dental intervention.

Delayed and immediate orofacial reactions following contact with rubber gloves during dental treatment

Allergic reactions during or after dental examination are uncommon. However, such reactions may be serious and distressing. Allergy to local anaesthetics and dental materials may be considered, but reactions to rubber in gloves worn by the dentist should be remembered. Two patients are reported who experienced symptoms following contact with rubber gloves worn by their dentists, with skin tests subsequently showing an allergic reaction to glove constituents, and in one case latex. With the increasing use of rubber gloves by dental and medical personnel, reactions in sensitised patients are likely to become more common. In patients with a history of symptoms related to dental work, it is important to remember delayed and immediate reactions to rubber.

[Latex allergy: from contact urticaria to asthma]

Latex, a natural plant material, has gained increasing interest over the last years because of its allergenic potency inducing problems in medical professions as well as in daily life. Since 1979 reports on allergic spontaneous reactions induced by latex products (such as gloves, condoms, balloons, cofferdam) have increased steadily. Symptoms manifest clinically as contact urticaria, rhinoconjunctivitis, asthma or anaphylactic shock. Some of these patients may additionally have an alimentary allergy (avocado, banana, maron i.e.), possibly containing agents cross-reacting with latex. Pathophysiologically the allergy is IgE-mediated, because antigen-specific IgE antibodies have been found in vitro as well as in vivo. Health professionals, workers in gum manufacturing and individuals with spina bifida have been found to be at special risk for a latex allergy therefore, it is important that these persons at risk are recognized and occasionally tested prior to interventions or operations. Strict avoidance of the use of latex products is the primary preventive measure, which may occasionally be difficult, particularly in patients with respiratory diseases.

A medical-center-wide, multidisciplinary approach to the problem of natural rubber latex allergy

Latex is a common cause of occupational allergy in health care workers; latex-sensitized patients are at increased risk of allergic reactions in medical environments. Skin test reagents and latex-specific immunoglobulin E immunoassays were established for diagnosis of latex allergy. Inhibition immunoassays were developed for measuring latex aeroallergens and latex allergens in rubber products. A registry of latex-sensitive employees was established. High-allergen gloves were removed from the medical center inventory; latex aeroallergen levels subsequently declined. Despite an increasing number of gloves used annually, expenditures for gloves in 1994 were lower than in previous years. Latex-sensitive individuals can be identified using skin tests or immunoassays. Latex aeroallergen levels in medical environments can be reduced substantially at lower cost by using powder-free rubber gloves with lower allergen content.

The potential risks of latex

Natural Latex is the milky sap from the Rubber Tree (Hevea brasiliensis) plant. Reports of patients developing sensitivities to latex following contact with items containing this product have risen considerably since 1979 when they were first described by Nutter. These allergies should not be taken lightly. At one end of the scale they can be mildly uncomfortable, at the other they can be life threatening. The problem of acquired latex allergy confronts not only health care workers in the daily delivery of healthcare but also individuals in the home and everyday life as the use of latex in products has greatly increased in recent years.

Safety of intravenous ketorolac therapy in children and cost savings with a unit dosing system

OBJECTIVE

To determine the incidence of side effects with the short-term use of intravenously administered ketorolac in children and the overall cost savings with a unit dosing system.

STUDY DESIGN

We prospectively examined the incidence of complications arising from the intravenous administration of ketorolac to 1747 children (14,810 doses) during a 3-year, 3-month period and assessed cost savings resulting from dividing 60 mg syringes into 7.5, 15, 30, and 60 mg unit doses. Complications were recorded prospectively into a computerized database. Estimated drug costs to the pharmacy were calculated on the basis of the total numbers of each drug fraction administered, with allowance for 1O% wastage as a result of drug expiration.

RESULTS

Side effects occurring with ketorolac administration were rare. Four patients (0.2%) had hypersensitivity reactions to the drug, two of them possibly on the basis of latex allergy. Two patients (O.1%) had renal complications but were subsequently found to have underlying causes that could account for their renal symptoms. One patient (0.05%) had massive gastrointestinal bleeding in the postoperative period. With fractionation of 60 mg syringes, total drug cost to the pharmacy was $34,786, rather than the $86,639 that would have been spent had a single syringe been used for each dose.

CONCLUSION

Ketorolac proved safe for short-term intravenous use in children more than 1 year of age when patients with known contraindications to the use of non-steroidal antiinflammatory drugs were excluded. A considerable reduction in drug costs can be achieved with fractionation of premixed syringes into unit doses.