Latex sensitization by dermal exposure can lead to airway hyperreactivity

BACKGROUND

Using non-powdered, low-protein natural rubber latex (NRL) gloves has been shown to reduce the elicitation of respiratory symptoms in latex-allergic individuals; however, the role of dermal exposure in the induction of sensitization is not completely understood.

OBJECTIVE

These studies were conducted to (1) determine levels of NRL protein in gloves currently in use and (2) evaluate, using a murine model, the potential for dermal exposure to induce NRL sensitization and subsequent airway hyperreactivity upon respiratory challenge.

METHODS

Total extractable protein and NRL allergen levels were evaluated from 38 glove samples using the Lowry and CAP inhibition assays, respectively. BALB/c mice were dermally exposed to non-ammoniated latex (NAL, 6.25-25 microg) 5 days/week for 13 weeks and monitored weekly/biweekly for IgE levels. Airway hyperreactivity was determined following respiratory challenge with methacholine (MCH) or NAL proteins on days 60 and 93, respectively.

RESULTS

Glove total protein and NRL allergen levels ranged from below the limit of detection to 946 microg/g and from 0.002 to 112 microg/g, respectively. Mice demonstrated dose-dependent increases in total serum IgE levels by day 58 with increased airway hyperreactivity observed upon respiratory challenge with MCH (day 60) or NAL proteins (day 93).

CONCLUSIONS

These studies investigated the continued use of gloves with high levels of total extractable protein and NRL allergen. The potential for dermal exposure to induce NRL-specific IgE and airway hyperreactivity upon respiratory challenge suggests there should be continued concern regarding the induction of sensitization in individuals using non-powdered latex gloves.

Severe anaphylactic shock without exanthema in a case of unknown latex allergy and review of the literature

We describe a case of severe anaphylactic shock without exanthema in an 8-year-old boy who was undergoing elective surgery for an ileostomy. The boy had a history of four anorectal operations in the newborn period, but no history of allergies. Sudden, profound bronchospasm and cardiorespiratory collapse occurred 30 min after the beginning of the operation. No signs of exanthema or urticaria were seen. The patient was resuscitated successfully and remained ventilated for 25 h. During this time, he needed epinephrine in dosages of 0.3-0.05 microg.kg-1.min-1. Radioallergosorbent (RAST) tests for the patient were positive Cap Class 3 and 4, and specific immunoglobulin E was highly positive, suggesting a natural rubber latex allergy as the cause of the anaphylactic shock. Ethylene oxide was negative. Eleven days later, a further operation was performed with a strict latex-free protocol in the presence of histamine 1 and 2 receptor antagonists. On this occasion, the intraoperative course was uneventful. Incidence of anaphylactic reactions, prevalence of latex sensitization, special risk groups and management are discussed.

[Latex-fruit syndrome]

During the last decade, latex IgE-mediated allergy has been recognized as a very important medical problem. At the same time, many studies have dealt with allergic cross-reactions between aeroallergens and foods. In this context, there is clear evidence now on the existence of significant clinical association between latex and fruit allergies. Therefore, a latex-fruit syndrome has been postulated.Several studies have demonstrated that from 20% to 60% of latex-allergic patients show IgE-mediated reactions to a wide variety of foods, mainly fruits. Although implicated foods vary among the studies, banana, avocado, chestnut and kiwi are the most frequently involved. Clinical manifestations of these reactions may vary from oral allergy syndrome to severe anaphylactic reactions, which are not uncommon, thus remarking the clinical relevance of this syndrome.The diagnosis of food hypersensitivities associated to latex allergy is based on the clinical history of immediate adverse reactions, suggestive of an IgE-mediated sensitivity. Prick by prick test with the fresh foods implicated in the reactions shows an 80% concordance with the clinical diagnosis, and therefore it seems to be the best diagnostic test available nowadays in order to confirm the suspicion of latex-fruit allergy. Once the diagnosis is achieved, a diet free of the offending fruits is mandatory.Recently, some of the common allergens responsible for the cross-reactions among latex and the fruits most commonly implicated in the syndrome have been identified. Class I chitinases, with an N-terminal hevein like domain, which cross-react with the major latex allergen hevein, seem to be the panallergens responsible for the latex-fruit syndrome.

The prevalence of latex allergy in patients with rhinitis

Natural rubber latex hypersensitivity to the constituent proteins of natural rubber latex is now an international health problem. This study investigates the prevalence of latex allergy in patients presenting with rhinitis. Fifty-nine consecutive patients, who presented to a general Otolaryngology out-patient clinic with symptoms suggestive of rhinitis, completed a questionnaire and underwent skin prick testing. Three out of 59 (5.1 per cent) tested positive to latex. The overall positive rate (all standard aeroallergens) was 45.8 per cent. Our data supports the hypothesis that the prevalence of latex allergy in patients with rhinitis is higher than the general population and that rhinitis may be a presenting symptom.

Episodic stridor with latex nipple use in a 2-month-old infant

Latex allergy in the pediatric population is most commonly identified in patients who have undergone multiple operations for neural tube defects or exstrophic genitourinary anomalies. However, there are a significant number of children who, without the usual risk factors, clinically and/or serologically appear to be latex allergic. There is sporadic information in the medical literature regarding reactions to latex allergens in household items, especially in patients younger than 1 year old. Several recent reports even support the existence of reactions to latex pacifiers. We report a case of an atopic 2-month-old infant who experienced the previously unreported reaction of repeated stridor on exposure to a latex nipple while feeding. It is important that clinicians recognize stridor as a potential reaction to latex in infants.

Efficacy of latex avoidance for primary prevention of latex sensitization in children with spina bifida

Over 6 years, the prevalence of latex sensitization fell from 4/15 (26.7%) to 1/22 (4.5%) in children with spina bifida treated in a latex-free environment from birth compared with historic controls. These precautions appear to be efficacious for the primary prevention of latex sensitization.

[Latex allergy]

Within the last ten years, the IgE mediated type of allergy to natural rubber latex has become an increasing and clinically important problem. Health professionals, rubber industry workers and individuals with spina bifida have been found to be at special risk of latex allergy. Clinical symptoms manifest as contact urticaria, rhinoconjunctivitis, asthma or even as intraoperative anaphylactic shock. An association between allergies to latex proteins and to various food-"Latex fruit syndrome "has been reported. Strict avoidance of the use of latex products is the primary preventive measure. In this review, the author pays attention to epidemiology, risk factors, clinical symptoms, diagnostics and prevention strategies.

Type IV hypersensitivity reactions to natural rubber latex: results of a multicentre study

BACKGROUND

Positive patch test reactions to natural rubber latex (NRL) have been interpreted as allergic or irritant by different groups. Additives to the NRL test solution have also caused positive reactions in previous studies.

OBJECTIVES

Five centres of the British Contact Dermatitis Group conducted a prospective study on the prevalence of type IV hypersensitivity to NRL, using ammonia-preserved NRL solution for testing.

PATIENTS AND METHODS

A total of 2738 consecutive patients were patch tested. Where clinically indicated, specific IgE was measured or a prick test done.

RESULTS

Twenty-seven patients (1%) had a positive patch test reaction to NRL, which was considered to be allergic and of current relevance in 19 (70%) patients. Fourteen of these also had a positive prick test or specific IgE. Thirteen patients (48%) were male, 19 (70%) atopic and 13 (48%) had eczema on their hands.

CONCLUSIONS

We conclude that delayed-type hypersensitivity to NRL is a problem for a proportion of patients with eczema, particularly on their hands, and that patch testing with ammonia-preserved NRL can be recommended to identify these patients. Patients with a positive patch test should be investigated for contact urticaria to NRL.

Risk factors for latex sensitization in children with spina bifida

BACKGROUND

Children with spina bifida represent the major risk group for latex sensitization.

PURPOSE

To determine the prevalence of latex sensitization in these children and to identify risk factors.

MATERIAL AND METHODS

We studied 57 patients with spina bifida. The mean age was 5.6 years and the male/female ratio was 0.8/1. In all patients a questionnaire, skin prick test (SPT) with latex (UCB-Stallergènes, Lofarma and ALK-Abelló), common aeroallergens and fruits (UCB-Stallergènes) and serum determination of total IgE (AlaSTAT) were performed.

RESULTS

The prevalence of latex sensitization was 30 %; only two sensitized children (12 %) had symptoms after exposure. Risk factors for latex sensitization were age >/= 5 years (p = 0.008; OR = 6.0; 95 % CI = 1.7-22.1), having at least four previous surgical interventions (p < 0.0001; OR = 18.5; 95 % CI = 3.6-94.8), having undergone surgery in the first 3 months of life (p = 0.008; OR = 5.4; 95 % CI = 0.7-29.2) and total serum IgE >/= 44 IU/ml (p = 0.03; OR = 3.8; 95 %CI = 1.1-13.1). Multiple logistic regression analysis showed that only a history of four or more surgical interventions (p < 0.0001; OR = 26.3; 95 %CI = 2.9-234.2) and total serum IgE >/= 44 IU/ml (p = 0.02; OR = 8.6; 95 % CI = 1.4-53.4) were independently associated with latex sensitization. Sex, family and personal allergic history, hydrocephalus with ventriculoperitoneal shunt, cystourethrograms, intermittent bladder catheterization and atopy were not related to latex sensitization.

CONCLUSIONS

In children with spina bifida, significant and independent risk factors identified for latex sensitization were multiple interventions and higher levels of total serum IgE. A prospective study will clarify the clinical evolution of assymptomatic children sensitized to latex.

Hair glue anaphylaxis: a hidden latex allergy

BACKGROUND

Increasingly popular cosmetic hair alterations use latex-containing bonding glue to attach hair to the scalp. Immunoglobulin E-mediated reactions to natural rubber latex may occur from unappreciated sources.

OBJECTIVE

Evaluation of a case of bonding glue anaphylaxis with immunochemical characterization of the glue.

METHODS AND RESULTS

A 37-year-old woman developed systemic anaphylaxis upon repeated exposure to hair bonding glue. Skin tests to the glue and latex RAST tests were positive. Her sera reacted to latex antigens including four recombinant Hev b allergens. Assays of the glue revealed antigen patterns resembling ammoniated latex. Antigen levels exceed those reported in other natural rubber latex-dipped products.

CONCLUSIONS

Hair bonding glue contains high concentrations of soluble latex antigen and may cause anaphylaxis without mucosal contact. Repeated glue exposure may potentially sensitize consumers. Physicians, cosmetologists, and latex-allergic patients should be aware of bonding glue-induced immunoglobulin E-mediated reactions associated with hair alterations.

Anaphylactoid reaction to etomidate: report of a case

We report an anaphylactoid reaction to etomidate twice in a 60-year-old male with coronary artery disease and peripheral vascular disease. Following the first anaphylactoid reaction, the patient developed myocardial infarction. In addition, the patient's blood was moderately positive for latex antibodies, which made the differential diagnosis difficult. We concluded that the patient had anaphylactoid reaction to etomidate due to the temporal relationship to induction with the drug. The patient did not manifest similar reaction to other induction drugs used for other surgeries. The patient recovered from both incidents of anaphylactoid reaction to etomidate following intravenous administration of epinephrine and fluids.

Natural rubber latex-related occupational asthma: association with interventions and glove changes over time

BACKGROUND

Exposure to natural rubber latex (NRL) has been recognized as a cause of occupational asthma (OA), especially among health care workers (HCWs) associated with use of gloves. Little or no population-based data are available which chart the changes over time in the number of cases of OA as this problem was increasingly recognized and then interventions instituted.

METHODS

We obtained the numbers of allowed asthma claims with exposure to latex by year in the province of Ontario, Canada from the Ontario Workplace Safety and Insurance Board; details of the cases from the largest teaching hospital were reviewed. Interventions included: (1) in 1996, the Board recommended in its focus for accommodation of sensitized workers, the reduction of aerosols of latex proteins and that hospital facilities use powder-free, low-protein or nonlatex gloves; and (2) hospitals instituted latex policies and glove changes at various dates. For example, at the largest teaching hospital, interventions included education and voluntary medical surveillance in 1994; substitution of low protein, "powder-free" NRL gloves for non-sterile powdered gloves in 1995; and replacement of powdered sterile NRL gloves by lower protein, "powder-free" NRL gloves in 1997.

RESULTS

Through 1999, there were 60 allowed claims for asthma in Ontario with exposure to latex; of these 49 (82%) were among HCWs. The number of claims among HCWs changed from 0 to 2 per year up to 1990; increased to 7 to 11 per year between 1991-1994; and declined to 3 per year in 1995-1996 and 1 to 2 per year in 1997-1999. Of the ten institutions having two or more OA latex claims, all claims occurred in 1996 or earlier at 8 (80%). At the largest hospital, there were five accepted claims with year of diagnosis in 1993 (1 case), 1994 (3 cases), and 1995 (1 case).

CONCLUSIONS

These findings suggest that, despite the effect of increasing recognition, the introduction of gloves with reduced powder and/or protein, as well as other interventions have been associated temporally with declines in the number of cases of latex OA.

Anaphylaxis during anaesthesia. Results of a two-year survey in France

Between January 1, 1997 and December 31, 1998, 467 patients were referred to one of the allergo-anaesthesia centres of the French GERAP (Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques) network and were diagnosed as having anaphylaxis during anaesthesia. Diagnosis was established on the basis of clinical history, skin tests and/or a specific IgE assay. The most frequent cause of anaphylaxis was a neuromuscular blocking agent (69.2%). Latex was less frequently incriminated (12.1%) than in previous reports. A significant difference was observed between the incidence of anaphylactic reactions observed with each neuromuscular blocking agent and the number of patients who received each drug during anaesthesia in France throughout the study period (P<0.0001). Succinylcholine and rocuronium were most frequently incriminated. Clinical reactions to neuromuscular blocking drugs were more severe than to latex. The diagnostic value of specific IgE assays was confirmed. These results are consistent with changes in the epidemiology of anaphylaxis related to anaesthesia and are an incentive for the further development of allergo-anaesthesia clinical networks.

Hev b 7 is a Hevea brasiliensis protein associated with latex allergy in children with spina bifida

BACKGROUND

In addition to their disease-associated handicaps, patients with spina bifida (SB) are at high risk of developing latex allergy. Individuals with SB represent a special group of latex-allergic patients, inasmuch as their IgE-binding patterns differ from those of other populations of latex-allergic individuals. Two allergens strongly associated with latex allergy in patients with SB--Hev b 1 and Hev b 3--have already been identified.

OBJECTIVE

We intended to identify a predominant IgE-binding band--in addition to Hev b 1 and 3--at 43 kDa in a study population of 38 latex-allergic (IgE antibodies to latex and symptoms on provocation with latex gloves) and 15 latex-sensitized (IgE antibodies to latex but no symptoms on provocation) children with SB (mean age, 12.3 years) and to determine its frequency of recognition.

METHODS

Sera of latex-sensitized or latex-allergic patients with SB were tested on latex C extract containing natural Hev b 1, Hev b 3, and Hev b 7 and with the recombinant 43-kDa Hev b 7 in immunoblot and inhibition studies.

RESULTS

Natural Hev b 1 was recognized by 82% and natural Hev b 3 by 79% of the latex-allergic children with SB. In addition to some other proteins, 15 (39.5%) of 38 latex-allergic and 2 (13%) of 5 latex-sensitized children with SB revealed IgE binding to a 43-kDa band in the latex protein extract. We identified this 43-kDa IgE-binding band as natural Hev b 7 by immunoblotting and inhibition experiments using recombinant Hev b 7.

CONCLUSION

From these data, we conclude that Hev b 7, the patatin-like Hevea latex protein, is the third SB-associated latex allergen. Future immunotherapy for latex-allergic individuals with SB will have to include Hev b 7 in addition to Hev b 1 and Hev b 3.

Dental surgery in pediatric patients with spina bifida and latex allergy

Dental rehabilitation is a common outpatient pediatric surgical procedure. It requires the dentist to restore or extract the teeth of children with severe tooth decay or poor dental hygiene. Medical, physical, or emotional problems can make safe treatment in an outpatient setting impossible. These children require sedation or anesthesia for the dentist to gain access to their oral cavities. This article discusses caring for pediatric patients with spina bifida and latex allergy undergoing dental rehabilitation. Perioperative nurses must act as patient advocates in providing a latex-safe environment and also ensure quality care.

Anaphylactic Shock from a Latex Allergy in a Patient with Spinal Trauma

Allergy to latex is a condition that affects patients as well as health care workers. It is a spectrum of immunologic disorders that ranges from mild hypersensitivity to life-threatening anaphylaxis. Beginning in the early 1970s, the health care community has become more aware of this entity, leading to many improvements in the understanding, diagnosis and treatment of patients with latex allergy. Many hospitals have developed protocols and procedures for patients with latex sensitivity. However, some physicians remain unaware of the logistics of taking care of patients with this disorder. We present a case of a severe anaphylactic reaction to latex in a trauma patient with a spinal cord injury. The difficulty of treating the acutely injured patient with this disorder is illustrated. A list of equipment that may be included in a latex-free emergency kit is provided.