Analysis of available diagnostic tests for latex sensitization in an at-risk population

A Comprehensive Review on Kiwifruit Allergy: Pathogenesis, Diagnosis, Management, and Potential Modification of Allergens Through Processing

Kiwifruit is rich in bioactive components including dietary fibers, carbohydrates, natural sugars, vitamins, minerals, omega-3 fatty acids, and antioxidants. These components are beneficial to boost the human immune system and prevent cancer and heart diseases. However, kiwifruit is emerging as one of the most common elicitors of food allergies worldwide. Kiwifruit allergy results from an abnormal immune response to kiwifruit proteins and occur after consuming this fruit. Symptoms range from the oral allergy syndrome (OAS) to the life-threatening anaphylaxis. Thirteen different allergens have been identified in green kiwifruit and, among these allergens, Act d 1, Act d 2, Act d 8, Act d 11, and Act d 12 are defined as the "major allergens." Act d 1 and Act d 2 are ripening-related allergens and are found in abundance in fully ripe kiwifruit. Structures of several kiwifruit allergens may be altered under high temperatures or strong acidic conditions. This review discusses the pathogenesis, clinical features, and diagnosis of kiwifruit allergy and evaluates food processing methods including thermal, ultrasound, and chemical processing which may be used to reduce the allergenicity of kiwifruit. Management and medical treatments for kiwifruit allergy are also summarized.

Profile Shift in Latex Sensitization over the Last 20 Years

BACKGROUND

Natural rubber latex (NRL) allergy is commonly diagnosed according to medical history, skin allergy tests, and serological analyses. However, skin tests are increasingly being abandoned because of (i) their time-consuming nature, (ii) latex preparations for skin tests being not commercially available, and (iii) the use of in-house prepared test solutions is becoming ever more difficult due to increasing regulatory hurdles. In this light, we have evaluated differences in the profiles of current and former patients with suspected latex allergy.

METHODS

Sera of skin test-positive patients from a historic cohort (1995-2001, n = 149 patients) and currently (2014-2015, n = 48 patients) were simultaneously analyzed for specific IgE to latex by ImmunoCAP. If the serological screening was positive (≥0.35 kU/L), component-resolved diagnostics including profilins and cross-reactive carbohydrate determinants (CCDs) were performed.

RESULTS

In contrast to 88% (131/149) of the skin test-positive patients from the 1990s, only 51.1% (24/47) of the current cohort were found positive for specific IgE to latex. While 48.3% (72/149) of the patients had a convincing positive history in the 1990s, current skin test-positive patients rarely reported a relevant medical history (8.5%, 4/47). Specific IgE levels to latex were significantly higher in former patients with suspected latex allergy (p < 0.001) than in former sensitized individuals without allergy. However, this significant difference was lost in current allergic and sensitized patients with positive skin tests.

CONCLUSION

Sensitization profiles in patients with latex allergy have changed significantly over the last 2 decades. Discrimination between NRL sensitization and clinical allergy remains a diagnostic challenge. Our data highlight the need for a combination of all 3 criteria, i.e., patient history, skin test, and analysis of specific IgE, for a correct diagnosis of latex allergy.

Latex Allergy: Where Are We Now and How Did We Get There?

Latex allergy emerged as an epidemic of anaphylaxis, occupational asthma, and clinical dilemmas in the 1980s. A systematic recognition, investigation, discovery, epidemiology, and prevention strategy followed. International attention and collaborations of investigators, government agencies, manufacturing, and health policy resulted in near elimination of a global epidemic. This article summarizes nearly 4 decades of work in control of this epidemic and focuses attention on future problems that still require resolution.

Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

Practical Management of Patients with a History of Immediate Hypersensitivity to Common non-Beta-Lactam Drugs

Immediate hypersensitivity reactions to medications are among the most feared adverse drug reactions, because of their close association with anaphylaxis. This review discusses a practical management approach for patients with a history of an immediate hypersensitivity to a non-beta-lactam medication, where reexposure to the implicated, or similar, medication is clinically necessary. Mechanisms associated with severe immediate hypersensitivity reactions include IgE-mediated mast cell activation, complement-mediated mast cell activation, and direct mast cell activation. Immediate hypersensitivity reactions may also be mediated by vasodilators, other pharmacologic mechanisms, or be secondary to underlying patient-specific biochemical abnormalities such as endocrine tumors or chronic spontaneous urticaria. The key features in the reaction history and the biochemistry of the implicated medication are discussed. Most individuals with a history of immediate hypersensitivity to a medication, who require reuse of that drug, can be safely retreated with a therapeutic course of the implicated drug after a full-dose challenge, graded challenge, or desensitization, with or without premedication and/or any preliminary diagnostic testing, depending on the specific situation.

Perioperative anaphylaxis: what should be known?

Perioperative anaphylaxis is a unique condition as a result of the additive cardiovascular effects of anesthetics on the cardiovascular disturbances of anaphylaxis. It occurs mainly in adulthood, primarily follows anesthetic induction, and for the most part, is an IgE-mediated pathomechanism. Neuromuscular blocking agents (NMBAs) and antibiotics are the main culprit drugs, while latex is now infrequently involved. The Ring and Messmer scale is a useful tool for demonstrating the clinical severity of perioperative immediate hypersensitivity and guiding its management. Grades III and IV are life-threatening and are referred to as anaphylaxis. Three different clinical patterns of grade III may be observed, where cardiovascular collapse is the cardinal sign. Grade IV presents as cardiac arrest. The initial diagnosis is presumptive, whereas the etiological assessment is linked to the clinical presentation, tryptase levels, and skin test results. Since anaphylaxis presents with significant hypovolemia and vasoplegia, aggressive fluid therapy and epinephrine are the cornerstones of management. Whenever possible, anesthetic discontinuation is also recommended. Scientific evidence in favor of preemptive therapeutic strategies to prevent anaphylaxis in the operative setting is lacking.

Occupational allergy: respiratory hazards in healthcare workers

PURPOSE OF REVIEW

Allergens are one group of respiratory hazards in the workplace of healthcare workers (HCWs). The purpose of this review is to summarize the recent advances in occupational allergy as well as potential hazardous agents in HCWs.

RECENT FINDINGS

The review covers new developments on the epidemiology, diagnosis and management of occupational allergy in HCWs. This article also provides updated information on the prevalence of work-related respiratory symptoms, as well as on respiratory hazards among healthcare providers.

SUMMARY

It is established that HCWs are at risk of asthma symptoms. The growing use of cleaning products is one of the causes of occupational airway disease in that group. Among healthcare professionals, the prevalence of asthma varies depending on worksite. Recent findings indicate a need for education among HCWs concerning occupational risks. A lack of knowledge of product components as well as about exposure to cleaning/disinfecting agents has been demonstrated. Further studies are necessary to determine the relative role of individual agents versus complex workplace exposures in the development of work-related asthma in HCWs.

World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis are a widely disseminated and used resource for information about anaphylaxis. They focus on patients at risk, triggers, clinical diagnosis, treatment in health care settings, self-treatment in the community, and prevention of recurrences. Their unique strengths include a global perspective informed by prior research on the global availability of essentials for anaphylaxis assessment and management and a global agenda for anaphylaxis research. Additionally, detailed colored illustrations are linked to key concepts in the text [Simons et al.: J Allergy Clin Immunol 2011;127:593.e1-e22]. The recommendations in the original WAO Anaphylaxis Guidelines for management of anaphylaxis in health care settings and community settings were based on evidence published in peer-reviewed, indexed medical journals to the end of 2010. These recommendations remain unchanged and clinically relevant. An update of the evidence base was published in 2012 [Simons et al.: Curr Opin Allergy Clin Immunol 2012;12:389-399]. In 2012 and early 2013, major advances were reported in the following areas: further characterization of patient phenotypes; development of in vitro tests (for some allergens) that help distinguish clinical risk of anaphylaxis from asymptomatic sensitization; epinephrine (adrenaline) research, including studies of a new epinephrine auto-injector for use in community settings, and randomized controlled trials of immunotherapy to prevent food-induced anaphylaxis. Despite these advances, the need for additional prospective studies, including randomized controlled trials of interventions in anaphylaxis is increasingly apparent. This 2013 Update highlights publications from 2012 and 2013 that further contribute to the evidence base for the recommendations made in the original WAO Anaphylaxis Guidelines. Ideally, it should be used in conjunction with these Guidelines and with the 2012 Guidelines Update.

Self-reported hand symptoms: a role in monitoring health care workers for latex sensitization?

BACKGROUND

The use of powdered natural rubber latex (NRL) gloves increased greatly in the 1980s because of concerns about transmission of blood-borne infections and the subsequent implementation of universal precautions. The most common clinical reactions to glove use are irritant and T-cell-mediated contact dermatitis. However, IgE-mediated immediate reactions to latex have become a serious concern for health care workers (HCWs). The diagnosis of latex allergy requires a comprehensive medical history and diagnostic tests. The skin prick test is the preferred diagnostic method, although it can be time-consuming.

OBJECTIVE

To determine the role of hand symptoms reported on questionnaires in monitoring HCWs for latex sensitization.

METHODS

Questionnaires were completed by 804 HCWs at 2 hospitals. Using a positive skin prick test (SPT) result as a criterion standard of latex sensitization, the diagnostic performance of hand symptoms was evaluated.

RESULTS

Increasing latex glove use was strongly related to increasing reports of hand symptoms. Hand symptoms were highly associated with glove-related respiratory and systemic symptoms. A positive SPT result was seen in 5% of HCWs and increased with the number of hand symptoms: 0 (1.6%), 1 to 2 (3.4%), and 3 to 7 (19.0%). Participants reporting more than 2 hand symptoms were 11 times more likely to have positive SPT results compared with those with 2 or fewer hand symptoms.

CONCLUSION

Hand symptoms are closely associated with latex sensitization. Questionnaires should be useful in health monitoring for HCWs who use latex gloves.

Anaphylaxis during pregnancy

Anaphylaxis during pregnancy, labor, and delivery can be catastrophic for the mother and, especially, the infant. Symptoms and signs can include intense vulvar and vaginal itching, low back pain, uterine cramps, fetal distress, and preterm labor. During the first 3 trimesters, etiologies are similar to those in nonpregnant women. During labor and delivery, common etiologies are β-lactam antibiotics, natural rubber latex, and other agents used in medical and perioperative settings. Important caveats in management include injecting epinephrine (adrenaline) promptly, providing high-flow supplemental oxygen, positioning the mother on her left side to improve venous return to the heart, maintaining a minimum maternal systolic blood pressure of 90 mm Hg to ensure adequate placental perfusion, and continuous electronic monitoring. Cardiopulmonary resuscitation and emergency cesarean delivery should be performed when indicated. In all women of child-bearing age, allergy/immunology specialists can help to prevent anaphylaxis in pregnancy through prepregnancy risk assessment and risk reduction strategies, such as confirming the etiology of systemic allergic reactions, providing written instructions for allergen avoidance, and initiating relevant immune modulation. In pregnant women the benefits versus risks of skin tests, challenge tests, desensitization, and initiation of immunotherapy with allergens should be carefully weighed; if possible, these procedures should be deferred until after parturition. Prospective interdisciplinary studies of anaphylaxis during pregnancy are needed.