Assessment of a rhinitis questionnaire in a seasonal allergic rhinitis population

Psychological Distress and Drug Provocation Test-Related Anxiety Levels of Pediatric Patients and Their Parents

Background: Drug provocation tests (DPTs) are the gold standard for the diagnosis of drug hypersensitivity reaction (DHR). To the best of our knowledge, there is no previous study reporting DPT-related anxiety levels in children and their parents. This study aimed to determine the difference in pre- and post-DPT anxiety levels of parents and children who were informed of the possibility of another DHR during the DPT, and to evaluate the relationship between parental psychological distress and anxiety levels. Methods: The study included children who underwent DPT in our clinic between July 1, 2019, and February 29, 2020, and accompanying parents who consented to participate. Age-appropriate State-Trait Anxiety Inventory scales were used to assess levels of state and trait anxiety in the patients and parents. The Symptom Checklist-90-Revised (SCL-90-R) was used to screen for psychological symptoms in parents. Results: Data were collected from the parents of 69 children who underwent DPTs. The patients' median age was 7.28 (interquartile range: 4.52-10.06) and their parents' mean age was 35.28 ± 5.38 years. Anxiety-related data were collected from 21 pediatric patients. The children and parents had higher state anxiety scores before DPT compared to after DPT. There was a positive correlation between the parents' trait anxiety and pre-DPT state anxiety scores. In addition, parental pre-DPT state anxiety scores were positively correlated with SCL-90-R general severity index, somatization, anxiety, obsessive-compulsive, and depression subscale scores. Conclusion: The risk of allergic reaction in DPT may cause anxiety. A high level of parental anxiety before DPT, which gradually decreased after negative test results, was associated with history of drug-induced anaphylaxis in their children and high trait anxiety. Appropriate evaluation of patients and parents before DPT and providing detailed information may be important to reduce this anxiety.

Association between serum zonulin level and severity of house dust mite allergic asthma

BACKGROUND

Increased intestinal permeability, either due to the exposure to antigens in asthmatic patients or due to a barrier defect, plays a critical role in susceptibility to environmental allergens. House dust mite allergy occurs more commonly than any other type of allergy among Egyptian asthmatic patients.

AIM

To assess the relation between serum zonulin level as a marker of increased intestinal permeability and the severity of house dust mite allergic asthma.

METHODS

A case-control study which included 48 patients with house dust mite allergic asthma and 48 healthy control subjects attending the Allergy and Immunology Unit, Microbiology and Immunology Department, Faculty of Medicine, Zagazig University.

RESULTS

A statistically significant difference was detected between the two studied groups with respect to serum IgE and serum zonulin levels (p ˂ 0.001 and ˂ 0.001, respectively). The mean serum zonulin was equal to 258.3 ± 153.01 ng/ml in the asthmatic group and 80 ± 13 ng/ml in the control group. Serum zonulin level significantly increased with the increase of asthma severity (p ˂ 0.001). The cut off value of serum zonulin was ≥ 198 ng/ml, and the area under the curve was 0.76. It displayed sensitivity equal to 80% and specificity equal to 71.4%. Its negative predictive value was equal to 83.3%.

CONCLUSION

Intestinal barrier dysfunction contributes to the pathogenesis of allergic asthma. Serum zonulin level reflects an increase in intestinal permeability. Zonulin acts as prognostic factor of severity in asthma. Correction of the gut barrier defect may have a potential positive prognostic effect in asthma.

Lipid Profile and IL-17A in Allergic Rhinitis: Correlation With Disease Severity and Quality of Life

BACKGROUND

Recent data display the possible role of cytokines such as interleukin-10 (IL-10), IL-17 and IL-23 as a link between dyslipidemia and atopy; however, the relationship between dyslipidemia, allergic rhinitis (AR), and the underlying mechanisms involved is unclear.

PURPOSE

To measure the lipid profile and IL-17A level in AR patients in comparison to healthy controls, and correlate serum lipid level with the severity of symptoms and quality of life (QoL) of AR patients.

PATIENTS AND METHODS

Peripheral blood samples were collected from AR patients (n=70) and a control group (n=80). Samples were analyzed for serum total IgE by ELISA, serum lipid profile, and IL-17A level by ELISA. Severity of AR symptoms was assessed by visual analogue scale (VAS) score and the rhinoconjunctivitis QoL questionnaire.

RESULTS

Serum lipid profile and level of IL-17A in AR patients were significantly higher in comparison to controls (P < 0.001). Positive correlations were found between total cholesterol (TC) and the severity of AR and QoL. IL-17A was positively correlated with triglyceride (TG) level and low-density lipoprotein cholesterol (LDL-C) (P=0.011, r=0.303; P=0.043, r=0.242, respectively). Additionally, IL-17A was negatively correlated with high-density lipoprotein cholesterol (HDL-C) level (P=0.036, r=-0.251). IL-17A was positively correlated with both age and VAS score with statistical significance (P=0.033, r=0.225; P=0.011, r=0.302, respectively).

CONCLUSION

Dyslipidemia might play a potential role in the severity of AR symptoms and impairment of patients' QoL. Highlighting this association might alert physicians to evaluate the lipid profile in AR patients for timely diagnosis and treatment of dyslipidemia in an attempt to improve disease control and improve QoL.

Design of an Optimally-Diagnostic Skin Test for Diagnosis of Sensitivity to Eight Allergens: A First-in-Human Study of Dose Escalation and Simultaneous Administration in Chinese Subjects

Background

Eight extracts from common native allergens, Artemisia annua pollen, Platanus pollen, Humulus pollen, Betula platyphylla pollen, Ambrosia artemisiifolia pollen, Blattella germanica, cat dander and dog dander were developed for skin prick test (SPT). Since standardization and composition alone cannot guarantee that the allergen extracts are within the concentration range that give the best chance of a true diagnosis, it is necessary to explore the optimal diagnostic concentration (ODC) of allergens in SPT.

Objective

To identify the optimal diagnostic concentration of eight allergen extracts in SPT and assess the safety of simultaneous administration.

Patients and Methods

Patients with a history of allergic disease were enrolled in this two-part open-label, parallel study. In Study 1, 92 patients were enrolled into eight groups according to their disease-causing allergens and were given three increasing concentrations of the corresponding allergen. In Study 2, 20 patients were divided into two concentration groups and were given all of the eight allergens. Safety and sensitivity were evaluated to determine the optimal diagnostic concentration.

Results

In Study 1, the sensitivity of seven allergen extracts was >80% at middle and high concentrations, except for Ambrosia artemisiifolia pollen. The optimal diagnostic concentration (in DU/mL) for eight allergens was 33,333, 12,000, 8667, 50,000, 40,000, 3333, 7000, and 5000. In Study 2, the prevalence of adverse events in the two groups was 70% and 80%, respectively. A total of 10 wheals of 8 patients did not subside <24 h after SPTs.

Conclusion

The eight allergens showed high sensitivity and safety at a certain concentration, which was defined as optimal diagnostic concentration. The results support further clinical research of investigated allergens and our study offers a scheme to determine the ODC of allergens in SPT.

Psoriasis and IgE-mediated allergy: correlation or mutual inhibition? : A prospective cohort study in patients with mild or moderate to severe psoriasis

BACKGROUND

Psoriasis is an autoimmune disease caused by overactivation of T_H1 (Type 1 helper cells) and T_H17 (T helper 17) cells. Overactivation of T_H1 cells inhibits the activity of T_H2 cells involved in type 1 allergies, therefore, psoriasis patients might be less affected by type 1 allergies. This study tested if allergies were less frequent in patients with moderate to severe than with mild psoriasis.

METHODS

Psoriasis patients at the study site reported possible allergy symptoms and were tested for common allergens by skin prick test and IgE levels. Psoriasis was classified by PASI scores (Psoriasis Area and Severity Index) as mild (PASI <10) or moderate/severe (PASI ≥10). Patients without systemic therapy were assessed separately. Fisher's exact test was used to test for differences.

RESULTS

A total of 97 patients were included, 21 with mild and 76 with moderate to severe psoriasis. Allergies were found in 27.8%, most commonly against dust mites (23.4%) and grasses (18.1%). Allergies were found in 23.8% of the patients with mild vs. 29.0% allergic patients with moderate to severe psoriasis (P = 0.786). In patients without systemic medication, allergies were found in 21.1% vs. 35.3% (P = 0.463).

CONCLUSION

Allergy prevalence was not reduced in patients with moderate/severe psoriasis, and generally close to the prevalence in the general Austrian population (24%). The inhibiting effect of psoriasis on type 1 allergies was not confirmed.

Pediatric Spectrum of Allergic Diseases and Asthma in a Tertiary Level Hospital in Botswana: an Exploratory Retrospective Cross-Sectional Study

Purpose

This study aims to describe the spectrum of allergic diseases of children and adolescents in a single allergy treatment centre in Botswana, over a period of 8 years.

Patients and Methods

A retrospective cross-sectional study was conducted using medical records of all patients aged 18 years or younger, seen at an allergy treatment centre in Botswana. Data were presented descriptively. Association between variables was explored by χ²-test.

Results

Four hundred and seven patients with a mean age of 5.8 years (SD 4.4) at the time of presentation included 239 (58.7%) females and 365 (87.5%) black Africans. The most common diseases were asthma (n=249, 61.2%) followed by allergic rhinitis (AR) (n=232, 57.0%) and atopic dermatitis (AD) (n=165, 40.5%). One hundred and fifteen cases (46.2%) of asthmatic patients were skin prick test positive; sensitized to grass, moulds, dust mites and animal dander, in decreasing frequency, whereas those with allergic rhinitis (AR) and allergic conjunctivitis (AC) were sensitized to trees and all allergens identified in asthmatics. Concomitant asthma was diagnosed in 171 (73.7%) with AR, 71 (68.3%) with AC, 75 (45.5%) with AD and 42 (47.7%) with food allergy. The most common triggers for asthma exacerbations include upper respiratory tract infections, weather changes, and exposure to passive cigarette smoke. Paternal allergy and allergic disease in grandparents are predisposing factors for asthma (p=0.016 and p=0.001, respectively). Paternal allergy is also predisposed to AR (p=0.007), while maternal history of allergic disease was associated with AD (p=0.019).

Conclusion

The most common chronic pediatric conditions seen in our allergic disease study were asthma, allergic rhinitis and atopic dermatitis with the most common triggers being viral upper respiratory tract infections, weather changes and exposure to cigarette smoke, all of which are modifiable risk factors. This exploratory study lays the foundation for future interventional studies that may be directed towards the spectrum of allergic diseases.

Current and Future Treatments of Rhinitis and Sinusitis

Advances in understanding the pathogenic mechanisms of both rhinitis and chronic rhinosinusitis have resulted in new treatment options, especially for chronic rhinosinusitis. A review of relevant medical and surgical clinical studies shows that intranasal corticosteroids, antihistamines, and allergen immunotherapy continue to be the best treatments for chronic rhinitis. Dupilumab is the first biologic approved for chronic rhinosinusitis with polyps. Omalizumab, mepolizumab, and benralizumab may have a future role in the treatment of chronic rhinosinusitis. Novel corticosteroid delivery devices such as an exhalation delivery system for fluticasone and bioabsorbable sinus implants provide enhanced and localized distribution of corticosteroids. Surgical management tailored to the underlying disease process improves clinical outcomes in chronic rhinosinusitis with or without nasal polyposis. Advances in the understanding of the heterogeneous nature of rhinitis and rhinosinusitis have resulted in more precise treatments. Improving the understanding of different endotypes should provide better knowledge to determine appropriate current and new therapies to treat these diseases.

Oxidative stress and immune aberrancies in attention-deficit/hyperactivity disorder (ADHD): a case-control comparison

The objective of this study is to compare oxidative stress and immune biomarkers between attention-deficit/hyperactivity disorder (ADHD) patients and controls without ADHD. A case-control comparison between 57 paediatric (6-12 years) untreated ADHD patients from the Antwerp University Hospital and 69 controls without ADHD from random schools in Flanders, Belgium, was conducted. Erythrocyte glutathione (GSH) and plasma lipid-soluble antioxidants (retinol, α-tocopherol, γ-tocopherol, retinyl palmitate, β-carotene, and co-enzyme Q10) were determined by HPLC with electrochemical detection, plasma malondialdehyde (MDA) by HPLC with fluorescence detection, plasma cytokines (interleukin (IL)-1β, IL-5, IL-6, IL-8, IL-10, tumour necrosis factor (TNF) and interferon (INF)-γ) and immunoglobulins (IgE, IgG and IgM) by flow cytometry and urinary 8-hydroxy-2'deoxyguanosine (8-OHdG) levels by ELISA assay. Dietary habits were determined by a food frequency questionnaire. Plasma MDA levels were on average 0.031 µM higher in patients than in controls (p < 0.05), and a trend for higher urinary 8-OHdG was observed. Erythrocyte GSH and plasma retinyl palmitate levels, as well as IgG and IgE levels, were higher in patients than in controls as well (on average 93.707 µg/ml, 0.006 µg/ml, 301.555 µg/ml and 125.004 µg/ml, resp., p < 0.05). Finally, a trend for lower plasma IL-5 levels was observed. After Bonferroni correction for multiple testing, the difference in GSH levels remained statistically significant (nominally significant for retinyl palmitate), while significance was lost for MDA, IgG and IgE levels. Dietary habits do not appear to cause the observed differences. These results point at the potential involvement of slight oxidative stress and immune disturbances in ADHD.

Sensitivity and specificity of standardised allergen extracts in skin prick test for diagnoses of IgE-mediated respiratory allergies

Background

Skin prick tests (SPTs) are essential for the diagnosis of IgE-mediated allergy and are influenced by extract quality, biological potency and concentration of allergen.

Methods

In this open multicentre study 431 patients, aged 18-64 years were enrolled. Patients had a history of IgE-mediated allergy and a sensitisation (previous positive SPT of any manufacturer) against at least one of the investigated allergens: 6-grass pollen, house dust mite, birch and mugwort pollen. In our study, these allergens were tested in five concentrations each. To establish the optimal trade-off between sensitivity and specificity, the area under the receiver operating characteristic (ROC) curve was estimated by comparing the outcome of the SPT with three methods referred to as 'reference methods' (specific IgE, clinical case history and a previous SPT).

Results

For all allergens and reference methods, the area under the ROC curves were highly significant (p < 0.001). Specific IgE reference method resulted in the largest area under the curve (AUC) for all allergens (0.80-0.90) followed by previous SPT (0.70-0.87) and case history (0.65-0.74). Sensitivity of SPT increased with increasing concentration and specificity decreased. For all allergens, compared to specific IgE, the highest sensitivity (specificity at least 80%) was observed for the SPT solution of 50,000 Standardised Units (SU)/mL (grass pollen, birch pollen, house dust mite and mugwort).

Conclusion

In this study, with a large number of patients, it was demonstrated that clinical case history, previous SPT and specific IgE measurement could all be used as reference methods for the assessment of sensitivity/specificity of SPT solutions. The comparison of SPT with specific IgE resulted in the largest AUC. The highest sensitivity was observed for the SPT solution of 50,000 SU/mL.Trial registration EudraCT: 2006-005304-14.

Efficacy and tolerability of a house dust mite allergoid in allergic bronchial asthma: a randomized dose-ranging trial

AIM

This multicenter randomized placebo-controlled double-blind clinical trial investigated which maintenance dose shows the optimal benefit-risk ratio for subcutaneous immunotherapy with a Dermatophagoides pteronyssinus allergoid preparation.

OBJECTIVE

To evaluate four maintenance doses of the allergoid preparation versus placebo.

METHODS

The late-phase reaction of the intracutaneous test was chosen as efficacy parameter and minimal dose of fluticasone required for asthma control.

RESULTS

A total of 146 adults with bronchial asthma were randomized. After subcutaneous immunotherapy, reductions in swelling size were greatest with 10,000 therapeutic units (TU). The 18,000 TU group showed the highest percentage of patients with fluticasone dose reduced to 0 μg/day.

CONCLUSION

The optimal dose of allergoid for the investigation in a confirmatory trial with inhaled corticosteroid reduction is 18,000 TU.

Dog and Cat Allergies: Current State of Diagnostic Approaches and Challenges

Allergies to dogs and cats affect 10%-20% of the population worldwide and is a growing public health concern as these rates increase. Given the prevalence of detectable dog and cat allergens even in households without pets, there is a critical need to accurately diagnose and treat patients to reduce morbidity and mortality from exposure. The ability to diagnose cat sensitization is good, in contrast to dogs. Component resolved diagnostics of sensitization to individual allergenic proteins will dramatically improve diagnosis. This review focuses on the current state of knowledge regarding allergies to dogs and cats, recent advances, therapies such as subcutaneous immunotherapy, and discusses important areas to improve diagnosis and therapy.

Detecting Allergens From Black Tiger Shrimp Penaeus monodon That Can Bind and Cross-link IgE by ELISA, Western Blot, and a Humanized Rat Basophilic Leukemia Reporter Cell Line RS-ATL8

Background

Black tiger shrimp Penaeus monodon is one of the common causes of shellfish allergy that is increasing worldwide. One of the important problems in the management of shellfish allergy is the lack of accurate diagnostic assay because the biological and immunological properties of allergens in black tiger shrimp have not been well characterized. This study aims to detect proteins with the ability to bind and cross-link immunoglobulin E (IgE) from black tiger shrimp by enzyme-linked immunosorbent assay (ELISA), Western blot, and a humanized rat basophilic leukemia reporter cell line RS-ATL8.

Methods

Sera from shrimp allergic subjects were subjected to ELISA and Western blots using raw or cooked shrimp extract as antigens. Pooled sera were used to sensitize the RS-ATL8 reporter cell line and cells were activated by shrimp extract. Eluted protein extracts separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) were tested on the RS-ATL8 cell line and subjected to mass spectrometry to identify potential candidate allergens.

Results

Allergic sera reacted stronger to raw shrimp extract than cooked shrimp extract (P=0.009). Western blot demonstrated that major IgE reactivity protein bands were at 32–39 kDa and 91–230 kDa in both raw and cooked shrimp extracts. The eluted protein bands at the molecular weight of 38 and 115 kDa from raw shrimp extract induced IgE cross-linking as assayed by the RS-ATL8 cell line. These protein bands were subjected to mass spectrometry for analysis. Ubiquitin-activating enzyme and crustacyanin were identified as potential candidate novel shrimp allergens.

Conclusions

The RS-ATL8 reporter cell line can be used to identify potential new shrimp allergens that can functionally cross-link IgE and induce mast cell degranulation.

Combination therapy in allergic rhinitis: What works and what does not work

Allergic rhinitis and other rhinitis subtypes are increasingly becoming some of the most prevalent and expensive medical conditions that affect the U.S.

POPULATION

Both direct health care costs and indirect costs significantly impact the health care system due to delays in diagnosis, lack of treatment, ineffective treatment, poor medication adherence, and associated comorbidities. Many patients who have AR turn to over-the-counter medications for relief but often find themselves dissatisfied with the results. Determining the correct diagnosis, followed by initiation of the most-effective treatment(s), is essential to provide patients with better symptomatic management and quality of life. Although there are many options, currently available combination therapies, e.g., azelastine with fluticasone and intranasal corticosteroids with nasal decongestants, offer distinct advantages for the management of complex rhinitis phenotypes. Further research is required to investigate the pathomechanisms and biomarkers for mixed rhinitis and nonallergic vasomotor rhinitis subtypes that will lead to novel targeted therapies for these conditions.

Food allergy and the gut

Food allergy develops as a consequence of a failure in oral tolerance, which is a default immune response by the gut-associated lymphoid tissues to ingested antigens that is modified by the gut microbiota. Food allergy is classified on the basis of the involvement of IgE antibodies in allergic pathophysiology, either as classic IgE, mixed pathophysiology or non-IgE-mediated food allergy. Gastrointestinal manifestations of food allergy include emesis, nausea, diarrhoea, abdominal pain, dysphagia, food impaction, protein-losing enteropathy and failure to thrive. Childhood food allergy has a generally favourable prognosis, whereas natural history in adults is not as well known. Elimination of the offending foods from the diet is the current standard of care; however, future therapies focus on gradual reintroduction of foods via oral, sublingual or epicutaneous food immunotherapy. Vaccines, modified hypoallergenic foods and modification of the gut microbiota represent additional approaches to treatment of food allergy.

Pearls and Pitfalls in Diagnosing IgE-Mediated Food Allergy

The term "food allergy" is used by many patients and clinicians to describe a range of symptoms that occur after ingestion of specific foods. However, not all symptoms occurring after food exposure are due to an allergic, or immunologic, response. It is important to properly evaluate and diagnose immunoglobulin E (IgE)-mediated food allergy as this results in reproducible, immediate onset, allergic reactions that can progress toward life-threatening anaphylaxis. Proper diagnosis requires understanding of the common foods that cause these reactions in addition to key historical elements such as symptoms, timing and duration of reaction, and risk factors that may predispose to development of IgE-mediated food allergy. Diagnostic testing for food-specific IgE can greatly aid the diagnosis. However, false-positive test results are very common and can lead to overinterpretation, misdiagnosis, and unnecessary dietary elimination. This review discusses important aspects to consider during evaluation of a patient for suspected IgE-mediated food allergy.

Infective endocarditis

Infective endocarditis (IE) is a rare, life-threatening disease that has long-lasting effects even among patients who survive and are cured. IE disproportionately affects those with underlying structural heart disease and is increasingly associated with health care contact, particularly in patients who have intravascular prosthetic material. In the setting of bacteraemia with a pathogenic organism, an infected vegetation may form as the end result of complex interactions between invading microorganisms and the host immune system. Once established, IE can involve almost any organ system in the body. The diagnosis of IE may be difficult to establish and a strategy that combines clinical, microbiological and echocardiography results has been codified in the modified Duke criteria. In cases of blood culture-negative IE, the diagnosis may be especially challenging, and novel microbiological and imaging techniques have been developed to establish its presence. Once diagnosed, IE is best managed by a multidisciplinary team with expertise in infectious diseases, cardiology and cardiac surgery. Antibiotic prophylaxis for the prevention of IE remains controversial. Efforts to develop a vaccine that targets common bacterial causes of IE are ongoing, but have not yet yielded a commercially available product.

Appropriateness in allergic respiratory diseases health care in Italy: definitions and organizational aspects

In a historical period in which sustainability of the National Health Service is mandatory because of the international economical situation, the limited available resources at national level and the tendency of passing from a “population medicine” model towards the concept of “individualized medicine”, the debate on appropriateness of medical and surgical procedures is of central importance. The choosing wisely campaign, started in United States in 2012 and then spread all over the world, tries to summarize which are the most inappropriate procedures for each medical and surgical speciality; as far as allergic respiratory diseases, the most relevant Italian societies and the American Academy defined the allergological procedures with the highest probability of inappropriateness. In Italy, a recent decree of the Ministry of Health defined a list of more than 200 procedures that will be considered as inappropriate in certain conditions; many of these procedures concern allergology, including allergic respiratory diseases. In this commentary we discuss the above mentioned decree and the concept of appropriateness in the field of allergic respiratory diseases, trying to figure out some practical considerations based on the current health resources available in the field of allergology in Italy.

A designer cell-based histamine-specific human allergy profiler

Allergic disorders are markedly increasing in industrialized countries. The identification of compounds that trigger the immunoglobulin E-dependent allergic reaction remains the key to limit patients’ exposure to critical allergens and improve their quality of life. Here we use synthetic biology principles to design a mammalian cell-based allergy profiler that scores the allergen-triggered release of histamine from whole-blood-derived human basophils. A synthetic signalling cascade engineered within the allergy profiler rewires histamine input to the production of reporter protein, thereby integrating histamine levels in whole-blood samples with remarkable sensitivity and a wide dynamic range, allowing for rapid results or long-term storage of output, respectively. This approach provides non-intrusive allergy profiles for the personalized medicine era.

The advancement of sensitive, accurate and non-invasive methods to identify the allergen that drives allergic disease in an individual remains a challenge. Here, the authors develop a synthetic biology approach using human designer cells to profile allergic reactions against an array of allergens measuring histamine release from whole blood.

Skin testing versus serum-specific IgE testing: which is better for diagnosing aeroallergen sensitization and predicting clinical allergy?

An accurate diagnosis of aeroallergen sensitization is pivotal to clinical practice and research. Given the recent technological advances in analyzing serum allergen-specific IgE, the question of which testing method, skin or serum testing, is superior in diagnosing allergic sensitization must be readdressed, as well as their value in predicting clinical disease. This review article provides a detailed summary of recent studies addressing these questions. Conclusively, most studies show substantial discordance between serum-specific IgE and skin testing results, suggesting that the two testing methods compliment each other and cannot be used interchangeably. On average, using only one testing method may misdiagnose every fourth allergically sensitized patient as non-sensitized. In addition, depending on the allergen tested, skin prick testing and serum-specific IgE testing appear to be the methods of choice in predicting outcomes of experimental allergen challenge, while intradermal testing is less contributory.

Older adults with asthma: does age of asthma onset make a difference?

OBJECTIVE

Older adults with asthma can develop symptoms early in life or during adulthood. Differences between these groups may have diagnostic and therapeutic implications. Our goal was to identify differences in demographics, control, quality of life and healthcare utilization between those with long-standing asthma (LSA) and late-onset asthma (LOA).

METHODS

Data from a cross-sectional study of asthma patients over age 65 were analyzed. LSA or LOA was based on age of diagnosis (before or after age 40). Demographic and asthma specific information were analyzed, and allergy prick tests and lung function testing (spirometry and FENO) were performed.

RESULTS

After regression analysis, LSA subjects were more likely to demonstrate positive prick tests (92 versus 71%, p = 0.04), with both groups demonstrating higher levels of atopy than previously reported. LSA subjects were also more likely to have received a peak flow meter (p = 0.07). LOA subjects were more likely to have moderate or severe asthma (OR = 3.1, p = 0.05), and had higher FENO readings (p = 0.02). They also had more hospitalizations (p = 0.04), though significance was lost after regression analysis. No differences were noted in demographic information, medical comorbidities, spirometry, compliance, asthma control, or asthma quality of life between LSA and LOA subjects.

CONCLUSION

LSA subjects are more atopic and more likely to be given a peak flow meter, while LOA subjects have higher FENO levels and more severe asthma. Defining age of asthma onset may help improve treatment recommendations and outcomes for older adults.

Molecular diagnosis of peanut allergy

Peanut allergy prevalence has increased in developed countries over the last few decades in the frame of the allergy epidemics, currently affecting 1-2% of children. While less frequent in developing countries, its prevalence is rising as these countries adopt a more westernized lifestyle. There is no curative treatment for peanut allergy at present so patient management relies on peanut avoidance, which requires an accurate diagnosis. Recent progress in peanut allergy diagnosis was made with the introduction of component resolved diagnosis that allows the assessment of IgE specific to individual peanut allergens. Component-resolved diagnosis needs to be interpreted in the context of clinical data but overall increases the diagnostic accuracy, as described in the typical cases that we present. Novel diagnostic tools have been proposed recently, such as the basophil activation test, mRNA expression and resonance magnetic evaluation of biomarkers.

Characterization of food allergies in patients with atopic dermatitis

We examined the characteristics of food allergy prevalence and suggested the basis of dietary guidelines for patients with food allergies and atopic dermatitis. A total of 2,417 patients were enrolled in this study. Each subject underwent a skin prick test as well as serum immunoglobulin E (IgE) measurement. A double-blind, placebo-controlled food challenge was conducted using milk, eggs, wheat, and soybeans, and an oral food challenge was performed using beef, pork, and chicken. Food allergy prevalence was found among 50.7% in patients with atopic dermatitis. Among patients with food allergies (n = 1,225), the prevalence of non-IgE-mediated food allergies, IgE-mediated food allergies, and mixed allergies was discovered in 94.9%, 2.2%, and 2.9% of the patients, respectively. Food allergy prevalence, according to food item, was as follows: eggs = 21.6%, milk = 20.9%, wheat = 11.8%, soybeans = 11.7%, chicken = 11.7%, pork = 8.9% and beef = 9.2%. The total number of reactions to different food items in each patient was also variable at 45.1%, 30.6%, 15.3%, 5.8%, 2.2%, and 1.0% for 1 to 6 reactions, respectively. The most commonly seen combination in patients with two food allergies was eggs and milk. The clinical severity of the reactions observed in the challenge test, in the order of most to least severe, were wheat, beef, soybeans, milk, pork, eggs, and chicken. The minimum and maximum onset times of food allergy reactions were 0.2-24 hrs for wheat, 0.5-48 hrs for beef, 1.0-24 hrs for soybeans, 0.7-24 hrs for milk, 3.0-24 hrs for pork, 0.01-72 hrs for eggs, and 3.0-72 hrs for chicken. In our study, we examined the characteristics of seven popular foods. It will be necessary, however, to study a broader range of foods for the establishment of a dietary guideline. Our results suggest that it may be helpful to identify food allergies in order to improve symptoms in patients with atopic dermatitis.

Evaluation of banana hypersensitivity among a group of atopic egyptian children: relation to parental/self reports

Purpose

To evaluate the frequency of banana sensitization and allergy among a group of atopic Egyptian children in relation to parental/self reports.

Methods

This is a case-control study included 2 groups of allergic children with and without history of banana allergy, each included 40 patients. They were subjected to skin prick test (SPT) using commercial banana allergen extract and prick-prick test (PPT) using raw banana, in addition to measuring the serum banana-specific IgE. Oral banana challenge was performed in suspected cases.

Results

Banana allergy was diagnosed in 3 (7.5%) patients based on positive history of allergy on exposure to banana, positive SPT/PPT and elevated banana-specific IgE. The 3 patients had bronchial asthma with exacerbation upon banana exposure. The PPT results conform with those of SPT both in diagnosis of banana allergy and in the skin reactivity to banana. Serum banana-specific IgE was detectable in the whole studied sample with higher serum level among those without history of banana allergy (P=0.005). Oral banana challenge was negative for 20 patients with history of banana allergy and positive serum banana-specific IgE but negative SPT and PPT.

Conclusions

Self/parental reports of banana allergy is high while the actual banana allergy is uncommon. The PPT seems as reliable as SPT in diagnosis of banana allergy unlike specific IgE which reflects sensitization rather than allergy. Oral food challenge remains the most helpful tool for diagnosis of food allergy in suspected cases.

Clinical characteristics of chronic rhinitis patients with high vs low irritant trigger burdens

BACKGROUND

Patients with chronic allergic rhinitis (AR) and nonallergic rhinitis (NAR) often experience irritant-induced symptoms. The clinical relevance of the magnitude of their symptoms in response to these nonspecific stimuli remains unclear.

OBJECTIVE

To determine the internal consistency and validity of an irritant index questionnaire (IIQ) and whether reclassification of physician-diagnosed rhinitis subtypes based on IIQ scores results in rhinitis subtypes with different clinical characteristics.

METHODS

Patients 18 to 65 years old with physician-diagnosed AR (n = 404), mixed rhinitis (MR; n = 129), or NAR (n = 123) completed an IIQ that rated rhinitis symptom severity in response to 21 nonallergic irritant triggers on a 1- to 10-point scale. Multistage sex-specific statistical analyses were performed using IIQ responses to reclassify physician-diagnosed AR, MR, and NAR into categories with high and low irritant burdens.

RESULTS

The IIQ demonstrated good internal consistency and cross-validation. After reclassification, 48% and 52% of patients with physician-diagnosed AR patients (n = 533) were categorized as having low-burden AR and high-burden AR, respectively, whereas 64% and 36% of NAR (n = 123) patients were categorized as having low-burden NAR and high-burden NAR, respectively. Reclassified high-burden AR and high-burden NAR patients were more likely to have a physician diagnosis of asthma and a greater number of self-reported rhinitis symptoms and perennial symptoms with seasonal exacerbations than reclassified low-burden AR and low-burden NAR patients, respectively (P < .01).

CONCLUSION

The IIQ resulted in significant reclassification of physician-diagnosed rhinitis patients into different diagnostic categories with unique clinical characteristics. Further studies are necessary to confirm the IIQ's utility as a tool for characterizing rhinitis patients in clinical practice and research.

Nonallergic rhinopathy (formerly known as vasomotor rhinitis)

This review focuses on the poorly understood condition of nonallergic rhinopathy (NAR) at a clinical level, with an eye on current optimal treatment. NAR is the new designation for the conditions formerly referred to as vasomotor rhinitis or nonallergic idiopathic rhinitis. The clinical characteristics and differential diagnosis are provided in detail in this review, and the disease should now be characterized sufficiently for clinical studies.

Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis

Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.

Inverse correlation between allergy markers and Helicobacter pylori infection in children is associated with elevated levels of TGF-β

OBJECTIVES

We evaluated allergy/hypersensitivity clinical markers and their correlation with Helicobactor pylori infection in children and adults to analyze how early acquisition of H. pylori could modulate allergic disorder expression.

PATIENTS AND METHODS

H. pylori presence was assessed by the rapid urease test and histology of antrum biopsies in 165 patients. Skin tests, serum IgE, and two clinical allergy questionnaires were performed. Allergy severity was operationally defined using a combined score. Findings were correlated with H. pylori status and cytotoxin-associated gene A presence in pediatric and adult patients. Transforming growth factor β (TGF-β) levels were measured by an enzyme-linked immunosorbent assay in serum and gastric biopsies of H. pylori (+) patients.

RESULTS

H. pylori (-) children had more positive skin tests to a higher number of antigens than H. pylori (+) children (P<0.05). Operationally defined allergy inversely correlates with H. pylori infection in children, but not in adults. The percentage of H. pylori infection was lower in children with severe allergy (32.3%) compared with children with mild allergy (43.4%) or no allergy (64.3%) (P<0.05). Colonization with virulent strains (cytotoxin-associated gene A+) showed a nonsignificant inverse correlation with severity of allergies in pediatric patients. H. pylori-infected children, but not adults, without allergy markers showed increased levels of TGF-β compared with allergic children both in serum and gastric mucosa (P<0.05).

CONCLUSION

There was a strong inverse correlation between allergy markers and H. pylori infection in pediatric patients associated with elevated levels of TGF-β locally and systemically. H. pylori-associated chronic gastritis might downregulate clinical allergy expression.

Alteration of brain activation patterns in nonallergic rhinitis patients using functional magnetic resonance imaging before and after treatment with intranasal azelastine

BACKGROUND

Although nonallergic rhinitis (NAR) patients tend to be more sensitive to chemical/olfactory stimuli, a suprathreshold olfactory response or the presence of specific olfactory receptor genes do not explain why their symptoms are triggered by such exposures.

OBJECTIVE

To investigate differential neurogenic responses to azelastine in NAR patients, using functional magnetic resonance imaging (fMRI) in response to specific olfactory triggers.

METHODS

A longitudinal study design on 12 subjects with a physician diagnosis of NAR previously demonstrated to be clinically responsive to intranasal azelastine (Astelin) was performed. Subjects underwent fMRI during exposure to unpleasant (hickory smoke) and pleasant (vanilla) odorants while off and then on azelastine for 2 weeks. The olfactory fMRI paradigm consisted of a visually triggered sniff every 21 seconds with synchronized delivery of a 4 second pulse of odorant. Each odorant was presented 18 times over 4-6-minute fMRI runs. Continuous fresh air was presented to wash out each odorant after presentation.

RESULTS

Nonallergic rhinitis patients exhibited increased blood flow to several regions of the brain in response to both pleasant and unpleasant odorants, specifically in odor-sensitive regions, while off intranasal azelastine. Treatment with intranasal azelastine significantly attenuated blood flow to regions of the brain relevant to either olfactory sensation or sensory processing in response to these odorants compared with fresh air.

CONCLUSION

The general reduction compared with increase in brain activation in NAR patients on versus off azelastine suggests that a possible effect of this medication may be reduction of brain responses to odorants.

Methyl methacrylate and respiratory sensitization: a critical review

Methyl methacrylate (MMA) is a respiratory irritant and dermal sensitizer that has been associated with occupational asthma in a small number of case reports. Those reports have raised concern that it might be a respiratory sensitizer. To better understand that possibility, we reviewed the in silico, in chemico, in vitro, and in vivo toxicology literature, and also epidemiologic and occupational medicine reports related to the respiratory effects of MMA. Numerous in silico and in chemico studies indicate that MMA is unlikely to be a respiratory sensitizer. The few in vitro studies suggest that MMA has generally weak effects. In vivo studies have documented contact skin sensitization, nonspecific cytotoxicity, and weakly positive responses on local lymph node assay; guinea pig and mouse inhalation sensitization tests have not been performed. Cohort and cross-sectional worker studies reported irritation of eyes, nose, and upper respiratory tract associated with short-term peaks exposures, but little evidence for respiratory sensitization or asthma. Nineteen case reports described asthma, laryngitis, or hypersensitivity pneumonitis in MMA-exposed workers; however, exposures were either not well described or involved mixtures containing more reactive respiratory sensitizers and irritants. The weight of evidence, both experimental and observational, argues that MMA is not a respiratory sensitizer.

Anaphylaxis during skin testing with food allergens in children

Skin testing is the diagnostic cornerstone for allergies and is considered extremely safe. It is usually performed with the prick and the prick-to-prick method. The aim of this study is to report the first two pediatric cases of systemic allergic reactions during skin prick tests (SPT) with commercial food allergens. Both patients had a history of fish allergy. A 5-year-old girl, with a history of atopic dermatitis and asthma, reported an episode of urticaria and angioedema due to ingestion of fish, which had occurred 2 years before consultation. Ten minutes after having completed SPT to fish extracts, which had resulted positive, she suffered from generalized pruritus, nausea, stomach pain, and loss of consciousness. A 9-year-old boy, with a history of asthma and two episodes of acute urticaria and angioedema upon eating fish during infancy, reported a recent episode of oropharyngeal pruritus after tasting salmon. He was evaluated for fish allergy with SPT but developed conjunctivitis and acute urticaria during the first 10 min of the test. Anaphylaxis appears to be a rare side effect of skin testing in pediatric patients. Children with a history of asthma and atopic dermatitis are more likely to react.

Influenza vaccination in patients with suspected egg allergy

Egg allergy is not necessarily a contraindication to influenza vaccination. For patients with suspected egg allergy, if the clinician determines benefits to outweigh risks, cautionary measures are available that can enhance safe vaccine administration. Batch to batch variability of egg content in extant influenza vaccines necessitates an informed and cautious approach to vaccination of an egg allergic individual. Although patients with egg allergy are likely to develop egg tolerance by late childhood, tolerance to ingestion of "baked egg" products may not predict tolerance to "native egg" proteins present in the influenza vaccine. Even in cases where the skin test to the vaccine is positive, vaccination may still be cautiously administered, if necessary, in a graded dose protocol.

Skin Testing With Water Buffalo's Milk in Children With Cow's Milk Allergy

BACKGROUND: Cow's milk allergy is the most common food allergy in young children. In areas outside the United States, milk from other mammals has been studied as a possible and desirable alternative for children with cow's milk allergy. OBJECTIVES: We chose to further investigate water buffalo's milk as an alternative for cow's milk allergic children in the United States. METHODS: Children with cow's milk allergy were skin prick tested with water buffalo's milk. Additionally, subjects were followed clinically for 1 year after the test to determine how many of the subjects had persistent cow's milk allergy. RESULTS: In total, 30 children, age 8 months to 8 years, were skin prick tested to water buffalo's milk with 73% (22/30) having a positive test. All children with a negative water buffalo's milk skin test also had a negative cow's milk skin test. In follow-up, most (7 of 8) of the children with a negative skin prick test (SPT) to water buffalo's milk were found to have outgrown their cow's milk allergy. In comparison, all of the subjects with a positive skin test to water buffalo's milk had persistent cow's milk allergy. After adjusting for this, we determined that 96% (22/23) of the children with persistent cow's milk allergy were positive on skin testing to water buffalo's milk. CONCLUSIONS: In this population, the vast majority of children with persistent cow's milk allergy were positive on skin prick testing to water buffalo's milk. These results indicate that water buffalo's milk is unlikely to be a successful alternative for children with cow's milk allergy.

Characteristics of nonallergic vasomotor rhinitis

Nonallergic rhinitis (NAR) conditions are currently considered diagnoses by exclusion. A diagnosis of NAR requires negative specific IgE responses by skin or serologic testing and more recently testing to exclude localized production of specific IgE in the nose. Symptoms are classically aggravated by irritant triggers such as tobacco smoke, perfumes/fragrances, and temperature or barometric pressure changes. A previously developed questionnaire survey designed to help physicians recognize differences between allergic rhinitis and nonallergic rhinitis subtypes found that patients with symptom onset later in life (> 35 years), no family history of allergies, no seasonality or cat-induced symptoms, and symptoms induced by perfumes and fragrances had > 95% likelihood of having a physician diagnosis of NAR. Of note, clinical symptoms were not generally useful for differentiating chronic rhinitis subtypes which has also been confirmed in a more recent study investigating the relationship between headaches and chronic rhinitis subtypes (Table 1). In subsequent studies it was found that a significant percentage of NAR patients did not experience irritant-induced symptoms, suggesting that these triggers are not a clinical characteristic that can be uniformly used for all NAR patients. However, a newly developed Irritant Index Scale can be used to reliably differentiate pure allergic rhinitis from nonallergic rhinitis with trigger phenotypes. The use of standardized and validated questionnaires allows objective characterization of chronic rhinitis subtypes that appears to improve the accuracy of clinically diagnosing these patients.