Cross‐reactivity between methylisothiazolinone, octylisothiazolinone and benzisothiazolinone using a modified local lymph node assay

Cross-reactivity between thiuram disulfides and dithiocarbamates. A study of TETD and ZDEC using mouse models

BACKGROUND

Rubber accelerators are used in the vulcanization of rubber. However, rubber accelerators for example tetraethylthiuram disulfide (TETD) and zinc diethyldithiocarbamate (ZDEC) may cause contact allergy. Concomitant reactions between ZDEC and TETD have been observed in patients which could be explained by co- or cross-reactivity.

OBJECTIVES

To investigate cross-reactivity between TETD and ZDEC and vice versa.

METHODS

Groups of mice were sensitized with TETD or ZDEC based on reported EC3-values. Proliferation of lymphocytes were measured on day 5. To test cross-reactivity, mice were sensitized and challenged 3 weeks later with TETD or ZDEC. The inflammatory response was measured by changes in ear thickness and the proliferative response in CD4+ and CD8+ T cells in the submandibular and cervical draining lymph nodes.

RESULTS

Sensitization of mice with doses of ZDEC 3%, TETD 5.6% or TETD 16.2% induced significant increased ear thickness and proliferation of CD4+ and CD8+ T cells. Challenge with ZDEC or TETD in these groups induced significant increased ear thickness. Challenge with ZDEC in mice sensitized to TETD 5.6% or TETD 16.2% induced significant increased proliferation of CD4+ and CD8+ T cells.

CONCLUSIONS

We show cross-reactivity between TETD and ZDEC. Patients sensitized to TETD or ZDEC should avoid exposure to both ZDEC and TETD.

Contact sensitization and self-reported eczema in Swedish painters with occupational exposure to isothiazolinones

BACKGROUND

Due to an increasing occupational usage of isothiazolinone (IT)-containing preservatives, and their potential to cause skin sensitization and allergic contact dermatitis, that is, chronic disease, there is a need for more knowledge on how highly exposed workers are affected.

OBJECTIVES

The overall objective was to explore dermatological symptoms of potentially long-lasting or chronic character in Swedish painters.

METHODS

Building painters from western and southern Sweden were initially invited to perform a questionnaire on occurrence of skin symptoms. Participants with affirmative responses, and the right inclusion criteria, were further invited to patch testing with four different ITs: benzisothiazolinone (BIT), methylisothiazolinone, methylchloroisothiazolinone and octylisothiazolinone.

RESULTS

There was a tendency towards higher occurrence of positive patch test reactions among the painters compared with occupationally unexposed registry patients; however, not statistically significant differences. BIT was the substance most frequently causing positive test results in both groups. The occurrence of adult-onset eczema was higher in painters than in the control group of electricians, and just shy of statistical significance concerning any of several skin locations (face/legs/arms/hands).

CONCLUSION

Building painters present with positive patch test reactions to common paint preservatives (ITs), and they report adult-onset eczema more often than do less occupationally exposed groups.

Increasing non-cosmetic exposure and sensitization to isothiazolinones require action for prevention: Review

Frequent use of methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and MI in cosmetic products has been the main cause of widespread sensitization and allergic contact dermatitis to these preservatives (biocides). Their use in non-cosmetic products is also an important source of sensitization. Less is known about sensitization rates and use of benzisothiazolinone (BIT), octylisothiazolinone (OIT), and dichlorooctylisothiazolinone (DCOIT), which have never been permitted in cosmetic products in Europe. BIT and OIT have occasionally been routinely patch-tested. These preservatives are often used together in chemical products and articles. In this study, we review the occurrence of contact allergy to MI, BIT, OIT, and DCOIT over time, based on concomitant patch testing in large studies, and case reports. We review EU legislations, and we discuss the role of industry, regulators, and dermatology in prevention of sensitization and protection of health. The frequency of contact allergy to MI, BIT, and OIT has increased. The frequency of contact allergy to DCOIT is not known because it has seldom been patch-tested. Label information on isothiazolinones in chemical products and articles, irrespective of concentration, is required for assessment of relevance, information to patients, and avoidance of exposure and allergic contact dermatitis.

More than just methylisothiazolinone: Retrospective analysis of patients with isothiazolinone allergy in North America, 2017-2020

BACKGROUND

Isothiazolinones are a common cause of allergic contact dermatitis.

OBJECTIVE

To examine the prevalence of positive patch test reactions to isothiazolinones from 2017-2020 and characterize isothiazolinone-allergic (Is+) patients compared with isothiazolinone nonallergic (Is-) patients.

METHODS

Retrospective cross-sectional analysis of 9028 patients patch tested to methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI) 0.02% aqueous, MI 0.2% aqueous, benzisothiazolinone (BIT) 0.1% petrolatum, and/or octylisothiazolinone (OIT) 0.025% petrolatum. Prevalence, reaction strength, concurrent reactions, clinical relevance, and source of allergens were tabulated.

RESULTS

In total, 21.9% (1976/9028) of patients had a positive reaction to 1 or more isothiazolinones. Positivity to MI was 14.4% (1296/9012), MCI/MI was 10.0% (903/9017), BIT was 8.6% (777/9018), and OIT was 05% (49/9028). Compared with Is-, Is+ patients were more likely to have occupational skin disease (16.5% vs 10.3%, P <.001), primary hand dermatitis (30.2% vs 19.7%, P <.001), and be >40 years (73.1% vs 61.9%, P <.001). Positive patch test reactions to >1 isothiazolinone occurred in 44.1% (871/1976) of Is+ patients. Testing solely to MCI/MI would miss 47.3% (611/1292) of MI and 60.1% (466/776) of BIT allergic reactions.

LIMITATIONS

Retrospective cross-sectional study design and lack of follow-up data.

CONCLUSION

Sensitization to isothiazolinones is high and concurrent sensitization to multiple isothiazolinone allergens is common.

Sensitization to isothiazolinones in the Spanish Contact Dermatitis Registry (REIDAC): 2019-2021 epidemiological situation

BACKGROUND

Current frequency and risk factors for sensitization to methylisothiazolinone (MI), methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), benzisothiazolinone (BIT) and octylisothiazolinone (OIT) in Spain are not well known.

OBJECTIVES

To study the frequency of sensitization, risk factors and simultaneous sensitization between the four isothiazolinones.

MATERIALS AND METHODS

We analysed all 2019-2021 consecutive patients patch-tested with MI (0.2% aq.), MCI/MI (0.02% aq.), BIT (0.1% pet.) and OIT (0.1% pet) within the Spanish Contact Dermatitis Registry (REIDAC).

RESULTS

A total of 2511 patients were analysed. Frequencies of sensitization were: any isothiazolinone 15.7%, MI 6.8%, MCI/MI 4.8%, BIT 3.5% and OIT 0.5%. MI and MCI/MI sensitization was associated with being occupationally active, hand dermatitis, detergents and age over 40. BIT sensitization was associated with leg dermatitis and age over 40. About one in nine MI-positive patients were positive to BIT, whereas one in five BIT-positive patients were positive to MI.

CONCLUSIONS

Sensitization to MI, MCI/MI and BIT is still common in Spain, while sensitization to OIT is rare. Currently, sensitization to MI and MCI/MI seems to be occupationally related. Although its origin is unknown, sensitization to BIT is more frequent in patients aged over 40 years. Simultaneous sensitization between MI and BIT is uncommon.

North American Contact Dermatitis Group Patch Test Results: 2019-2020

Background: Patch testing is an important diagnostic tool for assessment of allergic contact dermatitis (ACD). Objective: This study documents the North American Contact Dermatitis Group (NACDG) patch testing results from January 1, 2019, to December 31, 2020. Methods: At 13 centers in North America, patients were tested in a standardized manner with a screening series of 80 allergens, and, as indicated, supplemental allergens. Results: Overall, 4121 patients were tested; 2871 (69.7%) had at least 1 positive/allergic patch test reaction and 2095 patients (51.2%) had a primary diagnosis of ACD. The most commonly positive allergens were nickel (18.2%), methylisothiazolinone (MI) (13.8%), fragrance mix (FM) I (12.8%), hydroperoxides of linalool (HPL) (11.1%), and benzisothiazolinone (BIT) (10.4%). Compared with that of 2017-2018, prevalence of top 20 allergens statistically increased for FM I, HPL, BIT, propolis, and hydroperoxides of limonene (3.5%). For the first time, MI positivity did not increase between reporting periods. Approximately one-fifth of patients (20.3%) had ≥1 clinically relevant reaction(s) to allergens/substances not on the NACDG series. Conclusions: The epidemic of MI contact allergy in North America may have reached a plateau. Patch testing using a robust screening series, and supplemental allergens as indicated, is necessary for comprehensive evaluation of ACD.

Thyroid hormone disrupting potentials of benzisothiazolinone in embryo-larval zebrafish and rat pituitary GH3 cell line

Benzisothiazolinone (BIT), one of the most widely used antimicrobial agents in consumer products, has frequently been detected in the water environment. The present study was conducted to determine the adverse effects of BIT on the thyroid neuroendocrine system of zebrafish embryos/larvae. Rat pituitary (GH3) cell line was employed to support the underlying mechanism of thyroid hormone disrupting effects. Significant coagulation and hatching delay were observed in embryos exposed to 30 μg/L of BIT, which in turn remarkably decreased hatchability and larval survival. In BIT-exposed larvae, tshβ, tshr, and trh genes were significantly upregulated along with a decrease in thyroxine and triiodothyronine content, indicating that BIT decreased thyroid hormones and increased thyrotropin-releasing hormone and thyroid stimulating hormone secretion through a feedback circuit. The downregulation of trα and deio2 genes in the zebrafish larvae suggests the inhibition of thyroid hormone receptors and deiodination. Similar to the results in zebrafish, upregulation of tshβ and downregulation of trα, trβ, deio1, and deio2 genes were observed in GH3 cells. Our observations suggest that BIT can decrease the level of thyroid hormones by influencing central regulation, receptor binding, and deiodination.

Allergic contact dermatitis to isothiazolinones in a rubber factory: A case report

Isothiazolinones, used as preservative, are known to be skin sensitizers. Although cosmetics represent their main source, occupational exposure may be a significant origin of eczema. While allergic eczema related to these derivates have been reported in a number of professional sectors, their presence in the same workplace was not common.

Effects of methylisothiazolinone and octylisothiazolinone on development and thyroid endocrine system in zebrafish larvae

Methylisothiazolinone (MIT) and octylisothiazolinone (OIT) are used as preservatives and biocides to prevent product decay or deterioration. In the present study, developmental toxicity and the effect on the thyroid endocrine system were investigated in zebrafish embryos exposed to MIT and OIT for 96 h. Coagulation was significantly increased when zebrafish embryos were exposed to a concentration of 300 μg/L MIT and ≥ 0.3 μg/L OIT, resulting in a significant decrease in hatchability and larvae survival. The body length in zebrafish larvae exposed to 30 μg/L OIT was significantly shorter than that of the control group. The whole-body levels of triiodothyronine and thyroxine were significantly decreased in larvae exposed to MIT and OIT. Significant upregulation of crh, trh, tshβ, and tshr genes and downregulation of trαa, tg, ttr, and deio2 genes were observed in fish exposed to two isothiazolinones. The expression of dre-miR-193b and dre-miR-499 was significantly increased in zebrafish larvae exposed to MIT and OIT, indicating that epigenetic deregulation of miRNAs modulated genes involved in thyroid hormone regulation. OIT has a higher magnitude of toxicity than MIT, corresponding to the observed changes in thyroid hormones and developmental toxicity.

Novel insights into contact dermatitis

Contact dermatitis is a common disease, caused by repeated skin contact to contact allergens or irritants, resulting in allergic contact dermatitis (ACD) and/or irritant contact dermatitis. Attempts have been made to identify biomarkers to distinguish irritant and allergic patch test reactions, which could aid diagnosis. Some promising candidates have recently been identified, but verification and validation in clinical cases still need to be done. New causes of ACD are constantly recognized. In this review, 10 new contact allergens from recent years, were identified, several relating to anti-age products. Frequent allergens causing considerable morbidity in the population such as the preservative methylisothiazolinone (MI) have been regulated in EU. A significant drop in cases has been seen, while high rates are still occurring in other areas such as North America. Other frequent causes are fragrance allergens especially widely used terpenes and acrylates used in medical devises for control of diabetes. These represent unsolved problems. Recent advances in immunology have opened for a better understanding of the complexity of contact dermatitis, especially ACD. The disease may be more heterogenous that previous understood with several subtypes. With the rapidly evolving molecular understanding of the disease, the potential for development of new drugs for personalized treatment of contact dermatitis is considerable.

Synergistic effects of ozone/peroxymonosulfate for isothiazolinone biocides degradation: Kinetics, synergistic performance and influencing factors

Synergistic effects of ozone (O₃) and peroxymonosulfate (PMS, HSO₅^-) for isothiazolinone biocides degradation was studied. The synergistic ozonation process (O₃/PMS) increased the efficiency of methyl-isothiazolinone (MIT) and chloro-methyl-isothiazolinone (CMIT) degradation to 91.0% and 81.8%, respectively, within 90 s at pH 7.0. This is 30.6% and 62.5% higher than the corresponding ozonation efficiency, respectively. Total radical formation value (R_ct,R) for the O₃/PMS process was 24.6 times that of ozonation alone. Calculated second-order rate constants for the reactions between isothiazolinone biocides and (k_SO4-,MIT and k_SO4-,CMIT) were 8.15 × 10⁹ and 4.49 × 10⁹ M^-1 s^-1, respectively. Relative contributions of O₃, hydroxyl radical (OH) and oxidation to MIT and CMIT removal were estimated, which were 15%, 45%, and 40% for O₃, OH and oxidation to MIT, and 1%, 67%, and 32% for O₃, OH and oxidation to CMIT at pH 7.0, respectively. Factors influencing the O₃/PMS process, namely the solution pH, chloride ions (Cl^-), and bicarbonate (HCO₃^-), were evaluated. Increasing the solution pH markedly accelerated O₃ decay and OH and formation, thus weakening the relative contribution of O₃ oxidation while enhancing that of OH and . Cl^- had a negligible effect on MIT and CMIT degradation. Under the dual effect of bicarbonate (HCO₃^-) as inhibitor and promoter, low concentrations (1-2 mM) of bicarbonate weakly promoted MIT and CMIT degradation, while high concentrations (10-20 mM) induced strong inhibition. Lastly, oxidation performance of O₃ and O₃/PMS processes for MIT and CMIT degradation in different water matrices was compared.

In vitro co-culture model of human monocyte-derived dendritic cells and T cells to evaluate the sensitization of dinitrochlorobenzene

Exposure to sensitizer has been suggested to be hazardous to human health, evaluation the sensitization of sensitizer is particularly important and urgently needed. Dendritic cells (DCs) exert an irreplaceable function in immunity, and the T cell receptor (TCR) repertoire is key to ensuring immune response to foreign antigens. We hypothesized that a co-culture model of human monocyte-derived dendritic cells (Mo-DCs) and T cells could be employed to evaluate the sensitization of DNCB. An experimental model of DNCB-induced sensitization in rat was employed to examine alterations of cluster of differentiation CD103⁺ DCs and T cells. A co-cultured model of Mo-DCs and T cells was developed in vitro to assess the sensitization of DNCB through the phenotypic and functional alterations of Mo-DCs, as well as the TCR repertoire. We found that the CD103⁺ DCs phenotype and T-helper (Th) cells polarization altered in sensitization rats. In vitro, phenotypic alteration of Mo-DCs caused by DNCB were consistent with in vivo results, antigen uptake capacity of Mo-DCs diminished and capacity of Mo-DCs to prime T cell increased. Clones of the TCR repertoire and the diversity of TCR repertoire were enhanced, changes were noted in the usage of variable, joining, and variable-joining gene combinations. DNCB exposure potentiated alterations and characteristics of Mo-DCs and the TCR repertoire in a co-culture model. Such changes provided innovative ideas for evaluating sensitization of DNCB.

Evolution of methylisothiazolinone sensitization: a Belgian multicentric study from 2014 to 2019

BACKGROUND

In the 2010s an epidemic of allergic contact dermatitis to methylisothiazolinone occurred in Europe. European authorities banned the use of methylisothiazolinone in leave-on cosmetics in 2017 and limited its use in rinse-off products in 2018.

OBJECTIVES

To investigate the sensitization rate to methylisothiazolinone in Belgium between January 2014 and December 2019, and to assess co-sensitizations to octylisothiazolinone and benzisothiazolinone in methylisothiazolinone -sensitized patients.

METHODS

A retrospective study of patch test results with methylisothiazolinone, octylisothiazolinone and benzisothiazolinone observed in patients attending five Belgian hospitals.

RESULTS

Overall, 560 of 10.029 patients (5.58%) had a positive patch test reaction to methylisothiazolinone, and its sensitization rate decreased from 7.9% in 2014 to 3.1% in 2019. Rinse-off cosmetics, paints and detergents were the most prevalent sensitization sources in recent years. Simultaneous reactions readily occurred to octylisothiazolinone, and, surprisingly, and increasingly, also to benzisothiazolinone.

CONCLUSIONS

Contact allergy to methylisothiazolinone in Belgium has reached a pre-epidemic level, reflecting the impact of recent regulatory measures. Leave-on cosmetics, in contrast to rinse-off products, have almost disappeared as sensitization sources in Europe. Paints and detergents also remain problematic. The remarkably high number of patients (co-) sensitized to benzisothiazolinone should be a focus of future research. This article is protected by copyright. All rights reserved.

In vivo demonstration of immunologic cross-reactivity to octylisothiazolinone in patients primarily and strongly sensitized to methylisothiazolinone

BACKGROUND

Notwithstanding that concomitant exposure to different isothiazolinone derivatives may result in concomitant sensitization, clinical and animal studies have suggested cross-reactivity between these derivatives, notably between methylisothiazolinone (MI) and octylisothiazolinone (OIT).

OBJECTIVE

To investigate if patients sensitized to MI show cross-reactions to OIT and/or to benzisothiazolinone (BIT) by applying the concept of the re-test method.

PATIENTS AND METHODS

From March to October 2019 consecutive patients were patch tested with MI 0.2% aqueous in duplicate at the two lower corners of both shoulder blades. Patients sensitized to MI, but not to OIT 0.1% petrolatum (pet.) nor to BIT 0.1% pet., were re-tested, 2 months later, with the latter two derivatives at the skin sites where the MI reactions had fully disappeared.

RESULTS

Of 116 patients, 15 (13%) were sensitized to MI, eight of these not sensitized to BIT nor to OIT. Of these, seven patients, all (very) strongly sensitized to MI, were re-tested: five patients showed positive patch test reactions to OIT 0.1% pet.; one patient to OIT 0.1% pet. and BIT 0.1% pet.; and one other patient showed no reactions.

CONCLUSION

This study suggests that patients primarily and strongly sensitized to MI may show immunologic cross-reactions to OIT, and to a far lesser extent to BIT.

Isothiazolinone Biocides: Chemistry, Biological, and Toxicity Profiles

The importance of isothiazole and of compounds containing the isothiazole nucleus has been growing over the last few years. Isothiazolinones are used in cosmetic and as chemical additives for occupational and industrial usage due to their bacteriostatic and fungiostatic activity. Despite their effectiveness as biocides, isothiazolinones are strong sensitizers, producing skin irritations and allergies and may pose ecotoxicological hazards. Therefore, their use is restricted by EU legislation. Considering the relevance and importance of isothiazolinone biocides, the present review describes the state-of-the-art knowledge regarding their synthesis, antibacterial components, toxicity (including structure–activity–toxicity relationships) outlines, and (photo)chemical stability. Due to the increasing prevalence and impact of isothiazolinones in consumer’s health, analytical methods for the identification and determination of this type of biocides were also discussed.

Isothiazolinones in cleaning products: Analysis with liquid chromatography tandem mass spectrometry of samples from sensitized patients and market

BACKGROUND

Methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) contact dermatitis is a severe problem. The high concentrations of these substances and other isothiazolinones such as benzisothiazolinone (BIT) and octylisothiazolinone (OIT) contained in cleaning products may cause allergic contact dermatitis in sensitized patients.

OBJECTIVES

To evaluate the exposure to isothiazolinones contained in cleaning products on the market and from sensitized patients, and to verify the accuracy of labeling.

METHODS

A total of 34 cleaning products were collected (17 supplied by sensitized patients and 17 bought randomly). Analysis was made of the concentrations of MI, MCI, BIT, and OIT using liquid chromatography tandem mass spectrometry (LC-MS/MS).

RESULTS

MI and BIT were the components most frequently detected. Of all the products analyzed, 76.5% contained at least one isothiazolinone. Twelve products had an MI concentration above the permitted level for rinse-off cosmetics. Most of them were coming into direct contact with the skin in daily use. Mislabeling occurred in eight products.

CONCLUSIONS

Some cleaning products with high concentrations of isothiazolinones may cause cutaneous symptoms in sensitized patients, especially in spray form. The labeling should be correct, also regarding the use of each article.

The epidemic of methylisothiazolinone contact allergy in Europe: follow-up on changing exposures

BACKGROUND

Methylisothiazolinone (MI) has caused an unprecedented epidemic of contact allergy in Europe and elsewhere. Subsequently, regulatory action has been taken, at least in Europe, aiming at reducing risk of MI sensitization.

OBJECTIVE

To follow-up on the prevalence of contact allergy to MI in consecutively patch tested patients and assess the spectrum of products containing MI or methylchloroisothiazolinone (MCI)/MI in patients positive to MI which elicited current allergic contact dermatitis.

METHODS

A cross-sectional survey was performed in 2016 and 2017, including all adult patients patch tested with the baseline series (including MI 0.2% aq.) between 1 May and 31 October at 14 centres in 11 European countries. Patients with positive reactions (+ to +++) to MI were further examined regarding history, clinical characteristics and eliciting products, which were categorized into 34 types and 4 classes (leave-on, rinse-off, household, occupational). The results were compared with the reference year 2015.

RESULTS

A total of 317 patients, n = 202 of 4278 tested in 2016 (4.72%) and n = 115 of 3879 tested in 2017 (2.96%), had positive reactions to MI; the previous result from 2015 was 5.97% (P < 0.0001). The share of currently relevant contact allergy among all positive reactions declined significantly as well (P = 0.0032). Concerning product classes, a relative decline of leave-on and a relative increase of rinse-off and household products was noted.

CONCLUSION

The prevalence of MI contact allergy decreased by 50% from 2015 to 2017. As a consequence of regulation, the share of cosmetics products (leave-on in particular) eliciting allergic contact dermatitis is decreasing. The chosen method of analysing causative products in sensitized patients has proven useful to monitor effects of intervention.

Isothiazolinone derivatives and allergic contact dermatitis: a review and update

Allergic contact dermatitis (ACD) from isothiazolinones has frequently been described in the literature. Following an epidemic of sensitization to methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) in the 1980s, and more recently to MI, the Scientific Committee on Consumer Safety of the European Commission banned their use in leave-on products, while restricting that in rinse-off cosmetics. Despite a decreasing prevalence of ACD from MCI/MI and MI, cases caused by occupational exposure and non-cosmetic isothiazolinone sources are on the rise. Moreover, sensitization to newer and lesser known isothiazolinones has been reported. This paper reviews the epidemiology of contact allergy to different isothiazolinones, clinical presentation of isothiazolinone-induced ACD, most relevant sensitization sources and potential cross-reactions between isothiazolinone derivatives. It also provides an update on recent legislative measures.

Patterns of concomitant allergic reactions in patients suggest cross-sensitization between octylisothiazolinone and methylisothiazolinone

BACKGROUND

Recent animal tests have indicated cross-reactivity between methylisothiazolinone (MI), octylisothiazolinone (OIT), and benzisothiazolinone (BIT).

OBJECTIVES

To retrospectively analyse concomitant reactions to different isothiazolinones in patients in an occupational dermatology clinic during the ongoing MI contact allergy epidemic.

METHODS

We searched patch test files (January 2012 to February 2017) for patients with allergic reactions to OIT, BIT, and MI, and analysed their patch test results, occupations, exposure, and diagnoses.

RESULTS

We found 61 (9.4%) allergic reactions to MI, 19 (2.9%) reactions to OIT and 9 (1.4%) reactions to BIT in a total of 647 consecutively tested patients. Seventeen (89%) of the OIT-positive patients had concomitant reactions to MI, whereas only 3 (33%) BIT-positive patients had allergic reactions to MI. The MI reactions in OIT-positive patients were almost exclusively extreme reactions (+++). Exposure to OIT was identified in 26% of the OIT-positive patients, and 56% of the BIT-positive patients had been exposed to BIT.

CONCLUSIONS

Allergic reactions to OIT were strongly associated with extreme reactions to MI, which suggests cross-sensitization. In contrast, BIT reactions were mostly independent.