Molecular diagnostics improves diagnosis and treatment of respiratory allergy and food allergy with economic optimization and cost saving

BACKGROUND

Component resolved diagnosis (CRD) allows to precisely identify the sensitization to specific molecules of a given allergenic source, resulting in an important improvement in clinical management, particularly of polysensitized subjects. This will end in the correct prescription of allergen immunotherapy (AIT) for respiratory allergy and in adequate avoidance diets or prescription of self-injectable adrenaline in food allergy.

OBJECTIVE

The aim of this multicenter, real life study is to evaluate the percentage change of the diagnostic-therapeutic choice in polysensitized patients with respiratory allergy and in patients with food allergy, after using CRD compared to a first level diagnosis, along with an economic analysis of the patient's overall management according to the two different approaches.

METHODS

An overall number of 462 polysensitized patients, as suggested by skin prick tests (SPT), and with clinical symptoms related to a respiratory (275 pts) or food (187 pts) allergy, were recruited. All patients underwent CRD for specific IgE against food or inhalant recombinant molecules, which were chosen according to medical history and positivity to SPT. The first diagnostic-therapeutic hypothesis, based only on medical history and SPT, was recorded for each patient while the final diagnostic-therapeutic choice was based on the results from CRD. The rate of change of the diagnostic-therapeutic choice from the first hypothesis to the final choice was statistically evaluated. The economic impact of CRD on the overall management of the allergic patients was analyzed to evaluate whether the increase in the diagnostic costs would be compensated and eventually exceeded by savings coming from the improved diagnostic-therapeutic appropriateness.

RESULTS

An approximate 50% change (k index 0.54) in the prescription of AIT for respiratory allergy as well as a change in the prescription of self-injectable adrenaline (k index 0.56) was measured; an overall saving of financial resources along with a higher diagnostic-therapeutic appropriateness was also detected.

CONCLUSION

There is moderate agreement concerning prescription of AIT and self-injectable adrenaline before and after performing CRD: this highlights the usefulness of CRD, at least in polysensitized patients, in indicating the risk assessment and therefore the correct therapy of respiratory and food allergy, which results in a cost-saving approach.

Hymenoptera Venom Allergy: Management of Children and Adults in Clinical Practice

Hymenoptera venom allergy is an epidemiologically underestimated condition and a major cause of morbidity worldwide. Preventing future allergic reactions in patients who experience a systemic reaction is based on the correct management of the emergency followed by an accurate diagnosis, prescription of adrenaline autoinjectors, and, where indicated, specific venom immunotherapy. Some epidemiological studies highlight our poor knowledge of this disease and the frequent inadequacy of its management. Moreover, they emphasize the importance of such a life-saving treatment as specific immunotherapy. The availability of high-quality hymenoptera venom extracts for diagnostic and therapeutic use has dramatically improved the prognosis and quality of life of allergic patients. Subcutaneous venom immunotherapy is currently the most effective form of allergen-based immunotherapy, with a carry-over effect lasting up to several years after its interruption. This report on the management of hymenoptera venom-allergic children and adults was prepared by a panel of Italian experts. The main objective of this consensus document is to review the scientific evidence related to diagnosis, therapy, and management of patients allergic to hymenoptera venom. Thus, we can improve our knowledge of the disease and promote good clinical practices. The present document provides practical suggestions for correct diagnosis, prescription of emergency therapy and immunotherapy, and strategies for patient care.

Laboratory tests for allergy diagnosis

The introduction of highly purified natural and recombinant single allergenic molecules represented an important improvement in the diagnosis of IgE sensitization. The identification of specific IgE against cross-reacting molecules such as profilin, lipid transfer proteins, calcium binding proteins or against “genuine molecules”, represents an added value and allows to distinguish between true and false polysensitization. In vitro tests add information to recognize patients with sensitization to genuine molecules that cause allergic diseases and to evaluate in childhood the spreading of sensitization for each molecule in order to choose the best treatment and to identify the ideal patient for allergen immunotherapy. Also, in order to detect patients with sensitization to pan-allergens it is important to manage the risk of anaphylaxis for patients allergic to latex and to identify IgE to particular molecules involved in occupational allergy. In patients with negative skin prick tests (SPT), that results in a lower sensitivity compared with in vitro tests, the negative test may be caused by the lack of some important allergenic molecules in the extract used for SPT.

An unusual case of wheat dependent exercise induced anaphylaxis (WDEIA) triggered by Tri a 14 in a pediatric patient: a case report

Summary

Anakinra, one of the novel biological agents, is a recombinant human IL-1 receptor antagonist. It is preferred as an alternative drug for familial Mediterranean fever cases where colchicine is not sufficient or cannot be used due to its side effects. Like all other biologics, hypersensitivity reactions to anakinra are quite rare. This is the first case which was successfully desensitized with anakinra after a severe immediate-type hypersensitivity reaction. We report a case of WDEIA in an asthmatic boy admitted to our Unit with suspected mushroom acute toxicity. The symptoms occurred during a gym session, approximately 2 hours after the ingestion of a meal based on pasta and cooked mushroom found in the family's garden. Acute toxicity due to mushroom ingestion was then excluded. Triptase serum levels resulted elevated in acute phase and normal after 24 hours. Food specific IgE showed a sensitization to lipid transfer protein Pru p 3 and to Tri a 14. This case highlights that WDEIA is underdiagnosed, especially when patients are firstly visited in Emergency Unit. Moreover, Tri a 14 is seldom described as responsible for WDEIA, compared to omega 5 gliadin.

Component resolved diagnosis (CRD): how much is it presently used by Italian allergists?

Component resolved diagnosis (CRD) represents an innovative and revolutionary tool in allergy diagnosis. At the same time, some criticisms can be outlined. The present web survey aimed at investigating the role of CRD in daily clinical practice, according to a sample of Italian specialists who manage allergic patients. 127 physicians, mostly allergists, completed the questionnaire, mainly coming from North and Center of Italy. Most of them (80%) were allergists. One physician out of three regularly takes into consideration CRD, that is currently available about in a half of the hospitals where the specialists work. CRD is mostly prescribed in the diagnostic work-up of suspected food allergy, as it can drive risk assessment, epinephrine prescription and dietary advice. Concerning respiratory allergy, CRD is considered useful in investigating cross-reactivity and in defining the best treatment option, even if only 32% of patients treated with immunotherapy had been previously studied with CRD. The present survey points out the need for the specialists to develop a more practical know-how about CRD. Its diagnostic accuracy and its real impact on the clinical management need to be better defined. The lacking of CRD technology in many hospitals limits the possibility for many allergists to directly experience molecular diagnosis.

Causes of SLIT discontinuation and strategies to improve the adherence: a pragmatic approach

Sublingual immunotherapy (SLIT) is often discontinued, and many patients do not renew the prescription. We evaluated the reasons for discontinuation and set up an educational/follow-up plan to improve the adherence. In a first phase, the adherence at 4 months was directly assessed. Based on those results, an action plan (education, frequent contacts, and strictly scheduled visits) was developed and tested in other patients. A group of matched patients did not undergo the follow-up plan (controls). In the first phase, involving 252 subjects, at 4 months, there were 30% dropouts, mainly due to side-effects. In the second phase, 149 patients underwent education/follow-up and 90 received no intervention. In the first group, discontinuations at 4 months were 5%, vs 18% in the controls (P = 0.01). After one year, 12% of patients were lost in the first group and 35% in the control group (P < 0.001). An adequate education and a strict follow-up can significantly reduce SLIT's discontinuations.

Heterogenity of IgE response to walnut and hazelnut in Italian allergic patients

BACKGROUND

The prevalence of IgE reactivity against genuine walnut and hazelnut allergens is poorly defined.

OBJECTIVE

The IgE response to walnut and hazelnut was investigated in Italian patients with primary allergy to these nuts.

METHODS

Sera from 36 patients allergic to hazelnut and/or walnut, not reactive to PR-10, profilin, and LTP, underwent immunoblot analysis with extracts of both nuts.

RESULTS

Most patients had a history of systemic symptoms following the ingestion of the offending food(s). Twelve patients were sensitized to both walnut and hazelnut, and 13 were sensitized to other nuts and seeds (cashew, peanut, sesame, pine nut, almond, Brazil nut, and pistachio). On walnut immunoblot, the 7 sera which scored positive showed much variability in their IgE profile. Two reacted uniquely at 10 kDa, and the others at 35 , 40, 45, 50, 67, and > 67 kDa. The profiles obtained under reducing and non-reducing conditions showed several differences. The 7 sera positive on hazelnut immunoblot under reducing conditions recognized sera at 10 kDa and at <10 kDa (n=1), 20 kDa (n=4), at about 22, 24, 30, 40, 43, 58, 60, and 90 kDa, and higher m.w. in other cases. Under non-reducing conditions IgE reactivity at 20, 28, 35, 40, 45, 60, 90, and 100 kDa, was detected. Only two sera scored positive under both conditions and showed an IgE profile that partly changed from one assay to another.

CONCLUSION

The current list of walnut and hazelnut allergens is far from being complete. Both reducing and non-reducing conditions are needed to detect IgE reactivity in individual patients.

Wellbeing, Illness Perception and Coping Strategies in Italian Celiac Patients

The clinical features of Celiac Disease (CD) are heterogeneous and both severity and extent of villous atrophy do not correlate with clinical presentation. This study aims to evaluate the psychological wellbeing of CD patients with a similar clinical pattern and to explore whether patients with different levels of wellbeing differed in illness perception and coping strategies. CD outpatients with proven diagnosis filled in validated questionnaires to investigate wellbeing (PGWBI), illness perception (IPQ-R) and coping style (COPE). One hundred and four patients underwent data analysis. Compared to Italian reference sample, CD patients reported a significantly reduced PGWBI total score (p<0.001), self-control (p<0.001), general health (p=0.002) and vitality (p<0.001) and increased anxiety (p=0.009). 7.7% of patients reported a positive wellbeing, 40.4% distress absence, 28.8% a moderate distress and 23.1% a severe distress. Patients with distress showed a different illness perception and reported more frequently two dysfunctional strategies: “focus on and venting emotions” (p= 0.009) and “substance abuse” (p= 0.01) compared to those having a positive wellbeing. A high percentage of CD patients experience distress and differ from those who reach wellbeing in illness perception and use of coping strategies. Assessing subjective viewpoint with standardized methods can provide useful information for a better management of CD patients.

Operative procedure for the monitoring of anaphylactic reactions and the prevention of recurrence

Prevention of anaphylaxis depends on optimal management of patient-related risk factors, an educational programme to teach how to avoid confirmed relevant allergens. We observed in our routine practice several patients who underwent allergological evaluation months or years after the occurrence of anaphylactic reaction or a relapse. The main issues of this proposal are to identify all patients arrived to Emergency Unit with anaphylactic reactions ranging from Mueller classification grade II-IV and to refer them to an Allergy Unit with the intent to promote, within 48 hours, a diagnostic and therapeutic programme, set the anaphylactic risk for each patient and deliver Fast Jeckt (Epinephrine autoinjectors). The programme is evaluated by Quality Unit of Piacenza's AUSL that suggests two monitoring indicators: "Efficacy" of the plan is checked measuring recurrence rate in a year,"Quickness" of Allergological consultation is monitored recording time of consultation request from Emergency Unit and time of first allergological visit. We observe an increase in the number of patients referred to the Allergy Unit within 48 hours to receive a diagnostic and therapeutic programme to prevent recurrence of anaphylaxis: 6 patients in 2007 and 31 in 2010 and a decrease in the number of patients arrived after anaphylaxis sent by practitioner: 7 in 2007 and 1 in 2010 (p < 0.05). All quarterly reports have reported an Efficacy less than 15% of recurrences and a Quickness more than 90%. The procedure has received an institutional accreditation by Emilia Romagna Health Agency. These observations underline the importance of an operative procedure for the monitoring of anaphylactic reactions, in order to provide an effective and immediate medical examination and also avoid the risk of recurrence.

Omega-5 gliadin anaphylaxis: an integrated diagnostic approach

We report the case of a 62-year old man who presented a wheat-dependent, exercise-induced anaphylaxis (WDEIA). The case illustrates the usefulness of skin prick test not only with wheat extract, but also with native gliadin extract. Moreover we confirm the value of recombinant IgE dosage with rTri a 19 omega-5 gliadin in the diagnostic pathway of this condition.

A prospective Italian survey on the safety of subcutaneous immunotherapy for respiratory allergy

BACKGROUND

Subcutaneous immunotherapy is effective for the treatment of respiratory allergy, and it is largely used in Italy, but no systematic safety assessment has been carried out so far.

OBJECTIVE

To assess prospectively the safety of injection immunotherapy in a multicentre, real-life survey.

METHODS

Eleven Italian allergy departments recorded the clinical characteristics of systemic reactions (SRs) due to immunotherapy. Vaccines were prescribed according to guidelines; only standardized depot extracts were used. SRs were graded according to the EAACI recommendations, and were classified as immediate or delayed.

RESULTS

One thousand seven hundred and thirty-eight patients (847 males, age range 5-71) received immunotherapy from eight different manufacturers, for a total of 2038 courses (300 patients received two extracts). A total of 60 785 injections were given over a mean immunotherapy duration of 3 years. Overall, 95 reactions were observed in 57 patients (3.28%), corresponding to 4.7% of the courses and 1.56/1000 injections. Twenty-five patients experienced more than one adverse event. There were 34 grade 2, 60 grade 3 and one grade 4 reactions and no fatality. SRs occurred more frequently in patients with asthma than in patients with rhinitis alone (4.1% vs. 1.1%), and were equally distributed between the build-up and the maintenance phase. Ragweed and grass extracts caused significantly more side effects than other allergens.

CONCLUSION

In this large prospective study, the rate of SRs was low, thus confirming that injection immunotherapy has an acceptable risk/benefit ratio when prescribed and carried out according to recommendations.

Cat-pork syndrome: a case report with a thee years follow-up

A case of cat-pork syndrome with subsequent follow-up in a 17-year-old male patient is reported. At the initial observation, the patient was sensitized to cat epithelium--along with house dust mites and grass pollen--from two years. In 2001 he had an immediate reaction with urticaria, angioedema and dyspnea after eating grilled meat and sausage, and skin tests and CAP/RAST revealed a sensitization to pork meat, with a value of 4.7 KU/L for pork meat, and of 55 KU/L for cat epithelium. The patient was followed up for three years with annual repetition of diagnostic tests. The elimination of pork meat from the diet was incomplete, with slight skin reactions to small amounts of cooked pork meat but tolerance to seasoned pork products such as salami. A challenge test with pork meat in 2004 was positive, with angioedema and asthma symptoms, and CAP/RAST showed a value of 43 KU/L for cat epithelium and 4 KU/L for pork meat. RAST inhibition confirmed the significant cross-reactivity between the two allergen sources. These findings provide some knowledge on the natural history of the cat-pork syndrome, and confirm that very prolonged avoidance of the offending foods are needed to expect a loss of sensitization.

Sublingual immunotherapy: a double-blind, placebo-controlled trial with Parietaria judaica extract standardized in mass units in patients with rhinoconjunctivitis, asthma, or both

BACKGROUND

New routes of administering immunotherapy in respiratory allergy are being studied as an alternative to conventional injective immunotherapy. We carried out a study to evaluate the clinical efficacy and effects of sublingual immunotherapy in patients with Parietaria judaica-induced respiratory allergy.

METHODS

A double-blind, placebo-controlled design was followed. Thirty patients with P. judaica rhinoconjunctivitis, mild asthma, or both were randomly chosen for sublingual immunotherapy (14 patients) or placebo treatment (16 patients). The patients underwent preseasonal rush induction treatment followed by coseasonal maintenance treatment during the Parietaria pollen season. Symptom and drug scores, as well as specific IgE and specific IgG4, were recorded.

RESULTS

Significantly lower symptom and drug scores were found (P=0.04), especially during the Parietaria pollination period, in the immunotherapy group. No significant difference in specific IgE and specific IgG4 was detected between the active and placebo groups; a statistically significant increase of specific IgE was detected in both groups (P=0.05). No patient undergoing active sublingual immunotherapy reported local or systemic side-effects.

CONCLUSIONS

Our data suggest that sublingual immunotherapy is both clinically effective and safe in treating patients with Parietaria-induced rhinoconjunctivitis and mild asthma.

Rush sublingual immunotherapy in Parietaria allergic patients

Forty patients, monosensitized to Parietaria judaica with a clinical history of at least two years of rhinoconjunctivitis with or without asthma, were selected and randomly allocated in two groups. According to an open controlled experimental plan, twenty patients were submitted to sublingual immunotherapy (SLIT) with a solution of purified and biologically standardized extract of Parietaria judaica, following a preseasonal rush schedule. All patients, twenty belonging to the SLIT group and twenty belonging to the control group, were allowed to take authorized rescue drugs at need. At the end of the Parietaria pollen season. 15 patients for each group resulted to have complied with the criteria of the study. SLIT tolerance turned out to be excellent as no side effects were noticed in the group under treatment. No change could be detected in specific IgE and IgG4 in either group. According to the daily symptom and drug scores registered by each patient in a diary card, the SLIT group showed a statistically significant lower symptom score (p = 0.032) and lower drug plus symptom score (p = 0.037) during the peak pollen period (May-June 1994) in comparison to the group treated only with symptomatic drugs. Moreover, 13 out of 15 patients submitted to SLIT expressed a very favourable subjective opinion about the therapy and asked to continue the same treatment the following season. According to our results, the rush SLIT schedule, followed by maintenance during the pollen season, is simple, safe and effective for Parietaria pollen allergy and showed an excellent compliance.

High prevalence of antibodies to hepatitis C virus among family members of patients with anti-HCV-positive chronic liver disease

We have evaluated the intrafamilial transmission of hepatitis C virus (HCV) by studying 1) the 107 household contacts of 43 patients with chronic HCV liver disease, 2) the household contacts of 30 anti-HCV-positive donors without liver disease, and 3) 3108 blood donors. We also studied the possible manner of the intrafamilial transmission. The prevalence of anti-HCV positivity in the families of index patients was significantly higher than in donors (14.9% as against to 1.7%). All the family members of the anti-HCV-positive donors were anti-HCV negative. We conclude that the person-to-person transmission of HCV is possible and most probable in contacts of anti-HCV-positive patients with liver disease.