Efficacy of omalizumab in severe asthma with fungal sensitisation: a case report

Severe asthma with fungal sensitisation (SAFS) is characterized by poor symptoms control and frequent hospital admissions for exacerbations despite treatment with high dose inhaled steroids, long-acting beta-2 agonists and leukotriene receptor antagonists. Treatment with oral steroids is usually necessary and courses of antifungal therapy may improve asthma symptoms. We report a case refractory to conventional inhaled therapies, continuous oral steroids and antifungal therapy courses, who was effectively treated with omalizumab.

Component resolved diagnosis in real life: the risk assessment of food allergy using microarray-based immunoassay

BACKGROUND

The development of component-resolved diagnostics constitutes a potential breakthrough in food allergy testing, as detection of specific IgE (sIgE) to individual allergens may make it possible to establish the risk of a mild versus severe reaction.

OBJECTIVE

To compare allergists' risk assessment based on the current decision making process with that of virtual allergen-oriented risk assessment through microarray-based immunoassay.

METHODS

An observational, real-life study was performed on 86 adults with food allergy. The prescription of epinephrine was the surrogate marker of a severe reaction. In the same patients, the prescription of epinephrine based on the current decision making of the allergist and the independently established allergen-oriented risk assessment determined by microarray-based immunoassay were compared.

RESULTS

Fair degree of agreement between the specialists' risk assessment and that of the microarray-based immunoassay (k index 0.372 (95% CI: 0.185- 0.559) p < 0.001) was documented. Three causes of discrepancy emerged: the poor sensitivity of the allergen microarray-immunoassay (51.9%), the differences in risk assessment established by the specialist and the microarray-immunoassay (33.3%), the non-inclusion of the causative allergen in the microarray-immunoassay platform (14.8%).

CONCLUSION

Improvement of the diagnostic accuracy of microarray-immunoassay, combined with marrying its results to clinical information, could one day soon lead to changes in clinical practice in food allergy.

Hen egg hair mask-induced food allergy: a case report

We report the case of a 46-year-old woman who treated her hair with a homemade egg-white based mask. After one year of weekly applications, the ingestion of egg triggered rhinitis, choking and systemic urticaria. Though the breakdown of oral tolerance to egg has been reported elsewhere in the literature, to the best of our knowledge, this is the first case of hair mask-induced allergy.

The dilemma of the negative skin test reactors with a history of venom anaphylaxis: will this always be the case?

The loss of sensitization over time, the involvement of a different pathogenetic mechanism and the poor sensitivity of diagnostic tests have been included among the causes of a non IgE-mediated anaphylaxis triggered by an insect sting. To provide further insight into this topic we describe the case of a patient suffering from urticaria pigmentosa, anaphylactic shock due to a Vespid sting and monosensitive to Polistes dominulus venom, who was previous diagnosed with non-IgE mediated insect sting anaphylaxis in subjects with urticaria pigmentosa. Therefore ultra-rush specific immunotherapy using an acqueous Polistes dominulus venom extract was performed over two mornings until a total dose of 100mcg was reached without any side effects. Presently the patient is undergoing maintenance therapy with a depot Polistes dominulus venom extract at 4-weekly intervals and is free of side effects. In conclusion, despite the high cross-reactivity among the venoms of the various species of Polistes, recent evidence of a selective specificity unique to European Polistes allergens raises the problem of the need to make the American Polistes venom as well as that of Polistes dominulus (a very common insect in Europe) available both for diagnostic and therapeutic purposes. Besides the fact that the presence of urticaria pigmentosa alone could have explained the anaphylactic reaction to the aspecific stimulation triggered by the venom, this case history also demonstrates that omitting to perform skin tests for Polistes dominulus venom would have led to the same misdiagnosis of non IgE-mediated anaphylaxis and served only to further delay commencing specific immunotherapy.

Intraoperative anaphylaxis: verba volant, scripta manent!

We describe a case of intraoperative gelatine-induced anaphylaxis whose diagnosis was delayed as the use of gelatine during surgical procedures was omitted for two times in patient's medical records. The subject is a 66-year old woman, with a negative medical history of atopy, food and drug allergy, with arterial hypertension on a course of beta-blockers and with bladder carcinoma requiring surgery. The patient had tolerated both general and local anaesthesia on several previous occasions. On the first occasion she experienced arterial fibrillation secondary to a severe episode of hypotension following local anaesthesia, while on a course of beta-blockers. On the second occasion she developed a very severe episode of hypotension followed by the outbreak of a generalised rash during general anaesthesia. The tryptase sera level was 109 mg/L one hour after the reaction had subsided, while the basal values were normal. On the third occasion the patient redeveloped severe hypotension and a generalised rash during general anaesthesia. The allergological work-up was negative, except for intradermal test with gelatine. A study of the intra-cellular cytokines in blood lymphocytes showed a production of IL4 from CD4+ lymphocytes after stimulation by gelatine. The patient underwent a successive surgical procedure without any adverse event.

Clinical study on Alternaria spores sensitization

BACKGROUND

sensitization to fungi spores is often associated with sensitization to other allergens and so it is difficult to estabilish the exact cause of illness.

OBJECTIVE

the aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization.

METHODS

37 subjects who were monosensitized to Alternaria (prick-test positive), according to a previous epidemiological study were evaluated. Clinical symptoms and the period of their occurrence were taken into consideration as well as immunological parameters (RAST).

RESULTS

20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23.

CONCLUSIONS

Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. Prick test is preferable to and more reliable than RAST as a diagnostic test.

Prevalence of sensitization to Alternaria in allergic patients in Italy

BACKGROUND

The actual prevalence of sensitization to Alternaria is not known, partly due to the unreliability of diagnostic extracts.

OBJECTIVE

To assess skin positivity to extracts of Alternaria in a wide population of Italian patients suffering from respiratory symptoms using a biologically standardized extract.

METHODS

A total of 2942 patients were skin prick tested with Alternaria, and a panel of common inhalant allergens. Blood samples for specific IgE quantitation were taken both from patients positive and from patients negative (control group) to Alternaria extract.

RESULTS

Three hundred six patients (10.4%, ranging from 1.8% in Turin to 29.3% in Cagliari) were positive to Alternaria; 37 were sensitized to only this mold, while the remaining 269 were sensitized to at least one other allergen. Of the Alternaria-positive patients, 79.7% suffered from rhinitis and 53.3% from asthma, either alone or associated with other symptoms.

CONCLUSIONS

We suggest that, at least in Italy and in countries with similar climatic and environmental situations, standardized Alternaria extract should be included in the panel commonly used in investigating the allergen responsible in patients suffering from respiratory allergy.

Paradoxical bronchospasm and cutaneous rash after metered-dose inhaled bronchodilators

The authors describe a case of paradoxical bronchospasm with laryngospasm and cutaneous rash occurring in an asthmatic woman after the use, via metered-dose inhaler, of different bronchodilators containing soy-derived excipients. It is noteworthy that the patient was not affected by soy allergy. After a short review of the relevant literature, the authors consider the possible aetiopathogenetic factors and outline the importance of this rare adverse reaction in the care of asthmatic patients.

Abnormalities of plasma lipoprotein composition and fluidity in psoriasis

We have studied the lipoprotein chemical composition and fluidity, using the fluorescence polarization of the probe 1,6-diphenyl-1,3,5-hexatriene (DPH) in two age- and sex-matched groups of subjects (14 healthy normolipidemic children and 15 psoriatic children). The compositional study has shown a significant increase of the percentage content in triacylglycerol and a significant decrease of the apo-protein content in all lipoprotein fractions of psoriatic children compared to the controls. A significant increase of the percentage content in total cholesterol and of the cholesterol/protein ratio has also been observed in low-density lipoproteins (LDL) and in high-density lipoproteins (HDL) of psoriatic children. The compositional changes were associated with alterations of fluidity in LDL and HDL of psoriatic patients. The modifications of lipoprotein composition and fluidity observed in psoriatic patients could be of physiopathological and clinical relevance in relation to the pathogenesis of the disease.

Changes of plasma lipids and erythrocyte membrane fluidity in psoriatic children

Psoriasis has been associated with an abnormal plasma lipid metabolism, and changes of erythrocyte membrane lipid composition and fluidity have been shown in adult patients. To investigate whether the alterations of plasma lipids appear also in pediatric patients, we have studied plasma lipids and lipoproteins in 15 prepubertal children affected by mild-to-moderate psoriasis with respect to healthy controls. The patients showed higher levels of plasma total cholesterol (4.44 +/- 0.78 versus 4.03 +/- 0.58 mmol/L), a significant increase of cholesterol associated with HDL (1.39 +/- 0.26 versus 1.13 +/- 0.28 mmol/L, p = 0.02), and a significant decrease of the ratio LDL cholesterol to HDL cholesterol (1.73 +/- 0.6 versus 2.46 +/- 0.8, p = 0.02). By using fluorescence polarization of 1,6-diphenyl-1,3,5-hexatriene, we have shown a significant increase in fluidity in erythrocyte membrane of psoriatic children that was associated with a slight, but not significant, decrease in the cholesterol to protein ratio (422 +/- 127 versus 503 +/- 117 nmol/mg). No significant changes of phospholipid fatty acid composition have been shown, in disagreement with previous studies in adult patients. Our results support the relation between childhood psoriasis and plasma lipid changes, which are likely related to the slight compositional changes in erythrocytes. However, the observed abnormalities are expressed differently in children than in adults.