Skin involvement is an early sign of anaphylaxis, but hypotension and respiratory symptoms can occur even without skin involvement. Various risk factors for severe anaphylaxis related to
Hymenoptera stings include:
· Elevated tryptase: possible mastocytosis
· Lack of urticaria or angioedema during the anaphylactic reaction.
· Symptoms developing less than 5 minutes after the sting.
· Older age
In contrast to previous reports, a recent German retrospective study reported comorbid illnesses and use of beta-blockers or angiotensin converting enzyme (ACE) inhibitors were not significantly related to severity of anaphylaxis. This study suggests that we should consider obtaining tryptase levels in our older patients who have had anaphylaxis following Hymenoptera stings, particularly if they have not had urticaria.
We have venom skin testing available through our office as well as venom immunotherapy. This is the treatment of choice for prevention of further systemic reactions to insect stings. It is indicated for patients with clinical history of anaphylaxis to insect sting and evidence of venom-specific IgE with skin test or serological testing. For large local reactions symptomatic treatment includes ice, NSAIDs, and H1 antihistamines. Short steroid bursts can be used for more bothersome local reactions. For systemic reactions, immediate administration of IM epinephrine and antihistamines should be given, and there should be an observation period following reaction to ensure symptoms subside.
The term PANDAS is used to describe a subset of children and adolescents who have obsessive compulsive disorder (OCD) and/or tic disorders whose symptoms get worse after strep throat and scarlet fever. It affects less than 200,000 people in the U.S. The ratio of boys to girls who have PANDAS is 2.6 to 1 over the age of 8 and 4.7 to 1 under the age of 8. It has an abrupt onset of symptoms unlike typical symptoms of OCD. Children with PANDAS have sudden and dramatic onset, (within 24 to 48 hours). They experience separation anxiety, anxiety attacks, irritability, extreme mood swings, tantrums, hyperactivity, and handwriting changes in addition to OCD and tics.
Presently, determining whether a child has PANDAS can be based only on a clinical diagnosis. There is no benefit of lab tests. Clinicians use five diagnostic criteria: presence of OCD or tic disorder, pediatric onset of symptoms, episodic course of symptom severity, associated with group A beta-hemolytic streptococcal infection, and association with neurological abnormalities (motor hyperactivity). The best treatment for acute episodes of PANDAS is to rid of the strep infection. Perform throat culture to detect presence of the bacteria. If it is negative, look for occult strep infection such as sinus infections. A single course of antibiotics such as amoxicillin is sufficient. To avoid recurrent infections, sometimes antibiotics are used for prophylaxis. In a study, IVIG vs. plasma exchange vs. placebo was evaluated. Children with IVIG or plasma exchange were significantly improved at one month and at one year. At our office, we can provide proper evaluation and treatment with IVIG. Most children outgrow PANDAS at puberty.
Link between Rhinitis and Otitis Media May Require Allergy
The correlation between recurrent otitis media and allergic rhinitis has long been assumed to occur due to mechanical obstruction of the Eustachian tubes. Allergic inflammation may very well contribute to the common problem of otitis media with effusion (OME).
This issue was addressed using strict definitions of atopic disease and OME in 6-year-old children from a birth cohort study. The analysis included 291 children in the sixth year of life. Tympanometry were used to determine the presence of OME. Associations between OME and allergic disease were analyzed, with adjustment for pet and smoking exposure, paternal atopy, household income, older siblings, sex, and number of acute OME episodes. The diagnosis of OME was made in 39% of children. There was a significant association between OME and allergic rhinitis: adjusted odds ratio 3.36. Otitis media with effusion was unrelated to the other allergic diagnoses assessed, or to nasal eosinophilia or mucosal swelling.
The close association between OME and allergic rhinitis in young children suggests a contribution of allergic inflammation, rather than nasal mucosal swelling. The findings highlight the need for increased attention to OME among children with allergic rhinitis.
Some Adults with Lactose Intolerance Have Milk Allergy
Lactose intolerance due to hypolactasia is a common condition. In adults reporting adverse reactions to cow's milk, physicians may not consider or test for the possibility of IgE-mediated cow's milk allergy. This may result in diagnostic bias, with patients being labeled as lactose intolerant without appropriate allergy testing.
A study was performed on 46 adults with convincing clinical histories of adverse reactions to cow's milk who were having continued symptoms despite a lactose free diet. All had lactose intolerance confirmed by hydrogen breath testing. The patients underwent skin prick and immunoblot testing for cow's milk allergy. Twenty subjects with clinical tolerance to cow's milk were studied as controls. Of this group of patients with lactose intolerance, 69.5% had positive skin-prick tests to whole cow's milk. The patients also had high rates of positive skin-prick tests to other milk proteins, including alpha-lactalbumin in 36.9%, beta-lactoglobulin and caseins in 56.5% each, goat's milk in 54.3%, and soy in 50%. Just 5 patients had no evidence of IgE-mediated sensitization--a rate of 10.8%.
Many adult patients with lactose intolerance may also have IgE-mediated sensitization to milk proteins. Testing for cow's milk allergy may aid diagnostic in treatment decision-making in patients with "lactose intolerance" who do not respond to a lactose-free diet.
Mannitol challenge kits are now approved and marketed for bronchial reactivity testing. This is the challenge of choice when exercise-induced bronchospasm (EIB) is the question, or to differentiate asthma from COPD. Indirect testing with mannitol, reduces the possibility of over and under diagnosis of asthma based on history and symptoms. It identifies patients who would benefit from ICS. Mannitol is a dry powder that is inhaled and provides osmotic challenge to the airway mucosa. Endpoint is a 15% fall in FEV1. In contrast to methacholine, mannitol challenges are promoted as tests that confirm the diagnosis of asthma if the test result is positive but do not rule out asthma if the test result is negative. We have mannitol challenge available at our office as a screening test for asthma.
We are pleased to announce the availability of a new alternative therapy for treatment of respiratory tract allergies; sublingual immunotherapy (SLIT).
SLIT involves a dosing schedule of increasing amounts of allergen, much like the allergy injection. However, rather than injections, the allergens are administered in a liquid form under the tongue. The effectiveness of SLIT has been studied in both adults and children as young as a year of age. SLIT has a favorable safety profile and can be performed at home. This is an alternative treatment for patients with dust mite, cat, dog, ragweed and grass allergy.
The primary side effects reported in some studies in only an occasional patient were oral itching, itchy skin, abdominal pain, and nausea and vomiting.
There have been over 60 controlled clinical trials published in the past 20 years with the majority of studies being done in dust mite or grass allergic individuals. There are currently no FDA-approved formulations but, several clinical trials with sublingual immunotherapy have been conducted in the United States that has demonstrated SLIT to be safe and effective.
We look forward to working with you in helping our patients seeking immunotherapy for control of their respiratory tract allergies.
Bush RK, et al. House dust mite sublingual immunotherapy: Results of a US trial. Journal of Allergy and Clinical Immunology Vol. 127, Issue 4, Pages 974-981.
Skoner D, et al. Sublingual immunotherapy in patients with allergic rhinoconjunctivitis caused by ragweed pollen. Journal of Allergy and Clinical Immunology Vol. 125, Issue 3, Pages 660-666.
Di Bona D, Plaia A. Efficacy of sublingual immunotherapy with grass allergens for seasonal allergic rhinitis: A systematic review and meta-analysis. JACI Vol. 126, Issue 3, Pages 558-566
Sugar and Spice and Everything Not So Nice
Spices are one of the most widely used products found in foods, cosmetics and dental products. They often are not noted on food labels, making spices possibly the most difficult allergen to identify or avoid. Roughly, spice allergy is responsible for 2 percent of food allergies.
With the constantly increasing use of spices in our diet and a variety of cosmetics, it is anticipated that more individuals will develop this allergy. Due to the wide use of spice in cosmetics, body oils, toothpaste and fragrances, women are more likely to develop spice allergy. Those with birch pollen or mugwort allergy are also more prone to spice allergy.
Common spice allergy triggers include cinnamon and garlic, but can range from black pepper to vanilla. Boiling, roasting, frying and other forms of applying heat to spices may reduce allergy causing agents, but can also enhance them.
An allergic reaction can be caused from breathing, eating or touching spices. Symptoms range from mild sneezing to anaphylaxis. Spice allergy should be suspected in individuals that have multiple reactions to unrelated foods, or those that react to foods when commercially prepared but not when cooked at home.
Holiday gatherings can serve up allergy and asthma triggers. Those that suspect they may have a spice allergy can be allergy skin tested at our office for proper diagnosis.
Longer Durations of Exclusive Breastfeeding Reduce Asthma Risk
BREASTFEEDING in infancy has been linked to a reduced incidence of childhood asthma. An analysis included 5,369 children. Breastfeeding duration and exclusiveness were evaluated for association with asthma-related symptoms through age 4.
Children who were never breast-fed had higher rates of asthma-related symptoms, compared to those with at least 6 months of breastfeeding. Odds ratios were 1.44 for wheezing, 1.26 for shortness of breath, 1.25 for dry cough, and 1.57 for persistent phlegm.
Exclusive breastfeeding for 4 months showed similar protective effects. The strongest protective effects were noted for wheezing at the ages of 1 and 2 years. The associations were partially explained by a reduction in respiratory tract infections.
Longer durations of breastfeeding and exclusive breastfeeding significantly reduce the rate of asthma related symptoms through the preschool years. The findings are consistent with an infectious,rather than atopic, mechanism.
Sonnenschein-van der Voort AM, Jaddoe VW, van der Valk RJ, et al: Duration and exclusiveness of breastfeeding and childhood asthma-related symptoms. Eur Respir J. 2012:39;81-89.
Anti-IgE therapy with Xolair (omalizumab) provides a new option for therapy in patients with uncontrolled moderate to severe persistent allergic asthma.
In 2003, analysis of clinical trial data suggested increased malignancy among omalizumab treated patients versus controls at a ratio of 0.5% versus 0.2%.
Recently, a pooled analysis from 67 phase I to IV clinical trials of omalizumab performed over two decades showed that the incidence rates of malignancy was not different between groups: 4.14 and 4.45 per 1,000 patient-years.
This suggests a reassuring lack of association between a risk of malignancy and use of omalizumab in the 7,789 patients studied in the clinical trials.
Investigators conclude that “a causal relationship between omalizumab therapy and malignancy is unlikely.”
Busse W, Buhl R, Fernandez Vidaurre C, et al: Omalizumab and the risk of malignancy: results from a pooled analysis. J Allergy Clin Immunol. 2012;129:983-989.
Intranasal Steroids May Help Minimize Antibiotic Use
Are intranasal steroids effective in minimizing utilization of antibiotics for acute rhinosinusitis?
A randomized placebo-controlled trial demonstrated that mometasone furoate nasal spray 200 mcg twice daily significantly enhanced minimal symptom days versus amoxicillin or placebo in rhinosinusitis patients aged 12 years and older. This benefit was noted within 2 days and allowed patients to return to activity earlier. The results are promising that inhaled corticosteroid therapy can enhance outcome in rhinosinusitis; while minimizing inappropriate antibiotic use.
Meltzer EO, Gates D, Bachert C, et al: Mometasonefuroate nasal spray increases the number of minimalsymptom days in patients with acute rhinosinusitis.Ann Allergy Asthma Immunol. 2012;108:275-279.