A case of the latex-induced anaphylaxis by contact with barium enema catheter]

The subject was a 34-year-old female with asthma and atopic dermatitis who had previously undergone a Cesarean section. In December 1995, the patient had an acute abdominal pain, so she underwent a barium enema examination. During the procedure, severe anaphylactic shock developed, and the examination was stopped. The patient responded well to appropriate emergency therapy, and her symptoms were resolved. However, the woman visited our outpatient clinic because the symptoms of her atopic dermatitis got worse. She indicated that she felt itchy when using rubber gloves. Also, at the age of thirty, she had urticaria and dyspnea after drinking a glass of fruit juice. Subsequently radioallergosorbent testing demonstrated the presence of specific IgEs against latex, banana, kiwi, grapefruit, and avocado. Skin prick tests were positive for banana, grapefruit, avocado, and latex extract at a dilution of 1:1000. A scratch test was positive to an extract of a balloon catheter which included 0.3 microg/g latex proteins by the LEAP method. In conclusion, the patient was diagnosed with an anaphylaxis to the latex contained in a balloon catheter used for the barium enema.     

The First Case of Erythritol-Induced Anaphylaxis in Korea

Erythritol is a natural sugar alcohol found in some fruits and fermented foods, which is used as a dietary sweetener because it has few calories. Here, we describe a 36-year-old woman who experienced anaphylaxis upon ingestion of an erythritol-containing drink. She presented to the emergency department with dyspnea and angioedema after drinking a peach-containing diet beverage. Her blood pressure dropped to 70/40 mmHg and the symptoms improved after administration of an antihistamine, glucocorticoid, and epinephrine. After 10 days, she drank another peach-containing diet beverage and experienced urticaria. No serum-specific immunoglobulin E findings were observed, including against peach components. A skin prick test (SPT) was performed using a peach, the two ingested diet beverages, and another peach-containing beverage. The SPT results for the peach and the peach-containing product were negative, but the wheal sizes for the two diet beverages were > 3 mm. The diet beverages contained erythritol as a food additive. The SPT result was positive for erythritol. The patient was diagnosed with anaphylaxis to erythritol and was instructed to avoid foods containing erythritol. She was prescribed a self-injectable epinephrine pen. To our knowledge, this is the first case of erythritol-induced anaphylaxis in Korea. Physicians should be aware of the possibility of allergic reactions to food additives, and additives should be evaluated to prevent the recurrence of symptoms.     

Allergy to Rosaceae fruits without related pollinosis

Background: Rosaceae fruit allergy is frequently associated with birch pollinosis in Central and Northern Europe and with grass pollen allergy in Central Spain. The main cross-reactive structures involved for birch pollinosis are Bet v 1 and profilin, and for grass pollinosis they are profilin and carbohydrate determinants. Rosaceae fruit allergy can occasionally be observed in patients without pollinosis. Objective: We investigated the clinical presentation and the allergens involved in allergy to Rosaceae fruit without pollinosis. Methods: Eleven patients from Central Spain allergic to apples, peaches, and/or pears but not to pollens were compared with 22 control subjects with combined grass pollen and fruit allergy. Skin prick tests and RASTs to apple, peach, and pear were performed. Cross-allergenicity was studied by RAST inhibition. Bet v 1 was tested with an indirect RAST, and profilin was tested in skin prick tests, histamine release, and RAST. Results: Rosaceae fruit allergy without pollinosis is severe with 82% of patients reporting systemic symptoms, mainly anaphylaxis (73%), whereas oral symptoms are less frequent (64%). Anaphylactic shock was observed in 36% of patients. The fruit allergens involved showed cross-reactivity among Rosaceae species but were not related to profilin or Bet v 1. Ninety-one percent of patients with combined grass pollinosis and fruit allergy reported oral allergy, 45% reported systemic symptoms, 18% reported anaphylaxis, and 9% reported anaphylactic shock. Conclusion: Allergy to Rosaceae fruits in patients without a related pollen allergy is a severe clinical entity. Profilin- and Bet v 1-related structures are not involved in Rosaceae fruit allergy without pollinosis.(J Allergy Clin Immunol 97;100;728-33)     

Clinical characteristics of melon (Cucumis melo) allergy.

BACKGROUND: Although melon is a frequent allergy-eliciting fruit, allergic reactions to melon have rarely been reported. OBJECTIVE: To evaluate and describe the clinical characteristics of melon allergy in melon-allergic patients. MATERIALS AND METHODS: We evaluated patients allergic to melon and a control group of patients allergic to pollen. The diagnosis of melon allergy was based on a convincing clinical history, positive skin test results (prick-by-prick test), and positive results on oral challenge tests to melon. RESULTS: A total of 161 patients were included in the study: 66 in the melon allergy group and 95 in the pollen control group. The melon allergy group included 35 female and 31 male patients with a mean age of 26.6 +/- 2.7 years (range, 5-61 years). Although all patients had oral symptoms, 13 (19.7%) of the patients had extraoral symptoms and none experienced generalized urticaria or anaphylaxis. Excluding other Cucurbitaceae fruits, peach, fig, and kiwi most frequently elicited positive skin test results and symptoms. Up to 23% of melon-allergic patients had a concomitant latex sensitization. Melon allergy was especially linked to pollen allergy, since all the melon-allergic patients were also allergic to pollen. Some differential features with respect to the pollen allergy control group were a higher prevalence of asthma (odds ratio [OR], 2.13; P < 0.05) and a statistical increase in the frequency of sensitization to several tree and weed pollens, including Ulmus (OR, 42.8) and Ambrosia (OR, 22.4). CONCLUSION: The most important conditions linked to melon allergy are pollen allergy (100%), allergy to other nonrelated fruits, mainly peach (up to 62%), and latex sensitivity (up to 23%). Some differential features of the pollinosis in melon allergy were a higher prevalence of asthma and a higher frequency of sensitization to several weed and tree pollens.     

The use of omalizumab in allergen immunotherapy

Although omalizumab (anti‐IgE) is currently only approved for the treatment of asthma and chronic idiopathic urticaria, it has also been studied as an off‐label treatment for numerous allergic conditions, including use as an adjunct to allergen immunotherapy in the treatment of allergic rhinitis, asthma, venom hypersensitivity and food allergy. We conducted a review of publications involving the use of omalizumab with allergen immunotherapy, by searching PubMed with key search terms of “omalizumab” and “immunotherapy.” Omalizumab has been used in combination with inhalant allergen immunotherapy for the treatment of seasonal allergic rhinitis and comorbid asthma. While there have been no randomized controlled trials evaluating the addition of omalizumab to venom IT, several case reports and small patient series have been published on the use of omalizumab with venom IT. Omalizumab has been used in conjunction with oral immunotherapy for the treatment of milk, peanut and egg, as well as other foods in multi‐allergen protocols. In conclusion, omalizumab used in conjunction with immunotherapy has shown promising results, especially in the reduction of adverse reactions. At this stage, larger, randomized, placebo‐controlled trials are needed to better identify those patients who would benefit the most from the addition of omalizumab to immunotherapy, as well as optimal dosing strategies and duration of treatment.     

Food allergy: identification of the major IgE-binding component of peach (Prunus persica).

Since peaches are a relatively common cause of food allergy, we set out to identify the allergens involved. With the use of a panel of 48 sera from patients allergic to peach, we demonstrate that most of the allergenicity of that fruit is confined to the skin, rather than to the flesh of peaches, and corresponds to a protein doublet with an estimated molecular weight of 8-10 kD.     

Omalizumab in allergic diseases, a recent review

Omalizumab is a biological engineered molecule, targeting the Cepsilon3 domain of the IgE molecule. It binds with free IgE and prevents free IgE from attaching to high-affinity IgE receptor (FcepsilonRI) on effector cells such as mast cells, basophils and also on dendritic cells. The result is a blocking of mediator release from these cells and the inhibition of antigen presentation by dendritic cells. In addition, omalizumab downregulates FcepsilonRI expression on these effector cells. Omalizumab prevents early and late phase allergic reactions of skin and lungs. Omalizumab has been investigated extensively in moderate-to-severe asthma in adults and children. It effectively reduces rates of asthma exacerbation, emergency visits for asthma and hospital admissions among these patients. Currently, omalizumab is primarily indicated for patients, age 6 years and over, with moderate to severe asthma (GINA step 4). Omalizumab was investigated in patients with seasonal allergic rhinitis (to ragweed, birch and grass pollens) and has been found to improve rhinitis symptoms and to reduce medication use among these patients. Administered together with allergen immunotherapy, omalizumab reduced incidence of side effects and rates of anaphylaxis from allergen immunotherapy. Omalizumab has been investigated in the treatment of food allergy, atopic dermatitis and urticaria. Despite benefits observed from these initial trials, it further deserves investigations to clarify optimal conditions for use in these conditions. Side effects from omalizumab were few, however, it requires careful considerations in administration of this agent. An observational period (up to 2 hours after the first three doses) and the availability of auto-injectable epinephrine are recommended. Pharmacoeconomics of omalizumab is briefly reviewed. Omalizumab represents a major breakthrough of translational medicine in allergy.     

Allergy to plant-derived fresh foods in a birch- and ragweed-free area

BACKGROUND: Allergy to plant-derived fresh foods has often been reported in geographical areas where birch or ragweed pollens are frequent and has been attributed to cross-reactivity to pollens. OBJECTIVE: The aim of this study has been to evaluate allergy to plant-derived fresh foods among pollen-allergic patients from a birch and ragweed-free area. METHODS: Ninety-five pollen-allergic patients took part in the study. The study consisted of a questionnaire, skin prick tests and challenge tests. Pollen skin tests to five grasses, eight trees and seven weeds were performed in duplicate. Prick tests (prick by prick) and challenge tests were carried out with the fresh foods. RESULTS: Most patients allergic to pollens were sensitized to grass (Lolium and Phleum; 97.9%), followed by tree (Olea; 82.1%) and weed pollens (Plantago; 64.2%). 35 of the 95 pollen-allergic patients had positive skin test responses to some plant-derived fresh foods, the highest percentage corresponding to several fruits in the Rosaceae family (peach and pear, 26.3%), followed by Cucurbitacea fruits (melon, 13.7%). The 21. 05% of the pollen-allergic patients were allergic to some type of plant-derived fresh food. Peach was the plant-derived fresh food which most frequently elicited allergy symptoms (12.6%), followed by melon (7.36%). The cluster of positive responses to Rosaceae fruits was higher for skin testing than for challenge testing. CONCLUSION: Peach was the most important allergy provoking fruit in a birch and ragweed free-area where apples were consumed at a rate of two times more than peaches and the patients allergic to pollen were principally sensitized to grass pollens.     

A case of oral allergy syndrome whose symptoms were dramatically improved after rush subcutaneous injection immunotherapy with pollen extracts of birch

We report a case of oral allergy syndrome, whose symptoms were dramatically improved after rush subcutaneous injection immunotherapy (SCIT) with pollen extracts of birch, ragweed and Japanese cedar. She was diagnosed as allergic rhinitis at 2 years old, and experienced oral allergy syndrome at 5 years old after eating cucumber. Then she had become allergic to wide range of fruits and vegetables. She was introduced to our department for the possible treatment for allergic rhinitis, and underwent rush SCIT at 15 years old. The symptom of single blind oral challenge test of apple up to 30 g, which had been positive before SCIT, turned to negative after the treatment. The threshold of apple measured by open oral challenge test increased from 3 g to more than 50 g. The symptoms to most fruits and vegetables were improved or disappeared. This suggests the possibility that SCIT of birch pollen can be a promising candidate as a radical treatment for pollen-food allergy syndrome.     

A case of latex allergy suspected drug allergy]

A 30-year-old female with paroxysmal supraventricular tachycardia (PSVT) underwent catheter ablation. About 30 minutes later, urticaria and dyspnea occurred suddenly. Blood pressure decreased to 62/41 mmHg, and she fell into the state of anaphylactic shock. She recovered within one hour following treatment. We initially suspected the onset of anaphylaxis was caused by either the local anesthetic or the intravenous antibiotic administered. Following thorough investigation (skin tests and challenge tests), we concluded that the anaphylaxis was not drug induced. Subsequently, we suspected latex allergy. Skin prick test showed a positive reaction to rubber gloves. The specific test for IgE antibody against latex was positive at 10.8 UA/ml. From these results, anaphylactic shock caused by latex (probably medical gloves) was diagnosed. Doctors should take preventive measures against latex allergy not only in operating rooms but also during minor treatments. It is possible that latex allergy is responsible for some cases of anaphylaxis of unknown origin.     

A case of allergy to cow's milk hydrolysate

We here report a girl, now 3 years old, who has suffered from severe food allergy since her first year of life. She was strongly allergic to cow's milk, and had high levels of IgE antibody (AB) to casein (210 kU/I), beta-lactoglobulin (43 kU/I), and alpha-lactalbumin (23 kU/l) at 12 months of age. In addition, at the same age, she showed positive (2-4+) skin prick reactions to both unboiled and boiled formulas (Profylac, Nutramigen, and Neocate), besides being positive in RAST to Nutramigen (0.6 kU/l). During the first 3 years, IgE Ab levels against casein and Nutramigen increased to 310 and 1.6 kU/l, respectively. Furthermore, at 3 years of age, she had positive RAST to 14 of 15 tested food allergens, being negative only to codfish. Assessment of eosinophil-related markers revealed high total eosinophil count, increased eosinophil activity, and a low ratio of interferon (IFN)-gamma:IL-5, indicating enhanced IL-5 production. The food allergy was correlated to poor weight gain and increasing problems with atopic allergy in the airways.     

Oral allergy syndrome due to cashew nuts in the patient without pollinosis]

A 26-year-old woman felt tingling on her tongue and itching both in the throat and on the face immediately after she put a cashew nut on her tongue. She had a history of atopic dermatitis and bronchial asthma, but not of pollinosis. CAP-FEIA and skin prick test (SPT) were positive for cashew nuts. The results showed negative for peanuts and other tree nuts than cashew nuts. Consequently, she was diagnosed with oral allergy syndrome due to cashew nuts. In addition, the result of skin prick test with cashew nuts normalized one year after she began avoiding cashew nuts, indicating that cashew nuts allergy would be due to sensitization by itself rather than to cross-reactivity between cashew nuts and pollens in this case.     

Safety and tolerability of omalizumab

Background Omalizumab (Xolair^®) is a recombinant humanized monoclonal anti-IgE antibody with proven efficacy in patients with moderate-to-severe and severe persistent allergic (IgE-mediated) asthma.
Objective To review clinical study data to assess the safety profile of omalizumab.
Methods We analysed the safety of omalizumab using data from completed clinical studies (up to 1 year) involving more than 7500 patients with asthma, rhinitis or related conditions and up to 4 years in one study of patients with severe allergic asthma, as well as post-marketing safety data. Analysis focuses on the risk of immune-system effects, hypersensitivity reactions, malignant neoplasia, parasitic infections and thrombocytopenia.
Results Omalizumab exhibited a good safety and tolerability profile that was maintained up to 4 years in one study. The incidence of anaphylaxis was 0.14% in omalizumab-treated patients and 0.07% in control patients. No omalizumab-treated patient developed measurable anti-omalizumab antibodies. Post-marketing, based on estimated exposure of 57 300 patients (June 2003–December 2006), the frequency of anaphylaxis attributed to omalizumab use was estimated to be at least 0.2% of patients. Current clinical trial data do not support an increased risk of malignant neoplasia or thrombocytopenia with omalizumab.
Conclusion Data indicate that the proven efficacy of add-on omalizumab in patients with moderate-to-severe or severe allergic asthma is accompanied by a favourable safety and tolerability profile.     

Characterization of an anaphylactoid reaction to omalizumab.

BACKGROUND: The novel humanized murine monoclonal antibody omalizumab prevents binding of human IgE to its high-affinity receptor. A contraindication to therapy with omalizumab is allergy to the medication or previous immediate-type hypersensitivity or anaphylaxis to omalizumab or similar medications. OBJECTIVE: To determine whether a 32-year-old woman with asthma, allergic rhinitis, and idiopathic chronic urticaria and angioedema with anaphylactoid reactions to omalizumab could tolerate the medication in a desensitization protocol. METHODS: Omalizumab was administered after pretreatment with nonsteroidal anti-inflammatory drugs (ibuprofen, 600 mg) while the patient was closely monitored in an intensive care unit. RESULTS: Omalizumab was well tolerated using this protocol, but a serum sickness-like reaction developed that required discontinuation of the medication after the seventh dose. CONCLUSIONS: Our experience suggests that some patients with anaphylactoid reactions to omalizumab can tolerate the medication when pretreated with nonsteroidal anti-inflammatory drugs but that a serum sickness-like illness may develop, requiring discontinued use of the medication.     

Anaphylaxis from mandarin (Citrus reticulata): identification of potential responsible allergens

We report on a patient with anaphylaxis from mandarin. Temporal relationship between consumption of the fruit, the presence of positive specific IgE, the positive skin test and the basophil activation test for mandarin strongly supported the diagnosis of an IgE-mediated allergy from mandarin. The lipid transfer protein allergen from mandarin fruit was isolated and characterized. Specific IgE levels and IgE immunodetection data indicated the patient's sensitization to orange (Cit s 3) and mandarin (Cit r 3) lipid transfer protein allergens, as well as to germin-like (Cit s 1) allergen. These results were fully confirmed by skin prick test and basophil activation test (BAT) for lipid transfer proteins, and a BAT for Cit s 1. This case report has several particularities. First, in Central and Northern Europe, it is not widely appreciated that citrus fruits, particularly mandarin, can elicit anaphylaxis. Second, this case report re-emphasizes sensitization from lipid transfer proteins to predispose for severe allergic reactions. Finally, it provides an opportunity to summarize the applications of flow cytometry-assisted analysis and quantification of in vitro activated basophils in the diagnostic approach of anaphylaxis from food.     

Currant allergy and the Rosaceae-grass pollen allergy syndrome: a case report.

BACKGROUND: Despite the increasing use of currants in culinary recipes, currant allergy has rarely been reported. OBJECTIVES: To study a case of currant allergy and to explore cross-reactivity between grass pollen and Rosaceae family fruit allergens. METHODS: Skin prick tests to pollen and skin prick-to-prick tests with currants and peach were performed. Specific IgE levels were determined using the CAP method. We prepared a protein extract of 0.1 mg/mL in phosphate-buffered saline using red currant in the presence of protease inhibitors. Immunoblot inhibition studies were performed to explore cross-reactivity between grass pollen and currant allergens. RESULTS: Skin prick test results were positive to Dactylis, arizonic, and olive pollens. Results of skin prick-to-prick tests with fresh red and black currants were negative and positive, respectively, to peach. The specific IgE level was 5.7 KU/L to red currant and 2.92 KU/L to peach (CAP). Western blot analysis with red currant extract revealed specific IgE protein bands of 37 and 26 kDa. Preincubation of sera with extracts from red currant and peach inhibited both IgE bands, and preincubation with Dactylis pollen inhibited the 37-kDa band only. CONCLUSIONS: We report a case of allergy to grass pollen with an oral allergy syndrome involving several fruits from 2 different families of the Rosidae subclass confirmed by in vitro tests. Inhibition studies demonstrated cross-reactivity between different fruits (currant and raspberry) from the Rosidae subclass and were incomplete with grass pollen allergens.     

Pectin anaphylaxis and possible association with cashew allergy.

BACKGROUND: Inhalation of pectin has been identified as a cause of occupational asthma. However, allergic reactions to orally ingested pectin have not been reported. OBJECTIVES: To describe a child with pectin-induced food anaphylaxis and to discuss its possible relationship to cashew allergy. METHODS: A 3 1/2-year-old boy developed anaphylaxis once after eating cashews and later after eating a pectin-containing fruit "smoothie." He also has a history of generalized pruritus after eating grapefruit. Skin tests or radioallergosorbent tests (RASTs) were performed to pectin and other suspected food allergens. RESULTS: The child had a positive skin prick test reaction to pectin and a high RAST reaction to cashew and pistachio. He had a low-level positive RAST reaction to grapefruit. Results of allergy tests for the other potential food allergens were negative. The pectin in the smoothie was confirmed to be of citrus origin. Review of previous case reports of pectin-induced occupational asthma revealed several patients with allergies to and cross-reactivity with cashew. CONCLUSIONS: Ingestion, not only inhalation, of pectin can cause hypersensitivity reactions. Cashew, and possibly pistachio, allergy may be associated with pectin allergy, and the possibility of pectin allergy should be considered in cashew- or pistachio-allergic patients who have unexplained allergic reactions.     

Food allergy—From food avoidance to active treatment

The prevalence of food allergy (FA) has increased too rapidly, possibly due to environmental factors. The guidelines recommend strict allergen avoidance, but FA is still the main cause of anaphylaxis in all age groups. Immunotherapy is the only treatment able to change the course of allergic disease, and oral immunotherapy (OIT) is the more effective route in FA. However, it carries the risk of adverse reactions, including anaphylaxis. To improve OIT safety, adjuvant therapy with the immunoglobulin E (IgE) monoclonal antibody omalizumab has been extensively used. Results suggest particular benefit in patients with high risk of fatal anaphylaxis. An alternative approach is to use omalizumab instead of OIT to prevent severe allergic reactions upon accidental exposure. This paper reviews current evidence regarding IgE-mediated FA, focusing on natural tolerance and food sensitization acquisition, and on avoidance measures and their limitations.     

Four cases with latex allergy followed by anaphylaxis to chestnut]

It is well known that patients with latex allergy have cross-reactions to various fruits, which is called a latex fruit syndrome. We report four cases with latex allergy followed by anaphylaxis to chestnut. They are all nurses of our hospital, who has personal history of atopic diseases. There were varieties in the methods of processing chestnut, presence of epicutaneous contact to chestnut, and clinical courses among the cases. All cases had positive skin prick test reactions while only two cases showed specific IgEs measured with AlaSTAT to chestnut. This fact suggests that we have to warn the risk of anaphylaxis even if one had not shown a serum specific IgE. We could follow the clinical courses and study specific IgEs to chestnut and latex in the two cases for more than two years. The titer of specific IgE was increased in the one, who could not avoid eating chestnut and contact to latex, while it was decreased in the other who could avoid the exposure to the antigens. Hevein is one of the panallergens among latex and related fruits. We studied specific IgEs to hevein on these four cases and 12 normal controls. The results showed that the former had significantly higher values of sIgEs to hevein compared to the latter (p < 0.05). We conclude that a patient with latex allergy has a high risk of contact urticaria or even anaphylaxis to the related fruits such as chestnut so that we recommend the patient with latex allergy to avoid them.