A discussion of natural rubber latex allergy with special reference to children: clinical considerations

Latex allergy is an increasingly common condition, because the use of latex products is widespread. Three types of reactions can occur in persons using natural latex rubber products: 1) Irritant contact dermatitis, 2) Allergic contact dermatitis, 3) and Type I hypersensitivity. Children's subpopulations at particular risk include: atopics, individuals with spina bifida, or individuals who required frequent surgical instrumentations. An association between allergy to latex and allergy to various fruits and vegetables has been reported. Recently, an homology between latex allergens and mold allergens has been reported leading to postulate a possible existence of a "latex-mold syndrome". Diagnosis of allergy is based initially on history, skin prick test and search for specific serum IgE. Provocation tests may confirm the suspicion, although these are seldom performed on children because they are not easy to bear with. The most effective strategy to decrease the incidence of NRL (natural rubber latex) sensitization is avoidance; however, this is virtually impossible, given the large number of latex products we encounter since childhood. Studies of secondary prophylaxis among children demonstrate that notwithstanding recommendations, children could manifest yet adverse reactions to latex products and have detectable levels of anti latex IgE.     

Toxicological and immunological aspects of occupational latex allergy

Latex allergy continues to be an important occupational health problem as latex products are used increasingly worldwide, particularly in healthcare. Although there are few epidemiological studies on the incidence of latex allergy, there has been an increase in the number of case reports over the last 10 years and, based on skin-prick tests, estimates of prevalence of latex allergy in healthcare workers range from 2% to 17%. The allergic health effects arise either from the latex proteins, generally causing a type I immediate hypersensitivity reaction, or from the chemicals added to latex during processing, causing a type IV delayed hypersensitivity reaction. Clinical manifestations of latex allergy depend on the route of exposure and occur by direct contact either with skin or mucosa, or by inhalation. The diagnosis of latex allergy is based on the history, skin tests, serological tests and challenge tests. Thirteen latex allergens have been identified and isolated so far from natural rubber latex. They differ in their potential to elicit immunological responses in individuals allergic to latex and thus have been designated as major or minor allergens. In latex gloves, cornstarch powder used as a donning agent carries latex proteins, thereby increasing inhalational and mucosal exposure to latex proteins. There also appears to be a positive correlation between protein content and allergenicity of gloves. The use of powder-free, low-protein gloves is effective in reducing symptoms and markers of sensitisation. Alternatives to latex gloves, such as nitrile or vinyl gloves are available but may be inferior in respect to manual dexterity and biological impermeability.     

Delayed allergy to aminopenicillins: clinical and immunological findings

Aminopenicillins are the most used beta-lactam antibiotics. Morbilliform or maculopapular rashes are rather frequent during therapy with aminopenicillins. The pathogenesis of these reactions is often due to a cell-mediated allergy. The aim of this work is to characterize patients with cell-mediated allergy to aminopenicillins and to identify alternative beta-lactam drugs that can be safely administered to these patients. We studied 27 subjects affected by cell-mediated allergy to aminopenicillins. The diagnosis was made on the basis of positivity of patch tests with aminopenicillins. These patients then underwent an allergological evaluation (skin and patch tests, oral and/or intramuscular challenge tests) with a wide spectrum of beta-lactam antibiotics. Our work highlights the following main characteristics of cell-mediated allergy to aminopenicillins: time elapsing between drug administration and onset of symptoms of about 2 days; the maculopapular rash and delayed appearance of urticaria/angioedema were the most typical symptoms (82.8 percent of cases); a cross-reactivity with aminocephalosporins is usually absent, or it is limited to cephalexin (in our study, in fact, just 3 out of 20 patients challenged with cephalexin showed a positive oral challenge test); all the beta-lactams, other than aminopenicillins, are well tolerated. Patch tests represent a specific diagnostic tool with a good predictive value of identifying alternative drugs that can be safely administered to patients with beta-lactam allergy. Our patients could tolerate other beta-lactam drugs after a complete allergological evaluation. On the basis of our study, cell-mediated allergy to aminopenicillins should be considered a well-defined nosologic entity.     

Oral desensitizing treatment in food allergy: clinical and immunological results

BACKGROUND: The possibility of inducing oral desensitization in patients with food allergy is still controversial and no standardized programmes are yet available. AIM: To evaluate the safety and efficacy of oral desensitization in patients with allergy induced by the most common food allergens. METHODS: Fifty-nine patients with food allergy underwent an oral desensitizing treatment according to standardized protocols. The control group consisted of age- and sex-matched subjects, who followed a strict elimination diet. Specific immunoglobulin E and immunoglobulin G4 were assessed at baseline and after 6, 12 and 18 months. RESULTS: The majority of patients (83.3%) successfully completed the treatment. During treatment, 51.1% of subjects experienced some mild side-effects, easily controlled by the oral administration of antihistamines or sodium cromolyn. Specific immunoglobulin E showed a significant decrease, whilst specific immunoglobulin G4 showed a significant increase in all patients. CONCLUSIONS: The immunological findings induced by oral desensitization in food allergy allow us to hypothesize that oral tolerance may be mediated by the same mechanisms as those involved in traditional desensitizing treatments for respiratory allergies. Moreover, the proposed standardized oral desensitization protocols may represent an effective alternative approach in the management of food-allergic patients.     

Oral desensitisation in cow milk allergy: immunological findings

In the literature there are several reports dealing with the possibility of a desensitising treatment in food allergy, but there are very few studies about the immunological mechanisms of oral desensitisation. We studied the immunological modifications in four children who underwent oral desensitisation with cow milk. Four children with cow milk allergy underwent oral desensitisation according to a standardized protocol. Total IgE, eosinophilic cationic protein in serum, and specific IgE and IgG4 to α-lactalbumin, to β-lactoglobulin and to casein were determined at the beginning of the treatment and after 6, 12 and 18 months in the 4 children treated. All the 4 treated patients successfully completed the treatment. Specific IgE to casein showed a significant reduction (p<0.01), while specific IgG4 to α-lactalbumin (p<0.02), to β-lactoglobulin (p<0.01) and to casein (p<0.01) showed a significant increase. Total IgE, eosinophilic cationic protein, and specific IgE to α-lactalbumin and to β-lactoglobulin did not show any significant modification. Control patients did not show any immunological modification and still had a positive double-blind, placebo-controlled food challenge. These results make us think that oral desensitisation in food allergy happens with the same mechanisms of traditional desensitising treatments for respiratory and insect sting allergies.     

Allergen challenge and deposition of nedocromil sodium in asthma.

We examined whether the acute protective effect of nedocromil sodium aerosol could be enhanced by increasing the deposition uniformity of the drug in the lungs of adult patients with allergic asthma. Ten patients with mild-to-moderate asthma were challenged with the same doses of allergen on two occasions in a randomized manner. Thirty minutes before these challenges, patients inhaled 4 mg nedocromil sodium, admixed with the radioisotope (99m)technetium. Radiolabeled drug was inhaled during slow (25.4 +/- 4.6 L/min) and faster (58.0 +/- 7.3 L/min) inhalations from a 700 ml holding chamber. Percent changes in FEV(1) at the same top dose of allergen on the two treatment visits were compared. Lung deposition fraction (LDF) and indices of distribution uniformity, quantified from gamma camera images, were also compared. Acute protection against allergen challenge was similar and complete after slow or faster inspiration of nedocromil sodium. Mean (+/- SD) allergen-induced changes in FEV(1) were -1.05 +/- 2.78% and -0.39 +/- 2.80%, respectively, compared to -26.30 +/- 8.49% on a screening challenge (no drug). Mean LDF was also similar on the two visits, averaging 16.4 +/- 4.6% and 16.1 +/- 7.2% of administered drug, respectively. Distribution of nedocromil sodium was most uniform after slow inspiration, but increased uniformity was not related to enhanced protection. Complete protection against acute bronchoconstriction induced by inhaled allergen can be obtained with 4 mg of nedocromil sodium aerosol, inhaled from a large volume holding chamber, 30 min before the exposure, and at inspiratory flow rates between approximately 20-60 L/min. Protection does not appear to be enhanced by increased uniformity of drug distribution within the lungs.     

Effects of iodine-enriched egg (IE-egg) on nasal allergy: basic and clinical investigations

The effect of iodine-enriched egg (IE-egg) on nasal allergy was investigated using an experimental allergic model. In addition, the effect of IE-egg was investigated using patients with yearly nasal allergy. IE-egg could suppress the leakage of pontamine sky blue dye in the experimental allergic model. beta-Glucuronidase activity in the perfusate was suppressed with the ingestion of IE-egg. The symptoms of the patients with yearly nasal allergy were mitigated by the ingestion of IE-egg. beta-Glucuronidase activity in the pituita of nasal allergic patients tended to be decreased.     

Estimation of some agents of humoral and cell-mediated immunological response in the families of children with food allergy.

The humoral and cellular agents involved in allergic reactions were examined in 85 persons from 25 families of children with food allergy. The raised level of immunoglobulin M, the lowered levels of C3 and C4 fractions of complement and the increase in the contents of immunological complexes were the abnormalities most frequently met both in food allergic children and their parents. The incidence of the lowered level of IgA in serum was also significant. However, the abnormal results of cellular tests were more often found in the children with food allergy than in their parents. Especially the normal Helper/Suppressor ratio prevailed in the parents (81.6%) as compared to their children (47.6%).     

Prevalence of latex allergy in spina bifida: genetic and environmental risk factors

AIM OF STUDY: To evaluate the prevalence of latex allergy in a population of children with spina bifida (SB) and to assess the role of early exposure to latex products and others risk factors. INTRODUCTION: SB is related with an higher incidence of latex allergic reactions. These patients received repeated surgical procedures, implant of latex-containing materials and catheterization. MATERIALS AND METHODS: Eighty consecutive subjects affected with SB besides answering a questionnaire, underwent a skin-prick test (SPT) to latex and the determination of the specific serum IgE (RAST CAP) to latex. 40% (32/80) of the patients showed a latex sensitization with specific IgE > 0.7 kU/I but only twelve of the 32 sensitized patients (40%) suffered from clinical reactions to latex (urticaria, conjunctivitis, angioedema, rhinitis, bronchial asthma). Number of surgical procedures, but particularly early exposure to latex and familiarity for allergy are correlated with latex allergy (p < 0.01). CONCLUSION: Latex allergy in SB children is multifactorial situation related with a disease-associated propensity for latex sensitization, early exposure and number of surgical procedures. Prophylactic measures to avoid the exposure, not only in the sanitary environment, through the institution of latex-safe routes and every day, prevent potentially serious allergic reactions.     

Identification of strabismus in children born to mothers misusing substances during pregnancy: A clinical and research challenge

Purpose: To increase awareness of the causal relationship between illicit drug use in pregnancy and the occurrence of strabismus in children amongst the relevant professionals and encourage the use of local arrangements for referral, assessment and treatment of this population at risk.

Method: A review of the literature regarding the occurrence of strabismus in children of mothers misusing substances and an outline the consequences of strabismus.

Results: Children prenatally exposed to the effects of psychoactive substances are at increased risk of neurodevelopmental and neurobehavioural abnormalities; ocular defects are frequently mentioned as some of them. Strabismus, the consequences of which are treatable, is amongst these.

Conclusion: Research in this area is challenging, but while more evidence is awaited, current evidence indicates the increased risk of strabismus in this group and recommendations regarding the early detection of, and referral for, this condition are made.     

Effect of short-term treatment with fluticasone propionate nasal spray on the response to nasal allergen challenge.

The aim of the study was to investigate the effect of short-term treatment with fluticasone propionate on the response to nasal allergen challenge in patients with allergic rhinitis. Responses to nasal allergen challenge were assessed subjectively by recording symptom scores on visual analogue scales, and objectively by measuring histamine, PGD2 and LTC4 in nasal lavage and by measuring nasal inspiratory peak flow following challenge. Nasal allergen challenge resulted in an increase in all symptom scores (P < 0.05); an increase in histamine and PGD2 (P < 0.05), and a decrease in nasal inspiratory peak flow at 1 h, 5 h and 7 h following challenge (P < 0.05). The allergen-induced changes in symptom scores, mediator levels and nasal inspiratory peak flow were attenuated by treatment with fluticasone propionate (P < 0.05 for all parameters measured). Post-challenge nasal obstruction was decreased by 45%; sneezing, itching and rhinorrhoea by 73, 78 and 80% respectively in the group as a whole comparing scores whilst on fluticasone propionate with those on no therapy. Fluticasone propionate, 200 micrograms twice daily for 2 weeks is effective in reducing significantly the early and late response to nasal allergen challenge.     

Pharmacokinetics and clinical evaluation of cefpirome in children

Pharmacokinetics and clinical effects of cefpirome (CPR, HR 810) in children were studied. When 20 mg/kg and 40 mg/kg doses of CPR were administered to 4 children through 30 minutes' drip infusion, half-lives were 1.23 +/- 0.23 (mean +/- S.D.) hours and 1.37 +/- 0.35 (mean +/- S.D.) hours, respectively for the 2 dose levels, and recovery rates in urine in the first 6 hours after administration were 74.8% and 56.1%, respectively. CPR was administered to 15 cases (3 tonsillitis, 3 bronchitis, 5 bronchopneumonia, 1 acute cystitis, 1 coxoiliatitis, 1 otitis media, 1 otitis externa). The efficacy rate was 86.7%. Seven strains of bacteria were isolated and identified 4 Haemophilus influenzae, 3 Staphylococcus aureus, 1 Pseudomonas sp. from these cases. These bacteria in children were followed after administration of CPR. Six strains were eradicated and one was reduced in number. No adverse effects of CPR were observed except in 2 cases, one of which showed transient eosinophilia and the other showed a transient increase of transaminase. These results suggest that CPR may be an effective and safe drug to use on children clinically.     

A clinical evaluation of aspoxicillin in children

Eighteen infants and children with infectious diseases were treated with aspoxicillin (ASPC), a new semisynthetic penicillin. The result was as follows: The clinical responses to ASPC were excellent in 6 patients and good in 5 patients of 11 children with bacterial infections. The bacteria isolated from the culture of throat swab and urine in 5 patients were Streptococcus pneumoniae, Escherichia coli, and Staphylococcus aureus which were all eradicated by the treatment of ASPC. The mean serum concentration of ASPC reached the peaks of 73.3 micrograms/ml in 5 cases with dose of 20 mg/kg, and 136.3 micrograms/ml in 3 cases with dose of 40 mg/kg 15 minutes after the intravenous administration. The mean half-lives of ASPC in the serum were 1.08 hours for the dose of 20 mg/kg and 1.07 hours for the dose of 40 mg/kg. The mean urinary recoveries of ASPC in 6 hours following the intravenous administration were 73.7% in 3 cases with dose of 20 mg/kg, and 79.6% in 1 case with dose of 40 mg/kg. No clinical side effect of ASPC was observed. An increase of platelet was noticed in a child with infectious mononucleosis in the course of administration of ASPC.     

糖尿病合并感染——临床工作中的难题

感染是糖尿病及其并发症防治中的重大问题.糖尿病患者由于自身抵抗力低下、高血糖、血管神经病变和营养不良、脱水、水肿等综合因素,特别容易发生感染,最常见的感染是呼吸系统感染和泌尿系统感染,泌尿系统感染更常见于女性.     

An evaluation of short-term corticosteroid response in perennial allergic rhinitis using histamine and adenosine monophosphate nasal challenge

AIMS: To evaluate the role of AMP nasal challenge as a measure of short-term treatment response in patients receiving intranasal corticosteroids. Adenosine monophosphate (AMP) challenge has been shown to be a good inflammatory surrogate in the lower airways, but it has not been properly evaluated as a nasal challenge test. METHODS: Fourteen patients with perennial allergic rhinitis (PAR) were randomized to receive 2 weeks treatment with placebo (PL) or 200 microg intranasal mometasone furoate (MF) once daily in a randomized single-blind crossover study. AMP (25-800 mg ml-1) and histamine (0.25-8 mg ml-1) nasal challenge testing were performed after each treatment period with 30% decrease in minimal cross-sectional area (MCA). Domiciliary symptom data were collected. RESULTS: There was a significant (P < 0.05) improvement in PC30 MCA and nasal volume with AMP but not with histamine comparing MF vs PL. This amounted to a 2.8 (95% CI 1.5, 4.0) and 0.7 (95% CI -0.5, 1.9) doubling-dose change for AMP and histamine challenges, respectively. There were significant (P < 0.05) improvements in nasal symptoms and quality of life. CONCLUSIONS: AMP nasal challenge using acoustic rhinometry may be a useful test to assess short-term treatment response in patient with PAR.     

Sublingual immunotherapy for latex allergy: tolerability and safety profile of rush build-up phase

ABSTRACT

Objective: Sublingual immunotherapy represents an efficient therapeutic tool for the management of latex allergic patients. Local and systemic adverse reactions are reported, and risk factors for those reactions are poorly understood. The aim of this study is to compare two different rush induction protocols (2-day and 3-day) in terms of safety and tolerability and effectiveness in reaching the maintenance dose.

Methods: Twenty-three outpatients (F/M = 18:5; 5–64 years of age), with latex allergy were randomly assigned to: Group 1 (2-day) and Group 2 (3-day). Adverse reactions were classified by their type and severity.

Results: Twenty-one subjects, 10 from Group 1 and 11 from Group 2, reached the maintenance dose, 70% of them without side effects. Seven adverse events were reported in Group 1: three were local (oral itching) and spontaneously remitted; four were systemic (Grade-2: two reactions; Grade-3: two reactions) and were effectively controlled with drugs. The protocol was interrupted in two cases because of recurrent reactions. No reactions were reported in Group 2. Age, gender, atopy, specific IgE, skin prick tests and sublingual challenge did not seem to influence the risk of side effects significantly. No signif­icant modification of skin tests and specific IgE levels were reported in both groups. The cutaneous test turned negative in 16 patients, eight from Group 1 (80%) and eight from Group 2 (73%). The remaining patients (two from Group 1 and three from Group 2) showed a reduction of latex reactivity, in terms of symptom score (MIS: 2 vs. 0.5 in Group 1, 3 vs. 1 in Group 2).

Conclusions: This study confirms the safety of rush induction. The 3-day protocol was better tolerated than the 2-day. Significant risk factors for the occurrence of adverse reactions were not identified. Only the type of protocol but not patient-related parameters seemed predictive of side-effects.