A 1-day imported fire ant rush immunotherapy schedule with and without premedication.

BACKGROUND: Rush immunotherapy (RIT) schedules can expedite protection in individuals sensitive to imported fire ant (IFA) stings. OBJECTIVE: To evaluate the safety and efficacy of 1-day RIT with IFA whole body extract (WBE) and determine the benefit of premedication with antihistamines and prednisone. METHODS: Patients with systemic reactions to IFAs and evidence of specific IgE by skin test or serologic test started a 1-day RIT protocol without premedication. The 1-day RIT protocol consisted of a total of 10 injections every 30 to 60 minutes to achieve a 0.3-mL 1:100 (wt/vol) dose. A higher systemic reaction rate (SRR) prompted protocol revision to include a 3-day course of oral 20 mg of prednisone twice daily, 150 mg of ranitidine, and 10 mg of loratadine started 2 days before the 1-day RIT. Patients returned on days 8 and 15 to receive a 0.5 mL 1:100 (wt/vol) maintenance injection. The effectiveness of the RIT was evaluated with a sting challenge on approximately day 22. RESULTS: Eighty of the 96 patients enrolled initiated the 1-day RIT. The first nonpremedicated group exhibited a SRR of 24.3% (9 of 37 patients), whereas the revised premedicated group had a SRR of 9.5% (4 of 42 patients; P = .07). The most severe reaction during RIT included dizziness, angioedema, and urticaria. Sting challenges on 53 patients resulted in 1 mild rhinitis reaction (efficacy, 98.1%). CONCLUSION: One-day RIT with IFA WBE for IFA hypersensitivity is efficacious. Although there was a trend with premedications to reduce SRRs during the RIT, safety data with premedication require confirmation in a larger trial.

Exhaled breath condensate pH in the evaluation of asthma.

As a marker of inflammation, exhaled breath condensate (EBC) pH may be a useful screening tool in the evaluation of asthma, especially in a military recruit population. To evaluate the utility of EBC pH in the diagnosis of asthma, EBC pH levels were determined in basic military trainees prior to an evaluation for asthma that included a history, physical exam, baseline spirometry, and a methacholine or exercise challenge. Of 86 basic trainees who had symptoms suggestive of asthma and underwent methacholine or exercise challenges, 51 (59.3%) had a positive methacholine or exercise challenge and were diagnosed with asthma. The mean EBC pH of the trainees who were diagnosed with asthma (6.39, range 5.91-6.82), was significantly (p < 0.001) lower than those trainees without asthma (6.64, range 6.34-7.18). There was, however, some overlap of the EBC pH values between the two groups. The measurement of EBC pH did show a significant mean difference between asthmatic and nonasthmatic patients in a military recruit population.

Prevalence of positive skin test responses to 53 allergens in patients with rhinitis symptoms.

Prior studies looking at allergic sensitization have focused on narrow age ranges or small numbers of allergens. This study is the first to examine the prevalence of positive skin test responses in a symptomatic military population with a wide age range of patients and large number of allergens. This study was a retrospective analysis of our skin test database. We included 1137 patients aged 4-79 years old who underwent our standard skin-prick testing panel of 53 aeroallergens and 2 controls using the Quintest device (Hollister-Stier, Spokane, WA). Results indicated that 81.6% of patients had at least one positive skin test. Rates of atopy were similar between male and female patients; 9.2% of patients were monosensitized. The average number of positive skin tests peaked in the 10- to 19-year age group at 13.1 and declined in older age groups. The prevalence of atopy peaked in the 30- to 39-year age group at 85.5% and decreased in older age groups. The most common allergens were grasses, mountain cedar, and dust mites. Sensitization rates for many underreported allergens, including mouse and rat, are presented. This study shows that 81.6% of patients in a symptomatic military population were atopic. These rates are high, even when compared with other allergic populations. Atopy peaked in young adulthood and declined in older age groups. Grasses, mountain cedar, and dust mites were the most common allergens. Although performed in a military population, these results should be applicable to many allergy practices.

Exhaled nitric oxide levels in military recruits with new onset asthma.

Approximately 800 United States Air Force basic military trainees (BMTs) are diagnosed with asthma, annually, resulting in separation from the military. With training costs of approximately 10,000 dollars/person, around 8 million dollarsis lost per year. Improved methods in diagnosing asthma would be beneficial. The aim of this study was to determine the fraction of exhaled nitric oxide (FENO), a marker of airway inflammation, in a military recruit population referred for an asthma evaluation. In BMTs referred for respiratory complaints during basic training, FENO levels were determined before an asthma evaluation consisting of a history, physical, baseline spirometry, and histamine bronchoprovocation. Of 172 BMTs who had symptoms suggestive of asthma and underwent histamine bronchoprovocation, 80% were diagnosed with asthma. FENO levels were significantly higher in asthmatic patients than nonasthmatic patients (mean, 30 parts per billion [ppb] versus 19 ppb, p < 0.001; median, 21 ppb versus 17 ppb, p < 0.02). Various FENO cutoff points provided a range of sensitivity and specificity for the diagnosis of asthma. However, an optimal FENO cutoff level for asthma was not obtained. An FENO value of 10.5 ppb provided a sensitivity of 86% for the diagnosis of asthma, but specificity was only 21%. In contrast, an FENO value of 46 ppb provided 100% specificity but only 17% sensitivity. FENO levels were significantly elevated in BMTs diagnosed with asthma but the lack of an optimal cutoff level limits the test as a diagnostic tool for asthma. Additional studies are necessary to determine the value of FENO for asthma screening in a military population.

Multicolored Asian lady beetle hypersensitivity: a case series and allergist survey.

BACKGROUND: Multicolored Asian lady beetles (Harmonia axyridis) have been used as a biological control agent against crop-destroying aphids in the United States. Outside their natural habitat, H. axyridis seeks refuge in homes during fall and winter, leading to patient complaints and symptoms of rhinitis, wheezing, and urticaria on exposure to the beetles. OBJECTIVE: To gain a better understanding of the character and spectrum of allergic disease provoked by exposure to home-infesting lady beetles. METHODS: Eight patients with allergic symptoms suspected of being caused by H. axyridis and consistent with an IgE-mediated process were identified and interviewed. A whole-body extract from H. axyridis was prepared. Western blots using the patients' serum identified specific IgE antibodies in the extract. Through a novel technique, immunohistochemical analysis using beetle sections overlayed with patient serum was performed. A random survey of allergists from across the United States was also performed to evaluate experience with cases of lady beetle allergy. RESULTS: Western blots revealed IgE binding to 5 proteins with molecular weights of approximately 8.6, 21, 28, 31, and 75 kDa. Specific IgE bound to proteins localized in the beetle's mouth and leg areas. The allergist survey revealed positive responses in North Central, Mid-Atlantic and New England states. CONCLUSION: In 8 patients with allergic symptoms on exposure to high levels of lady beetles, specific IgE bound to proteins from H. axyridis. There was also an increased frequency of suspected cases of lady beetle allergy in endemic areas.

Generalized cutaneous reactions to the anthrax vaccine: preliminary results of anthrax vaccine-specific cell mediated immunity and cytokine profiles.

Over two years, the Vaccine Adverse Event Reporting System reported that 0.042% of all anthrax vaccine (Biothrax, Bioport Corporation) doses administered were associated with cutaneous reactions, half of which were eczematous. This case series attempts to immunologically detail this eczematous reaction in four patients by measuring anthrax vaccine-specific cell mediated immunity (ASCMI), profiling TH1 and TH2 cytokine response to the anthrax vaccine in vitro, and analyzing of skin biopsy specimens. Results demonstrated that (1) ASCMI was variable and likely unrelated to this reaction; (2) a lack of TH1 cytokine response to anthrax vaccine may be associated with an increased risk of this eczematous reaction; and (3) skin biopsy findings were nonspecific but supportive of a clinical diagnosis of eczema. Future studies with more patients may yield data to further characterize the ASCMI response and cytokine profiles among patients with this type of reaction.

Intraoperative anaphylaxis to bacitracin during pacemaker change and laser lead extraction.

BACKGROUND: Bacitracin is widely used in operating rooms to soak implants, irrigate compound fractures, and apply to surgical incisions. However, bacitracin is a known sensitizer and causes not only allergic contact dermatitis but also anaphylaxis. OBJECTIVE: To describe a 72-year-old woman with anaphylaxis after irrigation and packing of an infected pacemaker pocket with a bacitracin solution. METHODS: Skin prick testing to bacitracin and latex; serum tryptase, serum histamine, serum IgE to latex, and serial cardiac enzyme measurements; blood cultures, transthoracic echocardiograms, and venograms were performed to characterize the reaction. RESULTS: Six hours after the anaphylactic event, the patient had an elevated serum tryptase level of 49 ng/mL (reference range, 2-10 ng/mL), which normalized the next morning. She had immediate-type skin prick test reactions to full-strength bacitracin ointment (500 U/g) and bacitracin solution (150 U/mL). Serum IgE level to latex was undetectable, and results of skin testing to latex were negative. CONCLUSIONS: To our knowledge, this is the first case report of anaphylaxis to bacitracin during pacemaker surgery. This case illustrates that intraoperative anaphylaxis to bacitracin can be life-threatening.

An unusual case of laryngomalacia presenting as asthma refractory to therapy.

BACKGROUND: Laryngomalacia is the most common cause of stridor in infants, but few reports exist of clinically relevant laryngomalacia in adults. OBJECTIVE: To present and discuss an unusual late presentation of laryngomalacia and its significance in the evaluation and management of asthma. METHODS: An 18-year-old woman presented to an academic medical center with symptoms of "wheezing" on inspiration and exertion, with relatively normal spirometric findings. She was clinically diagnosed as having asthma at the age of 13 years, but her symptoms were poorly controlled by maximal medical therapy. Further evaluation with rhinolaryngoscopy demonstrated laryngomalacia characterized by redundant soft tissue overlying the right arytenoid cartilage and aryepiglottic fold. RESULTS: The patient demonstrated positive bronchoprovocation, with a 33% decrease in forced expiratory volume in 1 second after the administration of histamine, 1 mg/mL. However, with the otolaryngology evaluation, it was determined that her laryngeal findings were clinically significant. She subsequently underwent operative laryngoscopy with carbon dioxide laser excision of the laryngeal abnormality, resulting in improvement in her symptoms and a marked decrease in her need for asthma medication. CONCLUSIONS: We report an unusual case of laryngomalacia presenting as asthma that was successfully treated with laser surgical excision. This case emphasizes the necessity of differentiating classic wheezing from stridor and upper airway obstruction.

Cross-reactivity between allergens in the venom of the common striped scorpion and the imported fire ant.

BACKGROUND: The common striped scorpion, Centruroides vittatus, and the imported fire ant (IFA) are endemic to the south-central United States. There is evidence of venom-specific IgE in patients experiencing hypersensitivity reactions to scorpion stings. The infrequency of repeated scorpion stings and the presence of immediate reactions to an initial sting suggest prior sensitization. OBJECTIVE: In the present study we evaluated the cross-reactivity of C vittatus venom with IFA whole-body extract (WBE). METHODS: Sera were obtained from patients with symptoms of immediate hypersensitivity to C vittatus stings and from scorpion sting-naive patients allergic to IFA venom. Inhibition IgE immunoblots were performed by using scorpion venom and IFA WBE. Skin testing with scorpion venom was performed on scorpion sting-naive patients allergic to IFA venom. RESULTS: Sera from patients with scorpion venom allergy demonstrated IgE binding to multiple allergens of similar sizes against both scorpion venom and IFA WBE. This binding was completely inhibited by preincubation of the sera with scorpion venom and IFA WBE. Pooled sera from patients with IFA venom allergy demonstrated similar bands on IgE immunoblotting against both IFA WBE and scorpion venom, with the latter being completely inhibited by preincubation of the sera with IFA WBE. Skin testing with scorpion venom was positive in 6 of 9 patients with IFA venom allergy. CONCLUSION: Significant cross-reactivity exists between the venom of C vittatus and IFA WBE. The high sensitization rate to IFA venom in endemic areas may therefore be a risk factor for subsequent immediate reactions to an initial scorpion sting. Patients with immediate hypersensitivity reactions to scorpion stings may potentially benefit from immunotherapy with IFA WBE.

Cross-reactivity between coconut and hazelnut proteins in a patient with coconut anaphylaxis.

BACKGROUND: The medical literature reports few cases of severe allergic reactions to coconut. We encountered a patient with anaphylaxis to coconut and oral symptoms to tree nuts. OBJECTIVE: To identify cross-reactive antibodies between coconut and other tree nuts. METHODS: We performed commercial radioallergosorbent tests to coconut and various tree nuts using the patient's serum. Skin prick testing was performed to fresh coconut and commercial extracts of coconut, almond, Brazil nut, cashew, pecan, walnut, and hazelnut. Proteins from fresh coconut, commercial coconut extract, and tree nuts were extracted. Immunoblot and inhibition assays were performed to evaluate for cross-reacting IgE antibodies between similar-sized allergens in coconut and hazelnut. RESULTS: Positive skin test results occurred to the coconut and multiple tree nut extracts. In vitro serum specific IgE was present for coconut, hazelnut, Brazil nut, and cashew. Immunoblots demonstrated IgE binding to 35- and 50-kDa protein bands in the coconut and hazelnut extracts. Inhibition assays using coconut demonstrated complete inhibition of hazelnut specific IgE, but inhibition assays using hazelnut showed only partial inhibition of coconut specific IgE. CONCLUSIONS: Our study demonstrates the presence of cross-reactive allergens between hazelnut (a tree nut) and coconut (a distantly related palm family member). Because there are many potentially cross-reactive allergens among the tree nuts, we recommend patients with coconut hypersensitivity be investigated for further tree nut allergies.

Factors affecting compliance with allergen immunotherapy at a military medical center.

BACKGROUND: Allergen immunotherapy (AIT) is a safe and effective treatment for certain allergic disorders; however, noncompliance with therapy is common. We evaluated the compliance rates among groups receiving AIT at a military medical center and identified factors affecting compliance. METHODS: The charts of the 381 actively enrolled patients in our AIT program were evaluated for patient compliance. Noncompliant patients were contacted to determine the reason for stopping therapy. Patients were then grouped by diagnosis, age, sex, military status, and schedule of AIT and evaluated for differences. RESULTS: The overall compliance rate was 77.4%. The most common reasons for noncompliance included inconvenience, precluding medical condition, and adverse systemic reaction. There were no differences in compliance rates by diagnosis or sex. Noncompliant patients were younger than compliant patients, 35.4 years versus 42.4 years (P = 0.001); however, when patients were divided into three age categories (<18, 18 to 45, and >45 years), the youngest and oldest groups were more compliant (P < 0.001). Active-duty members were less compliant than retirees and family members, 65.7% versus 83.1% and 81.4%, respectively (P = 0.004). Patients receiving a conventional schedule of AIT were more compliant than those on a rush schedule, 80.0% versus 48.4% (P < 0.001). CONCLUSIONS: Factors found to affect patient compliance with an AIT regimen at our military medical center include age, military status, and schedule of AIT. The most common reasons for noncompliance included inconvenience, precluding medical conditions, and adverse systemic reactions. Clinicians need to be aware of the factors limiting patient compliance with AIT in an attempt to maximize treatment effectiveness.

Safety and efficacy of an imported fire ant rush immunotherapy protocol with and without prophylactic treatment.

BACKGROUND: Hypersensitivity to the sting of the imported fire ant (IFA) is a growing and significant cause of morbidity and mortality in the United States. Conventional immunotherapy with IFA whole body extract (WBE) has been shown to be effective; however, rush immunotherapy (RIT) with IFA WBE has not been studied. OBJECTIVE: In this study, we evaluated the safety and efficacy of RIT with IFA WBE and sought to determine whether prophylactic pretreatment with antihistamines and steroids reduces the systemic reaction rate associated with RIT. METHODS: Patients with IFA hypersensitivity were randomized to placebo or twice-daily terfenadine 60 mg, ranitidine 150 mg, and prednisone 30 mg initiated 2 days before RIT in a double-blinded study. The 2-day RIT protocol consisted of hourly injections to achieve a final dose of 0.3 mL 1:100 wt/vol. Patients returned on day 8 to receive 2 hourly injections of 0.25 mL 1:100 wt/vol (total, 0.5 mL) and again on day 15 for a single injection of 0.5 mL 1:100 wt/vol. Efficacy of the protocol was determined on day 22, a pair of IFA sting challenges being performed 2 hours apart. RESULTS: Fifty-nine patients were enrolled into the study; a total of 58 patients (age range, 18 to 49 years) initiated the 2-day RIT. Only 3 patients (5.2%) experienced a mild systemic reaction during the protocol. Among those experiencing a systemic reaction with RIT, there was no statistical difference between the 2 premedication groups (3.6% active and 6.7% placebo; P =.87). Sting challenges were performed on 56 patients for a total of 112+ stings; only 1 mild systemic reaction occurred (efficacy, 98.2%). CONCLUSION: RIT with IFA WBE for IFA hypersensitivity is both safe and efficacious; the rate of mild systemic reactions is low. Premedication is not necessary, inasmuch as prophylactic pretreatment with antihistamines and steroids did not reduce the systemic reaction rate associated with RIT.