Spontaneous resolution of profound hypogammaglobulinemia.

A 3-month-old, full-term female infant was hospitalized with pneumonia and bronchiolitis. Laboratory studies revealed a profoundly low level of IgG (41 mg/dL) and low level of IgA (< 6.67 mg/dL). Other causes of immunodeficiency were ruled out, and there was no evidence of protein loss to account for the low immunoglobulin levels. The immunoglobulin levels normalized over time. Our patient had a transient hypogammaglobulinemia of infancy, with severely low IgG and low IgA levels. We found no other reports of cases with such low values of IgG that proved to be transient.

Expanding habitat of the imported fire ant (Solenopsis invicta): a public health concern.

Residents in the southeastern United States would hardly describe life with the aggressive imported fire ant as peaceful coexistence. The continued spread of these insects has produced agricultural problems, changes in the ecosystem, and increasing numbers of subjects with sting sequelae, including hypersensitivity reactions, secondary infections, and rare neurologic sequelae. Evolutionary changes have facilitated their expansion northward into Virginia and westward into California, and increasing urbanization will likely permit further expansion. Recent reports of building invasion with sting attacks inside occupied dwellings, including health care facilities, heighten public health concerns. This article reviews the medically important entomology, clinical aspects of stings, and the current approaches to chemical control of fire ants. We also propose directions for future research and treatment.

Management of imported fire ant allergy: results of a survey.

BACKGROUND: Fire ant allergy is a significant health problem in the southern United States. Management of fire ant allergy is less clearly defined than management of allergy to the winged Hymenoptera. OBJECTIVE: To determine how fire ant allergy is managed by practicing allergists. METHODS: A survey form was developed and distributed to American College of Allergy, Asthma & Immunology members practicing in fire ant endemic states. Completed forms were returned to the American College of Allergy, Asthma & Immunology central office and forwarded to the authors for analysis. RESULTS: Three hundred twenty-nine of 879 (37.4%) surveys were returned; 81% of respondents have evaluated patients with imported fire ant allergy. Immunotherapy is used by 96.7% of respondents to treat fire ant allergy. A wide range of maintenance dosages are prescribed. Skin testing is the most common diagnostic method. Systemic reactions to stings while on maintenance immunotherapy were reported by 19%. Allergists utilize different criteria in consideration for stopping immunotherapy; 19% continue it indefinitely. CONCLUSIONS: There are many areas of general uniformity and other areas of divergence in how allergists manage imported fire ant allergy. These findings suggest continued need for further investigation regarding the efficacy, dosage, and duration of immunotherapy, as well as further elucidation of the natural history of fire ant allergy.

Candida endocarditis in a child with hyperimmunoglobulinemia E syndrome.

Hyperimmunoglobulin E syndrome (HIE) is a disorder characterized by extremely elevated serum levels of IgE and recurrent infections. Patients are particularly predisposed to have staphylococcal abscesses, usually involving skin, lungs, and joints; but they are also at risk for infections with other bacteria and fungi. We report the case of a 46-month-old boy with HIE who had Candida endocarditis and sepsis with a large fungal mass extending through the tricuspid valve and into the surrounding heart tissue, requiring surgical excision and replacement with a prosthetic valve. He had an indwelling central line for previous antibiotic therapy and had oral thrush for a month before presentation, which had been treated with oral nystatin. He was first seen with very dark urine, a new murmur, petechial rash, in shock, and disseminated intravascular coagulation. The white blood cell count was 38,700 with 70% segmented neutrophils, 9% banded neutrophils, 15% lymphocytes, 4% monocytes, and 2% eosinophils. Hemoglobin was 7.1, and platelet count was 14,000. Prothrombin time was 15.5, and partial thromboplastin time was 31; fibrinogen level was 110 mg/ml, and fibrin degradation products were greater than 40 mg/ml. Serum IgE was 38,664 and 44,510 on repeat measurement. He has had recurrent staphylococcal pneumonias with pneumatoceles, twice requiring segmental lung resection. Blood and tricuspid valve cultures grew Candida albicans. He was treated with amphotericin and flucytosine, and later switched to fluconazole, with good response to therapy. A literature search revealed no other reported case of Candida endocarditis in patients with HIE. Fungai endocarditis is a rare complication, which may occur in patients with HIE and indwelling central catheters.

Management of asthma in children.

Management of chronic asthma has changed significantly in recent years. Most of the changes in management are the result of an increased recognition of the importance of the inflammatory component in the pathogenesis and treatment of asthma. The National Heart, Lung, and Blood Institute issued guidelines for the management of asthma in 1991. Beta agonists, cromolyn and nedocromil are mainstays of treatment in patients with mild to moderate asthma. Inhaled steroids are useful in the treatment of patients with moderate to severe asthma. Nonpharmacologic management of asthma includes avoidance of allergens and irritants, the use of peak flow meters, and patient and family education.

Allergy to insect stings. A need for improved preventive management.

Allergy to insect venom is a major health problem for a significant number of people. Immunotherapy can reduce the risk of subsequent reaction from about 60% to less than 5%. Standard preventive care should include (1) advice concerning avoidance of insects, (2) prescription of an epinephrine kit or syringe for self-administration (unless medically contraindicated), and (3) referral for evaluation. Results of several studies from various regions of the country raise concern about the preventive care and advice given these patients and suggest a need for continuing medical education to improve preventive management of allergy to insect stings.

Primary immunization series for infants: comparison of two-component acellular and standard whole-cell pertussis vaccines combined with diphtheria-tetanus toxoids.

At 2 months of age, 145 infants were randomized to receive either a two-component acellular pertussis vaccine [lymphocytosis-promoting factor (LPF)/filamentous hemagglutinin (FHA)] or standard whole-cell pertussis vaccine, each combined with diphtheria-tetanus toxoids, as their primary immunization series. Of the 132 subjects (91%) who completed the study, those receiving the acellular vaccine had significantly fewer adverse reactions: 5% vs 30% (local) and 17% vs 30% (systemic, including fever). During the first 24 hours acetaminophen usage, a general measure of adverse reactions, was lower in the test group. Overall, 35% of the acellular vaccine doses were reaction free vs 12% of the whole-cell doses. No serious reactions occurred in either group. Antibody responses to LPF and to FHA were significantly increased after the second and third immunizations with the test vaccine and were consistently higher than levels achieved with the standard vaccine. Thus the two-component acellular pertussis vaccine was associated with fewer adverse reactions and improved serologic responses to LPF and FHA as compared with the currently recommended whole-cell vaccine.

Comparison of acellular (B type) and whole-cell pertussis-component diphtheria-tetanus-pertussis vaccines as the first booster immunization in 15- to 24-month-old children.

We compared an acellular (B type) pertussis-component diphtheria-tetanus-pertussis (DTP-Ac) vaccine containing equal amounts of filamentous hemagglutinin and lymphocytosis-promoting factor with a conventional whole-cell vaccine as the first booster immunization in 162 healthy children 15 to 24 months of age. Fewer local reactions (e.g., erythema, swelling, and tenderness at the injection site) were seen in DTP-Ac vaccine recipients during the first 48 hours of observation. This group also had fewer episodes of fever (> or = 38 degrees C) and other systemic reactions (e.g., irritability, drowsiness, and anorexia). Overall, 57% of the DTP-Ac vaccine recipients had no obvious adverse reactions, in contrast to 5% in the comparison group. At 4 to 8 weeks after vaccination, serum antibody responses to filamentous hemagglutinin and lymphocytosis-promoting factor were greater in recipients of the acellular vaccine as determined by an enzyme-linked immunosorbent assay. We conclude that this B-type acellular vaccine is both immunogenic and much less likely to cause an adverse reaction than a currently licensed whole-cell vaccine, and is suitable for routine booster immunizing doses to protect against pertussis.

Allergens in Hymenoptera venom. XXII. Comparison of venoms from two species of imported fire ants, Solenopsis invicta and richteri.

Venoms were collected by electrical stimulation from the two major species of imported fire ants found in the United States, Solenopsis invicta (Sol i) and S. richteri (Sol r). Antigens similar to three of the four known Sol i venom proteins (I, II, III, and IV) were isolated from Sol r. The N-terminal amino acid sequences for the antigens III were identical; but those for the antigens II demonstrated only nine of 20 residues to be identical. Two monoclonal antibodies raised against Sol i II did not react to Sol r. No protein IV could be detected in Sol r by molecular weight, charge, or immunologically with either polyclonal mouse antibodies or five monoclonal antibodies. Both venoms were compared with a panel of 60 sera from Sol i-allergic individuals; mean bindings were similar with an r = 0.94 for linear regression. RAST inhibition was performed with 17 individual sera representing a variety of Sol i allergen specificities. Four sera were tested from patients resident in the Sol r endemic area and five sera from patients who experienced reactions to S. xyloni stings. All sera reacted comparably to both imported fire ant venoms. The two venoms appear to be allergenically similar, although antigen IV is absent from Sol r and the antigens II have significant sequence variation. Sol i venom appears to be sufficient for diagnostic purposes.

Comparison of in vivo and in vitro tests in the diagnosis of imported fire ant sting allergy.

The specificities and sensitivities of skin test reactivity to imported fire ant (IFA) whole body extract (WBE) and IFA venom were compared with IFA WBE RAST and IFA venom RAST in the diagnosis of IFA allergy. Study groups consisted of 18 IFA allergic patients and 21 control subjects with no history of allergy to insect stings. All IFA allergic patients had positive skin tests to both IFA WBE and IFA venom. Six of 21 (29%) control subjects also had positive skin tests to both IFA WBE and IFA venom. A commercial IFA WBE RAST was positive in 10 of 18 (56%) IFA-allergic patients and 2 of 21 (10%) control subjects. Imported fire ant aqueous venom RAST was positive in 11 of 11 (100%) IFA-allergic patients and three of ten (30%) control subjects. Vespa IFA venom RAST was positive in 16 of 18 (89%) IFA-allergic patients and 5 of 21 (24%) controls. The sensitivities and specificities of IFA WBE skin testing, IFA venom skin testing, and IFA venom RAST did not differ significantly. Imported fire ant WBE RAST was less sensitive than the other diagnostic methods.

Cimetidine in the treatment of refractory anaphylaxis.

After preoperative intubation and administration of intravenous cefuroxime, a 48-year-old white female developed anaphylactic shock that was refractory to the usual therapeutic measures but was responsive to treatment with intravenous cimetidine. Beta-lactam sensitivity was subsequently confirmed by skin testing. Cimetidine, which antagonizes arterial H2 receptors, may be useful in the treatment of anaphylaxis refractory to the usual resuscitative measures.

Type I diabetes in an adolescent with common variable immunodeficiency.

A male adolescent with common variable immunodeficiency developed type I diabetes approximately 1 year after the initiation of immunoglobulin therapy. Immunologic evaluation revealed decreased numbers of T cells and an intrinsic B cell defect in immunoglobulin production. Lymphocytes from the patient failed to generate normal suppressor activity. There were no insulin or islet cell antibodies present in the patient's serum or in the commercial immunoglobulin preparations he received. The patient's HLA phenotype included HLA-DR3 and 4, placing him genetically at high risk for type I diabetes.

IgM deficiency: clinical spectrum and immunologic assessment.

Selective IgM deficiency has been associated with recurrent infections and enteric protein loss. We have evaluated eight patients with IgM deficiency presenting with recurrent infections and manifestation of atopy. A variety of subtle immunologic aberrations were noted, including depressed IgM and elevated IgG responses to immunization with bacteriophage OX174. Despite normal quantitative IgG in most patients, IgG antibody responses to diphtheria-tetanus and/or pneumococcal polysaccharide antigens were generally depressed. No correlation could be made between antibody responses (or lack thereof) and the nature of infections in any given patient.

Effect of interleukin-2 and mitogen on in vitro immunoglobulin production by peripheral blood lymphocytes from patients with selective IgM deficiency.

Immunoglobulin production by mitogen and recombinant interleukin-2-(rIL-2)-stimulated lymphocytes from IgM-deficient patients was studied. The findings were that subnormal serum IgM levels did not necessarily predict defective in vitro IgG or IgM production, lymphocytes from some IgM-deficient patients exhibited defective T cell function, and rIL-2 did not enhance defective in vitro immunoglobulin production.

Allergens in Hymenoptera venom. XXI. Cross-reactivity and multiple reactivity between fire ant venom and bee and wasp venoms.

The relationships between fire ant venom and bee and wasp venoms were explored by studying sera from five groups of subjects. Group 1 included adults not allergic to any venoms and who were not exposed to fire ants. Group 2 included adults with fire ant exposure who were not allergic to venoms. Group 3 included patients with recent systemic reactions to fire ant venom. Group 4 included patients allergic to bee and vespid venoms with no fire ant exposure. Last, group 5 included patients allergic to bee and vespid venoms with fire ant exposure. None of the serum samples from group 1 was RAST reactive to fire ant venom, but 24% of those from group 2 were fire ant positive, as were 100% of those from group 3, 51% of those from group 4, and 87% of those from group 5. The RAST-positive patients in groups 2 and 5 were also skin test positive. RAST inhibition studies demonstrated cross-reactivity in some cases and multiple reactivity in others. The serum samples were further investigated via nondenaturing electrophoretic immunoblot studies and RAST with highly purified allergens. Serum samples from group 4 reacted to a single band on immunoblots and with only one of the four purified allergens from fire ant venom (Solenopsis invicta I, or Sol i I). Serum samples from groups 2, 3, and 5 showed various patterns of allergen reactivity. All serum samples from patients allergic to fire ant venom who also reacted to bee and/or vespid venoms by RAST contained IgE antibodies binding to Sol i I.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaphylaxis to human serum albumin.

During her 26th week of pregnancy a 20-year-old woman developed generalized pruritus, urticaria, flushing, tinnitus, and tachycardia during plasmapheresis with 5% human serum albumin (HSA) as adjunctive treatment for anti-Kell isoimmunization. The reaction was controlled with intravenous diphenhydramine. Despite pretreatment with diphenhydramine and betamethasone a subsequent attempt to perform plasmapheresis with infusion of 5% HSA resulted in a more severe reaction which progressed to respiratory distress. Intradermal skin testing with 5% HSA produced a 9 x 11-mm wheal and 17 x 21-mm erythema at 15 minutes. An enzyme-linked immunoassay was positive for IgE antibody to 5% HSA before and after dialysis for removal of Na caprylate. These results are consistent with an IgE-mediated basis for this patient's reaction to HSA.