Dust-mite avoidance measures in patients on immunotherapy.

The compliance of dust-mite (DM) allergic patients receiving immunotherapy (IT) with environmental avoidance measures has not been reported. To investigate patient practices, a questionnaire was distributed to patients receiving IT for indoor allergens. Ninety-three of 200 patients (46%) with indoor allergies completed the questionnaire. Of the 93 patients, 69% were allergic to DMs, 45% were allergic to pets, 17% were allergic to mold, and 3% were allergic to cockroaches. Of 64 patients allergic to DMs, 53% reported use of mattress covers, 61% reported use of pillow covers, 81% reduced moisture in their homes, 83% washed their bed linens in water that was >130 degrees F, 77% vacuumed or dusted weekly, and 21% replaced carpets with polished flooring. Fifty-two percent of patients who did not use covers and 49% who did not replace their carpets cited cost as the most common reason. Education about the use of DM covers was reported by 97% of patients allergic to DMs, predominantly by physicians. In conclusion, many patients on IT for DM allergy do not use avoidance measures for decreasing allergen exposure. Cost appears to influence compliance with several measures including protective mattress and pillow covers. It may be unreasonable to require most patients to use such avoidance measures before being candidates for IT.

Cold urticaria: an under-recognized cause of postsurgical periorbital swelling.

PURPOSE: To report cold urticaria as an under-recognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery. METHODS: Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases. RESULTS: Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae. CONCLUSIONS: Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.

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.

Determination of the incidence of sensitization after penicillin skin testing.

BACKGROUND: Concerns for sensitization after penicillin skin testing are a factor in limiting the timing and population for whom this testing is offered. The sensitizing potential of the penicillin skin test has never been studied directly. METHODS: A total of 329 volunteers underwent prick and intradermal skin testing with penicillin G, benzylpenicilloyl-polylysine, and a minor determinant mixture. Those with negative skin testing had repeat testing 4 weeks later. Medical history and antibiotic use were determined by interview, questionnaire, and electronic pharmacy records. RESULTS: Seventy-two of the 329 subjects (22%) reported a history of previous beta-lactam reaction, of which 10 (14%) had a positive initial skin test. Overall, the initial skin test was positive in 23 of 329 (7%). Of the subjects with a negative initial skin test, 239 completed the second test 4 weeks later. Of these, 6 subjects (2.5%, 95% confidence interval 0.5% to 4.5%) converted to a positive skin test. None had taken a beta-lactam antibiotic between the two tests, and none had any previous history of beta-lactam reaction. One subject reported having never taken a beta-lactam antibiotic before. In comparison to the 233 subjects who did not convert their skin test, the statistically significant factors favoring sensitization were: female sex (odds ratio [OR] 6.53, P = 0.05), atopy (OR 5.31, P = 0.04), and history of food allergy (OR 6.35, P = 0.02). There was a trend toward more recent penicillin use in the newly sensitized subjects, but this was not statistically significant.. CONCLUSION: Penicillin skin testing may sensitize a small number of individuals to penicillin.

High-dose inhaled fluticasone and delayed hypersensitivity skin testing.

INTRODUCTION: Systemic steroids have been associated with anergy. Treatment with high-dose inhaled steroids has many documented systemic side effects, including adrenal suppression, reduction in growth velocity, and increased bone metabolism; however, little is known about their effect on delayed-type hypersensitivity (DTH). STUDY OBJECTIVES: The purpose of this study was to determine if a 28-day course of high-dose inhaled fluticasone suppresses DTH to a standard panel of antigens. METHODS: Forty-five healthy, steroid-naïve subjects volunteered for this randomized, double-blinded, placebo-controlled trial. All subjects had baseline DTH assessed by intradermal skin testing to a standard panel of antigens (tetanus, candida, mumps, and tuberculin) read 72 h after placement. Subjects were then randomized to receive placebo or high-dose inhaled fluticasone (880 micro g/d) for 28 days, after which a second DTH panel was performed. A third DTH panel was performed after a 30-day washout period. MEASUREMENTS AND RESULTS: Of the 45 enrolled subjects, 38 subjects completed the study, including 20 subjects in the placebo group and 18 subjects in the drug group. There was no significant difference in the amount of induration between drug and placebo groups for any of the three periods tested. CONCLUSION: Twenty-eight days of treatment with high-dose inhaled fluticasone did not suppress DTH in healthy volunteers.

Paget's disease of bone in an Indian patient: genetic and environmental factors.

Epidemiologic data have shown that Paget's disease of bone is common among people of Anglo-Saxon descent, but it is believed to be rare in India and Asia. The worldwide prevalence of the disease shows pronounced geographic and ethnic heterogeneity, and can vary in populations through migration or loss of geographic isolation. The risk to an individual who changes geographic locations, however, is difficult to quantify because the specific genetic or environmental factors responsible for Paget's disease have yet to be completely determined. We describe a case of monostotic Paget's disease in a 59-year-old Asian Indian man, and consider the potential epidemiologic and etiologic influences (moving to an area of higher disease prevalence, role of genetics, viral exposures) that may have increased his risk for the disorder. The patient presented with several months of right anterior leg pain, and was found on examination to have anterior bowing of the tibia as well as warmth and an audible bruit. Radiographs of the tibia demonstrated a V-shaped lucency, enhanced trabecular pattern, and cortical thickening. Whole-body bone scan confirmed monostotic disease with expansile uptake in the tibia, and laboratory data revealed an elevated urinary collagen N-telopeptide that normalized after bisphosphonate treatment, as did his clinical symptoms. In light of the environmental factors that appear significantly to influence the development of Paget's disease, the diagnosis should be considered in patients traditionally considered at low risk for the disorder.