Cefepime-Induced Generalized Fixed Drug Eruption With Morbilliform Rash.

Fixed drug eruption (FDE) is a cutaneous reaction that characteristically recurs in the same locations upon re-exposure to the offending drug(s). The typical presentation of FDEs is single or multiple violaceous plaques with hyperpigmentation due to inflammation. The causative agents for FDEs include antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, barbiturates, and anticonvulsants. We present an interesting case of a generalized fixed drug eruption secondary to cefepime that resolved with the cessation of the offending drug and the institution of antihistamines and topical steroids.

Creatures Great and Small: Horse and Dog Allergy Cross-Reactivity.

Cat, dog, and horse aeroallergens can cause allergic disease in susceptible individuals. Allergy cross-reactivity occurs when the body recognizes the protein of one allergen as being similar to a different protein, leading to an allergic response. Cross-reactivity has been demonstrated among animal species such as cat, dog, and horse. These allergens fall into the same protein families, with the lipocalin family predominating. We present a case demonstrating cross-reactivity among cat, dog, and horse allergens. Additionally, our case highlights the difficulty of managing and receiving allergen immunotherapy within the military health system due to the disruption of therapy due to frequent moves and temporary duty assignments.

Imported fire ant immunotherapy.

Imported fire ants (IFAs) permeate many areas of the United States. The IFA allergy is a significant health problem for children and adults. Stings from IFAs cause pustules, localized reactions, and anaphylaxis. There have been at least 32 deaths attributed to IFA stings. Because of the difficulty with the extraction of venom from the fire ants, whole body extracts are the only commercially available serum for immunotherapy. Fortunately, whole body extract immunotherapy given conventionally or through the rush method has proven to be efficacious and safe. It is recommended for the treatment of IFA hypersensitivity. Maintenance immunotherapy is typically given at 4-week intervals. However, more recent research has revealed that these intervals can gradually be extended up to 12 weeks similar to flying Hymenoptera venom immunotherapy. Long-term adherence to IFA immunotherapy remains an obstacle for many patients despite its potential as a life-saving treatment.

A Complicated Case of Aspirin-Exacerbated Respiratory Disease With Kounis Syndrome.

Kounis syndrome is angina or acute coronary syndrome caused by mast cell degranulation and inflammatory cell activation. We present a case of a patient with underlying aspirin-exacerbated respiratory disease (AERD) and previous anaphylaxis to aspirin. The patient underwent aspirin desensitization and was then treated with high-dose aspirin. Unfortunately, he developed recurrent angina and myocardial infarction (MI). Numerous left heart catheterizations revealed vasospasms as the etiology of his MIs; however, therapy with increasing doses of vasodilators yielded no improvement in the patient's condition. Ultimately the patient's aspirin was discontinued and he had no recurrence of angina or MI.

The Curious Case of Elevated Tryptase: Workup and Differential in Family of Four.

Elevated basal serum tryptase (BST) levels are markers of both mast cell activation and overall mast cell burden. We present a family of four individuals with elevated tryptase levels greater than or equal to 20 mcg/L, all of whom exhibited signs and symptoms suggestive of mast cell activation. Differential diagnoses included hereditary alpha tryptasemia (HaT), systemic mastocytosis (SM), and mast cell activation syndrome (MCAS). In three individuals, SM was ruled out with normal morphology on bone marrow biopsy combined with negative genetic markers. Further workup would be required for the diagnosis of MCAS since serum tryptase levels were not obtained in our emergency department during acute episodes. Although genetic testing for HaT was not available upon initial workup, HaT remains the most likely explanation for this family's elevated BST.

A Failure of Rapid Drug Desensitization.

We present the case of a patient who was unable to tolerate rapid drug desensitization protocol to receive a continuous penicillin (PCN) G infusion for the treatment of neurosyphilis. A 38-year-old male with past medical history for human immunodeficiency virus, migraines, PCN allergy, doxycycline allergy, shellfish allergy, and untreated latent syphilis presented to the emergency room for a posterior migraine with associated nausea, vomiting, photophobia, right-sided paresthesias, and "shaky" vision. He was diagnosed with neurosyphilis and underwent rapid drug desensitization with the goal to receive a continuous infusion of PCN G. The patient's hospital course was complicated by intermittent drug reactions consisting of tachycardia, rash, and dyspnea, followed by periods of being able to tolerate the infusion. After being able to tolerate the recommended dose of PCN infusion, the patient was discharged home to complete the course. However, he returned almost immediately after a recurrence of symptoms at home requiring the use of intramuscular epinephrine. Ultimately, the patient was transitioned to ceftriaxone and completed the infusion course as an inpatient because of continued intermittent recurrence of drug reaction symptoms.

A Case of Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis Masquerading as Septic Shock.

Trimethoprim-sulfamethoxazole-induced aseptic meningitis (TSIAM) is a rare adverse reaction to a commonly prescribed antibiotic. We describe a case of severe TSIAM which resembled septic shock. A 30-year-old male with relapsed Hodgkin's lymphoma 25 days status post autologous stem cell transplant presented to our clinic for evaluation of trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity. After review of patient's history and records, we had a low suspicion for a TMP-SMX adverse reaction and conducted an oral challenge to one 160 mg/800 mg tab of TMP-SMX. Four hours later, the patient developed vomiting, lightheadedness, and disorientation with progression to rigors, fever, tachycardia, and hypotension. He was admitted for fluid resuscitation and broad-spectrum antibiotic coverage for neutropenic fever and possible septic shock. A lumbar puncture performed due to complaints of headache, photophobia, and neck pain showed 375 white blood cells/µL with 73% neutrophil predominance, normal glucose (75 mg/dL), and elevated protein (101 mg/dL); additional cerebrospinal fluid (CSF) studies were negative for infectious etiologies. Fever and headache resolved by hospital day 4, at which time patient was discharged home. We believe this case represents TSIAM given the characteristic timing of symptom onset, CSF findings, and timing of symptom resolution without other clear etiology found on extensive infectious evaluation. It is important for allergists to recognize TSIAM, including its potential presentation as shock, in order to appropriately diagnose and counsel patients who seek evaluation for TMP-SMX adverse reactions.

The first reported case of Blaptica dubia cockroach allergy.

BACKGROUND: Periplaneta americana and Blattella germanica cockroaches are widespread, and risk of sensitization increases in urban environments where these roaches thrive as household pests. There are no prior reports of Blaptica dubia cockroach allergy, though human exposure to B. dubia is increasing through commercial breeding as feeder insects. CASE PRESENTATION: A 50-year-old B. dubia cockroach breeder presented with progressively worsening upper and lower respiratory symptoms in recent years. Symptoms were worse with exposure to her B. dubia roach colony. Skin prick testing (SPT) to B. dubia cast skin, internal organs, and feces was performed in both the subject and a human control. Testing for P. americana and B. germanica sensitization was also performed in the subject. SDS-Polyacrylamide gel electrophoresis (PAGE), immunoblots, and enzyme-linked immunosorbent assays (ELISA) studies were performed using the subject and control serums to explore for specific IgE binding to B. dubia as well as P. americana. Our results showed SPT was positive to B. dubia internal organs in the subject and negative in the control. In the subject, SPT was negative to P. americana though intradermal (ID) testing was positive and serum specific IgE (sIgE) testing was negative to B. germanica. Immunoblotting of the subject's serum to B. dubia internal organ extract showed several distinct bands of IgE binding at 47 kilodaltons (kD), 68 kD, 74 kD, 83 kD, and 118 kD. The strongest band was at 118 kD on B. dubia immunoblotting, which was absent in P. americana on SDS-PAGE. ELISA studies showed an increased IgE response to both B. dubia and P. americana in the subject versus the control. CONCLUSIONS: This case confirmed the first reported allergy to B. dubia cockroaches. There may be cross-reactivity between B. dubia and P. americana, though our case suggests SPT and sIgE testing using P. americana and B. germanica extract has potential to miss a B. dubia cockroach allergy. This allergy is likely underreported, and further study is needed to explore the natural history of B. dubia cockroach allergy.

Long-Term Successful Treatment of Indolent Systemic Mastocytosis With Omalizumab.

This case study suggests that omalizumab may help prevent anaphylaxis and reduce disease burden associated with systemic mastocytosis, but further studies and formal clinical trials are needed to confirm these findings.

ß-Blockers and angiotensin-converting enzyme inhibitors with sublingual immunotherapy: are risks related to individual product safety profile?

PURPOSE OF REVIEW: The objective of this article is to review the available literature regarding the risks associated with sublingual immunotherapy and angiotensin-converting enzyme (ACE) inhibitors or ß-blocker use. It also evaluates for any differences in these risks among the available sublingual immunotherapy (SLIT) tablets. RECENT FINDINGS: A literature search was conducted in PubMed to identify peer-reviewed articles using the following keywords: anaphylaxis, ACE inhibitor, ß-blocker, and sublingual immunotherapy. Minimal data exist regarding their safety of SLIT in patients concomitantly taking ACE inhibitors or ß-blockers. The adverse reaction rates seem similar between SLIT products. SUMMARY: A risk-versus-benefit discussion should be communicated with the patient taking a ß-blocker before beginning SLIT but automatic denial of SLIT to these patients is not warranted.

Anaphylaxis to MMR Vaccine Mediated by IgE Sensitivity to Gelatin.

The measles-mumps-rubella (MMR) vaccine is generally well tolerated, and reports of anaphylaxis to the vaccine are rare. IgE-mediated reactions to vaccines are often caused by additives or residual vaccine components. An inability to obtain proper immunizations can be a disqualifying component to military service. We report a case of anaphylaxis to the MMR vaccine in a new military recruit sensitized to gelatin IgE.

Pollen food allergy syndrome (PFAS): A review of current available literature.

OBJECTIVE: Pollen food allergy syndrome (PFAS) is a complex syndrome posing a diagnostic and therapeutic challenge. Our objective was to summarize the available literature regarding its prevalence, pathogenesis, diagnosis, and treatment. DATA SOURCES: A PubMed search was performed to include English language articles with the following search terms: pollen food syndrome, pollen food allergy syndrome, PFAS, oral allergy syndrome, OAS, food anaphylaxis, food components. STUDY SELECTIONS: Human articles discussing PFAS. RESULTS: Varying reports have been made of the prevalence of PFAS, ranging from 4.7% to greater than 20% in children and 13% to 58% in adults. Prevalence varies widely by geographic region. PFAS is typically the results of class II food allergens (e.g. sensitized to anaeroallergen, but reaction occurs due to cross reactivity from a food allergen). Commonly these reactions are limited to the oropharynx due to the lability of the proteins causing the reaction. As multiple families of proteins with varying stability cause PFAS, severe systemic reactions are also possible, as anaphylactic shock has been documented in up to 1.7% of reactions. CONCLUSION: Pollen food allergy syndrome therefore cannot be dismissed as a benign food allergy, but it needs to be approached individually based on known risk factors.

Food allergy guidance in the United States military: A work group report from the American Academy of Allergy, Asthma & Immunology's Military Allergy and Immunology Assembly.

A diagnosis of food allergy adversely affects one's ability to join or remain in the military. Inadequate knowledge or misconceptions of current military-specific standards regarding food allergy and how these apply to enlistment, induction, and retention in the US military can lead potentially to inaccurate counseling because each military service has specific regulations that affect the evaluation and decision-making process. Recognizing this knowledge gap, the American Academy of Allergy, Asthma & Immunology's Military Allergy and Immunology Assembly established a work group that reviewed and summarized all aspects of military instructions, policies, and regulations regarding IgE-mediated food allergy. A flowchart was developed outlining each step of the military entry process for an applicant with a history of food allergy. Furthermore, summary tables were made to provide improved "fluency" regarding each service's medical regulations, whereas key considerations were outlined for the allergist who is evaluating a subject who is seeking military entry or retention. Both civilian and military allergists play an essential role in the evaluation, counseling, and management of patients with a food allergy history. Understanding the service-specific language and regulations regarding food allergy will improve the allergist's awareness, counseling, and management of these individuals.

Extremely Delayed Diagnosis of Type II Hereditary Angioedema: Case Report and Review of the Literature.

We present a case with extremely late diagnosis of type II hereditary angioedema (HAE). Given recent advances in HAE treatment, we want to bring physician awareness to this condition and aid in earlier detection. HAE is a disorder associated with episodes of angioedema of the face, larynx, lips, abdomen, or extremities. Late diagnosis of HAE can lead to significant morbidity and is severely impairing due to recurring attacks. The diagnosis of HAE is ordinarily made during childhood and adolescence. Delayed diagnoses in early and middle adulthood have been documented in the literature. Gastrointestinal symptoms are common features of HAE and can be misdiagnosed as disease of primary gastrointestinal pathology, such as irritable bowel syndrome, recurrent pancreatitis, or appendicitis. These attacks are characterized by recurrent attacks of subcutaneous and submucosal edema without the presence of urticaria.We present a case of an elderly veteran whose diagnoses was extremely delayed into the eighth decade of life subsequent to unexplained abdominal symptoms. After diagnosis, the patient's symptoms were well controlled with medication due to advances in HAE treatment. To prevent further atypically delayed diagnoses, physicians should consider HAE in patients with recurrent attacks of unexplained abdominal pain.

Long-term omalizumab use in the treatment of exercise-induced anaphylaxis.

Reported is a case of a 39-year-old male who was diagnosed with exercise-induced anaphylaxis (EIA). He was initially treated prophylactically with fexofenadine, montelukast, and ranitidine. He also used an epinephrine autoinjector as needed. He was refractory to these medications and continued to have episodes of EIA. He was then started on a trial of omalizumab, an immunoglobulin E monoclonal antibody, and had resolution of the EIA episodes. After discontinuation of the omalizumab, the EIA episodes returned. He was restarted on omalizumab and since that time, has had 5 years free of EIA episodes and can now exercise without any symptoms. To our knowledge, this is only the third case in the literature of successful treatment of EIA by using omalizumab. This case was unique because it provided successful long-term use of omalizumab for EIA. Further studies are recommended for the use of omalizumab in the treatment of EIA.