Inpatient allergy/immunology consultations in a tertiary care setting.

Few studies have examined inpatient referral patterns for fellowship training programs and none for allergy/immunology (AI) since 2003. The primary end point was the reason for consultation, and secondary end points included the AI diagnosis made and outcomes. We retrospectively reviewed all inpatient AI consultations from July 1, 2001 through June 30, 2007. These 6 years of data were combined with 14 years of data examining the reason for consult from a previous study. The data were analyzed for trends and changes over the entire 20-year period. A total of 254 AI inpatient consults were reviewed over the 6 years studied. Thirty-six percent (92/254) of inpatient consults were for evaluation of adverse drug reactions (ADRs), 22% (55/254) miscellaneous reasons, 17% (43/254) urticaria/angioedema, 13% (32/254) for possible immunodeficiency, 9% (23/254) for anaphylaxis, and 3% (8/254) for asthma. AI inpatient consults show a significant decline over the recent 6-year period (p = 0.0023) despite stable total hospital admissions since 1998. Over the last 20 years, an 85% decrease (p < 0.00001) in inpatient asthma consults and increases (p < 0.05) in immunodeficiency, rash, and urticaria/angioedema evaluations have been observed. Not following AI recommendations resulted in a 16.6 odds ratio (95% CI, 5.55-49.93) that a patient's clinical status would be worse or unchanged. Inpatient AI consults have declined with associated reduction in asthma inpatient consults. Although ADRs and anaphylaxis consults have been stable, evaluations for immunodeficiency, rash, and urticaria/angioedema have increased. Following inpatient AI recommendations is associated with improved patient outcomes.

Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge.

OBJECTIVES: To provide a review of the literature and discuss the clinical, pathophysiologic, diagnostic, and therapeutic challenges of oral allergy syndrome (OAS). DATA SOURCES: English-language publications on OAS (and pollen-food allergy syndrome) were identified through MEDLINE and through the reference lists of each identified article and review. STUDY SELECTION: Articles pertaining to OAS with respect to its varied clinical presentation, underlying pathophysiology, available and investigational diagnostic testing, and evidence-based treatment options were selected. RESULTS: OAS occurs in patients with a prior cross-reactive aeroallergen sensitization and clinically presents with initial oralpharyngeal symptoms after ingestion of a triggering fruit or vegetable. Although controversial, these symptoms may progress to systemic symptoms outside the gastrointestinal tract in 8.7% of patients and anaphylactic shock in 1.7%. OAS's underlying pathophysiology may play a role in clinical presentation and outcome, depending on whether the cross-reactive protein is a heat-labile PR-10 protein, a partially labile profilin, or a relatively heat-stable lipid transfer protein. Diagnostic testing is variable based on the underlying food tested, but fresh food skin prick test typically has the highest sensitivity. Treatment centers on avoidance and the consideration of self-injectable epinephrine. Because of its relationship with a cross-reactive aeroallergen sensitization, subcutaneous immunotherapy and sublingual immunotherapy have also been therapeutically tried with mixed results. CONCLUSION: OAS is a challenging diagnosis to the practicing allergist because of its many clinical, diagnostic, and therapeutic considerations. Understanding these challenges and their underlying mechanisms can facilitate a knowledgeable approach to treating an oral allergy patient.

The evolution of gene therapy in X-linked severe combined immunodeficiency.

OBJECTIVES: To review the evolution of gene therapy in infants with X-linked severe combined immunodeficiency (XL-SCID) and to evaluate the current challenges facing this evolving field. DATA SOURCES: The MEDLINE, OVID, CINAHL, and HealthSTAR databases were searched to identify pertinent articles using the following keywords: gene therapy, XL-SCID, bone marrow transplant, and viral vectors. STUDY SELECTION: Journal articles were selected for their relevance to human gene therapy in patients with XL-SCID. RESULTS: Gene therapy with a retrovirus-derived vector has been used to treat 20 patients with XL-SCID internationally. Although most patients derived improvements in T- and B-cell immune numbers and function, severe adverse effects have occurred. After gene therapy, 5 of the 20 patients developed leukemia. This outcome has been associated with insertion of the corrected gene near the T-cell proto-oncogene LMO2. One of the 5 patients subsequently died. CONCLUSIONS: Within the past decade, effective improvements in vectorology and cell culture conditions have resulted in clinical success in some infants with SCID and have revived interest after many years of setbacks. However, clinical success and significant adverse events have been reported in patients with XL-SCID who have undergone gene therapy using a retroviral vector. As extensive research into improving safety through vector development and monitoring of gene therapy continues, further progress in gene therapy development can be anticipated.

Reasons for outpatient consultation in allergy/immunology.

There is little data in the literature regarding outpatient consultation in allergy/immunology (A/I). The purpose of this study was to determine the relative frequency of different reasons for A/I outpatient consultation to help guide graduate medical education (GME) and assist with A/I practice management. We retrospectively reviewed the electronic medical records of all outpatient A/I consultations from January 1, 2006 to December 31, 2006. The study was performed at our tertiary care referral center which is a GME training site. There were 1412 A/I consults requested during the 1-year period. The consults per month ranged from a low of 69 to a high of 157. The referrals consisted of 35% pediatric and 65% adult patients. There were 52.8% female and 47.2% male patients. We received 74.3% of referrals from primary care, 19.8% from specialty care, and 5.9% from the emergency department. The most common reasons for consultation included 808 (57.2%) patients for chronic rhinitis, 288 (20.4%) for asthma, 196 (13.9%) for food allergy, 89 (6.3%) for venom allergy, 68 (4.8%) for atopic dermatitis, 66 (4.7%) for drug allergy, 62 (4.4%) for chronic urticaria, 45 (3.2%) for acute urticaria, 34 (2.4%) for immunodeficiency, 31 (2.2%) for anaphylaxis, and 162 (11.5%) for other reasons. More than one reason was given for 27.1% of consults, and there was an average of 1.3 reasons for consultation per patient. Although the allergist/immunologist is consulted for a variety of reasons, the top three reasons make up a majority of outpatient consults, and consults are often requested to address more than one diagnosis.

Safety of angiotensin-converting enzyme inhibitors while receiving venom immunotherapy.

BACKGROUND: Case reports have raised concern about concurrent use of angiotensin-converting enzyme inhibitors (ACE-Is) in patients receiving venom immunotherapy (VIT). No surveys have been performed on the number of venom allergic patients who take ACE-Is and their outcomes. OBJECTIVE: To survey the use of ACE-Is and systemic reaction (SR) characteristics in patients receiving VIT. METHODS: A retrospective medical record review was performed on all patients evaluated for Hymenoptera venom allergy at a single center from 2000 to 2005. Patient records were evaluated for presenting symptoms, specific IgE testing, VIT treatment course, ACE-I use during VIT, and the presence of any SRs to field stings or VIT. RESULTS: Of 288 patients evaluated from 2000 to 2005 for Hymenoptera venom allergy, 157 were found to have venom specific IgE. Of these 157 patients, 79 (50%) of those with Hymenoptera venom allergy underwent VIT. Seventeen of these 79 patients (21%) were taking an ACE-I during VIT. The mean overlap of a patient taking an ACE-I with the time they were receiving VIT was 30.9 months (range, 3-114 months). Patients taking ACE-Is were older (mean age, 56.2 vs 36.4 years; P < .001) and received VIT for a longer period (mean, 72.3 vs 29.9 months; P < .04). Thirteen of 62 patients not taking an ACE-I (21%) experienced an SR during their VIT. No patients taking an ACE-I experienced an SR to VIT while taking an ACE-I (P = .03). CONCLUSIONS: This study suggests that there is not an association between ACE-I use and increased frequency of SRs to venom immunotherapy.

Extensive keloid formation and progression after each vaccination.

Keloids are scars that extend beyond the original wound boundaries. They typically occur in darker skinned individuals with a familial tendency. Keloid formation has occurred after vaccination with bacilli Calmette-Guerin (BCG), small pox and hepatitis B vaccinations. We report the case of a 45-year-old female patient who developed extensive keloidal scars on her bilateral upper arms beginning in childhood after routine vaccinations. These keloids progressed with additional vaccines given at the same sites. Keloidal scars develop in anatomic areas exposed to increased skin tension as was seen in this patient. Treatment of these keloids is difficult but typically involves surgical excision, cryotherapy, radiation and intralesional and topical corticosteroids.

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.

Severe refractory cholinergic urticaria treated with danazol.

BACKGROUND: Cholinergic urticaria is a form of physical urticaria triggered by a rise in core body temperature. Antihistamines are the mainstay of treatment; however, adequate symptom control can sometimes be difficult to maintain. Limited data suggest danazol may be an effective alternative in severe, refractory cases. METHODS AND RESULTS: We present a case of a 22-year-old male with severe, refractory cholinergic urticaria. Despite treatment with high doses of antihistamines, he continued to have symptoms that impaired his ability to function. Treatment with danazol resulted in a significant improvement in the control of his urticaria. DISCUSSION: Cholinergic urticaria can sometimes be severe. In cases that fail to respond to traditional forms of treatment, danazol is a viable alternative for the treatment of cholinergic urticaria. Given the potential adverse effects associated with its use, danazol should be reserved for more severe and refractory cases.

Allergic fungal sinusitis presenting with proptosis and diplopia: a review of ophthalmologic complications and treatment.

Allergic fungal sinusitis is a noninvasive, but vigorous, inflammatory response to mold that occurs in immunocompetent patients with chronic sinusitis and nasal polyposis. It typically occurs in patients who have a history of atopic disease. Occasionally, the patients with allergic fungal sinusitis present with ophthalmic signs and symptoms--most commonly proptosis and diplopia. We report the case of a 23-year-old man with right-sided proptosis, diplopia, and nasal obstruction. He had a history of sinusitis in the past. On presentation, sinus computed tomography scan showed pansinusitis. Subsequent workup revealed elevated immunoglobulin E and positive skin testing to several molds including Bipolaris spicifera and Aspergillus fumigatus. Functional endoscopic sinus surgery was performed, and the surgical specimen revealed allergic mucin with eosinophils, Charcot-Leyden crystals, and a silver stain showing fungal elements. His symptoms, including proptosis and diplopia, improved after surgical debulking and use of systemic corticosteroids.

Allergic bronchopulmonary aspergillosis masquerading as invasive pulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a noninvasive complex hypersensitivity reaction that occurs in immunocompetent patients with asthma. Aspergillus can invade and disseminate, but this more commonly occurs in severely immunocompromised patients receiving high-dose corticosteroids. We report the case of a 13-year-old immunocompetent male patient with moderate persistent asthma who appeared to have invasive pulmonary aspergillosis on radiographic studies. With further evaluation and workup, it was determined that the patient did not have invasive pulmonary aspergillosis, but that he met the diagnostic criteria for ABPA. Although initially there was a deceptive invasive appearance, proper identification of ABPA facilitated selection of corticosteroid treatment that resulted in prompt clearing of the concerning infiltrates.

Inpatient consultation of allergy/immunology in a tertiary care setting.

BACKGROUND: Few studies examine the referral patterns for allergy/immunology (A/I) inpatient consultation. OBJECTIVE: The purpose of this study was to examine the primary reason and trends for A/I inpatient consultation to improve fellowship training. METHODS: We performed a retrospective chart review of all inpatient A/I consults from July 1, 1987 to June 30, 2001 to determine the primary reason for consultation. We also reviewed trends in the total admissions and the average daily patient load compared with A/I consultation. RESULTS: A total of 1,284 A/I inpatient consults were reviewed. Thirty-six percent (460 of 1,284) of inpatient consults were for evaluation of adverse drug reactions, 21% (270 of 1,284) asthma, 21% (272 of 1,284) miscellaneous reasons, 8% (109 of 1,284) possible immunodeficiency, 7% (93 of 1,284) angioedema/urticaria, and 6% (80 of 1,284) anaphylaxis. Our results demonstrated a fall in inpatient consults that correlated with a similar fall in total hospital admissions. The ratio of A/I inpatient consults to total admissions remained constant. Additionally, the ratio of A/I consults to average daily patient load increased over the study period. There was a decrease in asthma and adverse drug reaction consults, whereas immunodeficiency and anaphylaxis referrals remained stable. CONCLUSIONS: Identifying the most common reasons for inpatient consultation provides a guide for the education of A/I fellows and primary care residents. Inpatient consultation continues to play a crucial role in A/I training as it provides unique opportunities to evaluate serious life threatening diseases. An unchanged trend of consultation for immunodeficiency and anaphylaxis reaffirms the importance of the allergist/immunologist as a valuable resource for inpatient consultation.

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.

Immediate cutaneous hypersensitivity after treatment of tattoo with Nd:YAG laser: a case report and review of the literature.

BACKGROUND: To our knowledge this is the first reported case of an immediate cutaneous reaction to Q-switched neodymium:yttrium-aluminum-garnet (Nd:YAG) laser tattoo removal. A 26-year-old female presented with two 6-year-old tattoos placed at different times. These were of different colors and had remained entirely asymptomatic since placement. There was a Mardi Gras mask on her thigh and a Tasmanian devil on her chest. With laser treatment of the Tasmanian devil, she experienced no untoward effects. However, with treatment of the Mardi Gras mask tattoo, she developed an extensive urticarial and indurated reaction 30 minutes posttreatment. The identical reaction occurred twice with subsequent laser treatments. Dermatology consulted allergy to provide prophylaxis against possible systemic reaction with subsequent Nd:YAG laser therapy. The patient was treated with 3 days of prednisone, cetirizine, and ranitidine before subsequent laser treatments. Prophylactic treatment suppressed all subsequent reactions to laser therapy. RESULTS: Delayed hypersensitivity to tattoo pigments occurring days to weeks after placement is well documented. There are no previous reports of immediate hypersensitivity during placement or laser removal. However, there are two previous reports of local and systemic delayed reactions after laser therapy. CONCLUSIONS: As far as we know, this is the first case report of immediate hypersensitivity after Nd:YAG laser treatment of a tattoo. Prophylactic treatment with steroids and antihistamines prevented reactions with subsequent laser treatments. Reactions after laser removal are rare, but may increase as popularity of skin art increases with the need for subsequent removal.