The cow's milk allergy that wasn't: allergy to supplemental oral lactase enzyme.

BACKGROUND: Allergy to supplemental lactase is sparsely reported in the literature with only one prior case of anaphylaxis documented [2]. Reactions to this agent can occur following cow's milk ingestion which could lead to an erroneous diagnosis of cow's milk allergy in the absence of another explanation. CASE PRESENTATION: Our patient, a 48-year-old male with eczema, exercise-induced asthma and rhinoconjunctivitis, presented with four episodes of systemic reactions characterized by mucosal swelling and asthma symptoms following ice-cream exposure. It was later recognized that he had been taking a lactase enzyme supplement just prior to all of his reactions. Epicutaneous testing was strongly positive to a saline slurry of the lactase supplement he had been using. The patient has been avoiding supplemental lactase since with no subsequent reactions. DISCUSSION: Our patient was diagnosed with an allergy to supplemental lactase enzyme on the basis of convincing Immunoglobulin E (IgE) mediated symptoms and positive skin testing. He continued to eat cow's milk products, ruling out an IgE-mediated allergy to cow's milk. In the literature, there is one prior case of anaphylaxis documented. Another case of localized oropharyngeal symptoms described in the literature was thought to be a form of oral allergy syndrome as the patient had positive epicutaneous testing to Aspergillus oryzae-derived lactase as well as Aspergillus species. Occupational sensitization, rhinitis/asthma, and protein contact dermatitis have also been detailed in the literature. Although rare, this case highlights the importance of a thorough history of over-the-counter supplements when assessing a patient with features of anaphylaxis.

Blastomycosis in Southern Saskatchewan 2000-2015: Unique presentations and disease characteristics.

In the literature, cases of blastomycosis in Canada have been documented in provinces bordering the Great Lakes, including Ontario and Quebec, as well as Manitoba. This is the first study to our knowledge reporting cases of mycosis seen in southern Saskatchewan suggesting a broader area of endemicity. We searched the Regina Qu'Appelle Health Region (RQHR) Microbiology Laboratory for all culture-confirmed cases of Blastomyces from January 2000 to December 2015 and identified 15 cases. Thirteen cases were reviewed, identifying common presenting symptoms, misdiagnosis, comorbidities, travel history, time from presentation to diagnosis, diagnostic specimen, treatment, and clinical outcome. Nine patients had no travel to areas known to be endemic to environmental blastomycosis. Eight patients presented with respiratory symptoms, four with skin lesions, four with constitutional symptoms, and one presented with chest pain after a fall. Initial misdiagnosis occurred in nine (69%) of the 13 cases, and all six patients that died of the disease were misdiagnosed. These six patients (46%) were acutely ill with refractory disseminated disease, leading to respiratory failure. It is probable that Blastomyces is present as an endemic fungus in the soil of southern Saskatchewan. Possibly due to a lack of awareness of this pathogen in the area, initial misdiagnoses were common and likely contributed to significant morbidity and mortality.