Variation of asthma characteristics with atopic march, gastroesophageal reflux, and ENT pathologies.

BACKGROUND: Asthma is a significant cause of morbidity and mortality in the pediatric population. Atopic dermatitis (AD) is often the first step in the atopic march leading to the development of asthma, allergic rhinitis, and food allergies in the future. OBJECTIVE: This study aimed to evaluate the severity differences between asthmatic children with and without atopic march in addition to characteristics of asthmatic patients with GER and ear-nose-and-throat (ENT) pathologies. METHODS: A total of 616 pediatric asthmatic patients were enrolled. The study subjects were divided into two groups. Group A included asthmatic children with a history of AD. Group B had asthmatic children without a history of AD. Multiple factors were studied, including sex, race/ethnicity, family history of atopy, asthma severity, allergic rhinitis, food allergies, smoke exposure, ear-nose-and-throat (ENT) pathologies, gastroesophageal reflux (GER), frequency of systemic steroid use, and hospital admission rates. RESULTS: Our results revealed that patients with atopic march are at risk of developing a higher severity of asthma, resulting in increased morbidity. In contrast, asthmatic patients without atopic march had a milder asthma severity, less need for steroids, and fewer hospital admissions. A higher prevalence of ENT pathologies and/or GER existed among asthmatic children without atopic march. CONCLUSION: Our findings suggest that patients with atopic march should be expected to exhibit a more severe phenotype of asthma with increased asthma morbidity. Asthmatic patients without atopic march had a milder asthma phenotype, less need for steroids, and fewer hospital admissions. A higher prevalence of ENT pathologies and/or GER existed among asthmatic children without atopic march.

Eosinophilic esophagitis in children: Updates and practical aspects of management for allergists in a non-tertiary care private practice setup.

Background: Eosinophilic esophagitis (EoE) is a chronic immune and/or antigen-mediated disease characterized by eosinophilic infiltration of mucosa (≥15 eosinophils per high power field) without any secondary etiology. Non-immunoglobulin E mediated mechanisms predominate in EoE. Objective: This review concentrated on a stepwise approach for the allergist working in non-tertiary care private practice. Methods: A medical literature search that focused on several areas of the latest developments in the diagnosis and management of EoE was conducted. Results: There has been a steady increase in the prevalence and incidence of EoE. Clinical symptoms can vary from dysphagia to failure to thrive, depending on the age at presentation; some children develop adaptive behaviors to compensate for dysphagia, such as food preferences and slow eating. The diagnosis is based on a high index of clinical suspicion and is confirmed with endoscopy with biopsies after ruling out other causes of esophageal eosinophilia. Treatment options may include dietary therapy, pharmacologic therapies, or combination therapy. Therapeutic options may also include endoscopic dilation for stricturing disease. Conclusion: Providers should be aware of recent recommendation changes in the diagnostic workup, the role of skin-prick testing, and role of the proton-pump inhibitor as first-line therapy for EoE. Also, clinicians should be aware of the emerging role of empiric dietary therapy as a preferable therapeutic option when compared with the testing-directed diet and the elemental diet. Furthermore, topical glucocorticoid therapies are available, and new developing therapies are being investigated. Reevaluation of esophageal mucosa with biopsies is required approximately 2 months after therapy for a response and after a change in therapies to confirm continued resolution.

Hyper IgM Syndrome with low IgM and thrombocytosis: an unusual case of immunodeficiency.

We report a 5 years old male child with low serum IgG, IgA and IgM levels, who presented with recurrent perianal and oral ulcers, intermittent fever, and protracted diarrhea. Despite the lack of typical respiratory symptoms, low serum IgM level and persistent thrombocytosis, an X-linked hyper-IgM syndrome (X-HIGM) was considered. Laboratory investigations revealed a diagnosis of hyper-IgM syndrome caused by CD40L deficiency.

Early intervention with high-dose inhaled corticosteroids for control of acute asthma exacerbations at home and improved outcomes: a randomized controlled trial.

Various studies have examined the efficacy of a temporary increase in the dose of inhaled corticosteroids (ICSs) during acute asthma exacerbations with conflicting results. This study was designed to investigate the efficacy of high-dose ICSs in controlling asthma exacerbations in children. Data were collected on asthmatic children, aged 2-17 years, who were maintained on ICSs. Participants were randomly assigned to a 12-day treatment protocol for acute asthma exacerbation at doses of ICS that were two, four, or eight times their maintenance ICS dose. The primary outcome was the frequency of need to progress to systemic steroid therapy. The secondary outcome was difference in symptom scores among the three treatment groups to determine if one dosing protocol was superior to another. Eighty-two of 197 enrolled patients experienced acute asthma exacerbation and completed the increased dosing protocol. No significant difference in systemic corticosteroid use was detected between patients treated with two, four, or eight times their maintenance dose of ICS, but we observed a trend toward a larger reduction in mean total symptom score with increasing ICS dose at the end of the study. We did not observe a significant difference in need for systemic corticosteroids between doubling the maintenance dose and increasing to four or eight times the dose, but we observed a trend suggesting that higher doses may improve symptoms better than doubling the dose. A more specific design may be needed to provide a more reliable answer to this question.

The prevalence of antibiotic skin test reactivity in a pediatric population.

Although adverse drug reactions (ADRs) are not uncommon, true allergic (i.e., immunologic) reactions are infrequent. Estimates are that only 10% of reported "penicillin (PCN)-allergic" patients have true allergic drug reactions. Most studies of PCN-related ADR have been conducted in adult populations and suggest that the majority of adult patients presenting with PCN allergy history can safely receive the drug. The goal of this study was to examine the outcome of provocative drug challenges to antibiotics in a pediatric population and correlate outcomes with predictive factors. Through chart review, we identified 96 pediatric patients with history of an ADR to antibiotics who underwent skin testing (ST) and/or graded challenges to PCN (n = 52), cephalosporins (n = 7), azithromycin (AZT; n = 24), or clindamycin (n = 4). Of these children with an ADR, 87 (90.6%) tolerated provocative drug challenges and 9 (9.4%) were instructed to continue drug avoidance because of positive ST or failed challenge. Eight of the nine patients continued drug avoidance due to positive PCN ST (n = 4) or ADR during drug PCN challenge (n = 4). All AZT and cephalosporin challenges had negative outcomes, and only one patient did not proceed with the clindamycin challenge after a positive ST. True "antibiotic allergy" denoted by positive ST or failed challenge in patients with a history of ADR occurred in <10% of children included in this study, suggesting that without such testing nearly 90% might be treated with alternative antibiotics unnecessarily.

Evaluation of the relationship between IgE level and skin superinfection in children with atopic dermatitis.

Increased Th2 polarity weakens the innate immune response and predisposes children with atopic dermatitis (AD) to skin superinfection. This study was designed to evaluate the relationship between IgE level and bacterial superinfection in children with AD. A medical chart review was performed on 103 children with AD to assess the association between IgE level and skin superinfection. A multivariable logistic regression model was used to assess the relationship between categorized IgE level and the presence of bacterial superinfection after adjusting for cofounding variables including allergic rhinitis, asthma, and food allergy. A Wilcoxon signed-rank test was used to compare pre- and postskin superinfection median IgE levels in a subset of patients. Compared with children with an IgE level of <300 IU/mL, children with an IgE level of >1001 IU/mL were 66.00 times more likely to have a skin superinfection (p = 0.003) and children with an IgE level between 301 and 1000 IU/mL were 12.38 times more likely to have a skin superinfection (p < 0.001). After controlling for cofounding variables including asthma, allergic rhinitis, and food allergy, children with an IgE level of >1001 IU/mL were 71.89 times more likely to have a skin superinfection (p = 0.018) and children with an IgE level between 301 and 1000 IU/mL were 8.79 times more likely to have a skin superinfection (p < 0.001) when compared with children with an IgE level of <300 IU/mL. There was a significant increase in IgE levels from baseline in 13 children treated for a skin superinfection (p = 0.001). IgE level is associated with Staphylococcus aureus superinfection in children with AD.

Association between peanut allergy and asthma morbidity.

OBJECTIVE: To evaluate the relationship between peanut allergy and asthma morbidity in school-age children. STUDY DESIGN: The study involved a medical chart review to assess the association of peanut allergy with asthma morbidity in children beyond age 3 years. Peanut allergy was assessed by specific and validated criteria. A Poisson regression model was used to compare the frequency of systemic steroid use and of hospitalization for asthma beyond age 3 years in children with asthma with and without peanut allergy. RESULTS: Children with peanut allergy had a 2.32-times greater rate of hospitalization (P = .03) and a 1.59-times greater rate of systemic steroid use (P <.001) after controlling for covariates. CONCLUSIONS: Peanut allergy serves as an early marker for asthma morbidity. Early prevention and intervention can improve quality of care.

Correlates of outcome for atopic dermatitis.

BACKGROUND: The worldwide incidence and prevalence of atopic dermatitis (AD) are increasing. Few good studies have addressed AD in terms of the factors affecting disease prognosis. OBJECTIVE: To identify significant correlates of persistent AD because this would be clinically valuable information. METHODS: Potential correlates of AD, including race, onset age, age of solid food introduction, breastfeeding, sinopulmonary infections, other atopic diseases, peripheral eosinophilia, total IgE level, and eosinophilic cationic protein levels, were investigated in 177 patients aged 5 to 18 years. Correlates were compared with AD remission vs nonremission status. RESULTS: A total of 133 patients (75.1%) were not in remission at the age of 5 years or older and were, thus, classified as having persistent AD. Patients with histories of peanut allergy (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.30-6.55), egg allergy (OR, 2.71; 95% CI, 1.17-6.30), or dust mite allergy (OR, 4.02; 95% CI, 1.84-8.82) were significantly more likely to have persistent AD than those without these factors. There was a trend toward increased odds of persistence in those with peripheral eosinophilia (P = .06) and decreased odds of persistence in those with frequent sinopulmonary infections (OR, 0.51; 95% CI, 0.25-1.03). CONCLUSIONS: Egg, peanut, and dust mite allergies are significant correlates of AD persisting beyond school age. There may also be increased odds in those with peripheral eosinophilia and decreased odds in those with frequent sinopulmonary infections. This highlights the importance of assessing these correlates in patients with AD and modifying the correlates that can be modified. Further studies on whether modification of these correlates and/or early aggressive AD management improves outcome are needed.

The acceptability of a four-part protocol for penicillin allergy testing by practicing allergists.

Currently, there is no standard protocol to test for penicillin (PCN) allergy since PrePen (manufactured benzylpenicilloyl polylysine; AllerQuest, West Hartford, CT) was discontinued in 2004. Our article reviews allergist's opinions on a protocol to test for PCN allergy in patients without a history of a life-threatening reaction. This study was performed to determine whether fellows of the American Academy of Allergy, Asthma, and Immunology (AAAAI) would use a two-challenge PCN allergy protocol to test for PCN allergy while skin testing to the major determinant, benzylpenicilloyl polylysine, is unavailable. A questionnaire regarding PCN allergy and application of a four-step protocol was sent to 1210 allergists and immunologists. Of the 654 respondents, 324 (49.5%) believed that the protocol was practical in a busy, outpatient allergy practice and 64 (9.8%) wanted more information. One hundred ninety-four (29.7%) did not think it was practical. Two hundred ninety-five respondents (45.1%) then went on to respond that they would apply the protocol in an outpatient practice and 117 (17.9%) were undecided and wanted more information. One hundred thirty-five respondents (20.6%) would not apply the protocol in their practice. Of those who were undecided or did not think it was practical, 58 (8.9%) were awaiting PrePen, 33 (5%) wanted to see a larger protocol, 24 (3.7%) wanted more detail on the challenge, and 14 (2.1%) felt more comfortable desensitizing the patient. Forty-five percent of the fellows of the AAAAI would apply the proposed protocol to test for PCN allergy. Sixty-two percent said they may apply the protocol if a larger study was performed.

Prevalence of positive skin prick test results in children with Down syndrome: a case-control study.

BACKGROUND: Because many of the same otologic and nasal problems experienced by children with Down syndrome are also frequent in children with atopic disease, many children with Down syndrome are referred to an allergist for evaluation. OBJECTIVE: To determine the prevalence of positive skin prick test (SPT) reactions to common aeroallergens in children with Down syndrome. METHODS: Using a case-control design, we reviewed the medical records of children with Down syndrome who had undergone SPT. Each case was matched by sex and age with a control who had been evaluated by SPT at an initial visit. RESULTS: Thirty-nine cases and controls were identified. Eighteen percent of cases were found to have at least 1 positive SPT result compared with 54% of controls. This closely approximates the percentage of the general population with at least 1 positive SPT result (54.3%) as reported in the Third National Health and Nutrition Examination Survey. CONCLUSIONS: Given the low prevalence of positive SPT results in children with Down syndrome, it is unlikely that allergic rhinitis will be identified as the cause of many of the chronic rhinitis symptoms that many of these children are referred to an allergy practice to have evaluated. It may be helpful to the parents and to the patients themselves to avoid involving another specialist and appointment because they frequently are involved with many specialists for medical care. A larger study would be helpful in confirming the prevalence of positive SPT results in children with Down syndrome.

Systemic reaction to pneumococcal vaccine: how common in pediatrics?

The 23-valent-polysaccharide pneumococcal vaccine (PPV23) is currently recommended for patients at high risk for invasive disease from Streptococcus pneumoniae. It is also frequently used in the evaluation of patients with suspected immunodeficiency. Reports of systemic adverse reactions are rare. Our objective is to describe a patient with an apparent systemic reaction to PPV23 and review our hospital's 2-year experience with pneumococcal vaccine. Chart review of 173 patients given PPV23 between January 1, 2004 and December 31, 2005 revealed five who had significant adverse reactions, including local cellulitis, fever, and vomiting. Variables considered included age at immunization, indication for PPV23, and prior pneumococcal vaccines. The mean age of all patients given PPV23 during the defined time period was 8.6 years, and the most common indication for vaccination was recurrent infection. Of those patients who had adverse reactions, the mean age was 6.5 years. The time from prior pneumococcal vaccination was a mean of 20 months in children who did not have an adverse reaction. None of the patients who had an adverse reaction had documentation of receiving PPV23 before. Local reactions to PPV23 occur in approximately 50% of recipients, and revaccination of immunocompetent individuals increases the risk for local reaction. Systemic reactions are less common and only occur in approximately 1% of recipients. Our patient had no identifiable risk factors for development of an adverse reaction. Additional studies are indicated to determine whether there are identifiable risk factors for the development of adverse reactions to PPV23.

Radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction after medical management.

BACKGROUND: The presence of ostiomeatal complex obstruction can be a key component in chronic rhinosinusitis, and the medical management of this condition has not been well studied, particularly in children. OBJECTIVE: To compare the effectiveness of antibiotics, intranasal topical corticosteroids, and oral systemic corticosteroids on radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction. METHODS: We reviewed the reports of 1,741 computed tomography scans performed on children at Alfred I. duPont Hospital for Children, Wilmington, Delaware, from October 1, 2001, through February 28, 2007, identifying those patients who had 2 scans performed at least 2 weeks apart but no more than 6 months apart. Forty-five instances involving abnormal ostiomeatal complex anatomy documented on the initial study with obtainable treatment information were selected for further review. RESULTS: Of the 3 treatment modalities examined, only oral systemic corticosteroids (P = .03) and intranasal topical corticosteroids (P = .03) were found to provide significant independent contributions to predicting treatment outcome, with the former promoting a positive outcome and the latter predicting a negative outcome. The model that contained just these 2 factors also provided a significant fit to the outcome data (P = .01), producing a diminished rate of improvement expected from a combination of positive and negative influences. Neither antibiotics nor any other combination of modalities contributed to a significant improvement in model fit. CONCLUSION: The use of oral systemic corticosteroids was found to be the only beneficial intervention, with regard to radiologic improvement, in the treatment of ostiomeatal complex obstruction in children.

A 15-year-old girl with recurrent pneumonia.

Hodgkin's disease (HD) represents a group of lymphomas with distinct clinical and histopathological features that account for approximately 5% of cancers in patients who are <15 years old and approximately 15% in patients who are 15-19 years old. Although the cause of HD is unknown, serologically confirmed infectious mononucleosis has been associated with an increased risk of HD, in addition to its known association with Burkitt's lymphoma. The Reed-Sternberg (RS) cell, a large and multinucleated cell with unique morphology, is the hallmark cell of HD. RS cells are clonal tumor cells that recently have been shown to be derived from B cells originating from germinal centers. Of four histological subtypes of HD, three have a good to excellent prognosis when recognized and treated early. We report a case of HD in a 15-year-old adolescent with a 14-month history of recurrent pneumonia. Open lung biopsy ultimately led to the diagnosis of HD. Although uncommon in this age group, the need to consider the possibility of neoplasm in the setting of recurrent respiratory infection is illustrated in this case. Early diagnosis and intervention may determine the prognosis of such neoplasms.

Air quality and pediatric asthma-related emergencies.

BACKGROUND: Previous studies suggest a relationship between air pollutants, aeroallergens, and asthma exacerbations. OBJECTIVE: To simultaneously examine the role of seasonality, air quality, aeroallergens, and climate on asthma-related pediatric emergency department (ED) visits. METHODS: A retrospective 4-year study of asthma-related ED visits was conducted. RESULTS: September had the highest number of visits (p < 0.01). There were lower temperatures and precipitation (p < 0.01) and higher tree and weed pollen levels (p = 0.05) on days with more visits (p = 0.05), while grass pollen, mold, ozone, NO2, and PM2.5 levels showed no significant differences. CONCLUSIONS: Asthma-related visits were associated with aeroallergens and climatic factors and not air-quality factors.

Food allergy and asthma morbidity in children.

BACKGROUND: Coexisting food allergy and asthma is a significant problem in the pediatric population. Studies have looked at the association between food sensitization and asthma severity. It is unknown whether specific food allergies are associated with increased asthma morbidity. OBJECTIVE: We studied the independent effect that allergy to egg, milk, fish, and peanut has on the number of hospitalizations and courses of systemic steroids in children with asthma. METHODS: We performed a medical record review to evaluate the effect food allergy to egg, fish, peanut, and milk has on asthma morbidity. We reviewed the records of 201 children aged 3 months to 14 years with the diagnosis of asthma (ICD-9 codes 493.90, 493.91, and 493.92), of which 88 had coexistent food allergy. All children in the food allergy group had food-specific IgE concentrations greater than the 95% positive predictive value. We compared the rate of hospitalizations and use of systemic steroids between children with asthma and food allergies and those without coexisting food allergy using direct-entry, multiple regression analysis. Patients were adjusted for the severity of their asthma based on symptoms documented at their first visit to the allergist according to the National Asthma Education and Prevention Program guidelines and presence of environmental allergy, eczema, smoke exposure, and gastroesophageal reflux. RESULTS: Peanut and milk allergies were both associated with increased number of hospitalizations (P=0.009, 0.016), and milk allergy was associated with increased use of systemic steroids (P=0.001). CONCLUSION: Peanut and milk allergies were associated with increased hospitalization and steroid use and may serve as early markers for increased asthma morbidity.

Patient, home residence, and neighborhood characteristics in pediatric emergency department visits for asthma.

OBJECTIVE: To identify patient, home residence, and neighborhood characteristics of children with asthma-related emergency department visits. METHODS: Medical records of children with one (group A) or more than one (group B) asthma-related pediatric emergency department visit were reviewed. RESULTS: A significantly higher percentage of group B had Medicaid insurance (p = 0.04), history of asthma-related hospitalizations (p = 0.04), and passive tobacco smoke exposure (p = 0.03). Neighborhood characteristics were similar between the two groups. CONCLUSIONS: Smoking cessation counseling and close monitoring of patients with a history of asthma-related hospitalizations and patients with Medicaid insurance may be helpful in decreasing emergency department visits.