Allergy Notes: 07/2009

Allergy and Immunology News of the Day

Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

Variations in total-IgE levels at school age closely reflect variations in specific-IgE levels http://bit.ly/h687u
PubMed: Occupational asthma caused by octopus particles. http://bit.ly/9hQ3x
There is no "Wi-Fi Allergy" in case you had any doubts.. :) http://bit.ly/VX4Il

Nasal irrigation: rinsing your allergies away http://bit.ly/12Jzb0
Contact Dermatitis Due to Poison Ivy: "Never swing on a hairy vine" http://bit.ly/3zGjTD

Medical news tweets are not research articles - they are 140-character messages - please always go to the original source/links, etc. The inclusion of a Twitter update (tweet) does not represent endorsement or agreement of any kind. Tweets and links do not represent endorsement, approval or support.

Image source: OpenClipArt.org, public domain.

Does sinus surgery help asthma symptoms in patients with chronic sinusitis and asthma?

Left-sided maxillar sinusitis (absence of the air transparency of left maxillar sinus). Image source: Wikipedia, public domain.

Does sinus surgery help asthma symptoms in patients with chronic sinusitis and asthma?

Yes, according to most studies.

The long-term impact of functional endoscopic sinus surgery on asthma was positive: 90% of patients reported feeling better in a small study http://bit.ly/C9xSq

Endoscopic sinus surgery (ESS) had a favorable effect on asthma in patients with symptomatic chronic sinusitis http://bit.ly/bNlEB

Functional endoscopic sinus surgery improved nasal and asthma symptoms in patients with nasal polyposis http://bit.ly/3OXkHV

However, chronic rhinosinusitis in asthmatics showed worse postoperative outcomes than in nonasthmatics http://bit.ly/4s1Xfl

Related:
Sinusitis: A Short Review

Multi-symptom Asthma is Closely Related to Nasal Blockage, Rhinorrhea and Symptoms of Chronic Rhinosinusitis http://goo.gl/sU4AU

Allergy and Immunology News of the Day

Optimistic drug presentation increase placebo effect for patient-reported outcomes (symptoms) but not lung function. Headaches were more common in participants provided messages that mentioned headache as a montelukast side effect http://bit.ly/f2YWj
Inadequate health literacy is associated with increased asthma morbidity http://bit.ly/iBOBw
In older people with obstructive airway disease, 50% have overlapping diagnoses of asthma and COPD (overlap syndrome). Overlap syndrome - coexistence of increased variability of airflow with incompletely reversible airway obstruction. http://bit.ly/4I3lY
Traffic-related air pollution correlates with adult-onset asthma among never-smokers http://bit.ly/diQPK -- Chronic exposure to outdoor air pollution is associated with modestly reduced FEV1 in adults. http://bit.ly/3LZCfS
Rhinovirus and respiratory syncytial virus may play a role in the initiation of asthma http://bit.ly/3meZ8S
Sequential IgE-binding epitopes as biomarkers for characterizing various phenotypes of food allergy http://bit.ly/IG54k
Th2 cells express CCR4 chemokine receptor, increased production of CCR4 ligands by CD11c dendritic cells in asthma. CCR4 blockade inhibits the salient features of asthma, CCR4 antagonists may be useful as future therapy http://bit.ly/sqWtz

Mast cells: makers AND breakers of allergic inflammation

From Current Opinion in Allergy and Clinical Immunology:

Mast cells are traditionally viewed only as IgE-activated histamine-providing effector cells of allergic inflammation.

Mast cells. Image source: Wikipedia.

Challenging an old dogma: Mast cell tryptase breaks down IgE, hence breaking the key maker of allergic inflammation.

Mast cells have proinflammatory effects through nonhistamine and non-IgE-mediated routes, e.g platelet-activating factor.

Most surprisingly, mast cells have emerged as modulators and downregulators of allergic inflammation. Mast cells release IL-10.

The seminal work on histamine was published in 1910, but histamine was not identified as a mediator of anaphylactic reactions until 1932. Histamine is a major mediator responsible for the symptoms of allergic rhinitis, with its activities mediated through 4 G protein-coupled receptors. Most of histamine's effects are exerted through the H₁ receptor, but some effects are through the H₂ and H₃ receptors, and possibly also through the H₄ receptor (source: The basics of histamine biology. Lieberman P. Ann Allergy Asthma Immunol. 2011 Feb;106(2 Suppl):S2-5. Epub 2010 Sep 16).

What is Siglec-8 receptor and how it works?

Activation of Siglec-8 causes apoptosis of eosinophils.

Siglec-8 receptor might act as an inhibitor of mast cell degranulation. Sialic acid binding Ig-like lectin 8 (Siglec-8) has also been designated as CD329. Siglec-8 ligation inhibits eosinophil functions. Incubation of eosinophils with Siglec-8 binding monoclonal antibodies under cross-linking conditions caused rapid and profound caspase-dependent apoptosis, and this response could not be rescued by the survival-promoting cytokine interleukin (IL)-5. Activation via Siglec-8 could be used to inhibit eosinophil survival in vivo, providing a novel strategy for reducing or inhibiting these cells in allergic diseases.

Blood cell lineage. Image source: Wikipedia.

Mast cells (mind map).

Mediators released from mast cells

Preformed mediators (from the granules):

- serine proteases, such as tryptase

- histamine (2-5 pg/cell)

- serotonin

- proteoglycans, mainly heparin (active as anticoagulant)

- TNF

Newly formed mediators:

- prostaglandin D2 (PGD2, eicosanoid)

- leukotriene C4 (LTC4, eicosanoid)

- platelet-activating factor (PAF)

- cytokines, e.g. IL-4

- Eosinophil chemotactic factor

References:

Mast cells: makers and breakers of allergic inflammation. Hakim-Rad K, Metz M, Maurer M. Curr Opin Allergy Clin Immunol. 2009 Oct;9(5):427-30.

Mast Cells and Basophils
H(3) receptor antagonist is a new therapeutic strategy for allergic rhinitis, trials are ongoing. JACI, 2012.

Decay-accelerating factor (DAF) may play a role in allergies

Decay accelerating factor (CD55) is a membrane protein that regulates the complement system on the cell surface. CD55 prevents the assembly of the C3bBb complex (the C3-convertase of the alternative pathway) or accelerates the disassembly of preformed convertase, thus blocking the formation of the membrane attack complex.

CD55 molecule, decay accelerating factor for complement (Cromer blood group). Image source: Wikipedia, public domain.

DAF is not expressed on RBCs in paroxysmal nocturnal hemoglobinuria (PNH) type III. CD59 absence also leads to PNH. Type I cells have normal levels of CD55 and CD59, type II have reduced levels and type III have absent levels. CD59 is also called membrane inhibitor of reactive lysis (MIRL).

Mnemonic

CD59 blocks
C5-9
components of the complement, MAC, from perforating the cell membrane

In paroxysmal nocturnal hemoglobinuria, patients report episodic dark urine due to hemoglobinuria during intravascular hemolysis, which often occurs at night. Early morning urine is cola-colored. This may occur at different times of the day and vary from patient to patient.

The term "nocturnal" refers to the initial belief that hemolysis is triggered by acidosis during sleep and activates complement to hemolyze an unprotected and abnormal RBC membrane. However, hHemolysis occurs throughout the day and is not actually paroxysmal, but the urine concentrated overnight produces the dramatic change in color.

From Clinical & Experimental Allergy:

Decay-accelerating factor (DAF, CD55) is important for regulation of complement system. The question remains whether it plays a role in allergies.

DAF may be one of the genes involved in conferring susceptibility to allergic respiratory diseases.

In a recent study, decreased levels of DAF were associated with the enhanced specific IgE responses occurring in allergic diseases.

Eculizumab (Soliris) is a humanized mAb against complement protein C5. It is used for treatment of paroxysmal nocturnal hemoglobinuria (PNH).

References:
Paroxysmal Nocturnal Hemoglobinuria: eMedicine Hematology.
The Complement Inhibitor Eculizumab in Paroxysmal Nocturnal Hemoglobinuria. NEJM.
Paroxysmal nocturnal hemoglobinuria. Wikipedia.

Decay-accelerating factor from Roitt's essential immunology By Ivan Maurice Roitt, Peter J. Delves:

Updated: 11/18/2009

Allergy and Immunology News of the Day

Sinusitis now can be treated with balloon sinuplasty - minimally invasive sinus surgery. 14% of U.S. population has chronic sinusitis, 500,000 patients/year undergo functional endoscopic sinus surgery (FESS) http://bit.ly/uNQQm
The antihistamine ketotifen and cromolyn successfully treat diabetes and obesity in mice. Mast cells are abundant in fat tissues of obese and diabetic people and mice. Antihistamines could work as new therapy http://bit.ly/1UKKt4
Why Do Doctors and Patients Not Follow Guidelines? 10% of doctors ignore the existence of 78% of available guidelines. Why Do Doctors and Patients Not Follow Guidelines? 10% of doctors consider guidelines inapplicable in clinical practice http://bit.ly/JwMIG
Adamis Pharmaceuticals Launches Pre-Filled Epinephrine Syringe - an alternative to EpiPen http://bit.ly/suJbt
Some helpful tips: "Allergies from the Restaurant's Point of View" http://bit.ly/4afvK3

Venom Allergy Updates from ABC News

From ABC News:

3.3% of adults will experience anaphylaxis due to insect sting, 40 deaths are reported annually. People who develop anaphylaxis after being stung have a 60-70% chance that future stings will cause a similar reaction.

Chances of a reaction with a future insect sting decrease over time, but still remain at about 20% many years after the last sting. With insect allergy, "most people tend to have the same kind of reaction, same severity the next time. Once the allergic sensitivity in your system, any future sting could cause a systemic reaction."

Venom insect therapy was developed in the 1970s at Johns Hopkins University.

Mind map of insect venom allergy.

Related reading:
Anaphylactic Shock Due to Bee Sting
Venom Allergy: A Short Review. V. Dimov, 08/2007.
CNN: Skateboarder's death underscores insect allergy risks. 5 percent of Americans are at risk for a severe, potentially life-threatening allergic reaction from insect stings http://bit.ly/3PEVtK
Image source: Wikipedia, GNU Free Documentation License.

Updated: 08/15/2009

Allergy and Immunology News of the Day

EAACI/GA2LEN task force consensus report: the autologous serum skin test in urticaria. CU patients with a positive ASST more likely to have autoimmune thyroid disease, prolonged course, less responsive to H1-antihistamines.
Charcot-Leyden crystal protein (CLC) gene - a novel susceptibility gene for allergic rhinitis? http://bit.ly/q9ll8
Improved home ventilation did not achieve a reduction in mite allergen levels, but did improve evening PEF in asthma http://bit.ly/16iyf2
Even in rural areas, ozone might have an adverse impact on the worsening of childhood asthma http://bit.ly/onNsj
CDC: All U.S. children should get seasonal flu shot http://bit.ly/Ws9WJ
Man thinks he is 'allergic' to Wi-Fi 'electrosmog' http://bit.ly/2Imnfy and http://bit.ly/76WWc

Mina, an IL-4 repressor, controls T helper type 2 bias

In this video, a T cell becomes activated when it interacts with a dedritic cell. This video is from: Janeway's Immunobiology, 7th Edition Murphy, Travers, & Walport. Source: Garland Science.

T helper type 2 bias is the propensity of naive CD4 T cells to differentiate into IL-4-secreting T(H)2 cells. Initially secreted IL-4 feeds back positively through IL-4 receptor and transcription factors STAT6 and GATA-3 to drive T(H)2 development. Mina, an IL-4 repressor, controls T helper type 2 bias http://bit.ly/Bdw9w

Mina is a member of the jumonji C (JmjC) protein family that represses the IL-4 promoter.

Jūmonji is a Japanese word meaning "cross" - genes encode nuclear proteins with a JmjC domain http://bit.ly/250TTq

Allergy and Immunology News of the Day

Cysteinyl leukotrienes are the most potent bronchoconstrictors known. Leukotriene inhibitors should be reserved for patients who cannot or will not use ICSs. Leukotriene inhibitors are alternatives to LABAs as add-on therapy to ICSs, but their efficacy is less than ICS/LABA http://bit.ly/1PPnXO
Helping the Helpers: differentiation of T follicular helper cells is dependent on dendritic cell-derived interleukin-12 http://bit.ly/3sMVM
IL-33 is a member of the IL-1 family and is involved in polarization of T cells toward a T helper 2 (Th2) cell phenotype. Caspase-mediated proteolysis may act as a switch to dampen the proinflammatory properties of IL-33 http://bit.ly/VnEF8
RAG-1–RAG-2 complex nucleates a specialized subnuclear compartment - the 'V(D)J recombination factory' http://bit.ly/wBPgz
Jawless fish, the 'sister' group of jawed vertebrates, use leucine-rich repeat–containing proteins as antigen receptors http://bit.ly/2zrdg

Allergy and Immunology News of the Day

Is intrinsic asthma synonymous with infection? Persistent respiratory infections may play a key role. http://bit.ly/3snuMb
Possible high prevalence of non-IgE-mediated food allergy in young children with autism spectrum disorders (ASDs) http://bit.ly/18O545
History of IVIG: In 1981, improvement of ITP in patients receiving IVIg for immunodeficiencies opened a new era for autoimmune conditions. History of IVIG: first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies http://bit.ly/poo4m
“Corset-like” pressure in the lower chest may be indicative of neurosarcoidosis (myelopathy) http://bit.ly/vf2hT
Pregnant women with SLE are high risk patients: spontaneous abortion occurred in 6%, 16% had premature deliveries http://bit.ly/2m41Qr
Desloratadine is effective in intermittent allergic rhinitis: a GA2LEN study http://bit.ly/1AHJZh

Allergy and Immunology News of the Day

Latex allergy: the glove use test had a sensitivity of 81%, specificity of 90%. The nasal provocation test is more sensitive than the glove test for latex allerg (Allergy, 2009) http://bit.ly/G6tUT
Children living in high- stress homes may be more at risk for asthma associated with environmental triggers http://bit.ly/wuuLN
"A man went to Africa to become infected with a hookworm in an effort to cure his severe allergies and asthma" http://bit.ly/B5vio
"Are Indoor Pools Bad for Your Lungs?" http://bit.ly/13AbBZ

Lancet review: Glucocorticoid resistance in inflammatory diseases

Glucocorticoid resistance or insensitivity is a major barrier to the treatment of several common inflammatory diseases:

- COPD
- acute respiratory distress syndrome
- some patients with asthma, rheumatoid arthritis, and inflammatory bowel disease

Chemical structure of fluticasone propionate, a glucocorticoid. Image source: Wikipedia, public domain.

Several molecular mechanisms of glucocorticoid resistance have now been identified:

- activation of mitogen-activated protein (MAP) kinase pathways by certain cytokines
- excessive activation of the transcription factor activator protein 1
- reduced histone deacetylase-2 (HDAC2) expression
- raised macrophage migration inhibitory factor
- increased P-glycoprotein-mediated drug efflux

Patients with glucocorticoid resistance can be treated with alternative broad-spectrum anti-inflammatory treatments, such as calcineurin inhibitors and other immunomodulators, or novel anti-inflammatory treatments, such as inhibitors of phosphodiesterase 4 or nuclear factor κB, although these drugs are all likely to have major side-effects.

An alternative treatment strategy is to reverse glucocorticoid resistance by blocking its underlying mechanisms. Some examples:

- inhibition of p38 MAP kinase
- use of vitamin D to restore interleukin-10 response
- activation of HDAC2 expression by use of theophylline, antioxidants, or phosphoinositide-3-kinase-δ inhibitors, and inhibition of macrophage migration inhibitory factor and P-glycoprotein

References:
Lancet Review: Glucocorticoid resistance in inflammatory diseases. The Lancet, Volume 373, Issue 9678, Pages 1905 - 1917, 30 May 2009.

Allergy and Immunology News of the Day

Intestinal antigen presenting cells promote tolerance to dietary antigen via the induction of regulatory T cells. Retinoic acid, a vitamin A metabolite, is a key environmental factor in oral tolerance induction in food allergy http://bit.ly/9GBhH
Pre-tx allergen-specific IgE levels do not provide any better prediction of Xolair response to treatment than total IgE http://bit.ly/x5076
The most important causative factor for anaphylaxis in mastocytosis are insect stings. Venom immunotherapy should be considered in mastocytosis, patients should be carrying 2 adrenaline auto injectors http://bit.ly/urEF8
No association between obesity and asthma control in an urban population with asthma http://bit.ly/SNV5Z
Masitinib, a c-kit/PDGF receptor tyrosine kinase inhibitor, improves severe corticosteroid-dependent asthma http://bit.ly/MOzvw

Loratadine/montelukast start working in 1 hour and 15 minutes in allergic rhinitis

Onset of action is important for allergic rhinitis (AR) medications.

A single-center, double-blind, study of ragweed-sensitive AR subjects (n = 310) was performed in the Environmental Exposure Unit (EEU) where they were exposed to ragweed pollen.

The onset of action of loratadine/montelukas (L/M) for total symptom score (TSS) was 1 hour and 15 minutes (p = 0.005 versus placebo). L/M was well tolerated.

Medications for Allergic Rhinitis.

References:
Onset of action of loratadine/montelukast in seasonal allergic rhinitis subjects exposed to ragweed pollen in the Environmental Exposure Unit. Day, James H.; Briscoe, Maureen P.; Ratz, Jodan D.; Ellis, Anne K.; Yao, Ruji; Danzig, Melvyn. Allergy and Asthma Proceedings, Volume 30, Number 3, May/June 2009 , pp. 270-276(7).

Urinary leukotriene E(4)/exhaled nitric oxide ratio predicts montelukast response in childhood asthma http://goo.gl/i5cG
Allergic Rhinitis: A Short Review
Mind Maps: Allergic Rhinitis
Mnemonics: Allergic Rhinitis

Internet-based Self-management Programs and Control of Asthma Symptoms: Not Very Effective

From the Annals of Internal Medicine press-release (edited by me):

Asthma is a chronic lung disease that causes episodes of difficult breathing for 22 million Americans. Asthma attacks cause 4,000 deaths a year.

Researchers sought to determine if the Internet could help. They randomly assigned 200 adult asthma patients to either usual care by their doctor or an Internet-based asthma program in addition to usual care.

The Internet-based self-management program included:

- weekly asthma control monitoring and treatment advice
- online group education
- remote Web communication

At 12 months, patients in the Internet group reported improvements in asthma control and lung function compared with patients in the usual care group.

However, the improvements in quality of life were small and the number of asthma attacks did not improve.

References:
Published in the July 21, 2009 issue of Annals of Internal Medicine.
Van der Meer V, et al. "Internet-based self-management plus education compared with usual care in asthma" Ann Intern Med 2009; 151: 110-120.
Image source: Wikipedia, public domain.

Allergy and Immunology News of the Day

Epinephrine Auto-Injector Needle Length May Be Too Short for Intramuscular Delivery. EpiPen Needle May Be Too Short for Intramuscular Delivery in 12% of Children who weighed less than 30 kg. EpiPen Needle May Be Too Short for Intramuscular Delivery in 30% of Children who weighed more than 30 kg http://bit.ly/118TGN
Guidelines and experts agree that adrenaline (epinephrine) is the first line treatment for anaphylaxis. Antihistamines should never be given alone or instead of adrenaline in anaphylaxis. In anaphylaxis, antihistamines should be considered only after adrenaline administration and with caution. http://bit.ly/wgkp0
Fluticasone Nose Spray Useful as Acute and Long-Term Therapy for Nasal Polyposis http://bit.ly/7nZ75
VideoMD.com Search Results For "Allergy" http://bit.ly/szIlC
Allergist Matthew Greenhawt, MD is on Twitter @FoodAllergyMD http://bit.ly/ekMCt

Allergy and Immunology News of the Day

Western Lifestyle Increases Prevalence of Atopic Diseases from 0% to 6% on a Small Papua New Guinean Island http://bit.ly/rIlYF
New Point-of-Care Device, ImmunoCAP Rapid could identify 95% of the patients with allergies http://bit.ly/pB7FM
Prevalence of food allergy in children with atopic dermatitis: egg (16-39%) , cow's milk (35.13%), peanut (25%) http://bit.ly/Q1tyC
Serum and sputum eosinophilic inflammatory markers are associated with poor asthma control. http://bit.ly/vBvHK
10 Surprising Food Allergy Dangers Parents Should Watch For - San Fernando Valley Sun http://bit.ly/1ydKm

Image source: OpenClipArt.org, public domain.

FDA is reviewing possible heart risks with asthma drug Xolair (omalizumab)

What is Xolair (omalizumab)?

Omalizumab (Xolair) is a monoclonal IgG antibody that selectively binds to human immunoglobulin E (IgE) used mainly in asthma to reduce allergic hypersensitivity. Omalizumab binds to Cε3 region of IgE. Its main drawbacks have been anaphylaxis risk in 1 to 2 patients per 1,000 and cost ($10,000 to $30,000 a year). The drug is used by 30,000 to 35,000 patients, representing less than one half of 1 percent of the eligible patient population.

What happened?

The U.S. Food and Drug Administration is conducting a safety review of Xolair (omalizumab), a drug used to treat adults and adolescents with moderate-to-severe persistent asthma.

Reviewers are looking for a possible association between patients who use Xolair and an increased risk of heart attack, abnormal heart rhythm, heart failure, and stroke. The possible association has been identified based on interim results from an ongoing study of Xolair known as Evaluating the Clinical Effectiveness and Long-Term Safety in Patients with Moderate to Severe Asthma (EXCELS). The study is being conducted by the manufacturer, San Francisco-based Genentech Inc.

The FDA has not made any conclusions about these data yet. Genentech spokeswoman Tara Cooper also said limitations in the existing data "preclude a definitive association with Xolair use.

The FDA says results are from observational study, not a randomized trial and is not advising asthma patients who use Xolair to stop.

What to do?

Dr. Tom Casale, the executive vice president of the American Academy of Allergy, Asthma & Immunology (and chairman of the department I work at), said in a CNN interview he "will recommend that his patients who are on the drug remain on it. These are the patients that are more likely to have (emergency room) visits, hospitalizations and more problems with their asthma." Still, he said, he would like to see the data that the FDA regulators have seen.

References:
FDA Reviewing Preliminary Safety Information on Asthma Drug Xolair. FDA.
U.S. reviewing possible heart risks with asthma drug. Reuters.
FDA scrutinizing safety of asthma drug Xolair. CNN.
Image source: Wikipedia, public domain.

Related:
When to Use Xolair (Omalizumab) in Asthma?
Use of omalizumab (Xolair) anti-IgE therapy beyond asthma
Anaphylactic Reaction to Omalizumab (Xolair) in a Patient with Severe Asthma
Is Xolair cost-effective in severe asthma?
Does omalizumab (Xolair) cause bleeding or thrombocytopenia?
Joint Task Force Report on Omalizumab-associated Anaphylaxis

Asian ladybug has become a prominent cause of seasonal inhalant allergy in endemic areas

The exotic Asian lady beetle, Harmonia axyridis, has become a prominent cause of seasonal inhalant allergy.

The Asian ladybug was introduced into the U.S. environment as an agricultural pest-control predator 20 years ago to control plant lice (aphids).

Asian Ladybug. Image source: Wikipedia, Creative Commons Attribution ShareAlike 2.5, Bruce Marlin, http://www.cirrusimage.com/beetles_multicolored_Asian_ladybird.htm

Aphids (plant lice). Image source: Wikipedia, GNU Free Documentation License.

It was anticipated that the insects would not survive the winter but they did by invading houses. Asian ladybugs may cause seasonal indoor symptoms - chronic cough, rhinitis, and asthma.

Ladybug allergy prevalence in endemic areas has been reported as high as 10%.

Ladybug hemolymph is the primary source of allergens - Har a 1 and Har a 2. 'Reflex bleeding' from tibiofemoral joints (for communication and during alarm) disperses these allergens.

Ladybug skin testing should be routine in endemic areas. SCIT may be effective but a commercial extract is needed.

Control measures:

- treatment of the outside of a house with pyrethroid before the cold weather
- move to a tightly-built house or into an urban area

References:
Seasonal inhalant insect allergy: Harmonia axyridis ladybug. Goetz, David W. Current Opinion in Allergy and Clinical Immunology: August 2009 - Volume 9 - Issue 4 - p 329-333.
Indoor Allergen Avoidance

Allergy and Immunology News of the Day

Allergen advisory labels: warnings included "may contain" (38%), "shared equipment" (33%), and "within plant" (29%). Nonspecific terms, such as "natural flavors" and "spices," were found on 65% of products. Many product labels have ambiguities that present challenges to consumers with food allergy. http://bit.ly/SMNxg
Afamelanotide, a photoprotective drug, granted Orphan Medicinal Product for treatment of Solar Urticaria in Europe. Afamelanotide was approved in 2008 for treatment of erythropoietic protoporphyria (EPP). Solar urticaria affects approximately 3 per 100,000 people, as little as 5 minutes of sun exposure can cause hives http://is.gd/1xetz
Travel Tips Checklist for Patients with Allergy And Asthma from ACAAI http://bit.ly/yPEfF
Link between innate and adaptive immune system: Toll-like receptor 7 and 9 defects in common variable immunodeficiency http://bit.ly/2ZUSm
Increased urinary leukotriene E(4) excretion in obstructive sleep apnea due to obesity and hypoxia http://bit.ly/pcog4
The abstract submission site is now open for the 2010 AAAAI Annual Meeting, deadline is September 2, 2009 http://bit.ly/FUyrp
SpringerImages (biomedical) can be used for almost all noncommercial purposes, presentations, etc. http://bit.ly/9dZMh & http://bit.ly/cgHRJ

Image source: OpenClipArt.org, public domain.

Allergy and Immunology Trivia

Thucydides (Athens, 5th century BC) first mentioned immunity to an infection that he called "plague" http://is.gd/1qgAQ

Bust of Thucydides residing in the Royal Ontario Museum, Toronto. Image source: Wikipedia, public domain.

Who was the boy who received the first vaccine by Edward Jenner in 1796? James Phipps http://is.gd/1qgRs

1802 caricature of Jenner vaccinating patients who feared it would make them sprout cowlike appendages. Image source: Wikipedia, public domain.

When does adaptive immunity (antibodies, T and B lymphocytes) appear in evolution? Vertebrates. http://is.gd/1qhK9

What species has the most immunoglobulin types? Homo sapiens (human) has 9 immunoglobulin types: IgG (1-4), IgA (1-2), IgM, IgE, IgD (GAMED)

What is the first immunoglobulin to appear in evolution? IgM, in jawed vertebrates. http://is.gd/1qhK9

Discoverer of phagocytosis, Mechnikov, made 2 unsuccessful suicide attempts (1875, 1880), then won the Nobel prize in 1908 http://is.gd/1qiLo

Ilya Ilyich Mechnikov, Nobel Prize in Medicine (1908). Image source: Wikipedia, public domain.

Combination of loratadine/montelukast relieves congestion similarly to pseudoephedrine in allergic rhinitis

The most common and bothersome symptom of allergic rhinitis (AR) is nasal congestion.

This study assessed efficacy and safety of a once-daily tablet containing 10 mg of loratadine, an antihistamine, and 10 mg of montelukast, a leukotriene antagonist versus placebo and pseudoephedrine (PSE; 240 mg once-daily).

In a multicenter, double-blind, double-dummy, randomized study, 1095 subjects with documented history of seasonal AR and positive skin-prick test to a prevailing aeroallergen were treated for 15 days.

There were no significant differences between L/M and PSE for any efficacy analysis.

Subjects treated with L/M experienced a similar incidence of adverse events versus placebo and a lower incidence of adverse events (dizziness, insomnia, jitteriness, nausea, and dry mouth) versus PSE.

Nasal decongestant activity of L/M was similar to that of PSE and better tolerated than PSE.

The authors concluded that L/M offers a safe and efficacious alternative to PSE for the treatment of nasal congestion in AR.

Medications for Allergic Rhinitis.

References:
Efficacy and safety of fixed-dose loratadine/montelukast in seasonal allergic rhinitis: Effects on nasal congestion. Prenner, Bruce; Anolik, Robert; Danzig, Melvyn; Yao, Ruji. Allergy and Asthma Proceedings, Volume 30, Number 3, May/June 2009 , pp. 263-269(7).

Olopatadine nasal spray may be as effective as fluticasone for allergic rhinitis

The efficacy of nasal antihistamines (NAHs) for allergic rhinitis (AR) is comparable with or better than second-generation oral antihistamines. NAHs have a faster onset of action and greater effect on congestion.

Limited data suggest that NAHs may be equivalent to intranasal corticosteroids at reducing congestion.

Olopatadine. Image source: Wikipedia, public domain.

Fluticasone propionate, Flonase (US and Canada) Flixonase (EU and Brazil). Image source: Wikipedia, public domain.

The efficacy of olopatadine 0.6% nasal spray (2 sprays/nostril b.i.d.) was compared with fluticasone 50 microg nasal spray (2 sprays/nostril q.d.) in a double-blind, randomized trial of 130 patients.

Both treatments reduced nasal and ocular symptoms throughout the 2-week study period.

The nasal symptom score decreased by 45.4% for patients treated with olopatadine and by 47.4% for those treated with fluticasone.

No significant between-treatment differences were determined for for congestion, runny nose, sneezing, itchy nose, and ocular symptoms. But olopatadine had a faster onset of action for reducing all symptoms.

The authors concluded that both olopatadine and fluticasone nasal sprays reduced nasal and ocular SAR symptoms with a faster and greater onset of action with olopatadine.

Medications for Allergic Rhinitis.

References:
Comparison of olopatadine 0.6% nasal spray versus fluticasone propionate 50 μg in the treatment of seasonal allergic rhinitis. Kaliner, Michael A.; Storms, William; Tilles, Stephen; Spector, Sheldon; Tan, Ricardo; LaForce, Craig; Lanier, Bobby Q.; Chipps, Bradley. Allergy and Asthma Proceedings, Volume 30, Number 3, May/June 2009 , pp. 255-262(8).

Olopatadine 0.6% nasal spray better than placebo for allergic rhinitis in children http://goo.gl/G4AYy - Is it better than nasal steroids?
Allergic Rhinitis: A Short Review
Mind Maps: Allergic Rhinitis
Mnemonics: Allergic Rhinitis

Allergy and Immunology News of the Day

How does exercise cause asthma attacks? Dehydration of the airways results in release of mediators. http://bit.ly/FXUaF
Filaggrin gene defects increase the risk of developing allergic sensitisation, atopic eczema, and allergic rhinitis. Filaggrin gene defects are present in up to one in 10 western Europeans and North Americans http://bit.ly/S1r5b
Company offers temporary tattoos to identify an allergy as in "I have a peanut allergy" http://tottoos.org and http://bit.ly/V8bIH -- "Medical Tottoos used to quickly identify severe allergies" - for example, "Allergic to Tree Nuts" http://bit.ly/hquhH
Meaning of positive skin tests to foods? - a detailed answer by AAAAI Ask the Expert http://bit.ly/1wL91 -- If you want to find the answer to your allergy-related questions, search AAAAI Ask the Expert (bottom of the page) http://bit.ly/3PMFmN

Image source: OpenClipArt.org, public domain.

Contrary to popular belief, strawberry allergy is uncommon

Contrary to popular belief and the posts on some non-medical blogs, strawberry allergy is not common.

The largest specialty book, Middleton's Allergy (7th edition, 2008), does not even mention it on any of its 1924 pages. You can search for yourself another textbook - Allergy and Asthma: Practical Diagnosis and Management by Lange on Google Books - still no mention. In fact, AAAAI lists "Fresh Strawberry Sorbet" as Food Allergy-Free Recipe: http://l.pr/a4x1

Strawberry allergy is reported but not commonly. Only few cases of patients with adverse reactions to strawberry are listed in literature: http://bit.ly/grLe1

No strawberry allergen has been identified until 2004 when evidence about Bet v 1 emerged: http://bit.ly/gDbHO

No clinical reactivity was found in 66% of positive skin prick tests and 63% of positive specific IgE determinations to Rosaceae fruits: http://bit.ly/41XM8U. The species of Fragaria (strawberries) belongs to the family Rosaceae.

In summary, strawberry and tomato allergies are very rare. It is suspected that the acidity in these fruits in addition to the histamine content may cause hives especially in the sensitive and "chapped" skin of children with eczema.

The double blind placebo controlled food challenge test remains the gold standard for exclusion test in suspected strawberry allergy.

Food challenges, mind map diagram.

Mind map of food allergy.

Eight top allergens account for 90 percent of all food allergies. The 8 top allergens can be remembered by the mnemonic TEMPS WFS:

Tree nuts (almonds, cashews, walnuts)
Egg white (not egg yolk)
Milk
Peanuts
Shellfish (crab, lobster, shrimp)
Wheat
Fish (bass, cod, flounder)
Soy

Diagnostic algorithm for food allergy: SAD Child:

1. Symptoms: close relation between specific food intake and symptoms, often affect 2 or more organs
2. Allergy testing: skin prick testing or ImmunoCAP.
3. Diagnostic diet: restricted diet leads to symptoms disappearance or significant reduction
4. Challenge - oral food challenge.

References:

Exacerbation of eczema due to tomatoes and strawberries in the absence of demonstrable IgE against these foods. AAAAI, 2011.

Food Allergy: A Short Review

Clinical review: ABC of allergies, Food allergy. BMJ 1998;316:1299, figure.
Food Allergen Avoidance
Food Challenges
Mind Maps: Food Allergy
Mnemonics: Food Allergy
Image source: Fragaria × ananassa 'Gariguette,' a cultivar grown in southern France. Wikipedia, David Monniaux, GNU Free Documentation License.

Allergy and Immunology News of the Day

Children with untreated asthma are less fit and have a higher body per cent fat and frequency of obesity http://bit.ly/KG8cG
Obstructive sleep apnea-hypopnea was significantly more prevalent among patients with severe asthma http://bit.ly/5K7gQ
Sustained hapten access through a defective skin barrier is important in the etiopathogenesis of atopic dermatitis http://bit.ly/ENrIS
IL-9 has largely been regarded as a Th2 cytokine that makes multifocal contributions to allergic disease. `Th9' helper T cells can exist but their contribution in allergic disease is currently unknown http://bit.ly/pTwkM
Canadian Lung Assn. takes aim at Air Canada's new pet-friendly policy http://bit.ly/WJhfc
ED physician: "When I ask patients about their medical allergies, more often than not patients suffer from at least one" http://is.gd/1sgeK -- Updated: From the Blogs: When is a Drug Allergy Not a Drug Allergy? http://bit.ly/Y45ah
Flickr: Patient's perception of skin patch test for contact dermatitis: "Immobile" http://bit.ly/CxSgr

Image source: OpenClipArt.org, public domain.

Allergy and Immunology News of the Day

Dogs are good for you: dog ownership in early childhood may protect against development of inhalant sensitisation. Dog ownership in early childhood was not associated with dog sensitisation or allergic symptoms up to age 6 yrs http://bit.ly/wnY9E
Children with a family history of allergies are less likely to develop eczema if they live with a dog starting in infancy http://goo.gl/gost
Theophylline Might Restore Sense of Smell in 50% of Patients with Anosmia http://bit.ly/QjGb3
Basophil activation tests (BAT) sensitivity in beta-lactam allergy was 50%, and specificity ranged from 89 to 97%. BAT is the only in-vitro test validated for the diagnosis of both IgE-mediated and hypersensitivity reactions to NSAIDs http://bit.ly/M1t0A
CD8+ T cells play a major role in nonimmediate allergic drug reactions, responsible for the severity of bullous forms. Nonimmediate allergic drug reactions are mediated by T cells and mostly affect the skin. Nonimmediate allergic drug reactions range from frequent and benign maculo-papular exanthema to severe and rare toxic epidermal necrolysis http://bit.ly/I1VTE
State of World Allergy Report 2008: Allergy and Chronic Respiratory Diseases, by World Allergy Organization http://bit.ly/19ZTBQ
Breastfeeding and house dust mite reduction to prevent asthma: http://27s46.tk
"Quacks and Cures" - BBC audio slideshow http://bit.ly/4jkv3C

Image source: OpenClipArt.org, public domain.

Home-made spacers as effective as commercial spacers for bronchodilator therapy in children with acute asthma

Recently, I saw a blog post titled "Treating Asthma on the Cheap" which described a spacer device made out of a 500-ml water bottle. It sounds unlikely but this may work after all.

A Cochrane review showed no difference between commercial and home-made spacers in delivering bronchodilator http://bit.ly/1W7hD

Home-made spacers for bronchodilator therapy in children with acute asthma were as effective as commercial spacers in a RCT published in the Lancet. A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation in children with acute asthma http://bit.ly/VOXkj

Image source: Plastic bottles before processing. Wikipedia, dierk schaefer, Creative Commons Attribution 2.0 License.

Allergy and Immunology News of the Day

Utility of diagnostic tests in the follow-up of egg-allergic children: skin prick test (SPT) and specific IgE levels. An oral challenge should not be performed in egg allergic paediatric patients with either an egg white prick test above 7 mm or a white egg-sIgE determination above 1.3 KU/L, because there is a 90% probability of remaining allergic. http://bit.ly/2mps4
Prevalence of food hypersensitivity (FHS) in young adults: reported in 18%, confirmed in 1.7%. Most common allergenic food in young adults: peanut (0.6%), additives (0.5%), shrimp (0.2%), codfish, cow's milk , octopus, soy (0.1% each).
Major increase in allergic sensitization in school children in Sweden (1996-2006), sensitization to cat most common http://bit.ly/37JvdG
Oral immunotherapy induces clinical desensitization to peanut, with significant long-term humoral and cellular changes http://bit.ly/BlGS0
Defects along the T(H)17 pathway lead to genetically distinct forms of hyper IgE syndrome, some with normal STAT3 http://bit.ly/10g6lz
CDC launches a Web-based tool to track environmental exposure to diseases such as asthma http://bit.ly/8wNMF and http://bit.ly/ZZIac
Currently, many insurers consider exhaled nitric oxide testing investigational which means they will not pay for it. http://bit.ly/yAj7k

Image source: OpenClipArt.org, public domain.

Allergy and Immunology News of the Day

AAAAI explains why there is no IgE antibody-mediated "iodine allergy." IgE mediated seafood allergy has never been attributed to iodine, but rather to specific proteins in fish and shellfish http://is.gd/1oRpX
Children with allergic rhinitis or nasal symptoms had more severe asthma. Allergic rhinitis is both under-diagnosed and under-treated in school-aged children with asthma http://is.gd/1oRAJ
"SensiVida developing technology to replace allergy “stick” tests with minimally invasive option" http://bit.ly/2Xmigr http://bit.ly/BWugN

Image source: OpenClipArt.org, public domain.

Chocolate Allergy? It's Vanishingly Rare

"Do I have chocolate allergy?" is not an uncommon question.

According to the current guidelines however, chocolate allergy is extremely rare.

The practice parameter for food allergy postulates that since the proteins of cacao nut undergo extensive modification into relatively nonallergenic complexes during the processing of commercial chocolate, clinical sensitivity to chocolate is vanishingly rare.

Chocolate allergy vs. pseudoallergy

Most allergists have never seen a patient with "true" chocolate allergy. There is only one article in Pubmed about chocolate allergy from 1971. It was contradicted a few later by a second review which emphasized on chocolate pseudoallergy.

Allergy to contents of a chocolate bar

Symptoms of "chocolate allergy" could be due to allergy to any of the following:

- milk

- tree nuts

- peanuts

- soy

Adverse reactions to pharmacological agents

Adverse reactions after chocolate consumption could be due to pharmacological agents normally present in chocolate such as theobromine (chocolate, tea) and phenylethylamine (chocolate).

Table 1. Differential diagnosis of adverse food reactions (Adapted from Sampson. J Allergy Clin Immunol 1986; 78:212–219.)

Pharmacologic agents

Caffeine (coffee, soft drinks)

Theobromine (chocolate, tea)

Histamine (fish, sauerkraut)

Tryptamine (tomato, plum)

Serotonin (banana, tomato)

Phenylethylamine (chocolate)

Tyramine (cheeses, pickled herring)

Glycosidal alkaloid solanine (potatoes)

Alcohol

Psychological reactions - food aversions, food phobias, etc.

The recently launched "allergy-friendly" chocolate bars "boom CHOCO boom" are called so because they are supposedly the first dairy-, nut- and soy-free chocolate bars, not because they do not contain cacao products.

Common allergens

8 foods cause 90% of food allergies (TEMPS WFS) (click to enlarge the image). The likelihood of a negative oral food challenge is shown in relation to the respective values of skin prick test (SPT) and serum IgE (sIgE). See more Allergy and Immunology mind maps here.

References:

Food allergy: a practice parameter. American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol 2006 Mar;96(3 Suppl 2):S1-68. [682 references].
"Allergy-friendly" chocolate bars?
Food Allergy: A Short Review. Allergy Cases.
Chocolate from Wikipedia, the free encyclopedia

Chocolate allergy: a double-blind study. Maslansky L, Wein G. Conn Med. 1971 Jan;35(1):5-9.

Case in point: allergy, intolerance or pseudoallergy to chocolate? [Article in French] Riv Eur Sci Med Farmacol. 1989 Jun;11(3):247-9.

http://en.wikipedia.org/wiki/Theobromine

http://en.wikipedia.org/wiki/Phenethylamine

Flavored Coffee May Trigger Seasonal Allergies - due to oral allergy syndrome. Fox News, 2011.

Image source: Wikipedia.

From Twitter:

@DoctorMac: Currently skin testing a patient to chocolate. Must use varying contents of cocoa. Also must perform frequent quality control testing. Perhaps surprising no one, all tests were negative. The oral challenge went equally well, patient, M.D. & nurse all tolerated it fine.

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Home-made spacers as effective as commercial spacers for bronchodilator therapy in children with acute asthma

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