Performance of a component-based allergen-microarray in the diagnosis of cow's milk and hen's egg allergy.

BACKGROUND: The food challenge test (FCT) is the gold standard for the diagnosis of food allergy. This procedure is time consuming, costly and can induce potentially severe symptoms. An ideal in vitro test should allow to avoid the FCT. Objective To assess the clinical performance of microarray for specific IgE (sIgE) detection in children with challenge-proven/excluded cow's milk (CM) or hen's egg (HE) allergy. METHODS: One-hundred and four children with suspected IgE-mediated hypersensitivity to CM or HE were studied. In all patients, skin prick test, ImmunoCAP, microarray and FCT were performed. RESULTS: The microarray components Bos d 8 for CM (27/58 patients) and Gal d 1 (20/46 patients) and Gal d 2 (24/46) for HE were the most frequently recognized allergens. Using the FCT results as the reference parameter, sIgE to Bos d 8 and Gal d 1 had the highest area under the curves. These were not significantly different from those obtained using the ImmunoCAP. Use of 95% clinical decision points (CDP) for sIgE to Bos d 8 and Gal d 1 resulted in higher negative predictive values (78% and 79%, respectively) than those obtained with the ImmunoCAP (57% and 59%). CONCLUSIONS: Our results show that in children with suspected CM or HE allergy, the microarray has a good ability to predict the FCT results. In a clinical application perspective, the microarray could be used as a second-level assay, if the ImmunoCAP sIgE is <95% CDP. This approach would lead to a decrease in the number of the FCT to be performed, as well as of positive FCTs with a subsequent decrease in severe reaction risk.

Low-dose local nasal immunotherapy in children with perennial allergic rhinitis due to Dermatophagoides.

BACKGROUND: Allergen specific immunotherapy was known to be useful in the treatment of respiratory allergic disease. Local nasal immunotherapy (LNIT) offers advantages such as a good efficacy/safety ratio and a more convenient allergen delivery. The aim of this study was to assess the safety and clinical efficacy of a modified scheduling of LNIT in 32 children with allergic rhinitis due to Dermatophagoides. METHODS: A multicentre, randomized, double-blind placebo controlled study carried out for two years, with a modified schedule of LNIT treatment: a build-up phase at increasing dosages from 2.5 AU to 80 AU and a maintenance period at low dosage (80 AU) once a week. Symptom and medication scores. threshold dose with specific nasal provocation test (NPT) and immunological parameters (IgE and IgG4) were evaluated. RESULTS: No important local or systemic side-effects were observed in children who completed the study. Compared to placebo, the active treatment group showed significant improvement in rhinitis symptoms and a reduction of drug consumption after 18 months of LNIT. These results were confirmed by a significant reduction of allergen specific nasal reactivity. Serum and nasal specific IgE and IgG4 did not show any difference in the two groups. CONCLUSIONS: The safety and clinical efficacy of low-dose LNIT suggests that this therapy may be useful in the treatment of allergic rhinitis disease in children.

Determination of allergenicity to three cow's milk hydrolysates and an amino acid-derived formula in children with cow's milk allergy.

BACKGROUND: Products based on hydrolysed cow milk proteins or amino acid mixtures are recommended in children with cow's milk hypersensitivity. However, some children who are allergic to cow's milk and who clinically react to substitute milk formulas have been observed. OBJECTIVE: To determine the tolerance and allergenicity of protein hydrolysate or amino acid-derived formulas in children with IgE-mediated cow's milk allergy. METHODS: Twenty children with positive cow's milk challenges, positive skin prick tests and/or serum-specific IgE antibodies to cow's milk were selected. Oral challenges, skin prick tests and serum-specific IgE antibodies to extensively hydrolysed whey formula, partially hydrolysed whey formula, extensively hydrolysed casein formula and amino acid-derived formula were performed. RESULTS: Five out of 17 (5/17) children reacted to partially hydrolysed whey formula, (3/16) to extensively hydrolysed whey formula, (2/10) to amino acid-derived formula, (1/16) to extensively hydrolysed casein formula. Only extensively hydrolysed casein formula was tolerated by at least 90% (with 95% confidence intervals) of children. Hydrolysates provoked early and delayed clinical reactions, amino acid mixtures only delayed reactions. Partially hydrolysed whey formula elicited a significantly higher number of positive skin prick test reactions than other formulas. Two children had specific IgE antibodies to extensively hydrolysed whey formula, one to partially hydrolysed whey formula, one to extensively hydrolysed casein formula and none to amino acid-derived formula. CONCLUSION: In this study, none of the cow's milk substitutes has been found to be non-allergenic. Our results suggest that in children with IgE-mediated cow's milk allergy, the first ingestions of extensively hydrolysed cow's milk protein formulas require strict medical supervision because of immediate reactions. This is not the case for amino acid-derived formula. Moreover, our data suggest that treatment of children allergic to cow's milk with cow's milk substitutes should be monitored for several days to document tolerance.

Duodenal IgE-positive cells and elimination diet responsiveness in children with atopic dermatitis.

BACKGROUND: Parameters for identifying eczematous children who could respond to an elimination diet are needed. In children with food allergy, duodenal IgE-containing cells are enhanced. OBJECTIVE: To determine the presence of duodenal mucosal IgE-positive cells in atopic dermatitis and to determine whether duodenal IgE-positive cells may identify eczematous children who will benefit from an elimination diet. METHODS: Thirty-one children with severe eczema underwent gastrointestinal endoscopy because of gastrointestinal symptoms and were treated with an elimination diet. A clinical score to skin lesions was given before and after diet. All subjects were skin-prick tested with food antigens and aeroallergens. Serum IgE levels were measured. Duodenal IgE-positive cells were investigated in 18 control subjects and in all eczematous children before diet. RESULTS: The number of duodenal IgE-positive cells in children with atopic dermatitis was significantly increased compared with that of control group (P < 0.001). Nineteen (61%) eczematous children improved on a few food diet. Diet-responsive children had significantly higher IgE-positive cells compared with both nondiet-responsive and controls. Positive predictive accuracy of duodenal IgE-positive cells was poor, whereas negative predictive accuracy was high at the cutoff level of 50 IgE-positive cells/10 visual fields. Diagnostic accuracy both of SPT reactions with foods and of food-specific serum IgE antibodies was poor. CONCLUSIONS: An intestinal IgE-mediated reaction occurred in children with severe atopic dermatitis who underwent intestinal endoscopy because of gastrointestinal symptoms. In these eczematous children, the number of IgE-positive cells in the duodenal mucosa might be helpful for excluding a positive response to the elimination diet.

Preseasonal local allergoid immunotherapy to grass pollen in children: a double-blind, placebo-controlled, randomized trial.

BACKGROUND: We assessed the efficacy of preseasonal local allergoid immunotherapy in a group of children with asthma and/or rhinitis and/or rhinoconjunctivitis due to grass pollen. METHODS: We randomly assigned 24 children allergic to grass pollen to receive local allergoid immunotherapy for 3 months before the pollen season and 24 such patients to receive identically appearing placebo. The immunotherapy consisted of tablets of monomeric allergoid grass pollen allergens held in the mouth until they dissolved and then swallowed. The study was double-blind. Symptoms and medications were scored on diary cards during the pollen season. Nasal eosinophil cationic protein levels were measured by the monoclonal antibodies EG1 and EG2 outside the pollen season and at low and at high pollen concentration during the pollen season. RESULTS: The active-treatment group had a statistically significant reduction of total symptoms (P<0.05), especially bronchial symptoms (P<0.05), in comparison with the placebo group. Immunotherapy was well tolerated and compliance was good. Nasal levels of EG2 and EG1 increased significantly during the pollen season, but there was no difference between groups. EG2/EG1 increased significantly only in the placebo group during natural allergen exposure (P<0.01). CONCLUSIONS: Our results suggest that this immunotherapy is effective for the treatment of asthma due to grass pollen in children.

Treating asthma in children with beclomethasone dipropionate: Pulvinal versus Diskhaler.

Seventy-two children (mean age, 10.1 years) with stable moderate asthma who completed a 7-day run-in period were randomized to receive a 4-week treatment with beclomethasone dipropionate (200 micrograms twice daily) administered through two different powder inhalers (Pulvinal; Chiesi Farmaceutici S.p.A, Parma, Italy and Diskhaler; Glaxo-Wellcome, Evreux, France) in a parallel group design. Sixty-nine patients completed the study. Morning and evening peak expiratory flow values, the use of rescue salbutamol, and the severity of clinical symptoms were recorded daily on a diary card. Pulmonary function tests were performed at baseline and then after 2 and 4 weeks of treatment. Pulmonary function values, daily morning and evening peak expiratory flow, and most of the clinical symptoms significantly improved, although the use of rescue salbutamol significantly decreased from the second week of treatment until the end of the study in both groups. Equivalence of efficacy between groups was demonstrated for both pulmonary function and clinical parameters. We conclude that the Pulvinal inhaler is as efficacious as the Diskhaler in beclomethasone-based therapy of asthmatic children.

Cutaneous CD30+ cells in children with atopic dermatitis.

BACKGROUND: CD30 expression can be considered a marker of Th2 cells. We investigated the presence of CD30+ cells in the lesional skin of children with atopic dermatitis (AD). We also analyzed the possible relationship between CD30+ cells and serum soluble CD 30 (sCD30) levels, and IgE, soluble interleukin-2 (IL-2) receptor (sIL-2R) or soluble CD23 (sCD23) levels in the blood, and clinical score. METHODS: Ten eczematous children (4 males, 6 females; median age: 4 years and 5 months; range: 11 months to 14 years), 9 sex- and age-matched control children and an adult control group were studied. A clinical score (SCORAD index), was given to eczematous lesions. Blood was taken for the determination of IgE, sCD30, sIL-2R and sCD23 levels. Punch biopsies of lesional skin were stained with hematoxylin and eosin or incubated with anti-CD30 monoclonal antibodies. Skin prick tests (SPTs) were also performed. RESULTS: In the biopsy specimens, CD30 expression was observed in high proportions of infiltrating cells. In children with AD, total serum IgE, sCD30, sIL-2R, sCD23 and eosinophils were significantly elevated compared to controls. CD30+ cells were not associated with serum IgE, sCD30, sIL-2R, sCD23, or SPT results, score of inflammatory cells in lesional skin or clinical score. Children with AD who had high total IgE and specific IgE antibodies did not differ from those with normal total IgE and negative specific IgE in respect of age, clinical score, number of CD30+ cells, sCD30, sIL-2R and sCD23 levels, score of inflammatory cells in skin or clinical score. CONCLUSION: Our results showed remarkable numbers of CD30+ cells in the lesional skin and high sCD30 in the serum of children with AD. CD30+ cells did not correlate with systemic markers of IgE reaction.

[From atopic eczema to respiratory allergy]. / Dall'eczema atopico all'allergia respiratoria.

The prevalence of atopic eczema in childhood is increasing. This is probably related with a deviation of immune system to Th2 directed to allergen instead of Th2 directed to microorganisms. Atopic eczema is genetically linked, but its expression is principally determined by environmental factors, allergens and infections. In children with atopic eczema, the immune system is altered. The number of Langheran's cells is augmented. Th2 cells infiltrate the skin and produce cytokines which mediate both immediate and late allergic reaction. Most of eczematous children is allergic to food. A IgE-mediated reaction take place at the mucosal intestinal site. The food challenge test is the most reliable mean to identify offending foods. Soy formula can be used in the treatment of cow milk allergy. The tolerance of formulae based on cow milk hydrolysed protein should be tested under medical supervision in children with cow milk allergy. Prevention of atopic disease with dietary interventions has not been successful. To prevent asthma, the administration of immunotherapy in children with allergic rhinitis seems to be promising. In eczematous children with elevated total IgE and specific IgE to inhalant allergens, cetarizine seems to prevent onset of asthmatic symptoms.

[Model of integrated hospital project for the management of patients at risk of sudden death syndrome]. / Modello di progetto integrato Ospedale-Territorio per la gestione dei pazienti a rischio di SIDS.

Home cardiorespiratory monitoring (HM) is an accepted practice in infants at high risk for Sudden Infant Death Syndrome (SIDS) as those with the following conditions: 1) Siblings of SIDS; 2) Apparent Life Threatening Events (ALTE); 3) Apneas of prematurity. From 1998 the Division of Neanotology of the Policlinico of Modena has followed prospectively infants at high risk for SIDS, in collaboration with the General Health Service. To support the clinical trial 10 apnea monitors were provided by the General Health Service and managed from the Department of Neonatology. During 18 months 24 infants have been followed by HM, and among then 20 were at risk of SIDS (11 female and 9 male): 7 were siblings of SIDS (35%); 10 had previous episodes of ALTE (50%); 3 were born prematurely and had persistent apneas before discharge (15%). The mean period of HM was 5.85 months. None of the infants died for SIDS or had episodes of ALTE that required resuscitation measures. In only one case parents stopped earlier than recommended, but personal interview to parents showed that all the others families gained benefits and reassurance from HM.

Evaluation of the presence of bovine proteins in human milk as a possible cause of allergic symptoms in breast-fed children.

BACKGROUND: It is generally believed that the elimination of certain foods from the diet of mothers during the lactation period produces a significant improvement in breast-fed children who develop allergic symptoms. Several studies have shown the presence of food proteins in human milk; on the other hand, no study has been able to correlate unequivocally the presence of these allergens in human milk with newborn sensitization. OBJECTIVE: The aim of this study was to evaluate the presence of bovine proteins in breast milk. METHODS: Milk samples were separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). To detect bovine proteins in human milk, immunoblotting was performed by using monoclonal antibodies (MA) specific for beta-lactoglobulin and bovine caseins. RESULTS: The results of this study do not confirm the presence of bovine proteins in breast milk suggested by other authors and shows unequivocally that the conflicting results reported in the literature about the presence of betalactoglobulin in human milk are due to cross-reactivity between bovine milk proteins and human proteins. CONCLUSIONS: Components other than bovine betalactoglobulin or caseins could be involved in the induction of allergic symptoms in exclusively breast-fed children.

Cross-reactivity between milk proteins from different animal species.

BACKGROUND: Cow's milk allergy is quite frequent in the first years of human life. When breast-feeding is not possible, a cow's milk substitute must be provided for allergic subjects. Different alternatives to cow's milk have been suggested as protein sources (soy, hydrolysed proteins, goat's milk, etc.), but all these dietetic solutions are not without risks for polyallergic or more sensitive subjects. OBJECTIVE: To obtain new information on the suitability of other mammalian milks for allergic children, we evaluated the cross-reactivity between milk proteins from different animal species. METHODS: Milk samples were analysed by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). To detect antibody-antigen complexes, immunoblotting was performed by using sera from children allergic to cow's and ewe's milk (RAST class >/= 4) and monoclonal antibodies (MoAb) specific for bovine proteins (caseins and beta-lactoglobulin). RESULTS: IgEs from children allergic to cow's milk are capable of recognizing most part of milk proteins from mammals bred in European countries (ewe, goat, buffalo), while no serum used in this study contains IgEs reacting with camel's milk proteins. Camel's milk was also not recognized from circulating IgEs from a child specifically allergic to ewe's milk. Specific antibovine monoclonal antibodies cross-reacted with proteins from other mammalian species, apart from those of camel. CONCLUSIONS: Homologies in amino acidic composition could justify the cross-reactivity observed between proteins from different animal species. On the other hand, the phylogenetic difference could be responsible for the failed recognition of camel's proteins by circulating IgEs and monoclonal antibodies.

Gastrointestinal symptoms in atopic eczema.

AIMS: To determine the prevalence of gastrointestinal symptoms in children with eczema and the association of such symptoms with the extent of eczema or skin prick test results. METHODS: Sixty five children with atopic eczema and a control group matched for age and sex were recruited. Their parents completed a questionnaire about the children's gastrointestinal symptoms. The children's skin was examined; their weight, height, and abdominal circumference were measured; and skin prick tests were carried out. RESULTS: Gastrointestinal symptoms, especially diarrhea, vomiting, and regurgitation, were more common in the children with eczema. Diarrhea appeared to be associated with the ingestion of specific foods. Gastrointestinal symptoms were related to diffuse eczema and positive skin prick tests to foods. There was no anthropometric differences between the patient and control groups. CONCLUSIONS: A gastrointestinal disorder is common in children with eczema, especially with diffuse distribution. This may be responsible for substantial symptoms and may play a part in the pathogenesis of the disease and in the failure to thrive with which it is sometimes associated.

Atopy in children with otitis media with effusion.

BACKGROUND: Contrasting data have been found on the prevalence of atopy in children with otitis media with effusion (OME). A major issue would be to determine whether screening for atopy should be recommended. Setting Centre for Study of Otitis Media with Effusion, Tabiano Terme, Parma, Italy. OBJECTIVE: The purpose of this study was to investigate the relation of OME to atopy. METHODS: The subjects were 172 children with OME and a control group of 200 children. The protocol included a questionnaire survey of diseases associated with atopy, a skin-prick test and a clinical evaluation of allergic symptoms and hypersensitivity to aeroallergens. RESULTS: No significant difference between patients and control group was observed for family history of atopy or positive skin-prick test reactions. Symptoms associated with atopy occurred significantly more frequently in the group with OME (P<0.001), though only the presence of rhinitis or atopic eczema was significantly associated with OME. CONCLUSIONS: Prevalence of positive skin-prick tests results is not enhanced in children with OME. Nevertheless, the association of OME with symptoms associated with atopy suggests that such concomitant diseases may play a part in the pathogenesis of the disorder. Children with allergic rhinitis or atopic eczema should be investigated by tympanometry for OME.

Anaphylaxis in children: clinical and allergologic features.

BACKGROUND: Despite the importance of anaphylaxis, little information is available on its clinical features. OBJECTIVE: To evaluate the clinical and allergologic features of anaphylaxis in children referred to the allergology and immunology unit of A. Meyer Children's Hospital (Florence, Italy) from 1994 to 1996. RESULTS: Ninety-five episodes of anaphylaxis occurred in 76 children (50 boys and 26 girls). Sixty-six children (87%) had only one episode of anaphylaxis, while 10 (13%) had two or more episodes. Sixty-two (82%) of the 76 patients had a personal history of atopic symptoms, although 14 (18%) did not. Sixty (79%) of the 76 children studied had at least one positive skin prick test to one or more of the common inhalant and/or food allergens. Children with venom-induced anaphylaxis usually had negative skin tests to the allergens tested. A younger age and eczema were more frequent among children with food-dependent anaphylaxis, whereas an older age together with urticaria-angioedema were common among those with exercise-induced anaphylaxis. The mean latent period (+/-SD) of the anaphylaxis episodes was 15.4 +/- 27.5 minutes. Skin and respiratory manifestations had an earlier onset and were more common than the gastrointestinal and cardiovascular ones. The most frequent clinical manifestation in children with food anaphylaxis was gastrointestinal symptoms, whereas cardiovascular symptoms were rare. The most probable causative agents in the 95 episodes described were foods (57%), drugs (11%), hymenoptera venom (12%), exercise (9%), additives (1%), specific immunotherapy (1%), latex (1%), and vaccines (2%), but in 6 cases (6%) the agent was never determined. Among the foods, seafood and milk were the most frequently involved. As for location, 57% of the anaphylactic events occurred in the home (54/95), 12% outdoors (11/95); 5% in restaurants (5/95); 3% in the doctor's office (3/95); 3% in hospitals (3/95); 3% on football fields (3/95); 2% on the beach (2/95); 1% in the gym (1/95); 1% at school (1/95); and 1% in the operating room (1/95). In the remaining 12% of cases (11/95) the site remained unknown. Sixty-two percent of the patients (59/95) were treated in an emergency room or hospital, while 32% (30/95) were not (this information is lacking in 6% of the cases [6/95]). Patients were treated with corticosteroids in 72% of the cases (68/95), with antihistamines in 20% (19/95), with epinephrine in 18% (17/95), with beta2-agonists in 5% (5/95), and with oxygen in 4% (4/95). CONCLUSIONS: In our area, foods, particularly seafood and milk, seem to be the most important etiologic factors triggering anaphylaxis. Food-induced anaphylaxis often occurs in younger children with a severe food allergy, whereas exercise-induced anaphylaxis occurs more often in older children with a history of urticaria-angioedema. The venom-induced variant usually presents itself in nonatopic subjects. Given the fact that most of the children had only one anaphylactic reaction, prevention is almost impossible. Epinephrine, although it is the first-choice treatment of anaphylaxis, often goes unused, even in hospitals and doctors' offices.

Monoclonal and polyclonal antibodies against casein components of cow milk for evaluation of residual antigenic activity in 'hypoallergenic' infant formulas.

BACKGROUND: Hydrolysed casein and whey protein formulas have been developed with the aim of preventing sensitization in infants at high risk of cow milk allergy. Subsequently these products have also been used for treatment of children with cow milk allergy. However, severe reactions have occurred in some allergic infants fed with these formulas raising doubts about their absolute safety and suggest the need for developing in vitro techniques for detection of eventual residual allergenic activity in such preparations. OBJECTIVES: Our purpose was to evaluate the usefulness of monoclonal and polyclonal antibodies against casein components (alpha, beta and kappa casein) as reagents for the detection of the residual antigenic activity of casein components in several hydrolysed formulas. METHODS: The monoclonal and polyclonal antibodies were produced according to standard procedures by immunizing female Balb/c mice with casein fraction (a mixture of alpha, beta and kappa casein). ELISA assays were developed to test the specificity of the antibodies and to detect and evaluate the amount of residual antigenic activity of the casein components in hydrolysed formulas. RESULTS: Use of polyclonal antiserum specific for casein allowed detection of residual antigenic activity of casein components in all partial hydrolysates and in the two extensive whey protein hydrolysates in the amounts ranging from 0.05 to 0.67% of total protein. No such activity was detectable in either the two extensive casein hydrolysates tested or the aminoacid based formula. The polyclonal antiserum proved to be more suitable than monoclonals for detecting residual antigenic activity in the hydrolysates. The monoclonal antibodies were directed against epitopes expressed on different casein components. CONCLUSIONS: In this study the ELISA inhibition assay with polyclonal antibodies specific for casein components of cow milk proved to be a sensitive method for estimating residual antigenicity in the hydrolysed formulas commercially available for infants with cow milk allergy suggesting their potential application for the quality control of hypoallergenic infant formulas.

Anaphylaxis induced by exercise and related to multiple food intake.

In some patients, exercise-induced anaphylactic (EIAn) reactions occur only when a particular food is eaten before exercise. We describe three patients with EIAn induced by different foods. Patients who presented episodes of EIAn performed exercise challenges after fasting and 1 hour after a meal without foods suspected of predisposing the reaction. Subsequently, patients performed exercises after separate intake of each suspected food. Patients underwent skin prick tests (SPT) with food extracts. Serum total and specific IgE antibodies to food were determined. No reactions were provoked by exercise tests without prior intake of suspected foods. Eight of 30 food-exercise combination challenges were positive. In Patient 1, tomato, zucchini, and wheat resulted in adverse reactions: in Patient 2, potato, peanuts, and tomato; in Patient 3, rice and peanuts. SPTs and RASTs to foods predisposing the reaction were positive. Food-exercise combined challenge may be useful in identifying foods that favor EIAn in children with multiple food-dependent EIAn.

Increased nasal eosinophils in children with otitis media with effusion.

The pathogenesis of otitis media with effusion is still under debate, but allergic sensitization has been suggested in some cases. We investigated whether nasal cytology may indicate an allergic pathogenesis for otitis media with effusion. Atopic symptoms, results of skin prick tests to common aeroallergens, and nasal cytology by nasal scraping were evaluated in 40 children with current otitis media with effusion and compared with findings in a group of 40 healthy children. The presence of nasal eosinophils was significantly more frequent in children with otitis media with effusion than in the control group (p < 0.05). Nasal eosinophils were significantly associated with both allergic rhinitis (p < 0.001) and positive skin prick test results (p < 0.001). Allergic rhinitis with nasal eosinophilia was found in six children of the study group and in one child of the control group (p < 0.05). Our data suggest that nasal allergic inflammation may play a role in a subset of patients with otitis media with effusion. Therefore the possibility of allergic sensitization must always be considered in patients with serous otitis media.