Anaphylaxis to Vespa velutina nigrithorax: Pattern of Sensitization for an Emerging Problem in Western Countries.

OBJECTIVE: To define the sensitization pattern of patients with anaphylaxis to Vespa velutina nigrithorax (VVN). METHODS: We studied 100 consecutive Spanish patients with anaphylaxis to Hymenoptera venom and systematically determined specific IgE (sIgE) to whole venoms (Vespula species, Polistes dominula, Apis mellifera, Vespa crabro, and Dolichovespula maculata) and their molecular components (rApi m 1, rApi m 5, rApi m 10, rVes v 1, rVes v 5, rPol d 5, and cross-reactive carbohydrates). Specific IgE to VVN venom and its antigen 5 (nVesp v 5) were measured in a subsample. RESULTS: Seventy-seven patients had anaphylaxis to VVN. Of these, only 16 (20.8%) reported previous VVN stings, but were stung by other Hymenoptera. Positive sIgE (>0.35 kUA/L) to each of the whole venoms was detected in >70% of patients (Vespula species in 100%). The components showing >50% positivity were rApi m 5 (51.4%), rPol d 5 (80.0%), and rVes v 5 (98.7%). This pattern was similar to that of Vespula species anaphylaxis (n=11) but different from that of A mellifera anaphylaxis (n=10). Specific IgE to nVesp v 5 was positive in all patients (n=15) with VVN anaphylaxis and was correlated with sIgE to both rVes v 5 (R=0.931) and rPol d 5 (R=0.887). CONCLUSIONS: VVN has become the commonest cause of Hymenoptera anaphylaxis in our area. Most cases report no previous VVN stings. Their sensitization pattern is similar to that of patients with anaphylaxis to other Vespidae. Specific IgE to antigen-5 from VVN, Vespula species, and P dominula are strongly correlated in patients with VVN anaphylaxis.

Efficacy and Safety of Up-dosing Antihistamines in Chronic Spontaneous Urticaria: A Systematic Review of the Literature.

BACKGROUND AND OBJECTIVES: According to current guidelines, oral antihistamines are the first-line treatment for chronic spontaneous urticaria (CSU). Up-dosing antihistamines to 4-fold the licensed dose is recommended if control is not achieved. Such indications are based mainly on expert opinion. Objectives: To critically review and analyze clinical evidence on the efficacy and safety of higher-than-licensed dosage of second-generation oral antihistamines in the treatment of CSU. MATERIAL AND METHODS: A systematic literature review was performed following a sensitive search strategy. All articles published in PubMed, EMBASE, and the Cochrane Library between 1961 and October 2018 were examined. Publications with CSU patients prescribed secondgeneration antihistamines in monotherapy compared with placebo, licensed dosages, and/or higher dosages were included. Articles were evaluated by peer reviewers. Quality was evaluated using the Jadad and Oxford scores. RESULTS: We identified 337 articles, of which 14 were included in the final evaluation (fexofenadine, 6; cetirizine, 2; levocetirizine and desloratadine, 1; levocetirizine, 1; rupatadine, 2; ebastine, 1; and bilastine, 1). Only 5 studies were placebo-controlled. The number of patients included ranged from 20 to 439. The observation lapse was ≤16 weeks. High fexofenadine doses produced a significant dosedependent response and controlled urticaria in most patients. Cetirizine, levocetirizine, rupatadine, and bilastine were more effective in up-dosing. The most frequent adverse events were headache and drowsiness. CONCLUSION: The low quality and heterogeneity of the articles reviewed made it impossible to reach robust conclusions and reveal the need for large-scale randomized clinical trials.

Sensitization pattern of crustacean-allergic individuals can indicate allergy to molluscs.

This study investigated the sensitization pattern of crustacean-allergic patients according to tolerance to molluscs. Thirty-one patients with anaphylaxis to crustaceans (14 with mollusc allergy and 17 with mollusc tolerance) were studied using skin prick tests (SPTs), specific IgEs (sIgEs) and SDS-PAGE immunoblotting. IgE-reactive shrimp proteins were identified by proteomic analyses. Patients with mollusc allergy presented more frequently SPTs positive to molluscs and higher sIgE titres in response to both molluscs and crustaceans. Shrimp-sIgE and rPen a1-sIgE values of 1.57 kUA /l and 4.38 kUA /l, respectively, showed positive likelihood ratios of 4.3 and 10.9 for the identification of mollusc allergy. Patients with mollusc allergy reacted more frequently to tropomyosin in immunoblots than did patients without it (93% vs 35%, respectively, P = 0.004). Reactivity to proteins other than tropomyosin (n = 14) was not different between the two groups. Among patients with crustacean anaphylaxis, patients with mollusc allergy and mollusc tolerance show a different pattern of sensitization, something that may help identify them.

Cross-Sectional Validation of a Quality of Life Questionnaire in Spanish for Patients Allergic to Hymenoptera Venom.

INTRODUCTION AND OBJECTIVES: The first quality of life questionnaire for Vespula-allergic patients (Vespid Allergy Quality of Life Questionnaire [VQLQ) was developed in 2002. Our objective was to perform the cross-sectional validation of the Spanish version of this questionnaire. PATIENTS AND METHODS: Using the original English-language version of the VQLQ as a starting point, the Spanish translation and cultural adaptation were performed and the first Spanish version was backtranslated into English and discussed with the authors of the original version. The result was the Spanish Health-related Quality of Life Questionnaire for Hymenoptera Venom-Allergic Patients (HRQLHA). Cross-sectional validation was carried out in a multicenter study using a test-retest design. Patients over the age of 14 diagnosed with systemic allergic reaction to venom from Apis, Vespula, or Polistes species were included. The test-retest reliability, external validity, and internal consistency of the questionnaire were measured. RESULTS: The sample comprised 116 patients. The mean HRQLHA score was 3.48. Test-retest reliability showed an intraclass correlation coefficient of 0.85. HRQLHA showed a positive correlation (0.5) with an external questionnaire, thus demonstrating its external validity. Analysis of the internal consistency of the HRQLHA yielded a Cronbach α of 0.95, which can be considered to be excellent. CONCLUSIONS: Statistical analysis revealed the high test-retest reliability, internal consistency, and external validity of the HRQLHA. The HRQLHA is the first validated questionnaire to include patients allergic to Polistes species, which is common in our area. Our findings show that the questionnaire is also valid for these patients.

[Eosinophilic esophagitis due to allergy to sheep and goat milk proteins]. / Esofagitis eosinofílica por sensibilización a proteínas de leche de cabra y oveja.

Eosinophilic esophagitis is an inflammatory disease of the esophagus characterized by the presence of high numbers of eosinophils in the esophageal mucosal layer (> 20 high-power field). It is uncommon in adults but in such cases intermittent dysphagia and food impaction are the most common presenting symptoms. We report the case of a male with long-standing intermittent dysphagia after eating selected goat and sheep cheese types, who required medical help following the impaction of an ibuprofen pill in the esophagus. A biopsy demonstrated the presence of eosinophilic inflammation, and allergy testing showed specific IgE against proteins in the milk of goats and sheep. Topical steroid therapy with oral fluticasone, and the elimination of these dairy products from the diet induced complete symptom resolution, and biopsy specimens taken 4 months later showed no eosinophils.

Prawns, barnacles, and nonsteroidal anti-inflammatory drugs: effect modifiers or diagnostic confounders [corrected].

A 42-year-old woman with no history of atopy reported several episodes of generalized urticaria and shortness of breath after eating shellfish (prawns and barnacles) but with good tolerance of the same foods between episodes. Skin prick tests (SPTs), serum enzyme allergosorbent tests (EAST) for specific immunoglobulin (Ig) E, Western blot and inhibition assays, and oral challenge tests with prawns, barnacles, nonsteroidal anti-inflammatory drugs (NSAIDs), and alcohol as potential effect modifiers were performed. Specific IgE to both barnacle and prawn were detected by SPTs and EAST. Results from a Western blot of raw prawn revealed an IgE binding band of 37 kDa and IgE binding bands of 143, 83, 38, 32, and 20 kDa appeared in the raw barnacle assay. Oral challenge tests were positive with prawns and prawn extract only if preceded by NSAIDs. Oral challenges with NSAIDs alone, prawns alone, barnacles with or without NSAIDs and alcohol led to no reaction. A synergistic effect of NSAIDs in inducing anaphylaxis after prawn intake was confirmed. No similar effect was achieved with barnacles despite the presence of specific IgE. Additional factors needed to elicit a clinical reaction in food allergy may not be obvious and several oral challenge protocols are mandatory in such cases.

Anaphylaxis to Vespa velutina nigrithorax: Pattern of Sensitization for an Emerging Problem in Western Countries

Objective: To define the sensitization pattern of patients with anaphylaxis to Vespa velutina nigrithorax (VVN). Methods: We studied 100 consecutive Spanish patients with anaphylaxis to Hymenoptera venom and systematically determined specific IgE (sIgE) to whole venoms (Vespula species, Polistes dominula, Apis mellifera, Vespa crabro, and Dolichovespula maculata) and their molecular components (rApi m 1, rApi m 5, rApi m 10, rVes v 1, rVes v 5, rPol d 5, and cross-reactive carbohydrates). Specific IgE to VVN venom and its antigen 5 (nVesp v 5) were measured in a subsample. Results: Seventy-seven patients had anaphylaxis to VVN. Of these, only 16 (20.8%) reported previous VVN stings, but were stung by other Hymenoptera. Positive sIgE (>0.35 kUA/L) to each of the whole venoms was detected in >70% of patients (Vespula species in 100%). The components showing >50% positivity were rApi m 5 (51.4%), rPol d 5 (80.0%), and rVes v 5 (98.7%). This pattern was similar to that of Vespula species anaphylaxis (n=11) but different from that of A mellifera anaphylaxis (n=10). Specific IgE to nVesp v 5 was positive in all patients (n=15) with VVN anaphylaxis and was correlated with sIgE to both rVes v 5 (R=0.931) and rPol d 5 (R=0.887). Conclusions: VVN has become the commonest cause of Hymenoptera anaphylaxis in our area. Most cases report no previous VVN stings. Their sensitization pattern is similar to that of patients with anaphylaxis to other Vespidae. Specific IgE to antigen-5 from VVN, Vespula species, and P dominula are strongly correlated in patients with VVN anaphylaxis (AU)

Efficacy and Safety of Up-dosing Antihistamines in Chronic Spontaneous Urticaria: A Systematic Review of the Literature

Background: According to current guidelines, oral antihistamines are the first-line treatment for chronic spontaneous urticaria (CSU). Up-dosing antihistamines to 4-fold the licensed dose is recommended if control is not achieved. Such indications are based mainly on expert opinion. Objectives: To critically review and analyze clinical evidence on the efficacy and safety of higher-than-licensed dosage of second-generation oral antihistamines in the treatment of CSU. Material and Methods: A systematic literature review was performed following a sensitive search strategy. All articles published in PubMed, EMBASE, and the Cochrane Library between 1961 and October 2018 were examined. Publications with CSU patients prescribed secondgeneration antihistamines in monotherapy compared with placebo, licensed dosages, and/or higher dosages were included. Articles were evaluated by peer reviewers. Quality was evaluated using the Jadad and Oxford scores. Results: We identified 337 articles, of which 14 were included in the final evaluation (fexofenadine, 6; cetirizine, 2; levocetirizine and desloratadine, 1; levocetirizine, 1; rupatadine, 2; ebastine, 1; and bilastine, 1). Only 5 studies were placebo-controlled. The number of patients included ranged from 20 to 439. The observation lapse was ≤16 weeks. High fexofenadine doses produced a significant dosedependent response and controlled urticaria in most patients. Cetirizine, levocetirizine, rupatadine, and bilastine were more effective in up-dosing. The most frequent adverse events were headache and drowsiness. Conclusion: The low quality and heterogeneity of the articles reviewed made it impossible to reach robust conclusions and reveal the need for large-scale randomized clinical trials (AU)

Telangiectasia macularis eruptiva perstans presented as a pseudoallergic food reaction.

Telangiectasia macularis eruptiva perstans (TMEP) is a rare form of cutaneous mastocytosis observed in less than 1% of cases of mastocytosis. Clinically, anaphylaxis may appear as a result of increased mast cell degranulation in different circumstances. A case of TMEP presented as pseudoallergic reactions to foods is reported in which the appearance of typical lesions on the trunk and their histological analysis together with a negative food allergy study confirmed the diagnosis.

Factors influencing the clinical picture and the differential sensitization to house dust mites and storage mites.

Sensitization to house dust mites and storage mites has been studied in a number of papers, but several environmental factors and clinical conditions that differently affect sensitization to these mites are still controversial. The purpose of this study was to determine the influence of climatic conditions, occupation and patient age in the differential sensitization to house dust and storage mites, and also to search for possible different symptoms caused by each group of mites. Eighty patients sensitized to mites but not to other inhalant allergens were studied by case history and by skin prick test and serum IgE to Dermatophagoides pteronyssinus. Dermatophagoides farinae, Lepidoglyphus destructor and Tyrophagus putrescentiae. Home conditions, including content of the allergens Der p 1, Der f 1, Lep d 2 and Tp, were determined for all patients. Human activities, such as farming or similar occupations, and humidity are conditions for preferential sensitization to storage mites, while we found no difference between living in rural or urban areas. Mean age for the onset of sensitization was 6.7 years for house dust mites and 18.7 years for storage mites. Conjunctivitis was more frequent in patients allergic to storage mites, whereas perioral syndrome (itching of the tongue and swelling of the lips) was only seen in patients sensitized to T. putrescentiae. We concluded that climatic and damp conditions and human activity, but not urban or rural living environments, influence the differential sensitization to house dust mites and storage mites.

Relationship of clinical and aerobiological pollen data in the north-west of Spain.

BACKGROUND: few studies report clinical and aerobiological pollen data in the north-west of Spain, a region similar to northern and central Europe. Moreover, it is difficult to obtain patients' collaboration in filling out symptom cards. The aim of this study was to establish a relationship between pollen types and clinical data obtained through questionnaire and telephone calls. PATIENTS AND METHODS: from January to December 2000, 24 patients aged 28 10.6 years and allergic to pollens were studied. The seasonal and hourly rhythm of symptoms and their intensity were obtained monthly by telephone calls. Atmospheric pollen was collected over the same period using a Hirst-type volumetric pollen sampler. RESULTS: the most important pollen types recorded were Poaceae, Betula, Parietaria and Plantago. Most patients (83 %) showed symptoms during March and in the period between May and July (99 %), which coincided with the greatest quantity of atmospheric pollen. Fifty-six percent of the patients complained of symptoms during the first hours of the morning, 63 % during the central hours of the day and 22 % at nightfall. In specific sensitizations, symptoms were more evident during the hours of maximum atmospheric levels of their taxa. CONCLUSIONS: the method employed in the present study to obtain information on patients' symptomatology (telephoning their homes once a month) proved useful and revealed a clear relationship between the presence of certain pollens in the atmosphere and the development of symptoms.

Cross-sectional validation of a quality of life questionnaire in spanish for patients allergic to hymenoptera venom

Introducción: En 2002 se desarrolló el primer cuestionario de calidad de vida para alérgicos a veneno de Vespula (VQLQ). El objetivo de este trabajo es desarrollar y validar una versión en español de este cuestionario. Métodos y Pacientes: Partiendo del VQLQ en inglés se realizó la traducción al español y adaptación cultural del cuestionario con una posterior retraducción consensuada con los autores de la versión original. Así se desarrolló el cuestionario de calidad de vida en español para pacientes alérgicos a veneno de himenópteros (HRQLHA). La validación transversal se realizó mediante un estudio multicéntrico, con diseño test-retest en el que se incluyeron pacientes mayores de 14 años con reacción sistémica por alergia a veneno de Apis, Vespula o Polistes . Se analizó la fiabilidad test-retest, la validez externa y la consistencia interna del cuestionario. Resultados: Se incluyeron 116 pacientes alérgicos a venenos de Apis, Vespula o Polistes . La puntuación media del HRQLHA fue 3.48. El estudio de fiabilidad test-retest mostró un coeficiente de correlación intraclase de 0.85. El HRQLHA mostró una correlación positiva (0.5) con el cuestionario de referencia externa, confirmando su validez. En el análisis de la consistencia interna se encontró una Alpha de Cronbach de 0.95 Conclusiones: El análisis estadístico muestra una elevada fiabilidad test-retest y consistencia interna del HRQLHA, además de su validez externa. En la validación del HRQLHA se han incluido por primera vez pacientes alérgicos a veneno de Polistes, muy prevalente en nuestra área, demostrando la utilidad del cuestionario también en estos pacientes (AU)

Introduction and Objectives: The first quality of life questionnaire for Vespula-allergic patients (Vespid Allergy Quality of Life Questionnaire [VQLQ]) was developed in 2002. Our objective was to perform the cross-sectional validation of the Spanish version of this questionnaire. Patients and Methods: Using the original English-language version of the VQLQ as a starting point, the Spanish translation and cultural adaptation were performed and the first Spanish version was backtranslated into English and discussed with the authors of the original version. The result was the Spanish Health-related Quality of Life Questionnaire for Hymenoptera Venom–Allergic Patients (HRQLHA). Cross-sectional validation was carried out in a multicenter study using a test-retest design. Patients over the age of 14 diagnosed with systemic allergic reaction to venom from Apis, Vespula, or Polistes species were included. The test-retest reliability, external validity, and internal consistency of the questionnaire were measured. Results: The sample comprised 116 patients. The mean HRQLHA score was 3.48. Test-retest reliability showed an intraclass correlation coefficient of 0.85. HRQLHA showed a positive correlation (0.5) with an external questionnaire, thus demonstrating its external validity. Analysis of the internal consistency of the HRQLHA yielded a Cronbach a of 0.95, which can be considered to be excellent. Conclusions: Statistical analysis revealed the high test-retest reliability, internal consistency, and external validity of the HRQLHA.The HRQLHA is the first validated questionnaire to include patients allergic to Polistes species, which is common in our area. Our findings show that the questionnaire is also valid for these patients (AU)

Nonpigmenting fixed drug eruption due to pseudoephedrine.

BACKGROUND: The nonpigmenting fixed drug eruption is a distinctive drug reaction characterized by large, tender and symmetric erythematous plaques that disappear with no residual pigmentation. METHODS: A case of a non-pigmenting fixed drug eruption due to pseudoephedrine is reported. RESULT: The reappearance of typical lesions at the same sites after oral challenge with 60 mg pseudoephedrine together with the absence of pigmentation confirm the diagnosis. CONCLUSION: A new case of proven nonpigmenting fixed drug eruption to pseudoephedrine is described.

Influence of alcohol consumption on serum immunoglobulin E levels in atopic and nonatopic adults.

BACKGROUND: Total and specific serum immunoglobulin E (IgE) are routinely used as diagnostic tools in allergy clinics. Several studies have demonstrated an increase of total serum IgE concentrations in alcoholics, but the possible influence of lower quantities of ethanol intake on serum IgE values has not been fully evaluated. This study was aimed at analyzing the influence of alcohol intake on both total and specific serum IgE concentrations in patients studied in an allergy clinic. METHODS: A total of 460 patients were included in the study. According to skin-prick tests to common aeroallergens, 325 were classified as atopics and 135 as nonatopics. Most atopic patients (253; 78%) were allergic to mites. Alcohol consumption was recorded as the number of standard (10-g) drinking units regularly consumed per week. Two hundred subjects (43%) were abstainers, and 260 (57%) were regular consumers of a median of 30 g of alcohol per week. Total serum IgE was measured in all patients by latex-enhanced nephelometry. Serum-specific IgE was assayed by fluoroenzymeimmunoassay. RESULTS: Total serum IgE increased along with ethanol consumption. On multivariate analysis, regular alcohol consumption greater than 70 g per week was associated with increased total serum IgE levels, even when adjusting for age, sex, atopy, and smoking. Among house-dust mite-allergic patients, specific serum IgE values against the house dust mite Dermatophagoides pteronyssinus were higher in regular alcohol consumers than in abstainers. This difference was not observed among patients allergic to grass pollen (Lolium perenne). CONCLUSIONS: Alcohol consumption, even in moderate quantities, is associated with increased total and specific IgE concentrations in subjects studied in an allergy clinic. Alcohol intake should be taken into account in epidemiological studies of total serum IgE levels.

Esofagitis eosinofílica por sensibilización a proteínas de leche de cabra y oveja / No disponible

La esofagitis eosinofílica, entidad caracterizada por la infiltraciónde la mucosa esofágica por más de 20 eosinófilos por campo degran aumento, se suele presentar en forma de disfagia intermitentede larga evolución, pudiendo estar asociada a sensibilización alérgicaa aeroalérgenos y/o alimentos. Presentamos el caso de un varóncon clínica de disfagia intermitente coincidiendo con la toma dequesos curados de oveja y cabra que precisó asistencia urgente trasla impactación de un comprimido de ibuprofeno a 30 cm de la arcadadentaria. El estudio practicado demostró la existencia de estenosisen el esófago a ese nivel con infiltración eosinofílica difusa ysensibilización a proteínas de la leche de cabra, oveja y vaca, conespecial relevancia para la IgG bovina, lactoferrina y albúmina sérica.Tras tratamiento con fluticasona deglutida y medidas de evitaciónse consiguió la resolución del cuadro clínico y la desapariciónde los eosinófilos en la mucosa

Eosinophilic esophagitis is an inflammatory disease of theesophagus characterized by the presence of high numbers ofeosinophils in the esophageal mucosal layer (> 20 high-powerfield). It is uncommon in adults but in such cases intermittent dysphagiaand food impaction are the most common presentingsymptoms. We report the case of a male with long-standing intermittentdysphagia after eating selected goat and sheep cheesetypes, who required medical help following the impaction of anibuprofen pill in the esophagus. A biopsy demonstrated the presenceof eosinophilic inflammation, and allergy testing showedspecific IgE against proteins in the milk of goats and sheep. Topicalsteroid therapy with oral fluticasone, and the elimination ofthese dairy products from the diet induced complete symptomresolution, and biopsy specimens taken 4 months later showed noeosinophils