Should patients with a large local reaction be offered VIT? A Pro-Con debate.

Insect stings can cause large local reactions (LLRs) that are IgE-mediated and associated with considerable morbidity. A risk for systemic reactions including anaphylaxis to subsequent stings has been reported and is often noted by patients and health care providers. Guidelines do not recommend venom immunotherapy (VIT) for LLR based on the relatively low risk of anaphylaxis, but this is debated in this review. On the Pro side: the risk of anaphylaxis may be higher than reported in the limited literature, especially in patients who had only 1 LLR; new species with more potent stings are spreading into new areas; the quality of life can be markedly impaired by LLR; VIT is generally safe and highly effective. On the Con side: LLR are benign; stings occur infrequently; VIT has significant cost; systemic reactions occur more often to VIT than to stings in patients with LLR; FDA approval and published guidelines do not recommend VIT for LLR. In practice, shared decision-making is appropriate to incorporate knowledge of the natural history and known high-risk factors in the context of the patient's personal values and preferences.

Safety and Adherence to Venom Immunotherapy During COVID-19 Pandemic.

BACKGROUND: According to expert consensus, the time interval between Hymenoptera venom immunotherapy (VIT) injections can be extended up to 12 weeks, without significant impact on efficacy and safety. However, the coronavirus disease 2019 pandemic caused longer delays, and no recommendations are available to manage this huge extension. OBJECTIVES: To provide advice on how to resume VIT safely after a long delay from the last injection considering the potential risk factors for side effects, without starting again with the induction phase. METHODS: All the patients who delayed VIT because of the pandemic were consecutively enrolled in this single-center study. The time extension was decided according to their risk profile (eg, long prepandemic time interval, severe pre-VIT reaction, older age, multitreatments), and correlation analyses were performed to find potential risk factors of side effects. RESULTS: The mean delay from the pre- (7 weeks) to the postpandemic VIT interval (15.5 weeks) was 8.5 weeks. The total amount of the prepandemic VIT maintenance dose was safely administered in 1 day in 78% of patients, whereas only 3, of 87, experienced side effects, and their potential risk factors were identified in bee venom allergy and recent VIT initiation. CONCLUSIONS: In a real-world setting, long VIT delays may be safe and well tolerated, but more caution should be paid in resuming VIT in patients with long prepandemic maintenance interval, severe pre-VIT reaction, recent VIT initiation, older age, multidrug treatments, and bee venom allergy. This is useful in any case of long, unplanned, and unavoidable VIT delay.

RItA: The Italian severe/uncontrolled asthma registry.

BACKGROUND: The Italian severe/uncontrolled asthma (SUA) web-based registry encompasses demographic, clinical, functional, and inflammatory data; it aims to raise SUA awareness, identifying specific phenotypes and promoting optimal care. METHODS: Four hundred and ninety three adult patients from 27 Italian centers (recruited in 2011-2014) were analyzed. RESULTS: Mean age was 53.8 years. SUA patients were more frequently female (60.6%), with allergic asthma (83.1%). About 30% showed late onset of asthma diagnosis/symptoms (>40 years); the mean age for asthma symptoms onset was 30.2 years and for asthma diagnosis 34.4 years. 97.1% used ICS (dose 2000 BDP), 93.6% LABA in association with ICS, 53.3% LTRAs, 64.1% anti-IgE, 10.7% theophylline, and 16.0% oral corticosteroids. Mean FEV1 % pred of 75.1%, median values of 300/mm3 of blood eosinophil count, 323 kU/L of serum total IgE, and 24 ppb of FENO were shown. Most common comorbidities were allergic rhinitis (62.4%), gastroesophageal reflux (42.1%), sinusitis (37.9%), nasal polyposis (30.2%), and allergic conjunctivitis (30.2%). 55.7% of SUA patients had exacerbations in the last 12 months, 9.7% emergency department visits, and 7.3% hospitalizations. Factors associated with exacerbation risk were obesity (OR, 95% CI 2.46, 1.11-5.41), psychic disorders (2.87, 0.89-9.30-borderline), nasal polyps (1.86, 0.88-3.89-borderline), partial/poor asthma treatment adherence (2.54, 0.97-6.67-borderline), and anti-IgE use in a protective way (0.26, 0.12-0.53). Comparisons to severe asthma multicenter studies and available registries showed data consistency across European and American populations. CONCLUSIONS: An international effort in the implementation of SUA patients' registries could help to better understand the clinical features and to manage severe asthma, representing a non-negligible socioeconomic burden for health services.

Component resolved diagnosis in real life: the risk assessment of food allergy using microarray-based immunoassay.

BACKGROUND: The development of component-resolved diagnostics constitutes a potential breakthrough in food allergy testing, as detection of specific IgE (sIgE) to individual allergens may make it possible to establish the risk of a mild versus severe reaction. OBJECTIVE: To compare allergists' risk assessment based on the current decision making process with that of virtual allergen-oriented risk assessment through microarray-based immunoassay. METHODS: An observational, real-life study was performed on 86 adults with food allergy. The prescription of epinephrine was the surrogate marker of a severe reaction. In the same patients, the prescription of epinephrine based on the current decision making of the allergist and the independently established allergen-oriented risk assessment determined by microarray-based immunoassay were compared. RESULTS: Fair degree of agreement between the specialists' risk assessment and that of the microarray-based immunoassay (k index 0.372 (95% CI: 0.185- 0.559) p < 0.001) was documented. Three causes of discrepancy emerged: the poor sensitivity of the allergen microarray-immunoassay (51.9%), the differences in risk assessment established by the specialist and the microarray-immunoassay (33.3%), the non-inclusion of the causative allergen in the microarray-immunoassay platform (14.8%). CONCLUSION: Improvement of the diagnostic accuracy of microarray-immunoassay, combined with marrying its results to clinical information, could one day soon lead to changes in clinical practice in food allergy.

Honeybee venom immunotherapy: a comparative study using purified and nonpurified aqueous extracts in patients with normal Basal serum tryptase concentrations.

In this study, we compared a purified aqueous extract and the corresponding nonpurified aqueous preparation under the same build-up protocol in bee venom allergic patients with a normal baseline mast cell tryptase concentration. Eighty patients with a history of a systemic reaction were enrolled for immunotherapy using a 5-day rush protocol. Patients treated with the purified extract and those treated with the non purified aqueous extract who developed a systemic reaction underwent maintenance therapy with the purified aluminium hydroxide adsorbed preparations. Patients treated with the nonpurified aqueous extract who did not experience a systemic reaction during the rush phase underwent the maintenance phase with that extract. Systemic reactions during the build-up phase occurred significantly more often in patients treated with nonpurified aqueous extract than in those treated with the corresponding purified aqueous preparations. During the one-year maintenance phase, no systemic reactions occurred in either of the groups. Neither age nor baseline mast cell tryptase concentration presented a significant correlation with the occurrence of a systemic reaction during the treatment, while the type of extract did. In conclusion, nonpurified aqueous extracts induced more frequent systemic reactions than the purified aqueous preparations, during the same rush protocol. The efficacy seemed to be comparable.

Hen egg hair mask-induced food allergy: a case report.

We report the case of a 46-year-old woman who treated her hair with a homemade egg-white based mask. After one year of weekly applications, the ingestion of egg triggered rhinitis, choking and systemic urticaria. Though the breakdown of oral tolerance to egg has been reported elsewhere in the literature, to the best of our knowledge, this is the first case of hair mask-induced allergy.

Congruence between international guidelines and mite specific immunotherapy prescribing practices.

Both rhinitis (ARIA) and asthma (GINA) guidelines recommend allergen-specific immunotherapy (SIT) tailored to the specific levels of severity of each disease. Real world studies evaluating congruence between these recommendations and prescribing practice in the single patient with comorbidity are lacking. An observational polycentric study was carried out in 518 patients recruited from 34 allergy centers throughout Italy. A questionnaire was administered to each consecutive patient over a span of four months. Taking into account guideline recommendations for both diseases, concomitant in the same patient, three subsets resulted: patients not eligible for SIT (11%); patients eligible for SIT for one disease only (60%); patients eligible for SIT for both diseases (29%). SIT was prescribed in 257 (49.6%) subjects. The level of SIT prescription was about 50% in all three groups. Consistent with the ARIA guidelines, a correlation between the prescription of SIT and the severity of rhinitis was documented (r=0.87; p=0.001). An association with asthma severity was found (p=0.02), but the trend was inconsistent with the GINA recommendations. Young age was the most important factor for SIT prescription both in the eligible for one disease and in the eligible for both diseases subset. The tendency towards worsening of symptoms was a factor for SIT in the eligible for one disease subset. In mite allergic patients with rhinitis and asthma comorbidity, the severity of rhinitis and the young age are the most important factors driving the SIT prescription. The congruence of SIT prescription was better for the ARIA than GINA guidelines.

Characterization and comparison of commercially available mite extracts for in vivo diagnosis.

BACKGROUND: Assessment of sensitization by allergen-specific IgE testing and skin prick testing (SPT) are primary tools in routine clinical diagnosis of allergies. To perform a correct diagnosis, it is critical that the allergen reagent used contains an adequate amount of all relevant components. This study aimed at evaluating commercially available mite extracts for in vivo diagnosis from eight manufacturers. METHODS: Eight extracts from Dermatophagoides pteronyssinus and eight from Dermatophagoides farinae were analysed for total protein content by Bradford and for major allergen content by ELISA. SDS-PAGE, immunoblotting and SPT were also carried out. RESULTS: The protein amount ranged from 27.7 microg/ml extract to 361.1 microg/ml (D. pteronyssinus) and from 20.3 to 353.0 microg/ml (D. farinae). In regards major allergen concentration, Der p 1 ranged from 9.6 to 36.2 microg/ml, Der f 1 26.5-196.1 microg/ml, mite group 2 0.7-31.7 microg/ml in D. pteronyssinus and 1.3-10.4 microg/ml in D. farinae. SDS-PAGE experiments showed that some components are poorly represented or absent in extracts from most manufacturers. Similar results were obtained by IgE-immunoblotting and SPT with 10 mite allergic patients confirmed a broad spectrum of reactivity of the extracts in the same subject. CONCLUSIONS: Immunochemical analysis showed a heterogeneous amount of component/s among mite extracts from different manufacturers. These data were confirmed by in vivo testing, suggesting that, for some of the patient tested, the absence of relevant allergens could strongly affect the diagnosis.

Allergic rhinitis and associated pathologies: the rationale for steroid options.

The aim of this review article is to provide greater insight into the relationship between allergic rhinitis and the three most frequently diagnosed conditions of exacerbating viral infections, chronic rhinosinusitis with polyps and obstructive sleep apnoea syndrome. The alleged physiopathological effects of steroids are also investigated within the scope of this paper. Regarding the exacerbating viral infections, seems to establish a dynamic and counter relationship between the load and nature of the viral infection on one hand and widespread and pre-existing allergic inflammation on the other. If chronic rhinosinusitis with polyps and allergic rhinitis present overlapping picture of inflammatory cell and cytokine, the etyiological relationship between the two conditions appears to be influenced by the type of antigenic stimulus. Allergic rhinitis can influence the presence of OSAS through both obstructive and inflammatory mechanical factors. Topical corticosteroid therapy is a promising candidate as a new therapeutic tool able to improve symptoms and quality of life in patient with chronic rhinosinusitis with polyps and obstructive sleep apnoea syndrome. Other study are necessary to elucidate relationship between corticosteroids therapy and hypothetical benefit effect on viral infection when concomitant atopy inpatient.

Lymphotrophic nanoparticle enhanced MR imaging (LNMRI) for lymph node imaging.

Nodal staging is an integral part of the pretreatment staging of any patient with malignancy and has therapeutic and prognostic implications. Currently used imaging techniques used for nodal evaluation are limited in accuracy because they rely on size criteria for the detection of metastases. This has led to the emergence of lymphotropic nanoparticle enhanced magnetic resonance imaging as a promising tool for nodal characterization. This article reviews the properties of lymphotropic iron oxide nanoparticles and the technique, image interpretation, and initial clinical experience with lymphotropic nanoparticle enhanced magnetic resonance imaging.