Immediate hypersensitivity reaction to human serum albumin in a child undergoing plasmapheresis.

BACKGROUND: Human serum albumin (HSA) is a commonly used colloid for volume expansion and albumin replacement and during plasmapheresis. Colloids are an uncommon cause of anaphylaxis, and cases of hypersensitivity reactions to HSA are extremely rare. CASE REPORT: A 10-year-old boy with chronic inflammatory demyelinating polyneuropathy was treated with plasmapheresis, with albumin as the replacement fluid. He developed a severe reaction characterized by respiratory, gastrointestinal, and cutaneous symptoms. RESULTS: Skin testing to HSA was positive and resulted in objective systemic symptoms, suggesting an immediate hypersensitivity reaction to HSA. CONCLUSION: While colloids are an uncommon cause of immediate hypersensitivity reactions, they can lead to severe and potentially fatal reactions if not recognized and treated promptly.

Efficacy and safety of omalizumab in pediatric patients with high immunoglobulin E levels: A case series.

BACKGROUND: The efficacy and safety of omalizumab has been demonstrated in children as young as 6 years of age. Omalizumab is currently approved for a range of immunoglobulin E (IgE) levels that differ by age. In patients with IgE levels higher than the indicated therapeutic window, only a few studies have demonstrated the efficacy and safety of its use. Specifically, no reported studies exist to describe the use of omalizumab in pediatric patients with asthma ages <12 years and with high IgE levels. OBJECTIVE: We reported a series of pediatric patients who were initiated on omalizumab despite an IgE level higher than the age-indicated therapeutic windows and aimed to describe whether omalizumab was safe and improved asthma outcomes. METHODS: Patients who initiated omalizumab in our pediatric allergy clinic between January 2008 and December 2015, with serum IgE levels higher than the age-indicated therapeutic ranges were included. Patient charts were reviewed to determine the number of asthma-related events in the 12 months before and after initiation of omalizumab and the Asthma Control Test™ scores at the time of initiation and at 12 months of therapy. RESULTS: Eleven patients were identified with pretreatment IgE levels higher than the age-approved thresholds. Five patients were ages <12 years, and six patients were ages >12 years. For all but one patient, the maximum recommended dose of 375 mg every 2 weeks was effective in reducing the need for corticosteroids, emergency department visits, or hospitalizations in the year after initiation of therapy. During the period of therapy, there were no reports of severe reactions. CONCLUSION: Despite a small study group, our results indicated that omalizumab may be safely used in pediatric patients with IgE levels higher than the indicated therapeutic windows.

Epidemiology of atopic dermatitis: a review.

Atopic dermatitis (AD) is a common skin condition with significant associated social and financial burden. AD affects adults and children with worldwide prevalence rates of 1-20%. International study of epidemiology and geographic variability in prevalence of AD has been conducted in three phases with 1,000,000 subjects in the third phase study. Prevalence continues to vary and has changed in different regions of the world. Nigeria, the United Kingdom and New Zealand had been areas of the highest prevalence; Latin America has emerged as a region of relatively high prevalence in follow up data. The prevalence of AD seems to have reached a plateau around 20% in countries with the highest prevalence, suggesting that AD may not be on a continued rise but that a finite number of individuals may be susceptible to the condition. Risk factors associated with increased prevalence include higher socioeconomic status, higher level of family education, smaller family size and urban environment. Research indicates that food allergy and atopic sensitization to environmental allergens may not be directly causal of the condition and that a non-atopic form of the condition exists. ∼60% of patients will experience remission. The number of patients who will progress through the atopic march to develop asthma and allergic rhinitis depends on the underlying features of their condition.

Systemic reactions associated with subcutaneous allergen immunotherapy: timing and risk assessment.

BACKGROUND: Subcutaneous allergen immunotherapy (SCIT) is associated with risk of systemic reaction. Although risk factors have been identified, the incidence of immunotherapy-related systemic reactions has not changed in recent years. OBJECTIVES: To examine patterns of systemic reaction and determine whether risk of systemic reaction from SCIT is associated with patterns of response to skin tests to inhalant allergens recorded before receiving SCIT. METHODS: We carried out a retrospective review from January 2001 to December 2007. Patterns of systemic reaction from immunotherapy were examined. Cases were matched with controls by age (±10 years), sex, and time of injection (±1 week) to determine whether a pattern of more than 33% 3+ and 4+ skin test responses is associated with elevated risk for systemic reaction. RESULTS: Rate of systemic reaction from SCIT was 0.28% (46/16,375) per injection visit. Twenty patients had 46 systemic reactions. All severe reactions occurred within 30 minutes. The estimated odds of systemic reaction were almost 6 times higher for patients with more than 33% 3 to 4+ positive skin tests (OR = 5.83; 95%CI: 1.23-27.59, P = .026). For each additional 4+ skin test, the estimated odds for systemic reaction increased by 17% (P = .020). CONCLUSIONS: A small number of patients receiving SCIT account for a large proportion of systemic reactions. Skin test patterns demonstrating a greater number of larger skin tests responses to inhalant skin testing are associated with significantly elevated risk for systemic reaction in patients receiving SCIT.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations.

OBJECTIVES: A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization. METHODS: Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group. RESULTS: From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02). CONCLUSIONS: A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.