Food protein-induced enterocolitis syndrome by fish: Not necessarily a restricted diet.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food hypersensitivity usually due to cow's milk or soy. Recent researches show that fish is 1 of the most important triggers of FPIES in the Mediterranean countries. Due to the risk of multiple-food FPIES, avoiding foods in the same category or that often occur together may be reasonable. The aim of this study was to evaluate the evolution and follow-up of FPIES related to fish over a period of 20 years. We describe the clinical features of our population, discuss different approaches to oral food challenges, and analyze the possibility of introducing the culprit fish or other nonrelated fish to avoid unnecessary restricted diets.

Social Media as a Tool for the Management of Food Allergy in Children.

BACKGROUND: Food allergy markedly impairs quality of life, and avoiding the offending food requires extensive patient education. Social media have been proven a useful source of information for other chronic conditions. Our aim was to describe how pediatric patients with food allergy and their families are using social media. METHODS: We performed a cross-sectional study in the pediatric allergy unit of a tertiary hospital. Patients with food allergy were questioned about their disease and their use of social media. The survey was completed by the patients themselves in the case of those aged over 13 years and by parents or guardians in the case of younger patients. RESULTS: We included 193 patients (162 guardians, 31 adolescents). Social media were used by 109 guardians (67.3%) and 29 adolescents (90.3%), of whom 30.3% and 6.9%, respectively, used them for food allergy-related purposes. The most popular websites were Facebook for guardians (52.2%) and YouTube for teenagers (80.6%). Having cow's milk and/or egg allergy was the only feature related to using social media for food allergy. Using social media for information on food allergy did not correlate with the frequency of recent reactions, self-scored knowledge about food allergy, or opinion on evidence-based or alternative therapies for the disease. CONCLUSIONS: Most patients and guardians of patients with food allergy used social media. However, only a small portion accessed used them to increase their knowledge of the disease.

Clinical and immunological profile of children aged 5-9 years with persistent egg allergy before oral immunotherapy with egg. A multicenter, randomized controlled trial of the Spanish Society of Pediatric Allergy, Asthma and Clinical Immunology (SEICAP).

BACKGROUND: In children with egg protein allergy (EA), the probability of overcoming the allergy decreases with age, and the possibility of suffering severe adverse reactions as a consequence of dietetic transgressions results in worsened quality of life. One treatment option in such cases is oral immunotherapy (OIT) with foods. METHODS: We present a cohort of children with EA scheduled for OIT with pasteurized raw egg white, describing their clinical and allergic characteristics before the start of OIT. RESULTS: The median age was six years, and 93% of the patients also suffered other allergies (58% asthma and 38.6% allergy to more than two food groups). In the last year, 14.8% had suffered a severe reaction due to dietetic transgression with egg. The median IgE specific of egg white titer was 38.5kU/l. A double-blind placebo-controlled food challenge with cooked egg white was performed, and if the test proved positive, it was repeated with pasteurized raw egg white. The mean symptoms-provoking dose was 1.26g and 0.55g for cooked egg white and raw egg white, respectively. An IgE specific of ovomucoid titer of <2.045kU/l differentiated those patients that tolerated cooked egg white. CONCLUSIONS: OIT with egg is regarded as an option in patients with persistent egg allergy. In the previous challenge test, an IgE specific of ovomucoid titer of <2.045kU/l differentiates those patients that tolerate cooked egg white.

Skin test-positive immediate hypersensitivity reaction to iodinated contrast media: the role of controlled challenge testing.

BACKGROUND: Immediate hypersensitivity reactions (IHR) to iodinated contrast media (ICM) have traditionally been considered nonallergic; however, the increasingly frequent reporting of positive skin test and basophil activation test results suggests a specific allergic mechanism in some patients. Skin tests have been proposed as a useful tool for diagnosis, although their sensitivity and predictive values remain to be determined. The role of controlled challenge testing has not been assessed. OBJECTIVE: We aimed to evaluate the role of controlled challenge testing in skin test-positive IHR to ICM. PATIENTS AND METHODS: We evaluated 106 patients with IHR to ICM by performing skin tests with the agent that caused the reaction. Patients with a positive result were selected. Skin tests were extended to a series of 8 ICMs; 5 patients underwent controlled challenge test with an alternative skin test-negative ICM; a further 2 patients underwent computed tomography with an alternative skin test-negative ICM. No premedication was administered. RESULTS: Intradermal test results were positive to the ICM that caused the reaction in 11 out of 106 patients (10.4%). Five of the 11 patients tolerated a controlled challenge test with an alternative skin test-negative ICM. The 2 patients who underwent computed tomography with an alternative skin test-negative ICM tolerated the medium. CONCLUSIONS: Skin tests are useful for the diagnostic workup in patients with an allergic IHR to ICM. Since ICM cannot be avoided in many patients because they are irreplaceable in some diagnostic or therapeutic techniques, an alternative safe ICM should be investigated for future procedures. We propose the use of controlled challenge tests based on skin test results to address this need in skin test-positive reactions in order to identify an alternative non-cross-reactive ICM.

Specific oral tolerance induction in paediatric patients with persistent egg allergy.

INTRODUCTION: Desensitisation or specific oral tolerance induction (SOTI) to food is a new topical-therapeutic approach of food allergy for those children who have not achieved tolerance spontaneously. The objective of this study is to induce clinical tolerance in children with persistent allergy using an oral desensitisation protocol with powdered pasteurised egg. METHODS: Seventy-two patients with egg allergy confirmed by open oral challenge test were randomly assigned to SOTI or elimination diet as a control group. Forty children (5-15 years) underwent a SOTI beginning with 1mg and increasing the dosage weekly until a dose of 10g, equivalent to an egg. The control group included 32 patients (4-15 years). RESULTS: The procedure's average duration was 10 weeks (range 4-28 weeks). Three patients were withdrawn from the protocol for persistent gastrointestinal symptoms. During SOTI, 21 children (52.5%) presented symptoms. In eight the symptoms were mild and required no treatment. In the other 13 (61.90%), the reactions were more severe. Seventeen children finished the treatment over a year ago and 20 in the past 6-12 months. Thirty-seven patients (92.5%) in the active group achieved tolerance to egg, versus 21.8% in the control group. We only found statistically significant differences (p<0.05) for skin prick tests with powdered egg at various dilutions and IgG levels with egg white after SOTI. Specific IgE concentration did not change significantly. CONCLUSIONS: Our SOTI protocol is a safe, effective treatment for food allergy and of reasonable duration, confirming that tolerance can be induced in children who have not achieved it spontaneously.

Oral desensitization as a useful treatment in 2-year-old children with cow's milk allergy.

BACKGROUND: Limited published evidence shows oral desensitization to be a potential intervention option for cow's milk protein (CMPs) allergy. OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of oral desensitization in 2-year-old children with cow's milk allergy, as a treatment alternative to elimination diet. METHODS: A total of 60 children aged 24-36 months with IgE-mediated allergy to CMPs were included in this multi-center study and were randomized into two groups. Thirty children (group A: treatment group) began oral desensitization immediately, whereas the remaining 30 (group B: control group) were kept on a milk-free diet and followed-up for 1 year. RESULTS: After 1-year follow-up period, 90% of the children in group A had become completely tolerant vs. 23% of the children in group B. In group A, cow's milk skin reactivity and serum-specific IgE to milk and casein decreased significantly from the initial assessment, whereas group B showed no significant change after 1 year of follow-up. Twenty-four patients (80%) developed some reaction during the treatment period: 14 children developed moderate reaction (47%) and 10 mild reaction (33%). The most common manifestations were urticaria-angioedema, followed by cough. CONCLUSIONS AND CLINICAL RELEVANCE: In this study, oral desensitization was found to be effective in a significant percentage of 2-year-old children with cow's milk allergy. Oral desensitization appears to be efficacious as an alternative to elimination diet in the treatment of 2-year-old children with cow's milk allergy. The side-effect profile appears acceptable but requires further study.

Clinical evolution of patients with respiratory allergic disease due to sensitisation to Alternaria alternata being treated with subcutaneous immunotherapy.

INTRODUCTION: Sensitisation to Alternaria is a cause of respiratory disease in Spain, particularly in childhood, but it is also a significant marker of the severity of this disease. Therefore, the use of an aetiological treatment (allergen specific immunotherapy) is essential, and both subjective and objective clinical parameters should be used to follow up this treatment. OBJECTIVE: This open-label, uncontrolled, observational, prospective study was designed in order to study the evolution of these patients on allergen specific immunotherapy therapy in daily clinical practice and to assess the use of different monitoring tools. MATERIAL AND METHODS: A total of 99 patients were included. They were monosensitised to this perennial allergen and treated with subcutaneous allergen specific immunotherapy. After one year of follow-up, these patients were assessed for the presence of symptoms, use of medication, clinical incidents, quality of life and asthma control. RESULTS: After one year of treatment a significant fall was observed in the use of concomitant medication (ß2-agonists: p=0.0278, inhaled corticosteroids: p=0.0007, anti-leukotrienes: p=0.0495), nasal symptoms (p=0.0081), quality of life (PAQLQ, p<0.0001) and asthma control (ACQ, p<0.0001). Twenty-one patients had to attend emergency department due to exacerbation of their allergic disease, and only one of them had to be admitted to hospital. CONCLUSION: respiratory allergic disease due to Alternaria alternata is a disease which is hard to control, and in our daily practice, the use of specific subcutaneous immunotherapy can be of significant benefit in our paediatric patients.

Skin testing and drug provocation in the diagnosis of nonimmediate reactions to aminopenicillins in children.

BACKGROUND: Nonimmediate allergic reactions (NIR) to aminopenicillin include several entities, the most common of which are urticaria-like and maculopapular exanthemas. AIMS OF THE STUDY: To evaluate a group of children who developed one or more episodes of skin reactions suggestive of NIR after aminopenicillin administration. METHODS: The inclusion criteria required negative immediate skin tests and absence of specific IgE antibodies to different penicillins. Intradermal and patch tests were carried out with delayed readings and, if negative, a drug-provocation test including a full therapeutic course of the drug was given. Two different groups were compared: A) children with positive skin testing or a positive drug-provocation test and B) children with negative skin testing and good tolerance after a drug-provocation test. RESULTS: Group A was composed of 20 patients. Positive intradermal/patch tests were found in one patient and in the remaining 19, a positive response to a drug-provocation test confirmed the diagnosis. Group B (the control group) consisted of 19 patients with similar symptoms after aminopenicillin intake but good tolerance. No differences in age, dose or number of previous treatments were observed between the groups. The clinical entities were also similar in both groups. CONCLUSIONS: Reproducible nonimmediate skin reactions to aminopenicillins may occur in children in spite of negative skin testing. The value of this diagnostic procedure seems to be limited in this type of reaction, with drug-provocation tests (DPT) being a reasonable and safe alternative if the diagnosis has to be confirmed.

Oral desensitization in children with cow's milk allergy.

INTRODUCTION: Current treatment of food allergies consists of the elimination of the offending food from the diet. Desensitization or tolerance induction can be an alternative for those children who have not achieved tolerance spontaneously. We propose a cow's milk desensitization protocol carried out in an outpatient setting over a 9-10 week period. PATIENTS AND METHOD: Eighteen children older than 4 years with cow's milk protein allergy confirmed by open oral challenge with milk underwent a desensitization protocol beginning with 0.05 mL of cow's milk, reaching 1 mL on the first day, and increasing the dosage weekly until a dose of 200-250 mL of milk taken once a day was tolerated. RESULTS: By the end of the desensitization protocol, 16 of the 18 patients tolerated 200-250 mL of cow's milk in a single daily dose. The median length of the process was 14 weeks (interquartile range, 11-17 weeks). One patient withdrew due to recurrent symptoms with 2 mL and another reached a tolerance of 40 mL of milk a day. During the program, 11 children (68.75%) presented symptoms that were generally mild but which increased the length of the protocol. At the time of writing, the 16 patients who completed the program continue to tolerate milk, 13 of them for more than a year. CONCLUSIONS: Tolerance of cow's milk was achieved in 16 out of 18 patients who took part in this study. One patient only tolerated 40 mL, which prevents the risk of reactions caused by the inadvertent intake of the food substance; 1 patient is still on a milk-free diet. We believe this cow's milk desensitization protocol to be effective and reasonably safe.

[Consensus-based approach for severe paediatric asthma in routine clinical practice]. / Consenso para el abordaje del asma grave pediátrica en la práctica clínica habitual.

INTRODUCTION: Accurate identification of paediatric patients with severe asthma is essential for an adequate management of the disease. However, criteria for defining severe asthma and recommendations for control vary among different guidelines. MATERIAL AND METHODS: An online survey was conducted to explore expert opinions about the definition and management of severe paediatric asthma. To reach a consensus agreement, a modified Delphi technique was used, and practice guidelines were prepared after the analysis of the results. RESULTS: Eleven paediatric chest disease physicians and allergy specialists with wide expertise in severe asthma responded to the survey. Consensus was reached in 50 out of 65 questions (76.92%). It was considered that a patient has severe asthma if during the previous year they have required 2 or more cycles of oral steroids, required daily treatment with medium doses of inhaled corticosteroids (with other controller medication) or high doses (with or without other controller medication), did not respond to optimised conventional treatment, or if the disease threatened the life of the patient or seriously impairs their quality of life. The definition of severe asthma may also include patients who justifiably use health resources on a regular basis, or have psychosocial or environmental factors impeding control. For monitoring, the use of questionnaires designed specifically for paediatric population, such as CAN or ACT, is recommended. As regards treatment, the use of omalizumab should be considered prior to the use of oral corticosteroids. CONCLUSIONS: This paper provides consensus recommendations that may be useful in the management of severe paediatric asthma.

Description of Alaeuris stehlini n. sp. and Alaeuris numidica canariensis n. ssp. (Nematoda, Pharyngodonidae), parasite of Gallotia stehlini, lacertid of Grand Canary Island (Spain).

Pharyngodonid nematodes (Oxyuroidea) belonging to the genus Alaeuris Thapar, 1925, were collected from the posterior gut of Gallotia stehlini (Lacertidae) from Grand Canary Island. Two species Alaeuris stehlini n. sp. and Alaeuris numidica canariensis n. ssp. were identified. The new species is described in which the long thin males are characterized by narrow caudal alae, a rounded first pair of adanal papillae non pedunculate, the second pair attached and elongate, the three pair teated; a short narrow V plate and a relatively long caudal appendage. The females are also long and thin with a slightly salient vulva, a conical pointed caudal appendage, oesophageal length approximately one third of body, excretory pore below the oesophageal bulb. The new subspecies most closely resembles Alaeuris numidica numidica. (Seurat, 1918) Petter, 1966 and Alaeuris numidica madagascariensis Petter, 1966.

Identification of soybean proteins responsible for respiratory allergies.

Serum samples from 32 patients who suffered attacks during the asthma outbreaks of 1987 and 1988 in Cartagena, Spain, supposedly caused by soybean dust, were studied. At least 90% had specific IgE to shell components and only 13% showed specific IgE to shell-depleted soybean grains. A control group of 32 patients who also suffered asthma attacks but on different days from those of the outbreaks were negative. The shell's most important allergen with an apparent molecular weight of 8 kDa was not present in shell-depleted grains. This allergen as well as other less important shell allergens may be different from the allergens already identified by using serum from patients suffering food allergy to soya.

Purification and characterization of major inhalant allergens from soybean hulls.

Proteins responsible for respiratory allergy to soybean have been purified from an extract of soybean hulls. The purification procedure combined size exclusion and reverse-phase HPLC. Two pure glycoproteins (S1 and S2) exhibiting IgE-binding ability, as demonstrated by immunoblotting and ELISA techniques, were obtained. Both proteins displayed low molecular weight values on SDS-PAGE (S1, 7.0 kD; S2 7.5 kD). Protein S1 showed charge microheterogeneity, rendering two bands at pH 6.1-6.2 on IEF, whereas S2 showed a single band at pH 6.8. Amino acid composition analyses revealed a strong homology between S1 and S2 and, as a characteristic feature, a high percentage of hydrophobic residues, mainly leucine and isoleucine. Concerning the allergenic activity, both proteins were recognized by the specific IgE from 95% of patients who suffered asthma attacks during the asthma outbreaks of 1987 and 1988 in Cartagena (Spain), caused by soybean dust. Besides, proteins S1 and S2 were able to, separately, inhibit up to 75% the binding of specific IgE to the whole extract. Moreover, purified proteins totally crossreacted, even though protein S2 seemed to be slightly more active in all the immunochemical techniques employed. Results presented allow us to conclude that both proteins are isoallergens and to name them as Gly m IA (protein S2) and Gly m IB (protein S1), according to the IUIS-allergen nomenclature system.

Epidemic asthma in Cartagena, Spain, and its association with soybean sensitivity.

We conducted a matched case-control study to assess the association between epidemic asthma and soybean sensitivity in Cartagena, Spain. In skin tests, 81% of the cases and no control subjects were positive to the commercial soybean allergen; 87% of the cases and 12% of the controls were positive to the prepared soybean allergen; and 69% of the cases and 6% of the controls showed high levels of specific immunoglobulin E antibodies (odds ratio = 10; 95% confidence interval = 1.4-433). The association remained strong after adjustment for total immunoglobulin E and for 28 other allergens. The results indicate that soybean sensitivity may be causing asthma epidemics in Cartagena.

A study of allergy to penicillin antibiotics in 1995 in the Child Allergy Department of the Gregorio Marañón University hospital.

We present 219 cases of adverse reactions to penicillin and related antibiotics during 1995 in the Child Allergy Department of Gregorio Marañón University Hospital. Amoxicillin was the most frequent cause of the reaction. The most common clinical symptom was urticaria followed by angio-edema and other characteristic exanthemas. A diagnosis of allergy to penicillin and related drugs was only made in 20 cases in which the predominant symptomatology was urticaria and the antibiotic most commonly involved was again amoxicillin. Diagnosis was confirmed by a skin test, specific IgE determination and controlled provocation. In 3 of the 20 cases diagnosis was made in the reassessment or second study, which was carried out in all cases in which more than one year had passed between the reaction and the initial allergological study.