A case study of apple seed and grape allergy with sensitisation to nonspecific lipid transfer protein

Lipid transfer proteins can be an important cause of allergy given their stability and high degree of protein sequence homology. We describe the case of a child who developed two separate episodes of anaphylaxis after consuming apple seed and grape, with evidence that nonspecific lipid transfer proteins may have been responsible for these reactions. Lipid transfer protein allergy should be considered when anaphylaxis is inconsistent, such as in patients who can tolerate fruit pulp but react to fresh whole fruit juices.

In this issue of Asia Pacific allergy

No abstract available.

Rare diseases and expensive drugs

No abstract available.

Pholcodine consumption and immunoglobulin E-sensitization in atopics from Australia, Korea, and Japan

BACKGROUND: Accumulating data indicates that pholcodine (PHO)-consuming countries have higher sero-prevalences of immunoglobulin E (IgE)-antibodies to PHO and suxamethonium (SUX) and increased frequencies of IgE-mediated anaphylaxis to neuromuscular blocking agents (NMBAs) than nonconsuming. Withdrawing PHO-containing cough syrups resulted in a significant decrease of cases with anaphylaxis in Scandinavia. Nevertheless, the European Medicines Agency in 2011 advised to continue the unrestricted use throughout the European Union. OBJECTIVE: To extend studies on PHO consumption and prevalence of IgE-sensitization to morphine (MOR), PHO, and SUX to countries representing high (Australia), and low (Korea and Japan), consumers, respectively. METHODS: IgE-antibodies to SUX, MOR, and PHO in atopic subjects were determined by immunoassay and compared with official figures for PHO consumption and reported anaphylaxis to NMBA. RESULTS: The prevalences of IgE-antibodies to PHO, MOR, and SUX were 10%, 8.6%, and 4.3%, respectively, in Australia. The corresponding figures for Japan were 0.8%, 0.8%, and 1.5%, and for Korea 1.0% to PHO and 0.5% to MOR and SUX. Of the SUX-positive sera, 100% were positive to PHO or MOR in Australia and 0% in Japan and Korea. CONCLUSION: The study supports previous findings; exposure to PHO may induce IgE-antibodies to the substituted ammonium ion epitope of NMBAs, thus increasing risk of NMBA-induced anaphylaxis considerably. However, other, still unknown factors occasionally might induce IgE-antibodies to SUX.

Utility of penicillin allergy testing in patients presenting with a history of penicillin allergy

BACKGROUND: Current statistics show that approximately 10% of patients claim to be allergic to penicillin yet only 10% of these have demonstrable allergy. The most appropriate and cost-effective antibiotics are sometimes withheld on the basis of patient history of drug allergy. OBJECTIVE: Investigation of IgE hypersensitivity and delayed hypersensitivity in patients with a history of penicillin allergy to a teaching hospital allergy clinic. METHODS: Patients underwent skin prick and intradermal testing (IDT) with major and minor penicillin determinants. Those with negative skin tests were administered a three-day oral challenge. Demographic and clinical details about the reactions were noted. RESULTS: One hundred twenty eight patients underwent testing, of these, one hundred and ten had self-reported histories of penicillin allergy and eighteen were referred because of other antibiotic allergies. Seventeen patients with self-reported penicillin allergy had either positive skin tests or oral challenge results, corresponding to 15% of patients having proven allergy. None reacted on skin prick testing, four reacted to IDT, thirteen reacted to oral challenge (five immediate and eight delayed). Analysis of clinical histories showed that patients with a well-defined history of allergy and a history of anaphylaxis were more likely to have a positive test compared to patients with vague histories. Skin testing proved to be less sensitive than oral challenge. CONCLUSION: A minority of patients presenting with a history of penicillin allergy have evidence of immune-mediated hypersensitivity (17/110, 15%) in this study. Of these, eight out of seventeen (47%) had delayed reactions, demonstrating the usefulness and discriminating power of objective testing, which must include three-day oral challenge. Discriminating factors for immune-mediated allergy from patient history were a clear description of the original reaction and a history of anaphylaxis. Negative allergy testing enables the use of penicillin as first-line treatment when necessary and this can significantly reduce costs of antibiotics.

Immediate hypersensitivity reactions to IV non-ionic iodinated contrast in computed tomography

BACKGROUND: With use of computed tomography (CT), intravenous contrast media is used routinely to help define anatomy and identify any pathology. Non-ionic iodinated contrast agents have largely replaced ionic agents and although rare, reactions to contrast are still important and more so with the continual increase in CT examinations in the last decade. OBJECTIVE: To examine the incidence, severity and risk factors of immediate hypersensitivity reactions to intravenous non-ionic iodinated contrast in CT. METHODS: Data of consecutive patients in an Australian tertiary hospital who developed immediate hypersensitivity reactions to intravenous iopromide during CT were collected and compared with the results of all contrast CTs performed over a four year period. Chi-square statistics and odds ratio are calculated on the variables of age, gender, referral source and seasons of the study. RESULTS: Forty-seven patients had immediate hypersensitivity reactions of 29,962 patients who underwent contrast CT (0.16%). Thirty-three patients (70%) had a mild reaction, 11 (23%) moderate and three (7%) severe. Sixteen (34%) were male and 31 (66%) were female. Sixty-eight percent were under 55-years of age. Reactions occurred in 0.35% (34 patients) of all outpatients, 0.07% (6 patients) of all emergency patients, and 0.06% (7 patients) of all in-patients. Eighteen (38%) occurred in spring, seven (15%) in summer, 17 (36%) in autumn and five (11%) in winter. There is a statistically significant higher risk of contrast reactions in females (Odds Ratio [OR] 2.41 p = 0.005), patients younger than 55-years old (OR 2.46, p = 0.005), outpatients (OR 5.42, p < 0.001) and CTs performed in spring and autumn (OR 2.77, p = 0.002). CONCLUSION: The incidence of immediate hypersensitivity reactions in contrast CT is low and mostly mild. Risk factors include female, younger than 55-years of age, outpatients and CT examinations performed in spring and autumn. This is the first study to observe such a seasonal variation.

Ocular allergy in the Asia Pacific region

Allergic conjunctivitis (AC) represents a spectrum of disorders, comprising seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC) and giant papillary conjunctivitis. Of these ocular allergy types, SAC and PAC are the most common. The most striking difference within this group of ocular diseases is that SAC and PAC remain self-limited without ocular surface damage, while AKC and VKC can compromise the cornea, causing ulcers and scarring and can ultimately lead to vision loss. Data on AC in the Asia Pacific is scarce however some understanding of prevalence of the condition has been obtained from the International Study of Asthma and Allergies in Childhood (ISAAC) studies and more recently from the Allergies in Asia Pacific study as well as some information from individual country surveys. Unfortunately none of this data has been collected using validated survey instruments specifically designed for AC. Surveys such as ISAAC have been predominantly concerned with respiratory allergic symptoms with questions added that incorporate some ocular symptoms. These questionnaires do not detect individuals who may have AC in the absence of allergic rhinitis. Using hospital ophthalmology outpatient populations for prevalence studies of ocular allergy immediately introduces a bias towards the more severe, complex forms of the condition as patients with the milder forms of SAR and PAR will rarely present to a hospital outpatient clinic. There is a real need for the development of validated questionnaires specifically addressing ocular allergy. There are no widely accessible studies examining prevalence of the complex forms of ocular allergy (AKC, VKC) in Asia Pacific region. This review will provide an overview of ocular allergy, its classification, clinical presentation and differential diagnosis, and will also discuss what is known about the epidemiology of ocular allergy in the Asian Pacific region.

Impact of chronic urticaria on the quality of life in Australian and Sri Lankan populations

BACKGROUND: Chronic idiopathic urticaria (CIU) has a significant impact on patients' quality of life. OBJECTIVE: The purpose of this study is to assess that impact and to compare differences by culture, gender, age or duration of treatment. METHODS: We used the modified chronic urticaria quality of life questionnaire, consisting of 15 questions. Over the course of 6 months, patients attending Immunology clinics at Campbelltown Hospital and private rooms in Australia and at the faculty of Medicine, University of Kelaniya in Sri Lanka were asked to fill out the questionnaires. We have obtained the data from 125 patients (43 Australian vs. 82 Sri Lankan). There were significantly more female patients (P < 0.01). The data was analysed using SAS. RESULTS: Overall, patients were affected mostly by itch and wheals and least affected by the side effects of treatments. Sri Lankan populations were more affected by wheals and by interference on activities, mood and food choices but were less affected by tiredness due to sleep disturbances (P < 0.01). Females were more affected by sleep disturbance (P < 0.05) while those older than 40 years of age were more impacted by tiredness and by the side effects from medications (P < 0.05), though the complaints themselves were mild. Those who suffered from CIU for more than 1 year were more affected by wheal, tiredness and irritability (P ≤ 0.05). CONCLUSION: The questionnaire highlighted some differences between patients attending Australian versus Sri Lankan outpatients. Significant differences were found in one third of parameters which include mood, sleep, daily activities and food choices.

Mycophenolate mofetil; a review of indications and use in a large tertiary hospital

Mycophenolate Mofetil [MMF] has been registered for use in Australia since 1997 for prophylaxis of solid organ allograft rejection. MMF is now increasingly used for indications outside solid organ allograft rejection, often with limited supporting efficacy data. The purpose of this audit was to examine the patterns of use, reported side effects and cost impact of the drug in the Clinical and Immunology and Allergy [CIA] unit of Australia's largest teaching hospital. Prescription patterns for MMF by consultant immunologists at Westmead hospital between 2000 and 2004 were obtained from the pharmacy. These data were sorted for non- S100 indications. A single immunologist then reviewed the patient files. We also reviewed the literature on the use of this promising immunosuppressant. There has been a marked increase in use of MMF since year 2000 by the Department of CIA. A total of 75 patients were prescribed MMF for non-S100 indications. Common indications were systemic lupus erythematosus, pemphigus vulgaris, chronic idiopathic urticaria, myasthenia gravis, polymyositis, atopic dermatitis, Sjogren's disease, uveitis and vasculitis. It is clear that MMF has potential for use in a number of immunological disorders because of its relatively benign side effect profile and observed efficacy. Double blinded, placebo-controlled, multicentre trials are necessary to establish its therapeutic role. Our study highlights some of the conditions for which this agent is useful