Incidence, predictors, and treatment outcomes of biphasic anaphylaxis in the emergency department of a tertiary hospital:A 5-year retrospective study.

BACKGROUND: Biphasic anaphylaxis despite successful treatment has an incidence of 4-5% based on NIAID/FAAN criteria. Our study aimed to investigate the frequency and predictive factors associated with biphasic reactions within the emergency department (ED) at Siriraj Hospital. METHODS: This observational study assessed medical records of anaphylaxis and anaphylactic shock patients at Siriraj Hospital's ED from January 2015 to December 2019. Of these, a random sample was reviewed and validated by allergists. Telephone interviews were performed to collect more data. Uni- or biphasic response were analyzed descriptively. Prediction modeling was performed. RESULTS: Among 1888 ED anaphylaxis cases, 601 were randomly sampled; 239 patients completing interviews were analyzed. The incidence of biphasic reactions was 7.1% (17/239) of cases. Common triggers of biphasic responses were foods (57.7%), drugs (31%), other known allergens (5.9%). Shellfish, edible insects, and wheat were the leading food triggers. Biphasic responses were significantly associated with history of drug allergy, any allergic disease, allergic rhinitis, number of prior anaphylactic reactions, angioedema, less generalized erythema, less reaction to shellfish, reaction to NSAIDs, and no epinephrine giving at ED visit (all p < 0.1). From a 3-predictor prognostic model including drug/idiopathic reaction, duration from onset to first epinephrine > 60 minutes, and any cutaneous edema/angioedema with an area under the curve of 0.72 (95%CI 0.54, 0.90). CONCLUSION: The incidence of biphasic response was 7.1%. Predictors of biphasic response were drug/idiopathic reac- tion, any cutaneous edema/angioedema, and time from onset to first epinephrine > 60 minutes.

Revisiting Fruit Allergy: Prevalence across the Globe, Diagnosis, and Current Management.

Fruit allergies manifest with a diverse array of clinical presentations, ranging from localized contact allergies and oral allergy syndrome to the potential for severe systemic reactions including anaphylaxis. The scope of population-level prevalence studies remains limited, largely derived from single-center or hospital-based investigations. In this comprehensive review, we conducted a systematic literature search spanning the years 2009 to 2023, with full acknowledgment of potential analytical biases, to provide a global overview of fruit allergy prevalence. The primary mechanistic underpinning of fruit allergies stems from cross-reactivity between aeroallergens and food allergens, a consequence of structurally similar epitopes-a phenomenon recognized as pollen food allergy syndrome (PFAS). In the era of molecular allergology, numerous studies have dissected allergen components with substantial clinical relevance. Within this review, we explore important allergenic molecules found in plant-based foods, scrutinize pertinent cross-reactivity patterns, and offer insights into management recommendations. Additionally, we compare guideline recommendations to enhance clinical understanding and inform decision making.

Genetic association of beta-lactams-induced hypersensitivity reactions: A systematic review of genome-wide evidence and meta-analysis of candidate genes.

Importance: Beta-lactams (BLs) are the most prescribed antibiotics, being the most frequent cause of drug allergy. However, the association between BL allergy and genetic variations is still unclear. Objective: This systematic review and meta-analysis aimed to summarize the genetic effects of BL-induced hypersensitivity using existing evidence. Methods: We searched PubMed, Medline, Scopus, EMBASE, CINAHL, and Cochrane Library from inception to September 15, 2022 with no language restriction. Genetic association studies investigating genetic variant/polymorphism and risk of drug-induced hypersensitivity reactions among individuals receiving BL-antibiotics were included. We excluded studies of acute interstitial nephritis, drug-induced liver injury, serum sickness, and isolated drug fever. Data were comprehensively synthesized and quality of study were assessed using STrengthening the Reporting of Genetic Association Studies (STREGA). The record screening, extraction and quality assessment were performed by two reviewers and discussions were made to resolve discrepancies. The effects of each variant were pooled and evaluated by modified Venice criteria. Results: A total of 9276 records were identified, and 31 studies were eligible for inclusion. Twenty-seven were candidate-gene association studies (5416 cases and 5939 controls), while the others were next-generation sequencing (NGS) or genome-wide association studies (GWASs) (119 838 cases and 1 487 111 controls). Forty-nine polymorphisms were identified and most of them located in allergic reaction pathways. Meta-analyses of 15 candidate variants in a mixture of both immediate and non-immediate reactions revealed weak genetic effects of rs1801275 (8 studies; n = 1,560; odd ratio 0.73; 95%CI: 0.57-0.93) and rs20541 (4 studies; n = 1,482; odd ratio 1.34; 95%CI: 1.07-1.68) in IL4R and IL13, respectively. Results from GWASs and NGS identified, and confirmed associations in HLA regions including HLA-DRA, HLA-B, HLA-DQA, HLA-DRB1, and HLA-DRB3. Conclusion: Our study summarized genetic evidence influencing BL-induced hypersensitivity and estimated effects of potential variants. We postulated that the genomic studies provide better insights to the mechanism of reactions and suggest potential effects of HLA Class II variants. However, results were inconsistent and unable to generalize in different settings. Further high-throughput studies with a well-defined function, epigenetic interaction, incorporated with clinical factors, would be beneficial for risk identification in BL-induced hypersensitivity.

Food-Dependent Exercise-Induced Anaphylaxis: A Distinct Form of Food Allergy-An Updated Review of Diagnostic Approaches and Treatments.

Food-dependent exercise-induced allergic reactions (FDEIA) represent a distinct clinical phenomenon where symptoms arise during exercise following the consumption of specific trigger foods, with the most severe manifestation being anaphylaxis-a condition distinct from typical exercise-induced or food-induced anaphylaxis. In FDEIA, patients can either exercise or tolerate specific foods separately without experiencing any allergic reactions. Diagnosis relies on patient history and provocation testing, requiring rigorous implementation within a supervised hospital environment. Positive symptoms and clinical signs during testing confirm FDEIA, while negative outcomes do not preclude its presence. Exercise stands as the primary trigger, followed by nonsteroidal anti-inflammatory drugs (NSAIDs) and alcohol. The utilization of various protocols for food cofactor challenges to confirm FDEIA yields differing diagnostic outcomes. We highlight the updated concept of food cofactor challenges, incorporating protocols reported in the literature, and summarize current recommendations and comprehensive management approaches for FDEIA patients.

Validity and reliability of the Thai version of Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) and Food Allergy Independent Measure - Adult Form (FAIM-AF).

BACKGROUND: Food allergy affects the patient's quality of life (QoL) and leads to anxiety and depression. In addition to routine treatment, QoL evaluation should also be performed in patients with food allergies. The validated Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) and Food Allergy Independent Measure - Adult Form (FAIM-AF) have been well accepted and available in many languages. OBJECTIVE: Translate FAQLQ-AF and FAIM-AF into Thai and perform reliability and validity tests in Thai adult patients with food allergies. METHODS: The translation process was performed according to the ISPOR Task Force for Translation and Cultural Adaptation. Participants 18 years or older and with physician-diagnosed food allergies were included in the study. Thai versions of FAQLQ-AF and FAIM-AF were administered to participants at baseline and after two weeks. The intraclass correlation coefficient and Cronbach's α coefficient were evaluated to demonstrate both questionnaires' test-retest reliability and internal consistency. RESULTS: The study included 104 participants. The Thai version of FAQLQ-AF and FAIM-AF demonstrated good reliability, with intraclass correlation coefficients of 0.83 (95%CI 0.76, 0.88) and 0.85 (95%CI 0.79, 0.90), respectively. The validity was excellent, with Cronbach's α coefficient of 0.91 and 0.92, respectively. Both questionnaires were moderately correlated (r = 0.69, P < 0.001), but poorly correlated with the 36-Item Short Form Survey, which is usually used to evaluate general health status. CONCLUSIONS: To evaluate the QoL in adult patients with food allergies, the Thai versions of FAQLQ-AF and FAIM-AF are valid, reliable, and more suitable than the general questionnaire.

Not Just a Banana: The Extent of Fruit Cross-Reactivity and Reaction Severity in Adults with Banana Allergy.

This cross-sectional study aimed to investigate the prevalence and clinical characteristics of cross-reactivity and co-allergy to other plant foods among adult patients with IgE-mediated banana allergy in Thailand. A structured questionnaire was used to assess clinical reactivity, and cross-reactivity diagnoses were based on reactions occurring within 2 years of banana allergy onset, within 3 h of intake, and confirmed by allergists. Among the 133 participants, the most commonly associated plant foods with clinical reactions were kiwi (83.5%), avocado (71.1%), persimmon (58.8%), grapes (44.0%), and durian (43.6%). Notably, 26.5% of the reported reactions to other plant foods were classified as severe. These findings highlight the common occurrence of cross-reactivity/co-allergy to other plant foods in banana-allergic patients, with a significant proportion experiencing severe reactions. Travelers to tropical regions should be aware of this risk and advised to avoid specific banana cultivars and plant foods with reported high cross-reactivity. The inclusion of self-injectable epinephrine in the management plan for patients with primary banana allergy should be considered due to the substantial proportion of reported severe reactions and the wide range of clinical cross-reactivity and co-allergy observed.

Patient-rated angioedema severity using a novel photo-aid for predicting non-mast cell mediator-induced angioedema diagnosis.

Background: Patients with non-mast cell mediator-induced angioedema (NM-AE) usually experience a diagnostic delay. Therefore, a clinical tool for predicting NM-AE diagnosis is essential. Objective: To identify clinical predictors related to a confirmed diagnosis of NM-AE. Methods: Participants with a history of recurrent AE with unknown causes were enrolled. They were classified into mast cell mediator-induced AE (M-AE) and NM-AE according to the response to anti-mast cell mediator therapy. All participants were asked to rate their worst AE ever experienced (% Photomax) from 0 to 100% using a novel photo aid. Clinical characteristics were recorded and analyzed by univariable and multivariable analysis. Results: Thirty-five participants were included, 25 with NM-AE and 10 with M-AE. AE located at extremities, face, and genitalia and positive family history were significantly associated with NM-AE. The AE severity in the NM-AE group was significantly higher than in the M-AE group, with the mean % Photomax of 82.4 ± 20.3 vs 47.5 ± 25.6 (p < 0.001), respectively. Univariable analysis showed that the % Photomax (every 10% increase), feet AE and hands AE were predictive of being NM-AE with the area under the receiver operating characteristic curve (AuROC) of 0.87 (95% CI 0.75, 0.99), 0.85 (95% CI 0.72, 0.98), and 0.84 (0.69, 0.99), respectively. Multivariable analysis showed that the combination of hands AE and % Photomax enhanced diagnostic accuracy (AuROC 0.94, 95% CI 0.86, 1.0) and constituted the prototype formula for calculating the diagnostic probability. Conclusion: Patient-rated angioedema severity using a novel photo aid combined with hands AE had a high probability of diagnosing NM-AE.

Prevalence and characteristics of adult patients with adult-onset and childhood-onset food allergy.

BACKGROUND: IgE-mediated food allergy (FA) affects health-related quality of life, and may cause life-threatening reactions. Few studies characterizing adult FA patients have been reported, especially first ever reaction (FER) in adult-onset. OBJECTIVE: We describe the characteristics of adult FA patients, especially FER and compare these characteristics between childhood- and adult-onset FA. METHODS: A cross-sectional study of all adult patients visiting the Allergy Clinic, Siriraj Hospital at the outpatient department between January 2009 to December 2019 was conducted. Demographic, clinical data, and first reaction in life data were collected. Adult-onset was defined as ≥ 18 years old. RESULTS: Of 711 patients visiting the clinic, 174 (24.4%) were FA with a median age of 31.0 years (interquartile range 24.0, 44.0 years); 29.3% were male. FA patients had significantly higher prevalence of sensitization to cockroach compared with non-FA patients (67.4% vs. 56.3%); p = 0.016). The three most common food triggers were shellfish (68.0%), wheat (28.7%), and fruit and vegetables (10.0%). Before diagnosis, 56.7% (97/171) experienced at least 1 food-related anaphylaxis. Of the 166 patients compared on age of onset, 127 (76.5%) were adult-onset. In FER, patients with adult-onset had significantly more reactions to fruit and vegetables, more respiratory system involvement, and more other systems involvement [OR 8.95 (1.13, 1157); p = 0.034; OR 3.15 (95%CI 1.30, 8.25), p = 0.011; OR 10.8 (1.35, 1404), p = 0.019, respectively]. In sensitivity analysis, the cardiovascular system involvement was also significantly more common [OR 2.78 (1.05, 9.15); p = 0.038]. CONCLUSIONS: Shellfish was the most common trigger foods in adult FA patients. In FER, anaphylaxis was common for adult-onset. Adult-onset FA patients also had more respiratory, cardiovascular, and other systems involvements than childhood-onset ones. FA awareness, early diagnosis, and proper management are encouraged. Further studies on the adult-onset food allergic patients are required.

Perioperative immediate hypersensitivity incidence, clinical characteristics, and outcomes after allergological evaluation: A multi-disciplinary protocol from tertiary hospital, Thailand.

BACKGROUND: Perioperative immediate hypersensitivity reaction (POH) is an immediate hypersensitivity reaction during an anesthesiologist monitored procedure. We report data of clinically-suspected POH (csPOH) patients undergoing an allergist-performed unified diagnostic workup algorithm for POH. OBJECTIVE: To describe the characteristics of patients with csPOH, POH events, and the POH outcomes of procedures after the unified diagnostic workup algorithm for POH. METHODS: A prospective cohort was conducted in adult patients with csPOH at Siriraj Hospital, a tertiary hospital, in Thailand from January 2018 to August 2022. Diagnostic workup for POH by the allergist included an initial assessment, followed by comprehensive allergological evaluation. Patients were then follow-up for POH outcomes during subsequent anesthesia procedures. RESULTS: Of 68 patients were csPOH, only 52 patients were diagnosed with POH by allergists. The incidence was 1:4,304 anesthetic procedures for POH, and 1:11,900 anesthetic procedures for at least grade III POH. Most patients had a grade III (51.2%) or II (46.4%) reaction. The leading identified causative agents were antibiotics (36.8%), antiseptics (21%), latex (13.1%), and morphine (13.1%). Cefazolin and chlorhexidine were the most common antibiotic and antiseptic, respectively. During a median follow-up time of 2.1 years, all 14 patients completing comprehensive allergological evaluation underwent subsequent anesthesia without recurrence of POH. CONCLUSIONS: The incidence of POH at our hospital was comparable to the global incidence. Antibiotics were the most common causative agent. Complete records, collaboration among the multidisciplinary team, and comprehensive evaluation of POH allow for safe subsequent procedures.

Allergic rhinitis and other comorbidities associated with asthma control in Thailand.

Background: Asthma and allergic rhinitis (AR) can coexist and cause disabilities. This study aimed to assess the association between AR, asthma control, asthma-related quality of life, and other comorbidities. Methods: A cross-sectional study was conducted in adults with asthma in six hospitals in Thailand. The outcomes were association of asthma control assessed by the asthma control test (ACT), AR, and asthma comorbidities. Not-well-controlled asthma was defined as ACT scores ≤22. The severity of AR was determined by visual analog scale (VAS). Severe AR was defined as VAS ≥5. Asthma-related quality of life (AQLQ), comorbidities, and total IgE were recorded. Results: A total of 682 asthmatic patients were included. Median (IQR) age was 58.0 (47.0-64.0) years. 69.9% were female. Not-well-controlled asthma was present in 44.7%. The prevalence of AR was 86.1%. Moderate/severe persistent AR was diagnosed in 21.7% and severe AR was diagnosed in 30.2% of the patients. Inhaled corticosteroid-containing regimens were prescribed in 97.7% of patients. Intranasal corticosteroid and antihistamine were prescribed in 65.7 and 31.7%, respectively. Patients with not-well-controlled asthma had higher body mass index, VAS scores, proportions of pollution exposure, aeroallergen sensitization, severe AR, nasal polyp, urticaria, food allergy, gastroesophageal reflux disease, depression and anxiety, peptic ulcer, and asthma exacerbations, but younger age, lower AQLQ scores, and lower FEV1. Correlation was found between AR severity and ACT (r = -0.461, p < 0.001), AQLQ (r = -0.512, p < 0.001), and total IgE (r = 0.246, p < 0.023). Multiple regression analysis revealed that ACT, AQLQ, and percentage of FEV1/FVC were significantly associated with severe AR. Conclusion: Allergic rhinitis is prevalent in Thai asthmatic patients. AR severity is associated with asthma control, quality of life, and pulmonary function. Comprehensive care is essential for patients with uncontrolled asthma, particularly when coexisting with conditions.

Dietary Factors Associated with Asthma Development: A Narrative Review and Summary of Current Guidelines and Recommendations.

Asthma is a complex disease, caused by a combination of genetic and environmental factors. The prevalence of asthma is increasing too rapidly to be attributable to genetic factors alone. Thus, environmental factors are becoming increasingly recognized as the cause of asthma. Modifying these environmental factors may be a simple approach for asthma prevention. To date, dietary intervention is an interesting modifiable factor because it can be implemented at the population level. The modification of systemic inflammation, oxidation, and microbial composition might be a mechanistic basis for prevention. This review summarizes the mechanistic basis and evidence from clinical studies on the association between dietary factors and asthma development. We also summarize the recommendations from many organizations and regional guidelines to assist the practicing physician to improve patient care.

How Microbiomes Affect Skin Aging: The Updated Evidence and Current Perspectives.

The skin has a multifactorial aging process, caused by both intrinsic and extrinsic factors. A major theory of aging involves cellular senescence or apoptosis resulting from oxidative damage as the skin's antioxidant system tends to weaken with age. The human microbiota is a complex ecosystem that is made up of microorganisms (bacteria, fungi, and viruses). Both gut and skin microbiota have essential roles in the protection against invading pathogens, mediating inflammatory conditions, and the modulation of the immune system which is involved in both innate and adaptive immune responses. However, the human microbiome could be changed during the life stage and affected by various perturbations. An alteration of the intestinal bacteria results in "microbial dysbiosis" which is associated with the influence of various diseases, including aging. The skin interactome is a novel integration of the "genome-microbiome-exposome" that plays a significant role in skin aging and skin health. Mitigating the negative impacts of factors influencing the skin interactome should be the future strategy to protect, prevent, and delay skin aging along with preserving healthy skin conditions. This review summarizes the current evidence on how human microbiomes affect skin aging and demonstrates the possible interventions, relating to human microbiomes, to modulate skin health and aging. Probiotics-based products are currently available mainly for the add-on treatment of many dermatologic conditions. However, at this point, there are limited clinical studies on skin anti-aging purposes and more are required as this evolving concept is on the rise and might provide an insight into future therapeutic options.

Genetic Association of Beta-Lactams-Induced Hypersensitivity Reactions: A Protocol for Systematic Review and Meta-Analysis.

Beta-lactam (BL) antibiotics are among the drugs commonly related to hypersensitivity reactions. Several candidate gene studies and genome-wide association studies have reported associations of genetic variants and hypersensitivity reactions induced by BL antibiotics. However, the results were inconclusive. This protocol details a comprehensive systematic review of genetic factors associated with BL-induced hypersensitivity. A systematic search of literature related to genetic associations of BL-induced hypersensitivity will be performed through PubMed, Medline, Scopus, EMBASE, Web of Science, CINAHL, and the Cochrane central register of Controlled Trials (CENTRAL) from their inception dates with no language restrictions. Two reviewers will independently screen, extract, and appraise the risk of bias. Frequencies of genetic variants that comply with Hardy-Weinberg equilibrium will be extracted and pooled. Genetic models will be applied to variant effect calculation as per allele and genotype analysis. Based on statistical heterogeneity among studies, common effect estimation (odds ratio) and its corresponding 95% confidence interval will be analyzed. Sensitivity and subgroup analyses will be performed to determine the robustness of eligible studies. This systematic review and meta-analysis will provide comprehensive evidence of genetic effects regarding BL-induced hypersensitivity. The findings will enlighten the determination of disease-related genotypes that would potentially reveal allergy profiling in patients.

As-needed versus regular intranasal corticosteroid for allergic rhinitis: A systematic review and meta-analysis.

BACKGROUND: Daily intranasal corticosteroid (INCS) is recommended for treating allergic rhinitis (AR). Nevertheless, patients are generally not adherent and use it on-demand. The data on the efficacy of as-needed INCS was insufficient. OBJECTIVE: We conducted a systematic review and meta-analysis to assess the efficacy of as-needed INCS compared with regular use for AR. METHODS: We searched PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) until May 2021. A pairwise meta-analysis used a random-effects model to estimate the pooled standardized mean difference (SMD). The primary outcome was the total nasal symptom score (TNSS) changes from baseline at 4 and 6 weeks. Secondary outcomes were the changes of individual nasal symptom score and quality-of-life (QoL) score. RESULTS: We identified five eligible RCTs with a total of 436 patients with AR. Only four studies had adequate data for quantitative synthesis. The TNSS changes of as-needed INCS were not significantly different from the regular use at both 4 (SMD 0.23 [95%CI: -0.14 to 0.60], p = 0.230) and 6 weeks (SMD 0.21 [95%CI: -0.02 to 0.44], p = 0.080). Most of the changes of individual nasal symptom scores and QoL scores were not significantly different between the two regimens. At 50% or more INCS dose of regular use, as-needed and regular INCS provided a similar efficacy. The treatment effect was, however, less sustained with as-needed INCS. CONCLUSIONS: The efficacy of as-needed use of INCS at 50% of corticosteroid exposure was comparable to regular use in improving nasal symptoms and QoL.

Efficacy and Safety of House Dust Mite Sublingual Immunotherapy Tablet in Allergic Asthma: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: House dust mite sublingual immunotherapy (HDM SLIT) effectively treats allergic rhinitis (AR). However, the evidence of HDM SLIT for allergic asthma remained limited. OBJECTIVE: To systematically review the efficacy and safety of HDM SLIT tablets in patients with allergic asthma. METHODS: We performed a systematic search through PubMed, Scopus, EMBASE, Web of Science, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials (RCTs) that addressed the efficacy and safety of HDM SLIT tablets compared with placebo or no intervention in allergic asthma from their inception date until September 2021. The primary outcome was the reduction in inhaled corticosteroids (ICS) dose. Additional outcomes were asthma control, exacerbation, lung function, quality-of-life, and adverse events. RESULTS: There were 7 RCTs, 5 studies in allergic asthma (4 in adults and 1 in children), and 2 in AR with or without asthma. The 6 standardized quality (SQ) HDM effectively reduced ICS dose in well- to partly controlled mild-to-moderate asthma in 1 RCT. Two RCTs evaluated the efficacy of 6 SQ and 12 SQ HDM in reducing asthma exacerbation in partly controlled moderate-to-severe asthma, and their results were inconsistent. One study in children with mild-to-moderate asthma found no benefit of HDM SLIT. Two RCTs in AR with or without mild-to-moderate asthma showed improvement of asthma symptoms. Adverse events were primarily local, and anaphylaxis treated with epinephrine was reported in 3 patients. CONCLUSIONS: The HDM SLIT tablets tend to effectively reduce ICS use in adults and adolescents with well- to partly controlled mild-to-moderate allergic asthma with a favorable safety profile.

Fatal liver mass rupture in a common-variable-immunodeficiency patient with probable nodular regenerating hyperplasia.

BACKGROUND: Nodular regenerating hyperplasia (NRH) is the most common liver involvement in common variable immunodeficiency (CVID). Most patients are asymptomatic with gradually increasing alkaline phosphatase (ALP) and mildly elevated transaminase enzymes over the years. We report the first case of fatal liver mass rupture in a CVID patient with probable NRH. CASE PRESENTATION: A 24-year-old man was diagnosed with CVID at the age of 1.25 years. Genetic testing revealed a transmembrane activator and calcium-modulator and cyclophilin-ligand interactor (TACI) mutation. He had been receiving intravenous immunoglobulin (IVIg) replacement therapy ever since then. The trough level of serum IgG ranged between 750-1200 mg/dL. However, he still had occasional episodes of lower respiratory tract infection until bronchiectasis developed. At 22 years old, computed tomography (CT) chest and abdomen as an investigation for lung infection revealed incidental findings of numerous nodular arterial-enhancing lesions in the liver and mild splenomegaly suggestive of NRH with portal hypertension. Seven months later, he developed sudden hypotension and tense bloody ascites. Emergency CT angiography of the abdomen showed NRH with intrahepatic hemorrhage and hemoperitoneum. Despite successful gel foam embolization, the patient died from prolonged shock and multiple organ failure. CONCLUSIONS: Although CVID patients with NRH are generally asymptomatic, late complications including portal hypertension, hepatic failure, and hepatic rupture could occur. Therefore, an evaluation of liver function should be included in the regular follow-up of CVID patients.

Clinical characteristics and aspirin desensitization in Thai patients with a suggestive history of NSAID-exacerbated respiratory disease.

BACKGROUND: Non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by the triad of chronic rhinosinusitis with nasal polyp, asthma, and aspirin (ASA) or NSAID hypersensitivity. Previous study of NERD has rarely been reported in Asian population. OBJECTIVE: To investigate the clinical characteristics and outcomes of aspirin desensitization (ASAD) in Thai NERD. METHODS: This retrospective chart review included patients with a suggestive history of NERD with or without ASAD from the Adult Allergy Clinic of Siriraj Hospital (Bangkok, Thailand) during January 2008 to December 2018. RESULTS: Ten NERD patients were recruited. The median age of onset was 30 years. Comorbid atopic diseases were found in 4 patients. Asthma control level was step 3 of the Global Initiative for Asthma (GINA) guideline or greater in all patients. Five patients had reactions to more than one NSAIDs. Ibuprofen was the most common culprit agent. Reactions frequently involved the respiratory and cutaneous systems. Four patients underwent ASAD followed by ingestion of ASA 300-600 mg daily. One patient discontinued ASA after taking ASA 600 mg daily for 3 months due to severe gastrointestinal side effect. The remaining three patients successfully continued ASA 300 mg daily as maintenance to control sino-nasal inflammation and to prevent recurrence of nasal polyp. None of the 4 patients required sinus surgery revision. CONCLUSIONS: NERD is a difficult-to-treat disease with unique clinical characteristics. ASAD followed by a maintenance dose of ASA 300 mg daily was found to be effective and well-tolerated in most patients.

Allergen immunotherapy for respiratory allergies in clinical practice: A comprehensive review.

Allergen-specific immunotherapy (AIT) is the only treatment that modifies the underlying pathophysiology of IgE-mediated allergic diseases. Evidence shows the efficacy in achieving better control of the symptoms and reduction in medication use in patients with allergic rhinoconjunctivitis and/or asthma. It should be used in association with proper pharmacotherapy for at least three years. The benefits are sustained for several years after discontinuation of treatment. Moreover, it may prevent the development of new sensitization and progression of disease from allergic rhinitis to asthma in children. The favorable efficacy of AIT is associate to the appropriate selection of patients, allergen extracts, adherence, and duration of treatment. Safety during AIT is another concerning issue. AIT has an acceptable safety profile if administered under the appropriate circumstances. Future studies investigating the prescription, efficacy, and safety need to be developed. The new application routes, use of adjuvants, modification of allergens, and use of biologics are currently under evaluation. Moreover, there is an urgent need for real-world data in developing countries regarding the cost-effectiveness analysis, and optimization of AIT schedules and products, so that clinical practice and implementation of AIT for respiratory allergic diseases can be effective and safe.

Adult IgE-mediated food allergy is on the rise: A review of phenotypes, pathophysiologic mechanisms, diagnosis, and advances in management.

The prevalence of adult food allergies is increasing worldwide. Many aspects of food allergy in adulthood are different from childhood. We review the current evidence on adult food allergy regarding the global prevalence, adult phenotypes, cofactors, diagnostic methods, and management. A high proportion of severe reactions and unique phenotypes in adults have been characterized. Individual comorbidities could be risk factors for severe reactions and complicate the physician's diagnosis as various conditions can mimic food allergies. Many cofactors affect the eliciting threshold of reaction, affecting whether a reaction occurs and its severity. Large and complex meals, various food allergens, and contaminants increase diagnostic difficulties. An action plan should be devised to add a framework for national policies, thereby lessening the biophysical and health-related quality of life impacts of food allergy. Research into novel treatments is ongoing.