HLA variants and their association with IgE-Mediated banana allergy: A cross-sectional study.

Background: Banana allergy is on the rise in tropical regions. Advances in genomics and candidate gene identification have increased interest in genetic factors in food allergies. However, the genetic basis of IgE-mediated banana allergy is underexplored. Objective: To characterize HLA variants and their association with IgE-mediated banana allergy. Methods: This cross-sectional study recruited banana-allergic adults, confirmed by allergology tests, with non-allergic individuals as controls. Genomic DNA extraction and sequencing BAM files for HLA typing were conducted. Allele frequency was calculated using the direct counting method, and odds ratio (OR) with 95 % confidence interval (CI) were determined. Fisher's exact or chi-square tests were used to assess associations with Bonferroni's correction for multiple tests. The allele frequency of the Thai population from The Allele Frequency Net Database was used to compute the allele enrichment ratio (ER). Results: A total of 59 cases and 64 controls were recruited. HLA genotyping indicated potential associations of HLA-B*15:25 (OR 11.872; p-value 0.027), HLA-C*04:03 (OR 7.636; p-value 0.033), and HLA-DQB1*06:09 (OR 11.558; p-value 0.039) with banana allergy. However, after Bonferroni correction, none of these associations reached statistical significance. Comparing allele frequency with the general population from The Allele Frequency Net Database, our ER analysis revealed a higher prevalence in the banana allergy group for B*15:25 (ER 1.849), C*04:03 (ER 1.332), and DQB1*06:09 (ER 6.602) alleles. Conclusions: This study provides initial genetic insights into banana allergy, suggesting potential links with specific HLA alleles. Despite 12 initially identifying alleles, none were statistically significant after multiple testing correction. Larger studies are needed to detect possible significant correlations.

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.

Efficacy and Safety of Biologics for Oral Corticosteroid-Dependent Asthma: A Systematic Review and Network Meta-Analysis.

BACKGROUND: A maintenance oral corticosteroid (OCS) in addition to high-dose inhaled corticosteroids plus long-acting ß2-agonists in patients with severe asthma leads to long-term adverse events. Oral corticosteroid-sparing agents are of high priority. OBJECTIVE: This network meta-analysis assessed biologics' comparative efficacy and safety in OCS-dependent patients with asthma. METHODS: We performed a systematic search through PubMed, Scopus, Embase, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials that addressed the efficacy and safety of biologics compared with placebo in OCS-dependent patients with asthma from inception to July 2023. The primary outcome was an overall reduction in the OCS dose while asthma control was maintained. RESULTS: We included seven randomized controlled trials involving 1,052 OCS-dependent patients with asthma. Compared with placebo, benralizumab every 8 weeks, benralizumab every 4 weeks, dupilumab, and mepolizumab were efficacious in achieving a reduction in the OCS dose with low to moderate confidence (odds ratio [95% CI]: 4.12 [2.22-7.64]; 4.09 [2.22-7.55]; 3.25 [1.90-5.55]; and 2.39 [1.25-4.57], respectively) whereas tralokinumab, tezepelumab, and subcutaneous reslizumab were ineffective. An indirect comparison found no significant differences among benralizumab, dupilumab, and mepolizumab. Efficacy in reducing exacerbations was consistent with the primary analysis. High baseline blood eosinophil counts benefit from anti-IL-5 therapies, whereas high FeNO levels favor dupilumab regardless of blood eosinophil counts. Adverse events between biologics and placebo were comparable, except for eosinophilia with dupilumab. CONCLUSIONS: In OCS-dependent patients with asthma, benralizumab, dupilumab, and mepolizumab were superior to placebo in reducing the OCS dose. Evaluating baseline biomarkers helps in choosing the proper biologics to maximize treatment effects.

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.

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.

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.

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.

Comparative efficacy and acceptability of licensed dose intranasal corticosteroids for moderate-to-severe allergic rhinitis: a systematic review and network meta-analysis.

No evidence shows that one intranasal corticosteroid (INCS) is better than another for treating moderate-to-severe allergic rhinitis (AR). This network meta-analysis assessed the comparative efficacy and acceptability of licensed dose aqueous INCSs. PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until 31 March 2022. Eligible studies included randomized controlled trials comparing INCSs with placebo or other types of INCSs in patients with moderate-to-severe allergic rhinitis. Two reviewers independently screened and extracted data following the Preferred Reporting Items in Systematic Reviews and Meta-analysis guideline. A random-effects model was used for data pooling. Continuous outcomes were expressed as standardized mean difference (SMD). The primary outcomes were the efficacy in improving total nasal symptom score (TNSS) and treatment acceptability (the study dropout). We included 26 studies, 13 with 5,134 seasonal AR patients and 13 with 4,393 perennial AR patients. Most placebo-controlled studies had a moderate quality of evidence. In seasonal AR, mometasone furoate (MF) was ranked the highest efficacy, followed by fluticasone furoate (FF), ciclesonide (CIC), fluticasone propionate and triamcinolone acetonide (TAA) (SMD -0.47, 95% CI: -0.63 to -0.31; -0.46, 95% CI: -0.59 to -0.33; -0.44, 95% CI: -0.75 to -0.13; -0.42, 95% CI: -0.67 to -0.17 and -0.41, 95% CI: -0.81 to -0.00), In perennial AR, budesonide was ranked the highest efficacy, followed by FF, TAA, CIC, and MF (SMD -0.43, 95% CI: -0.75 to -0.11; -0.36, 95% CI: -0.53 to -0.19; -0.32, 95% CI: -0.54 to -0.10; -0.29, 95% CI: -0.48 to -0.11; and -0.28, 95% CI: -0.55 to -0.01). The acceptability of all included INCSs was not inferior to the placebo. According to our indirect comparison, some INCSs have superior efficacy to others with moderate quality of evidence in most placebo-controlled studies for treating moderate-to-severe AR.

Children with wheat anaphylaxis and with low wheat specific IgE have a different IgE immunoblot pattern than those with high wheat specific IgE.

BACKGROUND: Children with wheat anaphylaxis can present with a wide range of wheat-specific IgE (sIgE). OBJECTIVE: To identify differences in clinical features and predominant wheat allergens sensitized by these patients. METHODS: Children with history of wheat anaphylaxis were recruited. Skin prick test (SPT) to wheat, sIgE to wheat, omega-5 gliadin (ω5G), lipid transfer protein (LTP) were investigated. Profiles of IgE-bound wheat allergens were studied to identify predominant wheat allergens. RESULTS: Twenty-nine children (17 males) aged 1-18 years were enrolled. Sixteen patients (55.2%) had wheat-sIgE > 100 kUA/L (WAhi) and 13 patients (44.8%) had wheat-sIgE < 34 kUA/L (WAlo). The median of peak wheat-sIgE in WAhi and WAlo were 340.5 kUA/L (IQR 184.3, 564.5) and 12.2 kUA/L (IQR 1.4, 41.3), respectively. Oral food challenge test (OFC) was carried out in 12 of 13 patients in the WAlo group, all of which had positive results. Eight of these 12 patients developed anaphylaxis during OFC despite having wheat-sIgE less than 10 kUA/L. There were no differences in clinical characteristics and atopic history between WAhi vs. WAlo. Medium to low molecular weight gliadin (< 40 kDa) and glutenin (< 60 kDa) were commonly recognized by patients with WAhi. IgE immunoblot pattern among the WAlo group was more widely dispersed than those with WAhi. CONCLUSIONS: Wheat anaphylaxis can occur in patients with low wheat-sIgE. Predominant wheat allergens recognized by patients with WAlo were different than those with WAhi. Such difference could be responsible for anaphylaxis at even low levels of wheat-sIgE.

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.

House dust mite allergen immunotherapy for monosensitized versus polysensitized patients with allergic rhinitis: A systematic review and meta-analysis.

BACKGROUND: Most patients with allergic rhinitis are polysensitized. The efficacy of house dust mite (HDM) allergen immunotherapy (AIT) compared between monosensitized and polysensitized patients remains limited. OBJECTIVE: To systematically review the efficacy and safety of HDM AIT compared between monosensitized and polysensitized patients with allergic rhinitis. METHODS: We searched PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane central register of Controlled Trials (CENTRAL) until June 2022. The primary outcome was the changes from baseline in total nasal symptom score (TNSS). Secondary outcomes were changes from baseline in total medication score (TMS), combined symptom medication score (CSMS), visual analog scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score, immunological parameters, and adverse events (AEs). RESULTS: Of 13 eligible studies, 10 prospective cohorts, 2 retrospective cohorts, and 1 matched cohort, we identified 10 studies for quantitative synthesis. There were 1,113 patients with allergic rhinitis, 566 with HDM monosensitization and 547 with polysensitization to HDM and other allergens. There was no significant difference in the pooled mean changes of the 2 groups in TNSS (SMD -0.05, 95%CI: -0.22 to 0.11, p = 0.532) and VAS (SMD -0.20, 95%CI: -0.42 to 0.01, p = 0.060) with moderate certainty of evidence. The changes in TMS, CSMS, and RQLQ were similar between the 2 groups with very low certainty of evidence. The AEs were mild and comparable between the 2 groups. The immunological indices remained inconsistent and were not predictive of clinical responses. CONCLUSIONS: A single HDM AIT similarly improved clinical outcomes in monosensitized and polysensitized patients with allergic rhinitis.

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.

Effect of gene polymorphisms in ADAM33, TGFß1, VEGFA, and PLAUR on asthma in Thai population.

BACKGROUND: Most of the asthma susceptibility genes have demonstrated moderate effect. Gene-gene interaction may play a role in asthma. OBJECTIVE: To investigate the genetic and gene-gene interaction effects of single nucleotide polymorphisms (SNPs) in the ADAM33, TGFß1, VEGFA, and PLAUR genes on asthma in Thai population. METHODS: Two hundred and fifty control and 250 asthmatic Thai subjects were recruited. Asthma was diagnosed based on symptoms and spirometry assessments using criteria outlined by the American Thoracic Society. Degrees of asthma severity were determined according to guidelines provided by the Global Initiative for Asthma. Asthmatic subjects were subcategorized into the low-severity (n = 106) and high-severity (n = 144) groups. Eleven SNPs in four genes were genotyped, including ADAM33 SNPs (rs528557/S2, rs598418, rs44707/ST+4), TGFß1 SNPs (rs2241715, rs11466345), VEGFA SNPs (rs833069, rs3025010), and PLAUR SNPs (rs344781, rs344787, rs2239374, rs2239372). Association analyses between SNPs and asthma, and tests for gene-gene interaction were performed. RESULTS: The ADAM33 rs528557/S2 SNP was found to be associated with asthma according to the additive and dominant models. Comparison between the low-severity group and controls showed the VEGFA rs833069 SNP to be significantly associated with the low-severity group. No gene-gene interactions were observed in this study. CONCLUSIONS: The ADAM33 rs528557/S2 and the VEGFA rs833069 SNPs were associated with Thai asthmatics, as well as with other populations worldwide. Further studies are warranted to investigate the use these SNPs as biomarkers for establishing early diagnosis or for predicting future risk of asthma.

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.

Concomitant chronic spontaneous urticaria treatment might hinder the diagnosis of occupational latex-induced anaphylaxis: A case report.

BACKGROUND: Cutaneous manifestations of chronic spontaneous urticaria (CSU) are identical to type 1 hypersensitivity reactions. The daily occurrence of rash from occupational allergy could be misinterpreted as CSU exacerbation. OBJECTIVE: We aim to report a nurse with concomitant CSU suffering from latex-induced anaphylaxis. METHODS: Skin tests, specific IgE using ImmunoCAP, and gloves challenge were performed. RESULTS: A 27-year-old nurse with CSU suffered from several episodes of severe urticarial flare. H1-antihistamine up-dosing and oral corticosteroid burst were given. Unfortunately, she developed 3 episodes of anaphylaxis during her routine nursing care work on a medical ward, leading to allergist consultation. She had positive latex-specific IgE (6.86 kUA/L) and positive gloves challenge test. CONCLUSIONS: Concomitant CSU treatment might hinder the recognition of latex allergy by masking or delaying skin manifestations. IgE-mediated allergy should be suspected if there was a change in severity or frequency of previously controlled CSU or the presence of systemic symptoms.

Successful identification of culprit drugs of perioperative anaphylaxis by repeated skin testing after negative first skin tests in a patient with a long distant history of perioperative anaphylaxis.

BACKGROUND: Perioperative anaphylaxis is a severe immediate hypersensitivity reaction to drugs administered in immediate temporal association to surgical procedures. The European Academy of Allergy and Clinical Immunology recommends allergologic tests be performed within the golden period of between 1 and 4 months after the date of the event to avoid false negatives. Nonetheless, many obstacles prevent patients from receiving diagnostic tests within the recommended time frame. CASE PRESENTATION: A 39-year-old male with congenital glaucoma had a history of multiple episodes of perioperative anaphylaxis since the age of 1 year including generalized urticaria, bronchospasm, cyanosis, and hypotension. Because the sequence of events was unclear due to incomplete documentation of operations and the destruction of medical records, the allergists tested different perioperative drugs on the patient. Although the first test results were all negative, repeated tests at 6 weeks were positive for morphine and ketamine. We identified more than one causative drug at the second round of skin tests. Using recommended skin test concentrations, negative skin tests in 5 control subjects could support the validity of the second test. The patient underwent sinus surgery in the next 3 months after the second skin test using propofol, midazolam, sevoflurane, chlorhexidine, and cefazolin without any anaphylactic reactions. CONCLUSIONS: Repeated skin tests after negative results of the first tests may identify the causative drugs, thus providing optimal patient safety, and should be considered under the physician's discretion together with consideration of the severity of the allergic symptoms, time interval from last reactions, and the patient's consent.