[Anaphylaxis caused by dermal exposure with cow's milk in an adult with food allergy. A case report]. / Anafilaxia por contacto con leche en un adulto con alergia alimentaria. Reporte de caso.

BACKGROUND: Allergy to cow's milk proteins is the most frequent food allergy and its prevalence has increased in the last decade. Although most patients have symptoms after the intake of dairy milk, other routes of sensitization through skin and mucous membranes have been described. CASE REPORT: A 31-year-old male patient who is a professional chef and started with oropharyngeal symptoms after the intake of milk. Since he tolerated other dairy products, he did not suppress them from his diet. However, the clinical picture progressed and cutaneous symptoms were added; finally, anaphylaxis occurred by contact with bread dough that contained butter and milk. The patient was treated in the emergency department, where an increase in serum tryptase was verified. Skin prick tests and serological tests were positive for milk and its fractions. CONCLUSION: Reports of anaphylaxis caused by dermal contact with cow's milk are very scarce and they have been reported only in children. We believe that repeated food handling could favor cutaneous sensitization in adults with a personal history of atopy.

Antecedentes: La alergia a proteínas de leche de vaca es la alergia alimentaria más frecuente y su prevalencia se ha incrementado en la última década. Aunque la mayoría de los pacientes presenta síntomas por ingestión, se ha descrito sensibilización cutánea y de mucosas. Caso clínico: Hombre de 31 años, chef de profesión, en quien se iniciaron síntomas orofaríngeos después de la ingesta de leche. No suprimió de su dieta otros productos lácteos que toleraba en ese momento, sin embargo, los cuadros alérgicos fueron progresando y se añadieron manifestaciones cutáneas; finalmente presentó anafilaxia por contacto con masa de pan que contenía mantequilla y leche. El paciente fue atendido en urgencias, donde se comprobó la elevación de la triptasa sérica. Las pruebas cutáneas y serológicas resultaron positivas para leche y sus derivados. Conclusión: La anafilaxia por contacto con leche es infrecuente y solo se ha informado en niños. Consideramos que la manipulación repetida de alimentos pudiera favorecer la sensibilización cutánea en adultos con historia personal de atopia.

[Reactivation of patch-stage mycosis fungoides caused by oral administration of dialyzable leukocyte extract. Case report]. / Reactivación de micosis fungoide en estadio de placa por administración de extracto dializado de leucocitos vía oral. Reporte de caso.

BACKGROUND: Mycosis fungoides is a cutaneous T-cell lymphoma. The patch stage is limited to the skin and may spontaneously involute or progress, spreading to peripheral blood, lymph nodes and viscera. CASE REPORT: 64 year-old female with a 6-year history of dermatosis with scaly, poorly delimited and pruritic plaques on the chest and extremities. She had received oral steroids and antihistamines, with transient partial remissions been experienced. Skin biopsy revealed Pautrier's microabscesses, which are pathognomonic of mycosis fungoides. Positron-emission tomography and peripheral blood smear ruled out dissemination and confirmed patch-stage mycosis fungoides. She received nitrogen mustard topical derivatives, psoralen plus UVA therapy, steroids and tacrolimus. She achieved complete remission at 6 months. Two years later, she was treated with dialyzable leukocyte extract, which reactivated the patch lesions with severe itching; the extract was discontinued. The lesions resolved two weeks after topical clobetasol was applied. CONCLUSIONS: Th2 predominates in mycosis fungoides. Given that dialyzable leukocyte extract reinforces the Th1 profile, it was unlikely for it to reactivate the disease, but the diversity of lymphocyte immunophenotypes in mycosis fungoides and the complex activation networks caused a paradoxical reactivation.

Antecedentes: La micosis fungoide es un linfoma cutáneo de células T. El estadio de placa se encuentra limitado a piel y puede involucionar o progresar, diseminándose a sangre periférica, ganglios y vísceras. Reporte de caso: Mujer de 64 años de edad con dermatosis de seis años de evolución con placas descamativas, mal delimitadas y pruriginosas en tórax y extremidades. Había recibido esteroides orales y antihistamínicos, con los que presentaba remisiones parciales transitorias. Mediante biopsia cutánea se encontraron microabscesos de Pautrier, patognomónicos de micosis fungoide. La tomografía por emisión de positrones y el frotis de sangre periférica descartaron diseminación y confirmaron micosis fungoide en estadio de placa. La paciente recibió derivados tópicos de mostaza nitrogenada, psoralenos con radiaciones ultravioleta A, esteroides y tacrolimus. Presentó remisión total a los seis meses. Dos años después recibió extracto dializado de leucocitos, con el que se reactivaron las lesiones con prurito intenso; suspendió el extracto. Las lesiones involucionaron dos semanas después de iniciar el clobetasol tópico. Conclusiones: En la micosis fungoide predomina Th2. Dado que el extracto dializado de leucocitos refuerza el perfil Th1 no se esperaba que reactivara la enfermedad, pero los diversos inmunofenotipos de los linfocitos en la micosis fungoide y las complejas redes de activación ocasionaron reactivación paradójica.

[Angioedema and paradoxical bronchoconstriction secondary to ipratropium bromide/salbutamol administered by metered dose inhaler in patients with soy allergy]. / Angioedema y broncoconstricción paradójica secundarios a bromuro de ipratropio/salbutamol administrados por inhalador de dosis medida en pacientes alérgicos a la soya.

BACKGROUND: There are some reports on the association between the use of ipratropium bromide/salbutamol and paradoxical bronchoconstriction and urticaria in patients with soy allergy. METHODS: We describe four patients who displayed angioedema and paradoxical bronchoconstriction secondary to ipratropium bromide/salbutamol administered by metereddose-inhaler (MDI). In all of them soy allergy was demonstrated. RESULTS: Four patients, two children and two adults, exhibited paradoxical bronchoconstriction and angioedema secondary to ipratropium bromide/salbutamol administered by MDI. In all of them, soy allergy was substantiated by skin prick test and IgG/IgE RAST. The symptoms quickly disappeared with antihistaminics and nebulized salbutamol. CONCLUSIONS: In the cases where paradoxical bronchoconstriction and angioedema associated with the use of ipratropium bromide/salbutamol in MDI an immediate hypersentivity reaction to soy was confirmed, which is used as an additive in the MDI, through allergen-specific IgE determination and skin tests.

[Theophylline, a new look to an old drug]. / Teofilina, una nueva mirada a un medicamento antiguo.

OBJECTIVES: To emphasize the safety and efficacy of theophylline in chronic inflammatory respiratory diseases. To mention its immunomodulatory effects. DATA SOURCES: PubMed search using the keywords: theophylline, histone deacetylase, antiinflammatory, asthma, chronic obstructive pulmonary disease (COPD), corticoresistance. RESULTS: Theophylline is a methylxantine, that inhibits phosphodiesterase (PDE), induces histone deacetylase and antagonizes adenosine. Its main effect is to relax airway smooth muscle. The immunomodulatory effects of theophylline are obtained at low plasma concentrations (less than 10 mg/L). The combination of inhaled corticoesteroids and theophylline exerts a synergistic antiinflammatory effect that improves asthma control and reduces COPD exacerbations. Histones are a group of transcriptional cofactors involved in chromatin remodeling. Histone deacetylases (HDACs) suppress inflammatory gene expression. In patients with COPD and severe asthma there is a reduction in HDAC-2 secondary to the increased oxidative and nitrative stress. HDAC-2 is required by corticosteroids to switch off activated inflammatory genes, then its reduction favors corticosteroid resistance. Theophylline via HDAC-2 induction and PDE inhibition, suppresses inflammatory gene expression, and inhibits free oxygen radicals production. CONCLUSIONS: Theophylline at low plasma concentrations exerts antiinflammatory effects, restoring corticosteroid sensitivity in COPD and severe asthma.

[Scleroderma related to specific immunotherapy. A report of a case]. / Esclerodermia relacionada con inmunoterapia específica. Comunicación de un caso.

It has been described two main phenotypes of helper T cells. On activation, the immune system develops the most effective Th response. Whereas Th1 cells promote cell-mediate immunity against intracellular pathogens and an over expression could favor autoimmune diseases; Th2 cells develop humoral immunity against extracellular pathogens promoting allergic response. Normally, the two profiles coexist in the same individual with different grades of expression. Recently, it has been described a new subset: Th17, which is related to tissue injury in autoimmune diseases. Then, allergic and autoimmune diseases result from an unbalanced response of the immune system. Allergen-specific immunotherapy is the only curative treatment of a specific allergy, which leads to a life-long tolerance against allergens. There are no controlled studies about the effectiveness or risks associated with allergen-specific immunotherapy in patients with autoimmune disorders. On the other hand, scleroderma is an autoimmune chronic systemic disorder of unknown etiology characterized by excess collagen deposition in the skin and viscera, along with vascular injury. We report a girl with allergic asthma and with a second degree family history of systemic sclerosis who developed localized scleroderma during allergen specific immunotherapy. Because allergy vaccination alter the balance between effector and regulatory T-cell populations, which regulate immune tolerance, a positive family history of autoimmunity in first or second degree, could be a contraindication for allergen-specific immunotherapy.

[Failure of sublingual immunotherapy to treat latex allergy. A report of a case]. / Fracaso de la inmunoterapia sublingual para tratar la alergia al látex. Comunicación de un caso.

Natural rubber latex has been in widespread use for over a century. Reports of immediate hypersensitivity to latex have increased dramatically since the first case was reported in 1979, specially in persons with cumulative latex exposure. A 13 year old male was referred to our office. He had been wearing orthodontic rubber bands for two years. The previous year he started having itchy, red and watery eyes, with sneezing and runny nose when he was exposed to rubber products. Then he developed oral edema and lip ulcers. Finally, he experienced cough, wheezing, chest tightness and dyspnea. The patient had no history of undergoing surgery, and his mother denied pacifier use. He had no history of fruit and vegetables allergy. Physical examination revealed conjunctival hyperemia, with fine papillary response in the upper tarsal plate, hyaline rhinorrhea, turbinate hypertrophy and perioral ulcers. Skin prick test were positive for latex and Quercus albus. Patch test with latex glove was negative, but positive with rubber tourniquet. Total IgE was 365 UI/mL. Latex-specific IgE testing confirmed the diagnosis. Spirometric values were normal. He started rush sublingual immunotherapy with latex extract. When he had finished, he traveled abroad. At immigration the inspectors examined him with latex gloves. Immediately he developed anaphylaxis, needing urgent medical attention. Although the efficacy and safety of sublingual immunotherapy for latex allergy has been demonstrated, the most effective strategy is complete avoidance of latex-containing products. World Public Health Services must promote the use of synthetic elastomer gloves in airports worldwide.

[Sensitization to Olea europaea in a patients group of Mexico City]. / Sensibilización a Olea europaea en un grupo de pacientes de la Ciudad de México.

RATIONALE: Olea europaea (olive) which is original from Europe, was introduced to Mexico by the Spaniards in the 16th century. In 1777 olive farming was prohibited, and plantations were destroyed. At present there are only few trees in Southern Mexico City. The aim of this study is to investigate sensitization to Olea europaea, clinical features, IgE levels, and concurrent pollen sensitizations in a group of Mexican patients. METHOD: A retrospective chart review of all patients (n=232) with pollen allergy, between August 2003 and August 2004, in a medical office. RESULTS: The sensitization to Olea europaea was found in 41.5% (96). The median IgE levels was 387.2 UI/ml. Symptoms were: 95.8% with allergic rhinitis, 58.3% asthma, 66.6% chronic sinusitis, 36.4% otitis media with effusion, 29.1% allergic conjunctivitis, 16.6% atopic dermatitis, 16.6% oral allergy syndrome, mainly related to apple and strawberries; and 4.5% paranasal polyposis. Positive skin prick tests to Olea europaea were higher on April (27.2%), and lower on November (2.5%). CONCLUSION: Olea europaea is an important sensitizer in Mexico City. Cross-reaction to other pollens belonging to Oleaceae family, possibly Osmanthus americanus, could explain monosensitization to olive tree.