Idiopathic itch, rash, and urticaria/angioedema merit serum vitamin D evaluation: a descriptive case series.

BACKGROUND: Vitamin D insufficiency is epidemic. Rarely are cutaneous consequences attributed to low vitamin D. METHODS: A retrospective case series of 63 patients describes an association of pruritus, rash, and urticaria/angioedema with low 25-hydroxyvitamin D (25[OH]D <32 ng/mL). The 90% (57/63) of patients with low vitamin D were treated with 8 to 12 weeks of vitamin D 50,000 IU weekly followed by daily supplementation. Concurrent diagnoses were treated routinely. Complete resolution of cutaneous symptoms defined response. RESULTS: Patients were 3 to 80 years of age. The 90% (57/63) with low vitamin D (25[OH]D < 32 ng/mL) had a mean age of 47 (11 to 80) years old, 70% were atopic, and 77% were female. Median duration of idiopathic cutaneous symptoms was 18 months. Mean 25[OH]D was 18.0 ng/mL. With vitamin D treatment 70% (40/57) had complete resolution of symptoms. Mean 25[OH]D for vitamin D responsive patients (16.8 ng/mL) was significantly lower than for vitamin D non-responsive treated patients (20.9 ng/mL, P = 0.02 by unpaired t-Test). Resolution of cutaneous symptoms with vitamin D supplementation occurred in a mean of 4.2 weeks. Symptom recurrence was seen in subsequent months only if vitamin D insufficiency recurred. CONCLUSION: This retrospective case-series, with a 70% (40/57) vitamin D treatment success, suggests that vitamin D status should be assessed in patients with idiopathic cutaneous symptoms. If vitamin D is low, symptom resolution is often possible with oral supplementation of vitamin D. Controlled clinical studies are required to confirm these associations.

Seasonal inhalant insect allergy: Harmonia axyridis ladybug.

PURPOSE OF REVIEW: The exotic Asian lady beetle, Harmonia axyridis, has become a prominent cause of seasonal inhalant allergy (allergic rhinitis, asthma, and urticaria) in the last two decades in North America and Europe after being introduced into the environment as an agricultural pest-control predator. RECENT FINDINGS: Seeking winter hibernation sites, ladybug swarms will invade human habitats in the fall. Large fall swarms and smaller spring dispersions produce corresponding peaks in ladybug allergy. Ladybug allergy prevalence in endemic areas has been reported as high as 10%. For some individuals ladybug allergy is their first expression of allergic disease. Exposures at home, work, school, and in other settings may be sensitizing. Ladybug hemolymph is the primary source of allergens. Har a 1 and Har a 2 major ladybug allergens have been characterized. 'Reflex bleeding' from tibiofemoral joints (for communication and during alarm) disperses these allergens. SUMMARY: Ladybug skin testing should be routine in endemic areas. Avoidance continues to be the first step in treatment. Allergen vaccine therapy may be effective, but a commercial extract of H. axyridis is needed.

Harmonia axyridis ladybug invasion and allergy.

Beginning in 1916 Harmonia axyridis, an orange/red lady beetle with variable black spotting, was imported into the United States from Asia. This agricultural pest-control predator established independent feral populations in North America by 1988. Subsequently, Harmonia axyridis has become a pest to homeowners and various horticultural enterprises. Seeking winter hibernation sites, ladybug swarms invade human homes/habitats primarily in the fall. With increased Harmonia axyridis exposures, human ladybug allergy was first reported in 1998. Ladybug-specific IgE hypersensitivity has been reported in all ages (1-78 years old) and both sexes. Clinical ladybug allergy manifests variously as rhinoconjunctivitis, asthma, urticaria, and angioedema. A majority, but not all, allergic individuals are primarily exposed at home. Large fall swarms and smaller spring dispersions produce corresponding peaks in ladybug allergy. Ladybug hemolymph is a primary source of allergen. Har a 1 and Har a 2 major ladybug allergens have been characterized. Ladybug allergy prevalence in one endemic area was reported as 10%. Self-report of ladybug pests at home did not predict ladybug allergy, suggesting other exposures are important also. Some individuals have no history of atopy before manifestation of ladybug allergy. Ladybug, cat, cockroach, and house-dust mites are the most likely allergens to present as isolated single positive skin tests in an allergist's office. Ladybug should be a standard skin test allergen for all allergy patients tested in endemic areas. Avoidance of ladybug exposure is paramount to treatment.

Harmonia axyridis ladybug hypersensitivity in clinical allergy practice.

The imported Harmonia axyridis ladybug infests homes in northern West Virginia from fall through spring, causing allergic disease. Retrospective single-practice chart reviews were performed: (1) all skin prick tests (1400 included ladybug) in a community allergy practice over 4 years and (2) clinical analysis of 400 randomly chosen patients. The usual adult aeroallergen skin test panel included ladybug and 57 other allergens. Statistics used were contingency table analyses and the kappa-statistic for concordance. Home infestation with ladybugs was most common in rural areas but did not predict ladybug sensitization (kappa = -0.02). Ladybug sensitization and allergy occurred at all ages. Ladybug sensitization occurred with 21% frequency compared with cat at 24% frequency, cockroach at 27% frequency, and dust mites at 40% frequency. Only ladybug showed a significant (p < 0.0001) skin test sensitization decreasing from rural (30%), mixed (21%), to urban (16%) home demographics. Isolated single-positive skin tests constituted 10% of dust mites, 6% of cockroach, 6% of ladybug, and 4% of cat-positive skin tests. Skin test concordance was strongest between the pairs: ladybug-cockroach (kappa = 0.36), cockroach-dust mite (kappa = 0.29), and dust mite-cat (kappa = 0.25). Ladybug is a major allergen in endemic areas, causing rhinoconjunctivitis (8% prevalence), asthma (2% prevalence), and urticaria (1% prevalence). Ladybug skin test sensitization is more common in rural areas and is comparable in frequency and age distribution with cat and cockroach. Cockroach and ladybug have a high degree of skin test concordance. A quality commercial ladybug allergen extract and increased ladybug allergen research are needed.

Cross-reactivity among edible nuts: double immunodiffusion, crossed immunoelectrophoresis, and human specific igE serologic surveys.

BACKGROUND: As many as one third of all food allergen anaphylactic events are related to tree nut ingestion. Although concurrent allergen sensitivity to tree nuts is common, cross-reactivity among nut antigens is less well defined. OBJECTIVE: To survey serologic cross-reactivities among 7 tree nuts (walnut, pecan, hazelnut, cashew, Brazil nut, pistachio, and almond) and peanut. METHODS: Human specific IgE enzyme-linked immunosorbent assay inhibition was used to identify nut allergen cross-reactivities. Single-nut rabbit antisera were used in double immunodiffusion, crossed-line immunoelectrophoresis, and crossed immunoelectrophoresis with intermediate gel studies of nut antigen cross-reactivity. RESULTS: Nut specific IgE enzyme-linked immunosorbent assay inhibition demonstrated no cross-reactivities between peanut and tree nuts. Among tree nuts, 2 groups with allergen cross-reactivity were defined: (1) walnut, pecan, and hazelnut and (2) hazelnut, cashew, Brazil nut, pistachio, and almond. Double immunodiffusion, crossed-line immunoelectrophoresis, and crossed immunoelectrophoresis with intermediate gel results supported the same groupings of cross-reactive tree nuts and identified several less prominent nut-nut antigen cross-reactivities between groups and with peanut. CONCLUSION: With few exceptions (notably limited peanut cross-reactivity with pistachio and walnut), peanut antigens did not serologically cross-react with tree nuts. Walnut, pecan, and hazelnut form a group of strongly cross-reactive tree nuts. Hazelnut, cashew, Brazil nut, pistachio, and almond form a group of moderately cross-reactive tree nuts. Cross-reactivities between these groups are less pronounced (notably limited cross-reactivity of walnut and pecan with Brazil nut). The strongest cross-reactivities among tree nuts follow botanical family associations: (1) walnut and pecan in the family Juglandaceae and (2) cashew and pistachio in the family Anacardiaceae.