Favorable Prognosis of Wheat Allergy in Adults.

BACKGROUND AND OBJECTIVE: Wheat ingestion can lead to disorders such as IgE-mediated food allergy and wheat-dependent exercise-induced anaphylaxis (WDEIA), both of which are associated with impaired quality of life and significant morbidity. Allergy to wheat is relatively benign in children, although its natural history in adults is still unknown. Objective: We used placebo-controlled challenge to evaluate the natural history of wheat hypersensitivity in atopic patients with adultonset wheat allergy. METHODS: We enrolled 13 patients from an initial cohort of adult patients with IgE-mediated wheat allergy (mean age, 40 years). After diagnosis, the patients observed a wheat-free diet and were followed as outpatients for 5 years to evaluate wheat exposure. Wheat-IgEtiters were determined at the end of follow-up, and a second wheat-challenge was performed. RESULTS: Ten out of 13 patients took part in the study. The mean period of wheat avoidance was 4.2 years. Three patients had spontaneously reintroduced wheat before the second evaluation, after a mean (IQR) of 28 (18-36) months, with only mild gastrointestinal discomfort at reintroduction. At the end of follow-up, 9 of the 10 patients were wheat-tolerant. Two patients had a history of WDEIA. We observed a reduction in IgE levels, with median (IQR) IgE falling from 2.77 (0.35-100) kU/L at diagnosis to 0.88 (0.1-20.8) kU/L. The association between IgE and a negative challenge result was not statistically significant. CONCLUSION: IgE-mediated wheat allergy in adults is benign and represents a temporary break in gastrointestinal tolerance. Future studies may improve our knowledge of wheat allergens, routes of and factors leading to sensitization, and prognostic biomarkers.

Favorable prognosis of wheat allergy in adults

Background: Wheat ingestion can lead to disorders such as IgE-mediated food allergy and wheat-dependent exercise-induced anaphylaxis (WDEIA), both of which are associated with impaired quality of life and significant morbidity. Allergy to wheat is relatively benign in children, although its natural history in adults is still unknown. Objective: We used placebo-controlled challenge to evaluate the natural history of wheat hypersensitivity in atopic patients with adult-onset wheat allergy. Methods: We enrolled 13 patients from an initial cohort of adult patients with IgE-mediated wheat allergy (mean age, 40 years). After diagnosis, the patients observed a wheat-free diet and were followed as outpatients for 5 years to evaluate wheat exposure. Wheat-IgE titers were determined at the end of follow-up, and a second wheat-challenge was performed. Results: Ten out of 13 patients took part in the study. The mean period of wheat avoidance was 4.2 years. Three patients had spontaneously reintroduced wheat before the second evaluation, after a mean (IQR) of 28 (18-36) months, with only mild gastrointestinal discomfort at reintroduction. At the end of follow-up, 9 of the 10 patients were wheat-tolerant. Two patients had a history of WDEIA. We observed a reduction in IgE levels, with median (IQR) IgE falling from 2.77 (0.35-100) kU/L at diagnosis to 0.88 (0.1-20.8) kU/L. The association between IgE and a negative challenge result was not statistically significant.Conclusion: IgE-mediated wheat allergy in adults is benign and represents a temporary break in gastrointestinal tolerance. Future studies may improve our knowledge of wheat allergens, routes of and factors leading to sensitization, and prognostic biomarkers

Introducción: La ingesta de trigo puede originar varias patologías como alergia alimentaria mediada por IgE y la anafilaxia inducida por ejercicio previa ingesta de trigo. Todas ellas originan un descenso en la calidad de vida y una importante morbilidad. La alergia a trigo es relativamente benigna en niños, sin embargo, su historia natural en adultos es aún desconocida. Objetivo: Evaluamos la historia natural de la hipersensibilidad al trigo de inicio en la edad adulta en pacientes atópicos confirmado mediante pruebas de exposición oral. Métodos: Se incluyeron 13 pacientes de una cohorte de pacientes adultos (edad media 40 años) con alergia a trigo mediada por IgE. Tras el diagnóstico los pacientes siguieron una dieta exenta de trigo y fueron seguidos durante 5 años para valorar su tolerancia tras la exposición al trigo. Al final del seguimiento se determinaron los valores de IgE específica a trigo y se realizó una segunda provocación oral con trigo. Resultados: 10 de los 13 pacientes tomaron parte en el estudio. La duración media del periodo de no ingesta de trigo fue de 4,2 años. 3 pacientes reintrodujeron por iniciativa propia la ingesta de trigo antes de la segunda evaluación, después de un periodo medio de 28 meses (RIQ 18-36 meses), presentando solo leves síntomas gastrointestinales. Al final del seguimiento, 9/10 pacientes toleraron la ingesta de trigo. 2 pacientes tenían historia de anafilaxia inducida por ejercicio. Se observó una disminución de los valores de IgE específica desde una mediana de 2,77 kU/l (RIQ 0,35-100 kU/L) en el momento del diagnóstico hasta 0,88 kU/l (RIQ 0,1-20,8 Ku/L) al final del seguimiento. No se observó correlación entre los valores de IgE específica y los resultados de la tolerancia final. Conclusión: La alergia a trigo mediada por IgE en adultos es una patología benigna y representa una interrupción temporal de la tolerancia gastrointestinal. Futuros estudios podrían mejorar nuestro conocimiento sobre los alérgenos del trigo, rutas y factores que llevan a la sensibilización, y biomarcadores de pronóstico

Tryptase as a marker of severity of aortic valve stenosis.

BACKGROUND: Severe aortic valve stenosis is one of the most common cause of mortality in adult patients affected with metabolic syndrome, a condition associated with an active inflammatory process involving also mast cells and their mediators, in particular tryptase. The aim of this study was to characterize the possible long-term prognostic role of tryptase in severe aortic valve stenosis. CASE PRESENTATION: The baseline serum tryptase was measured in 5 consecutive patients admitted to our Hospital to undergo aortic valve replacement for severe acquired stenosis. Within 2 years after, the patients were evaluated for the occurrence of major cardiovascular events (MACE). The tryptase measurements were higher in patients experiencing MACE (10.9, 11.7 and 9.32 ng/ml) than in non-MACE ones (5.69 and 5.58 ng/ml). CONCLUSIONS: In patients affected with severe aortic stenosis, baseline serum tryptase may predict occurence of MACE. Further studies are needed to demonstrate the long-term prognostic role of this biomarker.

A case of atopic dermatitis caused by Ascaris lumbricoides infection.

BACKGROUND: Parasite infections stimulate total and specific IgE production that, in the case of Toxocara canis infection, corresponds to chronic allergic symptoms. There may also be other infections which have similar symptoms, such as Ascaris lumbricoides infection. Ascaris lumbricoides is a large nematode that causes abdominal pain, nausea, vomiting, bloating, anorexia and intermittent diarrhoea. Patients with ascaridiasis and high IgE levels may also have allergy-like symptoms such as asthma, urticaria and atopic dermatitis. CASE PRESENTATION: We report a case of atopic dermatitis caused by Ascaris lumbricoides which shows the important role of parasitic infection in patients with long-lasting dermatitis. The patient was a 12-year old female suffering since early infancy from atopic dermatitis and asthma. She was treated for dermatitis with oral bethametasone and topical pimecrolimus with little benefit. After two cycles of mebendazole therapy, the patient showed progressive improvement of symptoms. CONCLUSIONS: In patients with dermatitis, Ascaris lumbricoides infection should be not excluded: adequate anthelmintic treatment may result in complete regression from the disease.

Identification of risk factors of severe hypersensitivity reactions in general anaesthesia.

BACKGROUND: Hypersensitivity reactions to anaesthetic agents are rare but often severe, with a mortality ranging from 4 to 9% in IgE-mediated events. Identification of the risk factors may contribute to limit the incidence of these reactions. The aim of our study was to search for possible risk factors of severe perioperative hypersensitivity reactions in our study population. METHODS: For this study we retrospectively reviewed data from 193 patients who experienced drug hypersensitivity reactions during general anaesthesia. The diagnostic protocol consisted of 1) history of the reaction, 2) measurement of serum baseline tryptase and specific IgE-assays for latex, beta-lactams and succinylcholine, 3) skin tests for the agents listed in the anaesthesia chart and for others likely to be safe for future use, latex, and others medications administered during the perioperative period (i.e. antibiotics), 4) subdivision of our patients on the basis of two criteria: a) grade of severity of clinical reactions according to the Ring and Messmer classification; b) results of skin tests and/or serum specific IgE-assays. RESULTS: One hundred of 193 patients had reactions of grade I, 32/193 patients had reactions of grade II, 55/193 patients had reactions of grade III and 6/193 patients had reactions of grade IV. A diagnosis of IgE-mediated reaction was established in 55 cases (28.50%); the most common causes were neuromuscular blocking agents, followed by latex and beta-lactams. Severe reactions were associated with older age (p = 0.025), asthma (p = 0.042), history of hypertension (p = 0.001), intake of serum angiotensin converting enzyme inhibitor medication (p = 0.012) or serum angiotensin II antagonist (p = 0.033), higher levels of basal tryptase (p = 0.0211). Cardiovascular symptoms (p = 0.006) and history of hypersensitivity to antibiotics (p = 0.029) were more frequently reported in IgE-mediated reactions. CONCLUSIONS: We confirmed the relevance of several clinical features as risk factors for anaphylactic reactions induced by anaesthetic agents: older age, asthma, hypertension and antihypertensive drugs. We observed increased levels of serum basal tryptase in severe reactions: this finding may signify that this biomarker is useful for the identification of patients at risk.