Chloramine-induced anaphylaxis while showering: a case report.

INTRODUCTION: Sodium-N-chlorine-p-toluene sulfonamide, commonly known as chloramine-T, is a derivative of chlorine which is widely used as a disinfectant. For many years, chloramine-T has been described as a cause of immediate-type hypersensitivity, especially with regard to asthma and rhinitis, and as a cause of occupational dermatoses in cleaning personnel in hospitals, although no anaphylactic reaction has yet been reported. Hence, to the best of our knowledge we present the first case of anaphylaxis to chloramine-T with evidence of specific immunoglobulin E antibodies. CASE PRESENTATION: We describe the case of a 25-year-old Caucasian woman who was in good health and with a negative history for atopy, including no respiratory symptoms of rhinitis or asthma, and with no professional exposure to chloramine-T. She, while showering, applied a chloramine-T solution to a skin area with folliculitis on her leg, and within a few minutes developed generalized urticaria and angioedema, followed by vomiting and collapse with loss of consciousness. A skin prick test with a chloramine-T solution at 10mg/mL concentration was positive, and specific immunoglobulin E to chloramine-T was quantified at a value of 2.9 optical density as measured by the enzyme allergosorbent test technique. CONCLUSION: The strict cause-effect relationship and the results of the skin test and the in vitro test make certain the causative role of chloramine-T in this case of anaphylaxis. This suggests that chloramine-T, based on its wide use as a disinfectant, should be considered a possible cause in anaphylaxis of unknown origin.

Molecular cloning and characterization of Cup a 4, a new allergen from Cupressus arizonica.

Sensitization to Cupressaceae pollen has become one of the most important causes of pollinosis in Western countries during winter and early spring. However, the characterization of the extracts, the allergens involved and the cross-reactivity with other pollen sources still remain poorly studied; in the case of Cupressus arizonica only two allergens have been described so far. A new allergen from C. arizonica pollen, Cup a 4, was cloned and expressed in Escherichia coli as an N-terminally His-tag recombinant protein that was characterized biochemically, immunologically and by circular dichroism spectroscopy. The new allergen has high sequence identity with Prickly Juniper allergen Jun o 4 and contains four EF-hand domains. The recombinant protein has structural similarities with other calcium binding allergens such as Ole e 3, Ole e 8 and Phl p 7. Cup a 4 is expressed in mature pollen grains and shares antigenic properties with the recombinant form. Sera from 9.6% C. arizonica allergic patients contain specific IgE antibodies against recombinant Cup a 4.

Respiratory allergy to lipid transfer protein.

BACKGROUND: Due to unclear reasons, allergy to lipid transfer protein (LTP) is frequent in Mediterranean countries but rare in Northern Europe. OBJECTIVE: We report a paradigmatic case of primarily airborne sensitization to LTP that might explain the geographical distribution of this type of food allergy. METHODS: A 21-year-old woman began having severe perennial rhinitis 6 months after she started working in a wholesale fruit storehouse in Southern Italy where large amounts of fruits, including peaches, were handled; symptoms subsided when she left the workplace for >5 days and relapsed as soon as she was back at work. Later on, she developed severe food allergies to peach, hazelnut, peanut, apricot, plum and tomato. The patient underwent a nasal challenge with peach peel extract, and IgE reactivity was assessed by immunoblot analysis. RESULTS: In vivo and in vitro analyses showed sensitivity to LTP. The nasal challenge with peach peel extract (6 microg protein) induced acute, severe respiratory symptoms. On immunoblot with peach peel extract patient's serum reacted uniquely against LTP, as demonstrated by inhibition assays with the recombinant peach protein. CONCLUSION: LTP may induce sensitization via the respiratory tract due to inhalation of air-dispersed food particles, and this may precede the onset of food allergy. If this way of sensitization were effective in the majority of LTP allergic patients (e.g. by exposure to peaches showing intact fuzz in areas where peaches are grown and directly sold on the market) our findings could explain the strange geographical distribution of this type of food allergy.

Effect of sublingual immunotherapy with grass monomeric allergoid on allergen-specific T-cell proliferation and interleukin 10 production.

BACKGROUND: Sublingual immunotherapy (SLIT) is safe and efficacious in the treatment of patients with allergic rhinitis. Although favorable clinical effects have been observed with controlled trials as early as a few months since the beginning of treatment, few biological changes induced by SLIT have been demonstrated. OBJECTIVE: To investigate in grass-allergic patients the effect of a 2-month SLIT regimen, administered with a simplified protocol without up-dosing, on proliferation and production of cytokines characteristic of the regulatory T-cell phenotype (interleukin 10 [IL-10] and transforming growth factor beta [TGF-beta]) by allergen-specific T cells. METHODS: Patients were recruited to the study in January 2006. SLIT was performed by self-administration and was continued for 60 days from February to April 2006. Eleven grass pollen-allergic patients with seasonal rhinitis were treated daily before the pollen season for 2 months with a modified allergen (monomeric allergoid) derived from a 3-grass pollen extract. Allergen-specific proliferation and production of IL-10 and TGF-beta were measured on peripheral blood mononuclear cells at baseline and treatment end. Tetanus toxoid served as the control antigen. RESULTS: After SLIT, allergen-specific (P = .002) but not tetanus toxoid-specific proliferation decreased, whereas IL-10 transcription increased (P < .001). TGB-beta transcription was also increased after treatment, although not statistically significantly (P = .06). Changes in proliferation to allergen and in IL-10 transcription were correlated (r = -0.82, P = .003). CONCLUSIONS: A short-term course of SLIT with modified allergen in grass-allergic patients is associated with the reduction of allergen-specific proliferation and with the up-regulation of the IL-10 regulatory cytokine.

Respiratory and skin allergy to Galleria mellonella (bee moth).

This case report describes a patient with bee moth-induced rhinoconjunctivitis, asthma and contact urticaria. Immunoblot analysis showed IgE reactivity to two distinct bee moth proteins at 23 and 70 kDa, respectively. ELISA inhibition studies excluded cross-reactivity to the other popular live bait, fly larva.

Detection of some safe plant-derived foods for LTP-allergic patients.

BACKGROUND: Lipid transfer protein (LTP) is a widely cross-reacting plant pan-allergen. Adverse reactions to Rosaceae, tree nuts, peanut, beer, maize, mustard, asparagus, grapes, mulberry, cabbage, dates, orange, fig, kiwi, lupine, fennel, celery, tomato, eggplant, lettuce, chestnut and pineapple have been recorded. OBJECTIVE: To detect vegetable foods to be regarded as safe for LTP-allergic patients. METHODS: Tolerance/intolerance to a large spectrum of vegetable foods other than Rosaceae, tree nuts and peanut was assessed by interview in 49 subjects monosensitized to LTP and in three distinct groups of controls monosensitized to Bet v 1 (n = 24) or Bet v 2 (n = 18), or sensitized to both LTP and birch pollen (n = 16), all with a history of vegetable food allergy. Patients and controls underwent skin prick test (SPT) with a large spectrum of vegetable foods. The absence of IgE reactivity to foods that were negative in both clinical history and SPT was confirmed by immunoblot analysis and their clinical tolerance was finally assessed by open oral challenge (50 g per food). RESULTS: All patients reported tolerance and showed negative SPT to carrot, potato, banana and melon; these foods scored positive in SPT and elicited clinical symptoms in a significant proportion of patients from all three control groups. All patients tolerated these four foods on oral challenge. Immunoblot analysis confirmed the lack of IgE reactivity to these foods by LTP-allergic patients. CONCLUSION: Carrot, potato, banana and melon seem safe for LTP-allergic patients. This finding may be helpful for a better management of allergy to LTP.

Relationship between peach lipid transfer protein specific IgE levels and hypersensitivity to non-Rosaceae vegetable foods in patients allergic to lipid transfer protein.

BACKGROUND: Lipid transfer protein (LTP), the major allergen in Rosaceae in geographic areas where the prevalence of birch pollen allergy is low, is a widely cross-reacting pan-allergen, but the pattern of cross-reactivity to plant-derived foods botanically unrelated to Rosaceae shows much variability. OBJECTIVE: To examine the relationship between peach LTP specific IgE levels and cross-reactivity to several non-Rosaceae, plant-derived foods. METHODS: IgE specific for peach LTP was measured by enzyme-linked immunosorbent assay in serum samples from 40 patients with Rosaceae allergy monosensitized to LTP. Patients were considered monosensitized to this protein in the absence of sensitization to other cross-reacting, plant-derived foods as shown by negative skin prick test (SPT) results with both birch and mugwort pollen. SPTs with commercial extracts of walnut, hazelnut, peanut, celery, maize, rice, tomato, orange, and onion were performed to detect possible immunologic cross-reactivity to these foods. RESULTS: Patients with negative SPT results with non-Rosaceae foods showed significantly lower levels of IgE to peach LTP than patients showing skin reactivity to one or more non-Rosaceae foods (P < .001). A significant difference in specific IgE to peach LTP between patients with positive or negative SPT results was observed with each individual food (P < .001 in all cases). The level of IgE to peach LTP was strongly related to the number of positive SPT results with non-Rosaceae foods (r = 0.78; P < .001). Increasing levels of IgE to peach LTP were associated with skin reactivity to nuts (29/40 [72%]), peanut (27/40 [67%]), maize (16/39 [41%]), rice (14/39 [36%]), onion (13/37 [35%]), orange (9/32 [28%]), celery (11/40 [27%]), and tomato (8/39 [20%]). CONCLUSIONS: This study suggests that all allergenic determinants in LTP from vegetable foods other than peach cross-react with peach LTP determinants, whereas only some peach LTP epitopes cross-react with allergenic determinants on botanically unrelated, plant-derived foods. The high levels of IgE to peach LTP seem to reflect the presence of IgE targeting common allergenic determinants of LTP, causing cross-reactivity to botanically unrelated, vegetable foods. In LTP-allergic patients, increasing levels of IgE to peach LTP are paralleled by an increasing number of foods other than Rosaceae positive on SPT that cause clinical symptoms.

Parietaria profilin shows only limited cross-reactivity with birch and grass profilins.

BACKGROUND: In patients showing multiple reactivity to seasonal airborne allergens, a skin prick test (SPT) with Parietaria pollen scores frequently negative, suggesting that profilin from Parietaria might not share IgE-binding epitopes with profilin from botanically unrelated airborne allergens. This study investigated the immunologic cross-reactivity between profilins from Parietaria, grass and birch pollen. METHODS: 36 patients hypersensitive to birch profilin, Bet v 2, underwent SPT with Parietaria, and IgE to both whole Parietaria pollen and Phleum profilin were sought in their sera by ELISA. In ELISA inhibition studies, IgE reactivity to Phleum profilin was measured before and after absorption of sera from Parietaria reactors with both whole Parietaria pollen extract, and Par j 1/Par j 2 fraction. Further, their IgE reactivity to whole Parietaria pollen was measured before and after absorption with the Par j 1/Par j 2 fraction. RESULTS: All sera showed IgE reactivity to Phleum profilin. Only 14/36 (39%) patients had a positive SPT to Parietaria and 17/36 (47%) showed IgE to Parietaria. Absorption of sera from Parietaria reactors with whole Parietaria extract caused a marked reduction in IgE reactivity to grass profilin; in contrast, absorption of sera with the Par j 1/Par j 2 fraction did not exert any inhibitory effect on IgE reactivity to grass profilin. Absorption of sera with the Par j 1/Par j 2 fraction markedly reduced IgE reactivity to whole Parietaria extract in 8/9 cases. CONCLUSION: Less than 50% of patients sensitized to birch and grass profilin cross-react to Parietaria profilin. In most cases, cross-reactors are hypersensitive to major, specific Parietaria allergens as well. This findings may be of practical relevance when the prescription of specific immunotherapy is considered.

Detection of clinical markers of sensitization to profilin in patients allergic to plant-derived foods.

BACKGROUND: A proper classification of patients allergic to plant-derived foods is of pivotal importance because the clinical features of allergic reactions to fruits and vegetables depend on the nature and characteristics of proteins responsible for sensitization. However, in normal clinical settings this is presently impossible. OBJECTIVE: We sought to detect clinical markers of sensitization to profilin. METHODS: Seventy-one patients allergic to fruits and vegetables but not sensitized to lipid transfer protein or natural rubber latex were studied. Food allergy was ascertained on the basis of clinical history and positive skin prick test responses with fresh foods, commercial extracts, or both. Allergies to foods that had caused less than 2 adverse reactions were confirmed by means of open oral challenge. IgE reactivity to rBet v 1/rBet v 2 and to natural Phleum species profilin were detected. Moreover, IgE to the 30- to 40-kd and 60- to 90-kd birch pollen-enriched fractions, which also can be involved in cross-reactivity phenomena, were measured in sera from 52 patients by means of ELISA. RESULTS: On the basis of in vitro tests, 24, 18, and 25 patients turned out to be sensitized to Bet v 1, Bet v 2, or both, respectively. Four patients had negative test results for both allergens. Hypersensitivity to Bet v 2 was strongly associated with clinical allergy to citrus fruits (39% in patients monosensitized to Bet v 2 vs 4% in patients monosensitized to Bet v 1, P <.025), melon or watermelon (67% vs 0%, P <.001), banana (66% vs 8%, P <.001), and tomato (33% vs 0%, P <.05), whereas Bet v 1 sensitivity was associated with clinical allergy to apple (100% vs 39%, P <.001) and hazelnut (56% vs 0%, P <.001). The sensitivity of a history of allergy to gourd fruits, citrus fruits, tomato, banana, or a combination thereof as a means to detect profilin-hypersensitive patients was 85% (41/48). The specificity of an allergy to any of these fruits exceeded 85%, with positive predictive values ranging between 68% and 91%. CONCLUSION: In clinical settings in which laboratory investigations are not easily accessible, allergy to melon, watermelon, citrus fruits, tomato, and banana can be used as a marker of profilin hypersensitivity once a sensitization to natural rubber latex and lipid transfer protein is ruled out.