Bullous Skin Manifestations of Mycoplasma pneumoniae Infection: A Case Series.

Bullous skin lesions are uncommon in children. While it is well known that Mycoplasma infections are associated with papular skin manifestations, bullous skin lesions are not commonly reported. Mycoplasma pneumoniae is a very common bacterial pathogen causing respiratory tract infection in children and adults. We report 2 children with serology-confirmed Mycoplasma infection who were hospitalized for blistering skin lesions. Both of our patients responded well to corticosteroids and one of them required intravenous immunoglobulin. The aim of this case report is to raise awareness that Mycoplasma pneumoniae infection can present with bullous skin lesions, and to briefly review the pathophysiology, diagnosis, and management of the skin manifestation of Mycoplasma infection.

Association of MHC region SNPs with irritant susceptibility in healthcare workers.

Irritant contact dermatitis is the most common work-related skin disease, especially affecting workers in "wet-work" occupations. This study was conducted to investigate the association between single nucleotide polymorphisms (SNPs) within the major histocompatibility complex (MHC) and skin irritant response in a group of healthcare workers. 585 volunteer healthcare workers were genotyped for MHC SNPs and patch tested with three different irritants: sodium lauryl sulfate (SLS), sodium hydroxide (NaOH) and benzalkonium chloride (BKC). Genotyping was performed using Illumina Goldengate MHC panels. A number of SNPs within the MHC Class I (OR2B3, TRIM31, TRIM10, TRIM40 and IER3), Class II (HLA-DPA1, HLA-DPB1) and Class III (C2) genes were associated (p < 0.001) with skin response to tested irritants in different genetic models. Linkage disequilibrium patterns and functional annotations identified two SNPs in the TRIM40 (rs1573298) and HLA-DPB1 (rs9277554) genes, with a potential impact on gene regulation. In addition, SNPs in PSMB9 (rs10046277 and ITPR3 (rs499384) were associated with hand dermatitis. The results are of interest as they demonstrate that genetic variations in inflammation-related genes within the MHC can influence chemical-induced skin irritation and may explain the connection between inflamed skin and propensity to subsequent allergic contact sensitization.

Genetic Basis of Irritant Susceptibility in Health Care Workers.

OBJECTIVE: The aim of this study was to investigate the association of single nucleotide polymorphisms (SNPs) within genes involved in inflammation, skin barrier integrity, signaling/pattern recognition, and antioxidant defense with irritant susceptibility in a group of health care workers. METHODS: The 536 volunteer subjects were genotyped for selected SNPs and patch tested with three model irritants: sodium lauryl sulfate (SLS), sodium hydroxide (NaOH), and benzalkonium chloride (BKC). Genotyping was performed on genomic DNA using Illumina Goldengate custom panels. RESULTS: The ACACB (rs2268387, rs16934132, rs2284685), NTRK2 (rs10868231), NTRK3 (rs1347424), IL22 (rs1179251), PLAU (rs2227564), EGFR (rs6593202), and FGF2 (rs308439) SNPs showed an association with skin response to tested irritants in different genetic models (all at P < 0.001). Functional annotations identified two SNPs in PLAU (rs2227564) and ACACB (rs2284685) genes with a potential impact on gene regulation. In addition, EGF (rs10029654), EGFR (rs12718939), CXCL12 (rs197452), and VCAM1 (rs3917018) genes showed an association with hand dermatitis (P < 0.005). CONCLUSIONS: The results demonstrate that genetic variations in genes related to inflammation and skin homeostasis can influence responses to irritants and may explain inter-individual variation in the development of subsequent contact dermatitis.

Parental perception of efficacy of antihistamines for pruritus in pediatric atopic dermatitis.

BACKGROUND: Clinicians have previously prescribed antihistamines for relief of atopic dermatitis (AD) associated pruritus. The use of antihistamines in AD has recently received less emphasis from newly published practice parameters that currently only recommend short-term, intermittent use of first-generation antihistamines to induce sleep in patients with AD. OBJECTIVE: Our study aimed to determine parents' perception of the usefulness of antihistamines in reducing their child's itch due to AD. METHODS: A 12-question survey was mailed to parents of patients who were attending a pediatric allergy clinic. Patients with physician-diagnosed AD who had a clinic visit in the past 3 years were included. Questions included the following: time since AD diagnosis, itching frequency, impact on sleep, frequency and relief provided from using antihistamines, and comparison of antihistamines to other antipruritus treatments. RESULTS: Sixty-three percent of parents surveyed responded that antihistamines were helpful in the management of their child's AD, and only 5% did not find any itch relief. The majority of the responders were parents of younger patients (ages, 2-10 years) with immunoglobulin E sensitization and AD for more than a year. Eighty-five parents (68.5%) reported no interruption of sleep due to itching, and, among them, an almost equal number were currently solely using either a first- or second-generation antihistamine. The more antihistamines were perceived as relieving itching, the more they were used (ρ = 0.209, p = 0.025) and provided more relief than other products (ρ = -0.336, p < 0.001). When compared, parents ranked antihistamines to be as helpful as topical corticosteroids. CONCLUSION: Parents of pediatric patients with AD found that antihistamines were an important part of AD management.

Genetic variants within the MHC region are associated with immune responsiveness to childhood vaccinations.

The influence of genetic variability within the major histocompatibility complex (MHC) region on variations in immune responses to childhood vaccination was investigated. The study group consisted of 135 healthy infants who had been immunized with hepatitis B (HBV), 7-valent pneumococcal conjugate (PCV7), and diphtheria, tetanus, acellular pertussis (DTaP) vaccines according to standard childhood immunization schedules. Genotype analysis was performed on genomic DNA using Illumina Goldengate MHC panels (Mapping and Exon Centric). At the 1 year post vaccination check-up total, isotypic, and antigen-specific serum antibody levels were measured using multiplex immunoassays. A number of single nucleotide polymorphisms (SNPs) within MHC Class I and II genes were found to be associated with variations in the vaccine specific antibody responses and serum levels of immunoglobulins (IgG, IgM) and IgG isotypes (IgG1, IgG4) (all at p<0.001). Linkage disequilibrium patterns and functional annotations showed that significant SNPs were strongly correlated with other functional regulatory SNPs. These SNPs were found to regulate the expression of a group of genes involved in antigen processing and presentation including HLA-A, HLA-C, HLA-G, HLA-H, HLA-DRA, HLA-DRB1, HLA-DRB5, HLA-DQA1, HLA-DQB1, HLA-DOB, and TAP-2. The results suggest that genetic variations within particular MHC genes can influence immune response to common childhood vaccinations, which in turn may influence vaccine efficacy.

Efficacy of a parent-youth teamwork intervention to promote adherence in pediatric asthma.

OBJECTIVE: To determine whether a parent-youth teamwork intervention improved medication adherence and related outcomes among youth with asthma. METHODS: We used a randomized clinical trial with 48 youth (aged 9-15 years) assigned to 1 of 3 groups: Teamwork Intervention (TI), Asthma Education (AE), or Standard Care (SC). Treatment occurred across 2 months, with a 3-month follow-up assessment. Adherence to inhaled corticosteroids was assessed via the MDILog-II. Parent-adolescent conflict, asthma functional severity, and spirometry assessments were obtained pre-treatment, post-treatment, and on follow-up. Mixed linear model analysis was used to evaluate group and time effects for outcome measures. RESULTS: TI group had significantly higher adherence and lower functional severity scores than AE or SC conditions, and lower parent-reported conflict and a trend for higher spirometry values compared with the SC group. CONCLUSIONS: Results suggest support for the efficacy of TI for improving medication adherence as youth acquire more responsibility for their asthma management.

Sinusitis and chronic cough in children.

BACKGROUND: Chronic cough in children is a common problem, and sinusitis is a common etiology. The diagnosis of sinusitis is often clinical, but confirmation is thought to require a CT scan due to the difficulty of interpreting a Water's view sinus X-ray. OBJECTIVES: The purposes of the study were (1) to examine the frequency of an abnormal sinus X-ray in children with a chronic cough of more than 4 weeks duration; (2) to compare the interpretation of the sinus film between allergy/pulmonary clinicians and radiologists; and (3) to correlate symptoms with X-ray results. METHODS: A chart review of 2- to 18-year-old patients with coughing exceeding 4 weeks was performed. Data was collected for patients who had received a Water's view sinus film as part of their evaluation. Exam, X-ray results, and clinical outcomes were categorized and statistical analyses performed. RESULTS: A total of 86 patients were included. Clinicians found that 65% of the children had positive Water's view films, compared with the radiologist's reading of 62% (non significant). Significant associations between post-tussive emesis (P = 0.01) and purulence (P = 0.03) were noted with a positive film. Positive sinus X-ray was highly associated with all findings except wheeze when present together (P < 0.001). CONCLUSION: Sinus abnormalities on X-ray are associated with prolonged cough in 65% of children. The Water's view sinus film is a clinically useful screening tool for clinicians in the workup of chronic cough. Certain physical findings and clinical complaints, when present concurrently, correlate with the X-ray results.

Early Pollen Sensitization in Children Is Dependent upon Regional Aeroallergen Exposure.

Introduction. Aeroallergen sensitization occurs at an earlier age than previously noted. The purpose of this paper was to identify which pollens cause early sensitization in young children presenting with rhinitis symptoms. Methods. This paper was a retrospective analysis of skin test results from 2- to 8-year-old patients presenting with a history consistent with allergic rhinitis. Patients were tested to aeroallergens common to the Great Basin along with a histamine and saline control. Pollen counts were obtained from a Reno, NV-certified counting station. Results. 123 children less than 8 years of age were identified. Over 50% of these children were sensitized to at least one aeroallergen. Chemopodaciae, timothy, alfalfa, black walnut, olive, mountain cedar and willow were predominating sensitizing aeroallergens of the Great Basin Region. Pollen counts were notable for a early spring peak for the tree season, grass season in May and weed season in August. Pollen levels continued to November at low levels. Discussion. Aeroallergens causing early sensitization differed from those which had predominately been reported in other regions of the United States. Pediatric allergists should consider performing a local review of sensitizing aeroallergens in their region to assist with identification and management of allergic rhinitis in their youngest patients. Please make style changes as appropriate.

Skin barrier function and its importance at the start of the atopic march.

Atopic dermatitis can be due to a variety of causes from nonatopic triggers to food allergy. Control of egress of water and protection from ingress of irritants and allergens are key components of cutaneous barrier function. Current research suggests that a degraded barrier function of the skin allows the immune system inappropriate access to environmental allergens. Epidermal aeroallergen exposure may allow sensitization to allergen possibly initiating the atopic march. Further research into connections between epidermal barrier function and possible allergen sensitization will be important to undertake. Future clinical trials focused on skin barrier protection may be of value as a possible intervention in prevention of the initiation of the atopic march.

Electronic monitoring and feedback to improve adherence in pediatric asthma.

OBJECTIVE: To evaluate the effectiveness of electronic monitoring and feedback to improve adherence in children taking daily asthma controller medications. METHOD: Five patients with asthma and considered nonadherent participated. Inhalers were electronically monitored with the MDILogII(TM) device, and feedback was given by medical staff. Using a nonconcurrent multiple-baseline design, patients and their parents received bimonthly feedback regarding medication use. Following treatment, feedback was withdrawn and effects of monitoring alone were observed. RESULTS: Three participants showed improvements in adherence following treatment, with more notable increases when baseline adherence was low. Improvements in the inhaler technique occurred for all patients. Some patients demonstrated improvements in lung functioning and functional severity. When feedback was withdrawn, adherence decreased for some participants, but technique improvements maintained. CONCLUSIONS: Results support the use of objective monitoring devices for assessing pediatric asthma patients' adherence and indicate that feedback from medical staff may improve and maintain medication adherence for some patients.

Effect of evaporative coolers on skin test reactivity to dust mites and molds in a desert environment.

Dust mites and molds are usually not found in arid environments and have a lower prevalence in desert areas. Evaporative (swamp) coolers increase indoor humidity significantly. The purpose of this study is to determine whether evaporative coolers affect the skin test rate to dust mites and molds in patients. Patients with asthma or allergic rhinitis who were undergoing skin testing for molds, indoor allergens, grasses, weeds, and trees were asked about presence of central, window, and evaporative cooler air conditioning in their home. All were tested using the prick technique with controls. One hundred ninety patients between 1 and 42 years (mean, 5.4 years) were evaluated. Fifty-nine (31%) had an evaporative cooler in their home. Twenty-five (42%) of those with evaporative coolers had a positive skin test to at least one mold compared with 26 (19%) without coolers (chi-square, 10.5; p = 0.001). Twenty (34%) of those with evaporative coolers had a positive skin test to dust mites compared with 23 (17.5%) without coolers (chi-square, 6.2; p = 0.013). Children < or = 6 years of age had the greatest skin test prevalence (chi-square, 4.3; p = 0.03). In the desert, children in homes using evaporative coolers are significantly more likely to have positive skin tests to molds or mites. This appears to be because of humidity caused by these devices. Patients with asthma in homes with evaporative coolers should be counseled about the risk for mold and dust-mite allergy. Humidity monitoring, cooler maintenance, and filter changes should be discussed.

Influence of cytokine gene variations on immunization to childhood vaccines.

The magnitude of the immune response to vaccinations can be influenced by genetic variability. In the present study, we aimed to investigate whether cytokine or cytokine receptor gene polymorphisms were associated with variations in the immune response to childhood vaccination. The study group consisted of 141 healthy infants who had been immunized with hepatitis B vaccine (HBV), 7-valent pneumococcal conjugate (PCV7), and diphtheria, tetanus, acellular pertussis (DTaP) vaccines according to standard childhood immunization schedules. Genotype analysis was performed on genomic DNA using a 5' nuclease PCR assay. Post vaccination total, isotypic, and antigen-specific serum antibody levels were measured using multiplex immunoassays. Significant associations were observed between SNPs in the TNFalpha, IL-12B, IL-4Ralpha, and IL-10 genes and vaccine-specific immune responses (p<0.05). In addition, SNPs in the IL-1beta, TNFalpha, IL-2, IL-4, IL-10, IL-4Ralpha, and IL-12B genes were associated with variations in serum levels of immunoglobulins (IgG, IgA, IgM) and IgG isotypes (IgG1-IgG3) (p<0.05). These data suggest that genetic variations in cytokine genes can influence vaccine-induced immune responses in infants, which in turn may influence vaccine efficacy.

Otitis media as a presenting complaint in childhood immunodeficiency diseases.

Otitis media is one of the most common childhood infections and may result from a variety of underlying problems. Suspicion of immunodeficiency should increase when ear infections are frequent; suppurative; unresponsive to antibiotics; caused by unusual organisms; or seen in the context of other frequent infections, severe eczema, or failure to thrive. Humoral immune deficiencies, particularly with an inability to make antibody to encapsulated organisms, are the immunodeficiencies most likely to cause increased otitis media. Immune system evaluation should concentrate on humoral immunodeficiency disorders, but the presenting history and physical findings also should be considered when designing the work-up. Treating the underlying immune deficiency is usually necessary to adequately control the ear infections.

Prevalence of allergic sensitization to indoor fungi in West Virginia.

Exposure to indoor fungi is of growing concern in residential and occupational environments in the United States. The purpose of this study was to determine the prevalence of sensitization to common indoor fungal species in an atopic population. We evaluated 102 patients (73 female and 29 male patients) for immunoglobulin E (IgE) reactivity to a panel of skin-prick test (SPT) reagents used for routine allergy testing. Patients also were tested for six additional fungi that are common indoor contaminants. All patients had symptoms consistent with allergic rhinitis or asthma. The presence of specific IgE against the fungal species was determined using immunoblotting. Of the 102 eligible patients, 68% had at least one positive skin test. The most prevalent positive SPTs were to dust mites, cats, vernal grass, and short ragweed. Overall, 21/102 (21%) patients with asthma or allergic rhinitis were skin test positive to at least one fungal extract. Of the patients with a positive SPT to fungi, 12/21 (58%) showed sensitivity to one or more of the newly tested species; most notably Trichoderma viride (8%), Chaetomium globosum (7%), Paecilomyces variotii (7%), and Acremonium strictum (6%). Immunoblotting revealed specific IgE against a number of protein bands belonging to these fungal species. The prevalence of fungal sensitization was common, particularly for indoor fungal contaminants that are not routinely included in SPT panels. Cross-reactivity with other fungi may partially explain our results; however, skin testing for these indoor fungi may provide useful diagnostic information.

Prevalence of pollen sensitization in younger children who have asthma.

It is commonly believed that young children are incapable of pollen sensitization; therefore, skin testing usually is not performed to these allergens. The purpose of this study was to identify the frequency of positive skin tests to outdoor allergens among younger children who have asthma. Patients who have asthma, aged 6 months to 10 years, were evaluated for pollen sensitization over a 10-year period. Skin-prick testing was performed to relevant individual aeroallergens including trees, grasses, and weeds. Testing for perennial indoor allergens such as dust mites, cats, dogs, cockroaches, and molds was performed also. A total of 687 children with asthma were evaluated. No child <12 months old was sensitized to pollens. Children between 12 and 24 months of age had a 29% incidence of pollen sensitization. Three-year-old children were as likely to be skin test positive to pollen as an indoor allergen. Notably, 49% of 3- and 4-year olds were sensitized to outdoor allergens. Primary sensitizing pollens in this age group were short ragweed, box elder, and June grass. In this population, pollen sensitization was not related to tobacco or wood smoke exposure. Although it is widely believed that young children with asthma are most commonly allergic to indoor allergens, almost 40% of our 1- to 3-year old children with asthma showed IgE-mediated sensitivity to outdoor allergens. Pediatric allergists should consider performing skin-prick testing to their local common aeroallergens in young children with asthma and seasonal symptoms.

Spectrum of illness in pediatric common variable immunodeficiency.

BACKGROUND: Common variable immunodeficiency (CVID) may present at any age but usually presents during adulthood. OBJECTIVE: To study the presentation and associated medical conditions found in pediatric patients with CVID. METHODS: A medical record review of patients diagnosed as having CVID before the age of 18 years was performed at a tertiary care immunology clinic from 1992 to 2005. Inclusion criteria consisted of presentation with recurrent infections and decrease in 2 of 3 immunoglobulin isotypes (IgG, IgA, IgM) 2 SDs below the age-specific range, with a poor or absent response to immunization. There had to be no other identifiable predisposing cause of the immunodeficiency. RESULTS: A total of 12 patients were identified. The mean age at presentation was 8 years. All patients had low IgG levels with poor functional antibody responses. The most common presenting infections were sinusitis (75%), otitis media (67%), and pneumonia (58%). Bronchiectasis was seen in 3 children. One patient presented with chronic diarrhea due to Giardia. Two patients presented with failure to thrive. Asthma was seen in 10 patients (83%) but was usually diagnosed after the initial presentation. Autoimmune disorders were seen, including 1 patient with idiopathic thrombocytopenia and 2 with neutropenia. Other disorders encountered were growth hormone deficiency, hypothyroidism, end-stage renal disease, and sarcoma. CONCLUSIONS: CVID is a difficult diagnosis in the pediatric population because of an unpredictable presentation. Autoimmune disease, growth hormone deficiency, renal disease, and cancer were noted in our population. A high incidence of asthma also may be associated with pediatric CVID.

Child and caregiver psychosocial functioning in pediatric immunodeficiency disorders.

BACKGROUND: Children with chronic illness have been found to be at an increased risk of behavioral and emotional difficulties. To date, children with pediatric immunodeficiency disorders (PIDDs) and their families have not been the focus of extensive published psychosocial research. OBJECTIVE: To determine if children with PIDDs and their caregivers have altered psychosocial function and whether the severity of the PIDD was associated with such difficulties. METHODS: Twenty children with PIDDs and 20 children with asthma were recruited for this study. Children and their caregivers completed various psychosocial questionnaire forms. Responses were compared with normative data for the appropriate measure and with other variables. RESULTS: Higher frequencies of children with PIDDs were found to have a number of elevated psychosocial concerns when contrasted with normative data, particularly from parent report. These concerns included depression, anxiety, somatization, social withdrawal, and social skills. The severity of the PIDDs was significantly associated with a number of behavioral adjustment issues, including receiving psychiatric diagnoses and special education services. Although children with PIDDs had significantly more psychiatric diagnoses than did asthmatic children, these groups did not differ significantly on questionnaire scores regarding child or caregiver psychosocial adjustment. CONCLUSIONS: Children with PIDDs have significant behavioral problems. Children receiving intravenous immunoglobulin or immunomodulatory treatments were reported to have more problems than children not receiving them. This study highlights the need for further research in psychosocial functioning of children with PIDDs in an effort to develop interventions to promote their overall adjustment.

Modern prevalence of insect sensitization in rural asthma and allergic rhinitis patients.

Inhalant allergy to insects other than cockroaches and dust mites was described in the 1950s, but little attention has been paid to these findings. Sensitization rates for many allergens have increased since then. In this rural population, we describe the current prevalence of sensitization to commonly found insects. We evaluated 200 patients (38 adults and 162 children), for immunoglobulin E (IgE)-mediated sensitization to the caddis fly, mayfly, moth, carpenter ant, and housefly using the prick technique and commercially available whole-body extracts. All had symptoms consistent with asthma and/or allergic rhinitis. They also were tested to indoor and outdoor aeroantigens. Of the 200 patients, 60 patients (30%) tested positive to at least one of the five insects. The most prevalent positive skin test was to the mayfly (37/60), followed by the housefly (36/60), caddis fly (27/60), moth (14/60), and ant (10/60). Of the 60 patients positive for insects, 35 patients (58%) also tested positive to at least one species of mite, 36 patients (60%) tested positive to the cockroach. Twelve of the 60 patients (20%) with positive insect testing did not react to either cockroaches or mites. In our patients, the immunoglobulin E-mediated sensitization rate to insects excluding cockroaches is 30%. Many patients also were sensitized to mites and/or cockroaches. These insects are all present in the indoor/outdoor environment of this rural population. Cross-reactivity with mites and cockroaches (insect panallergy) may partially explain our results. The presence of skin test sensitivity in the absence of cockroach or mite allergy suggests possible true insect sensitization.