Elimination Of Allergens Research Articles

Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis

ObjectiveThis study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE). MethodsStudy of clinical, laboratory, endoscopic, and histologic data and response to conventional treatment of 43 previously followed pediatric patients with the classical form of EoE. ResultsA total of 43 patients diagnosed with EoE were included in the study, of which 37 were males (86%), with a mean age of 8.4 years. The most common symptoms were: nausea, vomiting, and abdominal pain (100%) in children younger than 7 years, and loss of appetite (60%), heartburn (52%), and food impaction (48%) in children older than 7 years and adolescents. Regarding the endoscopic findings, 12 (28%) patients had whitish plaques on the esophageal lining, 8 (18.5%) had longitudinal grooves, 2 (4.5%) had concentric rings, 3 (7%) had longitudinal grooves and whitish plaques, and the remaining 18 (42%) had esophageal mucosa with normal appearance. Despite the initial favorable response, 76.7% of patients required more than one course of corticosteroid therapy (systemic or aerosol) and diet (exclusion or elimination of food or elementary allergens). Persistence of eosinophil infiltration was found in some patients despite favorable clinical response. ConclusionsThe classic form of EoE typically shows different symptoms according age range. A significant number of patients required more than one treatment cycle to show clinical remission. Endoscopic and histologic improvement was observed; however, eosinophilic infiltration persisted in some patients.

Practical approach to nutrition and dietary intervention in pediatric food allergy

Although the need for nutritional and dietary intervention is a common thread in food allergy management, the type of food allergic disorder and the identified food allergen will influence the approach to dietary intervention. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. However, dietary elimination in food allergy may also have undesirable consequences. Frequently, an elimination diet is absolutely necessary to prevent potentially life-threatening food allergic reactions. Allergen elimination can also ease chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. However, removing a food with proven sensitivity to treat chronic symptoms may increase the risk of an acute reaction upon reintroduction or accidental ingestion after long-term avoidance, so it is not without risk. Additionally, it is not recommended to avoid foods in an attempt to control chronic symptoms such as AD and EoE when allergy to the specific food has not been demonstrated. Ultimately, allergen elimination goals are to prevent acute and chronic food allergic reactions in the least restrictive, but also the safest environment to supply a balanced diet that promotes health and growth and development in children.

Foglalkozás utáni perzisztáló dermatitis: egy gyakori kórkép ritka variánsa

Persistent post-occupational dermatitis is a rare variant of occupational eczemas characterized by skin symptoms which persist after the elimination of occupational allergens. Further diagnostic criteria are the followings: absence of dermatitis in past history of patients, presentation confined to both hands almost exclusively, and causal role of occupational allergens with both irritative and allergic origins is confirmed. The author presents a case which meets all these diagnostic criteria. Epidemiology of occupational dermatoses, impact on quality of life and social-economic aspects are also discussed.

Wirkmechanismen nasaler Glukokortikosteroide in der Therapie der allergischen Rhinitis

Allergic rhinitis (AR) is the single most common allergic disease and one of the most common chronic diseases. It affects approximately 25-30% of the population, and can substantially worsen patients' medical conditions, reduce quality of life, and contribute to absenteeism from work or school. It is also responsible for substantial direct and indirect economic burdens on the health care system. The medical management of allergic rhinitis includes several available pharmacotherapies, such as α-sympathomimetics, anticholinergic drugs, natural saline or other nasal rinses, mast cell-stabilizing agents, topical and systemic antihistamines, topical and systemic glucocorticosteroids, leukotriene-receptor antagonists and the new monoclonal antibodies following a stepwise approach. Allergen-specific immunotherapy is the only treatment option that interferes with the natural course of the disease and, besides allergen elimination, is thought to be the only causative treatment option. Nasal glucocorticosteroids (nGCS) are thought to be the most effective treatment choice for controlling the symptoms of AR. Double-blind, randomized clinical trials have demonstrated greater efficacy of nGCSs versus placebo, antihistamines or montelukast for relief of all nasal symptoms, especially congestion. Therefore, especially in the management of AR-related nasal inflammation and congestion, nGCSs are considered the most appropriate treatment. Patients should be informed that symptom improvement can be expected after 2-4 days for intermittent rhinitis and after up to 2-3 weeks for persistent rhinitis. The medication has to be taken regularly and not as "on-demand" treatment. Adherence to treatment also affects outcomes, and this may be influenced by patient preferences for the sensory attributes of an individual drug and the awareness of possible side effects. More recently, safety studies have shown that the newer nGCS agents have improved safety profiles compared with older nGCS agents. The newer nGCS drugs have been found to have minimal adverse effects on growth and hypothalamic-pituitary-adrenal-axis function in children. This review will discuss the pathophysiology of allergic inflammation in the nasal mucosa and the mechanism of action of nGCSs; also the efficacy and safety of nGCSs will be discussed by focusing on clinical evidence.

Atopic dermatitis and allergic rhinitis - do co-effects in therapy exist?

Atopic dermatitis and allergic rhinitis frequently appear together in the same patients. The pathogenesis of both disorders is complex and still incompletely understood. Nevertheless, pathophysiological overlaps suggest the existence of potential therapeutic co-effects. While data pointing towards a positive effect of allergen elimination for both diseases is still limited, there is now increasing evidence showing beneficial effects of specific immunotherapy in patients suffering from atopic dermatitis and additional type I allergies. H(1)-antihistamines were also found to exert moderate positive effects on the symptoms of atopic dermatitis in single studies. In summary, a limited therapeutic co-effect of the above mentioned treatment options can be expected in case of the parallel existence of atopic dermatitis and allergic rhinitis in the same patient. More studies on this issue during the next years are desirable. In addition, a better understanding of the pathophysiology should have a positive impact on the treatment of atopic manifestations such as atopic dermatitis and allergic rhinitis.

Eosinophilic Esophagitis

Eosinophilic esophagitis (EE) is a recently recognized form of pan-esophagitis, which is characterized by the presence of at least 15 eosinophils per high power field on esophageal histology. EE is closely associated with atopic disorders and occurs predominantly in male patients. Young children are more likely to be sensitized to food allergens whilst aeroallergen sensitization predominates in older children and adults--a pattern reminiscent of the "atopic march". EE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or refusal in infancy, in addition to dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained incidentally in patients undergoing gastroscopy for other suspected gastrointestinal conditions, such as gastroesophageal reflux disease or celiac disease. Complications mainly relate to subepithelial remodeling and fibrosis which may result in dysmotility, dysphagia and esophageal strictures. The proportion of EE patients at risk of these complications is unknown due to a paucity of data on the natural history of EE. There are only few randomized controlled trials assessing the efficacy of treatment modalities for EE, which currently either involve food allergen elimination or use of swallowed aerosolized corticosteroids. This article aims to discuss the complex issues of the diagnosis and long-term management that confront clinicians who care for children with EE.

Lability of IgE Levels Early in Life

We report a case of a very fast and intriguing decrease in IgE concentrations after exclusion from the diet of any CM lysate in an unusual clinical presentation of cow's milk allergy in an infant. Analysis of IgE kinetics after allergen elimination suggests rapid cessation of IgE biosynthesis and a short IgE half-life.

Emerging management concepts for eosinophilic esophagitis in children

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.

Deallergisation trials of pure celery juice and apple-celery juice mixture by oxidation

This work aimed to determine if it was possible to eliminate or reduce the content of the Api g1 allergen in celery juice by oxidation, utilising its natural polyphenol oxidase (PPO) content. We attempted to determine a possible relationship between the enzymatic browning of celery juice and the reactivity of the Api g1 allergen. Pressed celery juice was stirred, and samples for the colour measurement and allergenicity, determined using the Western Blot (WB) method, were collected at pre-defined times. Oxidation failed to eliminate the allergenicity of pure celery juice. Further trials were focused on celery allergen elimination in apple-celery juices mixtures in ratios of 3:1, 5:1, and 7:1. We selected the 5:1 ratio as the most acceptable from the sensory perspective, and monitored its allergenicity using the WB method, basophil activation test, and skin prick testing. The WB test showed that oxidation, caused by stirring for 120 min, reduced the allergenicity of the mixture. However, the basophil activation test showed no reduction in the allergic response to the oxidised juice mixture. Skin testing showed that the oxidised juice mixture stirred for 120 min exhibited a significantly lower reaction than the juice mixture stirred for 60 min or celery and apple juice stabilised with ascorbic acid. Due to the contradictory results in different tests, the method cannot be declared successful or safe, even for mixtures of apple-celery juices.

Food allergy-related paediatric constipation: the usefulness of atopy patch test

The aims of this study were to evaluate the implication of food allergy as a cause of paediatric constipation and to determine the diet period needed to tolerate the constipation-causing foods. Fifty-four children aged 6 months to 14 years (median, 42 months) suffering from chronic constipation (without anatomic abnormalities, cοeliac disease or hypothyroidism), unresponsive to a 3-month laxative therapy, were prospectively evaluated. All participants were evaluated for allergy to cow's milk, egg, wheat, rice, corn, potato, chicken, beef and soy, using skin tests (SPT), serum specific IgE and atopy patch test (APT). A withdrawal of the APT-positive foods was instructed. Thirty-two children had positive APT; 15 were positive to one; six, to two and 11, to three or more food allergens, wheat and egg being the commonest. After withdrawing the APT-positive foods for an 8-week period, constipation had improved in 28/32 children, but a relapse of constipation was noticed after an oral food challenge, so they continued the elimination diet. Tolerance to food allergens was achieved in only 6/28 after 6 months, compared to 25/28 after 12 months and to all after a 2-year-long elimination. Food allergy seems to be a significant etiologic factor for chronic constipation not responding to treatment, in infants and young children. APT was found to be useful in evaluating non-IgE allergy-mediated constipation, and there was no correlation of APT with IgE detection. Tolerance was adequately achieved after 12 months of strict food allergen elimination.

Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report

Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report

Role of Mucosal Inflammation in Eosinophilic Esophagitis: Review of the Literature

Eosinophilic esophagitis (EE) is increasingly recognized in adults. It is an inflammatory disease of the esophageal mucosa, with variable presentation, unresponsive to acid suppression therapy. The diagnosis requires histological confirmation of intense eosinophilic infiltration on esophageal biopsy specimen, however exact criteria required to make a diagnosis of EE is still being debated and a clear differentiation from gastroesophageal reflux disease (GERD) is important. Allergen elimination or anti-inflammatory therapy may be effective in such patients. The imperfect diagnostic criteria for EE mandate an understanding of the immunology and the pathophysiology of the disease. It may facilitate the introduction of novel treatment modalities in an individual unresponsive to acid suppression therapy. This paper describes basic elements of the immune-mediated injury to the esophageal mucosa and management aspects to provide a better understanding of the condition.

Elimination of Allergens in South American Shrimp by Protease Hydrolysis

In order to eliminate the allergens in South American shrimp,proteases such as trypsin,papain and bromelain were individually used to hydrolyze South American shrimp proteins.General immunity experiments in allergic guinea pigs and allergic contraction experiments of isolated ileum were used to evaluate the allergenicity of hydrolysates.The results showed that hydrolysates from South American shrimp proteins digested by each of the three proteases could result in an obvious attenuation of general allergic reactions (Compared with the group of South American shrimp protein,0.01P0.05 or P 0.01).Meanwhile,a reduced allergic contraction reaction of isolated ileum smooth muscle was observed in hydrolyzed South American shrimp proteins (Compared with the group of South American shrimp protein,0.01 P 0.05 or P 0.01).Comprehensive evaluation exhibited that papain hydrolysates could provide an excellent elimination effect on allergens and higher food safety.

Atopic Dermatitis and Ichthyosis

1. Roselyn E. Epps, MD* 1. *Chief, Division of Dermatology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC. After completing this article, readers should be able to: 1. Identify the characteristic features of atopic dermatitis and the factors that worsen it. 2. Understand that children who have atopic dermatitis are prone to recurrent infections, particularly with Staphylococcus aureus and herpes simplex virus. 3. Know the signs of Wiskott-Aldrich syndrome. 4. Plan the appropriate treatment of atopic dermatitis (emollients, corticosteroids, antibiotics, and allergen elimination when appropriate). 5. Recognize ichthyosis vulgaris and know that ichthyosis commonly occurs in children who have atopic dermatitis. 6. List the effective therapies in the management of ichthyosis vulgaris. 7. Distinguish between tinea pedis and atopic dermatitis. 8. Discuss the relationship of atopic dermatitis and food allergies and how to evaluate a patient who has both. 9. Explain why children who have one component of atopy syndrome (allergic rhinitis, asthma, atopic dermatitis) have a threefold greater risk of developing a second component. Atopic dermatitis (AD) is a chronic, relapsing dermatosis that features dry skin (xerosis), pruritus, and a personal or family history of eczema, allergic rhinitis or allergies, or asthma. Children who have one component of the atopic triad (AD, asthma, allergic rhinitis) are three times as likely to develop a second component. There is no sex predilection, and the onset frequently is in infancy. Although many affected children outgrow the condition by age 5 years, AD may persist into adolescence and adulthood. A smaller percentage of patients experience the onset of AD as older children or in adulthood. The incidence and prevalence of AD have increased in the United States and worldwide, particularly in developed nations. Fewer than 10% of children were affected in the 1970s, but recent epidemiologic studies estimate that 15% to 20% …

Dysregulated Th1 and Th2 responses in food-allergic children - Does elimination diet contribute to the dysregulation?

Infants with eczema and sensitization to foods are recommended skin care and, if food allergy is proven, an elimination diet. Although most of these children tolerate foods before 3 yr of age, some children experience prolonged food allergy. To our knowledge, no prospective study has investigated the cytokine profile in food-sensitized eczematous children with prolonged food intolerance. The aim of the study was to prospectively investigate the development of cytokine production induced by food allergen in food-sensitized eczematous children who, at 4(1/2) yr of age, were allergic or tolerant to egg or milk. Twenty-one eczematous infants, [age 5 (3-10) months; median and range], sensitized to egg and/or milk were included, put on elimination diet and followed prospectively. At 4(1/2) yr of age, the children were defined as tolerant or allergic to egg and/or milk based on open or double-blind placebo-controlled food challenges. Peripheral blood mononuclear cells (PBMC) were isolated from the children on inclusion, after 6 wk of elimination diet, and at 3 and 4(1/2) yr of age. Ovalbumin, beta-lactoglobulin and tetanus toxoid-induced IL-4, -5, -10, -13 and IFN-gamma production from PBMC were analyzed with enzyme-linked immunosorbent assay. The IFN-gamma and IL-5 secretion induced by food allergen at 4(1/2) yr was higher in cell cultures from children who were allergic to egg or milk than in tolerant children. In food-allergic children, the levels of IFN-gamma and IL-5 were higher at 4(1/2) yr compared with inclusion levels, but this increase was generally not observed in the tolerant children who consumed milk and egg. In conclusion, immune cells from food-allergic children on an elimination diet respond with up-regulated T helper 1 and T helper 2 cytokine secretion induced by food allergen. We hypothesize that allergen elimination may influence the regulatory mechanisms maintaining balanced immune responses to innocuous food antigens.

Fluticasone and Food Allergen Elimination Reverse Sub-epithelial Fibrosis in Children with Eosinophilic Esophagitis

Symptoms of vomiting and dysphagia in children with eosinophilic esophagitis may be related to the development of mucosal fibrosis. Our aims were to (1) investigate esophageal fibrosis in children with EoE compared to patients with gastroesophageal reflux disease and normal individuals, and (2) to assess the degree of mucosal fibrosis in patients with EoE before and after medical treatment. A retrospective analysis of esophageal biopsies from patients with EoE, GERD, and normal mucosa was performed. Demographic data, clinical information, eosinophil number, and sub-epithelial fibrosis was compared among the groups. A similar comparison was performed in EoE patients, before and after therapy. Esophageal biopsies from 53 children were included, of which 17 with EoE, 17 GERD, and 19 were normal. A significantly higher number of eosinophils and greater fibrosis was found in EoE patients vs. GERD and normal (fibrosis grade 2: 13 patients in the EoE group vs. one patient for each control group; p=0.0001). After therapy, a significant decrease in fibrosis and eosinophils number was noted in EoE patients [fibrosis grade 2: 10 (71.5%) patients vs. one (7.1%) patient, and eosinophil count was 35.5/HPF vs. 13.4/HPF, pre- and post-therapy, respectively; p<0.05]. The decrease in esophageal fibrosis paralleled the improvement in the related clinical symptoms. A higher degree of esophageal fibrosis was found in patients with EoE compared to GERD or normal esophagus. Conventional therapy in EoE improved obstructive symptoms, decreased eosinophils count, and reversed the degree of fibrosis. We suggest that appropriate therapy in patients with EoE will improve clinical symptoms and histology.

Atopic eczema or atopiform dermatitis

Age period prevalence of atopic eczema (AE), a very common skin disease, has increased during the past decennia. This expansion seems to be ending in wealthy countries, while an increase is observed in developing nations, for which there is no firm explanation. Recent steps in understanding AE are the detection of skin barrier related filaggrin null mutations in approximately 25% of patients and the recognition of IL-31 as a molecule possibly involved in the itch (pruritus). Also interesting are the recognition of thymus and activation-regulated chemokine (TARC) and proliferating-inducing ligand (APRIL), as being associated with AE severity and activity. Immunocentric and corneocentric views on pathogenesis (the inside-outside paradigm) and the diagnostic entity atopiform dermatitis (AFD) are discussed here. We emphasize that diagnosing AE is not simple but challenging. We accentuate that a diagnosis of AE is only possible when there is allergen-specific IgE. Advice as to the need for elimination of allergens and adjustment of lifestyle are only proficient in patients having atopy and true AE, not in those having AFD.

Periorbital dermatitis: Causes, differential diagnoses and therapy

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44%, IVDK 32%), atopic eczema (Erlangen 25%, IVDK 14%), airborne contact dermatitis (Erlangen 10%, IVDK 2%) and irritant contact dermatitis (Erlangen 9%, IVDK 8%). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave-on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first-line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.

Research in practice: the second barrier of the human skin

A major function of human skin is to form an effective barrier between the environment and the inside of the organism. Especially important for this function is the activity of the physical barrier of the skin, which is mainly located in the stratum corneum. To improve this barrier function of the skin, skin protection agents are used. Recent studies have revealed that application of skin protection agents before exposition to xenobiotics does not generally reduce the percutaneous uptake of these compounds. These findings indicate that besides new study designs and improved test systems, there seems to be a need for new therapeutic approaches for more effective skin protection. In this light, new findings regarding a second barrier function of the human skin, the biochemical/toxicological barrier, could be of interest. A crucial part of this barrier function are members of the cytochrome P450 (CYP) family and efflux-transport proteins of the multidrug resistance-related protein family (MRPs), which are mainly expressed by basal layer keratinocytes. Recent studies have revealed that besides the physiological and protective function of these transport proteins and CYP enzymes in skin cells, the same proteins also play a role in the transport of contact allergens and activation of prohaptens to haptens causing contact dermatitis. Inhibition of this metabolism mediated activation of prohaptens and stimulation of the active elimination of contact allergens from skin cells could represent novel mechanisms improving the established tools for skin protection.

What if it is the other way around? Early introduction of peanut and fish seems to be better than avoidance

For many years, the advice to prevent food allergy was to postpone the introduction of allergens like egg, fish and peanut. However, elimination of food allergens during pregnancy and infancy failed to prevent food allergy. Instead, several studies indicate that early introduction of food like fish and peanuts may be beneficial. The most compelling illustration of this has been presented for peanuts. The prevalence of peanut allergy is lower in children in Israel than in the UK, despite introduction of peanut during infancy in Israel. Other studies have reported that early introduction of fish reduced the risk of allergic sensitization and allergic diseases like eczema. Early introduction rather than avoidance may be a better strategy for the prevention of food allergy. The mechanism may be that early introduction of food allergens during infancy might induce tolerance, thereby preventing the development of allergy.