Epicutaneous Skin Tests Research Articles

A CASE OF ANAPHYLAXIS TO SUGAMMADEX SKIN PRICK TESTING

<h3>Introduction</h3> Sugammadex is a modified gamma-cyclodextrin gaining increasingly common usage as an anesthetic medication for the rapid reversal of the neuromuscular blocking agents rocuronium and vecuronium. While considered safer than traditional reversal agents, sugammadex is becoming more widely recognized as a rare cause of peri-operative anaphylaxis. There are no standardized skin prick testing protocols or commercially available IgE assays for sugammadex, although previous literature has used an undiluted concentration of 100mg/ml for epicutaneous skin testing. <h3>Case Description</h3> A 57 year old woman with a medical history of anaphylaxis to bee sting experienced peri-operative anaphylaxis upon first time exposure to sugammadex. Despite adequate treatment, she had subsequent rebound anaphylaxis. Four months after her reaction she completed skin prick testing to sugammadex. During the first round of epicutaneous skin prick testing with a diluted concentration of 0.1mg/mL of sugammadex she experienced diffuse hives, throat closer, and hoarseness of voice requiring treatment with epinephrine, diphenhydramine, and steroids. She again had rebound of symptoms shortly thereafter, requiring transfer to the emergency department for monitoring. <h3>Discussion</h3> The evaluation of a patient with peri-operative anaphylaxis can be challenging. As the use of sugammadex increases, clinicians should be aware of its ability to cause anaphylaxis. This case demonstrates anaphylaxis in a sugammadex naive patient, both intra-operatively and then during in-office skin prick testing. The case raises awareness of the possibility for anaphylaxis at a concentration of 0.1mg/ml for epicutaneous skin testing and highlights the need for standardized skin prick testing protocols.

In vitro testing for allergic and immunologic diseases.

In vitro tests are used to assist in the diagnosis of both allergic and immunologic diseases. Unfortunately, there is no single test that is pathognomonic for most allergic diseases. The most commonly ordered in vitro test by allergists is allergen specific IgE (sIgE), which is used to help diagnose IgE mediated hypersensitivity to foods, aeroallergens and venoms. Multiple assays exist, although none of these assays have been adopted as the industry standard. Epicutaneous skin test is also a fundamental test in the diagnosis of IgE mediated hypersensitivity. In addition, total IgE, basophil activation test (BAT), and serum tryptase may also be useful in elucidating allergic diseases. Immunologists rely on laboratory testing to diagnose primary immunodeficiency diseases. These tests include serum quantitative immunoglobulins, lymphocyte immunophenotyping by flow cytometry and immune cell functional testing. Furthermore, genetic testing is invaluable in the diagnosis of many primary Immunodeficiencies.

RAPID INTRAVENOUS DESENSITIZATION TO HORSE ANTITHYMOCYTE GLOBULIN IN A WOMAN WITH SEVERE APLASTIC ANEMIA

Introduction Antithymocyte globulin (ATG) and cyclosporine is a first line regimen for the treatment of severe aplastic anemia in patients without a matched sibling donor for transplant. Administration of ATG is associated with life threatening anaphylaxis in up to 5% of post-marketing cases. Accordingly, the manufacturer's insert recommends skin testing prior to first-time administration of ATG. We present a case of a 59 year-old woman with positive skin testing to horse ATG, who underwent successful desensitization to ATG for treatment of her severe aplastic anemia. Case Description A 59 year-old woman with severe aplastic anemia was admitted to our institution for induction therapy with ATG and cyclosporine. Pre-treatment skin testing to ATG was positive, with a 13 mm wheal after intradermal injection of 5 mcg of ATG. Epicutaneous skin testing was negative. She underwent successful rapid intravenous desensitization to ATG with no adverse reactions during the procedure. She completed a four-day cycle of ATG and was started on daily cyclosporine. She had good response to ATG treatment, and at six-month follow-up, she had continued clinical remission sustained with cyclosporine and eltrombopag. Discussion Our patient's positive intradermal skin testing was suggestive of a Type I hypersensitivity to ATG. Patients with positive skin testing should avoid ATG or undergo desensitization when medically necessary. Previous reports have described several cases of life threatening hypoxia and hypotension during ATG desensitization, but our patient successfully underwent a rapid intravenous desensitization and subsequently tolerated a four-day continuous infusion of ATG.

Prevalence of food allergens sensitization and food allergies in a group of allergic Honduran children

BackgroundFood allergy is a public health problem that has increased in the last decade. Despite the increasing rates in children, quality data on the burden of these diseases is lacking particularly in developing countries. Honduras has no studies in pediatric patients.ObjectivesThe objective of this research was to identify the most common sensitization patterns to food through epicutaneous skin testing and food allergy rates in children and their correlation with common allergic diseases in a group of patients from Hospital of Pediatrics Maria.MethodsCross-sectional retrospective, descriptive study in which records and database of all allergic patients in the immunology outpatient clinic from Hospital of Pediatrics Maria were reviewed between the periods of January 2015 through June 2016.ResultsA total of 365 children were analyzed, the age of participants were in the range from 1 to 18 years, with an average of 9.8 years. Sensitization to food allergens were found in 23, and 58.3% were poly-sensitized. The most common food allergens that patients were sensitized to: milk 9.0%, eggs 6.9%, peanut 4.9% and pork meat 4.4%. Food allergy was confirmed via oral food challenged in 9.3% of the patients. The most frequent food allergies found were: cow’s milk allergy 6%, hen’s egg allergy 5.2% and wheat allergy 1.9%.ConclusionsMilk and egg were the most common a food allergens found in the population studied. Most of the patients were found to be poly-sensitized. The frequent food allergies confirmed via oral food challenge were cow’s milk allergy, hen’s egg allergy and wheat allergy.

A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis

A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis

Allergy to sunflower seed and sunflower butter as proposed vehicle for sensitization.

BackgroundIt is hypothesized that household exposure to allergenic proteins via an impaired skin barrier, such as atopic dermatitis, may contribute to the development of IgE sensitization. Household presence of peanut is a risk factor for the development of peanut allergy in children. Sunflower seed butter is a peanut-free alternative to peanut butter, and sunflower seed allergy is an uncommon but reported entity.Case presentationA 3 year old boy presented with oral discomfort that developed almost immediately after he ate sunflower seeds for the first time. He was given a dose of diphenhydramine. Subsequently he vomited, and his symptoms gradually resolved. A similar episode occurred to a commercial snack made with sunflower seed butter. Skin prick testing demonstrated a large positive (10 mm wheal) wheal-and-flare response to a slurry of fresh sunflower seed within 3–4 minutes associated with severe pruritus.This child has an older sibling with confirmed peanut allergy (PNA). After the PNA diagnosis was made, the family home became peanut-free. In lieu of peanut butter, sunflower butter was purchased and eaten frequently by family members, but not by the child reported herein.Subsequent to the episodes above, the child ate a bread roll with visible poppy seeds and developed itchy throat, dyspnea, and urticaria. Epicutaneous skin testing elicited a >10 mm wheal size within 3–4 minutes in response to a slurry of whole poppy seeds and 8 mm to fresh pumpkin seed, which had never been consumed.ConclusionsA case of sunflower allergy in the context of household consumption of sunflower butter has not yet been reported. We suggest that homes which are intentionally peanut-safe may provide an environment whereby infants with impaired skin barrier are at increased risk of allergy to alternative “butter” products being used, via cutaneous exposure to these products preceding oral introduction to the child.

Successful desensitization of a patient with aplastic anemia to antithymocyte globulin.

Antithymocyte globulin (ATG) is a polyclonal gamma immunoglobulin derived from either rabbit or equine serum that serves as therapy for aplastic anemia; however, ATG causes serum sickness in up to 70% and anaphylaxis in up to 5% of recipients. Intradermal (ID) skin testing has been the primary technique used to evaluate for a preexisting Gell and Coombs type I hypersensitivity reaction to ATG. There are no data reporting the predictive value of delayed reactions to ID testing on the risk of serum sickness. This study was designed to establish the importance of epicutaneous and ID skin testing before the administration of ATG through a case report and literature discussion. We report a patient with severe aplastic anemia that was successfully desensitized to ATG after a negative epicutaneous skin test and positive ID skin test. The patient had neither systemic nor localized reactions during the desensitization. Desensitization to ATG in patients with positive epicutaneous skin testing has been shown to be associated with serious and potentially life-threatening complications and should only be considered when the benefits outweigh the risks. Epicutaneous skin testing should be considered in conjunction with ID skin testing when screening for potential sensitivity to ATG. Because of the serious risk of anaphylaxis, desensitization should be performed in an intensive care unit setting in conjunction with a physician familiar with drug desensitization and the management of anaphylaxis.

Variability In Measurement Of Allergen Skin Testing Results Among Allergy-Immunology Specialists

Epicutaneous skin testing for sensitization to aero-allergens in patients with allergic diseases requires measurement of skin wheal and erythema in response to antigens. This may be variable between different providers especially among patients with dark skin pigmentation. Purpose of this study is to determine whether Allergy-Immunology specialists vary in their measurement of epicutaneous skin tests in patients with differential skin pigmentation. 3 patients with differing skin tones were skin tested using various concentrations of histamine to produce increasing sizes of skin wheal and erythema reaction. High quality photographs of these were taken and sent to 20 board certified/eligible Allergy-Immunologists to measure the wheal and erythema size. There was poor agreement among specialists in measurement of both wheal and flare sizes from patient with darkest skin tone. In contrast in patients with lighter skin tones there was fair to good agreement and excellent agreement from specialists in measurement of wheal and flare sizes respectively. Measurement of skin test results in patients with dark skin pigmentation may have significant variability even among specialists and in vitro tests may be more appropriate in these patients.

Atopy at age 1 and traffic-related Air pollution: an investigation of exposure measures in the Canadian Health Infant Longitudinal Development (CHILD) birth coh

Background: The evidence for increased risk of sensitization in children due to traffic related air pollution (TRAP) exposure is equivocal and information from birth cohorts with spatiotemporal exposure assessment is rare. Aims: We used atopy data at age 1 from an ongoing birth cohort (CHILD) and land use regression (LUR) estimates of individual exposure to nitrogen dioxide (NO2) to examine the association between TRAP and sensitization in four Canadian cities. Methods: We identified 885 children who were ? one year old on July 31st, 2012 and with measurement of atopy for inhalant (Alternaria, Der p, Der f, Cat, Dog, Cockroaches) and food-related allergens (soybean, milk, peanuts, eggs). Participants with epicutaneous skin test 2mm greater than negative control were defined as atopic.Exposure was estimated from city-specific LUR models with and without bi-weekly temporal adjustment based on fixed-site monitoring network data. We examined sex, study center, SES, maternal smoking/atopy/asthma, siblings, pets, mold, and secondhand smoke exposure as covariates. Those showing significant associations with atopy were offered in mixed models evaluating TRAP exposure during pregnancy and the first year of life. Results: Within-city contrasts in TRAP exposure in utero and during the first year of life was positively associated with sensitization to inhalant allergens at age one (adj. OR [95%CI]: 2.16 [1.17 -4.04], 2.15[1.21 -3.71] per 10 ppb increase, for in utero and year 1, respectively). Temporal adjustments of LUR estimates led to increased odds ratios for both time windows with a more pronounced effect during the first year of life (2.6 [1.4 -4.8] and 3.3 [1.7 – 6.7], for in utero and year 1, respectively). Conclusion: Early-life TRAP exposure was associated with risk of sensitization. Increased specificity in exposure assessment increases effect estimates.

Diagnosis of Food Allergy: Epicutaneous Skin Tests, In Vitro Tests, and Oral Food Challenge

Food allergy is becoming an increasingly common diagnosis. Because of this increase in prevalence, it is imperative that physicians evaluating patients with possible adverse reactions to foods understand the currently available assays and how they should best be used to accurately diagnose the disease. Simple tests such as skin prick testing (SPT) and serum food-specific IgE testing are the most commonly used diagnostic tests to evaluate for IgE-mediated food reactions. However, these tests, which measure sensitization and not clinical allergy, are not without pitfalls, and their utility must be appreciated to avoid over- and underdiagnosis. Although the physician-supervised oral food challenge remains the gold standard for food allergy diagnosis, a careful medical history paired with SPT and serum food-specific IgE testing often can provide a reliable diagnosis. In this review, we examine the usefulness and pitfalls of SPT and serum food-specific IgE levels, as well as examine atopy patch testing and other emerging tests, such as component-resolved diagnostics and the basophil activation test. Finally, we describe the use of the double-blind, placebo-controlled oral food challenge as the current gold standard for food allergy diagnosis.

Serum IgE measurement and detection of food allergy in pediatric patients with eosinophilic esophagitis

Although associated allergies are common and the mechanism may include long-term exposure to allergens, measurement of serum specific IgE levels has not been studied in pediatric eosinophilic esophagitis (EE). To compare the results of serum IgE testing, patch testing, and epicutaneous skin testing to measure allergic sensitization in pediatric patients with EE. In a cross-sectional study of 53 pediatric patients with EE, relevant history was obtained by questionnaire, and patch testing to foods was performed. Food and inhalant sensitivities were also assessed using skin prick testing and serum specific IgE measurement. Streptavidin CAP was used to measure specific IgE to cross-reactive carbohydrate determinants and Helicobacter pylori. The overall prevalence of food and inhalant sensitization was 80%, with higher total IgE levels in sensitized vs nonsensitized patients (median, 150 vs 13 IU/mL; P < .001). For foods, serum IgE measurement detected more positive results than did skin prick testing. Specific IgE to milk was most common (43%). Inhalants were implicated as frequently as were foods. In keeping with this, 32% of patients had a cluster of multiple sensitivities that included pollens, soy, grains, peanut, and tree nuts and had higher total IgE levels (P = .001). Patch test results were interpreted as positive in 39% of patients (rye, wheat, and soy were the most common). Most, but not all, patients with EE are highly atopic individuals with frequent allergic sensitivities. Thus, serum IgE measurement of low-titer IgE antibody may be useful in identifying relevant food sensitivities and in distinguishing subgroups of patients with EE, making a more directed approach to food avoidance possible.

Safe administration of an inactivated virosomal adjuvanted influenza vaccine in asthmatic children with egg allergy

In order to evaluate whether the virosomal adjuvanted influenza vaccine that has been shown to have the lowest egg protein content (Inflexal V, Berna Biotech) could be administered to children with even severe egg allergy without any risk of allergic reactions, we used epicutaneous skin testing with the undiluted vaccine in 88 asthmatic children (44 with and 44 without egg allergy), none of whom had a positive response. They were then vaccinated with the whole dose of Inflexal V intramuscularly in a one-dose protocol, and the occurrence of any immediate or delayed adverse events were actively monitored for 28 days. The results showed the safety of the administration, and demonstrated that Inflexal V can be safely given without performing a vaccine skin test in children with any kind of egg allergy.

Elicitation response characteristics to mono‐ and to N,N′‐diacetyl‐para‐phenylenediamine

Para-phenylenediamine (PPD) is an important and common cause of allergic contact dermatitis. The mechanism of sensitization is still unknown. It is believed that PPD is a prohapten and thus the balance between activation and/or detoxification processes may influence responses to PPD. Beside auto-oxidation to Bandrowski's base, PPD is enzymatically acetylated to monoacetyl-PPD (MAPPD) and to N,N'-diacetyl-PPD (DAPPD) in skin and keratinocytes. We investigated if the 2 acetylated PPD derivatives are able to elicit allergic contact dermatitis by performing epicutaneous skin tests in subjects with dermatitis. Contact allergy to PPD and the 2 acetylated derivatives (1% in petrolatum) were detected by patch testing of 455 patients with eczema from our clinic who were tested with the baseline series. 16 subjects were found to be patch test positive to PPD (3.5%). No reactions were found for MAPPD, and just 1 PPD-positive patient was positive for DAPPD (0.2%). In agreement with our earlier published in vitro data, these in vivo patch test results indicate that acetylation of PPD can be regarded as a detoxification reaction.

Delayed-type hypersensitivity (type IV) reactions in dental anesthesia

The recommended methodology of evaluating patients who have presented with reactions to local anesthetics consists of epicutaneous skin testing and serial subcutaneous challenge. However, the role of type IV reactions in this group has been poorly documented. Epicutaneous routine testing and subcutaneous challenge to local anesthetic was performed, as well as patch testing and subcutaneous rechallenge of both at 24 and 48 hours with evaluation up to 72 hours was performed. Three patients presented with a history of localized edema after dental anesthesia. All had negative lidocaine and mepivacaine testing as well as negative lidocaine challenge on evaluation at 1 hour. The first patient, who had previously reacted to EMLA, reacted to both lidocaine and mepivacaine patch testing and challenge, with delayed swelling at 24 and 48 hours after challenge. This patient subsequently tolerated the ester anesthetic chloroprocaine. Two other patients had strong histories of contact dermatitis. Patch testing and challenge with lidocaine was negative, but strong reactions were found to benzocaine on patch testing. Patients undergoing local anesthetic testing should be screened historically for features and risk factors associated with type IV reactions. This should be considered in patients who react to multiple amide anesthetics, who have delayed swelling, or who have a history of severe contact dermatitis. We confirm previous data showing that patients reacting to benzocaine can tolerate lidocaine and that lidocaine-allergic individuals can tolerate ester anesthetics.

Anaphylactoid reactions in two patients after omalizumab administration after successful long-term therapy

Anti-IgE therapy with omalizumab, a recombinant humanized monoclonal antibody, has anti-inflammatory effects in allergic asthma and rhinitis. Although omalizumab has been exceptionally safe, reactions after its administration have been reported. The goal of this study was to assess two patients who experienced apparent anaphylaxis after omalizumab administration. Two cases of apparent anaphylaxis after omalizumab administration are reported with diagnostic evaluation using skin testing and unique IgE and IgG anti-omalizumab serological assays. At the time of evaluation, both atopic asthmatic patients had total (free and bound) serum IgE levels of 199 kIU/L (100% free) and 200 kIU/L (80% free and 20% bound), respectively. Epicutaneous skin tests to omalizumab were negative at 150 mg/mL of omalizumab in both subjects and the nonexposed negative control subject. Intradermal skin tests were positive at 0.15 mg/mL in subject 1 and negative at 1.5 mg/mL of omalizumab in subject 2 and the control subject. Intradermal testing to polysorbate produced significant wheal/flare reaction in subject 2 but not in the negative control subject. Serological assays for IgE or IgG antibodies reactive with omalizumab were negative. The in vitro and in vivo immunologic data support the conclusion that the adverse reactions experienced by two patients after omalizumab administration after more than a year of successful omalizumab therapy for asthma were likely anaphylactoid in nature. Polysorbate, an excipient in omalizumab, is known to cause similar reactivity to other medicines and is the most likely cause of these reactions.

IgE and atopy in perinatally HIV‐infected children

Elevated serum immunoglobulin E (IgE) and increased prevalence of atopy is reported in patients infected with human immunodeficiency virus (HIV). The elevated serum IgE may be attributed to polyclonal stimulation of B cells or IgE production against allergens, viruses, fungi and bacteria. This study investigates the prevalence of atopy in perinatally HIV-infected children, and the relationships between serum IgE (and other serum immunoglobulins) with atopy, CD4+ cell count and HIV-disease stage. Serum immunoglobulin levels, epicutaneous skin test for common aeroallergens, clinical Centers for Disease Control and Prevention (CDC) classification, CD4+ cell counts and allergy history were extracted from the charts of perinatally HIV-infected children on highly active antiretroviral therapy. The prevalence of atopy (52%) and the pattern of aeroallergen sensitivity were comparable with the US pediatric population. Serum IgE levels did not correlate with clinical disease stage. However, in non-atopic patients, serum IgE levels increased with disease progression (p = 0.02). There was an inverse relationship between the prevalence of elevated serum IgE levels and atopy with progression of disease (p = 0.019). Serum IgE did not correlate with atopy, CD4+ cell count, or duration of HIV infection or levels of serum immunoglobulins. This is the first study to show no increased prevalence of atopy in perinatally HIV-infected children compared with the general population. In advanced stages of HIV, elevated serum IgE may be specific for antigens other than those known as allergens.

Reactions to food in children recurs after negative oral challenge

Rationale To determine if patients sensitized to food remain tolerant after negative food challenge. Methods We assessed children who had allergic reactions, positive epicutaneous skin test, and/or positive capFEIA to peanut, egg or milk and subsequently had a negative food challenge between 1996 to 2003. Families were contacted by phone and questioned as to the frequency of ingestion of the food(s) in question and if any further reactions had occurred. Results There were 302 children <16 years of age with negative food challenges during this period. We randomly reviewed 107 patients (35%) with 121 challenges. 14 (12%) <6 months from challenge were excluded. 28 (23%) were lost to follow-up. Complete data were available for 59 (47%). 40/59 (68%) regularly ate the food with no problem. 4/59 (7%) subsequently reacted, all with egg (4/18; 22%), and all to raw or less well cooked egg; 1/4 completely avoided egg and 3/4 tolerated egg in baked goods. In spite of no reaction, 2/26 previously peanut allergic continued to completely avoid peanut and 10/26 had peanut < weekly. All 15 patients with negative milk challenge tolerated and continued to regularly consume milk. Conclusions Subjects with negative egg challenge were more likely to react again than subjects with negative peanut or milk challenge. Peanut allergy remains a concern for many patients, even with a negative challenge. Allergists should consider a second challenge for egg and/or peanut allergic patients.

IgE antibody in the serum--detection and diagnostic significance.

IgE antibody in the serum--detection and diagnostic significance.

The reproducibility of the allergy skin test scoring and interpretation by board-certified/board-eligible allergists

Allergy skin testing is a cornerstone in the evaluation of the allergic patient. This seemingly simple test is subject to multiple variables that can affect the result. To evaluate the degree of variability among board-certified/board-eligible allergists in the scoring and interpretation of allergen skin tests. A series of allergen prick skin tests were digitally photographed and a questionnaire generated. Approximately 70 board-certified/board-eligible allergists were asked to grade each test item and to interpret them as positive, negative, or indeterminate or if they desired a followup intradermal test. Thirty-three interpretable responses were obtained. The majority of respondents (24) used a grading scale of 0 to 4. Agreement among physicians using a 0 to 4+ scale ranged from a standard deviation of 0.26 to 1.35, with greatest agreement on items with median/mode scores of 4+. The largest standard deviations were found on test items with median/mode scores of 1+ to 2+. Interpretation of the test items also showed greatest variation for those items with median/mode scores of 1+ to 2+. The number of intradermal tests requested ranged from 0 to 11 (of 22 test items). The results demonstrate interphysician variation in the scoring and interpretation of epicutaneous skin tests. A questionnaire such as the one used here may serve a useful quality control instrument to ensure reproducible scoring of skin tests. In addition, the results highlight the need for greater study on the clinical utility of intradermal skin testing when epicutaneous tests are negative or equivocal.

Prevalence of positive skin prick tests to aeroallergens in children without symptoms of allergic disease: Analysis of the NHANES III data

VOLUME 109, NUMBER 1 7' Prevalence of Positive Skin Prick Tests to Aeroallergens in | Children Without Symptoms of Allergic Disease: Analysis of the NHANES III Data Jenny M Montejo*, Michael R Simon§, Merlin Hamre*, Ronald Thomas*, Abdul H Bahrainwala* *Children's Hospital of Michigan, Wayne State University, Detroit, MI §Wayne State University, Children's Hospital of Michigan, Detroit, MI Positive skin prick tests to aeroallergens do not necessarily indicate the presence of allergy symptoms. The prevalence of positive skin prick tests for common aeroallergens in children with absence of rhinitis and asthma symptoms has not been studied. The aim of this study was to determine the prevalence of positive skin tests to aeroallergens and absence of allergic rhinitis and asthma symptoms in children ages 7 to 16 years. METHODS: The Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, was the source of data for this study. NHANES III is a cross-sectional, random household survey of the civilian, non-institutionalized population that used a complex, multistage probability sampling design. The survey included an extensive questionnaire regarding asthma and allergic rhinitis symptoms, spirometry, and epicutaneous skin test performed using 9 common aeroallergens: dust mite, German cockroach, cat, ragweed, Bermuda grass, rye grass, Russian thistle, white oak and Alternaria. Analyses were conducted using SUDANN software (Research Triangle Park Institute, NC) to account for the complex, multistage sampling design of the survey. Sample weights were used to produce national estimates by adjusting for the oversampling of young children and minority groups. Differences in the proportions of African-American and White children with positive skin tests, no symptoms and normal spirometry were examined using crosstabs procedure, with statistical significance set at a p-value 0.8, 18.9% had positive skin tests to at least one of the 9 aeroallergens tested. Among 4610 White and African-American children with no such symptoms and FEV 1/FVC >0.8, 17.2% of whites and 24.1% of African-Americans had positive skin tests, chi square 15.4, p 20% of FVC and FEV 1 from baseline) and laboratory responses (marked leukocytosis and hypoxemia) was observed 6 hours after pulmonary inhalation provocation test. Bronchoalveolar lavage performed 24 hours after PIPT showed a total cell count of 220.000 with marked lymphocitosis. Histopathologic examination of a transbrochial biopsy specimen revealed intersticial alveolitis. DISCUSSION: Our case gathers sufficient criteria to be considered as hypersensitivity pneumonitis caused by the dust derived from corn. We were able to detect IgG antibodies against our corn extract, and within 6 hours after PIPT with corn extract, the patient had a systemic picture closely resembling the ones he had with corn harvest. 7 -~B~ Sinus CT and Markers of Inflammation in Vocal Cord DysfuncJF~ I tion and Asthma Tina Hatley, Edward Peters, Scott Crater, Timothy McLaughlin, Thomas AE Platts-Mills, Larry Borish University of Virginia, Charlottesville, VA The paradoxical inspiratory closure of the vocal cords is characteristic of vocal cord dysfunction (VCD). These patients present with wheezing and frequently receive a misdiagnosis of asthma. Treatment with beta agonists and corticosteroids tends to be unsuccessful, and these patients therefore develop refractory disease. Our purpose was to evaluate the presence and extent of sinus disease using computed tomography (CT) and compare the findings with other aspects of airway inflammation, and markers of atopy in a series of patients with vocal cord dysfunction, acute asthma and controls. Twenty patients presenting to the University of Virginia ER or Asthma Clinic were diagnosed with clinical obstructive airway symptoms consistent with vocal cord dysfunction. Diagnosis was confirmed by a combination of history, lung function and laryngoscopy. Comparisons were made between 71 patients presenting to the university ER with acute asthma, 27 non-acute asthmatics and 56 non-asthmatic controls. Evaluation consisted of spirometry with flow-volume loops, exhaled nitric oxide gas (eNO), cell blood count for eosinophils, total serum IgE and specific IgE, as well as sinus CT scan. Sinus CT's were scored using our validated system on the basis of the opacity in each of the sinus cavities and the osteomeatal complex (max score 30). Extensive sinus CT changes (score > 12) were present in 23/71 acute asthmatic patients, 4/27 non-acute asthmatics and 2/56 nonasthmatic controls. In addition, absolute eosinophil counts, eNO, and total IgE were significantly elevated among the asthmatics. Patients with extensive sinus disease had elevated total IgE (500 IU -+ 104). Sinus symptoms reported by questionnaire did not predict sinus CT findings and were equally common among controls. Among the 20 patients with VCD, none had extensive sinus disease (mean score 2). They also had normal eNO (<10 ppb), low IgE (< 100 IU/mL), and normal eosinophil count (<200 k/I.tL ). These results demonstrate that events in the upper airway that cause airway obstruction in VCD are not related to generalized airway inflammation.