History Of Anaphylaxis Research Articles

Prognotic Impact of Mutations in Systemic Mastocytosis

Introduction: Systemic mastocytosis (SM) is an heterogeneous myeloproliferative neoplasm characterized by uncontrolled growth of cKIT mutated clonal mast cells, with clinical manifestations ranging from indolent forms (ISM) with only skin lesions and/or anaphylactic shock to smouldering SM (SSM) with evidence of organ involvement to aggressive forms (ASM) with extensive organ damage. SM with an associated hematological neoplasm (SM-AHN) is a subtype with adverse prognosis possibly related to the associated neoplasm rather than SM. Recent data indicate that mutations in genes associated to myeloid malignancies correlate with survival and disease progression but information are still scanty and not completely concordant, and mutations apparently did not correlate with disease manifestations; furthermore, most patients analyzed were SM-AHN, therefore the contribution of mutations associated with the non-mast cell clone could not be ascertained clearly. The aim of this study was to address the prognostic relevance of mutations at diagnosis in a series of 70 pts with SM, excluding SM-AHD.Methods: There were 58 ISM, 4 SSM, 7 ASM and 1 mast cell leukemia (MCL) pts. cKITD816V mutation was assessed by RTQ-PCR. Mutations in myeloid-neoplasm associated genes were assessed by next generation sequencing (NGS) with Ion Torrent PGM platform; analyzed genes included ASXL1, CBL, cKIT, ETNK1, EZH2, IDH1, IDH2, SRSF2, RUNX1, TET2. We also evaluated the cKITD816V variant allele frequency (VAF) by NGS. Kruskal-Wallis test and Chi-squared test were used for analysis of continuous and categorical variables, respectively. Cox regression model was used for survival analysis; variables included were WHO subgroup, cKITD816V >2% VAF, mutations in additional genes, age at diagnosis >60 years, serum tryptase >200 ng/mL, alkaline phosphatase and white blood cells greater than upper normal limit. We did not considered as single entities the features included in B and/or C findings.Results: Median age at diagnosis was 45 years (y)(range 17-76) for ISM, 67 y (53-74) for SSM, 73 (41-81) for ASM (p<0.001).At last follow up (median 2 years, range 0.2-14) 2 pts with ASM evolved to acute myeloid leukemia (AML, 2.8% of all series, 28% of ASM), 1 ISM pts developed organ damage and shifted to ASM; 4 pts died (4/70, 5.7%). Skin involvement was found in 80.6% of pts, 31.3% had history of anaphylaxis and 27.8% osteoporosis. Median serum tryptase levels were 28.7 ng/mL (range 3-192) for ISM, 190 (60-591) for SSM, 64 (23-300) for ASM and 2000 in MCL.All but 3 pts (2 ISM, 1 ASM) were cKITD816V mutated by RT-PCR in bone marrow aspirate (BM) or peripheral blood (PB) (in pts with punctio sicca). 54/67 (80%) had a cKITD816V mutation detectable in PB, underlying that even with high sensitivity methods PB cannot replace BM analysis for diagnosis. Median VAF was 0.34% (range 0.03-38.4) in ISM, 17.2% (0.3-45) in SSM, 26.7% (0.9-81.7) in ASM and 71.7% in MCL.Pts with at least 1 additional mutation were 6.9% (4/54) ISM, 50% (2/4) SSM and 57% (4/7) ASM(p<0.001). Five pts (7%), 4 ASM (57%) and 1 MCL, had more than 1 additional mutations (p<0.001). TET2 was the most frequent mutated gene, in 9/70 cases (12.9%), followed by ASXL1 and SRSF2 in 2 pts (2.9% each) and EZH2, IDH2, CBL and RUNX1 in 1 pts each (1.4%). No mutation was found in IDH1 and ETNK1. No recurrent mutation types were found. All pts with more than one additional mutations other than cKITD816V carried a TET2 mutation combined with ASXL1 and SRSF2 mutation in two cases each and CBL in one case. One pt had a third additional EZH2 mutation. Karyotype was normal in all the 58 pts evaluated, including 5 ASM and 3 SSM.In univariate analysis the following parameters were associated with shorter survival: one or more additional mutations (HR 19.2, CI 2-185, p<0.001), TET2 mutation (HR 28, CI 2.9-271, p=0.004) (mutations in other single genes were not evaluated due to low number of cases) and ASM variant (HR 5.3, CI 1.7-16.1, p=0.003). Pts older than 60 y at diagnosis had higher frequency of additional mutations (35% versus 8% in pts <60 y, p=0.005) and of cKITD816V VAF >2% (68.8% versus 8.3%, P<0.001).None of the analyzed molecular features correlated with anaphylaxis, osteoporosis or skin involvement.Conclusions: With the limitations due the small number of events recorded in this series, these data suggest that knowledge of molecular asset in pts with SM might provide prognostically relevant information. DisclosuresVannucchi:Novartis: Consultancy, Research Funding, Speakers Bureau; Baxalta: Speakers Bureau; Shire: Speakers Bureau.

British Society for Allergy and Clinical Immunology Abstracts of the 2016 BSACI Annual Meeting, Telford International Centre, UK, 29 September – 1 October 2016

Objectives: Despite the evidence illustrating that allergy impacts on the psychosocial functioning of children and families, it is unclear to what extent clinicians are able to refer to psychological services. This survey aims to explore clinician views of psychological need and ability to access psychology services. Method: Professionals attending a regional Allergy Network meeting completed a structured questionnaire. The participant sample (n = 29) was multi-disciplinary: 12 Nurses, 7 Consultants, 5 Dieticians, 2 GPs, 2 Junior Doctors and 1 Nursery Nurse. Results: Based on their clinical experience, the overwhelming majority (28/29) of professionals strongly agreed or agreed that there is a real need to address the psychological aspects of allergy in children as well as the physical aspects. Almost all of the participants (n = 28; 97%) wanted to be able to access psychology services for parents of and or children with allergy in their care. When asked, based on their experience, which groups of parents and/or children could benefit from psychological services: 97% reported those with a history of anaphylaxis; 83% feeding difficulties; 83% nut allergy; 79% teenagers, 69% fears of needles and/or skin prick testing; 69% those with adrenaline auto injectors. Almost half (48%) reported that parents of children with milk allergy could benefit. Only 43% of respondents (12/28) were able to refer to psychology services. This was either via a general paediatric psychology service or by referral to a clinical psychologist working in an allied paediatric specialty, such as gastroenterology. Conclusions: These findings illustrate that, despite recognising need, fifty seven per cent of professionals who participated in a Paediatric Allergy Network survey reported that they were not able to access psychological services for children with allergy or their parents. Access to and models of psychology service provision in paediatric allergy require further attention.

Discrepancies in the diagnosis and classification of nonsteroidal anti-inflammatory drug hypersensitivity reactions in children

BackgroundHypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently encountered in daily clinical practice. The aim of this study was to determine the confirmation rates, risk factors of NSAID hypersensitivity in children and to try to classify them with a standardized diagnostic protocol. MethodsAll patients with a suspicion of NSAID-induced hypersensitivity were evaluated with European Network for drug Allergy (ENDA) recommendations. The children were classified as selective responders (SRs) or cross-intolerant (CI) depending on the drug provocation test (DPT) results. ResultsWe evaluated 106 children with a suspicion of NSAID hypersensitivity. NSAID hypersensitivity was confirmed with tests in 31 patients; 4 (12.9%) were diagnosed by skin tests and 27 (87.1%) by DPTs and two patients with a history of anaphylaxis by medical records. Eleven patients (33.3%) were classified as SRs, whereas twenty-two (66.6%) children as CIs. SRs and CIs were further classified as NSAID-induced urticaria/angioedema (n = 8), NSAID-exacerbated cutaneous disease (n = 6) and NSAID-exacerbated respiratory disease (n = 1) and single NSAID-induced urticaria/angioedema and/or anaphylaxis (n = 11). Eight (24.2%) patients could not be categorized according to ENDA/GA2LEN classification; one CI patient could not be classified based on pathomechanisms, seven CIs could not be categorized based on the underlying disease and clinical manifestations. A reaction within an hour of drug intake (aOR:3.0, 95% confidence interval: 1.18–7.67, p = 0.021), a history with multiple NSAIDs hypersensitivity (aOR:2.9, 95% confidence interval: 1.16–7.60, p = 0.022), and family history of atopy (aOR:4.0, 95% confidence interval: 1.50–10.82, p = 0.006) were found as the independent risk factors related to confirmed NSAID hypersensitivity. ConclusionsThis study suggests the presence of different phenotypes which do not fit into the current classifications in children with NSAID hypersensitivity.

O041 Anaphylaxis to ingested grasshopper

Two patients presented with a history of anaphylaxis (one with loss of consciousness), the other with severe asthma, uticaria and angioedema immediately after eating “chapulines” in Mexico. P/P testing to grasshopper antigen was 4+ in both and negative in 5 non-allregic controls. Both patients gave a history of urticaria /angioedema following ingestion of crustaceans. In-vitro IgE assay to crustaceans and cockroach was positive in both. Total IgE was 4234 in one patient and 96 in the other (nl<87 I.U.) Tryptase levels in both patients were not elevated. Pre-incubation of serum with grasshopper resulted in inhibition to cockroach and to crustacean specific IgE on retesting. Previous studies (Gershwin et.al.) reported a common antigen found in crab, grasshopper and cricket may be the responsible allergen. This report suggests that the same antigen may be found in cockroach. Although previous reports in the literature of Allergic Rhino-conjuctiviis and asthma after inhalation of grasshoppers are well known, this is the first report of Anaphylaxis to ingestion of grasshoppers. Ingestion of insects is very popular in Mexico, Asia and increasingly so in North America and Europe The purpose of this report is to alert the public to the possibility that there may be an increased risk of allergic reactions to the ingestion of grasshoppers in patients with a past history of crustacean and/or cockroach allergy. This report suggests that the same antigen may also be found in cockroach sensitive patients who are much more common than crustacean allergy patients.

Intraoperative medications associated with hemodynamically significant anaphylaxis

Study objectiveTo facilitate the identification of drugs and patient factors associated with hemodynamically significant anaphylaxis. DesignUsing an existing database containing complete perioperative records, instances of hemodynamically significant anaphylaxis were identified using a physiologic and treatment-based screening algorithm. All cases were manually reviewed by 2 clinicians, with a third adjudicating disagreements, and confirmed cases were matched 3:1 with control cases. Intraoperative medications given in instances of hemodynamically significant anaphylaxis and patient risk factors were compared with control cases. SettingUniversity of Michigan Hospital, a large, tertiary care hospital. PatientsAll adult patients undergoing surgery between January 1, 2004, and January 5, 2015. InterventionsNone. MeasurementsIncidence of hemodynamically significant anaphylaxis during anesthesia. Patient risk factors and intraoperative medications associated with hemodynamically significant anaphylaxis. Main resultsHemodynamically significant anaphylaxis occurred in 55 of 461 986 cases (1 in 8400). Hemodynamically significant anaphylaxis occurred in 52 patients, with 1 patient experiencing 3 instances and another patient 2 instances. Only 1 drug was associated with an increased risk of hemodynamically significant anaphylaxis: protamine (odds ratio, 11.78; 95% confidence interval, 1.40-99.26; P=.0233). No category of drugs was associated with increased risk. Of patient risk factors, only personal history of anaphylaxis was associated with an increased risk (odds ratio, 77.1; 95% confidence interval, 10.46-567.69; P=<.0001). Postoperative follow-up and evaluation of patients were low at our institution. A serum tryptase level was sent in only 49% of cases, and 41% of levels were positive, an overall positive rate of 20% of cases. Following instances of hemodynamically significant anaphylaxis, only 29% of patients were seen and evaluated by an allergist at our institution. ConclusionsHemodynamically significant anaphylaxis is a rare complication of anesthesia, with an incidence consistent with the existing literature. Contrary to most existing literature, only protamine was associated with increased risk. A personal history of anaphylaxis appears to best predict risk of hemodynamically significant anaphylaxis.

Impaired health-related quality of life in adolescents with allergy to staple foods.

BackgroundCow’s milk, hen’s egg and wheat are staple foods in a typical western diet. Despite the ubiquity of these foods, the impact of staple food allergy on health-related quality of life (HRQL) amongst adolescents is incompletely understood. The aims of this study were to make use of the Swedish version of EuroPrevall’s disease-specific food allergy quality of life questionnaire-teenager form (FAQLQ-TF) and to investigate the association between objectively-diagnosed staple food allergy and HRQL amongst adolescents.MethodsIn this cross-sectional study, 58 adolescents aged 13–17 years [n = 40 (69 %) boys] with objectively-diagnosed allergy to the staple foods cow’s milk, hen’s egg and/or wheat and living in Stockholm, Sweden were included. Adolescents completed the FAQLQ-TF, which has a corresponding scale of 1 = best HRQL, and 7 = worst HRQL. Overall HRQL and domain-specific HRQL were established. Adolescents also reported symptoms, adrenaline auto injector (AAI) prescription and presence of other food allergies. A history of anaphylaxis was defined among those reporting difficulty breathing, inability to stand/collapse, and/or loss of consciousness. Clinically different HRQL was set at a mean difference of ≥0.5.ResultsOverall mean HRQL was poorer than average [mean: 4.70/7.00 (95 % CI 4.30–5.01)]. The domain risk of accidental exposure was significantly associated with clinically better HRQL than the domain allergen avoidance and dietary restrictions (mean difference = 0.76; p < 0.001). Girls had clinically worse, but not statistically significantly different mean HRQL than boys (mean difference = 0.71; p < 0.07). HRQL tended to be worse amongst those with allergies to more than three foods or an AAI prescription. The number and types of symptoms, including a history of anaphylaxis were not associated with worse HRQL.ConclusionsAs ascertained via a food allergy-specific questionnaire, adolescents with staple food allergy report poorer than average HRQL, specifically in relation to emerging independence and the need for support. Girls have clinically worse HRQL than boys. The number and type of previous symptoms and history of anaphylaxis were not associated with worse HRQL.Electronic supplementary materialThe online version of this article (doi:10.1186/s13601-016-0128-5) contains supplementary material, which is available to authorized users.

English

AIMS AND OBJECTIVES: 1. To assess the site of obstruction of lacrimal passage. 2. To aid in the diagnosis and management of lacrimal passage pathology. 3. To reveal the anatomy of passage and the changes due to disease. 4. To aid in the diagnosis of diverticula, fistulae and filling defects caused by stones or tumours. STUDY DESIGN: Prospective Observational Study.This study is to be conducted among 40 patients with Chronic Dacryocystitis attending our department as outpatient as well as inpatient the wards of our Govt. Rajaji Hospital, Madurai. A total of 40 patients attending as outpatient and in the wards of the Department of Ophthalmology, Govt. Rajaji Hospital, Madurai who satisfy the inclusion criteria. STUDY PERIOD: 6 Months (April 2014 to September 2014). INCLUSION CRITERIA: 1. Patients diagnosed with chronic dacryocystitis. 2. Recurrence of disease after surgery (Dacryocystectomy) 3. Age > 12 years & < 70 years. EXCLUSION CRITERIA: 1. Pregnant Patients. 2. Patients not consenting for the study. 3. Hypertensive with BP > than 140 / 90 mm of Hg. 4. Age 70 5. Immunocompromised patients. 6. History of anaphylaxis. 7. Allergy to contrast drugs. Preliminary ocular examination done to detect swelling in lacrimal sac area/ fistula, With Slit-lamp careful examination of patient’s eyelids and then the lacrimal puncta are noticed. Then syringing performed with a 5-mL syringe and an irrigating cannula / 26-gauge blunt needle to flush saline via lower punctum which reveals complete/partial block involving the nasolacrimal duct / the lacrimal sac / atonic sac/fistula/residual sac. After verbal consent from the patient, using standardized techniques dacryocystogram performed under topical anesthesia. Initial dacryocystogram was more reliable in demonstrating the anatomy of lacrimal passage and identifying the level, type of block, morphology of lacrimal sac ,associated findings and also etiological factor for epiphora can be diagnosed based on it. Hence enabling us to meticulously plan the treatment for chronic dacryocystitis, there by better outcome following surgery can be achieved without recurrence.

Validation and reliability of the Japanese version of the Food Allergy Quality of Life Questionnaire–Parent Form

BackgroundFood allergy (FA) is a heavy burden for patients and their families and can significantly reduce the quality of life (QoL) of both. To provide adequate support, qualitative and quantitative evaluation of the parents' QoL may be helpful. The objective of this study is to develop and validate a Japanese version of the Food Allergy QoL Questionnaire–Parent Form (FAQLQ-PF-J), an internationally validated disease-specific QoL measurement of the parental burden of having a child with FA. MethodsThe FAQLQ-PF and the Food Allergy Independent Measure (FAIM), an instrument to test the construct validity of the FAQLQ-PF-J, were translated into Japanese. After language validation, the questionnaires were administered to parents of FA children aged 0–12 years and those of age-matched healthy (without FA) children. Internal consistency (by Cronbach's α) and test-retest reliability were evaluated. Construct validity and discriminant validity were also examined. ResultsOne hundred twenty-seven parents of children with FA and 48 parents of healthy children filled out the questionnaire. The FAQLQ-PF-J showed excellent internal consistency (Cronbach's α > 0.77) and test-retest reliability. Good construct validity was demonstrated by significant correlations between the FAQLQ-PF-J and FAIM-J scores. It discriminated parents of children with FA from those without. The scores were significantly higher (lower QoL) for parents of FA children with a history of anaphylaxis than those without, for those with >6 FA-related symptoms experienced than those with less FA-related symptoms. ConclusionsThe FAQLQ-PF-J is a reliable and valid measure of the parental burden of FA in children.

Allergy test outcomes in patients self-reported as having penicillin allergy: Two-year experience

BackgroundPenicillin allergy is associated with increased antibiotic resistance and health care costs. However, most patients with self-reported penicillin allergy are not truly allergic. ObjectiveTo summarize our experience with allergy tests in patients with a history of penicillin allergy and to compare them with the results of other groups. MethodsWe retrospectively reviewed all patients with a suspected clinical history of penicillin allergy referred to the Drug Allergy Unit at University College London Hospital between March 2013 and June 2015. ResultsIn total, 84 patients were reviewed. The index drugs included: unidentified penicillin (n = 44), amoxicillin (n = 17), amoxicillin–clavulanic acid (n = 13), flucloxacillin (n = 4), and other penicillins (ampicillin, benzylpenicillin, piperacillin-tazobactam; n = 7). Allergy diagnoses were confirmed in 24 patients (28.6%) (16 to penicillin, 3 to flucloxacillin, 5 to clavulanic acid). Twenty-two patients (91.7%) had allergy diagnosed by positive skin test results. Two patients (8.3%) developed IgE-mediated allergic symptoms during oral challenge (although the skin test results were negative). In vitro specific IgE test results for penicilloyl V, penicilloyl G, and amoxicilloyl were positive in 3 of 16 patients (18.8%). Moreover, reactions to cefuroxime were observed in 3 of 15 patients with penicillin allergy (20%). Selective clavulanic acid and flucloxacillin responders tolerated amoxicillin challenge. The interval between the index reaction and evaluation was shorter (P < .001), and the proportion of patients who could recall the name of the culprit drug was higher (P = .009) in the allergic group. Furthermore, histories of anaphylaxis (33.3%), urticaria, and/or angioedema (58.3%) were more common in the allergic group. Unspecified rashes (35.0%) and nonspecific symptoms (28.3%) predominated in the nonallergic group. ConclusionOnly 28.6% of patients with self-reported penicillin allergy were confirmed to be allergic. Importantly, when the index drug is amoxicillin–clavulanic acid or flucloxacillin, the patients may tolerate amoxicillin.

ASCIA‐P29: MANAGEMENT AND FOLLOW UP OF ANAPHYLAXIS PRESENTATIONS TO THE EMERGENCY DEPARTMENT: A ONE YEAR RETROSPECTIVE AUDIT ACROSS THREE HOSPITAL SITES

Anaphylaxis is a life threatening allergic reaction which requires prompt management in the Emergency Department (ED) and appropriate follow up with an Allergist. Despite widely available clinical guidelines ongoing deficiencies in the recommended management practices of anaphylaxis still occurs. This study aimed to evaluate the real time approach to patients presenting with suspected anaphylaxis within three hospitals in one Australian metropolitan health service. Paediatric and adult anaphylaxis presentations both as triaged and final diagnosis where included in a retrospective audit for a 12 month period (January-December 2015) across three hospital EDs in Eastern Health (eastern metropolitan Melbourne). Demographics, clinical features, identified triggers, management pre-hospital and in the ED, discharge management and follow up were determined. Of 399 patients presenting to ED with an initial triage or final diagnosis of anaphylaxis there were 292 patients who had a true diagnosis based on the current definition, of these patients 149 (51%) were triaged as anaphylaxis. There was 142 (48.6%) who had a past history of anaphylaxis, 92 (31.5%) did not call an ambulance, 239 (81.8%) were observed for the recommended 4hours, 229 (78.4%) received an adrenaline auto-injector script on discharge, 154 (52.7%) had anaphylaxis education and only 148 (50.1%) were referred to an Allergist for follow up. This retrospective audit highlighted the current issues with the acute management of anaphylaxis in the ED setting. Anaphylaxis presentations are under-triaged which may have a subsequent effect on early management. Current recommendations were not met with only 78.4% of patients receiving a prescription. Half of the patients did not receive follow up with an Allergist, which may reflect an inadequate referral process, and/or a lack of specialist allergy services. Education on anaphylaxis and the utilisation of emergency transport was low which raises further concerns about prompt management within the community setting.

Evaluation and characterization of 125 patients with a history of reaction to beta-lactams

Reactions to beta-lactams are frequent and it is difficult to establish the relationship between the drug and symptoms. To describe the clinical characteristics and explore the immunological mechanisms of patients with suspected adverse reaction to beta-lactams. Retrospective study of patients with a history of beta-lactam reaction and tests for reactions to drugs. Out of 125 patients, 71 were women (56.8%); 73 had a history of immediate reaction and 52 delayed reaction; 590 allergy tests were done: specific IgE measurement, skin prick, patch, and provocation tests. The drugs most often related were amoxycillin, in 62 patients (49.6%), crystalline penicillin in 17 (13.6%), benzathine penicillin in 15 (12%), and cefalexin in 13 (10.4%). The severity of the reaction was mild in the majority (82%). 7.7% had a history of anaphylaxis and 10.8% sought care for a positive penicillin skin test, without history of reaction. Only 6.7% resulted in a positive test. More than 62% began testing two years after the reaction for which they sought care. The clinical history is insufficient to determine allergy to beta-lactams. In our sample, few patients with a history of beta-lactam reaction had evidence of immune-mediated reactions.

Recurrent Anaphylaxis: An Unruptured Splenic Hydatid Cyst as an Unusual Cause

Anaphylaxis is an acute onset systemic hypersensitivity reaction that may result in death. Drugs, idiopathic triggers, Hymenoptera venom and food are the most common causes of anaphylaxis. In patients with a recurrent history of anaphylaxis and elevated IgE levels without evident etiology, spontaneous hydatid cyst rupture should be considered, especially in endemic areas.

Baklagillere Allerjisi Olan Bir Olguda Deri Testi Sırasında Anafilaksi

The most common causes of food allergy vary among countries according to the dietary habits and the frequency of consumption of foods. Legumes are important sources of protein that are widely consumed all over the world. The legume family includes lentils, chickpeas, beans, broad beans as well as peanuts and soybeans. Skin prick tests are generally considered safe. However, systemic reactions may develop during skin prick testing, Systemic reactions from skin testing are more frequent with food, drug, latex and venom allergens. Systemic reactions occur more frequently after prick to prick tests that are performed with fresh food than those with standard extracts. This paper reports a case with a history of anaphylaxis to lentils and peas. The patient was found to have type 1 reaction to chick peas, broad beans and green beans although she did not describe a reaction to these legumes in her history. The patient experienced anaphylaxis during skin testing with legumes when multiple tests were performed at the same time. There was no reaction when skin prick tests were performed in more than one session. The patient is noteworthy in this regard and discussed in detail.

P141 A service evaluation for and on behalf of the European Clinical Collaborative Group (ECCG) - The management of Gonorrhoea across Europe

Background/introduction Gonorrhoea (GC) cases appear to be rising as well as increasing problems with resistance to many antibiotic groups. With open boundaries and free movement of populations and doctors, a consistent standard of care is important across Europe. Regular evaluation is crucial in controlling the emergent spread of resistant GC. Aim(s)/objectives To evaluate current clinical practice amongst sexual health physicians across Europe against the current European guidelines. Also, key areas of controversy will be explored with to help inform further guideline development. Methods The ECCG is a network of 120 sexual health specialists across 38 countries, who conduct questionnaire-based research across the European region. An expert panel consisting of six ECCG members was established then interviewed to help identify areas of controversy. Subsequently, a clinical scenario based questionnaire was developed then disseminated to all ECCG members. Results Provisional results demonstrate variation in clinical practice across Europe. This is discernable from the choice of treatment for a patient with a history of anaphylaxis to penicillin and treatment for confirmed pharyngeal infection. In addition, data showed a lack of consensus to guidelines regarding choices of look back period for sexual contacts. Discussion/conclusion Management of GC varies across Europe and is not always in line with current European guidelines. Although there are minor variations between guidelines, there are vast discrepancies amongst European clinicians regarding clinical practice. There is a need for on-going Europe wide education to ensure that patients are receiving safe evidence based care.

A Safe and Novel Desensitization Protocol with Ferric Carboxymaltose to Treat Iron Deficiency Anemia.

Worldwide, iron deficiency anemia is the most common nutritional disorder. Treatment with oral iron supplementation may not be well tolerated due to gastrointestinal side effects. Therapy with Intravenous (IV) iron supplementation is more effective and better tolerated, especially in patients with underlying Inflammatory Bowel Disease (IBD) or malignancy. However, Hypersensitivity Reactions (HSR) and anaphylaxis to IV iron have been described. We evaluated the literature and developed an eleven step desensitization protocol for ferric carboxymaltose to be administered in high risk patients. We present the first case series demonstrating the safety of ferric carboxymaltose desensitization in patients with a history of anaphylaxis to IV iron and iron deficiency anemia. While there are many IV iron formulations available, ferric carboxymaltose can replenish iron stores with fewer doses. Ferric carboxymaltose is contraindicated in patients with prior hypersensitivity reactions to iron formulations. This novel eleven step desensitization protocol was well tolerated without any adverse reactions and allowed the patients to receive iron supplementation when limited therapeutic options existed.

The Basophil Activation Test Is Not a Useful Screening Tool for Hymenoptera Venom-Related Anaphylaxis in Patients with Systemic Mastocytosis

Background: Systemic mastocytosis (SM) patients are at a high risk for anaphylaxis, with Hymenoptera as the main culprit. A screening instrument to identify which patients are sensitized to Hymenoptera before they experience anaphylaxis would therefore be of great value. The basophil activation test (BAT) is proposed as a possible tool for diagnosing Hymenoptera venom-related allergy (HVA), especially in patients in whom conventional allergy tests yield contradictory results. Methods: We included outpatients with SM, according to WHO criteria, from September 2011 to January 2012. Next, to obtain various clinical data including intradermal test results, specific immunoglobulin E (sIgE) measurements and BAT were performed. Results: We included 29 patients, 9 of whom had a history of HVA and 4 of whom had experienced anaphylaxis due to other triggers. Sixteen patients had no history of anaphylaxis. sIgE was detected in 6 patients with HVA and in 2 patients with anaphylaxis due to other triggers. The BAT was positive in only 1 patient, in whom the skin test and sIgE were also positive. Compared to patients with skin lesions, those without skin lesions had significantly more anaphylaxis and sIgE to Hymenoptera. During a 3-year follow-up, no one experienced new anaphylactic episodes. Conclusion: The BAT is not a reliable tool for randomly screening SM patients for HVA.

The economic effect and outcome of delaying oral food challenges

BackgroundFood specific IgE (sIgE) is a useful marker to assess predictability of oral food challenge (OFC) outcome. A threshold of less than 2 kUA/L for peanut, egg, and milk has been proposed as a 50% negative predictive value at which patients may pass an OFC. ObjectiveTo assess the economic effect and outcome of delaying OFCs. MethodsA retrospective analysis was performed for peanut, egg, and milk OFCs conducted between 2001 and 2012 at a tertiary food allergy referral center. Delayed OFC was defined as greater than 12 months from the time the sIgE level became less than 2 kUA/L. Time to OFC was explored in association with skin prick test result (wheal size), OFC outcome, and the economic effect of delay. ResultsOf 319 challenges, 173 OFCs were delayed (54.2%) by a mean time of 35.5 months (range, 13–123 months) vs a mean time of 4.2 months in the 146 challenges that were not delayed (P < .001). The overall OFC passage rate was 89.9%. There was no association between delayed OFC and history of anaphylaxis, type of allergen, age at OFC, or challenge outcome. Delay in OFC was associated with an estimated mean economic cost of $12,203 per patient ($4,184 per 12 months) and $1,951,487 total (total delay, 5,597 months) in this population. ConclusionDespite a 50% negative predictive value, more than 50% of OFCs were delayed in this population by a mean time of nearly 3 years. Delaying OFC is associated with increased costs, and quality improvement is needed to help decrease time to OFC and reduce the economic burden of food allergy on families and the health care system.

Usefulness of molecular diagnosis in egg allergic children.

IntroductionEgg allergy is one of the most common food allergies in children. Egg white, including ovomucoid (OVM or Gal d 1) and ovalbumin (OVA or Gal d 2), is the major source of allergens. The aim of this study was to assess the role of Gal d 1 and Gal d 2 in predicting the risk of anaphylaxis caused by eggs in children, and to compare this new diagnostic tool with established methods of allergen-specific IgE detection.Material and methodsOne hundred and forty-eight children were divided into 2 groups according to a positive (group A, 33 children) or negative (group B, 115 children) history of anaphylaxis after ingestion/contact with eggs. All patients underwent an allergological evaluation by measurements of specific IgE against egg white: Gal d 1 and Gal d 2.ResultsHigher levels of Gal d 1, Gal d 2 and IgE against egg white were detected in group A compared to group B (p < 0.001). Although the area under the curve was similar for Gal d 1 and Gal d 2, egg white specific IgE showed a better sensitivity (85%) for a cut-off value ≥ 0.975 kUA/l, while Gal d 1 and Gal d 2 demonstrated a better specificity (90% and 80%, respectively) for cut-off values ≥ 1.460 kUA/l and ≥ 2.310 kUA/l, respectively.ConclusionsEgg white specific IgE showed a similar ability as Gal d 1 and Gal d 2 in differentiating children at risk for egg anaphylaxis, although Gal d 1 and Gal d 2 showed a better specificity.

Stinging insect allergy and venom immunotherapy.

The Hymenoptera order is divided into three families: Apidae, Vespidae, and Formicidae. Apidae include the honeybee, bumblebee, and sweat bee, which are all docile and tend to sting mostly on provocation. The Africanized killer bee, a product of interbreeding between the domestic and African honeybee, is very aggressive and is mostly found in Mexico, Central America, Arizona, and California. The yellow jacket, yellow hornet, white (bald) faced hornet, and paper wasp all belong to the Vespidae family. The Formicidae family includes the harvester ant and the fire ant. When a "bee" sting results in a large local reaction, defined as >10 cm induration and lasting > 24 hours, the likelihood of anaphylaxis from a future sting is approximately 5%. For comparison, when there is a history of anaphylaxis from a previous Hymenoptera sting and the patient has positive skin test results to venom, at least 60% of adults and 20-32% of children will develop anaphylaxis with a future sting. Both patient groups should be instructed about avoidance measures and about carrying and knowing when to self-inject epinephrine, but immunotherapy with Hymenoptera venom is indicated for those patients with a history of anaphylaxis from the index sting and not for patients who have experienced a large local reaction. Immunotherapy is highly effective in that, by 4 years of injections, the incidence of subsequent sting-induced reactions is 3%. This incidence may increase modestly after discontinuation of injections but has not been reported to be > 10% in follow up.

SAFETY OF INFLUENZA VACCINATION IN CHILDREN WITH SEVERE ALLERGY TO HEN'S EGGS: A PROSPECTIVE CASE SERIES STUDY

Influenza vaccination guidelines have recommended that pediatricians should consult with allergists in the case of for children with histories of anaphylaxis to hen's eggs. On the other hand, whether such children can be safely vaccinated is unclear. To evaluate the safety of influenza vaccination for children severely allergic to eggs. The study population consisted severe egg-allergic children that had never been immunized with influenza vaccine. The inclusion criteria of severe egg-allergic children included evidence of serum specific IgE antibodies to egg white or an ovomucoid level of class4 or more and complete elimination of dietary intake of eggs, or occurrence of Sampson Grade 3 to 5 anaphylactic reactions upon egg ingestion. Patients underwent skin prick tests, and received 0.1ml of influenza vaccine, followed in 30 minutes if no reaction with the remainder of an age-appropriate dose. We observed the subjects for 30 minutes afterwards, and they were observed by their patients during the subsequent 24 hours. A total of 17 patients were enrolled. All patients received influenza vaccination without an allergic reaction. Influenza vaccination is safe even in children with histories of severe egg allergy. influenza vaccination without an allergic reaction.