Intradermal Skin Test Results Research Articles

Comparison of intradermal and serum testing for environmental allergen-specific immunoglobulin E determination in a laboratory colony of cats with naturally acquired atopic syndrome.

Allergen testing is used to select antigens included in the desensitisation vaccine. Intradermal skin test (IDT) is the gold standard in cats, yet allergen-specific immunoglobulin (Ig)E serological testing (ASIS) is often used. Feline data are lacking regarding the agreement between IDT and ASIS results. The first objective of the study was to establish a colony of cats with naturally acquired feline atopic syndrome (FAS). Further objectives were to define their hypersensitivity disorder to detail the allergen tests results, and to assess similarity between the allergen tests. Thirty-five cats with FAS and 10 control cats. Enrolled cats went through a five phase-screening and quarantine process before joining the colony. An elimination diet trial was performed on all FAS cats. ASIS and IDT were consecutively performed on all cats under sedation. Reactions to 34 allergens were compiled for the 45 cats. Global sensitivity and specificity of ASIS were 34.7% and 78.9%, respectively. Only flea (ICC = 0.26, p = 0.040) and Dermatophagoides pteronyssinus (ICC = 0.48, p < 0.001) allergens had a significant intraclass correlation (weak agreement). Two FAS cats had negative tests including one cat with a concomitant food allergy. This study depicts the first reported colony of cats with naturally acquired FAS. This is the first feline study to compare and show the poor agreement between allergen tests with a panel of 34 allergens. This colony also harbours two cats with FAS with negative allergen tests. These may represent the first described cats with an intrinsic form of atopic syndrome.

Allergic reactions to coronavirus disease 2019 vaccines and addressing vaccine hesitancy: Northwell Health experience

BackgroundAllergic and nonallergic adverse reactions have been reported with global coronavirus disease 2019 (COVID-19) vaccination. It was previously hypothesized that polyethylene glycol (PEG) may be responsible for anaphylactic reactions to messenger RNA (mRNA) COVID-19 vaccines. ObjectiveTo report the workflow established at our institution, types, and frequency of adverse reactions to mRNA COVID-19 vaccines in patients presenting for allergy evaluation. MethodsA COVID-19 vaccine adverse reaction registry was established. We used PEG prick skin testing, followed by PEG challenges in selected cases, to ensure PEG tolerance and encourage completion of COVID-19 vaccination series. ResultsA total of 113 patients were included. Most vaccine reactions (86.7%) occurred in women. Anaphylaxis occurred only in women, all of which had a history of allergic disease and two-thirds had asthma. Anaphylaxis rate was 40.6 cases per million. None of the anaphylactic cases developed hypotension, required intubation, or required hospital admission. Systemic allergic symptoms, not fulfilling anaphylaxis criteria, were significantly more common in Pfizer-BioNTech than Moderna-vaccinated patients (P = .02). We observed a higher incidence of dermatologic nonurticarial reactions in men (P = .004). Among first-dose reactors, 86.7% received and tolerated the second dose. We observed a high rate of false-positive intradermal skin test results and frequent subjective symptoms with oral PEG challenge. ConclusionIntradermal PEG testing has limited utility in evaluating anaphylaxis to mRNA vaccines. Most severe postvaccination allergic symptoms are not caused by hypersensitivity to PEG. Most people with reaction to the initial mRNA vaccine can be safely revaccinated. Patients with anaphylaxis to COVID-19 vaccines benefit from physician-observed vaccination.

Machine Learning and XAI approaches for Allergy Diagnosis

This work presents a computer-aided framework for allergy diagnosis which is capable of handling comorbidities. The system was developed using datasets collected from allergy testing centers in South India. Intradermal skin test results of 878 patients were recorded and it was observed that the data contained very few samples for comorbid conditions. Modified data sampling techniques were applied to handle this data imbalance for improving the efficiency of the learning algorithms. The algorithms were cross-validated to choose the optimal trained model for multi-label classification. The transparency of the machine learning models was ensured using post-hoc explainable artificial intelligence approaches. The system was tested by verifying the performance of a trained random forest model on the test data. The training and validation accuracy rate of the decision tree, support vector machine and random forest are 81.62, 81.04 and 83.07 respectively. During evaluation, random forest achieved a rate of 86.39 accuracy overall, and 75% sensitivity for the comorbid Rhinitis-Urticaria class. The framework along with all the functionalities were deployed on mobile devices. The average performance of the clinicians before and after using the decision support system were 77.21% and 81.80% respectively. The diagnosis system integrated with mobile applications serves as a source of information whereby junior clinicians can use it to confirm their diagnostic predictions.

Comparing the results of intradermal skin tests for four dust mite allergens in dogs with atopic dermatitis in Thailand.

Background and Aim:Hypersensitivity to house dust mites is a common cause of atopic dermatitis in dogs. The intradermal test (IDT) identifies allergens to be included in allergen-specific immunotherapy. Common mite allergens used for IDT include single source extracts obtained from Dermatophagoides farinae or Dermatophagoides pteronyssinus or multisource extracts from multimite species (mixed mites), as well as a combination of multimite species and proteins from feces and shed skin (house dust). The objectives of the present study were to evaluate the prevalence of mite sensitivity in dogs diagnosed with atopic dermatitis in different Thailand provinces and to determine if positive test results to mite allergens aligned.Materials and Methods:Eighty-two dogs (median age [range]: 5 years [11 months-11 years]; 51 males and 31 females) diagnosed with atopic dermatitis underwent IDTs with four different mite-related allergens (D. farinae, D. pteronyssinus, mixed mites, and house dust). The skin reactions were reported on a scale of 0-4 and the reactions 2+ were considered clinically relevant. The relationship between IDT results from different allergens was determined using Pearson’s correlation coefficient (r). Fisher’s exact test was used to compare IDT results for different mite allergens as well as for dogs residing in Bangkok versus other provinces in Thailand.Results:The prevalence (95% confidence interval [CI]) of positive IDT results for D. farinae, D. pteronyssinus, mixed mites, and house dust in dogs with atopic dermatitis was 64.63% (52.30-74.88), 58.54% (47.12-69.32), 47.56% (36.41-58.89), and 35.37% (25.12-46.70), respectively. A moderate correlation was found in IDT results between D. pteronyssinus and house dust (r=0.514), between D. pteronyssinus and D. farinae (r=0.426), and between D. farinae and mixed mites (r=0.423). The prevalence of dogs with positive IDT results for mite allergens with mono-sensitization, bi-sensitization, tri-sensitization, and quadru-sensitization did not differ significantly between dogs residing in Bangkok (11.63%, 18.60%, 25.58%, and 16.28%) and dogs residing in other provinces (12.82%, 30.77%, 35.90%, and 10.26%). The overall sensitivity (95% CI) and specificity (95% CI) of the mixed mites test associated with atopic dermatitis in dogs were 60.32% (47.20-72.40%) and 94.70% (74.00-99.90%), respectively. The overall sensitivity (95% CI) and specificity (95% CI) of the house dust test associated with atopic dermatitis in dogs were 42.90% (30.50-56.00%) and 89.50% (66.90-98.70%), respectively.Conclusion:House dust mites are an important source of allergens for dogs with atopic dermatitis. In the present study, no significant difference in the prevalence of atopic dermatitis was found in dogs living in the urban area compared with dogs living in the countryside. Application of multisource extracts from mites for IDT revealed a higher reaction to mixed mites than that of house dust.

Validation of the Prescreening Intradermal Skin Test for Predicting Hypersensitivity to Iodinated Contrast Media: A Prospective Study with ICM Challenge

The number of hypersensitivity reactions associated with iodinated contrast media (ICM) is increasing with widespread use of radiographic contrast agents. These hypersensitivity reactions are unpredictable and sometimes lead to severe reactions such as anaphylaxis. To investigate the value of intradermal skin test (IDT) as a clinical screening tool for prediction of a hypersensitivity reaction to ICM. We performed IDT in the patients scheduled to receive an iodinated contrast agent between September 2015 and April 2017. After IDT, the contrast agent tested was administered intravenously, regardless of the results of skin testing, and the patients were carefully monitored. We recruited 2,918 patients in 2 hospitals, and 2,843 were included in the final analysis. Fifteen (0.5%) of the 2843 patients had a positive IDT result before scheduled computed tomography scan; however, none of these patients experienced a hypersensitivity reaction after the administration of a full dose of ICM. Meanwhile, 19 patients who experienced hypersensitivity reactions after ICM challenge had showed a negative IDT result. The sensitivity and the positive predictive value of IDT for ICM were both 0%. Routine IDT before the administration of an iodinated contrast agent does not predict hypersensitivity considering its extremely low sensitivity and a low positive predictive value.

Novel Strategy for the Prevention of Recurrent Hypersensitivity Reactions to Radiocontrast Media Based on Skin Testing

Hypersensitivity reactions to iodinated contrast media (ICM) is a persistent clinical issue with increased use of computed tomography. With the evidence indicating underlying allergic mechanisms, there have been studies regarding the skin tests using ICM. This study aimed to evaluate the intradermal skin test (IDT) as a tool for preventing recurrent hypersensitivity reactions to ICM in patients with prior reactions to a known culprit agent. Sixty-nine patients who had experienced immediate hypersensitivity reactions to ICM were included in the study. All patients underwent IDT with 7 different ICMs, including the causative ICM. We analyzed clinical data from 38 patients who were reexposed to ICMs, grouped by the IDT results to their original culprit ICM. Thirty-eight patients showed positive IDT results to the culprit ICM (CULPRIT+), whereas 31 patients showed negative results (CULPRIT-). Sixteen patients from the CULPRIT+ group and 22 from the CULPRIT- group were subsequently exposed to an ICM. In the CULPRIT+ group, 4 of the 5 patients who were subsequently exposed to an IDT-positive ICM reexperienced hypersensitivity reactions. When patients were exposed to IDT-negative ICM as an alternative, hypersensitivity reactions were not observed. In the CULPRIT- group, IDT-positive ICMs did not provoke hypersensitivity reactions whereas 2 patients using IDT-negative ICMs experienced hypersensitivity reactions. When the IDT results are positive for the culprit ICM, additional IDTs with other ICMs are needed to select a safe alternative. If the IDT results are negative against the culprit ICM, further IDTs might not play a role in selecting a safe alternative.

Allergic evaluation of Roystonea regia (Kunth.) O. F. Cook. among Keralites, India.

Aerobiological studies conducted in Kerala (India), revealed the incidence of pollen grains of Roystonea regia (Kunth.) O.F.Cook. belonging to the family Aracaceae as a common airborne pollen member. Previous clinical studies conducted in different parts of the world also proved its allergic potentiality among human beings. Present study concerned with the clinical studies of this particular airborne pollen type among Keralites. Intradermal skin test results of 1000 patients having the history of respiratory complaints was collected for the allergy evaluation study. Results showed that this particular pollen type is highly potent allergen and the degree of reactivity is depends the locality in which the patients inhabits.

Computer-assisted Medical Decision-making System for Diagnosis of Urticaria.

Background: Urticaria is a common allergic disease that affects all age groups. Allergic disorders are diagnosed at allergy testing centers using skin tests. Though skin tests are the gold standard tests for allergy diagnosis, specialists are required to interpret the observations and test results. Hence, a computer-assisted medical decision-making (CMD) system can be used as an aid for decision support, by junior clinicians, in order to diagnose the presence of urticaria. Methods: The data from intradermal skin test results of 778 patients, who exhibited allergic symptoms, are considered for this study. Based on food habits and the history of a patient, 40 relevant allergens are tested. Allergen extracts are used for skin test. Ten independent runs of 10-fold cross-validation are used to train the system. The performance of the CMD system is evaluated using a set of test samples. The test samples were also presented to the junior clinicians at the allergy testing center to diagnose the presence or absence of urticaria. Results: From a set of 91 features, a subset of 41 relevant features is chosen based on the relevance score of the feature selection algorithm. The Bayes classification approach achieves a classification accuracy of 96.92% over the test samples. The junior clinicians were able to classify the test samples with an average accuracy of 75.68%. Conclusion: A probabilistic classification approach is used for identifying the presence or absence of urticaria based on intradermal skin test results. In the absence of an allergy specialist, the CDM system assists junior clinicians in clinical decision making.

Cefaclor-Induced Generalized Fixed Drug Eruption.

Dear Editor: Fixed drug eruption (FDE) is characterized by the site-specific recurrence of dusky-red to brownish macules or patches that recur with re-administration of the causative drug1. Although FDE usually presents as a solitary lesion, the lesions can be generalized in rare instances. Although cephalosporins are some of the widely prescribed antibiotics worldwide, FDE due to cephalosporins is rarely reported. Here, we report a case of generalized FDE due to cefaclor confirmed by rechallenge. A 64-year-old man presented with generalized brownish patches (Fig. 1A). He had been diagnosed with macular degeneration approximately 2 months earlier, and received 3 injections of bevacizumab. After each injection, he took cefaclor, loxoprofen, and streptokinase/streptodornase at 4-week intervals to reduce pain and prevent secondary infection. Erythematous patches developed 6 hours after he took the oral medicines for the first time. The skin lesions resolved spontaneously, leaving hyperpigmentation. Whenever he took the medicines, new erythematous patches developed and previous hyperpigmented patches darkened. Skin biopsy results were concordant with a clinical diagnosis of FDE (Fig. 2). We explained to him the probable diagnosis, causative drugs, and methods for definite diagnosis. After 3 months, he volunteered to take the 3 abovementioned drugs to identify the causative drug. After he took cefaclor, existing skin lesions became reddish and new lesions developed within 24 hours (Fig. 1B). No skin lesions developed after taking the other drugs. Considering this and his clinical history, he was diagnosed with cefaclor-induced generalized FDE. No skin lesions developed after cefaclor was changed to ofloxacin. However, patch tests performed 8 months later on normal and hyperpigmented areas with 10%, 20%, and 30% pet. cefaclor powder were negative on days 2 and 4. Fig. 1 (A) Generalized brownish hyperpigmented annular patches over the whole body after taking cefaclor, ioxoprofen, and streptokinase/streptodornase. (B) Development of new lesions and darkening of existing lesions after taking cefaclor 250 mg. Fig. 2 Skin biopsy specimen showing edematous degeneration of the basal membrane of the epidermis, pigment incontinence, and superficial perivascular lymphocytic infiltration (H&E, ×200). Cefaclor is a second-generation cephalosporin. Adverse cutaneous drug reactions due to cephalosporin generally cause a morbiliform rash but rarely lead to FDE. There are several tests for identifying the causative drug, including the patch test, prick test, and intradermal skin test. However, the patch test at the site of a previous lesion shows a positive response in up to only 43% of cases2, and the positivity rate of patch test results using drugs other than nonsteroidal anti-inflammatory drug is very low3. Prick and intradermal skin test results are positive 24% and 67%, respectively. An oral challenge test with the suspected drug may be the best method, but it cannot often be performed because of its high risk. In the present case, the patient's voluntary provocation test aided the diagnosis of FDE. Only 5 cases of localized FDE due to cephalosporins including cefazolin, cephalexin, cefaclor, ceftazidime, and ceftriaxone have been reported. All cases were diagnosed by provocation tests and not by patch or intradermal test. To our knowledge, this is the first case report of cefaclor-induced generalized FDE. As cefaclor rarely causes FDE, patients as well as clinicians tend to ignore any skin lesions due to FDE. Furthermore, it is often difficult to identify the causative drug when patient is taking multiple medications. In summary, we report a case of cefaclor-induced generalized FDE proven by a self-rechallenge test.

Intradermal Skin Test Results Correlate with Atopy

Intradermal skin testing (IDST) is performed by most allergists, but its value remains controversial. In most previous studies assessing the value of IDST, a positive result was based on a 5- to 6-mm wheal and erythema. While a subject's immediate reaction upon allergen exposure is a common endpoint to determine "allergy," additional known allergic phenomena such as the delayed or late-phase response to allergen exposure suggest that correlation only with current history or acute challenge may result in an incorrect labeling of false-positive results when, in fact, there is a physiologic response to exposure, albeit a reaction not immediately evident. We conducted a retrospective study to determine if positive IDST reactions represent nonspecific irritation or if they correlate with atopy. We retrospectively reviewed the records of 100 patients who had undergone skin prick testing (SPT) and IDST and compiled data on their age, sex, diagnosis, and number of skin and intradermal reactions. Results were analyzed according to a general linear model to see if the development of a positive IDST result correlated with atopy (defined as SPT positivity). We found statistically significant differences between SPT-positive and -negative patients with regard to diagnoses of asthma, rhinitis, or both (p=0.008). Controlling for asthma and rhinitis, we also found a significant association between atopy and a positive IDST result; among atopic (SPT+) patients, a mean of 25.9% of IDST results were positive, compared with a rate of only 6.7% IDST positivity among the nonatopic (SPT-) patients (p<0.0001). We conclude that IDST is more commonly positive in atopic (SPT+) than nonatopic (SPT-) patients, suggesting that a positive IDST represents genuine atopy and bona fide sensitization rather than nonspecific irritation.

The results of intradermal skin tests (IDST) in dogs with atopic dermatitis from the Lublin voivodeship

The purpose of this study was to assess the positive immediate reactions received from intradermal skin tests (IDST) which confirmed the presence of IgE-dependent hypersensitivity in dogs with atopic dermatitis, which were patients of the Dermatology Consulting Section at the University of Life Sciences in Lublin between 2007 and 2009. Intradermal skin tests were performed on 142 dogs (72 females and 70 males) from the Lublin voivodeship of different breeds ranging in age from 1 to 6 years (average 2.8 years). The allergen set used in this study was the Artuvetrin Test (ARTU Biologicals Europe B.V, Holland). The owners of 84 dogs observed the presence of skin lesions all year round regardless of season, while 58 dog owners noted them only in spring and summer. Most immediate positive reactions were ascertained from mite allergens (70.61%), fewer from pollen allergens (19.55%), and the fewest from animal (4.15%) and mould allergens (1.66%). Immediate positive reactions for a flea allergen (4.03% of all positive reactions) were also ascertained. In 98.6% of dogs polysensitization was found.

Values of intradermal skin test and serum sIgE detection in diagnosing Humulus scandens pollinosis

To evaluate the values of intradermal skin test (IDT) and serum specific IgE detection in diagnosing Humulus scandens sensitivity in Chinese patients with autumnal hay fever. 1150 patients, 504 males and 646 females, aged 5 approximately 75, were evaluated as with autumnal rhinitis and asthma by experienced physicians. Then the patients underwent IDT by using 20 kinds of aeroallergen extracts, at the concentration of 1:1000 (w/v) for Artemisia spp. and ragweed or at the concentration of 1:100 (w/v) for Humulus scandens and others. The Humulus sIgE level was performed in all patients. A diagnosing criteria was established according to typical history, symptoms, and any one of the following findings: (1) wheal > or = 5 mm in diameter by IDT and sIgE to Humulus of the concentration > or = 0.35 kUa/L at same time; (2) wheal > or = 10 mm in diameter by IDT alone; and (3) sIgE to Humulus of the concentration > or = 0.70 kUa/L alone. When using the above diagnosing criteria as the reference standard, IDT had better sensitivity (97.2%), positive predictive value (PV+) (77.9%), negative predictive value (PV-) (90.6%) and efficiency (80.4% than using sIgE > or = 0.35 kUa/L alone as the reference criteria of IDT, however, had a lower specificity (49.8%); and sIgE detection had better sensitivity (89.0%), specificity (97.5%), PV+ (98.8%), PV- (88.0%) and efficiency (92.0%) than using wheal > or = 5 mm in diameter alone as the reference criteria of sIgE detection. The false positive rate of IDT decreased from 59.9% to 17.4% when using wheal diameter > or = 10 mm as the positive criteria. In the 288 patients with a negative sIgE result and a positive IDT result 84 cases had stronger positive IDT result (with the wheal diameter > or = 10 mm). IDT is correlated well with sIgE detection in diagnosing Humulus scandens pollinosis, but the false positive rate of IDT is higher than that of sIgE test. The false positive rate of IDT can be decreased by increasing the positive criteria to higher grading reaction. The immunotherapy according to the lower grading positive result of IDT alone or sIgE alone should be avoided.

Value of intradermal skin test and serum sIgE detection in diagnosing artemisia pollinosis

To evaluate the value of intradermal skin test (IDT) and serum sIgE detection in diagnosing Artemisia sensitivity in Chinese patients with autumnal hay fever. 1150 patients with autumnal rhinitis or asthma, 504 males and 646 females, aged 5 approximately 77, were evaluated by experienced physicians, then underwent IDT by using 20 kinds of aeroallergen extracts. The concentrations of Artemisia and Ragweed extracts employed in skin test were 1:1000 (W/V) and the concentrations of other aeroallergens were all 1:100 (W/V). Then all patients underwent detection of Artemisia sIgE. Diagnostic standards were established based on the results of IDT and sIgE results respectively. A reference standard was established according to the typical history, symptoms, and an wheal with a diameter >or= 5mm and a sIgE level >or= 0.35 kU(A)/L, an wheal with the diameter >or= 10 mm alone; or a sIgE level >or= 0.70 kUa/L alone. When using the reference standard as criteria, using IDT had better sensitivity (96.2%), specificity (74.2%), positive predictive value (+PV, 93.5%), negative predictive value (-PV, 85.7%), and efficiency (91.6%) than using sIgE >or= 0.35 kUa/L alone as the criteria of IDT; sIgE detection had better sensitivity (97.6%), specificity (94.9%), +PV (98.7%), -PV (91.1%), and efficiency (97.0%) than using wheal diameter >or= 5 mm alone as the criteria of sIgE detection. The false positive rate of IDT and sIgE detection decreased from 35% and 22.7% to 25.6% and 5.1% respectively when using the wheal diameter >or= 10 mm or sIgE >or= 0.70 kUa/L as a positive criteria. IDT and sIgE detection are correlated with each other well in diagnosing Artemisia pollinosis, both of them have the possibility of being false positive, but IDT has higher false positive rate than sIgE detection. The false positive rates of IDT and sIgE detection can be decreased by increasing the positive criteria to higher grading reaction.

Anaphylaxis to omeprazole: diagnosis and desensitization protocol

Omeprazole is an inhibitor of the parietal cell enzyme H+/K+ adenosine triphosphatase. Immediate-type hypersensitivity reactions, such as urticaria, angioedema, and hypotension, induced by omeprazole and other proton pump inhibitors are rare. To confirm the immediate-type mechanism of recurrent anaphylactic reactions to the repeated administration of omeprazole using skin testing and to enable safe administration of the drug after successful oral desensitization. Intradermal skin tests were performed with omeprazole (0.04 and 0.4 mg/mL) prepared from the oral and intravenous commercial preparations and with pantoprazole (0.02 and 0.2 mg/mL) prepared from the oral commercial preparation. Skin tests were repeated after completion of the desensitization. Oral desensitization was applied at a starting dose of 0.001 mg of omeprazole, and a full dose of 16 mg was achieved after 5.6 hours (cumulative dose of 32.6 mg). Intradermal skin test results were positive to omeprazole and pantoprazole at all tested concentrations. After successful desensitization, omeprazole was administered in the full dose uneventfully. The wheal size of the intradermal skin tests performed after completion of the desensitization was significantly reduced. When indicated, this newly designed desensitization protocol may be used in patients with omeprazole-induced anaphylaxis.

Carboplatin desensitization

IgE-mediated carboplatin hypersensitivity reactions occur in up to 30% of patients receiving this agent for chemotherapy of solid tumors, thus limiting therapeutic options. To describe our experience with intravenous carboplatin desensitization regimens, which culminated in a standardized, successful protocol for safe administration. Eight consecutive patients with ovarian cancer who had experienced severe anaphylactic reactions to carboplatin were referred to our hospital. Intradermal skin testing was performed by raising a 3-mm bleb by injection of undiluted carboplatin at 10 mg/mL, and the wheal size was read at 20 minutes. The outcomes of the various desensitization regimens were documented prospectively, and the experience gained was used to develop a standardized protocol for administration. All patients had positive intradermal skin test results. The first 3 patients were treated with short (90 minutes to 6 hours) desensitization protocols, and all protocols failed on the first or second infusions. These 3 and a subsequent 5 patients were given intravenous carboplatin according to a protocol of gradual dose escalation over a 4-log dose range given during a 4-day period, with subsequent 3-weekly infusions given more rapidly by omitting the most dilute log dose on each occasion. All patients tolerated the longer infusion protocol without event, and all but 1 patient experienced appropriate tumor marker response. Short carboplatin desensitization protocols (less than 6 hours) have an unacceptable failure rate in patients with carboplatin allergy, but longer infusion times (days) are well tolerated without recurrence of the allergic reaction and with good tumor response. In cases where carboplatin is the optimal therapeutic agent, clinicians should not be deterred by an anaphylactic reaction to it or by failure of shorter desensitization regimens.

Evaluation of adverse reactions to local anesthetics: experience with 236 patients

Adverse reactions to local anesthetics (LAs) are frequently reported. Although most of these reactions are not immune mediated, many patients are referred to allergy clinics and undergo extensive evaluation. To determine the prevalence of true LA allergy among the patients referred for suspected hypersensitivity and to evaluate the usefulness of the currently used evaluation protocol. A total of 236 patients referred to our allergy clinic for investigation of LA hypersensitivity were included in this study. The evaluation protocol was composed of skin prick and intradermal tests, followed by subcutaneous challenge with unrelated LA preparations that contained preservatives. Skin prick and intradermal test results were negative for all subjects. No objective adverse reactions were observed during the challenge in all but 1 patient, who developed local erythema at the site of injection and later underwent an uneventful challenge with a different LA. Allergic reactions were not reproduced during testing and challenge with LA preparations that contained preservatives or preservatives with adrenaline in our large group of patients with suspected LA allergy. Since both prick and intradermal skin test results were negative in all the patients and did not provide us with useful information, we propose to modify the standard protocol by omitting intradermal tests and shortening the challenge. We also suggest that the whole procedure be performed with LAs that contain preservatives, which are usually the preferred preparations widely used in daily practice.

In vivo and in vitro tests showing sensitization to Japanese cedar (Cryptomeria japonica) pollen allergen in atopic dogs.

Using both in vivo and in vitro tests, dogs with atopic dermatitis were examined for sensitization with Japanese cedar (Cryptomeria japonica, CJ) pollen allergen. Ten dogs with clinical manifestation of atopic dermatitis were shown to be sensitized to CJ pollen based on the results of intradermal skin test and serum antigen-specific IgE test. In vitro lymphocyte stimulation test showed blastogenic response after stimulation with crude antigen of CJ pollen in all of the 5 cases examined. The peripheral leukocytes showed increased histamine release after stimulation with crude antigen of CJ pollen in 2 cases examined. These data indicate that a proportion of dogs with atopic dermatitis is sensitized to CJ pollen in a cell-mediated manner and show immediate phase reaction of type I hypersensitivity.

Origin of late phase histamine release

The early response to antigen precedes the onset of a chronic inflammatory response that includes the late reaction, defined as the recurrence of symptoms and mediator release hours later. We hypothesized that during the late-phase nasal response to antigen provocation, released histamine originates from basophils, on the basis of the pattern of mediator release. ~ We subsequently showed the presence of basophils in the late reaction 2 but could not exclude mast cells as a source of histamine release. With the development of assays to measure tryptase, a sensitive and specific marker of mast cell degranulation, and 9c~,1113 PGF2, the major metabolite of prostaglandin (PG) D2, it became possible to exclude the mast cell as the source of histamine release. METHODS Study design Twe]ve volunteers who were free of symptoms but had a history of ragweed- or grass-induced allergic rhinitis, a positive intradermal skin test result, and a positive early response to nasal challenge were selected. The Internal Review Board of the Johns Hopkins Medical Institutions gave approval for the study, and each patient gave informed consent. Nasal challenges During the laboratory visit, the subjects underwent a nasal challenge with a relevant antigen extract5 The recovered fluid from the lavage was processed immediately for prostanoids, and the remainder was stored on ice until the completion of the experiment. After centrifuging, the supernatants obtained were processed for the

Anaphylaxis to 6-α-methylprednisolone in an eight-year-old child

Corticosteroids are widely used in the treatment of several diseases, including allergic or pseudoallergic reactions. It is therefore somewhat ironic that they may be responsible for adverse events and provoke allergic or allergic-like reactions. Allergic reactions to hydrocortisone have been reported since the 1950s. 1,2 These reactions may be immunologic or nonimmunologic in nature, and they are very rare. Allergic contact dermatitis caused by corticosteroids, however, seems to be more common, and prevalences near 4% have been reported in recent studies of patients who have undergone patch testing? Hydrocortisone and methylprednisolone are the most common drugs involved in systemic adverse reactions. Prednisone, betamethasone, and dexamethasone are reported less frequently as causative agents?, 2, 6 Allergic or pseudoallergic reactions to systemic corticosteroid therapy include bronchospasm, ~, 2, 4, 5 urticaria with or without angioedema,1, 2, 6 and anaphylaxis. :l, 2, 7 Previous contact dermatitis resulting from topical corticosteroid therapy may occasionally predispose the patient to a generalized reaction after systemic corticosteroid therapy. 6 We report a case of anaphylaxis resulting from an intramuscular injection of 6-e~-methylprednisolone. Type 1 hypersensitivity was proved by a positive skin test response. Other corticosteroids were tolerated.

Levels of Eosinophil Cationic Protein and Myeloperoxidase from Chronic Middle Ear Effusion in Patients with Allergy and/or Acute Infection.

Allergy may play a role in the middle ear inflammation that leads to otitis media with effusion. The purpose of this study was to determine whether an elevated mediator correlated with the patient's disease and thus could be used to differentiate allergy vs. infection as the cause of the middle ear inflammation. WE evaluated 57 individuals with otitis media with effusion, 32 with persistent effusion but no recent acute infection, 14 with recent infection and purulent otitis media with effusion, and II healthy subjects. The mediator activity of eosinophils and neutrophils in effusion was studied in patients characterized as having allergy by positive intradermal skin test results and positive radioallergosorbent test results. Eosinophils were characterized by measurement of eosinophil cationic protein in the effusion. Neutrophils were characterized by measurement of myeloperoxidase in the effusion. The levels of eosinophil cationic protein and myeloperoxidase in patients with and without allergy were correlated to patient history. Significantly elevated levels of both eosinophil cationic protein and myeloperoxidase indicated that inflammation in the ear of patients with otitis media with effusion was characterized by a pronounced involvement of both eosinophils and neutrophils. Eighty-nine percent of all patients with disease had allergy. A higher ratio of myeloperoxidase to eosinophil cationic protein in patients with purulent otitis media with effusion indicated that in patients with a superimposed acute infection, neutrophil activity was increased even further. The level of eosinophil cationic protein was elevated only during the effusion of patients with allergies as compared with controls (p < 0.01). Among 29 cases of nonpurulent otitis media with effusion, 96.5% had allergic immune-mediated disease proved by skin testing, which was related clinically to their ear disease. Eighty-nine percent (89.6%) of these patients had eosinophil cationic protein levels greater than 10 microgram/L. Middle ear eosinophil cationic protein may be used as a marker of related allergy.