White paper peanut allergy—part 2: Diagnosis of peanut allergy with special emphasis on molecular component diagnostics

Summary Background Peanut allergy is an immunoglobulin E (IgE)-mediated immune response that usually manifests in childhood and can range from mild skin reactions to anaphylaxis. Since quality of life maybe greatly reduced by the diagnosis of peanut allergy, an accurate diagnosis should always be made. Methods A selective literature search was performed in PubMed and consensus diagnostic algorithms are presented. Results Important diagnostic elements include a detailed clinical history, detection of peanut-specific sensitization by skin prick testing and/or in vitro measurement of peanut (extract)-specific IgE and/or molecular components, and double-blind, placebo-controlled food challenge as the gold standard. Using these tools, including published cut-off values, diagnostic algorithms were established for the following constellations: 1) Suspicion of primary peanut allergy with a history of immediate systemic reaction, 2) Suspicion of primary peanut allergy with questionable symptoms, 3) Incidental findings on sensitization testing and peanut ingestion so far or 4) Suspicion of pollen-associated peanut allergy with solely oropharyngeal symptoms. Conclusion The most important diagnostic measures in determining the diagnosis of peanut allergy are clinical history and detection of sensitizations, also via component-based diagnostics. However, in case of unclear results, the gold standard—an oral food challenge—should always be used.

White paper on peanut allergy: treatment pathway

Summary Background Peanuts are a member of the legume family (botanical family Leguminosae) and peanut allergies are the most common cause of food anaphylaxis in many countries. The prevalence of peanut allergy is increasing. Methods Experts from Germany and Austria performed a standardized literature search and published their consensus recommendations in a White Paper on Peanut Allergy, which this care pathway is based upon, thus, providing a comprehensive diagnosis and treatment algorithm. Results The most important diagnostic key elements include a detailed clinical medical history, evidence of peanut-specific sensitization by means of skin prick testing and/or in vitro determination of the peanut (extract)-specific IgE and/or the molecular component diagnostics (most important Ara h 2-specific IgE, sometimes also Ara h1-, 3-, 6-, 8- and 9-specific IgE) as well as the gold standard, the double-blind, placebo-controlled food challenge. The diagnostic algorithms were created for the following constellations: Suspected primary peanut allergy with a clear history of systemic immediate-type reaction, suspected primary peanut allergy with questionable symptoms, suspected secondary (possibly pollen-associated) peanut allergy with a history of solely oropharyngeal symptoms and incidental finding of sensitization and no peanut ingestion so far. Conclusions After established diagnosis the standard of care is counseling to avoid peanut contact and prescription of emergency medications (oral antihistamines, oral steroids, inhaled β2-agonists, injectable intramuscular epinephrine) as needed. Instruction on the use of these emergency medications should be provided. A preparation for oral immunotherapy (OIT) for 4 to 17 years old peanut allergic children/ adolescents has been recently approved by the regulatory authorities. OIT for peanut allergy shows high efficacy and an acceptable safety profile, improves quality of life, and health economic aspects. Thus it offers a therapeutic option for peanut allergic children and adolescents.

Carboxymethylcellulose excipient allergy: a case report

Background Excipients are widely used in pharmaceuticals, detergents, food, and drink because of their properties of low toxicity and hypoallergenicity. The excipient carboxymethylcellulose is used extensively as a thickener in foods such as baked goods, ice cream, gluten free, and reduced fat products, where it may be labeled as e-number E466. However, excipients can rarely cause type 1 hypersensitivity reactions. Several publications have described systemic allergy following carboxymethylcellulose exposure in pharmaceuticals, particularly systemic corticosteroids. Furthermore, there is one reported case in the literature of anaphylaxis following food containing carboxymethylcellulose. Case presentation We identify a case of anaphylaxis in a 45-year-old atopic Caucasian woman on receiving an injectable suspension of the corticosteroid triamcinolone acetonide containing carboxymethylcellulose, and subsequent allergic symptoms on reexposure to carboxymethylcellulose in a commercial drink. Diagnosis of carboxymethylcellulose excipient allergy was confirmed through skin prick testing using Celluvisc carmellose 0.5% eye drops, which contain carboxymethylcellulose as the active ingredient. Conclusion This case highlights the importance of identifying excipients such as carboxymethylcellulose as causes of allergy, to reduce burden of further hypersensitivity reactions, not just to drugs but to other consumables.

The first reported case of Blaptica dubia cockroach allergy

Background Periplaneta americana and Blattella germanica cockroaches are widespread, and risk of sensitization increases in urban environments where these roaches thrive as household pests. There are no prior reports of Blaptica dubia cockroach allergy, though human exposure to B. dubia is increasing through commercial breeding as feeder insects. Case presentation A 50-year-old B. dubia cockroach breeder presented with progressively worsening upper and lower respiratory symptoms in recent years. Symptoms were worse with exposure to her B. dubia roach colony. Skin prick testing (SPT) to B. dubia cast skin, internal organs, and feces was performed in both the subject and a human control. Testing for P. americana and B. germanica sensitization was also performed in the subject. SDS–Polyacrylamide gel electrophoresis (PAGE), immunoblots, and enzyme-linked immunosorbent assays (ELISA) studies were performed using the subject and control serums to explore for specific IgE binding to B. dubia as well as P. americana. Our results showed SPT was positive to B. dubia internal organs in the subject and negative in the control. In the subject, SPT was negative to P. americana though intradermal (ID) testing was positive and serum specific IgE (sIgE) testing was negative to B. germanica. Immunoblotting of the subject's serum to B. dubia internal organ extract showed several distinct bands of IgE binding at 47 kilodaltons (kD), 68 kD, 74 kD, 83 kD, and 118 kD. The strongest band was at 118 kD on B. dubia immunoblotting, which was absent in P. americana on SDS-PAGE. ELISA studies showed an increased IgE response to both B. dubia and P. americana in the subject versus the control. Conclusions This case confirmed the first reported allergy to B. dubia cockroaches. There may be cross-reactivity between B. dubia and P. americana, though our case suggests SPT and sIgE testing using P. americana and B. germanica extract has potential to miss a B. dubia cockroach allergy. This allergy is likely underreported, and further study is needed to explore the natural history of B. dubia cockroach allergy.

Identifying the Clinical Pattern of Eosinophilic and Non-Eosinophilic Asthma subtype in adult patients with Bronchial Asthma

Background Context:- Asthma is a heterogenous disease with various phenotypes, it is the most common chronic disease characterized by airway limitation due to bronchospasm and airway inflammation associated with excessive mucus secretion from agitated mucus gland that occur due to air way hyper responiveness. Purpose of the study Comparison between eosinophilic and non-eosinophilic asthma patients. Patients and Methods 100 bronchial asthma patients of age ≥ 18 years old divided into2 groups according to blood eosinophilia. All patients were subjected to: history. Total Asthma Control Test. Spirometry. Sputum eosinophil count. IgE levels 6-Skin prick testing (SPT). Nasal endoscopy. Results the mean age of all patients was (35.4 ± 12.8) years, majority (61%) of patients were males,; the mean ACT score was (18.7 ± 2); 39% of cases have obstructive pattern by spirometry, 39% of cases had abnormal nasal endoscopy, SPT had significant relation with asthma, there is significant correlation between total IGE,sputum eosinophilia with eosinophilic asthma. Conclusion Blood eosinophils had the highest accuracy in the identification of sputum eosinophilia in asthma. Total IgE values and sutum eosinophilia were markedly increased in patients with eosinophilic asthma more than patients with non-eosinophilic asthma.

The most prevalent allergenic airborne pollens among Egyptian patients with respiratory allergy

Background Allergy symptoms occur when the immune system overreacts to environmental allergens, such as pollen or dust, which are typically harmless to most individuals but induce a potentially severe reaction to those who are sensitive to them. Pollen is one of the main reasons to cause seasonal allergic respiratory diseases and it is influenced by multiple risk factors. Objective To determine the most prevalent types of allergenic pollens by skin prick testing among Egyptian patients with respiratory allergy (asthma and/or allergic rhinitis). Methods 200 adult patients, all were subjected to the following: full detailed medical history, clinical examination, asthma severity grading according to the GINA Guidelines, allergic rhinitis severity grading according to ARIA Guidelines, pulmonary Function tests for asthmatic patients. (PFTs), CBC with differential for detection of eosinophilic count, Skin prick testing (SPT) to common environmental allergens and common food allergen. Results The present study proved that the grass pollens; timothy grass and maize were the most prevalent pollens among Egyptian respiratory allergy patients. Conclusion Difference in results of SPT performed to patients across different countries is explained by the difference in climates, which affects pollination, Egypt is considered to have a dry, desert-like climate in addition to its coastal regions. Our results revealed that both timothy grass and maize pollens were the most prevalent among Egyptian respiratory allergy patients.

Pollen Sensitization in Association with Allergic Rhinitis in preschool asthmatic Children

Background Grass pollens are significant elicitors of IgE-mediated allergic disease in the world and timothy grass (Phleum pratense) is an important pollen in allergy induction. Objective We sought to determine the rate of pollen sensitization in group of Egyptian asthmatic children with allergic rhinitis using timothy grass pollen as a potential triggering factor for allergic rhinitis. Patients and Methods This analytical cross sectional study was conducted on a group of preschool children following up at the Pediatric Allergy and Immunology Clinic, Children's Hospital, Ain Shams University during the period from December 2018 to April 2019. We enrolled 52 asthmatic children with concomitant allergic rhinitis sampled in a consecutive manner. They were subjected to skin prick testing for timothy grass pollen, positive histamine control and negative control. Results The study revealed high frequency of timothy grass pollen(TGP) sensitization occurring in 60.3% of patients with concomitant allergic rhinitis .wheal diameters pointed to sensitization only rather than actual allergy to TGP. TGP sensitization showed no significant correlation to disease duration. Children with rhinosinsuitis had comparable rates of TGP sensitization to those without rhinosinsuitis. Conclusion It is concluded from our results that sensitization to timothy grass pollen (TGP) is common in allergic rhinitis. The findings are limited by the sample size and consecutive manner of sampling. Wider scale studies are needed to accurately evaluate the frequency of timothy grass pollen (TGP) sensitization in our country.