Delayed adverse reaction to sodium ioxaglic acid-meglumine

A patient had a maculopapular rash, fever, hepatic cytolysis, rhabdomyolysis, eosinophilia and raised total IgEs after coronarography with ioxaglic acid-meglumine (Hexabrix). Intradermal test to ioxaglic acid-meglumine was positive 48 hrs later. Histological examination revealed perivascular lymphocytic infiltration, with predominantly CD45Ro+ and CD8+ T cells and apoptotic basal keratinocytes. This case documents a late hypersensitivity reaction to ioxaglic acid-meglumine.

No correlation between wine intolerance and histamine content of wine

BACKGROUND

Histamine is thought to be the main cause of adverse reactions to wines.

OBJECTIVE

The purpose of this study was to test the hypothesis that the level of histamine in wine affects the tolerance to wine in 16 subjects with wine intolerance.

METHODS

We performed a study to examine the effects of wine histamine content in 16 adults with wine intolerance. Each subject underwent 2 double-blind provocation tests with wine: 1 with a wine poor in histamine (0.4 mg/L), and 1 with a wine rich in histamine (13.8 mg/L). Blood was collected for histamine and methylhistamine RIAs at 0, 10, 30, and 45 minutes after ingestion of the wine. Methylhistamine and methylimidazolacetic acid (gas chromatography and mass spectrometry) were measured in urine 5 hours before and 5 hours after ingestion.

RESULTS

No significant differences in the occurrence of adverse reactions were noted after ingestion of either of the wines (McNemar test). At 10 minutes, a significant increase was observed in plasma histamine with histamine-poor wine. No significant changes (Wilcoxon test) were observed in the methylhistamine and methylimidazolacetic acid levels after ingestion of either histamine-poor or histamine-rich wine.

CONCLUSION

This study demonstrates that there is no correlation between the histamine content of wine and wine intolerance. The increase of plasma histamine levels at 10 minutes with histamine-poor wine suggested the role of a histamine-releasing substance. The role of acetaldehyde is discussed.

Polyisotypic antipeanut-specific humoral responses in peanut-allergic individuals

BACKGROUND

Peanut-containing food products may induce severe clinical reactions in sensitized subjects, and high levels of antipeanut IgE have been reported in the literature. Immunotherapy, proposed for the prevention of severe accidents, is often ill-tolerated and only partly efficient. This could be due to the spontaneous development of polyisotypic antipeanut antibodies.

OBJECTIVE

To appreciate the presence and reactivity of other isotypes other than IgE of peanut-specific antibodies in serum samples from peanut-sensitized subjects.

METHODS

Serum samples were obtained from 20 non-sensitized subjects and 23 sensitized patients divided in three groups according to their response to peanut oral challenge (no response or response to high or low doses, respectively). Peanut-specific IgG, IgG subclasses, IgA and IgM were assayed using an ELISA, and their reactivity against peanut proteins tested using Western Blot.

RESULTS

A large dispersion of antipeanut antibody levels was observed in the three groups of patients, high levels of IgG, IgG1, IgG4 and IgA usually correlating with highly positive radioallergosorbent test (RAST). Such high levels were observed at onset in four patients who underwent peanut immunotherapy who had side effects and poor efficiency. Western blotting demonstrated that the polyisotypic response observed was directed to several peanut antigens, including the major allergens, Ara h1 and Ara h2.

CONCLUSION

Peanut-sensitized patients who spontaneously develop specific IgE, display polyisotypic-specific antibody responses, whatever their response to oral challenge. This might explain the poor efficiency of peanut rush immunotherapy attempts.

Influence of refining steps on trace allergenic protein content in sunflower oil

BACKGROUND

Although allergy to sunflower seed and oil is a relatively rare occurrence, several cases of sunflower seed allergy have been observed, and we have already described one case of anaphylaxis after eating sunflower oil and margarine.

OBJECTIVE

The aim of our study was to determine and characterize the allergens from sunflower oil at the different steps of the refining process: crude pressed oil (step A), acidification and neutralization (step B), pregumming by centrifugation (step C), washing (step D), bleaching (step E), gumming by filtration (step F), and deodorization (step G).

METHODS

A sample of oil from each step of the process (steps A to G) was heat extracted with PBS. The protein concentration of each extract was evaluated by using the micro-Bradford assay. Samples were run on SDS-PAGE. The immunoblot was performed with the serum of a patient sensitized to sunflower seed and oil.

RESULTS

The extracts obtained after each step reveal a decrease in total protein concentration from 13.6 microg/mL to 0. 22 microg/mL. The result of SDS-PAGE shows 5 bands, from 67 kd to 145 kd, with the most abundant being the 67-kd protein. The amount of this protein decreases after each step of the process. It is, however, still present in trace amounts in the refined oil. The 67-kd protein, which is mainly present in the crude oil and slightly in the refined oil, has been shown to be allergenic.

CONCLUSION

Because of the presence of allergenic proteins, refined sunflower oil may pose a threat to people highly sensitized to sunflower seeds.

[Efficiency of diagnosis of latex allergy by the combined use of three latex materials for prick-tests]

The diagnosis of latex allergy is mainly based on prick-tests. In order to improve the efficiency of the diagnosis, a comparative study of three latex materials is carried out in 64 controls and 29 patients allergic to latex = Stallergènes and Allerbio extracts, prepared from crude natural latex, and an ammoniated emulsion of rubber latex (AEL). No adverse reactions are recorded. The specificity is 100% for both extracts, 85% for AEL. Sensitivity is respectively 68%, 63%, 72%. The range of values of the wheal is significantly narrower for Stallergènes extract. 46% of allergic patients are reactive to the three materials. The combined use of three materials reaches an 80% efficiency similar to that of Rast Cap System and the addition of three prick-tests and Rast obtains an efficiency of 93.1%. Using several latex materials could increase the efficiency of the diagnosis, inasmuch as the extracts are generated from natural latex, whereas patients are sensitized to manufactured products originating from ammoniated latex.

[Allergy emergencies in children: care at school]

Half of the life of children is spent in schools. Emergencies may occur, due to food anaphylaxis or other allergic causes. Main clinical pictures are anaphylactic shock, laryngeal angioedema, acute asthma. Lethality is a risk. Recent French rules go into more details about the management of emergency cases and the need of training for teachers and other members of the educational staff. The need to use injectable i.m. adrenaline is underlined in a protocol with consents of parents and agreement of all parties. Eviction diets are not yet guaranteed so that parents are allowed to provide their children with suitable meals. The authors debate about the indications of such protocols.

[Food allergens in children]

Food hypersensitivity is increasing, with clinical indications and allergens multiplying and evolving. We report our experience with clinical indications and distribution of allergens in children with food hypersensitivity. Data were established in a prospective study at medical centres in Nancy and Toulouse (France). We studied 378 children with food hypersensitivity indicated by food challenge, which account for 74.2% of food hypersensitivity. Clinical features were: atopic dermatitis (46.5%), urticaria (17.9%), oedema (14.2%), asthma (8.4%), anaphylaxis (5.2%), gastro-intestinal symptoms (2.1%), oral syndrome (1.8%) and rhino-conjunctivitis (0.5%). Five allergens accounted for 82% of confirmed food hypersensitivity: egg (51.8%), peanut (34.3%), milk (11.6%), mustard (8.9%) and codfish (7.1%). Allergens according to the symptoms showed that peanut allergies were more serious than other food allergy. Allergens according to age showed that peanut allergy is the first food allergy occurring after the age of three. There exists a modification in children's allergen distribution. Peanut allergy is increasing seriously, and diagnosis with food challenge is a necessity.

Criteria of evaluation and of interpretation of Sepharose drug IgE-RIA to anaesthetic drugs

The detection of antidrug specific IgE in serum is usually performed by a sandwich-type immunoassay in which the serum IgE is first adsorbed to a reactive phase and subsequently quantified via the binding of an anti-IgE tracer. The preparation of a new drug-reactive phase requires one to establish carefully different steps of validation: 1) criteria of positivity of control sera 2) competitive inhibition assays with the soluble drug, which should include the determination of the inhibition constant rather than estimation of a single inhibition percentage, especially when the assay is performed for the identification of determinants 3) estimation of nonspecific binding of IgE to the solid phase, including hydrophobic binding. The competitive inhibition depends on the concentration of the competitor and of IgE in the test-tube and the concentration of reactive drug bound to the solid phase. We have improved the inhibition assay by performing the Dixon test for calculating the inhibition constant (Ki) of the competitor. The Ki of six different muscle relaxants was determined in 12 patients who experienced an anaphylactic reaction to muscle relaxants. The values ranged between 1.5 nM and 2.5 microM. This confirmed the great heterogeneity of drug IgE cross-reactivity among patients. The Ki value of the incriminated drug was the lowest (affinity, the highest) in eight of the 12 patients. It was better correlated to clinical data than the classical inhibition assay. A hydrophobic environment seemed to be necessary, close to the quaternary ion, to allow IgE binding to the muscle relaxant. By contrast, in tiemonium, a hydroxyl group present at a distance of about 3 A from the quaternary ion may explain why this molecule had a high Ki (microM). In conclusion, it should be recommended, in molecular-recognition studies, that the inhibition constant of the soluble drug and of the related compounds be determined to complement the experiments based only on hapten inhibition assays.

[Risk of serious acute asthma due to lupine flour associated with peanut allergy]

Lupine flour (lupinus albus), recently authorized in France in human food, cross-reacts with peanuts. We report a case of acute asthma in a patient with allergy to peanuts.

EXEGESIS

This patient has a severe allergy to peanuts, presenting as acute asthma. Skin prick-tests to raw and cooked lupine flour were positive. The level of specific-IgE (Allerbio, France) to lupine flour were high. Oral challenge test induced acute asthma at a dose of 965 mg of lupine flour. This quantity may be included in 100 g of bread.

CONCLUSION

This case report points out the fact that lupine flour is a high-risk allergen in patients presenting allergy to peanuts. It is necessary to evaluate the allergenic risk of new foods before their introduction into human daily food intake and to establish a network of allergy vigilance.

[The multifood allergy syndrome]

Multiple food intolerance in infants and young children is increasingly diagnosed. More than 40% of infants less than 1 y.o. could be affected. The syndrome is characterized by the seriousness of atopic dermatitis (SCORAD > 50), by enterocolitis or failure to thrive or various associations of symptoms that may change over time. The evolution is long-lasting. Common food allergens are milk, egg, soy, wheat, but other ones can be implicated. The diagnosis is established by standardized oral challenges. Multiple etiopathogenic factors are involved: atopy, gastro-enteritis induced intestinal hyperpermeability, precocity of food diversification, breast-feeding continued after the onset of symptoms. Amino-acid based formulas have changed the evolution.

[Food allergies]

Generally, environmental allergens are basically considered to include airborne allergens. Food however is an endogenous microenvironment which just as important, if not more so. This environment has undergone considerable modification over the past 30 years with the growing diversity of food proteins and by modifications of natural allergens related to techniques employed by the food and agriculture industry. These techniques can exacerbate the allergenecy properties of food or develop new allergens.

Cross-allergenicity of peanut and lupine: the risk of lupine allergy in patients allergic to peanuts

BACKGROUND

Peanut allergy is common, but cross-allergy between legumes is rare. Proteins from Lupinus albus are increasingly eaten in the form of seeds or additives to wheat flour. The risk of cross-allergenicity is still insufficiently known.

OBJECTIVE

We sought to study the risk of cross-allergy to lupine in patients allergic to peanut and to study lupine allergenicity.

METHODS

Twenty-four patients allergic to peanuts were studied by means of skin prick tests with native lupine flour from Lupinus albus. Double-blind oral challenge tests were performed with lupine flour and peanut in 8 of these patients. Specific IgEs were assayed for peanut, lupine flour, and pollen in 6 sera. RAST inhibition tests for lupine pollen by peanut were performed on 4 of these sera. Peanut and lupine flour immunoblots were carried out for 6 sera, and crossed immunoblot inhibitions for peanut by lupine flour and lupine flour by peanut were carried out for 2 sera.

RESULTS

The skin prick test responses with lupine flour were positive in 11 (44%) subjects. The challenge test responses were positive in 7 of 8 subjects at the same doses as with peanut. The major lupine flour allergen (molecular mass, 43 kd) is present in peanuts. The RAST inhibition and immunoblot tests indicated cross-reactivity of peanut with the lupine flour and pollen.

CONCLUSIONS

The risk of crossed peanut-lupine allergy is high, contrary to the risk with other legumes. The inclusion of 10% lupine flour in wheat flour without mandatory labeling makes lupine a hidden allergen, presenting a major risk of cross-reaction in subjects already allergic to peanut products. A high sensitizing potential can also be postulated for this legume.

[Measurement of levels of specific IgE by the Efficient New Enzymatic Allergy (ENEA) System II (CIS bio)]

The diagnosis of IgE dependant food allergy relies on the demonstration of specific IgE by prick tests or in vitro tests. The ENEA System II (CIS bio international) is a new automatic assay analyser of specific IgE, that uses allergens coupled to a solid phase and a urease marked anti-IgE antibody. This study aims to compare the performance of the ENEA System II to that of Pharmacia CAP System for the assay of food specific IgE (milk, eggs, peanuts) by means of unit tests and multitests. Sixty three patients were included: 10 non atopic controls, 19 egg-allergic patients, 10 patients allergic to cow's milk, and 24 patients allergic to peanuts. The food allergy was proved by means of a double blind oral, labial or bronchial challenge and/or effective avoidance of the food. For both systems, the specificity of unit tests was 100%. Sensitivity was 60% and 100% with both systems, using milk and peanuts respectively. However, using eggs, it was only 74% with ENEA System II versus 95% with Pharmacia CAP System. The intra-trial variation coefficients were comparable. In contrast, inter-trial variation coefficient was very high for the ENEA System II (20.3% versus 7.3%). The multitest named "children's food" showed an important inter-set variability. In conclusion, the ENEA System II is a rapid automatic tester whose performance has to be improved. The actual thermostatically control of the system was shown to achieve quality assay. The conservation of the solid phase, recently perfected, is expected to suppress the inter-set variability.

[A case of Kimura disease treated with interferon and general corticoid therapy]

INTRODUCTION

A case of Kimura's disease that occurred in a 5-year-old Caucasian boy after a tick bite is reported. When the child was 16 years old, symptoms developed. They included voluminous bilateral neck and head lymph nodes associated with hypereosinophilia (1,640/mm3), and increased IgE levels (18,866 KU/L). Clinical and immunological effects of treatment by interferon-alpha and steroids are presented.

EXEGESIS

Pathological and histological examination showed typical features of dense lymphoid cell infiltrates containing many eosinophils, mast cells, and vascular hyperplasia. Percentages of CD4+, CD27-, CD7- cells were increased In the blood and lymph nodes, showing a profile typical of TH2. IL-5 production by these cells was markedly increased and was inhibited by IFN-alpha and IFN-beta in vitro. No etiology was found. The role of antigens of Ixodes ricinus is discussed. Three surgical excisions of adenopathies were not successful. Treatment by IFN-alpha (Introna, Schering-Plough, 5.10(6) U/week) and a bolus of methylprednisolone hemisuccinate (1 g/month) was started. Eight months later, the size of the lymph nodes had decreased; however, eosinophil counts and ECP and IgE levels were still high. The decrease in corticosteroid induced a subsequent, slight increase in the size of the lymph nodes and a marked increase in ECP.

CONCLUSION

This is the first description of treatment of Kimura's disease by interferon-alpha and steroids. The disease outcome does not suggest that interferon-alpha may predominate.

Cow's milk allergy

The prevalence of cow's milk allergy is stable, between 2% and 5%. Clinical symptoms are numerous. Gastroesophageal reflux and persistent constipation have been recently described. The main point is the increasing prevalence of multiple food allergens. Double blind placebo controlled milk challenges are mandatory for the diagnosis, sometimes eight days long. The proof of the IgE-dependent sensitization, or of lymphocyte activation is not always brought. ECP, methylhistamine and tryptase dosages coupled to challenges are not clearly informative tests. The eviction of dairy products is completed by substitution by casein hydrolysates or pork collagen or soy hydrolysates, or by formula made from amino acids. Tolerance protocols are not standardized, however valuable. Review documented by 98 references.

Anaphylaxis in schools and other child-care settings--the situation in France

The American Academy of Allergology and Clinical Immunology joined to the Canadian Society published in August 1998 guidelines for the management of anaphylaxis in schools. The authors assess the situation in France. An emergency health care form entitled "Projet d'Accueil Individualisé", is carried out by allergologists, and countersigned by the physician in charge of the School Health Department. The clinical symptoms that may occur, are described, as well as the incriminated foods to be avoided, the treatment to be used, the content of the mergency kit. Epinephrine is the first drug to be used. Beta adrenergic drugs are advised on the account of severe attacks of asthma. School lunches being not safe are not allowed. Civil society's liability is a question that has not yet been solved.

[Rush desensitization to drugs: elements for protocol rationalization]

The need for some treatments that are without possible alternatives leads, for allergy or intolerance, to procedures of rapid re-introduction at increasing doses, under the term of rapid habituation (A.R.) which is different from specific immunotherapy. No postulated mechanism has been suggested. The successes reported in the literature are presented here. They raise a discussion on the indications, the rational and empirical elements and the preferable routes of introduction. The authors stress the need for biological studies of A.R.