The value of biomarkers in the therapy of CRSwNP with biologicals-a long-term follow-up of dupilumab therapy

PURPOSE

Since its release, Dupilumab has shown great results in treating severe uncontrolled CRSwNP. However, there is a lack of real-world data beyond 12 months of follow-up, and it is not clear to what extent biomarkers are appropriate for monitoring and predicting the Dupilumab therapy success. Hence, this study aims to analyze biomarkers for monitoring therapy, predicting therapy success and assess the effect of Dupilumab in real-world settings.

METHODS

The follow-up was performed with 104 patients retrospectively up to 22 months, assessing SNOT-22, NPS, olfactometry, ACS, FEV-1, and blood biomarkers (total serum IgE, Eosinophils, ECP). Patients were divided into subgroups depending on their pretherapeutic biomarker levels and subsequent development was analyzed.

RESULTS

There was substantially improvement in all clinical parameters up to 1 year and then continuously up to month 22. Patients with initially elevated baseline blood eosinophil counts (> 0.5 billion/L) had a trend of better SNOT-22 development after 1 year (- 12.19 points, p = 0.03). The course of total serum IgE showed moderate correlation with almost all clinical variables obtained. Therapy was well tolerated with only mild and transient adverse events.

CONCLUSION

Dupilumab has considerably reduced symptoms and disease severity even beyond 1 year of treatment, supporting its role as targeted and effective treatment option for CRSwNP. Our data shows that total serum IgE is a promising biomarker for the monitoring during the treatment with Dupilumab. Elevated pre-therapeutic serum eosinophil counts may be a predictor of good subjective response to therapy. Larger cohorts and a long-term-follow-up over years are needed to further consolidate these findings.

The Value of Current Laboratory Tests in Diagnosing Food, Venom, and Drug Allergies

An accurate diagnosis of IgE-mediated allergies is necessary to inform risk management for severe allergic reactions including anaphylaxis for food, venom, and drug allergies. The most widely available laboratory test for allergy is serum-specific IgE testing, which is routinely used for food allergy and insect sting allergy. Testing for specific IgE is limited by high sensitivity and low specificity, resulting in concern regarding overdiagnosis. Testing of allergen components has led to improved diagnosis for some food and venom allergens. Additional options for laboratory tests, such as epitope analysis, basophil activation, and mast cell activation, are being investigated for their potential to optimize diagnosis and provide predictors for reaction severity and treatment response. In contrast, laboratory testing for drug allergy is more limited because to date, there are no well-validated commercial assays in the United States. Furthermore, it is important to diagnose delayed reactions to medications, because these also significantly affect decision-making regarding therapeutic options for infectious disorders. Reliable tests for both immediate and delayed drug hypersensitivity are much needed, because drug allergy labels can significantly limit treatment options for patients. Research in this area is emerging.

Pharmacoeconomic Assessment of Antiallergic Drugs by Comparing Serum Immunoglobulin E Level as a Diagnostic and Monitoring Indicator of Allergic Rhinitis in Rural Population of India

Allergic rhinitis (AR) is a chronic inflammatory disease induced by IgE mediated reaction and identified clinically by presence of nasal discharge, sneezing, itching and nasal congestion. Aim of this study was to determine Serum IgE level which is an important indicator of AR. To analyse the diagnostic significance of serum IgE level and their pharmacoeconomic status in the management of AR with commonly used antihistaminic. Estimation of serum IgE can serve as a simple and reliable investigative tool in the diagnostic and management of AR. Fifty two adult patient with history of allergic rhinitis were randomly divided into four study groups and administered either Cetirizine, Levocetirizine, Loratidine or Fexofenadine respectively for one week. Blood samples were analysed to determine serum IgE level and the results were subjected to statistical analysis. The mean value and standard deviation were obtained and tabulated using paired t test. A total 52 patient were divided into four group, 13 in each group of age between 18 and 65 years (mean age 33.73 ± 10.23 years); 48.08% females and 51.92% male were randomized. Mean compliance with treatment was 100% for all study groups. The mean serum IgE level was significantly reduced in Levocetirizine as compared to Cetirizine, Loratidine and Fexofenadine groups. Levocetirizine controls the symptoms of AR better as compared to Cetirizine, Loratidine and Fexofenadine and is a better choice due to its cost effectiveness, tolerability and safety profile.

Incidence and Prevalence of Fungal Sinusitis in Cases of Chronic Rhinosinusitis

To study the incidence and prevalence of fungal sinusitis and its variants in cases of chronic rhinosinusitis in department of ENT and Head and Neck surgery. The study group consisted of 100 patients of chronic rhinosinusitis attending the outpatient and inpatients in department of Otorhinolaryngology. History was taken and diagnostic nasal endoscopy was performed. Patients underwent endoscopic sinus surgery and systemic treatment when required. Pre surgery serum IgE and post-surgery Histopathology was sent. Out of 100 patients, Males > Females and median age was 45.50 years (range 34.25-59.25 years). On DNE, 88% had polyps with 88.1% males and 87.8% females in their respective groups. 47% had allergic mucin with 49.2% males and 43.9% females in their respective groups. 34% had discharge with 28.8% males and 41.5% females in their respective groups. 37% had fungal filaments with 37.3% males and 36.6% females in their respective groups. 26% had fungal sinusitis in our study among which 53.8% were males and 46.1% were females. Peak fungal sinusitis was in 3rd to 5th decade. Commonest organism isolated was Aspergillus. Serum IgE was higher in patients with fungal sinusitis and nasal polyposis. In conclusion, the proportion of patients with Fungal Sinusitis was 26% among 100 patients with chronic rhinosinusitis. We isolated Aspergillus as the predominant fungus followed by Biporalis and Mucorales genus. Serum IgE was higher in patients with fungal sinusitis and Nasal polyposis. Both immunocompromised and competent individuals were managed surgically and/or medically when required. Our study showed that early fungal sinusitis detection leads to better management practices and prevents its progression into more severe disease with complications.

Food Allergy: Catering for the Needs of the Clinician

The practice of food allergy (FA) for clinicians has boomed, with a dramatic rise in the number of patients and families seeking care and with many advances on several fronts. The practice itself sometimes is evidence-based science and sometimes an art of pattern and phenotype recognition. This article examines the tools for diagnosis and management and therapy options available to physicians providing care for patients with FA. The article touches on pressing needs of clinicians and highlights the rapid and important movements in national and international support and advances that will have a positive impact on the field of FA.

Computed Tomography Score an Excellent Marker: Differentiates Eosinophilic and Non-eosinophilic Variants of Chronic Rhinosinusitis with Nasal Polyp

Eosinophilic and non-eosinophilic subtypes of chronic rhinosinusitis with nasal polyp (CRSwNP) have different clinical profile and management. Currently the 2 subtypes are differentiated based on tissue eosinophilic infiltration, which is identified after surgery by histopathological examination. Hence this study was conducted to compare utility of computed tomography (CT) scans, serum IgE levels, absolute eosinophil count (AEC) and Sino-nasal Outcome Test (SNOT)-20 score for discriminating the 2 subtypes. In this prospective study of 1 year duration, patients suspected of CRSwNP were recruited. Serum IgE levels and AEC estimation were performed by ELISA and standard numerical formula respectively, along with histopathological examination of nasal polyp biopsies. CT score and ratio of CT score for ethmoid sinus and maxillary sinus (E/M ratio) were calculated. Patients were asked to fill SNOT-20 questionnaire. Receiver-operating characteristic (ROC) curve analysis was performed. Out of 52 patients studied, 38 and 14 were no. of eosinophilic and non-eosinophilic CRSwNP cases respectively on the basis of histopathological examination. E/M ratio and overall CT score were found to be highly accurate with area under ROC curve of 0.990 and 0.964 respectively, while rest 3 parameters had low accuracy. Optimal cut-off of CT score and E/M ratio for eosinophilic CRSwNP were 6 and 2.065 respectively. This study demonstrated E/M ratio and total CT score as the most useful surrogate markers for preoperative differentiation of eosinophilic and non-eosinophilic CRSwNP, and hence can be used to predetermine postoperative management before surgery.

Kimura's Disease: A Diagnostic and Therapeutic Challenge

Kimura's disease, also known as Eosinophilic Granuloma, is a rare chronic condition seen mainly in Oriental population. It presents with subcutaneous nodules, lymphadenopathy, salivary gland hypertrophy with peripheral eosinophilia and raised serum IgE levels; rarely renal involvement may also be present. Its etiology mainly remains unknown. We present a case series of two patients. Our first case is a middle aged female which presented with a parotid swelling, mimicking a parotid neoplasm. Further investigations revealed associated intra-parotid and cervical lymphadenopathy. An excisional biopsy in the form of Superficial Parotidectomy with lymph node excision was done. Histopathological examination of the excised specimen revealed it to be a case of Kimura's disease. Our second case, a young adult, presented with a gradually increasing post-auricular swelling. Preliminary investigations in this case pointed towards Kimura's disease. Excision biopsy of the lesion was done. Histopathological studies confirmed the diagnosis for the same. Both the patients are under our regular follow up and remain disease-free at a follow up of 1 year and 8 months respectively.

Marijuana use is associated with hypersensitivity to multiple allergens in US adults

BACKGROUND

The recent legalization of marijuana use for both medical and recreational purposes in several states of the United Sates is expected to further increase the already high prevalence of marijuana use. Although allergic reactions are uncommon, the potential of marijuana use and cultivation to cause allergy should be considered. We aimed to investigate whether marijuana use is associated with the prevalence of sensitization to specific allergens.

METHODS

A total of 2671 adults (aged 20-59 years) who participated in the 2005-2006 National Health and Nutrition Examination Survey were included. Participants completed a questionnaire on marijuana use and underwent sensitization tests to 19 specific allergens. Those who reported marijuana use for at least 1 day in the past 30 days were considered marijuana users.

RESULTS

No difference was found in the history of allergy between marijuana users and non-users. Compared with marijuana non-users as a reference group, the adjusted odds ratio (AOR) of sensitization to a specific allergen among marijuana users was significantly greater for antibodies against the following: Alternaria alternata (AOR=1.67; 95% confidence interval (CI), 1.04-2.70), D. farinae (AOR=1.68; 95% CI, 1.27-2.22), D. pteronyssin (AOR=1.65; 95% CI, 1.32-2.06), ragweed (AOR=1.84; 95% CI, 1.30-2.59), rye grass (AOR=1.49; 95% CI, 1.12-1.97), Bermuda grass (AOR=1.55; 95% CI, 1.03-2.33), oak (AOR=1.76; 95% CI, 1.14-2.70), birch (AOR=2.09; 95% CI, 1.23-3.55), peanut (AOR=1.91; 95% CI, 1.25-2.92), and cat dander (AOR=1.51; 95% CI=1.13-2.03).

CONCLUSIONS

We provide preliminary findings to suggest that marijuana use is associated with sensitization to specific allergens, including molds, dust mites, plants, and cat dander.

A Real Life Comparison between Allergenic Extracts and Allergenic Molecules

Serum IgE assay is a mainstay step in the allergy work up. Allergenic extracts and molecular components are available at present. This real life study compared the serum specific IgE levels against allergenic extracts with allergenic molecules in patients allergic to Parietaria, Betulaceae, and mites. This retrospective real life study included 489 subjects with respiratory allergy. Inclusion criteria were 1) documented diagnosis of allergic rhinitis (AR) and/or allergic asthma, and 2) documented allergy to Parietaria judaica (Par j) 2 (216 patients: 112 females, mean age 42 years), or to Betula verrucosa (Bet v) 1 (62 patients: 35 females, mean age 3 years), or Dermatophagoides pteronyssinus (Der p) 1 (211 patients: 107 females, mean age 34 years); and mono-allergy. Serum IgE, specific both for total/crude allergen extracts and individual purified/recombinant allergens, were assessed by ImmunoCap system. The serum IgE levels to birch extract were very strongly (R2=0.96) related to IgE to Bet v 1. There was a strong (R2=0.71) correlation between Dermatophagoides pteronyssinus IgE and Der p 1. A very strong (R2=0.87) correlation also existed between Parietaria extract IgE and Par j 2 IgE levels. However, there was discrepancy between percentages of positivity between allergenic extracts and molecules. Therefore, allergen molecular diagnostics may represent a useful way in allergy work up, but deserves caution in particular circumstances.

Profiles of Birch Sensitization (Bet v 1, Bet v 2, and Bet v 4) and Oral Allergy Syndrome Across Italy

BACKGROUND

Birch allergy (BA) is a common pollinosis caused by the allergens Bet v 1, Bet v 2, and Bet v 4. Oral allergy syndrome (OAS) is frequently associated with BA. A gradient of sensitization to birch allergen across Europe has been reported. Therefore, this study aimed to investigate the birch sensitization profile, including OAS, across Italy.

METHODS

We performed a retrospective study of 854 patients (391 males, mean age 35.9 years, range 18-93 years): 196 patients were recruited in Genoa, 188 in northern Italy, 359 in central Italy, and 111 in southern Italy. Serum IgE to Bet v 1, Bet v 2, and Bet v 4 was assessed, and OAS was analyzed.

RESULTS

With respect to the geographical path Genoa-North-Center-South, the frequency of sensitization to Bet v 1 decreased significantly (P<.0001) from Genoa (95.41%) to southern Italy (58.56%). The frequency of sensitization to Bet v 2 increased significantly (P<.0001) from Genoa (6.12%) to southern Italy (52.25%). The frequency of Bet v 4 also increased significantly (P=.0002) from Genoa (6.12%) to southern Italy (14.41%). The distribution of patients with OAS differed significantly across the areas (P<.0001), the most marked difference ranging between 33.5% in Genoa and 76.9% in northern Italy. The frequency of birch allergens correlated with OAS in central Italy only.

CONCLUSIONS

The present study demonstrated a significant difference between sensitization to birch and its clinical expression across Italy.

Allergy-related evidences in relation to serum IgE: data from the China state key laboratory of respiratory disease, 2008-2013

OBJECTIVE

To investigate the serum total IgE (tIgE) and specific IgE (sIgE) to common allergens among allergic patients in Guangzhou, China.

METHODS

7 085 patients were examined for tIgE and sIgE to 15 allergens, based on the protocols of reversed enzyme allergosorbent test and the sandwich enzyme-linked immunosorbent assay.

RESULTS

3 758 (53.04%) patients tested positive for tIgE, and 4 640 (65.49%) for sIgE. Der pteronyssinus, Der farinae, eggs, and cow's milk were the most common allergens leading to higher positive rates of sIgE responses. Several peaks of sensitization were: Der pteronyssinus, Der farinae, and Blomia tropicalis at age 10-12; cow's milk at age below 3; eggs at age 4-6. The mean level and positive rate of tIgE tended to increase in subjects sensitized to more allergens. Sensitization to Der pteronyssinus (OR, 1.6; P<0.05), Der farinae (OR, 1.5; P<0.05), Blomia tropicalis (OR, 1.4; P<0.05), Blattella germanica (OR, 1.5; P<0.05), cow's milk (OR, 1.3; P<0.05), and soy beans (OR, 2.0; P<0.05) were independently correlated with allergy-related conditions in preliminary diagnosis.

CONCLUSION

The major allergens in Guangzhou include Der pteronyssinus, Der farinae, cow's milk, and eggs. Sensitization to these allergens appears to be predictors of allergy-related disorder.

Racial and ethnic disparity in food allergy in the United States: a systematic review

BACKGROUND

The prevalence of food allergy is rising among US children. Little is known about racial/ethnic disparities in food allergy.

OBJECTIVE

We performed a systematic literature review to understand racial/ethnic disparities in food allergy in the United States.

METHODS

We searched PubMed/MEDLINE, Embase, and Scopus for original data about racial/ethnic disparities in the diagnosis, prevalence, treatment, or clinical course of food allergy or sensitization, with a particular focus on black (African American) race. Articles were analyzed by study methodology, racial/ethnic composition, food allergy definition, outcomes, summary statistic used, and covariate adjustment.

RESULTS

Twenty of 645 identified articles met inclusion criteria. The studies used multiple differing criteria to define food allergy, including self-report, sensitization assessed by serum food-specific IgE to selected foods without corroborating history, discharge codes, clinic chart review, and event-reporting databases. None used oral food challenge. In 12 studies, black persons (primarily children) had significantly increased adjusted odds of food sensitization or significantly higher proportion or odds of food allergy by self-report, discharge codes, or clinic-based chart review than white children. Major differences in study methodology and reporting precluded calculation of a pooled estimate of effect.

CONCLUSION

Sparse and methodologically limited data exist about racial/ethnic disparity in food allergy in the United States. Available data lack a common definition for food allergy and use indirect measures of allergy, not food challenge. Although data suggest an increased risk of food sensitization, self-reported allergy, or clinic-based diagnosis of food allergy among black children, no definitive racial/ethnic disparity could be found among currently available studies.

Efficacy of korean red ginseng in the treatment of atopic dermatitis

In order to determine the efficacy of functional foods, objective measurement of the severity of atopic dermatitis (AD) after taking foods is important. The aim of this study was to conduct an objective evaluation of whether Korean red ginseng (KRG) might be helpful for improvement of skin condition and serum IgE in patients with AD. Thirty atopic patients (18 females and 12 males) participated in this study. Patients took KRG for 16 weeks. Bioengineering methods, including the corneometer and evaporimeter, were used at the start of the study and after 8 weeks and 16 weeks. In addition, we assessed serum IgE levels and the severity scoring of the atopic dermatitis (SCORAD) index. Transepidermal water loss and skin hydration showed significant improvement after 16 weeks. A significant decrease in the SCORAD index, as well as in serum IgE level, was observed after 16 weeks. Our results demonstrated that KRG may be helpful as a functional food for patients with AD.