Diagnosis and management of immunodeficiencies in adults by allergologists

Primary immunodeficiencies (PIDs) are genetic diseases that cause alterations in the immune response and occur with an increased rate of infection, allergy, autoimmune disorders, and cancer. They affect adults and children, and the diagnostic delay, morbidity, effect on quality of life, and socioeconomic impact are important. Therapy (gamma-globulin substitution in most cases) is highly effective. We examine adult PIDs and their clinical presentation and provide a sequential and directed framework for their diagnosis. Finally, we present a brief review of the most important adult PIDs, common variable immunodeficiency, including diagnosis, pathogenesis, clinical signs, and disease management.

In vitro diagnosis of immediate allergic reactions to drugs: an update

Evaluation of allergic reactions to drugs is difficult because of the poor sensitivity of in vivo tests, which makes controlled administration of the drug necessary to confirm the diagnosis. In vitro tests are important in order to avoid the risks of in vivo testing. In the present review, we describe the different methods for detecting immunoglobulin (Ig) E antibodies that are specific to drugs involved in the development of type I (immediate) reactions. The 2 main in vitro methods are immunoassays and the basophil activation test, both of which have sufficient sensitivity and specificity for the detection of specific IgE antibodies, although with a limited number of drugs, and they have proven complementary to in vivo methods. We show the importance of the allergological workup of the patient within less than 1 year from the occurrence of the allergic reaction in order to obtain positive results in both in vivo and in vitro tests.

Guidelines on the clinical usefulness of determination of specific immunoglobulin E to foods

The diagnostic gold standard for food allergy is challenge with the culprit food, particularly in double-blind placebo-controlled challenge. This approach involves risks and consumes both time and resources. A more efficient system would be desirable. The detection of serum specific immunoglobulin E (sIgE) against the culprit food enables us to establish sensitization, although this is not always accompanied by clinical reactivity. Age, symptoms (immediate/late reaction, local/systemic reaction), concomitant condition (eg, atopic dermatitis, pollinosis) and selection sample criteria (eg, presence of symptoms related to ingestion, positive skin prick test result) can influence the detection and concentration of IgE against foods. We analyze the clinical usefulness of sIgE determination in light of studies in which oral food challenge is used as the diagnostic method. We review clinical usefulness at diagnosis and in the decision to reintroduce the food, as well as the prognostic value of the determination of IgE to foods.

Endoscopic, bioptic, and manometric findings in eosinophilic esophagitis before and after steroid therapy: a case series

BACKGROUND AND AIM

Eosinophilic esophagitis can be associated with a wide range of endoscopic patterns. The aim of the present case series report is to describe and classify endoscopic appearances before and after corticoid therapy in relation to histopathology and manometry.

PATIENTS AND METHODS

In 30 patients (m : f, 27 : 3; mean age 36.2 years) with eosinophilic esophagitis, endoscopic findings were prospectively classified according to luminal diameter and mucosal pattern. Manometric and bioptic histopathologic findings were also recorded. Endoscopy was repeated following a 3-month course of steroid therapy.

RESULTS

In total, 20 % of patients showed a concentric esophageal stricture, and in 57 % simultaneous contraction rings were visible. Mucosal alterations consisted of granular mucosa (20 %), longitudinal furrows (33 %) and transversal undulations (3 %). Lower esophageal sphincter dysfunction and distal esophageal dysfunctional manometry were seen in 73 % and 57 % of cases, respectively. Following steroids, the esophagus showed a normal caliber in 97 % of patients, and 63 % of patients had normal mucosa.

CONCLUSIONS

The most frequent findings were narrowing of the esophageal lumen, which returned to normal following steroid treatment to a larger extent than mucosal alterations.

Associations among pollen sensitizations from different botanical species in patients living in the northern area of Madrid

OBJECTIVE

To determinate the existence of associations among sensitizations to antigens produced by pollen grains of different botanical species as assessed by skin prick tests in patients with respiratory disorders.

METHODS

Six hundred twenty nine consecutive patients living in the northern area of Madrid who underwent clinical evaluation because of rhinoconjunctivitis, and/or asthma were studied. All patients were tested with a skin prick test using a battery of inhalants including pollens, dust mites, molds and danders. The exploratory multivariate technique of Multiple Correspondence Analysis was used to compare the homogeneity of sensitizations between groups. Of the 629 patients, 459 (73.0%) had positive skin prick tests to pollen and were selected as the study group.

RESULTS

The most prevalent pollen sensitization was to Gramineae pollen (83.7%) followed by Oleaceae sensitisation (75.8%). Multiple Correspondence Analysis revealed the existence of an association among pollen sensitizations, showing that they clustered two groups: sensitizations to Gramineae, Oleaceae, Cupressaceae, Chenopodiaceae, Plantaginaceae (group I), and sensitizations to Betulaceae, Platanaceae, Compositae (group II). Sensitization to Parietaria was not included in any of the sensitization groups and showed an independent behaviour.

CONCLUSION

Pollen sensitizations in our area cluster into two association groups which have not previously been reported.

[Latex allergy]

Latex allergy has become an increasing cause of morbility in the last few years and is now recognized as an international health problem. The prevalence of latex sensitization among the general population is less than 1 %. The groups at highest risk include healthcare workers, rubber industry workers, patients with a history of multiple surgical procedures, particularly children with spina bifida and urogenital abnormalities, atopic individuals, and patients with certain fruit allergies (especially kiwi, avocado, chestnut and banana). The molecular and immunological characteristics of several natural latex allergens have been identified. Symptoms range from contact urticaria to anaphylaxis. Diagnosis is based on clinical history and is confirmed by skin prick tests. Measurement of serum specific IgE to latex can also be useful. The best treatment is latex avoidance and substitution by other materials. However, because latex products are ubiquitous in medical and nonmedical devices of daily use, a latex-free environment is not easy to achieve. In some patients, immunotherapy could be an alternative.

Anisakis simplex only provokes allergic symptoms when the worm parasitises the gastrointestinal tract

We analysed patients with allergic or digestive symptoms after seafood ingestion in order to assess a correct diet in Anisakis simplex sensitised individuals. A total of 120 patients who suffered allergic and/or digestive symptoms after marine food ingestion were studied. We performed skin prick tests for A. simplex and seafood, total serum and specific serum immunoglobulin E to A. simplex in the acute stage and 1 month later. A gastroscopy was carried out to find larvae in those patients with persistent abdominal pain. A challenge with non-infective larvae was performed to assess a correct diet. Some 96 patients were sensitised to A. simplex. Gastroscopy was performed in 47 and we detected larvae in 24. We compared symptoms, skin tests, total and specific IgE and the latency of appearance of symptoms in patients positive for Anisakis larvae, patients without larvae at gastroscopy and patients without digestive symptoms. There was no difference among the groups. We challenged 22 patients with frozen A. simplex larvae. After allowing deep-frozen seafood in the diet for more than 2 years, no patient suffered a reaction. At this time, we allowed all our patients well-frozen seafood without any allergic reaction occurring. Allergic symptoms are the most frequent manifestation of A. simplex parasitism. We could not find any patient allergic to the thermostable proteins of parasite.

Epidemiology of urticaria in Spain

BACKGROUND

In spite of the frequency of chronic urticaria there are very few epidemiological studies of its prevalence and distribution.

OBJECTIVE

We wanted to approach the real prevalence of chronic urticaria in a population-based study and to depict demographic distribution and personal perception of the disease. We also wanted to describe the frequency of acute urticaria episodes in the population studied.

METHODS

We conducted a population-based study among adults in Spain. We questioned 5003 individuals after calculating a sample size for a maximum variability (conservative approach p=q=0.5).

RESULTS

We found a 0.6% (95% CI: 0.4-0.8) prevalence of chronic urticaria. The prevalence is significantly higher in women than in men with a OR=3.82 (95%CI 1.56-9.37). Chronic urticaria is a self-limited disease, yet in 8.7% of cases chronic urticaria lasts from one to 5 years and in 11.3%, for more than 5 years. The average age of onset is 40 years.

CONCLUSIONS

We offer large epidemiology study data on the prevalence of chronic urticaria. The prevalence of chronic urticaria has not yet been defined in an adult population-based study. With this work we offer such data to describe the prevalence and features of this disease.

Sidelobe decline in single-photon 4Pi microscopy by Toraldo rings

We demonstrate theoretically the feasibility of single-photon 4Pi-confocal microscopy. By inserting a pair of properly designed multi-ring phase-only pupil filters in the illumination path of a 4Pi microscope the height of the sidelobes of the point spread function substantially reduced, so that there is no ambiguity in the 3D image. Then, an axial resolution up to four times higher than that of single-photon confocal microscope can be effectively achieved.

Optical sectioning by two-pinhole confocal fluorescence microscopy

A two-pinhole axially superresolving confocal fluorescence imaging system is presented. Based on the concept of subtractive incoherent imaging, the system described here is equipped with a zero-focus complex-transmittance pupil filter in one of the collector paths. The optical sectioning capacity of the system is 25% superior to that of a free-pupil one-pinhole instrument.

Focal-shift formula in apodized nontelecentric focusing systems

A single analytical formulation for evaluating the focal shift in any apodized nontelecentric focusing setup is reported. The formulation is also useful in the case of imaged paraxial beams. We show explicitly that the magnitude of the focal shift is determined by only one parameter that depends on the effective width of the pupil filter and its axial position. To illustrate our approach we examine different focusing setups.

Gastroallergic anisakiasis: findings in 22 patients

BACKGROUND AND AIMS

Ingestion of Anisakidae larvae in raw seafood may cause anisakiasis. However, despite the high level of consumption of seafood in Spain, only a few cases of anisakiasis have been reported until now. Anisakis simplex can cause allergic reactions in sensitized patients as a result of its parasitism in the gastrointestinal tract. The purpose of this study was to analyse the clinical findings in 22 patients with gastroallergic anisakiasis.

METHODS

Patients with allergic and/or gastric symptoms after seafood ingestion were evaluated in the emergency room of the La Paz General University Hospital. Skin testing for Anisakis simplex and tests on the implicated seafood were performed and amounts of serum-specific immunoglobulin E were assessed. A gastroscopy was performed in those patients with severe allergic or/and persistent gastric symptoms after ingestion of raw or undercooked seafood.

RESULTS

Twenty-two patients were diagnosed with gastroallergic anisakiasis in 1 year. Most patients presented to the emergency room of our hospital with allergic symptoms. Gastric symptoms were usually moderate. Gastroscopy revealed local mucosal oedema and gastric erosion at the point of fixation. Two or more worms were detected in three patients. The mean time of latency of allergic symptoms was 5 h, while the mean time for gastric symptoms was 3 h.

CONCLUSION

Anisakis simplex parasitism was the causative agent of allergic and gastric symptoms. Gastroallergic anisakiasis appears to be a relatively common disease, that may have been underdiagnosed.

Importance of albumin in cross-reactivity among cat, dog and horse allergens

Different allergenic proteins have been involved in cross-reactivity among animals. Albumins seem to be cross-sensitizing allergenic components. The aim of this study was to assess the importance of albumin as a cross-reactive allergen in patients sensitized to cat, dog and horse. One hundred and seventeen patients sensitized to cat were tested for IgE reactivity using skin prick tests and RAST assays with cat, dog and horse hair/dander extracts and their purified albumin extracts. RAST-inhibition studies were carried out to assess cross-reactivity among cat, dog and horse and among their purified albumins. It was found that 22% of patients exhibited specific IgE to cat albumin; 41% of patients sensitized to cat were also sensitized to dog and horse. Out of these patients, 21% had IgE to three albumins and 17% to two. Reciprocal inhibitions were observed among cat, dog and horse albumins and also among cat, dog and horse hair/dander extracts, using in the latter experiment sera from patients not sensitized to albumins. IgE binding to horse extract was inhibited 30% by its homologous albumin and IgE binding to cat and dog extracts in almost 15% by their respective albumins. It was concluded that albumins from these three animals share some epitopes that account for the cross-reactivity observed in around one-third of patients sensitized to cat, dog and horse. Nevertheless, more than 50% of specific IgE that cross-reacts among these three animals is directed to allergens other than albumin.

[Systemic inflammatory response syndrome: is it comparable with severe sepsis?]

BACKGROUND

In 1992, a consensus conference defined the terms systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock. Since then, numerous reports have validated the prognostic usefulness of these operative definitions.

AIM

To evaluate if sepsis severity criteria, as defined by the Consensus Conference, can be applied to noninfectious SIRS.

PATIENTS AND METHODS

Five hundred eighteen patients admitted to 5 intensive care units (ICU) from 4 hospitals were prospectively evaluated during a 3 months period. Patients that met at least one severity criteria were included. SIRS etiology, organ dysfunction and evolution were recorded in each patient.

RESULTS

One hundred two patients were included: 79 with sepsis (group I) and 23 with noninfectious SIRS (group II). ICU and hospital mortality were comparable (43 and 48% in sepsis compared to 43 and 51% in non infectious SIRS). The most common sources of sepsis were pneumonia and peritonitis. Group II patients had a wide variety of diseases. ICU stay, APACHE score and number of organs with dysfunction were not different among groups. Only the incidence of renal dysfunction was higher in the septic group.

CONCLUSIONS

The Consensus sepsis severity criteria can be applied to noninfectious SIRS, defining a population subset with similar high mortality and organ dysfunction incidence, although with greatly heterogeneous etiologies.

Delayed hypersensitivity to enoxaparin

A 65-year-old woman experienced immediate itchy erythematous patches at the subcutaneous injection sites of sodium enoxaparin. An erythematous and infiltrated 40 x 20 mm lesion on the abdominal wall could be observed at the site of enoxaparin injection when she was referred to our clinic 48 h after injection. Lesions subsided spontaneously within 1 week. She had been on this treatment 1 and 3 years before without any adverse reaction. To clarify the nature of the reaction, epicutaneous tests with sodium enoxaparin, calcium nadroparin and calcium heparin were performed, all with negative results. Skin prick test with sodium enoxaparin was also negative. Biopsy of the cutaneous lesion showed spongiotic dermatitis, strongly suggesting a delayed hypersensitivity mechanism. We report here on a new case of delayed hypersensitivity to enoxaparin. Being female, overweight and having prolonged application of the drug were suggested risk factors present in our patient. Biopsy was essential for diagnosis. Although type IV hypersensitivity reactions to enoxaparin are rare, we should start to suspect this condition in order not to underdiagnose it.

Allergic reactions to anisakis simplex parasitizing seafood

BACKGROUND

The ingestion of Anisakidae ssp larvae parasitized fish can cause anisakiasis. Allergic reactions after ingestion of safely cooked but parasitized fish have been reported.

METHODS

Twenty-three patients who suffered allergic reactions after seafood ingestion, with negative skin tests were studied. Anisakis simplex sensitization was assessed by skin prick test and/or specific serum Immunoglobulin E (IgE). Total serum IgE and specific IgE against the implicated seafood and Ascaris lumbricoides were also determined.

RESULTS

Manifestations of Anisakis simplex allergy were urticaria/angioedema (18/23) patients and anaphylaxis (5/23). Gastric symptoms were also observed (3/23). Sea fish and shellfish were implicated. Raw and cooked seafood ingestion caused reactions. Total serum IgE ranged from 13 to 7200 KU/L. Specific IgE to Anisakis simplex was positive (> 0.35 KU/L) in all patients, and skin tests were positive in 20. Serum-specific IgE and skin tests to the involved seafoods were negative in every patient. Serum-specific IgE to Ascaris lumbricoides was negative in 13 patients. No association between total IgE and the eosinophil count (r < 0.1) was observed, but there was some association between total IgE and specific IgE to Anisakis simplex (r = 0.58).

CONCLUSION

Anisakis simplex sensitization is the cause of allergic reactions after seafood ingestion. It is important to pay attention to this new "food allergy" to diagnose correctly the etiology of adverse food reactions.

Booster responses in the study of allergic reactions to beta-lactam antibiotics

The observation of negative skin and challenge tests to beta-lactams in some patients with prior histories of reactions to these antibiotics led us to develop a protocol ("booster study") which systematically included the performance of skin and challenge tests to beta-lactams ten to thirty days after the study to confirm the negative results. From a total of 430 patients who came to our outpatient clinic because of a reaction to a beta-lactam or unknown antibiotic, 249 completed the study. Out of the patients who completed the second phase, or "booster study," the results were positive in the first phase, or conventional study in 42 patients, and negative in 207. The booster study was negative in 197 patients (95 percent) and positive in ten patients (5 percent). Skin tests were positive in 5 of them (penicilloyl-polylysine: 5; benzylpenicillin: 3; amoxicillin: 2; minor determinant mixture: 1), and 5 patients developed an allergic reaction after rechallenge (benzylpenicillin: 4; amoxicillin: 1). One patient with both negative skin tests and amoxicillin oral challenge in the booster study developed an immediate generalized urticaria with the oral intake of amoxicillin one month later at home; skin tests became positive at that moment. The negative results in the first phase of the study and the development of positive results in the second phase could be due to the existence of an immunological amnestic reaction or to sensitization after reexposure to beta-lactams in the diagnostic procedures.

[Sweet's syndrome in an infant]

A new case of Sweet syndrome in a six mouth old child is reported. Interesting facts with respect to the age, hematology findings, localization and residual lesions are found. The disease in the pediatric age have been reviewed.