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BACKGROUND: Rush immunotherapy (RIT) schedules can expedite protection in individuals sensitive to imported fire ant (IFA) stings. OBJECTIVE: To evaluate the safety and efficacy of 1-day RIT with IFA whole body extract (WBE) and determine the benefit of premedication with antihistamines and prednisone. METHODS: Patients with systemic reactions to IFAs and evidence of specific IgE by skin test or serologic test started a 1-day RIT protocol without premedication. The 1-day RIT protocol consisted of a total of 10 injections every 30 to 60 minutes to achieve a 0.3-mL 1:100 (wt/vol) dose. A higher systemic reaction rate (SRR) prompted protocol revision to include a 3-day course of oral 20 mg of prednisone twice daily, 150 mg of ranitidine, and 10 mg of loratadine started 2 days before the 1-day RIT. Patients returned on days 8 and 15 to receive a 0.5 mL 1:100 (wt/vol) maintenance injection. The effectiveness of the RIT was evaluated with a sting challenge on approximately day 22. RESULTS: Eighty of the 96 patients enrolled initiated the 1-day RIT. The first nonpremedicated group exhibited a SRR of 24.3% (9 of 37 patients), whereas the revised premedicated group had a SRR of 9.5% (4 of 42 patients; P = .07). The most severe reaction during RIT included dizziness, angioedema, and urticaria. Sting challenges on 53 patients resulted in 1 mild rhinitis reaction (efficacy, 98.1%). CONCLUSION: One-day RIT with IFA WBE for IFA hypersensitivity is efficacious. Although there was a trend with premedications to reduce SRRs during the RIT, safety data with premedication require confirmation in a larger trial.

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Prior studies comparing skin testing to serum-specific IgE testing for inhalant allergy focused on older technologies or small numbers of allergens. The purpose of this study was to compare ImmunoCAP (CAP) testing to skin prick testing (ST) for 53 inhalant allergens. Subjects > or =18 years old with chronic rhinitis and who had at least 1 positive ST to a 53 inhalant allergen panel underwent testing to an analogous CAP panel. ST was performed with the Quintip device. Using ST as a clinical gold standard, the sensitivity, specificity, positive, and negative predictive values (PPV, NPV) were calculated for CAP for each allergen. Percent agreement between testing methods was also evaluated, and the results were analyzed in association with the subjects' total IgE levels. Two-hundred fifty patients (96 male, 154 female, mean 37.1 years) were enrolled. Mean number of positive ST and CAP results were similar. The ST was more often positive for 69.8% of allergens, and 64% of patients had more positive ST than CAP. Overall, the specificity and NPV (generally 80-90%) of CAP were higher than the sensitivity and PPV. The overall agreement between tests was 80.6%, with 11.7% ST+CAP- results and 7.7% CAP+ST- results. In patients with a total IgE level > or = 200 IU/L, the percentage of positive CAP results for 52/53 allergens was significantly higher with more CAP+ST- results. The performance characteristics of CAP compared to ST vary among 53 inhalant allergens. CAP should be considered complementary, not equivalent, to ST. Total IgE levels should be obtained with serum-specific IgE testing.

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OBJECTIVE: To provide an overview of the role of intradermal skin testing (IDST) in inhalant allergy. DATA SOURCES: A literature search was conducted in MEDLINE to identify peer-reviewed articles related to IDST using the following keywords: skin testing, intradermal, intracutaneous, aeroallergen, and inhalant allergen. In addition, references cited within these articles were also reviewed. STUDY SELECTION: Articles were selected based on their relevance to the topic. RESULTS: The use of IDST for inhalant allergy varies widely among allergists. When performed, it is necessary to use a 100- to 1,000-fold dilution from the stock allergen extract. IDST is used routinely in the standardization of extracts in the United States. With a negative skin prick test result, a positive IDST result has low agreement with in vitro and challenge results and generally adds little to the diagnostic evaluation. In contrast, a negative IDST result generally has a high negative predictive value. Only a few inhalant allergens have been evaluated with challenge models for IDST. A summary of the data is also presented in tabular form. CONCLUSIONS: Most of the literature suggests that with a negative skin prick test result, a positive IDST result adds little to the diagnostic evaluation of inhalant allergy. However, additional studies are necessary using challenge models for less potent and nonstandardized inhalant allergens (molds, trees, dog, weeds).

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As a marker of inflammation, exhaled breath condensate (EBC) pH may be a useful screening tool in the evaluation of asthma, especially in a military recruit population. To evaluate the utility of EBC pH in the diagnosis of asthma, EBC pH levels were determined in basic military trainees prior to an evaluation for asthma that included a history, physical exam, baseline spirometry, and a methacholine or exercise challenge. Of 86 basic trainees who had symptoms suggestive of asthma and underwent methacholine or exercise challenges, 51 (59.3%) had a positive methacholine or exercise challenge and were diagnosed with asthma. The mean EBC pH of the trainees who were diagnosed with asthma (6.39, range 5.91-6.82), was significantly (p < 0.001) lower than those trainees without asthma (6.64, range 6.34-7.18). There was, however, some overlap of the EBC pH values between the two groups. The measurement of EBC pH did show a significant mean difference between asthmatic and nonasthmatic patients in a military recruit population.

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BACKGROUND: Resistin is a protein produced by adipocytes and circulating macrophages that has been found to be associated with inflammatory states. OBJECTIVE: To determine the levels of resistin in relation to asthma disease state and severity, we investigated a cohort of adult patients with asthma. METHODS: A cohort of moderate to severe persistent asthma patients and control patients were recruited and underwent fasting labs to evaluate levels of serum glucose, C-reactive protein (CRP), and resistin. RESULTS: No significant differences were found between the control and asthma group with respect to serum CRP at 0.78 +/- 0.60 mg/dL and 0.48 +/- 0.60 mg/dL, (p < 0.36) or glucose at 92.2 +/- 11.9 mg/dL and 89.5 +/- 7.2 mg/dL, (p < 0.084), respectively (mean +/- SD). However, plasma resistin levels were found to be significantly elevated in asthma patients, 186 ng/mL (95%CI 169-202) compared with control patients 121 ng/mL (95%CI 90.4-151), (p < 0.005). CONCLUSIONS: Patients with asthma were found to have higher levels of resistin, and resistin levels were increased with disease severity in the asthma cohort.

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Prior studies looking at allergic sensitization have focused on narrow age ranges or small numbers of allergens. This study is the first to examine the prevalence of positive skin test responses in a symptomatic military population with a wide age range of patients and large number of allergens. This study was a retrospective analysis of our skin test database. We included 1137 patients aged 4-79 years old who underwent our standard skin-prick testing panel of 53 aeroallergens and 2 controls using the Quintest device (Hollister-Stier, Spokane, WA). Results indicated that 81.6% of patients had at least one positive skin test. Rates of atopy were similar between male and female patients; 9.2% of patients were monosensitized. The average number of positive skin tests peaked in the 10- to 19-year age group at 13.1 and declined in older age groups. The prevalence of atopy peaked in the 30- to 39-year age group at 85.5% and decreased in older age groups. The most common allergens were grasses, mountain cedar, and dust mites. Sensitization rates for many underreported allergens, including mouse and rat, are presented. This study shows that 81.6% of patients in a symptomatic military population were atopic. These rates are high, even when compared with other allergic populations. Atopy peaked in young adulthood and declined in older age groups. Grasses, mountain cedar, and dust mites were the most common allergens. Although performed in a military population, these results should be applicable to many allergy practices.

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BACKGROUND: Hypersensitivity pneumonitis (HP) is an inflammatory lung disease that requires a high index of suspicion and evaluation for potential causative antigens in the patient's environment. OBJECTIVE: To describe a patient referred for allergic rhinitis who was found to have progressive dyspnea and was ultimately diagnosed as having HP. METHODS: The history of progressive dyspnea with findings of diffuse pulmonary crackles on physical examination and restrictive pulmonary function testing prompted further radiologic, pathologic, laboratory, and home environment evaluations. RESULTS: The constellation of findings from these studies led to the diagnosis of HP secondary to parakeet antigens. Elimination of further antigen exposure and corticosteroid therapy led to resolution of the patient's symptoms. CONCLUSION: Prompt diagnosis and removal of the antigen source are of paramount importance in the management of HP.

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Approximately 800 United States Air Force basic military trainees (BMTs) are diagnosed with asthma, annually, resulting in separation from the military. With training costs of approximately 10,000 dollars/person, around 8 million dollarsis lost per year. Improved methods in diagnosing asthma would be beneficial. The aim of this study was to determine the fraction of exhaled nitric oxide (FENO), a marker of airway inflammation, in a military recruit population referred for an asthma evaluation. In BMTs referred for respiratory complaints during basic training, FENO levels were determined before an asthma evaluation consisting of a history, physical, baseline spirometry, and histamine bronchoprovocation. Of 172 BMTs who had symptoms suggestive of asthma and underwent histamine bronchoprovocation, 80% were diagnosed with asthma. FENO levels were significantly higher in asthmatic patients than nonasthmatic patients (mean, 30 parts per billion [ppb] versus 19 ppb, p < 0.001; median, 21 ppb versus 17 ppb, p < 0.02). Various FENO cutoff points provided a range of sensitivity and specificity for the diagnosis of asthma. However, an optimal FENO cutoff level for asthma was not obtained. An FENO value of 10.5 ppb provided a sensitivity of 86% for the diagnosis of asthma, but specificity was only 21%. In contrast, an FENO value of 46 ppb provided 100% specificity but only 17% sensitivity. FENO levels were significantly elevated in BMTs diagnosed with asthma but the lack of an optimal cutoff level limits the test as a diagnostic tool for asthma. Additional studies are necessary to determine the value of FENO for asthma screening in a military population.

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BACKGROUND: Multicolored Asian lady beetles (Harmonia axyridis) have been used as a biological control agent against crop-destroying aphids in the United States. Outside their natural habitat, H. axyridis seeks refuge in homes during fall and winter, leading to patient complaints and symptoms of rhinitis, wheezing, and urticaria on exposure to the beetles. OBJECTIVE: To gain a better understanding of the character and spectrum of allergic disease provoked by exposure to home-infesting lady beetles. METHODS: Eight patients with allergic symptoms suspected of being caused by H. axyridis and consistent with an IgE-mediated process were identified and interviewed. A whole-body extract from H. axyridis was prepared. Western blots using the patients' serum identified specific IgE antibodies in the extract. Through a novel technique, immunohistochemical analysis using beetle sections overlayed with patient serum was performed. A random survey of allergists from across the United States was also performed to evaluate experience with cases of lady beetle allergy. RESULTS: Western blots revealed IgE binding to 5 proteins with molecular weights of approximately 8.6, 21, 28, 31, and 75 kDa. Specific IgE bound to proteins localized in the beetle's mouth and leg areas. The allergist survey revealed positive responses in North Central, Mid-Atlantic and New England states. CONCLUSION: In 8 patients with allergic symptoms on exposure to high levels of lady beetles, specific IgE bound to proteins from H. axyridis. There was also an increased frequency of suspected cases of lady beetle allergy in endemic areas.

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Over two years, the Vaccine Adverse Event Reporting System reported that 0.042% of all anthrax vaccine (Biothrax, Bioport Corporation) doses administered were associated with cutaneous reactions, half of which were eczematous. This case series attempts to immunologically detail this eczematous reaction in four patients by measuring anthrax vaccine-specific cell mediated immunity (ASCMI), profiling TH1 and TH2 cytokine response to the anthrax vaccine in vitro, and analyzing of skin biopsy specimens. Results demonstrated that (1) ASCMI was variable and likely unrelated to this reaction; (2) a lack of TH1 cytokine response to anthrax vaccine may be associated with an increased risk of this eczematous reaction; and (3) skin biopsy findings were nonspecific but supportive of a clinical diagnosis of eczema. Future studies with more patients may yield data to further characterize the ASCMI response and cytokine profiles among patients with this type of reaction.

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BACKGROUND: The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy. OBJECTIVE: To review frontline providers' documented care and recommendations for imported fire ant and flying insect hypersensitivity reactions. METHODS: A retrospective medical record review was performed of emergency department and primary care clinic visits between November 1, 1999, and November 30, 2004. Using International Classification of Diseases, Ninth Revision, codes, medical records were selected for review to identify patients with potential insect hypersensitivity. RESULTS: A total of 769 medical records from patients who experienced an insect sting were reviewed. Of 120 patients with a systemic reaction, 66 (55.0%) received a prescription for injectable epinephrine, and 14 (11.7%) were given information regarding avoidance of the offending insect. Forty-seven patients with systemic reactions (39.2%) were referred to an allergist. Of 28 patients who kept their appointments and underwent skin testing, 3 had negative results and 25 (89%) had positive results and were advised to start immunotherapy. CONCLUSION: Adherence to the stinging insect hypersensitivity practice parameter recommendations is poor. Many patients who have experienced a systemic reaction after an insect sting and have sought medical care are not afforded an opportunity for potentially lifesaving therapy.

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STUDY OBJECTIVES: The S-stereoisomer found in racemic albuterol may have associated proinflammatory properties. We tested the hypothesis that airway inflammation as assessed by exhaled nitric oxide is no different in patients with COPD when using racemic albuterol relative to levalbuterol or placebo. MEASUREMENTS: Twelve mild to moderate COPD patients were assigned to five days each of nebulized racemic albuterol, levalbuterol, and saline placebo. Before and after each course of treatment, airway inflammation was assessed via exhaled nitric oxide breath testing. Secondary functional outcomes that were measured included spirometry, a functional assessment utilizing a six-minute walk, and symptoms score using the University of California, San Diego Shortness of Breath Questionnaire. RESULTS: There was no statistically significant difference in pre and post FeNO levels within and between treatment groups (p = 0.121). There were also no significant differences within or between treatment groups for the secondary outcome measurements of FEV1 (p = 0.913), functional assessment utilizing a six-minute walk (p = 0.838) and the symptom scores using Shortness of Breath Questionnaire (p = 0.500). CONCLUSION: We found no difference in mild to moderate COPD patients treated with racemic albuterol, levalbuterol or placebo for measurement of exhaled nitric oxide or the secondary outcomes that were measured.

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BACKGROUND: Bacitracin is widely used in operating rooms to soak implants, irrigate compound fractures, and apply to surgical incisions. However, bacitracin is a known sensitizer and causes not only allergic contact dermatitis but also anaphylaxis. OBJECTIVE: To describe a 72-year-old woman with anaphylaxis after irrigation and packing of an infected pacemaker pocket with a bacitracin solution. METHODS: Skin prick testing to bacitracin and latex; serum tryptase, serum histamine, serum IgE to latex, and serial cardiac enzyme measurements; blood cultures, transthoracic echocardiograms, and venograms were performed to characterize the reaction. RESULTS: Six hours after the anaphylactic event, the patient had an elevated serum tryptase level of 49 ng/mL (reference range, 2-10 ng/mL), which normalized the next morning. She had immediate-type skin prick test reactions to full-strength bacitracin ointment (500 U/g) and bacitracin solution (150 U/mL). Serum IgE level to latex was undetectable, and results of skin testing to latex were negative. CONCLUSIONS: To our knowledge, this is the first case report of anaphylaxis to bacitracin during pacemaker surgery. This case illustrates that intraoperative anaphylaxis to bacitracin can be life-threatening.

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BACKGROUND: Laryngomalacia is the most common cause of stridor in infants, but few reports exist of clinically relevant laryngomalacia in adults. OBJECTIVE: To present and discuss an unusual late presentation of laryngomalacia and its significance in the evaluation and management of asthma. METHODS: An 18-year-old woman presented to an academic medical center with symptoms of "wheezing" on inspiration and exertion, with relatively normal spirometric findings. She was clinically diagnosed as having asthma at the age of 13 years, but her symptoms were poorly controlled by maximal medical therapy. Further evaluation with rhinolaryngoscopy demonstrated laryngomalacia characterized by redundant soft tissue overlying the right arytenoid cartilage and aryepiglottic fold. RESULTS: The patient demonstrated positive bronchoprovocation, with a 33% decrease in forced expiratory volume in 1 second after the administration of histamine, 1 mg/mL. However, with the otolaryngology evaluation, it was determined that her laryngeal findings were clinically significant. She subsequently underwent operative laryngoscopy with carbon dioxide laser excision of the laryngeal abnormality, resulting in improvement in her symptoms and a marked decrease in her need for asthma medication. CONCLUSIONS: We report an unusual case of laryngomalacia presenting as asthma that was successfully treated with laser surgical excision. This case emphasizes the necessity of differentiating classic wheezing from stridor and upper airway obstruction.

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BACKGROUND: The common striped scorpion, Centruroides vittatus, is endemic to the southwestern United States and causes thousands of human stings annually. Immediate hypersensitivity reactions to C. vittatus venom have been reported. OBJECTIVES: To identify specific IgE in 11 patients with immediate hypersensitivity to C. vittatus and to characterize the allergens present in the venom. METHODS: Skin testing to dialyzed, filtered venom was performed in 5 patients. Immunoglobulin E immunoblots to whole milked venom was accomplished with serum samples from 8 patients. Enzymatic properties of whole venom were also determined. RESULTS: C. vittatus venom was found to contain 150 microg/microL of protein. Four of 5 patients tested had positive skin test reactions to the purified venom extract, with no late reactions. In all 8 patients, sodium dodecyl sulfate-polyacrylamide gel electrophoresis demonstrated multiple proteins, 9 of which were identified as allergens on IgE immunoblots, ranging in size from 30 to 170 kD. Enzymatic activity was found to include phospholipase A, alkaline phosphatase, esterase, esterase lipase, and acid phosphatase. CONCLUSIONS: C. vittatus envenomation may result in immediate hypersensitivity reactions in susceptible individuals. Venom specific IgE can be identified by using skin tests and IgE immunoblots. The allergens identified in these patients had molecular weights distinct from those of known scorpion neurotoxins. A safe and effective skin testing extract can be prepared from dialyzed pure venom and may lead to the widespread ability to diagnose C. vittatus venom allergy.

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BACKGROUND: The common striped scorpion, Centruroides vittatus, and the imported fire ant (IFA) are endemic to the south-central United States. There is evidence of venom-specific IgE in patients experiencing hypersensitivity reactions to scorpion stings. The infrequency of repeated scorpion stings and the presence of immediate reactions to an initial sting suggest prior sensitization. OBJECTIVE: In the present study we evaluated the cross-reactivity of C vittatus venom with IFA whole-body extract (WBE). METHODS: Sera were obtained from patients with symptoms of immediate hypersensitivity to C vittatus stings and from scorpion sting-naive patients allergic to IFA venom. Inhibition IgE immunoblots were performed by using scorpion venom and IFA WBE. Skin testing with scorpion venom was performed on scorpion sting-naive patients allergic to IFA venom. RESULTS: Sera from patients with scorpion venom allergy demonstrated IgE binding to multiple allergens of similar sizes against both scorpion venom and IFA WBE. This binding was completely inhibited by preincubation of the sera with scorpion venom and IFA WBE. Pooled sera from patients with IFA venom allergy demonstrated similar bands on IgE immunoblotting against both IFA WBE and scorpion venom, with the latter being completely inhibited by preincubation of the sera with IFA WBE. Skin testing with scorpion venom was positive in 6 of 9 patients with IFA venom allergy. CONCLUSION: Significant cross-reactivity exists between the venom of C vittatus and IFA WBE. The high sensitization rate to IFA venom in endemic areas may therefore be a risk factor for subsequent immediate reactions to an initial scorpion sting. Patients with immediate hypersensitivity reactions to scorpion stings may potentially benefit from immunotherapy with IFA WBE.

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