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Background: The normally acidic skin pH changes in atopic dermatitis (AD) to alkaline, which contributes to the associated skin-barrier dysfunction. Hence, acidic cleansers would be preferred, but such information is scarce. Objective: Guiding health-care providers and patients on selecting skin cleansers with a pH optimal for AD. Methods: A total of 250 products were tested: 37 soaps (32 bars, 5 liquid) and 213 syndets (14 bars, 199 liquid); 10% solutions were tested for pH by using a pH meter; pH values 6.65–7.35 were considered neutral. Results: The pH of the tested skin cleansers varied widely (3.59–10.83). All 37 soaps were highly alkaline. In the 14 syndet bars, the pH was neutral in 6, alkaline in 8, and acidic in none. In the 199 syndet liquids, the pH was acidic in 84.9%, neutral in 11.1%, and alkaline in 4.0%. The product’s pH was disclosed in none of the 37 soaps and in only 32 syndets (15%), of which 9 bars were labeled “balanced,” whose measured pH was neutral in 6 and alkaline in 3. Of the other 23 syndets, the labeled pH was referred to as “balanced” in 20 whose measured pH was neutral in 2 (6.80, 6.88) and acidic in 18 (3.59–6.59). The pH in the other three syndets was 4.25–6.00. Conclusion: All tested soaps had undesirable pH, whereas 84.9% of the liquid syndets were acidic (which is desirable) and 11.1% were neutral (which could be acceptable). Only 12.8% of the products disclosed the pH, an issue in need of improvement [ABSTRACT FROM AUTHOR]

Background: In recent years, an increase of allergies and asthma has been observed throughout the world, more so in Western countries than in less developed ones. Although genetics may play a role in this increase, there are many other factors that may have contributed to the upsurge. Objective: The purpose of the present report was to review the many factors associated with modernization and lifestyle that may have contributed to the allergy and/or asthma epidemic, with a particular focus on those aspects that have particular relevance for the allergist/immunologist. Results: The marked rise in allergy and asthma has been significantly seen in more-developed countries, greater in urban than in rural areas, more pronounced in affluent than in poorer societies, and in individuals who have migrated from developing countries to industrialized countries. A widely accepted explanation for this rise is the “hygiene hypothesis,” which postulates a critical dependence on microbial infection for maintenance of a healthy balanced immune system and that extremely clean external environments, often found in the developed world, can derail equilibrated immune development. With the control of infectious diseases, the immune system shifts from a balanced equilibrated immunologic structure to a more Th2 driven proinflammatory state often associated with IgE and eosinophil-related disorders. Conclusion: Modernization has been associated with increased development of allergies and asthma through a cleaner environment and more exposure to allergens and to multiple other contributory factors. The marked reduction in infectious diseases in recent decades permitted the immune system to switch from fighting infectious disease agents and parasites to reacting adversely (hypersensitivity) to benign environmental agents (allergens) and even to self-antigens (autoimmunity). [ABSTRACT FROM AUTHOR]

Background: Scoring systems are increasingly being developed for various diseases, including asthma and allergic disorders, with the objective of improving the classification of disease severity and the assessment of efficacy of therapeutic modalities. Objective: This review provided concise summaries of published scoring systems used for allergic rhinitis, asthma, atopic dermatitis, urticaria, Stevens-Johnson syndrome/toxic epidermal necrolysis, eosinophilic esophagitis, and systemic allergic reactions (anaphylaxis). Methods: We searched the medical literature between 1985 and 2018 for published scoring systems that have been developed and used in clinical trials or in practice for assessment of asthma and a variety of allergic disorders. Results: The scoring systems for each of these diseases were briefly presented in the text in chronological order of publication, and selected information was presented in the tables for easy comparisons. For more details, the reader should refer to the original relevant publications. Conclusion: Such assessment methods are useful for sound designing of clinical trials, fair comparisons of findings of studies, and objective measurements of patients' progress in clinical practice. The choice of using one scoring system over another would depend on its proven degree of validity, the purpose, and applicability. [ABSTRACT FROM AUTHOR]

Background: Some previous reports revealed suboptimal management of anaphylaxis (ANX) in the emergency department (ED). Objective: To evaluate the recorded diagnosis and management of patients who presented with ANX at our university hospital ED and to assess how the management correlated with the severity of the case and the training level of the ED staff. Methods: A descriptive study that involved reviewing the electronic medical records of patients who presented with ANX at the ED during a period of 4 years. Results: When reviewing 1341 charts of potential cases, 60 met the criteria for ANX, but only 23% were correctly coded. Inaccurate coding was noted in 77%, mainly as an "allergic reaction." Systemic corticosteroids were administered in the ED to 85% of the patients and H1-antihistamines to 73%; only 20% received epinephrine. Ten patients required hospital admission, and, on discharge, only four patients (40%) were given epinephrine autoinjector prescriptions. Of the 50 who were discharged home, 48% were given epinephrine autoinjector prescriptions and 16% were given a referral for allergy evaluation. Conclusion: The observed low rates of appropriate diagnostic coding of ANX, of epinephrine administration, epinephrine autoinjector prescribing at discharge, and referral for allergy evaluation call for more education on these issues. Some of these pitfalls can be partly attributed to the setting in a university ED where health providers are usually busy in rendering urgent care. [ABSTRACT FROM AUTHOR]

Objective: To provide a brief summary on food additives and to outline a practical approach for evaluating subjects suspected of having reactions to food additives. Data Sources: Information was derived from selected reviews and original articles published in peer-reviewed journals, supplemented by the clinical experience of the authors. Study Selection: Priority was given to studies that used blinded, placebo controlled, oral challenges to confirm adverse reactions to food additives. In addition, selected, appropriately evaluated case reports were included. Results: A large number of food additives are widely used in the food industry. Allergic reactions to additives seem to be rare but are very likely underdiagnosed, primarily due to a low index of suspicion. A wide variety of symptoms to food additives have been reported, but a cause-and-effect relationship has not been well documented in the majority of cases. Conclusion: Reactions to food additives should be suspected in patients who report symptoms related to multiple foods or to a certain food when commercially prepared but not when home made. It is also prudent to investigate food additives in subjects considered to have "idiopathic" reactions. Except for a limited number of natural additives, there is a small role for skin tests or in vitro testing. Oral challenge, in stages, with commonly used additives is the definitive procedure for detecting the offending agent. Once the specific additive is identified, management is strict avoidance, which can be difficult. [ABSTRACT FROM AUTHOR]

We presented a case of a male infant with annular patchy rash on his torso since 2 weeks of age. This was initially diagnosed as tinea corporis but did not respond to oral antifungal treatment. Because of the appearance of the rash and a history of a certain disease in a maternal aunt, we suspected the most probable cause of the rash and the diagnosis was confirmed by laboratory testing. Furthermore, laboratory screening of the mother, who was asymptomatic, revealed that she was seropositive for the disease and was counseled on the importance of follow-up. The infant's rash gradually improved and completely disappeared, without any sequalae by 8 months of age. [ABSTRACT FROM AUTHOR]

Anemia can be caused by, or be associated with, many clinical conditions, including pulmonary diseases, some of which are rare and can be misdiagnosed. Nontraumatic pulmonary bleeding may be caused by a variety of conditions and results in anemia and pulmonary hemosiderosis, even when it is subtle. The differential diagnosis in such cases is extensive. We present the case of a diagnostic dilemma in a 17-month-old child hospitalized for severe anemia and respiratory distress in which the diagnosis was settled through an allergy/immunology consultation. [ABSTRACT FROM AUTHOR]

Antihistamines are the cornerstone of allergy therapy and are not expected to cause hypersensitivity reactions. We describe two cases, one had urticaria to multiple anti-H1-preparations and the other had anaphylaxis to hydroxyzine. We also provide a review of the English literature on reported reactions regarding causative preparations and manifestations. The latter showed a wide range; most commonly urticaria/angioedema, contact dermatitis, anaphylaxis, and fixed drug eruption (FDE). Most reported cases were young to middle age adults, with apparent predilection to female subjects. The onset of reactions varied from a few minutes for anaphylaxis and urticaria/angioedema, several hours for maculopapular rashes, or longer for contact dermatitis and FDE. Almost all antihistamines have been reported as causing reactions; cetirizine was the most common oral preparation followed by its parent drug, hydroxyzine. Doxepin cream was the most commonly implicated topical preparation in causing contact dermatitis. A causal relationship is often difficult to recognize because the reaction may be similar to the disease being treated with that antihistamine preparation. Reactions to one preparation are likely to occur, but not always, to other members of the same class. Diagnosis is based on clinical suspicion and may be verified by challenge testing. Except for patch testing in contact dermatitis or fixed eruption, other tests have not shown optimal reliability. In most cases, challenge testing with multiple preparations would identify one or more preparations that can be tolerated. Although hypersensitivity to antihistamines seems to be very rare, awareness of the problem would reduce its misdiagnosis. [ABSTRACT FROM AUTHOR]

Specialists in allergy/immunology are often asked to evaluate patients with eosinophilia, with the general assumption of an underlying allergic or immunologic disease. We present a case of an infant referred for marked eosinophilia. Although atopic disease may be in the differential diagnosis, it is rarely associated with hypereosinophilia, and other conditions need to be investigated. Until the underlying cause is identified, systemic corticosteroid therapy may be initiated, mainly in severe cases. [ABSTRACT FROM AUTHOR]

Allergen immunotherapy is commonly incorporated in the management of allergic rhinoconjunctivitis, allergic asthma, and insect sting hypersensitivity. It is generally safe, but systemic reactions occasionally occur, mainly of the immediate type and rarely of the delayed type. We report a case of a 50-year-old man with allergic rhinoconjunctivitis on immunotherapy for 3 years and then received an injection from another patient's extract. The latter contained a higher concentration of house-dust mite and pollens of grasses, trees, and weeds. It also contained molds that the patient's correct extract did not have. Within half an hour, he developed a systemic reaction that resolved with symptomatic treatment. Two weeks later, he received one-half of his usual immunotherapy dose. Within a week, he developed urticaria, arthralgia, myalgia, fever, and lymphadenopathy. Laboratory abnormalities included leukocytosis, elevated erythrocyte sedimentation rate, hematuria, and elevated liver enzymes. Oral corticosteroid therapy for 3 weeks was ineffective. He developed significant myalgia and apparent mood changes, attributable to corticosteroid intake. After a single plasmapheresis, he felt remarkable improvement within <24 hours. Corticosteroid therapy was gradually withdrawn over 10 weeks without relapse of symptoms. This is a rare case of probable serum sickness after the administration of a wrong allergy immunotherapy extract. However, a causal relationship could not be proven. The response was poor to prolonged corticosteroid therapy but was remarkable to one plasmapheresis. [ABSTRACT FROM AUTHOR]

This presentation addresses four selected issues that are current controversies in the area of food allergy. First, the diagnostic proficiency of specific IgE (sIgE) measurement. sIgE testing has been a useful screening test; the higher the level, the more likely to be clinically relevant. However, published predictive values varied from one study to another. Levels derived from data on certain groups of patients reflect probabilities that can not be applied with certainty to individual patients. Several factors need to be considered in interpreting the value of sIgE in any particular patient. Definitive decisions require well-designed challenge testing. Second, a few studies suggested the usefulness of including patch testing in food allergy evaluation. It may reveal positive results that may or may not be clinically relevant. At present, its use is not generally accepted because of inconsistency in the reported findings and the lack of standardization of test materials and interpretation. It may possibly have a role in evaluating eosinophilic esophagitis (EE) more than in atopic dermatitis. Third, EE does not seem to be a new disease or is causing a miniepidemic. Its increasing diagnosis is probably because of a greater awareness and better biopsy assessment. Fourth, the usefulness of probiotics on allergy prevention or treatment has been reported by some studies but not by others. Appropriately designed studies are needed to identify the efficacious type(s) of probiotics, effective doses, method of administration, optimal time to begin, and duration of therapy. [ABSTRACT FROM AUTHOR]

We report a 16-year-old male patient who presented with headache, behavior changes, and fever. His cerebral spinal fluid and blood cultures grew Cryptococcus neoformans. His laboratory evaluation was negative for human immunodeficiency virus infection but flow cytometry revealed low CD4+ count of 39 cells/mm3 and CD4:CD8 ratio of 0.43. He was initially treated with antifungal agents with only partial clinical improvement, and he was discharged to home on oral fluconazole and prophylactic co-trimoxazole. After discharge, he continued to have persistent headache and recurrent episodes of vomiting. He was readmitted several times because of worsening of meningitis symptoms and received prolonged courses of multiple antifungal therapy, with clearance of infection from the central nervous system. He was subsequently placed on prophylactic therapy with fluconazole. His peripheral CD4+ cell count remained low after resolution of his meningitis. Eight months after the initial diagnosis, recombinant IL-2 therapy was initiated and within a few months, his CD4+ cell count started to increase. Treatment with rIL-2 and prophylactic antifungal therapy continued and he has been asymptomatic for almost 20 months so far. This case is the first reported pediatric idiopathic CD4+ T-lymphocytopenia case with cryptococcal meningitis that was successfully treated by the addition of rIL-2 therapy to antifungal therapy. [ABSTRACT FROM AUTHOR]

Proliferation of the lymphoid system should arouse suspicion of a potentially serious illness. We present a 4.5-year-old boy who developed fever, vomiting, diarrhea, lymphadenopathy, hepatosplenomegaly, lymphocytosis, anemia, thrombocytopenia, and increased liver enzymes. Lymph node and bone marrow biopsies showed lymphoproliferation, Epstein-Barr virus (EBV) infection, and hemophagocytosis leading to the diagnosis of hemophagocytic lymphohistiocytosis (HLH). Chemotherapy was initiated for HLH with dexamethasone, etoposide, and cyclosporine. Because of a high level of EBV viremia, rituximab was added a few days later and resulted in a remarkable drop in the EBV in the circulation but not in the cerebrospinal fluid. However, the patient succumbed to encephalitis, pneumonia, and cardiopulmonary failure. Autopsy revealed the presence of EBV in the brain, indicating the ineffectiveness of rituximab therapy in treating central nervous system infection with EBV. [ABSTRACT FROM AUTHOR]

The diagnosis of food allergy depends on thorough medical history-taking that may be supplemented with trials of dietary eliminations, skin testing, and specific IgE antibody measurement. However, the reliability of such procedures is often suboptimal. For most cases, oral challenge testing is needed to confirm the diagnosis of food allergy and to identify the causative food(s). Though blinded challenges are ideal, open challenges can be appropriate in some cases, particularly in young children. An optimal design of the procedure would depend on the age of the patient, the anticipated symptoms, and the provoking food quantity. The test is much safer than many surgical and medical procedures being routinely performed. This article presents a practical guideline that can reliably and safely encourage an increased use of this important test in the diagnosis of food allergy. [ABSTRACT FROM AUTHOR]

A woman with multiple illnesses including allergic rhinitis presented for a follow-up visit at our clinic with constant rhinorrhea for 2 weeks despite regular use of nasal corticosteroids. Two weeks earlier, after alcohol drinking and doubling some of her medications for missed doses, she fell on her face. The Emergency Department records documented headache, bradycardia, hypotension, dehydration, and right infraorbital swelling. She was admitted for hydration and observation, and was discharged after two days without radiologic evaluation of the head. At our clinic, physical examination revealed pale turbinates bilaterally and clear watery discharge from the right nostril. Cerebrospinal fluid (CSF) rhinorrhea was suspected, but glucose testing was not available at our clinic. The patient was immediately admitted into the hospital. A beta-2-transferrin test confirmed CSF from the right nostril. High resolution sinus CT revealed fluid in the right sphenoid sinus, a large cyst in the left maxillary sinus, a cribriform plate dehiscence on the right side, and fluid collection adjacent to the middle turbinate. A lumbar drain was placed to release the pressure and antibiotic prophylaxis was started. Nasal endoscopy revealed CSF leak from the cribriform plate with bone dehiscence and a dural tear. A graft from nasal septal cartilage and temporalis fascia was applied using Tisseal fibrin glue. The persistent rhinorrhea resolved and on follow-up visits, the patient remained asymptomatic. Thinking of CSF rhinorrhea in the differential diagnosis of rhinitis would lead to early diagnosis and prevention of serious medical complications and potential legal liabilities. [ABSTRACT FROM AUTHOR]

Our understanding of drug reactions and their management has changed markedly in recent years with the development of several new concepts. Epidermal cell death seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) may result from Fas-Fas ligand–mediated apoptosis. Intravenous immunoglobulin (IVIG) contains anti-Fas antibodies that can abrogate apoptosis. Most studies on IVIG in SJS and TEN reported improvement in arresting disease progression and reduction in time to healing. Furthermore, several studies have dispelled the myth of sulfonamide cross-reactivity. Immune-mediated reactions against antibacterial sulfonamides are directed against two unique side chains that non–antibacterial sulfonamides do not contain. Certain patients seem to have a genetic predisposition for “multiple drug sensitivities.” Hence, they may react to several drugs that are not necessarily cross-reacting. Also, multiple studies have shown that IgE-mediated nonsteroidal anti-inflammatory drugs (NSAIDs) cross-reactivity is uncommon. Rather, it is cyclooxygenase (COX) 1 inhibition that results in pseudoallergic reactions to multiple NSAIDs. Several studies have indicated that selective COX-2 inhibitors can be safely administered in patients with aspirin-exacerbated respiratory disease and NSAID-induced cutaneous reactions, although their use has been curtailed by their cardiovascular side effects. Biological agents, such as infliximab, are being increasingly used for a variety of diseases and have caused adverse reactions in some patients. Studies differ as to whether concomitant immunosuppressive use with infliximab affects the development of drug-specific antibodies and infusion reactions. Successful desensitization protocols have been developed for reactions to some of these agents. [ABSTRACT FROM AUTHOR]

Neutrophil dysfunction can result from oxidative burst defect or from glucose-6-phosphate dehydrogenase (G6PD) deficiency; we noted both in the same patient. A 4-month-old male infant with G6PD deficiency presented with swelling of the left middle finger, left leg, and right big toe. At 5 weeks of age he was hospitalized for fever for 2 days. A maternal uncle died at 5 years of age and a male maternal cousin died at the age of 21 months, both reportedly diagnosed with chronic granulomatous disease (CGD). On physical examination, he had a swollen erythematous left third finger, left distal leg swelling, and right big toe abscess. None of these areas was significantly tender. WBC was 18.7 × 103/mm3 with 37% PMN and 5% bands. The x-ray films showed osteomyelitis in the left third proximal phalanx and the distal right first metatarsal. Culture from the toe abscess grew Serratia marcescens. His neutrophil oxidative burst was tested by the dihydrorhodamine-123 assay and was markedly suppressed, typical of CGD. The mother and maternal grandmother were found to be CGD carriers. He was treated with i.v. antibiotics for 4 weeks and was discharged on prophylactic trimethoprim, itraconazole and interferon γ, with substantial reduction in infections. Infection in this infant was unusual in its nature, in affecting multiple sites, and in its causative organism. Immune deficiency was suspected, particularly of the phagocytic component, but could not be attributed to his moderate degree of primary G6PD deficiency. Additional immunologic evaluation and the family history led to the diagnosis of X-linked CGD. [ABSTRACT FROM AUTHOR]

Patients with dysmorphic disorders seem to have frequent respiratory infections that may be attributed to associated anatomic or neurological abnormalities, but immune defects may contribute to their susceptibility to infections. We screened subjects with dysmorphic conditions for major hematologic, B-cell and T-cell defects. We studied 84 subjects with dysmorphic disorders: 29 with chromosomal disorders, 27 with single gene disorders, and 28 with unclassified dysmorphic disorders. They were evaluated by physical examination; medical history suggestive of possible immune deficiency; complete blood count; serum immunoglobulin G (IgG), IgA, and IgM levels; and lymphocyte subsets. Low laboratory values (less than fifth percentile for age) were detected in 54.8%; was highest in the chromosomal disorder group (79.3%) followed by the single gene disorder group (55.6%) and was lowest in the unclassified dysmorphic disorder group (28.6%). The most common low values were in the CD19 and CD16/56 lymphocyte subpopulations followed by IgG and IgA levels. None of the subjects had neutropenia or thrombocytopenia. History of significant recurrent infections was noted in five subjects, all of whom had abnormal laboratory values. The highest frequency of abnormal laboratory values was in Down syndrome followed by Turner syndrome and chromosome deletions. We concluded that patients with dysmorphic disorders, particularly those with chromosomal disorders, have a high frequency of various B-cell and T-cell defects that may be contributing to their susceptibility to infection. Studies are needed to further delineate the immunologic defects in that population and to investigate a possible genetic basis at the molecular level. [ABSTRACT FROM AUTHOR]