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BACKGROUND: Rhinovirus frequently causes asthma exacerbations among children and young adults who are allergic. The interaction between allergen and rhinovirus-induced symptoms and inflammation over time is unclear. OBJECTIVE: Our aim was to compare the response to an experimental inoculation with rhinovirus-16 in allergic asthmatics with the response in healthy controls and to evaluate the effects of administrating omalizumab before and during the infection. METHODS: Two clinical trials were run in parallel. In one of these trials, the response to an experimental inoculation with rhinovirus-16 among asthmatics with high levels of total IgE was compared to the response in healthy controls. The other trial compared the effects of administering omalizumab versus placebo to asthmatics in a randomized, double-blind placebo-controlled investigation. The primary outcome for both trials compared lower respiratory tract symptoms (LRTSs) between study groups over the first 4 days of infection. RESULTS: Frequent comparisons of symptoms, lung function, and blood eosinophil counts revealed differences that were more pronounced among allergic asthmatics than among controls by days 2 and 3 after virus inoculation. Additionally, an augmentation of upper respiratory tract symptom scores and LRTS scores occurred among the atopic asthmatics versus the controls during the resolution of symptoms (P < .01 for upper respiratory symptom tract scores and P < .001 for LRTS scores). The beneficial effects of administering omalizumab on reducing LRTSs and improving lung function were strongest over the first 4 days. CONCLUSIONS: LRTSs and blood eosinophil counts were augmented and lung function was reduced among allergic asthmatics early after rhinovirus inoculation but increased late in the infection during symptom resolution. The effect of administering omalizumab on the response to rhinovirus was most pronounced during the early/innate phase of the infection.

Over the past decade, there have been substantial advances in our understanding about how viral infections regulate asthma. Important lessons have been learned from birth cohort studies examining viral infections and subsequent asthma and from understanding the relationships between host genetics and viral infections, the contributions of respiratory viral infections to patterns of immune development, the impact of environmental exposure on the severity of viral infections, and how the viral genome influences host immune responses to viral infections. Further, there has been major progress in our knowledge about how bacteria regulate host immune responses in asthma pathogenesis. In this article, we also examine the dynamics of bacterial colonization of the respiratory tract during viral upper respiratory tract infection, in addition to the relationship of the gut and respiratory microbiomes with respiratory viral infections. Finally, we focus on potential interventions that could decrease virus-induced wheezing and asthma. There are emerging therapeutic options to decrease the severity of wheezing exacerbations caused by respiratory viral infections. Primary prevention is a major goal, and a strategy toward this end is considered.

Importance As vaccines for children under the age of 12 are not yet approved, determining the SARS-CoV-2 infection rate in children is important for decisions about protective measures to be taken during the 2021–2022 school year. Objective To estimate the prevalence of SARS-CoV-2 antibodies in residual serum samples from pediatric patients in the state of Arkansas over the first year of the COVID-19 pandemic as an indicator of SARS-CoV-2 infection rates in children. Design The study is a survey of SARS-CoV-2 seropositivity in children in Arkansas over the first year of the COVID-19 pandemic. Fom April 2020 through April 2021, remnant serum samples were collected across five time periods (waves): April 2–May 6, June 6–August 10, September 8–October 17, November 7–December 17, 2020 and April 5–April 28, 2021. Setting The multi-site survey collected remnant serum samples from four clinics across the state of Arkansas: Arkansas Children’s Hospital (ACH, Little Rock, AR), Arkansas Children’s Northwest (Springdale, AR), and UAMS Family Medical Centers (Ft. Smith, AR and Pine Bluff, AR) Participants The study population consisted of 2400 convenience serum samples from children ages 1–18 who visited hospitals or regional clinics in Arkansas for non-COVID19-related reasons. Exposures Infection with SARS-CoV-2. Main outcomes and measures The presence of IgM and/or IgG antibodies to the SARS-CoV-2 Spike and Nucleoprotein were determined using a two-step enzyme-linked immunosorbent assay. Seroprevalence was estimated by demographic group, including age (1-4, 5-9, 10-14, and 15-18 years), sex, race/ethnicity (white, black, Hispanic), metropolitan status, SARS-CoV-2 PCR testing, and co-morbidities (respiratory virus infection within 6 months, asthma, hypertension, obesity, diabetes, autoimmune disease). Association with SARS-CoV-2 antibody reactivity was determined by demographic group. Results The overall SARS-CoV-2 seroprevalence rose from 7.9% in Wave 1 (95%CI, 4.9-10.9%) to 25.8% in Wave 5 (95% CI, 22.2-29.3%), as did the age- and sex-standardized seroprevalence rate which ranged from 8.6% in Wave 1 (95%CI, 5.1-11.1%) to 24.2% in Wave 5 (95% CI, 20.1-28.2%). Hispanic children had a significantly higher risk of testing positive for SARS-CoV-2 antibodies than non-Hispanic white children in Wave 3 (RR 2.82, 95% CI, 1.81-4.38), Wave 4 (RR 1.76, 95% CI, 1.03-3.00), and Wave 5 (RR 2.37, 95% CI, 1.69-3.33) Similarly, black children also showed a significantly higher risk of testing positive for SARS-CoV-2 antibodies than white children in Wave 3 (RR 1.71, 95% CI, 1.03-2.84) and Wave 5 (RR 1.59, 95% CI, 1.08-2.34). Conclusions and relevance The percentage of Arkansas children with SARS-CoV-2-specific antibodies increased from April 2020 to April 2021. These data indicate that many more children have been infected with SARS-CoV-2 than indicated by diagnostic testing. With the emergence of SARS-CoV-2 variants, recognition of long-term effects of SARS-CoV-2 even after mild or asymptomatic infections, and the lack of an authorized pediatric SARS-CoV-2 vaccine, these results highlight the importance of including children in SARS-CoV-2 public health, clinical care, and research strategies. These findings are important for state and local officials as they consider measures to limit SARS-CoV-2 spread in schools and daycares for the 2021–2022 school year.

Rhinovirus (RV) is ubiquitous and typically causes only minor upper respiratory symptoms. However, especially in children and adolescent asthmatics, RV is responsible for most exacerbations. This ability of RV to drive exacerbations typically requires the concomitant presence of exposure to a bystander allergen. Susceptibility to RV-mediated exacerbations is also related to the genetic background of the host, which contributes to greater infectivity, more severe infections, altered immune responses, and to greater inflammation and loss of asthma control. Given these responses, there are several treatments available or being developed that should improve the control of exacerbations related to RV infection.

Background Food insecurity (FI), limited availability of or access to nutritional foods, is linked to poor child/caregiver health. We examined FI in food-allergic and non-food-allergic children to determine whether dietary limitations associated with food allergy increases risk of FI. Methods Food-allergic and non-food-allergic children (1-17 years) were recruited from Arkansas Children's Hospital allergy/asthma clinics. The USDA Food Security Survey, the Newest Vital Sign Health Literacy (HL) questionnaire, and the Food Allergy Impact Scale QOL survey were administered. Logistic regression and analysis of covariance models were utilized for data analysis. Results Subjects (n = 650) included 325 food-allergic and 325 non-food-allergic children. Overall rate of FI was 21.5% (food allergic 22.2% and non-food allergic 20.9%) with no significant difference in the prevalence of FI between groups (OR = 1.30; 95% CI 0.86-1.96; P = 0.21). FI was increased in households of children with both milk and egg allergy when compared to those without food allergy and those with single food allergy (OR = 2.5; 95% CI 1.4-4.6; P = 0.003). Mean HL rates were higher in the food-secure vs food-insecure groups (mean diff = 0.31; 95% CI 0.03-0.59; P = 0.03). Among food-allergic children, QOL was better in the food-secure vs food-insecure group (mean diff = 0.61; 95% CI 0.002-1.23; P = 0.049). Conclusion Food allergy to milk and egg was associated with increased risk of household FI. Food-insecure participants had lower HL than their food-secure counterparts. Further work is needed to define risks associated with FI among food-allergic children to improve screening and management strategies.

ObjectiveOur objective is to estimate CoV-2 infection rates in a rural state using seroprevalence of antibodies to CoV-2 as an indicator of infection.Study Design and SettingThis is a single-site study within an academic center and regional programs within the state of Arkansas. We obtained residual serum samples from a convenience sample of adults who were outpatients and came to the hospital or regional clinic for non-COVID-related reasons. We collected remnant in three time periods (August 15 to September 5, September 12 to October 24, and November 7 to December 19).ResultsIn 2020, the overall age, gender, and race standardized prevalence of CoV-2 antibodies was 2.6% (August to September), 4.1% (September to October), and 7.4% (November to December). There was no difference in seroprevalence between urban compared to rural areas. Positive tests were not uniformly distributed across racial and ethnic minorities. Higher seroprevalence rates were found in Hispanics and Blacks or African Americans compared to whites across all time periods.ConclusionsIn a state with a large rural population, 2.6-7.4% of people experienced CoV-2 infection by December 2020. Blacks and Hispanics had disproportionately higher rates of CoV-2 infections than whites.What is new?Key findingsIn this prospective convenience sampling of remnant sera, we found increasing seroprevalence from 2.6% to 7.4% (August 2020 to December 2020). Higher seroprevalence rates were found in Hispanics and Blacks or African Americans compared to whites across all time periods, and no difference was determined between those individuals from rural or urban areas.What this adds to what is knownIn a largely rural population, Blacks and Hispanics had disproportionately higher rates of CoV-2 infections than whites, and these populations need to be studied further regarding outcomes.What is the implication?There are health disparities that exist regarding CoV-2 infections, and we should target vaccination information and education to these groups.Highlights-SARS-CoV-2 infections increased from 2.6% to 7.4% from August to December 2020.-Higher seroprevalence was found in Hispanics and Blacks as compared to whites.-There was no difference in the seroprevalence in rural compared to urban areas.

Background Activation of the immune system is implicated in the Post-Acute Sequelae after SARS-CoV-2 infection (PASC) but the mechanisms remain unknown. Angiotensin-converting enzyme 2 (ACE2) cleaves angiotensin II (Ang II) resulting in decreased activation of the AT1 receptor and decreased immune system activation. We hypothesized that autoantibodies against ACE2 may develop after SARS-CoV-2 infection, as anti-idiotypic antibodies to anti-spike protein antibodies. Methods and findings We tested plasma or serum for ACE2 antibodies in 67 patients with known SARS-CoV-2 infection and 13 with no history of infection. None of the 13 patients without history of SARS-CoV-2 infection and 1 of the 20 outpatients that had a positive PCR test for SARS-CoV-2 had levels of ACE2 antibodies above the cutoff threshold. In contrast, 26/32 (81%) in the convalescent group and 14/15 (93%) of patients acutely hospitalized had detectable ACE2 antibodies. Plasma from patients with antibodies against ACE2 had less soluble ACE2 activity in plasma but similar amounts of ACE2 protein compared to patients without ACE2 antibodies. We measured the capacity of the samples to inhibit ACE2 enzyme activity. Addition of plasma from patients with ACE2 antibodies led to decreased activity of an exogenous preparation of ACE2 compared to patients that did not have antibodies. Conclusions Many patients with a history of SARS-CoV-2 infection have antibodies specific for ACE2. Patients with ACE2 antibodies have lower activity of soluble ACE2 in plasma. Plasma from these patients also inhibits exogenous ACE2 activity. These findings are consistent with the hypothesis that ACE2 antibodies develop after SARS-CoV-2 infection and decrease ACE2 activity. This could lead to an increase in the abundance of Ang II, which causes a proinflammatory state that triggers symptoms of PASC.

Pharmacogenomics (PGx) is a growing field within precision medicine. Testing can help predict adverse events and sub-therapeutic response risks of certain medications. To date, the US FDA lists over 280 drugs which provide biomarker-based dosing guidance for adults and children. At Arkansas Children’s Hospital (ACH), a clinical PGx laboratory-based test was developed and implemented to provide guidance on 66 pediatric medications for genotype-guided dosing. This PGx test consists of 174 single nucleotide polymorphisms (SNPs) targeting 23 clinically actionable PGx genes or gene variants. Individual genotypes are processed to provide per-gene discrete results in star-allele and phenotype format. These results are then integrated into EPIC- EHR. Genomic indicators built into EPIC-EHR provide the source for clinical decision support (CDS) for clinicians, providing genotype-guided dosing.

Rhinovirus (RV) exposure has been implicated in childhood development of wheeze evoking asthma and exacerbations of underlying airways disease. Studies such as the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) and Childhood Origins of ASThma (COAST) have identified RV as a pathogen inducing severe respiratory disease. RVs also modulate airway hyperresponsiveness (AHR), a key characteristic of such diseases. Although potential factors underlying mechanisms by which RV induces AHR have been postulated, the precise mechanisms of AHR following RV exposure remain elusive. A challenge to RV-related research stems from inadequate models for study. While human models raise ethical concerns and are relatively difficult in terms of subject recruitment, murine models are limited by susceptibility of infection to the relatively uncommon minor group (RV-B) serotypes, strains that are generally associated with infrequent clinical respiratory virus infections. Although a transgenic mouse strain that has been developed has enhanced susceptibility for infection with the common major group (RV-A) serotypes, few studies have focused on RV in the context of allergic airways disease rather than understanding RV-induced AHR. Recently, the receptor for the virulent RV-C CDHR3, was identified, but a dearth of studies have examined RV-C-induced effects in humans. Currently, the mechanisms by which RV infections modulate airway smooth muscle (ASM) shortening or excitation-contraction coupling remain elusive. Further, only one study has investigated the effects of RV on bronchodilatory mechanisms, with only speculation as to mechanisms underlying RV-mediated modulation of bronchoconstriction.

Rhinovirus (RV) exposure evokes exacerbations of asthma that markedly impact morbidity and mortality worldwide. The mechanisms by which RV induces airway hyperresponsiveness (AHR) or by which specific RV serotypes differentially evoke AHR remain unknown. We posit that RV infection evokes AHR and inflammatory mediator release, which correlate with degrees of RV infection. Furthermore, we posit that rhinovirus C-induced AHR requires paracrine or autocrine mediator release from epithelium that modulates agonist-induced calcium mobilization in human airway smooth muscle. In these studies, we used an ex vivo model to measure bronchoconstriction and mediator release from infected airways in human precision cut lung slices to understand how RV exposure alters airway constriction. We found that rhinovirus C15 (RV-C15) infection augmented carbachol-induced airway narrowing and significantly increased release of IP-10 (IFN-γ-induced protein 10) and MIP-1β (macrophage inflammatory protein-1β) but not IL-6. RV-C15 infection of human airway epithelial cells augmented agonist-induced intracellular calcium flux and phosphorylation of myosin light chain in co-cultured human airway smooth muscle to carbachol, but not after histamine stimulation. Our data suggest that RV-C15-induced structural cell inflammatory responses are associated with viral load but that inflammatory responses and alterations in agonist-mediated constriction of human small airways are uncoupled from viral load of the tissue.

Aspirin-exacerbated respiratory disease (AERD) is a late onset condition characterized by the Samter triad (aspirin sensitivity [as well as sensitivity to any nonselective cyclooxygenase inhibitor], nasal polyps, asthma) and additional features, including eosinophilic chronic rhinosinusitis, hypereosinophilia, anosmia, frequent absence of atopy, and, intolerance to ingestion of red wine and other alcoholic beverages. The diagnosis is rare, and, because of this, it is also often missed by physicians. However, it is highly overexpressed in patients with severe asthma (and severe chronic rhinosinusitis with nasal polyps), which makes its recognition essential. For this review, we considered mechanisms involved in the pathogenesis of this disease and discussed the clinical symptoms of AERD. We also discussed the role of aspirin desensitization in the treatment of AERD. Also, we considered medications (e.g, leukotriene modifiers) and surgical interventions that have a role in the treatment of AERD.

Background T-helper (Th) type 2 cell inflammation is the hallmark of several disease processes, including asthma, atopic dermatitis, and some forms of chronic rhinosinusitis. Itraconazole has been used as both an antifungal and an anti-inflammatory agent, with some success in many of these diseases, in part, by altering Th2 cytokine expression by T cells. It is not known whether this merely reflects inhibition of established Th2-like cells or the inhibition of differentiation of naive T cells into Th2-like cells. Objective To evaluate the role of itraconazole in the differentiation of naive T cells during activation. Methods Naive CD45RA+ T cells were isolated from peripheral blood mononuclear cells from healthy volunteers. Th1 and Th2 type cells were differentiated in the presence of varying concentrations of itraconazole. After stimulation with anti-CD3 and anti-CD28 beads, carboxyfluorescein succinimidyl ester dilution was performed to evaluate proliferation and intracellular cytokine staining for interleukin (IL) 4 and interferon (IFN) gamma within proliferating T cells was measured along with enzyme-linked immunosorbent assay for secreted IL-5, IL-13, and IFN gamma. Results Itraconazole had no effect on proliferation of unbiased, Th1, or Th2 cells. Similarly, there was no effect of itraconazole on either intracellular cytokine staining of IL-4 and IFN gamma or secreted cytokine expression of IFN gamma, IL-5, and IL-13 in any of the cell populations. Conclusion Itraconazole did not alter the ability of naive T cells to proliferate or secrete cytokines under Th1 or Th2 deviating conditions in vitro. As such, reported inhibition of Th2-like lymphocyte function by itraconazole reflected action on mature effector cells and may have underscored why antifungal treatment failed in many clinical trials of eosinophilic chronic rhinosinusitis.

Epidemiologic studies have demonstrated an association between acetaminophen (APAP) use and the development of asthma symptoms. However, few studies have examined relationships between APAP-induced signaling pathways associated with the development of asthma symptoms. We tested the hypothesis that acute APAP exposure causes airway hyper-responsiveness (AHR) in human airways.Precision cut lung slice (PCLS) airways from humans and mice were used to determine the effects of APAP on airway bronchoconstriction and bronchodilation and to assess APAP metabolism in lungs.APAP did not promote AHR in normal or asthmatic human airways ex vivo. Rather, high concentrations mildly bronchodilated airways pre-constricted with carbachol (CCh), histamine (His), or immunoglobulin E (IgE) cross-linking. Further, the addition of APAP prior to bronchoconstrictors protected the airways from constriction. Similarly, in vivo treatment of mice with APAP (200 mg/kg IP) resulted in reduced bronchoconstrictor responses in PCLS airways ex vivo. Finally, in both mouse and human PCLS airways, exposure to APAP generated only low amounts of APAP-protein adducts, indicating minimal drug metabolic activity in the tissues.These findings indicate that acute exposure to APAP does not initiate AHR, that high-dose APAP is protective against bronchoconstriction, and that APAP is a mild bronchodilator. Epidemiologic studies have demonstrated an association between acetaminophen (APAP) use and the development of asthma symptoms. However, few studies have examined relationships between APAP-induced signaling pathways associated with the development of asthma symptoms. We tested the hypothesis that acute APAP exposure causes airway hyper-responsiveness (AHR) in human airways. Precision cut lung slice (PCLS) airways from humans and mice were used to determine the effects of APAP on airway bronchoconstriction and bronchodilation and to assess APAP metabolism in lungs. APAP did not promote AHR in normal or asthmatic human airways ex vivo. Rather, high concentrations mildly bronchodilated airways pre-constricted with carbachol (CCh), histamine (His), or immunoglobulin E (IgE) cross-linking. Further, the addition of APAP prior to bronchoconstrictors protected the airways from constriction. Similarly, in vivo treatment of mice with APAP (200 mg/kg IP) resulted in reduced bronchoconstrictor responses in PCLS airways ex vivo. Finally, in both mouse and human PCLS airways, exposure to APAP generated only low amounts of APAP-protein adducts, indicating minimal drug metabolic activity in the tissues. These findings indicate that acute exposure to APAP does not initiate AHR, that high-dose APAP is protective against bronchoconstriction, and that APAP is a mild bronchodilator.

The respiratory tract can be colonized with bacterial, fungal, and viral microorganisms, and the whole of the microbiota, their genes, and the surrounding environment is collectively termed the microbiome. Increasing evidence indicates that the respiratory microbiome has an important role in respiratory health and disease and is both impacted by and potentially contributes to the severity of symptomatic respiratory viral infections and asthma in children. A deeper understanding of the complex interactions between bacteria, viruses, and the host will provide further comprehension into the drivers and mechanisms of respiratory health and disease and will impart opportunities for clinical therapies.

Pediatric chronic rhinosinusitis (CRS) is a common disorder that carries significant morbidity. The diagnosis requires sinus symptoms that persist despite standard medical therapy greater than 3 months. Viral infections, allergies, and anatomic differences in children lead to chronic obstruction of the osteomeatal complex. Chronic rhinosinusitis as a diagnosis is a conglomeration of multiple phenotypes and endotypes. As such, the diagnosis and management are complex. New survey studies provide some consensus on prevalence and management of this disease in children. In this review, we highlight the differential diagnosis of pediatric CRS, including non-eosinophilic/infectious variants, eosinophilic variants with and without nasal polyps, allergic fungal sinusitis, aspirin-exacerbated respiratory disease, primary immunodeficiency, and disorders of mucociliary clearance. Further, we detail treatment options that should be considered. Finally, we feature emerging potential treatment options of CRS, including anti-immunoglobulin E, interleukin-5, and interleukin-4 receptor alpha subunit.

Asthma is a heterogeneous syndrome that might be better described as a constellation of phenotypes or endotypes, each with distinct cellular and molecular mechanisms, rather than as a singular disease. One of these phenotypes is eosinophilic asthma. As the development of eosinophilic inflammation is categorically dependent on the biological activity of Interleukin (IL)-5, IL-5 antagonism became an obvious target for therapy in this phenotype. Early trials of monoclonal antibodies targeting the biological activity of IL-5, including reslizumab, mepolizumab, and benralizumab, were performed on asthmatics with no concern for evidence of eosinophilia. These trials were largely unsuccessful. However, during these trials, researchers recognized the need to quantify eosinophilia in asthma subjects in order to identify those asthmatics in whom these medications would be more likely to improve symptoms and lung function. Using biomarkers, such as sputum and blood eosinophilia, recent studies of these medications have shown improvements in blood and sputum eosinophilia, forced expiratory volume in 1 second, and quality of life assessments as well as reducing occurrences of exacerbations. Moving forward, better and less invasive biomarkers of eosinophilia are necessary to ensure that the correct patients are chosen to receive these medications to receive maximal benefit.

Background Respiratory viral infections are a significant problem in patients with hematologic malignancies. We report a cluster of HPIV 3 infections in our myeloma patients, and describe the utility of next generation sequencing (NGS) to identify transmission linkages which can assist in infection prevention. Objectives To evaluate the utility of NGS to track respiratory viral infection outbreaks and delineate between community acquired and nosocomial infections in our cancer units. Study design Retrospective chart review conducted at a single site. All patients diagnosed with multiple myeloma who developed symptoms suggestive of upper respiratory tract infection (URTI) or lower respiratory tract infection (LRTI) along with a respiratory viral panel (RVP) test positive for HPIV 3 between April 1, 2016, to June 30, 2016, were included. Sequencing was performed on the Illumina MiSeq™. To gain understanding regarding community strains of HPIV 3 during the same season, we also performed NGS on HPIV3 strains isolated from pediatric cases. Results We saw a cluster of 13 cases of HPIV3 infections in the myeloma unit. Using standard epidemiologic criteria, 3 cases were considered community acquired, 7 cases developed infection during treatment in the cancer infusion center, while an additional 3 developed infections during hospital stay. Seven patients required hospitalization for a median duration of 20 days. NGS enabled sensitive discrimination of the relatedness of the isolates obtained during the outbreak and provided evidence for source of transmission. Two hospital onset infections could be tracked to an index case; the genome sequences of HPIV 3 strains from these 3 patients only differed by a single nucleotide. Conclusions NGS offers a significantly higher discriminatory value as an epidemiologic tool, and can be used to gather real-time information and identification of transmission linkages to assist in infection prevention in immunocompromised patients.

As immunologists, we are frequently asked to evaluate patients with recurrent infections. These infections can provide us with clues regarding what pathways might be aberrant in a given patient, e.g., specific pyogenic bacteria with Toll-like receptor problems, atypical mycobacteria with interferon gamma receptor autoantibodies, and Candida/staphylococcal infections with cellular immune abnormalities. We present a 55-year-old man who presented to our immunology clinic with onychodystrophy of the toenails and fingernails and recurrent oral-esophageal candidiasis. The differential diagnosis for recurrent yeast infections is complex and includes usual suspects as well as some that are not as straightforward.

Background The purpose of the study was to determine the age at which initiation of specific subcutaneous immunotherapy (SCIT) becomes more cost-effective than continued lifetime intranasal steroid (NS) therapy in the treatment of allergic rhinitis, with the use of a decision analysis model. Methods A Markov decision analysis model was created for this study. Economic analyses were performed to identify “break-even” points in the treatment of allergic rhinitis with the use of SCIT and NS. Efficacy rates for therapy and cost data were collected from the published literature. Models in which there was only incomplete improvement while receiving SCIT were also evaluated for economic break-even points. The primary perspective of the study was societal. Results Multiple break-even point curves were obtained corresponding to various clinical scenarios. For patients with seasonal allergic rhinitis requiring NS (i.e., fluticasone) 6 months per year, the age at which initiation of SCIT provides long-term direct cost advantage is less than 41 years. For patients with perennial rhinitis symptoms requiring year-round NS, the cut-off age for SCIT cost-effectiveness increases to 60 years. Hypothetical subjects who require continued NS treatment (50% reduction of previous dosage) while receiving SCIT also display break-even points, whereby it is economically advantageous to consider allergy referral and SCIT, dependent on the cost of the NS prescribed. Conclusion The age at which SCIT provides economic advantages over NS in the treatment of allergic rhinitis depends on multiple clinical factors. Decision analysis models can assist the physician in accounting for these factors and customize patient counseling with regard to treatment options.

BackgroundChronic hyperplastic eosinophilic sinusitis (CHES) is an inflammatory disease characterized by eosinophil infiltration of sinus tissue that can present with and without nasal polyps (NPs). Aeroallergen sensitization in CHES occurs regularly, but the causality between allergen sensitivity, exposure, and disease is unclear.MethodsAllergen is unlikely to directly enter healthy sinuses either by diffusion or ciliary flow, and, even this is more problematic given the loss of patency of the ostia of diseased sinuses. Inflammation and tissue eosinophilia can develop secondary to allergen exposure in the nares, with systemic humoral recirculation of allergic cells including eosinophils, Th2 lymphocytes, and eosinophil precursors that are nonspecifically recruited back to the diseased sinuses.ResultsThe possibility of an allergic reaction to peptides derived from bacteria (i.e., Staphylococcus or superantigens) or fungi that colonize the diseased sinus also provides a plausible allergic mechanism.ConclusionTreatments of this disease include agents directed at allergic mediators such as leukotriene modifiers and corticosteroids, although this does not necessarily signify that an IgE-dependent mechanism can be ascribed. However, more recently, omalizumab has shown promise, including in patients without obvious aeroallergen sensitization. Although many aspects of the role of allergy in CHES remain a mystery, the mechanisms that are being elucidated allow for improved understanding of this disease, which ultimately will lead to better treatments for our patients who live daily with this disease.

BACKGROUND AND OBJECTIVE: Despite a thorough history and comprehensive testing, many children who present with recurrent symptoms consistent with allergic reactions elude diagnosis. Recent research has identified a novel cause for “idiopathic” allergic reactions; immunoglobulin E (IgE) antibody specific for the carbohydrate galactose-α-1,3-galactose (α-Gal) has been associated with delayed urticaria and anaphylaxis that occurs 3 to 6 hours after eating beef, pork, or lamb. We sought to determine whether IgE antibody to α-Gal was present in sera of pediatric patients who reported idiopathic anaphylaxis or urticaria. METHODS: Patients aged 4 to 17 were enrolled in an institutional review board–approved protocol at the University of Virginia and private practice allergy offices in Lynchburg, VA. Sera was obtained and analyzed by ImmunoCAP for total IgE and specific IgE to α-Gal, beef, pork, cat epithelium and dander, Fel d 1, dog dander, and milk. RESULTS: Forty-five pediatric patients were identified who had both clinical histories supporting delayed anaphylaxis or urticaria to mammalian meat and IgE antibody specific for α-Gal. In addition, most of these cases had a history of tick bites within the past year, which itched and persisted. CONCLUSIONS: A novel form of anaphylaxis and urticaria that occurs 3 to 6 hours after eating mammalian meat is not uncommon among children in our area. Identification of these cases may not be straightforward and diagnosis is best confirmed by specific testing, which should certainly be considered for children living in the area where the Lone Star tick is common.

Background In children with eosinophilic esophagitis (EoE) foods are the most common disease triggers, but environmental allergens are also suspected culprits. Objective To determine the effects of environmental allergen sensitization on response to treatment in children with EoE in the southeastern United States. Methods Patients 2 to 18 years old who were referred to the Arkansas Children's Hospital Eosinophilic Gastrointestinal Disorders Clinic from January 2012 to January 2016 were enrolled in a prospective, longitudinal cohort study with collection of demographics, clinical symptoms, medical history, allergy sensitization profiles, and response to treatment over time. Comparisons were made between complete responders (peak esophageal eosinophil count 25 eosinophils per HPF) after treatment with diet elimination alone, swallowed corticosteroids alone, or diet elimination and swallowed corticosteroids. Sensitization patterns to environmental allergens found in the southeastern United States were analyzed for the effect on treatment response. Results A total of 223 individuals were enrolled. Of these, 182 had environmental allergy profiling and at least one endoscopy while receiving proton pump inhibitor (PPI) therapy. Twenty-nine individuals had PPI-responsive EoE and were excluded from further analysis, leaving 123 individuals with non–PPI-responsive EoE who were further analyzed; 72 (58.5%) were complete responders and 33 (26.8%) were nonresponders. Seventeen individuals (13.8%) were partial responders (≥1 but ≤25 eosinophils per HPF) and excluded from further analysis. Nonresponders were more likely to be sensitized to perennial allergens ( P = .02). There was no significant difference in response based on seasonal allergen sensitization. Individuals with mold or cockroach sensitization were more likely to fail combination diet and swallowed corticosteroid treatment ( P = .02 and P = .002). Conclusion Perennial allergen and mold sensitization may lead to nonresponse to EoE treatment in some patients. Additional studies are needed to further understand the effect of environmental allergens on EoE. Trial Registration ClinicalTrials.gov identifier: NCT01779154.

OBJECTIVES/SPECIFIC AIMS: We sought to investigate the role of the host microbiome during severe, acute respiratory infection (ARI) to understand the drivers of both acute clinical pathogenesis. METHODS/STUDY POPULATION: Nasopharyngeal swabs comprised of mixed cell populations at the active site of infection were collected from 192 hospitalized pediatric patients with ARI. We combined comprehensive respiratory virus detection and virus genome sequencing with 16S rRNA gene sequencing to evaluate the microbial content of the airway during ARI. This data was coupled with 11 clinical parameters, which were compiled to create a clinical severity score. The microbiome profiles were assessed to determine if clinical severity of infection, and/or specific virus was associated with increased clinical severity. RESULTS/ANTICIPATED RESULTS: We identified 8 major microbiome profiles classified by dominant bacterial genus, Moraxella, Corynebacterium, Staphylococcus, Haemophilus, Streptococcus, Alloiococcus, Schlegelella, and Diverse. Increased clinical severity was significantly associated with microbiome profiles dominated by Haemophilus, Streptococcus, and Schlegelella, whereas Corynebacterium and Alloiococcus were more prevalent in children with less severe disease. Independent of the microbial community, more than 60% of patients with the highest clinical severity were infected with either respiratory syncytial virus or rhinovirus. DISCUSSION/SIGNIFICANCE OF IMPACT: Our results indicate that individually and in combination, both virus and microbial composition may drive clinical severity during acute respiratory viral infections. It is still unclear how the complex interplay between virus, bacterial community, and the host response influence long-term respiratory impacts, such as the development of asthma. Nonetheless, during ARIs therapeutic interventions such as antibiotics and probiotics may be warranted in a subset of patients that are identified to have both a virus and microbiome profile that is associated with increased pathogenesis to limit both acute and long-term phenotypes.

The human rhinovirus (HRV) is commonly associated with loss of asthma symptom control requiring escalation of care and emergency room visits in many patients. While the association is clear, the mechanisms behind HRV-induced asthma exacerbations remain uncertain. Immune dysregulation via aberrant immune responses, both deficient and exaggerated, have been proposed as mechanisms for HRV-induced exacerbations of asthma. Epithelium-derived innate immune cytokines that bias Th2 responses, including interleukin (IL)-25, IL-33, and thymic stromal lymphopoietin (TSLP), have also been implicated as a means to bridge allergic conditions with asthma exacerbations. In this review, we discuss the literature supporting these positions. We also discuss new and emerging biotherapeutics that may target virus-induced exacerbations of asthma.

OBJECTIVES/SPECIFIC AIMS: Respiratory viruses cause enormous medical burden, yet many of the specific virus and host genetic factors that impact pathogenesis are still largely unknown or poorly understood. To better understand the drivers of both acute clinical pathogenesis and long-term impacts, such as the development of asthma, we investigated the host response to respiratory syncytial virus (RSV) infections in pediatric patients. METHODS/STUDY POPULATION: We collected nasopharyngeal swabs from 32 pediatric patients with acute RSV infection. The swabs represented a mixed cell population including epithelial and immune cells at the active site of infection. Unbiased RNA sequencing with ribosomal RNA depletion allowed the simultaneous detection of host gene expression and RSV infection. We sequenced samples 2×75 bp on an Illumina NextSeq 500. Sequences were mapped to the human genome using the TopHat 2 aligner and FPKM estimation of reference genes and transcripts and assembly of novel transcripts were conducted with Cufflinks 2. RESULTS/ANTICIPATED RESULTS: During acute RSV infection we identified 7343 genes that were significantly expressed. Pathway analysis using KEGG revealed significant upregulation of pathways involved in innate immune response infection, ribosome function, oxidative phosphorylation, spliceosome and autoimmune disorders. We found high levels of innate immune response genes including CXCL8, IFITM1, IFITM2, IFITM3, IL1RN, and ISG15. In comparing RSV subtype A to RSV B we found significant differential expression of multiple noncoding RNAs. DISCUSSION/SIGNIFICANCE OF IMPACT: Examination of the host gene response during acute RSV infections, yielded important insight into the mechanisms that cause clinical pathogenesis and may provide understanding of the mechanisms that lead to known long-term impacts, such as the development of asthma. Together, this data may be used to guide clinical treatment and management decisions for children with severe RSV infections.

BACKGROUND Rhinovirus and IgE act in concert to promote asthma exacerbations. While basophils are the principal cell type in the blood that is activated by IgE, their role in virus-induced asthma episodes remains elusive. OBJECTIVE To monitor IgE responsiveness in circulating basophils of rhinovirus-infected atopic asthmatics during acute infection and convalescence. METHODS The capacity for basophils to respond to IgE was assessed by testing the effects of allergen, or cross-linking anti-FceRI and anti-IgE antibodies, on surface TSLP receptor in 24-hour PBMC cultures. Activation profiles of basophils from atopic asthmatics challenged intranasally with human rhinovirus 16 were monitored directly ex vivo or else in 24-hour cultures, at baseline (day 0), and then at days 4 and 21 post-challenge. RESULTS Basophils in atopic asthmatics, but not in non-atopic controls, upregulated TSLP receptor upon IgE receptor ligation. The magnitude of this response was correlated with the proportion of serum total IgE that was allergen-specific (r = 0.615, P

Rationale: Most virus-induced attacks of asthma are caused by rhinoviruses (RVs). Objectives: To determine whether people with asthma are susceptible to an increased viral load during RV infection. Methods: Seventy-four children (4–18 yr old) were enrolled; 28 with wheezing, 32 with acute rhinitis, and 14 without respiratory tract symptoms. Nasal washes were evaluated using quantitative polymerase chain reaction for RV to judge viral load along with gene sequencing to identify strains of RV. Soluble intercellular adhesion molecule-1, IFN-λ1, and eosinophil cationic protein in nasal washes, along with blood eosinophil counts and total and allergen-specific IgE in sera, were also evaluated. Similar assessments were done in 24 young adults (16 with asthma, 8 without) who participated in an experimental challenge with RV (serotype 16). Measurements and Main Results: Fifty-seven percent of wheezing children and 56% with acute rhinitis had nasal washes testing positive for RV. The geometric mean of viral loads by quantitative polymerase chain reaction in washes from wheezing children was 2.8-fold lower, but did not differ significantly from children with rhinitis (7,718 and 21,612 copies of viral RNA per microliter nasal wash, respectively; P = 0.48). The odds for wheezing were increased if children who tested positive for RV were sensitized to one or more allergens (odds ratio, 3.9; P = 0.02). Similarly, neither peak nor cumulative viral loads differed significantly in washes from adults with asthma compared with those without asthma during the experimental RV challenge. Conclusions: During acute symptoms, children infected with RV enrolled for wheezing or acute rhinitis had similar viral loads in their nasal washes, as did adults with and without asthma infected with RV-16 experimentally.

Background: Despite the recognition that bacteria are universally present in the sinuses of patients with chronic rhinosinusitis (CRS) no compelling role for a primary infectious etiology of CRS has been elucidated. CRS is a constellation of inflammatory diseases that typically involve either noneosinophilic or eosinophilic processes, distinct conditions that must be treated individually. Methods: The bacteria that are present in the sinuses may be innocuous bystanders but alternatively may contribute to the presence and severity of the disease through their ability to influence immune responses, function as immune adjuvants, provide antigens or superantigens that contribute to adaptive immune activation, or in forming the basis for the frequent acute superinfections. However, those bacteria that do contribute to the persistence and severity of CRS primarily reside in biofilms, and, as such, are not capable of being eradicated with antibiotics at the doses at which they can be used, even when local irrigation is considered. Results: Biofilms create an inhospitable environment for antibiotic potency by down-regulating the metabolic activity of their “core” bacteria, decreasing the oxygen concentration, and altering the pH at the core of the biofilm. Conclusion: Ultimately, if topical antibiotics are considered, they should be primarily focused on treating acute exacerbations and choices of antibiotics should optimally be based on endoscopic culture. This should be done with the recognition that while under certain circumstances antibiotics can ameliorate the severity of CRS, even if bacterial eradication were possible, this would not eliminate the underlying primary pathogenic mechanism or the natural history of these conditions. (Am J Rhinol Allergy 27, 467–472, 2013; doi: 10.2500/ajra.2013.27.3960) C hronic rhinosinusitis (CRS) is a constellation of common and debilitating diseases affecting nearly 14.2% of the U.S. population.1 Historically, these diseases have been primarily categorized into two groups: CRS with nasal polyps (CRSwNPs) and CRS without NPs, reflecting the recognition that CRSwNPs is more prominently associated with eosinophilia. However, noneosinophilic pathogenic sinus disease is recognized to produce NPs and, similarly, not all patients with eosinophilic sinusitis have NPs (at least at the time they present). Insofar as noneosinophilic and the various eosinophilic presentations of CRS have distinct pathogenic mechanisms, for the purpose of this study, we will primarily focus on the pathology-based terms noneosinophilic and eosinophilic CRS with the recognition that the former comprises most of the CRS without NP and the latter most of the CRSwNP subjects.2,3 Eosinophilic sinusitis comprises at least two conditions, including aspirin-exacerbated respiratory disease (AERD) and, most commonly, chronic hyperplastic eosinophilic sinusitis (CHES). CHES is a disease of the upper respiratory tract that mirrors the disease of the lower airways that is often concomitantly expressed in these patients— asthma.4 It is a classically Th2-mediated condition with high levels of interleukin (IL)-4, IL-5, IL-13, and other cytokines and chemokines that together drive the influx of eosinophils into the tissues, cause allergic (IgE) sensitization, and drive goblet cell metaplasia.5–7 In addition to their

A variety of skin disorders are referred to allergists, especially when they are associated with other atopic symptoms and/or blood eosinophilia. Although urticaria and atopic dermatitis are the most common skin manifestations of allergic disease in children and adults, the clinician must maintain a high degree of suspicion with regards to other potential sources of IgE, including biting insects, in a patient with these symptoms.

Rhinovirus (RV) is the most frequent infectious agent associated with exacerbations of wheezing during childhood and among young adults. Areas of investigation which have been improving our understanding for the strong association between RV infections and attacks of asthma include studies that have 1) examined the role of RV infections during infancy in promoting the development of asthma (1-3); 2) demonstrated the striking association between RV infections, allergic sensitization and exposure to environmental allergens among children who wheeze during the pre-school and school-age years (4,5); and 3) examined the mechanisms of RV-induced exacerbations that will hopefully lead to new treatments. From birth through the school-age years, children are frequently exposed to a variety of respiratory tract pathogens and controversies persist as to why rhinovirus stands out as the dominant pathogen linked to wheezing. Surprisingly, mechanisms to explain how RV provokes an attack of asthma remain poorly understood. However, an abundance of data from pediatric population based studies indicate that RV-induced wheezing exacerbations leading to urgent care visits and hospitalizations after 3 years of age are most likely to occur among children who are atopic (4-6). More recently, data from adults with asthma indicate that innate anti-viral responses (e.g., the production of type I and type III interferons) may be deficient in the asthmatic airway and may be instrumental in explaining the susceptibility of the asthmatic population to wheezing attacks caused by RV and possibly other viral pathogens (7,8). Because asthma attacks associated with RV are more common among children than adults (9), the study in this issue of the Journal by Baraldo and colleagues is important and examines whether innate anti-viral responses to RV might also be deficient in the airway of asthmatic children is important. In addition, most pediatric data to date has been derived from studies using nasal washes to test for the presence of virus and associated biomarkers of airway inflammation. Thus, the study by Baraldo et al is unique because of their evaluation of samples obtained via bronchoscopy from four groups of children (mean age 5 years old). These children included two groups with physician-diagnosed asthma (both atopic and non-atopic individuals), one group of atopic children without asthma, and non-atopic children without asthma who were enrolled as controls (12 in each group). The atopic status of these children was evaluated using tests for total IgE and allergen-specific IgE antibodies in sera. Bronchoscopies were obtained when the children were asymptomatic and samples sufficient for the analyses were available from 8 to 9 subjects in each group. During the bronchoscopies, bronchial brushings were obtained to grow epithelial cells in culture along with biopsies for immunohistochemical analyses. The two asthmatic groups were well matched for previous hospitalizations, ER visits, and medication requirements. Only 6 of the children were being treated with low-dose inhaled corticosteroids, 3 in each group, and their results did not differ significantly from those who were not using inhaled steroids. Prior to inoculation of the broncho-epithelial cells with virus, RV (strain 16) RNA was undetectable in all of the primary cell cultures. Following inoculation, the expression of mRNA IFN-λ1 and s was evaluated at 8 hours and the production of protein (i.e., the quantities of IFN-s detected were sufficient for analysis) at 48 hours. Similar to the data previously reported in adults, the authors found that the expression of mRNA for IFN-λ1 and s and the production of IFN-s protein from epithelial cells after infection with RV-16 was also decreased in cells from the atopic asthmatic children, and also from the cells obtained from the non-atopic asthmatics and the atopic children without asthma, compared to samples from the controls. In addition, the production of these innate cytokines in vitro correlated inversely with RV replication as judged by qPCR in supernatants from these cells at 8 hours. The authors conclude that the decreased expression of these cytokines observed within hours after virus inoculation may impart susceptibility to infections with RV in the asthmatic host. Whether this deficiency and the increased viral load observed by the authors (and others in previous studies from adults) reflects how broncho-epithelial cells would respond to a RV infection in the intact airway, and whether this deficiency and increased viral load would persist throughout the course of the infection are important questions. In this regard, significantly higher levels of IFN-λ1 were recently reported in nasal washes from asthmatic children who tested positive for RV during an episode of acute wheezing compared to non-wheezing asthmatic children with RV-induced rhinitis (10). Thus, although the expression of IFN-λ1 in response to RV may be reduced after broncho-epithelial cells from asthmatics are infected in vitro, the production of this cytokine during an attack of RV-induced asthma appears to be enhanced, at least in the upper airway where this virus replicates vigorously. The beauty of the biopsy results reported by the authors is the discovery of increased tissue eosinophila and IL-4 expressing cells along with epithelial cell damage not only in samples from the atopic asthmatics, but also in biopsies from non-atopic asthmatics and the atopic children without asthma. These results were also inversely related to the expression of IFN-λ1 and s mRNA in the broncho-epithelial cells infected in vitro. The results from the children with asthma who were not atopic is of interest, because there is little information about this group in the literature, and because the presence of Th2-driven immunopathology in their lower airway may, as noted by the authors, also impart a greater risk for acute asthma symptoms provoked by RV, even in the absence of allergic sensitization. Of note, however, is that compared to the atopic asthmatic children in this study, the non-atopic asthmatics had significantly lower levels of blood eosinophilia and a trend toward lower tissue eosinophilia in their biopsies. This might suggest a better prognosis for these children; however, a larger longitudinal-based study is needed which may be difficult because non-atopic asthmatic children at this age represent a minority (< 20%) of those who need hospitalization or treatment in the ER for acute wheezing (4,6,11). Among the atopic children without physician-diagnosed asthma, the authors also discovered Th2-associated immunopathology in their biopsy samples along with reduced IFN-λ1 and s expression in their broncho-epithelial cells after RV-16 inoculation. However, like the other children in this study, the 8 children in this group had clinical indications for their bronchoscopies, including 5 who were being evaluated for recurrent pneumonias, 2 for chronic cough, and one for middle-lobe syndrome. So these children differ from the majority of children with allergic rhinitis who do not require bronchoscopic evaluations with reasons that might be consistent with asthmatic changes in their lower airway. More directly related to the relevance of atopy, the authors found a positive correlation between levels of total IgE in sera from the entire study population and the increased viral load detected in their epithelial cell supernatants at 8 hours and an inverse correlation between total IgE and the expression of IFN-λ1. These results are in keeping with a recent study of school-aged asthmatic children demonstrating that increasing serum titers of allergen specific IgE antibody (e.g., to dust mite allergen) substantially increases the probability of wheeze provoked by RV (11). Taken together, the data from the study by Baraldo and co-authors provide important information relevant to the pediatric population and help to highlight the importance of defining the atopic status of asthmatic subjects in studies to decipher the mechanisms of wheezing induced by rhinovirus.

Introduction In-office medical emergencies can be a source of trepidation for both medical and administrative personnel. Lack of preparation, equipment, training, and communication amongst staff are cited as the most frequent reasons for suboptimal patient care in an office emergency in a general pediatric or family practice clinic. This resource utilizes hybrid simulations using standardized patients and high-fidelity mannequins for anaphylaxis and asthma treatments in an office setting to teach medical students, nurses, residents, and physicians (learners) the importance of prompt treatment of allergic emergencies. Methods Within this resource, we provide three case presentations of patients requiring emergent treatment for allergic emergencies. These cases are considered hybrid scenarios because they require the use of both standardized patients with high-fidelity mannequins. Each simulation has a separate script required to introduce the case. We have also provided a flow diagram for the scenarios that will allow staff members who are responsible for real-time changes in the simulations to make adjustments in the outcomes of these simulations dependent upon learner input. Results We have utilized these simulations in a research study performed at the University of Arkansas Children's Hospital. Participant scores demonstrated improved team management skills with simulation training in office emergencies. Because the true outcome of interest in office emergencies is the outcome of resuscitations, we cannot determine whether utilizing these simulations improved emergency care to actual patients. Discussion Upon seeing the mannequin, some of the learners did not take the scenario seriously, perhaps taking longer than they would to perform an actual emergency resuscitation. We attempted to improve this outcome by stressing the importance of participant buy-in. In postworkshop feedback from learners, subjects felt as if they were responding to a true emergency if the scenario was thrust upon them during other instruction due to its unexpected nature.

It has been recognized for many years that leukotrienes play an important role in mediating various effects of the allergic reaction. Recent evidence has shown that they play a role in other diseases including chronic sinusitis, particularly those sub-types involving eosinophils. Leukotrienes can be separated into the fairly well characterized cysteinyl leukotrienes and less well characterized leukotriene B(4). Effects of the leukotrienes are mediated through receptors that are expressed on a variety of cell types and can be modulated based on the inflammatory environment present. The pharmaceutical industry has long been interested in blocking leukotriene action and as such, two approaches have been developed that led to drugs approved for treatment of allergic disease. The most widely used class is the cysteinyl type 1 receptor antagonists, which block binding of the cysteinyl leukotrienes to the cell. The second class is an inhibitor of the 5-lipoxygenase enzyme that prevents synthesis of both the cysteinyl leukotrienes and leukotriene B(4). This review will focus on the role that leukotrienes play in chronic sinusitis and consider the rationale for choosing either a leukotriene antagonist or synthesis inhibitor as a treatment option. We will also discuss off-label uses for other medications that might be useful in these diseases as they relate to their ability to modulate leukotriene action.