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195 Deaths associated with skin testing and immunotherapy
J ALLERGYCLINIMMUNOL
Abstracts
VOLUME 97, NUMBER t, PART3 193
Isolation and Partial Purification of Allergenic
195
Components of the Pollens Paspalum notatum and Melaleuca leucadendron. Susan Lee Hunter MS. RN Genn~Ir0 PhD. SD Klotz MD. M.I Sweeney PhD, RS White PhD. Orlando, FL Allergenic components obtained from extracts of the pollen of Paspalum notatum (bahia) and Melaleuca leucodendron (melaleuca) were separated using sodium dodecyl sulfatepolyaciTlamide gel electrophoresis (SDS-PAGE), skin testing and radioallergesorbent test (RAST) inhibition. IEF analysis of each pollen extract produced 20 fractions. These fractions were pooled according to their protein banding patterns in SDS-PAGE, resulting in six major fractions. SDS-PAGE analysis of each of the six resulting fractions of bahia (pH from 3.4 to 10.2) detected more than 17 protein components (M. W. ~ 17 kD to 70 kD). Similar analysis of each of the six major fractions of melaleuca elicited positive skin test reactions in allergic patients and inhibited the binding oflgE positive sera to allergen coated discs. RAST inhibition demonstrated that four of the six bahia fractions could inhibit the binding of anti-melaleuca-lgE to melaleuca allergen discs by greater than 60%. Less than 30% inhibition was observed when melaleuca fractions were used to inhibit the binding of antibahia-lgE to bahia allergen discs. IEF separation of Callistemon citrinis (bottlebrush) pollen extract was attempted but was not successful. These studies strongly suggest allergenic crossreactivity between bahia grass pollen and melaleuca tree pollen.
231
DEAIIiSASSOCIATE])WIll~ SKINTESTING~ IMvUkOII-ERAPY Michael Reid, ~D and Gary Gurka, ~ , San Francisco, CA and I~¢ling~o~l, l ~
Allergy skin testing and inmu~therapy have an i n t r i n s i c risk s i n ~ they iatrogenically expose individuals to allerg~ts. In order t o r~tt~-e or control t h i s risk, t h e St~ardization Ca~mittee of the Academyof Allergy, Asthma, and Irmu~ology decided to study these events. CoTfidential peer-revieweddata have beencollected for several years.
This a b s t r a c t is a continuation of the
previous study and covers events frcm January, 1990to J~w~, 1995. Twenty-eightdeaths were reported during these 66 months (average 5 per year), b~TForta~ately,data were incomplete in 19/28 (30%) reports. Analysis of the available data reveals: 1/28 (5%) frcm intradermal skin testing 27/28 (95%) from imJnotherapy 4/27 (15%) frcm hone injections or shots given with no ND present 3/27 (11%) associated with an "incorrect" dose 19/26 (73%) in individuals with atcpic asthma 15/22 (68%) death occurred despite appropriate post-reacti~1 intervention There was no male/female differo~e in events. The age r ~ e at the time of death v~s 12 to 73 years. V~ere data were available, no clear "in season" predcminance of events was obvious. No single aspect appears to predict an unfavorable o u t ~ from skin testing and inmunotherapy. Co]tinned caution, especially with atopic astl-matics, is
194
Variations in the Administration of Allergy I m m u n o t h e r a p y (AI) i n K a n s a s . Soeken RN. KA Fisher RN. D Walker. BS. Great Bend, KS AI is effective in reducing symptoms due to atopic disease. Fatalities from AI are rare, and guidelines to minimize the risk of systemic reactions from At have been published. The rate of adherence to these guidelines is unknown. The aim of this study was to survey the management of At in rural Kansas, and to compare these findings with the gaidclincs of the AAAI Position Statement on minimizing the risk from AI. Questionnaires were administered by the author to 21 health care providers (hcp) and 30 injectors (inj). The questions were based on the AAAI Position Statement and were conducted as a personal interview with an on-site visit. Only 13% of inj had received formal training in AI. Results of the inj survey included: 33% had no previous experience with At; 70% did not know tl~ correct dose of epincphrinc; 67% had not obtained IV access in the past year;, and 83% had not performed CPR in the past 12 months. Deviations from the Position Statement among hcp included: 33% had not initiated IV access within the past year (43% had within 1 month of the questiommirc); 57% did not have a written policy fo~ anaphylaxis; 24% had not performed CPR within the last year (55% manage cardiac arrest at least 4 times/year); 67% inftgqucnfly or never know the concentration ofaUergy extract injected; 52% and 33% did not know the dose of vasopressors or aminophylline, respectively. If currently published recommendations to minimize the risk from systemic reactions are followed, there should he: mote standardized training for injectors, including experience with IV access m~ CPR; more education of hcp regarding the importance of extract dilutions and dose adjustments; and less reliance on informal training for AL
196
Molecular Changes Following Vaccination and lmmunotherapy with a Multi-epitopic Recombinant AHergen. SS Mohavatra PhD,. Y Cao MD. Z Luo MD Winnipeg, Canada We have established a murine model to investigate the potepfial and mechanism of recombinant allergen (rAL)-vaccination and -immunotherapy (IT) of allergic disorders in humans. Vaccination of B6D2FI mice by i.v.or s.c.with soluble rKBG8.3, a recombinant Kentucky Blue Grass (KBG) pollen allergen comprising multiple T and B cell epitopes, prior to their immunization with the rAL in alum, led to marked suppression of IgE Abs with concomitant increases in lgG2a Abs. Analysis of cytokine patterns indicated marked reductions oflL-2, IL-4, and TGF - # levels, and to a lesser degree reduction of IFN-y production in vaccinated mice compared to untreated controls. Vaccination resulted in an increased ratio of IFN-.-FIL-4 suggesting induction de novo of preferential TH2 cell anergy. Further, vaccination with rat, followed by immunization with KBG extract led to an increzse in extract-specific lgG2a Ab production. Moreover, treatment with soluble rAL of mice primed with rAL and alum resulted in an increased IFN--/ production by splenocytes of treated mice compared to those of controls. In addition, preliminary analyses by differential display technique of spleen and lymphnode mRNAs led to identification of several ( - 1 0 ) transcripts which either increased or decreased in the vaccinated mice compared to those of the controls. Collectively, these results demonstrate that both vaccination and/or IT with rAL induce changes which parallel allergen-injection IT in allergic patients and that this model can be exploited to identify additional
molecular changes that may be pivotal to successful IT.
Abstracts
VOLUME 97, NUMBER t, PART3 193
Isolation and Partial Purification of Allergenic
195
Components of the Pollens Paspalum notatum and Melaleuca leucadendron. Susan Lee Hunter MS. RN Genn~Ir0 PhD. SD Klotz MD. M.I Sweeney PhD, RS White PhD. Orlando, FL Allergenic components obtained from extracts of the pollen of Paspalum notatum (bahia) and Melaleuca leucodendron (melaleuca) were separated using sodium dodecyl sulfatepolyaciTlamide gel electrophoresis (SDS-PAGE), skin testing and radioallergesorbent test (RAST) inhibition. IEF analysis of each pollen extract produced 20 fractions. These fractions were pooled according to their protein banding patterns in SDS-PAGE, resulting in six major fractions. SDS-PAGE analysis of each of the six resulting fractions of bahia (pH from 3.4 to 10.2) detected more than 17 protein components (M. W. ~ 17 kD to 70 kD). Similar analysis of each of the six major fractions of melaleuca elicited positive skin test reactions in allergic patients and inhibited the binding oflgE positive sera to allergen coated discs. RAST inhibition demonstrated that four of the six bahia fractions could inhibit the binding of anti-melaleuca-lgE to melaleuca allergen discs by greater than 60%. Less than 30% inhibition was observed when melaleuca fractions were used to inhibit the binding of antibahia-lgE to bahia allergen discs. IEF separation of Callistemon citrinis (bottlebrush) pollen extract was attempted but was not successful. These studies strongly suggest allergenic crossreactivity between bahia grass pollen and melaleuca tree pollen.
231
DEAIIiSASSOCIATE])WIll~ SKINTESTING~ IMvUkOII-ERAPY Michael Reid, ~D and Gary Gurka, ~ , San Francisco, CA and I~¢ling~o~l, l ~
Allergy skin testing and inmu~therapy have an i n t r i n s i c risk s i n ~ they iatrogenically expose individuals to allerg~ts. In order t o r~tt~-e or control t h i s risk, t h e St~ardization Ca~mittee of the Academyof Allergy, Asthma, and Irmu~ology decided to study these events. CoTfidential peer-revieweddata have beencollected for several years.
This a b s t r a c t is a continuation of the
previous study and covers events frcm January, 1990to J~w~, 1995. Twenty-eightdeaths were reported during these 66 months (average 5 per year), b~TForta~ately,data were incomplete in 19/28 (30%) reports. Analysis of the available data reveals: 1/28 (5%) frcm intradermal skin testing 27/28 (95%) from imJnotherapy 4/27 (15%) frcm hone injections or shots given with no ND present 3/27 (11%) associated with an "incorrect" dose 19/26 (73%) in individuals with atcpic asthma 15/22 (68%) death occurred despite appropriate post-reacti~1 intervention There was no male/female differo~e in events. The age r ~ e at the time of death v~s 12 to 73 years. V~ere data were available, no clear "in season" predcminance of events was obvious. No single aspect appears to predict an unfavorable o u t ~ from skin testing and inmunotherapy. Co]tinned caution, especially with atopic astl-matics, is
194
Variations in the Administration of Allergy I m m u n o t h e r a p y (AI) i n K a n s a s . Soeken RN. KA Fisher RN. D Walker. BS. Great Bend, KS AI is effective in reducing symptoms due to atopic disease. Fatalities from AI are rare, and guidelines to minimize the risk of systemic reactions from At have been published. The rate of adherence to these guidelines is unknown. The aim of this study was to survey the management of At in rural Kansas, and to compare these findings with the gaidclincs of the AAAI Position Statement on minimizing the risk from AI. Questionnaires were administered by the author to 21 health care providers (hcp) and 30 injectors (inj). The questions were based on the AAAI Position Statement and were conducted as a personal interview with an on-site visit. Only 13% of inj had received formal training in AI. Results of the inj survey included: 33% had no previous experience with At; 70% did not know tl~ correct dose of epincphrinc; 67% had not obtained IV access in the past year;, and 83% had not performed CPR in the past 12 months. Deviations from the Position Statement among hcp included: 33% had not initiated IV access within the past year (43% had within 1 month of the questiommirc); 57% did not have a written policy fo~ anaphylaxis; 24% had not performed CPR within the last year (55% manage cardiac arrest at least 4 times/year); 67% inftgqucnfly or never know the concentration ofaUergy extract injected; 52% and 33% did not know the dose of vasopressors or aminophylline, respectively. If currently published recommendations to minimize the risk from systemic reactions are followed, there should he: mote standardized training for injectors, including experience with IV access m~ CPR; more education of hcp regarding the importance of extract dilutions and dose adjustments; and less reliance on informal training for AL
196
Molecular Changes Following Vaccination and lmmunotherapy with a Multi-epitopic Recombinant AHergen. SS Mohavatra PhD,. Y Cao MD. Z Luo MD Winnipeg, Canada We have established a murine model to investigate the potepfial and mechanism of recombinant allergen (rAL)-vaccination and -immunotherapy (IT) of allergic disorders in humans. Vaccination of B6D2FI mice by i.v.or s.c.with soluble rKBG8.3, a recombinant Kentucky Blue Grass (KBG) pollen allergen comprising multiple T and B cell epitopes, prior to their immunization with the rAL in alum, led to marked suppression of IgE Abs with concomitant increases in lgG2a Abs. Analysis of cytokine patterns indicated marked reductions oflL-2, IL-4, and TGF - # levels, and to a lesser degree reduction of IFN-y production in vaccinated mice compared to untreated controls. Vaccination resulted in an increased ratio of IFN-.-FIL-4 suggesting induction de novo of preferential TH2 cell anergy. Further, vaccination with rat, followed by immunization with KBG extract led to an increzse in extract-specific lgG2a Ab production. Moreover, treatment with soluble rAL of mice primed with rAL and alum resulted in an increased IFN--/ production by splenocytes of treated mice compared to those of controls. In addition, preliminary analyses by differential display technique of spleen and lymphnode mRNAs led to identification of several ( - 1 0 ) transcripts which either increased or decreased in the vaccinated mice compared to those of the controls. Collectively, these results demonstrate that both vaccination and/or IT with rAL induce changes which parallel allergen-injection IT in allergic patients and that this model can be exploited to identify additional
molecular changes that may be pivotal to successful IT.