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Contact urticaria and anaphylaxis to latex
Journal of the American Academy of Dermatology
Adams 32. Hodgson G. Cutaneous hazards of lubricants. Ind Med 1970;39:41-6. 33. Rycroft RJG. Is Grotan BK a contact sensitizer? Br J Dermatol 1978;99:346-7. 34. Alomar A, Conde-Salazar L, Romaguera C. Occupational dermatoses from cutting oils. Contact Dermatitis 1985; 12:129-38, 35. van Ketel WG, Kisch LS. The problem of the sensitizing capacity of some grotans used as bacteriocides in cooling oils. Dermatosen 1983;31:118-21. 36. deGroot AC, Weyland JW. Kathon CG. A review. J AM AcAI~DERMATOL1988;18:350-8. 37. Adams RM. Allergic contact dermatitis due to o-phenylphenol. Contact Dermatitis 1981;7:332. 38. Fisher AA. Allergic contact dermatitis of the hands due to industrial oils and fluids. Cuds 1979;23:131-242. 39. Alomar A. Contact dermatitis from benzisothiazolone in cutting oils. Contact Dermatitis 1981;7:155-6. 40. Andersen KE. 1986. Contact allergy to chlorocresol,formaldehyde and other biocides. Guinea pig tests and clinical studies. Acta Derm Venereol (Stoclda) 554(suppl):1986; 180-90. 41. Samitz MH, Shmunes E. Occupational dermatoses in dentists and allied personnel Cutis 1969;5:180-4. 42. Gall H. Allergien auf zahn~irztlicheWerkstoffe und Dentalpharmaka. Hautarzt 1983;34:326.
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43. Kanerva L, Jolanki P, Esflander OD. Occupational dermatitis due to an epoxyacrylate. Contact Dermatitis 1986; 14:80-4. 44. American Dental Association.Dentist's desk reference.2nd ed. Chicago: American Dental Association, 1983:71-2. 45. Magnusson B. Sensitizing effect of eugenol/colophony in surgical dressing. Cont Derm Newsletter 1974;15:454-5. 46. Cronin E. Impregum (dental impression material). Cont Derm Newsletter 1973;13:362. 47. Groeningen G, Nater JP. Reactions to dental impression materials. Contact Dermatitis 1975;1:373-6. 48. Fisher AA. Allergic sensitivityof the skin and oral mucosa to acrylic denture material. JAMA 1959;156:238. 49. BakerI-LContact dermatitis:Triazine film hardener. Trans St John's Hosp Dermatol Soc 1971;57:243. 50. Brandao FM, Cardoso JPM. Contact dermatitis to CD4. Contact Dermatitis 1985;12:48-62. 51. Herin RW, Olivares IA. Tropical storage of processed negatives. Photographic Sci Eng 1960;4:229. 52. Dowrtham TF, Birmingham DJ. Contact dermatitis to photographic print coating liquid. Cuffs 1980;25:421-3. 53. Liden C. Contact allergy to the photographic chemical PBA-1. Contact Dermatitis 1984;11:256. 54. Nater JP: Allergic contact dermatitis due to potassium metabisulfite in developers. Dermatologica 1968;136: 477-8.
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Contact urticaria and anaphylaxis to latex James S. Taylor, M D , a Joan Cassettari, DO, b William Wagner, MD, b and T h o m a s Helm, M D a Cleveland, Ohio Contact urticaria and anaphylaxis to latex is reported in two patients. One case was associated with oral and vaginal exposure to a condom and the other with rectal exposure to a tatex glove. Both patients had positive reactions to scratch or prick tests to pieces of latex, as well as latex radioaUergosorbent test (RAST). The diagnosis of contact urticaria to latex is difficult to make on the basis of history alone. (J AM ACAD DERMATOL1989;21:874-7.) Contact urticaria to natural latex products, primarily medical-surgical gloves a n d balloons, has recently been reported. 1-12 Several of these cases have involved anaphylactic reactions.l' 6,12 W e report two cases of anaphylaxis to latex, one to a condom and the other to a glove.
From the Department of Dermatologya and Allergy? The Cleveland Clinic Foundation. Reprint requests: James S. Taylor, MD, Department of Dermatology, The Cleveland Clinic Foundation, 9500 Euclid Ave,, Cleveland, OH 44106. 16/0/12915
874
CASE REPORTS Case 1 A 48-year-old white woman c a m e to the Cleveland Clinic in April 1987 for evaluation of possible allergy to rubber. She had been a nurse at a community hospital for 6 years a n d had had hand eczema for 25 years. In 1986 localized pruritus and urticaria had developed within minutes of donning latex gloves. As the year progressed, generalized urticaria, facial angioedema, rhinitis, and bronchospasm developed after 15 to 30 minutes of exposure to rubber gloves. Recently she also experienced lip swelling when blowing a balloon. Occasionally she
Volume 21 Number 4, Part 2 October 1989
took diphenhydramine hydrochloride to control the symptoms. Just before admission to her local community hospital in March 1987, her husband used a latex condom during intercourse with the patient. She had oral and vaginal exposure to the condom, and there was vaginal irritation and bleeding. Within minutes generalized urticaria, facial and laryngeal angioedema, and respiratory distress developed. On arrival at the emergency room she was treated with epinephrine, diphenhydramine hydrochloride, intravenous fluids, and hydrocortisone sodium succinate. She was admitted to the intensive care unit, remained hospitalized for 2 more days, receiving additional systemic diphenhydramine and corticosterold therapy, and was discharged in good condition. No lubricant was used with the condom, and she had never previously been exposed to a condom. No allergic reaction occurred before or after this systemic reaction. The patient's medical history was significant for rhinitis and eczema of 25 years' duration, asthma that had been in remission for 20 years, nasal polypectomy, removal of a benign parotid tumor, and a hysterectomy. During a nasal polypectomy procedure, respiratory distress and urticaria of her upper body developed. Face-mask oxygen was administered to relieve shortness of breath. She also experienced urticaria and angioedema after administration of radiocontrast dye and amoxicillin. She was a nonsmoker. There was a family history of asthma. When we first examined the patient, her blood pressure was 120/76 mm Hg, pulse 84 bpm, and temperature 36.5 ° C. Findings of a complete physical examination were normal except for several chronic eczematous plaques on the nape of the neck, excoriated papules on the forearms, and pale nasal turbinates without polyps. Patch testing for delayed contact sensitivity was performed with chemical and methods of the North American Contact Dermatitis Group. At the 1-week readings there were past or present relevant positive reactions to ethylenediamine dihydrochloride 1% (2+), nickel sulfate 1.5% (1+), quaternium-15 2% ( 1+ ), cobalt chloride 1% ( 1+), toluene sult'onamide formaldehyde resin 10% (1+), and ethyl methacrylate 5% (2+). Results of patch testing with pieces of eight different surgical gloves (latex and vinyl) were negative at 1 week. Results of allergy skin testing by the scratch and
875
Contact urticaria and anaphylaxis to latex
Table
I, Immediate hypersensitivity skin test
results . _ Case 1 Test item
Latex glove* Triflex, nonsterile Triflex, sterile Eudermic Perry Elastyren Ansell (8605) (powderless) Vinyl glove* Becton Dickinson Tru Touch Latex glove(washed) Perry Talc Corn starch Dried centrifugedlatex Latex condom* Latex condom (washed)
I Scratch
+ + + + + -
Case 2
IPrick I S..c~t¢.h I Prie.k + +-~ ++ +NT
-
NT
+
NT
-
NT
-
N T
NT + +
+ + +
NT + NT NT NT NT
-
NT -
NT NT NT
NT NT NT NT NT NT
NT
NT NT NT NT NT NT
NT, Not tested.
*Soaked in salilaesolution. t + - denotes doubtful.
intradcrmal methods to the common inhalants and selected foods were positive only to house dust mite. She was tested for immediate hypersensitivity by the open patch test and scratch methods to latex and vinyl gloves and the latex condom. By the open patch test a 1.0 x 1.0 cm piece of each material was placed on the patient's forearm and observed for 15 minutes. All test findings were negative. For the scratch tests 1.0 X 1.0 cm pieces again soaked in sterile saline solution were placed on the scratch and observed for 15 minutes. One glove and the condom were tested again after washing in soap and water. Histamine (positive) and sterile saline (negative) controls were done. Significant wheal-and-flare reactions developed to the latex glove and condom only (both washed and unwashed). Three controls yielded negative results to scratch tests with the gloves and condom. At a subsequent visit, scratch testing to various glove powders and lubricants, ineluding corn starch, was negative. Prick testing with 1- or 24-hour latex glove and condom solutions according to the method of Turjanmaa 9 and Turjanmaa and Reunala 1° was performed on another visit. There was general concordance with the scratch test results except as noted in Table I.
876
Journal of the American Academy of Dermatology
Taylor et aL
A commercially available radioallergosorbent (RAST) test was performed for latex-specific IgE and was positive at 2.7 Phadebas RAST Units (PRU) (Latex-Hevea braziliensis Phadezym RAST allergen discs, MK82, No. 61682, Pharmacia, Piscataway, N.J.). The recommended test protocol was followed except for using a longer overnight incubation time for the discs and serum. The patient was instructed to avoid natural latex products (e.g., latex gloves, balloons, condoms, and rubber bands) and use vinyl gloves at work. She was treated with hydroxyzine for the pruritus and urticaria and instructed to use an Epi-Pen (Center Laboratories, New York) in the event of a serious allergic reaction. Exposure to condoms has been avoided, and no further anaphylactic reactions have occurred. When seen in follow-up she was wearing vinyl gloves at work and had no pruritus, contact urticaria, or angioedema. Case 2 A 10-year-old adopted white girl with myelomeningocele, hydrocephalus, neurogenic bladder, and biIateral congenital dislocated hips and leg length discrepancies was referred for evaluation of rubber allergy before elective surgery in May 1987. Since early childhood the patient would develop facial urticaria on exposure to balloons or rubber gloves. In 1986 when her mother used rubber gloves for manual disimpaction (the first time she had ever done this), within 10 minutes generalized urticaria, angioedema, and respiratory distress (bronchospasm) developed. She was treated at home by her physician with diphenhydramine hydrochloride, and symptoms resolved within 24 hours. She had at least three previous operations in the past 5 years for her multiple congenital problems, without apparent difficulties. She had no history of asthma or allergic rhinitis. A complete physical examination was entirely within normal limits. Her blood pressure was 95/70 turn Hg and pulse 88 bpm. The patient was skin tested for immediate hypersensitivity by the open patch and scratch methods with 2.0 by 2.0 cm squares of Becton Dickinson vinyl Tru Touch and Triflex sterile latex glove materials soaked in saline solution. Results of skin testing with vinyl glove pieces were negative. Within 4 minutes of applying the latex glove material to the scratch, the patient developed a strong localized wheal-and-flare reaction. On a subsequent visit the patient was scratch
tested with several glove powders, including corn starch, with negative results. The same commercially available RAST used for patient 1 was positive for latex-specific IgE at 1.8 PRU. DISCUSSION
Latex is found in the Hevea braziliensis tree, and the antigen responsible for symptoms is present in natural latex. The antigen appears to be a protein with a molecular weight of 30,000 daltons. 3 In 1979 Nutter 2 described contact urticaria to latex in a housewife wearing cleaning gloves. Since then a number of reports 1,3-12 have discussed immediate allergic reactions to latex. Some of the previously reported cases have been reviewed by Taylor 1~ and by Turjanmaa and Reunala. 1° Moreover, most patients have been medical personnel (nurses and physicians) or homemakers. Contact urticaria to latex products is not as uncommon as previously thought. A study to determine the frequency of immediate surgical latex glove allergy (contact urticaria) among hospital personnel was conducted by Turjanmaa 9 in Finland. Of 512 hospital employees screened with a latex glove prick and use test, 15 (2.9%) had confirmed positive reactions. In operating units 7.4% of the doctors and 5.6% of the nurses were allergic. In addition to surgical work other predisposing factors were atopy (67%) and hand eczema. Turjanmaa et al.1 also described two patients who had anaphylactic reactions while undergoing surgery (cesarean section and sterilization), probably from the surgeons' latex gloves and rubber anesthetic supplies. Interestingly, both patients were also nurses. In two separate articles Axelsson et al. 6,12reported two atopic children with anaphylaxis when blowing up rubber balloons t2 and five adults with anaphylaxis from wearing latex gloves, from exposure to a latex dental dam, and during surgery or routine gynecologic examination. 6 Juhlin has seen anaphylaxis develop from exposure to pollen in a latex condom (personal communication, August 1988). We have described two cases of anaphylaxis, one from a latex condom and the other from latex gloves. Both patients previously had dermatologic or respiratory symptoms on exposure to latex products. An anaphylactic reaction appeared to occur with mucosal contact (oral, vaginal, or rectal). We documented positive skin tests to many rubber products but not to vinyl products. Also, both patients had positive latex RAST (IgE) tests. In the
Volume 21 Number 4, Part 2 October t989
Contact urticaria and anaphylaxis to latex
first case seminal fluid was not the cause of the allergic reaction since the patient did not experience any other reactions during sexual intercourse before or after the anaphylactic episode. Also, powder on the latex products was not the cause, since in both cases reactions to washed materials were still positive and scratch tests to various powders were negative. Immediate hypersensitivity to rubber latex products not only includes dermatologic and respiratory manifestations but can often progress to more serious anaphylactic reactions. Allergists and dermatologists have to become aware of this medical problem as the use of latex gloves and condoms increases. Evaluation of suspected cases should include a careful history to elicit immediate symptoms and signs of urticaria, use test (one finger only), patch, scratch, or prick tests, and R A S T tests to latex. Concomitant hand eczema may mask the diagnosis. Care should be taken to interpret results correctly and avoid harmful, life-threatening test reactions. 1°
2. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979;101:597-8. 3. Carrillo T, Cuevass M, Munez T, Hinojosa M, Maneo I. Contact urticaria and rhinitis from latex surgical gloves. Contact Dermatitis 1986;15:69-72. 4. Kleinhans D. Contact urticaria to rubber gloves. Conhact Dermatitis 1984;10:124-5. 5. Forstrom L. Contact urticaria from latex surgical gloves. Contact Dermatitis 1980;6: 33-34. 6. Axelsson JGK, Johansson SGO, Wragsjo K. IgE-mediated anaphylactoid reactions to rubber. Allergy 1987;42:46-50. 7. Meding B, Fregert S. Contact urticaria from natural latex gloves. Contact Dermatitis 1984;10:42-3. 8. Forsch PJ, Wahl R, Bahmer FA, Mausch HJ. Contact urticaria to rubber gloves is IgE mediated. Contact Dermatitis 1986;145:241-5. 9. Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987; 17:270-5. 10. Turjanmaa K, Reunala T. Contact urticaria from rubber gloves. Dermatol Clin 1988;6:47-51. 11. Taylor JS. Rubber. In: Fisher AA, ed. Contact dermatitis. 3rd ed. Philadelphia: Lea and Febiger, 1986:632. 12. Axelsson JGK, Eriksson M, Wrangsjo K. Anaphylaxis and angioedema due to rubber allergy in children. Aeta Pediatr Scand 1988;77:314-16.
REFERENCES 1. Turjanmaa K, Reunala T, Tuimala R, Karkkainen T. Severe IgE mediated allergy to surgical gloves [Abstract]. Allergy 1984;2(suppl):35.
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The compilation of patch test information by the use of computerized data bases James R. Nethercott, MD, and D. Linn Holness, MD Toronto, Ontario, Canada The use of computer technology to store, retrieve, and analyze patient data is not new. This article reviews the use of computerized data bases in patch test result record keeping. Efforts of the North American Contact Dermatitis Group serve as an example of how to create, manage, and apply these data. (J AM ACAD D~RMATOL1989;21:877-80.) Many investigators have reported the results of patch testing carried out in many parts of the world) -7 Such group data give insight into the relative importance of particular chemicals as allergic contactants. They also allow the evaluation of such From the Department of Occupationaland EnvironmentalHealth, St. Michael's Hospital, Universityof Toronto. Reprint requests: J. R. Nethercott, MD, Johns Hopkins University, Occupational Health Department, School of Hygiene and Public Health, 615 N. Wolfe St., Baltimore, MD 21205. 16/0/12914
factors as age, sex, occupation, and site as contributing factors. ~s Manual data collection has been the standard method of tabulation of such information, but computerized record keeping is becoming more common. Fabbri and Sertoli 9 reported the use of a computer data management program in 1971. Their group subsequently reported the utilization of this data base in the evaluation of trends in patch test responses) ° Dooms-Goossens and her Belgian associates reported on their use of a computerized data base management system they used to compile 877
Adams 32. Hodgson G. Cutaneous hazards of lubricants. Ind Med 1970;39:41-6. 33. Rycroft RJG. Is Grotan BK a contact sensitizer? Br J Dermatol 1978;99:346-7. 34. Alomar A, Conde-Salazar L, Romaguera C. Occupational dermatoses from cutting oils. Contact Dermatitis 1985; 12:129-38, 35. van Ketel WG, Kisch LS. The problem of the sensitizing capacity of some grotans used as bacteriocides in cooling oils. Dermatosen 1983;31:118-21. 36. deGroot AC, Weyland JW. Kathon CG. A review. J AM AcAI~DERMATOL1988;18:350-8. 37. Adams RM. Allergic contact dermatitis due to o-phenylphenol. Contact Dermatitis 1981;7:332. 38. Fisher AA. Allergic contact dermatitis of the hands due to industrial oils and fluids. Cuds 1979;23:131-242. 39. Alomar A. Contact dermatitis from benzisothiazolone in cutting oils. Contact Dermatitis 1981;7:155-6. 40. Andersen KE. 1986. Contact allergy to chlorocresol,formaldehyde and other biocides. Guinea pig tests and clinical studies. Acta Derm Venereol (Stoclda) 554(suppl):1986; 180-90. 41. Samitz MH, Shmunes E. Occupational dermatoses in dentists and allied personnel Cutis 1969;5:180-4. 42. Gall H. Allergien auf zahn~irztlicheWerkstoffe und Dentalpharmaka. Hautarzt 1983;34:326.
I
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43. Kanerva L, Jolanki P, Esflander OD. Occupational dermatitis due to an epoxyacrylate. Contact Dermatitis 1986; 14:80-4. 44. American Dental Association.Dentist's desk reference.2nd ed. Chicago: American Dental Association, 1983:71-2. 45. Magnusson B. Sensitizing effect of eugenol/colophony in surgical dressing. Cont Derm Newsletter 1974;15:454-5. 46. Cronin E. Impregum (dental impression material). Cont Derm Newsletter 1973;13:362. 47. Groeningen G, Nater JP. Reactions to dental impression materials. Contact Dermatitis 1975;1:373-6. 48. Fisher AA. Allergic sensitivityof the skin and oral mucosa to acrylic denture material. JAMA 1959;156:238. 49. BakerI-LContact dermatitis:Triazine film hardener. Trans St John's Hosp Dermatol Soc 1971;57:243. 50. Brandao FM, Cardoso JPM. Contact dermatitis to CD4. Contact Dermatitis 1985;12:48-62. 51. Herin RW, Olivares IA. Tropical storage of processed negatives. Photographic Sci Eng 1960;4:229. 52. Dowrtham TF, Birmingham DJ. Contact dermatitis to photographic print coating liquid. Cuffs 1980;25:421-3. 53. Liden C. Contact allergy to the photographic chemical PBA-1. Contact Dermatitis 1984;11:256. 54. Nater JP: Allergic contact dermatitis due to potassium metabisulfite in developers. Dermatologica 1968;136: 477-8.
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Contact urticaria and anaphylaxis to latex James S. Taylor, M D , a Joan Cassettari, DO, b William Wagner, MD, b and T h o m a s Helm, M D a Cleveland, Ohio Contact urticaria and anaphylaxis to latex is reported in two patients. One case was associated with oral and vaginal exposure to a condom and the other with rectal exposure to a tatex glove. Both patients had positive reactions to scratch or prick tests to pieces of latex, as well as latex radioaUergosorbent test (RAST). The diagnosis of contact urticaria to latex is difficult to make on the basis of history alone. (J AM ACAD DERMATOL1989;21:874-7.) Contact urticaria to natural latex products, primarily medical-surgical gloves a n d balloons, has recently been reported. 1-12 Several of these cases have involved anaphylactic reactions.l' 6,12 W e report two cases of anaphylaxis to latex, one to a condom and the other to a glove.
From the Department of Dermatologya and Allergy? The Cleveland Clinic Foundation. Reprint requests: James S. Taylor, MD, Department of Dermatology, The Cleveland Clinic Foundation, 9500 Euclid Ave,, Cleveland, OH 44106. 16/0/12915
874
CASE REPORTS Case 1 A 48-year-old white woman c a m e to the Cleveland Clinic in April 1987 for evaluation of possible allergy to rubber. She had been a nurse at a community hospital for 6 years a n d had had hand eczema for 25 years. In 1986 localized pruritus and urticaria had developed within minutes of donning latex gloves. As the year progressed, generalized urticaria, facial angioedema, rhinitis, and bronchospasm developed after 15 to 30 minutes of exposure to rubber gloves. Recently she also experienced lip swelling when blowing a balloon. Occasionally she
Volume 21 Number 4, Part 2 October 1989
took diphenhydramine hydrochloride to control the symptoms. Just before admission to her local community hospital in March 1987, her husband used a latex condom during intercourse with the patient. She had oral and vaginal exposure to the condom, and there was vaginal irritation and bleeding. Within minutes generalized urticaria, facial and laryngeal angioedema, and respiratory distress developed. On arrival at the emergency room she was treated with epinephrine, diphenhydramine hydrochloride, intravenous fluids, and hydrocortisone sodium succinate. She was admitted to the intensive care unit, remained hospitalized for 2 more days, receiving additional systemic diphenhydramine and corticosterold therapy, and was discharged in good condition. No lubricant was used with the condom, and she had never previously been exposed to a condom. No allergic reaction occurred before or after this systemic reaction. The patient's medical history was significant for rhinitis and eczema of 25 years' duration, asthma that had been in remission for 20 years, nasal polypectomy, removal of a benign parotid tumor, and a hysterectomy. During a nasal polypectomy procedure, respiratory distress and urticaria of her upper body developed. Face-mask oxygen was administered to relieve shortness of breath. She also experienced urticaria and angioedema after administration of radiocontrast dye and amoxicillin. She was a nonsmoker. There was a family history of asthma. When we first examined the patient, her blood pressure was 120/76 mm Hg, pulse 84 bpm, and temperature 36.5 ° C. Findings of a complete physical examination were normal except for several chronic eczematous plaques on the nape of the neck, excoriated papules on the forearms, and pale nasal turbinates without polyps. Patch testing for delayed contact sensitivity was performed with chemical and methods of the North American Contact Dermatitis Group. At the 1-week readings there were past or present relevant positive reactions to ethylenediamine dihydrochloride 1% (2+), nickel sulfate 1.5% (1+), quaternium-15 2% ( 1+ ), cobalt chloride 1% ( 1+), toluene sult'onamide formaldehyde resin 10% (1+), and ethyl methacrylate 5% (2+). Results of patch testing with pieces of eight different surgical gloves (latex and vinyl) were negative at 1 week. Results of allergy skin testing by the scratch and
875
Contact urticaria and anaphylaxis to latex
Table
I, Immediate hypersensitivity skin test
results . _ Case 1 Test item
Latex glove* Triflex, nonsterile Triflex, sterile Eudermic Perry Elastyren Ansell (8605) (powderless) Vinyl glove* Becton Dickinson Tru Touch Latex glove(washed) Perry Talc Corn starch Dried centrifugedlatex Latex condom* Latex condom (washed)
I Scratch
+ + + + + -
Case 2
IPrick I S..c~t¢.h I Prie.k + +-~ ++ +NT
-
NT
+
NT
-
NT
-
N T
NT + +
+ + +
NT + NT NT NT NT
-
NT -
NT NT NT
NT NT NT NT NT NT
NT
NT NT NT NT NT NT
NT, Not tested.
*Soaked in salilaesolution. t + - denotes doubtful.
intradcrmal methods to the common inhalants and selected foods were positive only to house dust mite. She was tested for immediate hypersensitivity by the open patch test and scratch methods to latex and vinyl gloves and the latex condom. By the open patch test a 1.0 x 1.0 cm piece of each material was placed on the patient's forearm and observed for 15 minutes. All test findings were negative. For the scratch tests 1.0 X 1.0 cm pieces again soaked in sterile saline solution were placed on the scratch and observed for 15 minutes. One glove and the condom were tested again after washing in soap and water. Histamine (positive) and sterile saline (negative) controls were done. Significant wheal-and-flare reactions developed to the latex glove and condom only (both washed and unwashed). Three controls yielded negative results to scratch tests with the gloves and condom. At a subsequent visit, scratch testing to various glove powders and lubricants, ineluding corn starch, was negative. Prick testing with 1- or 24-hour latex glove and condom solutions according to the method of Turjanmaa 9 and Turjanmaa and Reunala 1° was performed on another visit. There was general concordance with the scratch test results except as noted in Table I.
876
Journal of the American Academy of Dermatology
Taylor et aL
A commercially available radioallergosorbent (RAST) test was performed for latex-specific IgE and was positive at 2.7 Phadebas RAST Units (PRU) (Latex-Hevea braziliensis Phadezym RAST allergen discs, MK82, No. 61682, Pharmacia, Piscataway, N.J.). The recommended test protocol was followed except for using a longer overnight incubation time for the discs and serum. The patient was instructed to avoid natural latex products (e.g., latex gloves, balloons, condoms, and rubber bands) and use vinyl gloves at work. She was treated with hydroxyzine for the pruritus and urticaria and instructed to use an Epi-Pen (Center Laboratories, New York) in the event of a serious allergic reaction. Exposure to condoms has been avoided, and no further anaphylactic reactions have occurred. When seen in follow-up she was wearing vinyl gloves at work and had no pruritus, contact urticaria, or angioedema. Case 2 A 10-year-old adopted white girl with myelomeningocele, hydrocephalus, neurogenic bladder, and biIateral congenital dislocated hips and leg length discrepancies was referred for evaluation of rubber allergy before elective surgery in May 1987. Since early childhood the patient would develop facial urticaria on exposure to balloons or rubber gloves. In 1986 when her mother used rubber gloves for manual disimpaction (the first time she had ever done this), within 10 minutes generalized urticaria, angioedema, and respiratory distress (bronchospasm) developed. She was treated at home by her physician with diphenhydramine hydrochloride, and symptoms resolved within 24 hours. She had at least three previous operations in the past 5 years for her multiple congenital problems, without apparent difficulties. She had no history of asthma or allergic rhinitis. A complete physical examination was entirely within normal limits. Her blood pressure was 95/70 turn Hg and pulse 88 bpm. The patient was skin tested for immediate hypersensitivity by the open patch and scratch methods with 2.0 by 2.0 cm squares of Becton Dickinson vinyl Tru Touch and Triflex sterile latex glove materials soaked in saline solution. Results of skin testing with vinyl glove pieces were negative. Within 4 minutes of applying the latex glove material to the scratch, the patient developed a strong localized wheal-and-flare reaction. On a subsequent visit the patient was scratch
tested with several glove powders, including corn starch, with negative results. The same commercially available RAST used for patient 1 was positive for latex-specific IgE at 1.8 PRU. DISCUSSION
Latex is found in the Hevea braziliensis tree, and the antigen responsible for symptoms is present in natural latex. The antigen appears to be a protein with a molecular weight of 30,000 daltons. 3 In 1979 Nutter 2 described contact urticaria to latex in a housewife wearing cleaning gloves. Since then a number of reports 1,3-12 have discussed immediate allergic reactions to latex. Some of the previously reported cases have been reviewed by Taylor 1~ and by Turjanmaa and Reunala. 1° Moreover, most patients have been medical personnel (nurses and physicians) or homemakers. Contact urticaria to latex products is not as uncommon as previously thought. A study to determine the frequency of immediate surgical latex glove allergy (contact urticaria) among hospital personnel was conducted by Turjanmaa 9 in Finland. Of 512 hospital employees screened with a latex glove prick and use test, 15 (2.9%) had confirmed positive reactions. In operating units 7.4% of the doctors and 5.6% of the nurses were allergic. In addition to surgical work other predisposing factors were atopy (67%) and hand eczema. Turjanmaa et al.1 also described two patients who had anaphylactic reactions while undergoing surgery (cesarean section and sterilization), probably from the surgeons' latex gloves and rubber anesthetic supplies. Interestingly, both patients were also nurses. In two separate articles Axelsson et al. 6,12reported two atopic children with anaphylaxis when blowing up rubber balloons t2 and five adults with anaphylaxis from wearing latex gloves, from exposure to a latex dental dam, and during surgery or routine gynecologic examination. 6 Juhlin has seen anaphylaxis develop from exposure to pollen in a latex condom (personal communication, August 1988). We have described two cases of anaphylaxis, one from a latex condom and the other from latex gloves. Both patients previously had dermatologic or respiratory symptoms on exposure to latex products. An anaphylactic reaction appeared to occur with mucosal contact (oral, vaginal, or rectal). We documented positive skin tests to many rubber products but not to vinyl products. Also, both patients had positive latex RAST (IgE) tests. In the
Volume 21 Number 4, Part 2 October t989
Contact urticaria and anaphylaxis to latex
first case seminal fluid was not the cause of the allergic reaction since the patient did not experience any other reactions during sexual intercourse before or after the anaphylactic episode. Also, powder on the latex products was not the cause, since in both cases reactions to washed materials were still positive and scratch tests to various powders were negative. Immediate hypersensitivity to rubber latex products not only includes dermatologic and respiratory manifestations but can often progress to more serious anaphylactic reactions. Allergists and dermatologists have to become aware of this medical problem as the use of latex gloves and condoms increases. Evaluation of suspected cases should include a careful history to elicit immediate symptoms and signs of urticaria, use test (one finger only), patch, scratch, or prick tests, and R A S T tests to latex. Concomitant hand eczema may mask the diagnosis. Care should be taken to interpret results correctly and avoid harmful, life-threatening test reactions. 1°
2. Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979;101:597-8. 3. Carrillo T, Cuevass M, Munez T, Hinojosa M, Maneo I. Contact urticaria and rhinitis from latex surgical gloves. Contact Dermatitis 1986;15:69-72. 4. Kleinhans D. Contact urticaria to rubber gloves. Conhact Dermatitis 1984;10:124-5. 5. Forstrom L. Contact urticaria from latex surgical gloves. Contact Dermatitis 1980;6: 33-34. 6. Axelsson JGK, Johansson SGO, Wragsjo K. IgE-mediated anaphylactoid reactions to rubber. Allergy 1987;42:46-50. 7. Meding B, Fregert S. Contact urticaria from natural latex gloves. Contact Dermatitis 1984;10:42-3. 8. Forsch PJ, Wahl R, Bahmer FA, Mausch HJ. Contact urticaria to rubber gloves is IgE mediated. Contact Dermatitis 1986;145:241-5. 9. Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987; 17:270-5. 10. Turjanmaa K, Reunala T. Contact urticaria from rubber gloves. Dermatol Clin 1988;6:47-51. 11. Taylor JS. Rubber. In: Fisher AA, ed. Contact dermatitis. 3rd ed. Philadelphia: Lea and Febiger, 1986:632. 12. Axelsson JGK, Eriksson M, Wrangsjo K. Anaphylaxis and angioedema due to rubber allergy in children. Aeta Pediatr Scand 1988;77:314-16.
REFERENCES 1. Turjanmaa K, Reunala T, Tuimala R, Karkkainen T. Severe IgE mediated allergy to surgical gloves [Abstract]. Allergy 1984;2(suppl):35.
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The compilation of patch test information by the use of computerized data bases James R. Nethercott, MD, and D. Linn Holness, MD Toronto, Ontario, Canada The use of computer technology to store, retrieve, and analyze patient data is not new. This article reviews the use of computerized data bases in patch test result record keeping. Efforts of the North American Contact Dermatitis Group serve as an example of how to create, manage, and apply these data. (J AM ACAD D~RMATOL1989;21:877-80.) Many investigators have reported the results of patch testing carried out in many parts of the world) -7 Such group data give insight into the relative importance of particular chemicals as allergic contactants. They also allow the evaluation of such From the Department of Occupationaland EnvironmentalHealth, St. Michael's Hospital, Universityof Toronto. Reprint requests: J. R. Nethercott, MD, Johns Hopkins University, Occupational Health Department, School of Hygiene and Public Health, 615 N. Wolfe St., Baltimore, MD 21205. 16/0/12914
factors as age, sex, occupation, and site as contributing factors. ~s Manual data collection has been the standard method of tabulation of such information, but computerized record keeping is becoming more common. Fabbri and Sertoli 9 reported the use of a computer data management program in 1971. Their group subsequently reported the utilization of this data base in the evaluation of trends in patch test responses) ° Dooms-Goossens and her Belgian associates reported on their use of a computerized data base management system they used to compile 877