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Food-dependent exercise-induced anaphylaxis in children: A single center experience
Abstracts AB227
J ALLERGY CLIN IMMUNOL VOLUME 139, NUMBER 2
Management of Exercise-Induced Anaphylaxis with Omalizumab
Mohini Pathria, and Juan Guarderas; University of Florida, Gainesville. RATIONALE: Omalizumab is a monoclonal antibody against immunoglobulin E used for management of moderate to severe allergic asthma. Exercise induced anaphylaxis is a rare condition characterized by diffuse pruritis, urticaria, and wheezing that can progress to life threatening laryngeal edema and hypotension with continued physical activity. We present a patient with exercise-induced anaphylaxis successfully treated with omalizumab. METHODS: The patient underwent skin prick testing and pulmonary function testing. IgE and tryptase levels were collected. RESULTS: An adolescent male presented with recurrent urticaria, facial edema, and wheezing after riding his bicycle and playing soccer, improving with discontinuation of activity. Skin prick testing was positive for allergies to several types of grass pollen. He tried sublingual immunotherapy and antihistamines with no improvement. His condition limited him in making friends and participating in school. Testing revealed elevated IgE level at 158 (range 0-100 IU/mL) and normal tryptase level at 3.3 (normal <10.9 ug/L). Pulmonary function tests were normal. He was treated with fexofenadine 180 mg daily, but his symptoms continued. He started doxepin 10 mg at bedtime and fluticasone 110 mcg 2 puffs twice a day with albuterol therapy as needed, but continued to experience recurrent urticaria and wheezing with activity. He was started on omalizumab therapy 300 mg subcutaneously every 28 days. After two doses, he noted significant improvement in symptoms. CONCLUSIONS: Few reports describe the use of omalizumab in preventing episodes of exercise-induced anaphylaxis. The utility of this immunomodulator with exercise-induced anaphylaxis needs to be further evaluated.
715
Food-dependent exercise-induced anaphylaxis in children: A single center experience
Seongyoon Song1, Hyun-Ju Cho2, Jisun Yoon2, Song-I. Yang3, Suwon Chung4, Jaeyoun Kim4, Jinho Yu5, and Soo-Jong Hong, MD, FAAAAI6; 1 Department of Pharmacy, Childhood Asthma Atopy Center, Asan Medical Center, Seoul, Korea, The Republic of, 2Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, The Republic of, 3Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea, The Republic of, 4Department of Pharmacy, Asan Medical Center, Seoul, Korea, The Republic of, 5Department of Pediatrics, Childnood Asthma Atopy Center, Asan medical center, University of Ulsan College of Medicine, Seoul, Korea, The Republic of, 6Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea, Seoul, Korea, The Republic of. RATIONALE: Food-dependent exercise-induced anaphylaxis (FDEIA) is a specific form of exercise induced anaphylaxis that develops only when exercise combined with ingesting a specific food. Clinical features and diagnostic results of FDEIA in children are investigated in this study. METHODS: The medical records of 13 patients younger than 18 years old diagnosed with FDEIA at Asan Medical Center from January 2003 to August 2016 were reviewed. RESULTS: Demographics of 13 patients with Food-dependent exerciseinduced anaphylaxis showed that 13 to 17-years-old patients (mainly male (n510)) had 1 to 7 episodes of FDEIA before diagnosis. The most dominant causative foods were wheat (46%). Other causative factors were rice, celery, cabbage, soybean, mungbean, and fish. The most common symptoms were angioedema and urticaria. The skin prick tests and immunoCAP tests for suspicious foods were positive in 4 of 8 patients and 9 of 12 patients, respectively. The provocation tests were positive in 7 of 8 patients. The 3 of 7 patients described severe symptoms such as
hypotension, dypnea and were injected epinephrine intravenously. The average interval between exercise and symptoms was approximately 21.6 minutes. CONCLUSIONS: The diagnosis of FDEIA is based on either causality between symptoms and causative factors or tests such as lab, prick test and provocation. To make exact diagnosis and treatment plan, provocation test should be conducted. Awareness of medical staffs and patients to diagnosis and treatment is also important features of FDEIA.
716
Hymenoptera Venom Hypersensitivity Evaluation (HVHE): Preliminary Results From A Prospective Study Comparing Skin And In Vitro Testing
Amanda Long, DO, Jeannie Bay, DO, Richard Wu, MD, Sarah Spriet, DO, and Douglas E. Beakes, MD, FAAAAI; Reed National Military Medical Center, Bethesda, MD. RATIONALE: Hymenoptera venom hypersensitivity is diagnosed based on a clinical history of a systemic reaction to hymenoptera coupled with positive skin and/or in vitro testing. Robust data on the concordance between skin and serum testing is currently lacking in the literature. This study investigates the concordance between skin and serum specific IgE (sIgE) to each of the five specific venoms in patients being evaluated for hymenoptera venom hypersensitivity. METHODS: Seventeen patients with a history of a systemic reaction to hymenoptera stings and 42 controls were recruited from the allergy clinic. Intradermal skin testing (IDST) was performed and serum sIgE to each of the five specific venoms and a baseline tryptase were measured. RESULTS: Preliminary data shows an overall higher discordance between IDST and serum sIgE testing in cases than controls (6.7% vs. 16.5%, p50.001, CI53.88-22.94). This discordance was observed with all hymenoptera venom except honey bee. Sensitivity was slightly higher with serum testing (53% vs. 47%) but specificity was higher with IDST (95% vs. 79%). CONCLUSIONS: Preliminary results reveal higher discordance between IDST and serum sIgE in cases versus controls for all hymenoptera venoms except honey bee. These initial results do not support or refute the current guidelines of pursuing serum sIgE testing to patients with negative IDST with a positive history. Further investigation and data is necessary to clarify the role of sIgE testing and its relationship to IDST in all patients with a positive history of venom hypersensitivity.
MONDAY
714
J ALLERGY CLIN IMMUNOL VOLUME 139, NUMBER 2
Management of Exercise-Induced Anaphylaxis with Omalizumab
Mohini Pathria, and Juan Guarderas; University of Florida, Gainesville. RATIONALE: Omalizumab is a monoclonal antibody against immunoglobulin E used for management of moderate to severe allergic asthma. Exercise induced anaphylaxis is a rare condition characterized by diffuse pruritis, urticaria, and wheezing that can progress to life threatening laryngeal edema and hypotension with continued physical activity. We present a patient with exercise-induced anaphylaxis successfully treated with omalizumab. METHODS: The patient underwent skin prick testing and pulmonary function testing. IgE and tryptase levels were collected. RESULTS: An adolescent male presented with recurrent urticaria, facial edema, and wheezing after riding his bicycle and playing soccer, improving with discontinuation of activity. Skin prick testing was positive for allergies to several types of grass pollen. He tried sublingual immunotherapy and antihistamines with no improvement. His condition limited him in making friends and participating in school. Testing revealed elevated IgE level at 158 (range 0-100 IU/mL) and normal tryptase level at 3.3 (normal <10.9 ug/L). Pulmonary function tests were normal. He was treated with fexofenadine 180 mg daily, but his symptoms continued. He started doxepin 10 mg at bedtime and fluticasone 110 mcg 2 puffs twice a day with albuterol therapy as needed, but continued to experience recurrent urticaria and wheezing with activity. He was started on omalizumab therapy 300 mg subcutaneously every 28 days. After two doses, he noted significant improvement in symptoms. CONCLUSIONS: Few reports describe the use of omalizumab in preventing episodes of exercise-induced anaphylaxis. The utility of this immunomodulator with exercise-induced anaphylaxis needs to be further evaluated.
715
Food-dependent exercise-induced anaphylaxis in children: A single center experience
Seongyoon Song1, Hyun-Ju Cho2, Jisun Yoon2, Song-I. Yang3, Suwon Chung4, Jaeyoun Kim4, Jinho Yu5, and Soo-Jong Hong, MD, FAAAAI6; 1 Department of Pharmacy, Childhood Asthma Atopy Center, Asan Medical Center, Seoul, Korea, The Republic of, 2Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, The Republic of, 3Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea, The Republic of, 4Department of Pharmacy, Asan Medical Center, Seoul, Korea, The Republic of, 5Department of Pediatrics, Childnood Asthma Atopy Center, Asan medical center, University of Ulsan College of Medicine, Seoul, Korea, The Republic of, 6Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea, Seoul, Korea, The Republic of. RATIONALE: Food-dependent exercise-induced anaphylaxis (FDEIA) is a specific form of exercise induced anaphylaxis that develops only when exercise combined with ingesting a specific food. Clinical features and diagnostic results of FDEIA in children are investigated in this study. METHODS: The medical records of 13 patients younger than 18 years old diagnosed with FDEIA at Asan Medical Center from January 2003 to August 2016 were reviewed. RESULTS: Demographics of 13 patients with Food-dependent exerciseinduced anaphylaxis showed that 13 to 17-years-old patients (mainly male (n510)) had 1 to 7 episodes of FDEIA before diagnosis. The most dominant causative foods were wheat (46%). Other causative factors were rice, celery, cabbage, soybean, mungbean, and fish. The most common symptoms were angioedema and urticaria. The skin prick tests and immunoCAP tests for suspicious foods were positive in 4 of 8 patients and 9 of 12 patients, respectively. The provocation tests were positive in 7 of 8 patients. The 3 of 7 patients described severe symptoms such as
hypotension, dypnea and were injected epinephrine intravenously. The average interval between exercise and symptoms was approximately 21.6 minutes. CONCLUSIONS: The diagnosis of FDEIA is based on either causality between symptoms and causative factors or tests such as lab, prick test and provocation. To make exact diagnosis and treatment plan, provocation test should be conducted. Awareness of medical staffs and patients to diagnosis and treatment is also important features of FDEIA.
716
Hymenoptera Venom Hypersensitivity Evaluation (HVHE): Preliminary Results From A Prospective Study Comparing Skin And In Vitro Testing
Amanda Long, DO, Jeannie Bay, DO, Richard Wu, MD, Sarah Spriet, DO, and Douglas E. Beakes, MD, FAAAAI; Reed National Military Medical Center, Bethesda, MD. RATIONALE: Hymenoptera venom hypersensitivity is diagnosed based on a clinical history of a systemic reaction to hymenoptera coupled with positive skin and/or in vitro testing. Robust data on the concordance between skin and serum testing is currently lacking in the literature. This study investigates the concordance between skin and serum specific IgE (sIgE) to each of the five specific venoms in patients being evaluated for hymenoptera venom hypersensitivity. METHODS: Seventeen patients with a history of a systemic reaction to hymenoptera stings and 42 controls were recruited from the allergy clinic. Intradermal skin testing (IDST) was performed and serum sIgE to each of the five specific venoms and a baseline tryptase were measured. RESULTS: Preliminary data shows an overall higher discordance between IDST and serum sIgE testing in cases than controls (6.7% vs. 16.5%, p50.001, CI53.88-22.94). This discordance was observed with all hymenoptera venom except honey bee. Sensitivity was slightly higher with serum testing (53% vs. 47%) but specificity was higher with IDST (95% vs. 79%). CONCLUSIONS: Preliminary results reveal higher discordance between IDST and serum sIgE in cases versus controls for all hymenoptera venoms except honey bee. These initial results do not support or refute the current guidelines of pursuing serum sIgE testing to patients with negative IDST with a positive history. Further investigation and data is necessary to clarify the role of sIgE testing and its relationship to IDST in all patients with a positive history of venom hypersensitivity.
MONDAY
714