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Methylene Blue as a Treatment for Refractory Anaphylaxis
CONCLUSION: These fast-disintegrating sublingual epinephrine tablets containing 40 mg of epinephrine but no sodium metabisulfite are stable, even when stored at elevated temperatures for four months. Funding: University of Manitoba
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Latex Allergy: Low Prevalence of IgE to Highly Purified Hev b 2 and Hev b 13 T. Palosuo1, M. Lehto2, A. Kotovuori3, N. Kalkkinen3, C. Blanco4, P. Poza4, T. Carrillo4, R. G. Hamilton5, H. Alenius2, T. Reunala6, K. Turjanmaa6; 1National Public Health Institute, Helsinki, FINLAND, 2Finnish Institute of Occupational Health, Helsinki, FINLAND, 3Institute of Biotechnology, University of Helsinki, Helsinki, FINLAND, 4Servicio de Alergia, Hospital Universitario de Gran Canaria, Las Palmas de Gran Canaria, SPAIN, 5Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, 6Department of Dermatology, Tampere University and University Hospital, Tampere, FINLAND. RATIONALE: Hev b 2 and Hev b 13 are reportedly major latex allergens, e.g., IgE antibodies have been detected in >50% of latex-allergic individuals. We wanted to assess the prevalence rates for sensitization to extensively purified latex allergens in patients from different geographical areas. METHODS: Native Hev b 2, Hev b 5, Hev b 6.01 and Hev b 13 were purified by non-denaturating chromatographic methods and used in ELISAs to assess sera from 215 latex-allergic patients and 172 atopic controls from Finland, Spain and USA to detect allergen-specific IgE antibodies. RESULTS: Unexpectedly, even highly purified Hev b 13 contained epitope(s) to which human IgE anti-Hev b 6 antibodies bound effectively. However, further purification reduced the prevalence of antibody reactivity to low levels: 15%, 5% and 11% for Hev b 2 and, 18%, 30% and 27% for Hev b 13 among latex-allergic Finnish, Spanish and American patients, respectively. Interestingly, Finnish patients had a lower prevalence of Hev b 5-specific IgE antibody (28%) as compared to Spanish (49%) and American (71%) patients. The prevalence of Hev b 6.01-specific IgE reactivity was uniformly >50% in all three populations. CONCLUSION: Neither Hev b 2 nor Hev b 13 appear to be major latex allergens when evaluated in serological assays using highly purified allergens. The reason(s) for the observed differences in sensitization rates in various geographic regions requires further study. Funding: Academy of Finland, Johns Hopkins University School of Medicine, Instituto de Salud Carlos III, Ansell Healthcare Corporation
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Imported Fire Ant Sublingual Immunotherapy for Large Local Reactions M. H. Tucker, C. W. Calabria, L. L. Hagan, J. P. Dice; Wilford Hall Medical Center, San Antonio, TX. RATIONALE: Many individuals experience debilitating large local reactions from imported fire ant (IFA) stings. A 36 year old male underwent SLIT with IFA extract in an attempt to modify large local reactions. METHODS: SLIT was given daily, upon awakening, on an empty stomach. The SLIT was held under the tongue for 2 minutes then swallowed. On days 1-4 he received 0.2, 0.4, 0.7, and 1.0 ml of 1:10,000 v:v (volume to volume) respectively. On this same regimen, he received 1:1000 v:v on days 5-8, 1:100 v:v on days 9-12 and 1:10 v:v on days 13-16. On days 17 50 he received 0.1 ml of manufacturer’s stock IFA extract. On day 50 of SLIT, he underwent fire ant sting challenge. RESULTS: Patient had a negative prick skin test and positive intradermal (1:1,000,000) test to IFA prior to immunotherapy. At 50 days of therapy the skin test results were unchanged. Prior to immunotherapy, he had 187mm x 120 mm large local reaction at 24 hours post fire ant sting. At day 50 of immunotherapy, he had a 110 cm x 95 cm reaction at 24 hours post fire ant sting challenge, approximately a 30-40% reduction in size. CONCLUSIONS: Patient tolerated IFA sublingual immunotherapy without side effects. Patient had a moderate decrease in large local reaction size at 24 hours post fire ant sting while on SLIT. Patient continues to take IFA SLIT at an increased in a further attempt to attenuate large local reactions.
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Single Intragastric Peanut Feeding Leads To Anaphylactic Shock In C3H/HeJ But Not In BALB/c Or C57BL/6 Mice B. Proust1, C. M. N. Astier2, S. Jacquenet3, V. Ogier3, E. Magueur3, B. Thouvenot3, M. Morisset1, D. A. Moneret-Vautrin1, H. A. Sampson4, A. W. Burks5, B. E. Bihain3, G. Kanny1; 1University Hospital, Vandoeuvre-Les-Nancy, FRANCE, 2INPL, Vandoeuvre-Les-Nancy, FRANCE, 3 Laboratory of Molecular Medicine and Therapeutics, Vandoeuvre-LesNancy, FRANCE, 4Mount Sinaı¨ Hospital, New-York, NY, 5Duke University Medical Center, Durham, NC. RATIONALE: Peanut allergy is a significant problem because of its severity and increasing prevalence. Currently, dietary avoidance is the sole treatment. Reliable animal models are needed to allow development of novel therapeutic strategies. This study aimed to characterize a sensitization protocol leading to quantitatively measurable allergy response in mice, and to compare mice strain susceptibility to this sensitization protocol. METHODS: C3H/HeJ mice received a single intragastric administration of ground whole peanut without adjuvant. Peanut-sensitization status was monitored by skin tests (ear swelling and intradermal skin tests) and specific IgE responses. Anaphylactic response after intraperitoneal challenge with crude peanut extract was quantified by monitoring vascular leakage, clinical score, body temperature, breathing rate and serum mouse mast cell protease-1. RESULTS: A single intragastric exposure of C3H/HeJ mice to peanut induced rapid peanut-sensitization validated by positive skin tests at day 4, a significant increase of peanut-specific IgE, and severe anaphylactic reaction after intraperitoneal challenge occurring 14 days post-sensitization, confirmed by increased mouse mast cell protease-1. This protocol applied to BALB/c and C57BL/6 strains elicited sensitization to peanut as demonstrated by positive skin tests, but failed to cause anaphylaxis. CONCLUSIONS: An animal model with severe peanut hypersensitivity can be established within 2 weeks following oral exposure without adjuvant. The clear differences between strains that share a genetic background provide the basis for genomic scanning to identify genes that are involved in the clinical outcome of IgE-dependent sensitization.
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Methylene Blue as a Treatment for Refractory Anaphylaxis S. S. Sheth, D. Del Duca, P. Ergina, A. E. Clarke; McGill University Health Centre, Montreal, PQ, CANADA. INTRODUCTION: Protamine is a polycationic protein added to insulin and used to reverse heparin-induced anticoagulation. We describe the case of a 71-year-old man who had anaphylaxis to protamine intraoperatively, which was refractory to conventional therapy. CASE REPORT: A 71-year-old diabetic man previously on insulin NPH was undergoing cardiac surgery. He was weaned off cardiopulmonary bypass and then received a slow infusion of 100 mg protamine for heparin reversal. He immediately developed systemic hypotension, pulmonary hypertension and diffuse urticaria. Resuscitative efforts with standard therapy for anaphylaxis were unsuccessful. Cardiopulmonary bypass was reinstituted and an intraaortic balloon pump was inserted. Based on a few published cases by a single group describing methylene blue as an effective treatment for protamine-induced and anaphylactoid reactions, the patient received 100 mg intravenous methylene blue. Within minutes, the patient’s systemic blood pressure and pulmonary artery pressure normalized, and he was weaned off pressors and bypass without using protamine. Thirty days later, skin testing to protamine and protamine-containing insulin preparations was positive. CONCLUSIONS: The mechanism of protamine-induced reactions is uncertain. In addition to being IgE-mediated, it is speculated that protamine directly leads to severe vasodilation by causing release of endothelium-derived relaxing factor and nitric oxide, which is inhibited by methylene blue. Our case supports methylene blue as an adjunctive treatment for refractory anaphylaxis and suggests that it may be prudent to skin test diabetics with previous protamine exposure to exclude protamine allergy. Increased awareness of this diagnosis and potential therapy among allergists, anesthesiologists, and surgeons may prevent perioperative fatalities from refractory anaphylaxis.
SATURDAY
Abstracts S33
J ALLERGY CLIN IMMUNOL VOLUME 119, NUMBER 1
125
Latex Allergy: Low Prevalence of IgE to Highly Purified Hev b 2 and Hev b 13 T. Palosuo1, M. Lehto2, A. Kotovuori3, N. Kalkkinen3, C. Blanco4, P. Poza4, T. Carrillo4, R. G. Hamilton5, H. Alenius2, T. Reunala6, K. Turjanmaa6; 1National Public Health Institute, Helsinki, FINLAND, 2Finnish Institute of Occupational Health, Helsinki, FINLAND, 3Institute of Biotechnology, University of Helsinki, Helsinki, FINLAND, 4Servicio de Alergia, Hospital Universitario de Gran Canaria, Las Palmas de Gran Canaria, SPAIN, 5Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, 6Department of Dermatology, Tampere University and University Hospital, Tampere, FINLAND. RATIONALE: Hev b 2 and Hev b 13 are reportedly major latex allergens, e.g., IgE antibodies have been detected in >50% of latex-allergic individuals. We wanted to assess the prevalence rates for sensitization to extensively purified latex allergens in patients from different geographical areas. METHODS: Native Hev b 2, Hev b 5, Hev b 6.01 and Hev b 13 were purified by non-denaturating chromatographic methods and used in ELISAs to assess sera from 215 latex-allergic patients and 172 atopic controls from Finland, Spain and USA to detect allergen-specific IgE antibodies. RESULTS: Unexpectedly, even highly purified Hev b 13 contained epitope(s) to which human IgE anti-Hev b 6 antibodies bound effectively. However, further purification reduced the prevalence of antibody reactivity to low levels: 15%, 5% and 11% for Hev b 2 and, 18%, 30% and 27% for Hev b 13 among latex-allergic Finnish, Spanish and American patients, respectively. Interestingly, Finnish patients had a lower prevalence of Hev b 5-specific IgE antibody (28%) as compared to Spanish (49%) and American (71%) patients. The prevalence of Hev b 6.01-specific IgE reactivity was uniformly >50% in all three populations. CONCLUSION: Neither Hev b 2 nor Hev b 13 appear to be major latex allergens when evaluated in serological assays using highly purified allergens. The reason(s) for the observed differences in sensitization rates in various geographic regions requires further study. Funding: Academy of Finland, Johns Hopkins University School of Medicine, Instituto de Salud Carlos III, Ansell Healthcare Corporation
126
Imported Fire Ant Sublingual Immunotherapy for Large Local Reactions M. H. Tucker, C. W. Calabria, L. L. Hagan, J. P. Dice; Wilford Hall Medical Center, San Antonio, TX. RATIONALE: Many individuals experience debilitating large local reactions from imported fire ant (IFA) stings. A 36 year old male underwent SLIT with IFA extract in an attempt to modify large local reactions. METHODS: SLIT was given daily, upon awakening, on an empty stomach. The SLIT was held under the tongue for 2 minutes then swallowed. On days 1-4 he received 0.2, 0.4, 0.7, and 1.0 ml of 1:10,000 v:v (volume to volume) respectively. On this same regimen, he received 1:1000 v:v on days 5-8, 1:100 v:v on days 9-12 and 1:10 v:v on days 13-16. On days 17 50 he received 0.1 ml of manufacturer’s stock IFA extract. On day 50 of SLIT, he underwent fire ant sting challenge. RESULTS: Patient had a negative prick skin test and positive intradermal (1:1,000,000) test to IFA prior to immunotherapy. At 50 days of therapy the skin test results were unchanged. Prior to immunotherapy, he had 187mm x 120 mm large local reaction at 24 hours post fire ant sting. At day 50 of immunotherapy, he had a 110 cm x 95 cm reaction at 24 hours post fire ant sting challenge, approximately a 30-40% reduction in size. CONCLUSIONS: Patient tolerated IFA sublingual immunotherapy without side effects. Patient had a moderate decrease in large local reaction size at 24 hours post fire ant sting while on SLIT. Patient continues to take IFA SLIT at an increased in a further attempt to attenuate large local reactions.
127
Single Intragastric Peanut Feeding Leads To Anaphylactic Shock In C3H/HeJ But Not In BALB/c Or C57BL/6 Mice B. Proust1, C. M. N. Astier2, S. Jacquenet3, V. Ogier3, E. Magueur3, B. Thouvenot3, M. Morisset1, D. A. Moneret-Vautrin1, H. A. Sampson4, A. W. Burks5, B. E. Bihain3, G. Kanny1; 1University Hospital, Vandoeuvre-Les-Nancy, FRANCE, 2INPL, Vandoeuvre-Les-Nancy, FRANCE, 3 Laboratory of Molecular Medicine and Therapeutics, Vandoeuvre-LesNancy, FRANCE, 4Mount Sinaı¨ Hospital, New-York, NY, 5Duke University Medical Center, Durham, NC. RATIONALE: Peanut allergy is a significant problem because of its severity and increasing prevalence. Currently, dietary avoidance is the sole treatment. Reliable animal models are needed to allow development of novel therapeutic strategies. This study aimed to characterize a sensitization protocol leading to quantitatively measurable allergy response in mice, and to compare mice strain susceptibility to this sensitization protocol. METHODS: C3H/HeJ mice received a single intragastric administration of ground whole peanut without adjuvant. Peanut-sensitization status was monitored by skin tests (ear swelling and intradermal skin tests) and specific IgE responses. Anaphylactic response after intraperitoneal challenge with crude peanut extract was quantified by monitoring vascular leakage, clinical score, body temperature, breathing rate and serum mouse mast cell protease-1. RESULTS: A single intragastric exposure of C3H/HeJ mice to peanut induced rapid peanut-sensitization validated by positive skin tests at day 4, a significant increase of peanut-specific IgE, and severe anaphylactic reaction after intraperitoneal challenge occurring 14 days post-sensitization, confirmed by increased mouse mast cell protease-1. This protocol applied to BALB/c and C57BL/6 strains elicited sensitization to peanut as demonstrated by positive skin tests, but failed to cause anaphylaxis. CONCLUSIONS: An animal model with severe peanut hypersensitivity can be established within 2 weeks following oral exposure without adjuvant. The clear differences between strains that share a genetic background provide the basis for genomic scanning to identify genes that are involved in the clinical outcome of IgE-dependent sensitization.
128
Methylene Blue as a Treatment for Refractory Anaphylaxis S. S. Sheth, D. Del Duca, P. Ergina, A. E. Clarke; McGill University Health Centre, Montreal, PQ, CANADA. INTRODUCTION: Protamine is a polycationic protein added to insulin and used to reverse heparin-induced anticoagulation. We describe the case of a 71-year-old man who had anaphylaxis to protamine intraoperatively, which was refractory to conventional therapy. CASE REPORT: A 71-year-old diabetic man previously on insulin NPH was undergoing cardiac surgery. He was weaned off cardiopulmonary bypass and then received a slow infusion of 100 mg protamine for heparin reversal. He immediately developed systemic hypotension, pulmonary hypertension and diffuse urticaria. Resuscitative efforts with standard therapy for anaphylaxis were unsuccessful. Cardiopulmonary bypass was reinstituted and an intraaortic balloon pump was inserted. Based on a few published cases by a single group describing methylene blue as an effective treatment for protamine-induced and anaphylactoid reactions, the patient received 100 mg intravenous methylene blue. Within minutes, the patient’s systemic blood pressure and pulmonary artery pressure normalized, and he was weaned off pressors and bypass without using protamine. Thirty days later, skin testing to protamine and protamine-containing insulin preparations was positive. CONCLUSIONS: The mechanism of protamine-induced reactions is uncertain. In addition to being IgE-mediated, it is speculated that protamine directly leads to severe vasodilation by causing release of endothelium-derived relaxing factor and nitric oxide, which is inhibited by methylene blue. Our case supports methylene blue as an adjunctive treatment for refractory anaphylaxis and suggests that it may be prudent to skin test diabetics with previous protamine exposure to exclude protamine allergy. Increased awareness of this diagnosis and potential therapy among allergists, anesthesiologists, and surgeons may prevent perioperative fatalities from refractory anaphylaxis.
SATURDAY
Abstracts S33
J ALLERGY CLIN IMMUNOL VOLUME 119, NUMBER 1