Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Are you requiring markers other than LTE4 to be elevated to diagnose MCAS?
The commercially available biomarkers to assess systemic mast cell activation in vivo include serum tryptase, N-methyl histamine (major metabolite of histamine), various forms of 11-beta-PGF2-alpha (PGD2 metabolite), and LTE4 (major metabolite of LTC4). The metabolites of these small molecules are m...
Do all patients initiating omalizumab need to have it administered in a healthcare setting?
In the trials, all cases of anaphylaxis were on first administration--suggesting it is not intrinsic to drug and is more likely because you are giving it to a group of people who may be more susceptible to anaphylaxis in general. FDA has cleared at home use, so my general approach in a patient witho...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
Should a patient who has hereditary alpha tryptasemia and has experienced multiple anaphylactoid reactions be tested for a venom allergy and started on VIT if positive?
No. Only individuals with a history of anaphylaxis following a Hymenoptera insect sting should be offered venom-specific IgE testing and/or skin testing. There are rare exceptions, including beekeepers with frequent large local reactions. The person from the question stem does not have a history of ...
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
What medications would you have a patient avoid with an IgE mediated reaction to cyclobenzaprine?
The mechanism of immediate hypersensitivity to cyclobenzaprine is likely MRGPRX2-mediated rather than IgE-mediated. MRGPRX2 is a G-protein coupled receptor (GPCR) predominantly expressed in human mast cells. Upon activation, MRGPRX2 triggers mast cell degranulation and anaphylactic reactions. MRGPRX...
Is it safe to use one TNF inhibitor (e.g., infliximab) in a patient who has had a severe allergic reaction to a different TNF inhibitor (e.g., adalimumab)?
The short answer is yes - it is ok to proceed with a different TNFi. First, it is important to determine whether the reaction was truly allergic or a nonspecific infusion reaction instead. If possible, obtaining a serum tryptase level at the time of the reaction can help clarify. Realistically, this...
Is asymptomatic long QT syndrome a contraindication for starting AIT?
No.
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
What is your second line therapy for patients with EGPA with mainly pulmonary and sinonasal features who did not respond to mepolizumab 300 mg/month and still require high doses of steroid?
This is an important question. Benralizumab has recently been shown to have similar efficacy to mepolizumab with a suggestion of a greater number of patients being able to fully discontinue steroids when treated with benralizumab as compared to mepolizumab. On the basis of this study I would use ben...