Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
Do you routinely take a cancer history from patients being evaluated for atopy?
I do take a cancer history (not only in the patient's PMH but the family history as well). Given the evidence described above (which is even more robust in the literature than mentioned above), therapies that alter immune function (such as AIT) should have shared decision-making as part of the proce...
What is the lowest maintenance dose you will use if a patient continues to have anaphylaxis when trying to achieve maintenance dosing?
Probably 1:1 0.2 ml. Most of the lesser dose maintenance patients are ones I inherited and had to go way back in the shot record to see what the indication for reduction was whether systemic vs long-lasting LLR or something else like an intolerance. I have a hard time believing that patients will ac...
With regard to cat immunotherapy, if testing is positive for cat pelt and cat hair, do you include include 50% pelt and 50% hair if doing immunotherapy?
The answer will likely depend on which extracts you have available and potentially on whether you can do any additional component resolved diagnostic testing. The major allergen in cat hair is Fel d 1. The major allergens in cat pelt are Fel d 1 and albumin. You could consider doing component testin...
Should the RSV vaccine be administered to pregnant mothers even if it is not seasonally circulating but they are 32-36 weeks pregnant?
Here is the official CDC/ACIP recommendation (accessed 3/30/2025): "CDC recommends one dose of Pfizer’s Abrysvo for women who are 32 0/7 weeks’ through 36 6/7 weeks’ gestation. Pregnant women who are more than 36 weeks 6 days pregnant should not be vaccinated, as it is unlikely there will be enough ...
Does a patient with known systemic mastocytosis need a bone biopsy of lytic vertebral lesions to rule out other etiologies?
Yes, as long as other etiologies have been ruled out, such as cancer, osteomyelitis, or other infections. Even though osteoporosis is more common in systemic mastocytosis patients, bone lytic lesions are not.
What is your preferred regimen for remission induction and maintenance in EGPA with cardiac involvement?
Cardiac involvement in EGPA is associated with a poor prognosis and is an independent predictor of mortality. Therefore, it needs to be treated aggressively. Depending on the study, between 15-30% of EGPA patients present with or develop cardiac manifestations. The manifestations are highly variable...
What features on PFT or flow-volume loops do you look at to suspect small airway dysfunction?
I would strongly advise against using the flow-volume loop to diagnose small airway dysfunction. It is difficult if not impossible to visually distinguish between small airway dysfunction and normal aging (I would point out that part of normal aging involves changes in small airway function). Althou...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...