Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Based upon recently published information in the journal Science, would you offer zileuton to a high-risk food allergy patient who declines oral immunotherapy and omalizumab?
The data suggests that zileuton was not effective in preventing anaphylaxis.
Which patient characteristics or scenarios drive you to choose tezepelumab over dupilumab for asthma?
I typically put adult patients with T2 high, and allergic phenotype on dupilumab whereas those that are T2 high only or T2 low are on tezepelumab. Additionally, if the patient has nasal polyps or AD, then I would prefer dupilumab over tezepelumab. I always have a discussion with the patient regardin...
Is there any genetic testing available for the CDHR3 receptor?
A common variant in CDHR3, Cys529Tyr, leads to susceptibility to a variety of respiratory symptoms, including symptomatic rhinovirus, asthma, chronic rhino sinusitis and more. Depending on the ethnic background, between 15%-35% of the population carries at least one copy. There are no clinical uses ...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
When would you pursue genetic testing for severe recalcitrant atopic dermatitis?
Not an easy question to answer, but severe and treatment-refractory AD, especially if early onset, is concerning for immune dysregulation and should warrant immune evaluation early. By treatment-refractory, I do not just mean topical therapies, but attempts to control the Th2 pathway that fail repea...
What factors do you consider prior to offering a trial of ICS/LABA therapy versus a methacholine challenge test in patients with suspected asthma but normal pulmonary function testing?
If there is a high suspicion of asthma, have the patient obtain a portable electronic spirometer. If peak flows/FeV1 drops >15% correlate with symptoms, start Rx and follow spiro results. If low suspicion for asthma or very mild symptoms, do methacholine.
What are your recommendations for managing perivascular dermatitis with eosinophils unresponsive to high-dose antihistamines, a prednisone taper, and topical steroids?
I would check and treat for scabies.
When a patient has CVID and is then diagnosed with lymphoma receiving ongoing chemotherapy, how do you manage the trough levels?
Assuming the patient is already on replacement therapy, I would make sure that at trough (if on IVIG, or steady state if on SCIG), the patient has protective levels against pneumococcal polysaccharides. If not, I would increase the dose and/or shorten the interval to achieve that, and record the tot...
How are you diagnosing chronic FPIES in adults?
Primarily through patient history; delayed onset of GI symptoms, shellfish is a common culprit in adults with acute FPIES. It is hard to differentiate chronic FPIES from intolerance since there is limited pathophysiology on non-IgE mediated mechanisms. Limited role for challenge if history is convin...
Do you recommend patients try antihistamines such as oral ketotifen that are not approved in the US but are approved in the EU for MCAS if currently available formulations have not been effective?
Oral ketotifen is a mast cell stabilizer as well as an antihistamine that targets the H1 histamine receptor. In patients with mast cell activation syndrome that have not had complete symptom relief with second-generation H1 antihistamines at higher doses, including 4 tablets a day, I will consider o...