Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
What is the best alternative oral therapy for treatment of non-severe pulmonary nocardiosis in an immunocompetent patient with sulfa allergy?
We have been using linezolid for this indication, based on a paper from ARUP Labs.Schlaberg et al., PMID 24247124
When do you consider de-escalating therapy such as dupilumab in eosinophilic esophagitis?
It is first important to recognize that EoE is a chronic condition. In a patient whose EoE is successfully being treated (whether it be with PPI therapy, swallowed steroids, food elimination, or dupilumab), the disease will invariably become active again over time if therapy is stopped. This is why ...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
How long do you apply patch testing before interpreting the results?
In most instances, patches are removed after 48 hours (2 days). This timeframe is specifically chosen to allow sufficient time for the allergen to penetrate the stratum corneum and trigger a T-cell-mediated response, while simultaneously reducing the potential for significant skin irritation that ca...
How would you approach diagnosis of a patient with recurrent episodes of abdominal pain, severe myalgias, low grade fevers and urticaria?
Without the mEFV variant, from a rheumatologist viewpoint, the differential includes IBD, a periodic fever syndrome such as FMF or FCAS, and MCAS. Therefore, I would consider that workup with genetic testing (anyone can send!), fecal calprotectin, and MCAS eval with A/I. I don't think of urticarial ...
With the difficulty in access to PPSV23 as the new pneumonia vaccine is now standard (non polysaccharide vaccine), have you used MPSV4 (meningococcal) vaccine for evaluation of response to polysaccharide vaccine?
No, but there is good data on using Typhim Vi vaccine, which is also polysaccharide and MCW has a good lab to evaluation for polysaccharide vaccine response.
When would you recommend prescribing an asthmatic patient budesonide/salbutamol rather than budesonide/formoterol?
This is another example of two approaches to the same issue (i.e. adding inhaled steroid to a rescue B2 adrenergic agent) which is actually more theoretical than practical since no head-to-head studies have been reported. For me, there is an intrinsic value to using a rapid onset LABA (i.e. formoter...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
What is the utility of remibrutinib or other tyrosine kinase inhibitors in MCAS?
MCAS can be due to clonal (mastocytosis) or non-clonal (IgE and non-IgE mediated mast cell activation or idiopathic) etiologies. Remibrutinib is a btk inhibitor, currently only approved for chronic spontaneous urticaria, but not for MCAS. Btk is involved in IgE receptor signal transduction. In patie...
Do you cycle through topical steroids in patients with CHE, and should the approval of delgocitinib change our approach on this?
In practice, I do often cycle topical steroids in chronic hand eczema to balance access, efficacy, and safety. Patients are often referred from primary care already having tried multiple topical steroids. Potent topical steroids can help with acute control, but long-term use is problematic. The avai...