Correspondence / Ann Allergy Asthma Immunol 116 (2016) 174e177
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Author response We thank Liccardi et al for their Letter to the Editor.1 Although we agree that asthma is a known risk factor for anaphylaxis,2 our data and experience do not agree with previously published recommendations3 that patients with severe asthma should avoid skin prick tests. We run a severe asthma clinic where we treat patients with poorly controlled asthma (ie, patients with poor lung function who have required multiple admissions to intensive care units for ventilatory). All these patients undergo skin prick tests when first seen in our clinic. None of these patients have had systemic reactions to skin prick tests despite many of them being sensitized to multiple allergens. In addition, 60% of patients in our general allergy clinics have asthma of various severities. Our findings support an association with the number and size of positive skin test results in those patients who have systemic reactions. Liccardi et al4 suggested that one factor may be due to simultaneous exposure to several allergens, inducing additive histamine release from cutaneous mast cells. However, as stated by Liccardi et al, this is one of several cofactors that may influence the risk of a systemic reaction to skin tests. At least 80% to 90% of our patients are polysensitized; however, hardly any of these (approximately 0.0056%) had a systemic reaction to skin prick tests. The anaphylaxis to tazocin in the nurse described in our article is an extremely rare and sensitive case. In this instance, skin testing should be performed starting with diluted concentrations of drug. This is an exceptional case which is indicated by our experience with more than 5,000 drug allergic patients, many with anaphylaxis to penicillins and none of whom had systemic reactions to skin prick tests. Thus, for investigation of standard patients, including those with anaphylaxis to oral or parenteral penicillins, normal drug concentrations should be used. We disagree that our selection of patients was questionable. We are a regional and national specialist center with a high proportion of severe cases. Most of our patients have anaphylaxis (of any cause), food allergy, drug allergy, and multisystem disease (eg, in nut allergy): 96% have asthma, rhinitis, and/or
eczema, 76% have asthma; 73% have rhinitis; 60% have eczema, and 96% have multiple positive skin prick test results. Most (almost all) of our patients with anaphylaxis and severe allergic reactions have no generalized reaction to skin prick tests (databases include >2,000 patients with nut allergy, 1200 with venom allergy, and 400 with anaphylaxis during general anesthesia but a much larger experience of skin testing in >100,000 patients). Of those children who reacted to skin prick tests (16 years and younger), more than half were tested with foods only, and a few were tested to foods and inhalants. In our experience, most children would be tested to foods and inhalants simultaneously with no systemic reaction. Priya Sellaturay, MRCP Pamela Ewan, FRCP Department of Allergy Cambridge University Hospitals National Health Service Foundation Trust Cambridge, United Kingdom [email protected]
References [1] Liccardi G, Salzillo A, Calzetta L, Piccolo A, Rogliani P. How many systemic reactions to skin prick tests could be preventable in defined conditions? Ann Allergy Asthma Immunol. In press. [2] Gonzalez-Pérez A, Aponte Z, Vidaurre CF, Rodriguez LA. Anaphylaxis epidemiology in patients with and without asthma: a United Kingdom database review. J Allergy Clin Immunol. 2010;125:1098e1104. [3] Bernstein DI, Wanner M, Borish L, Liss GM. Immunotherapy Committee of the American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol. 2004;113:1129e1136. [4] Liccardi G, Passalacqua G, Falagiani P, Russo M, D’Amato G. The effect of multiple allergens on histamine release in vivo assessed by skin prick test. Allergy. 2008;63:1559e1560.
A Colorado allergist's experience with marijuana legalization Although I appreciated the fine review by Ocampo and Rans entitled Cannabis Sativa: The Unconventional “Weed” Allergen,1 I thought it would be worthwhile to describe the few adverse reactions seen in our patient population. The relative paucity of these presentations since legalization of marijuana in Colorado suggests that cannabis sativa is a mild allergen, with significant exposure required to elicit respiratory and dermatologic allergic reactions. With the advent of marijuana legalization in Colorado, we describe 3 recent patients with distinct clinical presentations suggestive of marijuana sensitization. The results of skin testing by the “puddle” technique were positive in 2 of these patients but negative in the other. These cases indicate the need for clinicians to query their patients about marijuana exposure and, when appropriate, perform specific testing to establish sensitization. Further investigation to elucidate the specific sensitizing antigen(s) in marijuana or its derivatives (eg, wax, oils) is required to better understand the pathobiology of this environmental exposure.
Disclosures: Author has nothing to disclose.
Patient 1 is a 28-year-old white man who presented with the chief concern of nasal congestion worsening around “pot” in 2010. He had previously been evaluated by an allergist for allergic rhinitis and was found to be polysensitized to multiple indoor and outdoor aeroallergens. He began working as a trimmer at a marijuana growth facility and shortly thereafter he developed “extreme” nasal congestion, which was intermittent initially but soon became persistent. He tried holistic therapeutic approaches to manage the congestion, such as vaporized essential oils, eucalyptus, peppermint, and lavender several times per day, without relief. During his office visit he reported that during the past 2 months he had frequent wheezing with a chronic cough. The results of previous spirometry to assess lung function had reportedly been normal. Although no diagnosis of asthma was given, he had been given an albuterol inhaler for chest tightness by his primary care physician. He admitted frequent marijuana smoking. Of note, he had a history of an adverse food reaction where vinegar caused throat swelling. He had 2 cats at home, causing no symptoms. He was otherwise healthy and required no other drugs.
175
Author response We thank Liccardi et al for their Letter to the Editor.1 Although we agree that asthma is a known risk factor for anaphylaxis,2 our data and experience do not agree with previously published recommendations3 that patients with severe asthma should avoid skin prick tests. We run a severe asthma clinic where we treat patients with poorly controlled asthma (ie, patients with poor lung function who have required multiple admissions to intensive care units for ventilatory). All these patients undergo skin prick tests when first seen in our clinic. None of these patients have had systemic reactions to skin prick tests despite many of them being sensitized to multiple allergens. In addition, 60% of patients in our general allergy clinics have asthma of various severities. Our findings support an association with the number and size of positive skin test results in those patients who have systemic reactions. Liccardi et al4 suggested that one factor may be due to simultaneous exposure to several allergens, inducing additive histamine release from cutaneous mast cells. However, as stated by Liccardi et al, this is one of several cofactors that may influence the risk of a systemic reaction to skin tests. At least 80% to 90% of our patients are polysensitized; however, hardly any of these (approximately 0.0056%) had a systemic reaction to skin prick tests. The anaphylaxis to tazocin in the nurse described in our article is an extremely rare and sensitive case. In this instance, skin testing should be performed starting with diluted concentrations of drug. This is an exceptional case which is indicated by our experience with more than 5,000 drug allergic patients, many with anaphylaxis to penicillins and none of whom had systemic reactions to skin prick tests. Thus, for investigation of standard patients, including those with anaphylaxis to oral or parenteral penicillins, normal drug concentrations should be used. We disagree that our selection of patients was questionable. We are a regional and national specialist center with a high proportion of severe cases. Most of our patients have anaphylaxis (of any cause), food allergy, drug allergy, and multisystem disease (eg, in nut allergy): 96% have asthma, rhinitis, and/or
eczema, 76% have asthma; 73% have rhinitis; 60% have eczema, and 96% have multiple positive skin prick test results. Most (almost all) of our patients with anaphylaxis and severe allergic reactions have no generalized reaction to skin prick tests (databases include >2,000 patients with nut allergy, 1200 with venom allergy, and 400 with anaphylaxis during general anesthesia but a much larger experience of skin testing in >100,000 patients). Of those children who reacted to skin prick tests (16 years and younger), more than half were tested with foods only, and a few were tested to foods and inhalants. In our experience, most children would be tested to foods and inhalants simultaneously with no systemic reaction. Priya Sellaturay, MRCP Pamela Ewan, FRCP Department of Allergy Cambridge University Hospitals National Health Service Foundation Trust Cambridge, United Kingdom [email protected]
References [1] Liccardi G, Salzillo A, Calzetta L, Piccolo A, Rogliani P. How many systemic reactions to skin prick tests could be preventable in defined conditions? Ann Allergy Asthma Immunol. In press. [2] Gonzalez-Pérez A, Aponte Z, Vidaurre CF, Rodriguez LA. Anaphylaxis epidemiology in patients with and without asthma: a United Kingdom database review. J Allergy Clin Immunol. 2010;125:1098e1104. [3] Bernstein DI, Wanner M, Borish L, Liss GM. Immunotherapy Committee of the American Academy of Allergy, Asthma and Immunology. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol. 2004;113:1129e1136. [4] Liccardi G, Passalacqua G, Falagiani P, Russo M, D’Amato G. The effect of multiple allergens on histamine release in vivo assessed by skin prick test. Allergy. 2008;63:1559e1560.
A Colorado allergist's experience with marijuana legalization Although I appreciated the fine review by Ocampo and Rans entitled Cannabis Sativa: The Unconventional “Weed” Allergen,1 I thought it would be worthwhile to describe the few adverse reactions seen in our patient population. The relative paucity of these presentations since legalization of marijuana in Colorado suggests that cannabis sativa is a mild allergen, with significant exposure required to elicit respiratory and dermatologic allergic reactions. With the advent of marijuana legalization in Colorado, we describe 3 recent patients with distinct clinical presentations suggestive of marijuana sensitization. The results of skin testing by the “puddle” technique were positive in 2 of these patients but negative in the other. These cases indicate the need for clinicians to query their patients about marijuana exposure and, when appropriate, perform specific testing to establish sensitization. Further investigation to elucidate the specific sensitizing antigen(s) in marijuana or its derivatives (eg, wax, oils) is required to better understand the pathobiology of this environmental exposure.
Disclosures: Author has nothing to disclose.
Patient 1 is a 28-year-old white man who presented with the chief concern of nasal congestion worsening around “pot” in 2010. He had previously been evaluated by an allergist for allergic rhinitis and was found to be polysensitized to multiple indoor and outdoor aeroallergens. He began working as a trimmer at a marijuana growth facility and shortly thereafter he developed “extreme” nasal congestion, which was intermittent initially but soon became persistent. He tried holistic therapeutic approaches to manage the congestion, such as vaporized essential oils, eucalyptus, peppermint, and lavender several times per day, without relief. During his office visit he reported that during the past 2 months he had frequent wheezing with a chronic cough. The results of previous spirometry to assess lung function had reportedly been normal. Although no diagnosis of asthma was given, he had been given an albuterol inhaler for chest tightness by his primary care physician. He admitted frequent marijuana smoking. Of note, he had a history of an adverse food reaction where vinegar caused throat swelling. He had 2 cats at home, causing no symptoms. He was otherwise healthy and required no other drugs.
