severe marijuana allergy controlled with omalizumab
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J ALLERGY CLIN IMMUNOL
VOLUME 131, NUMBER 2
Abstracts AB215
UESDAY
766 Characterization of the Causative Allergens for Wheat-Dependent Exercise-Induced Anaphylaxis Sensitized withHydrolyzed Wheat Proteins in Facial Soap
Tomoharu Yokooji1, Saki Kurihara1, Tomoko Murakami1, Yuko Chi-
nuki2, Susumu Harada3, Hitoshi Takahashi2, Eishin Morita2, Kaori Ishii4,
Makiko Hiragun4, Michihiro Hide4, Hiroaki Matsuo1; 1Department of
Pathophysiology and Therapeutics, Graduate School of Biomedical and
Health Sciences, Hiroshima University, Hiroshima, Japan, 2Department
of Dermatology, Shimane University, Izumo, Japan, 3Harada Skin Clinic,
Nishinomiya, Japan, 4Department of Dermatology, Graduate School of
Biomedical and Health Sciences, Hiroshima University, Hiroshima,
Japan.
RATIONALE: Hydrolyzed wheat proteins (HWP) were reported to cause
wheat-dependent exercise-induced anaphylaxis (WDEIA) by transcutane-
ous sensitization through the use of HWP-containing soap in Japan. These
patients developed the allergic reactions not only with the use of soap, but
also on exercise after the intake of wheat protein (WP). In this study, we
identified the allergens and its IgE-binding primary epitopes in WP for
HWP-WDEIA patients.
METHODS: Sera were obtained from 13 patients with native WP-
sensitized WDEIA and 23 patients with HWP-sensitized WDEIA. The
allergenic activities of HWP and 6 recombinant wheat proteins, including
a/b-, g-, v1,2- and v5-gliadins and low- and high molecular weight
(HMW)-glutenins, were characterized by immuno-blot analysis and
histamine releasing test. The IgE-binding epitopes were identified using
arrays of overlapping peptides synthesized on SPOTs membrane.
RESULTS: The higher IgE-bindings to v5-gliadins and HMW-glutenins
were detected inWP-WDEIA patients, whereas the IgE-binding toa/b-, g-
and v1,2-gliadins were preferential in HWP-WDEIA patients. g-Gliadin
strongly induced the histamine releases from basophils of the patients with
HWP-WDEIA. In the inhibition study, the HWP significantly inhibited the
IgE-binding to a/b-, g- and v1,2-gliadins, indicating that HWP-specific
IgE cross-reacts with those proteins. An epitope ‘‘QFLQPQQPFPQQPQ’’
was identified within primary sequence of g-gliadin.
CONCLUSIONS: The specific-IgE to HWP cross-reacted with g-gliadin
in WP most strongly, and the major IgE-binding epitope was
QFLQPQQPFPQQPQ. Thus, HWP-WDEIA symptoms after wheat inges-
tion could be induced by g-gliadin at least partly.
767 Streptomycin in a Blueberry Pie? Risk of AllergicSensitization and Reaction to Antibiotics Contained in Foods
Francois Graham, MD, MSc1, Philippe Begin, MD, MSc1, Louis P.
Paradis, MD, FAAAAI1, Yves Babin, PhD2, Anne M. Des Roches, MD,
FAAAAI3; 1CHUM, Hopital Notre-Dame, Montreal, QC, Canada, 2Min-
ist�ere de l’Agriculture, des Pecheries et de l’Alimentation du Qu�ebec,
Quebec, QC, Canada, 3CHU Sainte-Justine, Montreal, QC, Canada.
RATIONALE: Widespread use of antibiotics in the agri-food industry is
highly controversial, mostly in light of the emergence of bacterial
resistances. Antibiotic sensitization is another potential risk that has
been described with reports of anaphylaxis to antibiotics contained in
meats. At our center, we investigated an 11-year-old girl with known milk
allergy who presented with anaphylaxis requiring ICU admission follow-
ing the ingestion of a blueberry pie, which was presumed to be contam-
inated with streptomycin.
METHODS: Skin prick tests to the pie ingredients were performed on the
subject with intradermal skin tests to streptomycin, as this was an antibiotic
used in orchards at the time. Contents of the pie were analyzed at the
Quebec Ministry of Agriculture, Fisheries and Food laboratory for
detection of milk and sulfites. Bacterial growth inhibition testing was
also performed.
RESULTS: Pie sample analyses showed milk and sulfites below
detection limit. However, samples inhibited bacterial growth. Skin tests
for ingredients other than milk, including blueberry, were negative.
Intradermal skin testing with 0.0008 mg and 0.008 mg of streptomycin
were strongly positive. A control subject had negative tests at these
concentrations. In the minutes following skin tests, the patient developed
an urticarial neck rash and was kept under observation and given an anti-
histaminic. She was discharged but was admitted for a late phase reaction
with stridor and urticaria. She had never been in contact with strepto-
mycin in the past.
CONCLUSIONS: To our knowledge, this is the first documented report of
an anaphylactic reaction likely caused by the ingestion of antibiotic
contaminated fruits.
768 Severe Marijuana Allergy Controlled with OmalizumabDavid B. Engler, MD, FAAAAI1, Alnoor A. Malick, MD,
FAAAAI2, Sunil K. Saraf, MD3, Lisa Adams Dargel, PA-C4; 1Houston Al-
lergy & Asthma Clinic, Houston, TX, 2The Allergy Clinic, Pasadena, TX,3The Allergy Clinic, The Woodlands, TX, 4The Allergy Clinic, Manvel,
TX.
RATIONALE: To see if omalizumab could decrease the frequency and
severity of anaphylaxis in a police detective.
METHODS: The patient has moderate asthma. She received treatment
with 375 mg omalizumab q 2 weeks.
RESULTS: Episodes of anaphylaxis decreased from 3 per month to 0 per
month after 4 months of omalizumab.
CONCLUSIONS: Omalizumab may be of benefit in patients with
anaphylaxis when they cannot avoid the allergen. A 29 y.o. police detective
began experiencing anaphylaxis from casual exposure to marijuana after
her daughter was born. Although she did not interact directly with the
marijuana as her specialty is battered women, casual exposure tomarijuana
plants, marijuana smoke, or even a person who had recently smoked
marijuana caused dyspnea, throat closing, generalized urticaria that
progressed to hypotension with loss of consciousness if she did not use
two epinephrine auto-injectors (each 0.3 mg). Reasonable accommoda-
tions for her to avoid marijuana could not be achieved as she works for a
county whose sheriff’s office is one small building. She continued to
experience anaphylaxis in spite of daily use of fexofenadine, cetirizine,
ranitidine, formoterol, mometasone, and montelukast. She was started on
omalizumab 300mg SQ q 4 weeks. Four months after starting therapy with
omalizumab, she could be exposed to large amounts of marijuana without
experiencing anaphylaxis, although she continues to feel her harbinger
symptoms of tingling of the skin. Omalizumab may be effective in
reducing the frequency and/or severity of anaphylaxis when a patient
cannot avoid the offending allergen.
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