A Protocol for Induction of Tolerance to Apomorphine in Patients With Parkinson Disease and Hypersensitivity to Apomorphine

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
PRACTITIONER'S CORNER
Successful Desensitization to Irinotecan After Severe
Hypersensitivity Reaction
Cubero JL1,2, Escudero P2,3, Yubero A2,3, Millán P4, Sagredo MA5,
Colás C1,2
1Allergy Department, University Hospital Lozano Blesa of
Zaragoza, Zaragoza, Spain
2Instituto de Investigación Sanitaria Aragón (IIS Aragón), Spain
3Oncology Department, University Hospital Lozano Blesa of
Zaragoza, Zaragoza, Spain
4Intensive Care Unit, University Hospital Lozano Blesa of
Zaragoza, Zaragoza, Spain
5Pharmacy Department, University Hospital Lozano Blesa of
Zaragoza, Zaragoza, Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-316
doi: 10.18176/jiaci.0075
Key words: Desensitization. Hypersensitivity reactions. Irinotecan.
Palabras clave: Desensibilización. Reacciones de hipersensibilidad.
Irinotecan.
Irinotecan is an antineoplastic drug that is widely used
to treat gastrointestinal malignancies. It prevents DNA
from unwinding by inhibition of topoisomerase I [1].
Hypersensitivity reactions (HSRs), which can occur with
most drugs, are unpredictable, can aect any organ or system,
and range widely in clinical severity from mild pruritus to
anaphylaxis. In most cases, the culprit drug is avoided in
the future, but for certain patients, the particular drug may
be essential for optimal therapy. Under these circumstances,
desensitization to the drug in question is a viable option. This
approach induces a temporary state of tolerance to the drug
responsible for a proven HSR [2].
A 57-year-old man with a personal history of dyslipidemia,
high blood pressure, and hyperuricemia and no history of
allergy was diagnosed in June 2014 with a low rectal neoplasm
7 cm from the anal margin with synchronous liver metastases
(T3N2M1). Short-course radiotherapy was administered,
followed by laparoscopic ultralow anterior resection with
manual colorectal anastomosis and removal of a surgical
specimen through the anus (pass-through) with protective
lateral ileostomy.
Postoperative evaluation revealed that the liver tumors
had progressed and were nonresectable; consequently,
chemotherapy was initiated with CAPOX (capecitabine and
oxaliplatin) in combination with bevacizumab (the patient
harbored a KRAS mutation), and by April 2015, the patient
had received 6 cycles.
The response of the liver metastases to chemotherapy was
poor, so it was decided to administer 4 cycles of irinotecan-
loaded drug-eluting beads (DEBIRI, BTG) via intra-arterial
infusion. The patient received 100 mg of irinotecan in DC
Bead (an embolic drug-eluting bead for controlled loading
and release of chemotherapeutic agents) (BTG) of 100-
300 µm between May and September 2015 and showed no
hypersensitivity symptoms.
Owing to disease progression (enlargement of the liver
nodules and emergence of new liver foci and pulmonary
nodules), treatment was initiated 2 months later with
aibercept in combination with FOLFIRI (irinotecan, calcium
levofolinate, and 46-hour 5-fluorouracil in a continuous
infusion). In the rst cycle, during the administration of
irinotecan alone, the patient presented lingual angioedema,
generalized urticaria, desaturation, and blurred vision that
lasted 6 hours and required various doses of corticosteroids,
systemic antihistamines, and oxygen. Given the severity of
the reaction, calcium levofolinate and 5-uorouracil were
discontinued. Before the diagnosis of allergy to irinotecan,
the patient had received aibercept, calcium levofolinate, and
5-uorouracil without symptoms.
The patient was assessed in the allergy department, where
skin tests with irinotecan were performed at the concentrations
described by Alvarez-Cuesta et al [3]: prick test, 20 mg/mL;
and intradermal tests, 2 mg/mL and 20 mg/mL. The result was
positive with the 20-mg/mL intradermal test. Drugs for prick
and intradermal tests were prepared by the cytotoxic unit of
the pharmacy department.
Drug desensitization was programmed using a 12-step
protocol adapted from Castells et al [4], which enabled a
cumulative dose of 336.4 mg of irinotecan to be administered
(Table). Pretreatment was with oral acetylsalicylic acid 500 mg
(instead of 325 mg, because of commercial availability)
and oral montelukast 10 mg at 48 hours and 24 hours
before and on the day of desensitization. The other drugs
in the patient’s protocol (aibercept 296 mg, fosaprepitant
150 mg, dexamethasone 12 mg, ondansetron 8 mg, atropine
0.5 mg, calcium levofolinate 373.8 mg, and 5-uorouracil
4486 mg) were administered following the order, dose, and
rate of the oncology department’s routine administration
protocol. Solutions were prepared by the cytotoxic unit
and then administered at the bedside by a specialized nurse
from the allergy department. An allergologist experienced
in desensitization was present throughout the infusion in the
outpatient center.
Desensitization was successful and the patient did not
experience a reaction during the infusion or during the
following hours. Subsequent cycles were scheduled according
to the original desensitization protocol.
We report a successful and rapid protocol for desensitization
to irinotecan in a patient who became sensitized to it during

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
intra-arterial chemoembolization of liver metastases.
The patient experienced a severe HSR to during the rst
intravenous dose of irinotecan, which was administered 2
months after the last chemoembolization session. We found
only 1 other recent case report of desensitization to the drug,
although the protocol used diered from ours, especially in
terms of premedication [5]: the regimen administered the night
before admission comprised intravenous dexamethasone 12
mg, oral fexofenadine 180 mg, and oral cimetidine 400 mg; the
regimen administered 2 hours before the procedure comprised
intravenous dexamethasone 20 mg, oral promethazine 50 mg,
oral fexofenadine 180 mg, and intravenous ranitidine 50 mg.
HSRs are unpredictable, can aect any organ or system,
and range widely in clinical severity from mild pruritus to
anaphylaxis. In the eld of oncology, they have been described
with many drugs, and their frequency has been reported to be
5%-27% for platins, 10%-30% for taxanes, and 0.6%-10% for
specic monoclonal antibodies [6]. In the study of Alvarez-
Cuesta et al [3], irinotecan was the suspected culprit drug in 11
of the 186 patients (5.9%) referred for desensitization over a
3-year period (data conrmed HSR to irinotecan, although the
characteristics of the reactions are not provided in the article).
Drug desensitization induces a temporary state of tolerance
to the drug responsible for a specic HSR [2]. The 12-step
protocol (3 bags) described by Castells et al [6] is the most
frequently used, although other protocols should be considered
in patients with severe HSRs and anaphylactic reactions [6].
Pretreatment was with oral acetylsalicylic acid 500 mg and oral
montelukast 10 mg at 48 hours and 24 hours before and on the
day of desensitization. In our department, we use systematic
premedication with acetylsalicylic acid and montelukast to
improve tolerability of the desensitization protocol [6,7]. We
do not use systematic premedication with antihistamines or
corticosteroids; these drugs are only used in patients who
develop repeated reactions during previous desensitization
protocols.
In conclusion, rapid desensitization is a promising
method for the delivery of antineoplastic drugs, monoclonal
Table. Irinotecan Desensitization Protocol
Solution Volume Solution Concentration Total Dose in Each Solution
Solution A 500.17 mL 0.007 mg/mL 3.4 mg
Solution B 501.68 mL 0.067 mg/mL 33.6 mg
Solution C 516.67 mL 0.645 mg/mL 333.4 mg
Step Solution Rate, mL/h Time, Min Volume Dose Cumulative
Administered, Administered, Dose
mL mg Infused, mg
1 A 6 15 1.50 0.010 0.010
2 A 11 15 2.75 0.019 0.029
3 A 23 15 5.75 0.039 0.068
4 A 45 15 11.25 0.076 0.144
5 B 11 15 2.75 0.184 0.329
6 B 23 15 5.75 0.385 0.714
7 B 45 15 11.25 0.753 1.467
8 B 90 15 22.50 1.507 2.974
9 C 23 15 5.75 3.710 6.684
10 C 45 15 11.25 7.259 13.944
11 C 90 15 22.50 14.519 28.463
12 C 180 159.1 477.17 307.937 336.400
Total infusion time: 324 min
Volume of each solution administered: solution A,21.25 mL;solution B, 42.25 mL; and solution C, 516.67 mL.
Solutions were prepared in the cytotoxicity unit of the pharmacy department. The tubing of each bag is primed with the antineoplastic drug in
the pharmacy and connected to a running saline line in close proximity to the patient, thus enabling delivery of small volumes during the initial
steps of the desensitization protocol.
The protocol was adapted from Castells et al [4]. Irinotecan is always diluted in 500 mL in our hospital, instead of 250 mL, as per the
original protocol, and the infusion rate is adapted to that change. No diluent is removed when a solution is prepared owing to our local safety
requirements: the amounts added are 0.17 mL of 20 mg/mL irinotecan (commercial concentration, total volume, 500.17 mL) in solution A,
1.68 mL (total volume, 501.68 mL) in solution B, and 16.67 mL (total volume, 516.67 mL) in solution C.
315

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
316
Manuscript received February 12, 2016; accepted for publication
May 9, 2016.
José Luis Cubero Saldaña
Servicio de Alergia
Hospital Clínico Universitario Lozano Blesa
Avda. San Juan Bosco 15. 50.009 – Zaragoza
E-mail: jlcubero@salud.aragon.es
antibodies, antibiotics, and other drugs after HSRs and should
be considered when no acceptable therapeutic alternatives are
available.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
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2. Cernadas JR, Brockow K, Romano A, Aberer W, Torres MJ,
Bircher A, Campi P, Sanz ML, Castells M, Demoly P, Pichler
WJ; European Network of Drug Allergy and The EAACI interest
group on drug hypersensitivity. General considerations on
rapid desensitization for drug hypersensitivity - a consensus
statement. Allergy. 2010;65(11):1357-66.
3. Alvarez-Cuesta E, Madrigal-Burgaleta R, Angel-Pereira D,
Ureña-Tavera A, Zamora-Verduga M, Lopez-Gonzalez P, Berges-
Gimeno MP. Delving into cornerstones of hypersensitivity to
antineoplastic and biological agents: value of diagnostic tools
prior to desensitization. Allergy. 2015;70(7):784-94.
4. Castells MC, Tennant NM, Sloane DE, Hsu FI, Barrett NA,
Hong DI, Laidlaw TM, Legere HJ, Nallamshetty SN, Palis RI,
Rao JJ, Berlin ST, Campos SM, Matulonis UA. Hypersensitivity
reactions to chemotherapy: outcomes and safety of rapid
desensitization in 413 cases. J Allergy ClinImmunol.
2008;122(3):574-80.
5. Abu-Amna M, Hassoun G, Hadad S, Haim N, Bar-Sela G.
Successful Desensitization Protocol for Hypersensitivity
Reaction Caused by Irinotecan in a Patient With Metastatic
Colorectal Cancer. Clin Colorectal Cancer. 2015;14(4):e49-
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6. Castells Guitart MC. Rapid drug desensitization for
hypersensitivity reactions to chemotherapy and monoclonal
antibodies in the 21st century. J Investig Allergol Clin
Immunol. 2014;24(2):72-9.
7. Breslow RG, Caiado J, Castells MC. Acetylsalicylic acid and
montelukast block mast cell mediator-related symptoms
during rapid desensitization. Ann Allergy Asthma Immunol.
2009;102(2):155-60.
Hypersensitivity to Quail Egg Proteins: What About
Hen Egg?
Micozzi S1,2, Bartolomé B3, Sanchís-Merino ME4, Alfaya T5,
Aldunate T6, Diaz M7, Pastor-Vargas C8
1University General Hospital Gregorio Marañón, Madrid, Spain
2Gregorio Marañón Health Research Institute, Madrid, Spain
3R&D Department Bial-Aristegui, Bilbao, Spain
4University Hospital Río Hortega, Valladolid, Spain
5University General Hospital of Ciudad Real, Ciudad Real, Spain
6Hospital Reina Sofía of Tudela, Navarra, Spain
7University and Polytechnic Hospital La Fe, Valencia, Spain
8Immunology Department, IIS-Fundación Jiménez Díaz, Madrid,
Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 316-318
doi: 10.18176/jiaci.0076
Key words: Egg allergy. Hen egg. Quail egg.
Palabras clave: Alergia a huevo. Huevo de gallina. Huevo de codorniz.
Food allergy is a major problem in society today. Since it
is consumed throughout the world, hen’s egg (HE) is the most
common type of egg allergy.
The main HE allergens are proteins from the white, namely,
ovalbumin (Gal d 2 [OVAh]), ovotransferrin (Gal d 3 [OVTh]),
lysozyme (Gal d 4 [LYSh]), and ovomucoid (Gal d 1 [OVMh]).
Allergy to egg from other species, especially quail’s egg
(QE), in patients who tolerate HE is much less frequent,
although some cases have been reported [1-3].
The objectives of the present study were to identify the
causative allergen in a group of patients with hypersensitivity
to QE who tolerate HE and to describe the pattern of
hypersensitivity to HE in this group.
We studied 5 patients (4 females and 1 male), with a mean
age of 25 years (range, 10-36 years). Symptoms induced by
undercooked QE (inclusion criteria) included angioedema (1
patient) and anaphylaxis (4 patients). All patients were atopic.
Prior to the anaphylactic reaction, all patients had tolerated QE
and HE (at dierent degrees of cooking), as well as chicken,
turkey, and quail meat. After the reaction, all 5 patients
tolerated cooked and undercooked HE, and 4 patients tolerated
quail, turkey, and chicken meat. The remaining patient has
not eaten quail meat since then, but he tolerates turkey and
chicken meat.
Informed consent was obtained in all cases. The study was
approved by the local ethics committee.
Skin prick-by-prick tests (SPPT) were performed with
cooked and uncooked yolk and white from QE. Skin prick tests
(SPT) were performed with commercial extracts of common
inhalant allergens, OVAh, OVMh, OVTh, LYSh, and HE yolk
and white (Bial-Aristegui, Leti, and ALK-Abelló). The results
of the tests are shown in the Table.
Serum total and specic IgE levels against yolk and white
from HE and against Gal d 1, 2, and 3 were measured using

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317
ImmunoCAP (Thermo Fisher Scientic) according to the
manufacturer’s instructions. Specic IgE from QE white
and yolk was determined using EAST; the solid phase was
obtained by coupling the extract solution (10 mg/mL) to
6-mm cyanogen bromide–activated paper discs, as described
by Ceska and Lunqvist [4]. The results were expressed in
accordance with the manufacturer’s instructions for the CAP
assay (HYTEC Specic IgE EIA kit) and EAST (HYCOR
Biomedical Ltd). Values ≥0.1 and ≥0.35 kUA/L were
considered positive for EAST and CAP, respectively (Table).
QE white and yolk extracts were analyzed using SDS-
PAGE, and immunoblotting was performed using the patient’s
serum, which was incubated overnight and revealed with a
second antibody antihuman IgE, as previously described [5].
The result of IgE-immunoblotting with QE white and yolk
extracts showed the same IgE-binding prole, although this
was much more intense in white than in yolk (data not shown).
Two main IgE binding bands were detected: a 42-kDa band,
which was revealed in all the assayed sera, and a 35-kDa
band, which was detected in 2 sera. In addition, a band of
about 97 kDa was detected in patients 3 and 4.
Proteins were identied at the Proteomics Department of
the Universidad Complutense de Madrid, a member of the
ProteoRed Network.
The 42-kDa and 35-kDa IgE-binding bands were
identied and proved to be ovalbumin and ovomucoid from
QE (OVAq, OVMq), respectively. The molecular weight of
OVMh is about 30 kDa; that of OVMq in a standard 12.5%
SDS-PAGE electrophoresis gel is slightly higher [6].
The 97-kDa binding protein was identified as
ovotransferrin.
We present 5 cases of hypersensitivity to QE in patients
who tolerated HE. As reported by other authors [7], the
proteins from dierent types of egg whites can present cross-
reactivity, especially if their phylogenetic homology is high.
Since both quail and hen belong to the Galliforme order,
their proteins present high homology. In fact, although all
patients tolerated cooked and uncooked HE, 3 of the 5 patients
were sensitized to OVAh (most likely by cross-reaction), as
deduced from positive SPT and specic IgE results.
All the patients’ sera had specic IgE against OVAq (heat-
sensitive), thus explaining why the allergic reaction occurred
with undercooked QE (fried, omelette) in all patients. In
addition, sera from patients 4 and 5 revealed OVMq in the
immunoblotting assay; the SPPT result to cooked QE white
was also positive. In patient 1, the SPPT was performed with
QE omelette, whose cooked level is dicult to establish;
consequently, the positive SPPT result to QE white, despite
being caused by OVMq, was not observed. Patients whose
serum did not reveal OVMq did not manifest milder reactions
than the others.
Only 1 patient had a positive SPT result with OVMh, and
1 had positive IgE against OVMh, possibly because of cross-
reactive carbohydrate-determining reagents.
Other discrepancies between SPT and ImmunoCAP are
probably linked to the diculties associated with extract
standardization: OVMh in SPT extracts is not as puried as
in those used for ImmunoCAP.
All the patients had a positive SPPT result to QE yolk,
although no major QE yolk proteins were revealed in the QE
Table. Results of SPT, SPPT, and IgE Testing
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
SPT SPPT IgE, SPT SPPT IgE, SPT SPPT IgE, SPT SPPT IgE, SPT SPPT IgE,
kUA/L kUA/L kUA/L kUA/L kUA/L
QEW - P 0.4 P P 9.7 P 1.0 - P 4.3 - P 15.9
(uncooked) (uncooked) (uncooked) (uncooked) (uncooked)
P (cooked) N (cooked) N (cooked) P (cooked) P (cooked)
QEY - P 0.5 P P 0.7 P 0.7 - P 4.5 - P 16.3
(uncooked) (uncooked) (uncooked) (uncooked) (uncooked)
P (cooked) N (cooked) N (cooked) P (cooked) N (cooked)
HEW N <0.35 P 2.1 P 0.5 P 0.4 N 0.84
HEY N <0.35 N <0.35 N <0.35 N <0.35 N <0.35
O VA h N <0.35 P 2.59 P 0.7 P <0.35 N 0.89
OVMh N <0.35 N <0.35 P <0.35 N <0.35 N 4.38
LYSh N <0.35 - - <0.35 N <0.35 - -
OVTh - <0.35 <0.35 - <0.35 N - - -
MS 42 kDa (OVAq) 42 kDa (OVAq) 42 kDa (OVAq) 42 kDa (OVAq)/ 42 kDa (OVAq)/
35 kDa (OVMq) 35 kDa (OVMq)
SYM Anaphylaxis Angioedemia Anaphylaxis Anaphylaxis Anaphylaxis
Abbreviations. HEW, hen egg white; HEY, hen egg yolk; LYSh, hen lysozyme; MS, mass spectrometry; N, negative; OVAh, hen ovalbumin; OVAq, quail ovalbumin; OVMh, hen ovomucoid;
OVMq, quail ovomucoid; OVTh, hen ovotransferrin; P, positive; QEW, quail egg white; QEY, quail egg yolk; SPT, skin prick test; SPPT, skin prick-by-prick test; SYM, symptoms.

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
318
Manuscript received February 19, 2016; accepted for publication
May 10, 2016.
Sarah Micozzi
Hospital General Universitario Gregorio Marañón
C/ Doctor Esquerdo, 46
28007 Madrid, Spain
E-mail: sarah.micozzi@gmail.com
immunoblotting assay. In addition, after the allergic reaction,
all patients tolerated poultry meat, indicating that a-livetin
(quail albumin) was not involved in any of these cases.
The diculty in obtaining a QE yolk sample without
QE white contamination, as reported elsewhere [7], could
explain the positive results for QE yolk in the SPPT and
immunoblotting assay.
Although allergy to QE—with or without HE sensitivity—
has been reported [2,3,8,9], ours is the rst case series in which
the causative proteins were identied.
We found only 1 case of non–IgE-mediated food
hypersensitivity reaction to QE [10].
In conclusion, in the 5 patients we report, the main QE
allergen is ovalbumin. Although proteins from HE and QE
showed cross-reactivity, patients commonly tolerate HE
consumption even when they have QE allergy. Since patients
with QE allergy can show different HE skin test results
(positive SPT and/or SSPT and/or specic IgE to HE proteins,
with good tolerance to HE), these results should not be used
to predict intolerance to HE.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
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eggs from duck and goose without sensitization to hen egg
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Pineda F. Duck egg allergy in a patient who tolerates hen's
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AS, Palacín A, Díaz-Perales A, de Las Heras Gozalo M,
Labrador-Horrillo M, Vivanco F, Cuesta-Herranz J, Pastor-
Vargas C. Identication of thaumatin-like protein and aspartyl
protease as new major allergens in lettuce (Lactuca sativa).
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6. Hjelmeland LM, Chrambach A. Electrophoresis and
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8. Alessandri C, Calvani M Jr, Rosengart L, Madella C. Anaphylaxis
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Conde J. Oral allergy syndrome to bird meat associated with
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10. Sanlidag B, Babayigit Hocaoglu A, Bahceciler N. Quail’s Egg–
Induced Severe Enterocolitis in a Child Tolerant to Hen’s
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2016;26(2):118-9.

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319
Is Vitamin D Deciency a Marker of Severity of
Wheezing in Children? A Cross-sectional Study
Urrutia-Pereira M1, Solé D2
1Faculty of Medicine, Federal University of Pampas and Pediatric
Program for the Prevention of Asthma (PIPA) – City Hall of
Uruguayana, Rio Grande do Sul, Brazil
2Division of Allergy, Clinical immunology and Rheumatology,
Department of Pediatrics, Federal University of São Paulo-Escola
Paulista de Medicina, São Paulo, São Paulo, Brazil
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 319-321
doi: 10.18176/jiaci.0077
Key words: Vitamin D. Children. Wheezing. Asthma. Immunoglobulin E.
Palabras clave: Vitamina D. Niños. Sibilancias. Asma. Inmunoglobulina E.
Wheezing is a common complaint in pediatric emergency
departments, especially in developing countries [1]. The
relationship between wheezing in childhood and subsequent
development of asthma remains unclear. Individual genetic
and immunological factors, environmental factors, lifestyle,
dietary habits, and deciencies of vitamins such as vitamin D
(VitD) have been associated with the development of
wheezing/asthma [2].
The association between serum VitD levels and various
diseases, including asthma, has been extensively studied.
However, the results for asthma are controversial [3].
We studied the relationship between serum VitD levels
and wheezing in children treated at the Pediatric Program for
the Prevention of Asthma (PIPA), Uruguayana, Brazil [4].
All children (3-47 months; n=370) with occasional
wheezing (OW; up to 2 episodes of wheezing in the previous
year, n=115) and recurrent wheezing (RW; ≥3 wheezing
episodes in the previous year, n=255) referred to PIPA (from
March 2012 to March 2013; outpatients) were enrolled in this
cross-sectional study. Children with other chronic diseases,
genetic syndromes, and/or birth defects were not included. At
admission, the patient’s parents and/or guardians completed
a standardized written questionnaire (International Study of
Wheezing in Infants; EISL) consisting of 45 questions about
demographic characteristics, wheezing and risk factors, as well
as the severity of wheezing [5]. RW patients were classied
according to the number of episodes in the previous year as
having had up to 6 episodes/year (n=150) or >6 episodes/
year (n=105).
Peripheral blood samples were obtained from all patients for
determination of total serum IgE using ImmunoCap (Thermo
Scientic) and VitD levels using electrochemiluminescence.
Patients were classied according to VitD level as having
deciency (<20 ng/mL [<50 nmol/L]), insuciency (21-
29 ng/mL [52.5-72.5 nmol/L]), and suciency (≥30 ng/mL
[75 nmol/L]) [2].
In the initial statistical analysis, OW was compared with
RW, and patients with <6 episodes/year were compared with
those with ≥6 episodes/year (Table). Categorical variables
(gender, visits to the emergency department, use of oral
corticosteroids, severe wheezing, hospitalizations due to
wheezing, hospitalizations due to pneumonia, and physician-
diagnosed asthma) were analyzed using the chi-square or
Fisher exact test. Continuous variables (age, weight, height,
age at rst episode, number of colds and age at rst cold,
serum VitD levels, total serum IgE levels) were analyzed
using the t test (normal distribution) or Mann-Whitney test
(nonnormal distribution). All analyses were performed with
SPSS 18.0 (SPSS Inc), and statistical signicance was set at
P<.05. The study was approved by the local ethics committee,
and all parents and/or guardians signed the informed consent.
The Table shows the main characteristics of the patients
enrolled in the study. Both groups (OW and RW) were similar
in gender, age, and current weight and height. None of the
patients were receiving VitD supplements during the month
before entering PIPA. RW children were younger at the rst
episode of wheezing and of upper respiratory tract infection,
used oral corticosteroids more frequently than OW patients,
and had a higher frequency of upper respiratory tract infection,
nighttime awakenings, and hospitalization for wheezing or
pneumonia.
These data are consistent with those previously observed
in the EISL study [5], in which the analysis of risk factors
associated with RW revealed that having a cold during the
rst 3 months of life indicated a 3-fold higher risk of RW [6].
Viral respiratory infections are considered a major cause of
wheezing, particularly when they are recurrent. As observed in
the patients we report, early onset of wheezing coincided with
the rst episode of viral respiratory infection, in addition to
being an associated factor for the subsequent development of
asthma [6]. A medical diagnosis of asthma was more frequent
in RW patients, especially those with >6 episodes of wheezing
in the previous year, than in OW patients.
The role of VitD in respiratory antiviral defense has been
evaluated in several studies, with conicting results. In our
study, we observed signicantly higher serum VitD levels in
RW children, especially those with more severe forms, than
in OW children and children with milder conditions. Although
obvious, these results do not allow us to draw more conclusive
ndings about the relationship between VitD and wheezing/
asthma for the patients in the present study owing to limitations
aecting our study, namely, its retrospective design, lack of
control with respect to breastfeeding, individual family atopic
status, and time of and age at collection of blood samples.
Therefore, we were unable to determine the causal connection
between VitD and the development of wheezing and/or
asthma. In addition, we provide no information about the
mother’s prenatal VitD levels or on VitD supplements before
or during pregnancy. Likewise, we provide no information
on the inuence of confounders related to maternal diet,
socioeconomic factors, lifestyle, or epigenetic changes caused
by the environment to which the mothers were exposed [7].
It is important to stress that for a given population, the
many factors that can modify the eect of variations in VitD
concentrations in children include season, sun exposure,
socioeconomic status, ethnicity, age, gender, dietary habits,
interaction with other vitamins and trace elements, prenatal

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Table. Children With Occasional Wheezing (≤2 Episodes of Wheezing; OW) or Recurrent Wheezing (≥3 Episodes) According to Main Clinical Characteristics and Serum Vitamin D (VitD) and Total IgE
Levels: Univariate Analysis
Recurrent Wheezing
Characteristic OW (N=115) Total P Value ≤6 episodes >6 episodes P Value
(N=255) OR (95%CI) n=150 n=105 OR (95%CI)
Males, No. (%) 59 (51.3) 145 (56.9) 0.906 87 (58.0) 58 (55.2) 0.700
0.97 (0.62-1.54) 1.05 (0.84-1.31)
Mean (SD) age, moa 18.5 (13.5) 17.6 (12.6) .788 17.9 (12.9) 17.2 (12.1)b <.0001
Mean (SD) weight, kga 11.4 (4.4) 10.8 (3.5) .304 11.0 (3.7) 10.5 (3.2) .349
Mean (SD) height, cma 78.1 (15.4) 77.8 (14.1) .793 78.5 (14.1) 76.8 (14.1) .456
Mean (SD) age at rst episode, moc 5.3 (4.1) 3.9 (3.0)b .007 4.3 (3.0) 3.3 (3.1)b .005
Mean (SD) number of coldsc 3.4 (2.0)b 4.4 (2.9) .0001 3.8 (2.2)b 5.3 (3.6) <.0001
Mean (SD) age at rst cold, moc 4.2 (3.1) 3.4 (2.8)b .033 3.6 (2.9) 3.0 (2.6)b .017
Night awakenings/wk, No. (%)c,d 82 (71.3)b 226 (88.6) .015 127 (84.7) 97 (92.4) .09
0.46 (0.25-0.84) 0.46 (0.20-1.06)
Visits to emergency department, No. (%)e 76 (66.0) 189 (74.1) .835 105 (70.0)b 84 (80.0) .049
0.91 (0.55-1.53) 0.53 (0.30-0.94)
Oral corticosteroids, No. (%)e 51 (44.3)b 147 (57.6) .018 79 (52.7) 68 (64.8) .07
0.59 (0.38-0.91) 0.61 (0.36-1.01)
Severe wheezing, No. (%)e 88 (76.5) 223 (87.5) .445 131 (87.3) 92 (87.6) .601
0.74 (0.39-1.40) 0.77 (0.37-1.59)
Wheezing – hospitalization, No. (%)e 12 (10.4)b 53 (20.8) .05 30 (20.0) 23 (21.9) .731
0.49 (0.26-0.96) 0.86 (0.46-1.58)
Pneumonia – hospitalization, No. (%)e 10 (8.7) 44 (17.3) .082 22 (14.7) 23 (21.9) .148
0.50 (0.24-1.05) 0.59 (0.31-1.13)
Physician-diagnosed asthmae 24 (20.9)b 87 (34.1) .048 41 (27.3)b 44 (41.9) .013
0.58 (0.34-0.96) 0.50 (0.29-0.84)
Mean (SD) VitD serum levels, ng/mLc 18.7 (4.9)b 37.3 (10.9) <.001 35.1 (9.7)b 39.6 (9.0) <.001
Mean (SD) total serum IgE levels, IU/L) 178.4 (369.9)b 209.6 (347.8) .007 242.8 (373.0) 164.4 (303.1) 0.126
at test.
bSignicantly lower than the other group.
cMann-Whitney.
dPercentage of children who presented ≥1 awakening during any week of the year.
eChi-square/Fisher exact.

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321
and postnatal tobacco exposure, type of delivery, maternal
educational level, exposure to paracetamol, and viral infections
during the rst year of life [8].
Although many studies have focused on the relationship
between high serum VitD levels and reduced risk of asthma
exacerbations, evidence of an association with the incidence,
prevalence, or severity of asthma is scarce.
We observed higher levels of total IgE among RW children,
although these were not associated with the frequency of
episodes, and found that they were parallel to serum VitD
levels. However, high levels of serum IgE were recently
reported to be a risk factor for severe asthma in a report
stressing the relationship between serum levels of VitD, IgE,
and inammatory T cytokines [10]. The authors postulated that
the relationship was U-shaped, ie, both high and low serum
VitD levels of were associated with high levels of IgE and a
similar immune response [10]. This relationship may explain
our ndings.
In conclusion, we observed earlier onset and higher
severity of wheezing among RW children followed at PIPA
than among OW children. We also observed high levels of
VitD and total serum IgE. Further cohort studies are necessary
to establish a cause-eect relationship.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Castro-Rodriguez JA, Garcia-Marcos L. Wheezing and
asthma in childhood: an epidemiology approach. Allergol
Immunopathol (Madr). 2008;36:280-90.
2. Saggese G, Vierucci F, Boot AM, Czech-Kowalska J, Weber
G, Camargo CA Jr, Mallet E, Fanos M, Shaw NJ, Holick MF.
Vitamin D in childhood and adolescent: an expert position
statement. Eur J Pediatr. 2015;174:565-76.
3. Gergen PJ, Teach SJ, Mitchell HE, Freishtat RF, Calatroni
A, Matsui E, Kattan M, Bloomberg GR, Liu AH, Kercsmar
C, O'Connor G, Pongracic J, Rivera-Sanchez Y, Morgan WJ,
Sorkness CA, Binkley N, Busse W. Lack of a relation between
serum 25-hydroxyvitamin D concentrations and asthma in
adolescents. Am J Clin Nutr. 2013;97:1228-34.
4. Urrutia-Pereira M, Avila JBG, Solé D. Childhood Asthma
Prevention Program (PIPA): The purpose of a specialized care
program for children with wheezing/asthma. J Bras Pneumol.
2015;41(5):1-6 ahead of print at - http://dx.doi.org/10.1590/
S1806-37132015000004480
5. Dela Bianca AC, Wandalsen GF, Miyagi K, Camargo L, Cezarin
D, Mallol J, Solé D. International Study of Wheezing in Infants
(EISL): validation of written questionnaire for children aged
below 3 years. J Investig Allergol Clin Immunol. 2009;19:35-
42.
Manuscript received October 20, 2015; accepted for publication
May 11, 2016.
Dirceu Solé
Rua dos Otonis 725
04025-002, Vila Mariana, São Paulo
Brazil
E-mail: dirceu.sole@unifesp.br
6. Garcia-Marcos L, Mallol J, Solé D, Brand P; EISL Study Group.
International study of wheezing in infants: risk factors in
afuent and non-afuent countries during the rst year of life.
Pediatr Allergy Immunol. 2010;21:878-88.
7. Martineu AR. Curiouser and curiouser: the role of vitamin D in
the prevention of acute respiratory infection. Acta Paediatrica.
2015;104:331-3.
8. Koistinen A, Turunen R, Vuorinen T, Söderlund-Venermo M,
Camargo CA Jr, Ruuskanen O, Jartti T. Vitamin D, virus etiology,
and atopy in rst-time wheezing children in Finland. Pediatric
Allergy Immunol. 2014;25:834-7.
9. Kull I, Bergstrom A, Melen E, Lilja G, van Hage M, Pershagen
G, Wickman M. Early-life supplementation of vitamins A and
D, in water-soluble form or in peanut oil, and allergic diseases
during childhood. J Allergy Clin Immunol. 2006;118:1299-
304.
10. Pfeffer PE, Mann EH, Hornsby E, Chambers ES, Chen Y-H, Rice
L, Hawrylowicz. Vitamin D inuences asthmatic pathology
through its action on diverse immunological pathways. Ann
Am Thorac Soc. 2014:11(S5):S314-S21.

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322
both questionnaires (baseline and retest). A gure was also
created following the Bland-Altman plot in order to determine
concordance between the questions at 2 different points
(baseline and retest).
Of the 30 patients who completed the DHRQoL
questionnaire, 20 also completed the Psychological General
Well-being Index (PGWBI) questionnaire, which consists
of 22 items grouped in 6 dimensions: anxiety, depressed
mood, positive well-being, self-control, general health, and
vitality [6].
The Spearman correlation coecient was used to analyze
the correlation between the DHRQoL and the dimensions of
the PGWBI.
The study population comprised 30 patients, 20 of whom
were women, with a mean (SD) age of 45 (15.5) years. The
median (IQR) time since the allergic reaction was 6 months
(3-60 months).
Five of the 30 patients (17%) had experienced an
anaphylactic reaction, 14 (47%) had developed urticaria,
and the rest (36%) had experienced other types of reactions.
The allergist’s suspicions before performing the allergy test,
combined with the information from each patient’s medical
history, indicated that 14 patients (47%) may have experienced
a drug allergy and that in the remaining 16 patients, the reaction
was not a true allergic reaction.
The global result of the baseline DHRQoL questionnaire
in all patients was a median (IQR) score of 29 (27-39)
and that of the retest questionnaire was a median score
of 27 (22-33). Patients with anaphylaxis obtained a median
score of 30 (27-35), and those who had not experienced an
anaphylactic reaction obtained a median score of 28 (27-39).
Furthermore, patients who were suspected of having had a
real allergic reaction obtained a median score of 28 (26-35),
whereas those in which an allergic reaction was not suspected
obtained a median score of 30 (28-43).
Psychometric Validation of the Spanish Version of the
DHRQoL Questionnaire
Gastaminza G1,5, Ruiz-Canela M2, Baiardini I3, Andrés-López B4,
Corominas M4,5
1Allergy Department, Clinica Universidad de Navarra, Pamplona,
Spain
2Department of Preventive Medicine and Public Health,
University of Navarra, Pamplona, Spain
3Allergy and Respiratory Diseases Clinic, DIMI, University of
Genoa, IRCCS AOU San Martino-IST, Genova, Italy
4Allergy Unit, Hospital Universitari de Bellvitge, IDIBELL,
L’Hospitalet de Llobregat, Spain
5Spanish Society of Allergy and Clinical Immunology (SEAIC),
Drug Allergy Committee
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 322-323
doi: 10.18176/jiaci.0079
Key words: Drug allergy. Health-related quality of life. Psychometric
validation. Questionnaire. Adverse drug reactions.
Palabras clave: Alergia a medicamentos. Calidad de vida relacionada
con la salud. Validación psicométrica. Cuestionario. Reacciones adversas
a medicamentos.
Drug allergy is a very common condition faced by both
primary care physicians [1] and hospital physicians [2]
worldwide. Drug allergy is further complicated by the
underlying disease, which frequently prevents the use
of the usual first-line treatments. Furthermore, allergists
know that patients who have experienced an allergic drug
reaction, especially those who have had a severe reaction, are
increasingly fearful of new allergic reactions and therefore
tend to avoid taking any type of medication. In a previous
study [3], we validated the Spanish version of the Drug
Hypersensitivity Quality of Life (DHRQoL) questionnaire,
which was developed in Italy by Baiardini et al [4]. In the
present paper, we report the results of our psychometric
validation of the questionnaire.
A total of 30 consecutive patients were admitted to the
Allergology Service of Bellvitge Hospital, L’Hospitalet de
Llobregat, Barcelona, Spain from February to April 2015. Each
patient was asked to ll in the DHRQoL questionnaire on 2
occasions separated by a 5-hour interval. No allergy tests were
carried out during the interval, and no information that could
have inuenced the patient’s answers to the questionnaire
was provided.
The Cronbach a (0 to 1) was used to determine the
questionnaire’s internal consistency [5]. A factor analysis was
also carried out to determine whether 1 or several dimensions
could be measured by the questionnaire. Quartimax rotation
was used because the existence of a general factor was
suspected [4].
Moreover, the Lin correlation coecient (CC) was used
to measure the degree of consistency between the answers to
Figure. Bland-Altman concordance analysis of the difference between
both consecutive questionnaires completed by each patient and the
mean score of both tests for each patient.
10
5
0
–5
20 30 40 50 60
Mean of Test and Retest Results
y=0 is line of perfect average agreement
Observed average agreement
95% limits of agreement
Difference Between Test and
Retest Results
The line commencing at zero indicates the expected values (the same in
both tests), and the thicker gray line indicates the result obtained from the
difference, with a mean value of 2.9 (3.8) points. The agreed minimum
and maximum limits were –4.6 and 10.6, respectively.

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323
The global CC was 0.911 (95%CI, 0.852-0.970). The
question with the greatest concordance was number 13
(CC, 0.919; 95%CI, 0.863-0.975), and that with the lowest
concordance was number 7 (CC, 0.575; 95%CI, 0.335-0.815).
The Figure shows the results of the Bland-Altman
concordance analysis. The mean dierence between the initial
test and the retest was 2.9 (3.8) points. Three patients fell
outside the expected limits of ±2 SD (–4.6 to 10.4).
Based on the Cronbach a, the questionnaire's global
internal consistency was 0.916. Question 3 had the greatest
inuence (Cronbach a without this question, 0.905), although
high internal consistency was observed in general.
The factor analysis carried out with quartimax rotation
revealed 3 dimensions: one included all questions except
numbers 2 and 9; another included questions 2, 5, 9, and 10;
and a third dimension included questions 1, 4, and 7.
A poor correlation was observed between the results of
both questionnaires (Spearman r, –0.279; P=.234). Analysis
of the correlation between the DHRQoL questionnaire and the
6 dimensions of the PGWBI questionnaire revealed a negative
and statistically signicant correlation for the depressed mood
dimension (r, –0.531; P=.016).
This study conrms that the DHRQoL questionnaire has
marked internal consistency (Cronbach a, 0.916), which is
very similar to that obtained by Baiardini et al [4] (0.928) [4].
Additionally, the test-retest analysis revealed a high degree of
concordance, as in the case of the original study carried out to
develop the questionnaire [4].
Our factor analysis revealed 3 dimensions. One included all
questions except question 2, which is consistent with the data
reported by Baiardini et al [4], who studied the questionnaire
as a whole. The other 2 dimensions analyzed patients’ fear
of receiving medications (questions 2, 5, 9, and 10) and
the limitations that a possible drug allergy entails for them
(questions 1, 4, and 7). These dimensions must be conrmed
by means of a conrmatory factor analysis.
The comparison of the results of the DHRQoL and PGWBI
questionnaires revealed a negative—albeit not statistically
signicant—correlation with the depressed mood dimension.
This nding diers from that reported by Baiardini et al [4],
whose study did not establish a correlation between the
DHRQoL questionnaire and any of the PGWBI dimensions.
In conclusion, we confirmed that the DHRQoL
questionnaire has the psychometric validity required for a
questionnaire developed following appropriate methodology,
as in the case of its original Italian version. In the future, it
would be of great interest to carry out additional studies to
determine to what extent an allergic drug reaction aects
the quality of life of the patient who experiences it. It would
also be interesting to determine whether the questionnaire’s
results depend on the type of drug, the severity of the allergic
reaction, or other factors.
Funding
The authors declare that no funding was received for the
present study.
Manuscript received April 11, 2016; accepted for publication
May 18, 2016.
Gabriel Gastaminza
Departamento de Alergología
Clínica Universidad de Navarra
Pío XII, 36
31008 Pamplona, Spain
E-mail: Gastaminza@unav.es
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J,
Burdick E, Seger DL, Shu K, Federico F, Leape LL, Bates DW.
Adverse drug events in ambulatory care. N Engl J Med.
2003;348:1556-64.
2. Thong BY, Tan TC. Epidemiology and risk factors for drug
allergy. Brit J Clin Pharmacol. 2011;71:684-700.
3. Gastaminza G, Herdman M, Baiardini I, Braido F, Corominas
M. Cross-cultural adaptation and linguistic validation of the
Spanish version of the drug hypersensitivity quality of life
questionnaire. J Invest Allergol Clin Immunol. 2013;23:508-
10.
4. Baiardini I, Braido F, Fassio O, Calia R, Giorgio WC, Romano
A, DrHy-Q PROs Research Italian Group. Development
and validation of the Drug Hypersensitivity Quality of Life
Questionnaire. Ann Allergy Asthma Immunol. 2011;106:330-
5.
5. Cronbach LJ. Coefcient alpha and the internal structure of
tests. Psychometrika. 1951;16:297-334.
6. Chassany O, Dubois D, Wu A. The psychological general well-
being index (PGWBI) user manual. In: 2004. MRI, editor. Lyon
(FR) Available at: http://178.23.156.107:8085/Instruments_
les/USERS/pgwbi.pdf.

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324
progressive generalized itchy wheals when the infusion rate
was 3 mg/h. Apomorphine was stopped, and the cutaneous
symptoms improved, although Parkinson disease worsened.
The patient also had allergic rhinitis due to mite sensitization.
He had tolerated tramadol. Neither patient had a history of
idiopathic or nonsteroidal anti-inammatory drug–related
anaphylactic reactions or life-threatening vascular collapse.
Neither had previously experienced urticaria or angioedema.
The patients were not taking antihypertensive medication
(angiotensin-converting enzyme inhibitors, ß-blockers, or
angiotensin receptor blockers). Apomorphine was considered
essential for treatment in both patients.
Allergic-like reactions with apomorphine are rare; therefore,
we wanted to record as much information as possible in order
to design a desensitization protocol. As we had previously
reported [8], patch, prick, intradermal, and challenge testing
were considered necessary to collect this information. We
performed skin prick tests with apomorphine 10 mg/mL and
intradermal tests with diluted apomorphine at concentrations
of 0.001 mg/mL, 0.01 mg/mL, and 0.1 mg/mL. An intradermal
test at a dilution of 0.1 mg/mL resulted in a 6-mm wheal in the
rst patient, as previously reported [8]. A negative response
was detected in the second patient and 14 controls (6 atopic and
8 nonatopic). Patch testing was performed with apomorphine
diluted in water to 50%, 5%, and 1% and in petrolatum 5%
and 1%. The results of patch testing with apomorphine were
negative in both patients. A single-blind, placebo-controlled
challenge test was performed with subcutaneous apomorphine.
Symptoms reappeared in both patients. In the rst patient,
apomorphine produced a positive response after approximately
20 minutes [8]. The second patient experienced urticaria and
angioedema 30 minutes after receiving 7 mg of apomorphine
and was treated with 5 mg of intravenous dexchlorpheniramine
maleate and 30 mg of oral deazacort. As the commercial
preparation of apomorphine contains 0.093% sodium bisulte,
the patients underwent a double-blind, placebo-controlled
challenge with sodium metabisulte, and the results were
negative. Although skin testing was negative in the second
patient, hypersensitivity to apomorphine was diagnosed taking
into account the clinical presentation and reproducibility of
the reaction upon reexposure.
A tolerance induction protocol was designed with
increasing concentrations of apomorphine (0.03 mg/mL
to 10 mg/mL) (Table). The route of administration was
subcutaneous, and each dose was administered intermittently.
The patients were premedicated with 10 mg of cetirizine
1 hour before starting the protocol. The initial dose was
0.003 mg of apomorphine, and intermittent subcutaneous doses
were increased every 15 minutes. The target dose was 3 mg
(cumulative dose 4.998 mg of apomorphine). During the third
step, the rst patient experienced mild pruritus, which resolved
with intravenous dexchlorpheniramine maleate (Table). At the
end of the procedure, subcutaneous apomorphine infusion was
initially continued at 1 mg/h and increased by 0.5 mg/h every
4 hours depending on the patient’s response. The rst patient
continued at 2.5 mg/h for 12 hours per day (no infusion at
night) and was completely able to tolerate apomorphine. The
second patient continued at 3 mg/h for 12 hours per day (no
infusion at night), with complete tolerance of apomorphine.
A Protocol for Induction of Tolerance to
Apomorphine in Patients With Parkinson Disease
and Hypersensitivity to Apomorphine
Gutiérrez-Fernández D1, Moreno-Ancillo A2, Foncubierta-
Fernández A3, Medina-Varo F1, Andrés-García JA1, Fernández-
Anguita MJ1
1Hospital Universitario Puerta del Mar, Cadiz, Spain
2Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
3Centro de Salud Dr Joaquín Pece, San Fernando, Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 324-325
doi: 10.18176/jiaci.0081
Key words: Apomorphine. Parkinson disease. Hypersensitivity.
Desensitization. Tolerance induction protocol.
Palabras clave: Apomorna. Enfermedad de Parkinson. Hipersensibilidad.
Desensibilización. Protocolo de inducción de tolerancia.
Apomorphine, a short-acting dopamine D1 and D2
receptor agonist, was the rst dopamine receptor agonist
used to treat Parkinson disease. Subcutaneous apomorphine is
currently used for the management of sudden, unexpected, and
refractory levodopa-induced o-states in uctuating Parkinson
disease, either as intermittent rescue injections or continuous
infusions [1-3]. Some of the most frequent adverse eects of
long-term apomorphine therapy are orthostatic hypotension,
nausea, brotic nodules at the site of infusion, and sedation [3].
Cutaneous nodules observed in patients with Parkinson disease
treated with continuous subcutaneous apomorphine are
sometimes characterized by orid eosinophilic panniculitis;
however, patch testing is universally negative, and the IgE
levels are normal [4]. Delayed hypersensitivity reactions with
positive patch test results [5-7] and immediate hypersensitivity
reactions have been reported [8].
We present a protocol for induction of tolerance to
apomorphine in 2 patients who experienced generalized
urticarial reactions to the drug. The rst patient (reported
elsewhere [8]) was a 56-year-old man with uncontrolled
Parkinson disease. Apomorphine injections were administered
intermittently via pen over 6 months as rescue therapy for
sudden o periods. This regimen was followed by continuous
infusion at a rate of 1 mg/h and then increased according to the
patient’s response. The drug was administered continuously
for an additional month via an apomorphine pump with an
infusion rate of 2.5 mg/h for 12 hours per day while the
patient was awake, stopping at night. The patient developed
raised itchy wheals on the underarms, groin, chest, lower
back, and buttocks approximately 20 minutes after he reached
the cumulative dose of 4 mg apomorphine administered at
2.5 mg/h [8]. The second patient was a 58-year-old man
with Parkinson disease treated with continuous infusion
of apomorphine for motor uctuations and dyskinesia. His
infusion was programmed based on a 12-hour regimen;
however, after the rst month of therapy, he experienced

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
325
Manuscript received December 15, 2015; accepted for
publication May 19, 2016.
Álvaro Moreno-Ancillo
Department of Allergy
Hospital Nuestra Señora del Prado
Ctra. Madrid, km 114
45600 Talavera de la Reina, Spain
E-mail: a.morenoancillo@gmail.com
Both patients tolerated continuous subcutaneous apomorphine
for more than 12 months after completion of the protocol.
We report 2 cases of hypersensitivity reactions after
administration of apomorphine and present the results of
a rapid protocol for induction of tolerance to this drug. To
our knowledge, no cases of desensitization or induction of
tolerance to apomorphine have been reported to date. The
cumulative therapeutic dose was reached in 2 hours, and
the protocol was completed successfully. The protocol was
administered because no alternative treatments were available
for Parkinson disease in these cases. The patients responded
well to the desensitization procedure and completed the
protocol safely.
Apomorphine can cause drug-related reactions, but the
exact etiology of these events remains unclear. Both patients
in the present report were successfully desensitized to
apomorphine. In the rst [8], the underlying cause seemed to be
an IgE-mediated mechanism; in the second, it was not possible
to dene the underlying mechanism. However, hypersensitivity
to apomorphine was also diagnosed taking into account the
clinical presentation and challenge test result.
The desensitization protocol, which was considered an
induction tolerance protocol in the second case, worked well
in both patients. Therefore, it can be recommended for other
cases of adverse reactions to apomorphine.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Millan MJ, Maioss L, Cussac D, Audinot V, Boutin JA,
Newman-Tancredi A. Differential actions of antiparkinson
agents at multiple classes of monoaminergic receptor. I. A
multivariate analysis of the binding proles of 14 drugs at 21
native and cloned human receptor subtypes. J Pharmacol Exp
Ther. 2002;303:791-804.
2. Ribaric S. The Pharmacological Properties and Therapeutic Use
of Apomorphine. Molecules. 2012;17:5289-309.
3. Deleu D, Hanssens Y, Northway MG. Subcutaneous
apomorphine: An evidence-based review of its use in
Parkinson’s disease. Drugs Aging. 2004;21:687-709.
4. Acland KM, Churchyard A, Fletcher CL, Turner K, Lees A, Dowd
PM. Panniculitis in association with apomorphine infusion. Br
J Dermatol. 1998;138:480-2.
5. Garcia-Gavin J, González-Vilas D, Fernández-Redondo V,
Campano L, Toribio J. Allergic contact dermatitis caused by
apomorphine hydrochloride in a career. Contact Dermatitis.
2010;63:112-5.
6. Carboni GP, Contri P, Davalli R. Allergic contact dermatitis
from apomorphine. Contact Dermatitis. 1997;36:177-8.
7. Dahlquist I. Allergic reactions to apomorphine. Contact
Dermatitis 1977;3:349-50.
8. Gutiérrez D, Foncubierta A, Espinosa R, Astorga S, Leon
A, Fernández S. Immediate type 1 hypersensitivity to
apomorphine: a case report. J Investig Allergol Clin Immunol.
2011;21:317-29.
Table. Tolerance Induction Protocol for Subcutaneous Apomorphine
Stepa Solution, mg/mL Amount, mL Dose, mg Cumulative Findings Findings
Dose, mg Patient 1 Patient 2
1 0.03 0.1 0.003 0.003 None None
2 0.03 0.5 0.015 0.018 None None
3 0.3 0.1 0.03 0.048 Mild pruritusb None
4 0.3 0.5 0.15 0.198 None None
5 3 0.1 0.3 0.498 None None
6 3 0.5 1.5 1.998 Mild dyskinesia None
7 10 0.3 3 4.998 None None
aEach step was 15 minutes.
bTreated with intravenous dexchlorpheniramine 5 mg.

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326
Aquagenic Urticaria: Report of a Case in an
Adolescent Girl
Muinelo A, Pérez O, Vila L
Pediatric Allergy Unit, Hospital Materno-Infantil Teresa Herrera,
La Coruña, Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 326-327
doi: 10.18176/jiaci.0082
Key words: Aquagenic urticaria, adolescent, antihistamines, physical
urticaria.
Palabras clave: Urticaria acuagénica, adolescente, antihistamínicos,
urticaria física.
Aquagenic urticaria is a rare condition. Fewer than 50
cases have been published in the literature and most of these
have been in the form of case reports [1]. The clinical picture
is characterized by small wheals (1-3 mm), erythema, and
intense pruritus occurring within 10 to 30 minutes of exposure
to water, regardless of its temperature. The condition resolves
within 30 to 60 minutes after the water is eliminated from
the skin. Systemic manifestations are rare but have been
reported [2]. We report the rst case of aquagenic urticaria in
a Spanish adolescent.
A 12-year-old girl presented with a 2-month history of
erythema, pruritus, and small wheals that developed on her
face, neck, and chest after contact with water (showering and
diving into a pool). The symptoms appeared within 10 to 20
minutes of contact with water, regardless of temperature, and
disappeared without medication in less than an hour.
She did not report angioedema, wheezing, or dyspnea
during these episodes. There was also no history of urticaria
with physical exercise, sweating, heat, or emotional stress.
She tolerated exposure to cold temperatures. There was no
present personal or family history of atopy, and none of the
girl’s relatives reported similar skin reactions related to water
exposure.
The physical examination was unrevealing, and
dermographism was negative. Additional studies, including a
complete blood count and urine analysis, were normal. A water
challenge test was performed by applying a compress soaked
in tap water at 35°C on the upper chest. Within 20 minutes
the patient reported pruritus and developed a micropapular
eruption and erythema in the contact area (Figure), conrming
the suspected diagnosis of aquagenic urticaria.
Short showers or baths were recommended, and we
prescribed medical treatment with oral levocetirizine only for
episodes of lasting or uncomfortable urticaria.
Aquagenic urticaria is an uncommon type of physical
urticaria that usually appears during puberty or several years
later and is more common in female patients [3-5]. Most cases
are sporadic, although a small number of familial cases have
been reported [6,7]. Its pathogenesis is not fully understood,
although several mechanisms have been proposed. Shelley
and Rawnsley [8], who described the rst cases of aquagenic
urticaria in 1964, postulated that water might interact with
sebum in the stratum corneum to form a substance capable of
acting as a direct mast cell degranulator, resulting in histamine
release. Czarnetzki et al [9], in turn, hypothesized that a water
soluble antigen at the epidermal layer might diuse into
the dermis, resulting in histamine release from mast cells.
Recently, in vitro basophil activation by ow cytometry assay
was detected after a water challenge test in a patient with
aquagenic urticaria [10].
Cold urticaria and cholinergic urticaria are major
considerations in the dierential diagnoses for aquagenic
urticaria. This condition must be distinguished from aquagenic
pruritus, in which intense itching occurs after contact with
water, but without visible skin lesions [1,6]. The standard test
for aquagenic urticaria is the application of a water compress at
35ºC to the upper body for 30 minutes. Keeping the compress
at room temperature avoids confusion with cold-induced or
local heat urticaria [1].
Antihistamines are usually recommended to treat
aquagenic urticaria, although response varies from one patient
to the next. In refractory cases, UV radiation (psoralen-UV-A
therapy or UV-B) alone or in combination with antihistamines,
barrier methods to protect the skin from water, and even
omalizumab, have been successfully used [1,5].
In the case of our patient, given the limited impact of
symptoms on her life and their spontaneous resolution
within minutes, we indicated symptomatic treatment with
antihistamines only if skin lesions worsened.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
Figure. Wheal and are reaction 20 minutes after applying a compress
soaked in tap water at 35°C to the upper chest.

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327
References
1. Dice J, MD. Physical urticaria. Immunol Allergy Clin N Am.
2004;24:225-46.
2. Luong K, Nguyen LTH. Aquagenic urticaria: report of a case
and review of the literature. Ann Allergy Asthma Immunol.
1998;80:483-5.
3. Park H , Kim SA , Yoo DS , Kim JW , Kim CW , Kim SS , Hwang
JI , Lee JY, Choi YJ. Aquagenic urticaria: a report of two cases.
Ann Dermatol. 2011 Dec; 23. Vol 23. Suppl 3. S371-4.
4. Yavuz ST, Sahiner UM, Tuncer A, Sackesen C. Aquagenic
urticaria in 2 adolescents. J Investig Allergol Clin Immunol.
2010;20(7):624-5.
5. Rorie A, Gierer S. A case of aquagenic urticaria successfully
treated with omalizumab. J Allergy Clin Immunol Pract.
2016;May-Jun;4(3):547-8.
6. Kai A, Carsten F. Aquagenic urticaria in twins. World Allergy
Organ J. 2013;6(1):2.
7. Treudler R, Tebbe B, Steinhoff M, Orfanos CE. Familial
aquagenic urticaria associated with familial lactose
intolerance. J Am Acad Dermatol. 2002;47(4):611-3.
8. Shelley WB, Rawnsley HM. Aquagenic urticaria. Contact
sensitivity reaction to water. JAMA. 1964;189:895-8.
9. Czarnetzki BM, Breetholt KH, Traupe H. Evidence that water
acts as a carrier for an epidermal antigen in aquagenic
urticaria. J AM Acad Dermatol. 1986;15(4):623-7.
10. Frances AM, Fiorenza G, Frances RJ. Aquagenic urticarial:
report of a case. Allergy and Asthma Proc. 2004;25(3):195-7.
Manuscript received March 15, 2016; accepted for publication,
May 19, 2016.
Leticia Vila Sexto
Unidad de Alergia Infantil
Hospital Materno-Infantil Teresa Herrera
C/As Xubias s/n
15006 La Coruña
Spain
E-mail: leticia.vila.sexto@sergas.es
Yogurt in the Treatment of β-Lactoglobulin–Induced
Gastrointestinal Cow’s Milk Allergy
Poza-Guedes P1, Barrios Y2, González Pérez R1, Sánchez-Machín I1,
Franco A2, Matheu V1
1Consulta de Alergia Infantil, Unidad de Alergología-Norte,
Hospital del Tórax/Ofra, San Cristóbal de La Laguna, Spain
2Immunology, Hospital Universitario de Canarias, La Laguna,
Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 327-329
doi: 10.18176/jiaci.0083
Key words: Cow’s milk allergy. Gastrointestinal allergy. ß-Lactoglobulin.
IgE-mediated allergy.
Palabras clave: Alergia a leche de vaca. Alergia gastrointestinal.
Betalactoglobulina. Alergia mediada por IgE.
The prevalence of food allergy (FA) is around 3.5% in
the general population and 5%-8% in children [1]. Cow’s
milk (CM) allergy is particularly noteworthy because of the
role of this food in children’s diet, especially when the child
is not breastfed.
Anaphylaxis is the most severe allergic reaction to
CM [2] and is currently treated with oral immunotherapy [3].
However, many patients are affected by gastrointestinal
(GI) conditions only, including IgE-mediated [4] and non–
IgE-mediated disorders [5], which are induced by food
antigens with a marked clinical overlap between them [1].
The disorders include eosinophilic esophagitis, eosinophilic
gastroenteritis [6], allergic proctocolitis [6], and food protein–
induced enterocolitis syndrome [6]. The most common GI
condition is immediate GI hypersensitivity, which involves
IgE-mediated clinical manifestations that can occur within
minutes (immediate reaction) in the upper GI tract or up to
several hours later (delayed reaction) in the lower GI tract.
Immediate GI hypersensitivity is usually considered a variant
of anaphylaxis [7]. The aims of this study were to assess the
follow-up of patients with GI allergy mediated by sIgE against
β-lactoglobulin [7] after 6 months of dairy products (Group A)
and to compare it with that of patients who did not undergo an
intervention (Group B, only elimination of CM).
In our area (northern Tenerife, Spain), with 105 910
inhabitants aged <14 years, we selected 40 patients from our
center (Infant Allergy Clinic [Northern Region], Tenerife,
Spain) who experienced specic GI symptoms 30-120 minutes
after intake of a glass of CM. The inclusion criteria also
comprised serum specic IgE (sIgE) >0.1 kUA/L to whole
CM or some of the CM proteins such as casein (CAS) and the
main whey proteins α-lactalbumin (ALA) and β-lactoglobulin
(BLG).
The exclusion criteria included a clinical history of
extraintestinal symptoms (cutaneous, ocular, respiratory,
and/or cardiovascular) immediately after a glass of CM or
sIgE <0.1 kUA/L to CM, CAS, ALA, and BLG, as well as

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328
a diagnosis of celiac disease based on the presence of IgA
antitransglutaminase antibodies (ELiA Immunocap 250, Phadia)
and antideaminated gliadin antibodies (Quanta Lite Gliadin IgA
II) and the results of a lactose intolerance inhalation test.
Skin prick tests (SPTs) with commercial extracts (BIAL)
were performed with whole CM (5 mg/mL), CAS (10 mg/mL),
ALA (5 mg/mL), and BLG (1 mg/mL). The concentration of
total immunoglobulin E and sIgE against whole CM, CAS,
ALA, and BLG in serum was measured (ImmunoCAP, Phadia
AB) based on a detection limit of 0.1 kUA/L.
Children underwent an open food challenge (OFC) with
CM at the hospital allergy unit under clinical observation by
experienced personnel. All participants were observed for
the 24 hours following the OFC at home by their parents,
who could phone the allergy unit at any time. Patients with
a positive OFC result were oered a new OFC with yogurt
under the same conditions (Group A). Patients who refused the
OFC with yogurt were assigned to an elimination diet. During
the 6-month study period, participants in the elimination diet
group (Group B), were kept on a CM-free diet, whereas those
in the dairy products group (Group A) were exposed daily to
yogurt. All patients and tutors gave their written informed
consent. The protocol was approved by the Regional Ethics
Committee (COLIVAC HUNSC P.I-35/11; 24/14).
The most prevalent symptom was abdominal cramps in
36 out of 40 patients (90%), followed by food refusal in 32
patients (80%), abdominal discomfort or distention in 30
patients (75%), diarrhea in 10 patients (25%), and constipation
in 5 patients (12.5%).
SPT yielded positive results in only 14 patients (35%).
The wheal was greater than 3 mm with CM in 12 patients,
CAS in 4 patients, ALA in 6 patients, and BLG in 8 patients.
Specic IgE (sIgE) to whole CM was >0.10 kUA/L (>0.1)
in 32 patients and <0.1 kUA/L (<0.1) in 8 patients. Mean (SD)
sIgE against whole CM was 1.36 (3.34) kUA/L. sIgE to CAS
was >0.10 kUA/L in 28 patients and <0.1 kUA/L in 12 patients,
with an average of 1.12 (3.21) kUA/L. sIgE to ALA was
>0.10 kUA/L in 22 patients and 0.1 kUA/L in 18 patients, with an
average of 1.09 (2.45) kUA/L. sIgE to BLG was >0.10 kUA/L in
40 patients, with an average of 4.13 (8.30) kUA/L. No patients
had sIgE to BLG <0.1 kUA/L (Table).
OFC with whole CM in patients in Group A (n=25) was
positive, reproducing the initial symptoms of the previous
clinical history. The results of OFC with yogurt in patients
in Group A were all negative, with good tolerance. Parents/
tutors agree that patients were able to take a daily yogurt
for 6 months. No symptoms or reactions were recorded
after 6 months, and all patients tolerated yogurt every day.
Mean levels of sIgE to BLG decreased from 6.51 kUA/L to
4.7 kUA/L (P<.05). Levels of sIgE to CAS also decreased from
1.51 kUA/L to 0.52 kUA/L.
The results of OFC with whole CM in patients in Group B
(n=15) were all positive, mimicking the symptoms in the
previous clinical history. Parents/tutors reported that patients
maintained a diet that eliminated CM and dairy products. After
6 months, no patients experienced symptoms or reactions,
and mean levels of sIgE to BLG increased from 3.3 kUA/L
to 5.8 kUA/L (P<.05). Similarly, levels of sIgE to CAS also
increased from 1.29 kUA/L to 3.98 kUA/L (P<.01).
The possible prevalence of β-lactoglobulin–induced GI
allergy has been reported to be around 11% in patients with
CM allergy [7]. Since BLG is absent or very decreased in
many yogurts [8], probably because of polymerization in
tetramers of BLG [9], we proposed a 6-month yogurt-only
diet after checking tolerance to CM in an OFC. After 6
months, tolerability was excellent in Group A, and levels
of sIgE to BLG had decreased significantly. Moreover,
sIgE to CAS also tended to decrease. In Group B, levels
of sIgE to both BLG and CAS increased significantly.
The significance of these trends should be investigated in
more detail. In this report, we used yogurt with modified
proteins to reduce sensitization to milk proteins, as
previously described with casein [10] in this GI phenotype
of CM allergy. Yogurt enabled only partial avoidance of
cow’s milk products. Further reports should evaluate our
intervention in order to design a successful protocol, as in
other allergy phenotypes.
Acknowledgments
We would like to thank all the registered nurses and the
laboratory technicians involved in this study.
Table. Levels of specic IgE in patients from both groups (rst line). Levels of specic IgE in group A (second line) treated with daily yogurt and group B
(third line) treated with total restriction of CM products at baseline (day 0) and after 6 months (6 mo). Data are expressed as mean specic IgE levels
in each group
GI phenotype Specic IgE
Total patients CM BLG CAS ALA
N=40 n=32 n=40 n=28 n=22
1.36 4.13 1.12 1.09
Group A
n=25 Day 0 6 mo Day 0 6 mo Day 0 6 mo Day 0 6 mo
1.35 1.2 6.51 4.7 1.51 0.52 0.76 0.50
Group B Day 0 6 mo Day 0 6 mo Day 0 6 mo Day 0 6 mo
n=15 1.06 1.55 3.38 5.88 1.29 3.98 1.53 1.8
Abbreviations: ALA, α-lactalbumin; BLG, β-lactoglobulin; CAS, casein; CM, cow's milk.

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
329
Manuscript received March 3, 2016; accepted for publication
May 23, 2016.
Victor Matheu
Consulta de Alergia Infantil, Unidad de Alergología-Norte
Hospital del Tórax/Ofra, CHUNSC
38320 San Cristóbal de La Laguna, Spain
E-mail: Victor.Matheu@gmail.com
Funding
This study was funded by Unidad de Gestión Alergología-
Norte, Hospital del Tórax/Ofra.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Morita H, Nomura I, Matsuda A, Saito H, Matsumoto
K. Gastrointestinal food allergy in infants. Allergol Int.
2013;62:297-307.
2. Poza P, Glez R, Barrios Y, Franco A, Matheu V. MIP-1alpha,
MCP-1, and desensitization in anaphylaxis from cow's milk. N
Eng J Med. 2012;367:282-4.
3. Martorell Calatayud C, Muriel García A, Martorell Aragonés
A, De La Hoz Caballer B. Safety and efcacy prole and
immunological changes associated with oral immunotherapy
for IgE-mediated cow's milk allergy in children: systematic
review and meta-analysis. J Investig Allergol Clin Immunol.
2014;24:298-307.
4. B Rodríguez Jiménez, J Domínguez Ortega, JM González
García, C Kindelan Recarte Gastroenteritis Due to Allergy to
Cow’s Milk J Invest Allergol Clin Immunol. 2011;21:150-2.
5. Chehade M, Sampson HA. The role of lymphocytes in
eosinophilic gastrointestinal disorders. Immunol Allergy Clin
North Am. 2009;29:149-58, xii.
6. Sicherer SH. Clinical aspects of gastrointestinal food allergy in
childhood. Pediatrics. 2003;111:1609-16.
7. Poza-Guedes P, Barrios Y, Sanchez-Machin I, Franco A,
Gonzalez R, Matheu V. Role of specic IgE to β-lactoglobulin
in the gastrointestinal phenotype of cow's milk allergy. Allergy
Asthma Clin Immunol. 2016;12:7.
8. Kontopidis G, Holt C, Sawyer L. Invited review: beta-
lactoglobulin: binding properties, structure, and function. J
Dairy Sc. 2004;87:785-96.
9. Ehn BM, Ekstrand B, Bengtsson U, Ahlstedt S. Modication of
IgE binding during heat processing of the cow's milk allergen
beta-lactoglobulin. J Agricultural Food Chem 2004;52:1398-
403.
10. Cases B, García-Ara C, Boyano MT, Pérez-Gordo M, Pedrosa
M, Vivanco F, Quirce S, Pastor-Vargas C. Phosphorylation
reduces the allergenicity of cow casein in children with
selective allergy to goat and sheep milk. J Investig Allergol
Clin Immunol. 2011;21:398-400.
Cross-reactivity in AED-Induced Severe Cutaneous
Adverse Reaction: A Case Report
Khor AHP1,2, Lim KS1*, Tan CT1, Kwan Z3, Ng CC2
1Division of Neurology, Department of Medicine, Faculty of
Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
2Genetics and Molecular Biology Unit, Institute of Biological
Sciences, Faculty of Science, University of Malaya, 50603 Kuala
Lumpur, Malaysia
3Division of Dermatology, Department of Medicine, Faculty of
Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 329-331
doi: 10.18176/jiaci.0085
Key words: Antiepileptic drugs. Cross-reactivity. Stevens-Johnson
syndrome. Toxic epidermal necrolysis. Hypersensitivity.
Palabras clave: Antiepilépticos. Reactividad cruzada. Síndrome de
Stevens-Johnson. Necrolisis epidérmica tóxica. Hipersensibilidad.
Aromatic antiepileptic drugs (AEDs), in particular
carbamazepine, phenytoin, phenobarbital, and lamotrigine,
are some of the most common medications associated with
severe cutaneous adverse reactions, such as Stevens-Johnson
syndrome (SJS), toxic epidermal necrolysis (TEN), and drug
reactions with eosinophilia and systemic syndrome (DRESS).
The reported incidence of SJS/TEN is 1.2 cases per million
inhabitants per year. Cross-reactivity between these aromatic
antiepileptic drugs is not uncommon [1]. A large-scale study
investigating risk predictors of AED-induced rash found that
one of the strongest predictors is a history of rash with another
AED [2]. This nding is supported by another study showing
a signicant association between carbamazepine-, phenytoin-,
and oxcarbazepine–induced hypersensitivity skin reactions
and a previous history of AED-induced rash [3]. However,
to the best of our knowledge, there has only been 1 previous
case report, without HLA genotype testing, of cross-reactivity
in AED-induced severe cutaneous adverse reactions [4]. We
report a case of SJS induced by lamotrigine after a history of
carbamazepine-induced SJS, and provide information on HLA
genotyping results.
A 63-year-old Indian woman with a diagnosis of right-
sided trigeminal neuralgia since 2002 presented with facial
pain described as sharp and piercing that lasted approximately
3 to 4 minutes and was aggravated by chewing and moving
of the jaw. Magnetic resonance imaging of the brain did
not reveal any masses or aberrant vessels compressing the
trigeminal nerve roots.
Carbamazepine 200 mg 3 times a day was prescribed
and resulted in complete pain relief. Fourteen days later, the
patient developed a generalized rash on the trunk and limbs
and was diagnosed with carbamazepine-induced SJS. The
rash regressed over a month. The algorithm of drug causality
for epidermal necrolysis (ALDEN) score was 6. (Table). The
patient was put on sodium valproate 200 mg twice a day but

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330
Negative results for known HLA-alleles associated with
AED-induced severe cutaneous adverse drug reactions,
such as in our case, does not predict against cross-reactivity.
Although these reactions are unpredictable, identication of
predisposing risk factors prior to drug selection can reduce
the probability of a hypersensitivity reaction. Patients with
a history of severe cutaneous adverse reactions to aromatic
AEDs such as carbamazepine, phenobarbital, phenytoin, and
lamotrigine are best managed with newer AEDs with a lower
risk of severe cutaneous adverse reactions.
This case showed cross-reactivity in aromatic AEDs that
induced a severe cutaneous adverse drug reaction. Although
HLA-genotyping helps to predict reactions, caution should
be taken when prescribing alternative AEDs to patients with
a previous history of AED-induced severe cutaneous adverse
drug reactions, despite negative results for known HLA-alleles.
Funding
This study is funded by University of Malaya under High
Impact Research Grant from the Ministry of Higher Education
research fund (reference no.: M.C/625/1/1HIR/MOHE/
CHAN-02 [H-50001-A000023]) and Postgraduate Research
Fund (grant no.: PG112-2015B).
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Hirsch LJ, Arif H, Nahm EA, Buchsbaum R, Resor SR Jr, Bazil
CW. Cross-sensitivity of skin rashes with antiepileptic drug
use. Neurology. 2008;71(19):1527-34.
2. Arif H, Buchsbaum R, Weintraub D, Koyfman S, Salas-
Humara C, Bazil CW, Resor SR Jr, Hirsch LJ. Comparison and
predictors of rash associated with 15 antiepileptic drugs.
Neurology. 2007;68(20):1701-9.
3. Alvestad S, Lydersen S, Brodtkorb E. Cross-reactivity pattern of
rash from current aromatic antiepileptic drugs. Epilepsy Res.
2008;80(2-3):194-200.
4. Aouam K, Ben Romdhane F, Loussaief C, Salem R, Toumi
A, Belhadjali H, Chaabane A, Boughattas NA, Chakroun
the adverse eects were intolerable. This drug was substituted
with gabapentin 300 mg twice a day, to which baclofen 10 mg
3 times a day was later added.
Ten years later, with increased pain intensity despite
increased gabapentin dosage, which caused drowsiness, the
patient was started on lamotrigine 25 mg once a day for 1 week,
titrated upwards at a rate of 25 mg per week. On day 20, while
on lamotrigine 100 mg a day, she developed a second episode
of SJS. The ALDEN score was 8 (Table). The patient was
subsequently treated with pregabalin 300 mg and amitriptyline
12.5 mg daily and experienced no adverse eects.
HLA-A and B allele genotyping detected HLA-A*02:11
and A*24:17 and HLA-B*40:06 and B*51:06. These alleles
have not been reported in association with AED-induced SJS/
TEN.
Assessment of causality between the severe cutaneous
adverse reaction and the AED was based on ALDEN scores,
which, at 6 and higher, supported the causal relationship
between the AEDs and SJS.
To our knowledge, cross-reactivity in AED-induced severe
cutaneous adverse reactions, such as SJS, has only been
reported once in the literature, by Aouam et al [4]. The causal
relationship between carbamazepine and lamotrigine and the
reaction reported in that case was conrmed with positive
skin patch tests at the 48-hour reading. Patch tests were not
performed in our case and the causality assessment was based
only on ALDEN scores.
Although the incidence is low, there have been
reports of cross-reactivity between AEDs and tricyclic
antidepressants [5]. Seitz et al [6] observed recurrence of
hypersensitivity syndrome in 5 of 36 patients on tricyclic
antidepressants with a prior history of hypersensitivity to
AEDs. The authors did not observe cross-reactivity between
amitriptyline and aromatic AEDs, but caution should be taken
when prescribing tricyclic antidepressants to patients with a
prior history of hypersensitivity to aromatic AEDs.
Recent studies have reported an association between
carbamazepine-induced SJS/TEN and the HLA-B*15:02 allele
in populations from Southeast Asia [7,8]. A similar association
was subsequently reported for phenytoin- and lamotrigine-
induced SJS [7,9]. The ndings of a large meta-analysis further
implicated HLA-A*31:01 in SJS and generalized rash [10].
Neither of these alleles were detected in our patient.
Table. ALDEN (Algorithm of Drug Causality for Epidermal Necrolysis) Scores for Patient
Drug Delay From Initial Drug Present in Prechallenge/ Dechallenge Type Other Final
Drug Intake to Onset Body on Index Rechallenge (Value) of Drug Cause Scorea
of Reaction; Index Day (value) (Value) (Notoriety)
Day (Value)
Carbamazepine 14 d (+3) Drug withdrawn No known Drug 3 None 6
on day of rash (0) previous stopped (0)
exposure (0)
Lamotrigine 20 d (+3) Drug withdrawn Previous Drug 3 None 8
on day of rash (0) Stevens-Johnson stopped (0)
syndrome induced
by carbamazepine (2)
aFinal score: <0, very unlikely; 0-1, unlikely; 2-3, possible; 4-5, probable; ≥6, very probable.

Practitioner's Corner
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331
Vitiligo Induced by Specic Immunotherapy With
Grass Pollen: The Koebner Phenomenon
Rodríguez-Jiménez B1, Muñoz-García E1, Veza Perdomo S1,
González Herrada C2, Kindelán-Recarte C1, Domínguez-Ortega J3
1Allergy Unit, Hospital Universitario de Getafe, Madrid, Spain
2Dermatology Service, Hospital Universitario de Getafe, Madrid,
Spain
3Department of Allergy, Hospital La Paz Institute for Health
Research (IdiPAZ), Madrid, Spain; CIBER de Enfermedades
Respiratorias (Ciberes)
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 331-332
doi: 10.18176/jiaci.0088
Key words: Grass pollen. Koebner phenomenon. Specic immunotherapy.
Vitiligo.
Palabras clave: Polen de gramíneas. Fenómeno de Koebner. Inmunoterapia
especíca. Vitíligo.
Vitiligo is an autoimmune disease of unknown origin
that aects approximately 1% of the world’s population. It
is characterized by local or generalized depigmentation of
the skin and/or mucosal membranes [1]. One of the features
that may help predict the course of disease and response to
treatment is the Koebner phenomenon (KP), also known as
the isomorphic response, which represents a basic principle in
dermatology. This phenomenon was originally described by
the German dermatologist, Heinrich Koebner, who observed
the appearance of psoriasis lesions in areas of healthy skin
in patients with psoriasis following local trauma, such as
excoriations, tattoos, and horse bites [2]. The phenomenon
has since been described in relation to other disorders such
as vitiligo and lichen planus (true koebnerization) [3]. These
posttraumatic lesions are clinically and histologically similar
to those of the underlying disease. A recently developed
method for the evaluation and classication of KP takes into
account dierent factors such as the patient’s clinical history
(type 1 KP), physical examination ndings (type 2 KP), and
experimental induction of skin lesions (type 3 KP) [4]. Vitiligo
has been shown to progress dierently in the presence of KP,
regardless of type, with a larger aected body surface, greater
disease activity in the preceding 12 months, and a poorer
response to treatment [1].
We present the case of a 42-year-old man, without
autoimmune diseases or any other history of interest, who
had been undergoing follow-up in the allergology unit since
2007 due to respiratory allergic disease (rhinoconjunctivitis
and moderate persistent asthma secondary to grass pollen
allergy) and oral allergy to fruits associated with prolin.
The allergy study showed positive skin prick tests for grasses,
Cynodon dactylon, olive, Platanus acerifolia, Chenopodium
album, birch, ash tree, and prolin (ALK, Abelló, Madrid,
Spain). Specific IgE (ImmunoCAP, Thermo Fisher) was
determined for grasses (72.40 kU/L), olive (4.18 kU/L),
Manuscript received April 5, 2016; accepted for publication,
June 1, 2016.
Lim Kheng-Seang
Neurology Laboratory, 6th floor
Menara Selatan
University Malaya Medical Centre
50603 Kuala Lumpur, Malaysia
E-mail: kslimum@gmail.com
M. Hypersensitivity syndrome induced by anticonvulsants:
possible cross-reactivity between carbamazepine and
lamotrigine. J Clin Pharmacol. 2009;49 (12):1488-91.
5. Gaig P, Garcia-Ortega P, Baltasar M, Bartra J. Drug
neosensitization during anticonvulsant hypersensitivity
syndrome. J Investig Allergol Clin Immunol. 2006;16(5):321-
6.
6. Seitz CS, Pfeuffer P, Raith P, Brocker EB, Trautmann A.
Anticonvulsant hypersensitivity syndrome: cross-reactivity
with tricyclic antidepressant agents. Ann Allergy Asthma
Immunol. 2006;97(5):698-702.
7. Locharernkul C, Loplumlert J, Limotai C, Korkij W, Desudchit
T, Tongkobpetch S, Kangwanshiratada O, Hirankarn N,
Suphapeetiporn K. Carbamazepine and phenytoin induced
Stevens-Johnson syndrome is associated with HLA-B*1502
allele in Thai population. Epilepsia. 2008;49(12):2087-91.
8. Wu XT, Hu FY, An DM, Yan B, Jiang X, Kwan P, Stefan H, Zhou
D. Association between carbamazepine-induced cutaneous
adverse drug reactions and the HLA-B*1502 allele among
patients in central China. Epilepsy Behav. 2010;19(3):405-8.
9. Cheung YK, Cheng SH, Chan EJ, Lo SV, Ng MH, Kwan
P. HLA-B alleles associated with severe cutaneous
reactions to antiepileptic drugs in Han Chinese. Epilepsia.
2013;54(7):1307-14.
10. Genin E, Chen DP, Hung SI, Sekula P, Schumacher M,
Chang PY, Tsai SH, Wu TL, Bellón T, Tamouza R, Fortier C,
Toubert A, Charron D, Hovnanian A, Wolkenstein P, Chung
WH, Mockenhaupt M, Roujeau JC. HLA-A*31:01 and
different types of carbamazepine-induced severe cutaneous
adverse reactions: an international study and meta-analysis.
Pharmacogenomics J. 2014;14(3):281-8.

Practitioner's Corner
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332
We have described the case of a patient who started to
develop hypopigmented skin lesions 1 year after the end of
subcutaneous AIT with grasses, administered on a monthly
basis over 4 years. Although the period between skin trauma
and the appearance of KP lesions is generally short (10-20
days), the reported latency ranges from 3 days to 2 years [5].
The etiopathogenesis of KP in vitiligo remains unclear, though
immune, neural, and vascular factors have been suggested to
play an important role [4]. In our case it is dicult to establish
whether the triggering cause of KP was repeated trauma due to
the needle, as has been described in cases of psoriasis induced
by acupuncture [7], or the immune response to administration
of the grass extract. To our knowledge, this is the rst case of
vitiligo associated with KP following the administration of
subcutaneous AIT with grass pollen. The possibility of such
phenomena in patients who develop vitiligo after a cycle of
AIT should be taken into account.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. van Geel N, Speeckaert R, De Wolf J, Bracke S, Chevolet
I, Brochez L, Lambert J. Clinical signicance of Koebner
phenomenon in vitiligo. Br J Dermatol. 2012;167:1017-24.
2. Koebner H. Zur Aetiologie der Psoriasis. Vjschr Dermatol.
1876;3:559.
3. Boyd AS, Neldner KH. The isomorphic response of Koebner. Int
J Dermatol. 1990; 29:401-10.
4. van Geel N, Speeckaert R, Taieb A, Picardo M, Böhm M,
Gawkrodger DJ, Schallreuter K, Bennett DC, van der Veen W,
Whitton M,Moretti S, Westerhof W, Ezzedine K, Gauthier Y;
VETF members. Koebner's phenomenon in vitiligo: European
position paper. Pigment Cell Melanoma Res. 2011;24:564-73.
5. Weiss G, Shemer A, Trau H. The Koebner phenomenon: review of
the literature. J Eur Acad Dermatol Venereol. 2002;16: 241-8.
6. Orzan OA, Popa LG, Vexler ES, Olaru I, Voiculescu VM, Bumbăcea
RS. Tattoo-induced psoriasis.J Med Life. 2014;7:65-8.
7. Zhu LL, Hong Y, Zhang L, Huo W, Zhang L, Chen HD, Gao
XH. Needle acupuncture-induced Koebner phenomenon
in a psoriatic patient. J Altern Complement Med. 2011;17
(12):1097-8.
and the recombinant allergens of Phleum pratense: rPhl p 1
(18.20 kU/L), rPhl p 5 (62.40 kU/L), rPhl p 7 (polcalcin), and
rPhl p 12 (Phleum p prolin) (6.50 kU/L).
Based on the above ndings, the patient received specic
allergen immunotherapy (AIT) via the subcutaneous route with
Depigoid 100% Grasses group (Dactylis glomerata, Festuca
pratensis, Lolium perenne, Phleum pratense, Poa pratensis)
(Leti, Barcelona, Spain) administered perennially on a monthly
basis for 4 years (2008-2012). The therapy resulted in an
improvement in respiratory symptoms. The patient showed
good tolerance of AIT over the 4 years of treatment, with
no early or late local or systemic reactions. Two years after
completion of the treatment, the patient was reviewed at our
unit and explained that approximately 1 year after the end of
AIT he started to develop hypopigmented point lesions on
both arms, coinciding with the vaccine dose administration site
(Figure). The lesions were more numerous on the right arm,
where they merged to form larger hypopigmented areas. The
patient explained that the treatment had been administered more
often in the right arm, since he had undergone surgery of the
left arm and preferred to be injected as little as possible in that
arm. There were no other similar lesions elsewhere on the body.
The patient was evaluated in the dermatology department,
where he was diagnosed with vitiligo and prescribed topical
0.1% tacrolimus; there had been no repigmentation of the lesions
by the time we saw him at our unit. He refused the option of a
biopsy because he did not want any more lesions on his arms.
The patient had not been previously diagnosed with vitiligo
and had no past history of skin lesions. However, KP has been
related to lesions in areas exposed to trauma in patients with no
pre-existing dermatosis [5]. None of the patient’s relatives had
vitiligo, but his father and his grandmother had been diagnosed
with rheumatoid arthritis. The literature cites a number of
triggering factors for KP, including physical trauma, burns,
insect bites, surgical incisions, allergic and irritating reactions,
radiation exposure, needle acupuncture, and tattoos [5-7].
Figure. A, Right arm. B, Left arm.
Manuscript received March 17, 2016; accepted for publication,
June 10, 2016.
Beatriz Rodríguez Jiménez
Unidad de Alergia
Hospital Universitario de Getafe
Carretera de Toledo Km 12,500
28905 (Getafe) Madrid Spain
E-mail: brodriguezjimenez@hotmail.com

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
333
in all cases serology tests for sexually transmitted diseases,
including HIV, were negative. In 2012, the patient was
admitted to the hospital on 2 occasions, the rst time for a
respiratory infection induced by Streptococcus pneumoniae,
and the second for a gastrointestinal infection due to Giardia
lamblia. Both infections coincided with a decrease in IgG
levels despite treatment with gamma globulin.
After a new episode of urethritis in June 2013, the patient
was diagnosed with HIV infection (positive HIV-1 antibodies
and a positive Western blot for gp120,gp41, p31, p24, and
p17 from HIV), surprisingly coinciding with an unexpected
increase in levels of IgG (>1500 mg/dL). HIV viral load in
serum was undetectable.
Over the next 6 months the patient’s levels of IgG remained
high despite monthly IVIG infusions; the infusions were
discontinued in December 2013. Antiretroviral treatment
was started in spite of an undetectable HIV viral load. Two
years later, the patient still has high levels of IgG but very
low levels of IgA (IgG, 1747; IgM, 264; IgA, 2; and IgE, 24).
The most recent immunophenotypic study revealed normal
total lymphocyte count with a correct distribution of natural
killer cells and B and T lymphocytes. The CD4/CD8 ratio
(676/1536 cells/μL) was inverted, though the CD4 count
remained normal. The level of B lymphocytes was normal,
and the proportion of virgin B cells and dierent types of
memory B cells were also within normal range. We observed
a correct distribution of immunoglobulin free light chains,
and no antigenic data suggested peripheral expression of a
monoclonal lymphoproliferative disorder. CD28 and CD27
(lymphoplasmocytoid cells) cells were in normal proportion.
No new, relevant infections were reported during this 2-year
period (Figure).
This case shows the association of HIV infection and
development of hypergammaglobulinemia and recovery of
IgG production in a patient with CVID over at least 2 years of
follow-up, and adds further evidence to the few similar cases
reported in the literature [4-7.]
As in similar reported cases, our patient has shown
recovery of IgG, IgM, and IgE while IgA levels remain
undetectable. This nding is compatible with the notion that
specic genetic—and possibly environmental—factors are
required to induce CVID in the context of IgA deciency [9] .
Hypergammaglobulinemia is a common finding in
the early stages of HIV infection due to polyclonal B-cell
activation, which could explain the course of these cases [10].
Resolution of Common Variable Immunodeciency
After HIV Infection
Balugo-López V, Hernández García de la Barrera E, Sastre J
Allergy Service, Fundación Jiménez Díaz and Universidad
Autónoma de Madrid, Madrid, Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 333-334
doi: 10.18176/jiaci.0090
Key words: Common variable immunodeficiency. HIV infection.
Hypogammaglobulinemia.
Palabras clave: Inmunodeficiencia común variable. Infección VIH.
Hipogammaglobulinemia.
Common variable immunodeficiency (CVID) is the
most common of the primary immunodeciency disorders
requiring immunoglobulin replacement, and aects about
1 in every 25
000 white people. The characteristic feature is
severe hypogammaglobulinemia, predominantly aecting the
IgG and IgA classes. The majority of patients present with
recurrent infections, mostly aecting the respiratory tract,
although gastrointestinal infections are also common [1,2].
The mechanisms underlying CVID are not known, though
evidence points to many dierent genetic defects inducing
abnormalities in B and T lymphocytes [1,3]. Autoimmune
diseases and malignancies may also complicate the course of
the disease, which is usually favorable with immunoglobulin
replacement therapy.
In rare cases, CVID has been reported to resolve transiently
or permanently with human immunodeciency virus (HIV)
infection [4-7].
We present the case of a 21-year-old male ex-smoker
with a history of repeat sinusitis since childhood. In March
2009 he presented to our allergy service with complaints of
dry cough and dyspnea of a few weeks’ duration. A physical
examination produced no abnormal ndings. Skin tests to
common inhalants were negative. Spirometry and fraction of
exhaled nitric oxide were within normal values. A chest x-ray
demonstrated no alterations. A complete blood count showed
5.9% eosinophils, and an analysis of biochemical data revealed
no abnormalities.
Immunoglobulin determinations showed a decrease in
IgG and IgM and undetectable levels of IgA and IgE (values
in mg/dL: IgG, 284; IgA, 0; IgM, 22). Immunophenotyping
showed 8% of B lymphocytes and 58% of T lymphocytes and
an inverted CD4/CD8 ratio (748/2006 cells/μL). The patient
was diagnosed with CVID (SmB+ EUROclass) [8] and
began treatment with intravenous human immunoglobulin
(IVIG) at a dose of 200 mg/kg once every 3 weeks. Monthly
immunoglobulin quantification was performed in order
to adjust the treatment and maintain levels of IgG above
500 mg/dL (Figure).
During follow-up, the patient experienced recurrent
episodes of urethritis due to his sexual behavior, although
Figure. Clinical course and changes in serum IgG levels in patient. IVIG
indicates intravenous immunoglobulin.
2500
2000
1500
1000
500
0
IgG, mg/dL
Mar-09
Jan-12
Jan-13
Jan-10
Dec-12
Jul-13
Jan-15
Jun-09
Mar-12
Mar-13
Mar-14
Dec-10
Jan-14
May-15
Dec-11
Course
Gastroenteritis due to
Giardia
IVIG
treatment
start IVIG
treatment
withdrawal
Diagnosis
HIV
IgG
1667 IgG
Urethritis
Urethritis
Pneumococcal
pneumonia
Antiretroviral
treatment
Mo

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
334
Treatment with antiretroviral drugs does not appear to aect
this B-cell activation, since both in our case and in the report
by Jolles et al [4], immunoglobulin recovery was maintained in
spite of antiretroviral therapy. Nevertheless, the cause behind
immunoglobulin recovery in these cases remains unanswered.
Acknowledgments
Oliver Shaw for editorial assistance.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
VBL and EHGB declare they have no conicts of interest.
JS reports having served as a consultant to Thermo Fisher
Scientic, Schering-Plough, Merck, FAES Farma, Novartis,
Roche, Sano, Gennetech, and GSK; having been paid lecture
fees by Novartis, GSK, Stallergenes, FAES FARMA, and
UCB; and having received grant support from Thermo Fisher,
GSK, and ALK-Abelló.
References
1. Bonilla FA, Barlan I, Chapel H, Costa-Carvalho BT,
Cunningham-Rundles C, de la Morena MT, Espinosa-Rosales
FJ, Hammarström L, Nonoyama S, Quinti I, Routes JM, Tang
ML, Warnatz K. International Consensus Document (ICON):
Common Variable Immunodeciency disorders. J Allergy Clin
Immunol Pract. 2016 Jan-Feb;4(1):38-59
2. Karakoc-Aydiner E, Ozen AO, Baris S, Ercan H, Ozdemir
C, Barlan IB. Alteration in humoral immunity is common
among family members of patients with common variable
immunodeciency. J Investig Allergol Clin Immunol.
2014;24(5):346-51
3. Abolhassani H, Cheraghi T, Rezaei N, Aghamohammadi A,
Hammarström L. Common Variable Immunodeciency or Late-
Onset Combined Immunodeciency: A New Hypomorphic
JAK3 Patient and Review of the Literature. J Investig Allergol
Clin Immunol. 2015;25(3):218-20
4. Jolles S, Tyrer M, Johnson M, Webster D. Long term recovery of
IgG and IgM production during HIV infection in a patient with
common variable immunodeciency (CVID). J Clin Pathol.
2001;Sep;54(9):713-5.
5. Morell A, Barandun S, Locher G. HTLV-III seroconversion in a
homosexual patient with common variable immunodeciency.
N Engl J Med. 1986;Aug 14;315(7):456-57.
6. Webster AD, Lever A, Spickett G, Beattie R, North M, Thorpe
R. l. Recovery of antibody production after HIV infection in
“common” variable hypogammaglobulinaemia. Clin Exp
Immunol. 1989;77:309-13.
7. Wright JJ, Birx DL, Wagner DK, Waldmann TA, Blaese RM,
Fleisher TA. Normalization of antibody responsiveness in a
patient with common variable hypogammaglobulinemia and
HIV infection. N Engl J Med. 1987;317:1516-20
8. Wehr C, Kivioja T, Schmitt C, Ferry B, Witte T, Eren E, Vlkova M,
Hernandez M, Detkova D, Bos PR, Poerksen G, von Bernuth
H, Baumann U, Goldacker S, Gutenberger S, Schlesier M,
Bergeron-van der Cruyssen F, Le Garff M, Debré P, Jacobs
R, Jones J, Bateman E, Litzman J, van Hagen PM, Plebani
A,Schmidt RE, Thon V, Quinti I, Espanol T, Webster AD, Chapel
H, Vihinen M, Oksenhendler E, Peter HH, Warnatz K. The
EUROclass trial: dening subgroups in common variable
immunodeciency. Blood. 2008;1;111(1):77-85
9. Vorechovsk I,Webster AD, Plebani A, Hammarström L. Genetic
linkage of IgA deciency to the major histocompatibility
complex: evidence for allele segregation distortion, parent-
of-origin penetrance differences, and the role of anti-IgA
antibodies in disease predisposition. Am J Hum Genet.
1999;64:1096-109.
10. Moir S, Fauci AS. B cells in HIV infection and disease. Nat Rev
Immunol. 2009;9: 235-45
Manuscript received February 22, 2016; accepted for
publication, June 17, 2016.
Joaquín Sastre
Servicio de Alergología
Fundación Jiménez Díaz
Av. Reyes Católicos 2
28040 Madrid
Spain
E-mail: jsastre@fjd.es

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
335
Kounis Syndrome After Levooxacin Intake: A
Clinical Report and Cross-reactivity Study
García Núñez I1,2, Algaba Mármol MA3, Barasona Villarejo MJ4,
Suárez Vergara M2, Espínola González F5, Reina Ariza E1
1Allergy Department, Hospital Quirón Málaga, Malaga, Spain
2Allergy Department, Hospital Quirón Campo de Gibraltar,
Cádiz, Spain
3DCCU Écija, Osuna Primary Care Unit, Osuna, Seville, Spain
4Allergy Department, Hospital Universitario Reina Sofía,
Cordoba, Spain
5Faculty of Medicine; Malaga University, Malaga, Spain
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 335-336
doi: 10.18176/jiaci.0091
Key words: Kounis syndrome. Levooxacin. Ciprooxacin. Basophil
activation test. Specic IgE.
Palabras clave: Síndrome Kounis. Levooxacino. Ciprooxacino. Test
activación basólos. IgE especíca.
Kounis and Zavras [1] described a case of histamine-
induced coronary artery spasm in 1991 and this concurrence
of an acute coronary event with an acute allergic reaction
(anaphylactic or anaphylactoid) is now known as Kounis
syndrome. It is due to extensive vasodilatation and low
cardiac output. In the last 20 years, numerous factors have
been implicated in Kounis syndrome, including drugs (eg,
β-lactams [2], ibuprofen [3], contrast media), hymenoptera
stings, and food.
We describe the case of a 35 year-old man who presented at
our allergy department with clinical symptoms (acute coronary
syndrome and generalized angioedema with urticaria) and ST
decline in several leads in an emergency electrocardiogram
performed 30 minutes after the rst intake of levooxacin,
which had been prescribed to treat sinusitis. The cardiac
evaluation (coronary angiography, cardiac catheterization, plus
an exercise stress test) showed normal results. The ndings
were compatible with a diagnosis of Kounis syndrome. After
ruling out all other possible causes, and after obtaining the
patient’s informed signed consent, we performed a prick test
(5 mg/mL) and intradermal test (0.005 mg/mL and 0.05 mg/mL) wi th
levooxacin. Additional tests included a basophil activation
test (BAT) with BasoTest (BD Biosciences), specic IgE
to quinolones, and a drug provocation test (DPT) with an
alternative drug from the same family.
The prick and intradermal tests were negative in our
patient, but positive in 2 patients from a control group of 10
patients with good tolerance of levooxacin, ciprooxacin,
and ofloxacin. The BAT, performed according to the
manufacturer’s instructions, showed a positive result for
levooxacin (4.5%) and a negative result for ciprooxacin
and ooxacin. All the patients in the control group had
negative BAT results. Specic IgE (ImmunoCAP, Thermo
Fisher Scientic) was negative to ciprooxacin and positive
to levooxacin (0.67 kU/L); the results in the control group
were again negative. With these results, we performed a DPT
with ciprooxacin (placebo-placebo-50-100-100-250 mg) to
identify an alternative treatment. The results were negative
at the immediate and delayed readings (2 and 48 hours,
respectively).
Three types of Kounis syndrome are now recognized [4]:
type I, occurring in patients with normal cardiac ndings
(normal arteriography); type II, occurring in patients
with pathological cardiac findings (atherosclerosis in
arteriography); and type III, occurring in patients with the type
II variant and previous heart problems. Our patient, a healthy
man who experienced severe heart failure after levooxacin
intake, was diagnosed with type I Kounis syndrome. This is
very important as the fact that no other clinical reasons can
explain the symptoms experienced by the patient demonstrates
that the drug was the trigger.
To our knowledge, this is the first clinical report of
Kounis syndrome due to levooxacin with a positive in vitro
study. As mentioned, several drugs have been implicated in
this syndrome, but there has only been 1 report involving a
quinolone (ciprooxacin) [5].
Kounis syndrome is challenging, as few cases are reported
annually [6] and there are no established clinical protocols for
conrming or excluding a diagnosis, which is established on
clinical grounds. Accordingly, the clinical report is the main
tool for conrming diagnosis, and it is therefore necessary
to focus on ruling out other allergic and nonallergic causes.
According to several authors, once the culprit drug has been
identied in a patient diagnosed with Kounis syndrome, all
other drugs in the same family must be avoided [7]. However,
in vitro studies could have an important role in identifying
an alternative to recommend to patients: BAT and/or specic
IgE are used to conrm a diagnosis and search for alternative
treatments, although published results show that an in vitro
study cannot rule out hypersensitivity (low sensitivity and/or
specicity of the studies) and must be conrmed by a DPT.
In our patient, the results of the in vivo studies for
levooxacin were unclear, as they were negative in our patient
but positive in 2 of the control patients. Contradictory results
regarding the sensitivity of skin tests in quinolone allergy have
been reported, and positive skin tests in controls have been
attributed to direct mast cell activation [8]. These conicting
reports led to the proposal for the use of low nonirritating
intradermal test concentrations for quinolones, but these
have low sensitivity. Based on the positive specic IgE and
BAT results for levooxacin and the negative results for
ciprooxacin, we advised our patient to undergo a DPT with
the alternative drug ciprooxacin, as low cross-reactivity has
been reported between ciprooxacin and levooxacin [9,10].
Few publications have reported cross-reactivity between
quinolones [7,9,10]. In addition, few patients have been studied
and the results have been very dierent (and contradictory).
The results show that cross-reactivity between quinolones is
unclear and that there are no general rules for predicting cross-
reactivity, which should be analyzed on a case-by-case basis.
To conclude, to the best of our knowledge this is the rst
report of Kounis syndrome due to levooxacin with a positive
in vitro study and tolerance of ciprooxacin.

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
336
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Kounis NG, Zavras GM. Histamine-induced coronary artery
spasm: the concept of allergic angina. Br J Clin Pract. 1991
Summer;45(2):121-8
2. Ralapanawa DM, Kularatne SA. Kounis syndrome secondary
to amoxicillin/clavulanic acid administration: a case report
and review of literature. BMC Res Notes. 2015 Mar 26;8:97.
3. Alves MF, Pitta Mda L, Peres M, Leal M, Almeida AG, Ferreira
da Silva G. Cardiac apical aneurysm secondary to ibuprofen-
induced type 1-Kounis syndrome. Int J Cardiol. 2012 Jul
12;158(2):e41-3.
4. Biteker M. A new classication of Kounis syndrome Int J
Cardiol. 2010 Dec 3;145(3):553.
5. Almpanis G, Siahos S, Karogiannis NC, Mazarakis A, Niarchos
C, Kounis GN, Kounis NG. Kounis syndrome: two extraordinary
cases. Int J Cardiol. 2011 Mar 3;147(2):e35-8.
6. Renda F, Landoni G, Trotta F, Piras D, Finco G, Felicetti P,
Pimpinella G, Pani L. Kounis Syndrome: An analysis of
spontaneous reports from international pharmacovigilance
database. Int J Cardiol. 2015 Oct 22;203:217-220.
7. González I, Lobera T, Blasco A, del Pozo MD. Immediate
hypersensitivity to quinolones: moxioxacin cross-reactivity.
JInvestig Allergol Clin Immunol. 2005;15(2):146-9.
8. Campi P, Manfredi M, Severino M. IgE-mediated allergy
to pyrazolones, quinolones and other non beta-lactam
antibiotics. In: Pichler WJ, editor. Drug hypersensitivity. Basel:
Karger Medical and Scientic Publishers; 2007. p. 216-32.
9. Chang B, Knowles SR, Weber E. Immediate hypersensitivity
to moxioxacin with tolerance to ciprooxacin: report of
three cases and review of the literature. Ann Pharmacother.
2010;44:740-5.
10. Lobera T, Audícana MT, Alarcón E, Longo N, Navarro B, Muñoz
D. Allergy to quinolones: low cross-reactivity to levooxacin. J
Investig Allergol Clin Immunol. 2010;20(7):607-11.
Manuscript received December 31, 2015; accepted for
publication, June 17, 2016.
Ignacio García Núñez
Allergy Department
Hospital Quiron Malaga
Avda Imperio Argentina nº1
29004 Malaga (Spain)
E-mail: h62ganui@hotmail.com
Therapeutic Potential of Zoledronate-Activated
Autologous γδT Cells in Atopic Dermatitis
Kamigaki T, Naitoh K, Goto S
Seta Clinic, Tokyo, Japan
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 336-338
doi: 10.18176/jiaci.0092
Key words: γδT cells. Vγ9γδT cells. Atopic dermatitis. TARC.
Palabras clave: Células T gamma/delta. Células T V gamma 9 gamma/
delta. Dermatitis atópica. Quimiocina regulada y activada del timo (TARC).
Current research on treatment of atopic dermatitis
(AD) focuses on creating biological antagonists of the TH2
cytokine pathway, such as anti-interleukin (IL)-4 receptor
α antibody, or nding drug candidates that repair epidermal
barrier function [1,2]. In clinical trials, repeated intravenous
injections of γδT cells proved feasible and safe for the
treatment of patients with malignancies [3]. We demonstrated
that zoledronate-activated γδT cells increase the frequency
of Vγ9γδT cells and produce mainly TH1 cytokines but not
IL-17 [4]. In cell-based therapy in allergy patients, the use
of TH1-polarized innate cells for establishing robust allergen-
specic tolerance is clearly dierent from that of regulatory
T cells (Tregs) or syngeneic hematopoietic stem cells [5,6]. In
this study, we evaluated the safety and clinical outcomes of γδT
cell therapy in AD patients who received a single intravenous
injection of zoledronate-activated γδT cells.
The trial was approved by the Research Ethics Committee
of Seta Clinic on February 2, 2012 (approval number:
SCG12063). The primary endpoint was the safety of γδT cell
therapy; the secondary endpoints were clinical outcome and
immunological status. The study population comprised 5 male
AD patients (3 with moderate AD and 2 with severe AD), and
the median age was 32 years (range, 31-34 years). Peripheral
blood mononuclear cells (PBMCs) were collected from the
whole blood of each patient and cultured with zoledronate,
IL-2, and autologous serum for 14 days. Cell preparations
were examined for the presence of bacteria and endotoxins,
as previously reported [3,4]. A single intravenous injection of
the ex vivo–expanded γδT cells activated by zoledronate was
administered to each patient. The use of topical medications
was allowed, but the use of systemic corticosteroids and
unapproved medicines was prohibited. For assessment of the
primary endpoints, adverse events were monitored according
to the Common Terminology Criteria of Adverse Events v4.0.
The severity and extent of AD were assessed using the
AD severity classication of the Japanese Dermatological
Association (simple method, maximum 20 points) [7]. The
secondary endpoint was the immunological status of the
patients, who received a single intravenous injection of
zoledronate-activated γδT cells. This was also monitored by
ow cytometry of peripheral blood before injection and 1, 2,
4, and 6 months after injection. Levels of the TH2 biomarker

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337
thymus and activation-regulated chemokine (TARC) [8]
and levels of IgE and eosinophils of each patient were also
evaluated within 6 months of administration of zoledronate-
activated γδT cells.
The number of injected zoledronate-activated γδT cells
ranged from 5.0 to 9.5 × 109. No adverse events were observed
during the 6 months after administration. The evaluation of
clinical outcome revealed that the clinical index of AD severity
improved in 2 of the 5 patients (Patient 2, 7 to 1; Patient 5,
10 to 4). In 1 patient (Patient 1), the clinical index returned to
the initial level of the evaluation after a transient improvement;
however, no improvement in atopic dermatitis was observed
for 2 patients (Patients 3 and 4). Flow cytometry of immune
cells in peripheral blood before treatment revealed that the
frequencies of γδT and Vγ9γδT cells ranged from 1.2% to
3.5% and from 0.3% to 2.5% of PBMCs, respectively. The
change in the frequency of γδT and Vγ9γδT cells in PBMCs
is shown in the Figure (Panel A). In the 2 patients whose AD
severity index improved, the frequencies of both γδT and
Vγ9γδT cells increased markedly and were maintained until
6 months after administration. At this point, the frequencies of
Vγ9γδT cells in Patients 2 and 5 increased to 11.9- and 4.7-fold
compared with before treatment, respectively. In Patient 3 (no
clinical improvement), the frequency of Vγ9γδT cells increased
transiently after administration but decreased promptly after
2 months of treatment. Flow cytometry also demonstrated
that the frequency of TH2 cells decreased in 2 patients, with
an improvement in the clinical index of AD severity (Patient
2, 1.4 to 0.9; Patient, 5, 7.4 to 4.4), although no decrease was
observed for the other 3 patients (data not shown). There were
no signicant changes in the frequencies of TH1 cells, B cells,
or Tregs after administration of zoledronate-activated γδT cells
in any of the 5 patients. The assessment of TH2 biomarker
levels demonstrated that the mean percentage change in TARC
levels in Patients 1, 2, and 5 was –35.9%, –54.1%, and –85.9%,
respectively, after treatment (Figure, Panel B). However, in
Patient 3 (no clinical improvement), TARC levels at 1, 2, 4, and
6 months after the injection were 237.8%, 56.6%, 159.2%, and
–7.6%, respectively. In Patients 2 and 5, eosinophil counts fell
below half after a month of treatment (data not shown). There
was no notable decrease in IgE levels in any of the patients.
This is the rst study of zoledronate-activated γδT cell therapy
for AD patients, in whom therapy was shown to be safe and
feasible. In the 2 patients whose clinical index of AD severity
improved, we observed a decrease in TH2 cell frequency, a
decrease in TARC levels, and a 5 to 10–fold increase in the
frequencies of Vγ9γδT cells in PBMCs compared with before
treatment. These data suggest that it is necessary to suppress
TH2-skewed immunity to markedly increase the TH1-polarized
Vγ9γδT cell frequency in PBMCs in AD patients. However,
zoledronate-activated γδT cells were not eective for AD
patients with TH1-skewed immunity caused by a bacterial
infection [9]. In treatment of cancer patients, more than 3
infusions of zoledronate-activated γδT cells signicantly
Frequencies of γδT and Vγ9γδT Cells
in PBMCs, %
Change From Baseline
in TARC, %
Before
Before
Before
Before 1 2 6
Pt.3
Pt.4
Pt.2
Pt.1
Pt.5
4
Before
Before
Months After Treatment
Months After Treatment
666 6 6 222 2 2 444 4 4 111 1 1
18.0
15.0
12.0
9.0
6.0
3.0
0.0
8.0
6.0
4.0
2.0
0.0
8.0
6.0
4.0
2.0
0.0
25
0
-25
-50
-75
-100
8.0
6.0
4.0
2.0
0.0
8.0
6.0
4.0
2.0
0.0
Pt.5Pt.2Pt.1
A
B
Pt.3 Pt.4
Figure. A, Change in the frequency of γδT (□+ ■) and Vγ9γδT (■) cells in AD patients receiving a single intravenous injection of zoledronate-activated γδTcells.
In Patients 2 and 5, the frequencies of Vγ9γδT cells were maintained until 6 months after administration and increased 11.9- and 4.7-fold compared with
before treatment, respectively. B, Change in the levels of the TH2 biomarkers TARC in AD patients who received a single intravenous injection of zoledronate-
activated γδT cells. In the 2 patients whose AD severity index improved, the decreases in the levels of TARC 1 month after treatment were 46.2% and 87.7%.
TARC indicates thymus and activation-regulated chemokine.

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338
9 Kasraie S, Niebuhr M, Kopfnagel V, Dittrich-Breiholz O,
Kracht M, Werfel T. Macrophages from patients with atopic
dermatitis show a reduced CXCL10 expression in response to
staphylococcal α-toxin. Allergy. 2012;67:41-9.
increased the numbers of Vγ9γδT cells [3,4]. Therefore, in
future clinical trials, at least 3 injections of zoledronate-
activated γδT cells should be administered to engraft a large
number of Vγ9γδT cells in PBMCs. The eect of zoledronate-
activated γδT cells for AD patients should be evaluated in
randomized controlled trials.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
References
1. Beck LA, Thaçi D, Hamilton JD, Graham NM, Bieber T, Rocklin
R, Ming JE, Ren H, Kao R, Simpson E, Ardeleanu M, Weinstein
SP, Pirozzi G, Guttman-Yassky E, Suárez-Fariñas M, Hager MD,
Stahl N, Yancopoulos GD, Radin AR. Dupilumab treatment in
adults with moderate-to-severe atopic dermatitis. N Engl J
Med. 2014;371:130-9.
2 Otsuka A, Doi H, Egawa G, Maekawa A, Fujita T, Nakamizo S,
Nakashima C, Nakajima S, Watanabe T, Miyachi Y, Narumiya
S, Kabashima K Possible new therapeutic strategy to regulate
atopic dermatitis through upregulating laggrin expression. J
Allergy Clin Immunol. 2014;133:139-46.
3 Noguchi A, Kaneko T, Kamigaki T, Fujimoto K, Ozawa M, Saito
M, Ariyoshi N, Goto S. Zoledronate-activated Vγ9γδ T-cell-
based immunotherapy is feasible and restores the impairment
of γδ T-cells in patients with solid tumors. Cytotherapy.
2011;13:92-7.
4 Abe Y, Muto M, Nieda M, Nakagawa Y, Nicol A, Kaneko T,
Goto S, Yokokawa K, Suzuki K. Clinical and immunological
evaluation of zoledronate-activated Vgamma9gammadelta
T-cell-based immunotherapy for patients with multiple
myeloma. Exp Hematol. 2009;37:956-68.
5 Böhm L, Maxeiner J, Meyer-Martin H, Reuter S, Finotto S, Klein
M, Schild H, Schmitt E, Bopp T, Taube C. IL-10 and regulatory
T cells cooperate in allergen-specic immunotherapy to
ameliorate allergic asthma. J Immunol. 2015;194:887-97.
6 Kim HS, Yun JW, Shin TH, Lee SH, Lee BC, Yu KR, Seo Y, Lee
S, Kang TW, Choi SW, Seo KW, Kang KS. Human umbilical
cord blood mesenchymal stem cell-derived PGE2 and TGF-β1
alleviate atopic dermatitis by reducing mast cell degranulation.
Stem Cells. 2015;33:1254-66.
7 Saeki H, Furue M, Furukawa F, Hide M, Ohtsuki M, Katayama I,
Sasaki R, Suto H, Takehara K; Committee for guidelines for the
management of atopic dermatitis of Japanese Dermatological
Association. Guidelines for management of atopic dermatitis.
J Dermatol. 2009;36:563-77.
8 Kakinuma T, Nakamura K, Wakugawa M, Mitsui H, Tada Y,
Saeki H, Torii H, Asahina A, Onai N, Matsushima K, Tamaki
K. Thymus and activation-regulated chemokine in atopic
dermatitis: Serum thymus and activation-regulated chemokine
level is closely related with disease activity. J Allergy Clin
Immunol. 2001;107:535-41.
Manuscript received May 16, 2016; accepted for publication
June 20, 2016.
Takashi Kamigaki
Center for Clinical Trials and Research
Seta Clinic, 2-1-45 Kanda-surugadai, Chiyoda, Tokyo
Japan
Zip code: 1010062
E-mail: kamigaki@j-immunother.com

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
339
Evaluation of Tolerance in Patients With Type-1
Hypersensitivity Reaction to Wheat After Oral
Immunotherapy
Khalili A¹, Khayatzadeh A², Ebrahimi M², Raemanesh H3, Azizi
G4,5, Movahedi M²
1Department of Pediatrics, Shahid Sadoughi University of Medical
Sciences, Yazd, Iran
2Department of Allergy and Clinical Immunology, Children’s Medical
Center, Tehran University of Medical Sciences, Tehran, Iran
3Department of Epidemiology, School of Public Health, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
4Department of Laboratory Medicine, Imam Hassan Mojtaba
Hospital, Alborz University of Medical Sciences, Karaj, Iran
5Research Center for Immunodeciencies, Pediatrics Center
of Excellence, Children’s Medical Center, Tehran University of
Medical Sciences, Tehran, Iran
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 339-340
doi: 10.18176/jiaci.0093
Key words: Tolerance. Type 1 hypersensitivity. Immunotherapy.
Palabras clave: Tolerancia. Hipersensibilidad tipo 1. Inmunoterapia.
Adverse food reactions are unwanted reactions after
ingestion of foods or food additives. The prevalence of
wheat allergy is 0.2%-0.9% in adults and 0.4%-1.3% in
children [1,2]. IgE-mediated reactions usually begin with
acute symptoms within 2 hours after exposure to food [3-6]. In
this study, we evaluate the development of tolerance in wheat-
allergic patients who had been desensitized according to a
known protocol. In our previous study, 13 patients with wheat
allergy completed 1 year of follow-up after the maintenance
phase of an immunotherapy protocol. These patients were
desensitized based on a previously reported protocol [7]. Ten
of the 13 patients were aged >5 years. At the time, oral food
challenge (OFC) was performed with Senan bread containing
10% protein after a 2-week wheat-free diet. The OFC was
performed at intervals of 15 minutes with doses of 0.8, 0.8,
1.6, 3.2, 6.4, 13.5, 26, and 52 g of sliced bread (Senan). The
cuto for clinical tolerance was 52 g of bread. Patients were
tested with skin prick test extract (Greer), and the size of
the wheal was compared before and after the desensitization
period. Moreover, serum-specic IgE was measured using
the RIDA qLine Allergy Panel (R-Biopharm) and compared
before and after desensitization. Statistical analyses were
performed using IBM SPSS Statistics for Windows, Version
20.0 (IBM Corp). The Fisher exact and chi-square tests
were used to compare categorical variables; the Pearson
and Spearman rank correlation tests were used to assess the
correlation between variables. Mean age was 9.1 years (range,
6-20 years). Two of the 10 patients were females and the rest
were males. Patients were divided into 2 groups according to
their primary presentations (anaphylaxis or no anaphylaxis).
Eight patients had anaphylaxis before desensitization. The
allergic manifestations before immunotherapy aected the
skin, respiratory tract, and gastrointestinal tract (Table). During
desensitization, patients were evaluated for complaints. Seven
Table. Frequency of Symptoms and Complaints Before and During Treatment
Variable Frequency, No (%)
Primary symptoms of anaphylaxis Yes 8 (80)
No 2 (20)
Symptoms before immunotherapy Facial angioedema 1 (10)
Urticaria 9 (90)
Wheezing and shortness of breath 7 (70)
Rhinorrhea, pruritus, and nasal congestion 2 (20)
Vomiting and stomach cramps 1 (10)
Symptoms during the wheat-containing diet Type 1 symptoms (occasionally)a 7 (70)
Initial symptomsb 3 (30)
Symptoms during the 1-year immunotherapy period Urticaria 4 (40)
Wheezing and dyspnea 2 (20)
Rhinorrhea 1 (10)
Generalized pruritus 1 (10)
Chronic constipation 1 (10)
Bloating and chronic abdominal distention 1 (10)
Symptoms during the open food challenge Urticaria 4 (40)
Ocular pruritus 2 (20)
Rhinorrhea 3 (30)
Dyspnea and wheezing 0 (0)
Gastrointestinal symptoms 0 (0)
aHives, wheezing, rhinorrhea, and pruritus.
bChronic constipation, abdominal bloating, and distension.

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J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
340
patients occasionally had type 1 allergic signs and symptoms.
However, clinical manifestations were not as severe as the
primary presentations before the desensitization period. The
allergic symptoms were urticaria, wheezing, rhinorrhea, and
pruritus. A 6-year-old boy experienced chronic constipation
when he ate wheat. This symptom may have been related to
his wheat-containing diet, although constipation was ruled
out by a gastroenterologist. A 9-year-old boy complained
of abdominal distention and atulence after following a
wheat-containing diet. Anaphylactic reactions were recorded
in 2 patients who did not develop tolerance. The reactions
occurred after intake of 12 g and 13 g of bread. In other
patients, allergic reactions were less severe and occurred at
doses >26 g. In summary, out of the 10 patients evaluated,
4 tolerated 52 g of bread, and 6 patients experienced allergic
reactions at doses of 12, 13, 26, 26, 26, and 52 g. Among
patients who had an anaphylactic reaction in the initial
presentation, 3 developed clinical tolerance. Nevertheless,
no significant correlation was found between tolerance
and anaphylaxis (P=.747) or between sex and age and
development of tolerance (P=.747 and P=.920, respectively).
No significant correlation was found between sex and
complications during the desensitization period (P=.745).
The mean wheal size before and after immunotherapy was
8.7 mm and 5.7 mm, respectively (P<.001). Mean specic
IgE before and after desensitization was 53.92 IU/mL and
19.06 IU/mL, respectively (P<.001). Staden et al [8] showed
that tolerance was achieved in 36% of milk- or egg-allergic
patients who received oral immunotherapy for 21 months
and then followed an elimination diet for 2 months. Allergen-
specic IgE also decreased in the immunotherapy group. In
2003, Nucera et al [9] desensitized a 7-year-old girl with
wheat allergy. After a 6-month treatment, skin prick tests were
performed and specic IgE was determined, and no signicant
change was observed. Burks et al [10] administered oral egg
immunotherapy to 55 egg-allergic patients after 12 months
of immunotherapy, and the patients followed an elimination
diet for 4-6 weeks. In the oral rechallenge, 28% of patients
were tolerant [10]. In our study, we eliminated wheat from
the patients’ diet for 2 weeks in order to respect the duration
of immunotherapy. After this period, tolerance was observed
in 40% of the patients after the OFC. Although other patients
did not achieve tolerance, the incidence of reactions prevented
us from administering higher doses.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conflicts of
interest.
References
1. Morita E, Chinuki Y, Takahashi H, Nabika T, Yamasaki M,
Shiwaku K. Prevalence of wheat allergy in Japanese adults.
Allergol Int. 2012;61(1):101-5.
2. Faber M, Van Gasse A, Sabato V, Hagendorens MM, Bridts CH,
De Clerck LS, Ebo DG. Marihuana allergy: beyond the joint. J
Investig Allergol Clin Immunol. 2015;25(1):70-2.
3. Sutton R, Hill DJ, Baldo BA, Wrigley CW. Immunoglobulin
E antibodies to ingested cereal our components: studies
with sera from subjects with asthma and eczema. Clin
Allergy.1982;12(1):63-74.
4. Ibanez MD, Escudero C, Sanchez-Garcia S, Rodriguez del
Rio P. Comprehensive Review of Current Knowledge on
Egg Oral Immunotherapy. J Investig Allergol Clin Immunol.
2015;25(5):316-28.
5. Lopez-Matas MA, Larramendi CH, Huertas AJ, Ferrer A, Moya
R, Pagan JA, Navarro LA, Garcia-Abujeta JL, Carnes J. Tomato
nsLTP as an "In Vivo" Diagnostic Tool: Sensitization in a
Mediterranean Population. J Investig Allergol Clin Immunol.
2015;25(3):196-204.
6. Rodriguez del Rio P, Diaz-Perales A, Sanchez-Garcia S,
Escudero C, do Santos P, Catarino M, Ibanez MD. Oral
immunotherapy in children with IgE-mediated wheat allergy:
outcome and molecular changes. J Investig Allergol Clin
Immunol 2014;24(4):240-8.
7. Sato S, Utsunomiya T, Imai T, Yanagida N, Asaumi T, Ogura K,
Koike Y, Hayashi N, Okada Y, Shukuya A, Ebisawa M. Wheat
oral immunotherapy for wheat-induced anaphylaxis. J Allergy
Clin Immunol. 2015;136(4):1131-3 e7.
8. Staden U, Rolinck-Werninghaus C, Brewe F, Wahn U,
Niggemann B, Beyer K. Specic oral tolerance induction
in food allergy in children: efcacy and clinical patterns of
reaction. Allergy.2007;62(11):1261-9.
9. Nucera E, Pollastrini E, De Pasquale T, Buonomo A, Roncallo C,
Lombardo C, Sabato V, Gasbarrini G, Schiavino D, Patriarca G.
New protocol for desensitization to wheat allergy in a single
case. Dig Dis Sci.2005;50(9):1708-9.
10. Burks AW, Jones SM, Wood RA, Fleischer DM, Sicherer SH,
Lindblad RW, Stablein D, Henning AK, Vickery BP, Liu AH,
Scurlock AM, Shrefer WG, Plaut M, Sampson HA, Consortium
of Food Allergy R. Oral immunotherapy for treatment of egg
allergy in children. N Engl J Med. 2012;367(3):233-43.
Manuscript received May 9, 2016; accepted for publication June
21, 2016.
Masoud Movahedi
Department of Allergy and Clinical Immunology
Children’s Medical Center
Tehran University of Medical Sciences
Tehran, Iran
E-mail: movahedm@sina.tums.ac.ir

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
341
Induction of Tolerance by Oral Immunotherapy in
Patients With Cow's Milk Allergy
Ebrahimi M1, Gharagozlou M1, Khalili A2, Magaji Hamid K3,4,
Azizi G5,6, Movahedi M1
1Department of Allergy and Clinical Immunology, Children’s
Medical Center, Tehran University of Medical Sciences, Tehran,
Iran
2Department of Pediatrics, Shahid Sadoughi University of medical
sciences, Yazd, Iran
3Department of Immunology, School of Public Health, Tehran
University of Medical Sciences, International Campus, Tehran,
Iran
4Immunology Department, Faculty of Medical Laboratory
Sciences, Usmanu Danfodiyo University Sokoto, Nigeria
5Department of Laboratory Medicine, Imam Hassan Mojtaba
Hospital, Alborz University of Medical Sciences, Karaj, Iran
6Research Center for Immunodeciencies, Pediatrics Center
of Excellence, Children’s Medical Center, Tehran University of
Medical Sciences, Tehran, Iran
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 341-343
doi: 10.18176/jiaci.0094
Key words: Immunotherapy. Desensitization. Cow's milk allergy. Tolerance.
Palabras clave: Inmunoterapia. Desensibilización. Alergia a leche de
vaca. Tolerancia.
Cow's milk allergy is the most common type of food
allergy [1]. In this study, we evaluated the ecacy of oral
desensitization in the induction of tolerance in children aged
>3 years with a history of cow's milk allergy. The inclusion
criteria were a positive history of cow's milk allergy, positive
skin prick test result, presence of specic IgE (sIgE) against
whole cow's milk proteins or any isolated cow's milk protein,
and a positive result in a double-blind, placebo-controlled
food challenge (DBPCFC). The exclusion criteria were
poor compliance, uncontrolled asthma, cardiovascular
disease, and severe systemic disease. The Institutional
Review Board approved the study, which was registered
with the Iranian Clinical Trials Registry (Registration Code:
IRCT2015041621793N1).
All of the patients underwent DBPCFC, in which the
test meal consisted of a strawberry-flavored milk-based
formula (BioMeal, Fassbel), and the placebo meal consisted
of a strawberry-avored soy-based formula (BioMeal Soy,
Fassbel). Initially, 3 drops of the solution were placed in
the lower labial fornix, and then oral doses of 0.5, 2, 5,
20, 60, and 162.5 mL were given every 15 minutes. Oral
immunotherapy was administered in 3 phases (rush, buildup,
and maintenance) [2]. After desensitization, patients were
followed for 1 year to monitor allergic reactions. The use of
cow's milk and dairy products was prohibited for 1 month in
patients who experienced less severe reactions, and an open
food challenge (OFC) test was subsequently performed. If
the OFC result was negative, the patient was considered to
have developed tolerance; if it was positive, the patient was
considered to be desensitized.
sIgE against casein and cow’s milk protein was measured
and a skin prick test (SPT) performed with cow's milk extract
(Greer Laboratories). From February 2014 to September 2015,
a total of 14 patients (10 male and 4 female) were conrmed to
have cow's milk allergy and were enrolled in the nal analysis.
The statistical analyses were performed using IBM SPSS
Statistics for Windows, Version 20.0 (IBM Corp). The Fisher
exact and chi-square tests were used to compare categorical
variables, whereas the Pearson test and Spearman correlation
coefficient were used to assess the correlation between
quantitative and qualitative variables, respectively.
The median age of patients was 4.75 (3.5-7) years, and
the median follow-up period before initiation of this study
was 14 (6-23) months. Seven patients (50.0%) had a history
of atopic disease, and 8 children (57.1%) had a history of
adverse reaction to other foods including fish, egg, tree
nuts, and peanut. The most common clinical manifestation
during the DBPCFC was rhinoconjunctivitis (57.1%). In the
buildup phase, 1190 doses of cow’s milk (5859 mL) were
administered to 13 patients, who completed the buildup phase
successfully, and allergic reactions were recorded in 24 doses
(2.0%). Details of allergic reactions are shown in the Table.
In addition, patient 9 left the study during the sixth week of
the buildup phase because of severe allergic reactions (Table).
During the maintenance phase, 1170 doses of cow's milk
(261 000 mL) were administered and 11 allergic reactions
(0.9%) were recorded in 9 patients (patients 1 and 12 had
2 episodes each). The result of SPT showed that the median
diameter of the wheal before and after desensitization was 10
and 6 mm, respectively. Moreover, the sIgE level to cow’s
milk proteins and casein decreased after desensitization from
39.30 to 10.40 kUA/L and 7.72 to 2.83 kUA/L, respectively.
After oral immunotherapy, the result of the SPT and sIgE
levels against casein and milk proteins decreased signicantly
(P=.002 and .003, respectively). Among 13 patients, the result
of the OFC test was negative in 6 cases (46.2%), and tolerance
was considered relevant in 4 patients (30.8%); 3 patients
(23%) were unable to tolerate milk, and clinical symptoms
developed after ingestion of 20 mL of milk. Age, sex, and
previous medical history had no signicant correlation with the
results of the OFC test. Induction of tolerance was signicantly
more successful in patients with a higher reactive dose in
the DBPCFC test and buildup phase, less severe reactions
during the immunotherapy protocol, and a shorter duration of
immunotherapy. In this study, most of the allergic reactions in
the buildup and maintenance phases were mild and could be
controlled with oral antihistamines. Short-acting ß-agonists
were administered to treat 15 allergic episodes in the build-up
phase and 2 episodes in the maintenance phase. Moreover,
2 patients had to be treated with intramuscular epinephrine
in the buildup phase (1 received 2 doses). Our results and
the results of similar studies show that oral immunotherapy
is a relatively safe approach if the necessary precautions are
taken [3-5]. We found that the dose tolerated at the beginning
of the study correlated with the development of tolerance at the
nal stage. Our results were similar to those of Staden et al [6]

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343 © 2016 Esmon Publicidad
342
Table. Results of the Oral Immunotherapy Protocol
Patient Buildup Dose of Allergic Allergic Reactions During Maintenance Maintenance Allergic Reaction
No. Period, wk Reaction, mL Buildup Phase Period, d Dose, mL (Maintenance Phase)
1 14 10 Generalized urticariaa 90 200 –
60 Localized urticaria, cough, wheezingb
2 12 10 Localized urticariaa 90 250 Localized urticaria,
rhinoconjunctivitisa,e
3 18 2 Generalized urticaria, 90 200 Cough,
cough, rhinoconjunctivitisb rhinoconjunctivitis,
wheezingb
40 Generalized urticaria, sneezing,
wheezing, rhinoconjunctivitis,
respiratory distressc
100 Generalized urticaria,
rhinoconjunctivitis, sneezinga
4 10 - - 90 250 Sneezing,
rhinoconjunctivitisa
5 18 10 Generalized urticaria, 90 200 Localized urticaria,
cough, wheezingb throat pruritusa
40 Generalized urticaria,
cough, rhinoconjunctivitisb
100 Generalized urticaria,
cough, rhinoconjunctivitisb
6 10 40 Generalized urticaria, sneezing, 90 250 Localized urticaria,
rhinoconjunctivitisa rhinoconjunctivitisa
7 10 - - 90 250 –
8 12 40 Generalized urticaria, coughb 90 250 Localized urticariaa
150 Localized urticaria, coughb
9 10 10 Vomiting, abdominal pain - - –
10 15 10 Cough, wheezingb 90 200 Sneezing,
rhinoconjunctivitisa
100 Cough, rhinoconjunctivitisb
5 Sneezing, rhinoconjunctivitisa
11 11 5 Generalized urticaria, coughb 90 200 Localized urticariaa
20 Generalized urticaria, coughb
150 Localized urticaria, throat pruritus,
rhinoconjunctivitisa
12 20 5 Cough, rhinoconjunctivitis, wheezingb 90 200 Cough,
60 Cough, rhinoconjunctivitis, wheezingb rhinoconjunctivitisb,e
100 Cough, rhinoconjunctivitis,
wheezing, ushingd
13 10 40 Sneezing, rhinoconjunctivitisa 90 200 –
100 Sneezing, throat pruritus,
rhinoconjunctivitisa
14 10 60 Throat pruritus, rhinoconjunctivitisa 90 250 –
aTreatment with oral diphenhydramine.
bTreatment with oral diphenhydramine and a short-acting ß-agonist.
cTreatment with oral diphenhydramine, a short-acting ß-agonist, and 2 doses of epinephrine and admission to hospital.
dTreatment with oral diphenhydramine, a short-acting ß-agonist, and a single dose of epinephrine.
eTwo episodes of allergic reactions.

Practitioner's Corner
J Investig Allergol Clin Immunol 2016; Vol. 26(5): 314-343© 2016 Esmon Publicidad
Manuscript received May 7, 2016; accepted for publication June
21, 2016.
Masoud Movahedi
E-mail: movahedm@sina.tums.ac.ir
and Longo et al [7]. Finally, based on the results obtained in
this study and other studies [8-10], it could be concluded that
oral immunotherapy leads to tolerance and may accelerate
induction of tolerance in patients with cow’s milk allergy.
Funding
The authors declare that no funding was received for the
present study.
Conicts of Interest
The authors declare that they have no conicts of interest.
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