Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
What is your approach to a patient with undetectable MMR titers checked prior to or during immunosuppression and a history of MMR vaccination in childhood?
MMR titers are good correlates of protection. If any titer is undetectable it could be one of these situations: Primary failure. The components of the MMR have different efficacy. Two doses of appropriately given MMR will have 96+% against measles, but only 88% for mumps. Thus 1 in 10 appropriately...
Would you consider levofloxacin graded challenge, extended IV aztreonam, or an alternative treatment in a patient with reported anaphylaxis to penicillin, fluoroquinolones, and cefuroxime with cavitary pneumonia secondary to Klebsiella and Pseudomonas?
The first and most important thing would be to establish whether the patient had a true penicillin (as well as other antibiotic) allergy since >90% of patients who think they are sensitive to PNC really are not. If it is established that the patient does have a PCN allergy, consultation with ID is a...
Do you perform a bone marrow biopsy in all patients with grade 5 anaphylaxis to stinging insects and negative workup for HAT, MCAS, c-KIT?
Before saying that bone marrow biopsy is the next step (which it is), we must be certain that we are correctly assessing the situation. Was there documented hypotensive shock (and not just subjective light-headedness or brief vasovagal syncope? Were there other objective signs like urticaria (althou...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
For a contact allergy, do you need to test for the metals individually or does it suffice to just test with a piece of metal from the device?
I asked Dr. Brandon Adler about this question and he said:Testing with metal discs or samples from a manufacturer is not recommended because irritant reactions, false negatives, and false positives are known to occur. Even if there were to be a true positive reaction, there would be no way to know w...
Is there a specific group of children that you start on AIT for prevention of asthma?
There are a few factors I consider in my decision to start allergy immunotherapy (AIT) in children with asthma. The age of the child, whether their asthma symptoms correlate with allergen trigger(s), the ability and willingness of the family to devote the time to build up and continue AIT. Asthma co...
Do you consider the efficacy of different nasal sprays when prescribing for allergic rhinitis or conjunctivitis?
When it comes to prescribing or recommending different nasal sprays for rhinitis, I tend to focus on the other considerations rather than efficacy, as for the most part all of the intranasal steroids are effective. The differences that I might highlight and/or consider include odor, drippiness, cost...
How are you choosing between Xolair, Dupixent or Rhapsido for patients with CSU?
Patient choice, many patients prefer a monthly shot as opposed to BOD meds every day or even q 2 weeks shot; also, co-morbidities--FA, eczema...
What are the implications of checking post-vaccine titers after administration of Prevnar 20 compared to PPSV23?
The landscape of pneumococcal vaccine choices has undergone considerable change in the past few years. Notably, the expanded pneumococcal conjugate vaccines (PCV15, PCV20, PCV21) approved for a broad age range which provide almost overlapping coverage of the pure polysaccharide pneumococcal vaccine ...
Are there specific conventional DMARDs and/or biologics that are contraindicated in patients with alpha-gal allergy?
Here is a Q&A from AAAAI (American Academy of Allergy, Asthma and Immunology) addressing this question for etanercept and other monoclonal antibodies that are manufactured in cell lines that glycosylate with alpha-gal. The author concludes, "The risk is not zero, but likely very low".