Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
When would you pursue genetic testing for severe recalcitrant atopic dermatitis?
Not an easy question to answer, but severe and treatment-refractory AD, especially if early onset, is concerning for immune dysregulation and should warrant immune evaluation early. By treatment-refractory, I do not just mean topical therapies, but attempts to control the Th2 pathway that fail repea...
What factors do you consider prior to offering a trial of ICS/LABA therapy versus a methacholine challenge test in patients with suspected asthma but normal pulmonary function testing?
If there is a high suspicion of asthma, have the patient obtain a portable electronic spirometer. If peak flows/FeV1 drops >15% correlate with symptoms, start Rx and follow spiro results. If low suspicion for asthma or very mild symptoms, do methacholine.
What are your recommendations for managing perivascular dermatitis with eosinophils unresponsive to high-dose antihistamines, a prednisone taper, and topical steroids?
I would check and treat for scabies.
When a patient has CVID and is then diagnosed with lymphoma receiving ongoing chemotherapy, how do you manage the trough levels?
Assuming the patient is already on replacement therapy, I would make sure that at trough (if on IVIG, or steady state if on SCIG), the patient has protective levels against pneumococcal polysaccharides. If not, I would increase the dose and/or shorten the interval to achieve that, and record the tot...
How are you diagnosing chronic FPIES in adults?
Primarily through patient history; delayed onset of GI symptoms, shellfish is a common culprit in adults with acute FPIES. It is hard to differentiate chronic FPIES from intolerance since there is limited pathophysiology on non-IgE mediated mechanisms. Limited role for challenge if history is convin...
Do you recommend patients try antihistamines such as oral ketotifen that are not approved in the US but are approved in the EU for MCAS if currently available formulations have not been effective?
Oral ketotifen is a mast cell stabilizer as well as an antihistamine that targets the H1 histamine receptor. In patients with mast cell activation syndrome that have not had complete symptom relief with second-generation H1 antihistamines at higher doses, including 4 tablets a day, I will consider o...
When would you consider initiating antibiotic sinus rinses for recurrent sinus infections, assuming no other underlying pathology and normal infunction?
Antibiotic sinus rinses are a great alternative to antibiotics by mouth. If indicated, I would favor the rinses after sinus surgery when there is better access to the sinuses. One commonly used preparation is Bactroban or bacitracin in a 45 ml Ocean nasal spray bottle.
When do you consider extending the dosing interval for patients on biologics with CRSwNP?
In patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) who are on biologics, I would wait four (4) symptom-free months before considering extending the dose interval. I can only cite personal experience and not evidence in the medical literature.
Does gastric bypass increase the risk of developing food allergies?
Not in the development of new/de novo food allergies. However, procedure can increase the sensitivity and/or severity of existing food allergies.