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...
How do you reassure families that no allergy testing is needed for urticaria?
There used to be a Choosing Wisely message about this. Here is a video on it. Diagnostic Testing and Chronic Urticaria Video - AAAAI The 2014 practice parameters on chronic urticaria also discuss this. The practice parameter update is looking at this in a GRADE fashion and will likely have even mo...
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...
If you have a patient with EoE on Dupixent 300 mg weekly, and they have severe tree nut allergies, would it be safe to add Xolair for severe food allergy?
Yes, it would be safe to add Xolair if deemed absolutely necessary through shared decision making with the family. However, I generally do not recommend using more than one biologic medication at a time. Additionally, while Dupixent has not been approved for the treatment or mitigation of food aller...
Does food sensitivity testing for IgG subclasses help guide your management of food allergy?
No, it absolutely does not. For clinical concerns about an IgE mediated event, the food specific IgE testing is what we reach for. For other adverse food reactions including intolerances or sensitivities, food IgG or subclass testing doesn't correlate with symptoms either. The presence of food speci...
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...