Allergy & Immunology
Expert discussions on allergic conditions, immunodeficiencies, drug hypersensitivity, and immunotherapy approaches.
Recent Discussions
What is your preferred regimen for remission induction and maintenance in EGPA with cardiac involvement?
Cardiac involvement in EGPA is associated with a poor prognosis and is an independent predictor of mortality. Therefore, it needs to be treated aggressively. Depending on the study, between 15-30% of EGPA patients present with or develop cardiac manifestations. The manifestations are highly variable...
What features on PFT or flow-volume loops do you look at to suspect small airway dysfunction?
I would strongly advise against using the flow-volume loop to diagnose small airway dysfunction. It is difficult if not impossible to visually distinguish between small airway dysfunction and normal aging (I would point out that part of normal aging involves changes in small airway function). Althou...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
What treatment options do you consider if eosinophilia with end organ dysfunction persists with q8 week dosing of benralizumab and you can't obtain approval for q4 week dosing?
Depending on the degree of eosinophilia and end-organ dysfunction, if the patient is not already on oral steroids, they probably should be pending a new plan for a steroid-sparing agent. Is the diagnosis more consistent with HES or EGPA? Has the patient failed mepolizumab 300 mg? There is good data ...
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...
What is your approach to biologic selection in a patient with resistant/persistent ABPA?
Omalizumab has been shown to be helpful in reducing OCS use/exacerbations in refractory ABPA despite OCS and voriconazole. There are several case reports and reviews of patients who have been on anti-IL5s which have led to a reduction in eosinophilia but not necessarily exacerbations. There are seve...
Is methacholine challenge on its way out?
I have not needed to order the challenge test for a long time now. I see the need for this test is declining.
Would you still consider omalizumab for CSU with angioedema in a patient with Factor V Leiden deficiency?
Heterozygosity of this genetic mutation increases the lifetime risk of thrombosis by about 7-fold, while homozygosity (which is rare) increases the risk by approximately 20-fold. Despite the increase in the risk of VTE, there is no clinical evidence that heterozygosity of factor V Leiden increases o...
What are the implications of immunosuppressive therapy in a chronic asymptomatic T cell lymphopenic adult undergoing lung transplant evaluation?
The details of T cell lymphopenia are not mentioned for this patient. Idiopathic CD4 T cell lymphopenia is a recognized clinical syndrome which has been studied extensively (Lisco et al., PMID 37133586). The need for lung transplant is not detailed and raises the question if the two are related. It ...