ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A1

ABSTRACTS
PRESENTED AT CONCURRENT SESSIONS

November 9-10, 2014

georgia world congress center
atlanta, georgia

TABLE OF CONTENTS

TOPIC ABSTRACT NUMBERS PAGES

Adverse Food and Drug Reactions, Insect
Reactions, Anaphylaxis and Food Allergy
Pharmacology/Pharmacotherapeutics 1-8 A3-A5
Aerobiology, Allergens, Allergen Extracts
Immunotherapy, Immunizations 9-16 A5-A8
Asthma and Other Lower Airway Disorders 17-24 A8-A10
Basic Science Allergy and Immunology
Clinical Immunology, Immunodeficiency 25-32 A10-A13
Allergy Testing, Clinical Laboratory Immunology
Clinical Case Reports 33-40 A13-A15
Food Allergy
Rhinitis, Other Upper Airway Disorders,
Ocular Disorders 41-48 A15-A18
Other 49-56 A18-A20
Skin Disorders
Asthma, Other Lower Airway Disorders
Clinical Immunology, Immunodeficiency 57-64 A20-A22

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ABSTRACTS: CONCURRENT SESSIONS

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1
ATYPICAL PRESENTATION OF HONEY BEE STING HYPER-
SENSITIVITY.
S. Melethil*, S. Ho, R.S. Mehta, Galveston, TX.
Introduction: A bee sting can result in a myriad of manifestations ranging
from acute localized cutaneous response to unusual delayed reactions. Here we
report a case of a 15 year old boy who developed bloody diarrhea 72 hours fol-
lowing a bee sting. To the best of our knowledge this is the first such report of
delayed gastrointestinal manifestation. Case Report: A 15 year old male pre-
sented for evaluation of allergy to honey bee. He stated that on 2 occasions he
was stung by a bee resulting in localized swelling of affected area, nausea, vom-
iting and abdominal pain after the sting, then bloody diarrhea approximately
72 hours after. The most recent episode was 1 week prior to clinic visit when
the patient was stung by a bee on his toe, following which he had a local reac-
tion. Then 3 days later he had abdominal pain and loose stools with blood.
Examination revealed a well healed puncture mark on his toe. His vitals were
normal and CBC, ESR, CMP and a stool culture were unremarkable. Skin prick
testing was positive for honey bees. Intradermal testing at lowest concentration
(1/100000) was positive for all other Hymenoptera (wasp, yellow jacket, hor-
net) with negative saline. Immunocap showed positivity to all Hymenoptera
species. Discussion: Delayed gastrointestinal hemorrhage is an unusual man-
ifestation after sting by a honey bee that cannot be explained by IgE-mediated
mechanisms. We postulate that this response could be due to a delayed type
hypersensitivity leading to deposition of immune complexes in the basement
membrane of small blood vessels causing vasculitis. This may explain the
delayed manifestation of bloody diarrhea 72 hours after the sting. It is also pos-
sible that the etiology of this unusual reaction may not be immunologically
mediated and may be due to a direct cytotoxic effect of honey bee venom com-
ponent like Melittin on gastrointestinal tissue. Melittin is known to cause com-
plement cleavage and the release of Bradykinin which are both associated
with hemolysis. Studies indicate that Melittin and Phospholipase A2 can
decrease smooth muscular contractility and thus potentially induce hemorrhage.
Conclusion: We report an unusual and rare case of bee sting induced bloody
diarrhea in an adolescent which was reproducible on two different occasions.
We hypothesize that this could be due to a delayed hypersensitivity reaction or
a direct cytotoxic effect of bee venom.
2 allergy when compared to historical controls. Results: Of the 384 patients
COW’S MILK ALLERGY IN SHORT BOWEL SYNDROME.
A. Diamanti, A. Fiocchi, L. Dahdah*, O. Mazzina, F. Bellucci, T. Capriati,
Rome, Holy See (Vatican City State).
Background: Early, massive exposure to milk allergens is traditionally con-
sidered a risk factor for cow’s milk allergy (CMA). Epidemiological studies,
however, beg the question whether it can be protective; high milk allergen
exposure has also been hypothesized as policy for food allergy prevention. In
this context, short bowel syndrome has been anecdotally associated with CMA,
and no studies have used confirmatory milk challenges. Methods: A review
of consecutive patients followed with short bowel syndrome over a ten-year
period at a tertiary pediatric institution. Patients included only the patients
who fulfilled the following criteria: - Intestinal failure following SBS, defined
as dependency on parenteral nutrition providing at least 50% of the total
required intake for at least three months - Clinical follow-up from surgery to
the complete introduction of a diversified diet including cow’s milk proteins.
Infants with symptoms of CMA underwent a milk-specific IgE sensitization
test and a confirmatory oral milk challenge. Results: Three infants in a case-
load of 32 eligible patients were confirmed with CMA at challenge (see Table).
This 9.4% proportion represents two to ten-folds the incidence of CMA in
open populations. Conclusion: With its 9.4% incidence, our caseload of SBS
children carry a two- to tenfold risk of CMA compared to open populations.
This suggests that a low digestive capacity may play a role in the high inci-
dence of food allergy in children. As their peptic digestion is not complete
during early life, protein remnants of the diet could act as allergens. If the over-
exposure to milk allergens is among the causes of CMA in these children, our
results warn against the hypothesis of massive antigen exposure as instru-
ment of food allergy prevention.
ABSTRACTS: CONCURRENT SESSIONS
Characteristics of the caseload of infants with SBS
Table legend. SBS: short bowel syndrome. ICV+: preserved ileo-cecal valve.
3
IMPROVING SURGICAL ANTIBIOTIC OPTIONS WITH PENI-
CILLIN ALLERGY TESTING.
T. Pongdee, A. Thethi*, E. Rodrigues, J. Irizarry Alvardo, Jacksonville, FL.
Background: Resistance to antibiotics is a serious worldwide problem. When
antibiotic choices are limited due to resistance, treatment alternatives for resist-
ant infections may have higher toxicity, be more costly, and be less effective,
and thus patients with resistant infections have higher morbidity and mortal-
ity. Core methods to prevent antibiotic resistance include the appropriate use
and choice of antibiotics. Objective: To reduce the use of prophylactic van-
comycin, levofloxacin, and clindamycin in patients with a history of penicillin
allergy undergoing surgery by implementing a new clinical pathway consist-
ing of allergy consultation and penicillin allergy skin testing as part of the pre-
operative evaluation clinic visit. Methods: The participants in this clinical prac-
tice improvement project were patients with a history of penicillin allergy who
were scheduled to undergo surgery and referred by the Preoperative Evalua-
tion Clinic team for allergy consultation and penicillin allergy skin testing from
August 2012 to August 2013, the first year of this new clinical pathway. The
primary outcomes were the percent reductions in the use of prophylactic van-
comycin, levofloxacin, and clindamycin in patients with a history of penicillin
with a history of penicillin allergy who underwent allergy consultation and
penicillin allergy skin testing, 360 (94%) had negative penicillin allergy skin
test results and were given clearance by the allergist to receive penicillin or
cephalosporin antibiotics. For patients who had reported penicillin allergy,
within six months of implementation of this new clinical pathway, vancomycin
use was reduced by 54%, levofloxacin use was reduced by 40%, and clindamycin
use was reduced by 22% compared to historical controls. Conclusions: Pro-
phylactic use of vancomycin, levofloxacin, and clindamycin in patients with a
history of penicillin allergy undergoing surgery can be reduced by allergy
consultation and penicillin allergy skin testing during the preoperative evalu-
ation process.
4
A CASE OF NEAR FATAL ANAPHYLAXIS TO ORANGE IN A
TODDLER.
S.B. Sindher*, S.P. DaVeiga, Philadelphia, PA.
Introduction: Most fruit allergies manifest as pollen-food allergy syndrome
characterized by pruritus and edema of the lips, tongue, palate and throat usu-
ally a few minutes after ingestion of the raw fruit. Orange is among fruits that
are associated with pollen-food allergy syndrome but rarely causes anaphy-
laxis. Methods: We review the case of a 31-month-old girl who developed severe
anaphylaxis after the consumption of one Cutie® orange. Results: A 31-month-
old female presented in anaphylactic shock to an emergency department (ED).
Prior to presentation, she was at a supermarket, ate one Cutie® orange and
was playing with the orange peel. Within a few minutes she had bilateral peri-
orbital swelling and pruritis. She was treated with diphenhydramine at the super-
market. The patient developed lip and tongue swelling and respiratory distress
so her parents drove her to the ED within 10 minutes. Examination was notable
for a pulse oximetry reading of 79% on room air, diffuse wheezing in all lung
fields, lip and tongue angioedema and hives. She was treated with nebulized
albuterol, IV diphenhydramine, ranitidine, 2 doses of subcutaneous epineph-
rine, methylprednisolone and an IV bolus of normal saline. She continued to
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ABSTRACTS: CONCURRENT SESSIONS
have worsening respiratory distress and hypoxia and subsequently required
intubation; she was noted to have significant upper airway edema on intuba-
tion. After intubation she was transferred via a helicopter to a Pediatric Inten-
sive Care Unit. A chest x-ray was performed to check endotracheal tube place-
ment and revealed right upper lobe atelectasis and pulmonary edema (Figure
1). Her symptoms improved overnight and she was discharged home after a 48-
hour hospitalization. Her past medical history was notable for a varied diet
and prior consumption of orange juice without reaction. She had reported nightly
cough at baseline with cough on exertion but was not on therapy for asthma.
In follow up at Allergy/Immunology as a new patient, she had a positive skin
prick test result to orange and peach. She was advised to avoid orange and peach
and also started on asthma therapy. Conclusion: We present the first case report
of near-fatal anaphylaxis to orange in a toddler. This case confirms that poorly
controlled asthma is a risk factor for difficult to treat IgE-mediated reactions
to foods, including orange.
Figure 1: Chest X-ray revealed right upper lobe atelectasis and pulmonary
edema.
5 Table 1
FOOD PROTEIN-INDUCED ENTEROCOLITIS SYNDROME OF
DIFFICULT MANAGEMENT.
A. Fiocchi*1, L. Dahdah2, O. Mazzina1, S. Corrente2, C. Riccardi1,
S. Salvatore3, 1. Rome, Holy See (Vatican City State); 2. Rome, Italy;
3. Varese, Italy.
Background: Food protein-induced enterocolitis syndrome (FPIES) usu-
ally presents in infancy. In the acute form, when food is ingested on an inter-
mittent basis or following a period of avoidance, FPIES typically presents
with profuse vomiting, diarrhea, and dehydration, starting 1–3h following
specific food ingestion. FPIES diagnosis is based on history and typical symp-
toms that improve with food avoidance, and with the exclusion of other eti-
ologies. Oral food challenge (OFC) remains the gold standard for diagnosis.
Case: A 6-month-old female infant was referred for FPIES of difficult man-
agement. The child was admitted to the hospital at 6 weeks of life for suspected
sepsis occurred 15 days after receiving milk thickened with rice cream; sepsis
evaluations were negative. At 5 months, soon after her first rice-containing
meal, she developped emesis, pallor, followed by diarrhea and lethargy, so she
was hospitalized for suspected anaphylaxis. Negative allergy tests (SPT,
ImmunoCAP for rice, milk, egg, wheat) and the clinical history indicated the
diagnosis of rice-induced FPIES. For the investigation of cereal tolerance she
was challenged with commercial maize to which she reacted with vomiting,
hypotonia and bloody diarrhea. Industrial maize food contamination with rice
was suspected. We requested a pure whole wheat flour from Heinz Baby Food,
Italy®, which was tolerated at challenge. A special diet was initiated, in col-
A4 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
laboration with Heinz, using the same rice-free flour to make pasta to which
she did not react. Introduction of solids was predicated on a series of OFCs,
including wheat, beef, pork, chicken, potato, carrot, spinach, zucchini, toma-
toes which were negative. However, each introduction of foods contaminated
with rice determined the characteristic symptoms of the syndrome. In one occa-
sion, a typical FPIES reaction followed the administration of mauve supposi-
tories containing rice starch. Conclusion: This case highlights how FPIES onset
can be very early and how tiny amount of food can be enough to provoke symp-
toms, reflecting the degree of hypersensitivity in individual patients. Early
recognition of this condition and the management with cross-contaminant-free
baby foods are crucial in preventing recurrences. The co-operation among pedi-
atricians and industry is of outstanding importance.
6
EFFECT OF DEVICE AND FORM FACTOR ON AUTO-INJECTOR
APPLICATION FORCE AND EFFICIENCY.
A. Barbir*1, M. Janelli1, M. Lin1, R.A. Wolf2, J. Dennerlein1, 1. Boston,
MA; 2. Plantation, FL.
Introduction: Various auto-injectors differ in their form factor, mechanism
of drug delivery, and user instructions, which can affect the successful use of
the device through applied force capability and consistency of device orienta-
tion during drug delivery. We hypothesized that (1) a device’s form factor will
impact users’ capability of applying force as measured by the maximum applied
force and (2) a device’s form factor, mechanism, and instruction will impact
motor control performance metrics. Methodology: Trainer devices of 3 com-
mercially available epinephrine auto-injectors with 3 different form factors
(cylindrical, elliptical, and prismatic) were tested in a laboratory-based repeated
measures experiment with 20 adult (aged 18-30 years) participants. Partici-
pants performed 2 tasks using a power grip with each of the 3 injectors: a max-
imum force capability task in which they applied their maximum possible force
onto a force plate positioned over their thigh and an application task in which,
after watching the device’s training video, they practiced an injection using the
trainer. For the application task, device performance included time to hold force,
force, and device orientation and its variability during the hold segment. Par-
ticipants rated their force confidence and preference for the 3 devices. Results:
Greatest force capability was exhibited by the device with the elliptical form
factor followed by the prismatic and then the cylindrical, with the difference
between the elliptical and the cylindrical form factors being statistically sig-
nificant. For the application task, the elliptical form factor device had the fastest
time to force. The prismatic form factor device had the largest angle and vari-
ability in the angle of the resultant applied force. Participants reported the high-
est force confidence when using the elliptical and cylindrical form factor
devices, ranking the elliptical as their preferred device. Conclusion: The results
suggest that the elliptical form factor may have better success in drug delivery
in a larger set of the population.
Parameters measured for (I) maximum force capability task, (II) application
task, and (III) self-reported survey. For significant main effects, Tukey’s post
hoc groupings are ranked such that A > B. Values with the same superscript
letters indicate no significant difference.
7
INHALED CORTICOSTEROIDS AND INCIDENT PNEUMONIA
IN PATIENTS WITH ASTHMA:SYSTEMATIC REVIEW AND
META-ANALYSIS.
V. Bansal, M. Mangi*, E. Festic, Jacksonville, FL.
Introduction: As asthma is a chronic inflammatory disease of the airway,
affected patients usually require long-term anti-inflammatory therapy. Inhaled
corticosteroids (ICS) are recommended as the first-line treatment for the per-
sistent disease; however, their routine use might raise certain safety concerns.
Although an increased risk of pneumonia have been established in patients with
COPD on chronic ICS, it is not clear whether this risk pertains to asthma patients,
as well. Methods: We performed a comprehensive literature search from Jan-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A5
uary 1, 1993, through March 31, 2014, using PubMed, Medline, CENTRAL,
EMBASE, Scopus, ISI, Regulatory Documents, Web of Science and manu-
facturers’ web clinical trial registries (GlaxoSmithKline and AstraZeneca) with
the clinical trial filters using multiple search terms with no language restric-
tions. We included all studies that compared patients 14 years of age and older
on ICS and not on ICS relative to the risk of incident pneumonia (community
acquired, lower respiratory tract infection, non-tuberculous mycobacterial pneu-
monia). We then summarized individual study estimates into two random-effect
meta-analyses, one including randomized controlled trials (RCTs) and another
one including observational studies (OBS). Results: There were total of 12 stud-
ies, 7 RCTs including total of 10,585 and 5 OBS including total of 44,127 par-
ticipants. There was no heterogeneity in RCTs and summarized estimated effect
of ICS was protective of pneumonia; OR 0.75 (0.57-0.99. p=0.05). On the con-
trary, OBS showed moderate heterogeneity (I2 =48%) with resulting summed
OR of 1.94 (1.42-2.65, p<0.0001), suggesting increased risk of pneumonia with
use of ICS in asthma patients. However, OBS had lower grade of confidence
compared to RCTs. Conclusions: ICS may carry protective effect or at the very
least do not have increased risk of incident pneumonia in patients with asthma,
based on our meta-analysis of available RCTs. While observational studies sug-
gested higher risk of pneumonia in similar patients, the observed heterogene-
ity and inherent methodological limitations confered lower grade of confidence
in these studies.
Meta-analysis of RCTs and OBS for pneumonia (Risk estimates shown are
odds Ratio (OR) for RCTs and OBS.
8
EFFICACY OF RECOMBINANT HUMAN C1 INHIBITOR FOR
THE TREATMENT OF HEREDITARY ANGIOEDEMA PATIENTS
WITH SEVERE ATTACKS.
H. Li*1, A. Reshef2, H. Farkas3, J. Baker4, G. Porebski5, D. McNeil6,
A. Relan7, A. Zanichelli8, 1. Chevy Chase, MD; 2. Tel Hashomer, Israel;
3. Budapest, Hungary; 4. Lake Oswego, OR; 5. Krakow, Poland; 6. Colum-
bus, OH; 7. Leiden, Netherlands; 8. Milan, Italy.
Background: Hereditary angioedema (HAE) due to C1 inhibitor deficiency
is characterized by recurrent episodes of disabling and painful tissue swelling.
Although some attacks are self-limiting and may resolve spontaneously, many
attacks progress before taking several days to improve. We reviewed the effi-
cacy of recombinant human C1 inhibitor (rhC1INH) in the treatment of severe
HAE attacks in a randomized controlled study. Methods: Seventy-five HAE
patients were randomized (3:2) to receive 50 IU/kg of rhC1INH or saline in a
multi-center double-blind study. Severity of attack symptoms was assessed at
baseline using a 100mm visual analog scale (VAS). Patients could be ran-
domized if the baseline VAS score was ≥50mm. Severe attacks were defined
as those with a baseline VAS score ≥75mm. The primary endpoint was time to
onset of symptom relief, assessed as time from start of study drug infusion to
onset of sustained beneficial effect, defined by patient responses demonstrat-
ing improved symptoms on a Treatment Effects Questionnaire (TEQ). Rescue
treatment with open-label rhC1INH was permitted if there was no relief of
symptoms by 4 hours or in case of life-threatening symptoms; these attacks
were censored in the primary analysis. IRB approval and written informed con-
ABSTRACTS: CONCURRENT SESSIONS
sent was obtained from all patients. Results: Among the 75 randomized patients,
the median VAS score at baseline was 76mm. Forty-three patients were deter-
mined to have severe attacks (rhC1INH: 24; saline: 19). Among patients with
severe attacks, the median (95% CI) time to onset of symptom relief in
rhC1INH- and saline-treated patients respectively, was 90 min (47, 120) ver-
sus 334 min (105, not estimable); hazard ratio 2.52, log rank p-value 0.02. The
proportion of patients with severe attacks who received open-label rhC1INH
as rescue medication was 1/24 (4%) in the rhC1INH group and 10/19 (53%)
in the saline group. After receiving rescue with rhC1INH, saline-treated patients
with severe attacks had a median time to relief of 60 min, as measured from
the time of rescue administration. Conclusions: rhC1INH was effective in resolv-
ing severe HAE attacks. Patients randomized to saline who had worsening or
sustained angioedema symptoms had rapid improvement following rescue with
rhC1INH.
9
THE PREDICTED TREE POLLEN BURST OF 2014 WAS A “BUST”
J.J. Anderson*, P. Pityn, London, ON, Canada.
Introduction: The long harsh winter of 2013-14 prompted allergy experts
to predict a “pollen vortex”. They reasoned that delayed antithesis would result
in the sudden release of greater than normal amounts of tree pollen. We eval-
uated the actual tree pollen data for London Ontario (Canada) to determine if
experts had predicted correctly. Methods: Daily samples of airborne pollen
were collected during the 2014 tree season with a Burkard spore trap located
3 stories above grade. The samples were analyzed and compared to our his-
torical 12 year data. The pollen counts were normalized against the 12 year
average count for each of the respective pollen types to assess the 2014 tree
season. The total tree pollen count and preponderance of 15 individual tree
pollen types were examined, along with the start and duration of their pollina-
tion. Results: Contrary to the experts’ predictions, the total seasonal pollen
count was not elevated, but was down considerably and several individual tree
pollen levels were far lower than at any other time in the previous 12 years.
Specifically, pollen levels of maple, juniper, birch, ash, mulberry and walnut
were considerably lower, as much as 4-5 times lower than the average. The other
tree pollen counts were within normal range. Conclusions: Not only did the
forecasted pollen burst fail to materialize this year, but the exact opposite hap-
pened. In 2014, the total tree pollen counts were at historic lows for London,
Ontario. Six major pollen producers of the fifteen tree types were at historic
lows despite otherwise typical duration and start of their respective seasons.
Experts need to refine their modelling skills to better predict pollen in the face
of global climate change.
10
THE ALLERGENICITY OF THE CYANOBACTERIA SPECIE
MICROCYSTIS AERUGINOSA IS DEPENDENT ON ITS MICRO-
CYSTIN PRODUCTION.
E. Geh, D. Ghosh, J.A. Bernstein*, Cincinnati, OH.
Background and Purpose: The cyanobacteria specie, Microcystis aerugi-
nosa (Ma), produces microcystin (MC) and an array of diverse metabolites
believed responsible for their toxicity and/or immunogenicity. Previously,
chronic rhinitis patients were demonstrated to elicit a specific IgE response to
non-toxic strains of Ma by skin-prick testing (SPT) indicating that cyanobac-
teria allergenicity likely resides in the non-toxin producing component of the
organism. The objective of this study was to investigate the functional inter-
actions between cyanobacteria toxins and their co-expressed immunogenic pep-
tides. Methods: Sera collected from chronic rhinitis patients previously found
to be sensitized by SPT to Ma were used to identify sensitizing proteins. Direct
and indirect IgE-specific ELISAs were used to confirm sensitization to Ma. A
2-D gel electrophoresis followed by specific IgE immunoblot and mass spec-
troscopy (MS) was performed to identify the relevant allergenic peptides. Cyto-
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ABSTRACTS: CONCURRENT SESSIONS
toxicity and mediator release assays were performed using lysates from Ma
toxic (MC+) and non-toxic strain (MC-). Results: Using lysates from MC+ and
MC- Ma strains and sera from Ma sensitized patients, specific IgE was increased
in response to the MC- but not the MC+ strain. In addition, MC- extracts induced
b-hexosaminidase release using rat basophil leukemia cells. 2-D gel elec-
trophoresis followed by MS revealed the relevant sensitizing peptides were phy-
cocyanin and the core-membrane linker peptide, both components of the
cyanobacteria phycobilisome complex. Of note, the IgE specific response was
dose-dependently inhibited by addition of microcystin to the MC- lysate. Con-
clusions: The allergenicity of Ma is inversely proportional to its microcystin
content suggesting a direct or indirect interaction between microcystin toxin
and the allergenic peptides. Further investigation is warranted to understand
the interplay between immunogenicity and toxicity of cyanobacteria under
diverse environmental conditions.
11
COMPARISON OF OUTDOOR AND INDOOR FUNGAL SPORE
COUNT IN KANSAS CITY.
D.A. Jara*, C.S. Barnes, J. Portnoy, M. Dhar, Kansas City, MO.
Rationale: Fungus can be found outdoors and indoors and can enter the
home through multiple mechanisms such as a window, on clothing, or open-
ings in the home. Patients have shown a higher risk of atopy with fungal expo-
sure. To determine if indoor mold count was elevated in relation to elevated
outdoor mold counts we conducted the following study. Methods: Data was
retrieved from the Kansas City mold and spore database for a 15 year period
from March 1998 thru August 2013. The community wide outdoor spore count
was performed with a with a Burkard device according to National Allergy
Bureau Protocols. The indoor spore count data was collected from an Aller-
genco MK3 or a Buck Bioaire from about 150 homes with a mean of 4 col-
lections taken from each home (Basement, Bedrooms, Living Room, Kitchen,
Bathroom, etc). Outdoor ground level data is the outdoor collection taken at
each home at the time the indoor collections were taken. Data included here
for comparative purposes is for 8 spore types that are easily identifiable indi-
vidual genera. Data is reported by percent of collections in which each genera
was observed. Spore counts were stored in an Access database and analyzed
using Excel. Results: Total spore percentages are seen in table 1. Cladospo-
rium was the most common spore collected indoors and outdoors. When com-
paring indoor counts, Cladosporium was most commonly seen in basement at
52% followed by child’s bedroom 20%. Alterneria was most commonly seen
in the child’s bedroom at 30% followed by bathroom 19% and master bed-
room 15%. Overall spores were most commonly seen in child’s bedroom 16%,
basement 13% and kitchen 10%. Alternaria was least commonly seen in fam-
ily room 4% basement 9% and living room 9%. Cladosporium was least com-
monly seen in family room 2%, master bedroom 3% and living room 6%. Over-
all spores were least commonly seen in family room 1%, master bedroom 2%
and living room 6%. Conclusion: Increased outdoor spore count is associated
with higher indoor spore counts but origin could not be inferred from this study.
Cladosporium was the most identified fungi both indoors and outdoors in this
study. Interestingly the child’s bedroom seems to be the most susceptible to
indoor mold amplification, while the living room and family room had the low-
est spore count. This may be secondary to the aesthetic desire most families
put into maintaining a home while negating lesser used rooms.
Table 1
Percentage of Total spore counts seen.
A6 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
12
CLIMATE CHANGE INDUCED WARMING IMPACTS RAGWEED
POLLINATION IN UKRAINE.
V. Rodinkova1, A. Prikhodko2, A. Maleeva2, O. Palamarchuk1, I. Motruk1,
L. Kremenska1, K. Musatova1, L.M. DuBuske*3, 1. Vinnitsa, Ukraine; 2.
Zaporizhzhia, Ukraine; 3. Gardner, MA.
Background: Ambrosia is increasing in abundance in south and east Ukraine
including Donetsk, Zaporizhzhia, Mykolaiv, Kherson, Kirovograd and Dne-
propetrovsk regions Methods: Pollen collection was done by gravimetric sam-
pling in Vinnitsa for years 1999 and 2000. From 2009 to 2013 volumetric meth-
ods employing a Burkard trap placed at a height of 25 meters above the ground
on the roof of a Vinnitsa Medical University building were used. Pollen counts
in Zaporizhya from 2006 to 2013 and in Poltava, Donetsk, Dnepropetrovsk,
Odessa and Simferopol in 2010 used volumetric Burkard spore traps sampling
from the March 1 until October 1. Results: Greatest ragweed pollen counts were
in the third ten-day period of August and for the first or second ten-day period
of September, seen in Vinnitsa since 1999 and in Zaporizhya from 2006 until
2010 similar to all other cities in 2010. Ragweed pollen increase occurred in
the third ten-day period of August being maximal August 22 (Zaporizhya) until
August 29 (Odessa) and August 25 in Vinnitsa for 2011 and 2012. The second
period of increased Ambrosia pollen concentrations occurs after September 5
each year but has been shifting to a later time being September 2, 2010 in
Dnepropetrovsk and September 5 in Vinnitsa in 1999 and Zaporizhya in 2007
later occurring September 18, 2012 in Vinnitsa. Greater ragweed counts are
now being seen later in Vinnitsa including 200 p.g./m3 on September 18 ver-
sus 100 August 25, 2012). In 2012 the seasonal peak was observed for the sec-
ond ten-day period of September in much of Ukraine, something not seen before.
In 2010 and 2013 rapid increases of ragweed pollen were seen in the second
ten-day period of August, two weeks earlier than usual being greater than the
mean seasonal maximum on August 27, 2010 (102 p.g./m3 versus 76 p.g./m3)
in Vinnitsa with 2013 ragweed pollen count increased to 82 p.g./m3 on August
11 peaking at 92 p.g./m3 on August 27. Seasonal maximum in Zaporizhya was
on August 19, 2013. Conclusion: The changing pattern of ragweed pollination
in Ukraine with early ragweed pollen count increases for the second ten-day
period of August and changes in maximum in September may be evidence of
the primary impact of temperature increase on Ambrosia season in Ukraine due
to global warming.
13
THE EVALUATION OF SERUM TRYPTASE LEVELS AFTER SUB-
CUTANEOUS IMMUNOTHERAPY-ASSOCIATED SYSTEMIC
REACTIONS.
P.H. Wong*1, H.C. Crisp2, T.S. Rans3, 1. San Antonio, TX; 2. Andrews AFB,
MD; 3. Lackland AFB, TX.
Background: Elevations in serum tryptase are used to support the diagno-
sis of anaphylaxis. Although tryptase has been studied in anaphylaxis to insect
stings and drugs, it has not been measured systematically in patients who have
systemic reactions (SRs) to immunotherapy (IT). Methods: This study was an
IRB-approved, prospective cohort study of aeroallergen or venom IT patients
who experienced SRs during the 30-minute post-IT period and were treated as
clinically indicated. Consent and serum total tryptase were obtained after a one-
hour observation period when the patient was ready for discharge. A baseline
tryptase was drawn 2-7 days post SR. Tryptase levels were determined using
commercially available ELISA kits. Results: Twelve patients had 13 reactions
over a 20-month study period. Patient and SR specifics are shown (Table 1).
All reactions were grade 1 or 2 in severity. Flushing was the most common,
objective symptom. One or 2 doses of epinephrine were administered for all
SRs. All SRs were non-life-threatening and occurred during the build-up phase
of immunotherapy. Median time from SR onset to resolution and from SR onset
to tryptase lab draw was 26 and 85 minutes, respectively. No elevation in tryptase
post-SR or change from reaction to baseline tryptase (>2 ng/ml) was observed.
Discussion: Tryptase is a marker of mast cell degranulation with clinical util-
ity, but it is not consistently elevated in all cases of anaphylaxis. In this study,
SRs after IT were of short duration and mild severity. Unlike field anaphylaxis
due to insect stings, post-IT SRs were promptly recognized and treated. The
low total serum tryptase levels may reflect post-epinephrine effects of a ter-
minated systemic reaction. Additionally, IT-associated SRs may represent a
unique or undefined phenomenon involving complement, anaphylatoxins,
kinins, or lipid mediators. Basophils rather than mast cells may be activated in
the early stages of IT-associated SRs. These data suggest that tryptase is of lim-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A7
ited utility in identifying patients with higher risk of IT-associated SRs or assist-
ing in the diagnosis of grade 1 or 2 SRs. Conclusion: No elevation or change
in total tryptase was observed in the first prospective cohort study of IT-asso-
ciated SRs. Tryptase appears to be of little clinical utility in evaluating mild
SRs to IT, however larger studies are needed.
Patient and Systemic Reaction Characteristics with associated Tryptase and
Histamine Levels
a. Severity based on WAO Subcutaneous Immunotherapy reaction grading
system scores Grade 1-5.
b. Same patient who experienced a post-IT SR on two separate dates.
Symptoms codes: F=flushing; C=conjunctivitis; G=globus sensation; D=dys-
pnea; A=angioedema; P=pruritis; CT=chest tightness; W=wheezing;
UC=uterine cramping; U=urticaria
NA = Not available data in patient 3.
14
EFFICACY, IMMUNOLOGIC RESPONSE, AND SAFETY OF RAP-
IDLY-DISSOLVING SUBLINGUAL IMMUNOTHERAPY TABLETS
IN SUBJECTS OVER 50 YEARS OF AGE WITH ALLERGIC
RHINITIS.
P. Creticos*1, D.I. Bernstein2, R. Weber3, N.J. Amar4, Z. Li5, A. Kaur5,
J. Maloney5, H. Nolte5, 1. Baltimore, MD; 2. Cincinnati, OH; 3. Denver,
CO; 4. Waco, TX; 5. Whitehouse Station, NJ.
Introduction: Use of allergen immunotherapy in older adults with allergic
rhinitis (AR) has been questioned because of age-related dampening of immuno-
logic responses. Efficacy, immunologic response, and safety in subjects ≥50
years and/or 18 to <50 years receiving rapidly-dissolving sublingual
immunotherapy tablets (SLIT-T) approved for treatment of Timothy grass- (and
related grasses) or short ragweed-induced AR was analyzed. Methods: Data
pools were constructed from phase 2/3 trials (24-wk to 1-yr duration) of grass
SLIT-T 2800 BAU (MK-7243; Merck/ALK-Abelló; 4 phase 3 trials for effi-
cacy, 6 phase 2/3 trials for safety) or ragweed SLIT-T 12 Amb a 1-U (MK-3641;
Merck/ALK-Abelló; two 28-day safety trials and two 52-wk trials). Efficacy
was assessed by total combined symptom and medication scores (TCS). The
ragweed SLIT-T efficacy trials excluded subjects ≥50 years, thus no efficacy
or immunologic data are available for this subgroup. Results: TCS improved
by 20% with grass SLIT-T vs placebo (mean difference: −1.36, 95% CI −1.74,
−0.97) in subjects <50 years (n=1988), and 15% vs placebo (mean difference:
−0.86, 95% CI −1.84, 0.13) in subjects ≥50 years (n=311). TCS improved by
23% with ragweed SLIT-T vs placebo (mean difference: −2.02, 95% CI −2.87,
−1.17) in subjects <50 years (n=311). Consistent increases in IgG4 from base-
line were observed in both age groups for grass SLIT-T; a similar increase was
observed with ragweed SLIT-T in subjects <50 years. The overall treatment-
emergent adverse event (TEAE) rate with grass SLIT-T was 83.4% in subjects
<50 years (n=1468) and 78.6% in subjects ≥50 years (n=201). The overall TEAE
rate with ragweed SLIT-T was 56.7% in subjects <50 years (n=841) and 55.6%
in subjects ≥50 years (n=216). The most common treatment-related AEs were
local application site reactions for both tablets, regardless of age. Conclu-
sions: Efficacy and immunologic data for grass SLIT-T reveal similar response
patterns in subjects <50 and ≥50 years. Although not studied, it may be inferred
that ragweed SLIT-T would result in similar efficacy and immunologic changes
in ragweed allergic patients ≥50 years. No new safety concerns were revealed
in subjects ≥50 years for either tablet. These data suggest that patients ≥50 years
with AR may benefit from grass and ragweed SLIT-T.
ABSTRACTS: CONCURRENT SESSIONS
15
OCCURRENCE AND DURATION OF LOCAL ALLERGIC REAC-
TIONS IS SIMILAR FOR RAGWEED, GRASS, AND HOUSE DUST
MITE SUBLINGUAL IMMUNOTHERAPY TABLETS AND CON-
SISTENT WITH AN IMMEDIATE IGE-MEDIATED REACTION.
H.S. Nelson*1, J. Maloney2, M.A. Calderon3, J.A. Bardelas4, A. Kaur2,
H. Nolte2, 1. Denver, CO; 2. Whitehouse Station, NJ; 3. London, United
Kingdom; 4. High Point, NC.
Introduction: The most common adverse events (AEs) with sublingual
immunotherapy tablets (SLIT-T) are local allergic reactions of the mouth and
throat. These AEs are expected as the allergen extract presumably elicits an
IgE-associated mediator release from mast cells located in oral tissues. Our
objective was to report the duration of local allergic reactions in response to
SLIT-T for 3 different allergens to characterize the reaction patterns. Meth-
ods: Symptoms and duration in minutes of local allergic reactions after SLIT-
T administration were collected during phase 1 studies of Timothy grass SLIT-
T 2800 BAU (MK-7243) and short ragweed SLIT-T 12 Amb a 1-U (MK-3641),
and during phase 1 and 2b studies for house dust mite (HDM) SLIT-T 12 DU
(MK-8237; all Merck/ALK-Abelló). Additionally, the duration in days (num-
ber of days that an event recurs) was collected for local allergic reactions dur-
ing the phase 3 trials for each of these tablets. IRB approval and informed con-
sent was obtained from all subjects. Results: The median durations in minutes
for the most common local adverse reactions after SLIT-T or placebo admin-
istration are shown in the Table. For each of the events, reactions typically
resolve within minutes. Events generally recur over several days prior to reso-
lution of the events. The median recurrence of symptoms after active treat-
ment varies in duration, ear pruritus (4 to 14 days); oral pruritus (5 to 8 days);
throat irritation (5 to 9 days). Conclusions: The occurrence and duration of local
adverse reactions related to SLIT-T were similar across studies, and appear to
be a class effect consistent with an IgE-mediated response. Although cautious
interpretation is required due to the limited sample size, the data reveals that
the reactions generally resolve within minutes of SLIT-T administration and
are experienced for less than 2 weeks.
Median Duration of Most Common Local Allergic Reactions in Response to
SLIT-T
*Sum of daily durations throughout entire 28-day trial.
†Duration on day 1 of treatment.
AE=adverse event; ND=not determined; SLIT-T=sublingual immunotherapy
tablet.
16
JTF PRACTICE PARAMETER-COMPLIANT SUBCUTANEOUS
IMMUNOTHERAPY FOR ALLERGIC RHINITIS DUE TO MOUN-
TAIN CEDAR INDUCES SKIN TEST ANERGY AND LONG-TERM
CLINICAL REMISSIONS.
M.P. Vaughn*, San Antonio, TX.
Rationale:The 2010 Joint Task Force (JTF) Practice Parameters on Aller-
gen Immunotherapy (www.AAAAI.org) recommends subcutaneous
immunotherapy (IT) for allergic rhinitis (AR) with aeroallergen extracts given
at “probable effective doses” (Table IX.) beginning weekly, from a 1000-fold
dilution of the maintenance vial (1:1), and incrementally progressing to a goal
of 0.5cc of the (1:1) concentrate (Appendix 1). Per the JTF guidelines for “con-
ventional” IT, “the intervals between the maintenance injections generally range
from every 2-4 weeks”. We have previously reported that 3 years of “conven-
tional” IT is typically sufficient to induce the loss of skin test reactivity to
aeroallergens however; this result appears to be highly dose-dependent. A ret-
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A8
ABSTRACTS: CONCURRENT SESSIONS
rospective survey was used to evaluate the association between the loss of skin
test reactivity during IT and long-term clinical efficacy. Methods: Patients (Age
18-65) were mailed a follow-up survey if they had stopped IT prior to 2010 and
met the following criteria: Skin test (+) to mountain cedar (MC) with ≥ mod-
erate AR during MC pollinations. Achieved 1:1 vial dosing for > 12 months
and had repeated skin testing prior to IT discontinuation. Results: Of 200 sur-
veyed, 28 of 40 respondents met inclusion criteria. Among the 14 patients reach-
ing the monthly goal of 0.5cc (mode volume), 100% reported “significant
improvement” of AR while receiving IT and a fall in skin test grading by ≥ 2
grades was seen in 93%. A sustained complete remission (CR) of symptoms
was reported by 43% while off IT for 5 to 10.1 years (median 6.9 yrs). In con-
trast, among those who had received a lower maintenance dose (Mean = 0.22
± 0.17cc.), a fall in skin test reactivity was seen in only 42% and CR was reported
in only 21% (n=14). No differences between groups were observed for: initial
symptom severity or skin test grading, subjective treatment efficacy (while on
IT), or the IT duration. Conclusion: “Real-world” JTF-compliant IT is highly
effective, both during and after treatment courses. Aeroallergen IT, formulated
and administered per JTF-recommendations, can induce allergen-specific skin
test anergy in a dose-dependant manner. The induction of a persistent remis-
sion was significantly more common among those in whom the loss of skin
test reactivity was observed.
17
POPULAR ON YOUTUBE: A CRITICAL APPRAISAL OF THE
EDUCATIONAL QUALITY OF INFORMATION REGARDING
ASTHMA.
A. Gonzalez-Estrada*, L. Cuervo Pardo, B. Ghosh, F. Pazheri, M. Smith,
K. Zell, X. Wang, D.M. Lang, Cleveland, OH.
Background: Asthma affects over 300 million people globally, including
25 million in the US. Patients with asthma frequently use the internet as a source
of information (Cabana MD, Le TT. J Allergy Clin Immunol. 2005). YouTube,
a video sharing website, is one of the three most popular websites
(http://www.alexa.com/topsites). We sought to determine the educational qual-
ity of asthma YouTube videos. Methods: We performed a YouTube search using
the keyword “asthma” from June 4-8, 2014. The 200 most viewed relevant
videos were included in the study. Asthma videos were analyzed for charac-
teristics, source and content. Source was further classified as asthma health-
care provider, other health-care provider, patient, pharmaceutical company, and
professional society/media. A scoring system was created to evaluate quality
(-10 to +30 points). Negative points were assigned for misleading informa-
tion. Five blinded reviewers scored each video independently; a mean score
was calculated by video source. Two-tailed analysis was performed for video
characteristics, ANOVAs were performed to compare scores by video type, and
intraclass correlation was used to assess similarity in scoring by reviewers.
Results: Two hundred videos were analyzed, with a median of 18,073.5 views,
31.5 likes, 2 dislikes, and lasted a median of 172 seconds. More video presen-
ters were male (60.5%). The most common type of video source was other
health-care providers (34.5%). The most common video content was alterna-
tive treatments (38.0%), including live-fish ingestion, reflexology, acupres-
sure/acupuncture, ayurveda, yoga, raw food/vegan/gluten free diets, marijuana,
Buteyko breathing, salt therapy, etc. Scores for videos supplied by asthma health-
care providers were statistically significantly different from all other sources
(p < 0.001) and had the highest average score (9.91). Table 1 summarizes all
scores by video source. Overall, there was a high degree of agreement among
reviewers (rho = 0.847; p < 0.001). Conclusion: We found that YouTube videos
on asthma are frequently viewed, but are a poor source of health care infor-
mation. Videos by asthma health-care providers were rated highest in quality.
The Allergy/Immunology community has a clear opportunity to enhance the
value of educational materials via YouTube.
Table 1. Scores by video source
A8 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
18
LOCAL REACTIONS DURING IMMUNOTHERAPY AND THEIR
IMPACT ON DOSE ADJUSTMENT.
Q. Kamili*, A.C. Gavino, R. Rossen, F. Orson, A. Casillas, Houston, TX.
Introduction: Local reactions are commonly noted during allergen
immunotherapy (IT) administration. These are usually mild and self-limiting;
with more than 80% of reactions smaller than the size of a palm (8-10 cm).
Studies have shown that local reactions may not be predictive of subsequent
systemic reactions. A common practice to empirically enhance safety is to repeat
or reduce the IT dose based on the size of the post-administration wheal. Con-
servative management of local reactions less than 25 mm in size may lead to
inadequate therapy. We report the incidence of local and systemic reactions
with IT administration and the time taken to reach maintenance therapy at our
institution which follows a conservative management of local reactions less
than 25 mm in size. Methods: We reviewed data on patients receiving aeroal-
lergen immunotherapy at an academic medical center where dosing practices
are based on a protocol that is altered according to local wheal size after IT
administration. Patients on immunotherapy for 23 weeks or more were included.
Post injection reactions were graded from 1-5, and dose adjustments were made
accordingly (see table). Other factors which led to dosage changes were a change
to a new vial and time delays over two weeks since last dose. Results: Fifty-six
patients received 6633 IT injections over 0.5- 7 years (mean of 2.1years ±1.2
years). Local reactions were observed in 89% of patients with an incidence rate
of 13% (grade 2 = 37%, grade 3=15% & grade 4=48%). Half of the reactions
(52%) were less than 25 mm. Thirty-eight percent of the reactions occurred
during build up phase delaying the initiation of maintenance therapy. The mean
time taken to reach maintenance (1:1 concentration) was 7.6 ± 3.4 months with
61% of all patients reaching this level over 5-22 months. Only 4 patients (7%)
reached the final therapeutic IT dose. Conclusions: We note that more than half
of the reactions were smaller than 25 mm in size. Most (93%) patients did not
achieve the prescribed maintenance IT dosage over the time period studied. It
may be possible to increase efficacy of IT by changing the dose adjustment cri-
teria for reactions that are smaller than 25 mm in size.
Protocol for Dose Adjustment During Immunotherapy Administration
19
THE HEDIS MEDICATION MANAGEMENT FOR PEOPLE WITH
ASTHMA MEASURE DOES NOT CORRELATE WITH
IMPROVED ASTHMA OUTCOMES.
A. Crans Yoon*1, W. Crawford1, J. Sheikh1, A. Gong1, R. Nakahiro2,
M. Schatz2, 1. Los Angeles, CA; 2. San Diego, CA.
Introduction: A new Healthcare Effectiveness Data and Information Set
(HEDIS) asthma measure has been implemented, however it is unknown if
meeting this care measure is associated with improved asthma outcomes. We
examined if the HEDIS Medication Management for people with Asthma meas-
ure (“MMA measure”) associates with asthma outcomes. Methods: Adminis-
trative data was used to identify 30,040 patients who met the HEDIS criteria
for persistent asthma during 2012. They were classified as meeting or not meet-
ing the MMA measure at the 75% and 50% adherence thresholds. Association
between MMA adherence in 2012 and asthma outcomes in 2013 was assessed.
Patients who were not MMA adherent but met the HEDIS asthma medication
ratio measure were compared to those adherent to the MMA measure. Results:
Patients who met the 75% or 50% MMA measure in 2012 had no difference
in asthma related hospitalizations, ED visits, short-acting beta agonist (SABA)
dispensing, and oral steroid dispensing events in 2013 compared to those who
did not meet the measure. Stepwise comparison of patients who were 75% com-
pliant, 50-75% compliant and < 50% compliant also showed no difference in
these outcomes. To address confounding by patients who met the measure due
to having a later index date, patients who met the 75% MMA measure with
index dates late in the year were compared to those who did not meet the 75%
measure whose index dates were early in the year and no difference was found
in their 2013 asthma outcomes. Additionally, patients who met the 75% and
50% MMA measures were compared to those who did not but had an asthma
medication ratio of >0.5. Asthma outcomes of hospitalization, ED visits and
greater than 6 SABA canisters dispensed were higher in the 75% adherent group
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A9
compared to the non-adherent but ratio >0.5 group. No difference in hospital-
izations or ED visits was found between the groups at the 50% adherence thresh-
old; however the 50% adherent group had more patients who required greater
than 6 SABA canisters. Conclusions: The HEDIS MMA measure does not cor-
relate with asthma-related hospitalizations, ED visits, SABA dispensing, or
oral steroid dispensing. Alternate measurements of asthma outcomes, such as
the asthma medication ratio and its correlate, the number of SABA canisters
dispensed, may better identify patients at risk for adverse asthma outcomes.
20
ALLERGY IMMUNOTHERAPY ADHERENCE: DOES RUSH
MAKE A DIFFERENCE?
S.P. Raschal, J.M. Holcombe, B.G. Carlton*, Chattanooga, TN.
Traditionally, immunotherapy consisted of regular (weekly/bi-weekly) injec-
tions over several months until a maintenance stage was reached. Rush
immunotherapy (RIT) allows the patient to achieve a maintenance stage much
quicker than traditional immunotherapy. The purpose of the current study was
to identify whether patients were more or less adherent to treatment when they
received RIT. A systematic chart review was conducted on all new patients who
started immunotherapy in 2011. Variables of interest included demographic
factors (age, gender, etc.), potential control variables (systemic reactions, prick
test results, and asthma diagnosis), RIT (hours), and duration of treatment
(months). Overall, 199 patients began allergy immunotherapy at the clinic in
2011. The average patient was 33 years old, female (65.3%), and Caucasian
(81.9%). The majority of patients had systemic reactions during their initial
screening (92.4%) and was also prick test positive (96.0%). The patients were
almost evenly divided by asthma diagnosis (yes=59.1%; no=40.9%), but analy-
ses showed no significant differences between these two groups in regards to
RIT hours and treatment duration. Patients were classified into one of three
groups at the time of chart review – (1) still on treatment, (2) stopped treatment
without restart, and (3) stopped treatment with restart(s). Of the 199 patients
who started treatment in 2011, 97 (48.7%) were still receiving treatment with
an average therapy duration of 14 months. Eighty patients (42.2%) had stopped
treatment and had not restarted while 18 patients (9.0%) had stopped treatment
and subsequently restarted, some on several occasions. The average number of
RIT hours for patients still on treatment (M=13.37) was significantly higher
than for patients who had stopped treatment (M=8.20) even if they restarted
(M=2.64) [F(2, 196) = 15.57, p = .000]. Further analyses were conducted clas-
sifying patients into groups dependent upon the number of RIT hours they
received, if any. Patients receiving 1-10 RIT hours had significantly lower treat-
ment duration (M=8.3) than patients receiving no RIT (M=14.4), 11-20 RIT
hours (17.2), or more than 20 RIT hours (18.77) [F(3,195) = 14.17, p = .000].
While RIT hours do play a role in treatment duration, results of these analyses
suggest that another variable, possibly related to commitment to treatment, may
also be involved in the prediction of adherence.
21
ASSESSING SUBJECTIVE MEASURES OF ASTHMA CONTROL
IN AN INNER CITY PEDIATRIC AND ADOLESCENT POPULA-
TION.
P.J. Patel*1, N. Abou Baker2, R. Travis2, A. Tentler2, E. Montalvo Stanton2,
1. North Brunswick, NJ; 2. Newark, NJ.
Introduction: In clinical practice where time and resources are limited, the
asthma control test (ACT) and the childhood asthma control test (C-ACT) were
developed by Nathan et al and Liu et al, respectively, to identify poorly con-
trolled asthma. The ACT contains questions for the patient >12 yrs of age and
the C-ACT contains questions for the caregiver and child 4-11 years of age.
The goal of this study was to evaluate whether patients are on optimal asthma
treatment based on subjective reporting of asthma control from the child and
the parent as assessed by the ACT/C-ACT. Methods: A random selection of
office visits made by children, ages 4-20 years, with asthma during 2013 was
surveyed. We reviewed 171 charts: 114 children 4-11 years completed the C-
ACT with their caregivers; 57 children 12-20 years completed the ACT. For
children ages 4-11 years old, a comparison was made between the responses
of children and their caregivers on their measure of asthma control. All sur-
veyed charts were examined for step-up in medications if they had uncontrolled
asthma (ACT/C-ACT score < 20) or appropriate maintenance or decrease in
medications if controlled. Results: In children ages 4-11 years, it was noted
that while caregivers’ ACT scores had a moderate correlation (R2 = 0.52) with
their child’s score, the caregiver’s score was, on average, 7% higher than the
child’s score, suggesting that caregivers may perceive their child’s asthma as
ABSTRACTS: CONCURRENT SESSIONS
more controlled than what the child reports. In children ages 4-11 years, 39%
with uncontrolled asthma received an appropriate increase in medications, while
76% with controlled asthma were maintained on their medication or decreased.
In children > 12 years of age, 36% with uncontrolled asthma received an increase
in medications, while 81% with controlled asthma were maintained on their
medication or decreased. Conclusion: Although results suggest a discrepancy
between ACT scores for uncontrolled asthma and subsequent step-up in asthma
management, there are other objective factors which play a role in determin-
ing asthma management, such as the pulmonary function test and physical
exam. Analysis of these measures along with the ACT should be considered
for asthma management. A communication gap about asthma symptom sever-
ity might exist between caregiver and child, which may be mitigated through
patient education.
22
UTILITY OF HIGH ATTENUATING MUCUS AND OTHER RADI-
OLOGIC FEATURES IN DIAGNOSED CASES OF ALLERGIC
BRONCHOPULMONARY ASPERGILLOSIS.
P. Agarwal*, A. Chowdhary, S. Gaur, Delhi, India.
Background: High attenuating mucus (HAM) impaction and other radio-
logic features (ORF) have been considered as important radiologic parameters
while diagnosing and classifying patients of Allergic bronchopulmonary
aspergillosis (ABPA). However, the exact significance of these radiologic find-
ings is controversial. Method: A total of 63 patients diagnosed as ABPA based
on the Rosenberg-Patterson criteria were categorized on the basis of HRCT
findings into 4 groups; ABPA-S (Serological), ABPA-CB (Central bronchiec-
tasis), ABPA-CB-HAM and ABPA-CB-ORF. These groups were studied for
their baseline characteristics at initial visit and their clinical, serological and
functional severity were assessed on follow up visits and ABPA exacerbations.
IEC approval and informed consent was obtained from all research subjects.
Results: The prevalence of HAM and ORF was found to be 9.5% and 41.3%
respectively. A statistically significant higher correlation was observed for
expectoration of brownish black mucus plugs (P < 0.03), anorexia (P<0.05),
weight loss (P<0.008), mean number of ward admission per year (P<0.015),
mean number of ABPA exacerbations per year (P<0.001), mean total IgE lev-
els (P<0.001) in patients with HAM on the initial visit. Also, significantly more
number of ORF patients had history of anti tubercular treatment for sputum
positive tuberculosis (P<0.01). Furthermore, severe and very severe grades of
obstruction on spirometry were observed in ORF group. The prospective analy-
sis revealed mean serum total IgE levels (P<0.03) to be significantly high in
HAM group, whereas, mean specific IgE levels against Aspergillus fumigatus
were found to be significantly higher (P<0.007) in patients with central
bronchiectasis . The follow up HRCT done during exacerbations detected pres-
ence of HAM in 3 patients of ABPA-CB, 1 of ABPA-CB-ORF and 4 of ABPA-
CB-HAM. A high serum total IgE and specific IgE values were found in HAM
impaction but were not statistically significant. Finally, comparisons made in
the exacerbation group between HAM positive and HAM negative patients
were also statistically insignificant. Conclusion: HAM and ORF appear to be
associate findings in ABPA patients which may or may not influence the sever-
ity of the disease. Also, these findings could not be used as a diagnostic tool
independently and do not predict the outcome. .
Comparison of ABPA exacerbation data among study groups,
* = Statistically significant data
VOLUME 113, NOVEMBER, 2014 A9
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ABSTRACTS: CONCURRENT SESSIONS
23
ASTHMA ALLY: TAKING ADVANTAGE OF THE CLOUD TO
UNDERSTAND ENVIRONMENTAL TRIGGERS OF ASTHMA
AND ALLERGIES.
R. Lucas*1, J. Dees2, R. Reynolds2, B. Rhodes3, N. Allen3, R.W. Hender-
shot4, 1. Phoenix, AZ; 2. Salt Lake City, UT; 3. Provo, UT; 4. North Salt
Lake, UT.
Asthma and allergies represent a substantial cost to society. Cloud com-
puting and mobile-based client technologies have the potential to improve dis-
ease control as well as expand the scientific and medical community’s insight
into these diseases. We report the results of a case series study in which we
employed a cloud computing and mobile phone-based platform, Asthma Ally,
in order to track patients’ asthma and allergy symptoms and automatically com-
pile temporally and spatially appropriate environmental data that are useful
for understanding individual triggers exacerbating their asthma and allergy
events. Participating patients used a cell phone application to interface with
Asthma Ally and log symptom information regarding their individual asthma
and allergy episodes and composite measures of asthma control based on a
questionnaire instrument. Approximately two years of anonymous patient data
were used for this study in addition to research subjects granting informed con-
sent. For every participating individual, environmental data (e.g. air quality,
ambient pollen counts, climate data, etc.) were regressed against individual
asthma or allergy symptoms. Where pollen data were available, grass pollen
counts were consistently the strongest covariate in individual regression mod-
els, contributing as much as 41.7 – 76.1% of the explained variation for all
asthma and allergy events. The covariates particulate matter size 2.5 mm (PM2.5)
and wind speed also commonly had high relative importance values in indi-
vidual regression models, contributing as much as 7.3 – 33.2% of the explained
variation. The strength of the coefficient of determination varied by individ-
ual, ranging from 0.053 – 0.730. During well controlled periods, asthma events
tended to not be significantly related to environmental variables. During uncon-
trolled periods, however, asthma events tended to be more strongly related to
environmental variables, the strength of the relationships increasing with increas-
ing lack of asthma control. Asthma Ally can improve asthma and allergy out-
comes because both healthcare providers and patients are better able to under-
stand specific environmental factors triggering asthma and allergy events at
an individual level and each can make treatment or behavior changes to improve
control and quality of life.
Example of longitudinal environmental exposures and asthma event data for
an individual. Environmental data compiled by automated algorithms of
Asthma Ally. Rose shaded area highlights uncontrolled asthma events. Trends
are indicated using loess regression with a weighting factor of 0.1.
24
THE PEDIATRIC ASTHMA ADHERENCE TEST (PAAT): A SUR-
VEY FOR PEDIATRIC PATIENT PROPENSITY TO ADHERE TO
CONTROLLER MEDICATIONS.
B.T. Kelly*1, W. An1, C. Bauer2, H. Zafra1, L. Gimenez1, L. Crandall1,
P. Simpson1, M. Nugent1, P. Vargas2, K.J. Kelly3, 1. Milwaukee, WI; 2.
Phoenix, AZ; 3. Chapel Hill, NC.
Introduction: Medication non-adherence leads to increased pediatric emer-
gency visits and hospitalizations. Tools to predict adherence in adults with
asthma have been successfully validated. No tool currently exists in pediatrics
that reliably predicts adherence to use of controller asthma medications. We
developed a PAAT to quantitatively predict adherence in children with per-
sistent asthma. Methods: Patients between ages of 2 and 18 with a new diag-
A10 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
nosis of persistent asthma who were started on inhaled corticosteroids were
prospectively enrolled with informed consent. Each subject completed the
PAAT. The PAAT was scored such that a higher score suggested better adher-
ence. Refill history was assessed through phone calls to the subject’s pharmacy
at 1 week, 3 months, and 6 months after initial visit. Adherence was defined
as 4 or more medication refills at 6 months. IRB approval and informed con-
sent was obtained from all research subjects. Results: At 6 months, only 10/74
subjects (13.5%) of patients filled 4 or more controller inhalers. The median
number of refills for controller medication at 6 months was higher for subjects
who answered “agree or strongly agree” compared to “neutral” to the question
regarding if their controller was necessary (median 3 vs. 2, p=0.028). There
was no difference in total PAAT score between the adherent and non-adherent
group (20 vs 18.5, p=0.406). Additionally, there were no clinically significant
differences in refill history for subjects for all other questions. Conclusions:
We have demonstrated that the vast majority of patients receiving a new con-
troller medication for their asthma are non-adherent. The PAAT was able to
identify that adherence is better in patients who believe that their controller was
necessary for their asthma. Asking this question during a pediatric visit may
indicate a patient at higher risk for non-adherence, and may improve patient
outcome through early intervention focusing on essential role of medication
education. Unfortunately, total PAAT score failed to identify adherent versus
non-adherent patients in our asthma patient population. Further investigation
is necessary to determine the validity of the tool to predict a child’s adherence
to a controller medication.
25
ASSOCIATION BETWEEN MOUSE AND COCKROACH SKIN
PRICK TEST, SERUM SPECIFIC IGE, ENVIRONMENTAL EXPO-
SURE AND ASTHMA MORBIDITY IN ATOPIC CHILDREN <4
YEARS OF AGE IN THE BRONX, NEW YORK.
A.L. Richler*1, Y. Jorge2, Y. Pichardo2, P. Polanco3, K. Achar2, R. Nazari4,
G. de Vos2, 1. Brooklyn, NY; 2. Bronx, NY; 3. San Juan, Puerto Rico;
4. Philadelphia, PA.
Background: Epidemiologic studies have found inconsistent associations
between cockroach and mice exposure, allergic sensitization and asthma mor-
bidity. Such studies used either skin prick testing (SPT) or serum specific IgE
testing (ssIgE) to determine allergic sensitization, possibly contributing to the
inconsistency of the results. Objective: To determine the association between
environmental roach and mice exposure, SPT and ssIgE results and asthma
morbidity in a population of atopic, asthmatic inner-city children < 4 years of
age residing in the Bronx, New York. Methods: Forty-nine (49) atopic asth-
matic children between 18 – 48 months of age were enrolled. An extensive
health interview was conducted with the parents, including questions about the
visual presence of mice and roaches at their home. Children underwent SPT
(ComforTen®) and ssIgE testing (Immulite 2000) with a cut-off ssIgE level of
≥ 0.35 kU/l considered as positive. IRB approval and informed consent was
obtained from all research subjects. Results: Reported mice infestation at home
was associated with a positive SPT to mouse (OR=5.0, 95% CI 1.6-54.3,
p=0.01), but not with mouse ssIgE (OR=3.1, 95% CI 0.7-13.8, p=0.12). In addi-
tion, children sensitized to mouse based on either testing method appeared to
be more likely to have at least 1 asthma related ED visit in the past 12 months
compared to children not sensitized to mouse (OR= 3.5, 95% Cl, 0.9.-13.9,
p=.075). In contrast, we did not find an association between reported roach
infestation at home and roach sensitization based on SPT (OR=1.5, Cl 0.4-5.7,
p=0.59) or ssIgE (OR=1.7, Cl 0.5-6.3, p=0.43). Roach sensitization based on
either testing method did not predict asthma related ED visits in the past 12
months, regardless if roach infestation was reported or not. Conclusion: Our
pilot study suggests that mice infestation is a strong predictor of mouse spe-
cific sensitization and asthma morbidity in young inner-city children, stronger
than roach infestation and roach sensitization. SPT appears to correlate stronger
with mouse exposure than ssIgE testing
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A11
Graph, Results of exposure, allergen sensitivity and morbidity. (+) ssIgE was
determined as ≥ .35 kU/L.”
Group 1 is made up of children with reported exposure to roach and positive
roach SPT. Group 2 is made up of children with reported exposure to mouse
and positive mouse SPT. Group 3 is made up of children with positive roach
SPT but without reported exposure to roach. Group 4 is made up of children
with positive mouse SPT but without reported exposure to mouse. Group 5
is made up of children with reported exposure to roach and positive roach
ssIgE. Group 6 is made up of children with reported exposure to mouse and
positive mouse ssIgE. Group 7 is made up of children with positive roach
ssIgE but without reported exposure to roach. Group 8 is made up of chil-
dren with positive mouse ssIgE but without reported exposure to mouse.
26
TARGETED GENE THERAPY IN THE TREATMENT OF
X-LINKED HYPER-IGM SYNDROME.
C.Y. Kuo*1, M.D. Hoban1, A.V. Joglekar2, D.B. Kohn1, 1. Los Angeles,
CA; 2. Pasadena, CA.
Introduction: X-linked hyper-IgM syndrome (XHIM) is a primary immun-
odeficiency with absent IgG, IgA, IgE and normal/elevated IgM due to defects
in the CD40 ligand (CD40L) gene. Hematopoietic stem cell transplantation
(HSCT) is the only curative modality, but it carries significant risks, suggest-
ing the need for improved methods of treatment. Previous studies using CD40L-
/- bone marrow corrected by retroviral-vector transfer of CD40L cDNA in
mouse models resulted in abnormal lymphoproliferation due to unregulated
expression of the gene. Hypothesis: Custom TAL effector nucleases (TALENs)
or Clustered Regularly Interspaced Short Palindromic Repeats (CRISPRs),
combined with the effective delivery of a homologous donor sequence con-
taining normal CD40L DNA, will allow for targeted integration and provide
physiologic expression of the endogenous CD40L gene to safely provide long-
term immune reconstitution. Methods/Data: TALENs targeting the 5’ UTR of
the CD40L gene were created and their function validated using a surveyor
endonuclease assay. Allelic disruption of up to 31% at the target locus in K562
cells was achieved. In order to evaluate the capacity for targeted integration of
a cassette at the cut site, K562 and Jurkat cells were electroporated with the
TALEN pair and a donor molecule with a promoterless GFP reporter gene
flanked by homology arms that parallel the cut site. In/Out PCR using a for-
ward primer within the GFP region and a reverse primer in the genomic DNA
outside the donor molecule demonstrated proper integration into K562 cells.
Targeted insertion of the GFP reporter into the CD40L locus should also pro-
vide a measure of physiologic induction of CD40L expression. Thus, expres-
sion of the GFP reporter was evaluated in Jurkat cells (which naturally express
60% CD40L), with up to 10% detected by FACs and increasing to 22% upon
PHA activation. In addition, CRISPRs targeting a patient-specific mutation in
intron 3 achieved >50% gene disruption in K562 cells. Co-electroporation with
a template donor modified to contain a unique restriction enzyme site demon-
strated site-specific gene integration by enzyme digest and gel electrophore-
sis. Conclusion: These results demonstrate that site-specific modification at
CD40L is achievable and that physiologic expression of the endogenous CD40L
gene could provide a viable therapy for immune reconstitution in XHIM.
ABSTRACTS: CONCURRENT SESSIONS
27
MACROPHAGE PHENOTYPE SHIFT TOWARD M1 AFTER
IGG STIMULATION WITH OMALIZUMAB IN AN IGE FREE
SYSTEM.
R. Steele*, M. Littlefield, I. Voloshyna, M. Davis-Lorton, M. Aquino,
L. Fonacier, A. Reiss, Mineola, NY.
Introduction: Classically activated M1 macrophages drive Th1 responses,
while alternatively activated M2 macrophages drive Th2 responses. A shift away
from Th2 toward Th1 is associated with decreased incidence of atopy. Anti-IgE
monoclonal antibody (mAb) therapy (omalizumab; a humanized IgG1 mAb)
is an FDA approved treatment for allergic asthma and chronic urticaria. In recent
studies, patients with non-allergic asthma and those with low serum IgE showed
improvement in clinical measures with omalizumab treatment independent of
IgE level. This may represent an unrecognized immunomodulatory effect of
omalizumab. IgE-independent effects of this mAb in antigen presenting cells
were examined in polarization of the THP-1 human monocytic cell line in an
IgE free system. Methods: THP1 were differentiated into adherent macrophages
(PMA), then stimulated with IFNγ/LPS and IL-4 to polarize them into the M1
and M2 state, respectively. Cells were stimulated with omalizumab at varying
concentrations (0.1, 1, 10 mg/mL) ± IFNγ/LPS and IL-4 (during and after polar-
ization). Then mRNA was isolated and subjected to QRT-PCR to examine pro-
file markers for M1 (CCR7 and IL12), and M2 (CD163 and CCL17). Results
were normalized to GAPDH. Results: Costimulation with mAb-IFNγ/LPS
upregulated M1 markers CCR7 (17-fold) and IL12 (3-fold) above polarization
with IFNγ/LPS alone. Treatment of already polarized cells with mAb did not
significantly impact transcription of CCR7 or IL12. The M2 marker CD163
was downregulated by costimulation by mAb-IFNγ/LPS (15-fold) vs. IFNγ/LPS
alone (8-fold) compared to PMA controls. IL-4 did not significantly affect M1
or M2 markers. M2 marker CCL17 transcription was enhanced by omalizumab
alone (11-fold) and with IFNγ/LPS (9-fold) over PMA controls. Conclusions:
This proof-of-concept study suggests that IgG mAB enhances transcription of
M1 markers in THP1 cells and attenuates transcription of some M2 markers.
This effect may be due to the Fab portion (omalizumab specific) or be isotype
specific (IgG1). Interestingly, CCL17 is an inducer of chemotaxis in T-cells,
particularly Th2 cells that play a critical role in atopic disease and this was
upregulated by our mAb. The interaction of the mAb may represent a point of
immunomodulation by omalizumab not previously recognized, or a novel
immunomodulatory effect of IgG1.
28
ASSOCIATION OF VDR GENETICS VARIANTS TO PEDIATRIC
ASTHMA: A CASE CONTROL STUDY IN A POOR COMMUNITY
OF THE COLOMBIAN CARIBBEAN AREA.
E. Egea1, G. Garavito de Egea*1, L. Visbal1, N. Lecompte1, G.E. Egea1,
M. Sanchez Borja2, L. Fang3, 1. Barranquilla, Colombia; 2. Caracas, Boli-
varian Republic of Venezuela, 3. Cartagena, Colombia.
Background: Vitamin D and its nuclear receptor (VDR) have been associ-
ated with asthma. Single nucleotide polymorphisms (SNPs) in the VDR gene
may alter the actions of vitamin D, and could influence the development and
severity of asthma. Objectives: To analyze the genetic association of the TaqI
VOLUME 113, NOVEMBER, 2014 A11
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A12
ABSTRACTS: CONCURRENT SESSIONS
SNP [rs731236 A> G], ApaI [rs7975232 A> C], BsmI [rs1544410 C> T] and
FokI [rs2228570 A> G] with susceptibility to asthma in children from the
Caribbean Coast Colombian. Methods: This was a case-control study that
included 1000 individuals : 500 asthmatic children belonging to a poor com-
munity and 500 non asthmatic children from the same socioeconomic charac-
teristic living in Barranquilla a city on the north of the Caribbean coast of
Colombia. The SNPs were genotyped by RT-PCR and TaqMan ® probes. Allelic
and genotypic frequencies were estimated using a Arlequin v3.5 software; D’and
r2 statistic Linkage disequilibrium (LD) were studied using Haploview v4.2
software and associated haplotypes were identified by haplo.stats v1.6.8 soft-
ware package R v3.0.2. Results: Our results showed that only the SNP BsmI
[rs1544410 C> T] was associated with the disease with a significantly higher
frequency of the CC genotype (57%, n = 280) in the asthmatic groups com-
pared with controls(49.2% n = 244)It was also found that the frecuency of CT
genotype was 35.6% in cases, n = 175, compared with the controls (43.8%, n
= 217), p = 0.031. Haplotype analysis showed that the haplotype A / C / T / G
was found to be a protective factor for asthma (OR = 0.49, 95% CI = 0.26 to
0.88, P = 0.028), while haplotype A / C / C / G was showed as a risk factor for
disease susceptibility (OR = 1.28, 95% CI = 1.03 - 1.60, p = 0.049). The LD
analysis showed that the best D’and r2 found in SNPs block understood by TaqI,
ApaI and BsmI; was D ‘= 0.753 and r2 = 0.565. Conclusion: This is the first
study conducted in asthmatic Colombian children searching for the associa-
tion of the VDR polymorphisms with pediatric asthma. Our results demonstrate
that the VDR gene locus is associated with susceptibility of asthma in this spe-
cific admixed ethnic group of children seated in the Colombian Caribbean
Coast.
29
M1 MACROPHAGES: A POTENTIAL ROLE IN THE DEVELOP-
MENT OF STEROID RESISTANT ASTHMA IN OBESE MICE.
J.M. Diaz*1, X. Xue2, M. Solanki2, M. Gupta2, P. Chatterjee2,
V.R. Bonagura2, C. Metz2, 1. North Bellmore, NY; 2. Manhasset, NY.
Background: The obesity epidemic has contributed to the development of
a new phenotype of “obese asthmatics” who are steroid resistant. To develop
more effective treatments for these asthmatics, it is important to understand the
etiology of this resistance. Using a mouse model of obese asthma, we previ-
ously reported a macrophage- (MΦ) predominant infiltrate in the lungs. We
hypothesize this non-eosinophilic cell composition contributes to steroid resist-
ance. Because MΦ can be pro-inflammatory (M1) & anti-inflammatory (M2),
we examined the infiltrating MΦ in lean vs. obese asthmatic mice. Methods:
Mice (C57BL/6, males) were fed a regular “lean” or high fat chow (60% fat).
After 6 months, mice were given intranasal saline or house dust mite extract
(HDM), 5 days/week for 4 weeks. During the last 2 weeks, mice were given
either saline or dexamethasone (dex) (1 mg/kg, IP) 5 days/week. After pento-
barbital euthanasia, bronchoalveolar lavage (BAL) and lungs were collected.
Differentials were established using Modified Wright stain. Quantitative PCR
(qPCR) using lung tissue was performed using F4/80 (MΦ marker), Fizz (M2),
Arg1 (M2) & Nos2 (M1) primers. Results: The absolute cell count in the BAL
was low in untreated obese & lean mice (<1x106 cells/mL), while HDM expo-
sure significantly increased cell count in both (3x106). Dex significantly
decreased BAL counts in lean-HDM mice (<1x106) but not in obese-HDM
mice (2.5x106). Both HDM groups had a significant increase in eosinophils
when compared to saline control mice. BAL of lean-HDM mice was comprised
of equal numbers of MΦ & eosinophils, while obese-HDM mice had more MΦ
& fewer eosinophils. Obese-HDM-dex mice had almost no eosinophils, but
high levels of MΦ. qPCR revealed increased expression of F4/80, M1 (Nos2)
A12 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
& M2 (Fizz, Arg1) markers in obese-HDM vs. lean-HDM mice in comparison
to their controls. Finally, DEX-significantly reduced M2 marker expression but
did not reduce M1 expression in obese-HDM mice. Discussion: Using a novel
model of obesity & asthma our findings suggest a potential role of dex-resist-
ant M1 MΦ in the etiology of steroid resistance in the obese asthmatic. Because
these findings are consistent with what has been observed in the obese popu-
lation, this model might be useful to test new treatments that target reducing
MΦ infiltration or shifting M1 pro-inflammatory to M2-antiiinflammatory
MΦ.
30
LONGITUDINAL STUDY OF CVID ILD.
P.J. Maglione*, C. Cunningham-Rundles, New York, NY.
Introduction: Evidence of interstitial lung disease (ILD) is a frequent radi-
ologic finding in common variable immunodeficiency (CVID), however, the
long-term consequence is unclear. We retrospectively examined CVID patients
who had pulmonary function testing (PFT) over the duration of 20 months or
more to gain insight into the natural history of CVID ILD. Methods: Retro-
spective chart review and statistical analysis was performed for 10 subjects
with CVID who had CT chest evidence of ILD and PFT covering at least 20
months. CT evidence of ILD was defined as the presence of numerous pul-
monary nodules, ground glass opacity, or interstitial infiltrate as noted by board-
certified radiologists in the medical record. Patients who received rituximab
had PFT measured 6-12 months after the completion of a single course of treat-
ment. Results: Of the 10 patients studied, 5 had evidence of progressive ILD
indicated by (1) DLCO less than 50% of predicted, (2) DLCO less than 80%
of predicted that decreased by 20% or more during the duration of the study,
or (3) FVC that decreased by 20% or more during the duration of the study.
Initial PFT parameters and conventional laboratory tests (quantitative
immunoglobulins, CBC with differential, alkaline phosphatase) did not statis-
tically differentiate these two groups, however initial serum IgM trended higher
in patients with progressive ILD (68±28 mg/dL vs. 13±4, P = 0.08). Four of
the 5 patients with progressive ILD received treatment with rituximab and had
a significant improvement in FVC (73±1% vs. 62±2%, P = 0.01), but no sig-
nificant restitution of other PFT parameters. Conclusions: Half of the CVID
patients with CT evidence of ILD in this retrospective study had worsening of
PFTs suggestive of progressive lung disease. Initial serum IgM trended higher
in patients with progressive ILD, but other conventional laboratory parame-
ters did not significantly differentiate those who went on to have worsening
PFT. Treatment with a single course of rituximab in patients with progressive
ILD resulted in improvement of FVC. Larger studies are indicated to define
the natural history of CVID ILD and determine the optimal indication and mode
of treatment
31
MULTIPLE UNRELATED HETEROZYGOUS GENE DEFECTS
PRESENTING AS A PRIMARY IMMUNODEFICIENCY.
P. Abghari*, E. Secord, P. Poowuttikul, Detroit, MI.
Introduction: Many syndromes of primary immunodeficiencies (PID) are
well described and have been identified by genetic analysis. We present a case
of a boy with hypogammaglobulinemia, malabsorption and recurrent skin
lesions with multiple heterozygous defects on genotyping; any of these alone
would not likely be clinically significant, but together constitute an immune
deficiency. Case Description: A 2 year old Chaldean boy was born full-term to
consanguineous parents. At approximately 7 weeks of age he presented with
skin lesions over the umbilicus and buttock. Biopsy revealed exuberant epithe-
lial hyperplasia. By 6 months of age he developed chronic diarrhea, oral thrush,
bacteremia, failure to thrive, poor wound healing and wound dehiscence. Lab-
oratory evaluation at 6 months revealed hypogammaglobinemia, inadequate
pneumococcal titers, normal oxidative burst, normal CD11, CD18, CD54 lev-
els, normal T, B and NK cell populations and normal mitogen proliferation
assays. Intravenous immunoglobulin (IVIG) infusions were initiated. The diar-
rhea and skin lesions responded to low dose prednisone, however despite the
response, total parenteral nutrition was necessary for nutrition. Genetic testing
revealed a negative panel for SCID, agammaglobulinemia, and chronic gran-
ulomatous disease. Whole exome sequencing revealed multiple mutations of
unknown clinical significance. Two defects in DOCK 8 were detected, how-
ever protein was demonstrated to be present and functional. A heterozygous
mutation for microvillus inclusion disease and a separate heterozygous defect
for congenital malabsorption type 4 were identified as well. In addition, a het-
erozygous mutation of PRKDC, which has been linked to severe combined
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A13
immunodeficiency when homozygous defects are present and a heterozygous
mutation of the IKBKB gene which has also been linked to an immune defi-
ciency when homozygous defects were identified. Finally, a heterozygous muta-
tion of the IGFB2 gene, which codes for CD18 was identified. All were sepa-
rately reported as of unknown significance. Conclusion: This case illustrates
that multiple heterozygous defects, although not previously reported as related,
together can present as a PID. Whole genome sequencing was able to provide
us with results and should be considered more often in PID cases that are not
straightforward and not easily diagnosed by immunology workup.
32
NOVEL CLINICAL DATA ACQUISITION TECHNOLOGY FOR
MONITORING OF HOME IG INFUSION FOR PIDD.
T. Walton1, J. Ney2, D. Schaefer1, B. Geng*3, 1. Lenexa, KS; 2. Boston, MA;
3. Los Angeles, CA.
PIDD patients are frequently managed by several physicians and care set-
tings, and usually only see Immunologist 1-4 times per year. Given increased
scrutiny on number of infections per year as a determinant of therapy and patient
success, with risk that more frequent infections may contribute to more severe
outcomes, we asked if present care model is sufficient for collecting rate of
infection data and whether new data acquisition technology could improve data
collection. We compared sample of 16 PIDD patients from 4 physicians in sin-
gle academic immunology clinic by conducting chart review of office visit
encounters, with sample of 40 PIDD patients from 23 physicians and 266 data
collection points on CareExchange®, to compare time between data collec-
tions, frequency of reported infections, and infection rates per year. CareEx-
change® is data collection software with multiple parameters focusing on the
patient’s infection rate, antibiotic use, provider visit, and overall health assess-
ment. Chart review of PIDD patients on IG replacement from single academic
center showed mean time between visits was 5.2 (1-24 months) and the mean
number of infections/year was 1.2 (0-5). Mean age for this group was 21 (8-
39 years). Primary diagnosis for single academic center was: 31.3% Bruton’s,
43.8% CVID, 12.5% SCID, 6.3% Hyper-IgM. CareExchange patients had data
collected on average 6.7 (1-15 times/year) and mean infection rate of 0.69
between infusions. Mean sum of infections from all sources at any one time
between infusions was 1.38. Mean acute health care used between infusions
was 0.4, and mean rate of new antibiotic usage between infusions was 0.25.
Mean age for the CareExchange group was 39.2 years (range 5-75). Primary
diagnoses for the group was: 48% CVID, 28% Hypogammaglobulinemia NOS
28%, 10% Congenital Hypogammaglobulinemia. This pilot study was lim-
ited, but revealed known gap in data collection, challenge of patient recall, and
variability of physician questions/notes/visit schedule as compared to an auto-
mated system which can collect patient infection data as frequently as needed.
There’s no established acceptable rate of infections for a patient to be deemed
well controlled. There is no well-validated system of acquiring data from home
infusion patients. Further study is needed to validate utility of this automated
uniform system of clinical data collection.
33
IMPACT OF PENICILLIN SKIN TESTING (PST) ON ANTIBIOTIC
(ABX) USE IN PATIENTS WITH A PENICILLIN ALLERGY (PA).
S. Challa*1, E. King2, K. Patel2, S. Anghel2, J. Brensilver2, L. Bielory2,
1. Springfield, NJ; 2. Summit, NJ.
Rationale: PA generally leads to the use of broad-spectrum abx that may
increase complications and cost. A PST pilot protocol was developed at Over-
look Medical Center to help reduce the use of broad-spectrum/high-cost
(BS/HC) abx and determine the cost effectiveness of PST. Methods: A retro-
spective analysis was conducted on patients who had PST performed by an
allergist between November 2013 – May 2014. PST included prick and intra-
dermal testing with major (Pre-Pen™) and minor (penicillin G) determinants
followed by an oral amoxicillin challenge. Abx were de-escalated based on
results of PST. Reduction in cost of abx, and adverse reactions were assessed.
Cost analysis was based on the material cost of abx and skin testing compo-
nents. Study was IRB approved. Results: A total of 38 adult patients had PST.
Median age was 64 yrs; 97%(n=37) were allergic to penicillin alone;
piperacillin/tazobactam (n=1), and a history of multiple abx allergies (n=9).
Sixty three percent had a reaction >20yrs ago with cutaneous reaction being
the most common reaction (45%). Aztreonam was the most common initial abx
used prior to PST (55%).Urinary tract (26.3%) and intra-abdominal infections
(18%) were the most common indications for abx treatment. Skin testing was
negative in 38 (100%) patients but one patient had anaphylaxis to oral amox-
ABSTRACTS: CONCURRENT SESSIONS
icillin challenge following a negative skin test. A cost analysis was performed
in 29 patients who had antibiotics switched to a beta-lactam after negative PST.
Fourteen patients (48%) were switched to a narrow-spectrum agent (i.e.
aminopenicillins, oxacillin, and non-pseudomonal cephalosporins). Total cost
of therapy with a beta-lactam after PST was $3,518. Total cost of therapy if
initial BS/HC abx prior to PST were continued was $14,670. Approximate cost
for PST materials for 38 patients was $3,631. Overall cost savings was
$7,521.The additional savings of impact on developing adverse reactions and
superinfections (i.e. C. difficile) was not assessed. Conclusions: Following the
implementation of a PST protocol, we observed a decrease in BS/HC antibi-
otic use in patients with previously documented PA. PST is a safe and cost-
effective procedure to serve as a negative predictor test for penicillin hyper-
sensitivity mediated by IgE.
34
SEVERE THROMBOCYTOPENIA WITH UPPER GI BLEED
AFTER MMR VACCINATION.
K. Winkler*, T. Abramowitz Saadia, J. Moallem, New York, NY.
Adverse effects of MMR vaccination, mostly self-limited and benign, are
reported. Fever in up to 15% of vaccinees 6 to 12 days after vaccination(1, 2),
transient rash in up to 5%, febrile seizure 5 to 12 days after immunization, as
well as mild lymphadenopathy (2) are reported. Thrombocytopenia after MMR
vaccination is reported in 1:25,000 to 1:2,000,000 (1). There is no report of
thrombocytopenia resulting in severe hemorrhagic complications or death in
immunocompetent recipients (2).Infrequency with which it occurs makes it a
challenging diagnostic task for practitioners. 13 month old African American
male presented to the emergency department due to two episodes of bloody
vomitus.Two days prior he had fallen from a height of two stairs and sustained
a rapidly enlarging hematoma on his forehead. A hematoma to the lip was noted
on the day of presentation.10 days prior to presentation he was vaccinated
with the MMR vaccine. There was no reported history of fever, recent upper
respiratory illness or other illness.Physical examination in the ED demonstrated
a fussy but alert child, HR 145, RR 36, T 100.2F, with a five centimeter
hematoma on the forehead, hemorrhagic lesion on the upper lip, gingival bleed-
ing and multiple petechiae on the upper and lower extremities.The rest of the
physical examination was unremarkable.Laboratory investigation was signif-
icant for platelet count of 5K/uL, Hgb 8.4 g/dL and Hct of 24.7% on CBC.
Indirect Coombs test and Stool Guaiac were positive.In PICU his hemoglobin
further dropped to 4.0 g/dL, requiring transfusion. Bone marrow aspiration
revealed absence of lymphoblasts with increased megakaryocytes and red blood
cell precursors. He was treated with IVIG 1g/kg/day for 2 days and Methyl-
prednisolone 4mg/kg/day for 4 days then continued on PO prednisone
2mg/kg/day to be continued for one week. CBC on the seventh day of admis-
sion showed platelets of 311 K/uL, and increase of hemoglobin hematocrit to
9.4 g/dL and 28%. ITP after MMR vaccination typically occurs within 6 weeks
of vaccination (3).Mild bruising and petechiae are common (4). Hospitaliza-
tion is rarely required.Transfusion is required in 1 of 1.8 million vaccinees
(5).Platelet counts are typically >20,000 K/uL, higher than non-vaccine asso-
ciated ITP (6).This is the first report of thrombocytopenia resulting in severe
hemorrhagic complications in an immunocompetent recipient of the MMR vac-
cine.
35
B-CELL IMMUNOPHENOTYPING IN PATIENTS WITH GL-ILD
(GRANULOMATOUS INTERSTITIAL LUNG DISEASE) ASSO-
CIATED WITH CVID (COMMON VARIABLE IMMUNE
DEFICIENCY).
E. Willits*, A. Joshi, Rochester, MN.
Introduction: Granulomatous interstitial lung disease (GL-ILD) develops
in a subset of patients with common variable immunodeficiency (CVID) and
is commonly confused with sarcoidosis. Little is known about the immunophe-
notyping of T and B lymphocyte subsets in GL-ILD. We reviewed the charts
of four patients with CVID and GL-ILD. Methods: The presentation, labora-
tory and imaging studies, and treatment recommendations were reviewed. Each
patient presented with thrombocytopenia and splenomegaly, and was subse-
quently found to have CVID and GL-ILD. Two patients, an 18 yr/M (#1), and
a 12 yr/M (#2), presented with Evan’s Syndrome. Results: All patients demon-
strated significant hypogammaglobulinemia. Chest CTs were obtained in all
patients and demonstrated diffuse nodular opacities. All patients underwent
BAL and bronchoscopy to rule out an acute or chronic infection in addition to
immunostaining and pathology studies on a lung biopsy sample. Tissue sam-
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A14
ABSTRACTS: CONCURRENT SESSIONS
ples were obtained to confirm the diagnosis of GL-ILD in three out of four
patients. Finally, B-Cell Immunophenotyping was obtained for all patients
and showed decrease in total memory B-Cells (CD27+),especially low class
switched memory B Cells (CD27+M-D-). Conclusions: These four cases illus-
trate the association between low class switched memory B Cells with GL-ILD
in CVID patients. Specifically, it was found that all patients had decreased
percent (3/4) or decreased absolute number (4/4) of class switched memory B
Cells. B cell immunophenotyping may therefore be a useful tool for identify-
ing patients with CVID and granulomatous disease. Implications for early iden-
tification include early initiation of specific treatment regimens, since this sub-
set of patients may have a poorer prognosis and decreased survival when
compared to their granuloma-free CVID counterparts. In this specific popula-
tion of CVID patients, the combination of Rituximab and Azathioprine has
been shown in preliminary studies to result in improvement in pulmonary func-
tion tests and lung disease. The combination of low serum IgA levels,
splenomegaly and low class switched memory B cells can be used to create a
prediction model for the diagnosis of GL-ILD in CVID patients in future.
Immunoglobulin and B-Cell Phenotyping in four patients with Common
variable immunodeficiency and Granulomatous interstitial lung disease
36
IN UTERO RITUXIMAB: DETECTION OF RITUXIMAB IN AN
INFANT AT 4 MONTHS OF AGE.
J. Jin*, J. Mills, E. Conboy, M. Snyder, D. Murray, U. Specks, A. Joshi,
Rochester, MN.
Background: Rituximab is a chimeric anti-CD20 antibody used in the treat-
ment of non-Hodgkin lymphomas, chronic lymphocytic leukemia, rheuma-
toid arthritis, granulomatosis with polyangiitis (GPA), and microscopic
polyangiitis. Rituximab is comprised of human IgG1(κ) heavy and light chain
constant regions with murine anti-human CD20 IgG1κ variable regions. Treat-
ment with rituximab results in complement-dependent cytotoxicity, antibody-
dependent cellular toxicity and direct cytotoxicity to CD20-expressing B-lym-
phocytes. Pharmacokinetic studies suggest that serum levels of rituximab can
still be detected 3 to 6 months after treatment with a half-life of elimination
ranging from 5 to 78 days. As an IgG antibody, rituximab may cross the pla-
centa and be secreted into human breast milk. However, it remains unknown
A14 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
what concentrations rituximab achieves in neonates in utero, and if breast feed-
ing after rituximab treatment is safe. Methods: Rituximab was quantified by
mass spectroscopy (MS) from serum of mother and infant. Results: A 31 year
old primigravid woman with GPA required a fourth cycle of rituximab (375
mg/m2) weekly for four weeks starting at 30 weeks gestation for management
of headache stemming from pituitary involvement by GPA. She delivered a
healthy term infant by cesarean section at 40 weeks gestation. The baby was
exclusively breast fed without major health issues. Cord blood samples were
not taken at the time of delivery. At four months post-partum, serum samples
from the infant and mother were checked and shown in Table 1. Trace amounts
of peptides corresponding to both the heavy chain and light chain of rituximab
were detected in the infant’s and mother’s serum by MS. Conclusions: Ritux-
imab peptides were detected in the serum of an infant who was exposed to rit-
uximab in utero and exclusively breast fed. The infant’s B-cell population and
immunoglobulin levels did not appear to be affected at four months of age
(approximately 6 months after initial rituximab exposure). Measuring ritux-
imab concentrations in breast milk may help to clarify if rituximab is secreted
into breast milk.
Laboratory results from infant and mother at 4 months post-partum
37
DIAGNOSTIC DILEMMA: PRIMARY IMMUNODEFICIENCY IN
A 3 YEAR-OLD PATIENT WITH GUILLAIN-BARRé SYNDROME.
S. Rogers*1, L. Potter2, 1. Kailua, HI; 2. Portsmouth, VA.
Background: X-linked agammaglobulinemia (XLA) is a primary immun-
odeficiency characterized by low immunoglobulins and an absence of B-lym-
phocytes. XLA is secondary to a mutation of the Bruton tyrosine kinase (BTK)
gene, which prevents the maturation of B cell lineages. Patients with XLA most
commonly present with recurrent sinopulmonary infections and are at risk for
severe enteroviral infections. We report the case of a 3 year old patient with a
history of recurrent infections, treated for atypical Guillain-Barré syndrome
(GBS), who was later discovered to have XLA. Case Report: The patient ini-
tially presented to our facility with proximal upper and lower extremity weak-
ness, which progressed to near complete flaccid paralysis. After initial labora-
tory and radiographic studies were unremarkable, he was diagnosed with an
axonal variant of Guillain-Barré syndrome. Empiric treatment with intravenous
immunoglobulin (IVIG) was initiated. Despite therapy, his weakness progressed
and the patient underwent plasmapheresis. After plasmapheresis he continued
to receive pulse doses of IVIG for residual neurologic deficits. Prior to his diag-
nosis of GBS our patient had recurrent otitis media. In the following 24 months,
he experienced recurrent infections such as sinusitis, pneumonia and an episode
of S. pneumoniae bacteremia. Infections often occurred 4-6 months after receiv-
ing IVIG. He was thereafter found to have low total immunoglobulin levels.
Flow cytometry revealed a total absence of CD19 B lymphocytes and non-
protective antibody responses to vaccination. Mutation analysis detected a
c.595A>T nonsense mutation of the BTK gene, confirming the diagnosis of
XLA. He was begun on monthly IVIG replacement therapy and transitioned
to weekly subcutaneous immunoglobulin replacement. He has remained infec-
tion free since beginning a regular replacement program. Discussion: Patients
with X-linked agammaglobulinemia often present with recurrent sinopulmonary
infections. However, this patient presented with atypical GBS that required
plasmapheresis and IVIG. Pulse IVIG therapy inadvertently resulted in inter-
vals without recurrent infection that likely contributed to a delay in his diag-
nosis of XLA. This case demonstrates the importance of considering primary
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A15
immunodeficiency in pediatric patients with a history of recurrent or severe
infections and atypical neurologic syndromes.
38
RESOLUTION OF ALCOHOL-INDUCED RESPIRATORY REAC-
TION FOR ASPIRIN EXACERBATED RESPIRATORY DISEASE
FOLLOWING ASPIRIN DESENSITIZATION.
C.J. Calais*, Rockville, MD.
Introduction: The purpose of this case is to shed more light on the link of
alcohol-induce respiratory symptoms with aspirin exacerbated respiratory dis-
ease(AERD). Rationale: There is a distinct link between alcohol-induced res-
piratory symptoms in patients with AERD. A recent questionnaire based study
of 50 patients which consisted of (4) clinical types (aspirin challenge confirmed
AERD, aspirin tolerant asthma, aspirin tolerance with chronic rhinosinusitis,
and a healthy control), characterized the prevalence of alcohol-induced reac-
tions to be highest in patients with AERD. We present a case of a patient with
confirmed AERD/Samter’s triad and alcohol-induced respiratory reaction that
experienced resolution of alcohol-induced symptoms with aspirin (ASA) desen-
sitization therapy. Methods: Review of clinical course, documentation as well
as ASA desensitization/challenge was conducted at Walter Reed National Mil-
itary Medical Center Allergy Clinic. Results: Our 56 year old patient had a
history of facial flushing and profuse rhinorrhea with ingestion of alcoholic
beverages, which arose concurrently with his diagnosis of severe recurrent nasal
polyposis, asthma, allergic rhinitis, anosmia, and ageusia. He first experi-
enced hypersensitivity to motrin in 2008 followed by ASA hypersensitivity in
2012 for which he related the symptoms of cephalic flushing, profuse rhinor-
rhea and ocular watering all of which mirrored his symptoms with alcohol
ingestion. ASA challenge/desensitization in 2014 elicited upper respiratory
symptoms and a reversible decline in FEV1 of >10% from baseline. Since the
desensitization therapy, he has remained on ASA 650mg twice daily and has
regained his sense of smell, taste, and can now tolerate alcohol consumption.
Conclusions: The pathogenesis of alcohol-induced respiratory symptoms asso-
ciation with AERD is unknown; however, current thought postulates that alco-
hol may have an inhibitory effect on the catabolism of leukotriene E4. This case
lends clinical evidence that bolsters the idea of a common pathway for both
conditions since ASA desensitization improved both disease processes. Clini-
cally, allergists should be cognizant of this link and the possibility that such
patients may be able to tolerate alcohol following successful aspirin desenti-
zation .
39
A SUCCESSFUL TREATMENT OF SOLAR URTICARIA WITH
OMALIZUMAB.
M. Chong*, M. Aquino, M. Davis-Lorton, L. Fonacier, Mineola, NY.
Background: Solar urticaria is a rare physical urticaria caused by ultravio-
let radiation. Managing solar urticaria can be challenging as treatment options
are limited to anti-histamines, sunscreen and UV light-hardening therapy, which
are usually ineffective. As Omalizumab has been shown to effectively treat
refractory chronic urticaria, we hypothesized that Omalizumab may be effec-
tive in the treatment of solar urticaria as well. We present a case of solar urticaria
treated successfully with Omalizumab. Case Report: A 29 year old male was
evaluated for a 9 year history of solar urticaria involving both exposed and
lightly covered skin areas. He noted improvement in his symptoms while work-
ing as a construction worker in Florida for 4 years. However, upon return to
New York 1 year ago he began to experience urticarial lesions every time he
was exposed to sunlight despite the use of high-dose antihistamines (Zyrtec
40mg or Allegra 360 mg daily) and sunscreen. His urticaria was not exacer-
bated by other physical factors. Challenge tests were negative to visible and
laser light. However, multiple erythematous macules developed within 15 min-
utes of sun exposure through a window pane and 5 minutes of direct sun expo-
sure on a different site. A skin biopsy of the macular lesion revealed a super-
ficial to deep perivascuar inflammatory cell infiltrate consisting of lymphocytes,
histiocytes, neutrophils and eosinophils. The biopsy and clinical findings were
consistent with a diagnosis of solar urticaria. The patient was placed on a
monthly trial of Omalizumab 300 mg SQ for a total of 3 doses. With daily chal-
lenges of sun exposure, the frequency of urticarial lesions significantly decreased
7 days after the first dose with complete control of urticaria after an additional
two doses of Omalizumab. Discussion: Omalizumab is a monoclonal anti-IgE
antibody that is FDA-approved for allergic asthma and chronic urticaria. A
few case reports have shown variable effectiveness of Omalizumab in the treat-
ment of solar urticaria; one case showed resolution, one showed improvement
ABSTRACTS: CONCURRENT SESSIONS
and the last case did not show any effect on solar urticaria. To our knowledge,
this is the first case reporting rapid symptom improvement within 7 days of
initiating therapy. Although the evidence is limited, Omalizumab may be con-
sidered in patients with solar urticaria that is refractory to standard therapies
with anti-histamines and sunscreen.
40
IGG4-RELATED DISEASE IN A PATIENT WITH ALLERGIC
RHINITIS, EOSINOPHILIA AND CHRONIC URTICARIA.
V. Bundy*, B. Geng, R. Kachru, M. Garcia-Lloret, Los Angeles, CA.
Introduction: The term Immunoglobulin G4-related disease (IgG4-RD)
refers to a newly recognized collection of fibroinflammatory disorders char-
acterized by tissue infiltration of IgG4-positive plasma cells and eosinophils,
obliterative phlebitis and elevated serum IgG4. While the clinical presentation
of IgG4-related disease will depend on the affected organ(s), the histopatho-
logical features, which are the cornerstone of the diagnosis, are strikingly sim-
ilar. Little is known about the pathogenesis of IgG4-RD, but TH2 cell responses
are activated at the affected sites and patients may present with concomitant
atopic symptoms. Case Presentation: A 66-year old Vietnamese man with a his-
tory of allergic rhinitis and chronic urticaria presented with a one year history
of worsening neck lymphadenopathy and bilateral parotid gland swelling. Lab-
oratory evaluation showed serum eosinophils 18.2%, IgE 270 mg/ml, total IgG
2870 mg/L, IgG1 640mg/dL, IgG2 1240mg/dL, IgG3 245mg/dL, IgG4
>300mg/dL, ESR 37mm/hr. Serum protein electrophoresis resulted in a total
protein 8.1gdL, albumin 52.7%, alpha 2 globulins 7.5%, beta globulins 6.3%,
gamma globulins 31.7%, with a possible monoclonal band present in the gamma
region. Histopathological analysis of lymph node biopsy found plasma cell
dyscrasia arising in the background of IgG4-related sclerosing sialadenitis.
Immunohistochemical studies detected sheets of monotypic plasma cells pos-
itive for IgG4 (IgG4 infiltrate >150/hpf), IgG (IgG4/IgG ratio 80-90%), CD138,
and Kappa light chain restriction, with periductal and perivascular onion-skin-
ning fibrosis. The lymphadenopathy and parotid swelling improved following
oral corticosteroid treatment. Discussion: Because of the intrinsic TH2 bias
that characterizes IgG4-related disease, patients’ initial clinical features may
suggest an allergic condition. The presence of lymphadenopathy, swollen parotid
or salivary glands or evidence of organ dysfunction should raise suspicion for
IgG4-RD. Prompt recognition is key because, if untreated, the expanding inflam-
matory lesions can potentially destroy the involved organ. Moreover, up to 16%
of patients develop malignancies during the course of the disease.
41
EOSINOPHILIC ESOPHAGITIS: IS THERE A FOOD ALLERGY
CONNECTION?
T.M. Nsouli*1, F.H. Al-Kawas2, N.Z. Diliberto2, C.M. Davis2, S.T. Nsouli2,
J.A. Bellanti2, 1. Burke, VA; 2. Washington, DC.
Rationale: Eosinophilic esophagitis (EoE) is a clinicopathological Th2-
driven atopic disorder with an escalating prevalence. The condition is charac-
terized by esophageal mucosal eosinophilic inflammation. Untreated EoE can
lead to irreversible damage of the esophagus. Random food elimination appears
to be effective; however, this regimen is empiric and is not evidence-based. The
goal of the present study was to investigate the association of EoE and food
allergy by means of an allergy evaluation, in order to determine the potential
pathogenic role of specific food allergen(s), and to avoid prolonged random,
unnecessary, and unsubstantiated empiric food elimination diet(s). Method: We
evaluated 54 patients (n=54; mean age= 43 years) with the diagnosis of EoE
based on clinical history of dysphagia, esophagogastroduodenoscopies (Fig-
ure 1), biopsies with > 15 eosinophils/high-power field. Patients underwent
food allergy evaluation by means of clinical history, allergy skin testing, and
in vitro specific IgE ImmunoCAP testing. Study participants eliminated the
putative offending specific food allergen for 16 weeks. Clinical and patholog-
ical improvement was assessed by a patient symptom scoring system (PSSS)
and by upper GI endoscopy with esophageal biopsy to monitor treatment
response. Results: The primary symptoms of EoE in our study included dys-
phagia (94%), food impaction (35%), and heartburn (96%). The common food
allergens detected included wheat (58%), dairy (53%), egg (35%), soy (28%),
peanut (25%) and tree nuts (21%). Avoidance of the above offending food aller-
gens for a 16-week period resulted in improvement of symptoms, with a decrease
(PSSS) of 98%, 100% and 90% in dysphagia, food impaction, and heartburn,
respectively. Mean average density esophageal eosinophilic infiltration (eos/hpf)
from mid-esophageal biopsies before and after specific food elimination diet
decreased from 36 to 6 eos/hpf. Amelioration and sustained remission occurred
VOLUME 113, NOVEMBER, 2014 A15
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A16
ABSTRACTS: CONCURRENT SESSIONS
in 82% of patients. Conclusion: The results of this study support the role of
food allergy in EoE and illustrate the need for a collaborative gastroentero-
logic/allergic approach not only for successful management of EoE, but also
for avoidance of unnecessary and potentially harmful, unsubstantiated exclu-
sion diets. This requires a multidisciplinary collaboration of gastroenterolo-
gists, allergist-immunologists, pathologists, and nutritionists.
Endoscopic Esophageal View:
Multiple Rings suggestive of EoE
42
THE PREVALENCE OF PEDIATRIC FOOD ALLERGY IN URBAN
KANSAS CITY.
A.L. Humphrey*, M. Reddy, J. Shroba, C. Ciaccio, Kansas City, MO.
Introduction: The prevalence of food allergy has been difficult to assess,
but previous studies report a range of 3.4%-8% in the pediatric population. It
is unclear how or if geographic factors affect the prevalence of this disease. As
our institution is the primary provider of pediatric allergy/immunology con-
sultation within the urban core of Kansas City, we aimed to estimate the preva-
lence of food allergy in children residing in this region. Methods: This study
was approved by the local Institutional Review Board. Pediatric outpatient clinic
data from 2004-2014 was obtained through our hospital’s electronic medical
record. Patients with ICD-9 codes 995.3, 995.60-995.69, 995.7, 693.1, 708,
V15.01-V15.05, and V15.09 were selected. United States Census data was used
to estimate total population by ZIP code. Multiple encounters by the same
patient were consolidated. Results: Representing 545 unique ZIP codes, 12,612
distinct food allergic children were seen from 2004-2014. Two thousand six
hundred and fifty nine children were identified within the city’s urban core
(26 ZIP codes). The average prevalence of food allergy in this urban core was
5.2% with the range being 1.6%-10.3%. Conclusion: The prevalence of pedi-
atric food allergy in urban Kansas City over the past decade is consistent with
previously reported values. Further investigation is needed to determine if vari-
ations exist between urban, suburban, and rural settings.
43
CHALLENGES WITH MEASUREMENT OF IGE ANTIBODIES IN
EOSINOPHILIC ESOPHAGITIS, PEANUT ALLERGY, AND MAM-
MALIAN MEAT ALLERGY.
A. Tripathi*1, L.J. Workman1, S.P. Commins1, R. Hamilton2, E.A. Erwin3,
T.A. Platts-Mills1, 1. Charlottesville, VA; 2. Baltimore, MD; 3. Columbus,
OH.
Background: In the investigation of food allergy syndromes, serum assays
detecting IgE antibodies (Ab) to food allergens use whole extracts on the solid
phase, which contain specific allergen components in varying amounts. The
interpretation of results assumes that the causative allergen components are
adequately represented in the extract and that the presence and level of specific
IgE titer to the whole extract of the relevant food(s) are diagnostic of the syn-
drome. IgE assays for beef or pork can underestimate the IgE Ab to a minor
component of mammalian meat, αgal. The inciting food allergens in
Eosinophilic Esophagitis (EoE) remain unclear, although IgE Ab to milk, wheat,
soy, and peanut are frequently present in low titer. Method: IgE Ab to relevant
allergens and their components were measured in the sera of adults and chil-
A16 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
dren with peanut allergy, delayed anaphylaxis to mammalian meat, or esophageal
biopsy-diagnosed EoE. Assay methods included: ImmunoCAP (CAP) using
whole and component extracts, CAP assays on serial dilutions (1:2 to 1:8) of
sera, and ImmunoCAP ISAC (biochip assay for 112 purified allergens).
Results:Analysis with ISAC correlated well with results using component-spe-
cific CAP assays for both peanut allergens (peanut allergy) and inhalant aller-
gens (EoE). By contrast, no positive results for food allergens were found by
ISAC in EoE sera that were positive for milk, wheat, or soy by CAP. Dilution
assays showed no change (undiluted value vs. calculated titer) for peanut in
peanut allergy sera or inhalants (dust mite and cat) in EoE sera in contrast, cal-
culated titers up to six times the undiluted value were noted for foods in EoE
sera (milk, wheat, and peanut) and in mammalian meat allergy sera (beef and
pork). CAP assays for 5 milk components revealed positivity to minor com-
ponents in over 50% of EoE sera. CAP assays for αgal revealed positivity in
100% of patients presenting with delayed anaphylaxis to mammalian meat.
Conclusion: Differences in the results of the dilution assays demonstrate that
assaying undiluted sera can significantly underestimate IgE Ab levels if the IgE
Ab are directed against a quantitatively minor component of the extract on the
solid phase. These results strongly suggest that the IgE Ab to milk and other
foods in EoE sera are directed against a minor component that has not yet
been identified.
44
EMERGENCY EPINEPHRINE USE FOR FOOD ALLERGY REAC-
TIONS IN CHICAGO PUBLIC SCHOOLS.
R. Gupta*1, L. DeSantiago-Cardenas2, V. Rivkina1, 1. Chicago, IL;
2. Phoenix, AZ.
According to the CDC, food allergy prevalence has increased by 50%
between 1997 and 2011. Currently, approximately 1 out of every 13 children,
or 2 children per classroom, has a food allergy. In addition, it is estimated that
more than 15% of school aged children with food allergies have had a reaction
in school and that 20-25% of epinephrine administrations in schools involve
individuals whose allergy was unknown at the time of the reaction. For this rea-
son, it is important for schools to have undesignated emergency epinephrine
available for use in the event of an anaphylactic reaction. Purpose: The aim of
this presentation is to demonstrate how Chicago Public Schools (CPS) was the
first large urban school district in the United States to develop and implement
a comprehensive stock epinephrine policy in accordance with state guidelines
and present Year 1 findings. Significance: Understanding how CPS developed
and implemented their Emergency Epinephrine Initiative will help districts
across the United States appreciate the benefits and challenges of such an under-
taking. Methodology: After updating a key health-related policy to include Dis-
trict Issued Emergency Epinephrine, EpiPens were distributed to all schools in
the district prior to the beginning of the 2012/2013 school year. Data was col-
lected on District Issued EpiPen usage based on school nurse progress notes
and principal reporting mechanisms. Findings: During Year 1 of the CPS Dis-
trict Issued Emergency Epinephrine Initiative, 38 lives were saved because of
the availability of stock epinephrine in schools across Chicagoland. Of these
38 individuals, 2 were school staff, and 36 were students between the ages of
3 and 19, with more than half of the reactions being first time incidents. Con-
clusion: After evaluating the distribution and tracking the usage of District
Issued EpiPens, the CPS Office of Student Health and Wellness has learned
key lessons which will inform the strategy for future years of the District Issued
Emergency Epinephrine Initiative. As the first large urban school district to
implement such a project, CPS is poised to be a national model of what a school
district can do to save the lives of its students.
45
OCCUPATIONAL AND ENVIRONMENTAL RISK FACTORS FOR
CHRONIC RHINOSINUSITIS: A SYSTEMATIC REVIEW.
A. Sundaresan*1, A. Hirsch1, M. Storm1, B. Schwartz2, 1. Danville, PA;
2. Baltimore, MD.
Introduction: Chronic rhinosinusitis (CRS) is a heterogeneous inflamma-
tory upper airway disease of significant morbidity. Environmental exposures
are thought to trigger sinonasal inflammation but no prior studies have sys-
tematically reviewed what is known about key exposures and how these influ-
ence CRS. Methods: We searched PubMed database for relevant peer-reviewed
articles. We included articles if they assessed associations of occupational and
environmental exposures with “chronic” sinusitis. Results: Literature search
yielded 1080 references and 48 articles met the inclusion criteria. Of these 37,
8 and 3 studies assessed occupational or environmental exposures or both,
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A17
respectively. The quality of exposure assessment ranged from measured expo-
sure by validated questionnaire (n=2) to exposure surrogates, including plant
(30 exposures), job title linked to job exposure matrices (n=3), geographic infor-
mation system (n=2) to self-reported exposures without validation (n=16). Con-
cerning outcome definition, no studies used the current clinical EPOS CRS
definition (symptoms plus objective evidence of inflammation). Studies were
thus classified based on the likelihood that their CRS definition represented
true CRS: “probable” n = 17 for objective criteria; “possible” n = 8 for vali-
dated definition without objective evidence; and “least likely” n = 23 for vary-
ing definitions. Associations were assessed for the “probable” or “possible”
studies. Fishing, grain farming, diving, cotton, pickling and glass blowing,
World Trade Center rescue work (n=1 study for each), self-reported work expo-
sure (n=5), second hand smoking (n=5), wood stove use (n=1) and air pollu-
tion (n=2) were the exposures that showed a positive association with CRS.
Since most exposures were only evaluated by one study, no between-study
evidence could be assessed. Among exposures with 3 or more studies, unclear
or non-quantitative exposure assessment, biased study design, varied outcomes
(eg. second hand smoking n=1 incident CRS, n=3 difficult-to-treat CRS with
3 different outcomes), and approach to analysis did not allow rigorous com-
parison or meta-analysis Conclusions: The published literature offers little
evidence of whether and how occupational and environmental exposures may
be associated with CRS. Studies are needed using current clinical case defini-
tions and rigorous approaches to exposure assessment.
46
EFFECT OF NASAL POLYPOSIS ON NOCTURNAL SLEEP DIS-
TURBANCES, DAYTIME SLEEPINESS, AND SLEEP SPECIFIC
QUALITY OF LIFE DISTURBANCES IN PATIENTS PRESENT-
ING WITH ALLERGIC RHINITIS.
K. Kumar*, A. Shah, Delhi, India.
Introduction: Allergic rhinitis (AR), chronic rhinosinusitis (CRS) and nasal
polyposis (NP) are known to coexist frequently. AR and CRS impair the qual-
ity of life (QoL) and also adversely affect the quality of sleep. NP remains
largely undiagnosed and is thought to independently affect negatively the qual-
ity of sleep in patients with AR. Methods: The study comprised 106 consecu-
tive patients with AR (males/females, 60/46), between 18 to 60 years, enrolled
from outpatients department of VP Chest Institute, University of Delhi. IRB
approval and informed consent was obtained from all research subjects. AR
was diagnosed according to “Allergic Rhinitis and its Impact on Asthma” guide-
lines. CT-PNS, done in all patients, assessed the presence of CRS/NP. The
patients were divided into three groups: AR alone (group 1), AR with CRS
without NP (group 2) and AR with CRS and NP (group 3). To assess the sever-
ity of the disease and impact on QoL, patients responded to Visual Analogue
Scale (VAS) and Sinonasal Outcome Test 22 (SNOT-22) respectively. To study
the effect of NP on sleep, patients responded to Nocturnal Rhinoconjunctivi-
tis Quality of Life Questionnaire (NRQLQ), the Epworth Sleepiness Scale
(ESS) and the Pittsburgh Sleep Quality Index (PSQI). Results: The 106 patients
were categorised as follows: group 1 with 34 (32%), group 2 with 36 (34%)
and group 3 with 36 (34%) patients. Mean global VAS score increased from
7.12 in group 1 to 7.66 in group 2 and 8.03 in group 3 (P=0.004). Mean SNOT-
22 score increased from 45.47 in group 1 to 66.83 in group 2 and 70.22 in group
3 (P=0.001). Similarly, mean NRQLQ score increased from 32.94 in group 1
to 49 in group 2 and 63.19 in group 3 (P=0.002). Mean ESS score too increased
from 9.76 in group 1 to 11.14 in group 2 and 12.24 in group 3 (P=0.001). Mean
global PSQI score also increased from 7.17 in group 1 to 9.67 in group 2 and
13.58 in group 3 (P=0.001). Conclusions: NP occurs in half of the patients with
AR and associated CRS. The presence of NP significantly increased the sever-
ity of the disease and negatively impacted the QoL. Instruments to assess the
effect on sleep highlighted the significant adverse impact of NP on the qual-
ity of sleep. Its presence denotes a more severe form of the disease, thus empha-
sising the need for early diagnosis.
47
VERNAL KERATOCONJUNCTIVITIS AS A SYSTEMIC DISEASE.
M. Duse*, A. Zicari, M. Nebbioso, F. Occasi, L. Leonardi, A. Zicari, Rome,
Italy.
Vernal keratoconjunctivitis (VKC) is a chronic disease affecting conjunc-
tiva even though the immunopathogenetic mechanisms underlying this inflam-
mation are unclear. Although many clinical and laboratory findings support the
presence of an IgE-dependent immediate hypersensitivity reaction in VKC [2],
the conflicting results concerning the association between VKC and atopy sug-
ABSTRACTS: CONCURRENT SESSIONS
gest that an IgE-independent mechanisms could also be involved. High-mobil-
ity group box protein 1 (HMGB1) has been recently identified as an important
proinflammatory mediator with many characteristics similar to classic proin-
flammatory cytokines The aim of our study is to investigate serum levels of
HMGB1 and circulating sRAGE in children affected by VKC before and after
treatment with cyclosporine A (CsA) eye drops and in a group of otherways
healthy children. Methods Twenty-four children affected by VKC aged between
5 and 12 yrs of life were enrolled. Twenty-four healthy children without atopy,
ocular, and systemic disease, cross-matched for sex and age to patients affected
by VKC, represented the controls. All children affected by VKC were treated
with CsA 1% eye drops for 4 wks, and blood samples were collected before
and 2 wks after the end of treatment while the controls underwent to a single
blood sample at the time of enrollment. Statistical analyses were performed
using SPSS (Statistical Package of Social Sciences, Chicago, IL, USA) soft-
ware version 19. Ethical Committee approuved the study. Results Serum basal
levels of HMGB1 and sRAGE were higher in children with VKC when com-
pared with controls while, in patients affected by VKC, no difference was
detected between atopic and non-atopic, and between ANA-positive and ANA-
negative children. A significant reduction in serum HMGB1 and sRAGE lev-
els was found after the therapy while CsA serum levels were negative. Dis-
cussion Our study gives a support to the definition of VKC as a systemic
inflammation in which HMGB1 and its soluble receptors could play a role. We
did not find any detectable levels of systemic CsA at the end of our study, but
serum levels of HMGB1 and sRAGE showed a significant reduction after 4
wks of therapy. Our findings lead us to hypothesize that the topical adminis-
tration of CsA may influence not only the ocular immunological responses but
also the regulation of systemic inflammation.
48
PERIOSTIN TISSUE EXPRESSION AND ITS POTENTIAL VALUE
AS A SERUM BIOMARKER IN ALLERGIC RHINITIS.
R. Patel*1, P. Howarth1, E. Beattie2, R. Modeste2, A. Salapatek2,
1. Southampton, United Kingdom; 2. Mississauga, ON, Canada.
Background: Serum periostin (SP) has been proposed as a potential bio-
marker of TH2-related airway inflammation in asthma. However, allergic rhini-
tis (AR), another TH2 disease, commonly co-exists with asthma. There is lim-
ited information on periostin expression in rhinitis and whether this could
confound the use of SP as a biomarker in allergic asthma. Here, we aimed to
1) To compare the presence and extent of periostin immuno-expression in nasal
biopsies from subjects with both IN and OUT-OF-season (grass pollen) AR,
perennial (house dust mite, HDM) AR, healthy subjects and in subjects with
non-atopic rhinitis; 2) To assess whether airborne ragweed challenge affects
SP levels in OUT-OF-Season ragweed-allergic subjects. Methods: Periostin
immunostaining was assessed in nasal biopsies obtained from subjects with
IN-season AR (n=17), perennial AR (n=13), non-atopic rhinitis (NAR, n=9),
OUT-OF-Season subjects 6hrs after a nasal allergen challenge (NAC) (n=9)
and healthy (n=9) and non-rhinitic subjects (n=9) (Figure 1). Serum SP was
evaluated in subjects with ragweed-induced seasonal AR (n=15) and healthy
(non-rhinitic, HNV) controls (n=5) before and after a 4 hour exposure to rag-
weed allergen in an environmental exposure chamber (EEC) on 2 consecutive
days. Results: The extent of nasal biopsy periostin immuno-expression was sig-
nificantly increased IN-Season AR (p<0.05), OUT-OF-Season NAC AR
(P<0.05) and perennial AR (p<0.05) compared to non-allergic rhinitis and
healthy subjects. No significant differences were noted between seasonal and
perennial AR groups (p=0.950) or between healthy and non-atopic rhinitis
groups (p=0.233) (Figure 1). There were no significant differences seen in SP
after ragweed challenge compared to HNV studied in the EEC. Conclusion:
Mucosal but not SP expression is increased in both seasonal and perennial AR
compared to non-atopic rhinitis and HNV controls. This suggests SP does not
reflect local nasal inflammation and is therefore not a reliable systemic bio-
marker for AR. Concomitant nasal disease should thus not interfere with the
value of SP as a biomarker in asthma.
VOLUME 113, NOVEMBER, 2014 A17
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A18
ABSTRACTS: CONCURRENT SESSIONS
Figure 1: Periostin staining in Allergic Rhintis Phenotypes.
49
SERUM 25-HYDROXYVITAMIN D LEVELS IN PATIENTS WITH
EOSINOPHILIC ESOPHAGITIS.
M. Slack*1, P.U. Ogbogu1, T.A. Platts-Mills2, E.A. Erwin1, 1. Columbus,
OH; 2. Charlottesville, VA.
Rationale: Studies have suggested that vitamin D deficiency is associated
with increased prevalence of atopic disorders such as asthma, food allergy,
and atopic dermatitis; however it has never been assessed in eosinophilic
esophagitis (EoE). Our objective was to determine the levels of 25-hydrox-
yvitamin D in a cohort of patients with EoE. Methods: We measured total serum
25-hydroxyvitamin D using liquid chromatography with tandem mass spec-
trometry in adults (n=35) and children (n=34) with EoE. We compared the
results to our patient demographics, EoE specific disease parameters, and mark-
ers of allergy using multiple logistic regression. Results: The median vitamin
D level was 29 ng/ml. Patients with insufficient vitamin D (<30 ng/ml) were
older (age 25.5 compared with 16.2 years) and had a higher body mass index
(BMI) (median 25.2 compared with 19.8, p<0.001). Peak esophageal eosinophil
counts were not different in vitamin D insufficient and sufficient patients; how-
ever, higher vitamin D levels were associated with higher tissue eosinophil
counts (R=0.26, p<0.05). While there were no differences in total IgE or titers
of specific IgE in insufficient and sufficient patients, positive skin prick test
to peanut was more common in patients who were vitamin D insufficient with
odds ratio (O.R.) 5.98 (95% CI 1.51-23.7). This result remained significant in
a logistic regression model in which the results were adjusted for age and BMI
(O.R. 7.57 (95% CI 1.66-34.6). Conclusions: In our group of adult and pedi-
atric patients with EoE, vitamin D levels were low overall (median <30 ng/ml)
indicating that this is a population at risk for vitamin D insufficiency. Inter-
estingly lower vitamin D levels were not associated with higher esophageal
eosinophil counts. The only marker of allergy associated with having an insuf-
ficient level in EoE patients was positive skin prick test to peanut.
50
ALLERGY MISCONCEPTIONS AMONG PHYSICIANS AT ACA-
DEMIC MEDICAL CENTERS.
K.J. Wada*1, S. Montandon2, T. Green2, D. Stukus1, 1. Columbus, OH;
2. Pittsburgh, PA.
Poor understanding of allergic conditions can influence patient care through
unnecessary diagnostic testing and/or management thus negatively impacting
quality of care, cost, and outcomes. We conducted an anonymous electronic
survey of pediatric (Ped) and internal medicine (IM) residents and faculty physi-
cians at two tertiary care academic medical centers. Participants completed a
6 (IM) or 9 (Ped) item questionnaire regarding allergy evidence and/or guide-
lines. 409 surveys were collected (Ped faculty=129, Ped residents=106, IM fac-
ulty=78, IM residents=96). An elective rotation in allergy (A/I) was completed
by <50% of faculty and <20% of residents. When asked for the best first treat-
ment for a patient experiencing urticaria and emesis immediately following
ingestion of a known food allergen, physicians reported: epinephrine=64%, 1st
generation antihistamine=31%, H2 antagonist=3%, prednisone=1%. Only 50%
of all IM physicians answered epinephrine (p<0.0001). Regarding allergies that
should be inquired about prior to ordering an imaging study with radiocon-
trast media: iodine=80%, shellfish=40%, artificial dye=21%. IM physicians
reported iodine (89 vs 73%) and shellfish (47 vs 34%) more than Ped physi-
cians (p<0.05). Regarding contraindicated (CI) immunizations in egg allergic
patients, they answered: influenza=85%, yellow fever=49%, measles, mumps,
A18 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
rubella (MMR)=18%, varicella=8%, rabies=4%. Ped physicians answered cor-
rectly regarding influenza (not CI) and yellow fever (CI) (49,50%) more than
IM physicians (12,16%)(p<0.05). IM residents (22%) answered MMR more
than any other group (p<0.05). Only 27% of all Ped physicians correctly iden-
tified common causes of IgE mediated food allergy in children <4 years old:
egg=69%, milk=40%, whereas strawberry=34%, artificial food coloring=13%.
The majority of Ped physicians (47%) responded that skin prick testing for food
or inhalant allergens is not accurate or reliable until 3 years old. Of all physi-
cians, 58% answered that medications may interfere with serum IgE results and
38% felt serum IgE testing was a useful screening test to detect the presence
of food allergy. Our survey identified substantial knowledge gaps regarding
common A/I conditions among IM and Ped faculty and residents at academic
medical centers. Improved education and quality improvement strategies are
needed to help provide the most accurate and up to date medical care for patients.
51
INCREASED COMORBIDITY OF ANTERIOR SEGMENT DIS-
EASE IN AN ALLERGIC POPULATION.
B.P. Bielory*1, J. Pepose2, E. Donnenfeld3, M. McDonald3, K. Nichols4,
L. Bielory5, 1. Valhalla, NY; 2. St Louis, MO; 3. Lynbrook, NY;
4. Houston, TX; 5. Springfield, NJ.
Rationale: The purpose of this study was to evaluate the prevalence and
severity of dry eye disease (DED) in a consecutive series of patients present-
ing to an allergy practice. Methods: 68 consecutive patients were tested for tear
hyperosmolarity and polled for binary DED symptoms: fluctuating vision, lens
discomfort, light sensitivity, watery eyes, tired eyes, redness, burning, itching
and grit. Data were compared to 9,407 subjects polled nationally across oph-
thalmologist and optometrist practices. Results: Of the patients reporting to the
allergy clinic, 42.6% were highly symptomatic (reporting ≥ 5 symptoms), while
15.8% reported ≥ 5 symptoms nationally. However, only 37.5% of the symp-
tomatic subjects were hyperosmolar in the allergy clinic, compared to 51.6%
nationally. Although a smaller prevalence, the hyperosmolar subjects present-
ing to the allergy center displayed a significantly higher severity, averaging
337±28 mOsm/L vs. 323±16 mOsm/L nationally (p < 0.0001). Non-DED sub-
jects were clinically identical, averaging 295.7 mOsm/L vs. 297.8 mOsm/L
nationally, which ruled out the possibility of instrumental variation or analyt-
ical drift accounting for the difference in severity. These data suggest that dry
eye in the presence of allergy may be more severe than dry eye alone, and that
symptoms alone were insufficient to determine diagnosis. Conclusions: There
is a significant overlap in symptoms of both allergy and dry eye disease. Objec-
tive testing can help differentiate between the two etiologies. Further, con-
comitant DED in the presence of allergy may be more severe than DED alone.
52
CORRELATION OF HOUSE DUST NICOTINE WITH REPORTED
SMOKING HISTORY.
C.S. Barnes*, F. Pacheco, R. Allenbrand, L. Gard, C. Ciaccio, Kansas
City, MO.
Introduction: Exposure to cigarette smoke is a major asthma trigger and
has a detrimental impact on pediatric asthma. Allergists frequently estimate
pediatric exposure to cigarette smoke through questions directed to parents or
care givers. To evaluate the relationship of reported indoor smoking to actual
levels of nicotine measured in house dust we performed the following studies.
Methods: Dust was collected from homes enrolled in the Kansas City Safe
and Healthy Homes Project. Project enrollees were asked a series of questions
concerning smoking in the home including the number of persons in the home
who smoke and if anyone was allowed to smoke inside the house. A conven-
ience sample of 58 homes containing 0 to 5 individuals who declared they
smoked cigarettes was selected for analysis. For all samples, nicotine was
extracted from 0.2 grams of dust and analyzed by immunoassay using com-
mercially available reagents. For conformation in one-third of samples nico-
tine was extracted from 0.5 grams of dust and analyzed for nicotine by gas chro-
matography mass spectroscopy (GCMS). Results: Enzyme immunoassay results
indicated nicotine values for the 58 dusts ranged from 0 to 330 nanograms per
gram of dust. GCMS analysis results ranged from 0 to 340 nanograms per gram
of dust. Correlation between the two methods was strong (r = 0.90). The lower
limit of detection for the immunoassay was calculated at 4.0 nanograms per
gram of dust and for the GCMS at 100 nanograms per gram of dust. Dust-
borne nicotine concentrations were greatest in homes where up to 3 declared
smokers resided. The highest nicotine concentrations came from houses with
declared smokers who smoked in the home. Dustborne nicotine concentrations
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A19
in homes where smoking was not permitted inside the house ranged from 0 to
50 nanograms per gram of dust. Conclusion: Nicotine concentration in house
dust can be measured by commercially available immunoassay methods. Homes
where smoking was permitted had higher dust nicotine than homes where smok-
ing was not permitted. However, homes where smoking was declared not per-
mitted were not without nicotine in house dust.
53
DEVELOPMENT OF A NONINVASIVE SCREENING ASSAY FOR
EOSINOPHILIC ESOPHAGITIS.
K.M. Maples*, T.C. Burch, A.M. Perkins, K.M. Cunnion, N.K. Krishna,
H. Minto, L.K. Willis, J.O. Nyalwidhe, Norfolk, VA.
Introduction: Currently there is no noninvasive assay to evaluate for the
possibility of eosinophilic esophagitis (EoE) in patients with suggestive symp-
toms. The current standard of diagnosis and monitoring is endoscopy but this
is an imperfect approach. Endoscopy is invasive, esophageal epithelial
eosinophilia is not uniform, there is not a standardized high-power field (hpf)
size and current diagnostic thresholds for eosinophils per hpf correlate poorly
with clinical measures of disease. Identification of a truly noninvasive bio-
marker for EoE and a standardized, reliable assay is an important unmet med-
ical need. Methods: Urine samples were obtained from patients with biopsy
proven EoE (n=27) and from atopic controls (n=24) without eosinophilic
esophagitis. We used a targeted Single Ion Monitoring LC-MS-MS strategy to
quantify the levels of 3-Bromotyrosine (3-BrTyr) in creatinine-normalized urine
samples. Descriptive statistical analysis was performed for 3-BrTyr level fol-
lowing stratification and compared using the Mann-Whitney U test. Results:
The median urine 3-BrTyr level was 12-fold higher for all subjects with EoE
(169.50 picograms 3-BT/400 mg creatinine/dL, IQR 40.74-412.86) compared
with atopic controls (12.87, IQR 3.51-114.69 (P=.01)). In order to evaluate
the potential utility of urine 3-BrTyr as a screening test we performed a subset
analysis evaluating only newly diagnosed and untreated patients with EoE com-
pared with atopic controls. The median urine 3-BrTyr level was 13-fold higher
for untreated subjects with EoE (172.62, IQR 81.30-327.60) compared with
atopic controls (12.87, IQR 3.51-114.69 (P=.0459)). Using a threshold cutoff
of 145 yields a sensitivity of 67% and a specificity of 79%. Thus, a 3-BrTyr
level<145 yields a negative predictive value of 90.48% in atopic individuals.
Conclusions: This proof-of-concept study demonstrates a reliable assay for uri-
nary 3-BrTyr. Further, urinary 3-BrTyr has the potential to be a useful, nonin-
vasive biomarker in the diagnosis and management of EoE.
54
ANALYSIS OF THE 2012 US MEDICARE REIMBURSEMENT
DATA: PUTTING ALLERGY/IMMUNOLOGY DATA INTO CON-
TEXT.
A.S. Nickels*, G. Volcheck, Rochester, MN.
Introduction: Released in April 2014 by the Center for Medicare and Med-
icaid Services (CMS),the Provider Utilization and Payment Data Physician and
Other Supplier Public Use File includes reimbursement information on 6000
different procedures/ services reimbursed to over 880,000 healthcare providers
in 2012. We have analyzed this database hoping to better understand how
Allergy/Immunology providers are contributing to the care of the Medicare
population. Methods: Using the Physician and Other Supplier PUF Aggregate
file, the average number of unique beneficiaries seen, total paid by medicare
to each physician, and the average amount paid per unique beneficiary was cal-
culated. These values were calculated for the other provider types for contex-
tualization of the results across the healthcare field. We excluded any organi-
zational provider types, non-MD/DO provider types, non-face-to-face diagnostic
specialties, as well as specialties with less than 100 providers. Eighty nine
providers types are included in the Physician and Other Supplier PUF with 53
provider types included in the final analysis. Focusing on Allergy/Immunol-
ogy providers only, we calculated the average number of unique beneficiaries
seen as new or established patients was also calculated from the database.
Results: A total of 3119 Allergy/Immunology providers saw for an average of
160.4 (SD ±179.6) unique Medicare beneficiaries and collected an average of
$52,762 (SD ± $103,425). Among Allergy/Immunology providers, the average
amount paid per unique beneficiary was $313 (SD ±$449). Of the 53 provider
types included in the final analysis, Allergists ranked 45th in average number
of unique beneficiaries seen, 40th in average amount collected from CMS, and
16th in average amount paid per beneficiary in 2012. Allergy/Immunology
providers billed for an average of 35.2 (SD ± 31.9) unique Medicare benefici-
aries for new patient visits (all types). The average number of established visit
ABSTRACTS: CONCURRENT SESSIONS
by A/I Providers were 123.34 (SD±178.5) for an average of 69.1 (SD±77.1)
unique Medicare beneficiaries. Conclusions: The Physician and Other Supplier
PUF provides a unique opportunity to better understand how Allergy/Immunol-
ogy providers fit into the overall healthcare landscape. Allergy/Immunology
providers can use this data better to understand how their practice compares to
national norms.
55
PRENATAL AND EARLY LIFE DETERMINANTS OF ATOPY:
PRELIMINARY FINDINGS OF THE KINGSTON ALLERGY
BIRTH COHORT.
M.L. North, J. Thiele, V. Omana, M. Soliman, A.K. Ellis*, Kingston, ON,
Canada.
Background: Many authorities have recognized that gene-environment inter-
actions likely play a key role in the developmental origins of allergy, now known
to be mediated largely by epigenetic modifications. Prospective epigenetic stud-
ies, beginning in utero involving the collection of umbilical cord blood pro-
vides a window into the prenatal environment and a prospective sample to iden-
tify epigenetic markers that precede the development of allergy. Methods: The
Kingston Allergy Birth Cohort (KABC) now includes over 400 children born
in Kingston, Ontario, and surrounding rural areas with mother/child pairs
recruited during the prenatal period, many of whom are between 18mo to 3y
of age. 60 mother/child pairs thus far have returned to undergo skin testing
(common environmental and food panel) and surveys completed regarding
symptoms of potential atopic disease in the child as well as relevant home and
dietary exposures in the first 2y of life. Some children have also been evalu-
ated in local Allergists offices for suspected allergy. Results: Of 60 children
evaluated thus far, 11 (18.3%) demonstrated at least one positive SPT: 8 had
positive SPT to a food allergen, only 4 of whom had a clinical history of sup-
porting food allergy, however. 5 children had at least one positive environmental
SPT, 2 of which had symptoms suggestive of early asthma. On preliminary
analysis, factors associated with, or trending with, positive SPT include furry
pet ownership (P=0.038; Fisher’s Exact Test), early-life second hand smoke
exposure (P=0.1) and breastfeeding for less than 3 months (P=0.074). Con-
clusions: Data collection is ongoing. Our early high rate of atopy likely reflects
interest-bias from parents concerned about allergies. Pets, second-hand smoke
and breastfeeding will be further explored. We anticipate epigenetic analysis
of cord blood from atopic children compared to age/gender-matched controls
will provide a window into the prenatal environment and potentially identify
biomarkers that precede allergic disease
56
THE ASSOCIATION OF HOUSEHOLD AIR POLLUTION WITH
ALLERGIC RESPIRATORY DISEASES IN CHILDREN.
R. Kumar*, K. Singh, U. Mehto, S. Nagar, R. Prasad, Delhi, India.
Background: Indoor air pollution is the third leading cause of disease bur-
den in South East Asia as per Global burden of disease study 2010. Children
are much more susceptible to household air pollutants as they spend most of
their time indoors. The present study was thus planned to assess the effect of
indoor air pollution on childhood asthma and/or allergic rhinitis. Methods: The
present study is a cross sectional study to assess the difference in household
air quality in houses having children (<17 years age) with or without asthma
and/or allergic rhinitis in a rural setting (Village Khanpurjupti, Loni, Ghazi-
abad) of Delhi NCR region. Seventy households were selected in which none
of the child had symptoms of asthma and/or rhinitis while the other seventy
households had at least one child with asthma and/or rhinitis. A standard ques-
tionnaire was filled for all children enrolled in study, information was collected
from parents of child during the study and potential pollutant sources were
identified in their residence. PM 2.5 was measured by using UCB Particle and
Temperature Sensor (UCB-PATS) from Berkley Air monitoring group,
USA.VOCs were measured by using Phocheck Tiger PID, Ion Science limited,
UK. The measurements of PM 2.5 and VOC were done at an interval of 10 min-
utes in each of 140 households for a day. Result: There were a total of 108 chil-
dren (52 asthma alone, 20 allergic rhinitis alone and 36 with co-existent asthma
and allergic rhinitis) in the 70 houses having children affected with asthma
and/or rhinitis. The level of pollutants was found to be twice higher in affected
children houses as compared to control houses. The average PM2.5 levels were
significantly higher (9.68mg/m3vs 4.31mg/m3; p 0.011) in affected houses as
compared to controls. Similarly VOCs levels were higher in these houses (2.222
ppm vs 1.161 ppm; p 0.128) but could not reach statistical significance. It was
also seen that houses of children with asthma and/or rhinitis had higher sec-
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A20
ABSTRACTS: CONCURRENT SESSIONS
ond hand smoke, kerosene and biomass fuel use. Conclusion: Household air
pollution from smoking, kerosene and biomass fuel combustion results in an
increased levels of PM2.5and VOCs in household air, which may be responsi-
ble for increased level of asthma and/or allergic rhinitis in children.
57
PATTERNS OF RESPONSE IN CHRONIC IDIOPATHIC/SPON-
TANEOUS URTICARIA (CIU/CSU) PATIENTS TREATED WITH
OMALIZUMAB IN TWO RANDOMIZED DOUBLE-BLIND
PLACEBO-CONTROLLED CLINICAL TRIALS (ASTERIA I AND
ASTERIA II).
A. Kaplan*1, E. Antonova2, B. Trzaskoma2, K. Raimundo2, S. Khalil3,
T. Omachi2, J. Zazzali2, 1. Charleston, SC; 2. South San Francisco, CA;
3. Basel, Switzerland.
Introduction: Little is known about how quickly chronic idiopathic/spon-
taneous urticaria (CIU/CSU) patients respond to omalizumab treatment and
for how long they maintain their response. We report patterns of treatment
response from ASTERIA I and ASTERIA II (pooled). Methods: Subjects were
randomized 1:1:1:1 and received placebo (PLB) or omalizumab 75, 150, or 300
mg (OMA75, OMA150, OMA300) every 4 weeks for 3 (ASTERIA II, n=322)
or 6 (ASTERIA I, n=318) doses. Patients completed the Urticaria Patient Daily
Diary (twice-daily), from which a daily Urticaria Activity Score (UAS) was
calculated; the 7-day sum of UAS is given as UAS7. Response was defined in
two ways: (1) well-controlled urticaria (UAS7≤6) and (2) complete response
(itch and hive free, UAS7=0). The duration of response was defined as the
percentage of the treatment period, during which patients experienced their
responses. IRB approval and informed consent were obtained from all research
subjects. Results: From baseline to week 12, UAS7≤6 was achieved at some
point in time by 28% of PLB, 49% of OMA75, 56% of OMA150, and 73% of
OMA300 patients; for UAS7=0: 13% of PLB, 26% of OMA75, 33% of
OMA150, and 53% of OMA300 patients. During the 12-week treatment period,
patients who reached a UAS7≤6 at some point in time, had this level of response
for a mean percent of time of 45% (PLB), 42% (OMA75), 54% (OMA150) or
65% (OMA300); for UAS7=0 the mean percent of time was 34% (PLB), 29%
(OMA75), 37% (OMA150), or 52% (OMA300). The median time to achieve
UAS7≤6 was 10 weeks (OMA150) and 4 weeks (OMA300) and to achieve
UAS7=0 was 10 weeks (OMA300). Less than 50% of patients achieved UAS7≤6
in PLB and OMA75 and UAS7=0 in PLB, OMA75, and OMA150, thus we
did not calculate their median time to respond. Conclusion: More CIU/CSU
patients in OMA300 achieved well-controlled or complete responses than
patients in other treatment arms. OMA300 patients achieved their responses
sooner and maintained them for longer than those in any other arm. These results
provide additional insights about how CIU/CSU patients might respond to oma-
lizumab therapy over time. These data can help healthcare providers by setting
expectations of likelihood of response in CIU/CSU patients at different time
points after omalizumab initiation.
Number and percentage of patients who achieved the state of well-con-
trolled urticaria or complete response by week and study arm.
BSL = baseline; PLB = placebo; OMA = omalizumab, UAS7 = Weekly
Urticaria Activity Score.
A20 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
58
DO PARENTS INFLUENCE HEALTH LITERACY AND IMPACT
ASTHMA SELF-MANAGEMENT IN RURAL GEORGIA HIGH
SCHOOL STUDENTS?
J.S. Bush*, J.L. Waller, D.R. Ownby, M.S. Tingen, Augusta, GA.
Introduction: Patients with lower health literacy (HL) have poorer under-
standing and self-management of chronic diseases, including asthma. We
hypothesized that parents/caregivers were an important source of HL for teenage
students, which would be indicated by agreement between student and care-
giver HL scores on standard instruments. Methods: HL status was assessed as
part of Puff City, a randomized controlled trial of a web-based asthma educa-
tion intervention in four rural Georgia high schools. Baseline sociodemographic
data was obtained. Due to the small percentage of “other race,” whites and other
races were combined for analyses. Three validated instruments were used:
REALM (Rapid Estimate of Adolescent/Adult Literacy in Medicine) and SILS
(Single Item Literacy Screener). To examine agreement between scores,
weighted kappa statistics were calculated. Bowker’s test of symmetry was used
to examine equality of disagreement in scores. Differences in REALM and
SILS scores were examined with t- and chi-square tests. Results: 243 students
and 203 caregivers completed HL assessments yielding 198 paired observa-
tions. The students attended grades 9-12, were 60.6% female, 72.7% African
American (AA), with mean age of 15.3 (SD 0.9) years. Parent education ranged
from less than high school diploma (19.1%) to college graduate (24.0%). Sig-
nificant differences of REALM scores were seen between AA and white stu-
dents, 56.2 (10.6) vs 60.8 (6.8), p<0.0005, respectively. Agreement between
student and caregiver REALM categories was poor (κw=0.26) while disagree-
ment did not significantly differ by scores or demographic variables. There was
significant disagreement between student and caregiver scores on SILS and
this differed by caregiver race, with students having higher scores when their
caregiver was AA. Agreement in SILS scores between student and caregiver
was poor for both caregiver race groups, but whites/other race caregivers had
a higher weighted kappa (κw=0.31) than AA caregivers. Conclusion: The poor
agreement between student and caregiver HL scores suggest that teens do not
primarily acquire HL from caregivers. Consistent with previous adult litera-
ture, there appears to be a disparity in adolescent HL between AA and whites.
The lower HL among AA teens suggests that they are likely to require more
physician effort to become proficient in asthma self-management.
59
PROFILING AND VISUALIZING UTILIZATION AND COST FOR
PEDIATRIC ASTHMA CARE IN THE MEDICAID SYSTEM.
R.P. Hilton1, N. Serban1, Y. Zheng*2, 1. Atlanta, GA; 2. Smyrna, GA.
Introduction: The aim of this study is to summarize and visualize the uti-
lization and cost relational system between providers for pediatric asthma care
in the Medicaid system using large patient-level claims data. We investigate
an inferential and graphical approach for uncovering patterns in the healthcare
utilization within the Medicaid system. We pilot this study for pediatric asthma
patients in Georgia and North Carolina using the 2009 patient-level claims data.
Methods: We apply sequence clustering analysis (SCA) to classify patients
according to their utilization profiles, and for each cluster, we derive a proba-
bilistic network of care where the probabilities are determined based on the
patient-level utilization across providers of different types. The underlying
utilization networks are the basis in deriving the cost relational system between
providers. Results: We use the Markov chain representation of the utilization
profiles to visualize the network model for each profile as derived from the
SCA with three profiles. Profile 1 is dominated by patients primarily utilizing
Emergency Department (ED) care services with a small proportion referred to
primary care. Profile 2 is dominated by patients primarily utilizing primary
care once or multiple times with a small proportion visiting ED. Profile 3 has
a high variation in utilization. Among the children with asthma in the 2009
Medicaid system of Georgia, about half of the patients utilize primary care
whereas the other half either seek care through ED or from multiple providers.
The cost analysis shows that the distribution of cost-per-visit for ED visits is
similar across the three profiles with a higher median for the ED-care preva-
lent profile. The costs for other provider types have similar symmetrically-
shaped distribution but with some differences in the median across all three
profiles. Conclusion: It is not surprising to find that ED visits contribute to a
large portion of the cost for pediatric asthma care where most of the ED cost-
per-visit values are in the range of other care visit types suggesting that many
ED visits are for routine care. However, we also find that about half of the
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A21
children in the Medicaid system in Georgia do utilize primary care, they stay
on this path, and thus cost less.
60
TRENDS OF ATTENTION OF ASTHMA AT THE INSTITUTO
MEXICANO DEL SEGURO SOCIAL 2007-2012.
M. Nunez*, M. Becerril-Angeles, V.H. Borja-Aburto, A. Rascon-Pacheco,
U. Angeles-Garay, M. Vargas-Becerra, Mexico City, DF, Mexico.
Introduction: The prevalence of asthma in Mexico is about 10%. The Insti-
tuto Mexicano del Seguro Social (IMSS) attends a population of 58 millions,
and one third of the new cases of asthma coming from public hospitals around
the country. Methods: The registries of consultations, emergencies, discharges,
and deaths, due to asthma of all medical units of the IMSS in the period 2007-
2012 were analized. Results: There was an annual average of 839, 363 con-
sultations, including new cases and subsequent cases of asthma. The consul-
tations increased 31%, from 720, 041 in 2007 to 947, 452 in 2012. The average
incidence was 236 cases per 100, 000 patients covered by Social Security. The
state with the highest rate of cases was Yucatan (3625.9); and the state with the
lowest rate was Hidalgo (697.6). The 10 states with the highest rates are located
on the coast, and 9 of the 10 states with the lowest rates are away from the coast.
There was an annual average of 265, 425 cases of asthma in the emergency
room. The emergency cases decreased from 37.3% in 2007 to 28.2% in 2012.
The hospital discharges decreased 9.3%, from 14, 313 in 2007 to 12, 987 in
2012. Five percent of the attended cases in the emergency room were hospi-
talized. The mortality from asthma around the country was 2.36 per million of
patients covered by Social Security. The states with the highest mortality and
incidence of asthma were Yucatan and Campeche. Conclusions: The consulta-
tions for asthma have increased nearly one third since 2007. The highest inci-
dence of asthma was observed in the states located at the sea level. The rate of
visits to the emergency room and of hospital discharges showed a decreasing
trend. The rate of mortality found in this report was low in relation to that found
in other countries.
ABSTRACTS: CONCURRENT SESSIONS
61
A RANDOMIZED PHASE 3 STUDY ASSESSING PATIENT-
REPORTED OUTCOMES AND SAFETY OF RESLIZUMAB IN
PATIENTS WITH ASTHMA WITH ELEVATED EOSINOPHILS.
J. Maspero*1, L. Bjermer2, C. Lemiere3, M. Ciesielska4, C. O’Brien4,
J. Zangrilli4, 1. Buenos Aires, Argentina; 2. Lund, Sweden; 3. Montreal,
Canada; 4. Frazer, PA.
Introduction: Reslizumab (RES), a humanized anti-human interleukin-5,
is in development for patients with moderate to severe persistent asthma with
elevated eosinophils (EOS). We compared patient-reported outcomes (PROs)
and safety of RES vs placebo (PBO) in patients with asthma and elevated EOS.
Methods: This multicenter, double-blind, 16-week study (NCT01270464)
included patients (N=311), 12-75 years of age, with uncontrolled asthma on at
least medium-dose inhaled corticosteroids with/without additional controllers,
Asthma Control Questionnaire score ≥1.5, and blood EOS level of ≥400/mL.
Randomization was to intravenous RES 0.3 mg/kg (n=104) or 3.0 mg/kg
(n=106) or PBO (n=105) once every 4 weeks. PROs included Asthma Quality
of Life Questionnaire (AQLQ) (7-point scale, 1 [all of the time]; 7 [none of
the time]; minimal important difference [MID], 0.5 U), and Asthma Symptom
Utility Index (ASUI) (0 [worst possible symptoms]; 1 [no symptoms]). Results:
Baseline clinical characteristics were similar among treatment groups. At 16
weeks, RES 0.3 mg/kg and 3.0 mg/kg improved AQLQ from baseline (mean
treatment difference vs PBO 0.278 and 0.359, respectively). The difference
between RES 3.0 mg/kg and PBO was statistically significant (P=0.0241). The
percentage of patients with a MID in AQLQ at week 16 was 59%, RES 0.3
mg/kg; 64%, RES 3.0 mg/kg; and 48%, PBO. The difference between RES 3.0
mg/kg and PBO was statistically significant (P=0.0189). RES-treated patients
had statistically significant (P≤0.016) ASUI improvements vs PBO (mean treat-
ment difference vs PBO: 0.51, RES 0.3 mg/kg; 0.47, RES 3.0 mg/kg). Most
(86%) patients received 4 complete infusions of RES. Incidence of adverse
events (AEs) was similar among treatment groups. Serious AEs for RES
occurred in the 3.0 mg/kg group (1 patient with pneumonia, road accident/rib
fracture, and asthma exacerbation; 1 patient with sinusitis; 2 patients with
asthma exacerbations). AEs led to discontinuation in 10%, <1%, and 6% of
PBO, RES 0.3 mg/kg, and RES 3.0 mg/kg patients, respectively. Conclusions:
In patients with uncontrolled asthma and elevated blood EOS, 4 monthly doses
of RES were well tolerated and associated with improvements in PROs of qual-
ity of life and symptoms. This study was sponsored by Teva Pharmaceuticals.
62
DEVELOPING A RISK STRATIFICATION MODEL TO ALLO-
CATE LIMITED ASTHMA RESOURCES.
J. Hanson*, H. Murphy, D. Williams, B. Lee, M. Reddy, Kansas City, MO.
Background: Current models for calculating asthma related risk require
clinical parameters or administrative data. Often, programs that conduct dis-
ease management, community outreach and environmental assessment do not
have access to either. The aim of this study is to develop a simple risk stratifi-
cation model to help allocate limited resources to children with high risk asthma.
Methods: This is an IRB approved retrospective study of 11,915 patients <18
years seen for an asthma diagnosis at one of 23 outpatient clinics at our insti-
tution between 1/1/10 and 5/31/12, regardless of whether asthma was the prin-
cipal diagnosis (PD). The frequency of asthma related acute care visits (ACVs)
in the 12 months prior to the outpatient visit was determined and a risk score
calculated based on ACV type (ED/UCC visit=1 point, inpatient admission=2
points, PICU admission=3 points). The total risk score was used to create four
risk categories: Very Low (0 points), Low (1-2 points), Medium (3-6 points)
and High (≥7 points). The odds of an asthma related ACV in the 12 months
following the outpatient visit were then compared across risk categories using
logistic regression. Results: Our study sample included 27,083 outpatient vis-
its representing 11,915 unique patients. Of these visits, 74% were Very Low
risk, followed by approximately 19%, 6% and 1% for Low, Medium and High
risk, respectively. Eighty-two percent of High, 57% of Medium, 36% of Low
and 11% of Very Low risk patients had an asthma related ACV in the 12 months
following the outpatient visit. After accounting for clustering of visits by patient,
the odds of a future ACV was significantly higher for High risk (odds ratio
(OR)=36.8; p<0.001), Medium risk (OR=10.6; p<0.001) and Low risk (OR=4.5;
p<0.001) patients, when compared to Very Low risk patients. The odds of a
future ACV was significantly higher for High (OR=8.2; p<0.001) and Medium
(OR=2.4; p<0.001) risk patients, as compared to Low risk patients. High risk
patients had 3.5 times greater odds of having a future ACV than Medium risk
patients (p=0.001). Conclusion: This scoring algorithm effectively stratified
VOLUME 113, NOVEMBER, 2014 A21
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ABSTRACTS: CONCURRENT SESSIONS
asthmatic patient risk for future asthma related ACVs. The potential utility
and scope of this model could be significant in the allocation of asthma resources
to those who need them most, particularly when access to detailed clinical
data is limited.
63
NEWBORN SCREENING FOR SEVERE COMBINED IMMUN-
ODEFICIENCY IN IOWA: RESULTS OF A ONE YEAR PILOT
STUDY.
S. Aleem*1, E. Phillips1, T. Henry1, C. Johnson1, P. Ferguson1,
S. Rumelhart1, C. Kremer1, K. Piper1, M. Fasano2, 1. Iowa City, IA;
2. Des Moines.
Introduction: Early recognition of severe combined immunodeficiency
(SCID) is integral in the adoption of timely life-saving interventions, like
hematopoietic stem cell transplantation for an infant born with the disorder.
Population-based, inexpensive, and sensitive newborn screening (NBS) for
SCID involves measurement of T-cell receptor excision circles (TRECs) via a
quantitative polymerase chain reaction (qPCR) assay. Here we summarize the
results of Iowa’s one year SCID NBS pilot program. Methods: A TREC qPCR
assay using DNA isolated from dried blood spots was developed by the State
Hygienic Lab and ran on all infants born in Iowa during the June 3, 2013-June
31, 2014 pilot year. Samples with initial abnormal results were repeated and
immunophenotyping was performed on all infants with abnormal results.
Results: Of 43,930 infants screened, 13 were presumptive positive for SCID;
one remained indeterminate on repeat screening. Threshold for abnormal results
was revised twice during the pilot. Of these 14 infants, 6 were identified in the
first month of the pilot and 8 were identified after cut-offs were revised in
February 2014; 10 (71%) were male, 8 (57%) were in an intensive care unit, 3
(21%) were Hispanic, 3 (21%) were infants of diabetic mothers and 2 (14%)
had congenital heart disease. Immunophenotyping was without significant T-
cell lymphopenia ( CD3 < 1500 cells/ml, or absence/marked reduction in CD4
naïve T cells [CD4/CD45RA] < 5% of total CD3 T cells) in 11 infants, includ-
ing one with 22q11.2 deletion syndrome. Significant T-cell lymphopenia was
found in 3 (21%) infants; however, T-cell function (assessed as lymphocyte pro-
liferation to phytohemagglutinin) was normal and none was found to have SCID.
Three infants with significant T-cell lymphopenia underwent additional testing
and clinical outcomes were monitored. One infant was diagnosed with Jacob-
sen syndrome with associated cytopenias, one with 18p deletion syndrome and
complex congenital heart disease and one with no causative genetic mutation
yet identified. Conclusion: In the first year of Iowa’s SCID NBS program no
SCID babies were identified; however, a variety of other conditions with T-
cell lymphopenia were found. This finding is similar to that of other states
reporting TREC NBS and may help to improve our understanding of other con-
ditions that present with T-cell lymphopenia.
A22 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
64
FINANCIAL AND MORBIDITY IMPACT OF ADDING TRECS TO
NBS.
S.E. Henrickson*1, J. Heimall2, S. Jyonouchi2, 1. Haddonfield, NJ;
2. Philadelphia, PA.
Introduction: TREC based NBS identifies newborns with asymptomatic
SCID and allows HSCT with lower morbidity, mortality and cost. TREC NBS
started in PA statewide July 2013, but hospitals can opt out. We review the cases
of 4 PA born infants who recently presented: 2 via positive NBS and 2 who
were born in hospitals not participating in TREC NBS and developed oppor-
tunistic infections. Results: Patients identified by positive NBS: Pt 1: Outpa-
tient phenotyping showed T-B+NK- SCID; confirmed as X-SCID. Prophylac-
tically admitted for 9d due to sibling illness. Readmitted DOL26 for 48h for
unconditioned MRD PBSC transplant (PBSCT). Readmitted with emesis and
blood streaked stools (15d), asymptomatic CMV and EBV reactivation (48h).
Total admissions 28d. Now well day+106. Pt 2: Outpatient phenotyping demon-
strated T+B-NK+; found to have RAG1 mutation. Admitted DOL120 for mye-
loablative conditioned UCB transplant (UCBT), hospitalized 39d, including
transplant associated microangiopathy. Readmitted with fever (7d), poor weight
gain (6d). Total admissions 52d. Now well day+175. Patients identified by
severe infections: Pt 3: Transferred from OSH at DOL154 with fevers,
pseudomonas UTI, pneumocystis pneumonia and CMV viremia. Found to have
T-B+NK+ SCID; confirmed as X-SCID. Received unconditioned MMRD
PBSCT at DOL167, hospitalized to day +8. 2 admissions for symptomatic CMV
viremia (20d), required CMV+ CTLs twice. Total admissions 41d. Now day+119
with asymptomatic CMV viremia. Pt 4: At birth admitted to OSH NICU (14d).
DOL 18 admitted with ALTE and UTI (11d). DOL59 admitted with FTT/
chronic diarrhea, diagnosed with ADA SCID. During 221d admission, aspira-
tion and pneumocystis pneumonia, chronic respiratory failure. Treated with
PEG-ADA and developed autoreactive T cells. Received myeloablative condi-
tioned UCBT DOL178. Total admissions 232d, with168d NICU/PICU. Now
well at day+155. Conclusion: Patients identified with SCID via NBS are healthy
at diagnosis and have shorter hospital stays with less morbidity and mortality.
From 2000-2010, 11 SCID patients were identified at our institution. SCID
diagnosis at < 3 m/o cost an average of $460K, diagnosis at >3 m/o cost an
average of $1.5M. The cost of a single TREC screen is ~$4-5. With ~150K
babies born annually in PA, 1 SCID patient identified via NBS pays for a year
of screening. This supports the national inclusion of TRECs in NBS on a manda-
tory participation basis.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A23

ABSTRACTS
PRESENTED AT POSTER SESSIONS

November 8-9, 2014

georgia world congress center
atlanta, georgia

TABLE OF CONTENTS

TOPIC ABSTRACT NUMBERS PAGES

Adverse Food and Drug Reactions,
Insect Reactions, Anaphylaxis P1 – P26 A25-A32
Aerobiology, Allergens, Allergen Extracts P27 – P38 A32-A35
Allergy Testing, Clinical Laboratory
Immunology P39 – P42 A35-A36
Asthma and Other Lower Airway Disorders P43 – P80 A36-A47
Basic Science Allergy and Immunology P81 – P93 A48-A50
Clinical Case Reports P94 – P207 A50-A84
Clinical Immunology, Immunodeficiency P208 – P242 A84-A93
Food Allergy P243 – P256 A93-A97
Immunotherapy, Immunizations P257 – P270 A97-A101
Other P271 – P284 A101-A104
Pharmacology and Pharmacotherapeutics P285 – P295 A104-A108
Rhinitis, Other Upper Airway and
Ocular Disorders P296 – P310 A108-A112
Skin Disorders P311 – P331 A112-A118

VOLUME 113, NOVEMBER, 2014 A23

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ABSTRACTS: POSTER SESSIONS

A24 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A25
P1
A CASE OF SUCCESSFUL DESENSITIZATION TO ALGLU-
COSIDASE ALFA IN A 7 WEEK-OLD WITH INFANTILE-ONSET
POMPE DISEASE.
C. Adkins*1, C.M. Makris2, S. Kankirawatana2, 1. Hoover, AL;
2. Birmingham, AL.
Introduction: Pompe disease (PD) is an inherited disorder caused by a defi-
ciency of the lysosomal enzyme alpha-1,4-glucosidase and characterized by
accumulation of lysosomal glycogen in many organs, including the heart and
skeletal muscle, leading to myopathy. Patients with infantile-onset PD can
develop severe cardiomyopathy, which if left untreated, may result in death
within the first year of life. A recent breakthrough treatment with recombinant
enzyme replacement has significantly improved patients’ survival, but is often
complicated by the development of enzyme specific antibodies precluding fur-
ther administration. Here we report a case of successful desensitization to alglu-
cosidase alfa in an infant who previously developed a systemic allergic reac-
tion during enzyme replacement therapy. Methods: Specific IgE to alglucosidase
alfa was obtained and reported to be negative. The patient underwent desensi-
tization using our protocol starting approximately at a 1:10,000 dilution of the
therapeutic dose, with doubling of the dose every 15 minutes until the cumu-
lative dose approximated the therapeutic dose (See Table 1). Results: Patient
was a 7 week-old neonate with infantile-onset PD receiving weekly intravenous
infusions of alglucosidase alfa at 20mg/kg. He developed a diffuse urticarial
rash, respiratory distress with wheezing, and periorbital and oral angioedema
approximately 5 minutes into his 4th infusion. The following day, we proceeded
with desensitization. He developed two generalized cutaneous allergic reac-
tions during dose titration, but was able to complete the protocol. He was con-
tinued on dose escalation weekly and was eventually able to transition to his
former outpatient infusion protocol. Discussion: The incidence of anaphylaxis
from administration of this medication has been reported in the range of 1-
14%. It is unclear if these cases are truly IgE vs. non-IgE mediated. Our patient’s
clinical history and cutaneous reactions during his desensitization suggest an
IgE mediated mechanism. The specific IgE blood sample was obtained within
hours of his anaphylactic reaction and thus may have caused a false-negative
result. We report our case to illustrate a protocol that was effective in inducing
temporary drug tolerance to alglucosidase alfa, allowing continuation of life-
sustaining treatment for this patient.
Table 1: Alglucosidase alfa desensitization protocol
P2
FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME
(FPIES) TO SWEET POTATO IN A HIGHLY ATOPIC CHILD.
B.J. Lanser*, N. Rabinovitch, Denver, CO.
Background: Food Protein Induced Enterocolitis Syndrome (FPIES) is a
rare, but increasingly prevalent non-immunoglobulin E (IgE) mediated gas-
trointestinal reaction to food proteins. It is outgrown in the majority of chil-
dren by 30 months of age, and does not show predominance for atopic indi-
ABSTRACTS: POSTER SESSIONS
viduals or families. We present the case of a 7 year old girl with severe atopic
dermatitis that was controlled with topical steroids and the soak and seal method.
She had a history of multiple food reactions consistent with IgE mediated
food allergy. At 18 months, she ingested sweet potato, resulting in profuse vom-
iting that was diagnosed by her pediatrician as anaphylaxis. Methods: Skin
prick and ImmunoCapp testing was performed followed by a food challenge
to sweet potato in an observed medical setting. Results: Skin prick testing
with commercial extracts revealed sensitivity to multiple foods including peanut,
tree nuts, milk, egg, shellfish and wheat but was negative to sweet potato. The
patient’s total serum IgE was 4504 kUA/L, and ImmunoCapp to sweet potato
was 2.73. In comparison, her milk IgE was >100. Based on these results an oral
food challenge was performed. There was no immediate reaction (within 20
minutes) to sweet potato given in increasing doses over 2 hours. One hour
after the full serving, she began to vomit profusely, and continued to vomit over
the following 3 hours, despite treatment with diphenhydramine, IM epineph-
rine and IV ondansetron. IV fluid resuscitation was also performed. A com-
plete blood count obtained during the reaction revealed a significantly elevated
neutrophil count of 17,100, compared to baseline of 2,800. She also had a nor-
mal tryptase. These results are consistent with an FPIES reaction to sweet potato.
Conclusion: FPIES is generally considered in the differential diagnosis when
infants and toddlers present with acute reactions to food ingestion, but not in
older children. This child posed a further diagnostic challenge given her con-
comitant IgE mediated food allergies to multiple foods. This unusual case, never
reported in the literature, demonstrates the potential for distinct pathogenic
mechanisms in children with multiple food sensitivities. Physicians should con-
sider in the differential diagnosis and be prepared to treat FPIES in any child
with a history of profuse vomiting after ingestion of certain foods.
P3
ENZYME REPLACEMENT THERAPY: A CASE OF SUCCESSFUL
ELOSULFASE ALFA DESENSITIZATION IN A MORQUIO A
SYNDROME PATIENT.
A. CaJacob*1, C. Adkins2, M. Descartes1, C. Allen1, J. Anderson1,
1. Birmingham, AL; 2. Hoover, AL.
Introduction: Morquio A Syndrome (also known as mucopolysaccharidase
type IVA deficiency) is an autosomal-recessive lysosomal storage disease char-
acterized by a deficiency of the N-acetylgalactosamine-6 sulfatase enzyme.
Until the recent FDA-approval of elosulfase alfa (Vimizim™) enzyme replace-
ment therapy (ERT) in February 2014, treatment of this progressive, multior-
gan disease had been symptomatic care. In pre-market clinical trials it was
determined to carry a 7.7% risk of anaphylaxis. We present a patient who was
successfully desensitized to elosulfase alfa after an anaphylactoid reaction.
Methods: An nine hour desensitization protocol was devised. We began with
an approximate initial dose of 1/10,000, with doubling of the dose until the
patient received her goal dose of 200mg. Results: A 54 year old female with
Morquio A syndrome began elosulfase alfa ERT in October 2013. She toler-
ated weekly infusions without difficulty until March 2014 when after approx-
imately 2.5 hours into her twenty-third infusion she developed a reaction char-
acterized by fever to 102.7, tachycardia, hypotension, wheezing and hypoxia
(O2 sat 75%). Reaction was treated with intravenous fluids, antihistamines,
nebulized albuterol and methylprednisolone. She was referred to the Allergy
service one week later for evaluation. Skin prick testing (patient and control)
was negative to 1:1, 1:10 and 1:100 dilutions with good histamine control. The
patient’s intradermal testing was positive at a 1:10 dilution. The control’s intra-
dermal testing was negative at 1:10 and 1:1 dilutions. One month after her
reaction, we proceeded with the above desensitization protocol. The desensi-
tization was well-tolerated. After its completion, the patient resumed her weekly
infusions at a slower rate without further reactions. Repeat skin testing four
months from initial desensitization was negative at 1:10 and 1:1 dilutions.
Conclusions: Vimizim™ is an FDA-approved ERT for Morquio A syndrome
patients which carries an anaphylaxis risk. The immunologic basis of our
patient’s anaphylactoid reaction is unclear, particularly given the fever and the
absence of any skin manifestations. After desensitization, she had conversion
to negative skin testing. No antibody assay is currently available. To our knowl-
edge, this case represents the only elosulfase alfa ERT desensitization in pub-
lished literature.
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ABSTRACTS: POSTER SESSIONS

Vimizim™ Desensitization Protocol desquamation on her torso and arms. Her initial laboratory evaluation showed
WBC 21,700 cells/mm3, AEC 10,200 cells/mm3, normal C3 and C4. With three
days of systemic steroids, her AEC improved to 8650 cells/mm3. The edema
was not improved and she developed hepatic injury (AST 215, ALT 242, Alk
Phos 1201) with mild hepatitis suggested on ultrasound. Phenytoin and Lisino-
pril were discontinued as her picture was consistent with DRESS. She quickly
improved and was extubated 4 days following Phenytoin discontinuation. Dis-
cussion: Facial edema is common in DRESS however oropharyngeal and laryn-
geal involvement have not been described. Tongue edema has been reported
previously in a patient concomitantly on an ACE inhibitor, as was our patient.
This may implicate a synergistic effect of ACE inhibitors and DRESS presen-
tation. To our knowledge this is the first report of DRESS presenting with laryn-
geal involvement and intubation.

P4
FIRST STUDY OF PATTERN OF EPINEPHRINE AUTO INJEC-
TOR PRESCRIPTIONS FOR ANAPHYLAXIS IN A LARGE TER-
TIARY CARE HOSPITAL IN SAUDI ARABIA.
S. Al Gazlan*, R. Amin, A. Khaliq, T. Al Otaibi, S. Alhashim, F. Sheikh,
Riyadh, Saudi Arabia.
Anaphylaxis is a serious allergic reaction that may cause death. The pres-
ent study examined the symptoms, triggers and demographic patterns of patients
treated for anaphylaxis at a large tertiary care hospital in Riyadh, Saudi Ara-
bia. The protocol was approved by the Institutional Review Board of the hos-
pital. All the patients who were prescribed Epinephrine auto-injectors ( EA )
between 1/1/2010 and 31/12/2011 were included in this study. 238 new patients
were identified using hospital pharmacy database and the medical records of
these patients were reviewed. To date, Epinephrine auto-injectors ( EA ) are
available at very few hospitals in Saudi Arabia. Since our hospital is the main
tertiary care hospital with allergy&immunology service in the Kingdom, these
data may reflect Anaphylaxis presentations in our region. The mean age at the
time of first EA prescription was 22.9 years, (2years to 73 years). SD +/- 18.2
Female to male ratio was 52:48. 54% for subjects were less than 18 years of
age. 18 % were Non Saudis living in the Riyadh region. Most of these were
employees of the hospital or their dependents. Although most of the signs and
symptoms were similar to other published data, there were some differences
observed in our population. Urticaria and angioedema was the most common
presentation accounting for 70% in adults and children followed by shortness
of breath in 33% in adults and 23% in children. Food was the commonest trig-
ger for anaphylaxis with Tree Nuts and Egg the most frequent, followed by
Sesame and Peanut. Drug Allergy was also a common trigger, with Penicillins
and NSAIDs being the commonest. Regarding Insect allergy, Samsum Ant was
the commonest trigger in our population. This is the first such study on Ana-
phylaxis in Saudi Arabia. While there are many similarities, some of the pre-
senting signs, symptoms, and triggers of anaphylaxis are significantly differ-
ent in our population than in others. While treating Anaphylaxis, we should be
mindful of these differences. This improved understanding should help reduce
the morbidity and mortality associated with Anaphylaxis in our region.
P6
PEANUT IGE THRESHOLD FOR REFLEX PEANUT COMPO-
P5 NENT TESTING.
PHENYTOIN INDUCED DRESS PRESENTING WITH LARYN- M. Altrich*1, H.D. Wells1, J.C. Thompson2, 1. Lee’s Summit, MO;
GEAL EDEMA REQUIRING INTUBATION. 2. Atlanta, GA.
H.N. Hartman*, L. Gimenez, Milwaukee, WI. Introduction: Patients with suspected peanut allergy (PA) come to medical
Introduction: DRESS is a severe and potentially fatal drug reaction char- attention following an adverse food reaction or in the course of in vivo or in
acterized by fever, rash, lymphadenopathy and visceral organ damage. We vitro testing. An IgE level of 15 kU/L or above has been suggested as 95%
describe the case of a patient with Phenytoin induced DRESS presenting as likelihood of PA, however the majority of patients sensitized to peanut have an
eosinophilia and laryngeal edema. Case Report: The patient is a 59 yo AA IgE level below this cut off. As some patients avoid peanut after initial symp-
Female with Hypertension, Type 2 Diabetes, Hyperlipidemia, Hypothyroidism toms, a negative history of systemic reaction to peanut has uncertain predic-
and a history of Cerebral Vascular Event and subsequent seizure. She has no tive value. This creates a diagnostic dilemma for clinicians who wish to rec-
history of previous angioedema. Her home medications include alendronate, ommend avoidance, consumption or the option of a food challenge. At what
atorvastatin, cholecalciferol, folic acid, insulin, levothyroxine, lisinopril, omepra- lower limit of peanut IgE should component testing be considered? Peanut com-
zole and phenytoin which was initiated 2-3 months prior. Initially she presented ponent testing provides a more certain decision point; sensitization to peanut
to the ED for fever and an urticarial and maculopapular rash on her neck, chest seed storage proteins (SSP), Ara h 2 in particular, correlates well with symp-
and abdomen. She was placed on antimicrobial therapy for presumed UTI for tomatic peanut allergy. Based on food challenges, Codreanu proposed an IgE
which she took for two days before returning to the ED with worsening rash threshold for Ara h 2 of 0.23 kU/L for identifying peanut allergic subjects, Nico-
and desquamation. At this evaluation she was given oral prednisone burst. laou and Custovic proposed 0.35 kU/L as a threshold. This study considers the
Five days following completion of steroids she again presented to the ED with peanut IgE level that may be used as a decision point for reflex component test-
fever and facial edema. She was emergently intubated by ENT for oropharyn- ing. Methods: This prospective study utilized sera with de-identified patient
geal edema. She was started on Dexamethasone 8mg q8 for edema and a CT health information. Samples from 25 peanut sensitized subjects, age 12 years
obtained demonstrated extensive angioedema of her tongue and larynx with and younger with specific IgE 0.35-15 kU/L, were assayed for peanut SSP Ara
cervical lymphadenopathy. On exam she had no rash, but was noted to have h 1, Ara h 2, Ara h 3, for PR-10 Ara h 8, and lipid transfer protein (LTP) Ara

A26 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A27
h 9. Results: 76% of the subjects were sensitized to peanut SSP, 56% to Ara h
2, 20% were sensitized to PR-10, Ara h 8 and 12% to LTP, Ara h 9. Ara h 2 of
at least 0.35 kU/L was seen at the lowest extent of the peanut IgE data set. In
one sample a value for Ara h 2 of 0.44 kU/L corresponded to a peanut IgE of
0.41 kU/L. Within the complete data set it was not possible to predict sensiti-
zation to Ara h 2 or SSP based on peanut IgE as the profile may contain IgE
to SSP or cross-reactive proteins. Conclusions: There is not a lower peanut
IgE threshold for component testing and it is not possible to predict the com-
ponent profile based on the peanut IgE alone. Peanut IgE values <15 kU/L may
be associated with values of Ara h 2 exceeding peanut challenge decision points.
Component testing has improved in availability and affordability. Medical deci-
sion-making based on the component profile allows a more accurate risk assign-
ment than decisions based on peanut IgE alone.
P7
UTILITY OF PATCH TESTING IN FIXED DRUG ERUPTION.
D.A. Cariño Cartagena*, A.A. Velasco-Medina, J.C. Fernández de
Córdova-Aguirre, S. González-Flores, M.E. Arroyo-Cruz, G. Velázquez-
Samano, Mexico City, DF, Mexico.
Introduction: Fixed drug eruption is characterized by the sudden onset of
a single or few circular macular erythematous-violaceous lesions, that could
happen in a specific location repeatedly after exposure to a particular drug in
85 to 100 % of cases; drugs most often involved are sulfonamides, NSAIDs,
tetracyclines, paracetamol, anticonvulsants and other anecdotal drugs as anti-
fungal. There are five clinical forms: a) classic characterized by an asymmet-
ric and erythematous pigmented shape b) symmetrical form with erythema-
tous unpigmented plaques, c) is minor or individual lesion, d) Disseminated
bullous form, e) linearly. The responsable drug was identified through patch
test. Case Presentation: Thirty eight years old female presents multiple slim,
erythematous, assymetrical lesions 24 hours after treatment with Trimethoprim
- Sulfamethoxazole located in the back with regular discoid margins with slow
progressive involution. After suspension of TMP-SMZ exposure the patient
preserved a lesion in the calf with residual pigmentation. She had a history of
previous similar episodes with unspecified drug exposure, 6 weeks later fixed
drug eruption by TMP-SMZ was confirmed with patch testing. Discussion:
Fixed drug eruption has a better prognosis than other drug induced skin lesions
and is considered a form of delayed hypersensitivity mediated by T cells CD8
+, the disease could determine important physical and psychological impair-
ment due to discomfort and cosmetic appearance, thereby physicians should
be alert of this possibility to avoid subsequent recurrent episodes. The litera-
ture indicates that patch testing is less dangerous than oral challenge to iden-
tify the responsible drug with positivity of 23.6% to 20%, which proved effec-
tiveness in the presented case, thereby this diagnostic tool should be considered
as a first step approach for fixed drug eruption.
P8
UNUSUAL SEVERE RASH CAUSED BY ADALIMUMAB.
A.A. Mourad*, S.L. Bahna, Shreveport, LA.
Introduction: Rashes are common in patients receiving multiple medica-
tions. Most rashes are benign but some can be life-threatening and require
urgent identification & discontinuation of the culprit which can be difficult.
Case: A 49-y-o AA man was transferred from another hospital because of severe
generalized rash started 2 wk earlier as pustules on legs then spread as bul-
lous-pustular all over his body except the face; accompanied by on-off fever
up to 101F. He did not improve on TMP/SMX & rifampicin or on IV van-
comycin, piperacillin-tazobactam & prednisone 20 mg daily. Review of sys-
tems revealed HTN, RA, gout, obstructive sleep apnea & peptic ulcer; on
amlodipine, olmesartan, aliskiren, nebivolol, clonidine, methotrexate, allop-
urinol, modafinil, pantoprazole, iron and folic acid. He was started on adali-
ABSTRACTS: POSTER SESSIONS
mumab (Humira) for his RA 7 wk & 1 wk before the rash started. On presen-
tation, his VS & PE were normal except for generalized ulcerated bullous pus-
tular eruption without facial or mucous membranes involvement. Lab findings:
WBC 23000 with 95% N, ESR 81mm/hr, CRP 45mg/dl & normal CMP. Lesion
smear showed neutrophils with negative culture & no fungi or AFB. Blood
culture was also negative. He was treated with hydrotherapy, wound care, and
IV methylprednisolone 60mg daily & diphenhydramine 25mg q 6 hr. Biopsy
showed dermal microabscesses & leukocytoclastic vasculitis consistent with
pyoderma gangrenosum (PG). Methylprednisolone was increased to 1 g daily
for 5 d then switched to PO prednisone 60 mg daily. Further evaluation showed
positive ANA with no specific pattern, and negative RF, CCP, Ds-DNA, anti-
Smith Abs, ANCA & PSTPIP1 mutation. Serum & urine electrophoresis and
C3 & C4 were normal. Serum Humira Abs (IgG) was 15.8 U/ml. The rash grad-
ually improved until completely resolved over 3 wk while prednisone was being
gradually tapered to 20 mg daily on discharge. Conclusion: PG was diagnosed
based on biopsy & negative workup for other bullous pustular disorders. Humira
was the most suspect because it was the most recent medication received, ele-
vated serum Humira IgG Abs, and resolution while on all his other medica-
tions. This may be the first reported PG case caused by Humira. PG is uncom-
mon neutrophilic dermatosis affecting mainly young adults; > 50% of cases
have an associated systemic inflammatory disease (e.g., IBD, hematologic or
rheumatologic). Most patients achieve remission on immunosuppressants but
relapse can occur.
P9
AN UNUSUAL PRESENTATION OF DRESS SYNDROME IN A
POST-TRANSPLANT PATIENT: A CASE REPORT.
S.B. Sindher*, J. Heimall, Philadelphia, PA.
Introduction: Drug reaction with eosinophilia and systemic symptoms
(DRESS) is a severe acute drug reaction with a highly variable clinical pres-
entation. It is characterized by a polymorphic skin eruption associated with
fever, eosinophilia, lymphadenopathy and the involvement of multiple organs
(liver, kidney and lung) along with a long latency (two to eight weeks) between
drug exposure and disease onset. Methods: We evaluated a 14-year-old boy
with history of allogenic peripheral blood stem cell (PBSC) transplant for acute
myelogenous leukemia (AML). He presented to Allergy clinic for evaluation
of rash and eosinophilia. Results: The patient received a matched unrelated
donor PBSC transplantation for high-risk AML 7 months prior to his presen-
tation. He had history of chronic skin graft-versus-host disease requiring long-
term therapy with prednisone. Daily medications also included lisinopril, acy-
clovir, cetirizine, vitamin D, omeprazole and sulfamethoxazole/trimethoprim.
After 6 months of therapy, prednisone was slowly weaned to a physiologic dose
of hydrocortisone. Within a week of stopping prednisone he developed inter-
mittent low-grade fevers and an erythematous and pruritic rash on his legs that
progressively worsened despite treatment with topical triamcinolone 0.1% oint-
ment and oral diphenhydramine. Over a period of 2 months he had 3 hospital
admissions for work-up of fever and worsening rash. Blood cultures were neg-
ative. During his 3rd admission new-onset eosinophilia and worsening
transaminitis were noted. Based on these findings he was diagnosed with
DRESS. Therapy with sulfamethoxazole/trimethoprim was stopped and he
received 7 days of prednisone resulting in improvement of his rash. Within a
few days of completing the prednisone course he developed recurrence of his
fever and rash and was readmitted. A skin biopsy confirmed a drug reaction.
He was initiated on a 3-month course of prednisone with complete resolution
of his symptoms. Conclusions: Our case report highlights the difficulty of diag-
nosing DRESS syndrome. Though the syndrome is known for its long latency
between exposure and symptom onset, the diagnosis and symptoms in our
patient were likely initially masked by his chronic prednisone use.
P10
SUCCESSFUL MYCOPHENOLATE MOFETIL DESENSITIZA-
TION IN A DOUBLE HEART-KIDNEY TRANSPLANT RECIPIENT.
M.A. Smith*1, A. Gonzalez-Estrada2, E. Glancy2, D. Fernandez2,
A. Subramanian2, 1. South Euclid, OH; 2. Cleveland, OH.
Introduction: Mycophenolate mofetil (MMF) is increasingly being used in
place of azathioprine in organ transplantation, as it is associated with less
bone marrow suppression, fewer opportunistic infections, and a lower incidence
of acute rejection. MMF, a purine nucleotide analogue, blocks lymphocyte pro-
liferation by inhibiting guanine nucleotide synthesis in lymphocytes. Methods:
A case report Results: A 46-year-old African-American female with systemic
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A28
ABSTRACTS: POSTER SESSIONS
lupus erythematosus (SLE) induced dilated cardiomyopathy and end stage renal
disease underwent double heart-kidney transplant. Following the transplant the
patient was placed on azathioprine, tacrolimus and methylprednisolone. MMF
was not included in her immunosuppressive regimen due to a previous episode
of oral pruritus within minutes after the first dose for lupus nephritis approxi-
mately 10 years ago. A second trial of MMF three weeks after the first resulted
in urticaria, pruritus and angioedema. MMF was discontinued and her symp-
toms subsided within 3 days.Allergy and Immunology was consulted to evalu-
ate for possible reinitiation of MMF. Skin testing to MMF was performed, how-
ever the patient had a blunted response to the histamine control. Given the urgency
of the situation and inability to interpret our skin tests, we designed a novel 12-
step desensitization protocol (Table I) adapted from current Drug practice param-
eters1. In an intensive care unit setting, an oral desensitization with MMF was
performed with diphenhydramine 25 mg IV and famotidine 20 mg IV given as
premedications. She completed the desensitization without adverse reactions.
Conclusion: The use of MMF has become standard practice in many solid organ
transplant recipients due its efficacy and favorable risk profile compared to other
immunosuppressants. There has been a single case report of successful MMF
desensitization2. However, this protocol did not follow current Drug practice
parameters and was done over a three-day period. We report a successful desen-
sitization to MMF in a double heart-kidney transplant recipient.
Table I. Mycophenolate Mofetil Oral Desensitization
P11
AMPHOTERICIN DESENSITIZATION.
A. Ravi*, D. Maddox, Rochester, MN.
Rationale: Although rare, amphotericin adverse reactions may occur. Meth-
ods: Report of a case and review of the literature. Case Presentation: A 39 year
old male with disseminated cryptococcus meningitis infection after exposure
to deceased birds and feces presents with rash. His only new medications were
flucytosine and liposomal amphotericin. The rash presented as itchy, slightly
raised, diffuse erythema most consistent with an urticarial lesion on bilateral
knees on Day 7 of antifungal therapy. No lip/tongue swelling, difficulty breath-
ing, abdominal pain, or vomiting. No oral ulcers or skin peeling. Flucytosine
was continued and liposomal amphotericin was held to help further determine
the causative agent. On Day 8 of antifungal therapy, he tolerated flucytosine.
The rash was nearly resolved. On Day 9, flucytosine was continued and lipo-
somal amphotericin re-initiated. 1 hour into liposomal amphotericin infusion,
he developed a similar rash on bilateral knees. Thirty minutes after the infu-
sion, he developed chest tightness lasting 30 minutes. On Day 10, he under-
went liposomal amphotericin desensitization with an initial concentration of 1
ng/ml infused at 1.67 ml/min rate with 3 fold increments in concentration every
30 minutes for a cumulative dose of 300mg. There were a total of 14 incre-
ments. 4 hours after completing the desensitization, he developed a similar rash
on his bilateral knees, left calf, and right foot. On Day 11, rash was nearly
resolved. On Day 11 evening, he underwent a conventional amphotericin (with-
out liposomal component) desensitization with a similar protocol except to a
cumulative dose of 0.7mg/kg (54mg). There were a total of 10 increments.
Results: He was successfully desensitized to conventional amphotericin B after
failing desensitization with liposomal amphotericin. Discussion: Amphotericin
is the drug of choice for treatment of severe invasive fungal infections. The
use of liposomal amphotericin has increased given the less adverse side effects.
In review of the literature, there was a case of a child who had urticaria to lipo-
somal amphotericin but tolerated conventional amphotericin. In patients who
adversely react to liposomal amphotericin, one may consider desensitization
to conventional amphotericin B, as the patient may be reacting to the liposo-
mal component or to an epitope array of amphotericin that only gets presented
by a liposomal formulation.
A28 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P12
CATAMENIAL ANAPHYLAXIS: A RARE CASE.
N. Kharod*1, M. Sands2, 1. Orchard Park, NY; 2. Buffalo, NY.
Introduction: Catamenial anaphylaxis, a.k.a. cyclical anaphylaxis, is char-
acterized by recurrent episodes of serious, possibly fatal, multisystem allergic
reactions occurring at the time of menstruation. It is an uncommon clinical
entity with few reports. Presentation: A 38-year-old Caucasian female patient
with recurrent anaphylaxis: abdominal cramping, diarrhea, injection and
swelling of the eyes, nasal congestion, wheezing, respiratory distress, throat
closing. First episode occurred while she was working at a breakfast restau-
rant. She had worked there on and off for 4 years previously without any such
issues. Continued to have recurrent episodes x 2 over the next three months,
then every 4 weeks. Each time, the episodes resolved with oral antihistamine.
The patient never used epinephrine and never sought medical attention after
the episodes. No identifiable food or medication triggers. CBC and CMP within
normal limits. RAST IgE positive for dog, cat, ragweed, total IgE 179. Base-
line tryptase normal at 3.2; did not get acute tryptase drawn. No prior medical
history other than asthma and allergic rhinitis. On questioning, patient noted
that she had very good control of asthma symptoms except during her peri-
menstrual period, when she would have wheezing and dyspnea on otherwise
normal exertion. Patient also noted that all anaphylactic episodes were occur-
ring on/around Day 1 of menses and that she was completely asymptomatic in
between. Patient was successfully treated with hormonal suppression of menses.
Discussion: Catamenial anaphylaxis is a rare, possibly underdiagnosed clini-
cal condition. It is a diagnosis of exclusion which can be identified after an
appropriate evaluation, and when conditions such as mastocytosis and C1-
esterase inhibitor deficiency/dysfunction have been ruled out. No obvious patho-
genesis identified, but possible theories include hypersensitivity to proges-
terone, hypersensitivity to estrogen, prostaglandins in menstrual fluid. There
is no one universal method of treatment, as several of these pathways require
different interventions.
P13
TREE NUT ALLERGY AND ANAPHYLAXIS: A CASE OF
DELAYED DIAGNOSIS.
S. Joychan*1, K. Dass2, 1. Kalamazoo, MI; 2. Chicago, IL.
Anaphylaxis is an acute, potentially life-threatening systemic hypersensi-
tivity reaction, resulting from exposure to an allergen. Classically, this occurs
when an individual is exposed to an allergen, leading to sensitization and sub-
sequent exposures result in an immunologic response. A 22-year-old female
with a history of polysubstance abuse presented with anaphylaxis. The patient
had a history of frequently presenting to the emergency room (ER) with vague
complaints of abdominal pain, nausea, and vomiting usually after meals. No
cause had been found for her symptoms, which were attributed to drug-seek-
ing behavior. She presented to the ER one day prior to admission with mild
uvular swelling, tachycardia, diffuse urticaria, and voice hoarseness. Her symp-
toms were attributed to an allergic reaction of unknown etiology. She was given
intravenous (IV) methylprednisolone, IV famotidine, IV diphenhydramine, and
two doses of intramuscular (IM) epinephrine. The patient was monitored and
discharged when symptoms resolved. The next day, she presented again with
dyspnea, nausea, and urticaria after consumption of garlic bread. She reported
“outgrowing” a childhood peanut allergy. She also reported having recently
started working at an Italian restaurant but denied workplace exposure to
peanuts. She was unaware of any new exposures. IV methylprednisolone, IV
famotidine, IV diphenhydramine and IM epinephrine were given, in addition
to aggressive IV hydration. Tree nut panel confirmed allergy to almond, Brazil
nut, cashew, coconut, hazelnut, macadamia nut, pecan, pine nut, pistachio,
peanut, sweet chestnut, and walnut. Upon further questioning, the patient noted
pine nuts on her garlic bread. All other allergy tests were negative. The patient
received extensive counseling regarding her allergies and risk for anaphylaxis.
She was provided with a prescription for an epinephrine auto-injector and rec-
ommended to follow up with an allergist outpatient. This case demonstrates the
importance of taking a detailed allergy history and performing a thorough exam-
ination when presented with a case of anaphylaxis. Clinicians should be con-
scientious about recognizing vague symptoms that might precede an allergic
reaction. This case also highlights the importance of differentiating signs and
symptoms related to a patient’s substance abuse from similar symptoms that
can represent a true allergic reaction.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A29
P14
POSITIVE PATCH TEST TO LAMOTRIGINE IN A PEDIATRIC
PATIENT WITH DRESS SYNDROME.
J.A. Mendez*, C. Acantilado, S. Nazario, San Juan, Puerto Rico.
Introduction: Drug reaction with eosinophilia and systemic symptoms
(DRESS) is a rare and life threatening delayed hypersensitivity reaction caused
by exposure to certain medications. However, identification of the culprit drug
may be challenging, particularly in patients receiving multiple medications.
Patch testing is a well-known method used to identify the culprit drug in delayed
Type IV hypersensitivity reactions. Here, we report the case of a pediatric patient
in whom lamotrigine-induced DRESS syndrome was successfully confirmed
through patch testing. Case description: A 5 year-old boy with epilepsy had
been receiving valproic acid for over 1 year to control seizures. He had per-
sisted with symptoms despite medical therapy and a follow-up electroen-
cephalogram (EEG) still revealed abnormal electrical activity. A decision was
made to change his antiepileptic therapy to lamotrigine 125mg daily. Two weeks
after starting therapy with lamotrigine, the patient experienced the sudden onset
of fever of 103° F and a diffuse maculopapular skin rash. Laboratory workup
was remarkable for an elevated eosinophil count of 0.86x109/L. A hypersensi-
tivity reaction to lamotrigine was suspected and the medication was stopped
immediately. A complete resolution of symptoms was observed after 2 weeks.
He was referred to our clinics due to suspected drug allergy. Patch testing was
performed to lamotrigine 30% in water and in petroleum jelly. Patch test read-
ing at 72 hours revealed a positive result to lamotrigine in water. Conclusion:
Patch testing of medical products is a useful tool in the evaluation of patients
with delayed Type IV hypersensitivity drug reactions. In this case, patch test-
ing was successfully used to confirm lamotrigine-induced DRESS syndrome
in a pediatric patient with epilepsy.
Positive patch test to lamotrigine 30% in water at 72 hours.
ABSTRACTS: POSTER SESSIONS
P15
TREATMENT OF DRUG REACTION WITH EOSINOPHILIA AND
SYSTEMIC SYMPTOMS (DRESS) WITH MYCOPHENOLATE
MOFETIL AS A STEROID-SPARING AGENT.
M. Mortezavi*, J.M. Lomas, R.J. Looney, Rochester, NY.
Introduction: Drug reaction with eosinophilia and systemic symptoms
(DRESS) is a drug-induced hypersensitivity reaction that includes skin erup-
tions, eosinophilia, lymphocytosis, lymphadenopathy and internal organ involve-
ment. First line therapy includes high dose corticosteroids, however, patients
with DRESS often require a slow, prolonged taper to prevent relapse. Here, we
describe the case of a patient with DRESS effectively treated with mycophe-
nolate mofetil as a steroid sparing drug. Case Presentation: Our patient is a
14-year-old white female, previously in good health. She developed a cough,
malaise and sore throat treated at home with ibuprofen and pseudoephedrine.
Her father also gave her one dose of amoxicillin left over from an old pre-
scription. A few days later her symptoms subsided. Four weeks after the onset
of the initial illness, she developed a flat pink rash, joint pains, fever, and cer-
vical lymphadenopathy. Her symptoms continued to escalate until she became
lethargic, had altered mental status and dyspnea. She was brought to the hos-
pital hypotensive and required intubation. A CT scan revealed diffuse cervi-
cal, axillary, hilar, intra-abdominal, pelvic mesenteric and inguinal lym-
phadenopathy. She had leukocytosis of 80 K/ml, 20% bands, eosinophilia of
28 K/mL, lymphocytosis 29 K/mL, acute hemolytic anemia, thrombocytopenia,
elevated creatinine, ferritin of 5500 ng/ml, and sIL2R 79,000 pg/ml. A bone
marrow and lymph node biopsy showed no evidence of hemophagocytosis or
malignancy. Workup for lupus, vasculitis, and infection was negative. She was
diagnosed with DRESS. She received 1gm IV steroids for three days with
remarkable recovery of pulmonary, renal and hepatic function and normaliza-
tion of labs. She was transitioned to oral prednisone at 1mg/kg and started on
mycophenolate mofetil 500 mg bid before discharge. Her steroid dose is tapered
without relapse. Conclusion: DRESS is characterized by a profound immuno-
logic response involving overproduction of multiple cell lines including T-cells,
B-cells, eosinophils and production of abnormal antibodies. Mycophenolate
mofetil is a non-competitive inhibitor of inosine monophosphate dehydroge-
nase that inhibits T and B Cell proliferation. To our knowledge, this is the first
described case of using this agent to successfully treat a patient with DRESS.
P16
PREVALENCE OF ALLERGY TO HYMENOPTERA STING
AMONG SCHOOLCHILDREN IN MONTERREY, MEXICO.
H. Hernandez-Sanchez*, A. Arias Cruz, S.N. Gonzalez Díaz, L. Leal
Villarreal, M. Hernandez Robles, J.A. Buenfil Lopez, I.V. Yanez Perez,
Monterrey, Nuevo Leon, Mexico.
Background: Hymenoptera stings can cause allergic reactions in individu-
als sensitized to their venom. There is few epidemiological data on the preva-
lence of this type of allergy in children in México. The aim of this study is to
know the prevalence of Hymenoptera sting allergy in school children of Mon-
terrey, Mexico. Method: We conducted a transversal and observational study
where hymenoptera allergy was surveyed among children attending to ele-
mentary school. The study was divided into two phases. First phase consisted
in design and validation of a questionnaire to survey hymenoptera allergy. In
the second phase, questionnaire was applied to parents whose children attended
to any of the different elementary schools of the city. Finally, questionnaires
were collected and submitted to analysis. The clinical reactions and epidemi-
ological characteristics to ant bites, bee and wasp were investigated. Allergy to
hymenoptera sting was correlated with personal history of atopy. Results: A
total of 323 questionnaires were completed and selected for analysis. The age
of the students ranged from 5-13 years (mean 9.6 ± 21) and 162 (50.2%) were
female. Ninety-three children (28.8%) had a personal history of atopy and 23%
had some clinical suspicion of atopy. Of the total sample, 217 children (67%)
had a history of at least one wasp sting. The 10.5% of children had large local
reactions and 6.5% systemic reactions. Anaphylaxis occurred in 0.9% of the
children. We found no significant difference in the prevalence of allergy to
Hymenoptera between atopic and non-atopic subjects (p = 0.09). Conclusions:
The prevalence of large local reactions and systemic reactions found in this
study was similar to what has been reported by other authors. However, the
prevalence of anaphylactic reactions was lower than what has been reported in
other epidemiological studies in the pediatric population.
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ABSTRACTS: POSTER SESSIONS
P17
SUCCESSFUL MEROPENEM CHALLENGE IN A PATIENT WITH
FULMINANT PIPERACILLIN-INDUCED IMMUNE HEMOLYTIC
ANEMIA.
B. Prince*, A. Peters, Chicago, IL.
Introduction: Drug induced immune hemolytic anemia (DIIHA) is a rare
but often severe cause of hemolysis that was first described in the 1950’s. Cur-
rently, there are more then 125 different drugs known to cause DIIHA with
cephalosporin and penicillin antibiotics being the most common agents. A diag-
nosis of DIIHA is made by a clinical history of drug associated hemolysis and
positive serologic testing. Once DIIHA is identified, the causal drug should be
discontinued, and avoidance of similar classes of medications is generally rec-
ommended since the cross reactivity between related medications is not well
established. Methods: Case Report Results: A 43 year old female with cystic
fibrosis (CF) and a history of life-threatening, piperacillin-induced immune
hemolytic anemia was hospitalized with worsening productive cough and short-
ness of breath refractory to tobramycin, aztreonam, and azithromycin. Sputum
cultures were notable for persistent pseudomonas aeruginosa infection sensi-
tive to piperacillin/tazobactam (PT) and meropenem (MP); however, two years
prior to admission, the patient developed severe hemolytic anemia with her
hemoglobin reaching a nadir of 2.7gm/dL 5 days after starting PT. Laboratory
evaluation at that time was significant for an elevated LDH and bilirubin, an
undetectable haptoglobin, and a strongly IgG positive DAT. The patient was
admitted to the ICU and required multiple blood transfusions but improved
within a few days of stopping PT. Given the patient’s history of DIIHA to
piperacillin and serious nature of her current CF exacerbation, MP was deemed
medically necessary for treatment, and informed consent was obtained. A 16
day graded dose challenge was performed starting at 1mg IV to a goal dose of
2 grams IV q8hrs without any evidence of hemolysis. The patient has contin-
ued to tolerate subsequent courses of MP without any adverse events. Con-
clusion: This is the first known report of a patient with a history of piperacillin-
induced immune hemolytic anemia tolerating meropenem through a cautious
graded dose challenge.
P18
NSAIDS ARE THE MOST COMMON CAUSE OF DRUG INDUCED
ANAPHYLAXIS AT A VILNIUS UNIVERSITY HOSPITAL.
A. Blaziene1, N. Buterleviciute1, V. Paltarackiene1, K. Linauskiene1,
L.M. DuBuske*2, 1. Vilnius, Lithuania; 2. Gardner, MA.
Background: Anaphylaxis is a life threatening condition. NSAIDs a most
common pain relief medicine, may induced anaphylaxis. Methods: 70 patients
(38 women (54.3%) and 32 men (45.7%) with anaphylaxis hospitalized in a
Vilnius University Hospital from 2009 to 2012 were assessed. The mean age
of patients was 47.31 ± 17.63 (range 20-83) years old. A total of 26 patients
with drug-induced anaphylaxis were included in this study. The causes, symp-
toms and diagnosis of anaphylaxis were analyzed using WAO criteria. Results:
NSAIDs were the main suspected cause of anaphylaxis for 10 (38.5%) patients.
Other triggers of anaphylaxis were antibiotics (30.8%), local anesthetics (3.8%)
and other drugs (26.9%). 9 cases of NSAIDs induced anaphylaxis fulfilled the
second WAO criteria for anaphylaxis diagnosis and 1 met the third criteria.
90.0% of patients had cardiovascular symptoms, 70.0% had skin symptoms,
60.0% had respiratory symptoms and 40.0% had gastrointestinal symptoms.
One patient experienced NSAID induced anaphylaxis twice. Provocation tests
were performed and safe alternative NSAIDs were chosen for 2 patients. Con-
clusion: Drug induced anaphylaxis was most commonly induced by NSAIDS.
Anaphylaxis manifestation typically involved the cardiovascular system, fol-
lowed by skin and respiratory systems.
P19
TREATMENT OF BETA BLOCKER-INDUCED CUTANEOUS
REACTION AND ANGIOEDEMA WITH SYSTEMIC
CYCLOSPORINE.
M. Imran*, Y. Zgherea, S. Gierer, J. Martinez, Kansas City, MO.
Introduction: Cyclosporine is an immunosuppressive and immunomodu-
latory drug that acts selectively on T-cells by inhibiting calcineurin. It has been
used in the treatment of a variety of T cell-mediated inflammatory and immune-
mediated skin diseases. Methods: A 40 year old Caucasian female was started
on a beta adrenergic receptor blocker (metoprolol) for ischemic cardiomyopa-
thy. On the third day, the patient developed a non-urticarial, pruritic and vesic-
ular rash on her upper chest and extensor surface of her hands, along with
A30 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
angioedema of her face and fingers. The patient had no other systemic symp-
toms. The medication was discontinued and the patient responded to oral pred-
nisone and hydroxyzine. After a few weeks, her cardiologist started her on a
different beta blocker (carvedilol). The patient had a similar cutaneous reac-
tion with angioedema on the third day without anaphylaxis, again responding
to prednisone and hydroxyzine. Results: We believed her cutaneous reactions
were not IgE-mediated; rather they were T-cell mediated, occurring within a
few days of the initiation of two beta blockers. There are no validated skin test-
ing or in vitro serum testing assays available for proving beta-blocker sensi-
tivity. We empirically suggested the patient start a low dose beta-blocker under
cover of oral cyclosporine in an attempt to abrogate the cutaneous reaction.
With the reinitiation of carvedilol the patient developed no rash, dermal pru-
ritus, or angioedema. After two months the cyclosporine dose was slowly
tapered, the carvedilol dose was escalated, and such was well tolerated. After
6 months, we recommended that the patient discontinue the low dose
cyclosporine (25 mg twice daily) while continuing the carvedilol (12.5 mg twice
daily), but the patient relocated to Europe prior to dose changes. Conclusions:
Cyclosporine has been used off-label for the treatment of various inflamma-
tory and autoimmune skin conditions. This is a prime example of successful
use of cyclosporine to prevent a drug-induced skin reaction. Further studies
need to be performed to evaluate the efficacy of cyclosporine in T cell-medi-
ated, drug-induced allergic dermatoses, wherein the use of such drug is deemed
necessary.
P20
IN VITRO CHARACTERIZATION OF A DELAYED HYPERSEN-
SITIVITY REACTION TO DOCETAXEL USING GENE EXPRES-
SION PROFILING IN A PATIENT WITH STAGE 3 BREAST CAN-
CER.
T. Kelbel*, F. Ishmael, Hershey, PA.
Introduction: The diagnosis of T-cell mediated drug hypersensitivity reac-
tions is challenging due to lack of sensitive and specific assays. We describe a
case of delayed hypersensitivity reaction to docetaxel and use of an in vitro
assay using T-cell gene expression response to characterize the reaction and
preemptively test navelbine as a safe, alternative chemotherapy treatment. Patient
History: A 59 year old woman with stage 3 breast cancer developed whole body
erythematous rash shortly followed by desquamation about 24 hours after
cyclophosphamide and docetaxel treatment. It was not clear whether the reac-
tion was caused by cyclophosphamide or docetaxel. Methods: An in vitro T-
cell assay was used to quantify gene expression changes in a panel of cytokines
and inflammatory mediators (IL-2, -4, -5, -6, -8, -10, -13, -17a, GM-CSF, TNF-
α, CCL2, IFN-γ, Fas ligand) when exposed to docetaxel and cyclophosphamide.
Additionally, her oncologist requested navelbine be preemptively tested as it
would be indicated as her next chemotherapeutic option. Results: In vitro test-
ing showed significant elevation of T-cell response of IL-6 and CCL2 to doc-
etaxel compared to cyclophosphamide and navelbine (Figure). These results
suggest that the reaction was a type IVa delayed hypersensitivity reaction to
docetaxel. The patient was successfully treated with navelbine and cyclophos-
phamide and is currently in remission. Conclusion: In vitro T-cell response test-
ing may be used to characterize docetaxel allergy while also predicting the
absence of a type IVa reaction to navelbine. This is a novel approach to
chemotherapeutic drug reactions with significant clinical application poten-
tial. Nevertheless, more research is needed before mainstream application.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A31
P21
DRUG INDUCED HYPERSENSITIVITY WITH USE OF
AMLODIPINE.
P. Oza*, Ann Arbor, MI.
Introduction: Drug induced hypersensitivity reaction to amlodipine is rare.
We present a 59 year old woman who presented with a 3 month history of a
cutaneous manifestation drug induced hypersensitivity which started 2 days
after she was re-started on Amlodipine. Methods: Evaluation, diagnosis, and
treatment of a patient with serum sickness secondary to amlodipine. Results:
A 59 year old woman presented with a 3-month history of severe rash which
started 2 days after being placed on Amlodipine for uncontrolled hypertension.
The patient recalls taking the drug before, but did not know the duration or why
she stopped the therapy. Her rash was located primarily on her palms and soles.
It was painful, pruritic, showed significant desquamation and was associated
with a constant burning sensation. She also had swelling of her legs. Amlodip-
ine was discontinued after 2 weeks, but the rash persisted. She was treated
with a Medrol dose pack which improved her symptoms, but the lesions recurred
despite follow on therapy with Clobetasol cream BID, Vaseline, Vitamin E, and
Benadryl. Her pain was debilitating and prevented her from walking. Derma-
tology obtained a punch biopsy of her hands and feet revealed eczematous
dermatitis, and was noted to have mild largely perivascular dermal lymphoid
infiltrate. She was prescribed modified Goeckerman regimen which was not
helpful. Upon presenting to our clinic, her rash was clearly demarcated by ery-
thematous marginal lines present on both palms and soles (see image). Her
ESR was noted to be elevated at 30. She was started on a prednisone taper. At
her 2 week follow up visit, she showed resolution of the cracking on the palms
and burning sensation, with presence of mild residual erythema. Conclusion:
There have been only 3 case reports suggesting a cutaneous reaction to amlodip-
ine use. The cutaneous manifestations of serum sickness are variable. Promi-
nent skin changes at the lateral aspect of the feet and hands, especially at the
junction of the sole and side of the foot and at the junction of palm and dorsal
skin surface has been noted to be unique to serum sickness. Given that amlodip-
ine is lipid-soluble, it can take months for the body to clear, which explains the
persistent nature of the rash. Conclusion This case demonstrates Amlodipine
induced drug hypersensitivity can present as an isolated cutaneous manifesta-
tion that is responsive to treatment with oral steroid.
ABSTRACTS: POSTER SESSIONS
P22
RECURRENT DRUG REACTION WITH EOSINOPHILIA AND
SYSTEMIC SYMPTOMS (DRESS) TRIGGERED BY A STRUC-
TURALLY UNRELATED DRUG.
S. Spriet*, T. Banks, T. Love, Bethesda, MD.
Introduction: Drug reaction with eosinophilia and systemic symptoms
(DRESS) is a rare, drug-induced reaction characterized by rash, fever, lym-
phadenopathy, elevated liver enzymes, and leukocytosis with eosinophilia and
has a long latency period between exposure and disease onset. We describe a
case of recurrent DRESS triggered by a structurally unrelated drug. Case Pres-
entation: A 54-year-old female with Neurofibromatosis type I and seizure dis-
order presented to her primary physician with a diffuse morbilliform eruption
and facial edema approximately 4 weeks after transitioning from levetirac-
etam to lamotrigine. As a result, lamotrigine was discontinued; however, the
patient was soon admitted due to persistent cutaneous symptoms and new fever,
abdominal pain and dyspnea. Laboratory studies were significant for a leuko-
cytosis of 35,000 cells/mcL, an absolute eosiniphilia count of 7500 cells/mcL,
elevated liver enzymes and an increase in serum creatinine from a baseline of
0.7 to 2.7 mg/dL. Bilateral pulmonary infiltrates were noted on chest radiog-
raphy. There was no mucosal involvement. Intravenous corticosteroids were
initiated and the patient’s symptoms and laboratory values steadily improved.
Following discharge, the patient continued on a planned oral steroid taper. Three
weeks later she was started on a ten day course of clindamycin (1200mg/day)
for treatment of a newly diagnosed cellulitis. This process quickly resolved, but
on day 10 of the antibiotic course she developed a recurrence of her morbilli-
form rash, evolving to significant erythroderma that resolved with an increase
in the daily dose of prednisone from 50 to 60mg. Due to the clinical course
and temporal relation to clindamycin, the patient was diagnosed with recur-
rent DRESS triggered by the antibiotic. Discussion: Antibiotics are the most
commonly implicated drugs in cases of recurrent DRESS however, the mech-
anism by which these or other structurally unrelated agents trigger the abnor-
mal immune response remains unclear. As in our case, recurrent reactions
tend to be limited to cutaneous findings. Providers should be aware of this
potential complication in patients with a history of DRESS and recognize the
need for prompt treatment.
P23
BACITRACIN IRRIGATIONS AS A CAUSE OF ANAPHYLAXIS
AND RASH.
S.E. Chiarella*, D. Nayak, N. Fenny, C. Saltoun, Chicago, IL.
Bacitracin is a polypeptide antibiotic that was approved by the FDA in 1948.
Topical bacitracin ointment has traditionally been used to prevent skin infec-
tions. More recently prophylactic bacitracin irrigations are being used during
surgical procedures. Seven cases of intraoperative anaphylaxis after exposure
to bacitracin irrigations have been previously reported. Here we present the
cases of two patients who developed hypersensitivity reactions after receiving
prophylactic bacitracin irrigations. The first case is a 47 year-old female with
a history of breast cancer status post mastectomy and prior patch testing that
was positive for bacitracin who presented for breast revision. Upon starting
the procedure, lidocaine 1% with epinephrine was employed for local anes-
thesia and the surgical wound was irrigated with a bacitracin solution. A few
minutes after receiving these medications, she developed generalized erythema
and hypotension. Intravenous hydrocortisone, diphenhydramine, and famoti-
dine were given with improvement in her blood pressure. Full recovery ensued.
Laboratory tests done later that day were all normal, except for an elevated
serum tryptase at 77.9 mg/L (normal <11 mg/L). Subsequent skin testing for
lidocaine and latex was negative. The second case is a 51 year-old female with
a history of breast cancer status post mastectomy who also presented for a breast
revision. She was given cefazolin before the procedure, prepped with chlorhex-
idine and, as in the prior case, the surgical wound was irrigated with a baci-
tracin solution. No immediate complications were noted. One day after the pro-
cedure she developed a pruritic erythematous papular rash over the left breast
that later spread to her back and abdomen. The rash resolved after completing
a short course of oral prednisone. Bacitracin patch testing done in our clinic
was positive. In addition, skin testing for penicillin and chlorhexidine was
negative. In summary, these are two very interesting cases of patients who devel-
oped hypersensitivity reactions after intraoperative exposure to a bacitracin
solution. This problem is particularly relevant since prophylactic bacitracin irri-
gations of clean surgical wounds are becoming more common.
VOLUME 113, NOVEMBER, 2014 A31
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A32
ABSTRACTS: POSTER SESSIONS
P24
DRESS IN A PEDIATRIC PATIENT TO MEXILETINE.
C. Collins*1, J. Sherr2, A. Liu2, 1. Cupertino, CA; 2. Palo Alto, CA.
DRESS (drug reaction with eosinophilia and systemic symptoms) is a seri-
ous and sometimes fatal drug reaction that is difficult to diagnose. Mexiletine
has been reported as a cause of DRESS in case reports in the adult literature.
Here we report the first case of drug reaction with eosinophilia and systemic
symptoms (DRESS) in a pediatric patient caused by the antiarrhythmic drug
mexiletine. Our patient developed DRESS on mexiletine started for non-sus-
tained ventricular tachycardia associated with nonischemic idiopathic car-
diomyopathy. Her symptoms included fever, rash and facial swelling, lym-
phadenopathy, and peripheral eosinophilia approximately 6 weeks after starting
mexilitene. Though mexilitene was initially discontinued with improvement
in reaction symptoms, it was restarted when the patient had multiple PVCs
and there was concern for the subsequent development of ventricular tachy-
cardia, for which she did not have good long-term alternatives. This case is
unusual and significant because a re-exposure was associated with syndrome
recurrence, confirming the culprit medication.
P25
SUSPECTED METHYLPREDNISOLONE SUCCINATE ANAPHY-
LAXIS CONFIRMED WITH SKIN TESTING.
L.M. Cristiano*, J.W. Caldwell, Winston Salem, NC.
Perioperative anaphylaxis is often a difficult diagnostic dilemma as multi-
ple medications are administered in a short timeframe. Considering all agents
in this setting is prudent. Anaphylaxis due to corticosteroids is rare with only
about 100 case reports available. Hydrocortisone, prednisolone, and methyl-
prednisolone are the formulations most often implicated in anaphylactic reac-
tions. We present a case of near-fatal anaphylaxis attributed to methylpred-
nisolone succinate. A 45-year-old female presented for ophthalmological surgery
requiring general anesthesia. Within 30 minutes, the patient suffered severe
hypotension and cardiac arrest with pulseless electrical activity. She was resus-
citated and transferred to the ICU. The Allergy/Immunology service was asked
to confirm anaphylaxis and identify the culprit. Our institution has recently
adopted a new electronic medical record system (EMR). The system allows
recording of operative events which are presented in graphical format includ-
ing vital signs and medication administration in the context of time. This for-
mat proved helpful in identifying the causative agent of anaphylaxis in this case.
According to the operative record, the patient entered the OR in stable condi-
tion. Induction of anesthesia included propofol, rocuronium, and fentanyl.
She also received ocular lidocaine. Approximately 30 minutes later, a second
dose of rocuronium was administered with 500mg of IV methylprednisolone.
Vital signs were stable prior to dosing; however, within minutes, severe hypoten-
sion and cardiac arrest ensued. The patient received epinephrine and CPR with
return of spontaneous circulation. There were no reports of rash or flushing.
Using information from the EMR graph, skin testing was planned for rocuro-
nium, cisatracurium, fentanyl, and methylprednisolone. SPT and intradermal
testing to rocuronium, cisatracurium, and fentanyl were negative. SPT to methyl-
prednisolone was positive with wheal/flare of 10/35mm. Positive and negative
controls had wheal/flare of 10/30mm and 0/5mm, respectively. This case illus-
trates the need to consider corticosteroids as a cause of anaphylaxis. The EMR
and graphical record are useful tools in recognizing the timing of anaphylaxis
and guided drug testing. The EMR in combination with positive and negative
SPT results helped in making a diagnosis of methylprednisolone anaphylaxis.
P26
ANAPHYLACTIC REACTIONS TO MURINE BITES: A CASE
REPORT AND REVIEW OF THE LITERATURE FOR MANAGE-
MENT GUIDELINES.
L.M. Cristiano*, G. Krishnaswamy, Winston Salem, NC.
Background: Anaphylaxis is a severe and potentially life-threatening reac-
tion caused by an IgE-mediated systemic response to drugs, foods, and other
allergens. Anaphylaxis associated with laboratory animal exposure is a recog-
nized but rare occurrence. The development of atopic symptoms such as
rhinoconjunctivitis and asthma is common among those who work with labo-
ratory animals, estimated to affect 11-44% in close contact with rats or mice.
However, only a few cases of true anaphylaxis have been reported. Objective:
To report a case of anaphylaxis which occurred after rat bite in a laboratory
worker with history of atopic disease exacerbated by rat exposure. We will
review this case and published literature for diagnosis and management guide-
A32 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
lines. Materials and Methods: We will review the medical record of this patient,
including results of laboratory and RAST testing. We conducted a MeSH search
for “anaphylaxis”, “rat”, “mouse”, “murine”, and “bite”. Results: Review of
literature revealed 7 previously reported cases of severe allergic reaction after
rat or mouse bites. One case was an anaphylactoid reaction in a 9-year-old that
was bitten by a pet mouse. 6 other cases of true anaphylaxis involved labora-
tory workers. 5 of the 7 previously reported reactions occurred in patients with
atopy exacerbated by murine exposure. Our patient was evaluated in the ER for
an episode of anaphylaxis that occurred minutes after sustaining a rat bite to
the finger. He was treated with epinephrine, prednisone, and antihistamines
with prompt recovery and referred to our clinic for follow up. We used RAST
testing to assess for sensitization to laboratory animals, and he was found to
have strongly positive IgE to rat and mouse urine and epithelium (rat urine
IgE>100). Recommendations were made for avoidance of laboratory animals,
and he was provided with an epinephrine autoinjector. Conclusion: Murine
anaphylaxis is an unusual but important entity to recognize in the workplace.
Laboratory workers who develop allergic sensitization to animals as evidenced
by exacerbation of asthma and rhinoconjunctivitis should be aware of the risks
of development of serious reactions, and career counseling may be indicated.
Murine specific immunotherapy can also be considered. The genetic and molec-
ular bases of murine anaphylaxis are unknown and require further study.
P27
COMPATIBILITY OF SHORT RAGWEED EXTRACTS IN CON-
CENTRATED MIXTURES WITH HIGH-PROTEASE AND LOW-
PROTEASE GLYCERINATED EXTRACTS AT REFRIGERATION
OR AMBIENT TEMPERATURES.
T.J. Grier*, D. Hall, E. Duncan, T. Coyne, Lenoir, NC.
Background: The stability of short ragweed allergens in immunotherapy
vaccines can be compromised by mixing with other extracts, particularly those
containing active hydrolytic enzymes. Delivery of inaccurate or inconsistent
allergen levels can reduce the effectiveness of patient treatment regimens using
these mixtures. Objectives: To confirm the compatibilities of standardized short
ragweed extracts in mixtures with a variety of other phenolated, glycerinated,
high-protease (mold, cockroach) and low-protease (tree, grass, cat, dog epithe-
lia, dust mite) extracts at concentrations targeted for maintenance immunother-
apy administrations. Methods: Two-part and three-part mixtures containing
short ragweed and other glycerinated extract concentrates were analyzed by
Amb a 1 radial immunodiffusion assay, the method currently used for short
ragweed extract standardization, after storage for up to 12 months at 2-8°C or
up to 6 months at 20-25°C. Results: Short ragweed extract controls and all mix-
tures displayed favorable Amb a 1 recoveries during storage at either temper-
ature. Control sample recoveries ranged from 90-107 (2-part) and 49-72 (3-
part) Amb a 1 U/mL, and mixtures retained 85-117% (2-part) and 70-116%
(3-part) of control values in these analyses. There was no evidence of pro-
gressive changes in short ragweed extract potency in the stored samples. Con-
clusions: Diverse combinations of short ragweed and other glycerinated extracts
frequently used for immunotherapy displayed very stable ragweed allergen lev-
els under all conditions examined. These data support refrigerated storage of
these and related extract mixtures for up to 12 months in clinical settings. Ambi-
ent temperatures (20-25°C) were evaluated as an accelerated (worst-case) exper-
imental condition, and are not recommended for storage of actual patient
immunotherapy formulas.
P28
STABILIZATION OF LABILE GRASS-FUNGAL AND GRASS-
INSECT EXTRACT MIXTURES DURING STORAGE AT
SUB-ZERO (CONVENTIONAL FREEZER) TEMPERATURES.
T.J. Grier*, D. Hall, E. Duncan, T. Coyne, Lenoir, NC.
Background: Preparation of optimal extract mixtures for allergen
immunotherapy can be restricted by changing regulations or limits for reim-
bursement. Stabilization of allergen combinations known to be incompatible
under conventional storage conditions, such as pollens mixed with protease-
rich fungi or insects, can provide viable alternatives to help allergists admin-
ister the desired immunotherapy formulations to their patients. Objectives: To
examine the compatibilities of standardized Meadow fescue and Timothy grass
pollen extracts in mixtures containing fungal or insect extracts at elevated glyc-
erin concentrations after storage for up to 12 months at refrigerator (2-8°C) or
freezer (-15 to -20°C) temperatures. Methods: Meadow fescue and Timothy
extracts were combined with individual fungal (Alternaria, Aspergillus, Peni-
cillium) or insect (American cockroach, German cockroach, fire ant) extracts
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A33
at glycerin concentrations ranging from 25-50%, in 5% increments. Extract
levels corresponded to those producing effective maintenance doses for sub-
cutaneous immunotherapy. Grass extract potencies were determined by IgE
ELISA inhibition assay, the same method used to standardize these products.
Results: Grass allergens in mixtures with fungal or insect extracts were stabi-
lized considerably by storage in a conventional freezer. Several mixtures at
25-30% glycerin were partially frozen, but those at 35-50% glycerin remained
in liquid phase. All combinations exhibited significant improvements in grass
allergen potency relative to identical mixtures maintained at 2-8°C (up to 10-
fold for Meadow fescue; up to 16-fold for Timothy). Recoveries for most mix-
tures at 25% glycerin in freezer exceeded those at 50% glycerin in refrigera-
tor. Conclusions: Storage of glycerinated extract mixtures at freezer temperatures
stabilizes labile allergens, supporting formulation of specific product combi-
nations that must currently be separated into different treatment vial sets.
P29
CORRELATION OF POLLEN COUNT WITH NEW ALLERGY
AND ASTHMA VISITS.
J. Turbyville*1, R. Arora2, P. Hall3, S. Pollard3, 1. Fort Knox, KY;
2. Lexington, KY; 3. Louisville, KY.
Background: Aeroallergen surveys help clinicians select appropriate aller-
gens for skin testing and immunotherapy.Knowing local pollen and spore pat-
terns might also help optimize access to care and scheduling for patients. Objec-
tives: To evaluate patterns of pollen and spore dispersal in Louisville, Kentucky
and correlate these with the number of new appointments scheduled with an
Allergist-Immunologist and with the number of acute visits for pediatric asthma.
Methods: A National Allergy Bureau certified counter in Louisville, Kentucky
performed daily pollen and spore counts.The mean daily pollen/spore count
was determined and graphs were generated indicating the onset, peak, and dura-
tion of total tree, grass, and weed pollen and mold spores.These graphs were
compared to the number of monthly new office visits in a large Allergy-
Immunology practice.In addition, the pollen counts were compared to the
monthly emergency room visits and admissions for asthma in a large children’s
hospital. Results: Daily pollen/spore counts were available for 7 of 10 years
from 2003-2013. Tree pollen was present from mid-February through mid-June
with a bimodal peak; the first in mid-March dominated by juniper and the sec-
ond in mid-May dominated by oak. Grass pollen was present from April through
August with a peak in mid-May. Weed pollen increased in mid-August with a
peak in early September and resolution by late-October. Mold spores were pres-
ent year round, but began rising around the first week of April, with maximum
levels occurring from June 01 through October 01, and decreasing to baseline
winter levels in early December. New allergy visits showed a bimodal peak
with the first occurring in early May and the second in late September. These
peaks occurred approximately 4 weeks later than peak pollen and the adjusted
total monthly pollen curve demonstrated significant correlation with new office
visits (R2 =0.725). The pollen curve also correlated with total monthly asthma
visits from March through September (R2=0.77), but asthma visits and pollen
count did not correlate when including the winter months in the data set
(R2=0.03). Conclusions: Acute asthma visits correlate with the pollen count
during the pollen season and demand for new office Allergy-Immunology vis-
its correlates with peak pollen counts with a lag time of about 4 weeks.
P30
HIGH CEDAR ELM POLLEN COUNTS IN THE FALL IN
ATLANTA, GEORGIA: 2009-2013.
M.R. Shams*1, S. Fineman2, 1. Atlanta, GA; 2. Marietta, GA.
Rationale: Hayfever symptoms directly correlate with atmospheric pollen
concentrations. Climatic and environmental factors have the ability to influ-
ence local botany and aerobiology. National Allergy Bureau pollen count sta-
tions determine the presence of local, clinically relevant allergens and track
patterns of prevalence. This data is extremely valuable to treating allergists as
knowledge regarding yearly and seasonal fluctuations in pollen counts is impor-
tant in the managing patients with allergic rhino-conjunctivitis, in order to
provide appropriate treatment regimens. Methods: Atmospheric sampling for
aeroallergens in Atlanta, GA was preformed over a nine-year interval accord-
ing to National Allergy Bureau standards using Rotorod sampler. Samples were
collected each morning by trained observers and various pollens are counted.
Atmospheric concentrations are determined by calculation from the raw counts.
The pollen counting station was moved a distance of 2.2 miles in 2010. The
staff is certified through the American Academy of Allergy, Asthma and
Immunology Aeroallergen Network. Results: The southeast has an intense spring
ABSTRACTS: POSTER SESSIONS
pollen season with very high tree pollen counts. Late summer-fall pollen sea-
son in past years is less intense and characterized by a ragweed bloom. How-
ever, through 2009-2013, there were very high levels of Cedar Elm during
August and September. The pollen counts were consistently within the mod-
erate range as determined by NAB criteria as greater than 15 grains per cubic
meter. Peak counts ranged between 39.1- 475.2 grains/cubic meter and 4-day
average ranged between 23.5- 206.2 grains/cubic meter. Notable, was the
increasing duration of the season and days spent within the moderate pollen
range. Conclusions: Cedar Elm has not been a dominant local aeroallergen in
Atlanta, Georgia. It appears that due to a variety of climatic and environmen-
tal factors over the last several years, the prevalence of Cedar Elm pollen in
metro-Atlanta has increased. The change of positioning of the pollen collec-
tion device may also be a factor for these extremely high counts, nevertheless
Cedar Elm is an important aeroallergen and should be considered in patients
having predominant summer-fall symptoms, especially if they fail to respond
to Ragweed testing or immunotherapy which presents during the same time of
year.
Cedar Elm Pollen Counts in the Fall in Atlanta, Georgia: 2005-2013
P31
ANAPHYLAXIS FROM COMPRESSION BANDAGE POST
DIALYSIS.
K. Chotikanatis*, A. Mathew, R. Barth, R. Joks, Brooklyn, NY.
Introduction: Medical adhesive bandages frequently cause irritant contact
dermatitis, occasionally allergic contact dermatitis. Systemic hypersensitivity
reactions from the adhesive bandages are exceptionally rare. We report algi-
nate, a component of compression bandages used after hemodialysis (HD), as
causing anaphylaxis. Case: A 31-year-old woman with end stage renal disease
due to prolong hypertension, received HD therapy via arteriovenous fistula for
8 years, presented with 5-months of recurrent generalized pruritus urticarial
eruption, along with shortness of breath immediately after hemodialysis ses-
sions. She had no history of angioedema; and no history of chemical, medica-
tion or food allergies. Skin prick testing to hydrocolloid gel from TipStop®
(Gambo, Hechingen, Germany) bandage was positive and negative to medica-
tions administered at the time of HD including intravenous iron, erythropoi-
etin and paricalcitol. Total IgE, latex IgE and tryptase levels were unremark-
able. The patient was advised to avoid TipStop® bandage and became symptoms
free for 3-month follow up. Discussion: TipStop® is one of the modern com-
pression bandage that claims to be hypoallergenic. The Bandage has hydro-
colloid gel in the center made from alginate which is designed to stop bleed-
ing after vascular punctures and to protect the fistula. Alginate, an extract
from brown seaweed, is used extensively in medical devices and products such
as dental impressions, prosthetics, soft tissue dermal fillers, dressings and com-
pression bandages. It is also used in food industry, for thickening soups and
jellies. This is the first case of anaphylaxis to bandages. The more severe reac-
tion in our case might be caused by direct contact of alginate with vascular
system. Conclusion: The allergenic potential of modern wound dressings should
not be underestimated.
P32
RELATIONSHIP BETWEEN POLLEN COUNTS AND EMER-
GENCY DEPARTMENT VISITS FOR ASTHMA.
O. Gourgy-Hacohen*, J. Jacobs, Walnut Creek, CA.
Background: Asthma exacerbations triggers include environmental factors.
Objective: The objective of this study was to investigate the relationship between
Emergency Department visits for asthma and pollen counts. Methods: The num-
ber of emergency department visits for Asthma between the years 2008-2013
was recorded at John Muir Hospital in Walnut Creek, California. Pollen counts
were collected in Pleasanton, California during the same time period. Results:
VOLUME 113, NOVEMBER, 2014 A33
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A34
ABSTRACTS: POSTER SESSIONS
The number of emergency department (ED) visits for Asthma varied through-
out the year with a peak number of visits occurring in May. We found a sig-
nificant correlation between the number of Asthma ED visits and: 1. The
monthly averaged total pollen counts (rho=0.629, p<0.05) and 2. The monthly
averaged tree pollen counts (rho=0.678, p<0.05). The daily ED visits for Asthma
significantly correlated with: 1. The total pollen counts (rho=0.212, p<0.0001),
2. The grass pollen counts (rho=0.192, p<0.0001) and 3. The tree pollen counts
(rho=0.201, p<0.0001). There was a significant difference in the number of
daily visits between days with high grass pollen counts vs. low grass pollen
counts (Mann Whitney. p<0.0005. High grass pollen days: Mean=2.024 visits
per day. Low grass pollen days: Mean=1.302 visits per day). A significant dif-
ference in the number of daily visits was also observed when comparing days
with high tree pollen counts vs. low tree pollen counts (Mann Whitney. p<0.001.
High tree pollen days: Mean=1.894 visits per day. Low tree pollen days:
Mean=1.312 visits per day). Conclusions: ED Asthma visits in this study were
associated with tree pollen counts and with grass pollen counts.
Monthly averages of the different pollen types and ED Asthma visits between
the years 2008-2013 with SEM. Pollen data presented as pollen grains per
cubic meter. Asthma visits data presented as the monthly averaged number of
visits.
P33
ALLERGEN EXTRACT STABILITY: NON-STANDARDIZED
EXPIRATION DATING.
G. Plunkett*, B. Mire, Round Rock, TX.
Introduction: In the US, the standardized extracts, grass pollen, dust mite,
short ragweed, cat hair/pelt, and venoms have expiration dating determined by
formal manufacturer studies and approved by the FDA. Non-standardized
extracts have expiration dating specified by the FDA. 50% glycerin extracts
are dated for 6 years from extraction, but only 3 years from shipping, and non-
glycerin extracts are dated for 3 years and 1.5 years from shipping. Little evi-
dence is available to support this dating, so the purpose of this study is to eval-
uate various extracts produced over the last 10 years for protein and allergen
content. Methods: Allergen extract concentrates were analyzed for protein diver-
sity by SDS-PAGE. Potency of some extracts was determined by IgE binding
and major allergen assays such as Bet v 1 in Birch, Pla l 1 in English plantain,
Ara h 1,2,6 in peanut and tropomyosin in shrimp. The commercial extract lots
were manufactured over a 10 year period and were stored in their final con-
tainer vials at 2-8C. Results: SDS-PAGE protein patterns generally maintain
consistent patterns for the mandated expiration dating. Most aqueous extracts
began to show changes after the 3 year expiration and most glycerin extracts
showed little change over 6 years. Remarkably, some extracts maintain con-
sistent patterns for up to 10 years. Potency assays helped support the gel data.
Conclusion: The characterization methods used in this study provide evidence
for the expiration dating for many non-standardized allergen extracts. The sta-
bility enhancing ability of glycerin has been confirmed.
A34 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P34
A QUALITATIVE ANALYSIS OF A NEW ROTOROD SYSTEM UTI-
LIZING MICROCONTROLLERS AND OPTICAL SENSOR TECH-
NOLOGY IN THE ENVIRONMENTAL EXPOSURE UNIT (EEU).
T.J. Walker*, L.M. Steacy, B. Hobsbawn, A.K. Ellis, Kingston, ON, Canada.
Background: Certainty of continual Rotorod® impact sampler revolutions
per minute(RPM) is unknown during normal operation using accepted tradi-
tional design and RPM calibration techniques; only during RPM calibration
can one be definitive. As EEU pollen concentration levels are monitored and\or
adjusted based on accurate sampling, monitored constant RPM values are pre-
ferred. Methods: Custom programmable microcontroller boards, optical encoder
technology, secure digital(SD) storage, wireless connectivity, and touch screen
control are combined to provide real time monitoring, alerts, and data storage.
Pulse width modulation(PWM) using the proportional-integral-derivative con-
troller(PID) and encoder feedback ensure accurate motor control. The 2400
RPM speed is calculated and recorded per second and stored along with device
name, date, time, and user stamp on the onboard storage or wirelessly to a sep-
arate location. A standard 30 second spin cycle was initiated multiple times
over a 15 minute period while simultaneously taking RPM measurements with
a handheld National Institute of Science and Technology(NIST) certified opti-
cal tachometer. Voltage was monitored until the rotorod system was unable to
sustain the minimum RPM and noted. All data was stored and then compared
in our central database. Results: The RPM comparison speeds captured by the
new system averaged 2380.90 RPM, st dev 35.86. Readings from the hand-
held tachometer averaged 2394.52 RPM, st dev 9.65. The minimum voltage
causing RPM under tolerance was 11.85 volts. The new design allows for con-
tinual, noncontact, real time monitoring and storage of data from multiple
devices simultaneously, therefore, lessoning labor time requirements.
Conclusions: The redesigned rotorod particle sampler will allow for real-time
verification feedback and alerts for all particle sampling in the EEU. This
advancement assures that all particle sampling using rotorod impact sampling
is accurate for the entire duration of all duty cycles. Qualification/ validation
of these devices addresses any mitigations deemed necessary to meet regula-
tory guidelines.
P35
OCCUPATIONAL ALLERGY TO PEACH (PRUNUS PERSICA)
POLLEN AND CROSS-REACTIVITY BETWEEN ROSACEAE
FAMILY POLLENS.
N. Jiang*, L. Wen, J. Yin, Beijing, China.
Background: Orchard workers are highly exposed to several allergic agents,
especially peach pollen and other Rosaceae family pollens. However, no occu-
pational allergy in this branch has been described before. Methods: First, skin
tests, serum-specific IgE tests with home-made extracts of peach pollen and
other four Rosaceae family pollens (apricot pollen, cherry pollen, apple pollen
and pear pollen) of the working environment were executed. Furthermore, con-
junctival challenge with peach pollen was performed, western immunoblots
with these five Rosaceae family pollens were performed. In addition, ELISA
inhibition and western blotting and inhibition experiments among five Rosaceae
family pollens were performed. Result: Skin prick tests with five Rosaceae pol-
lens extracts were positive in patient. Specific IgE against three pollens (peach
pollen, apricot pollen and cherry pollen) could be demonstrated in the patient
by ELISA. Cross reactivity studies by ELISA inhibition performed with the
patient’s sera, when peach pollen used as solid phase, IgE binding to peach
pollen could be inhibited by precubation the other four pollens with inhibition
rate ranging from 45% to 87%, the strongest inhibitor was apricot pollen extract.
Sera from patient showed clear IgE binding to 20kD,60kD,80kD proteins in
peach pollen extract, similarly the patient’s sera recognized apricot pollen pro-
teins of 20KD,55kD,80kD, the sera showed weak IgE binding to 20KD,80KD
component of cherry pollen, and the IgE reactivity protein in apple pollen
appeared to be 80kD and 110 kD. The 20KD IgE binding component in patient’s
serum could be demonstrated with peach pollen, apricot pollen and cherry
pollen. The IgE binding to the 20kD protein in peach pollen extract was com-
pletely inhibited with apricot pollen (10mg/ml) as inhibitor. When cherry, apple,
and pear pollen were used as inhibitors, 20kD band was partly inhibited. Con-
clusion: We conclude that peach pollen is a potential cause of IgE mediated
occupational respiratory disease, extensive cross reactivity among Rosaceae
pollens. An increasing number of patients are needed to confirm these inter-
esting preliminary finding, and epidemiologic studies are necessary to assess
the importance of this aeroallergen among exposed orchard workers.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A35
P36
UNIQUE ALLERGY AND ASTHMA SMARTPHONE APP.
S. Kagen*, Appleton, WI.
Smartphone applications are now playing a new and critical role in mon-
itoring the success or failure of allergy and asthma treatments, especially as
new healthcare reforms reward successful patient outcomes and performances.
Monitoring allergy patients has been difficult, but a new and unique Smart-
phone software application (KagenAir®) enables consumers to simultaneously
monitor their allergy and asthma symptoms and discover local environmental
factors that affect how they feel using patent pending methodologies and com-
puter generated animated maps and graphics. The KagenAir App is unique in
that it measures symptoms scores and also directly connects consumers with
uncontrolled allergy and asthma symptoms to Board Certified Allergy-Asthma-
Immunology Specialists within their communities using both cell phone and
video-chat technologies. Beta testing on allergy and asthma patients established
the KagenAir App to be easy to understand, simple to use and helpful in con-
necting consumers with local allergy specialists.
P37
GRASS POLLINATION OCCURS EARLIER AND IS MORE ABUN-
DANT IN CENTRAL UKRAINE LIKELY DUE TO CLIMATE
CHANGE.
V.V. Rodinkova1, O.O. Palamarchuk1, I.I. Motruk1, L.V. Kremenska1,
K.V. Musatova1, L.M. DuBuske*2, 1. Vinnitsa, Ukraine; 2. Gardner, MA.
Background: Recent pollen seasons in Ukraine have demonstrated rapid
changes in the pollination patterns of key taxa producing allergenic pollen.
Poaceae is one of the pollen types causing severe symptoms for patients in
Ukraine. Method: Pollen collection from 2009 to 2014 used volumetric meth-
ods employing a Hirst Burkard trap placed at a height of 25 meters above the
ground on the roof of a Vinnitsa Medical University building. All samples were
taken from March 1 until October 31. Results: Poacea pollen season start has
shifted at least 10 days earlier for the 2013 and 2014 year seasons than seen in
2009 to 2012. Thus, year 2009 and 2011 were characterized for the latest sea-
sonal start in the third ten-day-period of May. Years 2010 and 2012 were char-
acterized with the season start in the second ten-day-period of May. Poaceae
pollination was seen during the first ten-day period of May for both 2013 and
2014. However, the season end is always the first ten-day period of September
in each year. Interestingly, May 24, 2014 was characterized by a significant
pollen count increase to 73 pollen grains per cubic meter of air (p.g./m3). The
grass pollen season for 2009 and 2011 had just begun around this date. The
pollen count increase exceeded seasonal peak values seen in 2009, 2012 and
2013 (71, 62 and 43 p.g./m3 respectively). Total pollen number collected in
2014 by June 18 in Vinnitsa is already comparable with the total annual val-
ues recorded in years 2012 and 2013 (819 p.g versus 911 and 896 respectively).
Conclusion: Poaceae pollination has became more abundant and starts early in
recent years in Central Ukraine. This phenomenon may be related to climate
change and global warming.
P38
INFLUENCES OF EARLY PET EXPOSURE ON CYTOKINE LEV-
ELS IN LATER CHILDHOOD.
H. Nguyen*, J.M. Biagini Myers, U. Sivaprasad, G.K. LeMasters,
D.I. Bernstein, T. Reponen, P.H. Ryan, G.K. Hershey, Cincinnati, OH.
Background: Though exposure to pets is a known trigger of allergic dis-
ease, it has been shown that such exposures, particularly at a young age, can
be immunoprotective. Early dog exposure especially has been associated with
decreased risk of wheezing and atopic dermatitis. Methods: Data from the
Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS) provided cat
and dog allergen levels contained within dust samples collected from the homes
of infants born between the years of 2001 and 2003 with at least one atopic par-
ent. Cytokine levels were measured from blood samples obtained when
CCAAPS study participants were 11-12 years of age. IRB approval and
informed consent was obtained from all research subjects. The study data from
the first 40 participants with available serum samples were included in this
study, and levels of cytokines were measured via a Luminex® multiplex cytokine
assay. High allergen level was defined as a level at or above the calculated
median. High cytokine level was also defined as a level at or above the calcu-
lated median. Differences in the proportions of high and low allergen levels
with high and low cytokine levels were tested by Chi-square. Results: Although
the differences in cytokine levels did not reach statistical significance, impor-
ABSTRACTS: POSTER SESSIONS
tant trends were noted. Study participants with early life exposure to high lev-
els of dog allergen had a nearly 50% reduction in levels of the following
cytokines compared to those with exposure to low levels of dog allergen: G-
CSF, IL-10, MCP-3, TGFalpha, IL-9, and IL-3. No cytokine was elevated in
participants with exposure to high levels of dog allergen compared to the low
dog allergen level group. In contrast, study participants with early exposure to
high levels of cat allergen had significantly higher levels of the following
cytokine compared to those with exposure to low levels of cat allergen: IL-
12p70, G-CSF, Mip-1alpha, IL-9, and TNFbeta. Only VEGF was substantially
elevated in participants with exposure to low levels of cat allergen. Conclu-
sions: The observed trends support that early exposure to high levels of dog
allergen is immunoprotective and associated with lower serum levels of
cytokines in later childhood. Notably, a similar relationship was not found with
high cat allergen exposure at a young age. In contrast, early exposure to high
levels of cat allergen was associated with higher cytokine levels.
P39
THE CORRELATION OF BODY MASS INDEX (BMI) TO ALLER-
GEN SKIN TESTING AND SERUM SPECIFIC IGE.
M.Z. Braunstein*, R. Joks, Brooklyn, NY.
Background: Obesity has been linked to asthma exacerbations, total serum
IgE, and severity of atopic dermatitis. The correlation of obesity on allergy test-
ing responsiveness has not been well studied. Objective: We sought to investi-
gate the relationship of BMI to allergen skin prick tests and serum specific
allergen IgE levels of common aeroallergens and foods. Methods: We reviewed
adult patient charts (n=288) who presented to the allergy and immunology clinic
from 1998-2013. Data from patients with physician diagnosed allergic rhinocon-
junctivitis or asthma who underwent routine epicutaneous skin prick testing
(SPT) for common environmental allergens (n=124) or who had allergen spe-
cific IgE levels (FEIA) to common environmental and food allergens (n=92)
were included for analysis. Spearman coefficients were generated to determine
an association of BMI with the number of positive SPT, the mean wheal diam-
eter, and the maximum specific IgE class. Results: BMI significantly corre-
lated with the number of positive SPT (p=0.01) and inversely with the mean
wheal diameter (p=0.05). There was no significant correlation with the maxi-
mum specific IgE class. Conclusions: Obesity, as measured by BMI, is asso-
ciated with increased specific cutaneous allergic responses. However, the cuta-
neous response to allergen decreases with increasing BMI, suggesting an
attenuated response to allergic mediators released during immediate hyper-
sensitivity reactions with increasing BMI.
Spearman correlation (r) of BMI with:
*statistically significant
P40
THE ASSOCIATION BETWEEN SERUM IGE, EOSINOPHIL LEV-
ELS AND CANCER, NHANES 2005-2006.
S. Nagarajan*1, Q. Meng1, L. Bielory*2, 1. Piscataway, NJ; 2. Springfield,
NH.
Background: Cancer is an important cause of health morbidity in adults.
One in four deaths are due to cancer (ACS, 2014). There is little published lit-
erature of serum IgE and eosinophil level associations with cancer on a national
level. Objective: To examine the association between serum IgE, eosinophil %
and the overall vs. type-specific prevalence of cancer. Methods: Data from a
nationwide survey conducted by the Centers for Disease Control and Preven-
tion, National Health and Nutrition Examination Survey (NHANES 2005-2006)
was used. Bivariate analyses with chi-square tests, logistic regression and strat-
ified models assessed the relationship between serum IgE and eosinophil %)
and the overall prevalence of cancer (defined as ever having been diagnosed
by a physician with cancer of any kind) versus the type-specific prevalence of
cancer. Results: A total of 4,893 adults constituted our study population. After
controlling for age, gender, ethnicity, education and income, smoking status
and duration of cancer diagnosis, subjects with high serum IgE had a negative
odds of overall cancer (OR = 0.83, 0.64-1.09), as did subjects with higher
eosinophil levels (OR = 0.90, 0.82-0.99). Interaction models demonstrated the
significant protective effect of cancer for IgE for males (OR= 0.85, 0.74-0.99)
VOLUME 113, NOVEMBER, 2014 A35
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A36
ABSTRACTS: POSTER SESSIONS
and eosinophil levels in females (OR= 0.73, 0.54-0.98). Finally, IgE levels had
a negative odds of lung (OR= 0.28, 0.15-0.52) and cervical cancers (OR= 0.84,
0.61-0.16). High eosinophil levels also had negative odds of lung (OR=0.39,
0.15-1.00) and cervical cancers (OR=0.57, 0.41-0.78). Conclusion: This study
shows that atopy and eosinophilia were associated with a decreased preva-
lence of overall cancer after covariate adjustment, using a large, nationally
representative dataset. This suggests the need for continued allergy surveillance
and longitudinal studies of the possible protective role of serum IgE and
eosinophil levels in lung and cervical cancers.
P41
CONTACT SENSITIVITY TO METAL AND ACRYLATES IN
PATIENTS UNDERGOING JOINT REPLACEMENT.
M. Goebel, J. Tan*, D. Bernstein*, Cincinnati, OH.
Introduction: Allergy to metals and acrylates in bone cement have been
implicated in joint implant failures. Over 900,000 hip and knee replacement
surgeries are performed annually in the US. The purpose of this study was to
evaluate contact hypersensitivity to metals and acrylates in patients undergo-
ing joint replacement. Methods: Sixty-five subjects were referred for evalua-
tion of possible allergy to metal between 2012-2014. Subjects underwent either
pre-operative (N=46) or post-operative (N=19) patch testing to a standard panel
of metal salts (nickel, cobalt, chromium, palladium, vanadium, and zirconium)
and methyl and ethyl acrylate. Patients and referring providers were contacted
for information regarding component materials in the prostheses and postsur-
gical outcomes. Results: Of 65 patients, 46 with a self-reported history of metal
allergy were tested pre-operatively (PRE) and 19 patients were referred post-
operatively (POST) for implant failure. Thirty-five (76%) of the PRE group
had a positive patch test; all these patients had an alternative material (eg zir-
conium, polyethylene, ceramic, or titanium) implanted. Fourteen of POST
patients had positive patch tests (74%); 8/14 (57%), however, gave no prior
metal allergy history. Nickel was the most common offending antigen in both
groups with 54% of PRE and 32% of POST patients reacting to nickel. Rare
metals such as palladium caused several reactions with 8 PRE and 4 POST pos-
itive patch tests. Two PRE and 3 POST patients, all female, reacted to ethyl
acrylate as well. Conclusion: A history of metal allergy and/or contact hyper-
sensitivity confirmed by patch testing may influence choice of implant mate-
rial. In addition to infection and biomechanical failure, metal allergy should
be considered as a potential cause of prosthetic joint failure.
P42
HEPATITIS C VIRUS-ASSOCIATED CRYOGLOBULINEMIA PRE-
SENTING AS CHRONIC URTICARIA.
S. Bantz, M. Rodenas*, New Haven, CT.
Introduction: A 48 year old male presents with a 20 year history of chronic
urticaria that has been worsening in severity for the past 4 years. He reports a
long-standing pruritic urticaria that comes and goes on his arms, legs, abdomen,
and back. For the past 4 years he has had more painful lesions occurring over
a greater area and with increased frequency, almost daily. The pain and itch are
relieved by oral steroids and antihistamines, but he has been requiring greater
doses of short-acting antihistamines recently. On review of systems, he also
reports nasal congestion, cough, abdominal pain, BRBPR due to hemorrhoids,
joint aches and swelling. Social history revealed a 25 pack-year smoking his-
tory, heavy alcohol consumption, and previous incarceration for ten years. Phys-
ical examination revealed raised, erythematous, circumscribed lesions that are
not blanchable on his upper and lower extremities, abdomen, and back. Results:
Laboratory evaluation revealed mild anemia Hb13.1g/dL, Hct 39.6%. IgE 28
kU/L. CMP unremarkable. Absent CH50 and C4. Low C2 (0.9mg/dL) and C3
(36mg/dL). Rheumatoid factor positive. C1q, ANA, ANCA, ESR (2mm/hr),
anti-Smith, anti-dsDNA and anti-RNP antibodies were normal. SPEP unre-
markable. Quantiferon Gold negative. HIV negative. Hepatitis C antibody reac-
tive, HCV Quantitative 1,160,000 IU/mL and HCV Quantitative Log 6.06. Hep-
atitis C genotype 1b. Biopsy was consistent with vasculitis. Cryoglobulins
positive. The patient is scheduled to start anti-viral therapy. Discussion: Cryo-
globulinemia is a systemic inflammatory syndrome that involves small-to-
medium vessel vasculitis due to immune complexes. Clinical presentations of
cryoglobulinemia vary widely. Cryoglobulinemia has different underlying eti-
ologies, and is associated with up to 65% of patients with hepatitis C virus.
Cryoglobulinemia can cause a triad of palpable purpura, arthralgia, and myal-
gia when viral associated, while cryoglobulinemia due to monoclonal
immunoglobulins or hematological malignancies is generally associated with
hyperviscosity. Cryoglobulinemia is diagnosed by the demonstration of serum
A36 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
cryoglobulins in association with characteristic clinical signs and symptoms.
Prognosis is generally dependent on the degree of resolution of the underlying
condition. This case marks the importance of an infectious work-up and vas-
culitic evaluation in a patient with non-remitting urticarial lesions.
P43
IMPACT OF WEIGHT LOSS ON MARKERS OF SYSTEMIC
INFLAMMATION IN OBESE SAUDI CHILDREN WITH ASTHMA.
O.H. Al Jiffri*, Jeddah, Saudi Arabia.
Background: Weight loss studies were conducted in children without asthma
have demonstrated a reduction in systemic inflammation. However, the impact
of weight loss in the obese paediatric population with asthma has not been
investigated. Objective: To measure the effects of weight loss on markers of
systemic inflammation in obese children with bronchial asthma. Methods:
Eighty obese children with bronchial asthma (42 boys, and 38 girls) with mean
age 13.86± 3.21 years were divided into two equal groups. The training group
received diet regimen, exercise training in addition to the medical treatment for
two months, where the control group received the medical treatment only.
Results: There was a 17.5%, 15.5%, 22.4%, 14.1% and 15.9% reduction in
mean values of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6),
interleukin-8 (IL-8), Leptin and body mass index (BMI) respectively and 38.7%
increase in mean values of adiponectin in the training group. While, there was
a 0.7%, 9.0%, 2.8%, 1.6% and 1.2% increase in mean values of TNF-alpha,
IL-6, IL-8, Leptin and BMI respectively and 3.9% decrease in mean values of
adiponectin in the control group. The mean values of TNF-alpha, IL-6, IL-8,
Leptin and BMI was decreased and adiponectin was increased significantly in
the training group, however the results of the control group were not signifi-
cant. Also, there were significant differences between both groups at the end
of the study. Conclusion: Weight loss improves markers of systemic inflam-
mation in obese Saudi children with bronchial asthma. Key words: obesity,
asthma, weight loss, cytokines.
Mean value and significance of TNF- α, IL-6, IL-8, Leptin, Adiponectin
and BMI in group (A) and group (B) after treatment.
TNF- α = tumor necrosis factor – alpha. IL-6 = Interleukin-6
IL-8= Interleukin-8 BMI= Body Mass Index
P44
THE USEFULNESS OF SERUM HIGH SENSITIVITY C-REAC-
TIVE PROTEIN AS A MARKER OF AIRWAY INFLAMMATION
IN BRONCHIAL ASTHMA.
T. Shimoda*1, Y. Obase2, M. Imaoka1, R. Kishikawa1, T. Iwanaga1,
1. Fukuoka, Japan; 2. Nagasaki, Japan.
Rationale: Serum high sensitivity C-reactive protein (hs-CRP) has been
shown to be useful as a marker of airway inflammation in bronchial asthma.
However, various factors have been reported to affect hs-CRP levels. We con-
ducted a study in patients with mild bronchial asthma without complications
to determine whether hs-CRP could serve as a useful indicator in assessing air-
way inflammation. Methods: The subject population consisted of 40 healthy
volunteer (HV) controls, and 45 patients with bronchial asthma (BA). Induc-
tion of sputum with the use of inhaled 3% hypertonic saline and bronchial
hyperresponsiveness test were performed, in addition to serum hs-CRP. Results:
The log serum hs-CRP levels were higher in BA patients (2.49 ± 0.41) com-
pared with healthy subjects (2.21 ± 0.39) (p=0.002). When receiver operator
characteristic (ROC) analysis was performed to compare healthy subjects and
BA patients, the sensitivity was 0.64 and specificity was 0.71 at a log serum
hs-CPR of 2.3. The log serum hs-CRP levels were negatively correlated with
FEV1.0,%pred (r = -0.31, p = 0.04), positively with sputum eosinophils (r = 0.34,
p = 0.02), but not with log PC20 (r = -0.09, p = 0.56). Multiple regression analy-
sis demonstrated that the log serum hs-CRP concentrations were significantly
correlated with both eosinophils (p = 0.004) and neutrophils (p = 0.011) in spu-
tum. Conclusions: Serum hs-CRP is useful in assessing airway inflammation
in BA patients without complications such as heart disease, hypertension, hyper-
lipidemia, chronic obstructive pulmonary disease, and infections.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A37
P45
ASTHMA SEVERITY AND INCREASED RISK OF CARDIOVAS-
CULAR AND CEREBROVASCULAR OUTCOMES IN PATIENTS
WITH MODERATE-TO-SEVERE PERSISTENT ASTHMA.
T.A. Omachi*1, T. Haselkorn1, D.P. Miller2, M. Shah2, M.D. Eisner1,
H. Chen2, C. Iribarren3, 1. South San Francisco, CA; 2. San Francisco, CA;
3. Oakland, CA.
Introduction: Studies have shown higher risk of cardiovascular disease
(CVD) in asthma than non-asthma populations. However, there are limited data
examining whether asthma severity is linked to CVD incidence within asthma
populations. Methods: The Evaluating Clinical Effectiveness and Long-Term
Safety in Patients with Moderate-to-Severe Asthma study (EXCELS) is a mul-
ticenter, prospective, 5-year, observational cohort study of patients with mod-
erate-to-severe persistent asthma, including cohorts treated and not treated with
omalizumab. This post hoc analysis examined the association between base-
line asthma severity factors and longitudinal outcomes over 5 years in the non-
omalizumab cohort. Cardiovascular- and cerebrovascular-related events were
combined into a single endpoint of arterial thrombotic events (ATE), defined
as the first of the following: cardiovascular death, myocardial infarction,
ischemic stroke, transient ischemic attack, or unstable angina. An independent
expert panel blindly adjudicated all ATEs. Asthma severity measures included
spirometry, physician-assessed asthma severity, oral steroid usage, and the
Severity of Asthma Score (SOA), a validated instrument that assesses asthma
symptoms, asthma medication burden, and asthma emergency utilization his-
tory (range 0-28). Multivariable Cox models were used to assess risk of ATE
for each individual asthma severity measure, controlling for potential con-
founders. Results: A total of n=2,829 patients in the non-omalizumab cohort
were analyzed. Baseline mean age was 46.2±17.1 years, 66.5% were female,
and 82.2% were white. Mean pre-bronchodilator % predicted forced expira-
tory volume (FEV1) was 80.0±21.6 and mean SOA was 10.0±4.5. After con-
trolling for potential confounders, lower pre-bronchodilator FEV1 % predicted,
higher SOA, and chronic oral corticosteroid usage were each statistically sig-
nificantly associated with increased risk of ATE (Table). Conclusions: Multi-
ple asthma severity measures were associated with increased risk of ATE in
this cohort. Further work is required to delineate mediators, but this analysis
utilizing a large cohort followed over an extended timeframe provides some of
the most robust evidence linking higher asthma severity to greater risk of car-
diovascular and cerebrovascular outcomes.
Adjusted Predictions for Time to First ATE Event (n=2,829 Patients)
ATE, arterial thrombotic event; FEV1, forced expiratory volume in 1 second
a) Analyses of FEV1 % predicted controlled for tobacco history (none, cur-
rent, former) and education but not age, gender or race/ethnicity because
these demographic factors are included in the calculation of percentage pre-
dicted.
b) Controlling for age, gender, race/ethnicity, education, and tobacco history
(none, current, former).
P46
LONGITUDINAL CHANGE IN ASTHMA SYMPTOM CONTROL
IN PATIENTS WHO CONTINUED VS. DISCONTINUED OMAL-
IZUMAB: RESULTS FROM THE XPORT STUDY.
J. Antonova, B. Trzaskoma, K. Raimundo, P. Solari*, J. Zazzali, South San
Francisco, CA.
Introduction: Little is known about the effect of omalizumab (OMA) con-
tinuation vs. discontinuation after its long-term use on patient-reported asthma
symptom control. XPORT was the first rigorous study of long-term benefit of
OMA continuation. Methods: XPORT was a randomized, double-blind, placebo-
ABSTRACTS: POSTER SESSIONS
controlled withdrawal study of patients with moderate-to-severe persistent aller-
gic asthma receiving long-term therapy with OMA for ≥5 years. Patients were
randomized to either continue the same dose of OMA (n=88) or switch to
placebo (PLB, n=88) and were followed every 4 weeks for 1 year. Patients com-
pleted the Asthma Control Questionnaire (ACQ) and the Asthma Control Test
(ACT) at baseline (BSL) and every 4 weeks until week 52. High ACQ (range
0-6) and low ACT (range 0-25) scores indicate poor asthma symptom control.
We compared changes in ACT and ACQ scores from BSL to week 52 and
ACT and ACQ scores at each time point against the BSL (ANOVA tests). We
compared the percentage of PLB and OMA patients (chi-square test) whose
decline reached minimal important difference (MID) from BSL to Week 52 on
ACT and ACQ. IRB approval and informed consent were obtained from all
research subjects. Results: On average, patients had good asthma symptom con-
trol at the BSL (Table). Patients randomized to continue OMA maintained
better asthma symptom control than patients randomized to PLB. The mean
change from BSL to Week 52 for ACT score was -2.88 for the PLB arm and -
1.16 for the OMA continuation arm [p=0.0188]. The mean change from BSL
to Week 52 for ACQ score was 0.63 in the PLB arm and 0.22 in the OMA con-
tinuation arm [p = 0.0039]. Compared to the BSL, the decline in asthma symp-
tom control in ACT and ACQ was statistically significant for the PLB arm start-
ing at week 4. There was no statistically significant change for the OMA arm
at any time point (Table). By week 52, the percentage of patients whose decline
of asthma control reached MID comprised 28.4% (OMA) vs. 43.2% (PLB) on
ACQ (p = 0.041) and 23.9% (OMA) vs. 39.8% (PLB) on ACT (p=0.024). Con-
clusions: Patients with allergic asthma who continue on OMA therapy main-
tain asthma symptom control. However, patients who discontinue OMA ther-
apy report significant decline in asthma symptom control, and this is evident
as early as week 4.
ACQ and ACT scores by study visits and treatment arms
PLB = placebo; OMA = omalizumab.
High ACQ and low ACT scores indicate poor asthma symptom control.
* P < 0.05. ** P < 0.01. P-values were derived from ANOVA, comparing
against baseline.
P47
ASTHMA KNOWLEDGE AND DISEASE CONTROL.
M. Stevens*1, J. Stokes1, A. Bewtra1, M. Fasano2, 1. Omaha, NE; 2. Iowa
City, IA.
Background: Multiple studies have shown inadequate parental knowledge
about asthma is common among pediatric patients seen in Emergency Rooms
(ER) for acute asthma. Furthermore educational interventions have resulted in
improvements in both the asthma knowledge of parents, as well as disease con-
trol of patients. However in adult populations there are conflicting data regard-
ing the relationship between asthma knowledge and disease control. Methods:
We measured asthma knowledge with the Asthma Self-Management Ques-
tionnaire, a validated 24 item true/false instrument, in 49 adult asthmatics while
visiting any of 3 primary care clinics at a single tertiary referral center. Asthma
control was measured by Asthma Control Test (ACT), mini- Asthma Quality
of Life Questionnaire (m-AQLQ), as well as patient reported: monthly short
acting beta-agonist (SABA) use, ER visits for asthma in the past year, and life-
time hospitalizations for asthma. Other demographic, socioeconomic, includ-
ing literacy as measured by the Newest Vital Sign (NVS), and asthma care
data were also collected. Results: Asthma knowledge was correlated with asthma
control as measured by monthly SABA use (r=-0.29 p=0.05) but was not with
ACT (r=0.17, p=0.24), m-AQLQ (r=0.19, p=0.19), ER visits (r=-0.13, p=0.13),
and hospitalization (r=-0.11, p=0.47). Asthma knowledge was correlated with
specialist referral (r=0.41, p=0.003) and patient literacy (r=0.37, p=0.01), but
not with the patient’s reported highest level of formal education (r=0.19, p=0.20),
patient income (r=0.08, p=0.60), time since asthma diagnosis (r=0.22, p=0.13),
VOLUME 113, NOVEMBER, 2014 A37
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A38
ABSTRACTS: POSTER SESSIONS
and controller medication prescription (r=0.04, p=0.8). Discussion: In this pop-
ulation asthma knowledge was correlated with SABA use, patient literacy and
specialist referral, but did not correlate with other measures of asthma control,
socioeconomic status, and asthma management. However this was a small
survey conducted in a single facility and the study population had significantly
higher scores than the population in which the knowledge measurement tool
was validated. Consequently further investigation into adult patient knowledge
and asthma control is warranted.
P48
THE ASSOCIATION OF BLOOD EOSINOPHIL LEVELS AND
SEVERE ASTHMA DEFINED BY NEW GUIDELINES.
J. Casciano*1, J. Krishnan2, M. Buatti Small3, S. Bajpai1, C. Li4,
Z. Dotiwala1, 1. White Plains, NY; 2. Chicago, IL; 3. Frazer, PA; 4. Little
Rock, AR.
Background: Recently published European Respiratory Society (ERS) and
American Thoracic Society (ATS) asthma guidelines provide a new definition
of severe asthma based on control measures and medication use. The relation-
ship between asthma severity and blood eosinophils (EOS) was examined using
this new guideline definition. Objective: To study the association of asthma
severity defined by ERS/ATS guidelines with blood EOS levels. Methods:
Records of patients at least 12 years of age with at least two medical claims
with a primary or secondary diagnosis of asthma defined by ICD-9-CM code
493.xx between January 2004 and July 2011, were extracted from the EMR-
Claims+ database (eMAX Health, White Plains NY) containing electronic med-
ical records linked to insurance claims across 6 Midwestern states in the U.S.
The date of first diagnosis was defined as the ‘index date’. Patients were required
to have at least 1 peripheral blood EOS test in the 12 month ‘assessment’ period
following the index date. Patients’ asthma was classified as severe or non-severe
using intensity of treatment and level of asthma control during the assessment
period, as recommended by the 2014 ERS/ATS guidelines. An elevated EOS
was defined as > 400 cells/mL. Chi-square tests were utilized to compare the
proportion of patients with elevated EOS between the two severity groups. Mul-
tivariable logistic regression was used to assess the relationship between asthma
severity and EOS, after controlling for potential confounders. Results: Among
the 2,164 patients with asthma and EOS test results in the assessment period,
9% (n=184) had severe asthma according to ERS/ATS guidelines. A signifi-
cantly greater proportion of patients with severe asthma had elevated EOS,
compared to patients with non-severe asthma (30% vs. 19%, p=0.0002). In
multivariable analysis, severe asthma was associated with an 83% increased
odds of elevated EOS (Odds Ratio = 1.83, p=0.0005), compared to those with
non-severe asthma after adjusting for differences in patient demographic char-
acteristics and comorbidities. Conclusion: An elevated EOS is associated with
nearly double the odds of severe asthma.
P49
REDUCING BEDSIDE EDUCATION TIME BY EXPANDING
PARENTAL ACCESS TO AN INPATIENT ASTHMA CLASS.
H. Murphy*, D. Williams, J. Wolverton, M. Reddy, Kansas City, MO.
Background: Prior to 2011, patients admitted with asthma to this tertiary
care children’s hospital received bedside education from a registered respira-
tory therapist (RRT) with variable intensity and consistency. To address this
problem, an Inpatient Asthma Class (IAC) was implemented three days a week
in 2011, which was increased to five days a week in 2014. Our specific aim
was to evaluate the relationship between expanding parental access to an IAC
and RRT time spent on bedside education. Methods: ORI determination was
obtained for non human subjects research. The study population included chil-
dren with asthma admitted from February 2011 to May 2014. RRT’s were asked
to document in the electronic medical record (EMR) the amount of time spent
on bedside education with each family as: 〈15 minutes, 15 minutes, 30 min-
utes, or 〉30 minutes. Data was extracted from the EMR to investigate RRT time
spent on bedside education when the IAC was offered three days a week, com-
pared to five days a week. Analyses were performed in Stata 11.2 and Excel
(.xlsx) using chi-squares and differences in proportions. Results: About 100
RRT’s provided bedside education for 2546 patients and their families during
the study period. When the IAC was offered three days a week, 21% (469/2197)
of patients did not have documentation of time spent on education, similar to
26% (91/349) who did not have documentation when the IAC was offered five
days a week. When the IAC was offered three days a week, 46% (787/1728) of
parents attended; whereas 61% (157/258) attended when the IAC was offered
five days a week (p〈0.0001). When the IAC was offered three days a week, 33%
A38 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
(261/787) of families required 〈15 minutes of bedside education, compared to
48% (75/157) when the IAC was offered five days a week (p=0.0005). Over-
all, 8% (75/944) of families required ≥30 minutes of bedside education with
parental attendance in the IAC, compared to 17% (172/1042) of patients with-
out parental attendance in the IAC (p〈0.0001). Conclusion: Expanding the IAC
from three days a week to five days a week increased parental attendance, result-
ing in a reduction in bedside education time. This time-savings has allowed re-
allocation of RRT’s to more urgent clinical needs throughout the hospital. The
increasing importance of cost-efficient, value-based care supports the future
provision of educational programs such as the IAC.
P50
EFFECTS OF BUDESONIDE/FORMOTEROL ON FIXED AIR-
FLOW OBSTRUCTION STATUS AND EARLY STUDY WITH-
DRAWAL DUE TO PREDEFINED ASTHMA EVENTS IN
PATIENTS WITH MODERATE TO SEVERE ASTHMA.
B.E. Chipps*1, D.P. Tashkin2, M. DePietro3, F. Trudo3, 1. Sacramento, CA;
2. Los Angeles, CA; 3. Wilmington, DE.
Background: The effect of budesonide/formoterol (BUD/FM), BUD, or FM
on fixed airflow obstruction (FAO) and withdrawal due to predefined asthma
events (PAEs) is unclear. Methods: This was a post-hoc analysis of a 12-week,
randomized, placebo (PBO)-controlled study (NCT00652002) of patients aged
≥12 years with moderate–severe asthma. After 2-week run-in with twice-daily
BUD 160 mg via pressurized metered dose inhaler (pMDI), patients received
twice-daily BUD/FM pMDI 320/9 mg, BUD pMDI 320 mg, FM 9 mg via dry-
powder inhaler, or PBO. Worsening asthma event criteria were predefined
(PAEs; Drugs. 2006;66:2235-54). Postbronchodilator FAO status was assessed
at screening, weeks 2, 6, and 12 via forced expiratory volume (FEV1)/forced
vital capacity (FVC) ratio for patients who completed the study. This analysis
excluded patient withdrawals for any reason before week 2. Persistent FAO−
(FEV1/FVC ≥ lower limit of normal [LLN]) and persistent FAO+ (FEV1/FVC
〈 LLN) patients retained their FAO status at all visits. FAO status of variable
patients was not consistent on all visits. FAO status and withdrawals due to
PAEs were assessed. Results: In 258/389 patients (66%), FAO status was per-
sistent throughout the study (135 FAO− and 123 FAO+). The remaining 131
patients (34%) had variable FAO, changing status after screening. The per-
centage of patients with persistent FAO− (44%, 37%, 28%, and 30%), persist-
ent FAO+ (30%, 29%, 35%, 33%), and variable FAO (26%, 34%, 38%, and
37%) differed in the BUD/FM, BUD, FM, and PBO groups, respectively. Over-
all, persistent FAO− patients had fewer PAEs than FAO+ or FAO variable
patients. The numbers of patients who withdrew due to PAEs in the persistent
FAO− (n = 2, 4, 3, and 7), persistent FAO+ (n = 1, 4, 15, and 15), or FAO vari-
able (n = 6, 8, 15, and 12) classifications also differed for the BUD/FM, BUD,
FM, and PBO groups, respectively. Conclusions: Patients with moderate to
severe asthma treated with BUD/FM are most likely to remain persistent FAO−,
least likely to become FAO variable, and least likely to withdraw from the study
if FAO+. Patients who were persistent FAO− vs persistent FAO+ or FAO vari-
able had fewer withdrawals due to PAEs. Irrespective of FAO status, patients
receiving BUD/FM experienced the fewest withdrawals due to PAEs. Supported
by AstraZeneca LP
P51
EFFECT OF FIXED AIRFLOW OBSTRUCTION STATUS ON
PEAK EXPIRATORY FLOW AND RESCUE MEDICATION USE
IN RESPONSE TO BUDESONIDE/FORMOTEROL TREATMENT
IN PATIENTS WITH MODERATE TO SEVERE ASTHMA.
B.E. Chipps*1, D. Tashkin2, M. DePietro3, F. Trudo3, 1. Sacramento, CA;
2. Los Angeles, CA; 3. Wilmington, DE.
Background: The effects of fixed airflow obstruction (FAO) on peak expi-
ratory flow (PEF) and rescue medication (RM) use with budesonide/formoterol
(BUD/FM) in patients with moderate to severe asthma is unclear. Methods: In
a 12-week, double-blind, double-dummy, placebo (PBO)-controlled study
(NCT00652002), moderate to severe asthma patients aged ≥12 years were
randomized to twice-daily BUD/FM via pressurized metered dose inhaler
(pMDI) 320/9 mg, BUD pMDI 320 mg, FM dry powder inhaler 9 mg, or PBO
after a 2-week run-in with twice-daily BUD pMDI 160 mg. In a post-hoc analy-
sis, postbronchodilator FAO status was assessed via forced expiratory volume
in 1 second/forced vital capacity (FEV1/FVC) ratio at screening and weeks 2,
6, and 12 for patients who completed the study, excluding patient withdrawals
for any reason before week 2. Persistent FAO− (FEV1/FVC ≥ lower limit of
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A39
normal [LLN]) and persistent FAO+ (FEV1/FVC〈 LLN) patients remained
FAO− or FAO+ throughout the study. FAO variable patients had inconsistent
FAO status at different visits. Percentage of patients with ≥30-L/min increase
in morning and evening PEF and ≥0.5-inhalation/d (inh/d) decrease in RM
use from baseline were evaluated. Results: Of 389 patients, 135 had persistent
FAO−, 123 persistent FAO+, and 131 FAO variable. More BUD/FM vs BUD,
FM, and PBO patients, respectively, improved ≥30 L/min in morning PEF
(55.3% vs 14.7%, 22.2%, and 11.1% for FAO−; 56.3% vs 18.5%, 5.9%, and
6.7% for FAO+; 46.4% vs 21.9%, 16.2%, and 5.9% for FAO variable) and
evening PEF (51.1% vs 20.6%, 33.3%, and 7.4% for FAO−; 46.9% vs 11.1%,
8.8%, and 3.3% for FAO+; 39.3% vs 18.8%, 8.1%, and 8.8% for FAO variable).
The percentage of patients decreasing RM use ≥0.5 inh/d was greater with
BUD/FM vs BUD, FM, and PBO, respectively (57.4% vs 35.3%, 51.9%, and
22.2% for FAO−; 65.6% vs 40.7%, 38.2%, and 43.3% for FAO+; 53.6% vs
53.1%, 40.5%, and 23.5% for FAO variable). Conclusions: The percentages of
patients who experienced ≥30-L/min morning and evening PEF increases and
≥0.5-inh/d decreased RM use were similar for BUD/FM in FAO+ and FAO−
patients and numerically greater than BUD, FM, or PBO, irrespective of FAO
status. Increased responses occur with the combination of BUD and FM in
FAO+ patients. Supported by AstraZeneca LP
P52
A PERSISTENT ASTHMATIC PATIENT AFTER LOVEBIRD CON-
TACT: CASE REPORT.
S. Kaygusuz, M. Nursoy*, A. Gedik, S. Uzuner, E. Cakir, Istanbul, Turkey.
Introduction and Aim: Asthma is chronic respiratory disease characterized
with recurrent episodes where environmental factors are important. An asth-
matic patient whose clinical and radiological findings persisted after lovebird
contact was presented. Case: A nine-years-old allergic asthmatic patient was
admitted due to persistant cough and wheezing for 1 months. Her complaints
increased after living with a lovebird at home. Her father, aunt, and cousins had
asthma, tuberculosis (TB) contact wasn’t mentioned. Bilateral roncus and pro-
longed expiration were found in examination. Inflammation in chest X-ray and
mite-allergy in prick test (eosinophil 3.9%, ImmunglobulinE 92 mg/dl) were
determined. Asthma and allergic rhinitis were treated with inhaled steroid, long-
acting beta-2 agonist, leucotrien antagonist, nasal steroid. Macrolid was given
for atypical Mycobacteria. Symptoms persisted after two weeks of these ther-
apies. Computarized tomography revealed atelectasis, infiltrations and frosted-
glass appearance. Extrinsic allergic alveolitis due to lovebird was thought. Bird
feather specific IgE, Aspergillus antigen, Chlamydia and Mycoplasma serol-
ogy, and sputum cultures were negative, Quantiferon test was positive. Fiberop-
tic bronchoscopy was normal, ARB in BAL and gastric aspirates were nega-
tive. Anti-TB therapy was begun due to resistant clinical and radiological
symptoms and positive Quantiferon test. During the follow-up, Mycobacterium
complex was obtained from BAL culture. Family screening was negative, after
a while her adolescent neighbour had TB was told by the family. Clinical and
radiological complete improvement was seen after therapy. Conclusion: The
diagnosis of TB disease should be excluded in the patients where clinical and
radiological symptoms and findings are resistant to therapy.
P53
POORLY CONTROLLED ASTHMA: NEW THERAPEUTIC
OPTIONS.
J. Fernandez de Cordova Aguirre*, A. Velasco-Medina, D. Carino-
Cartagena, M.E. Arroyo-Cruz, S. Gonzalez Flores, G. Velazquez-Samano,
Mexico City, DF, Mexico.
Poorly controlled asthma is diagnosed when despite high doses of inhaled
corticosteroids daily plus short and long acting β-2-agonists, and other thera-
pies, symptoms interfere significantly with daily activities, frequent exacer-
bations need to be solved with the administration of corticosteroids, frequent
emergency room visits or hospital admissions and the need for oral corticos-
teroids. Material and Methods: We performed a pilot, prospective, open study
from June to December 2013. We included 30 asthmatic patients who signed
informed consent and were over 18 years old. They were clasified according
to GINA in partly controlled or uncontrolled and treated with inhaled steroids
at high doses plus long acting β-2-agonist. In the first visit we registered a
spirometry with bronchodilator, asthma control test of 5 questions (ACT) and
the quality of life of asthma (mini-AQLQ). We then indicated ICS and LABA
plus tiotropium 2.5 mcgs a day or roflumilast 500 mcgs a day or theophylline
200 mg every 12 hours. ACT were evaluated and mini-AQLQ once a month
via phone and on 2 visits at 3 and 6 months, spirometry with bronchodilator at
ABSTRACTS: POSTER SESSIONS
6 months and peak flow meter measured at home. The main objective was to
measure the ACT, the second objective was to assess mini-AQLQ, FEV1 and
peak flow. Results: Mean age was 48 years. 65% were women. ACT <16: 10
uncontrolled patients and between 16 and 19 ACT: 20 patients partially con-
trolled. The mean duration of asthma was 11 years. Fifteen patientys received
tiotropium, 10 patients Roflumilast and 5 theophylline. 3 patients discontinued
treatment during the 6 months. In all 3 groups improved ACT and mini-AQLQ
(p <0.0001). The total values of lung function with tiotropium improved FEV1
2.46 ± 0.89 L at baseline to 2.60 ± 0.92 L at 6 months (p <0.0001); with rof-
lumilast 2.50 ± 0.90 L at baseline to 2.63 ± 0.96 L at 6 months (p <0.0001);
and 2.43 ± 0.84 theophylline L at baseline to 2.53 ± 0.91 L at 6 months (p
<0.0001). PEF with tiotropium increased from 5.76 ± 2.38 to 6.22 ± 2.47 L /
s (p <0.0001); with roflumilast increased from 4.65 ± 2.22 to 5.11 ± 2.32 L /
s (p <0.0001); and theophylline increased from 5.13 ± 2.17 to 6.01 ± 2.31 L /
s (p <0.0001). Conclusion: It is premature to ensure that these drugs are safe
and effective. We conclude that adding tiotropium, theophylline and roflumi-
last achieves a better disease control, increases FEV1, PEF and improves qual-
ity of life.
P54
CHRONIC COUGH WITH RESTRICTIVE CHANGES ON
SPIROMETRY DIAGOSED AS HYPERSENSITIVITY PNEU-
MONITIS FROM EXPOSURE TO NYMPHICUS HOLLANDICUS
(COCKATIEL).
R. Harris*, Beverly Hills, CA.
This a case report of a 59 year old female presenting with a persistent severe
cough of 10 months duration. She had multiple evaluations for asthma, GERD,
and treament with multiple inhalers and antibiotics without response. History
was negative for occupational exposures to known agents causing hypersensi-
tivity pneumonitis such as gases, paints (TDI) or other agents. There was no
history of emphysema in non smokers in her family and she is a lifelong non
smoker. When asked about pets previously she stated that she had no cats or
dogs. When questioned in detail about bird exposure such as pigeons close to
her windows, etc,she stated that she had a Cockatiel that she purchased 12
months before her presentation to our office. On further history she stated that
she was the one who cleaned the cage of droppings and that no mask was worn.
On physical exam she had no dyspnea she did have cough ( with no inspira-
tory stridor), no clubbing, pO2=95, she had diffuse crackling breath sounds on
auscultation. Her Spirometry showed FVC=59% predicted and FEV1=69%
predicted. We ordered chest xray, arranged for a Spirometry with DLCO gas
exchange, titers for Chlamydia pneumonia and Mycoplasma pneumonia,hyper-
sensitivity pnuemonitis panel plus titers and precipitins for parrot/cockatiell (
if available) and alpha 1- antitrypsin was considered if the above was negative.
Unfortunately due to the expense after insurance the patient declined the test-
ing. She removed the Cockatiel from the home and within 3 months her cough
totally abated. She declined followup spirometry and was lost to followup. In
patients with chronic respiratory issues or chronic cough a thorough investi-
gation of pets, including birds, and fish ( we had one patient with HSPneu-
monitis to silkworm powder used to feed fish). In this case she refused to do
diagnostic studies but our clinic suspicion was that her Cockateil and her expo-
sure to the cage droppings were considered highly likely to be the cause. There
are studies showing Cockatiel to be an antigen stimulating precipitins.
McClusky, et.al. published on a case where a similar patient showed positive
precipitating antibody to cockatiel dropping mix (CDM) .
P55
PHARMACOKINETICS, SAFETY, AND TOLERABILITY OF FLU-
TICASONE PROPIONATE MULTIDOSE DRY POWDER
INHALER AND FLUTICASONE DISKUS® ADMINISTERED IN
HEALTHY SUBJECTS: AN OPEN-LABEL, RANDOMIZED,
THREE-PERIOD CROSSOVER, SINGLE-DOSE STUDY.
A.B. Vutikullird1, M. Gillespie2, S. Song2, J. Steinfeld*2, 1. Cypress, CA;
2. Frazer, PA.
Introduction: Fluticasone (Fp), an inhaled corticosteroid, was approved in
1993 for the maintenance treatment of asthma. It has well-established safety
and efficacy profiles and is available as a dry powder inhaler formulation and
a hydrofluoroalkane inhalation aerosol. In the present study, Fp is delivered via
a novel, inhalation-driven multidose dry powder inhaler (MDPI) that eliminates
the need to coordinate actuation with inhalation. Methods: This was a single-
center, open-label, randomized, 3-period crossover, single-dose study in healthy
Japanese and Caucasian subjects aged 20-45 years, inclusive. Subjects (N=30)
VOLUME 113, NOVEMBER, 2014 A39
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A40
ABSTRACTS: POSTER SESSIONS
were randomized to 1 of 6 treatment sequences including combinations of 4
inhalations of Fp MDPI 100 mg (total dose of 400 mg), Fp MDPI 200 mg (total
dose of 800 mg), and Fp-DISKUS® (GlaxoSmithKline, Research Triangle Park,
NC) 100 mg (total dose of 400 mg). The primary objective was to assess phar-
macokinetics (PK) (maximum plasma concentration and time, terminal rate
constant and half-life for plasma elimination, area under concentration-vs-time
curve) for each treatment; safety and tolerability also were assessed. Results:
Over the range of all Fp doses evaluated, PK parameters were similar in Japan-
ese and Caucasian subjects. Differences were observed between the systemic
exposures produced by each of the 3 doses, with the Fp plasma concentration-
vs-time curves being highest for the Fp MDPI 800 mg total dose and lowest for
the Fp DISKUS 400 mg total dose (Figure). The most frequently occurring
adverse event was presyncope, which occurred in 2 Caucasian subjects, 1 treated
with Fp MDPI 400 mg total dose and 1 treated with Fp MDPI 800 mg total dose.
There were no clinical laboratory, electrocardiographic, vital signs, or physi-
cal examination findings that were considered clinically significant. Conclu-
sions: The PK profiles for Fp MDPI 400 mg, Fp MDPI 800 mg, and Fp DISKUS
400 mg were similar in Japanese and Caucasian subjects; however, there were
differences in the systemic exposures dependent on total dose, with Fp MDPI
800 mg being highest and Fp DISKUS 400 mg being lowest. The safety and
tolerability profiles of all treatments were consistent with the known profile of
Fp. This study was sponsored by Teva Pharmaceuticals
P56
A NOVEL ALBUTEROL MULTIDOSE DRY POWDER INHALER
IN ADULT AND ADOLESCENT PATIENTS WITH EXERCISE-
INDUCED BRONCHOCONSTRICTION: A SINGLE-DOSE STUDY.
N. Ostrom*1, H. Taveras2, H. Iverson2, D. Pearlman3, 1. San Diego, CA;
2. Miami, FL; 3. Denver, CO.
Introduction: A novel, inhalation-driven, multidose dry powder inhaler
(MDPI) has been developed that eliminates the need to coordinate actuation
with inhalation and may reduce administration errors in comparison with con-
ventional metered-dose inhalers. Studies show that albuterol (AB) is effective
and well tolerated for the prevention of exercise-induced bronchoconstriction
(EIB). Methods: This single-dose, double-blind, 2-way crossover study
(NCT01791972) randomized adolescents and adults with EIB (≥20% fall from
pre-exercise challenge FEV1) to treatment sequences AB MDPI 180 mg/placebo
(PBO) MDPI (n=19) or reverse sequence (n=19). IEC/IRB approval and
informed consent from all subjects were obtained. FEV1 was measured at 30
minutes post-dose, 5 minutes before treadmill exercise challenge (baseline) and
5, 10, 15, 30, and 60 minutes after exercise challenge. The primary efficacy
endpoint was maximum percentage fall from baseline in FEV1 up to 60 min-
utes post-exercise challenge. Secondary efficacy endpoints included percent-
age of patients whose maximum percentage fall from baseline FEV1 post-exer-
cise challenge was <10% (protected by treatment) and time to recovery (from
exercise challenge completion to the first measured post-challenge FEV1 within
10% of the pre-challenge baseline FEV1). Results: Age, gender, and baseline
FEV1 were comparable between subjects in both sequences. Mean maximum
percentage fall in FEV1 within 60 minutes post-exercise challenge for AB MDPI
was 6.21±1.44% (95% CI, 3.28%-9.14%) vs PBO, 22.38±1.44% (95% CI,
19.44%-25.31%; p<0.0001). Thirty-two (84.2%) AB MDPI subjects had a <10%
maximum FEV1 fall post-exercise challenge vs 6 (15.8%) PBO subjects. Pro-
tection with AB MDPI was significant (p<0.001) vs PBO within 5 minutes and
A40 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
maintained through 30 minutes; recovery was complete for both groups at 60
minutes. Median time to recovery for AB MDPI was 5.07 minutes vs PBO,
30.07 minutes (p<0.0001). Adverse events (AEs) included severe migraine
(n=1, PBO) and moderate sinus bradycardia (n=1, AB MDPI). No serious AEs,
discontinuations due to AEs, or deaths occurred. Conclusions: AB MDPI pro-
vided clinically significant protection from EIB in adolescents and adults with
a history of EIB. There were no safety issues with short-term AB MDPI use.
This study was sponsored by Teva Pharmaceuticals.
P57
RESULTS FROM TWO TRIALS EVALUATING THE POTENTIAL
EFFECTS OF FLUNISOLIDE HFA (AEROSPAN) ON GROWTH
IN PEDIATRIC PATIENTS WITH MILD-TO-MODERATE
ASTHMA.
G. Bensch*1, L. Greos2, N. Ruiz3, J. Karafilidis3, 1. Stockton, CA;
2. Centennial, CO; 3. Somerset, NJ.
Introduction: While recognized as the most effective maintenance treat-
ment for mild-to-moderate persistent asthma, inhaled steroids have the poten-
tial to cause growth suppression in children. Several studies performed with
inhaled corticosteroids demonstrated an impact on growth velocity (ranging
from -0.3 cm/yr to -1.8 cm/yr) with recent studies suggesting that this effect is
not reversible once treatment with the inhaled steroid is stopped. Two 1-year
trials were performed with flunisolide HFA (Aerospan), a small-particle inhaled
corticosteroid with a built-in spacer for the treatment of asthma in asthmatics
6 years and older, to evaluate growth velocity changes in pre-pubescent chil-
dren 4 to 11 years of age. Methods: The first study was an open-label, ran-
domized, 1-year safety study of flunisolide HFA, inhaled beclomethasone (BDP)
CFC, and inhaled cromolyn (as a negative control) in children 4 to 11 years of
age with mild-to-moderate asthma. The second study was a double-blind ran-
domized 1-year safety study of flunisolide HFA and placebo in children 4 to 9
years of age with mild-to-moderate asthma. Each study was analyzed simi-
larly for growth velocity (via stadiometry assessments) and change in height
over 1 year (measured as cm/yr). The dose of flunisolide HFA in both studies
was 160 mcg (2 puffs) twice daily, which represents the maximum FDA-
approved dose of flunisolide HFA for children. Results: In the open-label study,
206 patients age 6-11 years, were analyzed for growth and growth velocity.
Mean changes from baseline height were 6.2 cm for the flunisolide HFA and
cromolyn groups versus 5.1 cm for the BDP group. Mean growth velocity was
6.2 cm/yr for the flunisolide HFA group versus 5.3 cm/yr (BDP) and 6.9 cm/yr
(cromolyn). In the double-blind study, of 218 evaluable patients age 4-10 years,
the mean growth velocity was 6.01 cm/yr for flunisolide HFA versus 6.19 cm/yr
for placebo, a non-significant difference (P=.425). Conclusion: The results from
two trials demonstrated that flunisolide HFA did not result in significant growth
suppression in pre-pubescent pediatric asthma patients 4 to 11 years of age
when compared to placebo or the negative control (cromolyn).
P58
INHALER-DEVICE SATISFACTION, SMOKING HISTORY,
ALLERGIC RHINITIS AND ADHERENCE IN US ADULT
ASTHMA PATIENTS: RELATIONSHIP TO HEALTH-RELATED
OUTCOMES.
D. Price1, B. Harrow*2, L. Gever*2, J. Pike3, M. Small3, V. Higgins3,
1. Aberdeen, Scotland, United Kingdom; 2. Somerset, NJ; 3. Macclesfield,
United Kingdom.
Improving asthma control has focused on potentially modifiable clinical
and behavioural characteristics including correct inhaler technique, allergic
rhinitis (AR), adherence and smoking. This research aims to establish these
relationships with asthma control, outcomes and quality of life. A US cross-
sectional survey of adult asthma patients seeking routine care, informed Par-
tial Least Squares Path Modelling to quantify inner model relationships between
latent variables of patient-reported satisfaction of drug delivery, device func-
tionality, device feedback, concomitant AR, adherence (Morisky Medication
Adherence Scale), smoking history, patient-reported outcomes (Asthma Con-
trol Test, Jenkins Sleep Questionnaire, EuroQol-5D-3L) and physician-reported
asthma exacerbations in last 12 months. Patients not receiving inhaled main-
tenance therapy were excluded. 243 patients were included. All actual variables
were positively correlated with the appropriate latent variable. Cronbach’s Alpha,
a measure of consistency for a group of variables, measured at least 0.659 for
latent variables indicating that the hypothetical variables of inhaler satisfac-
tion, smoking history, concomitant AR, adherence and outcomes were well
reflected by the composition of the actual variables in the dataset. Cross-load-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A41
ings were also supportive of the hypothesized outer model. Better patient out-
comes were significantly associated with patient satisfaction regarding drug
delivery attributes related to the inhaler (p=0.002). A negative smoking his-
tory coupled with absence of concomitant AR were also significantly associ-
ated with better patient outcomes (both p<0.001). Improved adherence did result
in enhanced outcomes, but this relationship was not statistically significant
(p=0.060). The R2 value for outcomes was 14.6% and pseudo goodness of fit,
measuring overall prediction performance of the path model, was 20.56% indi-
cating a fifth of the variance was explained by this model. Improving patient
satisfaction with inhaler drug delivery parameters represents one modifiable
aspect of asthma management contributing to better control. Interventions based
on improved recognition of impact of severe AR, allergy phase and smoking
on patient’s asthma control are also likely to have a positive impact on asthma
patient health-related outcomes.
P59
EVALUATION OF RECURRENT RESPIRATORY INFECTIONS
IN PATIENTS WITH ALLERGIC RHINITIS, ASTHMA, AND/OR
COPD PRE- AND POST-TREATMENT WITH BACTERIAL
LYSATE VACCINES.
A.M. Koatz*, Buenos Aires, Argentina.
Introduction: Recurrent acute infections of the upper and lower airways are
frequent and often require multiple therapies. This is especially true for patholo-
gies such as allergic rhinitis and/or asthma and/or COPD. The etiology of recur-
rent infections is generally viral, but the additional complication of bacterial
infection worsens the symptoms of the underlying pathology. For these rea-
sons, preventive measures should be considered when treating acute infections.
Methods: a randomized, double-blind, placebo-controlled clinical trial was con-
ducted. Patients aged 16-65 years who had not received a lysate vaccine in the
previous year were included. Eighty-four (84) patients were randomly assigned
to 2 groups of 42 subjects each one :- Group A (active) – receive either OM-
85 bacterial lysate vaccine capsule or equivalent placebo. Capsules were admin-
istered daily for 10 consecutive days per month for a duration of 3 consecutive
months..Group C (healthy controls) serologic studies were performed in 10
subjects. Serum and secretory IgA levels were determined before and after
treatment along with symptom score and the number of infections and exac-
erbations. Written informed consent was obtained from all study participants.
Results: Eighty-four (84) patients were enrolled and 42 patients that received
OM-85 had a decrease in the number of recurrent infections from 82% to 45.5%
(p< 0.05) compared to 78.9% in the placebo group. Similarly, the exacerba-
tions of the underlying pathology decreased from 65.7% to 34.9% with OM-
85 versus 62.3% in the placebo group (p<0.05) There was also a substantial
reduction of the symptoms of the underlying pathology. (p<0.01) A signifi-
cant increase in serum and secretory IgA levels was observed only in the OM-
85 group (both p<0.001) during which parallels the 3 cycles of therapy. Con-
clusion: This study demonstrated a clinical benefit of OM-85 for reducing
reinfections and exacerbations in patients with allergic rhinitis and/or asthma
and/or COPD. The use of OM-85 lead to an increase in serum and secretory
IgA levels which provides a new perspectives regarding the immunological
mechanism of action, namely immunostimulation and immunodesviation. Fur-
ther investigation is warranted to better understand these encouraging outcomes.
ABSTRACTS: POSTER SESSIONS
P60
CHILDHOOD OBESITY IN DIFFICULT TO CONTROL PEDI-
ATRIC ASTHMA PATIENTS IN A TERTIARY PEDIATRIC SUB-
SPECIALTY CLINIC.
Y. Hamzavi Abedi*, A.M. Perkins, M.B. Morales, Norfolk, VA.
Introduction: It is important to identify clinical features associated with
asthma for the development of new interventions to be most effective. Our clin-
ical observation suggested the hypothesis that the proportion of overweight/obe-
sity is significantly higher in difficult to control (DTC) than in well-controlled
asthmatics. Methods: This was a retrospective chart review of 100 patients,
aged 5 to 18 years, who were seen in a CHKD or one of the CSG Allergy out-
patient clinics between 5/1/2013 and 3/31/2014, and diagnosed with asthma.
Cases (n = 50) were identified as severe persistent DTC asthmatics based on
their required high dose of ≥1000 mg/day of inhaled corticosteroids (ICS). The
control group (n = 50) included subjects with well-controlled mild or moder-
ate persistent asthma defined by a dose of ≤ 500 mg/day of ICS. A subject’s
weight status was classified by the BMI percentile for age as normal weight
(BMI < 85%), overweight (BMI 85-94%), or obese (BMI ≥ 95%). The chi-
square test was used to assess the relationship between overweight / obesity
status and DTC asthma status. IRB and HRC approval and waivers of consent
and authorization to access protected health information were obtained. Results:
The BMI percentile in the DTC asthma group was significantly higher than in
the well-controlled group (75.74 ± 25.63 vs. 51.69 ± 24.43, p < 0.001). 36 %
of the DTC asthmatics were obese (vs. 0% of the well-controlled asthmatics,
p < 0.001), 14% overweight (vs. 10% of the well-controlled asthmatics, p =
0.99) and 50% normal weight (vs. 90% of the well-controlled asthmatics, p <
0.001). Mean age in the DTC asthmatics was 13.2 ± 3.3 vs. 10.0 ± 3.2 in the
well-controlled group (p < 0.001). Notably, a significant difference was observed
in the race between the DTC and the well-controlled asthma group. 74% of the
DTC asthmatics were African American (AA) (vs. 30% AA in the well-con-
trolled asthma group, p < 0.001), 14% were White (vs. 66% in the well-con-
trolled group, p < 0.001). There was no significant difference in gender between
the DTC and well-controlled asthmatics. (Table 1). Conclusion: The results of
this study suggest that there is a significant association between obesity and
severe persistent DTC asthma. This finding underlines the need for new treat-
ment approaches for DTC asthmatics involving a simultaneous treatment of
asthma and obesity.
TABLE 1. Demographics by difficult to control asthma status
SD – standard deviation; a P value calculated using two-sample t test; b P
value calculated using Fisher’s exact test; c P value calculated using chi-
square test
P61
INHALED MOMETASONE FUROATE-INDUCED ADRENAL SUP-
PRESSION IN AN ADOLESCENT.
M. Hanna*1, D.P. Mack2, 1. Oakville, ON, Canada; 2. Burlington, ON,
Canada.
Introduction: High dose inhaled corticosteroids have been increasingly rec-
ognized to cause adrenal suppression. Patients reported in the literature typi-
cally have presented in the first decade of life. We report on the first case of
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A42
ABSTRACTS: POSTER SESSIONS
mometasone furoate (MF) induced adrenal suppression on MF therapy. Case
Description: A sixteen-year-old female with asthma and allergic rhinitis since
the age of five was initially maintained on a regimen of FP 500mcg per day
and MF nasal spray 50-100 mcg per day. As she had uncontrolled symptoms
she was changed to MF/formoterol fumarate 800/ 20 mcg per day in addition
to her nasal spray. She was more stable in follow-up but presented with increas-
ing fatigue, weight loss and nausea. She also reported striae. Extensive initial
hospital investigations were normal. A random glucose was 5.0 (3.4-7.0) and
an AM cortisol was reported at < 50 nmol/L (170-540). She was started on
hydrocortisone therapy and changed to ciclesonide, as well as montelukast
and formoterol. Her energy and weight have improved after initiation of replace-
ment hydrocortisone therapy with plans for an ACTH stimulation test after dis-
continuation of oral corticosteroids. Discussion: While inhaled FP has been
most commonly implicated in adrenal suppression, to our knowledge this is the
first reported case of symptomatic MF-induced adrenal suppression. Despite
having high protein binding, we hypothesize that the pharmacokinetics of MF
with a high receptor affinity, long half-life and decreased hepatic clearance
when used at a high dose result in similar adrenal suppression as has been
reported in FP. Physicians need to remain aware of the possibility of adrenal
suppression in any patient on high dose inhaled corticosteroid.
P62
EFFICACY OF FLUNISOLIDE HFA (AEROSPAN) IN ADULT AND
ADOLESCENT PATIENTS 12 YEARS AND OLDER WITH
ASTHMA BY BASELINE INHALED STEROID.
L. Greos*1, J. Corren2, N. Ruiz3, J. Karafilidis3, 1. Centennial, CO; 2. Los
Angeles, CA; 3. Somerset, NJ.
Introduction: Inhaled steroids (ICSs) are the most effective maintenance
treatment for mild-to-moderate persistent asthma. Flunisolide HFA, a small
particle ICS with a built-in spacer, is approved for treatment of asthma in patients
12 years and older at doses of 160 mcg (2 puffs) and 320 mcg (4 puffs) BID.
Efficacy and safety comparisons to each patient’s prior ICS offer important
perspective. Methods: This was a multi-center, double-blind, placebo-controlled
trial consisting of a 2-week run-in with flunisolide CFC (500 mcg BID), fol-
lowed by double-blind treatment with placebo, flunisolide HFA (80, 160 and
320 mcg BID), or flunisolide CFC (250, 500 and 1000 mcg BID) for 12 weeks
in patients 12 and older with mild-to-moderate asthma. The primary efficacy
endpoint was change from baseline in % predicted FEV1. A retrospective analy-
sis of the primary efficacy endpoint by baseline ICS (all patients were previ-
ously treated with an ICS) was performed to evaluate potential differences in
efficacy in patients previously treated with another ICS. The most commonly
used previous ICSs were: fluticasone (FP-195 patients), beclomethasone (BDP-
190 patients), triamcinolone acetonide (TAA-174 patients) and flunisolide
(FLN-98 patients). Patients were required to be on a stable dose of ICS for at
least 30 days prior to trial entry. Results: Of the 669 randomized patients, 548
(82%) completed the trial. Compliance was >90% at all visits in each treatment
group. Patients experienced about a 12% improvement in FEV1 after the 2-
week run-in with flunisolide CFC. After 12 weeks of treatment, patients treated
with flunisolide HFA 160 mcg BID maintained the 12% improvement achieved
during run-in, patients treated with 320 mcg BID had a 0.4% improvement over
run-in, and patients treated with placebo had a 4.5% decrease (p<0.007; active
HFA treatments vs placebo). LS mean changes from baseline in % predicted
FEV1 did not significantly differ based on previous ICS, with the most sig-
nificant improvements seen with the 160 and 320 mg BID doses of flunisolide
HFA compared with placebo. Conclusion: The results from this retrospective
evaluation by baseline ICS suggest that the efficacy with flunisolide HFA 160
and 320 mcg BID is at least equivalent to other ICSs, as demonstrated by sim-
ilar % improvements in FEV1 for each of the baseline ICS subgroups.
P63
PEANUT ASPIRATION IN AN ADULT WITH ALLERGIC
ASTHMA.
A.P. Nguyen*, K.G. Clay, S.M. Fineman, Atlanta, GA.
Rationale: Foreign body aspiration (FBA) occurs more commonly in chil-
dren than adults. Diagnosing FBA in adults with allergic asthma and allergies
is challenging because patients may not remember choking and there may be
confounding symptoms. Case: A 41 year old female with history of allergic
asthma, rhinitis, and nasal polyps was seen for evaluation in March 2014. She
complained of cough and intermittent wheezing that had worsened since Thanks-
giving 2013. Her symptoms began with bronchitis that developed into chronic
wheeze and productive cough; she had minimal improvement after treatment
A42 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
with antibiotics and oral corticosteroids. Chest x-rays were clear in January and
March, 2014. She was started on inhaled fluticasone-salmeterol by a pulmo-
nologist and referred for allergy evaluation after minimal improvement of res-
piratory symptoms. She had a course of allergen immunotherapy in the early
‘90s and surgery to remove nasal polyps in 1992. Findings: On initial visit, she
had end-expiratory wheezing auscultated in the right lung. FEV1 was 100%,
and FeNO was 30 ppb. Allergy skin tests were positive to multiple inhalant
allergens. In-office nasopharyngoscopy showed purulent sinus discharge and
scarring from previous nasal surgery. She was treated with cefdinir and started
on inhaled budesonide, montelukast, mometasone intranasal sprays, sinus irri-
gations, and allergen immunotherapy. Her cough improved somewhat after cef-
dinir, but she reported a persistent nighttime cough and had end-expiratory
wheeze on exam on follow-up. In May 2014, CT chest showed calcified gran-
uloma in the intra-inferior aspect of the right lower lobe. Subsequent bron-
choscopy identified a foreign body (suspicious for peanut) that was removed
from the right bronchus intermedius. Pathology reported a foreign degraded
organic material. The patient subsequently recalled an episode of choking on
peanuts in January 2014. Conclusion: This is a report of an adult with previ-
ously diagnosed allergic asthma, rhinitis, and nasal abnormalities that con-
founded the diagnosis of FBA. Although initial history and diagnostic evidence
did not suggest FBA, FBA should be considered in adult patients with persist-
ent wheezing unresponsive to asthma therapy. CT imaging and bronchoscopy
are sometimes necessary for a conclusive diagnosis.
P64
EYE SYMPTOMS CORRELATE WITH ASTHMA SEVERITY.
M. Chen*1, E. Rael2, 1. State College, PA; 2. Hershey, PA.
Rationale: Eye symptoms are commonly seen in patients with allergic
asthma and the combination can have significant effects on quality of life and
work productivity. Common allergic eye conditions include allergic conjunc-
tivitis, vernal keratoconjunctivitis and atopic keratoconjunctivitis. Here we
report amongst a cohort of asthmatics at a university based allergy, asthma, and
immunology specialty clinic, correlations between subjective eye symptoms
and asthma symptoms. Methods: After informed consent and IRB approval,
370 asthmatics, recruited to the study between 2011 and 2014, underwent
clinical assessment including review of the Eye Symptom Score as part of the
mini RQLQ score, the total mini RQLQ score, and ACQ quality of life asthma
symptom score to determine whether there is a correlation between eye symp-
toms and asthma severity. The mean assessment divided the cohort by ACQ
scores into group 1, low risk asthmatics for future asthma events in the next 2
weeks as demonstrated by ACQ < 1.50 and group 2, high risk asthmatics for
future asthma events in the next 2 weeks as demonstrated by ACQ > 1.50.
Results: Group 1 asthmatics represented 243 subjects and group 2 asthmatics
represented 127 subjects. Subjects in group 1 had a mean mini RQLQ eye symp-
tom score of 4.4 in comparison to a higher score of 7.1 amongst group 2 sub-
jects. The average total mini RQLQ score in group 1 subjects was 25.9, versus
41.9 amongst group 2 subjects. Conclusions: This study shows that patients
who have higher immediate risk for asthma flares concurrently have higher
ocular and total upper airway symptoms scores further validating the one air-
way hypothesis. Further studies are necessary and future research could assess
whether there are different ocular phenotypes associated with asthma severity.
P65
SERUM LEVELS OF VITAMIN D AND IGE IMMUNE RESPONSE
TO ALLERGENS IN PEDIATRICS ASTHMATIC CHILDREN:
CONTROVERSIAL RESULTS FROM A POOR CARIBBEAN
COLOMBIAN COMMUNITY.
E. Egea*1, G. Garavito de Egea1, L. Fang1, G. Egea1, L. Visbal1,
N. Lecompte1, J. Escamilla2, 1. Barranquilla, Colombia; 2. Cartagena,
Colombia.
Background: Humans have the ability to synthesize vitamin D during the
action of ultraviolet (UV) radiation upon the skin. The term “vitamin D insuf-
ficiency” has been associated with asthma. However, little is known about the
link between total and serum specific IgE levels and vitamin D in asthmatic
children. Today dust mite allergens and cockroach are the most important sources
of clinically relevant allergens sensitizing patients with asthma in the tropics,
Objective: To investigate the relevance of Vit D levels on the total Ig E and
allergen-specific sensitization(Cr and Mite) in asthmatic children living a poorer
communities within a Barranquilla, a city on the Colombian Caribbean Coast.
Method: A case-control study with 1000 individuals, which included 500 asth-
matic children and 500 healthy children from the Colombian Caribbean coast
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A43
was made. Serum 25-hydroxy vitamin D was measured by a EIA. Total IgE,
specific IgE to Dermatophagoides farinae-D f- and Blomia tropicalis-B t.-
and Periplaneta americana –Cr-were determinated by ELISA (ImmunoCAP ®
Phadia AB, Sweden technology). The independent effects of these variables
were estimated from obtaining odd ratios (OR) trough logistic regression mod-
els adjusted for sex and age. Results: Elevated total IgE (> 100UI/mL) were
observed in both study group. Showing as a risk factor for susceptibility to
childhood asthma (OR = 1.63, 95% CI = 1.08 - 2.46). Serum levels of vitamin
D were found normal or insufficient in both groups (52.21 ng / mL and 52.2
ng / mL, P = 0.907). Also, insufficient vitamin D was associated with elevated
levels of Total Ig E (15% vs 8.7%, P = 0.037); showing a negative correlation
(Spearman r = -0.28, p = 0.00). However, our data is not clear regarding what
effect it may have the insufficient levels of vitamin D on the IgE immune
response (OR = 1.84, 95% CI = 0.9 - 3.6). On the other hand, elevated Total
IgE levels were associated with specific IgE sensitization to B. tropicalis, D.
farinae and P. americana. Conclusion: Despite the growing evidence of the role
of vitamin D in incident asthma and asthma exacerbation, studies are not all
consistent Taking together our results are showing that insufficient serum lev-
els of vitamin D is not a risk factor for developing asthma in poores comuni-
ties children of the Caribbean area.
P66
IDENTIFYING RISK FACTORS ASSOCIATED WITH ELEVATED
BLOOD EOSINOPHIL COUNTS IN PATIENTS WITH ASTHMA
FROM PRIMARY CARE CLINICAL RECORDS.
D.B. Price*1, E.R. Bleecker2, J.D. Campbell3, C.J. Corrigan4, I.D. Pavord5,
A. Rigazio6, A. Burden6, J. von Ziegenweidt6, V.L. Ashton6, G.H. Gopalan7,
M. Buatti Small7, 1. Aberdeen, United Kingdom; 2. Winston-Salem, NC;
3. Denver, CO; 4. London, United Kingdom; 5. Oxford, United Kingdom;
6. Cambridge, United Kingdom; 7. Frazer, PA.
Introduction: A previous study concluded that blood eosinophil counts in
patients with asthma could be used as an indicator of prospective asthma out-
comes. We aimed to identify risk factors associated with elevated blood
eosinophil counts in patients with asthma from UK primary care clinical records.
Methods: Retrospective, observational study using the Clinical Practice
Research Datalink and the Optimum Patient Care Research Database. Patients
were aged 12-80 years with asthma and no other chronic respiratory disease.
Study period was 1 year before (baseline period) date of last recorded blood
eosinophil count. Comparison at date of last recorded blood eosinophil count:
≤400 eosinophils/ml (low) vs. >400 eosinophils/ml (elevated). Baseline char-
acteristics: biomarkers, demographics, comorbidities and markers of disease
severity. Univariable logistic regression was used to identify baseline charac-
teristics associated with >400 eosinophils/ml (p≤0.05). These characteristics
were then included in a multivariable model and reduced to a list of noncollinear
factors. Results: Of 130,248 patients, 16% had >400 eosinophils/ml. Thirty-
nine percent of the patients with ≤400 eosinophils/ml and 31% with >400 were
male. Median age (Interquartile range) was 45 (31-61) and 50 (37-63) for ≤400
and >400 eosinophils/ml, respectively. Table shows baseline risk factors asso-
ciated with >400 eosinophils/ml (Reference category=1.00). Conclusion: In this
study, several clinical and demographic features were predictive of elevated
blood eosinophil counts in asthma patients. These data could be used to strat-
ify patients who could benefit from more intensive and/or targeted asthma ther-
apies, potentially improving control and reducing costs.
ABSTRACTS: POSTER SESSIONS
Baseline risk factors associated with >400 blood eosinophils/ml
(Reference category=1.00)
P67
CORRELATION BETWEEN GASTROESOPHAGEAL REFLUX
DISEASE AND ASTHMA SYMPTOMS.
A. DeWaters*1, M.P. Henao2, E. Rael2, 1. Hummelstown, PA;
2. Hershey, PA.
Rationale: Gastroesophageal reflux disease and asthma are both among the
most common diseases treated in the outpatient setting. Studies suggest that
asthma and gastroesophageal reflux disease are comorbid conditions and con-
trol of gastroesophageal reflux disease may lead to improvement of asthma
symptoms. Therefore, it was hypothesized that the presence of gastroesophageal
reflux disease would be associated with less control of asthma symptoms. Here
we report the correlation between the presence of gastroesophageal reflux dis-
ease and the severity of asthma symptoms, as measured by the Asthma Con-
trol Questionnaire. Methods: After informed consent and IRB approval, 389
asthmatics recruited to the study between 2011 and 2014 underwent clinical
assessment including review of the ACQ quality of life, and assessment of
gastroesophageal reflux disease. The independent sample t-test divided the
cohort by ACQ scores into group 1 (ACQ < 1.50) and group 2 (ACQ > 1.50).
Results: 63 percent of 257 asthmatics in group 1 reported having a diagnosis
of gastroesophageal reflux disease versus 65 percent of group 2 subjects. Group
1 asthmatics with gastroesophageal reflux disease had an average ACQ score
of 0.63, whereas group 1 asthmatics without gastroesophageal reflux disease
had an average ACQ score of 0.56. Group 2 asthmatics with and without gas-
troesophageal reflux disease had an identical average ACQ score of 2.6. Con-
clusion: Among asthmatics with well-controlled symptoms, the presence of
gastroesophageal reflux disease resulted in a slightly increased ACQ score.
However, among asthmatics with uncontrolled symptoms, the presence of gas-
troesophageal reflux disease did not result in any increase in the ACQ score.
There was no statistically significant correlation between the presence of gas-
troesophageal reflux disease and more severe asthma symptoms in patients with
uncontrolled asthma.
P68
ASSOCIATION BETWEEN ASTHMA CONTROL AND BODY
MASS INDEX IN ASTHMATICS.
P.K. Gleeson*, E. Rael, Hershey, PA.
Rationale: Emergency room visits and hospitalizations due to acute asthma
exacerbations result in substantial healthcare costs and loss of productivity in
the workforce. Although hospitalizations and deaths due to asthma have steadily
declined since the 1980s, asthma prevalence is increasing. Obesity is also on
the rise, and several studies have shown that obesity is a risk factor for asthma
and poor asthma control. The Asthma Control Questionnaire (ACQ) is a vali-
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ABSTRACTS: POSTER SESSIONS
dated instrument for measuring asthma control in adults, with a score greater
than 1.5 predicting a higher risk of visiting an emergency department in the
subsequent two weeks. We hypothesized that in a cohort of asthmatics at a
university-based allergy, asthma, and immunology specialty clinic, body mass
index (BMI) would correlate with ACQ score. Methods: After informed con-
sent and IRB approval, 356 asthmatics recruited to the study between 2011 and
2014 underwent clinical assessment including review of BMI and ACQ-7 scores.
The independent sample t-test divided the cohort by ACQ scores into group 1
(ACQ < 1.5) and group 2 (ACQ > 1.5). Results: Groups 1 and 2 had 236 sub-
jects and 120 subjects, respectively. The average ACQ score for group 1 was
0.6, and for group 2 was 2.6. Group 1 had a lower average BMI (27.1, 95% CI
26.2 – 28.0) than Group 2 (29.9, 95% CI 28.2 – 31.5). Conclusions: Asthmat-
ics with ACQ scores less than 1.5 had a lower BMI than asthmatics with ACQ
scores greater than 1.5. This finding contributes to the growing body of evi-
dence showing a link between BMI and asthma. Further research is needed to
elucidate this relationship.
P69
IMPROVING DOCUMENTATION OF THE ASTHMA CONTROL
TEST™ USING PATIENT/CAREGIVER ELECTRONIC ENTRY.
H. Murphy*, L. Harte, J. Parker, M. Reddy, 1. Kansas City, MO.
Introduction: The NHLBI recommends ongoing assessment of asthma con-
trol using a validated self-assessment questionnaire such as the Asthma Con-
trol Test™ (ACT). Variable use and poor electronic medical record (EMR) doc-
umentation of the ACT prompted an organization-wide quality improvement
project. Methods: Use of the ACT has been advocated for all children ≥4 years
presenting with asthma to clinics within this tertiary care children’s hospital.
In 2011, a process was initiated to facilitate consistent completion at outpatient
visits and subsequent documentation in the EMR, with an iPad version of the
ACT created in 2012. Electronic data reports guided monthly assessment of
barriers. Plan-Do-Study-Act (PDSA) cycles facilitated local improvement.
Interventions were spread from the pilot clinic to a total of seven clinics in 2013.
Data was analyzed using Excel QI Macros. The Office of Research Integrity
determined that this project does not involve human subjects research. Results:
In 2011, age appropriate paper questionnaires were programmed to print out
with registration paperwork for patient/caregiver completion. Providers man-
ually entered calculated ACT scores into EMR-based Asthma Action Plans. In
September 2012, a pilot clinic began patient/caregiver completion of the ACT
on iPads with the score auto-populating the EMR. This clinic increased ACT
documentation from an average of 17% to 75% by May 2014, with one month
as high as 92%. Iterative PDSA cycles focused on reducing variation and embed-
ding process changes into daily activities. Survey results uncovered barriers.
Provider support tools, such as pictorial EMR guidance, were created. Ongo-
ing refinement of electronic reports optimized the approach for identifying
the appropriate patients for the iPad–based ACT. Sharing incremental results
fostered competition that drove improvement. The ACT was also set up on each
exam room computer in case of a lapse in iPad connectivity. Once these
processes spread to six more clinics, the aggregate EMR documentation by all
clinics improved to 62% by May 2014. Conclusion: Facilitating PDSA cycles
aimed at addressing obstacles and adapting processes can improve completion
and documentation of the ACT. The goal of 75% was achieved and sustained
for 12 months in the pilot clinic, but the overall goal of 90% for all clinics may
depend on more direct engagement of providers.
The pilot clinic increased EMR documentation of the ACT from an average
of 17% to 45% by March 2013, but with wide variation in results. Iterative
PDSA cycles focused at reducing variation and embedding the process
changes into daily activities resulted in improvement to an average of 75% by
May 2014.
A44 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P70
TRENDS IN THE USE OF ASTHMA MEDICATIONS IN MEXICO.
M. Becerril-Angeles*, M. Vargas-Becerra, J.L. Estrada-Aguilar,
V. Borja-Aburto, Mexico City, DF, Mexico.
Introduction: Asthma guidelines recommend controller medications for per-
sistent asthma, plus short-acting bronchodilators in case of symptoms. It has
been shown a greater use of rescue medications than controllers, which asso-
ciates with poor asthma control. The Instituto Mexicano del Seguro Social
(IMSS) provides medical care to 58 million people and has a group of med-
ications for asthma treatment. Objective: To know the trend of the use of con-
troller, rescue and emergency medications for asthma during a 6-year period.
Methods: The use of controller (fluticasone, salmeterol/fluticasone, budes-
onide/formoterol, beclomethasone, montelukast, zafirlukast), rescue (salbuta-
mol, salbutamol/ipratropium) and emergency (aminophyline, nebulized: salbu-
tamol, salbutamol/ipratropium, beclomethasone and budesonide) medications
for asthma was analyzed according to the nationwide registries of the IMSS
from 2007 to 2012. Results: In the analyzed period, the rescue medications
increased from 2,537,882 to 3,205,101 units (26.3%), and controllers from
1,702,606 to 3,565,548 units (109.4%). The controllers with greater incre-
ment were: salmeterol/fluticasone (702%), montelukast (79%) and beclometha-
sone (77%). Between 2010 and 2011 the trend in the use of controllers was
greater than that of rescue medications. In the emergency medications there
was a 56.8% decrease in the use of aminophyline, and a 320% and 244%
increase in the use of salbutamol/ipratropium and budesonide, respectively. In
2009 we developed and communicated our institutional asthma clinical prac-
tice guidelines. Conclusion. Although both types of medications for chronic
asthma increased within the studied period, the trend in the use of controllers
greatly surpassed the increase in rescue drugs. As to the emergency medica-
tions, the antiinflammatory drugs revealed an increased tendency. Spreading
of the institutional asthma guidelines might partially explain these trends.
P71
ASTHMA BASELINE FOR CHILDREN IN THE GEORGIA AND
NORTH CAROLINA MEDICAID PROGRAM.
K.E. Johnson*, J. Swann, N. Serban, Atlanta, GA.
Research Objective: Pediatric asthma affects 10% of children age 0-10
and 15% of middle and high school students and is a significant contributor to
morbidity in children covered by public insurance. To evaluate the impact of
interventions, or to design interventions to have the greatest impact with lim-
ited resources, it is useful to understand the status quo within a system. This
study uses retrospective Medicaid claims data to develop and quantify a set of
measures around pediatric asthma in Georgia geographically and over time.
Methods and Data: The baseline measures were calculated using Medicaid
MAX claims data for children age 4-17 on Medicaid in Georgia and North Car-
olina from 2005-2009. We quantify asthma-related visits by race, age group,
location, provider type, and the costs of those services. We also identify patients
with persistent asthma and develop measures around medication adherence and
the use of long term controller medication. We use ICD-9-CM codes to extract
the relevant data, and we generate measures within areas such as counties and
by subpopulations. Results: The findings include a set of baseline measures for
pediatric asthma in Georgia and North Carolina 1) overall, 2) by geographical
area, and 3) over time. For utilization, we find the highest percentage of patients
with an asthma diagnosis among blacks but the highest number of visits in the
population that is non-black and non-white. The number of patients per 1000
children decreases with age but the cost per visit increases slightly with age.
On treatment measures, we find no differences with respect to age but statis-
tically lower adherence to medication among the black patients. Measures of
utilization, cost, and treatment varied significantly across the state, with a few
areas identified as extreme on each. Some results varied over time. Conclu-
sions: Significant variations in pediatric asthma measures exist geographi-
cally within Georgia and North Carolina, and some measures show changes
over time. The cost measures tend to be higher in some urban and rural areas
and may be driven by different underlying factors.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A45
P72
SHORT-TERM IMPROVEMENT OF ASTHMA KNOWLEDGE IN
ASTHMATIC CHILDREN FOLLOWING ASTHMA CAMP ATTEN-
DANCE.
J. Olsen*, M. Stevens, P. Foster, R. Hopp, Omaha, NE.
Introduction: Asthma camp allows children with asthma to participate in
camp activities while providing medical support to ensure a safe environment
for their camp experience. There is minimal data on the ability of asthma camp
to increase asthma knowledge in children with asthma. This study evaluated
the effectiveness of a local asthma camp in increasing asthma knowledge in
children ages 7-17 who have asthma. Methods: The Asthma Self-Management
Questionnaire (ASMQ), previously validated in adults, was given to 40 chil-
dren attending asthma camp. The survey was given on the first and sixth day
of camp. IRB approval and informed consent was obtained from all research
participants. Statistical significance was determined by a paired-samples t-test.
Results: Topics covered in the curriculum during asthma camp included the
definition of asthma, proper inhaler use, asthma symptoms and triggers, and
the difference between controller and rescue medications. Initial analysis of the
full ASMQ demonstrated no significant change between pre- and post-camp
scores (p = 0.14). Further analysis of the questions from the ASMQ that were
not covered in the curriculum during asthma camp was performed. There was
no significant change between pre- and post-camp scores (p = 0.34). Analysis
of the questions from the ASMQ that were covered in the curriculum during
asthma camp demonstrated a significant increase in the scores between pre-
and post-camp t(39) = 2.32, p < 0.05, with a mean score increase of 0.53, 95%
CI for difference = 0.07 to 0.98. Conclusion: With improvement between pre-
and post-camp test scores, our data suggests that asthma camp can improve
short-term asthma knowledge in asthmatic children attending camp. It is not
possible to draw conclusions regarding which aspect of asthma camp led to
the observed improvement. Asthma camp may provide opportunities for chil-
dren to understand their disease better. Caution should be used when inter-
preting these results as the ASMQ has not been validated in children. Further
studies are needed to investigate other potential benefits that could be provided
by attending asthma camp.
ABSTRACTS: POSTER SESSIONS
P73
ALBUTEROL MULTIDOSE DRY POWDER INHALER IN
PATIENTS 12 YEARS AND OLDER WITH PERSISTENT ASTHMA:
12 AND 52 WEEK SAFETY.
C. LaForce*1, D. Miller2, H. Taveras3, H. Iverson3, C. O’Brien4, G. Raphael5,
1. Raleigh, NC; 2. North Dartmouth, MA; 3. Miami, FL; 4. Frazer, PA;
5. Bethesda, MD.
Introduction: A novel, inhalation-driven albuterol (AB) multidose dry pow-
der inhaler (MDPI) has been developed that eliminates the need to coordinate
actuation with inhalation. Methods: Subjects aged 12 years and older with
persistent asthma were enrolled in 1 of 3 studies: two 12-week, multicenter,
randomized, double-blind, repeat-dose, parallel-group studies (NCT01424813
and NCT01747629) to evaluate the efficacy and safety of AB MDPI 180 mg
vs placebo MDPI (PBO) administered 4 times a day (QID) and one 52-week
study (NCT01698320) that included a 12-week, double-blind phase during
which subjects were randomized to receive either AB MDPI 180 mg or PBO
QID followed by a 40-week, open-label phase during which all subjects received
AB MDPI as needed. Safety results from the 12-week phases of all 3 studies
were pooled for evaluation. IRB approval and informed consent from all sub-
jects were obtained. Primary efficacy endpoints are reported elsewhere. Results:
Overall, adverse events occurred in 50% of patients in the PBO group (n=333)
and 40% of patients in the AB MDPI group (n=321) during the pooled 12-week
dosing period; upper respiratory tract infections (11% PBO and 10% AB MDPI),
nasopharyngitis (6% and 5%), and headache (6% and 4%) occurred most fre-
quently. The incidences of β2-agonist–related events during the pooled 12-week
dosing period were low (<1%) in both groups. The most frequent adverse events
reported in patients treated with AB MDPI during the 40-week open-label phase
were nasopharyngitis (12%), sinusitis (11%), and upper respiratory tract infec-
tion (9%). There were no clinically meaningful trends in clinical laboratory
variables and vital signs from screening to week 52 in those who remained on
AB MDPI for the entire study. There were no electrocardiographic findings
considered clinically relevant in AB MDPI-treated subjects at any time point
in the 52-week study; no subject had a QTc interval length (Bazett or Frideri-
cia) >500 msec at any time point. Conclusions: The safety profile of AB MDPI
in these studies was comparable to PBO and consistent with that of the well-
characterized profile of AB in subjects with asthma. This study was sponsored
by Teva Pharmaceuticals.
P74
EFFICACY OF ALBUTEROL MULTIDOSE DRY POWDER
INHALER VERSUS PLACEBO IN SUBJECTS 12 YEARS OF AGE
AND OLDER WITH PERSISTENT ASTHMA.
G. Raphael*1, H. Taveras2, H. Iverson2, C. O’Brien3, D. Miller4, 1. Bethesda,
MD; 2. Miami, FL; 3. Frazer, PA; 4. North Dartmouth, MA.
Introduction: A novel, inhalation-driven, multidose dry powder inhaler
(MDPI) has been developed that eliminates the need to coordinate actuation
with inhalation. Methods: Data from subjects 12 years of age and older with
persistent asthma who were enrolled in two 12-week, multicenter, random-
ized, double-blind, repeat-dose, parallel-group studies (NCT01424813 and
NCT01747629) were pooled to evaluate the efficacy and safety of albuterol
(AB) MDPI 180 mg compared with placebo MDPI (PBO) administered 4 times
a day (QID). IRB approval and informed consent from all subjects were
obtained. Safety endpoints are reported elsewhere. The primary efficacy end-
point was baseline-adjusted FEV1 area-under-the-effect curve over 6 hours post-
dose (FEV1 AUC0-6) over 12 weeks. Results: AB MDPI-treated subjects (n=153)
experienced significantly (p<0.0001) greater improvements in baseline-adjusted
FEV1 AUC0-6 compared with PBO subjects (n=163) over the 12-week study
period (AB MDPI, 1.20 L x hr vs PBO 0.33 L x hr; mean difference 0.87±0.10
L x hr). The mean change from baseline in FEV1 for the pooled population is
shown in the Figure. Significant (p<0.0001) increases in baseline-adjusted
FEV1 AUC0-6 in AB MDPI-treated subjects were apparent on days 1 and 8 and
maintained through day 85 compared with PBO subjects (mean differences of
1.06, 0.75, and 0.81 L x hr vs PBO for these 3 time points, respectively). Of
the 153 subjects treated with AB MDPI, 110 (72%) achieved a 12% increase
in FEV1 within 30 minutes postdose on day 1 with a median time to onset of
5.2 minutes, and median duration of effect (12% increase) of @3 hours for
one study and 4 hours for the other. Ninety-one AB MDPI-treated subjects
(59%) achieved a 15% increase in FEV1 within 30 minutes postdose on day 1
with a median time to onset of 5.4 minutes, and median duration of effect (15%
increase) of @2 hours for one study and 3 hours for the other. Conclusions:
AB MDPI was consistently superior to PBO over the 12-week treatment period
on spirometry-based measures. These data confirm that during periods of reg-
VOLUME 113, NOVEMBER, 2014 A45
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A46
ABSTRACTS: POSTER SESSIONS
ular usage over 12 weeks, AB MDPI continued to produce clinically signifi-
cant bronchodilation compared with PBO. This study was sponsored by Teva
Pharmaceuticals.
Mean Change from Baseline in FEV1
P75
IMPACT OF OBESITY ON PULMONARY FUNCTION: PROSPEC-
TIVE STUDY IN YOUNG ADULTS.
S. Melendez*, B. Del Río, J. Del Río, E. Navarrete, Mexico City,
DF, Mexico.
Asthma and obesity are chronic disorders, and are increased in prevalence
among young people. It is proposed that obesity and overweight has an inde-
pendent effect on lung function in asthmatic patients. We barely know long-
term obesity effects in this patients. Methodology: The study was conducted
in our Hospital. The study group where obese or overweight with or without
asthma. It was performed spirometry with reversibility in a baseline measure-
ment and after 5 years follow-up, besides weight, height and BMI (Body Mass
Index). Symptoms of asthma conducted through validated questionnaires:
ISAAC Questionnaire and Asthma Control Test. Results: We invited to partic-
ipate 90 patients, of whom 5 decided not participate. 85 patients were included
but cannot schedule appointment to 35, because change of residence and phone
number. We studied a total of 50 patients, of whom 33 realize spirometer, and
17 is still pending. Institutional Review Board approval and informed consent
was obtained from all research subjects.Of the 50 patients studied, 22 were
women and 28 men, the average age, after 5 years of follow-up for both groups
was 18.7. Within the studied groups compared with the 5-year follow-up, sig-
nificant difference was observed: in weight (p= 0.000), height (p= 0.000) and
BMI (p= 0.000). In spirometric values, the comparison group at baseline and
follow-up, significant differences was found in forced vital capacity (p= 0.000),
forced expiratory volume in one second (FEV1 p= 0.000), after bronchodila-
tor FEV1 (p= 0.004), reversibility (p= 0.009), (PEF expiratory flow p=0.001).Of
the 50 patients evaluated, at the beginning of the follow up 12 patients (24%)
had asthma. There were 6 patients who were monitoring newly diagnosed asthma
(33%). Of the 18 asthmatic patients in total, we classify according to symp-
toms, through the ACT questionnaire, 5 patients were in poor control, 7 with
partly controlled asthma and 6 with well-controlled asthma. Initial asthmatic
patients significant differences were found in weight and in spirometric values
in FVC, FEV1, and PEF (Table no. 1). Conclusion: In this study we found that
obese patients with asthma, they referred to be controlled and partially con-
trolled. We found that obese asthma patients remained with better spirometric
values compared to baseline values. In patients with newly found diagnosis
were in ranges of overweight and obesity.
A46 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P76
CUMULATIVE DOSE COMPARISON OF THE EFFICACY AND
SAFETY OF ALBUTEROL-MULTIDOSE DRY POWDER
INHALER AND ALBUTEROL-HYDROFLUOROALKANE
METERED DOSE INHALER IN ADULTS WITH ASTHMA.
D. Miller1, D. Wayne2, T. Ferro*3, H. Taveras2, H. Iverson2, 1. North Dart-
mouth, MA; 2. Miami, FL; Frazer; PA.
Introduction: Albuterol (AB) delivered via a novel, inhalation-driven, mul-
tidose dry powder inhaler (MDPI) eliminates the need to coordinate actuation
with inhalation. In a separate study, treatment of adolescents and adults with
persistent asthma with AB MDPI was well tolerated and demonstrated efficacy
significantly greater than placebo and comparable to AB hydrofluoroalkane
metered dose inhaler (HFA) at the intended doses of 90 and 180 mg. Methods:
This multicenter, randomized, double-blind, double-dummy, cumulative-dose,
2-period crossover study (NCT01056159) evaluated the efficacy, pharmaco-
kinetics (PK), extrapulmonary pharmacodynamics (PD), and safety of cumu-
lative doses (1440 mg) of AB via MDPI or HFA to subjects (aged 18-45 years;
N=47) with asthma. IRB approval and informed consent from all subjects were
obtained. Subjects were treated with AB MDPI or AB HFA (90 mg/inhalation)
and respective placebo in a randomized-sequence, two-period crossover. At
each treatment visit, study drug was administered by cumulative dosing of
1+1+2+4+8 inhalations (separated by 30 minutes) from each device. Treatment
visits were separated by 3 to 14 days of washout. The primary efficacy end-
point was baseline-adjusted FEV1 at 30 minutes after each of the cumulative
doses. Results: Thirty-eight subjects received both AB MDPI and AB HFA and
experienced increases in FEV1 over baseline at each cumulative dose level. The
differences between treatments in FEV1 at 30 minutes ranged from −0.07 to
−0.03 L and were not clinically meaningful. Mean systemic exposure over 14
hours was comparable (AUC0-t, 23,227 for AB MDPI and 20,939 for AB HFA),
Cmax was higher for AB MDPI (4422.8 pg/mL) vs AB HFA (3303.8 pg/mL),
and Tmax occurred earlier with AB MDPI (2.48 h) vs AB HFA (3.05 h). Extra-
pulmonary PD differences between treatments were not considered clinically
meaningful. Adverse events reported by ≥5% of subjects treated with AB (cumu-
lative dose of 1440 mg) included tremor (17% AB MDPI and 13% AB HFA),
palpitations (9 and 2), and headache (9 and 4). Conclusions: The overall effi-
cacy, PK, PD, and safety profile of AB MDPI and AB HFA were generally sim-
ilar. The results of this and previous AB MDPI studies support evaluation of a
dose of 180 mg in adults with asthma. This study was sponsored by Teva Phar-
maceuticals.
P77
POLYMORPHISM IN THE CD14 PROMOTER (CD14-C159T) IN
CRIMEAN ADULTS WITH EARLY AND LATE-ONSET ASTHMA.
Y. Bisyuk1, V. Beloglazov1, A. Dubovyi1, L.M. DuBuske*2, 1. Simferopol,
Ukraine; 2. Gardner, MA.
Introduction: The CD14 gene is located on chromosome 5q31-32, consid-
ered a critical region for asthma. The association of the CD14 C-159T SNP in
early and late-onset asthma patients remains to be determined. Methods: 262
early-onset and 69 late-onset persistent asthma patients were studied. Early-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A47
onset asthma was diagnosed when first episodes of symptoms occurred before
40 year old and late onset one after 40 according to GINA 2012 guidelines. The
control group included 285 non-atopic volunteers. Single nucleotide poly-
morphisms of CD14 C-159T were detected by PCR. Patients and volunteers
were recruited at the Crimean State Medical University, Simferopol, Crime,
and provided written informed consent for the genetic study. Results: In early-
onset asthma patients CC genotype was detected in 74 patients, CT in 142 and
TT in 46; in late-onset asthma: CC in 31, CT in 27, and TT in 11; while in the
control group CC in 97, CT in 146, and TT in 42. The allele frequencies were
55 % (n=290) for the C allele and 45 % (n=234) for the T allele in the early-
onset asthma c (OR, 1.19; 95% CI, 0.94-1.52; P=0.15); 64% (n=89) for the C
allele and 36% (n=49) for the T allele in the late-onset asthma (OR, 0.81; 95%
CI, 0.55-1.99; P=0.29); and 60% (n=340) for the C allele and 40% (n=230)
for the T allele in the controls. Conclusion: CD14-C159T polymorphism is
not associated with adult early and late-onset asthma in Crimean population.
The polymorphism in this population did not differ from that seen in healthy
control subjects.
P78
CLINICAL FEATURES OF ALLERGIC RHINITIS IN INTER-
MITTENT AND MILD PERSISTENT ALLERGIC ASTHMA.
V. Tsybulkina1, N. Kurmaeva1, N. Tsybulkin1, L.M. DuBuske*2, 1. Kazan,
Russian Federation; 2. Gardner, MA.
Introduction: Allergic rhinitis (AR) is frequently encountered in patients
with atopic asthma (AA). The influence of allergic rhinitis on clinical symp-
toms in asthmatics depends significantly on asthma severity. Methods: Con-
secutive patients 17-26 years of age with mild intermittent (MI) and mild per-
sistent (MP) allergic asthma were enrolled in the study with informed consent
obtained. Evaluation included lung function assessment, skin prick tests, bron-
cho-provocation tests,(BPTs), bronchodilator (BDT) response, total and aller-
genspecific IgE levels. Results: Patients in both groups, 63 in MI and 72 in MP,
had similar age(mean 19 years) and AA duration (mean 5 versus 6 years in MI
and MP groups) and were equally of rural and urban origin. Prevalence of per-
sistent AR (P-AR) was significantly greater in MP asthma (54% in MI asthma
and 78% in MP asthma, p<0.05). Patients with persistent AR had on average
higher rate of exacerbations independent of asthma severity: more than 1 exac-
erbation per month occurred in 26% of patients with intermittent AR (I-AR)
or without AR versus 68% of patients with persistent AR (p<0.05) in the MI
asthma group. More then 1 exacerbation per month was seen in 44% of patients
with I-AR or without AR versus 86% of patients with P-AR (p<0.05) in the
MP asthma group. Patients with persistent AR had much higher rates of symp-
toms in relation to overall dust load both in MP asthma (95% in P-AR patients
versus 25% in all others, p<0,05) and MI asthma (95% in P-AR versus 68% in
all others, p<0,05). In MI asthma patients presence of persistent AR was also
associated with a higher mean number of relevant non-specific triggers
(1.76±0.93 in P-AR versus 0.97±0,84 in all others, p<0.05), clinical reaction
to cold air (27% in P-AR patients versus 3% in all others, p<0.05) and exer-
cise-related symptoms (81% in P-AR versus 48% in all others, p<0.05). Con-
clusion: Allergic rhinitis has significantly higher prevalence in MP asthma.
Patients with persistent allergic rhinitis have two-fold or higher rate of exac-
erbations independent of asthma severity. Among non-specific asthma trig-
gers the most clinically relevant for all patients with persistent allergic rhinitis
was the total dust load. The number of non-specific asthma triggers was also
greater in patients with persistent allergic rhinitis in both mild intermittent and
mild persistent asthma.
P79
CORRELATION BETWEEN ATMOSPHERIC POLLUTANTS,
CLIME AND ASTHMA EXACERBATIONS IN CHILDREN OVER
A FIVE YEAR PERIOD IN MEXICO CITY.
C. Hernandez-Ramirez*, J. Vidal-Guzman, U. Angeles-Garay, A. Ortega-
Gonzalez, M. Becerril-Angeles, Mexico City, DF, Mexico.
Background: There is a relationship between atmospheric pollutants and
climatic factors and visits to the emergency room for asthma, however there is
lack of knowledge on the situation of this phenomenon in Mexico City. Objec-
tive. To assess the correlation of atmospheric pollutants and some climatic
factors with the number of cases of asthma exacerbations in children in a third
level hospital in Mexico City during the last five years. Methods: Case reg-
istries of asthma exacerbations at pediatric emergency room, stratified by age
(0-23 months, 24-71 months, 6-12 years, 12-17 years), and their correlation
with daily values of atmospheric pollutants (ozone, sulphur dioxide, nitrogen
ABSTRACTS: POSTER SESSIONS
dioxide, carbon monoxide and PM10), temperature and relative humidity, from
2009 to 2013, were analyzed. IRB/HAC approval was obtained. Results: Dur-
ing these five years there were 5331 visits for asthma exacerbations, with an
annual average of 1066. There was a gradual decrease in cases, from 2363 in
2009 to 505 (21%) in 2013. There was a male predominance in all ages (ratio
1.7 : 1). The age groups 24-71 months and 6-12 years had the highest number
of cases, 1766 (33.1%) and 1827 (34.3%), respectively. During fall there was
the highest number of visits 2069 (39%), and the lowest was in spring, 801
(15%). The correlation between asthma and environmental factors was: CO:
R=0.242, NO2: R=0.175, SO2: R=0.092, PM10: R=0.056, O3: R=-0.062, rela-
tive humidity R=-0.106 and temperature R=-0.36. Conclusions: A gradual and
significant reduction in the number of asthma visits to the emergency room
was observed during the period of five years. There was a significant increase
in asthma exacerbations related to seasonal effect. There was a predominance
of male pre-school and school children in relation to asthma exacerbations. The
highest correlation between atmospheric pollutants and asthma cases was related
to carbon monoxide. There was inverse correlation between asthma exacerba-
tions and weather factors (humidity and temperature).
P80
LAPSES IN ASTHMA CONTROL IN PATIENTS WHO CONTIN-
UED VS. DISCONTINUED OMALIZUMAB IN A REAL-WORLD
SETTING.
G. Sun1, E. Antonova2, E. Chang1, M. Broder1, P. Solari2, J. Zazzali*2,
1. Beverly Hills, CA; 2. South San Francisco, CA.
Introduction: Little is known about benefits of continuous omalizumab
(OMA) treatment to asthma patients in real world. We examined the lapses in
asthma control in patients who continued vs. discontinued OMA treatment in
a real-world setting. Methods: This retrospective cohort study used a large
HIPAA-compliant commercial healthcare claims database (1/1/08 to 12/31/10).
Identified patients were ≥12 years old, had ≥2 medical asthma-associated claims,
filled ≥2 asthma controller medications in the identification period (1/1/09-
12/31/09), and used OMA continuously for ≥6 months. After ≥6 months of
OMA therapy, patients were stratified as continuers (continued OMA until
dropout or 12/31/10) or early discontinuers (stopped OMA for >90 days) and
followed for ≥3 months after the index date. The primary outcome was the risk
of lapse in asthma control during follow-up, reported as episodes per 100 patient-
years (PY), measured as any asthma-related hospitalization or emergency room
visit, ≥2 oral corticosteroid (OCS) or ≥6 short-acting beta-agonists filled in 1
year. We used Cox regression models to assess risk of the outcome, adjusted
for baseline patient characteristics (e.g., demographics and the number of
chronic conditions). The study did not involve human subjects, thus IRB review
was not needed. Results: We identified 414 continuers and 240 discontinuers
among eligible patients; mean age: 46.2 years, 62.5% women, and 15.6% had
COPD. At baseline, the groups were balanced by demographics and asthma
control. Patients were followed for a median 415 days; the discontinuers had
no OMA use after the discontinuation date. Overall, there were 32.5 episodes
of lapses in asthma control per 100 PY of follow-up: 27.9 per 100 PY for con-
tinuers vs. 43.3 per 100 PY for discontinuers (p = 0.002, Table). Discontinuers
had worse individual clinical outcomes that defined lapses in asthma control
than did continuers (Table). Adjusting for patient characteristics, discontin-
uers had a significantly higher risk of having lapses in asthma control than con-
tinuers (adjusted hazard ratio 1.66, p<.001). Conclusions: Real-world evidence
suggests that asthma patients who receive continuous (>6 months) OMA treat-
ment may have fewer lapses in asthma control than those who prematurely
discontinue OMA after 6 months.
Lapses in Asthma Control in Patients who Continued vs. Discontinued
Omalizumab after ≥6 Months of Treatment
a Number of events per 100 patient-years
VOLUME 113, NOVEMBER, 2014 A47
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A48
ABSTRACTS: POSTER SESSIONS
P81
INHIBITORY EFFECTS OF SALIDROSIDE ON INFLAMMA-
TORY RESPONSES IN RAT ALVEOLAR MACROPHAGES.
X. Hu*, Hangzhou, China.
The genus Rhodiola is important herb used for thousands of years in Tra-
ditional Chinese Medicine for treating various kinds of diseases, including
inflammation-related diseases such as pneumonia, chronic bronchitis, asthma,
and rheumatoid arthritis. Salidroside (p-hydroxyphenethyl-beta-d-glucoside,
C14H20O7, molecular weight 300.30), which is one of the most potent ingre-
dients of the genus Rhodiola, has been reported to have a broad spectrum of
pharmacological properties. Recent study indicates an anti-inflammatory role
for salidroside in lipopolysaccharide (LPS)-induced acute lung injury (ALI),
but the mechanisms of anti-inflammatory action are not clear. In the present
study, anti-inflammatory activity of salidroside was analyzed in vitro using
LPS-induced inflammatory reactions in rat alveolar macrophages. Inflamma-
tory mediators such as TNF-α, IL-6, and NO were measured by the Griess reac-
tion for NO and Enzymelinked immunosorbent assay (ELISA) for other inflam-
matory mediators. QRT-PCR was used to measure the mRNA expression of
TNF-α, IL-6, and iNOS, and the protein levels of iNOS, p65, p-p65, IκB-α,
and p-IκB-α were analyzed by western blot. EMSAs and reporter gene assays
were used to evaluate DNA binding and transcriptional activities of NF-κB.
ChIP analysis was used to detect the binding of p65 to the iNOS promoter.
NF-κB nuclear translocation was analyzed by western blot. Salidroside sig-
nificantly inhibited LPS-stimulated production of NO by suppressing the expres-
sion of iNOS. EMSA demonstrated that LPS treatment increased p65-DNA
binding, whereas this interaction was decreased by salidroside. ChIP analysis
revealed that salidroside markedly inhibited LPS-induced p65 binding to the
iNOS promoter. Western blotting confirmed that salidroside effectively inhib-
ited the nuclear translocation of p65. We also examined the effect of salidro-
side on the induced degradation and phosphorylation of IκBα protein by LPS.
The results showed that salidroside could change the kinetics of IκBα phos-
phorylation and degradation. Salidroside also suppressed TNF- and IL-6 at
the mRNA level, and then reduced the release of TNF-α and IL-6 induced by
LPS. In conclusion, our results suggest that salidroside can block LPS stimu-
lated inflammatory responses, and may be used as a potential anti-inflamma-
tory agent for the prevention and treatment of inflammation-related diseases.
P82
REGULATION OF AIRWAY EOSINOPHILIA IN A MODEL OF
FELINE ALLERGIC ASTHMA BY KTN0158, A HUMANIZED
ANTI-KIT MONOCLONAL ANTIBODY.
E.M. Mandel*1, C.R. Reinero2, R.W. Gedrich1, C. Chang2, J. Trzil2,
J. Dodam2, L.A. Cohn2, C. Lubeski1, Y. Hadari1, T. LaVallee1, 1. New Haven,
CT; 2. Columbia, MO.
Immune response and pathologic events in allergic asthma are regulated by
specific T cell subsets and the cytokines that they secrete. Mast cells and
eosinophils are key effectors in the cascade of airway inflammatory events
which induce bronchoconstriction, influx of inflammatory cells and airway
remodeling. KIT, the receptor for Stem Cell Factor (SCF), is expressed on mast
cells and eosinophils in the lung, and for that reason, we are examining inhi-
bition of SCF/KIT signaling as a possible therapeutic in allergy and inflam-
mation. KTN0158 is a humanized IgG1 monoclonal antibody that inhibits
signaling through KIT. This antibody specifically binds the Ig-like domain 4
of KIT, and blocks SCF binding and receptor dimerization and activation. In
vitro studies demonstrate that KTN0158 is a potent inhibitor of SCF-depend-
ent KIT activation and of degranulation enhanced by SCF in the human LAD2
mast cell line. KTN0158 has similar binding affinity for human, monkey, dog
and cat KIT, but does not cross-react with murine KIT. A placebo-controlled,
cross-over design pilot study was conducted to evaluate the ability of KTN0158
to reduce airway eosinophilia and airway reactivity in experimentally asthmatic
cats sensitized with Bermuda Grass Antigen (BGA). Cats received 20 mg/kg
KTN0158 or placebo on days -1 and 14, and airway reactivity was assessed
using BGA or methacholine bronchoprovocation (day 0 or day 28) and venti-
lator-acquired pulmonary mechanics, as well as bronchoalveolar lavage to assess
airway inflammation. Cats treated with KTN0158 had significant reduction in
airway eosinophilia during the early- (p=0.009) and late-phase (p=0.032) asth-
matic reactions, suggesting further investigation of KIT inhibition with
KTN0158 in allergic asthma is warranted. To this end, studies to investigate the
potential benefit of KTN0158 in mast cell-related diseases and to evaluate
safety are ongoing.
A48 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P84
EVALUATION OF GENES INVOLVED IN TRANSITION FROM
AUTOIMMUNE DISEASE TO LYMPHOMA.
R. Anand*1, E. George2, M. Yu2, J.L. Ambrus2, L. Shen2, 1. Getzville, NY;
2. Buffalo, NY.
Introduction: There is a high incidence of secondary lymphomas in patients
with autoimmune diseases, especially Sjogren’s syndrome (SS). We have devel-
oped an animal model, the IL-14alpha transgenic mouse (IL14aTG) that repro-
duces all the features of SS seen in patients in the same relative time frame,
including the development of lymphoma. We have evaluated genetic changes
in the spleens of these mice during different stages of the disease to determine
when genes characteristic of SS lymphoma are aberrantly expressed in the
animals with the disease. Methods: QPCR was performed on the splenic RNA
of IL14aTG mice and control C57BL/6 mice for bcl-6 and bcl-10 at 6, 10 and
14 months of age. In this animal model, disease involving the salivary and
lacrimal glands starts at 6 months of age while systemic disease starts at 10
months of age. Some mice will start developing lymphoma at 14 months of age
while the majority of mice develop lymphoma only by 18-20 months of age.
Results: In IL14aTG mice but not C57BL/6 mice, expression of bcl-6 and bcl-
10 decreased at 14 months of age, but not at earlier time points. None of the
mice with these genetic changes had yet developed lymphoma.
P85
CUTANEOUS NON-TUBERCULOUS MYCOBACTERIAL INFEC-
TION IN A PATIENT WITH SEVERE T-CELL LYMPHOPENIA
AND SELECTIVE IGM DEFICIENCY.
A. Gharib*1, A. Gupta Louis2, S. Agrawal2, S. Gupta2, 1. Los Angeles, CA;
2. Irvine, CA.
Background: Detailed immunological analyses have not been reported in
recently recognized Non-tuberculous mycobacterial infection of the skin. The
main purpose of this investigation is to present extensive immunological analy-
sis of a patient with cutaneous non-tuberculous mycobacterial infection
(mycobacterium avium complex). Material and Methods: Peripheral blood from
the patient and healthy controls were analyzed for CD3+, CD4+, CD8+ T cells,
regulatory T cells (FoxP3+CD4+CD25+), naïve, transitional, marginal zone,
IgM memory, switched memory B cells and plasmablasts, expression of TACI
and BAFF-R on naive and memory B cells, expression of IFN-γ receptor and
IL-12 receptor on lymphocytes and monocytes, NK cell phenotype and cytox-
icity against K562 target cells using various effector:target ratio. Lymphocyte
functions were measured by in vitro response to mitogens (PHA, ConA, PWM)
and recall antigens (mumps, candidate, PPD, and tetanus toxoid) by 3H incor-
poration. Toll-like receptors (TLR) were analyzed on monocytes. Results: Analy-
sis of lymphocyte subsets showed severe T cell lymphopenia of CD3+, CD4+
and CD8+ T cells) and an impaired response to mitogens and antigens. T reg-
ulatory cells were significantly reduced. Analysis of B cells revealed low serum
IgM and an increased transitional B cells with normal marginal zone, IgM mem-
ory and class switch memory B cells, and marginal zone B cells. Expression
of TACI and BAFF receptor on both naiive and memory B cells, and expres-
sion of and IFN -γ receptor and IL-12 receptor on lymphocytes and monocytes
were normal. TLR4 expression was increased, whereas the expression of TLR5,
TLR7, and TLR9 was decreased. NK activity was found to be decreased. Con-
clusion: This patient illustrates that cutaneous non-tuberculous mycobacterium
infections may be associated with severe immune deficiency including T cell
lymphopenia, impaired cell mediated immunity, deficiency of T regulatory
cells, alterations in transitional B cells, selective IgM deficiency, altered TLR
expression, and an impaired NK cell cytotoxicity.
P86
COMPLEMENT DEFICIENCY PRESENTING AS GROUP A
STREPTOCOCCAL (GAS) SEPSIS WITH TOXIC SHOCK SYN-
DROME AND ESCHERICHIA COLI UROSEPSIS IN INFANCY.
L. Helfner*, A.M. Jongco, Great Neck, NY.
Introduction: Complement component deficiencies are rare, and predis-
pose to autoimmunity or increased susceptibility to recurrent infections with
encapsulated bacteria. The types of infection relate to the function of the miss-
ing components. For example, terminal complement component deficiency fre-
quently presents with Neisseria species infections. Methods: We describe an
11-month old male who presented originally with lethargy and fever that devel-
oped into GAS sepsis with toxic shock syndrome. He received a 10-day course
of IV antibiotics and was discharged on oral cephalexin. Shortly after discharge,
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A49
he was re-admitted with fever and found to have extended-spectrum beta lac-
tamase producing (ESBL) E. coli urosepsis, which responded well to a 10-day
course of IV ertapenem. For UTI prophylaxis, the patient now receives trimetho-
prim-sulfamethoxazole daily, and has done well following his second hospi-
talization. He is currently receiving routine vaccinations as per CDC guide-
lines. Results: Laboratory evaluation was remarkable for undetectable CH50
on two separate occasions, as well as mild T cell lymphocytosis (CD3+ of
8326/uL (reference range 1700-3600), CD4+ of 6285/uL (range 1700-2800),
and CD8+ of 1654/uL (reference of 800-1200)). B and NK cells were unre-
markable for age. Lymphocyte proliferation to pokeweed and phytohemag-
glutinin was normal. G6PD was mildly depressed at 3.5 U/g Hb (range 4.6-
13.5). Myeloperoxidase stain was normal. HIV serologies were negative, and
he had detectable hepatitis B surface antibody. Total IgE was elevated at 323
IU/mL (range 0-15), with normal IgA, IgM, and IgG for age. Levels of C2,
C3, C4, C5, C7, C9, C1q, mannose binding lectin and AH50 were normal. C8
was decreased at 20 ug/mL (range 33-58). Further investigation of other com-
plement components is underway. Conclusion: This patient had mildly decreased
G6PD and C8 with undetectable CH50 but normal AH50, suggesting that other
complement components are deficient in quantity and/or function, likely
upstream of the membrane attack complex. Physicians must remain vigilant
and include complement deficiency in the differential diagnosis. These patients
should receive routine vaccinations, especially against diseases for which they
are at increased risk.
P87
GUANYLYL CYCLASE-CGMP PATHWAY MEDIATES MITOGE-
NESIS INHIBITION BY NATRIURETIC PEPTIDES AND SODIUM
NITROPRUSSIDE IN RAT AIRWAY SMOOTH MUSCLE CELLS.
F.A. Placeres-Uray*, R. Gonzalez de Alfonzo, I. Lippo de Becemberg,
M. Alfonzo, Caracas, Bolivarian Republic of Venezuela.
The airway smooth muscle cells (ASMC) hyperplasia is a central feature
of airway remodeling. ASMC mitogenesis is promoted by several mediators
such as epidermal growth factor (EGF) and tumor necrosis factor-α (TNF-α),
which are countered by activators of guanylyl cyclases (GC)-cGMP pathway.
This study evaluated the effect of sodium nitroprusside (SNP), an oxide nitric
(NO) donator, and natriuretic peptides (ANP, CNP) on rat ASMC proliferation.
Cells were isolated from tracheal fragments and were characterized using
immunochemistry with specific antibody anti-α smooth muscle actin, indi-
cating that after 3rd passage were 100% positive. Proliferation assays were per-
formed by MTS-PMS method. Viability was confirmed by trypan blue exclu-
sion method. To determined GC enzyme activity, cells were pre-incubated with
100 M IBMX (PDEs inhibitor) and cGMP was measured using Amersham kit.
SNP (10-5M; n=6), ANP and CNP (n=3) in a doses-dependent manner inhib-
ited ASMC proliferation induced by fetal bovine serum (FBS), EGF and TNF-
α (p <0.05). ODQ (sGC inhibitor) reversed the action of SNP (p <0.05, n=3)
and improved basal proliferation and mitogenesis induced by FBS (p <0.05,
n=3). We found increased of cGMP levels in response to SNP, ANP and CNP.
cGMP synthesis induced by SNP, but not by natriuretic peptides, was inhib-
ited by 100nM ODQ (p <0.05, n=3). NO, ANP and CNP increase cGMP lev-
els by different transduction systems and inhibit ASMC proliferation. More-
over, basal activity of sGC regulates ASMC mitogenesis. This signaling pathway
might be altered in airway remodeling and represent an important therapeutic
target to ASMC hyperplasia.
P88
CYTIDINE DEAMINASE AND ADENOSINE DEAMINASE ARE
HIGHLY SENSITIVE ENZYMATIC REGULATORS OF IMMUNE
RESPONSE INTENSITY AND SPECIFICITY.
L. Titov1, K. Pavlov1, A. Hancharou1, O. Yanovitch1, S. Javoronok1,
L.M. DuBuske*2, 1. Minsk, Belarus; 2. Gardner, MA.
Background: Cytidine deaminase (CDA) and adenosine deaminase (ADA)
basal serum activity may be impacted by acute and chronic infection states.
Methods: Two groups formed on a wide (n = 10, male and female, 24-31 age)
and narrow (n = 19, only male, 18-25 age) principle of sampling as controls
were compared to infectious mononucleosis (IM) patients (n = 10, male and
female, 18-34 age), chronic HCV infection patients (n=29, male and female,
27-70 age), and patients with pneumonia developing in the 2012-13 influenza
epidemic season (n=10, male and female, 6-16 age) by assessing CDA and
ADA activity (indophenol colorimetric test), CD19 + cells content (flow cytom-
etry), B-cells clonal status (immunoglobulin heavy chains rearrangement) and
PCR analysis using ISH assay (InVivoscribe, USA) and GelAnalyzer 2010a
ABSTRACTS: POSTER SESSIONS
soft. Results: CDA activity in pneumonia (8.14±2.72 U), as well as in infec-
tious mononucleosis (4.37±2.22 U) was found to be high in comparison with
the control groups: 1.1±0.4 U for the wide cohort and 2.29±0.5 U for the nar-
row cohort. In contrast, chronic HCV patients had no increased CDA levels
(1.21±0.17 U). A polyclonal pattern was seen in both wide and narrow con-
trols, IM and chronic HCV infection patients. Both control cohorts show sim-
ilar ADA activity levels: 12.08±5.24 U for wide and 11.10±2.2 U for narrow
cohort. A two-fold increase in ADA activity in IM patients (27.56±9.87 U)
and the absence of significant deviations in ADA levels for chronic HVC (14.53
U) were seen. Despite the low absolute values, CDA and ADA enzymatic activ-
ity proved itself to be among the most individually variable immunologic param-
eters. Conclusions: CDA and ADA enzyme activity is an informative parame-
ter with potential to be a biomarker of hidden immunodeficiency status.
P89
ASSESSMENT OF SELECT SERUM CYTOKINES IN ORAL
LICHEN PLANUS PATIENTS.
G. Drannik1, A. Kurchenko1, R. Rehuretska1, L.M. DuBuske*2, 1. Kiev,
Ukraine; 2. Gardner, MA.
Introduction: Oral lichen planus (OPL) is the most common immune dis-
ease of oral mucosa, having an increased risk of malignancy. Cytokines (IL-1,
TNF-α, TGF-β) in blood may impact disease progression in erosive oral lichen
planus. Methods: 97 patients aged 18 to 60 years were studied including 35
with erosive oral lichen planus, 32 with non-erosive oral lichen planus and 30
healthy control subjects of similar age. The levels of serum cytokines IL-1,
TNF-α, TGF-β were determined by enzyme-linked immunosorbent assay
(“Immunotech”; France). Results: During relapse of erosive oral lichen planus
there is change in select cytokines compared with control group levels includ-
ing IL-1 (0.6±1.5 pg/ml) being 2- fold increased versus the healthy controls
and TNF-α being 4.3- fold increased (0.3±1.6 pg/ml versus 1.3±1.2 pg/ml).
TGF-β ( 3.2±1.2 pg/ml) however is reduced 3.8- fold versus healthy controls
(12.3±1.1 pg/ml). In erosive chronic OLP there is an increase in IL-1 by 1.8-
fold, an increase of TNF-α by 1.8- fold and an increase of TGF-β (29.6±2.2
pg/ml) compared to healthy controls (12.3±1.1 pg/ml). In chronic OLP IL-1
indexes were increased 3.7- fold in comparison to OLP relapse and TNF-α
increased 7.7- fold and TGF-β increased 9.2 – fold compared to disease
relapse(p<0.05). Conclusions: Acute relapse and chronic stages of lichen planus
of the oral mucosa are characterized by immunological changes detectable in
peripheral blood serum including increases in concentrations of IL-1, TNF -α,
TGF-β, characteristic of development of a recurrent inflammatory immune
response and chronic persistent erosive disease.
P90
IMMUNOSUPRESSIVE PROPERTIES OF HUMAN OLFACTORY
EPITHELIUM-DERIVED ECTOMESENCHYMAL STEM CELLS
CULTURED EX VIVO.
A. Hancharou1, N. Antonevich1, V. Chekan1, L.M. DuBuske*2, 1. Minsk,
Belarus; 2. Gardner, MA.
Introduction: Nasal mucosa contains olfactory epithelium-derived ectomes-
enchymal stem cells (hOE-EMSC), which are similar to mesenchymal stem
cells derived from bone marrow and adipose tissue and which may have
immunosuppressive properties. Methods: Nasal mucosa samples were taken
from 4 patients with non-inflammatory diseases of the nasal cavity. Explant
culture methods were used to obtain hOE-EMSC cells. Cells were assayed for
phenotype (CD90, CD105, CD45, CD273, CD274, CD80, CD86, CD40,
nestin). Culture media from hOE-EMSC were collected and used in further
experiments. PBMC isolated from donor blood were primed with CFSE, co-
cultured with hOE-EMSC for 3 days plus PHA, and then assayed for prolifer-
ation. PBMC were also cultured without hOE-EMSC with the addition of PHA
(positive control), and with the addition of hOE-EMSC conditioned media.
Results: Cells obtained were CD90+CD105+nestin+CD45–. The ability of hOE-
EMSC to inhibit mitogen-induced proliferation of CD4+ T cells was shown.
The immunosuppressive effect did not depend on soluble factors produced by
stem cells, including interleukin-10. Direct contact of hOE-EMSC with lym-
phocytes was required to exhibit immunosuppressive properties. HOE-EMSC
expressed the co-inhibitory molecules CD273 and CD274 but were negative
for CD80 and CD86. Immunosuppressive properties were dependent on CD273
and CD274 expression. Conclusion: The hOE-EMSC possesses immunosup-
pressive properties and may possibly be used in cellular immunotherapy of
immune system disorders including autoimmune diseases and could possibly
assist in prevention of organ and tissue rejection.
VOLUME 113, NOVEMBER, 2014 A49
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ABSTRACTS: POSTER SESSIONS

P91
ALTERATIONS IN MINOR SUBSETS OF PERIPHERAL BLOOD
LEUKOCYTES IN INFECTIOUS MONONUCLEOSIS PATIENTS.
A. Hancharou1, G. Davidovich1, I. Ramanava1, E. Duzh1, L.M. DuBuske*2,
1. Minsk, Belarus; 2. Gardner, MA.
Introduction: The content of minor leukocyte subsets in the patients with
infectious mononucleosis (IM) may be altered including monocyte, dendritic
cell (DC) and myeloid-derived suppressor cells (MDSC). Methods: 12 patients
with acute IM, confirmed by blood serum and saliva PCR analysis, were selected
for investigation. Whole blood from 10 healthy volunteers matched by age and
sex was used as a control. Relative and absolute counts of leukocyte subsets
were assayed using FACSCanto II cytometer: CD1c+ and CD141+ myeloid DC,
plasmacytoid DC, CD14+/CD16+ blood monocytes and monocytic (M-MDSC)
and granulocytic (CD15+ and CD33+) G-MDSC. Results: In patients with IM
statistically significant myeloid DC subset redistribution was seen with increase
of CD141+ cells (CD1c/CD141 index in patients: 1.9(1.4–2.6), versus in con-
trols: 6.2(5.6–7.3), =0.00013), suggesting a role in the pathogenesis IM.
Decrease of plasmacytoid dendritic cell counts in IM was observed (patients:
0.04(0.02–0.11)% versus controls: 0.4(0.250–0.520)%, p=0,000001; patients:
0.003(0.002–0.01)×106/ml versus controls: 0.022(0.013–0.032)×106/ml,
p=0.00017), suggesting migration to lymphoid tissue or selective depletion.
Monocytic myeloid-derived suppressor cell counts were reduced in acute IM
(patients: 0.075(0.05–0.135)% versus controls: 0.32(0.23–0.37)%, p=0.011),
explaining EBV-induced immune system hyper-stimulation and increase of
HLA-DR expression on virtually all APC and T-cells. Increase of absolute
(p=0.052) and relative (p=0.09) CD15+ G-MDSC counts were seen in IM but
no statistically significant differences in the number of CD33+ G-MDSC cells.
Significant variability of content of G-MDSC and “intermediate” and “non-
classical” monocyte subsets were noted such as in IM with CD15+ G-MDSC
minimum of 0.01% and maximum of 0.22% versus controls minimum of
0.022% and maximum of 0.167%. Conclusion: Significant changes in the num-
ber of minor leukocyte subsets in blood are seen in IM. These changes may
explain some of the clinical immune manifestations of IM.
P92
THE EFFECT OF GENDER ON THE PERIPHERAL BLOOD B
CELLS MATURATION.
A. Khojah*1, A. Bukhari1, O. Alpan2, 1. Chicago, IL; 2. Vienna, VA.
Rationale: Despite the growing use of flow cytometry in evaluation of var-
ious immunodeficiency disorders, there are limited number of studies that dis-
cuss the gender effect on the reference range of different B cell subsets, espe-
cially in the pediatric age group. The aim of this study was to evaluate the effect
of gender on B cell maturation in different age groups. Methods: Total of 988
subjects were included in this study. We excluded all adults whose age is 22 or
older, all subjects with known primary or secondary immunodeficiency and
patients with incomplete work up. All Subjects had normal evaluation includ-
ing CBC, serum immunoglobulin, antibody response to vaccine especially pneu-
mococcal titers (for subjects more than 2 years). Clinical and laboratory data
including B cell subset were obtained from patients’ records. Subjects were
divided into seven groups based on their age. Using T test, we compared between
males and females in each age group in terms of different B cell sub-popula-
tions. Data was analyzed using SPSS, version 22. Results: Both, the absolute
B cell count and the percentage of B cell, drop significantly in the first 7 years
of life. That drop was equal in the male and female groups. The mean of CD5+
B cell was 4 to10 % higher in males versus females in all age categories except
in subjects between 19 and 21 years of age. This difference reaches statistical
significance in the age groups between 13 and18 years, which might suggest
a possible, but not previously described, hormonal effect on the B cell matu-
ration. Overall, females have higher mean of switched B cell (IgG+, IgA+)
and lower mean of IgM+, IgD+ B cell. Yet, these differences are more signif-
icant between 10 to18 years of age. Conclusion: These graphs highlight the dif-
ference between males and females in terms of B cell sub-populations, and the
importance of having gender-specific reference ranges especially in the ado-
lescent age group. Our results suggest a possible hormonal influence on B cell
maturation. Further research is needed to investigate this theory.
P93
CREST SYNDROME IN AN 8 YEAR OLD AFRICAN AMERICAN
GIRL.
I. Katayeva*1, K. Chotikanatis2, S. Glick3, J. Moallem2, 1. Forest Hills,
NY; 2. Brooklyn, NY; 3. New York, NY.
Introduction: CREST syndrome (Calcinosis, Raynaud’s phenomenon,
esophageal dysmotility, sclerodactyle, and telangiectasia) or systemic sclero-
sis with limited scleroderma is very rare in children, and mainly involves skin,
subcutaneous tissues, muscle and bones, and does not involve internal organs.
The usual onset of scleroderma is approximately 30-65 years of age. Its inci-
dence in children is one per one million. Case Description: An 8 year old African
American girl with past medical history significant for being born at 28 weeks
GA, via C-section due to abruptio placenta and pre-eclampcia, intubated right
after delivery, required 3 months of NICU care, with multiple blood transfu-
sions, PDA closed with indomethacin, pubarche at 5 years of age, with nega-
tive work up, who presented with over all 10 months history of non-pruritic,
off white, rashes on elbows, knees that over the course of few months had turned
hard and looked as if they were warts and finally calcified over the next few
months . Also 10 months history of “icy cold” fingers and toes with bluish dis-
coloration. On physical examination there were multiple calcified nodules on
extensor surfaces of the elbows, finger tips with protruding calcified papules,
sclerodactily of fingers, and telangiectasia along with bluish discoloration of
finger tips to the level of PIPs. Biopsy of the lesions confirmed calcinosis cutis.
Laboratory investigation including CBC, ESR, CMP, ANA with reflex remained
inconclusive. Chest x-ray did not indicate any pathology. Treatment: She was
started on monthly IVIG infusion along with daily PO Prednisolone, weekly
PO Methotrexate and daily folic acid. Her symptoms greatly improved over 4-
5 month, calcinosis of the finger tips resolved, while the rate of eruption of the
new calcified lesions slowed .and resolved. Discussion: CREST syndrome is
a very rare disease in children, our patient had 4 out of 5 findings and improved
after outlined therapy. Treatment for scleroderma needs to be started promptly
to avoid future complications. In general prognosis of sclerosis in children is
better than in adults.
P94
ASEPTIC MENINGITIS WITH INTRAVENOUS GAMMAGLOB-
ULN ADMINISTRATION.
C.C. Randolph*, D.H. Dreyfus, Waterbury, CT.
Rationale:Intravenous gammaglobulin(IVIG) administration for immun-
odeficiency disease is rarely associated with a delayed serious, adverse reac-
tion of aseptic meningitis.This condition is usually related to high doses of
IVIG (1-2gm/kg).The pathogenesis is postulated to be an osmotic shift caused
by small amounts of IVIG penetrating the cerebrospinal fluid and/or antineu-
trophil antibodies in some IVIG products activating neutrophils in the central
nervous system.(1) Methods :Case Report We present a 36 year old white female
with 1) selective antibody deficiency and hypogammaglobulinemia 2)car-

A50 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A51
diomyopathy with implanted pacemaker (2009)and recurrent pericaridi-
tis3)moderate persistent asthma on Advair and Alvesco 4)depression and 5) a
migraine condition admitted with aseptic meningitis after first infusion of IVIG
400mg /kg over 3 hours in a monitored setting.She develped a severe,pulsat-
ing, diffuse occipital, temporal and parietal headaches with retro orbital pain
beginning 6 hours post infusion.The pain exacerbated with any motion of the
head or neck,cough or bearing down and was associated with visual alter-
ations and inability to register words or numbers.She experienced dull pain
radiating down the neck to left precordial area and left shoulder and arm with
fever,nausea and diarrhea 24 hours prior to admision.CT scan of the head
demonstrated right maxillary sinus air fluid levels.Lumbar puncture(LP)
revealed normal glucose 49mg/dl,normal protein 36mg/dl,WBC 512/mm3 and
RBC 59/mm3 47%segmented neutrophils,51%mononuclear cells and
2%eosinophils with negative cerebrospinal fluid cultures and relief of
symptoms consistent with aseptic meningitis . She had a history of recurrent
sinusitis and admissions for “pneumonia” 2009-13 .Her original immune
evaluation demonstrated IgG 651mg/dl(694-1618mg/dl),normal
IgM(132mg/dl),A(298mg/dl), and protective tetanus titers but nonprotective
pneumococcal titers( 13/14) despite recurrent immunizations and varicella
zoster titers were nonprotective. Results:Aseptic meningitis was treated with
systemic steroids and Omnicef for sinusitis. IgG replacement was subsequently
changed to subcutaneous route without further complications. Conclusion Asep-
tic meningitis is a rare delayed adverse event following IVIG administration.
Reference:Stiehm ER :Adverse effects of human immunoglobulin
therapy.Transfusion Medicine Reviews 2013:27:171-8
P95
HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: MAKING A
CHALLENGING DIAGNOSIS.
A. Mathur*, L. Yao, Phoenix, AZ.
Rationale: Hemophagocytic lymphohistiocytosis (HLH) is a rare clinical
syndrome characterized by uncontrolled activation of lymphocytes and
macrophages producing elevated levels of cytokines. A clinically challenging
diagnosis to make, HLH manifests as fevers, cytopenias, hepatosplenomegaly,
hyperferritinemia, elevated IL-2, hepatic failure, and neurologic symptoms. We
present a case of a patient with persistently high fevers, pancytopenia, hyper-
ferritinemia that was diagnosed as HLH. Methods: A 28 year old Native Amer-
ican male presented with fever, chills, myalgias, arthralgias, bilateral lower
extremity edema, and a fifty-six pound unintentional weight loss in three
months. Neither high dose prednisone for Adult Onset Still’s disease, nor broad
spectrum antibiotics for an infectious etiology improved the fever or hepatic
synthetic function. Results: Ferritin was extremely elevated to 16,173 ng/mL
(reference range 22-322). Serum immunoglobulins, including IgG, IgA, and
IgM, were within normal limits. Concentration of sCD25 and IL-2 receptor
were elevated. Fibrinogen was low and triglycerides were high. Infectious serolo-
gies and cultures including EBV and CMV were negative. Autoimmune mark-
ers were negative. White blood cell count with differential was normal. Liver
biopsy showed steatohepatitis with stage 2 fibrosis. Flow cytometry showed
normal phenotype. Bone marrow biopsy showed prominent hemophagocyto-
sis consistent with hemophagocytic lymphohistiocytosis. Conclusion: Our
patient met seven of the eight diagnostic criteria for HLH, including fever,
splenomegaly, cytopenias, hypofibrinogenemia and hypertriglyceridemia, ele-
vated ferritin, elevated sCD25 and hemophagocytosis in the bone marrow.
Delays in this challenging diagnosis can result in high mortality rates due to
multisystem organ failure. Because biopsies of affected sites may be normal
or misinterpreted, repeat biopsies are sometimes necessary if clinical suspicion
remains high. We suspect hepatic involvement in our patient despite the lack
of hemophagocytosis on liver biopsy. Treatment algorithms include etoposide,
dexamethasone, antithymocyte globulin, cyclosporine A, intravenous
immunoglobulin, alemtuzumab, and hematopoietic cell transplant. In patients
with persistent fever, hepatosplenomegaly and cytopenias, the challenging diag-
nosis of HLH should be considered for prompt therapy.
P96
A CASE OF EOSINOPHILIC ESOPHAGITIS IN A PATIENT WITH
STRONGYLOIDES STERCORALIS.
A. Ali*, M. Segal, Philadelphia, PA.
Introduction: Eosinophilic esophagitis (EoE) is a condition in which inflam-
matory cells invade the mucosa of the esophagus. Few cases have described the
association of EoE with parasitic diseases. We present a case of EoE in a young
man with Strongyloides infection. Methods: A 21 year old male returns from
ABSTRACTS: POSTER SESSIONS
a medical mission trip to Kenya. Upon his return, he develops an eruptive rash
on his abdomen that is self-limiting after 3 months. He also develops a cough
and worsening dysphagia and is initially treated medically for acid reflux.
Despite treatment, these symptoms worsen. He also experiences intermittent
diarrhea, ranging from loose to watery bowel movements. Labs display
eosinophilia (eosinophil count 600 c/mL (10.2%) (normal 500 c/mL)) and nor-
mal immunoglobulin E (IgE) level (93 kU/L). Results: After months of wors-
ening dysphagia and cough, an esophagogastroduodenoscopy reveals mucosal
changes including longitudinal furrows and circumferential folds in the entire
esophagus. Pathology displays squamous mucosal eosinophilia with 57 in 1
high power field (normal <15 per high power field), seen superficially and deep
with no microabcesses. A diagnosis of eosinophilic esophagitis is made. After
one month of no resolution with swallowed corticosteroid solution, his aller-
gist is prompted to pursue a parasitic work up. A strongyloides immunoglob-
ulin G (IgG) antibody (Ab) ELISA is elevated at 1.22 units/mL (normal, <1.00).
Ova and parasite stool test is negative. Treatment with ivermectin is initiated.
His dysphagia resolves after anti-parasitic treatment, but his shortness of breath
continues. Labs show persistent eosinophilia, and he is given a second treat-
ment of ivermectin with resolution of respiratory symptoms. Conclusion: EoE
is a condition that can lead to permanent sequelae including esophageal scar-
ring and fibrosis. Strongyloides infection can cause a systemic eosinophilia,
and in this patient the eosinophilia from the untreated Strongyloides infection
was associated with esophageal infiltration of eosinophils. Strongyloides is
treated with anti-parasitic agents, and can be monitored by symptom resolu-
tion, eosinophilia on labs, or repeat strongyloides Ab.
P97
COMBINED IMMUNODEFICIENCY IN WOLF-HIRSCHHORN
SYNDROME.
S. Galowitz*, M. DeFelice, Wilmington, DE.
Rationale: Wolf-Hirschhorn syndrome (WHS) is a genetic disorder due to
partial deletion of the distal short arm of chromosome 4, with characteristic
features including facial, cardiac and skeletal abnormalities, developmental
delay, growth retardation, and a high mortality rate in the first two years of
life. Though no known genes associated with immunodeficiency reside on the
short arm of chromosome 4, these patients can present with immune dysregu-
lation. Limited data shows patients with WHS most commonly have defects in
humoral immunity, while T-cell immunity remains intact. To date, there has
been one reported case of an isolated T-cell defect. We present the first reported
case of a child with WHS with deficiencies in both humoral and cellular immu-
nity. Methods: The patient is a 2 year old female with 4p16.3 chromosomal
deletion and characteristic clinical findings consistent with WHS. She was
referred to us for severe hypogammaglobulinemia noted on hospital admis-
sion for acute respiratory failure secondary to parainfluenza virus. Results: The
patient has a history of methicillin sensitive S. aureus bacteremia, two episodes
of pneumonia requiring intravenous antibiotics, recurrent acute otitis media
infections requiring two sets of myringotomy tubes, and bacterial colonization
of her bladder. Her childhood vaccinations are up to date. Immunologic eval-
uation revealed low IgG (185 mg/dL), IgM (13 mg/dL) and IgA (24 mg/dL),
poor antibody response to diphtheria vaccination (0.02 IU/mL), and absent anti-
body response to tetanus (<0.1 IU/mL) and Prevnar 13 (0/23 serotypes pro-
tective) vaccines. Lymphocyte subset enumeration demonstrated decreased
absolute CD3 (998 cells/mcL; normal 1400-3700), CD19 (154 cells/mcL;
normal 390-1400) and CD8 (240 cells/mcL; normal 490-1300) counts. Mito-
gen stimulation, CH50, AH50 and MBL were normal. Random stool alpha 1-
antitrypsin level was normal. She began monthly immunoglobulin replacement
and the severity of her infections has improved, with no further hospital admis-
sions for bacterial illness. Conclusions: Immunodeficiency is a possible cause
of early mortality in patients with WHS. This is the first report of a patient with
WHS with deficiencies in both B- and T-cell lineages. Thorough immunologic
evaluation and appropriate management for combined immunodeficiency may
drastically improve survival and quality of life for affected patients.
P98
IGE-MEDIATED ALLERGY TO BACITRACIN: KEY CONCEPTS
ILLUSTRATED VIA A CASE SERIES.
E. Glancy*, C. Radojicic, Cleveland, OH.
Bacitracin is often considered to be an innocuous over-the-counter med-
ication. However, both T cell-mediated and IgE-mediated allergic reactions
have been reported with increasing frequency, presumably due to its widespread
use. We describe two cases of IgE-mediated reactions to bacitracin confirmed
VOLUME 113, NOVEMBER, 2014 A51
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A52
ABSTRACTS: POSTER SESSIONS
by positive skin prick testing (testing for second case in figure below). The first
case is of a 53-year-old female who developed diffuse hives following baci-
tracin irrigation during breast augmentation surgery. The second case describes
a 40-year-old man who developed anaphylaxis following the application of a
topical bacitracin ointment to blistered skin. In both cases, the patient had a
history of prior reaction to a triple antibiotic preparation before reacting to bac-
itracin alone. This case series demonstrates the variable routes of exposure caus-
ing allergic reactions, initially suspected neomycin allergy with resultant rec-
ommendation to use bacitracin alone, and the utility of skin prick testing to
confirm bacitracin as the culprit allergen. Physicians need to be cognizant of
the potentially serious consequences of using topical antibiotics on damaged
skin and mucosal surfaces, and furthermore, consider bacitracin as equally
important as neomycin in causing allergic reactions. Allergists can provide skin
prick testing to the components of triple antibiotic ointments to confirm an IgE-
mediated mechanism for allergic reactions.
Positive skin prick tests to bacitracin and bacitracin/polymixin
P99
IGG4-RELATED DACRYOADENITIS IN YOUNG MALE.
V. Reddy*, T. Craig, Hershey, PA.
Introduction: Bilateral periorbital swelling raises a wide differential diag-
nosis that includes both benign inflammatory conditions and malignant disor-
ders. It may be a presentation of IgG4-related disease which is a recently
emerged systemic condition characterized by unique lymphoplasmacytic infil-
tration of soft tissues by IgG4 plasma cells that can affect a wide variety of
organs. Histopathologic and immunohistochemical analysis is important in the
diagnosis of this disease and to differentiate it from other inflammatory and
malignant conditions. We present a case of bilateral periorbital swelling which
was initially diagnosed as organ limited vasculitis. However with further inves-
tigation he was diagnosed with IgG4-related disease. Case Report: Patient is a
21 year old male with no significant past medical history who presented with
fluctuating bilateral eyelid swelling for 1 year. The swelling was associated with
pain and redness isolated to around the eyes. Review of systems was negative
A52 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
for throat swelling, hives, fevers, chills, night sweats, or weight loss. He was
initially placed on high dose prednisone which only temporarily improved his
swelling. Shortly after the steroids were discontinued the swelling reappeared.
MRI showed symmetric bilateral lacrimal gland enlargement. Labs including
ESR, CRP, ANCA, ANA, and IgG4 level were within normal range. He had
peripheral eosinophilia with absolute eosinophil count of 830. Initial lacrimal
gland biopsy was read as non-necrotizing perivascular granulomatous infiltrate
that involves small arteries and veins. He was initially diagnosed with
Eosinophilic Granulomatosis with Polyangiitis. He had no other medical his-
tory or organ involvement suggestive of small vessel vasculitic syndromes.
Biopsy slides were sent to a specialty laboratory who reported fibrosis, oblit-
erative phlebitis, as well as 174 IgG4 plasma cells/high powered field consis-
tent with the diagnosis of IgG4-Related Disease. He was subsequently treated
with azathioprine and had significant improvement of his periorbital swelling.
Conclusion: Integration of clinical, radiographic, and histopathologic data is
necessary to diagnose IgG4-related disease. Biopsy with special staining for
IgG4 plasma cells interpreted by an experienced pathologist is an important
part of diagnosis and should be considered in any patient with bilateral lacrimal
gland swelling to identify IgG4-related disease.
P100
COMMON VARIABLE IMMUNODEFICIENCY IN A PATIENT
WITH SYSTEMIC LUPUS ERYTHEMATOSUS: CASE REPORT.
E. Sandoval*1, C. Quezada-Chalita1, C. Cunningham-Rundles2, S. Enciso-
Pelaez1, M. Gutiérrez-Ceniceros1, 1. Mexico City, DF, Mexico; 2. New York,
NY.
Introduction: Common variable immunodeficiency (CVID) is the most
common clinically significant primary immune defect. Although 70% to 80%
of patients have had recurrent sinopulmonary infections, auto-immunity and
inflammatory complications are also common. Case Report: We present the
case of a 16 years old girl, who was admitted with a history of fatigue, weak-
ness, pallor, edema of lower limbs. Physical examination was positive for Ray-
naud phenomenon. The diagnosis of systemic lupus erythematosus (SLE) was
made based on 1. Proteinuria cellular casts, nephritis with low glomerular fil-
tration rate, requiring replacement management with hemodialysis, 2. Hemolytic
anemia and lymphopenia, 3. Pericardial effusion, 4. Central nervous system
disorder with acute confusional state with cerebral MRI angiography showing
irregular contours in distal segments and beading trend in vessels of medium
and small size . Laboratory work-up showed Antinuclear antibody with a speck-
led pattern at a low titer; ANCA, anti DNA, lupus anticoagulant, B2GP1 were
negative. Hypogammaglobulinemia and hypocomplementemia were found.
Antibodies in the urine were positive for anti DNA at high titers, 333.2 U/ml
(0-9.6U/ml): supporting the diagnosis of SLE.The patient had a torpid evolu-
tion, with severe sepsis, pancreatitis and gastrointestinal bleeding. She devel-
oped neurological impairment, seizures and Broca’s aphasia, an MRI revealed
ischemia in temporal and generalized vasospasm. Given the persistence of
hypogammaglobulinemia at the expense of IgG and IgM as well as a history
of multiple infectious events including pneumonia requiring mechanical ven-
tilation, urinary tract infection by Pseudomonas aeruginosa and Serratia
marscenses. Flow cytometry showing impaired lymphocyte subpopulation B
(marked decrease in CD19 and CD20), lymphopenia at the expense of the
subpopulation of T lymphocytes CD3 +, CD4 +. NK cells without alteration.
Isohemagglutinins (anti A1) for blood groups reported in 1:16 dilution, and no
response to immunization of Streptococcus pneumoniae. Conclusions: Clini-
cians should be aware about the relation between immunodeficiency and autoim-
munity. Autoimmune diseases affect about 20% of CVID patients and are com-
monly the first manifestations of immune deficiency. The pathogenesis of
autoimmunity in immune deficiency is unclear for the most part, further inves-
tigation must be done.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A53
Fig 1. MRI angiography showing irregular contours in distal segments and
beading trend in vessels of medium and small size.
P101
CASE REPORT: SUCCESSFUL BRONCHIAL THERMOPLASTY
IN A CASE OF SEVERE PERSISTENT ATOPIC ASTHMA.
C. Lee-Kim*1, S. Patel2, 1. Buffalo, NY; 2. Los Angeles, CA.
Introduction: Bronchial thermoplasty (BT), approved by the US Food and
Drug Administration in 2010, is a novel technique that uses radiofrequency
energy during bronchoscopy to reduce the amount of built-up excess smooth
muscle tissues and spasms in the airways of asthmatic patients. Several ran-
domized clinical trials (AIR, RISA, AIR2 Trials) have reported the efficacy of
BT on patients that have been unable to attain adequate control of their disease
with high doses of inhaled corticosteroids and long-acting beta-agonists. The
results from these studies demonstrated overall reduction of symptoms, reduc-
tion in the number of asthma attacks requiring emergency room care, and
improvement in patients’ AQLQ scores. Recently, the Global Initiative for
Asthma has recognized BT as an add-on treatment option at the GINA Step 5
level for select adults with severe persistent asthma. We report a successful case
of bronchial thermoplasty in a patient with severe-persistent atopic asthma.
Case Report: We present a 47 year old Iranian American male with allergic
rhinitis, nasal polyposis, obstructive sleep apnea, reflux disease, and severe per-
sistent allergic asthma who underwent bronchial thermoplasty. Previously, his
asthma remained difficult to control despite multi-drug therapy [mon-
telukast,mometasone furoate/ formoterol fumarate dihydrate, theophylline,
tiotropium bromide, loratadine, olopatadine nasal spray, fluticasone furoate
nasal spray, and omalizumab]. Prior to the procedure, he had an average FEV1
of 40%, ACT scores <19, and levalbuterol use 3-6 times a day for relief. Since
the completion of the BT procedure 1 year ago, the patient has been able to
decrease his levalbuterol use to about once a day, improve his latest FEV1 to
70%, and ACT score to 25. He has not experienced severe exacerbations requir-
ing ER visits or hospitalization over the past 12 months. Furthermore, he has
been able to discontinue several of his previous medications, such as mon-
telukast, tiotropium, and theophylline. Conclusion: This is the first case report
of an atopic asthmatic patient successfully treated by bronchial thermoplasty
after failure of conventional and several non-conventional therapies. This case
demonstrates that for some highly-select adult patients with difficult to man-
age allergic asthma, a referral to an asthma specialty center with bronchial ther-
moplasty should be considered
ABSTRACTS: POSTER SESSIONS
P102
A CASE OF IRBESARTAN-INDUCED ANGIOEDEMA WITH
SEVERE LARYNGEAL EDEMA.
R. Rishi*1, S. Ringwala1, S. Fatteh2, 1. Fort Lauderdale, FL; 2. Plantation,
FL.
Objective: To assess the safety of replacing angiotensin-converting enzyme
inhibitors (ACEI) with angiotensin II receptor blockers (ARBs) in patients with
a history of ACEI induced angioedema. Angioedema has been associated with
ACEI use in hypertension treatment. Angiotensin II receptor blockers have long
been considered a safe alternative treatment for hypertension in cases of ACEI
induced angioedema. Angiotensin II receptor blockers selectively block the
binding of angiotensin II to the AT1 receptor and therefore do not cause accu-
mulation of kinins which subsequently lead to angioedema. Methods: Case
Report Results: A 57 yr old Caucasian male experienced an acute episode of
angioedema with laryngeal edema. He experienced swelling of his tongue,
lips and larynx. The angioedema failed to respond to two doses of epinephrine
and IM diphenhydramine. He required a tracheostomy and ICU admission for
14 days. The patient was discontinued from his home medications, which
included irbesartan (Avapro). The angioedema persisted for 7 days, and failed
to respond to I.V. corticosteroids and antihistamines. His history revealed acute
episode of angioedema 5 years prior during a surgical procedure. The patient
was under conscious sedation, and he experienced unilateral tongue swelling
upon awakening. He was being treated with lisinopril at the time for hyper-
tension and was switched to irbesartan. Subsequently, the patient claimed he
experienced intermittent episodes of lip swelling. He was evaluated for Hered-
itary Angioedema, and all labs were within normal limits. Immunocap to food
and environmental allergy was unremarkable as well. An autoimmune panel
was also negative. He has not experienced any episodes of angioedema since
being discontinued from irbesartan. Conclusions: The patient’s angioedema
appeared to be related to his ARB therapy. In the ONTARGET trial, the inci-
dence of ARB induced angioedema was 0.1 % compared to 0.3% for ACEI
associated angioedema. Although the incidence of ARB induced angioedema
is lower than ACEI, life-threatening complications such as laryngeal edema
may result. The mechanism of ARB associated angioedema has not been clearly
established, but studies have shown that ARBs may also increase bradykinin
levels. Therefore, other classes of anti-hypertensive medications should be con-
sidered as first line replacements in patients with a history of ACEI induced
angioedema.
P103
BLACK RUBBER AND P-PHENYLENEDIAMINE CONTACT
DERMATITIS.
C. Lin*, M. Frieri, East Meadow, NY.
Introduction: Contact dermatitis is a common skin inflammation that occurs
when foreign substances irritate the skin, characterized by erythematous and
pruritic lesions. Contact dermatitis has been well documented in over 3000
chemical triggers. P-Phenylenediamine, as a chemical substance is widely used
in hair dye. Its partially oxidized state can cause allergic reactions in sensitive
individuals. Case: A 61 year old white female was referred to the allergy clinic
from the emergency department for an intensely diffuse rash on her skin dis-
seminated from the neck to waist for 2 weeks. She also complained of a pin
and needle sticking pain within the rash area. She had hair dye at a salon 2
days before she developed the pain and skin reaction. There was no shortness
of breath, stridor or throat symptoms. Past medical history included seasonal
allergy and food allergy. Skin prick tests revealed positive for grass, trees and
dust mite. She takes cetirizine all year around for allergy prophylaxis. On phys-
ical examination, she was alert, oriented, and afebrile with stable vital signs.
Her skin showed an extensively maculopapular rash randomized throughout
from her neck to chest and back area. Methods: A skin patch test disclosed a
positive test for p-Phenylenediamine and black rubber mix. sIgE testing for
latex was negative. She was advised to avoid known allergic related chemi-
cals, continue to take cetirizine or fexofenadine. The rash and pain gradually
improved. Conclusion: Contact dermatitis can result from hair dye hypersen-
sitivity. Its severity ranges from a mild localized rash to a widespread allergic
dermatitis reaction or even rarely, anaphylaxis. The diagnosis relies upon a
detailed history and physical examination. The skin patch test remains the
gold standard to confirm contact allergic reactions. Avoidance of exposure to
rubber products, causative hair dye should be withdrawn. Systemic anti-hista-
mines are often needed and in severe patients, a short course of systemic steroids
may be required. Prevention could be achieved by testing oxidative dyes before
use or switched to non-oxidative hair dye. Patients should also be careful with
VOLUME 113, NOVEMBER, 2014 A53
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A54
ABSTRACTS: POSTER SESSIONS
rubber products and cross- reacting chemicals or drugs such as printing inks,
temporary black henna tattoos
Representative photograph. From: Patricia Norris M.D., Allergy Clinic
Portland Contact Dermatitis
P104
SUCCESSFUL MONOCLONAL ANTIBODY DESENSITIZATION
IN A PEDIATRIC PATIENT WITH HYPERSENSITIVITY TO RIT-
UXIMAB.
S. Logsdon*, L. Schneider, Boston, MA.
Introduction: Drug allergy can limit essential therapeutic options for patients.
Hypersensitivity to monoclonal antibodies has been documented in adult
patients, but desensitization to this class of drugs has not been well described
in the pediatric population. Here, we present a pediatric patient with hyper-
sensitivity to rituximab who underwent successful drug desensitization. Meth-
ods: Desensitization to rituximab was completed via a modified 12-step, 3-bag
method in an inpatient unit. The protocol started at an initial dose of .0057 mg
with doubling of the dose at 20-minute intervals, with the proposed final step
to be infused at 75 cc/hr to provide at total therapeutic dose of 285 mg. The
child developed significant rash prior to the last step, and thus future protocols
reduced the infusion rate of the last step. The patient was monitored after com-
pletion of each desensitization protocol. Results: A 7-year-old boy with neona-
tal biliary atresia status post remote liver transplant developed EBV negative
post transplant lymphoproliferative disease (PTLD). Rituximab were required
for treatment of the child’s PTLD, but he developed urticaria and cough with
infusions despite premedication with antihistamines. As rituximab was a crit-
ical part of the child’s chemotherapy, urgent desensitization was required. The
patient underwent the desensitization protocol, but developed diffuse skin ery-
thema prior to completion of the last dose. The protocol was therefore modi-
fied as described above, with increased premedication. The child tolerated sub-
sequent desensitization protocols, and completed his chemotherapeutic regimen.
Conclusions: This is one of the only reported cases of successful desensitiza-
tion to rituximab monoclonal antibody in a pediatric patient, and includes strate-
gies for patients who have reactions during the procedure. This protocol will
be beneficial for future patients with rituximab hypersensitivity.
P105
CLEARING THE AIRE.
C. Lundberg*1, T. Banks2, 1. Silver Spring, MD; 2. Bethesda, MD.
Introduction: Autoimmune polyendocrinopathy-candidiasis-ectodermal
dystrophy (APECED) is a primary immune deficiency (PID) associated with
autoimmune sequelae; however, chronic idiopathic urticaria (CIU) is a very
rare manifestation. While omalizumab is effective in patients with CIU, its
mechanism of action in these patients is not completely understood and its
role in autoimmunity and anti-FceRI autoantibodies is unclear. We present a
case of CIU in an APECED patient refractory to standard therapy that resolved
with omalizumab. Case: APECED was diagnosed at age 9 after an ICU admis-
sion for severe hypocalcemia and tetany secondary to hypoparathyroidism.
Genetic testing revealed the patient was a compound heterozygote with muta-
A54 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
tions R257X and c.967_979del13 in the AIRE gene. The patient’s clinical man-
ifestations included chronic mucocutaneous candidiasis, hypoparathyroidism,
adrenal insufficiency with positive 21-hydroxalase antibodies, vitiligo, hypoplas-
tic dental and nail enamel, and delayed growth. At age 13 she developed chronic
urticaria despite high dose antihistamines and daily montelukast. Laboratory
workup revealed the presence of anti-FceRI autoantibodies without progres-
sion of autoimmune disease. Treatment with omalizumab 150mg led to reso-
lution of symptoms after one month and reduction of daily oral medications.
The patient is currently under treatment every 8 weeks with omalizumab and
will stop therapy soon to evaluate for possible remission of her urticaria. Con-
clusions: Omalizumab appears to be an effective therapy for CIU in APECED;
however, questions remain regarding its underlying mechanism of action. The
rare appearance of CIU in this patient population seems to run counter to the
hypothesis that CIU is associated with autoimmune disease. Our patient high-
lights the need for further research to better characterize the relationship of
CIU with immune dysregulation and how therapy with omalizumab influ-
ences this process.
P106
REFRACTORY HYPOTENSION IN A PATIENT WITH SYSTEMIC
MASTOCYTOSIS UNCOVERED AFTER ACUTE MYELOID
LEUKEMIA TREATMENT.
D. Ferastraoaru*, M. Janakiram, G. Hudes, Bronx, NY.
Background: Systemic mastocytosis (SM) can be associated with clonal
hematological disorders like myelodysplastic syndrome (MDS) and acute
myeloid leukemia (AML). Most of the SM-AML cases have translocation
t(8;21) and mutation of c-kit gene. Rarely, specific SM treatment is required.
We present a patient with SM-AML without t (8; 21) and c-kit mutation who
developed refractory hypotension due to mast cells mediators release. Meth-
ods: case report; review of literature Case Report: 53 year old female was diag-
nosed with myeloproliferative-myelodysplastic syndrome which evolved to
high risk MDS with complex cytogenetics (deletion of chromosomes 5,7 and
trisomy 8) for which she received induction chemotherapy. After discharge
she developed urticaria that slowly responded to daily antihistamines and was
thought to be medication related. She relapsed with AML (similar cytogenet-
ics) in 3 months and received re-induction therapy. The course was complicated
by Enterobacter bacteremia that cleared with daptomycin. However, she devel-
oped severe persistent hypotension along with new diffuse pruritic maculo-ery-
thematous rash. Skin biopsy showed spongiosis. The patient was transferred
to intensive care unit requiring vasopressors which were difficult to taper off.
Cardiac and septic shock were excluded as causes for refractory hypotension.
Repeat BM biopsy for induction response revealed clearance of myeloid blasts
but showed 20% CD 117+ oval spindle-shaped mast cells, which were positive
for tryptase and negative c-kit mutation. Serum tryptase level was 42 ng/ml.
The patient was diagnosed with SM-AML and started on histamine-1, hista-
mine-2 and leukotriene receptors blockers with significant improvement in
blood pressure and skin rash. After 2 weeks she died from multiorgan failure.
Conclusion: This is the first reported case of refractory hypotension due to mast
cells mediators release in a patient with SM-AML. Moreover, no cases of SM-
AML without t(8;21) or c-kit mutation were previously reported. From the
sequence of clinical events we believe that the mast cells were uncovered by
the treatment for AML. As a result, the diagnosis of SM was made after cytore-
ductive therapy. It is imperative that clinicians are aware of coexistence of SM
in clonal malignant hematological disorders. If clinically suspected, prompt
treatment improves the SM-related symptoms.
P107
SEED ALLERGY: WHEN NATURAL COLORS ARE DANGEROUS.
K. Tuano*, C. Hanson, K. Dillard, Houston, TX.
Color additives are frequently used in processed foods to impart color and
enhance its appearance. The US Food and Drug Administration (FDA) is respon-
sible for regulating color additives in commercial foods to ensure safety and
accurate labeling of approved ingredients. Synthetically produced colors are
FDA-certified and listed in food labels. However, natural color additives are
exempt from FDA-certification and labeled as natural color. Annatto is a nat-
ural color additive extracted from the seeds of Bixa Orella trees that imparts
an orange-yellow color to foods. The prevalence of adverse reactions to food
additives in the US is less than 1% in adults but 2-7% in children and higher
in those with atopy. We present an IgE mediated reaction to annatto in a 4 y/o
atopic child. She developed urticaria within minutes of eating mac and cheese
at a chain restaurant on two separate occasions. She also had urticaria with
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A55
angioedema immediately after eating ice cream sandwiches, pasteurized cheese
and boxed cheeseburger pasta. She tolerates chocolate, peanut, hazelnut, milk,
wheat and egg ingredients in above foods without reaction. Ingredient review
for the mac and cheese and ice cream sandwiches both contained annatto seed.
The boxed cheeseburger pasta only listed natural flavors and coloring. Skin
prick test to annatto extract was positive (8x30 mm) compared to negative
control (5x9 mm). Use of annatto as natural alternative to artificial color is
exempt from FDA certification and gaining popularity. It is labeled as all nat-
ural, no artificial food coloring, achiote, pimentao, bixin or norbixin. Annatto
is used in cheeses, dairy spreads, rice, custard powder, baked goods, snacks,
cereals and smoked fish. Despite its widespread use, there have only been 2
cases in adults of IgE mediated reaction to annatto. We present the first case
of IgE mediated reaction to annatto in a child. Our patient had no other food
allergies and the timing of ingestion of annatto-containing food and develop-
ment of symptoms with a positive immediate hypersensitivity skin test to annatto
extract is highly suggestive of an IgE mediated reaction. It is increasingly impor-
tant to investigate reactions to natural food coloring in patients with symp-
toms to multiple unrelated foods. As advocates for our patients, allergists should
advocate for FDA certification and specific labeling for all natural flavors and
coloring.
P108
EXTRAOVARIAN PRIMARY PERITONEAL CARCINOMA AND
ABDOMINAL COCOON SYNDROME INITIALLY PRESENTED
AS DERMATOMYOSITIS: A CASE REPORT.
N.F. Morgal*, M. Patrimonio, S. Sonza, A. Jesena, M. Tupas, V. Gasataya,
Iloilo, Philippines.
Background: Dermatomyositis (DM) is an idiopathic autoimmune myopa-
thy that predominantly targets the skin and skeletal musculatures. This report
describes an unusual case of a patient having both Extraovarian Primary Peri-
toneal Carcinoma (EOPPC) and Abdominal Cocoon Syndrome (ACS) who ini-
tially presented with Dermatomyositis. Case Summary: This is a case report
of 47-year old woman admitted due to rashes. History revealed that 7 months
prior to admission, there was note of multiple, pruritic erythematous macula
rashes prominent on the face, neck and chest. She was admitted and managed
as case of hypersensitivity reaction. Six months prior to admission, the skin
lesions over the face and chest recurred associated with raised violaceous, scaly
papules on the metacarpophalangeal, proximal interphalangeal and distal inter-
phalangeal joints on both hands and erythematous, cracked and roughened peri-
ungal areas. Patient was readmitted and diagnosed with dermatomyositis. She
was started on prednisone and methotrexate. Three months prior to admission,
an abdominal distention associated with difficulty of breathing was noted and
underwent abdominal CT scan revealing moderate ascites thus paracentesis
was done. Ascitic fluid analysis was positive for malignant cells. Medical onco-
logic consult was sought. Patient came in with BMI of 18.3 kg/m2, pale con-
junctivae, macular hyperpigmented lesions at the neck and shoulder area, scaly
papules at the MCP, PIP, DIP of both hands, distended abdomen with shifting
dullness and grade 1 pitting bipedal edema. CA-125 was elevated among the
requested tumor markers. Exploratory laparotomy with tenckhoff catheter inser-
tion was done with. intraoperative findings of encapsulated mass, thick walled
containing the bowels adherent to the anterior abdominal wall and sidewalls
and foul smelling ascitic fluid. Uterus and both ovaries were atrophic. Biopsy
of peritoneal tissue revealed psammoma bodies. With these pertinent find-
ings, EOPPC and ACS were considered. Patient endured cycles of chemother-
apy using Carboplatin and Paclitaxel. Conclusion: The incidence of classic DM
is 5.5 cases per million per year. The reported frequency of malignancy varied
from 6% to 60% with most large population based cohort studies revealing a
frequency of about 20 to 25%.
P109
A CASE OF A HYPERSENSITIVITY REACTION SECONDARY
TO SEABATHER’S ERUPTION.
S. Ringwala*1, R. Rishi1, S. Fatteh2, 1. Fort Lauderdale, FL; 2. Plantation,
FL.
Objective: To assess the appropriate evaluation and management options
for a patient with Seabather’s Eruption (Sea Lice). Seabather’s Eruption is an
entity that should be included in the differential diagnosis of patients present-
ing with rashes and appropriate supportive care should be offered. Methods:
Case Report Results: This is a 12 year old female from South Florida that pre-
sented with a rash that started under her bathing suit top after going swimming
in the ocean. The rash was maculopapular and pruritic. It spread from her
ABSTRACTS: POSTER SESSIONS
torso to her hands and feet and then became generalized with sparing of the
head and neck. Symptoms started about 2 hours after coming out of the ocean.
Patient had gone into the ocean previously even swimming at the same general
beach area without incident. Patient also claimed that her family was with her
in the same ocean water and did not develop the same symptoms. Crusting of
the rash with associated blistering with additional pruritis and discomfort fol-
lowed over the next 3-4 days. Vital signs were stable. There was blistering and
crusting noted on the skin on physical exam. Patient was given hydrocortisone
2.5% ointment to be applied topically in a thin layer to the affected areas as
needed only and placed on cetirizine 10 mg po daily for 2 weeks duration. Dis-
cussion: Seabather’s eruption is a self limited reaction that results in a highly
pruritic papular rash on exposure to seawater. It results from a hypersensitiv-
ity to thimble jellyfish larva (Linuche Unguiculata). Cases are noted from March
to August but peak incidence is in May and June. The eruption is seen in the
United States east coast of Florida. Bathing suits are believed to trap the lar-
vae which then discharge a venom, the significance of which is unknown. Swim-
mers washing themselves off with fresh water with their bathing suits off and
those that refrain from wearing their bathing suits for an extended period of
time are found to be better protected against Seabather’s Eruption. Conclusion:
Providers should be careful to avoid narrow differential diagnoses when patients
present with rashes. Seabather’s eruption should be considered in the differ-
ential in patients presenting with pruritus and papular rash and proper history
and physical exam should be conducted to ascertain relevant information for
this diagnosis. Supportive measures with symptomatic care is the treatment of
choice.
FIG1 - Seabather’s Eruption Rash.
P110
UTILITY OF A WEBSITE BASED DATABASE OF DRUG
ALLERGY: AMERICAN IMPRESSIONS.
N.P. Joshi*1, T. Pun2, V. Jain3, M. Sidhu4, L. Miller1, 1. St. John’s, NF,
Canada; 2. Toronto, ON, Canada; 3. Winnipeg, MB, Canada; 4. London,
ON, Canada.
Rationale: Drug allergy consults are challenging due to the dearth of pub-
lished data. Furthermore, there are few international journals who publish
case reports of drug allergies. This study aims to determine the utility of a web-
site-based database of drug allergy case reports and desensitization protocols
among American allergists. An online survey was administered to American
allergists, who are members of the American Academy of Allergy, Asthma and
Immunology (AAAAI). Methods: A semi-structured survey was created and
administered to members of the AAAAI. The questions were split into two
parts: demographics and database design. The demographics section of the sur-
vey strives to ascertain the types of drugs commonly consulted for and the fre-
quency of these consults. The next section attempts to elucidate how Ameri-
can allergists proceed with desensitization protocols- earlier research with
Canadian allergists showed that personal experience was the most used resource.
Results: 193 members of the AAAAI answered the survey. In terms of what
percentage of consults were related to drug allergies 62.1% estimated 1-10%,
with 22.6% estimating 10-25%. When discussing which drugs patients are con-
sulted about- the vast majority (>95%) said they had been consulted for Peni-
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A56
ABSTRACTS: POSTER SESSIONS
cillins, and Cephalosporins. Similarly when asked which drugs they had been
consulted for a desensitization protocol 93.1% of respondents named penicillin.
When asked what resources they use for researching desensitization protocols
82.8% said specific E-Journals, 76.6% said E Journal search database, and
69.3% use online search databases such as google or Uptodate. When asked if
they would utilize a website database of case reports on drug hypersensitivity
reactions and desensitization protocols 82.9% responded yes with 54.1% of
respondents also being interested in submitting to the database. In discussing
the characteristics that would be most important in the database respondents
felt overwhelmingly (>85%) that it should be structured and contain informa-
tion pertaining to patient demographics, medication usage, desensitization pro-
tocols and patient presentation. Conclusion: There is widespread support among
American Allergists for the creation of a database of drug allergy. The next log-
ical step is to gather support to create this database, which will require a mul-
tistakeholder approach.
P111
OLIVE OIL SENSITIVITY AND DESENSITIZATION: A NON-IGE
MEDIATED MECHANISM.
M. Karam*1, T. Franxman2, M. McMorris1, J. Baldwin1, 1. Ann Arbor, MI;
2. Lexington, KY.
Introduction: The pungency of extra virgin olive oil (EVOO) is attributed
to one of its phenolic compounds called oleocanthal (OC) and is mediated
through the transient receptor channel potential cation channel ankyrin sub-
type 1 (TRPA1) expressed in the posterior oropharynx. EVOO also mimics
the pharmacology of ibuprofen in that both agents cause a dose-dependent inhi-
bition of cyclooxygenase enzymes COX-1 and COX-2. EVOO sensitivity has
been described in the literature previously however EVOO desensitization has
not. Herein we report the first case of successful EVOO desensitization using
a novel EVOO desensitization protocol. Case Description: A 25-year-old patient
with medical history significant for aspirin sensitivity, exercise induce asthma
and mixed vasomotor and allergic rhinitis presented with a history of facial and
tongue pruritus, throat irritation, coughing and hives within minutes of olive
oil consumption. Symptoms required diphenhydramine however several prior
episodes required epinephrine. A series of food and drug challenges were enter-
tained to establish the mechanism of EVOO sensitivity in this patient. Also a
novel EVOO desensitization protocol was devised. Discussion: EVOO desen-
sitization has not been attempted previously in the literature and in this report
we describe the first case of successful EVOO desensitization using a novel
EVOO desensitization protocol. Furthermore the patient continues to be in a
desensitized state 2 years after the procedure maintained with daily doses of
10 ml EVOO. Although the mechanism of her reaction is likely due to OC stim-
ulation of TRPA1, the mechanism of desensitization and maintenance of the
desensitized state is unclear and requires further study.
P112
LONGITUDINAL MULTIMODAL THERAPY IN A PATIENT WITH
MAST CELL ACTIVATION SYNDROME.
A.S. Chau*1, L. Helfner2, V.R. Bonagura2, A.M. Jongco2, 1. Mineola, NY;
2. Great Neck, NY.
Background: Mast cell activation disorders (MCAD) affect multiple sys-
tems and are caused by episodic mast cell mediator release. Intrinsic defects
in mast cell proliferation or activation are found in primary MCAD such as sys-
temic mastocytosis (SM) and monoclonal mast cell activation syndrome. In
secondary MCAD such as allergic disorders, mast cells that are normal in quan-
tity and function respond to external stimuli (i.e., allergens). In idiopathic
MCAD, such as mast cell activation syndrome (MCAS), there is no identifi-
able cause of mast cell activation. We describe the longitudinal clinical course
and management of a patient with MCAS. Methods: A 49-year-old woman
diagnosed with autoimmune disorder, not otherwise specified, status post
thymectomy originally presented with chronically elevated IgE and ANA, alope-
cia universalis, weight loss, chronic idiopathic urticaria and multiple food sen-
sitivities. Extensive evaluation revealed multiple aeroallergen hypersensitivity
and unremarkable bone marrow studies. There was no evidence of immune
deficiency, autoimmunity, IgE-mediated food allergies, SM and celiac disease.
Results: Urine histamine and histamine release assay were normal. Serum
tryptase was unremarkable repeatedly. Her symptoms did not improve after tri-
als of immunosuppressive and immunoglobulin replacement therapy. In col-
laboration with the Center of Excellence for Mastocytosis and Mast Cell Acti-
vation Disorders at Brigham and Women’s Hospital, she was started on an
aggressive anti-inflammatory regimen including H1 and H2 antihistamines,
A56 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
cromolyn, monteleukast and omalizumab more than three years ago. This
resulted in sustained weight gain, improved tolerance to previously sensitive
foods and aeroallergens, minimal hair regrowth, and decreased frequency and
severity of urticaria. Despite improvements on optimal medical therapy, over-
all symptom control and quality of life remain poor. The patient is considering
other treatment modalities including allogeneic hematopoietic stem cell trans-
plantation, which has been described in two small series for SM with variable
outcomes. Conclusions: MCAS is a diagnosis of exclusion that warrants con-
sideration in patients with chronic multisystem complaints of unclear etiol-
ogy. MCAS diagnosis and management are evolving; additional research is
necessary for understanding the etiology and natural history of this disease.
P113
A RARE CASE OF BREASTFEEDING ANAPHYLAXIS.
A. Speck*, M. McMorris, Ann Arbor, MI.
Introduction: Breastfeeding anaphylaxis is rare, but potentially fatal. Symp-
toms range from urticaria to hypotension and syncope and occur in close rela-
tion to lactation. The pathogenesis of the reaction remains unclear; however,
hormone shifts related to the end of gestation and the beginning of lactation
seemingly play a role. Waning levels of progesterone postpartum and loss of
its mast cell stabilizing effect has been one hypothesized mechanism, though
the roles of oxytocin, prolactin, adrenocorticotrophic hormone (ACTH), cor-
ticotropin-releasing hormone (CRH) and increased numbers of antepartum
mammary and uterine mast cells have also been questioned. In addition, NSAIDs
may also be a contributing factor. Methods: Presentation, evaluation, diagno-
sis and management of a patient with breastfeeding anaphylaxis. Data: A 25
year old gravida 3 para 3 woman was admitted with anaphylaxis on postpar-
tum day 3 following the birth of her third child. She had breastfed her first child
for 2 months without difficulty. Three days after the delivery of her second
child, she developed isolated urticaria after breastfeeding. She discontinued
breastfeeding and symptoms resolved. Her third child was born via uncompli-
cated vaginal delivery. She had been taking 600 mg of ibuprofen every 8 hours
following the delivery, but was on no other medications. Breastfeeding was
uneventful for the first 48 hours after delivery. On postpartum day 3, however,
with the first breastfeeding after generation of mature milk, she developed dif-
fuse urticaria, tongue swelling, emesis, and dizziness. On admission, she was
tachycardic, tachypneic, and hypotensive. A tryptase level obtained 6 hours
after the episode was elevated at 14.6 ng/mL (normal < 11.5 ng/mL). The patient
desired to continue breastfeeding. She was placed on prophylactic cetirizine
10 mg BID and all NSAIDs were discontinued. She subsequently breastfed
successfully for 24 hours while under close observation. Conclusions: Our
patient had anaphylaxis with breastfeeding on postpartum day 3 when lacto-
genesis was established. She subsequently tolerated 24 hours of breastfeeding
without difficulty with the use of cetirizine 10 mg BID and avoidance of
NSAIDs. Our case suggests that mothers with a history of breastfeeding ana-
phylaxis and a desire to breastfeed can likely do so with appropriate treatment
and counseling.
P114
CROSS-REACTIVITY TO BALSALAZIDE IN A MESALAMINE
HYPERSENSITIVE PATIENT.
R. Rishi*1, H. Nasir2, S. Ringwala1, S. Fatteh3, 1. Fort Lauderdale, FL;
2. Miami, FL; 3. Plantation, FL.
Objective: To determine the safety of replacing mesalamine with other 5-
aminosalicylic (5-ASA) formulations in patients with hypersensitivity to
mesalamine. Patients with inflammatory bowel disease (IBD) such as ulcera-
tive colitis are usually treated with 5-ASA preparations such as mesalamine.
These drugs are first line medications used to treat mild to moderate ulcera-
tive colitis due to their steroid-sparing effects. Balsalazide is a dimerized 5-
ASA preparation that may be tolerated in patients with hypersensitivity to
mesalamine. Due to its structural differences, dimerized 5-ASA medications
may be considered to be safe alternatives due to a presumed lack of cross-
reactivity. Methods: Case Report Results: A 39-year-old Caucasian female pre-
sented to our service after experiencing anaphylaxis following use of
mesalamine (Asacol). She had been using mesalamine for 19 years to control
her mild to moderate ulcerative colitis. Six months ago, she experienced dif-
fuse urticaria and generalized pruritus one hour after taking her morning dose
of mesalamine. She took diphenhydramine, and her symptoms resolved within
hours. The next day, she took her morning dose of mesalamine and experienced
immediate anaphylaxis. She developed laryngeal edema, diffuse urticaria, and
generalized pruritus. The patient was treated with epinephrine, and her symp-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A57
toms resolved. The patient underwent a provocative drug challenge with bal-
salazide (Giazo) in our clinic over two days. The patient reacted on the second
day when she experienced swelling of her hands and generalized pruritus. The
patient was administered oral antihistamines and corticosteroids and her symp-
toms resolved within four hours. Conclusions: Cross-reactivity may occur
between different 5-ASA preparations despite their structural differences.
Patients with inflammatory bowel disease who are hypersensitive to mesalamine
may also react to balsalazide and olsalazine. Mesalamine hypersensitive patients
should not be started on these medications without undergoing a provocative
drug challenge. We designed an outpatient protocol that will safely enable
patients to undergo testing in an office setting.
Balsalazide (Giazo) Provacative Challenge Protocol
P115
A CASE OF TONGUE SWELLING CAUSED BY ENDOTRA-
CHEAL TUBE-INDUCED VASCULAR OBSTRUCTION.
M. Saifi*, J.A. Bird, Dallas, TX.
Introduction: Allergists are commonly asked to evaluate the etiology of
tongue swelling. We report a case of a woman with 16 days of tongue swelling
secondary to endotracheal tube (ETT)-induced vascular obstruction of the base
of the tongue. Methods: Case Report. Data: A 55 year-old female with systemic
lupus erythematosis, end-stage renal disease, hypertension, and congestive heart
failure presented to the emergency department with acute onset shortness of
breath and somnolence. MRI revealed bilateral intraventricular hemorrhage
and chest imaging revealed pneumonia. She was intubated secondary to res-
piratory distress. Tongue swelling was reported 2 days after intubation and wors-
ened over the next 2 days. Physical examination revealed a swollen tongue,
which was at least 2-3 times the size of normal, protruding out of her mouth.
Pressure ulcers were noted on the base of the tongue. Laboratory evaluation
revealed normal C3 and C4. Due to concern for oropharyngeal edema, a tra-
cheostomy was performed. Swelling had not improved 14 days after intuba-
tion and a 4 day course of dexamethasone was administered without improve-
ment in swelling. Tongue swelling improved 1 day post-extubation and resolved
within 2 days. Past medical history was significant for lisinopril-induced
angioedema. The patient did not receive an ACE-inhibitor or ARB prior to or
during admission and medication regimen did not change prior to or post-res-
olution of swelling. The differential diagnosis of tongue swelling includes hered-
itary angioedema (AE), acquired AE, medication-related AE, mechanical
obstruction, and sublingual hematoma secondary to a difficult intubation.
Tongue swelling was attributed to venous obstruction secondary to local
mechanical compression of the base of the tongue by ETT. This is supported
by a normal C4, onset of swelling after ETT placement and resolution after
ETT removal, and the prolonged course of swelling (16 days). Conclusion:
Mechanical obstruction of venous drainage should be considered as an etiol-
ogy of prolonged tongue swelling in intubated individuals.
ABSTRACTS: POSTER SESSIONS
Tongue swelling in endotracheally-intubated patient
P116
HYPERSENSITIVITY REACTION TO SUBCUTANEOUS
IMMUNOGLOBULIN.
Q. Rashid*, A. Grant, Galveston, TX.
Introduction: Immunoglobulins (Ig) are routinely used in management of
Primary Immune Deficiency diseases (PIDD). Ig formulations differ based on
the content of IgG, IgA, osmolality and stabilizer. Most adverse reactions to
IVIG are either due to a rapid rate of infusion or IgA deficiency. We report a
case of hypersensitivity reaction to the stabilizer in the Ig formulation. Meth-
ods: A 50 year old female with a 3-year history of CVID was referred by her
allergist for management of hypersensitivity reaction to subcutaneous
immunoglobulin. She had been treated with subcutaneous hizentra weekly for
2 years; however, 2 months ago she developed an urticarial rash 20 minutes
after taking her usual dose. Subsequent doses caused immediate symptoms of
throat closure, difficulty breathing, swallowing and low blood pressure requir-
ing treatment with epinephrine, prednisone and antihistamine in the ER. She
denied symptoms of nausea, vomiting, fever, chills or headache. Hizentra was
subsequently discontinued and she was referred to UTMB for further evalua-
tion. On evaluation, her history was negative for allergic or anaphylactic reac-
tions to other medications and IgA deficiency was ruled out. Skin prick test-
ing to Ig was not helpful due to dermatographism. The patient was treated
with Gammagard, chosen for the differences in osmolality and stabilizer con-
tent vs. Hizentra. Patient received a slow infusion of Gammagard and was
subsequently switched to SC administration without further reactions. Dis-
cussion: Hizentra contains the stabilizers L-proline and polysorbate 80, whereas
Gammagard contains only glycine. Polysorbate 80 is commonly used in vac-
cines, chemotherapy and tablet formulations. It has been reported to cause non
IgE mediated anaphylactic reactions in patients receiving Docetaxal and is the
most likely cause of hypersensitivity reaction in our patient. No hypersensi-
tivity reactions with L-proline have been reported in literature. Hizentra also
has higher osmolality as compared to Gammagard but the adverse reactions
due to high osmolality usually include thrombosis and kidney injury which
were not present in our patient. Conclusion: We report a rare case of hyper-
sensitivity reaction to a stabilizer in Hizentra, an Ig formulation used for treat-
ment of PIDD. This report alerts the allergist/immunologist about work up and
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A58
ABSTRACTS: POSTER SESSIONS
management of patient’s with hypersensitivity reaction to an immunoglobulin
formulation.
P117
EOSINOPHILIC CHOLECYSTITIS IN AN ASPIRIN EXACER-
BATED RESPIRATORY DISEASE (AERD) PATIENT.
L. Finkas*, R. Katial, Denver, CO.
Introduction: A rare case of eosinophilic cholecystitis in a patient with
AERD Case: 50-year-old male with past medical history of asthma, chronic
sinusitis with nasal polyps, and AERD. He underwent aspirin desensitization
a few years prior and had improvement in both his asthma and sinus disease.
Following desensitization, he was maintained on aspirin 650 mg BID and was
subsequently decreased to 325 mg BID. He presented for routine 6 month fol-
low up at which time he had been experiencing significant gastrointestinal
symptoms for the previous 3 weeks. His symptoms began as indigestion and
heartburn and progressed to diarrhea and vomiting. His PMD had placed him
on a course of antibiotics, but despite antibiotics, he continued to have symp-
toms. Stool studies were obtained and C-diff was negative. His aspirin dose
was decreased to 81 mg without improvement in GI symptoms. Further diag-
nostics were pursued and complete blood count was notable for an elevated
WBC of 14,000 with an absolute eosinophil count of 6100. Liver function tests,
ESR and CRP were within normal limits. He was evaluated in the emergency
room given his persistent symptoms and was found to have cholecystitis. He
underwent a cholecystectomy and pathology revealed transmural inflamma-
tory cell infiltrate composed predominantly of eosinophils. Bone marrow biopsy,
EGD and colonoscopy were performed for possible hypereosinophilic syn-
drome. His bone marrow biopsy was negative for FIP1L1/PDGFRA mutation
and was only notable for mild eosinophilia. EGD and colonoscopy were neg-
ative for eosinophilic infiltrate. He remained on aspirin during this time and
following his surgery increased to 325 mg daily. Following cholecystectomy,
the patient had significant improvement in his peripheral eosinophilia and his
eosinophil count retuned to his baseline of 400. His gastrointestinal symptoms
resolved. Conclusion: This is the first case of a rare eosinophilic process iso-
lated to the gallbladder in a patient with AERD, which in itself is manifested
by increased circulating eosinophils in over half the patients. The authors have
previously reported rare complication of pancreatitis after aspirin desensitiza-
tion and a few unpublished cases of increased GI symptoms with eosinophilia.
This shows another possible complication in AERD patients with underlying
eosinophilia.
P118
DIAGNOSIS OF CYSTIC FIBROSIS IN 59-YEAR-OLD WOMAN
REFERRED FOR IMMUNE DEFICIENCY.
C. Dutmer*, E. Gelfand, Denver, CO.
Introduction: Cystic fibrosis (CF) is a disease caused by mutations in the
CF transmembrane conductance regulator (CFTR) gene, resulting in deleteri-
ous effects on epithelia of various tissues. Though the classic CF phenotype is
characterized by progressive pulmonary disease and associated exocrine pan-
creatic insufficiency in childhood, disease phenotype varies greatly by specific
CFTR mutations, associated genetic modifiers, and environmental factors.
Nearly 2,000 CFTR gene mutations have been identified, highlighting the allelic
heterogeneity in the CFTR gene. Discovery of new mutations (and associated
factors) may explain the diverse nature of CF-related disease phenotypes with
varying age of onset and recognition. We describe a 59-year-old woman eval-
uated for immune deficiency in whom CF was diagnosed. Case Description:
A 59-year-old Caucasian woman with chronic obstructive pulmonary disease
and a 40 pack-year cigarette smoking history presented with an 18-month his-
tory of recurrent pneumonia and sinus disease as well as an episode of pan-
creatitis. Prior history was notable for the absence of significant infection. She
recently required numerous hospitalizations and had subsequently required sup-
plemental oxygen while suffering from chronic dyspnea and cough. Expecto-
rated sputum and bronchoalveolar lavage bacterial cultures revealed mucoid
Pseudomonas aeruginosa. Cylindrical and varicoid bronchiectasis as well as
chronic maxillary sinusitis were evident on CT (Image 1). Quantitative serum
immunoglobulin levels were normal as was the remainder of her immune eval-
uation. Family history identified a paternal first cousin once removed with CF
as well as carrier status for a CF gene mutation in the patient’s daughter. Sweat
chloride testing was elevated at 72 mmol/L and CFTR gene sequencing analy-
sis revealed two mutations: deltaF508 and R117H. Discussion: New-onset
sinopulmonary infections in the 6th decade of life of a long-standing smoker
prompted initial concern for secondary or acquired immune deficiency. Con-
A58 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
sideration of CF as an explanation of recurrent sinopulmonary disease in a pre-
viously “healthy” adult is certainly unusual. Growing evidence of the diverse
genotype-phenotype relationships in CF and reported variability in disease-
onset suggests that a diagnosis of CF be evaluated in adults with recent-onset
pneumonia, bronchiectasis, and sinopulmonary disease.
Image 1: Chest CT (left) revealing cylindrical and varicoid bronchiectasis;
sinus CT (right) revealing chronic maxillary sinusitis.
P119
PROTRACTED ANGIOEDEMA IN A 9-YEAR-OLD GIRL: PROPO-
FOL AND FOOD ALLERGY.
S.K. Lin*, T.B. Fausnight, Hershey, PA.
Introduction: According to package inserts, use of Diprivan brand propo-
fol or Fresenius brand propofol is contraindicated in patients with soy or egg
allergy. This is due to the use of soybean oil and egg lecithin as excipients and
the potential for soy or egg protein contamination. Fresenius is additionally
contraindicated in peanut allergic patients due to potential cross-reactivity
between peanut and soy. Case Report: A 9-year-old girl with history of Chiari
malformation was noted to have swelling of her face, lips, and tongue after neu-
rosurgery. She had a history of identical reactions to fresh egg and peanut, and
anesthesiology suspected her reaction was due to Fresenius and her peanut
allergy. She had tolerated Diprivan at least 7 times before, most recently 2
months prior. She was given H1 and H2-blockers and was extubated postop-
eratively, but then developed stridor, wheezing, desaturations, and again had
lip and tongue swelling. She continued to be symptomatic despite anaphylaxis
management and required an epinephrine drip and nasal intubation. She required
a slow 7 day wean off epinephrine. Results: Total tryptase level drawn at hour
four was 4 ng/mL. C4 and C1 esterase inhibitor levels were normal. IgE lev-
els for egg white, egg yolk, and soy were negative, while peanut was positive
at 1.27 kU/L. Follow up skin testing to egg and soy were negative, and peanut
was positive (5 mm wheal). Discussion: After literature review, we found that
the vast majority of patients with soy, egg, or peanut allergy receive propofol
without issue. In one study, there were no adverse reactions to propofol amongst
45 food allergic patients. Despite its contraindication in peanut allergic patients,
Fresenius does not contain any ingredients which make it more allergenic than
Diprivan in patients with egg, soy, or peanut allergy. While we have not yet been
able to identify the cause of our patient’s protracted reaction, we do not sus-
pect it was related to her peanut allergy. Conclusion: Care should be taken to
understand the reasoning behind food allergy contraindications of medications,
as these can often be given to food allergic patients without issue. Such con-
traindications may cause unnecessary avoidance of medications and/or may
distract from the identification of a true medication allergy.
P120
MANAGEMENT OF HYPOGAMMAGLOBULINEMIA DURING
MEASLES AND MUMPS OUTBREAK IN PATIENTS TRANSI-
TIONING OFF IMMUNOGLOBULIN REPLACEMENT.
K. Strothman*, R. Scherzer, Columbus, OH.
Introduction: In a country where the transmission of many diseases has
been largely eliminated by vaccination, the widespread outbreak of preventa-
ble illness could modify management and treatment options of patients with
hypogammaglobulinemia. We describe two patients with a history of hypogam-
maglobulinemia who were in the process of transitioning off IgG replacement.
In light of the measles and mumps outbreak in Ohio, these patients were either
continued or restarted on IgG replacement. This was due to their unvaccinated
status and the recommended interval between receiving antibody-containing
products and administration of a measles-containing vaccine. Case Reports:
Case 1 involves a 5 year-old female who was introduced to the Immunology
service at 5 weeks of age during an admission for bronchiolitis. Immunology
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A59
was consulted for recurrent respiratory infections. Her clinical course was com-
plicated by pneumothorax, bronchopleural fistula, and necrotizing pneumonia.
Her immune workup was normal except for a gradually declining IgG level.
Stool α-1-antitrypsin initially high, favoring the diagnosis of hypogamma-
globulinemia secondary to a protein-losing enteropathy. She started IgG replace-
ment at 15 months. By 4 years of age, there was discussion to begin weaning
IgG replacement. This was halted due to concern about the measles and mumps
outbreak. Case 2 is that of a 2 year-old male who presented in the first month
of life with enterocolitis and dehydration. He had a low total protein, albumin,
and IgG level thought to be due to GI losses, although stool α-1-antitrypsin
negative. Work-up for a unifying diagnosis was negative. History now thought
to be most consistent with transient hypogammaglobulinemia of infancy. He
was started on IgG replacement at 4 months. At 2 years he was weaned off IgG
replacement and remained off for 6 weeks. Secondary to concern over the
increased risk of exposure to measles or mumps through his particular daycare
setting, IgG replacement was restarted. Conclusions: These cases highlight
the challenges that exist for our patient population with Immunoglobulin Defi-
ciency due to the reemergence of vaccine-preventable illness. As these expo-
sures continue to increase, we must modify our treatment plans to provide opti-
mal care and ensure patient safety.
P121
MUSTARD SEED ANAPHYLAXIS.
L. Cuervo-Pardo*, A. Gonzalez-Estrada, J. Fernandez, Cleveland, OH.
Introduction: Food is the most common cause of anaphylaxis (Lieberman
P et al. J Allergy Clin Immunol. 2010). Very few cases of mustard seed induced
anaphylaxis have been reported. We present a case of mustard seed anaphy-
laxis. Methods: A case report Results: 29 year old man presented to our depart-
ment for evaluation of anaphylaxis. He had an episode of generalized urticaria
(Figure A), chest tightness, vomiting, facial flushing and angioedema (Figure
B), within 30 minutes of eating a prepared quinoa dish at home. He did not
seek medical attention and his symptoms resolved within hours of self-admin-
istration of loratadine and diphenhydramine. He had no relevant past medical
history of previous adverse reactions to foods. Upon further questioning, the
ingredients in the quinoa dish included: chicken, rice, avocado, ginger, onion,
potatoes, tomato, nutmeg, yeast, soy, wheat, black pepper, thyme, and mustard
seed. He had previously tolerated quinoa without adverse reactions. However,
the two last ingredients were obtained from a new brand. His physical exam
was unremarkable. Percutaneous skin testing was positive to soy and prick-
prick testing to mustard seed. He was instructed on avoidance measures includ-
ing food label reading and prescribed epinephrine auto injector. Conclusions:
This case report demonstrates the importance of an adequate clinical history
and detailed content of ingredients.
P122
ALLERGIC RHINITIS: UNASSUMING UNTIL MENINGITIS
RECURRED.
P. Uong*, R. Casper, Phoenix, AZ.
Introduction: We present a case of a toddler with recurrent bacterial menin-
gitis of unclear etiology, various upper respiratory infections, allergic rhinitis,
and persistent cough who was eventually found to have a cerebral spinal fluid
(CSF) leak. The case is interesting in that there were vague clues to her CSF
leak over the years, but it was not until her second case of meningitis that
prompted a cisternogram, which confirmed the diagnosis of a Mondini defor-
mity. Case History: A 3 year-old female with a past history of bacterial menin-
ABSTRACTS: POSTER SESSIONS
gitis and subsequent left-sided stroke, allergic rhinitis (based on positive skin
testing), and asthma, who presented to the hospital for headaches and vomit-
ing after two minor head traumas at daycare. Because of her history, CSF stud-
ies were obtained and revealed recurrent meningitis, which prompted further
workup confirming the CSF leak. She was found to have a congenital cochlear
malformation, which was then repaired by otolaryngology. Outcome & Dis-
cussion: Retrospectively, her history and various hospital visits were all con-
sistent with CFS leakage. The patient actually presented to the hospital at 9
months of age after a minor fall with reported vomiting and lethargy. After-
wards, she was seen at various points for upper respiratory infections, allergic
rhinitis, as well as meningitis with stroke, and asthma with hypoxia. She was
also seen by an allergist/immunologist for workup of her food allergies and
asthma. She was diagnosed with allergic rhinitis based on clinical history of
rhinorrhea and mildly positive environmental skin testing. The rhinorrhea
showed moderate improvement with intranasal corticosteroid treatments. Dur-
ing her first episode of meningitis, she had a basic immunological workup
including immunoglobulin and complement levels and vaccine titers, which
were all normal. It was not until her second episode of known meningitis that
there were considerations for CSF leak as a source of her infections. Both
instances of meningitis were only suspected because of acute neurological signs.
Conclusion: Though rare, CSF leakage should always be considered in the dif-
ferential for clear rhinorrhea and recurrent meningitis. In our case, there were
several clues for CSF leakage including: history of head trauma, persistent clear
rhinorrhea despite appropriate therapy for allergic rhinitis, and recurrent menin-
gitis despite a normal immune evaluation.
P123
OMALIZUMAB MAY PREVENT PERFUME TRIGGERED
LARYNGEAL ANGIOEDEMA.
R.M. Young*, P. Ciminera, East Meadow, NY.
Introduction: Omalizumab is a monoclonal antibody to IgE indicated for
use in asthma but also used in other IgE mediated conditions i.e.Allergic Rhini-
tis and recently indicated for use in chronic urticaria. But could it have a role
in irritant induced angioedema? Methods: N/A Case Report: This is a 16yr old
female who had multiple hospitalizations for status asthmaticus x 2 yrs. Sinusi-
tis, GERD, allegies to environment/foods were diagnosed as well as Paradox-
ical Vocal Cord (PVC) dysfunction by ENT via rhinoscopy. On exposure to
dust, acid reflux, chlorine in a pool or indoor pollutants like perfumes, she’d
develop nasal congestion, hoarseness, a barking cough, and throat tightness.
She was placed on maximal medicines of steroid inhaler/LABA, montelukast,
oral antihistamines, steroid nasal spray, pantoprazole, and oral steroids in an
effort to control these symptoms. But since PVC was also a problem, speech
therapy/counseling were started as well as immunotherapy (IT). Despite this
regimen, when the patient was exposed to perfume in school, she required
Epinephrine, Diphenhydramine, and Albuterol for symptoms of cough, throat
closure and syncope with eventual admittance to the Pediatric ICU. This reac-
tion was so severe that the child became home tutored due to the fear of per-
fume exposure. A similar reaction but milder to dust mite IT was witness and
quickly reversed with Epinephrine and Diphenhydramine IM. The patient had
an IgE level of 1033 IU/ml, so Omalizumab was started. For the past 1 year,
she has received 375mg SQ every 2 weeks. She has returned to school and
normal activities and hasn’t had any symptoms requiring Epinephrine or
Albuterol on exposure to perfumes. Conclusion: Since the patient was on med-
icines to control asthma, GERD, and sinusitis, it was thought that her throat
closure was due to PVC triggered by the perfume. But Laryngeal angioedema
seem to be the culprit. Irritants like perfume may have an IgE mediated process
or a mechanism of destablizing mast cells similar to idiopathic anaphylaxis that
hasn’t been identified. Therefore, Omalizumab should be considered as a trial
therapy. More studies are needed using omalizumab for these cases.
P124
UNCONTROLLED ASTHMA IN A PRIMARY CILIARY
DYSKINESIA PATIENT TREATED SUCCESSFULLY WITH
OMALIZUMAB.
J.X. Lee*, A. Rafi, W.B. Klaustermeyer, J.S. Yusin, Los Angeles, CA.
Primary cilia dyskinesia (PCD) is an autosomal recessive genetic disorder
characterized by recurrent and chronic infections of the upper and lower res-
piratory tract due to impaired mucociliary clearance. Patients with PCD can
have co-existing asthma. Omalizumab is a high affinity recombinant human-
ized monoclonal anti-IgE antibody which is commonly used to treat uncon-
trolled moderate to severe allergic asthma. We report a case of 58 year old
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A60
ABSTRACTS: POSTER SESSIONS
female with known diagnosis of PCD and persistent allergic asthma who pre-
sented with symptoms consistent with infections and expected course of PCD
but were in fact due to uncontrolled asthma and successfully treated with Oma-
lizumab. At the time of presentation, she was already on maximal therapy for
airway clearance for her PCD. She had been treated with numerous courses of
antibiotics for infection without improvement for the previous 5 years. At her
initial visit, her pulmonary function test revealed component of obstruction
with airway hyper-responsiveness that was reversible. Her physical exam
revealed coarse breath sounds and wheezing that improved after bronchodila-
tion. Despite PCD being her dominant disease pathology, she was thought to
have a component of uncontrolled allergic asthma. As she was maximized on
Beta 2 agonist and inhaled corticosteroid therapy, the decision was made to
start Omalizumab given her elevated total serum IgE level. Within 3 months
of starting Omalizumab, the patient reported significant improvement in her
shortness of breath from baseline and her appetite. At the time of this report,
approximately 2 years after starting Omalizumab, she has an overall improve-
ment in FEV1, improved symptoms of shortness of breath, and decreased exer-
cise induced bronchospasm symptoms. In summary, due to their motile cilia
disorder, PCD patients have variable degrees of decline in their pulmonary
function. While a majority of their respiratory symptoms are likely due to struc-
tural lung damage related to recurrent infections, other etiologies for short-
ness of breath such as concomitant allergic asthma should not be overlooked.
In addition, the use of Omalizumab in the treatment of allergic asthma as add-
on therapy should be considered in patients with elevated total IgE level even
in the setting of significant structural lung disease.
P125
A RARE CASE OF FOOD INDUCED ANAPHYLAXIS TO BEET-
ROOT.
F. Pazheri*1, B. Schroer2, 1. Shaker Heights, OH; 2. Cleveland, OH.
Background: Beetroot is a common food ingredient and are consumed all
over the world. It is used as a food additive in many food products. Allergy to
beetroot (Beta Vulgaris) is rare. Until now only one case of apparent anaphy-
laxis to beet root consumption has been reported (de Oliveira et al, Clinical
and Translational Allergy 2011) ; there are a few reports of asthma and rhinocon-
junctivitis induced by inhaling the vapor of cooked beet. Methods: We report
a case of a 17 year old young man who had an anaphylactic reaction after eat-
ing beetroot. His medical history was notable for anaphylaxis to tree nuts, aller-
gic rhinitis, Latex allergy and a subsequent diagnosis of Crohn’s disease. The
patient had oral and throat itching, vomiting, and a sensation of throat closing
up within one minute after ingestion of one shot glass amount of a juice smoothie
containing ¼ of a beet, carrots, and apples in 16 Oz glass of juice smoothie
made at home. Symptoms slowly resolved over the next hour after 50 mg of
diphenhydramine and monitoring in an urgent care clinic. He had never eaten
beets before and there are no tree nuts in his home due to his tree nut allergy.
He has safely eaten carrots and apples after the reaction. He was evaluated for
possible allergy to beetroot with blood testing and skin prick testing. Results:
Food specific IgE to beet root were positive at 2.52 KU/L. Skin prick test
using fresh beetroot juice using a prick-prick method with a bifurcated needle
on the forearm was positive with a 9 mm wheal and 20 mm flare (Negative con-
trol 0/0 mm wheal/flare, histamine 6/20 mm wheal/flare). Beet sugar prick-
prick skin testing and food challenge was negative. Patient has not had a sub-
sequent allergic reaction to any food since the reaction. Conclusion: Anaphylaxis
to beetroot is very rare and this is the first case reported with positive fresh
food prick-prick testing that we could find. Refined beet sugar may not lead
to reactions in beet allergic patients.
P126
DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC
SYMPTOMS (DRESS) PRESENTING IN AN HIV PATIENT
TREATED WITH INTERFERON AND ANTIRETROVIRALS.
S. Hamadani*, A. Wong, C. Parrish, S. Thobani, L. Scott, M. Li, Los
Angeles, CA.
Introduction: DRESS is a potentially life-threatening hypersensitivity reac-
tion associated with a variety of medications, generally anti-epileptics. Patients
present with rash, fever, hypereosinophilia, lymphadenopathy, and internal
organ involvement, often hepatitis, usually within two months after initiation
of a medication. Methods: Case report Results: A 50 year old African Ameri-
can Male with HIV (CD4=400), HCV Genotype 1a, and HTN, presenting with
rash for one week prior to admission (PTA). Patient was in his usual state of
stable health, with undetectable HIV viral load on HIV treatment, until 3 months
A60 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
PTA when he started Interferon gamma (IFN-g) for asymptomatic hepatitis C.
One week post IFN-g therapy, patient developed dyspnea and fatigue. Two
weeks PTA, patient self discontinued IFN-g and then one week PTA devel-
oped a rash. Patient noted a pruritic rash starting on his scrotum which he ini-
tially attributed to tinea cruris. He used nystatin powder, which temporarily
relieved the itching however the rash began to spread to his bilateral lower
extremities and then to his upper body. During the three months preceding
admission, HIV regimen was also adjusted multiple times for increase in HIV
viral load. Review of laboratory studies showed peripheral eosinophilia (absolute
eosinophil count: 1.8 K/cumm), peripheral smear with atypical lymphocyto-
sis, and stool examination for ova and parasites as well as serum testing for
Strongyloides were negative. Patient suffered from acute renal insufficiency.
Liver involvement was not detected. Patient was diagnosed with DRESS. Diag-
nostic criteria included fever, acute rash, hypereosinophilia, lymphadenopathy,
and atypical lymphocytosis. DRESS was likely attributed to abacavir; however,
other HIV medications or IFN-g could not be ruled out definitively as the cause.
Patient required large doses of steroids to control symptoms and had an exten-
sive hospital course. Post-mortem exam revealed cause of death to be gram-
negative sepsis (Acinetobacter baumannii) without evidence of hepatic necro-
sis. Conclusion: In general, DRESS carries a mortality rate of 5-10%, which
is in patients without co-morbid conditions. This case is unique because it illus-
trates patients with DRESS and underlying HIV maybe suspect to even higher
mortality rates.
P127
PERSISTENT HIGH IMMUNGLOBULIN E LEVELS AND TUBER-
CULOSIS: A CASE REPORT.
M. Yuksel, M. Nursoy*, A. Gedik, E. Cakir, Istanbul, Turkey.
Introduction: T helper1 (Th1) lymphocytes have important role in immune
response against Tuberculosis(TB). Relationship between TB and high
immunoglobulin E(Ig E) levels with Th1 related mechanism was told in recent
studies and reduction in high Ig E levels was noted with TB therapy. Aim: To
discuss relationship between high and persistant Ig E levels and TB. Case:
Twelve-years-old female patient who have had chronic productive cough, fre-
quent otitis and sinusitis since 6 months-old and was followed-up with asthma,
resistant atelectasis of right middle lobe, bilateral bronchiectasis was admitted.
Previous tests were normal except high IgE (494 mg/dl), TB history of her uncle
5 years ago. After admission, atelectasis was found in computarized tomogra-
phy (CT) and bronchoscopy revealed dense purulent mucus. Aspergillus fumi-
gatus and Hemophilus influenzae were observed in BAL culture. Symptoms
persisted and total IgE increased (1750 mg/dl) despite appropriate therapy.
Aspergillus fumigatus in prick test, Aspergillus spesific IgE, control sputum
culture, and immune deficiency tests were negative. PPD, Quantiferon test, and
ARB in gastric aspiratation were 20mm, positive and negative, respectively.
Control CT revealed multiple intrathoracic conglomerated lymph-nodes (30x25
mm). Mediastinoscopic biopsy for Lyphoma resulted reactive hyperplasia. Anti-
TB therapy was given to patient who had TB disease contact, PPD and quan-
tiferon positivity, infiltration and conglomerated lymph-nodes resistant to ther-
apy. Clinical and radiological improvement and reduction of IgE (289 mg/dl)
were seen in second months of therapy. Conclusion: This case was presented
due to rare presentation TB with high Ig E levels with almost complete improve-
ment.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A61
P128
EVALUATION OF EOSINOPHILIA: HYPEREOSINOPHILIC SYN-
DROME.
G. Rosner*1, D.W. Rosenthal2, 1. New York, NY; 2. Great Neck, NY.
Background: Eosinophilia can have multiple etiologies including atopy,
parasitic infections and Churg-Strauss. Hypereosinophilic syndrome(HES) can
be initiated by myeloproliferative and lymphocytic causes. Case Report: A 16
year old male was admitted for a 2-week history of new onset chest pain and
shortness of breath. Four months prior to admission(PTA), the patient presented
with transaminitis and peripheral eosinophilia to another academic medical
center, where corticosteroids were tapered over 2 months. Two weeks PTA, the
patient developed intermittent, severe, mid-sternal chest pain, shortness of
breath, a racing heart, blurred vision, and dizziness, which progressively wors-
ened as he developed bilateral joint pain. Results: Upon admission the patient
had eosinophilia(3.9x109/L), ESR 38, IgE 130, LDH 375. Results from the
prior admission showed an ultrasound with hepatic inflammation, and a liver
biopsy with fibrosis, and rare portal and lobular eosinophils(Eos). Esophageal
biopsy revealed mild Eos infiltrates and bone marrow biopsy showed myeloid
hyperplasia with increased Eos. Cytogenetic studies for FIP1L1-PDGFRA were
negative. During this admission, transaminases, bilirubin, alkaline phosphatase,
cardiac enzymes, ANCA, tryptase, vitamin B12 and IL- 5 were all normal. CTA
chest and cardiac MRI were unremarkable. Chest X-ray showed bibasilar small
pleural effusions, spirometry showed restrictive lung disease, and bronchial
biopsy had mild Eos infiltrate. Infectious disease studies were unremarkable.
The patient was restarted on corticosteroids and Eos decreased(1.8x109/L). As
corticosteroids were tapered over weeks, chest pain recurred with associated
increased Eos, C-reactive protein and LDH, which resolved with increased cor-
ticosteroids. Discussion: Multiple etiologies of eosinophilia were considered
including infection, hematopoietic clonal eosinophilic proliferation, over-pro-
duction of eosinophilic cytokines, Churg-Strauss and others. Symptoms were
controlled with corticosteroids. The diagnosis of HES remains without a spe-
cific molecular or laboratory biomarker. Thus, it remains essential to diagnose
and treat HES when patients present with peripheral hypereosinophilia(>1.5x
109/L on 2 examinations separated in time by at least 1 month) with tissue
hypereosinophilia(20% eosinophils on bone marrow biopsy, or significant
eosinophilic tissue infiltration) and with organ damage or dysfunction.
P129
TERMINAL ILEUM PERFORATION IN A PATIENT WITH
HYPER IGE SYNDROME.
J. Jiao*, C.C. Horner, A.L. Kau, St Louis, MO.
Introduction: Autosomal dominant hyper IgE syndrome (HIES) is a com-
plex primary immunodeficiency disorder characterized by recurrent skin and
sinopulmonary infections, eczematoid dermatitis, and elevated serum IgE lev-
els. Disseminated infections by endemic dimorphic fungi have been reported
to affect patients with HIES. However, invasive histoplasmosis rendering a cat-
astrophic terminal ileum perforation has not been previously described. Case
Description: We present the case of a 21-year-old man with HIES who devel-
oped recurrent episodes of diffuse abdominal pain, low-grade fever, intermit-
tent emesis and unintentional weight loss. CT of the abdomen and pelvis on
admission revealed partial small bowel obstruction. Laboratory findings demon-
strated significantly elevated urine histoplasma antigen (15.82 ng/mL) and pos-
itive serum histoplasma antibody, implying a disseminated infection by H. cap-
sulatum. He responded well to fluid resuscitation, GI decompression, and
intravenous liposomal amphotericin B which was later transitioned to oral
itraconazole 200 mg twice a day after the acute episode resolved. While he
was maintained on itraconazole over the following year, the level of urine histo-
plasma antigen was assessed periodically. The level was trending down grad-
ually but still remained detectable, likely due to his noncompliance to the anti-
fungal therapy. The patient ultimately developed terminal ileum perforation
which was successfully treated with partial small bowel resection and primary
anastomosis. GMS staining of the resected small intestine revealed H. capsu-
latum within histiocytes. He recovered well after the surgery and continued
the antifungal therapy. Discussion: In HIES, STAT-3 mutations result in an aber-
rant TH17 cell response and impaired β-defensin production and neutrophil traf-
ficking. These defects likely account for the susceptibility to invasive fungal
infections. Ileocecal histoplasmosis may clinically mimic inflammatory bowel
disease. Thus clinicians should be vigilant for the development of histoplam-
osis in HIES patients. Timely diagnosis and adequate antifungal therapy are
crucial in preventing severe complications.
ABSTRACTS: POSTER SESSIONS
P130
FIRST REPORTED CASE OF ANAPHYLAXIS INDUCED BY
POGONOMYRMEX SPP BITE IN MEXICO.
J. Fernandez de Cordova Aguirre*, A. Velasco-Medina, M.E. Arroyo-Cruz,
S. Gonzalez Flores, D. Cariño-Cartagena, G. Velazquez-Samano,
Mexico City, DF, Mexico.
Stings and bites are a common cause of allergic reactions. We report a case
of anaphylaxis by Pogonomyrmex ant bite. It was diagnosed by clinical fea-
tures and confirmed with skin tests. Currently in treatment with specific
immunotherapy. Case Report: Fifty-six years old male. A year ago, while work-
ing in the garden home, he is bitten by an ant on his right hand presenting ery-
thematous, pruritic confluent hives, swelling of eyelids, face and hands with-
out cough or respiratory distress. He improved with oral antihistamines. Six
months ago he suffers again an ant bite and besides the previous symptoms, he
has nasal obstruction, rhinorrhea, fatigue. He received treatment with intra-
muscular antihistamine and steroids. A month ago, he is bitten a third time by
an ant. He presented confluent pruritic erythematous rash, eyelids, mouth and
hands edema, cough and dyspnea, within minutes he had loss of conscious-
ness. He treated with oxygen, 0.5 ml intramuscular epinephrine, intravenous
steroids and intramuscular antihistamines, intravenous fluids and improves
gradually until he is discharged. Complementary studies show 7100 leukocytes
with 59% neutrophils (4200), 30% lymphocytes (2200), 2.3% eosinophils (200),
0.4% basophils (4), blood chemistry, renal function tests and liver function tests
are normal, nasal cytology with eosinophils, serum total IgE 1220 IU / ml. Skin
tests were performed with the criteria AAAIC at a dilution of 1: 10,000 with a
positive result for Pogonomyrmex harvester ants. Nonpharmacological therapy
(information, “allergic to ant” bracelets and emergency actions) and pharma-
cological (epinephrine, steroids, antihistamines, and albuterol) was initiated.
Immunotherapy starting at 1:1,000,000 dilution was indicated. He is currently
asymptomatic and in a dose escalating immunotherapy protocol. Discussion:
We show allergic reaction to Pogonomyrmex spp ant with positive intradermal
skin test. Immunotherapy is safe so far. Although it is still not established the
positive predictive value of a skin test, the combination of symptoms and skin
test reaction indicated an IgE-mediated reaction. Pogonomyrmex allergy could
be deadly. The immunological mechanism of anaphylaxis in this patient is
caused by a type I hypersensitivity reaction.
P131
THE DIAGNOSIS IS IN THE HISTORY: A CASE OF DRESS IN A
PEDIATRIC PATIENT.
B.J. Buelow*1, H.T. Zafra2, 1. Menomonee Falls, WI; 2. Milwaukee, WI.
Background: Drug reaction with eosinophilia and systemic symptoms
(DRESS) is a rare, possibly life-threatening drug reaction typically consisting
of recent exposure to a high-risk medication (initiation weeks to months prior
to symptoms) accompanied by skin eruption, systemic symptoms (fever, lym-
phadenopathy, hematologic abnormalities like eosinophilia) and end-organ
involvement. Failure to recognize this disease, especially with a history of expo-
sure to a high-risk medication, may lead to significant morbidity and mortal-
ity while removal of the offending agent can be lifesaving. Case: A 9 year-old
African American male with a history of cerebral palsy, epilepsy, and GERD
presented with a diffuse erythematous rash along with fever, cough and pro-
gressive dyspnea. His medications included phenobarbital and valproic acid
started two weeks prior to presentation with long-term use of omeprazole. Fam-
ily and social history were unremarkable. Initial physical exam was signifi-
cant for a diffuse maculopapular rash without mucosal involvement and coarse
breath sounds. His chest x-ray demonstrated patchy airspace opacities bilater-
ally. He was admitted to the hospital with continuation of his home medica-
tions and initiation of ampicillin for possible pneumonia. He clinically wors-
ened. He required CPAP for respiratory support. He developed facial edema,
eosinophilia (max AEC of 1560) and a transaminitis. His renal function
remained normal. Differential diagnosis included drug reaction such as DRESS,
infection or hypereosinophilic syndrome. His phenobarbital and valproic acid
were discontinued four and six days later, respectively. He concomitantly
received high-dose corticosteroids. His clinical status and laboratory findings
returned to baseline with a slow corticosteroid taper over the next eight weeks.
Conclusion: A history of high-risk medication use as well as clinical manifes-
tations of skin eruption with systemic symptoms and end-organ involvement
should prompt the possible diagnosis of DRESS. The most effective treatment
is to remove the offending agent along with supportive treatment. The use of
systemic corticosteroids is typically implored in patients with severe end-organ
involvement. Laboratory abnormalities should be monitored closely until nor-
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ABSTRACTS: POSTER SESSIONS

malized. Importantly, the allergist should be familiar with and serve as a knowl- cause and effect is not definitive, the patient had not previously responded to
edgeable resource for the diagnosis and treatment of DRESS. five days of aggressive conventional therapies. Review of the literature indi-
cates that this may be the first successful treatment of severe acute urticaria
with omalizumab. The cause of this patient’s outbreak remains unclear, but
P132 might be associated with chemicals used in the furniture, as indicated by other
CRYPTOCOCCUS MENINGITIS AS THE FIRST MANIFESTA- reports in the literature.
TION OF IDIOPATHIC CD4 LYMPHOCYTOPENIA.
J. Brooks*1, G. Ghaffari2, 1. Lititz, PA; 2. Hershey, PA.
Introduction: Idiopathic CD4 lymphocytopenia (ICL) is a rare disorder of
P134
A RARE CASE OF ACUTE COMPARTMENT SYNDROME SEC-
unknown etiology. Diagnostic criteria include a persistent CD4 T cell lym-
ONDARY TO INSECT BITE.
phopenia with no underlying primary or secondary immunodeficiencies, with
a CD4 T cell count < 300 cell/mL or a CD4 T cell count < 20% total lympho- F. Farri*1, T. Akande2, S. Baghian2, Y.K. Persaud2, 1. Ossining, NY; 2. Bronx,
cytes on multiple occasions. Case Report: 52 year old Caucasian female, with NY.
history of SLE controlled on plaquinil, presented with a 2 month history of Introduction: Acute compartment syndrome (ACS) is a surgical emergency,
headaches associated with confusion, dizziness, nausea/vomiting, and right eye mostly seen as a rare but severe complication of trauma; however there are non-
pain. Upon admission, an MRI revealed leptomeningeal enhancement. Cryp- traumatic causes. ACS secondary to insect bite is very rare; to our knowledge,
tococcus neoformans grew on CSF culture. Amphotericin B and flucytosine there is only one previously reported case of ACS due to a mosquito bite. Case
were initiated. An absolute CD4 count was 86 (normal (N): >500). HIV test- Report: A 21-month old female with past medical history of recurrent insect
ing with PCR, HSV, hepatitis panel, PPD, HTLV, and histoplasmosis and blas- bites presented with extensive swelling of the hand and forearm. She had a
tomycosis antigen tests were all negative. Immunology consult was obtained. small pruritic bump on dorsum of the left hand from a witnessed flying insect
B cell lymphocytes, NK cells, immunoglobulin levels, mitogen proliferation bite a few days prior. Subsequently, she developed decreased movement of the
studies, CH50 and C2 were normal. Antibody titers for diphtheria, tetanus, left wrist and tenderness with passive extension of the digits. There was no
and streptococcus pneumonia revealed protective levels. Based on the presen- improvement of the swelling with topical antibiotic ointment and oral antihis-
tation, lab findings, and no identifiable cause for low CD4 count, the patient tamine. X-rays of the wrist and forearm showed soft tissue swelling, but was
was diagnosed with ICL. She was discharged on amphotericin and flucytosine negative for fractures and or dislocations. A diagnosis of Acute Comparte-
and prophylactic treatment with trimethoprim/sulfamethoxazole was initiated. ment Syndrome was made and immediate surgical intervention was undertaken.
The patient was medication compliant and asymptomatic at her 2 week fol- Intra-operative findings showed maximally elevated pressures (45mmHg) in
low-up visit. The repeat labs revealed an absolute CD4 and CD8 count of 37 the adductor-pollicis compartment of the left upper limb. Surgical decom-
and 91 (N: >200), and a CD4/CD8 ratio of 0.41. Discussion: Patients with ICL pression of the affected area was performed with subsequent resolution of the
are usually identified when the CD4 count is less than 200 and complications pain and swelling. Diagnostic evaluation showed normal white blood cell counts
develop. Opportunistic infections are the most common initial manifestations. with differential, complement levels, total tryptase levels, total serum IgE, and
Patients also present with autoimmune conditions or malignancies. The inci- IgE to mosquito and house fly. Blood and wound cultures showed no growth
dence of asymptomatic patients with ICL is unknown. Currently, there are no during both episodes, she did however have significantly elevated serum his-
specific treatment guidelines. Therapies used to increase CD4 levels, IL-2, tamine levels Discussion: Most reaction’s to insect bites are non-allergic man-
interferon-gamma, and IL-7 or allogeneic hematopoietic stem cell transplan- ifestations of the venom’s toxic effect, and present as erythema, pain and
tation, have variable results. In children, immunoglobulin replacement is con- swelling. Insect bite hypersensitivity, may be mediated by immunologic mech-
sidered. Prophylactic treatments for opportunistic infections based on the CD4 anisms (IgE-mediated or non-IgE-mediated venom allergy) but also by non-
cell count should be considered. Conclusion: ICL is a diagnosis of exclusion immunologic mechanisms. An important question in the clinical management
when there is no identifiable underlying cause for a low CD4 count. A thor- of the patient was: did an infectious process (i.e. cellulitis) contribute to the ini-
ough immune system evaluation is necessary when contemplating this diag- tial clinical presentation of ACS? The absence of fever, the short duration from
nosis. time of bite to presentation, the absence of differential warmth, the normal
white cell count as well as negative blood and wound cultures made a bacter-
ial super-infection unlikely. The patient was placed on daily antihistamines and
P133 the parents were instructed to be vigilant in accessing immediate medical care
SUCCESSFUL TREATMENT OF ACUTE URTICARIA WITH during each subsequent reaction.
OMALIZUMAB.
K. Patel*, R. Ten-Boquera, K. Gundling, San Francisco, CA.
Introduction: Omalizumab is a monoclonal antibody that binds free IgE
and is used in treatment of allergic asthma and chronic idiopathic urticaria. We
report the first case of acute urticaria refractory to maximal conventional ther-
apy that responded to omalizumab therapy. Methods: A case report and review
of the literature. Data: A previously healthy 36 year old woman presented with
an acute episode of facial edema and full body hives 24 hours after receiving
new furniture in her home. She presented to the ED where she received epi-
nephrine, solumedrol, diphenhydramine and ranitidine; she was discharged
home after symptomatic improvement. The following day she had recurrent
symptoms; she was treated similarly as her prior episode with overall improve-
ment. She was discharged home on prednisone and loratadine. The next day
she again had similar symptoms and was admitted for management. During the
next 3 days of her admission, she received the following daily medications: 150
to 200 mg of diphenhydramine, 60mg prednisone, 150mg ranitidine, 25 to 50
mg hydroxyzine, 10 to 40 mg cetirizine, and 10 to 20 mg of montelukast. Despite
this maximal therapy, she continued to have full body urticaria with facial and
pedal edema. A skin biopsy confirmed acute urticaria. Due to ongoing severe
symptoms, she was given omalizumab (300mg), and within 24 hours had rapid
resolution of disease. A large panel of laboratory studies was negative, except
for elevated levels of plasma histamine (3.6 ng/mL) and total tryptase (12
ng/mL), supporting mast cell mediator release. To further evaluate the furni-
ture as a possible cause, fabric was ground with sterile water; the skin prick
test was negative. Patch testing was also negative. Her medications were tapered
over a month, and she continued to be symptom free at her 3 month follow up
off of all medications. Conclusion: A trial of omalizumab for severe, refrac-
tory acute urticaria was associated with rapid resolution of disease. Although

A62 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

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P135
A YOUNG IMMUNOCOMPETENT FEMALE WITH ASTHMA
AND ALLERGIC RHINITIS FOUND TO HAVE RARE FUNGAL
RHINOSINUSITIS WITH SKULL EROSION, SCHIZOPHYLLUM
RADIATUM.
R. Gupta*1, M. Segal2, 1. Vernon Hills, IL; 2. Philadelphia, PA.
Rationale: Fungal sinusitis is generally limited to immunocompromised
hosts including those with hematological malignancies, diabetes, and chronic
steroid use. The most responsible culprits include Aspergillus, Fusarium, Muco-
rales, and dermatiaceous molds. Here we present a young female found to have
a rare fungal species causing maxillary sinusitis requiring long term fungal
treatment. Methods: Computed Tomography of Sinuses, Magnetic Resonance
Imaging of Head, and sinus biopsies with gram stain and culture. Results: Our
patient has a longstanding history of allergic rhinitis and asthma with 3-4 hos-
pital visits a year never requiring intubation. She presented with complaints
of severe sinus symptoms and subsequently had a CT scan demonstrating
sinusitis with bony erosion at the base of the skull. Endoscopic surgery and
maxillary sinus biopsies revealed fungal species of Schizophyllum radiatum.
Itraconazole treatment was started with frequent monitoring of QT-interval
and drug levels, with microbiology confirming adequate susceptibility of treat-
ment. Clinically her sinusitis continued to improve. She remained on Itra-
conazole for 6 months, with total resolution of symptoms. Conclusion: We
believe this patient’s case demonstrates two facets of rarity. One, our patient
does not fit the typical demographic of those who acquire fungal sinusitis.
Second, Schizophyllum radiatum is an unfamiliar species to cause infection
and bony destruction. This case provides insight into evaluation of patients
deemed minimal risk for fungal sinusitis and the rare although morbid com-
plications of fungal sinusitis.
P136
TREATMENT OF GRANULOMATOUS-LYMPHOCYTIC INTER-
STITIAL LUNG DISEASE (GLILD) IN CVID WITH RITUXIMAB
AND MYCOPHENOLATE.
J.M. Lomas*, M. Mortezavi, R.J. Looney, Rochester, NY.
Introduction: Granulomatous-lymphocytic interstitial lung disease (GLILD)
is a non-infectious pulmonary complication of common variable immune defi-
ciency (CVID) that can have a profound impact on the quality of life and sur-
vival of affected patients. Combination chemotherapy with rituximab and aza-
thioprine has been previously shown to improve pulmonary function and
imaging in this subgroup ofthese patients. We describe a case of CVID with
GLILD treated with rituximab and oral mycophenolate mofetil that had a sim-
ilar positive outcome. Case Description: A 37 year-old female with history of
idiopathic thrombocytopenic purpura (ITP), initially presented to our clinic for
evaluation of a chronic cough and shortness of breath. Pulmonary function test-
ing showed a restrictive pattern, without evidence of obstruction or reversibil-
ity. Laboratory results were remarkable for profound hypogammaglobulinemia
(IgG 75, IgA < 5, IgM 13) with normal numbers of T and B cells on flow cytom-
etry. Computed tomography (CT) of the chest showed extensive interstitial dis-
ease, including innumerable bilateral pulmonary nodules, as well as multiple
enlarged mediastinal lymph nodes and splenomegaly. She was started on
monthly intravenous immunoglobulin (IVIG) therapy and underwent wedge
biopsy of the lung for diagnostic purposes. Pathology reported follicular bron-
chiolitis, lymphocytic interstitial pneumonia, and non-necrotizing granuloma-
tous inflammation as well as areas with fibrin deposition and organizing pneu-
monia. She was treated with 2 doses of rituximab (2g) two weeks apart and
1000mg of oral mycophenolate mofetil twice daily. The therapy was well tol-
erated. Six months following initiation of therapy, repeat imaging showed near
resolution of pulmonary nodules with significant improvement in mediastinal
lymphadenopathy and ground-glass opacities. Pulmonary function had returned
to normal and the patient’s cough and shortness of breath had resolved. Con-
clusions: Multiple authors have previously documented that monotherapy for
treatment of GLILD in CVID is not effective. Combination chemotherapy using
rituximab and azathioprine has previously been shown to be effective. This is
the first case describing case describing successful treatment of GLILD with
a combination of rituximab and mycophenolate mofetil.
ABSTRACTS: POSTER SESSIONS
P137
MASTOCYTIC ENTEROCOLITIS: CHRONIC INTRACTABLE
DIARRHEA, ABDOMINAL PAIN, WITH INCREASED MUCOSAL
MAST CELLS.
A.C. Netterville*, A. Ochoa, New Orleans, LA.
Introduction: Mastocytic enterocolitis is a proposed term for cases of diar-
rhea-predominant irritable bowel syndrome (IBS) with elevated numbers of
mucosal mast cells. GI mast cells excess is defined as the presence of greater
than 20 mast cells per high-power field of microscopy in the GI tract mucosa.
Presentation is chronic intractable diarrhea, often associated with abdominal
pain with unremarkable colonic or duodenal biopsy specimens on routine hema-
toxylin-eosin staining, but increased numbers of mast cells on immunohisto-
chemistry for mast cell tryptase. Case Description: This is a 6 year old male
who initially presented at 23 months with chronic diarrhea and abdominal pain.
He was evaluated by GI with an upper and lower endoscopy, and was found on
immunohistochemical stains for CD117 to have greater than 20 mast cells per
high power field. Elevated numbers were found throughout the colon and rec-
tum. He had extensive additional evaluation which revealed normal total
immunoglobulins, IgG subclasses, tryptase, C1 esterase inhibitor level and
function, and complete blood count. He also had negative immunocaps to all
foods and inhalant allergens tested. He was initially treated with hydroxyzine
and singulair with little improvement. He was later started on gastrocrom four
times a day, and at that time demonstrated significant improvement, with near
resolution of his symptoms of diarrhea and abdominal pain. Upon evaluation
by us we recommended adding an H2 receptor antagonist. Conclusion: Mast
cells play an important role in the regulation of GI visceral sensitivity and vas-
cular permeability. Increased numbers of GI mucosal mast cells has been doc-
umented in several studies in patients with irritable bowel syndrome, masto-
cytic enterocolitis, systemic mastocytosis, mast cell activation syndrome, and
allergic mastocytic gastroenteritis and colitis. Patients with chronic unexplained
diarrhea should undergo colonoscopic biopsies with special mast-cell stains.
If elevated mast cells are demonstrated on biopsies patients should be treated
with H1 and H2 receptor antagonist and also a mast cell stabilizing agent. In
more severe cases it has been proposed to add an antileukotriene or a 5-lipoxy-
genase inhibitor.
P138
COW’S MILK PROTEIN ALLERGY PRESENTING WITH
HYPEREOSINOPHILIA AND ELEVATED BRAIN NATRIURETIC
PEPTIDE.
C. Parrish*, A.K. Wong, S. Thobani, M. Li, L. Scott, Los Angeles, CA.
Introduction: Cow’s milk protein allergy is common in infancy. About half
of all cases are non-IgE-mediated, and allergic proctocolitis with bloody stools
is considered the most benign form. Methods: Case Report. Results: A 4-month-
old Hispanic female presented with complex febrile seizure and was inciden-
tally noted to have grossly bloody stools. After a full-term delivery, she had
been treated with prophylactic antibiotics due to maternal chorioamnionitis.
During the NICU stay she was breastfed with cow’s milk formula supplemen-
tation, and had intermittent heme-positive stools. Grossly bloody stools first
occurred at 1 month of age, after which the mother eliminated cow’s milk for-
mula and began to exclusively breastfeed. Over the subsequent months, the
patient had multiple episodes of grossly bloody stools after maternal dairy
ingestion, but was otherwise thriving. Serum IgE to milk protein was negative.
Review of laboratory studies showed peripheral eosinophilia (1.9k/mm3) 4 days
after birth and at time of presentation (3.3k/ mm3). Stool examination for ova
and parasites as well as serum testing for Strongyloides and Toxocara were neg-
ative. Given severe eosinophilia over a 4-month period beginning shortly after
birth, screening was done for target organ damage. Urinalysis and liver tests
were normal, but Brain Natriuretic Peptide (BNP) was elevated at 626 pg/mL,
(no cardiac symptoms and echocardiogram normal). All dairy products were
eliminated from the maternal diet, with subsequent resolution of eosinophilia
(absolute eosinophils 100/ mm3) and significant decrease in BNP (211 pg/mL).
Conclusions: Milk protein allergy presenting with bloody stools is common
and generally considered benign. The diagnosis is based upon clinical presen-
tation and resolution of symptoms upon withdrawal of the presumed food anti-
gen, and therefore labs are not routinely checked. However, this case illus-
trates that even intermittent exposure to cow’s milk protein over several months
may lead to persistent eosinophilia, which in other conditions has been shown
to cause target organ damage. Elevated BNP levels have not previously been
reported in hypereosinophilia. This case suggests that BNP may be a sensitive
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A64
ABSTRACTS: POSTER SESSIONS
early marker for eosinophilic myocardial insult, although further studies would
be needed to support this hypothesis.
P139
RASH ASSOCIATED WITH ANGIOIMMUNOBLASTIC T-CELL
LYMPHOMA MISTAKEN FOR DRESS.
A.K. Wong*, C. Parrish, S. Thobani, M. Li, L. Scott, Los Angeles, CA.
Introduction: Angioimmunoblastic T-cell Lymphoma (AITL) is a periph-
eral T-cell lymphoma which presents with non-specific systemic illness includ-
ing lymphadenopathy, hepatosplenomegaly, B-symptoms, rash, and/or ane-
mia. Rash is present in 20-60% of patients, and they are usually pruritic with
lymphohistiocytic vasculitis seen on biopsy. Methods: Case Report Results: A
64 year-old Hispanic male with no prior medical history presented to an out-
side clinic with a 2-week history of generalized, erythematous, papular, non-
blanching, pruritic rash over his trunk and extremities. After a 5-day steroid
burst, the rash did not improve. 2 weeks later, he presented for evaluation. He
was noted to have lymphadenopathy. Lymph node and bone marrow biopsies
yielded a diagnosis of AITL. He received 1 round of chemotherapy with com-
plete resolution of his rash. He was well for 2 weeks until he presented to the
emergency room with fever of 101.3°F and neutropenia of 700/mm3. Cefepime
and vancomycin were started on admission, and 2 days later he developed gen-
eralized facial swelling with a maculopapular erythematous rash over his trunk
and extremities. The patient developed a fever of 101.8°F around the time of
rash onset, and on physical exam, he was noted to have axillary and inguinal
lymphadenopathy. Review of laboratory studies showed peripheral eosinophilia
which increased from 0/mm3 on admission to 1100/mm3 on hospital day 7.
Allergy and Immunology was consulted to evaluate for drug reaction with
eosinophilia and systemic symptoms (DRESS). Conclusions: Allergists/Immu-
nologists are commonly consulted for rashes, especially in relation to drug hyper-
sensitivities. While DRESS is a potentially life-threatening adverse reaction to
medications, the onset of DRESS is typically 2-8 weeks after initial exposure
to the offending medication. The time course of this patient’s rash was not con-
sistent with DRESS. This case illustrates the importance of maintaining a broad
differential diagnosis including infection or malignancy in the evaluation of a
patient with rash of unknown origin. Generalized non-specific rash is a com-
mon presenting feature of AITL, and in this particular patient, his DRESS-like
symptoms of fever, lymphadenopathy, and eosinophilia and systemic symptoms
were explained by his underlying malignancy. His rash and DRESS-like symp-
toms improved after starting his second round of chemotherapy.
P140
DYSHIDROTIC ECZEMA INDUCED BY GAMUNEX INTRA-
VENOUS IMMUNOGLOBULIN THAT RESOLVED WITH GAM-
MAGARD IN A PATIENT WITH MYASTHENIA GRAVIS.
M. Shtessel*, D. Ferastraoaru, J. Graber, G. Hudes, Bronx, NY.
Rationale: Dyshidrotic eczema is a known rare side effect of intravenous
immunoglobulin (IVIG) therapy in patients who are most commonly treated
for neurologic diseases. Its pathophysiology is not clear. Eczematous eruption
has never been reported in patients treated with IVIG for immunodeficiency
states, highlighting the role of high doses of IVIG in this peculiar side effect.
The skin changes usually respond well to topical steroids and some patients
may improve with continuation of the IVIG. Methods: Review of the literature
and case report of a patient in which the use of Gamunex resulted in appro-
priate myasthenia gravis control but intolerable dyshidrotic eczema, which
resolved when the formulation was switched to the Gammagard liquid form.
Results: 37 year-old female with history of myasthenia gravis was started on
Gamunex 2g/kg over 3 days, every six weeks. After the first infusion she devel-
oped dryness and scaling lesions over hands, scalp and chest which were diag-
nosed as dyshidrotic eczema. Patient did not have a history of eczema prior to
receiving Gamunex. She was started on topical corticosteroids without much
improvement in her skin lesions. Patch testing with common contact allergens
and Gamunex was negative at 48 and 96 hours. Drug reaction was suspected
and the patient’s formulation of IVIG was switched from Gamunex to Gam-
magard 2g/kg over 3 days every 6 weeks. The skin changes remitted with the
new product, but she developed 2 flairs of myasthenia gravis. The decision
was made to switch back to Gamunex. Unfortunately, the patient’s eczema reoc-
curred but her treatment with Gamunex was continued for optimum myasthe-
nia gravis control. Conclusions: This is the first reported case of dyshidrotic
eczema in a patient receiving Gamunex IVIG that did not improve with topi-
cal steroids but resolved after switching to an alternative formulation. It is
unclear why the eczema improved with Gammagard. Both formulations use
A64 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
glycine and have similar osmolarity and content. Gamunex uses bromobutyl
rubber stoppers in their vials while Gammagard liquid utilizes halobutyl or
chlorobutyl rubber stoppers. Currently no comparative data exist describing
the side effect profile in terms of appearance of dyshidrotic eczema among dif-
ferent IVIG formulations.
P141
LöFFLER SYNDROME IN AN EIGHT-YEAR-OLD PIG FARMER.
H. Shah*1, K. Gipson2, L. Wall2, 1. Yorba Linda, CA; 2. New Orleans, LA.
Löffler syndrome is a hypersensitivity response to parasite larval migration
through the lungs, and is rare in the modern United States. It is classically attrib-
uted to Ascariasis, but can occur with other parasites. A previously healthy 8-
year-old male was hospitalized with tachypnea, cough, and fever of one week’s
duration. History revealed exposure to pigs on his family’s farm in southern-
most Louisiana, no travel, no asthma or atopy, and normal review of systems.
He was hypoxemic and imaging revealed diffuse reticulonodular lung opaci-
ties. He demonstrated leukocytosis, peripheral eosinophilia (39%), and high
serum IgE (3,480 IU/mL). Given his acute respiratory failure, systemic corti-
costeroids were initiated. He was treated empirically for atypical pneumonia
while undergoing diagnostic evaluation. Despite increasing serum IgE levels
(peaking at 12,700 IU/mL), he demonstrated rapid clinical improvement and
was weaned off of supplemental oxygen. Pulmonary function testing demon-
strated a mixed obstructive and restrictive pattern. Broncho-alveolar lavage
fluid showed profound pulmonary eosinophilia (86%). Subsequent evaluation
of his eosinophilia revealed highly elevated serology to both Ascaris and Tox-
ocara, which was treated with albendazole. Strongyloides serology was nega-
tive, as was an extensive evaluation for other infectious and allergic etiologies.
This case demonstrates that Löffler syndrome may be severe, yet elusive. It
may present with pulmonary involvement and fever without the involvement
of other organs expected from larval migration, requiring a high degree of sus-
picion to make the diagnosis. One should consider it even in the absence of
travel history, especially in endemic areas for Ascaris such as southeastern
United States. Strikingly elevated eosinophils in the lung washings should
prompt evaluation for parasites. Other aspects unique to our patient include liv-
ing in close association with pigs and being seropositive to both Ascaris and
Toxocara. Moreover, Ascaris suum is known to infect pigs and has rarely been
reported with visceral larva migrans in humans. Systemic corticosteroids were
effective in treating the patient’s respiratory compromise, despite concern for
dissemination of the parasite when host immunity is suppressed.
P142
AN ATYPICAL PRESENTATION OF GIANT CELL ARTERITIS.
J.R. Zaragoza*, N. Vernon, G. Ghaffari, Hershey, PA.
Giant cell arteritis (GCA) is a chronic vasculitis of large and medium cal-
iber blood vessels, mostly affecting individuals in the fifth decade of their life.
It is caused by arterial wall inflammation that leads to the clinical manifesta-
tions of vasculitis and tissue ischemia such as jaw claudication, temporal
headache and visual loss. Although it may be generalized, vessel inflamma-
tion most prominently involves the cranial branches of the arteries originating
from the aortic arch. We present an uncommon manifestation of GCA in a
patient with tongue swelling. Case Report: A previously healthy 68-year-old
female was presenting submandibular swelling a month prior to evaluation. She
was treated with antibiotics and intermittent doses of steroids for suspected
sialadenitis. Despite therapy, the patient presented increased swelling of the
tongue and pain with minimal headache, but had no blurred vision or jaw clau-
dication. She was admitted to the hospital where a lingual biopsy revealed no
amyloidosis or malignancies. Upon further testing, hereditary angioedema
screening was negative but she still had elevated C-reactive Peptide (1.3 mg/dL).
A trial of icatibant was administered for suspected bradykinin-induced
angioedema. With no improvement of the symptoms, the patient was trans-
ferred to our institution for further evaluation. A biopsy of the temporal arter-
ies revealed GCA and treatment was initiated with high-dose corticosteroids.
Unfortunately, the necrosis of the tongue led to its eventual self-amputation.
Conclusion: Lingual swelling and necrosis are extremely rare complications
in GCA. That atypical presentation may mimic an angioedema episode when
classic symptoms of GCA are subtle. This case reinforces the importance of
suspecting GCA upon evaluating elderly individuals that present lingual swelling
as to avoid a delay in diagnosis and treatment. We conducted a literature search
review using Ovid. A search using the keywords “Giant Cell Arteritis and tongue
necrosis” resulted in 43 published cases dating back to 1967. All cases were
almost identical in clinical presentation to our case with the exception of some
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A65
subtle differences. Six of the published GCA and lingual necrosis cases were
triggered by ergotamine use. Also, the severity and extent of necrosis varied
among cases, ranging from unilateral partial lingual necrosis to extensive necro-
sis of the tongue, scalp or bilateral vision loss.
P143
ADULT FEMALE WITH SERUM SICKNESS SECONDARY TO
MUPIROCIN.
A. Asawa*1, R. Bonds2, 1. Sugar Land, TX; 2. Galveston, TX.
Introduction: Serum sickness is a type III hypersensitivity reaction caused
by antigen-antibody complexes and presents with fever, urticaria, poly-arthral-
gia/poly-arthritis, and/or acute glomerulonephritis. In this type of reaction an
antigen binds to antigen specific IgG forming immune complexes. These then
bind to IgG receptors on inflammatory cells and activate complement causing
an inflammatory reaction. Methods: We report the case of a 44 year old female
referred to Allergy/Immunology clinic for hives and arthralgias. Patient first
noted symptoms 4 years ago after she was treated with trimethoprim-sul-
famethoxazole and mupirocin for cellulitis of her right foot. Two weeks later
she noted diffuse erythematous, well defined, burning, circular skin lesions that
blanched. She also had swelling and increased warmth in both knees and arthral-
gias in her knees, neck, elbows, and hands. Numerous antihistamines were tried,
but not helpful. The symptoms gradually resolved in a few months. She was
asymptomatic for four years. In April 2014 she treated blisters at the base of
her right foot with mupirocin. One day later she noted a return of her diffuse
urticaria, arthralgias, and fever. She was treated with a corticosteroid injection
which did not alleviate her symptoms. Subsequently, she was started on
cyclosporine which has provided her with moderate relief of symptoms. Dis-
cussion: The patient’s history of repeat episodes of arthralgias, fever, urticar-
ial rash triggered by a medication raises concern for serum sickness versus drug
induced lupus. Laboratory evaluation revealed normal levels of C3 (123 mg/dl;
reference range 86-184 mg/dl) and C4 (26.5 mg/dl reference range 20.0-59.0
mg/dl), elevated C1Q binding (4.7 ugE/mL; reference range 0.0 –3.9 ugE/mL),
and ESR (45 mm/hr; reference rage 0-20 mm/hr) suggesting evidence of cir-
culating immune complexes supporting the diagnosis of serum sickness over
drug induced lupus. In our literature search, we did not identify any previous
reports of mupirocin causing serum sickness. Conclusion: We report a 44 year
old female old presenting with elevated C1Q binding and ESR along with recur-
rent fevers, arthralgias, and urticarial rash most likely secondary to serum sick-
ness induced by mupirocin.
P144
WHEN WHEEZE IS MORE THAN ASTHMA: A CASE REPORT.
M. Gupta*, S.P. DaVeiga, Philadelphia, PA.
Introduction: Bronchiectasis can occur in children due to cystic fibrosis,
primary ciliary dyskinesia, infections, immunodeficiency, and anatomic eti-
ologies. Primary symptoms include productive cough, chest pain, dyspnea, and
fatigue. High-resolution computed tomography (HRCT) is the diagnostic imag-
ing modality of choice. Management involves treatment of the underlying dis-
ease process, mucociliary clearance, and treatment of infections. Untreated,
ABSTRACTS: POSTER SESSIONS
bronchiectasis causes worsening inflammation, airway obstruction, morbidity
and mortality. Methods: We review a case of an adolescent female who pre-
sented with uncontrolled asthma and seasonal allergies to the Allergy/Immunol-
ogy Division. Results: A 17 year old female presented with “uncontrolled
asthma” and seasonal allergies. She had transient tachypnea of the newborn
and RSV bronchiolitis at 2 months of age. At 1 year of age, she had her first
episode of pneumonia. She then had pneumonia about once a year, requiring
antibiotics. She had required high dose inhaled steroids and frequent oral steroid
courses for asthma. She reported wheezing when recumbent and a feeling of
fullness in her left lung with inability to sleep on her left side. Her examina-
tion was significant for crackles and inspiratory wheeze with dullness to per-
cussion at the left lung base. Spirometry demonstrated reversible airway obstruc-
tion. Skin prick tests were positive to pollens. Sweat test was negative and
immunologic evaluation demonstrated increase in antibody levels to pneumo-
coccus following booster vaccination. Chest CT scan showed bronchiectasis
in the left lower lobe. Bronchoscopy demonstrated narrowing of the orifice of
the left lower lobe due to collapsibility of the posterior wall of the bronchus
and thick, white secretions within the left lower lobe. Biopsy of the bronchus
demonstrated chronic inflammation with ciliary disorientation. She was diag-
nosed with impaired mucociliary clearance and retained secretions due to left
lower lobe bronchomalacia. She started an airway clearance regimen with sig-
nificant clinical improvement and capacity to wean asthma therapy. Conclu-
sion: In an asthmatic with wheezing, chronic cough, sputum production and
focal findings on examination, bronchiectasis should be considered. Missed
diagnosis, can create undue burden of disease and significant sequelae from
excess asthma therapy.
Chest CT: Airway dilatation in the left lower lobe
P145
UNUSUAL CASE OF ACQUIRED ANGIOEDEMA PRESENTING
INITIALLY AS HEREDITARY ANGIOEDEMA.
M. Joseph*, Saginaw, MI.
51 year-old female suffered from recurrent lip, tongue and laryngeal
angioedema for almost 2 years and she required two tracheostomies. Her daugh-
ter had a history of lip swelling. Laboratory reports: C4 undetectable, C1 esterase
low, C1 esterase function was 40% and C1q normal. She was diagnosed with
HAE. Danazol was started. Because of persistent cramping abdominal pain,
and because she was going to start danazol, a CT of the abdomen was obtained;
it showed mild splenomegaly. She was then evaluated by the oncologist who
entertained the possibility of hereditary versus acquired angioedema (AAE).
A bone marrow biopsy revealed the presence of a small CD5 negative, CD10
negative, CD19 & CD 20 positive Lambda restricted B-cell population. The
pathologist felt that the presence of a small abnormal monoclonal B-cell pop-
ulation was suspicious but not definitive for the diagnosis of lymphomatous
involvement of the bone marrow. Given the non-definitive bone marrow diag-
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ABSTRACTS: POSTER SESSIONS
nosis, the oncologist and the patient decided to observe with close follow up.
Despite danazol, she suffered from continued life threatening attacks of
angioedema. Two months later, C1 Esterase Inhibitor (Cinryze) infusion ther-
apy was started in an attempt to prevent episodes of angioedema. By this time,
her spleen was found be palpably enlarged. Repeat complement studies showed
C1q to be low, in contrast to a normal C1q previously. After 2 months of Cin-
ryze therapy, the patient underwent a splenectomy for Non-Hodgkin’s lym-
phoma. During the period she received Cinryze, she did not have angioedema.
One month post splenectomy, Cinryze was stopped. She continued to be free
from episodes of angioedema. Four months later, C4 and C1q remained
depressed, but C1INH function recovered nicely. This patient had an initial
diagnosis of HAE. Later, the low C1q and palpably enlarged spleen prompted
a diagnosis of AAE secondary to non-Hodgkin’s lymphoma. This was an unusual
presentation with an initially normal C1q in this patient with AAE. Cinryze
therapy is not approved for use in acquired angioedema but was necessary in
this patient with life threatening episodes. Cinryze therapy prevented further
episodes of life-threatening angioedema until definitive therapy with a splenec-
tomy was performed. Our patient has been completely free of angioedema for
more than one year after splenectomy and discontinuation of cinryze therapy.
P146
OROFACIAL GRANULOMATOSIS IN A PATIENT WITH HERED-
ITARY ANGIOEDEMA.
S.P. Brady*1, H.J. Wedner2, 1. Clayton, MO; 2. St. Louis, MO.
Introduction: Orofacial granulomatosis (OFG) is a rare, disfiguring illness
of unknown etiology characterized by the development of non-caseating gran-
ulomas in the oral and maxillofacial area. OFG can manifest as Melkersson-
Rosenthal syndrome, which is a triad of persistent lip or facial swelling, recur-
rent facial paralysis and fissured tongue, or as cheilitis granulomatosa of
Miescher, which primarily affects the lips. Although OFG can be associated with
systemic diseases such as tuberculosis, Crohn’s disease and sarcoidosis, it has
not been reported with hereditary angioedema (HAE). Case: A 43-year-old
woman presented with complaints of recurrent swelling of the face, lips, uvula,
neck, tongue and limbs. The episodes occurred twice weekly and resolved over
2-4 days. High-dose antihistamines were not beneficial. Laboratory work-up
revealed normal C4 level and normal C1 inhibitor level and function. She was
diagnosed with HAE with normal C1 inhibitor level and successfully treated
with C1 inhibitor concentrate, ecallantide and icatibant. However, six months
after her initial presentation, the episodic lip swelling progressed to persistent
lip swelling despite resolution of other symptoms. Physical exam revealed dif-
fusely edematous upper and lower lips with mild overlying maceration. A lip
biopsy demonstrated diffuse, submucosal infiltrate of lymphocytes, histiocytes,
and multinucleated giant cells forming non-caseating granulomas, as well as
negative Congo red stain, Periodic Acid-Schiff stain, and Fite stain. These find-
ings were consistent with cheilitis granulomatosa. Oral and intravenous corti-
costeroids led to only mild temporary improvement, while dietary modifica-
tion and topical corticosteroids were ineffective. The patient is scheduled to
undergo intralesional corticosteroid injections. If these are unsuccessful, the
next management consideration would be topical and/or systemic immunosup-
pressants. Conclusion: Orofacial granulomatosis is rare illness that can signif-
icantly affect patients’ quality of life. Our case describes a unique presentation
of OFG in the setting of HAE. Delay in recognition and diagnosis can result in
permanent disfigurement and impairment in eating and drinking. Therefore, it
is imperative for clinicians to consider OFG in their differential diagnosis for
orofacial edema, and recognize that it can develop in the setting of HAE.
A66 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Figure 1: Persistent lip swelling.
P147
TREATMENT OF POST-TRANSPLANT ACUTE REJECTION
WITH SUBCUTANEOUS IMMUNOGLOBULIN REPLACEMENT.
Z. Pirani, MD*, J. Shih, MD, Atlanta, GA.
Introduction: Acute antibody mediated rejection (AMR) is characterized
by graft dysfunction manifesting over months or years. It is a result of donor
specific antibodies that usually develop de novo after transplantation. A diag-
nosis of AMR typically indicates an increased incidence of allograft dysfunc-
tion and mortality. IVIG has been cited in previous studies as being used suc-
cessfully to treat AMR in cardiac transplant patients. However, there are
currently no studies that investigate the use of SCIG in the management of acute
AMR, which has shown in this case to be a promising treatment. Case Descrip-
tion: Patient is a 68 year old female who is currently being treated for hypogam-
maglobulinemia (HGG) and acute rejection s/p cardiac transplant in 2008. Mul-
tiple biopsies of the endomyocardium post-transplant from 2008-2009 showed
evidence of Grade 1A and 1B rejection. In 2010, the patient was found to have
multiple grade 3A rejections, and received 3 days of IV Solu-Medrol and 7-
days of Thymoglobulin for presumed T-cell mediated acute rejection. She was
subsequently admitted for photopharesis for 2 days and plasmapheresis with
concomitant IVIG for 3 days the following month. In March 2013, the patient
was admitted for another episode of 3A rejection, at which time she was also
found to have low Ig levels: IgG 326, IgA 119, IgM 41, and IgE 1.9 with
increased BUN/Cr. Patient was given IVIG, 1 gm/kg x 2 days. Subsequent
biopsy revealed grade 1B rejection, and the patient had much improvement in
her IgG levels. Patient was continued on monthly subcutaneous immunoglob-
ulins (SCIG) at 500 mg/kg for treatment of acute antibody mediated rejection
and HGG. She continued to maintain IgG levels within normal range in spite
of end stage renal disease. Her subsequent pathology specimen reports, with
the most recent from 4/2014, show grade 1B rejection, which is much improved
from previous 3A rejections. Discussion: This case illustrates the potential ben-
efit of using SCIG as part of the management for recurrent AMR. Early insti-
tution of this form of treatment could reduce the incidence of AMR, and there-
fore, prevent its complications including allograft dysfunction and mortality.
Research on this topic is warranted.
P148
ATYPICAL CASE OF KABUKI SYNDROME WITH INDETER-
MINATE IMMUNODEFICIENCY, LOW B CELLS AND AUTOIM-
MUNE ENTEROPATHY.
M. Gogna*, Glenshaw, PA.
Kabuki syndrome (KS) is a multiple malformation/mental retardation syn-
drome with an estimated frequency of 1/32,000 that is characterized by dis-
tinctive facial features, skeletal anomalies, short stature, and mental retarda-
tion. Increased infections especially otitis media, URIs, and Pneumonia have
been identified in 60-70%patients. It is unclear if these infections are due to
Immune problems (Hypogammaglobulinemia is a frequent finding in Kabuki
syndrome) or craniofacial abnormalities. We present the case of a 15 year old
female with Kabuki syndrome who presented with persistently low B cells
and Autoimmune enteropathy. Both these findings have previously not been
reported in KS. Her Immunoglobulins have been trending down since last 5
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A67
years (table 1) Our patient gets mostly line infections with MSSA, CONS, Ecoli
and Klebsiella and not sinopulmonary infections. This can possibly be explained
by a disruption in skin barrier and disruption in GI barrier(h/o chronic diar-
rhea). Her Memory B cells and Mitogen assays were wnl which is very reas-
suring. She had significantly low B cells over the course of atleast 5years.
Low B cells cannot be explained by chronic diarrhea or use of Tacrolimus (
started on Tacrolimus for Autoimmune-enteropathy). She was diagnosed with
Autoimmune enteropathy based on the following 1.Inflammation and increased
intraepithelial lymphocytes and numerous apoptoses on biopsy and 2.positive
anti-enterocyte antibody and 3. anal fissures on exam.
TREND OF IMMUNOGLOBULINS AND LYMPHOCYTE SUBSETS
OVER 5YEARS
Recommendations: We recommend that a basic Immunological work up
–quantitative Immunoglobulins, Specific antibody titers be done in all
patients with KS. If the Initial work up is abnormal, we recommend further
work up including Lymphocyte subsets, Mitogen assays and B CELL panel.
An index of suspicion should be kept for Autoimmune enteropathy leading to
Chronic Diarrhea.
P149
A CASE OF HASHIMOTO’S ENCEPHALOPATHY TREATED
WITH IMMUNOMODULATION AND THYROIDECTOMY WITH
INCIDENTAL FINDING OF THYROID CANCER.
J.A. Quirt*1, O. Perlov2, D.A. Haaland1, 1. Hamilton, ON, Canada;
2. Barrie, ON, Canada.
Background: Hashimoto’s encephalopathy is a rare and likely under rec-
ognized immune-mediated neurologic syndrome. While the exact pathophys-
iology remains unclear, the encephalopathy itself appears to be independent of
the biochemical thyroid status. Due to the rarity of the syndrome, minimal evi-
dence is available to guide treatment decisions. The mainstay of treatment is
corticosteroids, with some patients requiring other immunosuppressive agents.
Cases of success with use of IVIG have been published. Few case reports exist
in the literature of successful treatment involving thyroidectomy, with the
rational of removing the thyroid as an antigenic stimulus. Case Presentation:
We report a case of a 39 year old man who initially presented with a goiter and
non-specific symptoms of dizziness, palpitations and general malaise. He was
found to be hypothyroid and started on replacement therapy. He subsequently
developed ataxia, thought to be cerebellar in nature with head titubation, gait
dysfunction, cognitive impairment and inappropriate emotional responses. The
severity of his symptoms caused him to be bed-bound. He had a reassuring
MRI head, LP, and CT of his chest, abdomen and pelvis as well as a negative
paraneoplastic antibody work-up. His anti-thyroid peroxidase antibodies and
anti-thyroglobulin antibodies were significantly elevated. The treatment regi-
men initiated included high dose corticosteroids, with a prolonged taper as well
as IVIG, addition of mycophenolic acid and thyroidectomy. Interestingly, pathol-
ogy from the thyroidectomy revealed micropapilary cancer with local micro-
metastases in the lymph nodes. The patient returned to his baseline status, and
presently is continued on monthly IVIG, mycophenolic acid and a continued
prednisone taper. He has not had recurrence of his symptoms. Conclusion:
The above case highlights a rare and likely under-diagnosed immunologic
syndrome for which little guidance in the literature exists with respect to treat-
ment beyond corticosteroids. This case report serves to review the clinical pres-
entation, pathogenic theories, diagnosis and management options for
Hashimoto’s encephalopathy. The case also adds support to previous cases of
successful treatment with thyroidectomy.
ABSTRACTS: POSTER SESSIONS
P150
WEST NILE VIRUS ENCEPHALITIS IN GATA2 DEFICIENCY:
CLINICAL IMPROVEMENT AFTER IVIG AND INTERFERON
ALFA-2B THERAPY.
J.S. Rosa*1, S. Kappagoda1, A. Hsu2, S. Holland2, A.Y. Liu1, 1. Stanford,
CA; 2. Bethesda, MD.
Introduction: A twenty-four-year-old male was admitted to the ICU with
deteriorating mental status and cogwheel movements. Two healthy individuals
who accompanied the patient on a recent trip to Wyoming had spontaneous res-
olution of similar prodromal symptoms after exposure to mosquito bites. He
was subsequently found to have neuroinvasive West Nile virus infection with
positive IgM antibodies in his CSF and serum, and detectable serum RNA. The
patient had a history of recurrent sinopulmonary infections, chronic warts,
and leukopenia with monocytopenia. His father and grandfather died before
50 years of age due to viral illnesses. There was no known family history of
leukemia or nontuberculous mycobacterial infections. Methods: Peripheral
blood was analyzed by flow cytometry. NK cell function was measured by the
release of radioactive chromium from lysis of the erythroleukemia cell line,
K562. DNA amplification of all exons, flanking splice sites, and intronic non-
coding regulatory regions of GATA2 was performed on whole blood. The patient
received 1.2 g/kg IVIG divided over 3 days and 3 million units of subcutaneous
interferon alfa-2b daily for 14 days. Results: Monocytes (0), B lymphocytes
(8), CD4+ and CD8+ T lymphocytes (161 and 68), and NK cells (13) (/mL)
were low. Absolute CD16+56+ and CD56bright NK cell counts were markedly
reduced, with relative frequency within normal limits. NK cell function was
normal. Genomic sequencing revealed a heterozygous single base deletion,
c.1021delG; p.A341Pfs, causing the loss of the highly conserved second zinc
finger of GATA2. DNA sequencing for the same mutation in his mother was
negative. The patient had a significant improvement in his neurologic function
and most of his warts subsided after IVIG and interferon alfa-2b. He was referred
to our Hematopoietic Stem Cell Transplantation Program for bone marrow aspi-
ration/biopsy and evaluation for bone marrow transplantation. Conclusions:
This is the first report of a patient with GATA2 deficiency presenting with West
Nile virus encephalitis. Patients with heterozygous GATA2 mutations may be
more susceptible to neuroinvasive disease from West Nile virus infection, even
in the absence of a nontuberculous mycobacterial infection or familial history
of leukemia. IVIG and interferon alfa-2b may have been beneficial for this
patient with impaired viral immunity.
P151
EPOETIN ALFA HYPERSENSITIVITY REACTION AND SUC-
CESSFUL DESENSITIZATION IN A CHILD.
J.S. Rosa*, A.Y. Liu, Stanford, CA.
Introduction: Erythropoietin replacement is a key therapy of anemia asso-
ciated with chronic kidney disease. Rapid desensitization has been successful
in patients with immediate type I hypersensitivity to epoetin alfa, and a slower
two-day protocol has been described in an adult patient who had delayed type
hypersensitivity reactions to the same agent. An eleven-year-old girl with a his-
tory of end stage focal segmental glomerulosclerosis on hemodialysis devel-
oped a diffuse, pruritic, maculopapular rash one day after starting epoetin alfa,
which recurred when darbepoetin alfa was subsequently administered. She then
failed a two-day epoetin alfa desensitization protocol but subsequently toler-
ated epoetin alfa after a seventeen-day desensitization. Methods: Binding and
neutralizing anti-epoetin alfa and anti-darbepoetin alfa antibodies were meas-
ured using biosensor immunoassay (GE Healthcare-Biocare, Uppsala, Swe-
den). A two-day subcutaneous epoetin alfa (Epogen, Amgen) desensitization
schedule, adjusted by weight, was modeled after a previously published adult
epoetin alfa desensitization protocol. The patient developed an intensely pru-
ritic, maculopapular rash prior to the first dose of day two. She was started on
prednisone 0.3 mg/kg (10 mg) daily and a prolonged protocol was designed.
Results: Anti-epoetin alfa and anti-darbepoetin alfa antibodies were absent. On
day 4, the patient’s rash resolved, and desensitization was resumed. She did
not have pruritic rashes prior to subsequent doses. On day 17, she reached her
target dose of 700 IU, and the prednisone was discontinued. At her three-month
follow-up visit, she continued to tolerate the epoetin alfa without adverse reac-
tion. Conclusions: To our knowledge, this is the first epoetin alfa desensitiza-
tion for a child with delayed type hypersensitivity who experienced an adverse
reaction to a two-day regimen. Subsequently, a slower dose escalation (seven-
teen days), with the support of a low dose systemic steroid, was successful at
building a desensitized state to epoetin alfa. This case corroborates the princi-
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A68
ABSTRACTS: POSTER SESSIONS
ple that slower desensitization may increase tolerability in delayed type hyper-
sensitivity reactions.
Desensitization Protocol
P152
NICKEL AND COBALT ALLERGY: THE IMPORTANCE OF
PATIENT HISTORY.
P. Naik*, R. Steele, M. Aquino, L. Fonacier, Mineola, NY.
Rationale: Contact dermatitis (CD) is one of the most common inflamma-
tory skin diseases diagnosed by allergists, dermatologists, and primary care
providers. The presentation of CD is variable based on its time course; it can
range from red clustered vesicles to bullae with both scaling and pruritus. Aller-
gic CD can complicate or co-exist in the patient with atopic dermatitis (AD).
Methods: An 11 year old female with a history of AD was referred to the
Allergy/Immunology Clinic at Winthrop University Hospital for evaluation of
persistent chelitis despite evaluation and management by her primary care physi-
cian and dermatologist. Over the last four years, the patient reported worsen-
ing of perioral and lip lesions. She had been treated with topical tacrolimus and
corticosteroids with minimal improvement. She denied any perioral pruritis,
worsening of lesions with food ingestion, or use of any cosmetic or lip balm
products. She reported using the same toothpaste on a regular basis and denied
licking her lips. She reported skin irritation with costume jewelry and hobbies
included flute playing. Physical examination revealed dyshidrosis and chelitis
(dry cracked lips and perioral erythema with no other active eczematous lesions
present). Suspicion for allergic CD exacerbating atopic dermatitis. The patient
was treated with emollients and continued use of a low potency topical CS.
Results: The patient underwent patch testing with the North American Contact
Dermatitis panel which included a total of 69 allergens including metals, cos-
metics, fragrances, preservatives and medications. She had positive results to
nickel (3+), cobalt (2+), and neomycin(2+). The nickel and cobalt were deter-
mined to be of probable relevance as they were likely components of her flute.
The neomycin was considered to be of unknown or past relevance. She was
counseled on a trial avoidance of her metallic flute. Conclusions: Nickel remains
the most common allergen obtained from patch testing. In patients with lip der-
matitis one must consider allergens including lip balms, lipsticks, toothpastes,
gums and hobbies including playing an instrument. In patients with co-exist-
ing AD consider allergic CD, if there is not a response to medical pharma-
cotherapy and interventions, identification and avoidance of relevant aller-
gens is the mainstay treatment of CD.
P153
SUCCESSFUL DESENSITIZATION TO ANTITHYMOCYTE
GLOBULIN IN AN ADULT PATIENT WITH APLASTIC ANEMIA.
K. Lindgren*1, K. Conner2, B. Yu2, 1. Elmhurst, IL; 2. Chicago, IL.
Background: Antithymocyte globulin (ATG) is a lymphocyte-selective
immunosuppressant indicated for the management of allograft rejection in renal
transplant patients and aplastic anemia. ATG has the potential for adverse reac-
tions including type I hypersensitivity reactions as well as other more com-
A68 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
mon adverse reactions including fever, chills, rash, nausea, arthralgia, headache,
and phlebitis. Skin testing evaluates the potential for a type I hypersensitivity
reaction. Despite a positive skin test, there are circumstances in which receiv-
ing ATG is deemed necessary and in such circumstances, ATG desensitization
is recommended. Previous ATG desensitizations in adults have been unsuc-
cessful. Clinical Vignette: The patient was a 43 year old male with aplastic ane-
mia and mild intermittent asthma. His treatment started with cyclosporine and
ATG. On the first dose of ATG, he developed dyspnea, fevers, hypotension,
and tachycardia, which were treated with infusion cessation, acetaminophen,
morphine, and hydrocortisone, with relief of his symptoms. A second infusion
was attempted the next day per his initial protocol and again symptoms devel-
oped including dyspnea, tachypnea, chest tightness, fevers, and hypotension.
The infusion was stopped, supplemental oxygen given, and a CT chest with
contrast was obtained, which showed bilateral scattered ground glass opacities
with a few areas of focal consolidation. Given the possibility of ATG-induced
lung toxicity, no further ATG was given and the patient was maintained on
cyclosporine. Eighteen months later, the patient was found to have worsening
pancytopenia despite therapeutic cyclosporine serum levels. Given failure of
treatment with cyclosporine, treatment with ATG was deemed necessary. As
skin testing results would not have changed the plan for desensitization, skin
testing was deferred. The patient underwent the ATG desensitization protocol
outlined in Table I which was based on the protocol put forth by Ferdman and
colleagues. He tolerated the protocol well without symptoms except fever on
day 2 of the protocol which resolved with acetaminophen. Conclusion: Suc-
cessful desensitization to ATG has been documented in only pediatric patients
as adult patients have developed symptoms necessitating cessation of the desen-
sitization. This case illustrates a successful desensitization to ATG in an adult
patient with aplastic anemia.
P154
INTRANASAL MOMETASONE AS AN ALTERNATIVE TO FLU-
TICASONE IN AN HIV PATIENT ON RITONAVIR.
S. Deol*, D.A. Khan, Dallas, TX.
Introduction: Adrenal suppression and Cushing’s syndrome have been
reported due to the interaction between ritonavir and intranasal fluticasone. We
report the successful use of an alternative intranasal steroid (INS) in a patient
who previously had adrenal suppression due to ritonavir and intranasal flutica-
sone. Methods: Case report. Data: A 50 yo M with HIV on a boosting dose of
ritonavir 100 mg BID as well as emtricitabine-tenofavir, raltegravir, and darunavir
was treated with fluticasone intranasal spray 2 sprays per nostril daily for aller-
gic rhinitis. After 6 months, he reported good control of rhinitis and lacked signs
or symptoms of adrenal suppression. Three months later he was noted to have
abdominal striae and easy bruising. Early morning cortisol was <1.0 and ACTH
was found to be <5. He was started on a tapering dose of hydrocortisone and
intranasal fluticasone was discontinued. Upon further inquiry, on some occa-
sions the patient self-increased his INS dose up to 2 sprays tid. After comple-
tion of the hydrocortisone taper, early morning cortisol and ACTH were within
normal range and his Cushingoid appearance resolved. After 9 months of treat-
ment with intranasal antihistamines, oral antihistamines, as well as leukotriene
antagonist therapy, his rhinitis symptoms were still not controlled and were
greatly affecting his quality of life. A baseline morning cortisol and ACTH were
normal. Intranasal mometasone was prescribed and he was counseled on the
strict usage of mometasone 1 spray per nostril daily. After 4 weeks of continu-
ous therapy, early morning cortisol and ACTH remained normal. After 6 months
of follow-up, he continues to have excellent symptom control and absence of
Cushing’s syndrome on repeat examinations. Conclusion: Our case demonstrates
that adrenal suppression with the concomitant use of intranasal fluticasone and
ritonavir can also occur while on the lower boosting dose of ritonavir. This case
also suggests that intranasal mometasone is safe and effective with concomi-
tant ritonavir 100 mg twice a day in a patient with HIV.
P155
THE POTENTIAL EFFECTS OF ALLERGY IMMUNOTHERAPY
ON EOSINOPHILIC ESOPHAGITIS.
V. Miller*, E. Lanford, J. Kurz, S. Shah, G. Patel, Dublin, OH.
Background: We will describe two unique cases regarding the potential
effects of allergy immunotherapy (IT) on eosinophilic esophagitis (EE). Meth-
ods: Patients underwent a complete history, physical exam, skin prick testing
(SPT) by classical method, and an accelerated IT program. Both patients reached
their maintenance doses, which was 0.5ml of a 1:1 concentration. EE was diag-
nosed via EGD and biopsy. Results: Case 1: Patient presented for evaluation
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A69
of seasonal allergy symptoms and food allergies. Patient had a known history
of EE that was previously controlled with an elimination diet. SPT revealed
positive results to dust mites, cat, dog, grass, trees, weeds, milk, egg, peanut,
multiple tree nuts, and sesame. Patient was started on IT for allergic rhinitis,
and after six months of treatment the patient reported that dysphagia had pro-
gressively worsened despite avoidance of all known food triggers. Case 2:
Patient presented with complaints of dysphagia and seasonal allergy symp-
toms. SPT revealed positive results to trees, grass, weeds and cockroach. Daily
symptoms of dysphagia were uncontrolled on a proton pump inhibitor alone.
The patient was referred to a GI specialist for a definitive diagnosis, and EE
was confirmed with an EGD and biopsy. An elimination diet was not initiated.
Patient was prescribed a daily swallowed budesonide and Splenda mixture for
three months after which treatment was stopped with improvement in symp-
toms. Three months after swallowed budesonide was discontinued, allergy IT
was initiated for treatment of allergic rhinitis. IT was continued for 1.5 years
until discontinued by the patient. Upon completion, the patient reported that
dysphagia had continued to improve since starting IT. Conclusions: The inhala-
tion of aeroallergens may have an effect on the inflammation occurring in the
esophagus of EE patients. It is hypothesized that using IT to reduce sensitiza-
tion would greatly impact this inflammatory response, however, there are no
controlled studies on allergy IT as an adjunctive treatment for EE. Our case
reports indicate that there is conflicting data on whether or not IT can impact
EE, and if this impact is harmful or beneficial. Our recommendations are to
continue research on the role of aeroallergens in the pathogenesis of EE, to con-
sider the effects of IT on EE, and to assess the risks and benefits of continu-
ing IT on patients with EE.
P156
FUNCTIONAL ABDOMINAL PAIN OR MAST CELL GI DISOR-
DER: A STAIN AWAY.
K. Anthony*, L. Wild, New Orleans, LA.
Introduction: Chronic abdominal pain associated with bowel dysfunction
affects 15% of the general population. These patients often undergo extensive
negative work-ups and are diagnosed with functional pain disorders. Gas-
trointestinal mast cell disorders are not always considered in the differential
diagnosis; however, recent studies suggest patients with chronic abdominal pain
may have an underlying gastrointestinal mast cell disorder that will improve
with appropriate therapy. We present a case suggesting these patients should
be evaluated for a gastrointestinal mast cell disorder. Methods: A 32 y.o. male
with allergic rhinitis presented with a 3 year history of diffuse abdominal pain,
diarrhea, and a sensation of “itching” inside the abdomen. He denied any asso-
ciated flushing, rash, wheezing, difficulty breathing, syncope, or dizziness.
He had undergone an extensive evaluation including endoscopy, colonoscopy,
CT abd/pelvis, CBC, CMP, ESR, and celiac screening. Given his persistent
symptoms, he underwent a repeat endoscopy/colonoscopy with biopsies and
staining for CD 117+ cells. Results: CT abd/pelvis, CBC, CMP, ESR, and celiac
screening were normal. Previous endoscopy and colonoscopy were negative.
Repeat endoscopy and colonoscopy with staining for CD 117+ cells was sig-
nificant for >20-40 mast cells per hpf in the stomach, duodenum, terminal
ileum, and colon. Systemic mastocytosis was ruled out with normal serum
tryptase and normal bone marrow biopsy. He was started on daily H1 and H2
blockers with significant improvement in abdominal pain and diarrhea. Con-
clusion: Chronic abdominal pain and diarrhea in this patient were likely sec-
ondary to mast cell gastroenterocolitis. Treatments for mast cell gastrointesti-
nal disorders including oral antihistamines and oral mast cell stabilizers are
available and usually effective. Accurate diagnosis enables patients to start
appropriate treatment, leading to improved symptom control and quality of life.
This case suggests patients with persistent abdominal pain and bowel dys-
function may need evaluation for a mast cell GI disorder, even in the absence
of symptoms of systemic mastocytosis.
P157
ANAPHYLAXIS TO A LIFE-SAVING REMEDY.
P. Uong*1, K. Christine1, D. Wong2, 1. Phoenix, AZ; 2. Mesa, AZ.
Introduction: We teach patient with allergies to avoid allergen as the first
step in treatment, but what if that allergen is a life-saving treatment? We pres-
ent a case of a child with severe hemophilia B who developed anaphylaxis to
coagulation factor IX with subsequent desensitization attempts and associated
medical complications. Case: TL is a 15 year-old male with severe hemophilia
B who presented to the hospital for severe right arm pain and swelling, found
to be compartment syndrome requiring an urgent fasciotomy. Despite his ill-
ABSTRACTS: POSTER SESSIONS
ness, TL was not on coagulation factor IX, the one protein that he was miss-
ing, because of multiple instances of anaphylaxis and inhibitors to it. Interest-
ingly, he had undergone two desensitizations as a toddler with eventual fair
control of his bleeding despite high inhibitor levels. However, in recent years,
allergic symptoms to factor IX started to escalate, requiring change of therapy
to factor VII, which bypassed the factor IX-dependent step in the coagulation
cascade and kept his bleeding under variable control. Outcome: TL continues
to struggle with allergies to factor IX, acute on chronic pain exacerbations,
and ongoing complications including a recent large deep venous thrombosis
(DVT) in his left arm. He is now undergoing desensitization to factor IX again
but is now using Rixubis instead of BeneFIX, with the addition of rituximab.
Because the protocol by Sarah Alexander was denied by insurance, TL is now
desensitizing according to the protocol by Dioun et. al at Boston’s Children’s
Hospital. Advantages for rituximab include lowering inhibitor levels and bleed-
ing symptoms with a reported beneficial change in factor kinetics. The disad-
vantage, however, is that rituximab can be associated with anaphylaxis, and in
rare cases, multifocal leukoencephalopathy. With his debilitating disorder,
depression is certainly a concern, but TL is now doing better than ever before,
and hope exists for even newer therapies on the horizon, including several long-
acting formulations of factor IX. Conclusion: Hemophilia B is a chronic, life-
threatening, debilitating condition, but with a history of allergies and anaphy-
laxis to the one protein that is missing, treatment and management becomes
much more complex. This case report is an important reminder of the need for
a strong interdisciplinary team to stay involved and to stay abreast of new
medical advances to help maximize care for this patient.
P158
A NAVAJO INFANT WITH SCID PRESENTS WITH HYPOXIA,
SEVERE NEUTROPENIA AND A NORMAL IGG LEVEL.
P. Uong*1, N. Jain2, 1. Phoenix, AZ; 2. Gilbert, AZ.
Introduction: Defects in the gene Artemis are known to result in a form of
severe combined immune deficiency (SCID). The incidence of this defect in
the Athabascan-speaking Native American population is about 1/2000 live
births. Here, we describe a case of an infant with SCID with the Artemis gene
defect who presented with severe neutropenia despite a normal IgG level. Case:
A 5-month-old Navajo female with a history of poor weight gain and frequent
respiratory tract infections was admitted to the hospital due to hypoxemia and
respiratory distress. Initial chest radiograph from the ED revealed bilateral infil-
trates, and the child was placed on supplemental oxygen via nasal cannula. Res-
piratory culture was positive for respiratory syncytial virus (RSV) and rhi-
novirus. Initial lab work up revealed an abnormal complete blood count (CBC)
with leukopenia, lymphopenia, and profound neutropenia (absolute lympho-
cyte count approximately 1000/mm3 and an absolute neutrophil count of
300/mm3). HIV screen was negative. IgG was preserved at 811 mg/dL, IgA
was < 8 mg/dL, and IgM was 301 mg/dL. IgG subclasses revealed a total IgG
at 799 mg/dL (IgG1 681mg/dL, IgG2 8 mg/dL, IgG3 6 mg/dL, and IgG4
undectable). The patient developed ecthyma gangrenosum of the nose secondary
to infection at the site of nasal cannula with culture positive for pseudomonas
species. The patient was put on anti-pseudomonal therapy with meropenum
and ciprofloxacin. Immunology consult was obtained due to persistent severe
neutropenia of unclear etiology. Recommendations were made for bronchoscopy,
which revealed P. jirovici pneumonia and the patient was started on sul-
famethoxazole/trimethoprim. T-cell receptor excision circles (TREC) assay
revealed <74 TREC/106 cells suggestive of SCID. Due to her Navajo back-
ground, the patient was suspected of having a defect in the Artemis gene and
was transferred to the University of California at San Francisco Medical Cen-
ter for further management including a bone marrow transplantation. Conclu-
sion: This is the first reported case of a child with a defect in the Artemis gene
presenting with severe neutropenia and a normal IgG level. This unusual lab
presentation led to a delay in immunology consultation and a definitive diag-
nosis. Although the patient’s absolute lymphocyte count was also low, initial
work up focused on the patient’s neutropenia.
P159
METAL HYPERSENSITIVITY AS A CAUSE OF RECURRENT
INFECTIONS AFTER JOINT REPLACEMENT.
D. Hirsch*, V. Bonagura, Great Neck, NY.
Rationale: Hip replacement surgery is an increasingly common procedure
in the United States, as more than 300,000 individuals undergo total hip replace-
ment (THR) yearly. Common causes of joint replacement failure have histor-
ically included mechanical loosening, infection, fractures around the implant,
VOLUME 113, NOVEMBER, 2014 A69
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A70
ABSTRACTS: POSTER SESSIONS
and joint instability. Failure rates are as high as 6.1% for metal-on-metal THR
and 3.3% for ceramic-on-ceramic articulations[i]. In the general population,
10-15% of individuals have metal hypersensitivity[ii], which may represent an
increasing cause of joint replacement failure. We describe the presentation,
clinical course, and evaluation of a patient with recurrent infections after THR
who was ultimately diagnosed with metal hypersensitivity. Methods: A 48-year-
old man presented for an immunological evaluation because of recurrent infec-
tions after a THR. Three days after the operation, he developed a fever and
underwent a washout and temporary insertion of a spacer. A few weeks later,
he underwent re-implantation of hardware, but the wound did not heal prop-
erly so a spacer was inserted and he had another re-implantation of hardware
3 months later. One year after the original procedure, he developed an abscess
and a fistula in the hip. He was treated with intravenous antibiotics and had
another re-implantation of hardware. One year later, he again developed a
joint infection which required removal of the hardware and implantation of a
temporary spacer. Prior to the hip replacements, he had been very healthy with
no significant infections. Results: After an immunological workup was unre-
markable, patch testing to metals contained in the prosthetics elicited positive
responses to nickel and chromium. Conclusions: It is important to include metal
hypersensitivity in the differential diagnosis of individuals presenting with
recurrent infections after joint replacement.
P160
USE OF IVIG IN PATIENTS WITH SHWACHMAN-DIAMOND
SYNDROME.
J.M. Zibert*1, M. Scotten2, S. Gierer2, 1. Kansas City, MO; 2. Kansas
City, KS.
Introduction: Shwachman-Diamond Syndrome (SDS) is a rare, autosomal
recessive disorder characterized by pancreatic dysfunction, hematologic abnor-
malities, small stature, and recurrent infections. Dysgammaglobulinemia in
SDS has been reported, but the use of Intravenous Immunoglobulin (IVIg) to
reduce infection rate has not been studied. We present siblings with SDS treated
with (IVIg) whose rate of hospitalization was dramatically reduced. Case
Description: We present brothers, ages 15 and 17, diagnosed with SDS in early
childhood, who have exocrine pancreatic dysfunction, small stature, and recur-
rent infections. Since diagnosis, they have required repeated hospitalizations
for infections. Both had normal immunoglobulin levels, MBL function, total
complement, neutrophil oxidative burst, and post-vaccination antibody levels.
Between 2007 and 2013, the 15 year old had an average of 2 hospitalizations
per year for fever or infections. After initiation of IVIg in March 2013, he has
had no hospitalizations for fever or infections. Between 2007 and 2013, the 17
year old averaged 1.86 hospitalizations per year for fevers or infections. After
initiation of IVIg in March 2013, has had only one hospitalization for fever.
Since initiation of IVIg, both patients reported significant improvement in their
quality of life with improved fatigue and less missed school days. Discussion:
SDS is a rare congenital disorder with limited data on treatment options. Recur-
rent respiratory infections, beginning early in childhood, are frequently reported
and often require hospitalization to rule out sequelae. While SDS may be asso-
ciated with immunoglobulin deficiencies, a literature search did not reveal
any publications documenting the use of IVIg to reduce infection rate in patients
with SDS. In the two patients presented, the use of monthly IVIg has shown
objective health benefits including decreased overall infection rate and decreased
hospitalization rate; as well as subjective improvement in quality of life,
improved fatigue, and decreased number of missed school days. This unique
case study supports the use of monthly IVIg infusions in patients with SDS by
providing objective data. It also supports the important need for the develop-
ment of more scientifically supported clinical guidelines in the treatment of
rare genetic conditions causing immune deficiencies.
P161
STEROID REFRACTIVE ANGIOEDEMA ASSOCIATED WITH
MILD MAST CELL ACTIVATION AND HISTAMINEMIA.
J. Dara*1, A. Rubinstein2, 1. New York, NY; 2. Bronx, NY.
Introduction: 65-year-old female with linear scleroderma was evaluated for
recurrent angioedema refractory to high dose steroids and antihistamines. She
was initially found to have a mildly elevated serum tryptase, elevated serum his-
tamine, and eosinophilia. Bone marrow analysis and cytogenetic studies were
unremarkable. Serum abnormalities and angioedema resolved on high dose anti-
histamines and a modified mastocytosis diet. Methods: Immunological, genetic,
and pathological evaluations of a patient, LL, with atypical angioedema were
performed. Results: LL had a history of benign multinodular goiter and recent
A70 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
diagnosis of linear scleroderma. She presented with facial and both proximal
and distal extremity angioedema that was poorly responsive to oral corticos-
teroids, antihistamines and plaquenil. There was no associated urticaria or pru-
ritus and no identifiable exacerbating factors. C4 complement (44 mg/dL), C1
Esterase inhibitor (40 mg/dL), and C1q (8.3 mg/dL) were all normal. Quanti-
tative immunoglobulins (IgG 1010 mg/dL, IgM 206 mg/dL, IgA 141 mg/dL)
were normal. Serum protein electrophoresis was normal. Auto-antibodies (anti-
DNA, anti-SCL70, anti-nuclear, anti-TPO, anti-TG) were negative. Over a period
of 2 months, serum IgG decreased from 1010 mg/dL to 659 mg/dL and serum
IgG2 from 206 mg/dL to 153 mg/dL. Serum histamine was elevated (8.7ng/mL)
and tryptase was slightly elevated at 13 ng/mL. She acutely developed a marked
hypereosinophilia, AEC 3200/mL up from a baseline of 400/mL, 2 months ear-
lier. Parasitic workup was unremarkable. Bone marrow and cytogenetic evalu-
ations for hypereosinophilic syndrome, mastocytosis, and myeloproliferative
disorders was negative. She was started on hydroxyzine 200 mg daily and a low
histamine diet with resolution of the angioedema, tryptase levels dropped to
6ng/ml and serum histamine to 2.2 ng/mL and eosinophils decreased to 400/ml.
Conclusions: We report a case of atypical angioedema, mildly elevated tryptase
levels and histaminemia which has been responsive to high dose antihistamines
and modified histamine-restricted diet. Evaluations for mastocytosis and neo-
plasias have been unremarkable.
P162
USE OF RITUXIMAB TREATMENTS FOR ACQUIRED DEFI-
CIENCY OF C1 ESTERASE INHIBITOR.
T. Lee*, P. Busse, New York, NY.
Acquired deficiency of C1 esterase inhibitor (ACID) is a rare disorder with
recurrent episodes of self-limited angioedema that typically affects the skin or
mucosal tissues of the upper respiratory and gastrointestinal tracts. An under-
lying defect of ACID may be an undiagnosed malignancy or autoimmune dis-
ease, therefore further investigation to rule out these disorders is critical. The
management of a patient with ACID involves education about potential trig-
gers (including surgery, trauma, medications), ready access to acute treat-
ment, and in some patients consideration of a prophylactic treatment. We pres-
ent an 82 year old male that developed multiple episodes of angioedema of his
extremities and in an episode of airway swelling around age 75 years. A diag-
nosis of ACID was made by a decreased C4, C1-inh function, C1-inh protein
level and a low C1Q. There was no evidence of an underlying malignancy. He
was initially given C1 inhibitor concentrate (C1INHRP) for treatment of acute
attacks and danazol for prophylaxis as his attacks were becoming more fre-
quent. Initially his attack rate and severity decreased, but over the following
years, he required nearly weekly rescue dosing of C1INHRP for acute attaks.
His danazol was changed to aminocaproic acidwithout improvement. A high
antibody titer to C1-inh was detected and the patient was also given icatibant
for rescue medication. He was subsequently given a round of rituximab which
significantly decreased his frequency of attacks and need for rescue therapy.
After approximately 1 year, his angioedema symptoms increased in frequency
and he was given another course of rituximab with improvement again, which
waned over the following year. A third course of rituximab was administered.
The patient has been monitor for lymphocyte numbers and specific antibody
responses. In conclusion, treatment of ACID can be difficult and may require
rituximab. Although additional courses of rituximab may be warranted, it should
be done with careful monitoring of the patient’s immune status.
P163
EVALUATING THE USE OF ICATIBANT INJECTIONS
(FIRAZYR®) WITH C1 ESTERASE INHIBITORS (CINRYZE®
AND BERINERT®) DURING PREGNANCY OF A TYPE III
HEREDITARY ANGIOEDEMA PATIENT.
F.F. Ansary*1, T.J. Craig2, 1. Hummelstown, PA; 2. Hershey, PA.
Background: Hereditary angioedema (HAE) is a rare disease, character-
ized by localized swelling, inflammation, and pain. It is the over production of
bradykinin that leads to the angioedema. Icatibant (FIRAZYR®) is used to
treat acute attacks of hereditary angioedema by inhibition of the bradykinin
receptor. Icatibant is approved for use in type I and II, but is often used off label
for type III. Icatibant is contraindicated in pregnancy and at this time no data
are available on the safety of using icatibant in pregnancy. We report a case of
type III HAE with frequent use of icatibant that suggests icatibant may be safe
during pregnancy. Methods: The patient was first diagnosed with type III hered-
itary angioedema based on her history and normal compliment blood tests. C1-
inhibitor was given for prophylaxis. Icatibant was used frequently for attacks
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A71
and continued to be used despite onset of pregnancy without the prescribers’
knowledge. During the first two trimesters, icatibant was used multiple times
a week. Results: Despite the use, two births resulted in normal fetuses without
apparent teratogenic effects. One fetus was premature by 2 weeks and slightly
below gestational weight; however, is physically normal and up to date on devel-
opmental skills. Conclusions: It appears that the use of icatibant early during
pregnancy is safe; however, additional cases of accidental use during pregnancy
are needed to confirm this suspicion.
P164
THE PERPLEXING NATURE AND CLINICAL PROGRESSION
OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGITIS
IN A PREVIOUSLY HEALTHY ELITE ATHLETE.
T. Ocampo*, T. Rans, San Antonio, TX.
Eosinophilic granulomatosis with polyangitis (EGPA), formerly known as
Churg-Strauss syndrome, is a rare multisystem, antineutrophil cytoplasmic anti-
body (p-ANCA) associated vasculitis characterized by asthma and hypere-
osinophilia. Its clinical manifestations are variable and often develop over years,
making diagnosis challenging. We present a previously healthy 30 year old
female marathon runner with abrupt onset rhinitis without polyps, productive
cough of mucus plugs, intermittent dyspnea, and chest tightness while living
in Missouri. Although diagnosed clinically with allergic rhinitis and asthma,
antihistamines and inhaled corticosteroid (ICS) use provided minimal relief.
Symptoms initially improved upon relocation to Texas, but occasional respi-
ratory exacerbations occurred over the following year. Abruptly, during a bout
of sinusitis, she endorsed fatigue, weight loss, burning leg pain, facial
angioedema, and a blistering rash. Routine CBC demonstrated marked
eosinophilia (AEC 16,100) prompting hospital admission. Initial investigation
of primary (FIP1L1-PDGFRA) and secondary (medications, infectious, malig-
nancy, rheumatologic) etiologies of eosinophilia were unrevealing. Rheuma-
toid factor (RF), antineutrophil antibody (ANA), and ANCA (PR3 Ab 0.5, MPO
Ab 0) were negative. Sinus CT revealed extensive paranasal sinus disease. Chest
CT revealed tree in bud and ground glass opacities, mucus plugging, and lym-
phadenopathy (normal chest CT the year prior). Serum IgE (3901 IU/ml) and
CRP (1.4mg/dL) were elevated. Aspergillus precipitans were negative. Skin
biopsy revealed eosinophil infiltration and findings consistent with vasculitis,
which along with her constellation of symptoms led to the diagnosis of EGPA.
Prednisone (75mg daily) was started with rapid resolution of peripheral
eosinophilia and she has continued to clinically improve on a prolonged steroid
taper. Retrospectively, this patient demonstrated the prodromal, eosinophilic,
and vasculitic phases described in EGPA. However, her diagnosis was elusive
to her multidisciplinary team until a rapid surge of symptoms prompted a skin
biopsy. This case reminds the practicing Allergist of the importance of frequent
reassessments and to maintain a high index of suspicion for alternative diag-
noses in patients with emerging presentations.
P165
EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS
PRECIPITATED BY CORTICOSTEROID WITHDRAWAL.
J.L. Hill*, S. Patel, D. Sudano, T.F. Carr, Tucson, AZ.
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a
rare, systemic vasculitis characterized by a prodromal phase of chronic rhi-
nosinusitis, asthma, and eosinophilia. Treatment of asthma with CS (corticos-
teroids) may suppress clinical signs of EGPA. Further, agents such as omal-
izumab or leukotriene modifiers may enable weaning from CS, subsequently
unmasking EGPA. We report a case of EGPA with onset following cessation
of systemic CS and complicated by mesenteric vasculitis with bowel perfora-
tion. Case Presentation: A 56-year-old man with allergic rhinitis, chronic sinusi-
tis, one-year history of steroid-dependent asthma, and eosinophilia (0.4-
1.9K/uL) was hospitalized with severe epigastric abdominal pain, worsening
dyspnea, and left upper extremity weakness and numbness that developed one
week after abrupt discontinuation of oral prednisone. Asthma therapies included
inhaled CS, long-acting bronchodilators, montelukast, systemic CS, and oma-
lizumab. Extensive eosinophilia workup was previously negative. Physical
examination on presentation was significant for bibasilar crackles, periumbil-
ical tenderness, and decreased sensation to and weakness of the left hand. Data:
WBC 26K/uL, absolute eosinophil count 15.2K/uL, CT chest: peribronchial
ill-defined ground glass opacities and tree in bud nodules, BAL: 35%
eosinophils, EGD: patchy erosions from distal duodenum to the middle jejunum,
C-ANCA positive with a titer 1:256, Myeloperoxidase antibody elevated at 111
AU/mL. A diagnosis of EPGA was made and pulse dose methylprednisolone
ABSTRACTS: POSTER SESSIONS
was initiated. Xolair and montelukast were discontinued. He was subsequently
treated with Rituxumab 375mg/m2 for four weeks. Six weeks following dis-
charge, he developed severe abdominal pain and presented with an acute
abdomen. Exploratory laparotomy revealed full thickness perforation of the
proximal jejunum. Histopathological evaluation of the resected segment was
consistent with eosinophilic vascultitis. Post-operatively, prednisone 25 mg and
cyclophosphamide 100 mg daily have resulted in resolution of eosinophilia and
improvement in symptoms. Conclusion: EGPA may be precipitated by CS with-
drawal in patients with adult onset, steroid-dependent asthma. Consequently,
clinicians should cautiously monitor for signs of EGPA when tapering CS in
severe asthma patients, especially in those with eosinophilia.
P166
TREATMENT OF REFRACTORY MACROPHAGE ACTIVATION
SYNDROME IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRI-
TIS WITH HIGH DOSE ANAKINRA.
J. Kwong1, T. Peng*2, A. Mohiuddin1, P.F. Weiss3, R.Q. Cron4, D. Chefitz1,
V. Craig1, D. Weissmann1, J. Andujar-DeLaCruz1, L.N. Moorthy1, 1. New
Brunswick, NJ; 2. Edison, NJ; 3. Philadelphia, PA; 4. Birmingham, AL.
Background: Macrophage Activation Syndrome (MAS), a potentially fatal
complication of sJIA (systemic juvenile idiopathic arthritis), is characterized
by high persistent fevers, hepatosplenomegaly, lymphadenopathy, pancytope-
nia, hyperferritinemia, hypertriglyceridemia and liver dysfunction. Objective:
To describe a case of sJIA and MAS requiring high dose anakinra (interleukin-
1 receptor antagonist). Case Description: An 8-year-old female with sJIA
improved with pulse methylprednisolone (30 mg/kg/day IV x 3 days), anakinra
(3 mg/kg/day SQ), and tocilizumab (monoclonal interleukin-6 receptor anti-
body) infusion. Two weeks later, she developed unremitting fevers (105°F)
and MAS was suspected. Results: She had hyperferritinemia, elevated d-dimers,
transaminitis, and hypertriglyceridemia. Bone marrow biopsy revealed hemo-
phagocytosis and anti-CD163 staining identifying activated histiocytes. She
received high dose methylprednisolone (30 mg/kg/day IV x 6 days, then tapered
over 7 months), cyclosporine, intravenous immunoglobulin, and anakinra (Table
1) for MAS. Anakinra was increased from 3 mg/kg/day to 12 mg/kg/day. Fever
resolved in 4 days, laboratory markers improved and she was discharged home
in 14 days. Medications were tapered over 12 months. She subsequently flared
and was controlled on daily anakinra. She was then switched to monthly
Canakinumab, and her disease continues to be in remission on Canakinumab.
Discussion: We report a case of MAS occurring during the initial presentation
of sJIA. Excess interleukin-1 can lead to the clinical and laboratory findings
of sJIA and MAS, and the up regulation of interleukin-6. Uncontrolled pro-
duction and activation of macrophages and T lymphocytes lead to MAS man-
ifestations, including prolonged high fever, pancytopenia, coagulopathy, lym-
phadenopathy, hepatic insufficiency, and neurologic dysfunction. MAS can
rapidly progress to multi-organ failure and death if not treated aggressively.
Anakinra is a recombinant interleukin-1 receptor antagonist with a short half-
life (~ 4-6 hours). The usual dosage of anakinra is 1-2mg/kg/day. Our patient
responded to a 4-fold increase in standard dosing, without adverse events. Our
experience suggests that high dose anakinra is effective and safe in refractory
MAS secondary to sJIA.
Table 1 – Response after Increased Anakinra Dosing
VOLUME 113, NOVEMBER, 2014 A71
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A72
ABSTRACTS: POSTER SESSIONS
P167
PRIMING OF ANAPHYLAXIS WITH SEQUENTIAL ALLERGEN
EXPOSURE IN A 35 YEAR-OLD MALE.
R.S. Paul1, L. Anderson2, A. Rafi2, J. Yusin*2, 1. San Francisco, CA; 2. Los
Angeles, CA.
Background: The clinical evolution of anaphylaxis is highly variable,
depending on the volume of antigen exposure and degree of sensitization
amongst other factors. Such a reaction may even progress in a stepwise fash-
ion with sequential allergen exposures. A phenomenon of “anaphylactic prim-
ing” can be conceived given that the magnitude of basophil, Langerhans and
mast cell activation is quantitatively linked to the degree of IgE binding via
FcεRI, FcεRII and Galactin 3 receptors. It thus follows that an intimate series
of individually small allergen challenges may translate into a summation of
effector cell activation and ‘readiness’ for histamine and vasoactive mediator
release. We report a case of anaphylaxis that likely exemplifies this phenome-
non. Case presentation: A healthy 35 year-old male with no prior atopic his-
tory was outdoors when he was bitten on the left leg by a fire ant. The reaction
that ensued was limited to local swelling and irritation of the affected extrem-
ity. A few hours later, he ate lunch consisting of beef, sea bass and pesto. After
15 minutes, he developed facial and lip swelling, throat closure and dyspnea
and heralded emergency medical services. His management in the field and in
the emergency room entailed intramuscular epinephrine and intravenous diphen-
hydramine with relief of symptoms. Work-up in the allergy clinic found him
to have an obstructive pattern on spirometry with reversibility. Skin prick test-
ing demonstrated significant reactions to peanut, tree nut, dust mite, grass mix,
Bermuda mix, weed mix, fire ant, horse, dog and cat. He was advised to avoid
NSAIDs, sulphites, peanuts, tree nuts, fish and exposure to fire ant venom. He
was prescribed oral cetirizine 10 mg with an epinephrine auto-injector and an
albuterol inhaler to use as needed for anaphylaxis and/or bronchospasm. Con-
clusion: Anaphylaxis due to immediate hypersensitivity represents a state of
clinically significant histamine and inflammatory mediator release from effec-
tor cells upon binding and cross-linking of IgE. The short chemical half-life
argues that such mediators are released not only in remarkable quantity but in
synchrony in this setting. Recent allergen exposure in the form of fire ant venom
in this case may have recruited effector cells into a state of readiness, thereby
orchestrating a more profound level of mediator release following the second
allergen challenge.
Skin Prick Results
A72 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P168
PANCYTOPENIA IN A PATIENT WITH GOOD’S SYNDROME.
J. Regan*, W. Stevens, B. Stein, P. Avila, Chicago, IL.
Good’s Syndrome is a rare disorder associated with thymoma, hypogam-
maglobulinemia, low peripheral B cells, and abnormal cell-mediated immu-
nity. Complications from this disease include increased incidence of infec-
tions and autoimmune diseases. Since the discovery of Good’s Syndrome in
1955, the prevalence of this disease is estimated to be only approximately 5%
of patients with thymomas. We present a case of a 62 year-old male with a his-
tory of Good’s Syndrome status post thymectomy receiving intravenous
immunoglobulin replacement who presented with mild dyspnea on exertion
and right arm swelling. The patient was found to have a right upper extremity
deep venous thrombosis (DVT). Interestingly, he was also incidentally found
to be pancytopenic with a white blood cell count of 3, hemoglobin of 4.9, and
platelets of 27. A bone marrow biopsy showed normocellular marrow with lack
of red blood cell precursors and very rare megakaryocytic precursors concerning
for developing aplastic anemia or pure red cell aplasia. Infectious workup includ-
ing screening for human immunodeficiency virus, parvovirus, herpes virus,
Epstein-Barr virus, and cytomegalovirus was unremarkable. Hypercoagula-
bility workup for the DVT was negative including screening for Factor V Lei-
den, Prothrombin, Protein S, Protein C, Lupus Anticoagulant, and Antithrom-
bin III dysfunction. The patient was started on prednisone 100mg daily and
cyclosporine 250mg twice a day with improvement in anemia but very little
response in his thrombocytopenia. Unfortunately, the patient re-presented 1
month later with hearing loss, elevated liver function studies, and acute renal
failure attributed to cyclosporine toxicity and this medication was subsequently
discontinued. As he continued to be thrombocytopenic, the patient was then
started on N-plate weekly. The patient’s condition continued to deteriorate with
multiple hospitalizations for failure to thrive. His poor performance status
precluded aggressive treatments including immunosuppression and the patient
ultimately passed away. In summary, this is a very interesting case of a patient
with Good’s syndrome found to have pancytopenia.
P169
MINOCYCLINE-INDUCED ANAPHYLAXIS IN AN ADOLESCENT
FEMALE.
T. Peng*1, A. Ettinger2, C. Maccia2, A. Weller2, L. Moorthy2, 1. Edison, NJ;
2. New Brunswick, NJ.
Introduction: Minocycline is a semisynthetic tetracycline derivative used
in the treatment of acne vulgaris. It is associated with several adverse effects
including drug-induced lupus erythematosus, drug reaction with eosinophilia
and systemic symptoms, and serum sickness. There are few reported cases of
anaphylaxis to minocycline. Objective: To describe a patient with acne vulgaris
who developed minocycline-induced anaphylaxis. Case Description: A 16 year
old female with acne vulgaris treated with minocycline presented with a 2 day
history of diffuse, erythematous and pruritic rash, and fever (maximum tem-
perature of 38.8°C). Symptoms began approximately one hour following
minocycline ingestion and progressed to the development of arthralgias, eme-
sis, edema of the hands and feet and throat swelling. Patient was tachycardic
upon presentation in the emergency department. She received a 1 liter normal
saline bolus, diphenhydramine and was admitted. Results: Patient had ele-
vated c-reactive protein (12.6mg/dL) and sterile pyuria. Complete blood count,
complete metabolic panel C1 Esterase inhibitor functional assay, antinuclear
antibody (ab), anti-neutrophilic cytoplasmic ab, anti-double stranded DNA
ab, complements C3 and C4, were within range. Blood and urine cultures were
negative. Patient discontinued minocycline 2 days prior upon onset of symp-
toms when rash appeared. Patient was started on Solumedrol (2 mg/kg/day
divided every 6 hours). On HD (hospital day) #2, she was switched to Pred-
nisone 20 mg BID. Patient complained of “scratchy” throat, shortness of breath
and flushing concerning for anaphylaxis. 0.3 mg of Epinephrine was adminis-
tered intramuscularly. Patient’s rash continued to improve and symptoms of
edema, shortness of breath and fever resolved. Patient was discharged on HD#3
with Cetirizine, Ranitidine, 7-day steroid taper and EpiPen prescription. Dis-
cussion: Minocylcine-induced anaphylaxis has been discussed in a few case
reports in the existing literature. Our patient developed symptoms 1 month after
the initiation of minocycline. Patient’s symptoms partially improved after treat-
ment with antihistamines and steroids, but she required an intramuscular dose
of epinephrine, and was continued on an oral steroid course. As minocycline
continues to be one of the important treatments for acne vulgaris, clinicians
must be vigilant for its potential adverse effects.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A73
P170
DRESS FOLLOWING PRES.
S.M. May*, N.L. Ott, A. Joshi, M. Hartz, Rochester, MN.
Introduction: Drug Related Eosinophilia with Systemic Symptoms (DRESS)
is a rare reaction to medications that occurs 2-6 weeks after drug exposure and
typically presents with fever, rash, facial edema, lymphadenopathy, eosinophilia
and transaminitis. Common medications are aromatic anti-convulsants, sul-
fonamides, and Dapsone with immunosuppression being a risk factor. Reacti-
vation of herpes virus family is seen in 60-75% of the cases. The mainstay treat-
ment is removal of the offending agent and high-dose steroids. Case Description:
17 year-old white male with history of sideroblastic anemia status post bone
marrow transplant, immunosuppression, Posterior Reversible Encephalopathy
Syndrome (PRES) since January, adrenal insufficiency and atopic diseases that
presented to the hospital with a very pruritic, bright red rash, shaking chills and
fevers. He was admitted for presumed adrenal insufficiency and graft-versus-
host disease leading to the rash. Rash was biopsied, he was started on hydro-
cortisone 15 mg TID and cefepime. Family remarked that the fevers and chills
have been present since diagnosis of PRES that was being treated with leve-
tiracetam, amlodipine, furosemide. Patient was also on Dapsone for prophy-
laxis. He continued to have fevers and absolute eosinophil count was noted to
be 5,420 on steroids with elevated liver enzymes. Allergy was consulted, viral
titers at this time were negative. All the mentioned drugs were discontinued and
prednisone 100 mg daily was started with resolution of symptoms and labora-
tory abnormalities. A few months later, the patient had reactivation of EBV
treated with Rituximab and developed erythroderma, mild transaminitis and
later eosinophilia (1,240). Prednisone was increased back to 50 mg daily and
symptoms resolved. Conclusion: DRESS is a rare reaction to drugs that can be
difficult to diagnose and even more difficult to determine the culprit medica-
tion due to the delayed timing. There are common drugs associated with this
disorder, such as dapsone and amlodipine, but multiple medications have been
reported as individual cases including Levetiracetam and furosemide. Our
patient was taking all four of these. Reactivation of herpes viruses is common
and should be evaluated. Finally, immunosuppression is thought to be a risk
factor and DRESS should be included in the differential in these patients pre-
senting with rash, systemic symptoms and especially if eosinophilia is pres-
ent.
Rash biopsy site.
P171
ANTICONVULSANT HYPERSENSITIVITY SYNDROME ASSO-
CIATED WITH A SYMPTOM FREE PERIOD.
S. Patel*1, E. Nwaobasi-Iwuh2, A. Wolff3, 1. Summit, NJ; 2. Morristown,
NJ; 3. Newark, NJ.
Introduction: Anticonvulsant hypersensitivity syndrome (AHS) is a known
potentially life-threatening complication of phenytoin, carbamazepine and phe-
nobarbital therapy. Although its occurrence is rare, when AHS occurs, it often
results in hospitalization and even death. Although the exact mechanism is
unknown, it is thought to be an immunologic adverse drug event that is a T-
cell–mediated, delayed hypersensitivity reaction. Case: An 8 year old male with
a history of seizure disorder maintained on phenytoin for 10 days, presented
to the ED with high fevers and a pruritic rash on his trunk, extremities and face.
On exam, pertinent positives included a temperature of 102F and a general-
ized erythematous, maculopapular rash. Phenytoin was discontinued. His fevers
and rash resolved within 48 hours without steroids. He was subsequently dis-
charged only to return to the ED 24 hours later with worsening rash and a
fever of 103F. On examination, he appeared ill with tachycardia and hypoten-
sion. His pharynx was erythematous with cervical lymphadenopathy and he
had a generalized maculopapular, nonblanching rash. He was started on a
dopamine drip, vancomycin and ceftriaxone for presumed sepsis. Results: His
CBC revealed a WBC count of 14,000/ml, with 73% neutrophils, 11% lym-
ABSTRACTS: POSTER SESSIONS
phocytes, 10% monocytes, 2% eosinophils. His LFTs were significant for an
elevated AST of 80 U/L, and ALT of 100 U/L. Sepsis workup including blood
cultures was negative. Skin biopsy was consistent with the diagnosis of drug
hypersensitivity reaction. Discussion: The time from starting phenytoin and
appearance of rash with other positive findings noted above were all consis-
tent with AHS. The patient was treated with intravenous steroids and improved.
AHS is unusual in that it occurs later than most other drug reactions; about 2-
6 weeks after initiation of the offending agent. Frequently, the hallmark fea-
tures of fever, rash, and lymphadenopathy are accompanied by multiorgan-sys-
tem decompensation. Recognition of this syndrome, which may have variable
presentations, is the key to prompt discontinuation of the drug and further man-
agement. This case demonstrates one such variable presentation and stresses
the importance of recognizing a symptom free period prior to progression of
the disease to the state of shock. Furthermore, it reinforces the importance of
including AHS and DRESS in the differential diagnosis of sepsis.
P172
FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME
(FPIES) IN A PATIENT WITH PRIOR IGE MEDIATED FOOD
ALLERGY.
J. Giacinto Lawrence*1, P. Ponda2, 1. Roslyn, NY; 2. Manhasset, NY.
Introduction: FPIES is a disorder presenting as repeated bouts of emesis
within 1-3 hours with or without subsequent diarrhea 5-8 hours after ingestion
of an offending food. It is primarily a non-IgE-mediated hypersensitivity dis-
order commonly diagnosed during infancy. The pathophysiology although not
yet fully defined, likely involves stimulation of antigen-specific T cells and a
resulting proinflammatory cytokine cascade inducing increased permeability
of intestinal mucosa. The gold standard for diagnosis is the oral food chal-
lenge (OFC). The most common food triggers are milk and soy though solid
foods can also induce FPIES. We present a case of IgE-mediated soy allergy
treated with years of avoidance that presented as FPIES upon re-introduction
of soy. Methods: A 6 month old female with eczema who developed a facial
rash after drinking soy formula was found to have positive serum and skin prick
tests (SPT) to soy, milk and eggs (see Figure 1). She had an OFC for baked egg
at approximately 3 years old and passed. One year after incorporating baked
egg into the diet, the patient presented for a soy OFC. Results: The patient tol-
erated 5oz. (150mL) of liquid soy challenge without reaction and was subse-
quently discharged. She returned approximately 2 hours after initiation of the
soy challenge due to emesis. The patient’s vital signs remained stable; exam
was unremarkable with the exception of pallor; no rash was present. She
remained alert, responsive and talking with continued repetitive nausea and
vomiting. She received IM Benadryl and Epinephrine and was subsequently
transferred to the ER by ambulance for continued monitoring where she received
fluids, steroids and an antiemetic. The patient recovered and continues to avoid
soy. Conclusion: Although rare, cases of IgE-mediated allergy converting to
FPIES have been reported. Although FPIES is thought to be a predominantly
non-IgE-mediated reaction, the role of IgE remains unclear. A future role for
other diagnostic measures, such as patch testing, to quantify the risks of food
challenge has been suggested however more research is necessary before these
tests can be recommended. Given these rare cases, there should be a higher
awareness and vigilance when diagnosing or challenging a patient with prior
IgE-mediated food allergy for possible non-IgE mediated reactions.
Figure 1: Serum IgE and skin testing over time.
P173
AN ATYPICAL PRESENTATION OF CHRONIC EOSINOPHILIC
PNEUMONIA.
A. Yang*, R. Ganim, J. Mueller, P. Gurung, Springfield, MA.
Introduction: Chronic Eosinophilic Pneumonia (CEP) is an eosinophilic
lung disease that is idiopathic and progressive. It is an uncommon disorder
affecting females, usually of the fifth decade, who present with chronic respi-
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ABSTRACTS: POSTER SESSIONS
ratory and systemic symptoms. An atopic history is common but may not be
present.The diagnosis is supported by eosinophilia greater than 1000cells/uL,
biopsy or bronchoalveolar lavage, pulmonary function tests (PFT), imaging
and the exclusion of other causes for eosinophilic lung disease. We present a
case of an uncommon condition with an atypical presentation which illus-
trates the importance of having a differential diagnosis in cases that may seem
ordinary. Case Presentation: A 64 year old female without a smoking history
presented to clinic with a four month history of left posterior cervical painless
lymphadenopathy. She denied any weight changes, fever, chills, hemoptysis,
poor appetite, dyspnea or cough. Physical examination showed she was breath-
ing on room air at 97% with clear lungs sounds bilaterally without egophony
nor dullness to percussion. There were two lymph nodes which were smooth,
nontender and mobile of 1cm. HRCT showed multiple mediastinal, and bilat-
eral hilar lymphadenopathy measuring 1.3 to 2.2 cm with groundglass opaci-
ties in subpleural distribution with basilar predominance. No honeycombing,
bronchiectasis, pleural effusion, consolidation, nodules nor masses were noted.
She was referred to pulmonary clinic for workup for an inflammatory lung
process. PFT showed a FEV1/FVC ratio of 82% and a diffusion capacity of
59%. Additional findings showed eosinophilia of 43.4%, with absolute
eosinophil count of 5,000cells/uL. Hypersensitivity pneumonitis panel, ANA,
ANCA, and anti-CCP were negative. IgE was elevated at 838IU/mL. She had
a right lung wedge resection which showed patchy eosinophilic infiltrates and
intra-alveolar macrophages indicative of chronic eosinophilic pneumonia. Dis-
cussion: The initial presentation of posterior cervical lymphadenopathy and
lack of respiratory symptoms presented a diagnostic challenge. CEP shows
peripheral consolidation with upper lobe predominance. Although the pattern
of HRCT indicated an interstitial lung pneumonia such as usual or fibrotic sub-
type, biopsy confirmed it to be CEP. The combination of clinical history and
supporting clinical studies will guide the clinician towards a diagnosis for appro-
priate management.
P174
IGM DEFICIENCY PRESENTING AS STRONGYLOIDES HYPER-
INFECTION.
J.G. Ghably*1, A. Kapila1, G. Shaw1, T. Roy1, R. Byrd1, K. Guha2,
1. Johnson City, TN; 2. Winston-Salem, NC.
A 59 year old male with a history of type 2 diabetes, peripheral vascular
disease, chronic kidney disease, and multiple lacunar infarcts is hospitalized
for pontine stroke and treated for klebsiella and enterococcus pneumonia and
Clostridium difficile colitis. He was readmitted following month for oxygen
desaturation and altered mental status eventually requiring intubation and
mechanical ventilation. EEG and lumbar puncture revealed normal findings.
Cultures of sputum and bronchial washings grew Klebsiella pneumonia, van-
comycin resistant enterococcus, candida, HSV1 and he was placed on appro-
priate antibiotics. Stool studies were positive for C. difficile and he was con-
tinued on oral vancomycin. Patient developed transient eosinophilia that was
initially attributed to underlying infection. Eventually, tracheotomy was per-
formed and patient was placed on chronic mechanical ventilation. After com-
pletion of antibiotics, he continued to exhibit leukocytosis and eosinophilia,
chest infiltrates remained stable, and his diarrhea had not resolved despite con-
tinued vancomycin treatment. Strongyloides titer tested normal so further infec-
tive workup was pursued revealing sinusitis, otitis media, and candida cystitis.
Despite receiving appropriate treatments, leukocytosis and diarrhea persisted.
Stool was tested for ova and parasites and results were positive for Strongy-
loides stercoralis. After receiving 3 doses of invermectin, his diarrhea and
encephalopathy resolved and he was able to be weaned completely off venti-
lator. Immunodeficiency evaluation revealed elevated IgE levels, low IgM
levels, and normal IgG and IgA levels. Hyperinfection with Strongyloides ster-
coralis is generally seen in immunocompromised hosts with prolonged steroid
therapy, acquired immune deficiency, malignancy, or chronic illness. Since
the disseminated infection has a high mortality rate, it is imperative to recog-
nize the disease and offer early treatment. Ivermectin is the treatment of choice.
This nematode primarily affects the gastrointestinal system and the lungs, but
may rarely manifest in the central nervous system as mycotic aneurysm, intracra-
nial hemorrhages, or vasculitis. Primary selective Ig M deficiency is a rare form
of the immune disorder associated with severe life threatening infections and
severe allergic reactions. Intravenous immunoglobulin is the only treatment
modality available without clear benefits.
A74 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P175
A CASE OF HYPEREOSINOPHILIC SYNDROME PRESENTING
WITH MYOCARDITIS.
N. Fenny*, K. McGrath, A. Peters, Chicago, IL.
Hypereosinophilic syndromes (HES) are characterized by persistent hyper-
eosinophilia with eosinophilic infiltration and mediator release that cause dam-
age to multiple organs. The peripheral blood hypereosinophilia is defined as
eosinophils exceeding 1.5 x 10 9/L on two separate occasions separated by at
least one month. We describe a 53 year old female with a history of ovarian
cancer, asthma, chronic rhinosinusitis with nasal polyps (CRSwNP) and
eosinophilia who presented with chest pain of 4 days duration and was found
to have an absolute eosinophil count (AEC) of 15. 4 x 10 9/L. Her troponins
and CKs were elevated. She denied initiation of any new medications. She was
previously seen as an outpatient for eosinophilia, asthma and CRSwNP. At her
most recent clinic visit 18 months ago, while undergoing chemotherapy with
steroids for the ovarian cancer, her eosinophil count was 0. Her highest previ-
ous AEC was 8.85 x 10 9/L. Previous workup for Churg Strauss and skin test-
ing for Aspergillus fumigatus to evaluate for ABPA was negative. Workup
included a peripheral smear showing absolute eosinophilia with normal mor-
phology. ANA, cANCA, pANCA, tryptase and quantitative immunoglobulins
were normal. She was HIV negative. Strongyloides serology as well as stool
O &P were negative. An echocardiogram showed an ejection fraction (EF) of
59% and a small pericardial effusion. A cardiac MRI revealed a normal EF,
subtle evidence of edema and diffusely elevated gadolinium ECV fractions
thought consistent with myocarditis. FISH analysis was negative for the pres-
ence of a deletion of CHIC2, or translocations involving the FIP1L1 and
PDGFRA genes. She was treated with methylprednisolone 60mg IV every 6
hours with decline of her AEC to 0.4 x 10 9/L She was discharged home on
prednisone 60 mg daily for 1 week with follow up with hematology for possi-
ble bone marrow biopsy and cardiology for a cardiac catheterization with biopsy.
However, she was unable to follow up and presented 1 month later with chest
pressure. She was found to have an AEC of 11.5 x 10 9/L. She underwent an
endomyocardial biopsy that showed eosinophilic myocarditis and was treated
with high dose steroids with improvement. The most likely diagnosis is idio-
pathic HES. A bone marrow biopsy is pending to exclude other etiologies such
as primary HES due to myeloproliferative disorder or systemic mastocytosis.
P176
EMERGING TREND OF HENNA TATTOOS CAUSING A CLINI-
CAL CONTACT DERMATITIS.
P. Buddiga*, Fresno, CA.
Introduction: Henna painting or temporary Henna tattooing traditionally
known as “Mehndi” is a custom used for centuries in the eastern world for bridal
parties or other celebratory occasions. The dyeing agent is Hennotannic acid
and very rarely leads to an allergic reaction or an adverse skin hypersensitiza-
tion. Nevertheless Henna tattoos or painting are usually mixed with para-
phenylenediamine [PPD] to assist with drying as well as darkening the color
hence beautifying the different patterns of Henna art. Methods: A 21 year old
girl with history of allergic rhinitis on Allergen Immunotherapy presents for
her weekly allergy shot and complains that 6 weeks ago she attended a bridal
shower for one of her friends and along with another 6 girls in the same age
range had Henna tattoos painted on their hands and feet. She noticed that a
week later after placement it started to itch, burn and started to swell only at
the site of the tattoo. She immediately applied itch cream and 1% Hydrocorti-
sone with no resolution. She did not seek any professional medical care hop-
ing it would resolve on its own. Henna tattoos usually dissipate by themselves
on their own in 2 weeks. This case is clearly abnormal since the swelling and
coloring is still very distinct at 6 weeks out from application. Upon a serende-
pity consultation in the Allergy shot room she was given high dose topical cor-
ticosteroid plus dimethicone and wrapping at the site with periodic ice com-
presses for comfort. No blisters or other adverse events occured and the lesion
dissipated in 10 days with treatment. Conclusion: Henna is a potent contact
dermatitis agent and must be skin tested or patch tested prior to application. It
contains paraphenyldiamine that can be a significant trigger. Recommenda-
tions are to patch test this agent prior to use and if the Henna artwork does not
dissipate in 2 weeks to see your local allergist or dermatologist for relief and
resolution.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A75
Contact Dermatitis due to Henna Tatoo Six weeks from Application
P177
GRANULOMATOUS DISEASE ASSOCIATED WITH IMMUNOD-
EFICIENCY.
D. Shah*, T. Truong, Denver, CO.
Introduction: Granulomatous disease is a well-documented complication
of Common Variable Immunodeficiency, primarily seen in lung, but can also
involve skin, liver, spleen, and the GI tract. Autoimmune and lymphoprolifer-
ative disorders are common associations. We present a case of unexplained
granuloma involvement of skin and bone marrow in the setting of selective anti-
body deficiency and MGUS. Case Report: A 56 year-old man with history of
vitiligo, shingles, and pneumonia presented with a 9-year history of chronic
leg ulceration after falling on a boat anchor. Vascular work-up was negative.
Lesions were recurrent despite wound care, antibiotics for secondary infections
and hyperbaric oxygen, but were prednisone responsive. Exam showed numer-
ous pustular ulcers on legs and was otherwise normal. Studies for HIV, hepa-
titis, cryogloblulins, ANA, RF, anti-SSA, anti-SSB, and ACEI were negative.
MRI was negative for osteomyelitis. Multiple ulcer biopsies showed extensive
granulomatous process with no vasculitis. Bacterial, fungal and mycobacter-
ial cultures were negative. Immune evaluation showed low IgA and IgM and
high IgG levels. SPEP/IFE was positive for IgG lambda monoclonal protein.
Antibody titers to H. Influenzae, diphtheria, and tetanus were normal. Strep-
tococcus titers were low despite repeated vaccination with Pneumococcal and
Prevnar vaccines. Lymphocyte subsets showed low lymphocytes and NK cells
and stimulation was low with PHA and tetanus. IL-1 and IFN-gamma responses
were low. Complement levels, toll-like receptor, and IL-12 receptor assay were
normal. CT chest did not show any ILD or lymphadenopathy, including medi-
astinal. Subsequent work-up for myeloma revealed normal bone scan and flow
cytometry. However, bone marrow biopsy revealed numerous non-caseating
granulomas and 15 % plasma cells with normal cytogenetic studies and nega-
tive cultures for bacteria, fungus, AFB and mycobacteria. Patient responded to
treatment with prolonged steroids and IVIG for selective antibody deficiency.
Trial off IVIG after six months resulted in increased sinus and wound infec-
tions and thus was resumed. Conclusion: Diminished cellular responses with
IL-1 and IFN-gamma have been implicated in host defenses against mycobac-
terium; however numerous biopsy cultures in this case were unrevealing. Fur-
ther studies are needed to elucidate the underlying etiology of granulomatous
disease in immunodeficiency states.
P178
ASPIRIN EXACERBATED RESPIRATORY DISEASE (AERD) AND
CEREBROSPINAL FLUID RHINORRHEA: CASE REPORT.
D.A. Carino Cartagena*, A.A. Velasco-Medina, J.C. Fernandez de
Cordova-Aguirre, M.E. Arroyo-Cruz, S. Gonzalez-Flores, G. Velazquez-
Samano, Mexico City, DF, Mexico.
Introduction: Aspirin-exacerbated respiratory disease (AERD) usually join
sinonasal polyposis and bronchial asthma exacerbated by ASA. Given the per-
sistence of symptoms like rhinorrea is important to consider differential diag-
ABSTRACTS: POSTER SESSIONS
noses. Cerebrospinal fluid (CSF) leak could be classified as traumatic and non-
traumatic causes, it’s considered idiopathic when no cause is identified, and
benign conditions of elevated intracranial pressure are ruled out. The cardinal
clinical presentation is persistent rinorraquia confirmed by cytology/cyto-
chemical detection of CSF or ß2-transferrin as part of the diagnostic approach.
Case Report: Female of 52 years old with 1 year of evolution with hyaline ante-
rior rhinorrhea, persistent nasal pruritus, without identificable pattern of pres-
entation, coughing and wheezing exacerbated with the intake of ASA; spirom-
etry with bronchodilator reversibility of 14%, partial response to conventional
therapy for persistent rhinorrhea, no trauma history, CT scan of nose and
paranasal sinuses showed soft tissue density in entire left maxillary sinus, with
concommitant occupation of anterior left ethmoid cells in intimate contact with
cribriform plate. Cytochemical and cytological study confirms the presence
of CSF. As intraoperative finding concommitant maxillary chronic rhinosi-
nusitis were identified due to sinonasal polyposis, after endoscopic closure of
CSF leak total control of symptoms were achieved. Discussion: AERD is a per-
sistent inflammation condition of nasal mucosa, that has been linked to asthma
exacerbations, sometimes sinonasal polyps are not evident clinically or endo-
scopically, its important to assess the specific anatomy of patients with sub-
optimal control sino-nasal symptoms. The non-traumatic CSF leak is one of
the differential diagnoses that should be considered in patients with persistent
rhinorrhea.
Sinus CT Scan. Box: Polyps in Left Maxillary Sinus; Arrow: cerebrospinal
fluid fistula, Oval: Fluid-Air Level suggestive of Chronic Rhinosinusitis
P179
SUCCESSFUL APPROACH TO A PATIENT WITH MULTIPLE
DRUG REACTIONS (INCLUDING SERUM SICKNESS) TO RIT-
UXIMAB.
J.K. Kim*1, S. Deol2, C. Wysocki2, D.A. Khan3, 1. Dallas, IL; 2. Dallas,
TX; 3. Grapevine, TX.
Introduction: We report a case of a patient with 3 mechanistically different
reactions to rituximab and a successful management approach. Methods: Case
report Results: A 30 year old male with steroid-dependent oral pemphigus
vulgaris developed subjective chest and throat tightness, hoarseness, and dif-
ficulty breathing 1 hour after his first rituximab infusion at an outside facility,
which resolved within 15 minutes of stopping the infusion and treatment with
intramuscular (IM) epinephrine. He was evaluated by us 2 years later for rit-
uximab desensitization. Based on his symptoms, we considered the possibil-
ity of drug-induced vocal cord dysfunction, and he received his rituximab
dose after premedication with H1/H2 antagonists and oral corticosteroids with-
out any initial reactions. Eleven days later, he noted a pruritic, red facial and
truncal rash along with severe joint pain which he self-treated by increasing his
daily steroid dose. Serum sickness-like reaction was diagnosed, and he was rec-
ommended to receive high-dose corticosteroids post-infusion. He developed
objective tongue, soft palate, lip, and facial swelling; pruritus; and throat tight-
ness within 30 minutes of his next dose, which resolved over 1 hour with stop-
ping the infusion and treatment with IM epinephrine, IV methylprednisolon,
and diphenhydramine. Due to the immediacy of the visible angioedema, an
IgE-mediated reaction was diagnosed. He underwent a 17 step rapid desensi-
tization protocol to rituximab. The infusion was briefly halted at step 11 (32.5
cc/hr at 4mg/ml) after he experienced subjective chest tightness. It was restarted
30 minutes later at 20 cc/hr when the patient noted subjective lip edema and
palmar pruritus without objective evidence of rash, angioedema, or wheezing.
He was treated with IV diphenhydramine and lorazepam with improvement of
symptoms. At a maintenance dose of 20 cc/hr, he developed 2 urticarial episodes
that resolved with IM epinephrine, antihistamines, and montelukast. After desen-
sitization, he completed 10 days of prednisone 60 mg with no recurrence of
the serum sickness-like reaction. Conclusions: Allergists should be familiar
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ABSTRACTS: POSTER SESSIONS
with the various adverse reactions to rituximab. This case illustrates a patient
with multiple reactions (including serum sickness) who successfully received
rituximab via desensitization and post-infusion corticosteroid therapy.
P180
AN UNUSUAL CASE OF RECURRENT ABDOMINAL PAIN SIM-
ULATING ANGIOEDEMA.
L. Rampur, A. Rubinstein, Z. Ren*, Bronx, NY.
Introduction: Recurrent abdominal pain is frequent in patients with hered-
itary and acquired angioedema. We present a case of recurrent abdominal pain
presumed to have abdominal angioedema, found to have eosinophilic segmental
serosal and muscular enteritis. Methods: Case description Results: 31 year
female was referred for episodic abdominal pain since 2007, recurring every
3 to 6 months lasting several days. She was presumed to have abdominal vis-
ceral angioedema in 2009 treated with systemic steroids with relief of symp-
toms within 2-3 days. MRI during several episodes was consistent with local-
ized Jejunal wall edema in the same 5-6” segment. Lab work at baseline and
during attacks revealed normal C1 esterase inhibitor function of 102%, nor-
mal C4 (20mg/dl), C3 (97mg/dl), Tryptase (5.9 ug/L), autoimmune antibody
panel, Celiac panel, alpha 1 anti-trypsin and quantitative immunoglobulin assay
including ESR, electrolytes, liver and renal function and stool examination. But
C1q level was low (< 1.2 ugeq/ml). Absolute Eosinophil count was1400k/ul
(15%) when she was asymptomatic and as high as 3500k/ul (33%) during an
episode. IL-5 levels were normal. FISH analysis did not detect translocations
or deletions of the chromosome 4q12 resulting fusion of FIP1L1 and PDGFRA
genes and rearrangement of PDGFRB and FGFR1. Peripheral blood did not
show a mutation for JAK2 V617F myeloproliferative disorder and and molec-
ular analysis showed normal alleles detected RT-PCR for BCR-ABL P210. Mul-
tiple upper endoscopies and colonoscopies including capsule endoscopy have
been unremarkable. In a recent admission a MRI showed further spread of the
jejunal thickening to around 10”. A laparoscopic jejunal biopsy of the edema-
tous region showed dense serosal and muscularis propria eosinophil infiltrates
suggestive of eosinophilic enteritis, not involving the jejunal mucosa. Conclu-
sion: This patient’s presentation of recurrent abdominal pain with localized
jejunal wall edema was suggestive of abdominal angioedema attacks. Work up
for hereditary or autoimmune angioedema was negative. The only clue for the
diagnosis was the fluctuating peripheral eosinophilia albeit with absence of
increased eosinophil infiltrates in mucosal jejunal biopsies. Hyper eosinophilic
syndrome was excluded by the absence of the relevant mutations in
FIP1L1/PDGRA. Diagnosis was obtained by serosal and muscularis biopsy of
the edematous jejunal segment.
P181
A CASE OF MULTIPLE MYELOMA MANIFESTING AS LIFE-
THREATENING ANGIOEDEMA.
S. Bose*, D. Nayak, C. Saltoun, Chicago, IL.
Introduction: A deficiency in C1 esterase inhibitor (C1-INH) can be caused
by hereditary angioedema (HAE) or acquired angioedema (AAE). HAE occurs
from a gene mutation that leads to either lack of C1-INH or production of non-
functional C1-INH. AAE results from consumption or inactivation of C1-INH,
usually in the setting of lymphoproliferative disorders. Several cases of AAE
have been reported in conjunction with monoclonal gammopathy of undeter-
mined significance (MGUS) and non-Hodgkin’s lymphoma. We report a rare
case of a patient, who presented with AAE, leading to a diagnosis of multiple
myeloma (MM). Case: A 70-year-old male with asthma and chronic idiopathic
urticaria presented to the ED with tongue and right anterior neck swelling with-
out urticaria. Because his uvula could not be visualized on presentation, he was
intubated. The patient’s admission laboratory results were indicative of anemia,
acute kidney injury and hypercalcemia. They also showed an increased glob-
ulin gap, an elevated serum IgG level, high serum free lambda light chains and
a low C4. The patient’s presentation was concerning for AAE due to an under-
lying malignancy. His angioedema did not improve approximately 12 hours
after administration of intravenous steroids in the ED. The patient received 1
dose of C1-INH concentrate and within a few hours his angioedema rapidly
regressed. C1-INH and C1-INH functional levels were normal, but the C1q
level was found to be low, suggestive of AAE. A bone marrow biopsy revealed
~35% plasma cells, consistent with a diagnosis of MM. The patient’s
angioedema resolved after administration of C1-INH concentrate and initia-
tion of treatment for his MM. Discussion: The most common malignancies
known to cause AAE are indolent lymphomas. However, we report a unique
case of MM manifesting as AAE. The patient in our case suffered from AAE
A76 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
likely secondary to autoantibodies against C1-INH that are produced by aber-
rant plasma cells. Mechanistically, it is believed that autoantibodies bind to and
destabilize the C1-INH complex, leading to proteolytic cleavage and inactiva-
tion of C1-INH and downstream generation of bradykinin. Conclusion: To our
knowledge, this is the first reported case of AAE due to MM. This case high-
lights the principle that the management of AAE requires treatment of its under-
lying cause, which may be an autoimmune disorder or a malignancy.
P182
FATAL ASEPTIC MENINGITIS DUE TO COXSACKIE B3 VIRUS
INFECTION IN A PATIENT WITH ACQUIRED HYPOGAMMA-
GLOBULINEMIA.
T.V. Palacios*, M. Lawrence, L. Borish, Charlottesville, VA.
Introduction: Human enteroviral infections are the most common cause of
meningoencephalitis in the United States. Enteroviral infection is usually a self-
limited disease. However, in an immunocompromised patient, infections can
be fatal. We present a case of an adult female patient with a history of Evan’s
syndrome treated with prior splenectomy and rituximab who subsequently
developed panhypogammaglobulinemia after which, despite receiving antibody
replacement, she developed a progressive and ultimately fatal meningoen-
cephalitis due to human Coxsackie B3 virus. Case Description: A 28-year-old
white female presented to the University of Virginia with a 4-month history of
progressive encephalopathy. She had a history of Evan’s Syndrome (autoim-
mune hemolytic anemia and idiopathic thrombocytopenia purpura) for which
she had received treatment with rituximab and splenectomy 5 years prior to
presentation. 5 months previously, she was hospitalized for Influenza A with
concurrent facial Pseudomonas cellulitis and bacteremia. During that admis-
sion, she was found to have severe panhypogammaglobulinemia with 0% cir-
culating CD19+ B cells and intravenous immunoglobulin (IVIG) was started.
Her exam on admission was also consistent with aseptic meningitis. She was
subsequently readmitted with worsening encephalopathy and repeat lumbar
puncture and MRI were negative for an infectious process. A stereotactic brain
biopsy was obtained, which was also negative for infection. Despite empiric
treatment with broad-spectrum antibiotics, she continued to decline neu-
rocognitively and hospice care was pursued. The patient expired and subse-
quent post-mortem brain biopsy identified human Coxsackie virus B3, on the
basis of positive viral protein (VP)2, VP4 and VP 5` untranslated region (UTR)
by PCR. Conclusion: Previous treatment of this patient with rituximab for Evan’s
syndrome was associated with persistent profound B cell lymphopenia and sec-
ondary hypogammaglobulinemia. Given the observation that some patients
treated with rituximab will develop persistent lymphopenia and hypogamma-
globulinemia, and the increasing use of rituximab in the treatment of malig-
nancies and autoimmune disorders, physicians must have increased awareness
of the risk of secondary B cell and antibody deficiency and susceptibility to
enteroviral meningeal infections in this population.
P183
PREVENTION OF KOUNIS SYNDROME EPISODES USING A
COMBINATION OF KETOTIFEN AND NON-SEDATING ANTI-
HISTAMINES.
J. McCracken*1, C. Schlegel2, S. Sur2, 1. League City, TX; 2. Galveston,
TX.
Introduction: Kounis syndrome is a rare condition when allergy or hyper-
sensitivity can lead to cardiovascular symptoms. Symptoms are caused by the
release of inflammatory mediators from mast cells which can have cardiovas-
cular effects including coronary spasm. Methods: We report the case of a 61
year old male with a history of allergic rhinitis, asthma, monoclonal gam-
mopathy of undetermined significance (MGUS) and eosinophilic esophagitis
who was referred to us for evaluation of urticaria, chest pain and shortness of
breath (SOB). His symptoms have been occurring over the past 2.5 years and
rash typically precedes the cardiac symptoms. Six months prior to his first visit
in our clinic, he had an acute myocardial infarction requiring stent placement.
Physical exam was normal. Laboratory work-up was significant for elevated
eosinophils, elevated IgE, and intermittently elevated tryptase with these
episodes. Skin prick testing was positive for trees, weeds, grass, dust mite, cock-
roach, and cat. Bone marrow biopsy was c-kit negative. He was started on fex-
ofenadine 180 mg in the morning, cetirizine 10 mg in the evening, and keto-
tifen 1 mg twice a day. Two weeks later, he again had chest and jaw pain
associated with development of a rash on his palms that required hospitaliza-
tion. Angiography showed patent stent. His medications were increased to fex-
ofenadine 180 mg 2 tabs in AM, cetirizine 10 mg 2 tabs in PM and ketotifen
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A77

ABSTRACTS: POSTER SESSIONS

2 mg twice a day. He was unable to tolerate the increased doses of fexofena-
dine and cetirizine so he resumed his initial dosing of those medications. He
now reports symptoms improved since last follow-up. Discussion: We believe
his presentation of urticaria associated with severe chest pain and SOB is sug-
gestive of Kounis syndrome. Current literature focuses more on the acute treat-
ment of the allergic and cardiac symptoms, and less on the prevention of symp-
toms. In this patient, ketotifen, a mast cell stabilizer, and non-sedating
antihistamines were utilized to control symptoms. Conclusion: We present a
case of possible Kounis syndrome in a patient who is successfully being treated
with non-sedating antihistamines and ketotifen. This reports to the allergists
that this combination therapy can be a useful management option when treat-
ing patients with Kounis syndrome.
P184
RECURRENT PERIOPERATIVE ANAPHYLAXIS IN A 24 YEAR
OLD FEMALE WITH UNTREATED ASTHMA.
J. Kannan, J. Bernstein*, Cincinnati, OH.
Introduction: Perioperative anaphylaxis is a life threatening IgE or non-IgE
mediated condition presenting with symptoms including urticaria, angioedema,
bronchospasm, arrhythmias, and hypotension.1 Its prevalence has been reported
from 1:3,500 to 1:20,000 with a mortality rate of 3 to 9%. The most common
culprits include antibiotics, neuromuscular blocking agents, latex, hypnotics,
opioids, colloids, dyes, and nonsteroidal anti-inflammatory medications. Case
Description: The patient was a 24 year old female with a history of asthma,
rhinitis, egg allergy, eczema, and prior tonsillectomy who presented after two
episodes of anaphylaxis while undergoing oral jaw surgery. During the first
surgery she developed hypotension, wheezing, and hypoxia leading to car-
diopulmonary arrest. She was treated with epinephrine, fluids, and corticos-
teroids. Skin prick testing was found positive to vecuronium, succinylcholine,
rocuronium, cisatracurium, penicillin, sulfa, ciprofloxacin, and cefazolin. These
agents were avoided during the next operation, but systemic symptoms recurred.
Further evaluation showed a normal FEV1 with 14% reversibility post bron-
chodilator and an exhaled nitric oxide (eNO) of 52ppb indicative of airway
inflammation. Urine tryptase and thyroid stimulating hormone (TSH) were nor-
mal. She was started on an inhaled corticosteroid. Twenty four hours prior to
her third surgery she was treated with corticosteroids and antihistamines, and
neuromuscular blocking agents and beta blockers were avoided. She tolerated
her subsequent surgeries without complication. Discussion: This case illus-
trates the serious nature of perioperative anaphylaxis. Despite avoidance of
the sensitized agents, anaphylaxis reoccurred. This led to further exploration
discovering poorly controlled asthma which is a known risk factor for ana-
phylaxis.2
deaminase (ADA), purine nucleoside phosphorylase (PNP), DNA ligase 4,
TAC1, BTK, and 22q11 deletion studies were negative and telomeres were
not consistent with dyskeratosis congenita. Thymus was identified on ultra-
sound. Conclusion: Early detection of T cell lymphopenia has led to early treat-
ment and improved prognosis of severe combined immune deficiency. We pres-
ent a case of T and B lymphopenia and IgM and IgA deficiency of unclear
etiology to date. Further studies including whole exome sequencing may reveal
the etiology.
P186
PROLACTINOMA MIMICKING REFRACTORY RHINITIS.
M.S. Motosue*, Rochester, MN.
A 24 year old male presented to the allergy clinic with a four month his-
tory of persistent clear left nasal drainage. Patient denied any history of facial
trauma, facial surgery, nasal polyps, or nasal deviation. Beyond the rhinor-
rhea, the review of systems was otherwise negative. Prior to presenting to allergy
clinic, the patient was seen by his primary care physician and was on daily cet-
irizine, montelukast, and fluticasone nasal spray without any symptom improve-
ment. Given the persistent unilateral rhinorrhea without history of trauma or
surgery, further diagnostic workup was pursued. Computed tomography sinus
imaging revealed a 6.5 x 5.6 x 4.4 cm infiltrative, destructive mass centered in
the sella turcica with intracranial nasopharyngeal extension which was subse-
quently confirmed by MRI. Laboratory results were remarkable for a positive
beta-2 transferrin and an elevated prolactin (532, normal range 3-13 ng/mL).
An endoscopic left nasopharyngeal biopsy was performed with pathology con-
sistent with an atypical pituitary adenoma. The staining profile of the ade-
noma was of a prolactinoma. The patient subsequently underwent neurosurgery
for repair of the CSF leak followed by treatment with cabergoline. Conclu-
sion:Nasal symptoms such as rhinorrhea are commonly encountered in both
the allergy and primary care clinics. Frequently, these symptoms are related to
inflammatory conditions such as sinusitis, rhinitis, and nasal polyps. How-
ever, rarely they may be related to malignant lesions. Red flags of a unilateral
distribution along with a refractory response to standard medical treatment
should prompt the physician to examine for other differentials including sinus
masses.

P185
LYMPHOPENIA AND AGAMMAGLOBULINEMIA OF UNCLEAR
ETIOLOGY.
L. Bornstein*, R. Herzog, New York, NY.
Introduction: Early diagnosis of severe combined immune deficiency has
led to timely treatment and improved prognosis for patients. We present a 17
month old male with lymphopenia and agammaglobulinemia of unclear etiol-
ogy identified by TREC assay on newborn screen. Case Report: The patient
was a full term newborn with low T-cell receptor excision circle (TREC) lev-
els. The patient was well until 53 days of age, when he developed fever to 38.5C
and upper respiratory infection symptoms. Labs revealed low T and B cell
counts and agammaglobulinemia, and he was treated with antibiotics and intra-
venous gamma globulin (IGIV). Cultures and viral PCR were negative. There-
after, the patient developed recurrent otitis media and viral infections due to
RSV, coronavirus, rhinovirus, enterovirus, and metapneumovirus. In addition
to IGIV, the patient has been given prophylaxis with palivizumab, acyclovir,
pentamidine (due to intermittent neutropenia on TMP-SMX), and filgrastim
as needed. The patient has been developing normally for his age. Results: New-
born TREC was 132, 132, 164 (nl>200/ml), with repeat of 0, 0, 0, 31, 33/ml.
Naïve CD45RA+ CD4 count was normal. Absolute lymphocyte count (ALC)
was 900/ml (1,000-4,800), CD4+CD3+ 468/mm, 48% (2,780-3,908, 50-57%), MRI demonstrating a infiltrating mass in the sella turcica with biopsy and
CD8+CD3+ 127/mm, 13% (351-2,479, 8-31%), CD19+ 63/mm, 7% (432- pathology consistent with a prolactinoma.
3,345, 11-45%), normal NK function, IgG 522, IgA: <7, IgM 9 (20-87 mg/dl).
T cell proliferative response to phytohemagglutinin (PHA), Concanavalin (con
A), OKT3, and mixed lymphocyte culture was normal. Responses to Candida
and Tetanus were low normal. There was no evidence of maternal engraftment
or clonal T or B cells. Immunization with DTaP did not result in increased titers.
Anti-neutrophil antibodies were negative. Artemis, RAG1, RAG2, adenosine

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ABSTRACTS: POSTER SESSIONS

used to eradicate the inhibitor in some patients. As B-cells recover, the inhibitor
P187 may reappear in selected patients, and maintenance rituximab may need to be
CASE OF HYPOGAMMAGLOBULINEMIA FOLLOWING RIT-
considered.
UXIMAB THERAPY.
M. Egan*, C. Cunningham-Rundles, New York, NY.
Rituximab is a B cell depleting anti-CD20 monoclonal antibody often used P189
in the setting of malignancy or autoimmune conditions. Transient B cell deple- A COMMON SKIN ERUPTION WITH AN UNCOMMON CAUSE.
tion is often seen but immunoglobulin levels are not often affected 1. However, J.T. Abraham*, J. Fernandez, Cleveland, OH.
there is growing literature documenting hypogammaglobulinemia requiring
Background: Autoimmune Progesterone Dermatitis is an IgE mediated reac-
intravenous immunoglobulin following rituximab therapy1,2. In some cases, the
tion to endogenous or exogenous progesterone. Clinical presentations are
presentation of hypogammaglobulinemia was years after completion of ritux-
described as varied, with cutaneous lesions mostly on abdomen and lower
imab therapy3. We present the case of a 71 year old female with a history
extremities. The rash occurs cyclically, typically during the luteal phase of the
microvascular polyangiitis treated with rituximab, cyclophosphamide and pred-
menstrual cycle when progesterone levels are high. Methods: A 28 year-old
nisone who was diagnosed hypogammaglobulinemia, specifically IgG defi-
healthy Caucasian female presents to Allergy and Immunology clinic with inter-
ciency, two years after completing therapy. The patient had a history of recur-
mittent lower extremity and abdominal rash since May 2013. The erythema-
rent pneumonias preceding the immune modulating regiment, however all
tous maculopapular rash occurred every 4-6 weeks initially, then increased in
episodes required only outpatient antibiotic therapy. After completion of treat-
frequency. It normally lasted three days and self-resolved. The rash progres-
ment the patient required frequent inpatient admissions for pulmonary infec-
sively became associated with myalgias and malaise. She had been using a
tions, including three to the intensive care unit. Subsequent evaluation revealed
NuvaRing for contraception during this time. Results: The patient was initially
an IgG of 412 mg/dL, IgM of 31mg/dL and IgA level of 129 mg/dL. She had
evaluated by rheumatology with concern for the rash being consistent with vas-
an appropriate antibody response to pneumococcal polysaccharide vaccine with
culitis. Skin biopsy was performed, demonstrating perivascular dermatitis with
11 of 23 titers positive. B cells were present in normal numbers. Thus, a diag-
eosinophils and neutrophils as well as extravasation. Laboratory evaluation was
nosis of IgG deficiency was made4,5. She was started in intravenous
remarkable for elevated IgG levels (2960 mg/dL), a speckled pattern ANA
immunoglobulin therapy and has been well since initiation of treatment. This
(1:1280), positive SSA (122 units) and SSB (75 units) antibodies. She was sent
patient adds to the cases in the literature of hypogammaglobulinemia requir-
to Allergy and Immunology for evaluation due to the cyclical nature of her rash
ing immunoglobulin therapy after rituximab treatment. In our patient the
and concurrent use of hormonal contraception. Epicutaneous and intradermal
immunoglobulin levels prior to initiation of therapy are not available so it is
skin testing was performed with progesterone (50mg/ml) as well as positive
not known if treatment accelerated an already existing condition or represents
(histamine) and negative (normal saline) controls. Epicutaneous testing with
a truly new illness following therapy. There are case reports of clinically asymp-
1:1 concentration was negative. Intradermal injection of 1:1000 and 1:100 dilu-
tomatic patients with reduced immunoglobulin prior to rituximab treatment
tions showed positive wheal/flare reactions of 5mm x 12mm and 8mm x 15mm,
that experienced clinical deterioration after therapy1. It is possible a similar sce-
respectively. Intradermal injections were also placed in three healthy subjects
nario occurred in our patient given the history of frequent, though milder, infec-
to ensure the dilutions used were not irritant doses. The healthy controls showed
tions prior to therapy. Retrospective studies have shown that only a small minor-
minimal to no reaction to these dilutions. Conclusions: Autoimmune Proges-
ity of patients develop hypogammaglobulinemia following rituximab therapy
terone Dermatitis is a rare condition, however it should be considered in women
indicating there is likely a specific subset of patients at risk6. More research is
of child bearing age who present with cutaneous lesions in a cyclic pattern.
needed to determine if this association is due to an aggravation of an existing
condition and the utility of screening.

P188
USE OF RITUXIMAB IN HEMOPHILIA B PATIENTS WITH ANA-
PHYLAXIS AND FACTOR IX INHIBITOR.
J. Kiehm*1, N. Qamar2, S. Acharya3, B. Kaplan1, 1. Great Neck, NY;
2. Manhasset, NY; 3. New Hyde Park, NY.
Introduction: The development of Factor IX (FIXi) inhibitor (antibodies)
in severe Hemophilia B (FIX deficiency) patients is a rare phenomenon (1%-
6% incidence), increasing morbidity and mortality. Treatment of these patients
can be complicated by the association of FIX inhibitor (FIXi) with anaphylaxis
to FIX replacement therapy. More recently, the use of rituximab to eradicate
inhibitors has been reported. Methods: We describe two Hemophilia B patients
(Pt#1-8 year old and Pt#2-4 year old males) who developed anaphylaxis to
recombinant FIX replacement product, BeneFIX (RFIX), in the setting of an
inhibitor. Results: After 9 months of RFIX therapy for the treatment and pre-
vention of bleeding episodes, Pt#1 developed anaphylaxis shortly after RFIX
infusion. FIXi titer was 4.3 BU. Pt#2 was receiving RFIX therapy that was dis-
continued due to detection of a FIXi of 0.6 BU on routine screening. After his
inhibitor titer became undetectable, he was re-challenged with RFIX. He devel-
oped an anaphylactic reaction after 5 weeks of RFIX therapy. FIXi was 2.4
BU. Skin testing to RFIX and plasma derived FIX, Mononine (PFIX), was
performed for both patients. Pt#1’s skin test was negative to RFIX but positive P190
to PFIX. Pt#2’s skin test was negative to both products. The patients were treated IGE MEDIATED ALLERGIC REACTION TO METHIMAZOLE IN
with rituximab 375mg/m2/dose weekly x 4 and successfully completed desen- A PEDIATRIC PATIENT WITH SUBSEQUENT SUCCESSFUL
sitization to RFIX. Pt#1’s FIXi decreased to 0, and he has been tolerating RFIX DESENSITIZATION.
with no resurgence of his inhibitor for 9 months thus far. Pt#2’s FIXi and B- E. Akl*, B. Ward, A. Kumar, W. Zhao, Richmond, VA.
cells dropped from 6.3 BU to 0 and 603 cells/uL to 0 respectively. After 6 months
Introduction: Methimazole is a common reagent used to treat hyperthy-
of tolerance, Pt#2 developed diffuse urticaria and dyspnea within minutes of
roidism. Its side effects such as rash, vasculitis, have been widely reported but
completing his RFIX infusion. FIXi was 0.8 BU, and B-cells were 270 cells/uL.
rarely has an IgE mediated reaction been reported in a child and no desensiti-
Repeat skin testing was minimally positive to RFIX and negative to PFIX. Sub-
zation protocol exists for this medication. We present a case of IgE mediated
sequently, patient failed graded challenge to PFIX (generalized hives). Con-
allergic reaction after administration of methimazole on two occasions along
clusion: These cases highlight the importance of recognizing that an inhibitor
with a successful desensitization to the medication with subsequent treatment
can play a role in anaphylaxis to biologic agents. Skin testing to FIX prepara-
of hyperthyroidism. Case Description: A 7 year old Hispanic female with a his-
tions is not necessarily predictive of systemic reaction. Rituximab has been
tory of intermittent asthma and hyperthyroidism treated with methimazole

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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A79
and developped a generalized itchy rash and hives with myalgias and arthral-
gias. Her symptoms resolved within 1 day after stopping the medication. She
was then switched to propylthiouracil (PTU) and had no issues. Another trial
of methimazole lead to the same symptoms and the patient was again switched
to PTU which result in elevated liver enzyme within a few months. The patient
presented to our allergy clinic for evaluation. Skin prick testing showed a pos-
itive reaction to methimazole at 100 mcg/ml concentration. Intradermal test-
ing showed a 6 mm wheal to the 1 mcg/ml concentration. The starting dose of
desensitization was calculated to be 100 fold less than that which yielded a 5-
8 mm wheal by skin testing. Patient was monitored in our clinic for possible
local and systemic reaction. Desensitization was started at a concentration of
10 ng/ml in a volume of 0.3 ml (dose of 3 ng) with no reaction. The dose was
increased half log every 15 minuntes until a cumulative dose of 29.5 mg was
reached. Our patient had no reactions during the desensitization and was started
on a dose of 5 mg daily and increased to therapeutic dose for her hyperthy-
roidism. Conclusion: Drug desensitization protocols exist for a few medica-
tions mainly beta lactam antibiotics, vancomycin, aspirin, NSAIDS and some
chemotherapy reagents and monoclonal antibodies. To our knowledge, no methi-
mazole desensitization case has been reported. Our report provides a useful
tool in treating hyperthyroism of patients with allergic reaction to methimazole
who are not tolerating PTU.
Desensitization protocol
P191
WAS TRAUMA THE CAUSE? A CASE OF HEREDITARY
ANGIOEDEMA.
M.B. Reddy*, Denver, CO.
A 15-year-old male with a history of hereditary angioedema (HAE) type 1
presented to the local children’s hospital emergency department (ED) with a
chief complaint of 4 days of sore throat and abdominal pain. He had 7 prior
admissions for HAE attacks, with 2 in the past year. His typical attacks included
angioedema of his feet and face, and occasionally abdominal pain. He was
always treated with C1 esterase inhibitor. Preventative therapy had been dis-
cussed at his prior allergy clinic visits, however he had been lost to follow-up
prior to this presentation. On his current presentation, the patient noted that
his abdominal pain was similar to prior flares, but denied any emesis, dysp-
nea, or angioedema. He had multiple sick contacts at home with similar symp-
toms. On exam, the patient had stable vital signs. He appeared to be in no
acute distress. On HEENT examination he had clear tympanic membranes,
PERRLA, clear oropharynx with 2+ tonsils with mild erythema and without
palatal, tongue, or uvula edema, moist mucous membranes, and supple neck.
His lungs were clear to auscultation, and heart had regular rate and rhythm with-
out any murmurs. His abdominal examination was positive for mild tenderness
to palpation diffusely without rebound or guarding. His skin exam was unre-
ABSTRACTS: POSTER SESSIONS
markable and there was no swelling or edema noted. A rapid strep test was
performed. Approximately 30 minutes passed and on reexamination the uvula
was noted to be edematous. The patient then began to have progressive palatal
edema that involved the entire posterior oropharynx. The patient had no respi-
ratory distress and continued to have stable vital signs, however the decision
was made to electively intubate him to protect his airway. C1 esterase inhibitor
therapy was initiated at this time. On direct laryngoscopy, the patient’s palate
was noted to be edematous, however the glottis, trachea and larynx were all
normal. The patient remained intubated for less than 24 hours, was success-
fully extubated and discharged to home within 72 hours. Our case of an HAE
attack with isolated palatal edema after the rapid strep test was performed raised
the unique question: did the rapid strep test incite enough trauma to the poste-
rior oropharynx to provoke an attack of HAE? Our case suggests that the patient
was at the beginning of an attack and the trauma of the rapid strep test may
have caused him to have isolated angioedema to the posterior oropharynx.
P192
A CURIOUS COUGH.
C. Caruthers*, J. Vitale, M. Warrier, St. Louis, MO.
41-year-old female with past medical history of Gastroesophageal Reflux
(GERD) well-controlled on famotidine and obesity status post lap-band sur-
gery three years prior presented with a one year history of cough. Her cough
was intermittently productive of yellow (morning) to clear sputum (later in the
day) alternating with dry cough that was worse with exertion and associated
with wheezing and dyspnea. She had frequent nocturnal awakenings. She also
had perennial clear rhinorrhea with postnasal drip, nasal and ocular pruritus
and sneezing. Social history was notable for cat and dog at home and tobacco
use. Physical exam was unremarkable except for obesity, clear rhinorrhea, post-
nasal drainage and non-productive cough. Percutaneous skin testing was pos-
itive for cat and dog. Pulmonary function tests (PFTs), chest x-ray, and sinus
CT were normal. She was diagnosed with perennial allergic rhinitis, cough and
GERD. Initial treatment included environmental controls, a nasal steroid and
albuterol for rescue. She continued to have nocturnal rhinitis and a wet cough.
Pulmonary function tests progressively declined and demonstrated a positive
bronchodilator response. Management over the next few years included trials
of immunotherapy for cat and dog, high dose proton pump inhibitor, antibi-
otics, montelukast, steroids (nasal, inhaled and oral) and omalizumab. Cough
with frequent nocturnal awakenings continued to be her main complaint. GERD
was repeatedly assessed and reported to be well-controlled by the patient.
Approximately four years after initial presentation, chest CT and esopha-
gogastroduodenoscopy (EGD) were performed due to worsening of symp-
toms and oral steroid dependence. The CT showed a fluid distended thoracic
esophagus, and EGD revealed food in her esophagus despite being NPO the
night prior to the procedure. She recalled two episodes over the past several
months of coughing up food that she had eaten 24-48 hours earlier. It was sub-
sequently realized that her lap-band was inflated one to two years prior to the
initial onset of her symptoms. Her lap-band was deflated with dramatic improve-
ment in symptoms and PFTs. She was able to discontinue oral steroids and
maintenance asthma medications. There is one other report of chronic cough
and nocturnal rhinorrhea following lap-band surgery. Chronic cough is a com-
plication of lap-band that may be under-recognized outside the general sur-
gery community.
P193
NON-TUBERCULOUS MYCOBACTERIA (NTM) INFECTION
PRESENTING AS DIFFICULT-TO-CONTROL ASTHMA.
J.M. Rodrigues*, A. Katta, R. Nayak, R. Slavin, St Louis, MO.
Introduction: Although NTM infection is known to exist in patients with
chronic lung diseases, it is seldom considered in the evaluation of severe or dif-
ficult-to-control asthma. Case Report: A 66 year old woman was referred to
the allergy clinic with difficult-to-control asthma. She had recurrent daytime
productive cough with yellow sputum and frequent nocturnal awakening. She
described repeated use of short acting β agonist despite compliance with com-
bination (high dose) inhaled corticosteroids (ICS)/long acting β agonist and
leukotriene receptor antagonist. Pulmonary function tests were consistent with
severe obstructive ventilatory limitation. A High resolution chest CT scan
showed multiple bilateral pulmonary nodules. She had two positive sputum cul-
tures for Mycobacterium avium-intracellularae and was started on ethambutol,
rifabutin and azithromycin. She has had marked improvement in symptoms and
decrease in albuterol use since starting treatment. Discussion: A recent study
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ABSTRACTS: POSTER SESSIONS

showed that the estimated prevalence of NTM infections among asthmatic drome in response to azithromycin, so it was stopped. Symptoms progressed
patients was 1.7% with an average interval of 2 years from symptom change and he was seen in allergy/immunology clinic 1 day later where he was thought
to diagnosis. Patients commonly present with symptoms of worsening lung dis- to have herpetic stomatitis and was started on valaciclovir. Oral swab for HSV-
ease including progressive dyspnea, productive cough and frequent asthma 1/2 was sent. He was seen 2 days later when he had hives. He continued to
exacerbations. Imaging studies may reveal bronchiectasis, nodules < 5 mm or have oral mucositis with improving facial swelling. His HSV-1/2 PCR were
fibrosis. American Thoracic Society (ATS)/ Infectious Diseases Society of negative, so valaciclovir was stopped. Mycoplasma IgG and IgM were sent.
America (IDSA) guidelines require at least two positive expectorated sputum After consultation with dermatology, his mucositis, which was characterized
cultures for diagnosis of NTM infection. Recent studies have indicated that by extensive ulcerations covered with a pseudomembrane on the buccal mucosa,
older patients with severe airflow limitation receiving long term high dose labial mucosa, tongue, and palate as well as with bloody crusted lip ulcerations,
ICS are at a higher risk of acquiring NTM infection. The current recommended was determined to be diagnostic of oral EM. Positive Mycoplasma IgM and
treatment for pulmonary disease comprises a triple drug regimen with IgG titers confirmed the infection as the trigger for oral EM. He was treated
azithromycin, ethambutol and rifabutin for duration of at least 12 months after with topical and systemic steroids with rapid improvement. Conclusion: Oral
conversion of sputum to negative. It is imperative to consider NTM infection EM is a unique and much less described variant of EM. It is most often trig-
in the differential of difficult-to-control asthma that has been unresponsive to gered by HSV infections, less commonly by drug reactions, and rarely by
conventional therapy. Mycoplasma infection. Unlike acute herpetic stomatitis, which involves kera-
tinized mucosa and which can be confused with oral EM, our patient devel-
oped lesions only on nonkeratinized tissues. The triggers of oral EM and its
P194 characteristic presentation are important to recognize as repeated attacks often
AN EARLY PRESENTATION OF DRUG REACTION WITH result in more severe forms of EM involving both the oral mucosa and skin.
EOSINOPHILIA AND SYSTEMIC SYMPTOMS.
S. Waqar*1, S. Farzan2, 1. Dix Hills, NY; 2. Great Neck, NY.
Introduction: Drug Reaction with Eosinophilia and Systemic Symptoms
(DRESS) is a rare, but potentially life-threatening syndrome, which typically
presents two to eight weeks after drug exposure. It is characterized by multi-
ple system involvement, which may include skin eruption, hematologic abnor-
malities, lymphadenopathy, and affect internal organs such as the liver, kid-
neys, and lungs. Patients usually face several relapses despite discontinuation
of the drug. Here we describe the presentation, diagnosis, and clinical course
of a patient with early-onset DRESS. Methods: A 15-year-old male, with past
medical history of hypertension presents with recurrent pruritic rash and short-
ness of breath two weeks after treatment of a MRSA skin infection with
trimethoprim-sulfamethoxazole (TMP-SMX). He reports initial development
of a rash on day 4 of TMP-SMX. The rash was a full-body pruritic erythema-
tous papular rash sparing the mucus membranes and most prominent on the
face. TMP-SMX was discontinued. He was treated with an oral prednisone
taper, as well as intravenous fluids for acute kidney injury with a creatinine of
1.5. The rash resolved within two days but reappeared on day 6. He was read-
mitted approximately 10 days after initial TMP-SMX treatment with fever, rash,
and shortness of breath. On readmission, his physical exam was notable for
fever of 39.4 degrees C and a pruritic full-body morbilliform erythematous rash
including the palms and soles, and again sparing the mucus membranes. Results:
Laboratory work-up showed eosinophilia (1200 per microliter; 13.9%) with
an elevated C-reactive protein of 18.7. ESR, hepatitis panel, liver function tests,
Lyme screen, rapid plasma reagin were normal. HIV was non-reactive. EBV
P196
A SUCCESSFUL PRE-MEDICATION PROTOCOL FOR A
testing was consistent with a past infection. ANA, dsDNA, and histone anti-
PATIENT WITH ANAPHYLATOID REACTION TO INTRA-
bodies were normal. Chest X-ray revealed small bilateral pleural effusions. Uri-
nalysis, respiratory viral panel, throat culture and blood cultures were negative.
VENOUS RADIOCONTRAST MEDIA IN SPITE OF STANDARD
He was started on a very slow taper of prednisone for early-onset DRESS. On PRE-MEDICATION PROTOCOL.
follow-up, rash had not recurred and eosinophilia had resolved. Conclusion: M.H. Chong*, S.L. Mawhirt, J. Sher, M. Aquino, M. Davis-Lorton,
In patients with recurrent rash and multiple system involvement, DRESS should L. Fonacier, Mineola, NY.
be considered. Early-onset DRESS should be in the differential in cases con- Background: Immediate hypersensitivity reactions (IHR) to low osmolar
sistent with the syndrome but with presentation of symptoms earlier than radiocontrast media (RCM) have an overall reported incidence of up to 3%.
expected, and after exclusion of other etiologies. Pre-medication regimens reduce IHR rates in subsequent studies requiring
RCM. However, breakthrough IHR (BIHR) may occur despite the use of pre-
medication and low osmolar RCM. Consensus on successful pre-medication
P195 protocols for patients requiring RCM after BIHR is lacking. Case Report: A
DIAGNOSIS OF ORAL ERYTHEMA MULTIFORME IN A 50 year old male with a history of asthma presented for elective cardiac catheter-
PATIENT WITH MYCOPLASMA PNEUMONIA. ization for unstable angina. He reported one previous RCM reaction with sneez-
K.R. Brown*1, D. Eisen2, J. Li2, A. Assa’ad2, 1. Lakeside Park, KY; ing, hives, and ocular pruritis. Prior to catheterization, the patient received a
2. Cincinnati, OH. modified Greenberger pre-medication protocol with oral prednisone 50mg (13,
7, and 1 hr pre-procedure), oral diphenhydramine 50mg and methylprednisolone
Introduction: Erythema multiforme (EM) is an immune-mediated hyper-
125mg 1 hour pre-procedure. Despite pre-medication, the patient developed
sensitivity reaction typically presenting with cutaneous and mucous membrane
generalized urticaria, periorbital angioedema, nasal congestion, and wheezing
involvement. EM is known to be associated with exposure to drugs and viral
upon administration of a 3cc dose of low osmolar iohexol (640 mosm/kg). The
pathogens. The most commonly associated pathogen is herpes simplex virus
procedure was immediately terminated and albuterol, diphenhydramine, and
(HSV). However, there are reports of EM in patients diagnosed with
methylprednisolone were administered at that time and for two days post pro-
Mycoplasma pneumonia. We describe a case of oral EM, a distinct but less
cedure. As the patient still required catheterization, a subsequent pre-medica-
well-recognized variant of EM, presenting as isolated oral mucositis in a patient
tion protocol was implemented: prednisone 80mg daily, montelukast 10mg
with Mycoplasma pneumonia. Clinical Case: A 10 year old previously healthy
daily, cetirizine 10mg and famotidine 20mg twice daily for four days prior to
male presented to his pediatrician with fever, cough, and lip swelling. Crack-
the subsequent study. Additionally, he received methylprednisolone 125mg,
les were found on exam and he was prescribed azithromycin for treatment of
diphenhydramine 75mg, and albuterol 1 hour pre-procedure. The patient under-
atypical pneumonia. His facial swelling spread and he presented to the emer-
went second cardiac catheterization one week later with successful placement
gency department. He had buccal mucosal lesions with sloughing of oral mucous
of two drug-eluting stents using lower osmolar iodixanol (290 mosm/kg) with-
membranes without skin rash. There was concern for Stevens Johnson Syn-

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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A81
out any adverse effects. Discussion: Breakthrough IHR to RCM are reported
to occur at a rate of 0.11-18% and patients may experience symptoms compa-
rable to their index reaction. Successful pre-medication regimens to prevent
repeat BIHR in patients requiring utilization of RCM for subsequent imaging
studies are not well documented. We describe a regimen which allowed our
patient to receive critical coronary intervention. Further investigation into effec-
tive pre-medication in patients who successfully receive RCM may elucidate
optimal regimens which may be most beneficial.
P197
POST-INFUSION MYOCARDIAL INFARCTION IN A PATIENT
RECEIVING IVIG.
S. Draikiwicz*1, S. Arakali2, E. Capitle3, 1. Scotch Plains, NJ; 2. New
Brunswick, NJ; 3. Newark, NJ.
Adverse reactions have been reported in up to twenty percent of all patients
receiving IVIG infusion.1 From October 1997 through July 2007, there were
10 reports of stroke, 6 reports of thrombosis, 4 reports of myocardial infarc-
tion, 2 reports of pulmonary embolus and 1 report of transient ischemic attack
suspected of being associated with IVIG.2 While multiple known factors such
as hypertension and diabetes contribute to the development of coronary artery
disease and myocardial infarction (MI), it is also important to acknowledge
the association of IVIG and post-therapy myocardial infarction. Our case is a
48 year-old man with a history of diet-controlled hypertension, steroid induced
diabetes mellitus and polymyositis who developed a MI following IVIG. The
patient was diagnosed with polymyositis in August 2013. His initial CPK was
10,000, elevated ANA titer at 1:640, and with a positive single-stranded DNA
antibody. His polymyositis was refractory to multiple therapies including pred-
nisone and mycophenolate mofitil. He was then started on IVIG therapy. He
completed a three day course of IVIG from July 7 through July 10. On the morn-
ing of July 16th, he developed severe, constant, non-radiating chest pain. He
presented to the ED more than 12 hours later and was diagnosed with a myocar-
dial infarction. He had no history of cigarette smoking or prior cardiac history.
His admission troponin T was elevated to 7.29 and he had a CPK of 2315. Car-
diac catheterization revealed a 100% occlusion of the mid left circumflex artery
for which he underwent angioplasty. We believe that IVIG caused a MI in this
patient due to his lack of prior cardiac disease, relatively short term course of
steroid induced diabetes mellitus (approximately 6-12 months), and a time
course consistent with prior reported thromboembolic events caused by IVIG.3
This case is important because the application of IVIG continues to grow and
providers need to be aware of the possible risks associated with this therapy.
References: 1.Pierce LR, Jain N. Risks associated with the use of intravenous
immunoglobulin. Transfus Med Rev. 2003;17(4):241. 2.WHO Drug Informa-
tion Vol 22, No. 1, 2008 3. Rajabally YA, Kearney DA. Thromboembolic com-
plications of intravenous immunoglobium therapy in patients with neuropathy:
a two-year study. J Neurol Sci. 2011;308(1-2):12-7. Epub 2011 Jun
P198
GRANULOMATOSIS WITH POLYANGITIS IN AN ADOLESCENT
BOY.
S. Burke-Mcgovern*, Middle Village, NY.
Introduction: Granulomatosis with Polyangiitis (GPA) is an antineutrophil
cytoplasmic antibody (ANCA)-associated vasculitis (AAVs) with hallmark fea-
tures of necrotizing granulomatous inflammation and pauci-immune vasculi-
tis in small- and medium-size blood vessels. It has a predilection for the res-
piratory system and kidneys. GPA is extremely rare in children and adolescents
especially of African American descent. Here we report a case of Granulo-
matosis with Polyangiitis in an African American teen. Case Report: 13 year
old black boy born and lived in Grenada, in his usual state of health began to
experience productive cough, blood tinged sputum, dyspnea, chest pain, malaise,
and intermittent fevers. Chest x-ray (CXR) showed bilateral infiltrates, cystic
changes and a 2.3 cm RUL cavitary lesion. Intradermal tuberculin test as well
as sputum and gastric aspirate for acid fast bacilli (AFB) and HIV / HTV anti-
body were negative. Despite a 2 weeks course of antibiotics and 18 months
empiric treatment for tuberculosis in Grenada his symptoms persisted. 17
months after initial symptoms he demonstrated microscopic hematuria along
with rising serum creatinine. Five months later, in USA, his chest CT revealed
a large thick walled cavity with an air fluid level in the RUL, tree and bud for-
mation and a thin walled cavity in the left upper lobe. Laboratory investigation
was significant for serum BUN / Creatinine of 65/4.1, positive ANA, and anti-
Proteinase 3 .Renal biopsy revealed pauci-immune diffuse sclerosing and cre-
sent glomerulonephritis with severe tubular atrophy and interstial fibrosis. He
ABSTRACTS: POSTER SESSIONS
was diagnosed with GPA and started on high dose steroids and cyclophos-
phamide. Relapses were treated with rituximab. Currently he has hemodialy-
sis dependent end stage renal disease, hypertension, dilatation of coronary
artery, pericardial effusion required pericardiocentesis, concentric left ven-
tricular hypertrophy, hypogammaglobinemia secondary to chemotherapy, on
IVIG infusion, bilateral cataract secondary to chronic use of prednisone and
posterior reversible encephalopathy syndrome. Conclusion: GPA is extremely
rare in children and aldolescents especially of African descendant. Attributing
symptoms of GPA to more common but less harmful disease processes, espe-
cially in areas of the world where it is less prevalent may occur. Earlier diag-
nosis and treatment is extremely important in preventing permanent renal dam-
age.
P199
CASE REPORT: A PATIENT WITH ACQUIRED C1-INH DEFI-
CIENCY (ACID) AND HYPOGAMMAGLOBULINA.
E. Schussler*, P. Busse, New York, NY.
Introduction: Acquired angioedema with C1 inhibitor deficiency is a rare
disease characterized by recurrent episodes of angioedema without urticaria or
pruritis. Attacks may be triggered by trauma, psychological stress, or infection,
but may also occur without an identifiable trigger. The etiology of ACID is
frequently due an underlying malignancy (lymphatic or adenocarcinoma), a
monoclonal gammunopathy of uncertain significance or an autoimmune con-
dition. Case Presentation: A 70 year old female was referred for evaluation after
a recent onset of recurrent episodes of angioedema without urticaria. Her ini-
tial episode developed in her lip approximately 24 hours after cataract surgery.
A subsequent episode of angioedema occurred in her neck and jaw after a res-
piratory tract infection. Treatment with anti-histamines and corticosteroids
did not improve symptoms. Blood work revealed a C4 <5 mg/dL (normal 10-
40 mg/dL), C1-INH function=23% (normal >41%), C1-INH protein=6 mg/dL
(normal 21-39 mg/dL) and a C1q < 3.6 mg/dL (normal 5.0-8.6 mg/dL) and a
diagnosis of ACID was made. The patient was started on Aminocaproic acid
1gm TID to prevent attacks and Icatibant to treat acute attacks. To evaluate for
a possible underlying malignancy, the patient had a CBC, lymphocyte profile,
and a MRI of her abdomen, all of which were unremarkable except for a mildly
elevated B-cell number at 482/cu mm (normal range 75 – 375). Her ANA titer
was 1:320 (normal 1:40). As part of the evaluation a SPEP and immunofixa-
tion was performed which revealed an IgG at 438 (normal 700-1600 mg/dL),
and IgA 59 (normal 70-400 mg/dL), and normal IgM 81 (normal 40-230 mg/dL)
with a polyclonal pattern. On review of symptoms, the patient reported 2
episodes of pneumonia, confirmed on CXR. Specific IgG to pneumococcal
antigens was detectable for 7/14 serotypes, which decreased 5 months later (to
6/14 seropyes) after Pneumovax administration. Conclusion:To our knowledge,
this is the first reported patient with ACID and a specific antibody deficiency
P200
A DELAYED PRESENTATION OF SEVERE COMBINED IMMUN-
ODEFICIENCY.
J. Bergerson*, B. Pelz, B. Prince, R. Fuleihan, Chicago, IL.
Introduction: Severe combined immunodeficiency (SCID) syndromes are
primary immunodeficiencies that result from the absence or diminished func-
tion of T cells and are classified by the presence or absence of B and NK cells.
T-B-NK+ SCID occurs with autosomal recessive genetic defects involving
V(D)J recombination or DNA repair mechanisms necessary to produce diverse
T and B cell receptors and ultimately mature T and B cells. We present a case
of T-B-NK+ SCID presenting with microcephaly, growth retardation, hypogam-
maglobulinemia, and recurrent infections. Case: An 18 month old female with
a history of a multicystic, dysplastic right kidney, microcephaly, failure to thrive,
and eczema presented with hypogammaglobulinemia identified while inpatient
for a recurrent sinopulmonary infection and chronic diarrhea. History was
significant for oral candidiasis at 8 months of age, sinusitis, recurrent acute oti-
tis media, and diaper dermatitis since 16 months. Physical examination was
notable for a small female with microcephaly, and xerotic, excoriated skin on
the trunk and lower extremities, as well as inguinal erythroderma. Previous lab-
oratory evaluation was significant for lymphopenia on CBC, undetectable IgG,
IgA, and IgE, low IgM, and stool culture positive for yeast and rare
Pseudomonas aeruginosa. Results: Repeat analysis confirmed hypogamma-
globulinemia and lymphopenia. T, B, and NK cell quantification revealed low
T and B cell counts with an increased number of activated, memory T cells
and NK cell numbers that were low normal. T cell receptor analysis showed a
polyclonal V beta repertoire for both CD4+ and CD8+ T cell subsets. The
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ABSTRACTS: POSTER SESSIONS
patient’s lymphocytes did not proliferate in response to mitogens, confirming
a diagnosis of T-B-NK+ SCID. Genetic testing revealed a previously reported
H282R missense mutation and a novel L242IfsX5 frameshift mutation in the
LIG4 gene producing a truncated DNA ligase IV protein. Conclusion: Hypo-
morphic mutations in DNA ligase IV are a rare cause of radiosensitive, SCID
that can have a delayed clinical presentation from classic forms. Patients with
LIG4 mutations typically have microcephaly and growth retardation, but can
have a wide range in phenotype from mild immune deficiency to embryonic
lethality depending on the residual function of the DNA ligase IV protein.
P201
G6PC3 DEFICIENCY AND POLAND SYNDROME IN A THREE
YEAR OLD.
G. Coscia*, M. Foca, K. Anyane-Yeboa, K. Ender, Y. Demirdag, New York,
NY.
Introduction: Mutations in glucose-6-phosphatase catalytic subunit 3
(G6PC3) are characterized by syndromic and non-syndromic severe congeni-
tal neutropenia. The syndromic form is associated with a wide spectrum of clin-
ical findings, including thymic hypoplasia, primary pulmonary hypertension,
cardiac, urogenital, and musculoskeletal abnormalities. Dursun Syndrome, a
rare condition characterized by familial primary pulmonary hypertension,
leukopenia, and atrial septal defect (ASD), is in the spectrum of G6PC3 defi-
ciency. To date, over 60 patients with G6PC3 mutation have been reported. Here
we present a patient with G6PC3 mutation associated with severe congenital
neutropenia, lymphopenia, pulmonary hypertension, ASD and Poland syn-
drome. To our knowledge this is the first reported case of G6PC3 mutation
and Poland syndrome. Case Report: A 3-year-old boy from non-consanguineous
parents of Dominican descent with leukopenia and recurrent infections pre-
sented to our clinic at 8 months of age. He also has Poland syndrome (associ-
ated with absence of left pectoralis muscle, shortened left upper extremity,
and syndactyly of the 3rd and 4th fingers of the left hand), a large secundum
atrial septal defect, pulmonary hypertension, chronic lung disease, failure to
thrive, aspiration, grade III vesicoureteral reflux, hydronephrosis and an inguinal
hernia. He has had recurrent pneumonia as well as cellulitis and skin abscesses
caused by S. aureus (MRSA), P. aeruginosa, E. coli, S. maltophilia, and E. cloa-
cae. These illnesses have prompted many hospitalizations including ICU admis-
sions for septic shock. Laboratory analysis is summarized in Table 1. Genetic
analysis revealed a homozygous G6PC3 mutation c.218+1G>A which was pre-
viously reported. He continues to have recurrent skin infections requiring hos-
pitalizations despite filgastrim treatment. Discussion: Dursun Syndrome is a
rare condition recently linked to G6PC3 deficiency associated with severe con-
genital neutropenia. Here we report a case of G6PC3 deficiency, Dursun syn-
drome, and Poland syndrome. Our patient’s findings emphasize the wide clin-
ical spectrum of G6PC3 deficiency.
Laboratory Analysis
P202
RECRUDESCENT EXANTHEM SECONDARY TO STREPTO-
COCCUS PYOGENES PHARYNGITIS.
G. Imperato*1, A. Khokhar2, S. LaBarba1, P. Ponda1, 1. Great Neck, NY;
2. Manhasset, NY.
Introduction: Streptococcus pyogenes pharyngitis causes an associated exan-
them in a minority of cases. Here we report a patient with an atypical prolonged
and recrudescent exanthem secondary to Streptococcus pyogenes infection.
Methods: A 51 year-old Hispanic female with no significant past medical his-
tory presented for evaluation of an erythematous and pruritic rash on her bilat-
A82 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
eral arms and legs. The rash first appeared approximately four weeks previ-
ously; six days after the rash appeared, the patient presented to a local emer-
gency department for evaluation and was prescribed benadryl and instructed to
be evaluated in an allergy clinic. Over the next three weeks, the rash gradually
resolved with benadryl, and subsequently recurred four days prior to her initial
clinic visit. The patient reported no history of food, environmental, or seasonal
allergies. The patient works as a housecleaner, and reported a history of con-
tact exposure to various household chemicals on regular a regular basis. Review
of systems was positive for throat soreness which preceded the appearance of
the rash. Physical examination revealed 1-2 cm erythematous blanching mac-
ules on the bilateral lower extremities with sparing of the soles, with scattered
overlying excoriations. Erythematous papules were noted on the bilateral upper
extremities, with a follicular eruption noted on the back. Areas of periungual
desquamation (not present during the initial episode of rash) were noted on the
hands bilaterally. Results: Laboratory studies included a comprehensive meta-
bolic panel, as well as a complete blood count with differential, both of which
were within normal limits. An anti-streptolysin O screen was elevated at 1220
IU/mL (ref 0-408 IU/mL). A throat culture grew Streptococcus pyogenes and
mixed upper respiratory flora. The patient was treated with a five-day course
of amoxicillin; her rash gradually improved but was still present ten weeks fol-
lowing its initial appearance. Conclusion: Streptococcal infection may cause
prolonged and recrudescent exanthem in affected patients. While a range of
diagnoses may be considered, Streptococcal pharyngitis should remain a lead-
ing suspicion for both adult and pediatric patients with atypical dermatologic
findings when there is a clear clinical history of antecedent pharyngitis.
P203
DELAYED HYPERSENSITIVITY REACTIONS TO ADHD MED-
ICATIONS: A CASE SERIES.
S. LaBarba*, P. Ponda, Great Neck, NY.
Rationale: Attention Deficit Hyperactivity Disorder (ADHD) is character-
ized by hyperactivity, impulsivity and/or inattention. ADHD affects 8-10% of
all children, making it one of the most common childhood disorders. In the
2011 National Survey of Children’s Health, the prevalence of ADHD in U.S
children ages 4-17 years was 11%. This is a 42% increase from a prevalence
of 7.8% in 2003. Up to 70% of children with this diagnosis have persistent
symptoms into adulthood. Currently, ADHD is treated with 3 different types
of medications: phenylphenidates, amphetamines and “other” class. These med-
ications work to various degrees to inhibit norepinephrine and dopamine reup-
take, thereby increasing the concentration of these neurotransmitters in the
synaptic cleft. This in turn improves executive functioning, motivation, and
reward perception. We describe three patients who had delayed reactions to dif-
ferent classes of ADHD medications. Methods: A 9 year old boy with ADHD
was started on amphetamine and developed diffuse urticaria one week later.
The rash resolved within two days of stopping the medicine. He then tried
methylphenidate and lisdexamfetamine dimesylate respectively and developed
urticaria one week after starting each medication. The rash resolved one day
after stopping the medication on both occasions. Skin prick testing to all three
drugs was negative. The patient was then placed on guanfacine and tolerated
this drug without reaction. A 5 year old boy developed diffuse urticaria one
week after starting guanfacine. This resolved two days after the medication was
discontinued. A 34 year woman developed generalized pruritis five days after
starting bupropion for ADHD. This resolved one day after stopping it. She
then started lisdexamfetamine dimesylate and developed generalized erythema,
pruritis, and sensation of throat closure one week later. These symptoms resolved
after this medication was discontinued. Conclusions: Given the increasing fre-
quency of ADHD in the U.S. population and the persistence into adulthood, it
is important for clinicians to recognize ADHD medications as a possible source
of delayed cutaneous reactions. Therefore skin testing may not be predictive in
these cases. Both IgE mediated and non-IgE mediated reactions to these med-
ications should be considered when the appropriate clinical history is elicited.
P204
EOSINOPHILIC CYSTITIS: A RARE CAUSE OF DYSURIA AND
HEMATURIA IN CHILDREN.
I.R. Bachove*, Philadelphia, PA.
Rationale:Eosinophilic cystitis (EC) is an inflammatory condition, often
misrepresented as a bladder tumor due to its presenting symptoms of
gross/microscopic hematuria, urinary frequency, dysuria and suprapubic abdom-
inal pain. It is a rare condition seen in children and is thought to be caused by
antigenic stimulation of IgE-mediated activation of eosinophils causing mast
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A83
cell degranulation. This accounts for much of the inflammation and fibrosis to
the bladder wall. We review our experience of treating patients with this con-
dition in our allergy clinic. Methods:Two children with a history of acute onset
of urinary frequency, suprapubic abdominal pain and gross hematuria were
referred to allergy with the diagnosis of eosinophilic cystitis for the evaluation
of potential allergens as a cause of eosinophilic cystitis. Results:Our patients
include a 4 year old female and a 17 year old male who present with a history
of hematuria referred for evaluation after routine urine and microscopy showed
> 50 RBC’s/high power field. Urine culture was negative. Both patients were
diagnosed via cystourethroscopy with biopsy demonstrating a prominence of
eosinophils with scattered neutrophils and lymphocytes. Allergic disease
(asthma, allergic rhinitis, etc) was present in both patients. The 4 year old female
had skin testing to common indoor and outdoor allergens which was negative.
She was treated with antihistamines with resolution by 2 months follow-up.
The 17 year old male did not have skin testing although immunocap testing
showed egg IgE 38, milk IgE 52, peanut IgE 14, wheat IgE >100 and total IgE
1156. He was not started on any medications and had spontaneous resolution
at 3 months follow-up. Conclusion: Eosinophilic cystitis is a rare inflamma-
tory disorder of the urinary bladder. The exact etiology of eosinophilic esophagi-
tis remains elusive though an allergic response has been proposed. Manage-
ment comprises of removal of any suspected allergen, followed by antihistamine
and corticosteroids. The course is usually benign and self-limited in children,
although progression to fibrosis of the bladder with obstructive uropathy has
been reported in some cases.
P205
CASE REPORT: CASHEW AS AN INCITING FOOD FOR FPIES.
E.J. Feuille*, New York, NY.
Food Protein-Induced Enterocolitis (FPIES) is a non-IgE mediated food
hypersensitivity that typically presents in infancy with vomiting and diarrhea.
The diagnosis is made based on history and clinical presentation, and is con-
firmed by a supervised oral food challenge; there is no specific laboratory test
to aid in diagnosis or in identifying the inciting food. Knowledge of potential
trigger foods for FPIES thus is important in making the diagnosis, and subse-
quently counseling patients appropriately on food avoidance. In young infancy,
the most common triggers are cow milk and soy formula. In older infants and
children, FPIES may occur with ingestion of solid foods such as grains (most
commonly rice and oat), meat and poultry, egg white, vegetables, fruit, legumes,
and seafood. FPIES to cashew, however, has not been previously reported in
the literature. In this report, we present the case of a 2.5 year-old boy who devel-
oped FPIES to cashew. His allergic history includes infantile FPIES to cow
milk, which transitioned to development of IgE mediated allergy to cow milk
at 9 months of age. After ingesting several cashews at 2.5 years of age, he had
one episode of emesis. When skin testing with an allergist was negative for
cashew, the mother was advised to reintroduce cashew. On re-introduction of
cashew however, the patient had a reaction consistent with FPIES 2 hours after-
wards: he developed repetitive emesis, lethargy, cyanosis, and diarrhea, notably
without any cutaneous or respiratory symptoms. He was brought by ambulance
to the emergency department for treatment, where he improved rapidly after
administration of intravenous fluids. On repeat testing 3 months after this reac-
tion, he was found to have small wheal in response to cashew on skin testing
with diameter of induration 3 mm and diameter of erythema 0 mm. He also
had mildly elevated specific IgE to cashew at 0.75 kIU/L. In conclusion, here
we present the first reported case of atypical (older age of onset and associa-
tion with detectable serum cashew-specific IgE) FPIES to cashew, adding to
the list of potential allergic triggers for FPIES. Though rare, tree nuts such as
cashew should be considered when identifying potential inciting food in chil-
dren infants presenting with symptoms consistent with FPIES.
P206
HYPERSENSITIVITY REACTION DURING HEMODIALYSIS.
Z. Li*, J. Celestin, M. Pasha, Albany, NY.
Introduction: Dialyzer reactions refer to all of the abnormal sequelae result-
ing from the interaction between blood constituents and the hemodialysis (HD)
membrane. There are two types of reactions: type A (0.004%) and type B (3-
5%). In the past, these reactions were grouped under the term “first use syn-
drome” because they primarily occurred with new dialyzers. Here we present
a case of hypersensitivity reaction during hemodialysis. Case: A 28 year old
male was referred to the allergy clinic for diffuse urticarial rash during HD for
the past 2 months. The pruritic rash starts within 2 hours of HD, on his face,
chest and back sparing his lower extremities. The discomfort was such that he
ABSTRACTS: POSTER SESSIONS
could not finish his 4 hours treatment. His Vitals remained stable and he denied
any respiratory symptoms such as difficulty breathing, wheezes and cough.
There was no angioedema, headache, blurry vision or GI complaints. He denied
any history of medication, food, contact or environmental allergies. Past med-
ical history: End-stage renal disease from IgA nephropathy, hypertension. Cur-
rent medications: Procardia XL 30mg daily. Physical examination: He was alert,
BP: 126/84 mm Hg, pulse 96/min, RR: 16/min. Cardiopulmonary and neuro-
logical examinations were normal. Skin revealed diffuse urticarial rash with
blanching wheals on the face, trunk and upper extremities [Fig]. Methods: Lab-
oratory data showed WBC: 5.2K/mm3 with 10% eosinophil. Serum tryptase
level: 22.8mg/L (2hours after rash started); IgE-EIA: 44 U/ml, CH50: 57U/ml
and C1Q binding: <1.2 Eq/ml. We suspected that the reaction was dialyzer
related. We contacted the dialysis center and suggested that dialyzer be changed
or reused. Prewashing the dialyzer with the patient’s blood temporarily helped
to alleviate his symptoms. We then prescribed Prednisone PO 40mg the night
before, and 2 hours before dialysis. PO Benadryl 50mg just prior to dialysis.
On follow up visit, the patient did very well with premedication, even when
prednisone dose was tapered down to 10 mg. Conclusion: Common causes for
dialysis resulted reactions include sensitivity to dialyzer. However, some patients
continue to exhibit hypersensitivity reaction despite dialyzer changes. Pre-
medication with steroid can successfully prevent the reactions. More studies
are needed to better identify the cause of hemodialysis reactions in order to
develop better management strategies to treat affected patients.
P207
INFECTION AS THE CULPRIT IN ANGIOEDEMA.
M.L. Curtiss*, J.T. Anderson, T. Hwangpo, Birmingham, AL.
Background: Angioedema causes self-limited, localized subcutaneous
swelling especially likely to affect the periorbital and circumoral areas. Here
we report a case of lip swelling in the context of angiotensin-converting-enzyme
inhibitor (ACEi) use caused by extensive odontologic, maxillary and parasep-
tal abscesses. Case: A 44-year-old African American female smoker with a his-
tory of obstructive lung disease, atopy, hypertension on ACEi for 2 months,
and diabetes mellitus type 2 was admitted to the hospital for her eighth pul-
monary exacerbation in one year. She was treated with IV steroids and antibi-
otics, her second course of high dose IV steroids in six weeks. One week later,
she reported sore throat and right ear pain, nasal discharge, pain in upper teeth,
fevers, chills, neck tenderness and progressive swelling of nose, cheeks and
upper lip. Allergy consult was made to evaluate patient’s facial swelling. Results:
Physical exam showed swelling of upper lip, nostrils and cheeks. Laboratory
results significant for normal C1 esterase level but WBC elevated to 34,000.
Sinus CT scan done 3 days prior to lip swelling showed a maxillary periapical
abscess. Lip swelling and pain persisted for several days in spite of stopping
ACEi and starting oral antibiotics. She then had spontaneous eruption of a large
foul-smelling fluid collection from her nostrils. Subsequent maxillary-facial
CT demonstrated cortical breakthrough of maxillary periapical abscess and
interval development of septal abscess extending down into the philtrum with
likely phlegmonous infection of the upper lip. She underwent I&D of septal
abscess with aspiration of frank purulent material and placement of septal
splints. She received more aggressive antibiotic treatment thereafter. Discus-
sion: ACEi involvement is the culprit of the majority of drug-induced
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ABSTRACTS: POSTER SESSIONS
angioedema. However, angioedema that persists and worsens over time after
ACEi discontinuation may point to other causes. In this case, a severe sinus
infection with multiple abscesses led to inflammatory changes resulting in local
facial swelling. Propensity toward development of this infection is likely mul-
tifactorial, including high dose steroids and poor oral hygiene, and protracted
use of IV steroids likely made control of her sinus infection more difficult.
P208
ANTERIOR UVEITIS IN A PATIENT WITH UNDERLYING
IMMUNODEFICIENCY.
R. Kreiner*1, R. Rosenbaum1, A. Rubinstein2, 1. New York, NY;
2. Bronx, NY.
Introduction: Anterior uveitis is the process of intraocular inflammation
that results most commonly from a systemic immune-mediated disease. Meth-
ods: We evaluated a 9 year old previously healthy female who presented with
anterior uveitis poorly responsive to conventional medical management and
subsequently found to have an underlying familial immunodeficiency. Results:
9-yr-old female BZ was referred for immunologic evaluation after developing
acute anterior uveitis presenting as red right eye, absent pupillary reaction to
light and blurred vision. Initial diagnosis was made by ophthalmology on slit
lamp examination. She was seen by multiple specialists including rheumatol-
ogy for a suspicion of JIA as she briefly complained of joint pain. She also had
a history of a mycoplasma pneumonia affecting several family members. BZ,
however, had a persisting IgM response to Mycoplasma with a delayed class
switch to IgG. At the onset of uveitis BZ was otherwise asymptomatic and
afebrile. She was started on ophthalmic steroid drops for 6 weeks with resolu-
tion of symptoms and decreased signs of inflammation on slit lamp exam.
Several weeks later she was found to have recurrent insidious inflammation.
She was placed back on steroid ophthalmic drops with a marked improve-
ment. Upon further analysis she was found to have low serum immunoglobu-
lins. The family history revealed that her paternal grandfather and a paternal
aunt suffer from Common Variable Immunodeficiency (CVID) who presented
with recurrent infection and are being treated with periodic intravenous gam-
maglobulin (IVIG). BZ had no history of infections other than recurrent otitis
in infancy. Conclusion: This is the first case report describing a patient with
an underlying immune deficiency and family history of CVID. Her immune
parameters do not completely fulfill the criteria for CVID. She presented with
a persisting IgM to Mycoplasma infection with delayed class switch to IgG as
well as an autoimmune uveitis. BZ responded well to topical and systemic
steroids but the uveitis recurred promptly with a decrease of or discontinua-
tion of steroids. She had a sustained response after 3 doses of IVIG at 1 gram/Kg
and is now on prophylactic periodic treatment. Uveitis is a challenging disease
as the differential is largely idiopathic. Early diagnosis is key as untreated uveitis
can result in severely impaired vision.
P209
THE IMMUNOGLOBULIN DIAGNOSIS, EVALUATION, AND KEY
LEARNINGS (IDEAL) PATIENT REGISTRY: RESULTS FROM
OUR PRIMARY IMMUNE DEFICIENCY POPULATION
TREATED IN ALTERNATE SITES OF CARE.
S. Kearns*1, L. Kristofek1, B. Bolgar1, L. Seidu2, 1. Denver, CO;
2. Atlanta, GA.
The IDEaL Patient Registry collects longitudinal information on subjects
receiving immunoglobulin (Ig) replacement therapy from Coram CVS/spe-
cialty infusion services in an alternate care setting. Long-term outcomes and
patient-reported quality-of-life assessments are not widely available for patients
on Ig therapy for different disease types. In the IDEaL primary immune defi-
ciency (PID) population, we examined baseline lab values for treated patients,
A84 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
and infection rates and quality-of-life assessments over time. Patients from our
140 investigators are eligible. IRB approval was obtained, as well as informed
consent from all subjects. Information collected by Coram nurses and phar-
macists was entered into the IDEaL database. Additionally, patients were asked
to complete an SF-36 questionnaire and a Life Quality Index Questionnaire
(LQIQ) every six months. Currently 310 subjects are enrolled in the Registry.
The average age for diagnosis of adult patients was 59 years, and their average
serum IgG level was 508 mg/dL. The average dose for subcutaneous Ig (SCIg)
was 134 mg/kg/week; for intravenous Ig (IVIg), it was 465 mg/kg/month. In
patients who switched from IVIg to SCIg, the average conversion ratio was
1:1.21. The average annual number of infections was three, with no significant
difference between administration routes. Similar side-effect incidence rates,
with differences in specific side effects depending on route, were noted. LQIQ
results showed that most patients had a positive perception of their treatment,
including how worthwhile and effective they felt it was, but were evenly split
on how expensive they felt it was. These results from the IDEaL Registry sug-
gest an overall profile of PID patients receiving Ig. Key findings include that
adult patients were diagnosed later in life, SCIG dose was toward the lower end
of the recommended dose range, and in patients switched from IVIg to SCIg,
the dose conversion was 1:1.21. Patients appeared to have good infection con-
trol; however, with a limited dose spread, we could not demonstrate a strong
dose response curve. Side effects were generally mild. Patients reported gen-
erally positive quality-of-life perceptions. Continued data collection will allow
for further long-term data analysis on outcomes of patients on Ig treatment.
P210
FREQUENCIES OF AUTOIMMUNE DISEASES ASSOCIATED
POLYMORPHISMS IN MEXICAN POPULATION.
B. Esquivel*, Mexico City, DF, Mexico.
Aim: This study was aimed to determine the allelic frequencies of 22 related
immune polymorphism (10488631, 1061170, 1265159, 12722489, 1799964,
1800629, 1800630, 2187668, 2476601, 3087243, 3135388, 3761847, 3890745,
4112788, 4140564, 6457617, 6822844, 6897932, 725613, 7574865, 800292,
9888739) in Mexican population and estimated the risk for immune diseases.
These polymorphism have been commonly associated whit 9 immune dis-
eases as; rheumatoid arthritis, macular degeneration, Type 1 diabetes, celiac
disease, graves’ disease, multiple sclerosis, lupus, osteoarthritis and psoriasis,
and also are located in several of the most important immune genes as; HLA,
STAT4, TNF, TNPO3, IL21, IL2RA, IL7R, MHC, C2, CFH among others.
Method: Genotyping was carried out in 100 genomic DNA samples from dried
blood spots supplied by the Mexican patients of Gene Test TQMedicine using
custom made multiplex array in Sequenom Massarray System technology.
Results: The frequency for all the polymorphism was calculated and previous
risk alleles for autoimmune diseases determined in Mexican population. Our
data shows similarities with those frequencies founded in human genome proj-
ect and suggest an increase genetic probability for psoriasis and lupus in Mex-
ican population. Patients with several risk alleles show an exacerbated immune
response for several clinical conditions. For this patients that shown genetic
risk for immune diseases, relevant clinical events were not observed since nutri-
tional and clinical care were established to avoid the previous calculated genetic
risk.. Conclusion: The Mexican population showed a slight frequency of immune
associated diseases polymorphism, however those who have several risk alle-
les shown an exacerbated immune response. Follow up with immune modula-
tors should be perform in this population to control this conditions.
P211
ARE PATIENTS WITH PRIMARY IMMUNODEFICIENCY (PID)
AT GREATER RISK OF INFECTION AFTER CARDIOPUL-
MONARY BYPASS FOR HEART VALVE REPLACEMENT?
M. Stein1, R. Price2, A. Koterba*1, W. Tuer3, 1. North Palm Beach, FL;
2. Palm Beach Gardens, FL; 3. West Palm Beach, FL.
Reports from JS Rankin in the surgical literature suggest that cardiopul-
monary bypass (CPB) may have immune depleting effects with some patients
having low IgG levels. He reports that this in turn leads to pulmonary dys-
function which improves with intravenous immune globulin (IVIG). In our
practice in the past 3 years, 3 patients with PID have undergone aortic valve
replacements. One patient had significant post operative pulmonary prob-
lems. Case Reports: Case 1, 61 year old female with PID was receiving IVIG
25 gm every 5 weeks with trough IgG = 866 mg/dl on12/12/12. The next dose
of IVIG was increased to 35 gm on 1/14/13. Aortic valve was replaced on
1/22/13, and she was on CPB for 87 mins. On 1/25/13 respiratory distress
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A85
with a small infiltrate on chest X-ray leading to reintubation. On 1/29/13 IgG
= 490 mg/dl and patient received IVIG 30 gm. There was subsequent rapid
improvement over the next 48 hours. Two other females with PID had aortic
valve replacement with no pulmonary or infectious complications. Case 2, 72
year old on 30 gm IVIG with trough IgG = 799 mg/dl and was on CPB for 85
mins. Case 3, 58 year old was on subcutaneous immune globulin 29.7 gm every
2 weeks. IgG trough was 1300mg/dl and she was on CPB for 64 mins. Con-
clusion: Reports from the surgical literature suggest that CPB may lead to a
decrease in IgG. In one of three patients with therapeutic levels of IgG preop-
eratively, there was a significant drop in IgG after CPB and aortic valve replace-
ment. Multiple factors could contribute to this drop including dilutional effects
of intravenous fluids, active bacterial infection, and the use of CPB. The pul-
monary infection and respiratory distress were accompanied by the decrease
in IgG. A prospective study is needed in patients with and without PID, with
measurement of IgG before surgery and 24,48 and 72 hours post CPB. At the
present time it is important to consider whether there is a need for an extra load-
ing dose of IVIG before surgery or whether careful monitoring of IgG levels
after surgery will help assure that the PID patient will not have serious post-
operative infections.
P212
MOWAT-WILSON SYNDROME (MWS) WITH ASPLENIA AND
LOW IMMUNOGLOBULIN LEVELS.
S. Wu*1, C.M. Bollard2, B.S. Vartabedian1, K. Paull3, B.P. Chumpitazi1,
I.C. Hanson1, 1. Houston, TX; 2. Washington, DC; 3. Bryan, TX.
Introduction: MWS is characterized by peculiar facial appearance, heart
defects, Hirschsprung disease (HD), genitourinary anomalies and brain anom-
alies. It is caused by mutation of ZEB2 gene. Pons et al have described con-
genital hypo/asplenia in 4 patients with MWS and ZEB2 mutation, and sug-
gest ZEB2 as a candidate gene for asplenia. Immune abnormalities have not
been reported in MWS patients. Here we report two unrelated patients with
MWS, ZEB2 mutation, congenital and/or functional asplenia and immune
abnormalities. Methods: Chart and literature review Results: Patient 1 is a 6-
year-old boy with MWS, HD, heart defects, and congenital asplenia. He had
no significant infection history. His immunological studies showed low IgG,
IgA and IgM, but normal response to vaccination. T&B cell phenotyping showed
normal percentages and numbers of mature B cells (CD19/CD20), but low per-
centages of CD19/27+ memory B cells. CD3 and CD8 T cell numbers were
low but lymphoproliferative studies showed normal responses to mitogen and
specific antigen. He lacked serologic evidence for past viral infection. In vitro
cytotoxic-T-lymphocyte (CTL) function appeared normal with cellular ability
to release interferon g in response to autologous EBV-transformed B cells
(Elispot assay) and kill EBV-transformed B cells in cytotoxicity assay docu-
mented. In sum, no T cell defect was identified. Patient 2 is a 4-year-old girl
with MWS, malrotation, hypogangolionosis, developmental delay, seizure dis-
order, and minimal splenic function from presumed splenic infarct. She had
recurrent infections of URI, otitis, and sinusitis. Her immunological studies
showed low IgG and IgA, and normal response to vaccination. T&B cell phe-
notyping showed normal percentages and numbers of T (CD3, CD4, CD8)
and B (CD19, CD20, CD19/27+) cells including transitional and class-switched
B cells. This child received empiric immunoglobulin supplementation and then
antibiotic prophylaxis. Conclusion: Like the MWS patients reported by Pons
et al, our 2 subjects also had congenital and/or functional asplenia associated
with ZEB2 mutation. Both patients had evidence of immune discrepancies with
low immunoglobulin levels. Physicians caring for patients with MWS should
be aware of asplenia risk and possible immune abnormalities specifically B
cell defects. Abdominal ultrasound and immune evaluation are recommended
to reduce infectious morbidity.
P213
BALANCING INFLAMMATION AND INFECTION IN A PATIENT
WITH COMMON VARIABLE IMMUNODEFICIENCY (CVID)
AND CHRONIC GIARDIASIS.
D.A. Andreae*, C. Cunningham-Rundles, New York, NY.
CVID is a collection of diverse and distinct diseases characterized by pri-
mary antibody deficiency (hypogammaglobulinemia). Clinical manifestations
include autoimmunity, inflammatory disease, recurrent infections and increased
malignancies, especially lymphoproliferative disorders. Inflammatory disease
of the gastrointestinal tract is seen in about 50 % of patients and lymphocytic
intraepithelial infiltration is common. Gastrointestinal infections, especially in
patients with absent IgA are common and Giardia is a recognized culprit. We
ABSTRACTS: POSTER SESSIONS
describe the case of a 21 year old male who was diagnosed with CVID at the
age of 17 years after an episode of prolonged diarrhea and weight loss that
required total parenteral nutrition. His quantitative Immunoglobulins were
decreased (IgG 146 mg/dl (700-1600 mg/dL) IgA= <7 mg/dl (70-400 mg/dL)
(IgM=<5 mg/dl (40-230 mg/dL)). He had protective antibody levels to measles,
mumps, rubella and varicella but absent antibodies to tetanus vaccine. Replace-
ment with intravenous immunoglobulins (IVIG) was started; because of low
trough levels dose increases were necessary. A biopsy of his Duodenum showed
complete absence of plasma cells, several non-necrotizing microgranulomata
were found in gastric samples. Diphenoxylate and atropine was started for treat-
ment of diarrhea. In the following the patient continued to have daily exten-
sive diarrhea that prevented weight gain. Giardia was identified by stool cul-
ture. Despite prolonged treatment with various antibiotic regimens no
eradication could be achieved. Treatment with Metronidazole, Tinidazole, Nita-
zoxanide, Paromomycin, Quinacrine alone and in different combinations was
attempted for 2 years. Oral Budesonide and Loperamide were needed for con-
trol of his diarrhea on most days. Control of inflammation was also attempted
with oral prednisone intermittently. Environmental precautions as avoidance
of tap water were advised. A prolonged course of Quinacrine and Tinidazole
cleared the infection and has kept him in remission for almost 11 months. Dif-
ferent components of CVID at interplay in the gastrointestinal tract required a
delicate balance of controlling inflammation with corticosteroids and treatment
of infection with antibiotics. Increased protein loss necessitated various dose
adjustments of IVIG to allow adequate protection of reinfection.
P214
TSUKAMURELLA SPECIES INFECTION PROMPTING DIAG-
NOSIS OF CHRONIC GRANULOMATOUS DISEASE IN A 17
YEAR OLD MALE.
C.D. Kubiak*, J.R. Trotter, J.K. Potthast, A. Petrovic, J.W. Leiding,
St. Petersburg, FL.
Chronic granulomatous disease (CGD) is an innate defect caused by muta-
tions in any of the five subunits of the NADPH oxidase leading to impaired
superoxide production and reduced intracellular killing of certain bacteria and
fungi. Recurrent infections of the skin, lungs, lymph nodes, and liver are caused
by a narrow spectrum of bacteria and fungi with particular susceptibility to
catalase positive organisms. We report a case of Tsukamurella species pneu-
monia prompting diagnosis of p47 deficient CGD in a 17 year old male. A 17
year old Hispanic male developed cough, fever, and fatigue over one week.
Cavitary necrotic lobar pneumonia of the right upper lobe, left lower lobe, and
lingula was found on computed tomography. Sputum culture yielded Tsuka-
murella species and methicillin-sensitive Staphylococcus aureus. Prolonged
treatment with meropenem and trimethoprim-sulfamethoxazole led to clinical
improvement and resolution of consolidations. Past history included bacterial
lymphadenitis at 18 months and 12 years, recurrent viral upper respiratory
infections, and ulcerative colitis diagnosed at 17 years. In addition he had recur-
rent granulomatous skin disease with slow wound healing. Infection with Tsuka-
murella, an opportunistic organism, prompted immune evaluation. Dihy-
drorhodamine assay revealed abnormal oxidative burst pattern consistent with
autosomal recessive CGD. Analysis of NCF1 showed a 2 base pair deletion
(c.75_76delGT ) confirming the diagnosis of autosomal recessive CGD. Tsuka-
murella species are partially acid fast, aerobic, castalase positive, Gram-posi-
tive rods found in soil. Infections with Tsukamurella typically occur in immuno-
compromised hosts, particularly when neutropenia is present. Indwelling central
venous catheter placement is also a risk factor. Cases of Tsukamurella have
been reported in patients with severe combined immunodeficiency, leukemia,
myelodysplasia, and in those receiving immunosuppressive chemotherapy.
We report the first case of Tsukamurella infection in a patient with CGD.
P215
RENAL COMPLICATION OF COMMON VARIABLE IMMUN-
ODEFICIENCY.
H.M. Tartibi*, S.L. Bahna, Shreveport, LA.
Introduction: Primary immunodeficiency diseases can have a variety of
complications, mostly infections. We report a case with a renal complication.
Case: A 26-y-o male presented with fever, pleuritic pain & productive cough
for 1 d. He had adenotonsillectomy as a child and multiple pneumonias over
the past 4 y. He appeared ill, in mild respiratory distress, T 1010F, RR 20/min,
HR 118/min, BP 134-151/70-89 mmHg, Wt 97.5 kg, with dry mucous mem-
branes, decreased breath sounds on the right lower lung field, and mild lower
extremity edema. CXR showed RUL & RLL infiltrate with right-sided pleu-
VOLUME 113, NOVEMBER, 2014 A85
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A86
ABSTRACTS: POSTER SESSIONS
ral effusion. CBC: Hgb 10.1 g/dL, Hct 29.9%, Platelets 310 K/uL, WBC 20.12
K/uL, N 16.86 K/uL (84%), L 1.7 K/uL (8.4%), M 1.15 K/uL (5.7%), E 0.3
K/uL (1.6%). Serum protein was 4.5 g/dL, with albumin 1.1 g/dL. He was rehy-
drated with IVF & started on antibiotics (blood culture grew S. pneumoniae).
His BUN 13 mg/dL & Cr 2.1 mg/dL increased to BUN 48 mg/dL and Cr 6.5
mg/dL by day 10. UA showed 500 mg/dL protein, Pr/Cr ratio 7.9 (nl <0.2).
Renal biopsy demonstrated post-infectious glomerulonephritis (secondary to
S. pneumoniae). Our evaluation showed IgG 102 mg/dL, IgM 31 mg/dL, IgA
<8 mg/dL, IgE <0.3 IU/mL. He had nonprotective Ab titers to diphtheria (<0.1
IU/mL) & tetanus (<0.1IU/mL). Pneumococcal Abs were not done due to lab
error. We administered IVIG 1g/kg. Upon obtaining his past medical records,
we discovered that 3 y ago he had IgG 169 mg/dL, IgM 2 mg/dL, & IgA <5
mg/dL without intervention. At that time had normal BP and renal function.
HIV test was negative. Flow cytometry was WNL. UPEP was consistent with
non-selective proteinuria & SPEP was suggestive of acute inflammatory
response. His stool α-1-ATP was negative. For glomerulonephritis, he was
started on high dose steroid therapy with gradual reduction to 60 mg/day pred-
nisone & anti-hypertensives. His findings were compatible with CVID com-
plicated by nephrotic syndrome. IVIG continued (500 mg/kg) every 2-3 wk
with peak 1280 mg/dL & troughs 370-662; and IgG half-life 6.3 d. His renal
function fluctuated depending on his adherence to Lisinopril; with Cr 1.3 mg/dL
& Pr/Cr ratio 2.3. He has remained infection-free with radiographic resolution
of his pneumonia & pleural effusion. Conclusion: To our knowledge, this is
the first reported case of CVID complicated with post-streptococcal glomeru-
lonephritis possibly due to marked delay in IVIG therapy.
P216
SARCOIDOSIS WITHOUT GRANULOMA PRESENTING AS
LYMPHOPENIA.
A. Kleva*, A. Jongco, Great Neck, NY.
Introduction: Sarcoidosis is a granulomatous disorder of unclear etiology
that affects multiple systems. Monocytes, macrophages, and activated T cells
increase production of inflammatory mediators in noncaseating granulomas.
Peripheral lymphopenia correlates with disease severity. Methods: We report
a relatively healthy 22-year old male with a history of psoriasis who presented
with fever, cough, malaise after traveling to Cancun. He was diagnosed with
bibasilar pneumonia and treated with levofloxacin. He was readmitted for fever,
abdominal pain, diarrhea, hypoxia and neutropenia requiring filgrastim. Hos-
pitalization was complicated by pneumothorax after bronchoscopy. Bron-
choalveolar lavage showed Balantidium coli that was treated with doxycycline
and metronidazole. After a few days, he was readmitted with fever, hypoten-
sion, hypoxia, diarrhea, and a new purpuric rash on the extremities. High dose
steroids, imipenem, vancomycin and levofloxacin improved respiratory status
and rash. He returned soon after discharge with pneumothorax needing a chest
tube. As outpatient, prednisone was titrated to 40 mg daily without exacerbat-
ing rash or respiratory status. Bactrim prophylaxis was started. Results: At first
readmission, T-cell lymphopenia was found (CD4+ = 83/uL, CD8+ = 35/uL).
Bone marrow biopsy and extensive autoimmune and infectious workup were
nondiagnostic. On readmissions, he had low IgG of 547 mg/dL. Open lung
and skin biopsies showed a predominantly T-cell lymphohistiocytic infiltrate
with CD4+>CD8+. Noncaseating granulomas were absent in both biopsies. As
outpatient, lymphopenia persisted (CD4+ = 112/uL, CD8+ = 54/uL, CD19+
=6/uL, and CD 16+/56+ = 20/uL). Lymphocyte proliferation to PHA, IgG, IgA,
IgM, CH50, and G6PD level were normal. He had protective titers to MMR,
tetanus, diphtheria, pertussis and polio, but not to pneumococcus or varicella.
A skin biopsy performed 6 months later showed noncaseating granulomas con-
sistent with sarcoidosis. Lymphopenia persists (CD4+ = 82/uL, CD8+ = 32/uL
and CD16+/56+ = 33/uL) while on weekly low-dose methotrexate, daily dap-
sone and prednisone 10 mg. Conclusion: Whether an underlying immune defi-
ciency was present is unclear, but medication-induced immune suppression
does not adequately explain his course. This case underscores the need for re-
evaluation of affected systems. Sarcoidosis should be considered in the differ-
ential diagnosis of lymphopenia.
A86 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P217
IDENTIFICATION OF GATA2 MUTATION IN ASYMPTOMATIC
PATIENT.
M.R. Shams*, L. Kobrynski, Atlanta, GA.
Rationale: Whole exome sequencing (WES) is being used as a screening
and diagnostic test for a number of rare diseases. The significance of mutations
identified through WES requires interpretation by experts with knowledge of
disease causing mutations. Methods: A 22 month old male presented to the
Immunology clinic after WES revealed a mutation in GATA2. Genetic testing
was performed because of a history of mild dysmorphic features, laryngoma-
lacia, and obstructive sleep apnea. The only infectious history was recurrent
acute otitis media requiring tympanostomy tubes and severe gingiva-stomati-
tis. Results: WES revealed a 3 distinct mutations; COMP R381H heterozygous
mutation, TMCO C35Y heterozygous mutation and a de novo GATA2 R396W
heterozygous mutation associated with known disease. GATA 2 defects are
inherited in an autosomal dominant and cause increased susceptibility to severe
viral infections, the development of mononuclear cytopenias, myelodysplastic
syndrome/acute myeloid leukemia and lymphedema. GATA2 R396W has been
previously reported in 2 patients, who developed symptoms in late childhood
with infections with Epstein-Barr virus, herpes-simplex virus, human papil-
loma virus, mycobacterium avium intracellulare and the development of
myelodysplastic syndrome. Our patient had a history of oral herpetic lesions
due to herpes simplex but had no other significant viral infections. T, B, NK
lymphocyte enumeration was normal. Neither parent had the R396W mutation.
The other two identified mutations were carried by his father but are of unknown
significance. Conclusions: WES is a useful testing modality to confirm sus-
pected diagnoses. However, providers should use caution when interpreting
genetic reports, especially if used as a screening modality, as many genetic vari-
ations are benign polymorphisms. It is critical to perform WES on both par-
ents and, if available, affected family members to confirm the pathogenicity of
a mutation.
P218
EFFECTIVE USE OF 20% SUBCUTANEOUS IMMUNOGLOBU-
LIN THERAPY IN AN ADULT MALE WITH PRE-EXISTING
THROMBI.
C.M. Duff*1, M. Sher2, J. Leiding2, 1. Parrish, FL; 2. St. Petersburg, FL.
Rationale: Immunoglobulin replacement therapy is prescribed for patients
with immunodeficiency characterized by hypogammaglobulinemia and/or the
inability to make antibodies to recall antigens. Administration can occur intra-
venously or subcutaneously. Currently there is a black box warning on all
immunoglobulin replacement products indicating a possible increased risk of
thrombogenic events. Data regarding the use of subcutaneous immunoglobu-
lin (SCIG) therapy in patients with known thrombotic events is limited. Meth-
ods: A 36 year old Caucasian male with cystic fibrosis was diagnosed with
selective antibody deficiency based on absent pneumococcal responses (0/14
protective serotypes) with intact tetanus and diphtheria responses and normal
immunoglobulin profile (IgG 1020mg/dl, IgA, IgM). He is the survivor of a
double lung transplant at 24 years and a single lung transplant at 33 years. A
left leg deep vein thrombosis and sagittal vein thrombosis developed two years
after second transplant. Causes of primary thrombophilia were excluded. In
parallel recurrent bacterial pneumonias, primarily caused by S. pneumonia led
to multiple hospitalizations. Based on poor antibody responses and clinical sta-
tus, immunoglobulin replacement therapy was initiated. Results: To decrease
the potential risk of a thrombotic event, 20% SCIG was administered more
frequently at twice weekly. Concurrent treatment of thrombi continued with
warfarin maintaining INR at a therapeutic level of 2-3 units. No bleeding or
bruising occurred at infusion sites. A magnetic resonance angiogram performed
6 months after starting SCIG showed no increase in size or new thrombi. Pro-
tective pneumococcal titers were measured and were found to be protective to
10/14 serotypes and the patient has had only one hospitalization for bacterial
pneumonia since starting SCIG. Conclusion: SCIG can be safely and effec-
tively administered to patients with thrombi receiving anticoagulant therapy.
Concurrent use of anticoagulant medications did not increase the occurrence
of local site reactions with the use of 20% SCIG treatment in this patient.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A87

ABSTRACTS: POSTER SESSIONS

domain, leading to a malformation of the functional enzyme similarly found

P219 in homozygous mutation. Our patient does not have microcephaly or growth
DIVERGENT PHENOTYPES IN SIBLINGS WITH X-LINKED
retardation, but does show clear evidence of radiosensitivity and T cell lym-
CGD. phopenia, which we suspect will worsen with age.
F. Alkhatib*1, D.M. Robertson2, 1. Holyoke, MA; 2. Hadley, MA.
Introduction: CGD is a rare immunodeficiency of phagocytes character-
ized by increased susceptibility to bacterial and fungal pathogens. We describe P221
the first report of two siblings with X-linked CGD due to the same mutation STAT3 MUTATION IN GOOD SYNDROME.
with significant variation in phenotype. Methods: A 6 week-old full term boy L. Buyantseva*, T. Craig, Hershey, PA.
presented with fever, lymphadenopathy, and dyspnea. Imaging showed multi-
Background: Good syndrome is a rare cause of combined immune defi-
focal pneumonia. His hospital course was complicated by ARDS, septic shock,
ciency that occurs in association with thymoma. TACI and BAFF-R receptor
Candida lusitaniea fungemia, a cutaneous Candida and Rhizomucor abscess,
mutations have been described in association with this syndrome. Signal trans-
multi-organ dysfunction, and HLH (Hemophagocytic Lymphohistoiocytosis).
ducer and activator of transcription 3 (STAT3) is a transcription factor essen-
The “healthy” 18-month old brother of patient 1 was considered as a stem cell
tial for differentiation of the TH17 helper T cells. Mutation of STAT3 gene has
donor, but was found to have CGD caused by the same mutation. He was thriv-
been described in association with HyperIgM syndrome and a variety of autoim-
ing with no major illnesses, but serological evaluation revealed systemic inflam-
mune diseases. We present a case of STAT 3 mutation associated with Good
mation, normalizing on triple prophylaxis of Bactrim, Itraconazole and INF-
syndrome. Case Presentation: A 73-year-old female with Common Variable
gamma. Results: In patient 1, Immunoglobulin B & T cells levels were normal,
Immunodeficiency (CVID) and thymoma removed 20 years ago. She presented
while NK cells were slightly low (92 c/mm3). DHR showed absent neutrophil
with chronic watery diarrhea, 20 pound weight loss and frequent sinus infec-
function: genetic testing revealed a hemizygous mutation in the CYBB gene
tions. Her physical exam was remarkable for extensive onycomycosis. Immune
of gp91phox, consistent with X-linked CGD. After stabilizing medically, he under-
workup showed lymphopenia, deficiency of B and T absolute cell counts (<1%
went hematopoietic stem cell transplant (HSCT) from an unrelated donor com-
and 58% respectively), normal NK cells count, and low IgA, IgG and IgM lev-
plicated only by mild cutaneous GVHD. The second sibling had a negative DHR
els (<33 mg/dL, 6.7 mg/dL and 4.2 mg/dL respectively). Gastroenterology
assay and the same mutation. ESR was >120, Plt 719, Hct 26.3, Alk Phos 310
workup revealed celiac disease as a cause of her diarrhea. Gluten-free diet was
and immunoglobulins were elevated. Screening CT showed 2-3 <1cm non-
initiated and her diarrhea resolved. Patient was started on Atovaquone for pro-
enhancing hepatic hypodensities, not amenable to biopsy. Lab abnormalities
phylaxis of opportunistic infections and IVIG replacement. Genetic analysis
normalized within weeks of starting prophylactic therapy. At age 3, he remains
identified STAT 3 mutation. Conclusions: This is a first published report of a
free of recurrent bacterial and fungal infection. Discussion: CGD is caused by
patient with Good syndrome associated with STAT 3 mutation. This case
mutations in phagocyte NADPH oxidase, with considerable variability in dis-
demostrates the variability of phenotypic responce to STAT 3 mutations.
ease severity. For many years, treatment consisted primarily of antimicrobial
prophylaxis. Recently, HSCT has emerged as an attractive alternative, though
there is debate about candidates for transplant. Generally, patients with very
low super oxide production have worse long-term survival. Previous cases of
P222
siblings with AR-CGD have shown variable phenotype, presumably due to pen-
MANNOSE BINDING LECTIN DEFICIENCY WITH A CONCUR-
etrance of the functional allele. Our cases are unique in that the patients have RENT ESOPHAGEAL CANDIDIASIS AND RECURRENT HER-
the same level of phagocyte function but very different phenotypes and high- PES GINGIVALIS.
light the potential difficulty in using level of super oxide production to assess K. Achar*1, D. Ferastraoaru2, D.L. Rosenstreich2, 1. New York, NY;
patients for HSCT. 2. Bronx, NY.
Introduction: Mannose binding lectin (MBL) recognizes carbohydrate pat-
terns found on the surface of pathogenic microorganisms leading to activation
P220 of the lectin pathway of the complement system and contributing to ultimate
NEWBORN TREC SCREENING IDENTIFIED AN INFANT WITH pathogen elimination. MBL plays an important role in the first-line defense
NHEJ1 HETEROZYGOUS MUTATION LEADING TO THE DIAG- against Candida albicans and its deficiency is associated with herpes virus sim-
NOSIS OF ATYPICAL RADIOSENSITIVE SCID. plex (HSV) infection in mice. Method: Review of the literature and case report
H. Bhatti*, P. Poowuttikul, E. Secord, Detroit, MI. of a patient with MBL deficiency, esophageal candidiasis and recurrent oral
herpes virus simplex infection. Results: 50 yo male with well controlled sea-
Background: Radiosensitive forms of SCID are due to defects in compo-
sonal allergies was referred for evaluation of a possible immune deficiency
nents of the NHEJ DNA repair mechanism during the process of V(D)J recom-
after he was found to have one episode of esophageal candidiasis that resolved
bination. Mutations in several genes involved in the NHEJ mechanism result
with oral fluconazole treatment. The patient did not have any other factors that
in a T-B-NK+ SCID. About 1/3 of patients with SCID have the T-B-NK+ phe-
could predispose to candidiasis, predisposing factors such as diabetes mellitus
notype, which is associated with a poorer prognosis after receiving hematopoi-
or treatment with oral or inhaled corticosteroids, and was HIV antibody neg-
etic cell transplantation in various studies. The components of DNA repair
ative. Further history revealed that he had been experiencing recurrent oral
that are known to lead to radiosensitive SCID include Artemis, DNA Ligase
ulcers for the past 10 years the worst of which were over the lip, with more fre-
IV, DNA-PKcs, Ku70, Ku80, XRCC4 and Cernunnos-XLF or NHEJ1. Patients
quent and longer episodes for the past year. A repeat immunological evalua-
with NHEJ1 deficient SCID typically have microcephaly with growth retar-
tion revealed normal lymphocyte subsets, serum immunoglobulin levels, anti-
dation; however there are a few cases who do not. Objective: We report the case
body responses (tetanus toxoid and pneumococcal titers), complement levels
of 21-month old female with a heterozygous NHEJ1 defect and T cell defi-
and a negative repeat HIV test. The serum MBL level on the first visit was low
ciency identified on newborn TREC screening. Case Report: A full term new-
(12ng/ml ; normal: >100 ng/ml) and when repeated 3 months later was less
born was found to have very low TREC on newborn screening leading to sus-
than 0.5 ng/ml. The patient did not have any recurrence of esophageal can-
pected SCID versus a combined immunodeficiency. Exam of the baby revealed
didiasis and he was prescribed acyclovir for recurrent oral HSV which reduced
normal growth parameters and no dysmorphism. Subsequent testing revealed
the frequency and severity of the oral lesions. Conclusion: This is the first
T and B cell lymphopenia (CD4 = 750/mm3, CD19 = 75/mm3) with normal
documented case of associated esophageal candidiasis and recurrent oral HSV
IgG and IgM with low IgA. Genetic testing revealed a heterozygous defect in
infection in a patient with MBL deficiency. The exact mechanism through which
the NHEJ1 gene. The lymphoblastoid cells revealed abnormal radiosensitivity
MBL deficiency predisposes to mucosal infections in patients with an other-
of 15%. The T cell lymphopenia progressed until our last labs at 16 months.
wise normal immune system is not completely understood. We would like to
Testing for 22q11 deletion was normal. PHA was initially low but was ade-
highlight the importance of maintaining a high level of suspicion for MBL defi-
quate at 16 months and the child experienced no serious infection during that
ciency in these challenging cases. Making a correct diagnosis will help to pre-
time. The family refused further care and the patient remains lost to follow up.
vent possible future complications by keeping these patients under closer obser-
Discussion: Deficiency of NHEJ1 is one of the variants of radiosensitive SCID.
vation. At the present there is no specific treatment available for MBL deficiency.
Five SCID patients reported to date have homozygous mutation of NHEJ1. Typ-
ically patients with this variant exhibit severe recurrent infections, microcephaly
and growth retardation. Mild to severe T and B cell lymphopenia have been
reported with progressive lymphopenia over time. We report a patient with het-
erozygous NHEJ1 deficiency in which the defect involves the dimerization

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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A88
ABSTRACTS: POSTER SESSIONS
P223
RISK FACTORS RELATED TO MORTALITY IN CHILDREN
WITH HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A
CHILDREN’S HOSPITAL FROM MEXICO CITY.
L.I. Calderon*, A. Partida, B.E. Del Rio, O. Saucedo, C. Cicero, Mexico
City, DF, Mexico.
Introduction: Haemophagocytic lymphohistiocytosis is a life-threatening
disease of immuneregulation. A large proportion of deaths occur early into
treatment. We investigated association with early death for laboratory and clin-
ical parameters. Methods: A total of 45 children from Federico Gómez Chil-
dren’s Hospital in Mexico city wich fulfill the diagnostic criteria and/or with
familiar disease, receiving diferent treatments were included. We discribed
demographic, clinical and laboratory data with frecuencies and proportions and
also stadistics with central tendancy and dispersión tendancy. We made a risk
analysis in two steps. The first was about an univariated análisis with propor-
tional diferences in the survivor group and in non-survivers, using X2 or exact
Fisher test acording to the number of observations. From the variables that show
statisticaly significant diferences, they were introduced in a model of multiple
OR, in wich we also include time in months until clinical presentation, genus
and etary group, getting a statisticaly significant model (LR X2 (6g-l) = 13.32;
p=0.038). Results: We observed a significant relation of risk for mortality for
neutropenia (OR 8.96 IC95% 1.08 a 74.49, p = 0.042). The presence of clini-
cal infection at the time of diagnosis show a relation with mortality without
significant relevance (OR 7.17 IC95% 0.97 a 53.16; p= 0.054). The presence
of hepatomegaly and absence of epistaxis are perfect predictors of surveillance.
The surveillance curves point out the group between 1 and 4.9 years to be the
more vulnerable with a higher mortality get in the first month after diagnosis
of 50% and 70% thereafter. The group of less than 1 year show a mortality of
62%. The group of 5 to 10.9 years show a mortality rate of 66%. Finally the
group of 11years and older, get a mortality rate of 55% at 3 months after diag-
nosis. Conclusión: In 45 patients with the diagnosis of haemophagocytic lym-
phohistiocytosis in the Hospital Infantil de México Federico Gomez, we found
a mortality of 53%. The risk factor asociated to mortality was the presence of
neutropenia. We also found a relationship with the presence of infection, but
it wasn’t statistically relevant. Moreover, in this study, we found posible pro-
tector factors related to mortality like the abscence of epistaxis and presence
of hepatomegaly.
Table 4. Differences between survivours and non-survivours & univariate
risk analysis.
A88 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P224
NEUTROPENIA: A CLUE FOR THE DIAGNOSIS OF X-LINKED
AGAMMAGLOBULINEMIA.
M. Tallar*1, M. Hintermeyer1, H.N. Hartman2, J. Verbsky1, J. Casper1,
J. Routes1, 1. Wauwatosa, WI; 2. Milwaukee, WI.
Background: X-linked Agammaglobulinemia (XLA) is a primary immun-
odeficiency secondary to a mutation in the gene coding for the Bruton’s tyro-
sine kinase (Btk) protein, which is essential for the differentiation of B cells.
Immunological evaluation typically demonstrates a low/absent CD19+ B cells
and agammaglobulinemia/severe hypogammaglobulinemia. The clinical pres-
entation of XLA is usually between 6-18 months of age and is characterized
by recurrent upper and lower respiratory tract infections gastrointestinal tract
infections, conjunctivitis, skin infections/pyoderma, meningitis and sepsis. Ten
to 20% of patients have neutropenia at the time of initial diagnosis. Case Descrip-
tion: An 18 month old male with a history of atopic dermatitis was admitted
to hospital for a rash concerning for bullous impetigo. He had an absolute
neutrophil count of 0/mm3 on admission which improved to 3500/mm3 after
starting antibiotics for methicillin sensitive staphylococcal aureus (MSSA).
Quantitative immunoglobulins were obtained revealing IgG<80 mg/dL (431-
1109), IgA<6 mg/dL (20-100), and IgM<5 mg/dL (19-146). Vaccination titers
to tetanus, diphtheria, haemophilus, and pneumococcus were absent. Flow
cytometry on peripheral blood revealed no CD19+ B Cells and absence of BTK
expression in monocytes. Conclusions: Although there are several proposed
mechanisms for neutropenia in XLA, two non-mutually exclusive mechanisms
have recently gained prominence. One proposed mechanism is that Btk is nec-
essary for PMN function and development. In mouse models, neutrophils defi-
cient in Btk have decreased expression of granular proteins (elastase, myeloper-
oxidase, gelatinase, and neutrophilic granular protein) and arrest of maturation
at the myelocyte/promylocyte stage. Another proposed mechanism is that Btk
negatively regulates cytokine and Toll Like Receptors (TLR) induced Reduced
Oxygen Intermediates (ROI) production. In studies using human PMNs, a defi-
ciency in Btk results in the overproduction of ROI during infection leading to
increased neutrophil apoptosis compared to neutrophils from normals. How-
ever, neither of these mechanisms explains why neutropenia only occurs with
infection prior to diagnosis and not subsequently following administration of
replacement antibody. Regardless, XLA should be on the differential diagno-
sis of males between the ages of 6-18 months of age presenting with neutropenia.
P225
LONG-TERM PROPHYLACTIC TREATMENT OF HEREDITARY
ANGIOEDEMA: FINDINGS FROM AN INTERNATIONAL
HEREDITARY ANGIOEDEMA EXPERT SURVEY.
B. Zuraw*1, T. Craig2, J.A. Bernstein3, H. Farkas4, I. Boccon-Gibod5,
L. Bouillet5, M. Cicardi6, M. Cancian7, A. Reshef8, M. Stobiecki9,
P. Nordenfelt10, H. Longhurst11, M. Guilarte12, T. Caballero13,
M.B. Ferreira14, K. Bork15, M. Magerl16, I. Martinez-Saguer17,
E. Aygören-Pürsün18, A. Bygum19, 1. La Jolla, CA; 2. Hershey, PA;
3. Cincinnati, OH; 4. Budapest, Hungary; 5. Grenoble, France; 6. Milan,
Italy; 7. Padova, Italy; 8. Tel Hashomer, Israel; 9. Cracow, Poland;
10. Jönköping, Sweden; 11. London, United Kingdom; 12. Barcelona,
Spain; 13. Madrid, Spain; 14. Lisbon, Portugal; 15. Mainz, Germany;
16. Berlin, Germany; 17. Frankfurt- Mörfelden, Germany; 18. Frankfurt,
Germany; 19. Odense, Denmark.
Introduction: Orally administered attenuated androgens (AAs) have been
used since the 1970s for prophylactic treatment of hereditary angioedema (HAE)
attacks, although they may be associated with dose-dependent undesirable side
effects. Intravenous plasma derived C1-INH (C1-INH) has become available
for prophylaxis in the last 5 years in some countries. However, long-term expe-
rience and safety data on this therapy is limited and its use varies by region
and country. Our aim was to assess AA use across several international HAE
centers and identify medical reasoning which may support switching patients
from AAs to C1-INH prophylaxis. Methods: An 8-question survey exploring
physician opinions on the use of prophylactic medications for HAE was sent
to 17 HAE experts’ in Europe (EU) and 3 in the United States (US). Experts
reported on the percentage of patients receiving prophylaxis with AAs, side
effects observed in patients receiving AAs and barriers preventing the switch-
ing of patients to alternative therapies. Results: The use of AAs varied among
the HAE experts surveyed being most common in the EU compared to the US
(Fig 1), and was more common in men (27.6%) than women (13.4%). Other
therapies used included C1-INH, antifibrinolytics and progestin (Fig 1). Side
effects reported in males receiving AAs included weight gain, lipid abnormal-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A89
ities and hypertension. Most reported side effects in females were menstrual
irregularities, virilization and weight gain. A small number of patients discon-
tinued AAs due to side effects (12%) while some patients (12%) switched to
alternative treatments, e.g., C1-INH. Physicians reported that barriers pre-
venting patients switching to prophylactic C1-INH included AA efficacy (n=10),
ease of oral administration (n=10) and cost (n=7). Conclusions: The HAE expert
survey demonstrates that AAs are widely used for prophylaxis in many coun-
tries. Experts noted that while AAs are effective they may be associated with
side effects; however, at low doses (i.e., 50–100 mg/day) they may be well tol-
erated. In the absence of objective, comparative, randomized, controlled stud-
ies of the benefit/risks of new prophylactic therapies compared to AAs no
consensus could be reached regarding switching patients from AAs to other
prophylactic modalities.
Figure 1: Use of attenuated androgens and other therapies for the prophylac-
tic treatment of HAE attacks across centers in US and Europe
P226
A CASE OF GATA2 MUTATION PRESENTING WITH CRYPTO-
COCCAL MENINGITIS.
K. Welch*, New York, NY.
Introduction: Mutations of the GATA2 gene have recently been implicated
as causes of MonoMAC syndrome, a primary immunodeficiency associated
with monocytopenia and B and NK cell lymphopenia. The clinical ramifica-
tions are broad and include mycobacterial, viral and fungal infections, as well
as pulmonary alveolar proteinosis and myelodysplasia. Long-term complica-
tions of the genetic defect include recurrent infections and likely leukemia.
Case Presentation: A 33 year-old Hispanic woman presented to the emergency
department with intermittent fever and a severe frontal headache of one week
duration. Imaging revealed enhancing leptomeningeal nodules, and subsequent
lumbar puncture identified cryptococcal meningitis. Her labs were notable for
a white count of 6.3x103 and a monocyte count of zero. On further review, the
patient’s history was notable for interstitial fibrosis with pulmonary alveolar
proteinosis, characterized by intermittent hemoptysis for the past 6 years. She
also notes a varied infectious history, including Mycobacterium avium and
Aspergillus fumigatus pneumonias as well as HPV infection with cervical
intraepithelial neoplasia. A unifying diagnosis had not been offered in the past
6 years since she became symptomatic. There was no family history of immun-
odeficiency. Taking into consideration her disseminated fungal infection and
monocytopenia, as well as the history of mycobacterial infection, PAP and HPV,
GATA2 deficiency was suspected and genetic analysis revealed a frameshift
mutation in the gene leading to MonoMAC syndrome. Conclusions: GATA2
deficiency is a relatively newly identified genetic mutation that can lead to a
characteristic presentation of pathologic changes and infectious disease. Patients
in whom this defect is suspected should undergo genetic sequencing to con-
firm the diagnosis. Ultimate treatment involves bone marrow transplant to pre-
vent the likely long-term outcome of hematologic malignancy.
ABSTRACTS: POSTER SESSIONS
P227
RECOMBINANT HUMAN HYALURONIDASE [RHUPH20]-
FACILITATED SUBCUTANEOUS (SC) INFUSION OF IMMUNO-
GLOBULIN G (IGG) (HYQVIA; IGHY) IN PATIENTS AGED ≥16
YEARS WITH PRIMARY IMMUNODEFICIENCIES (PI): LONG
TERM SAFETY, EFFICACY, AND TOLERABILITY.
R.L. Wasserman1, M. Stein2, I. Melamed3, L. Kobrynski4, J.A. Grant5,
S. Gupta6, W. Engl7, H. Leibl7, L.Yel*8, R.I. Schiff8, 1. Dallas, TX; 2. North
Palm Beach, FL; 3. Centennial, CO; 4. Atlanta, GA; 5. Galveston, TX;
6. Irvine, CA; 7. Vienna, Austria; 8. Westlake Village, CA.
Introduction: IGHy allows for SC administration of IgG at a similar fre-
quency (every 3–4 weeks) and bioavailability to that of intravenous (IV) IgG
(IGIV). Compared with conventional SC-administered IgG (IGSC), IGHy
requires fewer infusions per month (median 1.09 in the pivotal phase 3 study)
using one or occasionally two sites. We report efficacy, safety and tolerability
of IGHy in patients aged ≥16 years who were treated with IGHy for up to 3
years. Methods: Sixty-one patients aged ≥16 years received IGIV for 3 months
followed by IGHy at 3-or 4-week intervals for approximately 18 months; 55
were treated for up to an additional 21 months at the same dose and interval.
rHuPH20 was infused at 75U/g IgG followed by IgG at 108% of the IV dose.
rHuPH20 was discontinued after up to 3 years of exposure; patients were fol-
lowed for an additional 6–12 months. Assessments included rates of adverse
events (AEs), serious AEs (SAEs), and infections; tolerability; and rHuPH20
antibody levels. These studies were approved by the appropriate ethics com-
mittees. Results: The maximum IGHy exposure for patients aged ≥16 years
was 3 years (144 patient-years). Over the full study course, rates of temporally-
associated AEs/patient-year were 2.99 (local) and 2.78 (systemic; excluding
infections). No SAEs were related to IGHy. The annual infection rate was 3.05
(95% CI: 2.63–3.52)/patient-year, including ramp-up. Of 2307 IGHy infusions
administered (including ramp-up), 98% required no administration changes
due to tolerability concerns or AEs. Thirteen patients ≥16 years developed non-
neutralizing anti-rHuPH20 antibody titers ≥1:160 on 1 or more occasion with
no associated AEs; titers declined despite continuing rHuPH20 in 12 of 13
patients. No patients developed neutralizing anti-rHuPH20 antibodies. Con-
clusion: In patients with PI who were treated with IGHy for up to 3 years, infec-
tion rates were low and AE rates were comparable to previously reported rates
for patients treated with IGSC, but with infusion volumes and rates equivalent
to that of IGIV.
P228
NEW COMPLEX CHROMOSOME ABNORMALITY IN A
PARTIAL DIGEORGE PATIENT ASSOCIATED WITH LATE
PRESENTATION OF IMMUNE ALTERATIONS.
V. Cavero Chavez*, S.A. Schwartz, Buffalo, NY.
Introduction: DiGeorge syndrome (DGS) is characterized by defective
development of the pharyngeal pouch system. The triad is: cardiac anom-
alies, hypoplasic thymus and hypocalcemia. Patients are divided in two sub-
types: complete DGS, with total absence of thymic tissue that is a type of SCID
and fatal within the first year of life unless treated, and partial DGS which
usually have not severe variable immunologic defects. The typical deletion
associated is 22q11.2. Methods: We describe a 26 year old male patient with
partial DGS and Tetralogy of Fallot surgically corrected, who presented with
new recurrent sino-pulmonary infections for the past 8 months requiring mul-
tiple courses of antibiotics. He underwent immunological studies including:
Lymphocyte subset counts, lymphocyte mitogens an antigen stimulation test,
quantification of specific antibody titers for S. pneumoniae pre and post
vaccination, immunoglobulin levels. Results: Immunological evaluation
revealed Lymphopenia: Absolute lymphocyte count: 487/mcl(NR:1400-3300),
CD3:409/mcl(NR: 1000-2200), CD4:143/mcl(NR:530-1300), CD8:231/mcl(NR:
330-920), CD19:25/mcl(NR:110-570), CD56:53/mcl(NR:70-480). Mitogen
stimulation of mononuclear cells revealed a normal response to Pokeweed,
decreased response to PHA and CON-A. Antigen studies included positive
responses to Tetanus and Streptolysine O antigens, decreased responses to MMR
and Candida. Serum immunoglobulins included low IgG (396 mg/dL), low IgA
(59 mg/dL), normal IgM (55mg/dL). Serum antibody responses revealed base-
line S. pneumoniae titers: 8/23 non–protective and post vaccination S. pneu-
moniae titers: 7/23 non-protective. Tetanus toxoid, varicella and Polio anti-
bodies, were protective. Karyotype 45, XY, der (19) t(19;22) (p13.3, q11.2),
-22, no previously described. Conclusions: Our 26 year old partial DGS patient
with complex chromosome abnormality presented with late onset of humoral
deficiency, lymphopenia and impaired T cell function. He required immunoglob-
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ABSTRACTS: POSTER SESSIONS

ulin replacement and prophylaxis for opportunistic infections. In this particu-

lar case genetic heterogeneity may play a significant role in time of presenta-
P231
OPTIC NEURITIS IN A 29-YEAR-OLD WITH COMMON VARI-
tion, manifestations and severity of impaired immunity. More understanding
of this genetic variations will help to better know about prognosis of Partial ABLE IMMUNODEFICIENCY TREATED WITH INFLIXIMAB.
DGS patients and continue close follow up even during adulthood. M. Mortezavi*, E. Weis, R.J. Looney, Rochester, NY.
Introduction: Non-infectious complications are now the major cause of mor-
bidity and mortality in patients with Common Variable Immunodeficiency
P229 (CVID). We describe the case of a young woman with CVID who has both
IGG4-RELATED DISEASE PRESENTING AS ABDOMINAL PAIN granulomatous-lymphocytic interstitial lung disease (GLILD) and unilateral
WITH MASS. optic neuritis. Case Presentation: Our patient is a white female who was diag-
L. Zhou*, G.D. Marshall, Jackson, MS. nosed with CVID at age 16 but was not treated due to lack of insurance. At age
26, she presented with headaches, difficulty walking and profound hyopgam-
Introduction: IgG4-related disease is a systemic malady that has been
maglobulinemia (IgG 75, IgA < 5, IgM 32). She had multifocal brain lesions,
reported to involve multiple organ systems, especially the pancreas with plasma
which on biopsy were non-specific lymphoid tissue. Her symptoms and lesions
cell infiltrates. It has also been found to affect skin, lacrimal glands, salivary
resolved after treatment with maintenance IVIG and oral corticosteroids. At
glands, thyroid, pericardium, aorta, lungs, kidneys, pancreas, liver, retroperi-
age 28, she developed dyspnea, a restrictive pattern on spirometry and ground
toneum, breast, and prostate. Regardless of which organ is involved, tissue biop-
glass opacity on CT thorax. She underwent an open lung biopsy, which showed
sies show great histopathological similarities such as diffuse lymphoplasma-
GLILD. All her biopsies stained negative for viral and bacterial agents, and for
cytic infiltrates, abundant IgG4 positive plasma cells, and extensive fibrosis.
IgG4 plasma cells. She was treated with four weekly rituximab infusions for
Methods: Case files of patient was reviewed. Literature reviewed was perofmed
GLILD. She improved symptomatically, but a CT two months later showed sev-
using PubMed searches with the terms “IgG4” and “abdomen”. Results: A 53
eral new lung nodules. Soon after, she developed complete loss of vision in
year old African American female presented to her primary care physician with
her left eye. Ophthalmologic examination showed a bulging optic disc and MRI
chronic abdominal pain. She was referred for specialty care and had unre-
of the orbit showed enhancing optic nerve consistent with optic neuritis. She
markable esophagogastroduodenoscopy and colonoscopy. Subsequent CT scan
improved after three doses of 1 gm IV methylprednisolone and mycophenolic
revealed finding a 28x28x33mm soft tissue mass in the right lower
acid, but relapsed shortly after. MRI of the brain and spine did not show any
abdomen/pelvis mesentery anteriorly abutting several loops of small bowel.
evidence of a demyelinating central nervous system disease. She was treated
Exploratory surgery was performed with abdominal wall mass and partial small
with pulse dose steroids and infliximab. She has regained her vision and con-
bowel resection. The pathological report of the mass showed a storiform pro-
tinues to do well as her steroids are being tapered. Conclusion: There is only
liferation of dense fibrous tissue with marked infiltration by plasma cells.
one previously reported case of optic neuritis in CVID. Patients with CVID can
Immunohistochemistry for IgG4 showed up to 60 plasma cells staining per high
present with granulomatous lesions of the lung, skin and other organs. Optic
power field. There was an associated phlebitis with infiltration by plasma cells.
neuritis is usually seen in demyelinating neurologic disease, such as multiple
Blood IgG4 level was increased. These findings are consistent with IgG4-related
sclerosis (MS). Patients with MS-related optic neuritis usually show a quick
disease. Conclusions: IgG4-related disease is a disease that can involve a wide
and sustained response to pulse treatment with steroids. Given the quick relapse
range of organ systems. The pathological findings of IgG4-related disease have
after stopping steroids and lack of evidence for demyelinating disease, we extrap-
striking similarities. IgG4-related disease has broad clinical heterogeneity with
olated that her optic neuritis may be due to a granulomatous process. We
multi-system involvement. Differentiation of IgG4 related disease from malig-
employed infliximab due to its success in treatment of neurosarcoidosis and
nancy and other autoimmune disorder along with more clinical insight into the
had positive results.
management of this disease are needed. More details of the radiologic mani-
festations of this disease aided by clinical and laboratory findings maybe essen-
tial for the accurate diagnosis of this disease and avoiding unnecessary inva-
sive procedures.
P232
TOPICAL GM-CSF FOR WOUND-HEALING IN LYMPHOPENIC
PATIENT WITHOUT KNOWN NEUTROPHILIC DYSFUNCTION.
P230 B. Geng*, M. Breslin2, M. Garcia-Lloret, R. Roberts, Los Angeles, CA.
OUTCOMES OF SPLENECTOMY IN CVID: A SURVEY OF Neutrophil and monocyte function is crucial for normal wound healing.
44 PATIENTS. GM-CSF enhances function of both neutrophils and monocytes, and has been
J.M. Camacho*, C. Cunningham-Rundles, New York, NY. shown to improve wound healing in neutrophil dysfunction patients. Use of
GM-CSF in wounds of normal patients has produced mixed results. We pres-
Introduction: Common Variable Immunodeficiency (CVID) is a heteroge-
ent case of successful treatment of refractory post-surgical wound with lym-
neous group of disorders characterized by low levels of serum IgG, IgA and
phopenia but without any known neutrophilic defects. 18 month old male with
/or IgM and with loss of antibody production. The diagnosis is most commonly
truncus arteriosus s/p failed surgical repair and subsequent heart transplant
made between the ages of 20 and 40 years of age but children and older adults
developed refractory non-healing post-operative wounds. He had history of
can also be diagnosed with this condition. There are many known clinical man-
recurrent fevers with persistent Coagulase-negative Staph Aureus bacteremia,
ifestations associated with CVID that include acute and chronic infections,
but otherwise negative bacterial, fungal and viral cultures. He received multi-
inflammatory and autoimmune disease as well as an increased incidence of
ple courses of empiric broad-spectrum antibiotics as well as antifungals and
cancer and lymphoma. For patients with inflammatory and hematologic com-
remained afebrile while on therapy, but was unable to stay afebrile off antimi-
plications, there is a risk of developing lymphadenopathy, splenomegaly, autoim-
crobials. Prior to transplant he presented with initial IgG 249, IgA 53 and IgM
mune cytopenia, and/or granulomatous disease. Splenectomy has been used in
23. He had hypoalbuminemia and high alpha-1-antitrypsin in stool(220 mg/dL)
patients with CVID often in the case of refractory autoimmune cytopenia or
suggesting protein-losing enteropathy. He also had severe lymphopenia(200
malignancy. Aside from a recent European report, there is limited information
cells/ml) with CD4 46 cells/ml, CD8 8 cells/ml, CD 19 25 cells/ml and NK 99
as the medical reasons and outcomes have not been well defined. Methods: A
cells/ml. He received IVIG weekly to keep IgG>1000. PMN oxidative index
retrospective chart review on patients seen at an Immunology clinic based a
was 60 ruling out Chronic Granulomatous Disease. Whole Exome Sequenc-
tertiary academic center. The IRB approved chart review encompassed patients
ing found compound heterozygous c.422C>G and c.6064T>C variants of uncer-
seen over the last 20 years and includes 43 patients with CVID and a history
tain significance in PRKDC gene. Mutations of this gene have been impli-
of a splenectomy. Results: The most common reasons for splenectomy in our
cated in forms of autosomal recessive SCID due to defects in DNA repair. No
patient cohort included hypersplenism (n=14), ITP (n=14), AIHA (n=8), pre-
mutations were found in any genes associated with neutrophil defects. GM-
sumed lymphoma (n=2), staging of Hodgkins disease (n=2) and lymphoma
CSF aqueous solution was applied to 2 refractory surgical wounds 3 times daily
(n=1). These were not mutually exclusive reasons. Twenty-five patients had res-
over 2 weeks. Significant improvement in color, size and degree of healing was
olution of their symptoms at some point after splenectomy for either hyper-
observed by multiple physicians and nurses. GM-CSF leads to enhancement
splenism, AIHA or ITP. There were 13 significant complications after splenec-
of granulation tissue development in wound healing, and has been shown to be
tomy in this cohort, which included pulmonary hypertension (n=4),
beneficial for wounds in neutrophil dysfunction patients. Very little data exists
hepatopulmonary syndrome (n=2), sepsis/infection (n=3) fistulae development
in its efficacy in patients with immunodeficiencies other than primary neu-
(n=2), liver decompensation (n=2). Conclusion: There are significant risks asso-
trophil defects. Given that T-cells are a significant source of GM-CSF, and the
ciated with splenectomy in patients with CVID. Splenectomy has been used in
observed improvement in wound healing seen in this patient, use of GM-CSF
patients with CVID and its role needs to be re-examined.

A90 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A91
may be considered in refractory wounds in patients with severe primary or
acquired lymphopenia.
P233
CYTOKINE AND SLPI LEVELS IN BLOOD AND URINE OF
PATIENTS WITH CHRONIC CYSTITIS AND PYELONEPHRITIS.
G. Drannik1, F. Gaisenyuk1, V. Driyanska1, N. Stepanova1, L.M. DuBuske*2,
1. Kiev, Ukraine; 2. Gardner, MA.
Introduction: Cytokines are key factors in pathological processes includ-
ing urinary tract diseases. Urinary tract mucosa contains various protective
effector molecules including antimicrobial peptides and inhibitory proteinases
such as secretory leukocyte protease inhibitor (SLPI) produced by mucosa cells,
macrophages and neutrophils which assists in defense against elastase secreted
by activated neutrophils, and has antibacterial and anti-inflammatory proper-
ties. Levels of cytokines and SLPI in plasma and urine of the patients with
chronic infections of urinary system (USCI) including cystitis and pyelonephri-
tis may be critical in disease pathogenisis. Methods: Levels of interleukin
(IL)-1, -4, -6, -10, TNF-, TGF- 1 in peripheral blood of 12 patients with chronic
cystitis ( 1st group) and 25 patients with chronic pyelonephritis (2nd group) were
assessed by ELISA methods using STAT FAX-303 PLUS (“Immunotech”,
“Diaclon”, France; “DRG”, Germany and “Hycult biotechnology” for Human
SLPI (Netherlands). Results: Patients in both groups showed high levels of
cytokines compared with normal persons (p<0.05). Serum TNF- levels were
greater in Group 1 99.6±6.5 versus Group 2 43.5±2.0 pg/ml (p<0,001) but the
urine levels in Group 1 exceeded the levels in Group 2 by 3-fold (p<0.001);
IL-1, IL-4, IL-6, IL-10, IL-17, IFN-γ, TGF-, though exceeding normal levels,
did not differ between Groups 1 and 2. The SLPI level in urine from Group 1
was greater (4171±225) than in Group 2 (1857±203 pg/ml; <0.05). SLPI lev-
els in serum of Group 1 (2052+378) and Group 2 (2240+178) were greater than
normal but did not differ( 2240±178 versus 2052±316 pg/ml; P>0.05). Con-
clusion: TNF-, that was greater in cystitis than in pyelonephritis, The elevated
SLPI-levels were seen in urine with levels >3200 pg/ml typical for the pres-
ence of cystitis. Cytokines and SLPI have an important role in immunity of
the urinary bladder mucosa and antibacterial immunity in USCI.
P234
INTERRELATION OF ANTIENDOTOXIN AND HUMORAL
IMMUNITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHE-
MATOSUS.
D.V. Shaduro1, V.A. Beloglazov2, A.I. Gordienko2, L.M. DuBuske*3,
1. Minsk, Belarus; 2. Simferopol, Ukraine; 3. Gardner, MA.
Background: Lipopolysaccharide (LPS) or endotoxin of Gram-negative
enterobacteria may help to maintain autoimmune inflammatory responses in
SLE. One indicator of the strength of immunity is antiendotoxin CD14 expres-
sion. Methods: 48 SLE patients were studied. Levels of potential of specific
receptors to endotoxin (CD14) on granulocytes in peripheral blood were deter-
mined by laser double staining flow cytometry using monoclonal antibodies
to anti-CD14-REIO-Test® (CD14). Levels of general Ig, IgM and IgG anti-
bodies were assessed by ELISA. Circulating immune complexes (CIC) were
determined spectrophotometrically by precipitation with polyethyleneglycol
(PEG). Results: The levels of CD14 receptors in SLE patients on granulocytes
was 18.57 ± 0.502 fluorescence units (UF). The level of total IgA was 2.041 ±
0.059 g/l, IgM was 1.927 ± 0.087 g/l and IgG was 11.34 ± 0.171 g/l. CIC level
was 19.288 ± 1.546 conventional units (CU). In studying the relations of these
parameters an inverse relationship between CD14 receptor level and the level
of total IgA was found with R= –0.404 (Pearson correlation) at a significance
level of p = 0.004. Dependence was described by the formula: IgA = –1.734 *
CD14+3.258. There was also a direct significant correlation of receptors CD14
and CIC (R = +0.371; p = 0,009) expressed by the formula: CIC = 41.47 *
CD14 – 9.81. Significant relationships between CD14 and IgM and IgG anti-
bodies were detected. Conclusions: An association of cellular anti-endotoxin
immunity as represented by the CD14 receptor with humoral immunity (IgA,
CIC) was seen in patients with SLE. This support s arole for LPS of Gram-neg-
ative intestinal flora in modulating the immune status of SLE patients.
ABSTRACTS: POSTER SESSIONS
P235
INTERACTION BETWEEN SPERM AND MUCOSAL IMMUNITY
AS ASSESSED BY REACTIVE OXYGEN SPECIES GENERATION
IN SEMINAL FLUID OF CHRONIC ABACTERIAL PROSTATITIS
PATIENTS.
G.N. Drannik1, T.V. Poroshina1, V.S. Savchenko1, K.R. Nyrimanov1,
L.M. DuBuske*2, 1. Kiev, Ukraine; 2. Gardner, MA.
Background: Spermatozoa and leukocytes in semen may produce reactive
oxygen species (ROS) which may have and importance in chronic abacterial
prostatitis. Methods: Reactive Oxygen species can be assessed by using nitrob-
lue tetrazolium (NBT). Levels of ROS can be measured by chemiluminescence.
The NBT test was performed according to the method adapted to ejaculate. In
the light microscope with an increase in x 100 counted stained percentage of
neutrophils and spermatozoa in the ejaculate. To avoid additional procedures,
determination of ROS in cells was performed using native ejaculate without
using a density gradient. Cells that had large and small dark blue deposits occu-
pying more than 50% of the sperm cytoplasm were called positive. Results:
Based on leukocyte concentrations in semen,patients samples were classified
into 2 separate groups: leukocytic -sperm group (leukocytic count > 1 x 106
peroxidase-positive leukocytes[PPL]/mL semen; n = 20) and non-leukocytic
sperm group(leukocytic count 1 x 106 PPL/mL; n = 63). In Group 1 the NBT-
test showed that the overwhelming number of patients (75%) had 60% of sperm
producing reactive oxygen species (ROS), more than in healthy men with sperm
ejaculate normally characterized by low ROS generation; percentage of NBT
positive sperm is 15.5 ± 4.2%). Antioxidant properties of ejaculate based upon
NBT test in 75% of patients was decreased by 90%. Group 2 had ROS pro-
duction by sperm by NBT test in 75% of patients with 56% of sperm produc-
ing ROS. Antioxidant properties of the ejaculate by NBT test in 75 patients was
decreased by 70%. Conclusions: The NBT test can be used to assess the con-
tribution of seminal leukocytes and defective spermatozoa towards ROS gen-
eration in semen. In infertile patients with a chronic abacterial prostatitis pro-
duction of ROS by seminal spermatozoa is increased and does not depend on
the quantity of leukocytes in the ejaculate.
P236
CONCENTRATION OF TGF-β1 IN URINE OF CHILDREN WITH
OBSTRUCTIVE AND REFLUXING MEGAURETER.
G.N. Drannik1, N.A. Kalinina1, V.F. Peterburgskiy1, T.V. Poroshina1,
V.S. Savchenko1, L.A. Mygal1, L.M. DuBuske*2, 1. Kiev, Ukraine;
2. Gardner, MA.
Background: Obstruction of the upper urinary tracts results in the re-mod-
ulation of the tubulointerstitial tissue that is a precondition for nephrosclero-
sis. TGF-β1 influences each stage of development of tubulointerstitial and
glomerular lesions. Levels of TGF-β1 in the urine of children with obstructive
and refluxing megaureter (MU) may be critical in disease development. Meth-
ods: The TGF-β1 level in urine was assessed in 54 children (1 – 9 years old)
with obstructive (23) and refluxing (31) MU; with or without pyelonephritis
(PN). The control group consisted of 10 healthy children. The TGF-β1 con-
centrations were assessed by the immuno-enzymatic method with “DRG” (USA)
test system. Results: TGF-β1 concentration in urine taken from the urinary
bladder of children with obstructive and refluxing MU statistically exceeded
the values in the control group being 15.3 ± 4.35 pg/ml (P<0.001). The distri-
bution of values in controls was 0 to 5.4 pg/ml, while in children with MU it
was 8.8 – 50,9 pg/ml. There was an increase in MU when compared with the
control of TGF-β1 excretion in the patients with obstructive (15.7 ± 2.1 pg/ml)
and refluxing MU (16.9 ± 3.8 pg/ml) (P<0.001); no difference was noted
between the groups and was similar to the TGF-β1 excretion in urine of groups
of MU patients complicated by pyelonephritis (16.6 ± 1.6 pg/ml) (P<0.05 ver-
sus controls). Conclusion: Increase in the TGF-β1 level above normal at the
first examination, or continuous increase during examination every 3 to 4
months in comparison with the values of the first examination, are considered
evidence of aggravation of the functional state of the kidney due to the active
fibrotic processed in patients with megaureter. TGF-β1 plays a role in the patho-
genesis of renal disease in these patients.
P237
RECURRENT LUNG ABSCESSES.
L. Bornstein, R. Herzog*, New York, NY.
Background: The spectrum of autoinflammatory disorders has broadened
in recent years, and interleukin-1 inhibitors have been introduced as success-
VOLUME 113, NOVEMBER, 2014 A91
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A92
ABSTRACTS: POSTER SESSIONS
ful treatment options. We present a 9 month old patient with recurrent lung
abscesses who was successfully treated with an interleukin-1 antagonist. The
case illustrates the importance of early diagnosis and treatment of autoinflam-
matory disorders. Case Report: A female patient presented in the newborn
period with recurrent sterile skin abscesses that resolved after antifungal and
antibiotic therapy. She was then well until 9 months of age, when she devel-
oped recurrent sterile lung abscesses which were unresponsive to trials of anti-
bacterial and antifungal treatment, but which resolved completely with Anakinra
and Canakinumab therapy. Results: Laboratory testing revealed negative cul-
tures with persistent leukocytosis, thrombocytosis, and elevated acute phase
reactants. Lung biopsy was sterile and without granulomas, and lung
parenchyma showed reactive type 2 pneumocyte hyperplasia, chronic intersti-
tial inflammation, and detached acute inflammatory debris. The drained abscess
showed evidence of acute inflammation and debris with 90% neutrophils, 12%
macrophages, 4% eosinophils and 4% small lymphocytes. Skin biopsy showed
neutrophilic folliculitis with organizing dermal abscess. Conclusions: The spec-
trum of clinical presentations of autoinflammatory disorders is growing. Low
threshold for early treatment initiation with IL-1 antagonists is necessary in the
setting of persistently elevated inflammatory markers and sterile neutrophilic
biopsy without evidence of infectious etiology.
P238
NONCASEATING GRANULOMATOUS DISEASE WITH
EOSINOPHILIC SPONGIOSIS ASSOCIATED WITH POTENTIAL
COMMON VARIABLE IMMUNODEFICIENCY (CVID).
B. Patel*, A.S. Nickels, G.W. Volcheck, A.Y. Joshi, Rochester, MN.
Background: Diagnosis of CVID presents a diagnostic challenge given vari-
able interpretation of the diagnostic criteria. Clinical findings are not included
as part of the diagnostic criteria, however they can be helpful in further sup-
porting or refuting the diagnosis. CVID is associated with many other dis-
eases including granulomatous disease, though the mechanism of association
is unclear. Case Presentation: 47 year old female presented with a progressive
rash for 2.5 years, lymphopenia and hypogammaglobulinemia, though she
denied an infectious history. Rash consisted of well circumscribed plaques with
lichenification and mild scaling on the face and trunk. Biopsy of her rash demon-
strated eosinophilic spongiosis and noncaseating dermal granulomatous inflam-
mation with eosinophils. Staining for an infectious etiology was negative. Exam
demonstrated axillary lymphadenopathy and follow up PET/CT demonstrated
mild uptake in areas of thickened skin overlying the right breast and left axilla
and multiple prominent right axillary lymph nodes. An excisional right axil-
lary lymph node biopsy demonstrated non-necrotizing granulomatous lym-
phadenitis. Bone marrow biopsy and peripheral flow for lymphoma/leukemia
were negative. An angiotensin-converting enzyme (ACE) level was elevated at
68. Blood work demonstrated a low IgG of 587 (reference range 767-1590mg/dl)
and a low IgA of 50 (reference range of 61-356mg/dl) but normal IgM and
IgE levels. She had a mildly reduced response to the pneumococcal vaccina-
tion as defined by the 2012 AAAAI working group statement, but she had
protective titers to diphtheria and tetanus vaccination. A lymphocyte flow report
demonstrated a decrease in the class switched memory B cells (CD27+M-D-
). Conclusion: This case describes granulomatous disease as the primary pres-
entation of possible CVID. This patient meets the least stringent diagnostic
criteria for CVID, but interestingly does not have an infectious history. How-
ever, recurrent infections can develop over time in patients who meet criteria
for CVID and would not be uncommon in patients who initially present with
granulomatous or autoimmune disease. Therefore, this patient should be closely
monitored for infection and consideration of treatment with IVIG.
A92 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P239
ANTI-NEUTROPHIL ANTIBODY POSITIVITY IN SEVERE CON-
GENITAL NEUTROPENIA.
S.E. Henrickson*1, S. Jyonouchi2, 1. Haddonfield, NJ; 2. Philadelphia, PA.
Introduction: Two toddlers presented with skin abscesses, recurrent acute
otitis media (AOM) and neutropenia with both weakly positive anti-neutrophil
antibodies and ELANE mutations consistent with severe congenital neutrope-
nia (SCN). Here we consider when it may be necessary to consider genetic test-
ing even after anti-neutrophil antibodies are positive. Clinical Cases: Patient
1: 17-month-old female presented with neutropenia, delayed umbilical cord
separation, recurrent AOM, oral ulcers and progressive, refractory skin
abscesses. She was referred to Infectious Disease where an assessment yielded
appropriate humoral immune responses, normal B and T cell flow cytometry
and CBC with ANC 126. With persistent skin abscesses, she was referred to
Dermatology and then Immunology. A repeat CBC with ANC of 0 led to urgent
referral to hematology and BM biopsy with evidence of blockade in granulo-
cyte development. She was had weakly positive anti-neutrophil antibodies and
an ELANE mutation consistent with severe congenital neutropenia (SCN).
Patient was started on G-CSF and required high dose G-CSF (15mcg/kg/day),
with a full sibling match identified for BMT. Patient 2: 8-month-old male pre-
sented with a history of chronic AOM, perirectal abscess complicated by fis-
tula formation and pneumonia requiring prolonged IV antibiotic therapy. Based
on recurrent infections, he was referred to Immunology and labs showed per-
sistent neutropenia, with referral to Hematology and a bone marrow biopsy
with decreased granulocyte maturation, consistent with severe congenital neu-
tropenia. He was found to have weakly positive anti-neutrophil antibodies and
an ELANE mutation consistent with severe congenital neutropenia (SCN). He
was started on G-CSF, requiring high doses (10mcg/kg/day), with only mod-
est increases in his neutrophil count. He received an identically matched sib-
ling bone marrow transplant. Conclusion: We have not identified any prior case
reports of anti-neutrophil antibody positivity in patients who have SCN. Patients
with autoimmune neutropenia do not generally have difficulty with recurrent
infections. Therefore, In neutropenic patients with multiple, severe, recurrent
infections at an early age and weakly positive anti-neutrophil antibodies, SCN
should be fully evaluated.
P240
A CASE OF IDIOPATHIC CD4 LYMPHOPENIA WITH CUTA-
NEOUS HPV INFECTION.
J. Toh*1, J. Dara1, A. Rubinstein2, 1. New York, NY; 2. Bronx, NY.
Introduction: Idiopathic CD4 Lymphopenia (ICL) is a disorder defined by
persistently low CD4 T-lymphocyte count (CD4 < 300/mm3) or CD4 count less
than 20% of total lymphocytes on more than one occasion with no evidence of
human immunodeficiency virus (HIV-1/2) or human T-cell lymphotropic 1/2
(HTLV-1/2) infection and no other secondary causes of immunosuppression.
Other features include high serum IL-7 levels, but poor signaling through IL-
7. ICL patients can present with autoimmune disease, malignancies or oppor-
tunistic infections. The most common infections include Cryptococcus, non-
tuberculosis mycobacterial infection and human papilloma virus (HPV). Very
low CD4 counts (< 150/mm3), low CD8 counts (< 180/mm3; normal 212 –
1007/mm3) and low natural killer (NK) cell counts (< 100/mm3; normal 97 –
421/mm3) are all associated with increased morbidity. Treatment options con-
sidered were immunomodulators such as interleukin-2 (IL-2), interleukin-7
(IL-7) and interferon-gamma. We describe a case of cutaneous HPV infection
in ICL treated with interferon-gamma. Methods: Case Report Results: A 34
year-old female with known ICL presented to Immunology clinic with digital
warts and severe plantar warts on her left sole which were scraped monthly.
Her previous treatment with IL-7 was ineffective. Warts were unresponsive to
Imiquimod and Urea 40% gel. Laboratory results were significant for a very
low CD4 count at 18/mm3, low NK cells 86/mm3, low CD8 count 69/mm3.
Mitogen and antigen-induced lymphocyte proliferation profile was decreased
to candida, tetanus toxoid, tuberculin purified protein derivative (PPD), phy-
tohemagglutinin (PHA), pokeweed mitogen (PWM) and concanavalin A (Con
A). Serum immunoglobulins and mannose-binding lecithin (MBL) levels were
within normal range. We started treatment with Interferon-gamma-1b 100mcg
three times a week for one month. Our patient’s digital warts resolved and the
plantar warts significantly decreased after one month of treatment with Inter-
feron-gamma-1b. Conclusion: ICL is a rare immunodeficiency that can pres-
ent with HPV infection. Severe cases of cutaneous HPV infection with very
depressed T-lymphocyte counts may be unresponsive to topical or destructive
therapy. However, treatment with immunomodulators such as Inteferon-gamma-
1b may be promising.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A93

ABSTRACTS: POSTER SESSIONS

this diagnosis should be considered in very young infants with severe infec-
P241 tions and persistent leukocytosis even in the face of largely normal immuno-
EARLY ONSET OF MARKED LYMPHOPENIA, NEUTROPENIA
logic testing.
AND MILD THROMBOCYTOPENIA IN AN AFRICAN-AMERI-
CAN GIRL.
L.E. Moore*1, L. Zhou2, A.B. Yates2, 1. Navarre, FL; 2. Jackson, MS. P243
Rationale: The prevalence of lymphopenia, neutropenia and thrombocy- EOSINOPHILIC ESOPHAGITIS SECONDARY TO FRESH
topenia in children without HIV infection, malignancy, or aplastic anemia is CILANTRO INGESTION.
rare. Frequent infections are the primary clinical manifestation. Methods: An K. Cook*, Orange, CA.
8 year old (yo) African American female with recurrent infections since 1 yo
Introduction: Spice allergy is relatively rare accounting for approximately
was monitored with serial CBC’s, immunoglobulins, lymphocyte subsets, spe-
2% of all observed food allergy. Cilantro has been implicated in IgE mediated
cific antibody titers, and bone marrow biopsies. Results: From 1 yo, this patient
hypersensitivity reactions varying from mild cases of urticaria to anaphylaxis.
had recurrent otitis media, pneumonia, and skin abscesses. She had diffuse ver-
To our knowledge this is the first reported case of eosinophilic esophagitis sec-
rucae plana for the last 2 years. Serial CBCs showed intermittent neutropenia
ondary to cilantro. Case Description: A 31 year old man with no prior medical
(ANC ranging 570-6248 cells/uL), marked lymphopenia (ALC 272-943
history initially presented to gastroenterology clinic with episodic dysphagia
cells/uL), and thrombocytopenia (platelet counts 54,000-120,000 cells/uL).
and food impaction for approximately 7 years. Five years prior, an EGD revealed
Lymphocyte subsets (CD3, CD4, CD8, CD19, and CD3-CD16+CD56+) were
a Schatzki ring which was treated with dilation. He was maintained on Omepra-
persistently very low, as well as low CD27+ B cells (memory B cells). HIV
zole daily but subsequently self discontinued as he was relatively asympto-
PCR, HIV-1/2 antibody, and Parvovirus antibody were negative. Neutrophil
matic. The patient returned after experiencing 6 distinct episodes of dyspha-
associated antibody was negative. Specific antibody titers to Streptococcus
gia associated with increased mucous production over a 2 year period. Repeat
pneumoniae and Haemophilus influenzae b normalized following booster vac-
EGD with biopsy of the lower esophagus showed “strikingly abundant
cines, with fairly good amnestic titers. Quantitative immunoglobulins were nor-
eosinophils, consistent with eosinophilic esophagitis”. He was started on Lan-
mal, until recent onset of low IgM levels. Lymphocyte response to mitogens
soprazole by his gastroenterologist. The patient was asked to record a food diary
and specific antigens were normal. Flow cytometry for paroxysmal nocturnal
of all foods he consumed in relation to episodes of dysphagia. He underwent
hemoglobinuria was negative. 1,2:3,4-diepoxybutane (DEB) clastogen assay
skin prick testing for corn, potato, soy, wheat, chicken, pork, egg, milk, almonds
for Fanconi anemia was negative. Chromosomal study showed 46, XX, with
and peanuts with commercial extracts, all of which were negative. Skin prick
no clonal abnormality. Fluorescent in situ hybridization (FISH) for Myelodys-
testing to aeroallergens was positive for dust mites only. As he noted symptoms
plasia panel and DiGeorge (22q11 and 10p13p14) were negative. Bone mar-
with intake of fresh salsa, the patient later underwent fresh food skin prick test
row at 1 yo showed normocellular trilineage marrow with erythroid and
to tomato and cilantro, which was positive to cilantro. ImmunoCAP testing for
megakaryocytic hyperplasia, and at 5 yo showed hypocellular marrow (60-80%
cilantro/coriander was negative at <0.1kU/L. Lansoprazole was changed to
cellularity) with trilineage maturation and mild 1+ fibrosis. Megakaryocytes
Omeprazole which has been shown to decrease IL-13 and eotaxin 3 levels as
were normal in number and morphology. Chromosomal microarray analysis
additional benefit. With strict cilantro avoidance measures and omeprazole
showed duplication at 10q26.3, confirmed by FISH and a deletion at 11p11.12.
the patient noted no further episodes of dysphagia at three month follow up.
She began daily trimethoprim/sulfamethoxazole prophylaxis 3 years ago, with
Conclusion: This case illustrates the importance of fresh food skin prick test-
very few bacterial infections since then. Conclusions: Patients with lymphopenia
ing in evaluating eosinophilic esophagitis associated with intake of foods and
and frequent infections may benefit from antibiotic prophylaxis. Monitoring
spices. Although skin prick with commercial extracts and ImmunoCAP test-
with appropriate lab tests can guide the treatment plan. Given this patient’s
ing are used as first line in diagnostic work ups, fresh food skin prick testing
onset of verrucae plana, additional evaluation for WHIM syndrome may be
with cilantro should be considered with a suggestive history.
warranted.

P242 P244
AN UNUSUAL CASE OF ASPARAGUS ALLERGY.
SEVERE AND EARLY PRESENTATION OF NEMO/IKBKG
DEFICIENCY. K.M. White1, P.H. Wong*2, R.A. Gomez1, M.H. Tucker3, 1. Lackland AFB,
TX; 2. San Antonio, TX; 3. Bonita, CA.
V. Nayima*, P. Atkinson, Birmingham, AL.
Rationale: Asparagus food allergy is rare and usually associated with pos-
Rationale: Nuclear factor-κB essential modulator (NEMO) deficiency is a
itive skin or serum IgE testing. Methods: A 26 year-old male reported urticaria
combined immunodeficiency due to hypomorphic mutations in the X-linked
over 3 years associated with eating asparagus. He had no history of atopy.
IKBKG gene. Symptoms include antibody deficiency, susceptibility to nontu-
Skin testing with fresh asparagus was negative. An open challenge resulted in
berculous mycobacteria, and ectodermal dysplasia. Female carriers of severe
a diffuse urticarial rash within minutes of ingestion. Serum IgE via Immuno-
loss of function mutations in IKBKG have a condition called incontinentia pig-
CAP was less than 0.35 KU/L. Serum was analyzed using ELISA testing.
menti. Case description: A Caucasian male infant (36.5wga) presented to clinic
Asparagus was lyophilized and protein content determined by a modified Lowry
at one week after circumcision with MRSA infection of the penis. Five weeks
technique. The food extract was added to ELISA plate wells, incubated, washed,
later he again presented for evaluation with thrush, severe eczema, bloody stools,
blocked, and re-washed. Serum was then added and the plate was incubated,
and a submandibular mass that grew MSSA. At 12 weeks of age he was admit-
washed, and anti-human IgE antibody was added. After incubation, plate was
ted for fever, diarrhea, and leukocytosis (WBC 40K) and was found to have
washed and pNPP AP substrate was added. Optical density readings were taken
significant eosinophilia ( 24%) and severe panhypoimmunoglobulinemia. He
at 30 minutes and at 1,2,3, and 20 hours. Inhibition ELISA testing was also
was treated with empiric antibiotics and IVIG. At 14 weeks the patient was
performed, with asparagus inhibited by itself. Controls included cord blood as
admitted for weight loss and leukocytosis (WBC 45K) and was found to have
well as serum from an atopic patient. The assay was performed in triplicate.
a right inguinal abscess that grew MSSA and multiple bowel flora. He was re-
Results: The patient’s serum exhibited IgE binding to asparagus antigens at a
admitted at 5 months for a planned bone marrow transplant after positive genetic
ratio of 2.5 times that of the cord blood control. The binding was completely
tests. He continued to have poor weight gain and experienced multiple infec-
inhibited by preincubation of the serum with asparagus. An atopic control exhib-
tions during the pre-transplant interval with MSSA, MRSA, coagulase nega-
ited binding to asparagus which was also inhibited by asparagus. Immunoblot
tive staphylococci. Results: Complement tests, CD11/CD18 protein expres-
was performed and was negative. Conclusions: To our knowledge this is the
sion, mitogen stimulation, neutrophil respiratory burst, FOXP3 protein
first patient with asparagus allergy manifesting as systemic urticaria with neg-
expression, NK cell function, T and B cells and subsets including Th17 cells
ative fresh asparagus skin testing and negative commercial serum IgE testing
by flow, and HHV 6/7/8 PCR testing were all normal/negative. CD45 RO (naïve)
demonstrated to have specific IgE to asparagus via an IgE-ELISA inhibition
CD4+ T cells were decreased by flow. During his evaluation it was discovered
assay. Further testing is needed to identify the specific allergens involved.
that his mother had an extensive patchy hyperpigmented birthmark that was
consistent with incontinentia pigmenti. Gene sequencing revealed a hemizy-
gous IKBKG gene (H413D) variant which has not been published as mutation
or benign polymorphism, not identified in 1200 individuals with Euro-
pean/African American ancestry, and predicted to be pathogenic. Conclusion:
This early and severe presentation of NEMO/IKBKG deficiency suggests that

VOLUME 113, NOVEMBER, 2014 A93

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A94
ABSTRACTS: POSTER SESSIONS
P245
PINEAPPLE ANAPHYLAXIS.
K.E. Bruner*1, R. Gomez2, J. Freiler2, K. White2, A. White3, 1. Lackland
AFB, TX; 2. San Antonio, TX; 3. San Diego, CA.
Introduction: Pineapple is rarely reported to cause anaphylaxis. We pres-
ent two cases of pineapple anaphylaxis with evidence of IgE antibodies to
pineapple. Methods: Two patients with histories consistent with pineapple ana-
phylaxis underwent ImmunoCAP and immunoblot testing to pineapple and one
underwent skin prick testing. Results: Both patients reported regularly eating
pineapple prior to their initial episode of anaphylaxis. Pt 1 initially experienced
a feeling of throat swelling, lip numbness and unsettled stomach after eating
pineapple but did not associate it as an allergic reaction. Three weeks later, he
ate 4-5 pieces of pineapple and experienced generalized sweating, prolonged
abdominal cramping and recurrent vomiting that lasted approximately one hour.
He had no rash or angioedema. His skin testing revealed a 15x40mm wheal
and flare to fresh pineapple, 15x50mm to pineapple extract. He was skin test
negative to bromelain, other fruits including fig, kiwi and papaya, and an aeroal-
lergen panel. An immunoblot was performed which revealed a faint band at 23
kD consistent with bromelain and correlated with a weak positive Immuno-
CAP of 0.42 kU/L. Patient 2 developed generalized hives, angioedema, throat
closing, diarrhea and a sense of impending doom shortly after ingesting pineap-
ple. She received steroids, epinephrine and IV fluids in the emergency depart-
ment with resolution of symptoms over 90 minutes. Her initial ImmunoCAP
to pineapple was 2.24 kU/L. She deferred pineapple skin prick testing due to
fear of recurrent reaction. Repeat ImmunoCAP was obtained one year later and
was negative at <0.35 kU/L. Immunoblot performed at that time was also neg-
ative suggesting that her sensitivity may have waned over the intervening 12
months. She was not interested in food challenge. Conclusion: Pineapple can
cause anaphylaxis with presence of IgE demonstrated on skin prick testing,
ImmunoCAP and immunoblot. Bromelain was identified on immunoblot as
the reactive substance. One patient’s ImmunoCAP converted to negative after
one year indicating that sensitivity to pineapple may decrease over time.
Patient 1 skin prick test. Pin=pineapple extract, F.P.=fresh pineapple
P246
A CASE OF FPIES TO SWEET POTATO.
B. Navetta*, Manhasset, NY.
Introduction: FPIES is a non-immunoglobulin E (IgE) mediated GI food
hypersensitivity which presents with profuse, repetitive vomiting, often with
diarrhea leading to dehydration and lethargy after ingestion of a food allergen.
The exact mechanism is unknown, however it is thought that the ingestion of
an allergen causes local inflammation (mediated by T cells) leading to increased
intestinal permeability and fluid shift. The most common allergens are cow’s
milk or soy protein, however solid food proteins can also elucidate these symp-
toms. The common solid food that has been known to cause FPIES is rice.
Methods: An 8 month old female with a history of atopic dermatitis presented
for initial consultation after she developed two episodes of profuse vomiting,
A94 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
listlessness and non-bloody diarrhea requiring ICU admission status post inges-
tion of homemade sweet potatoes. The first instance occurred at 6.5 months of
age for which she was diagnosed with a viral sepsis syndrome in the setting of
a positive parainfluenza culture. Symptoms then reoccurred at 7.5 months of
age when she was fed sweet potato mixed with pear, and then she was diag-
nosed with FPIES. She had already been consuming cheerios, oatmeal, banana,
peas, and broccoli. The patient’s mom had questions regarding the proper tim-
ing to introduce new foods. Results: There are no specific recommendations
regarding introduction of new foods for patients with FPIES. Among infants
with solid food FPIES in one study, 80% reacted to more than one food and
65% were previously diagnosed with cow’s milk and/or soy FPIES. Typically,
if a patient is tolerating foods from one group then other foods of that group
are considered OK to eat. It is suggested that in children with solid food FPIES,
the introduction of grains, legumes and poultry should be delayed until the first
year of life. Conclusions: It was recommended to our patients mother that she
continue foods she is currently tolerating. It was also recommended that mom
can introduce other fruits one at a time. Since she was eating peas, it was sug-
gested that she try lentils as her next legume. Since she was eating oat, quinoa
was recommended as her next grain. Mom was instructed to continue breast
feeding. She was instructed to wait to until one year of age to consume soy and
milk. Approximately two weeks later she had tolerated lentils, quinoa and blue-
berries at home without any issues. She still had not exposed her to dairy.
P247
ANAPHYLAXIS DUE TO TOPICAL PRAMOXINE.
S.J. Kim*, C.K. Lin, B.J. Goldberg, Los Angeles, CA.
Introduction: Pramoxine is a local anesthetic agent that has long been used
in various surgical specialties. A few cases of contact dermatitis have been
described; however anaphylaxis has not been reported. Though pramoxine has
low sensitizing potential, it was implicated in our case of anaphylaxis. Case
Description: A 47-year-old Caucasian man was brought to our emergency
department with a widespread pruritic rash, generalized edema, chest pain, dys-
pnea, nausea, and diaphoresis. An acute anaphylactic reaction was suspected,
and treated immediately. Serum laboratories revealed tryptase 2.6 (< 15.8
mcg/L), total IgE 44.5 (< 113 kU/L), and WBC 14.7 (4-11 x 1000/mcL) with
no eosinophils. He had applied Neosporin + Pain Relief® cream (active ingre-
dients neomycin, polymyxin B, and pramoxine) to a cut on his hand minutes
prior to his anaphylactic event. He had applied topical Neosporin® ointment
(without the Pain Relief component) numerous times previously without any
adverse reaction. At allergy clinic follow-up 5 weeks later, topical application
of Neosporin + Pain Relief® cream to the patient’s forearm produced a 30 x
30-mm wheal. Skin prick testing revealed a 7 x 9-mm wheal to histamine and
to pramoxine. Testing of neomycin and polymyxin B were negative. In vitro
assays were performed (ImmunoCAP 1000 System, Thermo Fisher Scientific,
Waltham, MA). Direct coupling of pramoxine to the solid phase was not fea-
sible as there was no free amine or hydroxyl group available on this compound.
Specific IgE against polymyxin B, neomycin, and bacitracin were not detected
in the patient’s serum (< 0.1 KUA/L). Therefore, of the 3 active components in
Neosporin + Pain Relief® cream, pramoxine was the culprit. Discussion:
Pramoxine is used only for surface anesthesia; therefore sensitization should
not entail any risk of future systemic reaction. Low sensitization potential has
been demonstrated, and patients sensitive to other topical anesthetics showed
no sensitization to pramoxine. To our knowledge, ours is the first report describ-
ing anaphylaxis to topically applied pramoxine. Ready access to the systemic
circulation seems to be a prerequisite for the development of anaphylaxis. In
contemplating topical therapy, patients should consider the integrity of the skin.
If the skin barrier is compromised, an anaphylactic reaction is possible. Physi-
cians should be aware that topical pramoxine may give rise to life-threatening
anaphylaxis.
P249
CHARACTERISTICS OF FOOD ALLERGY IN AN ADULT POP-
ULATION.
T. Shankar*, A. Petrov, M. Fajt, Pittsburgh, PA.
Introduction: Food allergies appear to be increasing in prevalence (Boyce,
JACI 2010), and aside from physical effects, lead to poor quality of life. Epi-
demiologic studies to date have focused on the pediatric population, and as a
result, there is limited data on food allergies in adults, with available data sug-
gesting differences in both presentation of allergy and underlying causative
agents in these two groups. This study aimed to evaluate the characteristics of
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A95

ABSTRACTS: POSTER SESSIONS

patients presenting to an adult Allergy/Immunology clinic with food allergy as
well as to determine the most prevalent food allergies reported. Methods: We
conducted a retrospective analysis of demographic and clinical data from adult
patients seen in an outpatient university Allergy/Immunology Clinic from June
2010-June 2014 for a complaint of food allergy as evidenced by ICD-9 code
of 995.7. Data: Preliminary results from evaluation of 10 patients demonstrated
a female predominance (90%) with onset of symptoms in adulthood (age >18
yrs) in 80%. Concomitant environmental allergy was present in 80% of patients
and drug allergy, most commonly penicillin, was present in 40% of patients.
Though nearly all of the patients (70%) had previously sought medical care
for food allergy, only 1 patient had injectable epinephrine previously prescribed
at the time of visit. The most common food allergen reported and confirmed
was shrimp (40%). Other confirmed food allergies were fish (salmon), peanuts
and tree nuts. 80% of patients reported allergy to >3 foods, but only 30% had
positive serum specific IgE testing to >3 foods. Of the 10 patients evaluated,
40% opted to have no further testing beyond the initial visit and were discharged
with injectable epinephrine prescription, training for use if needed, and an action
plan for food avoidance. Conclusion: Our preliminary data suggests that onset
of food allergy can occur in adulthood and is under-recognized and undertreated
by the medical community. Specific features such as female gender and co-
existence of both environmental and drug allergies may help to identify adult
patients with food allergy. Additional analysis with larger sample sizes is needed
to confirm these associations.
testinal disorders, the most frequent was esophageal and functional dyspepsia.
Positive test to aeroallergens were 76.19% Betulaceae (Birch 45.2%, Alnus
30.95%), 78.57% Oleaceae (42.5% Fraxinus, Olive 35.09%), 38.09% Aster-
aceae (Red Oak 38.09%), 38.9% Fagaceae (Thistle 38.09%). For food were
positive test were peach, orange and plum 38.09%, raw apple, 35.7% raw broc-
coli, celery, 33.3% raw carrot, strawberry, 30.95% raw onion, corn, banana,
kiwi, hazelnut and almond 28.57%. Positivity LTP extract 14% and 12% were
positive to profilins. Conclusion: In our populations, 12% of patients were pos-
itive to profilins and 14% to LTPs. 100% was positive to multiple pollens which
is similar to the prevalence reported worldwide 10-30% patients with pollen
allergy react to profilin. This is of great importance since it is considered a
risk factor for developing food allergies as well as most of these patients with
oral allergy syndrome. Also it has been reported that anaphylaxis is more com-
mon in patients with only sensitization to LTPs.

P250
RITUXIMAB AND FOOD ALLERGY IN A PEDIATRIC LIVER
TRANSPLANT PATIENT.
W.M. Rassbach*, J. Wang, New York, NY.
As a monoclonal antibody to CD20 on B lymphocytes, rituximab is used
to treat a variety of lymphoproliferative disorders, including post-transplant
lymphoproliferative disorder (PTLD). It is unknown to what degree this ritux-
imab-induced B cell depletion could affect pre-existing IgE-mediated food
allergy in children. We report a case of a three year-old patient who developed
hives and lip swelling to peanut butter after receiving tacrolimus immunosup-
pression for a living-related liver transplant performed for biliary atresia. She
subsequently developed PTLD and underwent treatment with rituximab, lead- P252
ing to B cell depletion. In the allergy evaluation that followed, her skin prick DIFFERENCES IN COMMON FOOD ALLERGENS, FOOD
testing revealed a negative histamine control, and her serum food-specific IgE ALLERGY SEVERITY AND THRESHOLDS IN 16 COUNTRIES.
levels were undetectable. As the patient had demonstrated clinical reactivity to R. Gupta*1, J. Blumenstock1, L. Bilaver2, L. Harada3, M. Marchisotto4,
peanut despite a negative serum peanut IgE, her case raises the question as to 1. Chicago, IL; 2. DeKalb, IL; 3. Toronto, ON, Canada; 4. New York, NY.
whether rituximab could have played a role in masking her IgE-mediated sen- Introduction: Food allergy prevalence is increasing globally in developed
sitivity to peanut and other foods. Rituximab targets actively dividing B cells, and developing countries especially in children. Avoidance is still the best rec-
particularly those present in the peripheral blood, and as such her case may indi- ommendation for management; however, strict avoidance impacts quality of
cate that the IgE active in food allergy is being produced by B cells in a body life. Recent research has focused on food allergen threshold levels, the lowest
compartment other than the peripheral blood. amount of an allergen that causes a reaction. After years of recommendations
to avoid allergens at any level, it is unknown how families feel about thresh-
olds. This would be the first international study of its kind to examine differ-
P251 ences in food allergy types, severity, diagnosis, and opinions about food allergy
FREQUENCY OF SENSITIZATION TO FOODS RICH IN LIPID thresholds between countries. Methods:A survey prepared by FARE gathered
TRANSFER PROTEINS AND PROFILIN IN PATIENTS OF THE consumer comments on allergen thresholds and was distributed by patient organ-
NATIONAL INSTITUTE OF RESPIRATORY DISEASES. izations in 16 countires to 10,225 respondents. The survey was designed for
R.D. Ruiz Morales*, M.D. García Cruz, V.A. Maldonado Ríos, F. Ramírez people with food allergies, family members, and caregivers who purchase their
Jiménez, G.F. Pavon Romero, M. Molina Macip, N. Camacho Ordonez, food. The public was asked to comment on opinions of food allergen thresh-
P. Sanchez de la Vega Reynoso, Z. Perez Estrella, L.M. Teran Juarez, olds, current approaches to managing food allergies through food selection,
Mexico City, DF, Mexico. and knowledge of thresholds. The results from these surveys were compiled
and analyzed by country. Results: Differences were observed by country in per-
Background: Food allergy affects many millions of people. May develop
cent of respondents with food allergy to each of the common food allergens,
allergy to almost any food, but in some cases it may be result of cross-reactiv-
percent of respondents with history of severe reaction, source of diagnosis,
ity between food and inhalant allergens. Clinical manifestations can be included
knowledge of food allergy thresholds, and willingness to consume food that
in the pollen-food syndrome sometimes leading to trigger anaphylaxis. These
contains varying amounts of food allergen. Overall, while 73% of respondents
syndromes are related to proteins like pathogenesis related protein family (PR-
said they had some knowledge about allergen thresholds, only 21% said they
10), profilin, lipid transfer proteins (LTPs) and storage proteins. Objective:
would buy a product that contained levels of an allergen low enough that it
Determine the frequency of sensitization to food rich in LTPs and profilin in
would not trigger a reaction and 4% would purchase a product with levels only
patients of the National Institute of Respiratory Diseases of Allergy and
capable of triggering a mild reaction. Responses to all threshold opinion ques-
Immunology Department. Methods: Patients were seen at the Allergy and
tions varied by country. Conclusion: There are clear differences in food allergy
Immunology Department with suggestive symptoms of oral allergy syndrome
in each of the countries participating in the survey. This is the first study of its
or food anaphylaxis underwent questionnaire to determine functional gas-
kind to analyze the breakdown of food allergy by common allergen and sever-
trointestinal disorders with subsequent skin testing to aeroallergens and food
ity in each country and opinions about the emerging topic of food allergen
with LTPs and profilins. Results: 42 patients were included, 75.6% were female
thresholds. It is apparent that if a food contains an allergen a family is avoid-
and 26.1% male, mean of IgE levels were 506 IU / L, average eosinophils in
ing, they may avoid the food regardless of thresholds and allergen levels. As
peripheral blood 422 cells/mm3. 71% of patients had symptoms of oral allergy
this topic develops, patient input is crucial as industry labeling policy shifts.
syndrome, 19% anaphylaxis to food intake and 60% had functional gastroin-

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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A96
ABSTRACTS: POSTER SESSIONS
P253
FOOD PROTEIN-INDUCED ENTEROCOLITIS SYNDROME
(FPIES) CAUSED BY AVOCADO.
A. Doshi*, S. Leonard, San Diego, CA.
Introduction: FPIES is a non-IgE mediated gastrointestinal food hyper-
sensitivity that is characterized by delayed profuse, repetitive vomiting and
often diarrhea. Severe cases can also lead to acute dehydration; weight loss and
failure to thrive can result if chronic. We present 2 cases of FPIES caused by
avocado, a trigger that has not previously been reported. Case 1: A breastfed
10-month-old male presents with a history of reflux, failure to thrive, and inter-
mittent vomiting, which improved with restricted maternal diet. Solids were
introduced at age 6 months, one new food every 3 days. At age 7 months, 4
hours after the second introduction of peas, zucchini and avocado he experi-
enced 2 episodes of emesis and appeared lethargic, returning to baseline by
the next morning. Shortly thereafter he developed repetitive vomiting, pale-
ness, limpness and lethargy 3 hours after the second introduction of sweet potato
and squash, separately. He was treated in the emergency room with ondansetron
and intravenous fluids for the sweet potato episode, but recovered at home after
the squash reaction. At this point he was diagnosed with sweet potato and squash
FPIES. At age 10 months, avocado was ingested again, and 3 hours later he
developed vomiting, limpness, paleness and lethargy. He recovered at home
after 3 hours. Case 2: A 9-month-old female was diagnosed with rice and milk
FPIES after presenting with a history of repetitive vomiting 2 hours after inges-
tion of rice and milk-based formula, separately, at age 7 months. When avo-
cado was introduced at age 12 months, she developed repetitive episodes of
vomiting 5 hours after ingesting a few bites. She was back to baseline a few
hours later. Discussion: These cases highlight avocado as an unreported trig-
ger of FPIES. The most common causative foods are milk, soy, rice, and egg;
reactions to meats, nuts, and other fruits/vegetables have also been reported.
To our knowledge, there have not been any other published accounts of avo-
cado FPIES. There is often a delay in FPIES diagnosis due to the lack of bio-
markers and because symptoms overlap with other more common disease
processes, such as gastroenteritis. FPIES is a clinical diagnosis based on his-
tory and it is important to not overlook uncommon or unreported triggers.
P254
SEVERE SEQUELLAE OF DEHYDRATION IN A FOOD PRO-
TEIN-INDUCED ENTEROCOLITIS PATIENT.
M.A. Ruffner*1, J. Fiedler2, 1. Rutledge, PA; 2. Philadelphia, PA.
Introduction: Food protein-induced enterocolitis syndrome is a non-IgE
mediated food allergy which usually presents in infancy as severe vomiting and
diarrhea. Onset of symptoms are delayed and occur 2-4 hours after ingestion
of a food. FPIES patients often experience delayed diagnosis due to the simi-
larity of its presentation with gastroenteritis, surgical abdominal processes, and
sepsis. This case illustrates that acute FPIES can be accompanied by profound
dehydration and a high clinical suspicion should be maintained for the poten-
tial clinical sequelae of severe dehydration. Case Summary: An exclusively
breastfed 6 week old full-term male was transferred to our institution for the
management of hyponatremia and severe dehydration in the setting of one week
of worsening vomiting and diarrhea. He had been breastfeeding and gaining
weight appropriately until six days prior to admission. He presented with 6 days
of multiple episodes of nonbloody, nonbilious emesis and four days of loose
nonbloody diarrhea. He had 0.52 kg weight loss over one week’s time, with
exam notable for sunken fontanel, delayed capillary refill and dry mucous mem-
branes and laboratory workup notable for hyponatremia to 128. He required
rehydration with IV fluids, and during the hospitalization he developed per-
sistent rightward eye deviation which progressed to apnea and bradycardia
requiring resuscitation. Electrolytes were normal and brain MRI/MRV revealed
thrombosis of the medullary vein. Hypercoagulable workup was negative.
Workup of his vomiting and diarrhea was negative, including: LFTs, lipase,
infectious stool studies, testing for neurometabolic disorders, anti-enterocyte
and FoxP3 staining as well as normal IgA staining of intestinal biopsies. His
hospital course was significant for multiple attempts to restart breastmilk or
alimentum complicated by recurrence of vomiting and diarrhea; he was even-
tually able to tolerate NeoCate with resolution of GI symptoms and was dis-
charged home on NeoCate. At followup visits he demonstrated normal growth
pattern and stooling pattern on NeoCate, but at 28 months had accidental expo-
sure to a small amount of milk and developed diarrhea secondary to this expo-
sure. Although FPIES is a diagnosis of exclusion given the severity of symp-
toms in this patient, and the reproducibility of his symptoms, FPIES to milk
seems is the most likely diagnosis.
A96 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P255
A SPOONFUL OF SUGAR HELPS BUDESONIDE GO DOWN.
J. Lee*, M.M. Shuker, T.F. Brown-Whitehorn, A. Cianferoni, L.M. Gober,
C.A. Liacouras, R. Verma, J.M. Spergel, Philadelphia, PA.
Introduction: Two methods for treating Eosinophilic Esophagitis (EoE)
are off-label use of swallowed steroids and dietary therapy. For swallowed
steroids, the two main options are swallowing MDI actuated inhaled corticos-
teroids or mixing budesonide into a slurry with sucralose (Splenda®). How-
ever, some patients do not like sucralose. We describe our treatment success
with other agents used to mix budesonide. Methods: We retrospectively reviewed
data from EoE patients treated with swallowed budesonide at our institution.
EoE was defined using the standard consensus criteria of > 15 eosinophils/hpf
(eos/hpf) on esophageal biopsy after ruling out gastroesophageal reflux. A value
of < 15 eos/hpf was considered adequate improvement. IRB approval and
informed consent was obtained from all subjects. Results: Fifty-four children
between ages 2 and 18 years (mean 6 years) were treated with swallowed budes-
onide over a 5 year period and had sufficient data to review. The most com-
mon delivery vehicle for budesonide was sucralose (n=32, 59%). A variety of
other agents were also used: 11 patients used apple sauce; 3-honey; 1-alter-
nating apple sauce and ice cream; 1-banana puree; 1-pear sauce; 1-hot cocoa
mix; 1-rice cereal; 1-tapioca starch; 1-xanthan gum; and 1-compounded for-
mulation. Of the patients using sucralose, 30 of 32 patients had improvement
on their esophageal biopsy (down to mean 1.27 eos/hpf). Of the 11 apple sauce
patients, 7 had improvement (down to mean 2.86 eos/hpf); 2 had no repeat
biopsy data, 1 did not respond adequately to budesonide, and 1 improved after
switching to honey as the vehicle. The patient on alternating apple sauce and
ice cream went from 60 eos/hpf to 20 eos/hpf. All 3 honey patients had improve-
ment (down to mean 3.33 eos/hpf). The patients using banana puree, pear sauce,
hot cocoa mix, xanthan gum and the compounded formulation as the vehicle
all had improvement to 0 eos/hpf. The patients using rice cereal or tapioca starch
did not have improvement on their biopsies. Conclusion: Splenda® (sucralose)
is the most commonly used delivery vehicle for swallowed budesonide in EoE
patients. Various other vehicles can also be effective, including apple sauce,
pear sauce, honey, banana puree, hot cocoa mix, xanthan gum, and a com-
pounded formulation. Certain other agents, however, may not work.
P256
WHEN IGE CRASHES THE PARTY: A CASE OF BEER ALLERGY.
J.D. Waldram*1, K.M. Woessner2, 1. La Jolla, CA; 2. San Diego, CA.
Case Presentation: An 18-year-old female presented to the allergy clinic
with concern for beer intolerance. She drank beer for the first time at age 14
and did not develop symptoms. Recently she has begun experiencing lip and
mouth tingling and numbness within minutes of drinking beer, followed by nau-
sea and vomiting within an hour. She denied additional skin or mucosal symp-
toms, and never experienced respiratory symptoms. Her symptoms occur with
a single sip of beer and are present with every exposure, regardless of the type
of beer. She has consumed wine, champagne and distilled spirits without any
adverse reactions, both before and since her symptoms with beer. She also
reports developing a localized, urticarial rash if beer is splashed on her skin.
Her past medical history is remarkable for migraine headaches for which she
takes sumatriptan as needed. She has no history of atopic diseases. She has no
known drug allergies. Her mother has allergic rhinitis. Review of systems and
physical examination were unremarkable. Skin prick test was adequate for inter-
pretation with a histamine control of 10mm/34mm and a negative glycerin con-
trol. She reacted to barley extract (5mm/17mm), malt extract (10mm/32mm)
and Pabst Blue Ribbon beer (10mm/40mm). She did not react to corn, hops,
wheat or yeast (Saccharomyces cerevisiae) extracts. She was instructed to avoid
beer and food or beverages containing barley or malt. Follow up was arranged
to perform oral food challenges to barley and malt, in order to determine whether
she can safely consume foods containing these ingredients. Conclusion:
Although uncommon, beer allergy should be suspected in a patient who reacts
adversely to beer and whose presentation is consistent with an allergic reac-
tion. Several beer components have the potential to cause IgE-mediated reac-
tions, including barley, hops and yeast, in addition to various other starches.
[3] Identifying a specific allergen, although often difficult, will assist in aller-
gen avoidance and prevent unnecessary dietary restrictions.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A97
P257
QUANTITATIVE BENEFIT AND RISK ASSESSMENT OF TIMO-
THY GRASS AND SHORT RAGWEED SUBLINGUAL
IMMUNOTHERAPY TABLETS IN THE TREATMENT OF ALLER-
GIC RHINITIS.
A. Kaur1, G. Koch2, S. Durham3, J.M. Portnoy4, Z. Li1, J. Maloney1,
H. Nolte*1, 1. Whitehouse Station, NJ; 2. Chapel Hill, NC; 3. London, United
Kingdom; 4. Kansas City, MO.
Introduction: Number needed to treat (NNT) and needed to harm (NNH)
is a quantitative approach to assess relative efficacy and safety of a treatment.
Lower NNT indicates more effective treatment, and higher NNH indicates safer
treatment. NNTs for allergic rhinitis (AR) treatments depend on the clinical
response definition and range from 3–34.5; NNHs depend on the frequencies
and types of adverse events and range from 13–167. We determined the NNT
and NNH to quantify benefit-risk for 2 sublingual immunotherapy tablets (SLIT-
T) approved for Timothy grass- (and related grasses) or short ragweed (RW)-
induced AR. Methods: For grass SLIT-T 2800 BAU (MK-7243; Merck/ALK-
Abelló), efficacy data vs placebo from 3094 subjects was used for NNT; safety
data from 4195 subjects was used for NNH evaluation. For RW SLIT-T 12 Amb
a 1-U (MK-3641; Merck/ALK-Abelló), efficacy data vs placebo from 644 sub-
jects was used for NNT; safety data from 1814 subjects was used for NNH eval-
uation. In the absence of an established responder definition, NNT was based
on 2 exploratory post-hoc responder definitions. Definition 1 required the sub-
ject to achieve ≥50% well days during the pollen season (grass full season,
RW peak season). Well days were days with no rescue medication use, and with
the worst score as none or mild for each of the 6 symptoms measured. Miss-
ing data were considered non-well days. Definition 2 required the subject’s total
combined symptom and medication score (TCS) to be ≤3 (~10% of the observed
endpoint range to be considered a responder). NNH was based on the adverse
event rate for epinephrine use and treatment-related systemic allergic reactions,
the safety endpoints of clinical concern. IRB approval and informed consent
was obtained from all subjects. Results: For grass SLIT-T, the NNT was 7.9
using the ≥50% well days definition and 9.4 using the TCS ≤3 threshold. NNH
was 305 based on epinephrine use and 303 based on systemic allergic reac-
tions. For RW SLIT-T the NNT was 10.3 using the ≥50% well days definition
and 16.4 using the TCS ≤3 threshold. NNH was 230 based on epinephrine use
and no harmful effect could be determined based on systemic allergic reac-
tions. Additional sensitivity analysis corroborated the NNT results. Conclu-
sions: Grass SLIT-T and RW SLIT-T have favorable benefit-risk ratios based
on NNT and NNH.
P258
ANALYSIS OF DUST MITE IMMUNOTHERAPY MAINTENANCE
GOAL ACHIEVEMENT.
N. Khoiny*1, J. Chase2, J. Sheikh2, M. Kaplan2, 1. Long Beach, CA;
2. Los Angeles, CA.
Introduction: This study investigated the percentage of patients who
achieved their pre-set dust mite immunotherapy maintenance goal within 1
ABSTRACTS: POSTER SESSIONS
year. Patient demographics were analyzed to see if specific populations were
less likely to achieve goal. Methods: An IRB approved retrospective chart review
of all current immunotherapy patients at one allergy clinic was conducted. Only
patients on standardized dust mite mix immunotherapy for at least 1 year were
included. One year was chosen as the inclusion time because it would take 32-
43 weekly incremental dosage steps to achieve maintenance goal if there were
no gaps or skipped doses, assuming a starting dose of 0.05cc of 0.001AU-0.1AU
and a goal maintenance dose of 0.20cc of 10,000AU using our standard pro-
tocol for dose advancement. Patients were excluded if they received combina-
tion shots with other allergens in the same extract vial or were on house dust
immunotherapy. Chi-square analysis was used to determine if differences were
significant. Results: There were 36 females and 46 males that met criteria for
the study. Of the 82 patients, 41 (50%) achieved their pre-set maintenance
goal target in 1 year. 41.7% of females achieved goal maintenance compared
to 56.5% of males. However, chi-square analysis found no significant gender
difference in achieving goal (p=0.182). Participants were also stratified into 3
different age groups: young (0-39 years), n=35, middle aged (40-59 years),
n=32, and elderly (60+ years), n=15. The age group differences were statisti-
cally significant (p=0.003). Odds ratio showed middle aged patients were 3.2
times and elderly patients 6.0 times more likely to achieve goal when compared
to young patients. Also, patients with no reactions to immunotherapy were
significantly more likely to achieve maintenance goal than those who had reac-
tions (p=0.027). Patients who consistently visited clinic for immunotherapy
treatments were more likely to achieve goal than those who missed appoint-
ments (p≤0.000). Conclusion: Patients who consistently visit clinic for
immunotherapy treatments, have no major reactions to treatments, and are older
are more likely to achieve maintenance goal in a timely manner. Patients younger
than age 40 are at high risk of not meeting goal. Improving success for this pop-
ulation may indicate a need for more resources for them such as special adher-
ence counseling on each injection visit and visit reminders.
P259
GASTROINTESTINAL ADVERSE EVENTS IN SUBJECTS
RECEIVING RAPIDLY DISSOLVING TIMOTHY GRASS OR
SHORT RAGWEED SUBLINGUAL IMMUNOTHERAPY
TABLETS.
J. Maloney*1, D. Skoner2, G. Berman3, B.Q. Lanier4, A. Kaur1, H. Nolte1,
1. Whitehouse Station, NJ; 2. Pittsburgh, PA; 3. Minneapolis, MN; 4. Fort
Worth, TX.
Introduction: Saliva may carry concentrated allergen extract to areas of
the gastrointestinal (GI) tract distal to the mouth and throat when swallowed
after administration of sublingual immunotherapy tablet (SLIT-T) or liquid.
Unabsorbed contents of a rapidly dissolving SLIT-T may be swallowed fewer
times than that of a SLIT-T that takes minutes to dissolve or liquid extracts,
minimizing allergen exposure contact with the non-mouth/throat GI tract. There-
fore, it is important to characterize the non-mouth/throat GI adverse events
(AEs) associated with each SLIT product. We report the GI AEs associated
with 2 SLIT-T products approved for the treatment of Timothy grass (and cross-
reactive grasses) or short ragweed (RW)-induced allergic rhinitis that dissolve
VOLUME 113, NOVEMBER, 2014 A97
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A98
ABSTRACTS: POSTER SESSIONS
within seconds under the tongue. Methods: AE data from 8 randomized, dou-
ble-blind, placebo-controlled trials (24-week to 1-year) of daily Timothy grass
SLIT-T 2800 BAU (MK-7243; Merck/ALK-Abelló) were combined into adult
and pediatric safety pools. AE data from 4 randomized, double-blind, placebo-
controlled trials (two 52-week trials and two 28-day trials) of daily RW SLIT-
T 12 Amb a 1-U (MK-3641; Merck/ALK-Abelló) were combined into a 28-
day safety pool. Results: A total of 3173 subjects received grass or RW SLIT-T
and 2836 subjects received placebo (Table). The majority of treatment-related
GI AEs were associated with the oral mucosa (Table). Dysphagia and dyspep-
sia did not affect a large number of subjects but did occur at a numerically
higher rate than in the placebo group for each pool (Table). Abdominal pain
and gastroesophageal reflux disease (GERD) occurred in ≤1% of subjects receiv-
ing grass or RW SLIT-T. Only 1/2116 (0.05%) subjects receiving grass SLIT-
T (none for RW SLIT-T) reported eosinophilic esophagitis; this AE was mild
in intensity, did not result in study discontinuation, and was not assessed as
treatment-related by the investigator. No serious GI AEs were reported in any
subject receiving grass or RW SLIT-T. Only 2/2116 (0.09%) subjects receiv-
ing grass and 1/1057 (0.09%) receiving RW SLIT-T discontinued due to treat-
ment-related abdominal pain or GERD. Conclusions: GI AEs associated with
grass SLIT-T and RW SLIT-T treatment predominately affected the oral mucosa.
Non-mouth/throat GI AEs were infrequent and rarely resulted in study dis-
continuation.
Treatment-related GI AEs in ≥1% of Subjects in Any Treatment Group
AE=adverse event; GI=gastrointestinal; SLIT-T=sublingual immunotherapy
tablet.
P260
IMMUNOMODULATORY THERAPY OF RECURRENT AND
RECALCITRANT WARTS: EFFICACY USING CANDIDA
ALBICANS ANTIGENS.
T.M. Nsouli*1, L.E. Firestone2, N.Z. Diliberto2, S.T. Nsouli2, J.A. Bellanti2,
1. Burke, VA; 2. Washington, DC.
Rationale: Recalcitrant warts are benign epidermal cutaneous skin lesions
caused by human papillomavirus (HPV), commonly seen in clinical practice.
Plantar warts are associated with severe pain and tenderness when walking or
standing and are not only particularly bothersome for patients, but can also sig-
nificantly affect their quality of life. The treatment of recurrent plantar warts
usually poses a therapeutic challenge to the clinician and is often difficult,
painful, time-consuming and, in some cases, unsatisfactory. Optimal treat-
ment with absence or low recidivism has not yet been established for recurrent
and recalcitrant warts. (Nofal A, et al. Am J Clin Dermatol 2013;14:253) Meth-
ods: Four patients (27 y/o WM, 24 y/o WF, 33 y/o WF and 44 y/o WF), each
with severe and recalcitrant plantar warts affecting their ambulation due to
significant pain (Figure 1), were studied. Immunologic assessment of all patients
revealed normal humoral and cell-mediated immune function. The warts had
A98 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
failed to respond to multiple courses of destructive modes of treatment, includ-
ing cryotherapy, salicylic acid 6%, imiquimod 5%, and electrodessication These
patients were started on immunotherapy consisting of intralesional injections
of 0.4 mL of a Candida albicans antigen preparation (Hollister-Stier) with a
concentration of 1,000 PNU/mL. This treatment was given at 3-week intervals
with an average of 3.5 sessions. Results: The patients’ plantar warts achieved
complete and striking resolution without scarring (Figure 2a, 2b) following
immunotherapy with multiple intralesional injections of Candida albicans anti-
gen. No relapses have been reported to date (average follow-up ~2.3 years).
The mechanism of action is still uncertain, but most likely due to the stimula-
tion of a T-helper type 1 (Th1) cell cytokine response leading to induction of
local and distal cell-mediated immune responses. The most common side effect
was pain during intralesional injections. Conclusion: The striking favorable
response to multiple stratified intralesional immunotherapeutic injections of
Candida albicans antigen in these 4 patients with recalcitrant warts unrespon-
sive to usual destructive forms of treatment, provides support for a promising
effective and safe mode of immunomodulator therapy.
P261
THE EFFICACY OF THE UNITED ALLERGY SERVICES SELF-
ADMINISTERED IMMUNOTHERAPY PROTOCOL.
F.M. Schaffer*1, L. Garner1, M. Ebeling2, T. Hulsey2, A. Naples1, 1. San
Antonio, TX; 2. Charleston, SC.
Introduction: Controversy exists about the efficacy of self-administered
SCIT protocols. We previously reported the safety study results of the United
Allergy Service (UAS) self-administered SCIT protocol (WAO J 2014, 7 (Suppl
1), 24). We now report the results of the efficacy trial. Methods: An IRB/HAC
approval and informed consent was obtained from all research subjects. A ret-
rospective efficacy study was completed for 56 control patients and 60 SCIT
patients (in accordance with the UAS protocol). Enrollment criteria in part
included only patients: who demonstrated positive SPTs to at least 3 of 6 com-
mon study site geographic allergens (Timothy, Bermuda, Cedar, Oak, Ragweed,
and Cocklebur) and had associated seasonal symptomology. The study con-
trasted statistical assessment of pretreatment and ongoing symptom scores (SS),
medication scores (MS), SS + MS, and quality of life scores (QOL). Results:
Assessment demonstrated significantly improved SS (SMD: -1.74; 95% CI: -
2.15, -1.34; p< 0.0001), MS (SMD: -1.17; 95% CI: -1.50, -0.84; p< 0.0001),
SS+MS (SMD: -1.61; 95% CI: -2.01, -1.21 ; p< 0.0001) and QOL (SMD: -
1.01; 95% CI: -1.40, -0.63; p< 0.0001) for the treatment group during
immunotherapy (mean of 16 months) compared to pre-immunotherapy scores.
A comparison of SS, MS, SS+MS, and QOL scores demonstrated significant
treatment group improvement in contrast to the control group (p<0.0001). There
was a 41% improvement in SS+MS for the treatment group compared to the
control group (p< 0.0001) and a comparison to a recently published meta-analy-
sis of 12 SCIT studies (DiBona et al, JACI 2012; 130: 1097-1107) demonstrated
equivalent efficacy. Conclusions: These efficacy results, and our previously
reported safety results, demonstrate that a carefully designed and implemented
self-administered SCIT protocol is safe and efficacious.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A99
P263
SAFETY OF SUBCUTANEOUS SPECIFIC ALLERGIC
IMMUNOTHERAPY IN PATIENTS WITH ALLERGIC RHINITIS
FROM THE NATIONAL INSTITUTE OF RESPIRATORY DIS-
EASES FROM 2005 TO 2014.
G.F. Pavon Romero, J.I. Rodríguez Gaspar*, M.E. Cervantes Malagon,
F. Ramírez Jimenez, M.H. García Cruz, L.M. Teran Juarez, Mexico City,
DF, Mexico.
Background: Subcutaneous specific allergic immunotherapy (SSAI), in
conjunction with drug therapy and patient education, is the cornerstone for the
treatment of allergic diseases. So far SSAI is the only treatment able to mod-
ify the allergic disease in addition to helping prevent the development of asthma.
Complications of SSAI are rare but possible. Currently there is insufficient
information to describe the incidence of adverse reactions in daily clinical prac-
tice. Collecting information that assesses SSAI’s safety could help us to iden-
tify allergens, dose, time of administration, and other factors in order to reduce
the incidence of potentially serious reactions. Objective: To assess the safety
of SSAI in patients with allergic rhinitis from 2005-2014. Methods: Patients
with Allergic rhinitis who received SSAI between 2005-2014 were included.
SSAI was performed using Alk-Abello® allergens with monthly applications
according to Mexican guidelines for immunotherapy. An adverse reaction to
SSAI (AR) was considered as the presence of any clinical manifestation pro-
posed by the European Academy of Allergy and Clinical Immunology. Fre-
quency analysis and survival curve were performed using the software SPSS
v. 21. Results: 1,923 patients were included, 3.7% (72) had AR, the average age
of the patients was 19 years, 63% were female and 37% male, 67%(48) were
children and 33% (24) adults. The most frequent allergens detected by skin
test and reported as managed with SSAI were Dpt (94%) and Ash (25%). Of
the 72 patients with AR, 66% were polisensitized (POL) and 34% monosensi-
tized (MONO); 39% received SSAI with standardized allergens (E), 25% with
non-standard () and 26% a combination. The average duration of the SSAI treat-
ment was 15 months, and the AR was presented during the build up phase at
1:1 concentration in E and 1:200000 in . POL patients developed AR earlier
than MONO patients, and the same phenomenon was observed when compar-
ing vs E. Of those with AR 65% of the cases had mild reactions, 24% moder-
ate and 11% severe. Conclusion: The polisensitized pediatric patients who
received SSAI with non-standardized allergen had mild adverse reactions that
were presented earlier in our population.
P264
SAFETY OF THE 5-GRASS POLLEN SUBLINGUAL TABLET IN
ADULT AND PEDIATRIC POPULATIONS WITH GRASS
POLLEN-INDUCED ALLERGIC RHINOCONJUNCTIVITIS.
R.K. Zeldin*1, Y. Amistani1, L. Paolozzi1, U. Wahn2, 1. Antony, France;
2. Berlin, Germany.
Background: The efficacy and safety of the 5-grass pollen sublingual tablet
has been demonstrated in patients with grass pollen-induced allergic rhinocon-
junctivitis. Using pooled data from across the development program, we eval-
uated the safety by age group. Methods: Patients (age: 5-65 years) with med-
ically confirmed grass pollen-induced allergic rhinoconjunctivitis for at least
2 years were included in one of eight double-blind, placebo-controlled studies
conducted worldwide. IRB/EC approval and informed consent was obtained
from all patients. Those who received 300IR (9,000 BAU) 5-grass pollen sub-
lingual tablet or placebo were considered for the age subgroup (i.e., chil-
dren/adolescents [5-17 years] and adults [≥18 years]) analysis. Adverse events
were monitored throughout the studies. Treatment-emergent adverse events
(TEAEs) were analyzed descriptively. Results: 1,878 adults (300IR=1,038;
placebo=840) and 312 children/adolescents (300IR=154; placebo=158) were
included in the analysis. TEAEs were reported by 78% of adults and 84% of
children/adolescents receiving active treatment and 66% and 79% of those
receiving placebo. The most commonly reported TEAEs by both actively-treated
subgroups were application site reactions (e.g., oral pruritus, throat irritation,
mouth edema), with similar incidences. The incidence of severe TEAEs was
similar in actively-treated adults (102 patients [9.8%]) and children/adolescents
(17 patients [11.0%]). Similar percentages of adults and children/adolescents
receiving the 300IR sublingual tablets withdrew from the studies due to TEAEs
(49 [4.7%] adults and 7 [4.5%] children/adolescents), mainly as a result of
application site reactions. Three serious TEAEs (hypersensitivity, angioedema
and diarrhea) considered related to the study drug by the investigator were
reported in adults; none were reported in children/adolescents. No actively-
treated patients received epinephrine and there were no ICU admissions. Con-
ABSTRACTS: POSTER SESSIONS
clusions: The incidence, nature and severity of adverse reactions reported dur-
ing treatment with the 300IR (9,000 BAU) 5-grass pollen sublingual tablet were
similar in the adult and pediatric populations.
P265
SAFETY OF THE 5-GRASS POLLEN SUBLINGUAL TABLET IN
MONO- AND POLY-SENSITIZED PATIENTS WITH GRASS
POLLEN-INDUCED ALLERGIC RHINOCONJUNCTIVITIS.
D.B. Golden*1, K. Abiteboul2, R.K. Zeldin2, 1. Baltimore, MD; 2. Antony,
France.
Background: The efficacy of the 5-grass pollen sublingual tablet has been
demonstrated in both mono- and poly-sensitized patients with grass pollen-
induced allergic rhinoconjunctivitis. Using pooled data from across the devel-
opment program, we report the safety profile according to the sensitization sta-
tus of patients at study entry. Methods: Eight double-blind, placebo-controlled
studies were conducted worldwide. Patients (age 5-65 years) with medically
confirmed grass pollen-induced allergic rhinoconjunctivitis for at least 2 years
were enrolled. IRB/EC approval and informed consent was obtained from all
patients. At entry, all patients underwent skin testing to 5-grass mix or timo-
thy and a panel of geographically relevant aeroallergens. Mono-sensitized
patients had a positive test to 5-grass mix/timothy alone and poly-sensitized
ones had a positive test to 5-grass/timothy and at least one other aeroallergen.
Of note, these other sensitizations were not to cause potential confounding
symptoms of allergy during the period of evaluation. Adverse events were mon-
itored throughout the study. Treatment-emergent adverse events (TEAEs) were
analyzed descriptively. Results: A total of 951 patients were mono-sensitized
(active=587; placebo=364) and 1,560 were poly-sensitized (active=927;
placebo=633). Similar incidences of TEAEs were reported in active and placebo
groups, whether patients were mono-sensitized (77.2% vs. 67.9%) or poly-sen-
sitized (76.7% vs. 70.9%) and the most frequently reported TEAEs (i.e., appli-
cation site reactions such as oral pruritus, throat irritation, mouth edema) were
reported at similar incidences in actively-treated mono- and poly-sensitized
patients. Mono- and poly-sensitized patients receiving active treatment reported
serious TEAEs with similar frequencies (1.5% and 1.4%, respectively). Actively-
treated patients withdrew due to TEAEs with similar frequencies whether mono-
sensitized (31 patients [5.3%]) or poly-sensitized (46 patients [5.0%]). Con-
clusions: Treatment with the 5-grass pollen sublingual tablet was similarly well
tolerated in mono-sensitized and poly-sensitized patients.
P266
EFFICACY OF HOUSE DUST MITE SUBLINGUAL
IMMUNOTHERAPY TABLET ON OCULAR SYMPTOMS USING
AN ENVIRONMENTAL EXPOSURE CHAMBER.
H. Nolte*1, J. Maloney1, H.S. Nelson2, D.I. Bernstein3, Z. Li1,
R. Zieglmayer4, P. Zieglmayer4, P. Lemell4, F. Horak4, 1. Whitehouse
Station, NJ; 2. Denver, CO; 3. Cincinnati, OH; 4. Vienna, Austria.
Rationale: Allergic rhinitis is frequently associated with ocular symptoms
which can have a significant impact on quality of life and daily activity. The
effect of house dust mite (HDM) sublingual immunotherapy tablet (SLIT-T)
on ocular symptoms is unknown; therefore, the efficacy on ocular symptoms
of MK-8237 (Merck/ALK-Abelló), a HDM SLIT-T currently under clinical
development, was evaluated in an environmental exposure chamber trial. Meth-
ods: Adults with HDM-induced allergic rhinitis with/without conjunctivitis
and/or asthma (n=124) received daily MK-8237 12 DU, 6 DU, or placebo for
24 weeks in this randomized, placebo-controlled, double-blind, single-site trial.
HDM exposure challenges of 6 hours duration were conducted at screening
and weeks 8, 16, and 24. The total ocular symptom score (TOSS) was assessed
and was the sum of 2 scores: gritty/red/itchy eyes and watery eyes, scored on
a 0 to 3 point scale (maximum=6). Total nasal symptom score (TNSS) was also
assessed and was the sum of scores for runny nose, blocked nose, sneezing,
and itchy nose, scored on a 0 to 3 point scale (maximum=12). IEC approval
and informed consent was obtained from all subjects. Results: Overall 83% of
subjects reported ocular symptoms at the screening chamber challenge. Improve-
ments of 34.1% and 67.9% in TOSS with MK-8237 12 DU versus placebo were
observed at week 8 (mean difference: −0.61; P=0.023) and week 24 (mean
difference: −1.27; P<0.001), respectively. Similarly, an improvement of 41.2%
with MK-8237 6 DU was observed at week 24 (mean difference: −0.77;
P=0.023). Efficacy for nasal symptoms was also demonstrated with improve-
ments of 20.4%, 30.1%, and 48.6% in TNSS with MK-8237 12 DU versus
placebo observed at week 8 (mean difference: −1.37; P=0.007), week 16 (mean
difference: −2.08; P<0.001), and week 24 (mean difference: −3.62; P<0.001),
VOLUME 113, NOVEMBER, 2014 A99
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A100
ABSTRACTS: POSTER SESSIONS
respectively. Similarly, improvements of 17.8% and 26.6% with MK-8237 6
DU were observed at week 16 (mean difference: −1.23; P=0.032) and week 24
(mean difference: −1.98; P=0.003), respectively. Both MK-8237 doses were
well tolerated. No anaphylactic reactions or reactions requiring epinephrine
were reported. Conclusions: A dose- and time-dependent effect of HDM SLIT-
T MK-8237 on ocular and nasal symptoms was observed, with maximum effi-
cacy of 67.9% for ocular symptoms observed at week 24 with the 12 DU dose.
P267
SAFETY OF THE SUBLINGUAL TABLET OF HOUSE DUST MITE
ALLERGEN EXTRACTS IN AN ENVIRONMENTAL EXPOSURE
CHAMBER STUDY: FOCUS ON ASTHMA-RELATED
SYMPTOMS.
M. Roux*1, W.H. Yang2, P. Devillier3, R.K. Zeldin1, 1. Antony, France;
2. Ottawa, ON, Canada; 3. Suresnes, France.
Background: The efficacy and safety of a sublingual tablet of house dust
mite (HDM) allergen extracts was tested in an environmental exposure cham-
ber (EEC) study, in which patients were exposed to a stable concentration of
HDM allergens. Here, we focus on asthma-related symptoms. Methods: Adults
(18-55 years) with medically confirmed HDM-associated allergic rhinitis were
randomized in this double-blind study to receive either placebo or active treat-
ment at the doses of 500IR, 300IR or 100IR with daily administration for 6
months. Patients with intermittent asthma controlled with therapies consistent
with GINA treatment step 1 could be enrolled. IRB approval and informed con-
sent was obtained from all patients. During the study, patients participated in
five 4-hour allergen challenges in the environmental exposure chamber. Analy-
ses were performed to evaluate the incidence of bronchospasm, asthma and
asthma-related symptoms, such as dyspnea, cough, wheezing, occurring in rela-
tion to the EEC challenges (i.e., peri-EEC periods defined as the day of and
the day after an allergen challenge) and that occurring outside of these peri-
ods. Results: 355 patients received at least 1 dose of the investigational prod-
uct and comprised the safety set (500IR=93; 300IR=86; 100IR=89;
placebo=87); 12.7% had asthma. During the peri-EEC periods, the incidence
of bronchospasm, asthma and asthma-related symptoms was similar across
treatment groups (range: 36.6%-44.9%). The incidence of these symptoms out-
side of the peri-EEC periods was approximately half of that during these peri-
ods (range: 16.1%-21.3%). The majority of patients experiencing these events
did not have asthma at study entry. Seven patients in the 3 active treatment
groups (none with asthma at baseline) withdrew due to peri-EEC asthma symp-
toms. No Patients withdrew outside of these periods. All events were of mild
or moderate intensity; 2 resolved without treatment, 4 with inhaled β2-agonist,
and 1 with an OTC treatment. Conclusions: Treatment with sublingual tablet
of house dust mite allergen extracts tested in an environmental exposure cham-
ber was generally well tolerated and without adverse effects on respiratory func-
tion. During the challenges, asthma-related symptoms of mild-moderate sever-
ity were reported in patients receiving placebo or active treatment.
P268
ALLERGY IMMUNOTHERAPY ADHERENCE: DOES RUSH
MAKE A DIFFERENCE?
S.P. Raschal, J.M. Holcombe, B.G. Carlton*, Chattanooga, TN.
Traditionally, immunotherapy consisted of regular (weekly/bi-weekly) injec-
tions over several months until a maintenance stage was reached. Rush
immunotherapy (RIT) allows the patient to achieve a maintenance stage much
quicker than traditional immunotherapy. The purpose of the current study was
to identify whether patients were more or less adherent to treatment when they
received RIT. A systematic chart review was conducted on all new patients who
started immunotherapy in 2011. Variables of interest included demographic
factors (age, gender, etc.), potential control variables (systemic reactions, prick
test results, and asthma diagnosis), RIT (hours), and duration of treatment
(months). Overall, 199 patients began allergy immunotherapy at the clinic in
2011. The average patient was 33 years old, female (65.3%), and Caucasian
(81.9%). The majority of patients had systemic reactions during their initial
screening (92.4%) and was also prick test positive (96.0%). The patients were
almost evenly divided by asthma diagnosis (yes=59.1%; no=40.9%), but analy-
ses showed no significant differences between these two groups in regards to
RIT hours and treatment duration. Patients were classified into one of three
groups at the time of chart review – (1) still on treatment, (2) stopped treatment
without restart, and (3) stopped treatment with restart(s). Of the 199 patients
who started treatment in 2011, 97 (48.7%) were still receiving treatment with
an average therapy duration of 14 months. Eighty patients (42.2%) had stopped
A100 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
treatment and had not restarted while 18 patients (9.0%) had stopped treatment
and subsequently restarted, some on several occasions. The average number of
RIT hours for patients still on treatment (M=13.37) was significantly higher
than for patients who had stopped treatment (M=8.20) even if they restarted
(M=2.64) [F(2, 196) = 15.57, p = .000]. Further analyses were conducted clas-
sifying patients into groups dependent upon the number of RIT hours they
received, if any. Patients receiving 1-10 RIT hours had significantly lower treat-
ment duration (M=8.3) than patients receiving no RIT (M=14.4), 11-20 RIT
hours (17.2), or more than 20 RIT hours (18.77) [F(3,195) = 14.17, p = .000].
While RIT hours do play a role in treatment duration, results of these analyses
suggest that another variable, possibly related to commitment to treatment, may
also be involved in the prediction of adherence.
P269
EFFICACY OF SUBCUTANEOUS IMMUNOTHERAPY IN
PATIENTS POLYSENSITIZED COMPARED TO PATIENTS
MONOSENSITIZED WITH ALLERGIC RHINITIS AND ASTHMA.
D. Rivero Yeverino, M. Molina Macip*, M.H. García Cruz, G. Pavon
Romero, F. Ramírez Jimenez, L. Teran Juarez, Mexico City, DF, Mexico.
Background: The World Health Organization estimates that 40% of the
world population suffers any type of allergic disease lilke allergic rhinitis (AR),
currently the mainstay of treatment of AR is the use of topical steroids, how-
ever the specific allergy immunotherapy (SAIT) is the only treatment capable
of modifying the natural course of the disease. Currently the studies that eval-
uate the SAIT in patients with AR describes a favorable clinical efficacy, how-
ever the are performed in monosensitized patients, the results of these investi-
gations have traspolated to polysensitized, without having assessed the same
clinical consistency and biological support. Objective: To evaluate the effi-
cacy of subcutaneous immunotherapy in patients polysensitized (POL) versus
monosensitized (MONO) with allergic rhinitis and asthma. Methods: We
enrolled asthmatic patients with AR; skin prick test were developed with ALK-
bello allergens classifying the groups of study in POL if there are two or more
allegens positives in the test and MONO if only has a one. SAIT was devel-
oped according Mexican guideline for immunotherapy. All participants real-
ized spirometry, Asthma Control Test, control of AR symptoms with statement
of ARIA in each phase of build up and measure of eosinophils, levels of Ig E
and inhaled steroids dosage at the begging and end of this phase. Statics was
developed using Wilcoxon test compared 0 time vs 4 time in each grupo and
U Mann Whitney between the groups with SPSSv21. Results: 23 patients par-
ticipated, were xx female and xx male, the average of age was xx years old, 12
patients integrated monosensitized group and 11 polysensitized, the principal
allergen was Dpt in both groups, the average of allergens in POL group were
5; FEV1 increases in each group (p = 0.006), there were decrease of 32 % in
the dosage of inhaled steroid (p = 0.001) and increased of ACT questionnaire
score (p = 0.001),there were not differences in these variable when comparing
POL vs MONO. The levels of IgE,eosinophils and evaluation of symptoms of
AR were similar in 0 vs 4 time in each and both groups. Conclusions:
Immunotherapy has the same efficacy in polysensitized patients as in mono-
sensitized
P270
SAFETY OF SUBCUTANEOUS SPECIFIC ALLERGIC
IMMUNOTHERAPY IN PATIENTS WITH ALLERGIC RHINITIS
FROM THE NATIONAL INSTITUTE OF RESPIRATORY DIS-
EASES FROM 2005 TO 2014.
G. Pavon, I. Rodriguez*, M. Cervantes, F. Ramirez, M. Garcia, L. Teran,
Mexico City, DF, Mexico.
Background: Subcutaneous specific allergic immunotherapy (SSAI), in
conjunction with drug therapy and patient education, is the cornerstone for the
treatment of allergic diseases. So far SSAI is the only treatment able to mod-
ify the allergic disease in addition to helping prevent the development of asthma.
Complications of SSAI are rare but possible. Currently there is insufficient
information to describe the incidence of adverse reactions in daily clinical prac-
tice. Collecting information that assesses SSAI’s safety could help us to iden-
tify allergens, dose, time of administration, and other factors in order to reduce
the incidence of potentially serious reactions. Objective: To assess the safety
of SSAI in patients with allergic rhinitis from 2005-2014. Methods: Patients
with Allergic rhinitis who received SSAI between 2005-2014 were included.
SSAI was performed using Alk-Abello® allergens with monthly applications
according to Mexican guidelines for immunotherapy. An adverse reaction to
SSAI (AR) was considered as the presence of any clinical manifestation pro-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A101
posed by the European Academy of Allergy and Clinical Immunology. Fre-
quency analysis and survival curve were performed using the software SPSS
v. 21. Results: 1,923 patients were included, 3.7% (72) had AR, the average age
of the patients was 19 years, 63% were female and 37% male, 67%(48) were
children and 33% (24) adults. The most frequent allergens detected by skin
test and reported as managed with SSAI were Dpt (94%) and Ash (25%). Of
the 72 patients with AR, 66% were polisensitized (POL) and 34% monosensi-
tized (MONO); 39% received SSAI with standardized allergens (E), 25% with
non-standard () and 26% a combination. The average duration of the SSAI treat-
ment was 15 months, and the AR was presented during the build up phase at
1:1 concentration in E and 1:200000 in . POL patients developed AR earlier
than MONO patients, and the same phenomenon was observed when compar-
ing vs E. Of those with AR 65% of the cases had mild reactions, 24% moder-
ate and 11% severe. Conclusion: The polisensitized pediatric patients who
received SSAI with non-standardized allergen had mild adverse reactions that
were presented earlier in our population.
P271
GASTROESOPHAGEAL REFLUX DISEASE (GERD) THERAPY
DOSING MISSES THE MARK.
J.L. Mutnick*, Morris, MN.
Rationale: Gastroesophageal reflux disease (GERD) is a chronic disease
and very common in the evaluation of chronic cough. Oftentimes, GERD is
silent and patients do not realize they are experiencing symptoms. When treated,
the dosing of medication is often a significant component in ensuring improve-
ment and efficacy in therapy. Yet, under-dosing seems to be a common prob-
lem that is not meeting the needs of appropriate therapy. Methods: 28 patients
with GERD (diagnosed by EGD or classic symptoms) were evaluated in clinic.
The patients had failed conventional proton-pump inhibitor therapy with
omeprazole 20mg once daily. Patients were randomized to two groups. 14
patients were placed on omeprazole 20mg twice daily; the remaining 14 patients
were placed on omeprazole 40mg once daily. 12 weeks of therapy were per-
formed and the REFLUX-QUAL (RQS) quality of life (QoL) questionnaire
was used to evaluate symptom improvement. Results: The REFLUX-QUAL
(RQS) questionnaire is a validated and simple tool consisting of 8 items cov-
ering the principal domains of the patients’ QoL. A score is rapidly obtained
ranging from 0 to 100; the higher the score, the better the QoL. The median
score amongst both groups at Week 0 was 36. Patients in the Omeprazole 20mg
twice daily group had RQS scores improve by an average of 16 points at Week
12 whereas the 40mg once daily group RQS scores improved by an average of
44 points at Week 12, an almost three-fold improvement. Conclusions: GERD
is a common diagnostic consideration in the Allergy and Asthma practice. It
has been my finding that increased frequency (qday vs. BID) of failed omepra-
zole doses do not alleviate or improve symptoms. Rather, it appears that an
increased dose of omeprazole is associated with much improved REFLUX-
QUAL symptoms scores and quality of life (QoL). A steady state of the same
failed dose is not appropriate to control symptoms. It is likely that this might
be a class finding and relatable to other proton pump inhibitors.
P272
INPATIENT CONSULTATIONS TO THE ALLERGY AND
IMMUNOLOGY SERVICE AT A TERTIARY CARE PEDIATRIC
REFERRAL CENTER.
E.E. Kempe*1, D. Stukus1, K. Strothman2, R. Scherzer1, 1. Columbus, OH;
2. Dublin, OH.
Background: There is a paucity of data examining patterns for inpatient
pediatric Allergy and Immunology (A/I) consultations. Objective: This analy-
sis was to determine the reasons for inpatient consultation to the A/I service at
a tertiary care pediatric referral center. Patient demographics and patterns for
establishing A/I follow-up (if recommended) were also examined. Methods:
We performed a retrospective chart review of all inpatient A/I consults from
January 1, 2013 to December 31, 2013. Results: In 2013, 82 inpatient consults
were placed to the A/I service, with 76 unique patients. Of these, 55 represented
patients who had not previously been evaluated by the Section of Allergy and
Immunology. Fifty-six percent (31/55) of new patient consults were to assess
for possible immunodeficiency, 16% (9/55) for angioedema/anaphylaxis, 13%
(7/55) for possible food allergy, 7% (4/55) for adverse drug reactions, 5% (3/55)
to assist with immunoglobulin replacement therapy, and 2% (1/55) for rash.
Of the consultations placed for possible immunodeficiency, 71% (22/31) were
for patients under 2 years of age. The majority of new inpatient consults were
requested by Infectious Disease (ID) (23%, 13/55), Hospital Pediatrics (14%,
ABSTRACTS: POSTER SESSIONS
8/55), and Gastroenterology (13%, 7/55). The remaining 50% of consults were
placed by 11 other subspecialty services. Outpatient A/I follow up was rec-
ommended for 31 (56%) of the 55 new patients evaluated in the hospital. Of
these 31 patients, 55% (17/31) presented to our clinic for scheduled follow up
evaluation. Established patients of the A/I service accounted for 27 inpatient
consults on 22 unique patients. Fifty-two percent (14/27) of these consults were
for co-management related to a previously diagnosed immunodeficiency. The
majority (67%, 18/27) of consults for established A/I patients were placed by
ID (20%, 11/55) and Hospital Pediatrics (13%, 7/55). Conclusions: Our review
of inpatient A/I consultations demonstrates the need for expert evaluation of
both allergic and immunologic disorders in the inpatient setting. Additionally,
inpatient evaluation by the A/I service is helpful for establishing outpatient A/I
follow-up for patients new to the A/I service. Understanding the inpatient con-
sultation patterns has implications for A/I fellow training, resident and med-
ical student education, as well as patient care.
P273
ASSESSING EPIPEN® PROFICIENCY AMONG INTERNAL MED-
ICINE INTERNS.
S. Bodner*, S. Akbar, R. Sejour, S. Chaudhry, M. Tamuz, A.M. Jongco,
Manhasset, NY.
Introduction: Many clinicians under-utilize and incorrectly dose epineph-
rine in anaphylaxis. Residents report being confident in diagnosing and man-
aging anaphylaxis despite limited clinical experience with this relatively uncom-
mon condition. We designed a simple training module to teach interns how to
use an EpiPen®, as well as developed and validated a scoring tool to reliably
measure an intern’s autoinjector proficiency. Methods: We developed the
EpiPen® proficiency assessment tool (E-PAT), a two-part tool including a
checklist that outlines 8 steps of proper autoinjector use and questions about a
clinician’s prior EpiPen® experience. We recruited 58 interns from an ACGME-
accredited internal medicine training program at an academic medical center
during orientation where they underwent skills training. This study was IRB
approved. Each intern participated in a 30-minute training module, followed
by an assessment. First, the interns watched a part of the manufacturer’s instruc-
tional video. Second, an allergist recapped the key points in the video and
encouraged questions. Third, the interns used EpiPen® trainers to practice on
themselves and their colleagues, with the opportunity to receive feedback from
the observing allergist. Finally, two independent coders (an allergist and a sen-
ior resident with allergy training) used the E-PAT to individually assess each
intern’s EpiPen® proficiency. Results: All 58 interns participated in the study.
Prior to this activity, 74% of the interns reported having never used an EpiPen®
trainer, none have used an EpiPen® in the past year and 7% have ever used an
EpiPen®. Over one-third (37%) of the interns knew someone who uses an epi-
nephrine autoinjector. After the training, the interns’ mean EpiPen® proficiency
score was 7.5±0.85 out of a maximum of 8 points (range 6-8), suggesting that
this module was effective. Inter-rater reliability for each item on E-PAT was
high and the overall kappa was 0.63, p<0.0001. Conclusion: Interns reported
limited experience with epinephrine autoinjectors prior to starting residency.
Our brief training module resulted in high, measurable EpiPen® proficiency
immediately. E-PAT demonstrated substantial inter-rater reliability. Future stud-
ies will assess whether residents retain proficiency longitudinally and if E-PAT
is equally reliable when used by non-clinician coders.
P274
SUCCESSFUL SWITCH FROM LONG-TERM PROPHYLAXIS
WITH DANAZOL TO ACUTE TREATMENT WITH C1 ESTERASE
INHIBITOR CONCENTRATE (BERINERT) IN A PATIENT WITH
HEREDITARY ANGIOEDEMA.
I. Martinez-Saguer*, W. Kreuz, Moerfelden-Walldorf, Germany.
Background: Several treatment options exist for the treatment of heredi-
tary angioedema (HAE), a rare genetic disease that manifests in episodes of
swelling in different parts of the body. Attenuated androgens, including dana-
zol, are well established for long-term use but are associated with multiple side
effects and contraindications. C1 esterase inhibitor concentrate (C1-INH)
replaces the missing or dysfunctional protein and is recommended as a first-
line treatment by international guidelines. Case Description: A 51-year-old
male patient with HAE had his first symptoms of HAE (abdominal pain) at an
age of 13 years. He was initially misdiagnosed with indigestion and allergies.
His first laryngeal attack occurred at an age of 23 years. Upon diagnosis of
HAE, the patient received a daily dose of 200 mg danazol for long-term pro-
phylaxis. During danazol therapy, he experienced side effects, including
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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A102
ABSTRACTS: POSTER SESSIONS
increased transaminases, and arterial hypertonia. Reduction to a daily dose of
100 mg danazol triggered HAE attacks (≥ 1 attack per week). When the patient
expressed the wish to switch from danazol to C1-INH, he was trained in intra-
venous self-infusion and learned how to recognize early symptoms of HAE
attacks. Danazol was then reduced stepwise (tapering down over several weeks).
During this period, recurrent attacks occurred approximately every 8 days and
were successfully treated with self-infusion of human pasteurized nanofil-
tered C1-INH (pnf-C1-INH, Berinert®; CSL Behring, Marburg, Germany).
Currently, the patient experiences HAE attacks every 5 days. All attacks are
treated successfully with self-infusion of pnfC1-INH. The patient has no side
effects and transaminases have returned to normal. Arterial hypertonia is ongo-
ing but is well-controlled with lercanidipine. Conclusions: Self-infusion of
pnfC1-INH is an effective and safe alternative for patients with severe HAE
who experience side effects or show lack of response to attenuated androgens.
Before switching from long-term prophylaxis with danazol to acute treatment
with pnfC1-INH, we inform the patient about a possible increase of attack fre-
quency and train the patient in intravenous self-administration techniques. We
do not stop androgens immediately and taper down danazol over several weeks.
P275
THE PRACTICAL USE OF A REAL WORLD DATA BASE IN CLIN-
ICAL PRACTICE.
G. Steven*, Milwaukee, WI.
Objectives: Health decision-makers involved with treatment, coverage and
payment policies are increasingly developing policies that seek information
on “real-world” (RW) data base outcomes. Motivated by these initiatives, we
have begun to develop a framework to assist health-care decision-makers in
dealing with RW clinical data, especially related to treatment, coverage and
payment decisions. Methods: Since 2008, a relational database has been devel-
oped and refined to complement the EHR by providing clinical decision sup-
port in ways that are not currently possible in most certified software. Data
from skin testing, spirometry, eNO analysis, impulse oscillometry are com-
bined with medication lists, immunotherapy formularies and injection admin-
istration records, smoking history, demographics, quality of life assessments
and immunization status. Results: We defined RW clinical information (P4P)
as data used for decision-making in day-to-day clinical care that are more prac-
tical than the low-level paradigms formulated by data collected in conventional
randomized controlled trials (RCTs) “evidence-based medicine.” We consid-
ered several characterizations: by type of outcome (clinical, economic, and
patient-reported), by hierarchies of evidence (which rank evidence according
to the strength of research design), and by type of data source (supplementary
data collection alongside RCTs, large simple trials, patient registries, admin-
istrative claims database, surveys, and medical records). P4P data base key
issues: 1) the importance of RW data; 2) limitations of RW data; 3) data depends
on the circumstance; 4) good practices for collecting and reporting RW data;
5)good process in using RW data in coverage and reimbursement decisions; 6)
the need to consider costs and benefits of data collection; 7) need for model-
ing; and 8) the need for continued stakeholder dialogue. Conclusions: Real-
world databases are essential for sound coverage and reimbursement decisions.
Of greatest utility is our use of clinical data to provide high-level treatment
decisions that maximize outcomes. It is critical that policymakers recognize
the benefits, limitations, and methodological challenges in using RW data from
private practice data bases (P4P), and the need to consider carefully the costs
and benefits.
P276
RECONCILIATION OF HEALTH RECORDS FOLLOWING PENI-
CILLIN ALLERGY TESTING OF HOSPITALIZED PATIENTS.
R. Pratt*1, A. Romanova2, J. Greenbaum3, M. Cyr3, 1. Stoney Creek, ON,
Canada; 2. Ottawa, ON, Canada; 3. Hamilton, ON, Canada.
Background: Medication errors are a very common problem, which can
lead to a range of sequela, including disclosure with no harm to a substantial
degree of morbidity. As a result, medication reconciliation is being implemented
as a formal process in many hospitals. Similarly, inaccurate medication allergy
lists can lead to increased cost to the system, unnecessary repeat allergy test-
ing, inappropriate or inferior antibiotics being prescribed on readmission or
even allergic reactions. We hypothesized that the majority of inpatients tested
for penicillin allergy were not allergic and that this information was not ade-
quately documented in the EMR or communicated to the general practitioner.
Methods: We retrospectively reviewed the charts of all inpatients at a teaching
hospital that were seen by a consultant allergist over the year of 2012. Data col-
A102 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
lected included basic demographics, penicillin allergy test results, current allergy
status on the EMR, readmission rates, prescribed antibiotics and discharge sum-
mary contents. Results: 146 patients were tested for penicillin allergy in 2012.
Of these, 144 (98.6%) were not allergic to penicillin. Although orders were
written in the charts of 145 (99.3%) patients to update their allergy status after
testing, 32 (22.23%) of these patients with negative tests were still listed as
allergic to penicillin in the EMR. Only 19 (15.2%) discharge summaries noti-
fied family physicians of the allergy testing results and discharge summaries
were missing for 25 (20%) patients. Further assessment of 50% of the charts
revealed that in 41% of cases the negative allergy test resulted in a change of
antibiotics to penicillin or its derivative. Of the 60 readmitted patients, 20 (33%)
were still listed as allergic to penicillin in the EMR (only one patient tested pos-
itive on skin testing) and 14 (70%) of the 20 patients required antibiotics. 12
of the 14 patients (86%) were prescribed antibiotics in the penicillin family
despite their positive allergy status. Conclusions: A significant proportion of
health records were not amended following antibiotic allergy testing and the
patient’s new allergy status was not communicated to the majority of general
practitioners in the discharge summary. A more efficient and reliable system
needs to be implemented to ensure changes to allergy status are communi-
cated to all members of the healthcare team.
P277
USE OF A PRIVATE PRACTICE ALLERGY SPECIALTY HEALTH
CARE DATA BASE IN IDENTIFICATION OF PATIENTS THAT
MAY BENEFIT FROM NEW THERAPIES.
G. Steven*, Greenfield, WI.
Clinical and demographic data have been entered in a diagnosis-related
administrative database (P4P) at AASC since 2008. This database was used to
estimate the prevalence of ragweed seasonal allergic rhinitis and to examine
the capture of data in P4P, considered in different time frames. Methods: A
case-finding algorithm identified patients with a positive skin test to ragweed
among those who had had skin testing done since 1996 and healthcare contact
at AASC within the last six years for whom we had current and correct con-
tact information. Prevalence rates were calculated as the ratio of the number
of identified patients to the total number of allergic rhinitis patients tested.
Results: Of the 6877 skin test records in the database, 534 patients were iden-
tified who had at least a moderate SPT to short ragweed (approximately an
8mm wheal or greater), had a diagnosis of allergic rhinitis, were not already
on SCIT, had a current email address on file and, based on the prescribing infor-
mation of the recently approved sublingual ragweed extract tablet, were between
the ages of 18 and 65. Only 42 of these patients called in to request more infor-
mation about this new treatment option. Since this medication had been only
recently approved, we found lack of formulary coverage to be a significant
obstacle to getting patients treated with this new therapy. Nonetheless, although
there was only about 2 weeks’ time between the drug appearing in pharmacies
and the last day to start therapy this year (12 weeks prior to the start of the RW
season, per the package insert), we were able to initiate treatment with 12
patients. Conclusions: Clinical and administrative healthcare databases in pri-
vate practice today can be important tools in identifying populations that may
benefit from new therapies, notifying patients of new information (e.g., boxed
warnings) regarding medications they are currently taking, as well as identify
potentially eligible patients for clinical research trials as part of the drug devel-
opment process. However, data collection needs to be judicious, relevant and
used on a daily basis in order to have a positive impact on clinical care.
P278
ALLERGIC DISEASES AND CORRELATED RISK FACTORS IN
PRESCHOOL CHILDREN.
M. Duse*, G. Forastiere, D. Porta, T. Melengu, A. Di Coste, L. Indinnimeo,
Rome, Italy.
Background: Allergic diseases affect 40% of the population with an increas-
ing prevalence. In the SIDRIA study, prevalence of allergic diseases changed
with the age: asthma and rhinitis raised (respectively from 9.3% to 10.3% and
12.3% to 20.9%), while eczema decreased (from 15.9% to 11.9%). However,
data on younger children are lacking. The aim of the present study is to assess
the prevalence of allergic and respiratory diseases as well as related risk fac-
tors in a population of 3 to 5 years old preschool children. Methods: The study
includes children attending 4 Nursery Schools in an urban district of Rome.
Data on the allergic diseases were collected using standardized questionnaire
(SIDRIA-2) and Skin prick tests (SPT) was performed. We investigated the
association of atopy, rhinitis, wheezing and asthma with a list of potential deter-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A103
minants, calculating the Odds Ratios (OR) and 95% Confidence Limits (95%CI)
from logistic regression models. Results: 494 children (46% male) aged 3-6
years were studied. More than 75% were breastfed (> 2 months) and 87%
were weaned after the 5th month of life. Most of them started attending school
after the 11th months and 64% had previously attended daycare. Sixty-seven
percent of children had at least 1 sibling; 72.3% lived at home with at least
other 3 persons; 42% reported to live in a street with heavy traffic; 20.6% had
a pet at home, and 22.9% had smoking parent. SPT was positive in 12% of chil-
dren. Asthma was positively associated with nationality not Italian (OR: 2.54,
95%CI: 1.09-5.92), breastfeeding >1 month (OR: 2.78, 95%CI: 0.97-7.97),
daycare attendance (OR: 2.26, 95%CI: 1.14-4.52), mother’s atopy (OR: 2.04,
95%CI: 1.13-3.66), and dermatitis (OR: 2.02, 95%CI: 1.13-3.61). Allergic rhini-
tis was positively associated with father’s atopy (OR: 3.11, 95%CI: 1.30-7.44),
and dermatitis (OR: 11.6, 95%CI: 4.52-29.6). Atopic status was positively asso-
ciated with mother’s atopy (OR: 2.09, 95%CI: 1.15-3.77). Conclusion: Our
study found a high prevalence of atopic sensitization in children under five
years, and confirms the high prevalence of allergic diseases, to an extent com-
parable to those seen later in life. The mother’s atopy increases the risk of devel-
oping asthma, father’s atopy increases the risk of allergic rhinitis while pollu-
tants (smoke and vehicular traffic) are not significant risk factors in these setting.
P279
EFFECTS OF DELIVERY AND FEEDING ON INCIDENCE OF
ATOPIC DISORDERS.
M. Hauk1, B.A. McGoey2, M. Michelis*2, 1. Mahwah, NJ;
2. Hackensack, NJ.
Introduction: Breastfeeding and vaginal delivery are known to be benefi-
cial to a child’s health. This study investigates the prevalence of atopic disor-
ders in children who are breastfed versus bottle fed and method of delivery,
spontaneous vaginal delivery (SVD) or cesarean section (C-section). Methods:
A retrospective chart review was conducted on 100 patients 0.5 to 17 years of
age (average 6.3 years of age ± 4.3). Patients were separated by duration of
breastfeeding or formula fed with no breastfeeding. Breastfed infants and tod-
dlers were subdivided into 5 groups based on length of feeding, <3 months, 3-
<6 months, 6-<9 months, 9-<12 months, and 12 or more months. Prevalence
of atopic skin disorders, such as eczema and atopic dermatitis (AD),
Immunoglobulin E (IgE) disorders, such as food allergies, asthma, allergic
rhinitis (AR), and a family history of pertinent atopic diseases (FHX) were
identified in each patient. Student’s t test was performed. Results: Out of the
100 children, 52 were males and 48 were females. The children breastfed for
9-<12 months and born via SVD group had the lowest atopic skin disorders,
but had a low FHX. The 6-<9 months breastfed and born via C-section group
had the lowest amount of IgE disorders, but the highest amount of atopic skin
disorders. The 6-<9 months breastfed SVD group had the highest FHX. The
12+ months breastfed SVD group had the highest number of IgE disorders.
All breastfed children had a lower occurrence of atopic skin disorders with a
p value of 0.02. With regards to breast fed versus formula fed, the 9-<12 months
breastfed group had the lowest atopic skin disorders, IgE disorders, and FHX
prevalence. The 6-<9 months breastfed group had the highest atopic skin dis-
orders and FHX. The <3 months breastfed group had the highest occurrence
of IgE disorders. Conclusion: Breastfeeding for 9-<12 months seemed to reduce
the amount of atopic skin disorders and IgE disorders; however, the genetic
lack of prevalence of atopy may explain this observation. Children breastfed
for <3 months had higher incidence of atopy. Patients that were born via SVD
were shown to have a less likely occurrence of atopic skin disorders and FHX
and a higher occurrence of an IgE disorder when compared to patients born
via C-section. A future study with a larger population size is needed to con-
firm these results.
P280
TEMPOROMANDIBULAR JOINT DISEASE AND ITS RELA-
TIONSHIP TO SLEEP HYGIENE AND SLEEP DEPRIVATION.
C. DiMaio*1, P. Henao2, E. Rael2, 1. Palmyra, PA; 2. Hershey, PA.
Rationale: TMJ, or temporo-mandibular joint disease, is a common disor-
der with significant morbidity affecting the quality of life for many people in
the United States. TMJ is more common in non-hispanic Caucasian women and
has been attributed to pain threshold, behavioral factors, and past trauma. How-
ever, to date no clear etiology has been identified and this disease is likely
multifactorial. Characterized primarily by pain, headache, and ear pain, TMJ
is very difficult to treat given the complex nerve root anatomy of the skull and
foramina. Given the significant morbidity TMJ carries on patients, we hypoth-
ABSTRACTS: POSTER SESSIONS
esize a correlation between the presence of TMJ symptoms and the Epworth
sleep score which measures degree of daytime drowsiness during a variety of
activities. Methods: After informed consent and IRB approval, 44 subjects were
identified to have doctor diagnosed TMJ consisting of a constellation of ten-
derness to palpation over the TMJ with joint movement. 763 subjects did not
have clinically diagnosed TMJ in a university academic allergy/immunology
clinic. Results: The average Epworth Sleepiness Scale (ESS) score amongst
subjects with TMJ was 7.8 in comparison to controls with an average ESS score
of 7.1. Conclusions: Our results show a positive correlation between the pres-
ence of TMJ symptoms and Epworth sleep score. Our findings indicate a need
to further evaluate the relationship between TMJ symptoms, day time sleepi-
ness, and the role of sleep hygiene in symptomatic TMJ patients to improve
patient quality of life.
P281
THE ASSOCIATIONS OF ALLERGY SKIN TEST, OCULAR AND
NASAL SYMPTOMS AND ASTHMA DURING NHANES II (N-II)
AND NHANES III (N-III).
Q. Meng*1, S. Nagarajan1, L. Bielory2, 1. Piscataway, NJ; 2. Springfield,
NJ.
Background: The prevalence of allergy skin test (IST), ocular and nasal
symptoms (ONS), and asthma has been reported from N-II and N-III. How-
ever, the associations of among these symptoms over time are unknown. Meth-
ods: N-II (1976-1980) and N-III (1988-1994) collected allergy IST data, ONS
and asthma prevalence. IST, ONS and asthma results were assessed for 6 com-
mon allergens (Ags) to N-II and N-III: cat, ragweed, perennial rye, oak, Bermuda
grass, and A. alternata. The IST+ (sensitized for 1 or more Ags) populations
were then assessed for ONS, and asthma status. ONS was identified using sur-
vey responses and asthmatics based on having a history and still having asthma.
The associations among IST, ONS and asthma were characterized with con-
tingency tables and correlation analyses. Results: IST+, ONS, and asthma sta-
tus were collected from N-II (n=11,044) and N-III (n=10,833). The number of
IST+(n=2144), ONS(n=991), and asthma(n=275) from N-II; and IST+(n=4538),
ONS(n=3242), and asthma(n=547) from N-III. Comparing N-II to N-III, the
prevalence increased: asthma 2.0 times, IST+ 2.2 times, ONS 3.3 times. The
concurrent prevalence of asthma, ONS, and +IST increased 5.3 times (all p<
0.0001; Χ2 test). From N-II to N-III, sensitivity increased to an increasing num-
ber of Ags. ONS prevalence in N-III was 2-3 times > N-II (p< 0.0001, except
for all 6 Ags, p=0.069). Within each NHANES survey, the associations among
+IST, ONS and asthma were all statistically significant with stronger associa-
tions observed in N-III vs. N-II. Correlation coefficients between asthma and
positive skin tests doubled or tripled in N-III (r=0.04 in N-II & 0.12 in N-III
for oak). A linear association (p< 0.0001) between the cumulative number of
IST+ (ranging from 0-6) and the prevalence of ONS or asthma was stronger in
N-III. Conclusion: From N-II to N-III, the prevalence of asthma, ONS, and IST
increased with greatest associated with more than one symptom. From N-II to
N-III, sensitivity increased to an increasing number of Ags. The associations
among IST, ONS, and asthma became stronger during N-III vs. N-II. Supported
in part by US EPA STAR Grant #: RD834547; Observational, Laboratory, and
Modeling Studies of the Impacts of Climate Change on Allergic Airway Dis-
ease; PI: Leonard Bielory, M.D.
P282
PEDIATRIC ALLERGY AND GI COMBINED CARE IMPROVES
EOSINOPHILIC ESOPHAGITIS SYMPTOM CONTROL IN
CHILDREN.
M. Hogan1, A. Wonnaparhown2, R. Scherr*2, N. Wilson2, 1. Reno, NV;
2. Las Vegas, NV.
Introduction: Eosinophilic esophagitis (EE) is an inflammatory esophagi-
tis which can be associated with IgE sensitization to food and aeroallergens.
Food avoidance, swallowed glucocorticosteriods, and proton pump inhibitors
have been utilized therapeutically in pediatric EE patients. Information regard-
ing pediatric follow-up of EE is limited. Methods: Patients (1-18 years) with
biopsy proven EE co-managed with pediatric GI from 2010-2013 in the
UNSOM A/I clinic and having at least one follow-up visit were evaluated ret-
rospectively for skin test IgE sensitization to food, aeroallergens, and EE symp-
toms. Statistics were performed with Fischer’s exact test with graphpad.com.
IRB exclusion was obtained. Results: 23 children with EE meeting study cri-
teria were identified. IgE sensitization occurred to food in 87%, aeroallergens
96% and 87% of children had sensitization to both. A/I and GI therapy for EE
and AR increased after the first A/I visit with 9/23 swallowing GCS, 3/23 on
VOLUME 113, NOVEMBER, 2014 A103
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A104
ABSTRACTS: POSTER SESSIONS
proton pump inhibitors, 8/23 avoiding most likely contributing foods and 16/23
with prescribed aeroallergen avoidance or immunotherapy for allergic rhinitis
or/asthma. Most common food sensitizations identified were legumes (14/23)
and tree nuts (8/20). Other foods were noted at lesser frequencies. Common
aeroallergens identified in the population in order of frequency were cat 69%,
sagebrush 63%, maple 61%, dog 57% and timothy 54% of the study popula-
tion. Eosinophilic esophagitis symptoms of stomachache (p<0.037) and
GERD/heartburn (p<0.033) improved with this comprehensive care. Conclu-
sion: Pediatric EE is a complex inflammatory disease with multiple possible
triggers and follow-up information after initial evaluation is limited. Aeroal-
lergens and food IgE sensitization was notable in this population. Compre-
hensive care in this population resulted in decreased GI symptoms of pain and
should be studied further as a working model to improve pediatric EE care.
P283
HYPERSENSITIVITY COURSE: EMPOWERING FELLOWS
TO DESIGN/CONDUCT THEIR OWN EFFECTIVE ALLERGY
CURRICULUM.
A.C. Gavino*, Q. Kamili, Z. Maskatia, N. Chokshi, D. Bayer, K. Tuano,
S. Wu, S. Hasan, M. Garcia Buheis, L.M. Noroski, Houston, TX.
Introduction: National training programs answer to the Accreditation Coun-
cil for Graduate Medical Education (ACGME) to meet competency require-
ments. Allergy and Immunology (AI) requirements include core competency
achievements in allergy (hypersensitivity). Methods that empower learners to
take ownership in their own course curriculum are not standard, yet can max-
imize content retention important for accreditation, exam scores and practice
performance. Our objective was to develop an innovative and effective Hyper-
sensitivity Course (HSC) by/for AI fellows. Methods: Needs assessment was
performed for actual competence and perceived efficacy in aeroallergen diag-
nostics, allergic disorders and procedures, based on in-training exam results,
patient/procedure logs and confidence/experience/satisfaction. Gaps in allergy
knowledge, practice and self-efficacy were identified and fellows became part-
ners in creating an allergy-focused and shared-group interactive course with
expert oversight. Modified flipped design with project-based learning and real-
life applications to master allergy was applied. Results: AI fellows successfully
designed (2008-2009) and implemented (2009-2014) their own HSC course
to master ACGME AI competencies in allergic diseases/procedures, aeroaller-
gen identification and desensitizations, and continue to modulate it (by prac-
tice parameters/literature updates and learner needs) and teach it (weekly-10
months/year). All HSC AI fellows (2008-2014) reached increased in-training
exam scores and board pass rates (100%), met log requirements to 50%ile
(2013-2014), ranked it highest among courses, achieved increased allergy self-
efficacy and, in 2013, earned the ACGME David Leach Award for a trainee-
driven educational program. Conclusion: HSC AI fellows conquered compre-
hension-performance in allergic diseases and procedures with confidence and
competence through becoming teachers while learners. They became empow-
ered as leaders in their own sustainable curriculum for themselves and their
clinical team. Their HSC methods may serve as a feasible and effective model
not only for meeting AI training requirements but also for those seeking mas-
tery in allergy practice and knowledge.
P284
EVALUATION OF AN ELECTRONIC DAILY DIARY FOR MEAS-
URING SYMPTOMS AND IMPACT OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE.
K. Kulich1, B. Tiplady*2, D. Banerji3, 1. Basel, Switzerland;
2. Peterborough, United Kingdom; 3. East Hanover, NJ
Introduction: Patient-reported outcomes are increasingly important in eval-
uating the severity and impact of chronic conditions such as chronic obstruc-
tive pulmonary disease (COPD). Electronic patient diaries (eDiaries) have been
found to be highly acceptable to patients, who often prefer them to paper.
Also, eDiaries allow time-stamping of entries, automatic tailoring of entries to
the time of day, and limit entries to valid options. Methods: Qualitative patient
interviews have been used in the development of a new COPD eDiary, which
includes five symptom items and two impact items rating bother and diffi-
culty (BD). Two morning assessments (since awakening, M1; since last assess-
ment, M2) and one evening assessment (E) were made each day. The eDiary
was completed by a subset of 209 patients (140 males, aged 44 - 86) in a 26-
week QVA149 SHINE study. Results: Patient compliance with the eDiary was
90.1% over the 7-day baseline period, and 80.0% at Week 26. The frequencies
of reporting of each of the 5 symptoms were ≥60% of baseline, with shortness
A104 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
of breath, mucus/phlegm and cough occurring in ≥70% entries while chest
tightness and wheezing occurring in ≥60% of entries over the 26-week study
period. Exploratory factor analysis gave a single factor, including both symp-
toms and the BD items. Internal consistency was extremely high, being >0.95
for all three assessment points (M1, M2 and E) at baseline, Week 12 and Week
26. Thus the scale is unidimensional, so that the overall mean of the seven items
(OM7) could be used as a summary measure. Test-retest reliability was assessed
in 44 patients who showed no change in their symptoms between baseline and
Week 1. The intraclass correlation coefficients (ICC) for OM7 were 0.97 for
M1 and M2 and 0.96 for E. The lower 95% confidence limit was >0.92 in all
cases. The eDiary was sensitive to change: the effect size for change over 26
weeks in patients identified as having improved on both clinical and patient
global measures, was large (0.79) as compared to a minimal change in patients
classified as uncertain/no change (0.16). Anchor-based comparison suggests
that a change of 0.6 on the OM7 Score of the eDiary (range 0-10) represented
a meaningful change for patients. Conclusion: The new COPD eDiary showed
good measurement properties, being valid, reliable, internally consistent, and
sensitive to change.
P285
THE CHARACTERIZATION OF RPC4046, A NOVEL ANTI-IL13
MONOCLONAL ANTIBODY THAT BLOCKS BINDING TO IL-13
RECEPTOR α1 AND α 2 IN DEVELOPMENT FOR
EOSINOPHILIC ESOPHAGITIS: RESULTS OF A FIRST-IN-
HUMAN STUDY.
C. Tripp*1, A. Campbell2, B. Hendrickson2, C. Cuff1, R. Miller1, C. Wu1,
K. Kim3, 1. Worcester, MA; 2. North Chicago, IL; 3. Cypress, CA.
Eosinophilic esophagitis (EoE) is a chronic, immune/food antigen-medi-
ated disease characterized clinically by esophageal dysfunction and histologi-
cally by eosinophil-predominant inflammation with overexpression of cytokines,
including interleukin 13 (IL-13). RPC4046 (previously known as ABT-308) is
a humanized, high-affinity, neutralizing antibody that prevents IL-13 binding
to both IL-13Rα1 and IL-13Rα2. The first-in-human (FIH) study
(NCT00986037) was a single center, randomized, double-blind, placebo-con-
trolled, 3-part, dose escalation study. RPC4046 was administered to healthy
volunteers (HV) and patients with mild to moderate, controlled asthma to assess
the safety, tolerability and PK of single escalating intravenous (IV) doses or
multiple escalating subcutaneous (SC) doses. Twenty HV and 15 asthma patients
received single IV infusions of RPC4046 (0.3 to 10 mg/kg) or placebo. Sub-
sequently, 12 asthma patients received 3 weekly SC doses of RPC4046 (0.3 or
3.0 mg/kg) or placebo. IRB approval and informed consent was obtained from
all research subjects. RPC4046 pharmacokinetic (PK) parameters were simi-
lar after a single IV infusion between HV and asthma patients. Following mul-
tiple SC administration, Tmax was ~4 days, exposure was dose-proportional and
the absolute bioavailability was ~70%. In 27.8% of subjects receiving RPC4046,
measurable anti-drug antibodies were detected transiently, which did not appear
to affect PK or safety. The AE profile was similar in HV and asthma patients
and with different administration routes. For RPC4046 subjects, all AEs were
mild to moderate in severity, with none reported as probably related to study
drug. There were no dose-related increases in AEs and no discontinuations
due to AEs. The proportion of subjects reporting an upper respiratory tract
infection was greater among those receiving RPC4046 compared to placebo.
A single SAE of worsening foot bunion was reported in Group 1 HV and con-
sidered not related to study drug by the investigator. There were no study drug
related infusion-related reactions and no suggestion of worsening asthma. These
results support further investigation of RPC4046 for allergic/inflammatory dis-
eases involving IL-13, including the ongoing phase 2 clinical trial in adults with
EoE (NCT02098473).
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A105
PK Parameters (Mean ± SD) of RPC4046 Following a Single IV Infusion in
Healthy and Asthma Subjects
a N = 4 for Cmax and Cmax/Dose for Groups 2 and 3
b Mean ± SD
c Harmonic mean ± pseudo-standard deviation
P286
EFFICACY OF SULFASALAZINE, AN ANTI-INFLAMMATORY
AGENT, FOR THE TREATMENT OF SEVERE CHRONIC IDIO-
PATHIC URTICARIA PATIENTS NOT CONTROLLED ON ORAL
ANTIHISTAMINES.
S. Nsouli*, Danville, CA.
Previously, we have shown the efficacy of Omalizumab, a recombinant,
humanized, chimeric anti-IgE monoclonal antibody, for the treatment of Severe
Chronic Idiopathic Urticaria (CIU) patients not controlled on oral antihista-
mines. Clinical observations have led us to believe that sulfasalazine, an anti-
inflammatory agent, composed of a sulfapyridine covalently linked to 5-aminos-
alicylic acid, may provide additional efficacy in sub optimally controlled Chronic
Idiopathic Urticaria (CIU) patients that remain symptomatic on an H1-Recep-
tor Antagonist, Cetirizine. In this open labeled 16 week trial, 60 adult patients
with symptomatic Severe Chronic Idiopathic Urticaria using Cetirizine, 10
mg orally QD, were randomized to continue the existing therapy Cetirizine or
to add on Sulfasalazine 500 mg oral tablets (increased by 500mg weekly) until
control of clinical symptoms occurred or until reaching a maintenance dose
according to patient’s weight, 30 to 50 mg/kg per day, in 2 evenly divided doses,
not to exceed 2g per day to the existing therapy Cetirizine. The end points of
the trial include: weekly itch severity score on a scale. The mean of measure-
ments at the end of the 16-week trial revealed a significant improvement in all
parameters examined in the treatment group receiving Sulfasalazine (as add-
on to the existing therapy), compared to the other group. In conclusion, the
addition of Sulfasalazine to the combination of Cetirizine is more effective than
Cetirizine, for the treatment of Severe Chronic Idiopathic Urticaria patients. It
appears that when Sulfasalazine is added to the combination H1-receptor antag-
onist, Cetirizine, the end points and symptom scores are significantly improved.
P287
PATIENT ACCEPTANCE AND PREFERENCE FOR THE WARM-
ING SENSATION ACCOMPANYING FLAVOUR AGENT 316282 IN
AN OVER-THE-COUNTER COUGH AND COLD SYRUP.
R. Furcha1, A. Amin*2, 1. Nyon, Switzerland; 2. Parsippany, NJ.
Introduction: An over-the-counter (OTC) cough and cold syrup containing
paracetamol, phenylephrine, and guiafenesin was reformulated with flavour
agent 316282, which has been shown to cause a warming sensation in the mouth
and back of the throat. This agent is included for the taste of the product, but
also may have a soothing effect appropriate to the indication. The ability of a
warming sensation to help patients suffering from cough, cold, and flu feel bet-
ter is well known anecdotally. However, there are no studies to date that have
evaluated the warming sensation of liquids, rubs, or drug ingredients in terms
of patient acceptability and preference. Objective: We sought to assess the
warming sensation associated with the flavour agent 316282 in terms of patient
acceptability. Methods: This was a single dose, single cohort, single treatment
arm, open-label study. Subjects received one 30 mL dose of syrup containing
paracetamol (500 mg), phenylephrine (10 mg), guaifenesin (200 mg) and flavour
agent 316282 (0.15% weight/volume). Onset and duration of the warming sen-
sation in the mouth/throat were recorded, and subjective assessments of strength
and appeal of the sensation and overall acceptability of the product as a cough
and cold remedy were surveyed. IRB/HAC approval and informed consent was
ABSTRACTS: POSTER SESSIONS
obtained from all research subjects (or parents for adolescents). Results: Of 51
subjects included, 47 (92.1%) experienced a warming sensation within 60 sec-
onds of ingestion. The median duration of the sensation was 100 seconds (95%
Confidence Interval: 82, 112 seconds). Most subjects (71%) liked the warm-
ing sensation; no subjects expressed significant dislike (i.e., very much or
extreme dislike) of the sensation. About 67% thought the strength of warming
was “just about right.” There were no safety concerns, and the syrup was well
tolerated and effective for treating cough and cold symptoms. Conclusions: The
flavour agent 316282 is associated with a warming sensation, which may be a
desirable attribute for a cough and cold product for some patients. Lack of a
control group – i.e., unflavored syrup – limits interpretation of the findings.
More data are needed to overcome the challenge of appropriate controls for
these types of studies.
P288
ONCE-DAILY TIOTROPIUM RESPIMAT® ADD-ON TO MAIN-
TENANCE THERAPY IMPROVES LUNG FUNCTION IN
PATIENTS WITH MODERATE OR SEVERE SYMPTOMATIC
ASTHMA, INDEPENDENT OF T HELPER 2 INFLAMMATORY
STATUS.
M.L. Vandewalker*1, J. Karpel2, G. Bensch3, L. Ford4, M. Engel5,
R. Sigmund5, P. Moroni-Zentgraf 5, H. Kerstjens6, 1. Columbia, MO;
2. New York, NY; 3. Stockton, CA; 4. Bellevue, NE; 5. Ingelheim am Rhein,
Germany; 6. Groningen, Netherlands.
Background: In many patients (pts) current asthma control is inadequate,
resulting in impaired quality of life and increased risk of exacerbations. T helper
2 (TH2) immune response mediates allergic airway inflammation, may influ-
ence individual asthma expression, and is the target of many asthma treatments.
Once-daily tiotropium Respimat® add-on to at least medium-dose inhaled cor-
ticosteroid (ICS) ± long-acting β2-agonist (LABA) maintenance therapy pro-
vides sustained lung function improvements in pts with symptomatic asthma.
Pre-specified analyses of pooled data from replicate Phase III, randomized,
double-blind, placebo-controlled, parallel-group trials were performed to assess
whether tiotropium Respimat® treatment response was dependent on TH2 inflam-
matory status. Methods: Pts with severe symptomatic asthma (PrimoTinA-
asthma®, n=912) from two 48-week trials of tiotropium Respimat® 5 mg add-
on to high-dose ICS (≥800 mg budesonide or equivalent) + LABA, and pts with
moderate symptomatic asthma (MezzoTinA-asthma®, n=2100) from two 24-
week trials of tiotropium Respimat® 5 mg or 2.5 mg or salmeterol add-on to
medium-dose ICS (400-800 mg budesonide or equivalent), were evaluated. Peak
and trough forced expiratory volume in 1 second (FEV1) were assessed (pooled
data) in the TH2-low and TH2-high subgroups according to baseline total serum
IgE ≤ or >430 mg/L, blood eosinophils ≤ or >0.6×109/L, and clinical judgment
of allergic asthma as “no” or “yes”. COPD was excluded. Results: 3012 pts
were included in the treated set, with baseline demographics and disease char-
acteristics balanced between treatment regimens and subgroups. Peak and trough
FEV1 responses were improved with tiotropium Respimat® versus placebo,
independent of total serum IgE level, blood eosinophil count, and clinical judg-
ment of allergic asthma (Table). Safety and tolerability of tiotropium Respi-
mat® were balanced compared with placebo. Conclusion: Once-daily tiotropium
Respimat® add-on to at least medium-dose ICS ± LABA maintenance therapy
provides sustained improvements in lung function, independent of TH2 inflam-
matory status, in pts with moderate or severe symptomatic asthma. Tiotropium
Respimat® add-on therapy may therefore be beneficial in both allergic and non-
allergic asthma.
VOLUME 113, NOVEMBER, 2014 A105
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A106
ABSTRACTS: POSTER SESSIONS
Adjusted mean difference for tiotropium Respimat® versus placebo at Week
24 (mL)
aValues for active and placebo groups combined. Pts may be included in more
than one subanalysis; bFor treatment × subgroup interaction BID, twice-daily;
QD, once-daily
P289
PHARMACOLOGIC MODELING TO GUIDE THE DX-2930 DOS-
ING REGIMEN IN INVESTIGATING LONG-TERM PROPHY-
LAXIS OF HEREDITARY ANGIOEDEMA.
Y. Chyung*, D. Sexton, C. TenHoor, J. Kenniston, R. Faucette, R. Iarrobino,
J. Biedenkapp, B. Adelman, Burlington, MA.
DX-2930 is a fully human monoclonal antibody inhibitor of plasma
kallikrein (pKal) under investigation for prophylaxis against acute attacks of
hereditary angioedema (HAE). It is well established that pKal plays a critical
role in HAE pathogenesis but the minimum level of pKal inhibition necessary
to prevent attacks is unknown. We hypothesize that continuously maintaining
levels of pKal inhibition associated with peak plasma drug levels (80 nM) of
ecallantide (approved in the US to treat acute HAE attacks) would prevent
attacks (mid-dose hypothesis). Alternatively, lower or higher levels may be nec-
essary. To inform future clinical trial design we performed analyses to evalu-
ate these low, mid, and high-dose hypotheses. Publicly available data from
OPuS-1, a clinical study of the pKal inhibitor BCX-4161 for HAE prophy-
laxis (BioCryst Pharmaceuticals Inc.), was reviewed. In vitro inhibition of pKal
by ecallantide and DX-2930 was assessed using a synthetic substrate assay.
Modeling was conducted using pharmacokinetic (PK) data from a single ascend-
ing dose study of subcutaneous DX-2930 in healthy subjects. IRB approval and
informed consent was obtained from all subjects. Review of the OPuS-1 data
suggested that therapeutic response correlated with higher plasma drug con-
centrations of BCX-4161 and that pKal inhibitor levels below 80 nM might
offer only partial prophylactic effect, lending further credence to the mid- and
high-dose hypotheses over the low-dose hypothesis. In an in vitro pKal assay,
DX-2930 and ecallantide displayed comparable pharmacodynamic activity at
80 nM concentrations. Thus, continually maintaining DX-2930 drug levels
above 80 nM should attain the level of pKal inhibition delineated by the mid-
dose hypothesis. PK modeling predicts that chronic DX-2930 dosing will yield
steady state plasma drug concentrations above 80 nM with 100 mg every 2
weeks (or 300 mg every 4 weeks) and above 200 nM with 300 mg every 2
weeks. Available data support the mid- and high-dose hypotheses for long-term
prophylaxis of HAE with DX-2930. Chronic dosing with 100 mg and 300 mg
is estimated to provide therapeutic coverage relevant to testing the mid and
high-dose hypotheses in an efficacy and safety study. Plans for future clinical
trial efforts will further be refined by PK and biomarker data from an ongoing
Phase 1b study in HAE subjects.
A106 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P290
REVIEW OF HISTAMINE RECEPTOR (H1, H2, AND H3) ANTAG-
ONIST BINDING AFFINITIES YIELDS THREE TRENDS OF
BINDING PROPERTIES.
J. Maik*1, L. Bielory2, 1. New York, NY; 2. Springfield.
Introduction: Histamine receptor antagonists bind to several types of recep-
tors causing various wanted and unwanted physiological responses. By iden-
tifying the affinity levels (Ki) of ligands to three Histamine receptors (H1, H2,
H3), one could utilize a given antagonist by identifying low Ki values to
unwanted ligand-receptor binding (H3 which is consider to be an itch ago-
nist), and high Ki values for wanted ligand-receptor binding (H1, H2). Meth-
ods: A review of literature of Histamine antagonist affinities was performed to
tabulate affinity values for H1, H2, and H3 receptors. 12 chemicals were iden-
tified with affinity values for the receptors. Ki corresponds to [M] of the given
ligand when 50% of receptors are occupied. Results: Ki [M] for Pheniramine:
H1=34, H2=14567, H3=10567. Pyrilamine; H1=.8 H2=9510 H3=1016. Diphen-
hydramine; H1=14 H2=1600 H3=25000. Emedastine: H1=1.3 H2=49067
H3=12430. Levocabastine; H1=56 H2=23500 H3=4597. Antazoline; H1=160
H2=44483 H3=42400. Chlorpheniramine; H1=1.4 H2=7980 H3=3103. Keto-
tifen H1=1.3 H2=1115 H3=2277. Histamine; H1=180000 H2=18350 H3=4.6.
Methylhistamine; H1=138000 H2=72100 H3=1.4. Thioperamide; H1=28000
H2=57967 H3=1.1. Cimetidine; H1=6190 H2=2377 H3=20750. Ranitidine;
H1=46100 H2=187 H3=10537 Summary: Using Ki=1000 as a cutoff for high
or low affinity, three trends of Histamine receptor affinity emerge. Low H1
affinity, High H2 affinity, and High H3 affinity that includes Pheniramine,
Pyrilamine, Diphenhydramine, Emedastine, Levocabastine, Antazoline, Chlor-
pheniramine and ketotifen; high H1 affinity, high H2 affinity, and low H3 affin-
ity that includes Methyl histamine, Thioperamide, and Histamine; high H1
affinity, low H2 affinity, and high H3 affinity that includes Cimetidine, and
Ranitidine. Conclusion: Different antihistamines have different effects that may
further guide the improved used of these agents in the care of patients with
histamine related disorders.
P291
TREATMENT WITH RECOMBINANT HUMAN C1 INHIBITOR
SHORTENS DURATION OF HEREDITARY ANGIOEDEMA
ATTACK SYMPTOMS.
M. Riedl*1, D. Moldovan2, W.Yang3, H. Wedner4, M. Stobiecki5, A. Relan6,
M. Cicardi7, 1. San Diego, CA; 2. Tirgu-Mures, Romania; 3. Ottawa, ON,
Canada; 4. St. Louis, MO; 5. Krakow, Poland; 6. Leiden, Netherlands;
7. Milan, Italy.
Background: Hereditary angioedema (HAE) due to deficiency in C1
inhibitor is characterized by recurrent attacks of tissue swelling affecting mul-
tiple anatomic regions. Recombinant human C1 esterase inhibitor (rhC1INH)
was previously shown effective for treatment of angioedema attacks in patients
with HAE by reducing the time to symptom relief. In addition to onset of relief,
the duration of attack symptoms is recognized as a clinically meaningful end-
point. The current analysis reviews the time to reach minimal symptoms after
treatment with rhC1INH across six clinical studies. Methods: HAE patients
treated with rhC1INH for acute angioedema attacks in three randomized-con-
trolled trials (RCT) and three open-label (OL) studies were reviewed. Patients
treated in the RCTs received rhC1INH or placebo (saline) for a single
angioedema attack. In the OL studies, patients could be treated with rhC1INH
multiple times for repeated attacks. Severity of attack symptoms at each affected
anatomical location was assessed using a 100 mm visual analog scale (VAS)
prior to treatment and at regular intervals following administration of study
medication. Time to minimal symptoms was defined as occurring when VAS
scores were <20 mm at all attack locations. Data were analyzed by study. IRB
approval and written informed consent was obtained from all patients. Results:
In the three RCTs, a total of 145 patients were randomized to receive either
rhC1INH at doses of 50-100 IU/kg or saline. The median time to minimal symp-
toms for patients in rhC1INH 50 IU/kg groups (240, 247 min) and 100 IU/kg
groups (245, 480 min) was significantly shorter than for patients in the saline
groups (362, 1101, 1440 min), p<0.05 for all within study comparisons. In the
OL studies patients were treated with an initial dose of 2100 IU or 50 IU/kg
with an option for a second dose. Data were available on 171 patients who
received rhC1INH for 449 acute attacks. Across the three studies, the median
time to minimal symptoms was 241 minutes for the 2100 IU dose group, and
240 and 243 minutes for the 50 IU/kg groups. Conclusions: In addition to pro-
viding rapid onset of relief, as previously shown, treatment with rhC1INH
resulted in consistently short duration of attack symptoms in HAE patients with
acute angioedema attacks across six clinical studies.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A107
P292
GLOBAL AVAILABILITY OF HEREDITARY ANGIOEDEMA
DRUGS.
N. Onyango*, K. Karikari, T. Craig, Hershey, PA.
Rationale: Hereditary Angioedema (HAE) is a rare autosomal dominant
disease that is caused by a deficiency in C1, a serine protease inhibitor. It is
currently estimated that the prevalence of HAE worldwide is 1:50000. There
are several drugs that have been developed to prevent and/or treat HAE. We
report on most of these drugs in order to highlight the challenges of treating
HAE in some parts of the world and to provide awareness of this condition,
especially to help assess travel risks for patients with diagnosed HAE and to
advocate for patients in areas without sufficient HAE drugs. Methods: The
study was conducted by literature reviews, case reports and by obtaining rele-
vant information from the manufacturers. Results: We identified the main cat-
egories of drugs that are in current use in the treatment of hereditary angioedema.
The therapies used to treat HAE focus: on either replacing the deficient or
dysfunctional C1 protein; or, on blocking the activation of specific pro-inflam-
matory proteins. These include: recombinant human C1 inhibitors (INH),
bradykinin antagonists, and kallekrein inhibitors. Bradykinin B2 antagonists
were widely available in most of Europe and in the US. Plasma kallekrein
inhibitors are only available in Israel and in the US. Plasma derived C1-INH
products are available in the US for HAE prophylaxis; but are approved for
both propylaxis and treatment in eleven European countries. The most widely
available drug was a human C1-esterase inhibitor; which was found in the US,
Europe, parts of South America and Asia. A recombinant human C1 inhibitor
is available in all 27 European Union countries, plus Norway, Iceland and Liecht-
enstein. Conclusions: Overall, there is a distribution differential in the avail-
ability of hereditary angioedema drugs. These drugs are mostly available in the
European Union and in the United States. Most other countries outside these
zones have either one or none of the therapies that are available for the pro-
phylaxis and treatment of HAE. Patients should take precautions when travel-
ing to countries without HAE therapies and have a plan of care available in case
of an exacerbation. Also, since ill-health seems to be a trigger for HAE, patients
should ensure that vaccinations and preventive medications are up to date, in
addition to having their HAE medications available with them.
P293
SAFETY EVALUATION OF OLOPATADINE HCL OPHTHALMIC
SOLUTION 0.77%, A TOPICAL OCULAR ANTI-ALLERGIC
AGENT, IN ASYMPTOMATIC SUBJECTS.
E.J. Meier*, Mason, OH.
Introduction: The objective of this study was to evaluate the safety of a new
topical ocular anti-allergic formulation, Olopatadine HCl, 0.77% in subjects 2
years of age and older. Methods: This was a multicenter, double-masked, vehi-
cle-controlled, parallel-group safety study. Asymptomatic adult and pediatric
subjects were randomized in a 2:1 ratio to receive Olopatadine 0.77% or vehi-
cle once daily in both eyes for 6 weeks. Safety assessments were conducted at
Day 0, weeks 1, 3 and 6. Safety assessments and parameters included adverse
events (AEs), best-corrected visual acuity (BCVA), ocular signs, intraocular
pressure (IOP), dilated fundus exam and vital signs (blood pressure, heart rate).
Results: The safety population included a total of 499 subjects ranging from 2
to 74 years of age; 330 subjects were in the Olopatadine 0.77% group and 169
subjects were in the vehicle group. Treatment-related adverse events occur-
ring in ≥ 1% subjects included blurred vision (4.5% vs 4.1%), abnormal sen-
sation in eye (2.1% vs 4.1%), dry eye (2.4% vs 3%), eye irritation (0.3% vs
3%), and dysgeusia (2.4% vs 0%), in olopatadine and vehicle groups, respec-
tively. No deaths or serious adverse events were reported during the study. No
subjects with exposure to Olopatadine 0.77% discontinued study participation
due to an adverse event. Based upon analysis and review of safety parameters
measured over the course of this trial, no clinically meaningful differences were
noted between the treatment groups. Conclusion: Olopatadine 0.77% was well-
tolerated in the overall safety population and no safety concerns were observed
with the higher concentration of Olopatadine.
ABSTRACTS: POSTER SESSIONS
P294
ONCE-DAILY TIOTROPIUM RESPIMAT® ADD-ON TO INHALED
CORTICOSTEROIDS ± LONG-ACTING β2-AGONISTS
IMPROVES LUNG FUNCTION AND ASTHMA CONTROL AND
REDUCES RISK OF ASTHMA WORSENING IN PATIENTS WITH
MODERATE OR SEVERE ASTHMA.
K. Murphy*1, G. Bensch2, W.E. Berger3, M. Engel4, H. Schmidt5,
P. Moroni-Zentgraf4, H.A. Kerstjens6, 1. Boys Town, NE; 2. Stockton, CA;
3. Mission Viejo, CA; 4. Ingelheim Am Rhein, Germany; 5. Biberach an
der Riss, Germany; 6. Groningen, Netherlands.
Background: The goal of asthma treatment is to achieve control and min-
imize future risk. Here we assess the efficacy of once-daily tiotropium Respi-
mat® add-on to inhaled corticosteroid (ICS) ± long-acting β2-agonist (LABA)
maintenance therapy in patients with symptomatic asthma: lung function, asthma
control, and asthma worsening data are presented. Methods: Four Phase III,
randomized, double-blind, placebo-controlled, parallel-group trials were eval-
uated: two 48-week trials of tiotropium Respimat® 5 mg add-on to high-dose
ICS (≥800 mg budesonide or equivalent) + LABA (PrimoTinA-asthma®) in
patients with severe symptomatic asthma; two 24-week trials of tiotropium
Respimat® 5 mg or 2.5 mg or salmeterol add-on to medium-dose ICS (400-800
mg budesonide or equivalent) in patients with moderate symptomatic asthma
(MezzoTinA-asthma®). Lung function was assessed as peak forced expiratory
volume in 1 second (FEV1) within 3 hours post-dosing (0-3h) and trough FEV1.
Asthma symptoms and control were assessed as responder rate (percentage of
patients with minimally important change of ≥0.5) using the seven-question
Asthma Control Questionnaire (ACQ-7). Time to first episode of asthma wors-
ening (pre-specified as exacerbation) was also assessed. Results: Tiotropium
Respimat® provided statistically significant and sustained improvements in
both peak FEV1(0-3h) and trough FEV1. A higher proportion of patients achieved
an ACQ-7 response with tiotropium Respimat® compared with placebo (Table).
Risk of asthma worsening was reduced with tiotropium Respimat® compared
with placebo: 31% risk reduction [RR] with 5 mg (hazard ratio [HR] 0.69;
95% confidence interval [CI] 0.58, 0.82; p<0.001) in PrimoTinA-asthma® at
Week 48; 13% RR with 5 mg (HR 0.87; 95% CI 0.69, 1.08; p=0.211) and 34%
RR with 2.5 mg (HR 0.66; 95% CI 0.52, 0.84; p<0.001) in MezzoTinA-asthma®
at Week 24. Safety and tolerability of tiotropium Respimat® were balanced
compared with placebo. Conclusion: Once-daily tiotropium Respimat® add-on
to at least medium-dose ICS ± LABA provided significant and sustained
improvements in lung function, improved asthma control, and reduced risk of
asthma worsening in adults with moderate or severe symptomatic asthma.
ACQ-7 response with tiotropium Respimat® compared with placebo
VOLUME 113, NOVEMBER, 2014 A107
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A108
ABSTRACTS: POSTER SESSIONS
P295
24-HOUR LUNG FUNCTION RESPONSE TO TIOTROPIUM
RESPIMAT® ADD-ON TO MAINTENANCE THERAPY IN SYMP-
TOMATIC PATIENTS WITH MODERATE PERSISTENT
ASTHMA.
T. Casale*1, W.W. Carr2, L. Greos3, M. Engel4, L.J. Bour5, P. Moroni-
Zentgraf4, H.A. Kerstjens6, 1. Tampa, FL; 2. Mission Viejo, CA;
3. Centennial, CO; 4. Ingelheim am Rhein, Germany; 5. Biberach an der
Riss, Germany; 6. Groningen, Netherlands.
Background: Tiotropium Respimat® is a once-daily long-acting bron-
chodilator currently being investigated as a potential treatment option in asthma.
Tiotropium Respimat® add-on to medium-dose inhaled corticosteroids (ICS)
has previously been shown to improve both peak forced expiratory volume in
1 second (FEV1) within 3 hours post-dosing (0-3h) and trough FEV1, compared
with placebo, in patients (pts) with moderate symptomatic asthma. Here we
evaluate the degree to which these improvements in lung function are sustained
over 24 hours in a subset of these pts. Methods: 24-hour spirometric pulmonary
function tests (PFTs) were performed on a subset of pts from two 24-week,
Phase III, randomized, double-blind, placebo-controlled, parallel-group trials
(MezzoTinA-asthma®). Pts were required to be symptomatic (seven-question
Asthma Control Questionnaire score ≥1.5), to have pre-bronchodilator FEV1
60-90% of predicted, never to have smoked, or to be ex-smokers for ≥1 year
(with <10 pack-years). Pts with chronic obstructive pulmonary disease were
excluded. Pts received once-daily tiotropium Respimat® 5 mg or 2.5 mg, sal-
meterol, or placebo, each as add-on to medium-dose ICS (400-800 mg budes-
onide or equivalent) maintenance therapy. PFTs were performed at Week 24,
10 minutes pre- and post-dose and at intervals throughout the 24-hour period.
Results: Overall, 580 pts were included in the 24-hour PFT subset (pooled data).
At 24 weeks, tiotropium Respimat® 5 mg and 2.5 mg add-on to medium-dose
ICS significantly improved lung function responses compared with placebo
(Table), as did treatment with salmeterol. Results for all three active treatment
arms were comparable versus placebo. Both doses of tiotropium Respimat®
provided sustained and similar improvements in FEV1 at all time points
throughout the 24-hour dosing interval at Week 24. Safety and tolerability of
tiotropium Respimat® were comparable with placebo. Conclusion: Once-daily
tiotropium Respimat® add-on to medium-dose ICS maintenance therapy pro-
vided significant and sustained improvements in lung function throughout the
24-hour dosing interval in pts with moderate symptomatic asthma. These
data support the previously reported improvements in both peak FEV1(0-3h) and
trough FEV1 in pts from the same studies following add-on treatment with
tiotropium Respimat®.
Adjusted mean difference versus placebo (95% CI) at Week 24 (mL)
24-hour PFT subset from full analysis set (pooled data); placebo (n=146)
AUC, area under the curve; BID, twice-daily; CI, confidence interval; QD,
once-daily
A108 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P296
CETIRIZINE-PSEUDOEPHEDRINE COMBINATION EFFEC-
TIVELY RELIEVES BOTH OCULAR AND NASAL ALLERGY
SYMPTOMS IN SUBJECTS WITH SEASONAL ALLERGIC
RHINITIS.
E.R. Urdaneta*1, X. Tian2, M. Wu3, Q. Du2, K.B. Franklin1, M.K. Patel1,
1. Fort Washington, PA; 2. Shanghai, China; 3. MorrisPlains, NJ.
Objective: Evaluate the efficacy of combination cetirizine-pseudoephedrine
(CTZ-PSE) for ocular and nasal allergy symptom relief in subjects with sea-
sonal allergic rhinitis (SAR). Methods: Two randomized placebo-controlled
SAR studies of subjects aged ≥12 years taking CTZ-PSE 5mg/120mg twice
daily were evaluated post hoc. The studies were approved by institutional review
boards; informed consent was obtained from all research subjects. Total ocu-
lar symptom score (TOSS) was sum of severity scores for itchy eyes and watery
eyes. Total nasal symptom score (TNSS) was sum of severity scores for sneez-
ing, runny nose, itchy nose, postnasal drip, and nasal congestion. Individual
symptom scores were rated on 4-point scale (0=none to 3=severe). TOSS
changes were assessed for subjects with any baseline ocular symptom score
≥1 and TNSS changes were assessed for subjects with any baseline nasal symp-
tom score ≥1. Changes from baseline in TOSS and TNSS over a 2-week treat-
ment period, by day in first week, and weekly were assessed. Results: In the
CTZ-PSE group, TOSS (N=605) improved 36.8% and 36.2% from baseline
and TNSS (N=682) improved 32.4% and 31.6% over 2 weeks (adjusted mean
change: -1.29 and -1.25 for TOSS and -3.02 and -2.89 for TNSS, respectively).
Compared with placebo (TOSS, N=627; TNSS, N=683), TOSS and TNSS
improvements in the CTZ-PSE groups were statistically superior in both stud-
ies over 2 weeks (P<0.001) (95% CI for difference: TOSS, [-0.69, -0.33] and
[-0.70, -0.33]; TNSS, [-1.77, -1.03] and [-1.79, -1.05], respectively). Effect
sizes were 0.44 and 0.45 for TOSS and 0.56 and 0.58 for TNSS. Conclusion:
CTZ-PSE 5mg/120mg twice daily effectively relieved both ocular and nasal
allergy symptoms in subjects with SAR.
P297
CETIRIZINE-PSEUDOEPHEDRINE COMBINATION EFFEC-
TIVELY RELIEVES OCULAR ALLERGY SYMPTOMS IN SUB-
JECTS WITH SEASONAL ALLERGIC RHINITIS.
M.K. Patel*1, E.R. Urdaneta1, K.B. Franklin1, X. Tian2, M. Wu3, Q. Du2,
1. Fort Washington, PA; 2. Shanghai, China; 3. Morris Plains, NJ.
Objective: To evaluate the efficacy of combination cetirizine-pseu-
doephedrine (CTZ-PSE) for ocular allergy symptom relief in subjects with sea-
sonal allergic rhinitis (SAR). Methods: Two randomized placebo-controlled
SAR studies of CTZ-PSE 5mg/120mg administered twice daily to subjects
aged ≥12 years were evaluated post hoc. The studies were approved by insti-
tutional review boards; informed consent was obtained from all research sub-
jects. Total ocular symptom score (TOSS) was the sum of severity scores for
itchy eyes and watery eyes in both studies. Individual symptom scores were
rated on a 4-point scale (0=none to 3=severe). Subjects with a baseline ocular
symptom score ≥1 were included in the analysis. Changes from baseline in
TOSS over a 2-week treatment period, by day in the first week, and weekly
were assessed. Results: Over 2 weeks in the two studies, TOSS improved 36.8%
and 36.2% from baseline in CTZ-PSE subjects (N=605), with adjusted mean
changes of -1.29 and -1.25, respectively. TOSS improvements in the CTZ-PSE
groups were statistically superior (P<0.001) to those in the placebo groups
(N=627) in both studies (95% CI for difference: [-0.69, -0.33] and [-0.70, -
0.33], respectively). The effect sizes were 0.44 and 0.45 for the CTZ-PSE groups
in the two studies. After the first dose, the daily TOSS for the CTZ-PSE groups
showed significant improvements compared with the placebo groups in Week
1 in both studies (P<0.001). Weekly TOSS for the CTZ-PSE groups was sig-
nificantly reduced compared with the placebo groups in both studies (P<0.001).
Conclusion: CTZ-PSE 5mg/120mg twice daily effectively relieves ocular allergy
symptoms in subjects with SAR.
P298
ALLERGIC RHINITIS IN THE ELDERLY: A PILOT STUDY OF
VITAMIN D SUPPLEMENTATION.
M. Columbo*, A. Rohr, Bryn Mawr, PA.
Allergic rhinitis in the elderly is poorly understood as very few studies have
investigated this patient group. VitD insufficiency and deficiency are very com-
mon and VitD appears to play a role in respiratory disease. We studied the effect
of VitD supplementation for 6 weeks in elderly subjects with perennial aller-
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A109
gic rhinitis (PAR).This is a double-blind, placebo controlled, cross-over study.
Fifteen subjects with symptomatic PAR (Total Nasal Symptom Score, TNSS≥5
out of 12) received VitD (4,000 I.U./day) and placebo each for 6 weeks. TNSS
(reflective and in the previous 3 weeks) and Rhinitis Related Quality of Life
Questionnaire (RQLQ) were evaluated at 5 study visits (baseline, and 3, 6, 9,
and 12 weeks later). This study was performed in the period November 1,
2013 to March 20, 2014, to try to avoid seasonal fluctuations of serum VitD
due to sun exposure. All study subjects signed an informed consent and this
study was approved by the Main Line Hospitals Institutional Review Board.
Data were analyzed by the two-tail t test for unpaired data and the Pearson cor-
relation coefficient. The study subjects’ average age was 77.5±7.3 years, the
Body Mass Index (BMI) was 26.5±4.9, the duration of rhinitis was 57.9±17.8
years, the total medication score (TMS) was 1.9±1.1. Baseline serum vitamin
D was 29.7±10.6 I.U. and serum calcium was 9.6±0.5 mg/dl. TNSS was 7.3±2.2
(reflective) and 8±2.6 (3 week). RQLQ score was 58.3±30.9. After the 6 week
VitD supplementation, its serum levels increased significantly (to 39.7±8.9
I.U., p<0.01), whereas serum calcium remained unchanged. Reflective TNSS
(4.6±2.7 and 4.3±3.4 for placebo and VitD at 3 weeks, respectively), 3 week
TNSS, and RQLQ (including its individual values) remained unchanged com-
pared to placebo (p>0.4). There was no association between serum VitD and
age, BMI, duration of rhinitis, or TMS (p≥0.57). However, in subjects with
poorly controlled symptoms (TNSS ≥8 of 12, RQLQ for nasal symptoms ≥16
of 24), there was an inverse association with serum vitamin D (r>-0.55) that
was significant for the 3 week TNSS (r=-0.81, p=0.008, n=8). In summary,
VitD supplementation for 6 weeks did not improve nasal symptoms or RQLQ
in elderly subjects with PAR. These results and the inverse association between
VitD and nasal symptoms will require confirmation in larger studies.
P299
DEPOSITION CHARACTERISTICS OF DYMISTA NASAL SPRAY
(AZELASTINE HCL 137 mG / FLUTICASONE PROPIONATE
50 mG) IN AN ANATOMICAL MODEL OF THE HUMAN NASAL
CAVITY.
A. D’Addio*1, N. Ruiz1, M. Mayer2, L. Gever1, E.O. Meltzer3,
1. Somerset, NJ; 2. Baltimore, MD; 3. San Diego, CA.
Introduction: Intranasal antihistamines or steroids must be delivered in a
volume and with a technique that allows optimal deposition and distribution
within the nasal cavity. Too little spray volume may not cover the entire nasal
cavity, whereas excess volume may result in outflow from the front of the
nasal cavity or backflow into the throat. In the case of Dymista (AZ/FP) Nasal
Spray, it has been suggested that two generic sprays of the components is equiv-
alent to the single AZ/FP product, although no evidence exists to support that
approach. This in vitro evaluation simulated nasal deposition and distribution
of AZ/FP compared to sequential sprays of the commercially available AZ and
FP components. Methods: A model of a normal adult human nasal cavity was
used to visualize deposition and distribution of nasal spray products. A single
spray of Dymista (0.137 mL [137 mg of azelastine/50 mg of fluticasone propi-
onate]) or single sequential sprays of azelastine nasal spray (0.137 mL) fol-
lowed by either Flonase or generic fluticasone propionate nasal spray (0.100
mL) were manually actuated into the model. The interior of the cast was coated
with a water-sensitive dye that changes color when exposed to aqueous-based
formulations. A slight vacuum (15 L/min) was applied during spray delivery
to simulate inhalation. Results were photographed using anterior and lateral
views. Results: Three replicates of Dymista showed no dripping or back flow
from the nasal cavity. Visually, the turbinates in the anterior third of the nasal
cavity were coated with nasal spray. In contrast, three replicates of azelastine
nasal spray followed in 1 minute by either Flonase or generic fluticasone nasal
spray showed significant dripping from the nostril and toward the back of the
nasal cavity. Visually, the turbinates were coated with nasal spray as was the
top portion of the nasopharynx. Conclusions: A single spray of Dymista resulted
in retention in the nasal cavity compared to sequential administration of the
two component products, which caused dripping from the front of the nostril
and run-off to the nasopharynx. The two components of AZ/FP Nasal Spray
delivered sequentially provide a spray volume that exceeds the volume of the
nasal cavity and therefore may negatively impact therapeutic efficacy and patient
tolerability.
ABSTRACTS: POSTER SESSIONS
P300
RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
TRIAL OF THE SAFETY AND EFFICACY OF ASTEPRO
(AZELASTINE 0.15% SOLUTION AND 0.10% SOLUTION) IN
CHILDREN AGES ≥6 TO <12 WITH PERENNIAL ALLERGIC
RHINITIS.
J.A. Bernstein*1, S. Meltzer2, L. Gever3, N. Ruiz3, J. Blessing-Moore4,
1. Cincinnati, OH; 2. Long Beach, CA; 3. Somerset, NJ; 4. Palo Alto, CA.
Introduction: Astepro 0.10% and 0.15% are currently approved for use in
patients 6 years and older with seasonal allergic rhinitis (SAR) or perennial
allergic rhinitis (PAR). The objective of this clinical trial was to evaluate the
safety and efficacy of the 0.10% and 0.15% azelastine formulations compared
to placebo at a dosage of 1 spray per nostril twice daily in pediatric patients ≥6
to <12 yrs with perennial allergic rhinitis (PAR). The results of this study were
the basis of approval for the pediatric indication. Methods: This was a 4-week,
randomized, double-blind, parallel-group study in patients ≥6 to <12 years of
age with moderate-to-severe PAR. The studies were IRB-approved and all
patients or guardians signed written, informed consent before participation.
The 12-hour reflective Total Nasal Symptom Score (rTNSS), consisting of nasal
congestion, runny nose, sneezing and nasal itching, was the primary efficacy
variable. Symptoms were scored twice daily on a 0 to 3 scale (0=none, 1=mild,
2=moderate, 3=severe) such that the maximum daily rTNSS was 24. Treatment
group comparisons were made by analysis of covariance (ANCOVA). Results:
A total of 489 patients were randomized to treatment and >90% of patients in
each treatment group completed the study. The change from baseline in rTNSS
was statistically significant compared to placebo for both formulations (0.15%;
P = .005 and 0.10%; P = .015). Treatment with the 0.15% formulation resulted
in a mean change of -3.45 rTNSS points from a baseline value of 16.60. The
0.10% formulation resulted in a mean change of -3.37 points from a baseline
value of 16.35. The mean change with placebo was -2.48 from a baseline value
of 16.09. The most frequently reported adverse events with the 0.15% formu-
lation were epistaxis (4.3%), nasal discomfort (4.3%), dysgeusia (3.7%), and
sneezing (2.5%). The most frequently reported adverse events with the 0.10%
formulation were epistaxis (4.8%), dysgeusia (2.4%), URI (2.4%), and sneez-
ing (1.8%). There were no serious or unexpected adverse events. Conclusions:
Both the 0.10% and 0.15% Astepro formulations were effective and well tol-
erated in this pediatric study population.
P301
RANDOMIZED TRIAL OF THE SAFETY OF DYMISTA NASAL
SPRAY COMPARED WITH FLUTICASONE PROPIONATE
NASAL SPRAY IN CHILDREN AGES ≥4 YEARS TO <12 YEARS
WITH ALLERGIC RHINITIS.
W. Berger*1, P. Ratner2, D. Soteres3, L. Gever4, N. Ruiz4, 1. Mission Viejo,
CA; 2. San Antonio, TX; 3. Colorado Springs, CO; 4. Somerset, NJ.
Introduction: Azelastine hydrochloride (AZ) with fluticasone propionate
(FP) in a single nasal spray (Dymista) is approved for the treatment of patients
12 years of age and older with seasonal allergic rhinitis. The objective of this
study was to evaluate the safety of AZ/FP Nasal Spray compared to FP Nasal
Spray, administered as 1 spray per nostril twice daily in pediatric subjects ≥4
years to <12 years with allergic rhinitis (AR). Methods: This randomized, open-
label, 3-month study was conducted at 42 investigational sites in the US. The
study was approved by a central IRB and informed consent (from caregiver)
and pediatric informed assent (from subjects 7 years and older) were obtained
before participation. Qualified subjects had a history of AR, were in good health,
and had no evidence of nasal mucosal erosion, nasal ulceration, nasal septum
perforation, or any significant nasal disease. Subjects were randomized in a 3:1
ratio to AZ/FP (n=304) and FP (n=101) and were stratified by age as follows:
(1) ≥4 years to <6 years; (2) ≥6 years to <9 years; and (3) ≥9 years to <12
years. Safety was assessed by subject and/or caregiver-reported adverse events
(AEs), nasal examinations, vital signs, and laboratory assessments. Results:
Overall, 94% of subjects treated with AZ/FP and 92% treated with FP com-
pleted the study. Completion rates were similar in each age strata. The per-
centage of subjects with AEs was comparable between treatment groups and
across the age strata. The most frequently reported AEs with AZ/FP and FP,
respectively, were: epistaxis (10% and 9%), headache (7% and 3%), cough (4%
and 3%) and pyrexia (3% and 2%). The discontinuation rate due to AEs was
2% with AZ/FP and 4% with FP. Laboratory parameters showed no meaning-
ful increase in mean or median values in either treatment group. Improve-
ments in nasal examination findings were observed in both treatment groups
and in each age stratum and there were no findings of nasal mucosal ulcera-
VOLUME 113, NOVEMBER, 2014 A109
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A110
ABSTRACTS: POSTER SESSIONS
tion or septal perforation. The two treatment groups were comparable for mean
changes in vital sign measurements regardless of age stratification. Conclu-
sions: AZ/FP and FP were well-tolerated during this 3-month study when admin-
istered as 1 spray per nostril twice daily in pediatric subjects ≥4 years to <12
years with AR.
P302
EFFICACY OF AZELASTINE HCL AND FLUTICASONE PROPI-
ONATE IN A SINGLE NASAL SPRAY (DYMISTA) IN TREATING
OCULAR SYMPTOMS OF SEASONAL ALLERGIC RHINITIS.
B. Stanaland*1, R. Settipane2, S. Gawchik3, N. Ruiz4, F. Hampel5,
1. Naples, FL; 2. Providence, RI; 3. Upland, PA; 4. Somerset, NJ; 5. New
Braunfels, TX.
Introduction: The efficacy of azelastine HCL (AZ) and fluticasone propi-
onate (FP) in a single nasal spray (Dymista [AZ/FP]) for treating nasal symp-
toms of seasonal allergic rhinitis (SAR) has been demonstrated in four well-
controlled clinical trials of 2 weeks duration.1,2,3 The reflective total ocular
symptom score (rTOSS), consisting of itching, watering, and redness, was a
secondary variable in the studies. This post-hoc analysis compared the efficacy
of AZ/FP to monotherapy with AZ, FP, and placebo for the treatment of ocu-
lar symptoms of SAR. Methods: A total of 3996 patients 12 years of age and
older with moderate-to-severe SAR were included in the analyses. The studies
were IRB-approved and all patients signed written, informed consent before
participation. Patients were randomized to AZ/FP, AZ, FP or placebo nasal
spray administered 1 spray/nostril twice daily (total daily doses: AZ=548 mg;
FP=200 mg). The three ocular symptoms were scored twice daily on a 4-point
scale (0=no symptoms; 1=mild, 2=moderate, 3=severe) such that the maximum
daily score was 18. Treatment group comparisons of change from baseline in
rTOSS were made by analysis of covariance (ANCOVA). Time to response
(defined as a ≥50% change from baseline) was evaluated by log-rank test.
Results: Overall, patients treated with AZ/FP had a significantly greater
improvement from baseline in rTOSS compared to AZ (P=.048), FP (P<.0001),
and placebo (P<.0001). Patients treated with AZ/FP achieved at least a 50%
reduction in rTOSS significantly sooner than patients treated with FP (P=.02)
or placebo (P≤.0001). The difference approached significance versus AZ
(P=.08). When patients with baseline rTOSS ≥8 were analyzed (n=3341; rep-
resenting 84% of the total population), significant differences were seen com-
pared to AZ (P=.04) as well as to FP (P<.01) and placebo (P<.001). Conclu-
sions: In this population of patients with moderate-to-severe SAR, AZ/FP
improved ocular symptoms to a significantly greater extent than AZ or FP alone.
1
Hampel FC et al. Ann Allergy Asthma Immunol. 2010;105:168-173; 2Carr W
et al. JACI. 2012;129:1282-1289; 3Meltzer EO et al. Allergy Asthma Proc.
2012;33:324-332
P303
ASSESSMENT OF SYMPTOM SEVERITIES OF ALLERGIC
RHINITIS PATIENTS SENSITIVE TO MULTIPLE ALLERGENS
COMPARED TO SINGLE ALLERGEN IN MAST.
B. Yu*1, J. Lee2, D. Lee2, 1. Uijeongbu, Republic of Korea; 2. Daejeon,
Republic of Korea.
Background and Objectives: To assess the symptom severities of allergic
rhinitis patients sensitive to multiple allergens compared to single house dust
mite allergen. Subjects and Method: Total 56 allergic rhinitis patients were clas-
sified into 2 groups. The multiple allergens group was defined as patients sen-
sitive to multiple allergens including house dust mite in MAST. The single aller-
gen group was defined as patients sensitive only to house dust mite. Symptom
severity was evaluated with visual analogue scale (VAS) for following symp-
toms: postnasal drip, anosmia, sneezing, itching, nasal obstruction, cough, spu-
tum, headache, and rhinorrhea. For in vitro test, total IgE and blood eosinophil
count were also analysed. IRB approval and informed consent was obtained
from all research subjects. Results: Among 56 patients, 32 patients were clas-
sified to the multiple allergens group and 24 patients were classified to the
single allergen group. The mean symptom scores of multiple allergens group
for postnasal drip, anosmia, sneezing, itching, nasal obstruction, cough, spu-
tum, headache, rhinorrhea were 4.56±3.4, 1.25±2.40, 1.25±3.40, 4.25±3.11,
3.44±3.56, 5.75±3.30, 3.87±3.25, 3.50±3.45 and 5.21±3.17. On the other hand,
the mean symptom scores of single allergen group for postnasal drip, anos-
mia, sneezing, itching, nasal obstruction, cough, sputum, headache, rhinorrhea
were 2.75±2.77, 1.29±3.01, 1.29±3.01, 4.46±3.60, 3.41±3.67, 5.75±3.13,
2.88±3.03, 2.75±3.57 and 3.70±3.22. Total summation of symptom scores for
two groups was 33.75±22.24 and 37.75±16.89 each. Statistically these scores
A110 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
showed no differences between two groups as in vitro test, total IgE and blood
eosinophil count. Conclusion: Symptom severities of allergic rhinitis patients
sensitive to multiple allergens showed no differences with those of patients sen-
sitive only to house dust mite.
P304
THE EFFICACY OF A NASAL ANTIHISTAMINE AZELASTINE
HYDROCHLORIDE AND CORTICOSTEROID FLUTICASONE
PROPIONATE FOR THE TREATMENT OF SEROUS OTITIS
MEDIA.
S. Nsouli*, Danville, CA.
Since chronic inflammation is the histopathologic landmark of otitis media
with effusion, clinical observations have led us to believe that the combination
of a nasal antihistamine Azelastine and corticosteroid Fluticasone propionate,
with an oral antibiotic may be more effective than monotherapy with an oral
antibiotic in the treatment of serous otitis media. We studied forty adult patients
in a randomized open labeled 2-week trial to compare the efficacy of the com-
bination nasal Azelastine and Fluticasone propionate (137mcg/50 mcg), one
spray per nostril twice daily, with an oral antibiotic Amoxicillin/Clavulanate
potassium (875mg/125mg) every 12 hours, for the treatment of otitis media
with effusion. The efficacy of the treatment options was assessed using pneu-
matic otoscopy, impedance tympanometry, and audiometry to monitor the clin-
ical course of the middle ear effusion in both treatment groups. In the combi-
nation group nasal Azelastine and Fluticasone with oral antibiotic, a resolution
of otitis media with effusion occurred at the 8th day. In contrast in the group
treated with monotherapy with the oral antibiotic, the resolution of otitis media
with effusion occurred on the 14th day. In conclusion, the combination of nasal
Azelastine and Fluticasone plus an oral antibiotic may be a safer and shorter
therapy than monotherapy with an oral antibiotic in the treatment of serous oti-
tis media, given the safety issues with long-term use of systemic antibiotics.
P305
EFFICACY AND SAFETY OF BECLOMETHASONE DIPROPI-
ONATE NASAL AEROSOL IN CHILDREN (4-11 YEARS OF AGE)
WITH PERENNIAL ALLERGIC RHINITIS.
W. Berger*1, R. Jacobs2, N. Amar3, S. Tantry4, J. Li4, C. Small4, 1. Mission
Viejo, CA; 2. San Antonio, TX; 3. Waco, TX; 4. Frazer, PA.
Introduction: Beclomethasone dipropionate (BDP) nasal aerosol (non-
aqueous) is approved for management of seasonal and perennial allergic rhini-
tis (SAR/PAR) in adolescents and adults. This study evaluated the efficacy
and safety of 80 mg/d BDP nasal aerosol in children with PAR. Methods: A
12-wk, phase 3, randomized, double-blind, placebo-controlled, parallel-group,
clinical trial was conducted at 62 US centers to investigate the efficacy and
safety of BDP nasal aerosol in children (4-11 y of age) with PAR. A total of
547 patients were randomized (2:1) to receive 2 actuations of BDP nasal aerosol
(1 actuation/nostril; 40 mg/actuation) or placebo nasal aerosol once daily. The
primary end point was change from baseline in average morning (am) and
evening (pm) reflective total nasal symptom score (rTNSS) over the first 6 wk
of treatment in patients 6-11 y of age. Additional efficacy end points included
change from baseline in average am and pm instantaneous TNSS (iTNSS) in
children 6-11 y of age, and change from baseline in average rTNSS and iTNSS
in children 4-11 y of age. Results: Improvement was significantly greater with
BDP nasal aerosol (80 mg/day) than with placebo over the first 6 wk of treat-
ment in children 6-11 y of age in average am and pm rTNSS and iTNSS (mean
[95% CI] treatment difference: –0.66 [–1.08, –0.24], P = 0.002 and –0.58 [–0.99,
–0.18], P = 0.004, respectively). Improvement in average am and pm rTNSS
and iTNSS was significantly greater in patients 4-11 y of age receiving BDP
nasal aerosol than in those receiving placebo over the first 6 wk of treatment
(P = 0.002 and P = 0.004, respectively). Similar results were observed over 12
wk of treatment (P < 0.001). Improvement in average am and pm reflective
individual nasal symptoms over the first 6 wk of treatment in 6-11 y olds was
significantly greater for rhinorrhea (P = 0.004), nasal congestion (P = 0.001),
and sneezing (P = 0.002) with BDP nasal aerosol than with placebo. BDP nasal
aerosol was well-tolerated in children, with a safety profile comparable to
placebo. Conclusions: This study showed that once-daily treatment with 80 mg
BDP nasal aerosol (nonaqueous) in children 4-11 y of age was safe and effec-
tive in controlling nasal symptoms associated with PAR, suggesting that BDP
nasal aerosol is effective for children with PAR.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A111
P306
COMPLEMENTARY THERAPY FOR TREATMENT OF ALLER-
GIC RHINTIS.
J. Kern*1, L. Bielory2, S. Luster2, 1. Newark, NJ; 2. Springfield, NJ.
Introduction: Allergic rhinitis is a prevalent condition impacting approxi-
mately 20% of the US population. There is a growing section of the popula-
tion, up to 50% in some surveys, who are turning to alternative therapies for
the treatment of their allergic rhinitis. Methods: A literature search was per-
formed utilizing keywords rhinitis acupuncture, rhinitis traditional Chinese
medicine (TCM), and rhinitis alternative therapy. Randomized control trials
were reviewed in regards to their impact on symptom scores and objective equiv-
alents and are displayed in table 1. Results: Decrease in total IgE: 39% from
Yang et al. correlating with symptom improvement using various TCM for-
mulations. 13.7% reduction in Zhang et al. Jung et al. showed a 3% increase
in IgE levels in the group receiving TCM. Yang et al. demonstrated a 15% reduc-
tion in specific IgE to dust mites (p<.05). Acupuncture has been shown to
have an impact on patient symptom scores as evidenced in table 1. In a ran-
domized control trial by Brinkhaus et al. there was a minimal, however statis-
tically significant, improvement in symptom score with acupuncture compared
to sham therapy and medication alone. A follow up study comparing the com-
bination of acupuncture with medication versus sham therapy with medica-
tion showed a reduction of 9% in the utilization of medication [p=0.01]. A large
portion of studies were poorly constructed with significant bias given the oper-
ators’ awareness of real versus sham therapy when applying acupuncture. Home-
opathic therapy has been evaluated in several studies demonstrating mixed
results in regards to its impact on allergic rhinitis. Several have found signifi-
cant improvement. Taylor et al. demonstrated nasal airflow mean difference
19.8 L/min [p=0.0001], visual analogue score showed a symptom reduction of
28% in homeopathic group vs 3% reduction in placebo group [p=0.0007]. A
larger study conducted by Aabel et al found no difference in symptom scoring
from placebo. Conclusion: The evidence regarding the utilization of traditional
Chinese medicine is mixed. Complementary therapy for allergic rhinitis demon-
strates a potential benefit to patients in addition to current medical therapies.
Alternative therapy studies revealed mixed results, however safety studies have
shown minimal to no risk making them a safe addition to the treatment regime
in select patients.
Table 1
P307
PREVALENCE OF MOLD SENSITIZATION IN CHRONIC RHI-
NOSINUSITIS PATIENTS REQUIRING SURGERY.
R. Gawlik1, E. Czecior1, W. Scierski1, L.M. DuBuske*2, 1. Katowice,
Poland; 2. Gardner, MA.
Background: Mold sensitization is a risk factor for development and dete-
rioration of upper airway allergy, especially chronic rhinosinusitis including
those requiring surgery. Methods: 38 chronic sinusitis patients after surgery
were included into the study. Routine medical examination, skin prick tests
with common inhaled allergens an extended mold panel (Alternaria alternate,
Cladosporium herbarium, Aspergilus fumigatus, Candida albicans, Mucor
mucedo, Botrytis cinerea, Rhisopus nigricans, Penicilliumi notatum, Fusarum
moniliforme Pullularia pullulans (Allergopharma, Germany) was done and
IgE and allergen specific IgE measurement (Phadia, Sweden). All subjects were
seen by an otolaryngologist and mycological examination was performed.
Results: Sensitization to at least one allergen was present in 44.7% (17/38) of
sinusitis patients. The most prevalent was sensitization to house dust mite Der-
ABSTRACTS: POSTER SESSIONS
matophagoides pt., found in 21.0 % (8/38) patients. Positive skin prick tests
with Candida albicans occurred in 18.4% (7/38), with Alternaria alternata in
18.4% (7/38), with Cladosporium herbarium in 10.52% (4/38), with Aspergilus
fumigatus in 5.26 % (2/38), and with Botrytis cinerea in 2.63 % (1/38). None
of these patients had sensitization to other mold allergens. Elevated allergen
specific IgE was seen for Candida in 24% (9/38) patients, Alternaria alternata
26% (10/38), and Cladosporium herbarium in 8% (3/38). Conclusion: Nearly
half of chronic sinusitis patients had sensitization to at least one allergen. Mold
allergy was commonly seen in chronic sinusitis patients requiring surgery, being
comparable in occurrence to dust mite sensitization.
P308
EPIDEMIOLOGY OF ALLERGY IN VARIOUS CHILDREN OF
VARIOUS AGE GROUPS IN WESTERN HUNGARY FROM 2002
TO 2005 AND FROM 2006 TO 2009.
L. Soti1, Z. Petz1, L.M. DuBuske*2, 1. Szombathely, Hungary; 2. Gardner,
MA.
Background: The onset allergic diseases by age and gender may vary in
childhood. The prevalence of various allergic diseases in patients stratified by
gender into age groups who presented at the Allergy Outpatient Clinic of West-
ern Hungary from 2002-2005 and from 2006-2009 were assessed. Methods:
Only patients with newly diagnosed allergic diseases confirmed by skin prick
tests and/or allergen specific IgE were assessed, being stratified by age into
groups from newborn to 20 years old. From 2002 to 2005, there were 10,018
patients and from 2006 to 2009, there were 13,125 patients included in this epi-
demiologic study. Results: The total number of allergic patients increased from
0 through 5 years of age, then declined until adulthood in both investigated
periods. There were more male patients under the age of 15, especially in the
5 year old age group in every year of the investigated period. After 15 years of
age the female/male patient ratio increases rapidly. At 20 years of age, females
are twice as likely to present with allergic diseases. Both the female and male
patients in the age group analysis of various allergic diseases demonstrated
the pattern of the “allergic march”. Conclusion: Peak incidence of various aller-
gic diseases occurred in the 5 years old age group. In early childhood the
male/female ratio among allergic patients is high, this ratio being reversed in
later adolescence. Patterns of prevalence of various childhood and adolescent
allergic disease in Western Hungary demonstrated the progression from der-
matologic to respiratory allergy characteristic of the allergic march.
P309
CEREBROSPINAL FLUID (CSF) RHINORRHEA PRESENTING
THREE YEARS AFTER HEAD TRAUMA.
M. Shum*1, K. Chotikanatis2, T.A. Saadia2, R. Joks2, 1. New York, NY;
2. Brooklyn, NY.
Background: The time interval from diagnosis of pseudotumor cerebri to
development of CSF rhinorrhea is quite variable in literature. It can be inter-
mittent and undetected for many years or may be the presenting symptom. We
report a case of CSF rhinorrhea presenting three years after head trauma and
pseudotumor cerebri. Methods: A 35-year-old woman with a five-year history
of perennial allergic rhinitis to cat and mouse and moderate persistent asthma
complained of intermittent persistent unilateral clear rhinorrhea, without any
nasal congestion, sneezing or pruritus of six months duration. She denied any
associated headache or wheezing. Results: Further review of systems was
notable for history of head trauma three years prior to presentation, with devel-
opment of pseudotumor cerebri, sinovenous thrombosis, papilledema, and mac-
ular degeneration. However, there was no skull fracture. Nasal examination was
remarkable for swollen bilateral inferior turbinates. She was able to produce
left sided nasal clear rhinorrhea by leaning forward. Fluid was tested for glu-
cose and was found to be 307 mg/dL. She was promptly referred to neuro-
surgery. Confirmatory tests for new onset diabetes were performed given the
degree of elevated glucose in the CSF. Discussion: Etiology of CSF rhinorrhea
is classified as traumatic (>90%) or nontraumatic (<10%). Accidental head
injury accounts for most traumatic cases, followed by iatrogenic etiology sec-
ondary to neurosurgical or rhinologic procedure. Nontraumatic causes are
typically due to high intracranial pressure, tumors, erosive diseases, congeni-
tal defects of base of skull, or spontaneous without a specific etiology. Though
our patient had no history of skull fracture to account for a CSF leak, she did
have a history of pseudotumor cerebri after the trauma. While CSF rhinorrhea
is a relatively rare entity in comparison to other common sinonasal inflamma-
tory conditions such as the allergic rhinitis in our patient, this case illustrates
the importance of maintaining a high index of clinical suspicion when encoun-
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ABSTRACTS: POSTER SESSIONS

tering a complaint of unilateral clear rhinorrhea with a remote history of trauma
and/or increased intracranial pressure. This will ensure timely diagnosis and
proper neurosurgical management that can ultimately prevent further compli-
cations such as bacterial meningitis or other serious intracranial infections.
P310
CHALLENGES OF CHRONIC COUGH.
V. Ta*1, K. Woessner2, 1. Redondo Beach, CA; 2. San Diego, CA.
Introduction: Establishing gastroesophageal reflux disease (GERD) as the
cause of chronic cough is challenging despite a careful history and initial eval-
uation because not all patients present with the usual symptoms of GERD. The
term supraesophageal reflux disease (SERD) has been used to describe GERD
with additional symptoms such as sore throat, hoarseness, globus, and exces-
sive throat clearing. It should be emphasized that these laryngeal findings are
not specific for SERD as a causative factor and the precise pathophysiologic
mechanism responsible for the production of supraesophageal symptoms
remains contentious. Case: The patient is a 60 year old male who presented
with throat clearing and nonproductive chronic cough of one year duration. The
cough occurs daily and is associated with the sensation of postnasal drip
although he is unable to expectorate mucus. His symptoms are not positional
or triggered by fumes or exercise. He denies food impaction or heartburn symp-
toms. The patient has tried various nasal corticosteroids, antihistamines, sys-
temic corticosteroids and proton pump inhibitors (PPI) but these interventions
failed to control his symptoms. His workup included negative skin prick, intra-
dermal, and serum specific IgE testing to aeroallergens. His nasal cytology was
negative for eosinophils. His CT sinus showed maxillary sinus mucosal thick-
ening. He underwent an upper esophagogastro-duodenoscopy that showed no
furrows, white patches, or ulcers. However, mid/proximal esophagus biopsy
showed greater than 50 eosinophils on high power field. He also underwent a
24 hour pH probe which showed a supine pH average of 4.75. Discussion: Ini-
tial treatments include PPI and head of bed elevation even though acid sup-
pressing medications have been shown to be only partially effective in treating
SERD. Other options include surgery such as the Nissen fundoplication or the
LINX System. Although 50 eosinophils/HPF was observed histologically, the
patient denied any EoE symptoms and on these grounds the possibility of EoE
was dismissed. The more likely explanation for this patient’s cough is SERD,
evident by his positive 24 hour pH probe. The patient tried and failed a short
course of PPIs, however, a longer trial of a PPI is warranted. If ineffective, sur-
gery will be considered.
was positive in 11.4% patients, negative antinuclear antibodies in all cases but
the antibodies anti thyroid (AAT) positive in 11.4% of LE cells, lupic antico-
agulant and D dimer were negative in all patients and rheumatoid factor was
positive in 1 patient. Positive patients AAT 100% were women and 75% of them
had negative PSA. Tests of correlation between ASST and antibodies, was not
significant. Conclusion: Patients with UCE most are women and only 11% had
positive ASST but this does not correlate with anti thyroid antibodies or other
common parameters of autoimmunity
P312
A RETROSPECTIVE REVIEW OF CHRONIC URTICARIA AND
BODY MASS INDEX (BMI) IN A HISPANIC COHORT.
M. Rodríguez-Roa*, C.M. Pimentel, B.K. Di Giorgi, J. Méndez,
I. Malinow, C. Ramos, S. Nazario, San Juan, Puerto Rico.
Background: Chronic urticaria (CU) is a benign, idiopathic and disturbing
condition affecting a significant proportion of patients. A state of obesity has
been linked with atopic diseases such as asthma. The association of obesity and
CU has not been established. Methods: We performed a retrospective analysis
of 86 Hispanic patients with CU visiting an Allergy and Immunology Clinic
from June 2012 - August 2013 in Puerto Rico. Cases were stratified between
physical urticaria (PU) and idiopathic urticaria (CIU). Demographic charac-
teristics, comorbid diseases, and associated symptoms were compared. Data
was analyzed using SPSS v19. Results: Subjects mean age was 32 ± 20 years,
77% were female. Concurrent atopic diseases were reported in 48% of patients,
31% had asthma. Most commonly associated symptom was angioedema (38%).
Forty-four (51%) patients had CIU, while 41 (48%) had PU. 56% of the patients
with PU reported more than one physical trigger. No significant associations
were found between gender, thyroid disease, allergic rhinitis or food allergy
and type of urticaria. Thyroid disease was more prevalent in adult participants
(16/66; 24%), while allergic rhinitis was more common in adolescents and chil-
dren (19/27; 70%). Patients with BMI > 25 were significantly more likely to
have PU (20/31 (65%); p = 0.025), while subjects with a BMI <25 were two
times more likely to suffer from CIU (29/49 (59%); p = 0.039). Conclusions:
A significant association was found between increased BMI and PU com-
pared to CIU. Studies are needed to evaluate the modulation of adipose tissue
on mast cells and basophil degranulation.

24 hour pH probe

P311
EVIDENCE OF AUTOIMMUNITY IN PATIENTS WITH SPONTA-
NEOUS CHRONIC URTICARIA (SCU).
M.I. Rojo-Gutierrez, C.N. Flores Ruvalcaba*, J. Mellado Abrego,
G. Castillo Narvaez, P. Ramirez Rojo, Mexico City, DF, Mexico.
Spontaneous Chronic Urticaria (SCU ) is a common condition in adults and
mainly among women, which coincides this phenomenon with autoimmunity.
Our objective was assessed through laboratory studies whether patients with
CUS presented autoimmunity data. Material and Methods: Cross-sectional
study that 35 patients from the Allergy and Immunology at Juarez Hospital of
Mexico diagnosed with CUS included, to which complete blood count CBC,
thyroid antibodies (anti peroxidase and thyroglobulin), nuclear antibodies,
rheumatoid factor, lupus anticoagulant and autologous serum skin test (ASST).
Results: We evaluated 35 adult patients, 77.1% female and 22.9% male, ASST

A112 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A113
P313
EFFICACY OF ANTI-IGE MONOCLONAL ANTIBODIES AT A
DOSE OF 150 TO 300MG IN PATIENTS WITH CHRONIC
URTICARIA SPONTANEOUS (CUS) WITH FAILURE IN THE
EFFICACY OF ANTIHISTAMINE.
M.I. Rojo-Gutierrez*, C.N. Flores Ruvalcaba, J. Mellado Abrego,
G. Castillo Narvaez, M. Gonzalez ibarra, Mexico City, DF, Mexico.
Urticaria is a very common disease of skin, characterized by rapid onset of
hives with or without angioedema. It is classified by etiology ; in spontaneous
and inducible urticaria, and evolution in acute and chronic. IgE. CSU is more
common in women and international management guidelines recommend 2nd
generation antihistamines regulate dose or higher doses and in cases of failure
suggest the use of monoclonal antibodies against IgE. Monoclonal antibodies
are effective at doses of 150 and 300 mg so our aim was to determine their
effectiveness at doses of 150mg and 300mg in patients with CSU. Materials
and methods: We evaluated 35 patients who failed UCE in conventional anti-
histamine therapy .Two groups were randomly performed where the group :
A) 20 patients received 150 mg single subcutaneous dose of omalizumab and
B) 300mg 20 patients . Evaluate effectiveness by measuring frequency and
intensity of the lesions with a baseline measurement UAS7 (Urticaria activity
score 7 days) and weekly reviews and quality of life questionnaire (CUQ2oL)
on arriving a week 1, 2 and 3. Results: we evaluated 40 patients 22.5 % (9) were
male and 78.5 % (31) females. The mean was 226.93 CUQ2oL at baseline, 93.7
at the first week, 57 the second and the third 44.33. Hives/ pruritus in stock-
ings 2.2/2.5 at startup, the first week 1.35/1.45, 0.9/1.1 second and 0.98 / 1.08
the third, we find highly significant differences when comparing home against
1st week, 2nd week and 3rd week p < 0.0001 . Conclusions: Omalizumab is
highly effective in controlling symptoms of chronic spontaneous urticaria.
P314
SEVERE ATOPIC DERMATITIS EXACERBATED BY STAPHY-
LOCOCCUS INTERMEDIUS.
V. Bozoghlanian*, D. Levy, R. Gutta, Irvine, CA.
Introduction: Staphylococcus aureus is known to exacerbate atopic der-
matitis with production of bacterial enterotoxins and superinfection of lesions.
We report the first case of severe atopic dermatitis in a human exacerbated by
Staphylococcus intermedius, which has been associated with exacerbation of
atopic dermatitis in dogs. Case Description: A 26 year old Hispanic man pre-
sented with a 6-year history of extremely pruritic diffuse rash consistent with
atopic dermatitis. He was referred for total IgE >16,000 IU/ml and failure to
respond to high-dose topical and oral corticosteroids, methotrexate,
cyclosporine, and phototherapy. In our clinic, an immunodeficiency evaluation
was normal. Workup for hyper-IgE syndrome, including STAT-3 and Dock-8
gene mutations, was normal. Skin biopsies were negative for malignancy, fun-
gal staining, or vasculitis, and suggestive of severe atopic dermatitis with nor-
mal immunofluorescence and immunophenotyping. Workup for a 70-pound
unintentional weight loss was performed, with negative SPEP, UPEP, HIV, HTLV,
bone marrow biopsy, flow cytometry, CT chest/abdomen/pelvis, endoscopies,
and autoimmune evaluation. The patient had multiple severe exacerbations
requiring several hospitalizations. Aggressive skin care measures (including
wet/dry wraps), high-dose antihistamines, gabapentin, oral antibiotics, a one-
month trial of terbinafine, and a five-month trial of omalizumab were not effi-
cacious. Multiple skin cultures identified highly-resistant Staphylococcus inter-
medius. The patient developed malignant otitis externa treated with daptomycin
and meropenem. Cultures from the ear also grew Staphylococcus intermedius.
His skin lesions improved on the IV antibiotics, but he continued to have a
relapsing-remitting course when the antibiotics were withdrawn. Discussion:
Staphyloccocus intermedius has been associated with exacerbation of atopic
dermatitis in dogs. It may be transmitted to humans with close contact to dogs.
In patients with severe atopic dermatitis refractory to first and second line ther-
apies, it may be prudent to investigate for Staphyloccocus intermedius colo-
nization and/or infection, and if identified, should be treated with tailored antibi-
otic therapy based on drug sensitivity.
P315
WHY IS IT IMPORTANT TO KNOW ABOUT SWEET SYN-
DROME?
A. Hamad*, Madison Heights, MI.
Introduction: Sweet syndrome has a presentation that is not uncommon;
acute skin eruptions. It could be mistaken for many other conditions and expose
ABSTRACTS: POSTER SESSIONS
patients to unnecessary medications and stress for months before reaching a
diagnosis or worse delay a diagnosis of underlying malignancy. Case Descrip-
tion: Patient was a 52 year old female with past medical history of hyperten-
sion who was in her usual state of health until July 2013.She started having
raised, painful, edematous and erythematous lesions. The tended to appear first
in her hands and feet then rapidly spread to her forearms, legs and face. She
occasionally had them in her chest. These lesions would appear every 7-8 days.
They would last for 3-4 days then disappear, mostly spontaneously. She noticed
that they were preceded almost always by fever. The patient initially went to
the emergency room after the lesions first appeared. She was told that the lesions
were likely hives and she was discharged home to follow up with her primary
care physician. Her primary care physician switched her medication for hyper-
tension (lisinopril) to another drug but that did not help. Later she was started
on a short course of prednisone 40mg daily for 10 days. She also was prescribed
topical corticosteroid and anesthetic creams. Patient did not have any relief
with any of these interventions. Lesions continued to be a major concern for
her. So, she was referred to a dermatologist and biopsy was performed for one
of these lesions. The biopsy was consistent with “neutrophilic dermatitis”.
Patient later was referred to a hematologist/oncologist to rule out underlying
malignancy. She was also referred to an Allergy-Immunology clinic where we
had the chance to see her. She did not have active lesions at the time we saw
her in the clinic but she showed us pictures she took for them at different sites
of her skin. Our plan was to start the patient on colchicines as prednisone failed
to show any improvement in her symptoms. Conclusion: It is crucial for gen-
eral practitioners and allergists to keep sweet syndrome in the differential diag-
nosis of acute skin eruptions. As long as it is in the differential, the diagnosis
can be confirmed with a skins biopsy. However, management can be as easy
as discontinuing a causative drug or gets more complicated if there was an
underlying malignancy. That’s why it is important to increase awareness of
this rare condition.
P316
ATOPIC DERMATITIS IN CHILDREN: COST-EFFECTIVENESS
COMPARATIVE ESTIMATION OF VARIOUS IMMUNOTROPIC
THERAPY PROGRAMMES.
T. Slavyanskaya*1, V. Derkach2, B. Sangidorj1, 1. Moscow, Russian Feder-
ation; 2. Vladivostok, Russian Federation.
The study was aimed at conducting a comparative cost-effectiveness (CE)
analysis of various immunotropic therapy (IT) programmes of atopic dermati-
tis (AD) in children. 94 children at the age of from 3 to 18 with AD having
lasted for 1-15 years were examined. All the patients received routine clinical
and immuno-allergological examinations. The treatment was conducted in
two stages: background therapy (BT) and IT. The patients were divided into
three groups: the 1st group (n=30) received immunomodulator (IM) on a step-
by-step basis in the course dose of 20 mg; the 2nd group (n=31) received an
accelerated course of parenteral allergen-specific IT (PASIT); in the 3rd group
(n=33) a combination IT (CIT) - IM+PASIT at an accelerated pace was applied.
The CE comparative estimation of IT in the treatment of children with AD has
shown the most optimal ratio in the 3rd group of patients receiving CIT. How-
ever, in the 1st and the 2nd groups in which IM and PASIT were applied, AD
was not monitored well enough, that resulting from considerable expenses for
hospital care. The ratio of costs for treating children with AD in hospital envi-
ronment who received IM (the 1st group) was 42.95% of the total cost of AD
treatment per year within direct expenses; the medicinal treatment was 48.12%.
Among expenses for medications, 30.6% were for IM, and the other ones were
associated with conducting BT for improving AD monitoring. In the 2nd group
of children receiving PASIT, the principal item of direct expenses was the
amount spent for visiting the allergologist for administering injections. The
expenses for hospital care were 15.1%. In the 2nd group, the principal costs
were associated with medicinal treatment of infectious complications. In the
3rd group of children receiving CIT, the percentage of direct expenses for hos-
pital care was 8.92%, thus, being insignificant. Expenses for outpatient care
(5.95%) and BT (8.95%) in this group were much lower than in the 1st and the
2nd groups due to the absence of infectious complications and reduction of
BT volume. Inclusion of CIT in the integrated programme of therapy of chil-
dren with AD resulted in reduction of BT volume, less admissions to hospital,
prevention of secondary infection overlay; moreover, the disease was moni-
tored efficiently at the same time. Thus, the CE ratio of the treatment was
more rational.
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ABSTRACTS: POSTER SESSIONS
P317
CHRONIC IDIOPATHIC/SPONTANEOUS URTICARIA: PATIENT
CHARACTERISTICS AND RESOURCE USE.
G. Sun1, K. Raimundo2, E. Antonova3, E. Chang1, M. Broder*1, 1. Beverly
Hills, CA; 2. South San Francisco, CA; 3. San Francisco, CA.
Introduction: Chronic idiopathic (spontaneous) urticaria (CIU) is a rare and
symptomatic skin condition affecting patient health-related quality of life. Data
on CIU-related healthcare resource use (HCRU) are old. We examined HCRU
and costs in CIU patients using a healthcare claims database. Methods: We used
a HIPAA-compliant fully de-identified commercial healthcare claims database
from 2012 for this retrospective cohort study. We identified CIU patients with
a previously validated ICD-9-CM coding algorithm. We examined patient char-
acteristics, HCRU, and costs. Outcomes were stratified by demographics. We
used chi-square tests and F-tests to conduct bivariate analyses. Because the
study did not involve human subjects, IRB review was not needed. Results: The
prevalence of CIU was 0.1% among all continuously enrolled patients. We iden-
tified 6,350 CIU patients with mean age 42.4 years, 68.3% women, and mean
Charlson Comorbidity Index 0.9. CIU-related comorbidities included allergic
rhinitis (43.2%), angioedema (23.5%), and asthma (18.3%). The most com-
monly prescribed drug classes were oral corticosteroids (OCS; 54.7%), anti-
histamines (24.0%), and leukotriene receptor antagonists (17.5%). Mean all-
cause total annual healthcare costs were $9,142 per CIU patient; outpatient
services accounted for 43.0% of the costs. Per year, CIU patients averaged 15.1
physician office visits, 7.3% of patients had at least one hospitalization, and
15.9% – at least one emergency department (ED) visit. Total costs and HCRU
increased significantly with age. Women accrued higher costs and had more
hospitalizations and ED visits than men. CIU-specific annual costs totaled $997
per patient, and outpatient services accounted for about 2/3 of costs. Patients
averaged 3.4 office visits for CIU-specific claims; 0.1% of CIU patients had
at least one CIU-specific hospitalization and 1.9% at least one CIU-specific
ED visit. Costs associated with CIU-based claims increased with age and were
higher in women than in men; otherwise few consistent trends in HCRU
emerged. Conclusions: Despite being otherwise relatively healthy, CIU patients
had frequent HCRU, the majority of which were outpatient visits. CIU-specific
HCRU was small compared with the total use, which also primarily comprised
office visits. This indicates that CIU patients often see physicians for reasons
not directly related to their urticaria.
P318
TREATMENT OF CHRONIC URTICARIA WITH IMMUNOSU-
PRESSORS: CASE REPORT.
M.E. Arroyo-Cruz, A.A. Velasco-Medina, S. Gonzalez-Flores,
J.C. Fernandez-Cordova*, D.A. Cariño-Cartajena, G. Velazquez-Samano,
Mexico City, DF, Mexico.
Introduction: Chronic urticaria (CU) has a prevalence of 30%. It is a con-
dition that does not endanger life but has great impact on the quality of life.
Sometimes, its management is difficult. Case 1: 33 year old female with urticaria
for 1 year, and 2 months ago she has an exacerbation with the presence of ede-
matous-erythematous, pruritic plaques, positive dermatographism and insom-
nia; eyelid edema and arms, she was treated with multiple antihistamines with-
out success, we initiate methotrexate. We achieve a good control of symptoms.
Case 2: 60 years old female, with urticaria for 3 years, which exacerbates in
the past 3 months without responding to the multiple tratments, predominantly
generalized pruritus and rash on both arms and abdomen; we indicate methotrex-
ate with an good clinical response. Discussion: Urticaria management includes
H1 antihistamines as the first option. Recent studies have reported the useful-
ness of methotrexate at a dose of 10-15mg per week, due to its anti-inflam-
matory effect rather than immunosuppression, proving to be effective in chronic
idiopathic and autoimmune urticaria. Its mechanism of action is unclear, it
increases adenosine levels, inducing apoptosis of activated CD4 lymphocytes
and decreases neutrophil chemotaxis. It has an estimated response time of 3
weeks to 6 months. We report two cases of patients with urticaria with good
response to methotrexate. It is a good option for patients with no response to
antihistamines and other therapies.
A114 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P319
AN UNUSUAL PRESENTATION OF TOXIC EPIDERMAL
NECROLYSIS IN A PATIENT WITH SYSTEMIC LUPUS ERY-
THEMATOSUS.
R. Patel*1, G. Jyothirmayi2, E. Capitle2, 1. Long Island City, NY;
2. Newark, NJ.
Introduction: Toxic Epidermal Necrolysis (TEN) is a dermatologic disor-
der characterized by diffuse erythema and necrosis of the epidermis. TEN can
occur secondary to drugs, infections or autoimmune disorders (1). Methods:
This is a 43 year old female,with a history of SLE maintained on hydroxy-
chloroquine and azathioprine, hypertension and hypothyroidism, who presented
with a progressively worsening erythematous and tender skin rash affecting her
entire body. She was seen prior for a similar skin rash under the breast and dis-
charged on cephalexin and fluconazole for possible cellulitis vs a fungal infec-
tion. She reported myalgias but denied any fever, vision changes, chest pain,
shortness of breath, or genitourinary complaints. On physical examination,
the patient was afebrile, with a blood pressure of 81/57, heart rate of 106, and
a diffuse, erythematous, exudative, desquamating rash over 70 percent of her
body including mucous membranes but no ocular involvement. Results: Fur-
ther work up revealed leucocytois on CBC. The severity of illness score for
TEN (SCORTEN) was 5 out 7 indicating a 90% mortality rate. Her acute symp-
toms were managed with intravenous (IV) fluids and broad spectrum antibi-
otics. Infectious work up was negative. Skin biopsy was indicative of TEN and
she was treated with IV Immunoglobulin and steroids. Discussion: TEN is a
life threatening skin disease and must be managed rapidly. This disorder belongs
on a spectrum of skin diseases, which also involve Erythema Multiforme Major
and Minor and Steven’s Johnson Syndrome. History is an important aspect in
the diagnosis of this condition. Details involving medication history, recent
infections, and underlying autoimmune diseases must be thoroughly reviewed.
In this patient, the rash was present prior to the start of antibiotic therapy, thus
her underlying autoimmune disease of lupus most likely was the cause of TEN.
Image 1: Our patient with a diffuse erythematous, exudative, and desquamat-
ing rash involving more than 70% of her body surface area.
P320
IMPROVEMENT OF SLEEP IN PATIENTS WITH CHRONIC IDIO-
PATHIC/SPONTANEOUS URTICARIA (CIU/CSU) TREATED
WITH OMALIZUMAB: RESULTS OF A RANDOMIZED,
DOUBLE-BLIND, PLACEBO-CONTROLLED CLINICAL TRIAL
(GLACIAL).
J. Antonova, K. Raimundo*, B. Trzaskoma, P. Solari, T. Omachi, J. Zazzali,
South San Francisco, CA.
Introduction: Chronic idiopathic/spontaneous urticaria (CIU/CSU) symp-
toms interfere with patient sleep. Omalizumab has been shown to reduce dis-
ease activity in patients with CIU/CSU. We describe patient-reported data on
sleep from GLACIAL - a large randomized double-blind placebo-controlled
clinical trial. Methods: Subjects were randomized 1:3 and received placebo
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A115
(PLB, n=83) or omalizumab 300 mg (OMA300, n=252) every 4 weeks for 6
doses. Sleep was assessed in: Urticaria Patient Daily Diary (UPDD; sleep inter-
ference question; possible range 0-21), Chronic Urticaria Quality of Life Ques-
tionnaire (CU-Q2oL; sleep problems dimension; possible range 0-100), and a
Medical Outcomes Study Sleep Scale (MOS-SS; sleep problem index II [SPI-
II]; possible range 0-100). IRB approval and informed consent were obtained
from all research subjects. Results: On average, at baseline patients reported
substantial sleep impairment (Table). Patients in both arms experienced improve-
ment in sleep by week 12 compared with baseline. Comparing week 12 with
baseline, OMA300 arm demonstrated a larger reduction in patient-reported
sleep problems than the PLB arm (mean, % reduction): MOS-SS SPI-II: -19.0
(-39%) for OMA300 vs. -13.4 (-28%) for PLB; UPDD sleep interference item:
-9.2 (-77%) for OMA300 vs. -5.0 (-44%) for PLB; CU-Q2oL Sleep Problems:
- 29.4 (-64%) for OMA300 vs. -18.3 (22.2%) for PLB. Conclusion: CIU/CSU
patients receiving OMA300 achieved greater reduction in sleep problems than
those in the PLB arm. OMA300 helps reduce sleep impairment in patients with
CIU/CSU.
Sleep problems reported by CIU/CSU patients in GLACIAL
*Larger numbers indicate worse sleep
**Larger negative numbers represent higher degree of improvement
BSL = baseline; W12 = week 12; SPI II = Sleep Problem Index II, MOS-SS
= Medical Outcomes Study Sleep Scale; UPDD = Urticaria Patient Daily
Diary, CU-Q2oL = Chronic Urticaria Quality of Life Questionnaire.
P321
ALLERGIC CONTACT DERMATITIS TO HENNA HAIR DYE.
Q. Kamili*, Q.L. Nguyen, R. Katta, J. Schmidt, Houston, TX.
Introduction: Henna, derived from the plant Lawsonia inermis, has been
used for centuries in India as a hair dye. In recent years, it has experienced
resurgence, as consumers are increasingly drawn to natural products, includ-
ing natural hair dyes. Interest in henna has also arisen as it is an exceedingly
rare cause of allergy. Traditional hair dyes, on the other hand, make use of p-
phenylenediamine (PPDA). This is a common cause of allergic contact der-
matitis, and is found in almost all permanent, semi-permanent, and demi-per-
manent hair dyes in the United States. Because of the extremely low risk of
allergy, henna hair dyes are often recommended by physicians as appropriate
alternate hair dyes for those allergic to PPDA. Case: A 50 year old male pre-
sented to dermatology clinic with a rash of the frontal hairline, eyebrows, and
beard area. He reported that months earlier he had experienced an allergic reac-
tion several days following the use of a drugstore brand of hair dye. His physi-
cian had diagnosed allergic contact dermatitis, likely due to p-phenylenedi-
amine in the hair dye. He was instructed to use only henna hair dyes in the
future. He then purchased a henna hair dye at an ethnic grocery store and applied
it to his hair, eyebrows, and the beard area. Within three days he developed
erythema, itching and swelling in each of these areas. A review of the ingredi-
ent list on the henna hair dye package revealed the presence of PPDA. Given
his history, he declined patch testing. Conclusion: Henna is often recommended
as an alternate hair dye in patients with PPDA allergy. For patients reporting
PPDA allergy, henna has been recommended by physicians and hairstylists, as
well as via multiple outlets on the internet. This case demonstrates that this is
not always a safe strategy. Patients must be informed that some henna hair dyes
may contain additional PPDA. This may be due to the fact that henna naturally
produces a reddish tint to the hair. In order to produce a darker color, additional
ingredients may be added in commercially available henna hair dyes; in this
case PPDA. Patients must also be advised that packaging may not include dis-
ABSTRACTS: POSTER SESSIONS
claimers, and therefore a review of the full ingredient list of any hair dyes is
required prior to use.
P322
USEFULNESS OF A PURINE BIOSYNTHESIS INHIBITOR IN
ATOPIC DERMATITIS.
J. Fernandez de Cordova Aguirre*, A. Velasco-Medina, M.E. Arroyo-Cruz,
S. Gonzalez Flores, D. Cariño-Cartagena, G. Velazquez-Samano, Mexico
City, DF, Mexico.
We report a case of a patiente with atopic dermatitis and allergic rhinitis
with bad control with standard therapy. We added mycophenolate mofetil with
good results, assessed by SCORAD scale. Case Presentation: Twenty-eight
years old male from Veracruz. Since childhood, he has had pruritic erythema-
tous scaly lesions scattered across the whole body surface, especially in the
flexurar folds of the elbows, popliteal and ankle regions, creases of the neck
and on the face; he also has extremely dry scaly skin. Symptoms have periods
of remission and exacerbation. He also has hyaline anterior rhinorrhea, nasal
obstruction, nasal pruritus and sneezing. He received moisturizers, topical and
systemic steroids and calcineurin inhibitors without improvement. At initial
assessment he has a SCORAD of 60. He has pruritic erythematous scaly papules
with impetiginization. Studies show 9400 leukocytes, 3500 (38%) neutrophils,
2500 (27%) lymphocytes, 2400 (26%) eosinophils, 90 (1%) basophils. Blood
chemistry, stool test, acute phase reactants (CRP and ESR), IgG, IgM, IgA
and complement were normal. Total serum IgE 7830 IU /ml. Positive nasal
eosinophils. Skin prick test was positive for Fraxinus and Dermatophagoides
farinae. The diagnosis of severe atopic dermatitis and mild intermittent aller-
gic rhinitis is confirmed by clinical and complementary studies. We started
treatment for allergic rhinitis and atopic dermatitis based on intranasal saline
solution, intranasal steroids, oral antihistamines, skin hydration, specific
immunotherapy and added mycophenolate mofetil 1 g orally daily for 60 days.
Clinical response of both allergic rhinitis and skin pathology was successful
(SCORAD of 10). Discussion: Atopic dermatitis is a chronic inflammatory skin
disease commonly associated with allergic rhinitis. The goals of treatment are
to improve pruritus, papules, erythema, edema, vesicles and prevent impetigo
and lichenification of the skin. Treatment was established with skin hydration,
topical steroids, antihistamines and mycophenolate mofetil 1 g orally for 60
days. We conclude that mycophenolate mofetil is an effective treatment for dif-
ficult to control atopic dermatitis.
P323
PSORIASIFORM SPONGIOTIC DERMATITIS AND AUTOIM-
MUNE DISEASE.
S. Sran*, M. Taborga, M. Frieri, East Meadow, NY.
Inflammatory skin diseases manifest via reactive physiological pathways
to pathogens. Epidermal keratinocytes play a major role in skin inflammation.
In acute eczematous dermatitis, activated dermis-infiltrating T cells secrete
proinflammatory cytokines that direct epidermal keratinocytes to undergo either
apoptosis or survival. Tumor necrosis factor may promote keratinocyte apop-
tosis and limit the spread of keratinocyte damage, leading to the formation of
spongiosis, the histopathological hallmark of acute eczematous dermatitis. A
76 year old female presented to the allergy clinic with intermittent lesions in
her left lower extremity. The patient had similar lesions in her chest and upper
extremity in the past which resolved spontaneously. Her medical history is
significant for rheumatoid arthritis, Sjogren’s disease, fibromyalgia, breast can-
cer with bilateral mastectomy, gastroesophageal disease, myocardial infarction,
neuropathy, depression, anxiety disorder, COPD, dyslipidemia, and hypothy-
roidism. Physical examination was significant for a 6.4cm discoid ulcer near
the left ankle. RF, CCP, B cell markers, CD19, CD29, CD23, CD10, surface
immunoglobulin, myeloid, platelet and natural killer cell, stem cell, erythroid
cell markers and NBT were within normal limits. Allergen testing by sIgE was
normal. Immunoglobulin A and M, as well as complement levels were nor-
mal; however immunoglobulin G levels were decreased. Biopsy of the area
revealed spongiosis, epidermal hyperplasia, and a superficial perivascular and
interstitial mixed inflammatory cell infiltrate. Sjögren’s syndrome is a systemic
autoimmune disease characterized by dry oral mucosa, dry eyes, and arthritis.
Skin manifestations in Sjögren’s syndrome occur in half of the affected patients.
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ABSTRACTS: POSTER SESSIONS

There are reports of atopic dermatitis complicated by Sjögren’s syndrome and

these patients present with persistent itchy dry skin and eczematous lesions.
Perivascular infiltrates of lymphocytes, histiocytes, and occasional eosinophils
can occur in dyshidrotic eczema in rheumatoid arthritis. Drug eruptions may
present in virtually all patterns of cutaneous inflammation including spongi-
otic, lichenoid, and psoriasiform dermatitis. In psoriasiform dermatitis, the
microenvironment of interacting inflammatory cells, antigen presenting cells,
and epithelial cells is disturbed, leading to stereotyped reaction patterns in
inflammatory skin diseases.

P324
THE HAZARDS OF HENNA: AN EVALUATION OF COMMER-
CIALLY AVAILABLE HENNA HAIR DYES.
Q. Kamili*, R. Katta, Q.L. Nguyen, Houston, TX.
Introduction: The chemical p-phenylenediamine (PPDA), found in almost
all permanent hair dyes, is a common cause of allergic contact dermatitis. As
the treatment of PPDA allergy centers on avoidance, the identification of a safe
alternate hair dye is important. Henna is frequently recommended as an alter-
nate, as allergy to henna is exceedingly rare. Derived from the plant Lawsonia
inermis, henna has been used for centuries. This study was undertaken to eval-
uate commercially available henna hair dyes to determine their suitability as
hair dyes in PPDA-allergic patients. Methods: A cross-section of local stores,
including ethnic grocery stores, were surveyed in order to evaluate any henna
hair dyes. Products were included if they contained the word “henna” in the
name or on the package. The ingredient lists of all products were reviewed.
Packaging was reviewed for any other indicators of PPDA presence. Results:
A total of 6 stores were surveyed, and 25 brands of henna hair dyes identified.
Of these, 21 contained the word “henna” in the name of the product, 2 used
alternate words such as “mehandi” and 2 used the word “henna” elsewhere on
the packaging. Eight of the 25 products lacked an ingredient list. Of the remain-
ing 17 dyes, 7 listed PPDA as an ingredient and one contained disperse dyes.
Only 3 of the 7 dyes containing PPDA provided disclaimers; the remainder dis-
played no notification of the presence of PPDA apart from the ingredient list.
Conclusion: This analysis finds that multiple commercially available henna
hair dyes could prove hazardous to patients with PPDA allergy. Almost half of
labeled henna hair dyes in local stores contained PPDA, and the majority con-
tained no notification of the presence of PPDA apart from the ingredient list.
One additional product contained disperse dyes, a potential cross-reactor to
PPDA. Another notable hazard was our finding that almost 1/3 of products con-
P325
A CHALLENGING CASE OF ACUTE GENERALIZED EXAN-
tained no ingredient listing at all. This analysis makes clear that recommend- THEMATOUS PUSTULOSIS.
ing henna hair dyes to patients with PPDA allergy is not sufficient. Many of
the commercially available products would result in allergic reactions if used A. Kim*, San Diego, CA.
by those with PPDA allergy. Patients must therefore be advised to purchase Introduction: Acute generalized exanthematous pustulosis (AGEP) is a rare
only products that contain a full listing of ingredients, and to review the ingre- self-limiting drug eruption that classically presents with sterile pustules on an
dients carefully prior to use. edematous and erythematous base. Diagnosing AGEP can be challenging due
to potentially overlapping clinical features shared with septic shock, chronic
blistering diseases, Stevens Johnson syndrome (SJS) and toxic epidermal necrol-
ysis (TEN). Methods: Clinical case presentation. Results: A 49 year old woman
was admitted to the intensive care unit for multi-organism urosepsis and started
on vancomycin and ertapenem. Due to preexisting drug allergies, antimicro-
bial resistance and ertapenem-induced thrombocytopenia, Allergy/Immunol-
ogy was consulted to facilitate Ceftriaxone desensitization. Prior to desensiti-
zation, the patient had stable hemodynamics and absent history of AGEP,
DRESS, SJS/TEN, and visceral involvement from prior antibiotic administra-
tion. 2 hours following desensitization, the patient became febrile and tachy-
cardic. Clinical deterioration progressed to profound hypotension overnight
requiring initiation of two vasopressors. Infectious Disease evaluated the patient
for urosepsis recurrence, but cultures were unremarkable. 96 hours following
desensitization the patient developed erythema, edema, blistering, and desqua-
mation on the dorsal feet with progression to her neck, perioral region, chest
and upper back. Flaccid bullae and Nikolsky sign were present on the anterior
thighs. Dermatology and Burn teams were emergently consulted and IVIG was
initiated due to concerns of SJS/TEN. Skin biopsy revealed subcorneal neu-
trophilic pustular dermatitis with negative immunofluorescence. Blood analy-
sis did not reveal eosinophilia or liver abnormalities and diagnosis of presumed
AGEP secondary to Vancomycin was made. Conclusion: AGEP is a self-lim-
iting and acute cutaneous eruption that typically presents with fever, pustules
and erythema. Although AGEP generally has a clinical presentation distinct
from SJS/TEN, there can be considerable clinical overlap necessitating care-

A116 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A117
ful histopathologic evaluation. As in our patient, AGEP can manifest with skin
desquamation and positive Nikolsky sign, as well as profound disruption in
hemodynamics. Given that the prognosis and management of AGEP is notably
different from SJS/TEN, it is vital that physicians are aware of the diagnosis
and its myriad clinical features.
P326
ACQUIRED ACRODERMATITIS ENTEROPATHICA AND
HYPOTHYROIDISM IN A SEVERELY ATOPIC INFANT.
N.N. Shah*, K. Paris, New Orleans, LA.
Introduction: It is important to evaluate the nutritional deficiencies in
severely atopic infants in order to treat possible non-atopic causes of persist-
ent dermatitis. We describe a case of acquired acrodermatitis enteropathica and
endocrinopathy in an atopic child. Case Description: A full term 11 month old
male with history of failure to thrive, GERD, and atopic dermatitis presented
to our hospital with fever, dehydration, edema, and dermatitis. At 6 months of
age, the patient’s mother elected to feed with rice milk exclusively due to pos-
itive serum specific IgE testing to various foods. Our initial laboratory evalu-
ation revealed anemia, lymphopenia, hypoalbuminemia, and transaminitis. His
growth parameters were less than the 3rd percentile, and he had anasarca. Skin
exam revealed denuded, scaly, well demarcated erythematous plaques over the
diaper area and erythematous crusted lesions around the mouth and eyes. The
rash appeared 1 month prior to admission, and was not responsive to topical
steroids. Skin biopsy was consistent with acrodermatitis enteropathica. Inpa-
tient evaluation of his malnutrition further revealed markedly elevated thyroid
stimulating hormone, and low serum zinc. An elemental diet and levothyrox-
ine were started, and the patient’s symptoms improved. Appropriate re-evalu-
ation of his food hypersensitivity was performed and reintroduction of solids
was successful. Discussion: This report highlights the potential morbidity of
overly restrictive diets in children with severe atopic dermatitis. Patients with
atopic dermatitis may have positive sensitization to various foods without his-
tory of clinical reaction. Foods used in lieu of infant formula may have vary-
ing levels of carbohydrates, fats, proteins, and minerals. These differences must
be considered when dietary counseling takes place. Conclusion: Acquired acro-
dermatitis enteropathica should be considered in malnourished infants with
steroid resistant dermatitis. Minerals are important co-factors in hormone pro-
duction and function. Nutritionally appropriate alternatives should be recom-
mended when discussing food elimination.
P327
OVERLAPPING URTICARIC SKIN MANIFESTATION IN FOOD
ALLERGY AND GLUTEN- SENSITIVE ENTEROPATHY.
J. Baik*, A.B. Kim, Los Angeles, CA.
Introduction:Treatment for urticarial rash could be frustrating if the con-
ventional treatment fails but the side effect of medication seems to rise. We
report a case of urticaria secondary to food allergy along with concomitant
undiagnosed gluten-sensitive enteropathy.Methods: A 23 year old oriental
female presented with 1 week history of the generalized urticaria including
face and both palms. There were no GI symptoms at the initial presentation.
She took a chitosan pill which is a product of shrimp and shell fishes as a food
supplement prior to onset of the rash. There was a history of premenstrual
pain which required high doses of advil. She had a frequent indigestion with
unknown origin during chidhood. Initially,her urticarial rash responded well
to IM steroid with IM Benadryl, followed by oral prednisone, hydroxyzine. But
few days later, the patient started to have severe intermittent colicky abdomi-
nal pain with recurrent urticaria in spite of the treatment.The patient was seen
at ER, started on hydrocodone-acetaminophen for pain without relief.Oral
steroid was discontinued after the onset of the abdominal pain and changed to
IM steroid which controlled urticaria but abdominal pain persisted. The patient
was evaluated by two different gastroenterologists. The gastroendoscopy find-
ing was negative. The blood test was positive for t- transglutaminase IgA: 5u/ml
(0-3).The percutaneous skin test revealed multiple hypersensitivities to clam,
shrimp, oyster, barley, celery, coconut, sweet potato, salmon, squash, straw-
berry, string bean, tomato, dust mites and chinese elm tree pollen but negative
for wheat. Result:The gluten-free diet resulted in prompt remission of the recur-
rent colicky abdominal pain. The urticaria was under control with antihista-
mine along with elimination diets, allowing complete discontinuation of sys-
temic steroids. Urticaria came back twice over 2 months in spite of gluten-free
ABSTRACTS: POSTER SESSIONS
diet but subsided with antihistamines alone.Conclusion:The urticaria started
with food supplemental pill which contained shrimp and shell fish proteins
but undiagnosed gluten enteropathy became obvious during the treatment.
The urticaria also can be a cutaneous manifestation of gluten-sensitive enteropa-
thy aside from the food allergy. Therefore, the clinician should be aware of the
role of concomitant underlying gluten-sensitive enteropathy in the treatment
of urticaria.
P328
A NOVEL HUMAN-DERIVED PROBIOTIC EXTRACT WITH
FILAGGRIN PROMOTING THERAPEUTIC EFFECT.
B. Subhadra*, S. Shastri, M. Henson, J. Krier, N. Monsul, E. Berkes, Sara-
sota, FL.
Introduction: Skin health, especially in atopic dermatitis (AD), relies on
an intact skin barrier, a critical component of which is the protein filaggrin. If
filaggrin production is impaired, skin barrier function is also dysfunctional and
can lead to xerosis, infection, inflammation and allergic sensitization. Com-
mensals may help support a healthy skin barrier by helping support normal
filaggrin function. Using a patent-pending bio-extract from a novel probiotic
human commensal organism, we examined whether the extract could be used
to increase skin filaggrin protein levels. Methods: Using an ex vivo skin explant
culture model with normal excised skin from plastic surgery patients, filaggrin
induction by the proprietary bio-extract was tested via filaggrin antibody
immunohistochemistry, rtPCR and ELISA. Normal skin explants were also
used in a dry skin model induced by SDS treatment, with skin barrier
integrity/hydration assessed via skin conductance; bio-extract effect was com-
pared against dexamethasone. Results: Filaggrin immunohistochemistry: pro-
prietary bio-extract at 0.05% and 0.1% increased filaggrin staining vs control.
Filaggrin mRNA: filaggrin mRNA expression did not increase with bio-extract
treatment at 0.25% and 0.1% vs control. Filaggrin ELISA: proprietary bio-
extracts at 0.05% and 0.1% increased filaggrin protein levels by over 2-fold vs
control. Skin barrier function: after SDS treatment, 30 minute proprietary bio-
extract treatment increased skin conductance to or above normal levels; this
improvement lasted for all time points measured and performed at least as
well as dexamethasone. Conclusion: Patients look for “natural” disease treat-
ment options but often fail to find effective choices. Even small increases in
filaggrin have the potential to significantly improve AD clinical symptoms.
The 2-fold increase in filaggrin protein levels accompanied by normalization
of skin barrier function in human skin explants induced by a novel human-
probiotic derived bio-extract hold significant clinical promise in the treatment
of skin diseases characterized by low filaggrin expression and skin barrier
defects, such as AD.
P329
A NOVEL HUMAN-DERIVED PROBIOTIC EXTRACT WITH
ANTI-METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
(MRSA) BIOFILM THERAPEUTIC EFFECT.
E. Berkes, B. Subhadra*, M. Henson, J. Krier, N. Monsul, Sarasota, FL.
Introduction: It is increasingly recognized that maintenance of skin health,
particularly in patients with atopic dermatitis (AD), requires homeostasis among
the microbes comprising the dermatologic microbiome. Biofilms are the com-
munal phenotype preferred by most microbes, including pathogens, and form
on most surfaces. Commensals may help support a healthy skin barrier by
inhibiting pathogenic biofilms such as MRSA. Using a patent-pending bio-
extract from a novel probiotic human commensal organism, we defined MRSA
anti-biofilm activities of potential clinical utility in the prevention and treat-
ment of MRSA biofilms. Methods: Using a 96-well biofilm microplate assay,
proprietary bio-extracts were tested against clinical MRSA isolates for 2 anti-
biofilm activities: anti-biofilm adhesion and detachment of MRSA biofilm.
Results were compared against vancomycin and meropenem. Results: Anti-
adhesion: The bio-extract was 2-3x more effective than antibiotic controls, with
35% anti-adhesion at 0.01 mg/ml, 50% at 0.05 mg/ml, 58% at 0.1 mg/ml, 85%
at 0.5 mg/ml and 90% at 1 mg/ml when compared against untreated growth
control. Biofilm detachment: The bio-extract was up to 10 times more effec-
tive than antibiotic controls: 0.05 mg/ml detached 50% of MRSA biofilm; van-
comycin and meropenem both detached only approximately 5%. Unlike the
anti-adhesive assay, there was no apparent dose-dependence, as percent detach-
ment declined as bio-extract concentration increased. Lack of dose dependence
VOLUME 113, NOVEMBER, 2014 A117
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A118
ABSTRACTS: POSTER SESSIONS
may reflect non-metabolic mechanisms of action and/or brief application time.
Conclusion: We have discovered a novel human-derived probiotic extract with
anti-MRSA biofilm therapeutic effect. Skin of patients with AD is diffusely
colonized by Staphylococcus aureus and MRSA. Increased microbial burden
is associated with acute exacerbations, and chronically, these microbes are asso-
ciated with inflammation, decreased skin immune defense and a weakened skin
barrier. MRSA biofilms are a key factor in the persistence of these microbes
in AD patients. This human probiotic-derived bio-extract with the dual anti-
biofilm activities of inhibition of biofilm adhesion as well as detachment of
already formed pathogenic biofilm, could synergistically both treat and pre-
vent MRSA biofilms in chronic skin diseases, such as AD.
P330
DELAYED DIAGNOSIS OF ERYTHROPOIETIC PROTOPOR-
PHYRIA: A 36 YEAR OLD HISPANIC FEMALE WITH SUN-
INDUCED ANGIOEDEMA.
M. Rodríguez-Roa*1, S. Nazario2, 1. San Juan, Puerto Rico; 2. Hato Rey,
Puerto Rico.
Rationale: Angioedema is a self-limited, localized swelling of the skin or
mucosal tissues resulting from the extravasation of fluid into the interstitium.
Although angioedema is a common condition in allergy practices, solar induced
angioedema has a narrower differential diagnosis, including phototoxic drug
reactions, solar urticaria, contact dermatitis, autoimmune inflammatory disor-
ders and in rare cases metabolic disorders, such as cutaneous porphyrias. We
present a case of erythropoietic protoporphyria (EPP) presenting as sun- induced
angioedema in a 36 y/o Hispanic female. Methods: Case Report. Results: A
36 y/o female G1P1A0 presents to the clinic with burning, itching and swelling
within minutes upon sun-exposed areas since her childhood. These episodes
last several days, do not leave residual hyperpigmentation, but interfere sig-
nificantly in her quality of life. Neither antihistamines nor sunscreens have
been helpful to control her symptoms. Denies associated blisters, hives, hyper-
trichosis, anemia, exacerbation or provocation by any other physical stimuli,
anemia, concomitant liver disease, family history of sun induced angioedema,
nor NSAIDs use. Also denies gastrointestinal or respiratory complains or any
comorbid conditions. Her family emigrated from Cuba and there is no history
of intermarriage. Her only medication is vitamin D replacement. Past medical
history was remarkable for chemical hepatitis after surgery for an ovarian cyst
at 12 y/o and cholecystectomy for gallstones when she was 27 y/o. On physi-
cal exam a pale short size woman was noted without any visible eczema, hives,
blisters or organomegaly. Initial laboratories were significant for mildly ele-
vated liver function tests as well as elevated coproporphyrin and heptacarboxyl
in urine. Anemia was not present. A preliminary diagnosis of EPP was made
awaiting confirmatory porphyrin and protoporphyrin levels in RBC, which will
be available for the presentation. Conclusion: Although EPP is a rare cause of
sun- induced angioedema, it is important for allergists to consider it in the dif-
ferential diagnosis in order to diagnose at an early age and prevent life-threat-
ening complications such as hepatitis and hepatic failure requiring liver trans-
plant, and to initiate appropriate sun avoidance recommendations.
A118 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
P331
ELEPHANTIASIS NOSTRAS OF THE LIP.
K. Dass*, A. Ditto, Chicago, IL.
Elephantiasis nostras (EN) occurs secondary to a recurrent lymphangitis
often introduced by trauma. Rarely, EN can affect the lips, with only four
reported cases in literature. A 27 year old female presented to our allergy-
immunology outpatient office with complaints of painful edema, erythema,
peeling, and scabbing of her upper and lower lips. Her symptoms began 6 months
prior to her visit. There was no history of drug allergy or prior history of
angioedema. She denied any constitutional symptoms. Her symptoms were
worse in the morning or when any food touched her lips. She denied any globus,
tongue swelling, dyspnea. She denied any new medications or exposure to any
new detergents or bathing products. Examination was notable for erythema-
tous, edematous, painful lips with fissures at the vermillion border. There was
no cervical or post-auricular lymphadenopathy. She was concerned about her
appearance and lack of resolution of her symptoms. Elephantiasis nostras was
considered as a diagnosis. The patient was treated with five days of prednisone
and twenty-one days of amoxicillin clavulanate with complete resolution of her
symptoms. Unfortunately, she was lost to follow up. With recurrence of symp-
toms, the patient followed with a dermatologist. She was treated for contact
dermatitis despite avoiding all makeup or other skin products in the affected
area. After testing positive for a nickel allergy, she also followed a low nickel
diet. Despite her efforts, her symptoms persisted. . The patient returned to the
allergy and immunology outpatient office, where she was successfully treated
with a second course of 5 days of prednisone and 21 days of amoxicillin-clavu-
lanate. Elephantiasis nostras can lead to permanent swelling, hypertrophic fibro-
sis, and facial disfigurement with repeated attacks. Suspicion of EN as a clin-
ical entity may arise with unrelenting edema. Other disorders that should be
considered include angioedema, contact dermatitis, erysipelas, granulomatous
cheilitis, Melkersson’s syndrome, superior vena cava syndrome, and sclero-
derma. Treatment focuses on long-term antibiotic administration with plastic
surgery occasionally required. This case illustrates the importance of main-
taining elephantiasis nostras as a differential diagnosis in patients with chronic
edematous lips.
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A119

SPEAKER DISCLOSURES

Disclosures
Oral and Poster Abstract Presenters
American College of Allergy, Asthma & Immunology
Annual Scientific Meeting
Continuing Medical Education
November 6-10, 2014
Atlanta, Georgia
Disclosure Policy and Disclosures
As required by the Accreditation Council for Continuing Medical Education (ACCME) and in accordance with the American
College of Allergy, Asthma and Immunology (ACAAI) policy, all educational planners, presenters, instructors, moderators,
authors, reviewers, and other individuals in a position to control or influence the content of an activity must disclose all rele-
vant financial relationships with any commercial interest that have occurred within the past 12 months. All identified conflicts
of interest must be resolved and the educational content thoroughly vetted for fair balance, scientific objectivity, and appropri-
ateness of patient care recommendations. It is required that disclosure be provided to the learners prior to the start of the activ-
ity. Individuals with no relevant financial relationships must also inform the learners that no relevant financial relationships
exist. Learners must also be informed when off-label, experimental/investigational uses of drugs or devices are discussed in an
educational activity or included in related materials. Disclosure in no way implies that the information presented is biased or of
lesser quality. It is incumbent upon course participants to be aware of these factors in interpreting the program contents and
evaluating recommendations. Moreover, expressed views do not necessarily reflect the opinions of the ACAAI. (Please note
that posters were not certified for credit.)

Abiteboul, K. – P265 Bajpai, S. – P48 Bernstein, D. – 14, P266

Employee: Stallergenes Consultant/Advisory Board: Teva
Adelman, B. – P289 Baker, J. – 8
Employee: Dyax Research Grant: Amgen, Amphastar,
Array, AstraZeneca, Asubio, Celgene,
Allen, N. – 23 Circassia, CSL Behring, Dyax,
Consultant/Advisory Board: OSIA Galderma, Genentech,
Medical GlaxoSmithKline, Kythera, Maruho,
Meda, Merck, Mylan, Novartis, Pearl
Amar, N. – P305, 14 Therapeutics, Pfizer, Pharming,
Research Grant: AstraZeneca, Pulmagen, Sanofi, Merck, Shire,
GlaxoSmithKline, Merck, Teva; Data Teva, Tigercat
Monitoring Committee: Merck
Banerji, D. – P284
Amin, A. – P287 Employee: Novartis
Employee: Novartis
Barbir, A. – 6
Amistani, Y. – P264 Research Grant: Mylan Specialty
Employee: Stallergenes
Bensch, G. – P57
Antonova, E. – 57, P80, P317 Research Grant: Meda
Employee: Genentech
Berger, W. – P301, P305
Antonova, J. – P46, P320 Consultant/Advisory Board, Research
Employee: Genentech Grant: Meda
Aquino, M. – 39 Berkes, E. – P328, P329
Research Grant: Genentech Co-founder: Quorum Innovations
Ashton, V. – P66 Berman, G. – P259
Employee: Research in Real Life Research Grant: AstraZeneca,
Cerecor, Circassia, Forest, Genentech,
Aygören-Pürsün, E. – P225 GlaxoSmithKline, Janssen, Mylan,
Consultant/Advisory Board: CSL Novartis, Perrigo, Roche, Sunovion,
Behring Teva
Consultant/Advisory Board:
Circassia, Merck; Research Grant:
Greer, Merck, Stallergenes
Bernstein, J. – P225, P300
Consultant/Advisory Board: CSL
Behring
Biedenkapp, J. – P289
Employee: Dyax
Bielory, L. – P40, P306
Research Grant: EPA
Bjermer, L. – 61
Consultant/Advisory Board:
AstraZeneca, Airsonette, Aerocrine,
ALK-Abello, Almirall, Boerhringer
Ingelheim, Chiesi, GlaxoSmithKline,
Meda, Merck, Mundipharma,
Nigaard, Novartis, Orion, Sandoz,
Teva; Speaker: AstraZeneca,
Airsonette, Aerocrine, ALK-Abello,
Almirall, Boehringer Ingelheim,
Chiesi, GlaxoSmithKline, Meda,
Merck, Mundipharma, Nigaard,
Novartis, Orion, Teva
Blessing-Moore, J. – P300
Consultant/Advisory Board, Research
Grant: Meda
Boccon-Gibod, I. – P225
Consultant/Advisory Board: CSL
Behring

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SPEAKER DISCLOSURES

Borish, L. – P182 Carr, W. – P295 Davis-Lorton, M. – 39

Consultant/Advisory Board : Allakos, Consultant/Advisory Board and
Genentech, Novartis, Pluristem; Speaker: Alcon, Allergan,
Research Grant/Clinical Trials: AstraZeneca, Boehringer Ingelheim,
Allakos, Dupont, Genentech, Knopp, Meda, Mylan, Teva
National Institutes of Health (NIH)
Novartis Casale, T. – P295
Consultant/Advisory Board and
Bork, K. – P225 Research Grant: Boehringer
Consultant/Advisory Board: CSL Ingelheim
Behring
Casciano, J. – P48
Bouillet, L. – P225 Consultant/Advisory Board: Teva
Consultant/Advisory Board: CSL
Behring Chang, E. – P80, P317
Employee: Partnership for Health
Bour, L. – P295 Analytic Research
Employee: Boehringer Ingelheim
Chen, H. – P45
Broder, M. – P80, P317 Employee, Stocks: Genentech
Employee: Partnership for Health
Analytic Research Chipps, B. – P50, P51
Consultant/Advisory Board:
Buatti Small, M. – P66 AstraZeneca, Genentech,
Employee: Teva GlaxoSmithKline, Meda, Merck,
Novartis, Sunovion; Speaker:
Burden, A. – P66 AstraZeneca, Bausch & Lomb,
Employee: Research in Real Life Genentech, GlaxoSmithKline, Merck,
Novartis, Sunovion
Busse, P. – P162, P199
Consultant/Advisory Board: Dyax, Chyung, Y. – P289
Shire; Grant: CSL Behring, Dyax, Employee: Dyax
Shire
Cicardi, M. – P225, P291
Bygum, A. – P225 Consultant/Advisory Board: CSL
Consultant/Advisory Board: CSL Behring
Behring
Ciesielska, M. – 61
Caballero, T. – P225 Employee: Teva
Consultant/Advisory Board: CSL
Behring Corren, J. – P62
Research Grant: Meda
Calderon, M. – 15
Consultant/Advisory Board and Coyne, T. – P27, P28
Speaker: ALK-Abello, Employee: Greer
Allergopharma, Hal Allergy,
Stallergenes Craig, T. – P225
Consultant/Advisory Board: CSL
Campbell, A. – P285 Behring
Employee and Stocks: AbbVie
Creticos, P. – 14
Campbell, J. – P66 Consultant/Advisory Board and
Consultant/Advisory Board: Teva Research Grant: Circassia, Greer,
Merck
Cancian, M. – P225
Consultant/Advisory Board: CSL Cuff, C. – P285
Behring Employee, Stocks: AbbVie
D'Addio, A. – P299
Employee: Meda
Research Grant: Novartis
Dees, J. – 23
Consultant/Advisory Board: OSIA
Medical
Dennerlein, J. – 6
Research Grant: Mylan Specialty
DePietro, M. – P50, P51
Employee, Stocks: AstraZeneca
Devillier, P. – P267
Consultant/Advisory Board,
Honorarium, Research Grant: ALK,
AstraZeneca, Chiesi,
GlaxoSmithKline, Merck, Menarini,
Pierre Fabre, Sanofi, Stallergenes
Dotiwala, Z. – P48
Consultant/Advisory Board: eMAX
Health
Du, Q. – P296, P297
Employee: Johnson & Johnson
Consumer Products
Duff, C. – P218
Consultant/Advisory Board: Baxter,
CSL Behring, Immune Deficiency
Foundation
Duncan, E. – P27, P28
Employee: Greer
Durham, S. – P257
Consultant/Advisory Board: ALK-
Abello, Circassia, Merck,
Stallergenes: Research Grant: ALK-
Abello, Merck, Stallergenes
Ebeling, M. – P261
Statistical Analysis: United Allergy
Services
Eisner, M. – P45
Employee, Stocks: Genentech
Engel, M. – P288, P295
Employee: Boehringer Ingelheim
Engl, W. – P227
Employee : Baxter
Farkas, H. – 8, P225
Consultant/Advisory Board: CSL
Behring, Shire; Travel Grants: CSL
Behring, Shire, Swedish Orphan
Biovitrum

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SPEAKER DISCLOSURES

Faucette, R. – P289 Gupta, S. – P227 Kaplan, A. – 57

Employee: Dyax Consultant/Advisory Board and Consultant/Advisory Board:
Speaker: Baxter Genentech, Novartis: Research Grant:
Fernandez, J. – P121, P189 CSL Behring, Dyax, Shire; Speaker:
Speaker: Baxter Hadari, Y. – P82 Shire
Stocks: Kolltan
Ferreira, M. – P225 Karafilidis, J. – P57, P62
Consultant/Advisory Board: CSL Hall, D. – P27, P28 Employee: Meda
Behring Employee: Greer
Kaur, A. – 14, 15, P257, P259
Fonacier, L. – 39 Hampel, F. – P302 Employee: Merck
Research Grant: Genentech Research Grant: Meda
Kenniston, J. – P289
Ford, L. – P288 Harrow, B. – P58 Employee: Dyax
Research Grant: Boehringer Employee: Meda
Ingelheim Kerstjens, H. – P288, P294, P295
Haselkorn, T. – P45 Consultant/Advisory Board: Almirall,
Franklin, K. – P296, P297 Consultant/Advisory Board: Boehringer Ingelheim, Novartis,
Consultant/Advisory Board: McNeil Genentech Pfizer; Research Grant: Boehringer
Ingelheim, Chiesi, GlaxoSmithKline,
Furcha, R. – P287 Hendershot, R. – 23 Pfizer
Employee: Novartis Consultant/Advisory Board: OSIA
Medical; Speaker: AstraZeneca, Khalil, S. – 57
Garner, L. – P261 Merck Employee: Novartis
Consultant/Advisory Board: United
Allergy Services Hendrickson, B. – P285 Kobrynski, L. – P227
Employee and Stocks: AbbVie Consultant/Advisory Board: Baxter,
Gawchik, S. – P302 CSL Behring
Consultant/Advisory Board, Research Henson, M. – P328, P329
Grant: Meda Clinical Research Advisor: Quorum Koch, G. – P257
Innovations Principal Investigator: Merck
Gedrich, R. – P82
Employee: Kolltan Horak, F. – P266 Krier, J. – P328, P329
Employee: Vienna challenge chamber Microbiologist: Quorum Innovations
Gever, L. – P299, P300, P301
Employee: Meda Hulsey, T. – P261 Krishnan, J. – P48
Statistical Analysis: United Allergy Consultant/Advisory Board: eMAX
Gillespie, M. – P55 Services Health
Employee: Teva
Iarrobino, R. – P289 Kulich, K. – P284
Golden, D. – P265 Employee: Dyax Employee: Novartis
Consultant/Advisory Board:
Stallergenes; Speaker: Genentech; Iribarren, C. – P45 LaForce, C. – P73
Research Grant: Genentech, Merck, Consultant/Advisory Board: Consultant/Advisory Board: Novartis
Siemens Diagnostics Genentech
Lang, D. – 17
Gopalan, G. – P66 Iverson, H. – P56, P73, P74, P76 Consultant/Advisory Board: Hycor,
Employee: Teva Employee: Teva Merck, Quest: Honorarium: Merck,
Research Grant: Genentech, Novartis
Grant, J. – P227 Jain, N. – P158
Consultant: Baxter Consultant/Advisory Board: Lanier, B. – P259
Aerocrine; Speaker, Honorarium: Research Grant: Genentech, Merck;
Grier, T. – P27, P28 Abbott, AstraZeneca, Speaker: Novartis
Employee: Greer GlaxoSmithKline, Novartis
LaVallee, T. – P82
Guilarte, M. – P225 Janelli, M. – 6 Employee: Kolltan
Consultant Advisory Board: CSL Research Grant: Mylan Specialty
Behring Lawrence, M. – P182
Consultant/Advisory Board: Regado

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SPEAKER DISCLOSURES

Leibl, H. – P227 Melamed, I. – P227 Ostrom, N. – P56

Employee: Baxter Consultant/Advisory Board: Baxter,
BPL, ADMA; Investigator: CSL,
Lemell, P. – P266 ADMA, BPL, Baxter, Octapharma
Employee: Vienna Challenge
Chamber Meltzer, E. – P299
Consultant/Advisory Board, Research
Lemiere, C. – 61 Grant: Meda
Consultant/Advisory Board:
Aerocrine, AstraZeneca, Meltzer, S. – P300
GlaxoSmithKline; Speaker: Research Grant: Meda
AstraZeneca, Merck; Research Grant:
Aerocrine, GlaxoSmithKline Miller, D. – P45, P73, P74, P76
Employee: ICON Clinical Research;
Li, C. – P48 Research Grant: Genentech
Consultant/Advisory Board: eMAX
Health Miller, R. – P285
Employee and Stock: AbbVie
Li, H. – 8
Consultant/Advisory Board: CSL Mire, B. – P33
Behring, Dyax, Salix, Shire; Speaker: Employee: ALK
CSL Behring, Dyax, Shire; Research
Grant: Shire Moldovan, D. – P291
Research Grant: CSL Behring, Shire;
Li, J. – P305 CSL Behring, Pharming, Shire
Employee: Teva
Monsul, N. – P328, P329
Li, Z. – 14, P257, P266 Co-Founder: Quorum Innovations
Employee: Merck
Moroni-Zentgraf, P. – P288, P295
Lin, M. – 6 Employee of Boehringer Ingelheim
Research Grant: Mylan Specialty
Murphy, K. – P294
Longhurst, H. – P225 Consultant/Advisory Board:
Consultant/Advisory Board: CSL AstraZeneca, Genentech, Greer,
Behring Meda, Merck, Novartis, Teva;
Speaker, Honorarium: AstraZeneca,
Lubeski, C. – P82 Genentech, Merck, Mylan, Novartis,
Employee: Kolltan Teva
Magerl, M. – P225 Naples, A. – P261
Consultant/Advisory Board: CSL Employee: United Allergy Services
Behring
Nelson, H. – 15, P266
Maloney, J. – 14, 15, P257, P259, Consultant/Advisory Board:
P266 Circassia, Merck: Research Grant:
Employee: Merck Circassia
Mandel, E. – P82 Nolte, H. – 14, 15, P257, P259, P266
Employee: Kolltan Employee: Merck
Martinez-Saguer, I. – P225 Nordenfelt, P. – P225
Consultant/Advisory Board: CSL Consultant/Advisory Board: CSL
Behring Behring
Meier, E. – P293 O'Brien, C. – 61, P73, P74
Research Grant: Alcon Labs Employee: Teva
Omachi, T. – 57, P320, P45
Employee: Genentech
Consultant/Advisory Board: Allergan,
AstraZeneca, Meda, Merck, Novartis,
Teva; Speaker, Honorarium:
AstraZeneca, GlaxoSmithKline,
Meda, Merck, Novartis, Sunovion,
Teva, Sunovion; Research Grant:
Actavis, Alcon, Amgen, AstraZeneca,
Apotex, Boehringer Ingelheim, Cytos,
Genentech, GlaxoSmithKline, HRA,
Johnson & Johnson, MedImmune,
Merck, Mylan, Nestle, Novartis,
Proctor & Gamble, Rigel, Sunovion,
Teva
Paolozzi, L. – P264
Employee: Stallergenes
Patel, M. – P296, P297
Employee: McNeil Consumer
Healthcare
Pearlman, D. – P56
Research Grant: AstraZeneca,
Genentech, Novartis, Optinose,
Sanofi, Teva
Plunkett, G. – P33
Employee: ALK
Porebski, G. – 8
Speaker: CSL Behring, Swedish
Orphan Biovitrum; Research
Investigator: CSL Behring
Price, D. – P58, P66
Consultant/Advisory Board:
Aerocrine, Almirall, Amgen,
AstraZeneca, Boehringer Ingelheim,
Chiesi, GlaxoSmithKline, Meda,
Mundipharma, Napp, Novartis,
Pfizer, Teva; Speaker: Almirall,
AstraZeneca, Boehringer Ingelheim,
Chiesi, Cipla, GlaxoSmithKline,
Kyorin, Meda, Mundipharma,
Novartis, Pfizer, Skyepharma, Takeda,
Teva; Honorarium: Aerocrine,
Boehringer Ingelheim, Mundipharma,
Napp, Novartis; Research Grant Peer
Reviewer: Aerocrine, AstraZeneca,
Boehringer Ingelheim, British Lung
Foundation, Chiesi, Eli Lilly,
GlaxoSmithKline, Meda,
Mundipharma, Novartis, Orion,
Pfizer, Respiratory Effectiveness
Group, Takeda, Teva, UK National
Health Service, Zentiva, Medical
Research Council, HTA; Stock
Ownership: AKL, Research in Real
Life, Optimum Patient Care

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SPEAKER DISCLOSURES

Raimundo, K. – 57, P46, P317, P320
Employee, Stocks: Genentech
Ratner, P. – P301
Consultant/Advisory Board and
Research Grant: Meda
Reinero, C. – P82
Research Grant: Kolltan
Relan, A. – 8, P291
Employee, Stocks: Pharming
Reshef, A. – 8, P225
Consultant/Advisory Board: CSL
Behring, Shire; Research Grant,
Speaker, Honorarium: CSL Behring,
Pharming, Shire, Teva
Reynolds, R. – 23
Consultant/Advisory Board: OSIA
Medical
Sexton, D. – P289 Tashkin, D. – P51, P50
Employee: Dyax Consultant/Advisory Board:
AstraZeneca, Pearl, Sunovion,
Shah, M. – P45 Theravance; Research Grant:
Employee: ICON Clinical Research GlaxoSmithKline, Pearl, Sunovion;
Speaker: AstraZeneca, Boehringer
Shastri, S. – P328 Ingelheim, Forest
Laboratory Investigator: Quorum
Innovations Taveras, H. – P56, P73, P74, P76
Employee: Teva
Sigmund, R. – P288
Employee: Boehringer Ingelheim TenHoor, C. – P289
Employee: Dyax
Skoner, D. – P259
Consultant/Advisory Board, Research Tian, X. – P296, P297
Grant: Greer, Merck; Speaker: Merck Employee: Johnson & Johnson
Small, C. – P305 Tiplady, B. – P284
Employee: Teva Employee: ERT
Solari, P. – P46, P80, P320 Tripp, C. – P285
Employee, Stocks: Genentech Employee, Stocks: AbbVie

Rhodes, B. – 23 Song, S. – P55 Trudo, F. – P50, P51

Consultant/Advisory Board: OSIA
Medical
Riedl, M. – P291
Consultant/Advisory Board:
BioCryst, CSL Behring, Dyax, Isis,
Salix, Shire; Research Grant:
BioCryst, CSL Behring, Dyax, Salix,
Shire: Speaker: CSL Behring, Dyax,
Shire
Rigazio, A. – P66
Employee: Research in Real Life
Roux, M. – P267
Employee: Stallergenes
Ruiz, N. – P57, P62, P299, P300,
P301, P302
Employee: Meda
Schaffer, F. – P261
Employee/Chief Medical Officer:
United Allergy Services
Schiff, R. – P227
Employee: Baxter
Schwartz, S. – P228
Stocks: Merck, Pfizer
Seare, J. – 5
Research Grant: Mylan Specialty
Employee: Teva
Soteres, D. – P301
Research Grant: Meda
Stanaland, B. – P302
Speaker: Meda
Stein, M. – P227
Consultant/Advisory Board, Speaker:
Baxter, CSL Behring;
Research Investigator: ADMA,
Baxter, BPL, CSL Behring, Green
Cross, Kedrion
Steinfeld, J. – P55
Employee: Teva
Stobiecki, M. – P225, P291
Consultant/Advisory Board: CSL
Behring
Subhadra, B. – P328, P329
Employee/Research Director: Quorum
Innovations
Sun, G. – P80, P317
Employee: Partnership for Health
Analytic Research
Tantry, S. – P305
Employee, Stocks: Teva
Employee, Stocks: AstraZeneca
Trzaskoma, B. – 57, P46, P320
Employee: Genentech
Urdaneta, E. – P296, P297
Employee: McNeil Consumer
Healthcare
Vandewalker, M. – P288
Research Grant: Boehringer
Ingelheim
von Ziegenweidt, J. – P66
Employee: Research in Real Life
Wahn, U. – P264
Consultant/Advisory Board, Speaker:
Allergopharma, Danone, Merck,
Novartis; Speaker: GlaxoSmithKline,
Nestle, Nutricia, Stallergenes, Thermo
Fisher Scientific
Wasserman, R. – P227
Consultant/Advisory Board: ADMA,
Baxter, CSL Behring, BPL, Korean
Green Cross, Kedrion, Therapure;
Speaker: Baxter, CSL Behring;
Investigator : ADMA, Baxter, CSL
Behring, BPL, Kedrion
Wayne, D. – P76
Employee: Teva

Settipane, R. – P302 Weber, R. – 14

Consultant/Advisory Board and Speaker: Merck
Research Grant: Meda

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SPEAKER DISCLOSURES

Wedner, H. – P291 Wu, M. – P296, P297 Zazzali, J. – 57, P46, P80, P320
Consultant/Advisory Board: Employee: Johnson & Johnson Employee, Stocks: Genentech
BioMarin, CSL Behring, Genentech;
Speaker: CSL Behring, Dyax, Yang, W. – P291, P267 Zeldin, R. – P264, P265, P267
Genentech, GlaxoSmithKline, Merck, Consultant/Advisory Board: CSL Employee: Stallergenes
Mylan, Novartis, Shire, Teva; Behring, Shire; Research Grant: CSL
Research Grant: CSL Behring, Dyax, Behring; Zieglmayer, P. – P266
Genentech, Mankind, Merck, Employee: Vienna Challenge
Pharming, Shire, Teva; Advisory Yel, L. – P227 Chamber
Committee: Baxter, Genentech, Employee: Baxter
MedImmune, Shire Zieglmayer, R. – P266
Zangrilli, J. – 61 Employee: Vienna Challenge
Wolf, R. – 6 Employee: Teva Chamber
Employee: Mylan Specialty
Zanichelli, A. – 8 Zuraw, B. – P225
Wu, C. – P285 Consultant/Advisory Board: Shire; Consultant/Advisory Board: CSL
Employee, Stock: AbbVie Speaker: CSL Behring, Shire, Behring
Swedish Orphan Biovitrum

The following have no relevant financial relationships with commercial interests to disclose:

Abou Baker, N. – 21 Allenbrand, R. – 52 Arroyo-Cruz, M.E. – P7, P53, P130,

P178, P318, P322
Abraham, J.T. – P189 Alpan , O. – P92
Asawa, A. – P143
Abramowitz Saadia, T. – 34 Altrich, M. – P6
Assa'ad, A. – P195
Acantilado, C. – P14 Ambrus, J.L. – P84
Atkinson, P. – P242
Achar , K. – 25, P222 Amin, R. – P4
Avila, P. – P168
Acharya, S. – P188 An, W. – 24
Bachove , I.R. – P204
Adkins, C. – P1, P3 Anand, R. – P84
Baghian, S. – P134
Agarwal, P. – 22 Anderson, J.J. – 9
Bahna, S.L. – P8, P215
Agrawal, S. – P85 Anderson, J.T. – P3, P207
Baik, J. – P327
Akande, T. – P134 Anderson, L. – P167
Baldwin, J. – P111
Akbar, S. – P273 Andreae, D.A. – P213
Banks, T. – P22, P105
Akl , E. – P190 Andujar-DeLaCruz, J. – P166
Bansal, V. – 7
Al Gazlan, S. – P4 Angeles-Garay, U. – 60, P79
Bantz, S. – P42
Al Jiffri, O. H. – P43 Anghel, S. – 33
Bardelas, J.A. – 15
Al Otaibi , T. – P4 Ansary, F.F. – P163
Barnes, C.S. – 11, 52
Aleem, S. – 63 Anthony, K. – P156
Barth, R. – P31
Alfonzo, M. – P87 Antonevich, N. – P90
Bauer, C. – 24
Alhashim, S. – P4 Anyane-Yeboa, K. – P201
Bayer, D. – P283
Ali, A. – P96 Aquino, M. – 27, 39, P152, P196
Beattie, E. – P48
Al-Kawas, F.H. – 41 Arakali, S. – P197
Becerril-Angeles, M. – 60, P70, P79
Alkhatib, F. – P219 Arias Cruz, A. – P16
Bellanti, J.A. – 41, P260
Allen, C. – P3 Arora, R. – P29
Bellucci, F. – 2

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SPEAKER DISCLOSURES

Beloglazov, V. – P77, P234 Buelow, B. J. – P131 Chefitz, D. – P166

Bensch, G. – P288, P294 Buenfil Lopez, J.A. – P16 Chekan, V. – P90
Berger, W.E. – P294 Bukhari, A. – P92 Chen, M. – P64
Bergerson, J. – P200 Bundy, V. – 40 Chiarella, S.E. – P23
Bernstein, D. – P38, P41 Burch, T.C. – 53 Chokshi, N. – P283
Bernstein, J. A. – 10, P184 Burke-Mcgovern , S. – P198 Chong, M.H. – 39, P196
Bewtra, A. – P47 Bush, J.S. – 58 Chotikanatis, K. – P31, P93, P309
Bhatti, H. – P220 Buterleviciute, N. – P18 Chowdhary, A. – 22
Biagini Myers, J.M. – P38 Buyantseva, L. – P221 Christine, K. – P157
Bielory, B.P. – 51 Byrd, R. – P174 Chumpitazi, B.P. – P212
Bielory, L. – 33, 51, P40, P281, P290 CaJacob, A. – P3 Ciaccio, C. – 42, 52
Bilaver, L. – P252 Cakir, E. – P52, P127 Cianferoni, A. – P255
Bird, J. A. – P115 Calais, C.J. – 38 Cicero , C. – P223
Bisyuk, Y. – P77 Calderon, L.I. – P223 Ciesielska, M. – 61
Bjermer, L. – 61 Caldwell, J.W. – P25 Ciminera, P. – P123
Blaziene, A. – P18 Camacho Ordonez, N. – P251 Clay, K.G. – P63
Bleecker, E.R. – P66 Camacho, J.M. – P230 Cohn, L.A. – P82
Blumenstock, J. – P252 Capitle, E. – P197, P319 Collins, C. – P24
Bodner, S. – P273 Capriati, T. – 2 Columbo, M. – P298
Bolgar, B. – P209 Carino Cartagena, D.A. – P7, P53, Commins, S.P. – 43
P130, P178, P318, P322
Bollard, C.M. – P212 Conboy, E. – 36
Carlton, B.G. – 20, P268
Bonagura, V.R. – 29, P112, P159 Conner, K. – P153
Carr, T.F. – P165
Bonds, R. – P143 Cook, K. – P243
Caruthers, C. – P192
Borja-Aburto, V.H. – 60, P70 Corrente, S. – P248
Casillas, A. – P262
Bornstein, L. – P185, P237 Corrigan, C.J. – P66
Casper, J. – P224
Bose, S. – P181 Coscia, G. – P201
Casper, R. – P122
Bozoghlanian, V. – P314 Craig, T.J. – P99, P163, P221, P292
Castillo Narvaez, G. – P311, P313
Brady, S.P. – P146 Craig, V. – P166
Cavanaugh, P. – 5
Braunstein, M.Z. – P39 Crandall, L. – 24
Cavero Chavez, V. – P228
Brensilver, J. – 33 Crans Yoon, A. – 19
Celestin, J. – P206
Breslin, M. – P232 Crawford, W. – 19
Cervantes, M. – P263, P270
Brooks, J. – P132 Crisp, H.C. – 13
Challa, S. – 33
Brown, K.R. – P195 Cristiano, L.M. – P25, P26
Chang, C. – P82
Brown-Whitehorn, T.F. – P255 Cron, R.Q. – P166
Chase, J. – P258
Bruner, K.E. – P245 Cuervo Pardo, L. – 17, P121
Chatterjee, P. – 29
Buatti Small, M. – P48 Cunningham-Rundles, C. – 30,
Chau, A.S. – P112 P100, P187, P213, P230
Buddiga, P. – P176
Chaudhry, S. – P273 Cunnion, K.M. – 53

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SPEAKER DISCLOSURES

Curtiss, M.L. – P207 DuBuske, L.M. – 12, P18, P77, P78, Finkas, L. – P117
P89, P90, P91, P233, P234, P235,
Cyr, M. – P276 P236, P237, P307, P308 Fiocchi, A. – 2, P248
Czecior, E. – P307 Duff, C. M. – P218 Firestone, L.E. – P260
Dahdah, L. – 2, P248 Duse, M. – 47, P278 Flores Ruvalcaba, C.N. – P311,
P313
Dara, J. – P161, P240 Dutmer, C. – P118
Foca, M. – P201
Dass, K. – P13, P331 Duzh, E. – P91
Fonacier, L. – 27, 39, P152, P196
DaVeiga, S.P. – 4, P144 Egan, M. – P187
Forastiere, G. – P278
Davidovich, G. – P91 Egea, E. – 28, P65
Foster, P. – P72
Davis, C.M. – 41 Egea, G.E. – 28, P65
Franxman, T. – P111
Davis-Lorton, M. – 27, 39, P196 Eisen , D. – P195
Freiler, J. – P245
de Vos , G. – 25 Ellis, A.K. – 55, P34
Frieri, M. – P103, P323
DeFelice, M. – P97 Enciso-Pelaez, S. – P100
Fuleihan, R. – P200
Del Rio, B.E. – P75, P223 Ender, K. – P201
Gaisenyuk, F. – P233
Del Río, J. – P75 Engel, M. – P294
Galowitz, S. – P97
Demirdag, Y. – P201 Erwin, E.A. – 43, 49
Ganim, R. – P173
Deol, S. – P154, P179 Escamilla, J. – P65
Garavito de Egea, G. – 28, P65
Derkach, V. – P316 Esquivel, B. – P210
Garcia Buheis, M. – P283
DeSantiago-Cardenas, L. – 44 Estrada-Aguilar, J.L. – P70
García Cruz, M.H. – P251, P263,
Descartes, M. – P3 Ettinger, A. – P169 P269
DeWaters, A. – P67 Fajt, M. – P249 Garcia, M. – P270
Dhar, M. – 11 Fang, L. – 28, P65 Garcia-Lloret, M. – 40, P232
Di Coste, A. – P278 Farri, F. – P134 Gard, L. – 52
Di Giorgi, B.K. – P312 Farzan, S. – P194 Gasataya, V. – P108
Diamanti, A. – 2 Fasano, M. – 63, P47 Gaur, S. – 22
Diaz, J.M. – 29 Fatteh, S. – P102, P109, P114 Gavino, A.C. – P262, P283
Diliberto , N.Z. – 41, P260 Fausnight, T.B. – P119 Gawlik, R. – P307
Dillard, K. – P107 Fenny, N. – P23, P175 Gedik, A. – P52, P127
DiMaio, C. – P280 Ferastraoaru, D. – P106, P140, P222 Geh, E. – 10
Ditto, A. – P331 Ferguson, P. – 63 Gelfand, E. – P118
Dodam, J. – P82 Fernandez, D. – P10 Geng, B. – 32, 40, P232
Donnenfeld, E. – 51 Fernandez, J. – P121 George, E. – P84
Doshi, A. – P253 Fernandez de Cordova Aguirre, J. – Ghably, J.G. – P174
Draikiwicz, S. – P197 P7, P53, P130, P178, P318, P322
Ghaffari , G. – P132, P142
Drannik, G.N. – P89, P233, P235, Festic, E. – 7
Gharib, A. – P85
P236 Feuille, E.J. – P205
Ghosh, B. – 17
Dreyfus, D. – P94 Fiedler, J. – P254
Ghosh, D. – 10
Driyanska, V. – P233 Fineman, S.M. – P30, P63
Giacinto Lawrence, J. – P172
Dubovyi, A. – P77

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SPEAKER DISCLOSURES

Gierer, S. – P19, P160 Hamad, A. – P315 Holland, S. – P150

Gimenez, L. – 24, P5 Hamadani, S. – P126 Hopp, R. – P72
Gipson, K. – P141 Hamilton, R. – 43 Horner, C.C. – P129
Glancy, E. – P10, P98 Hamzavi Abedi, Y. – P60 Howarth, P. – P48
Gleeson, P.K. – P68 Hancharou, A. – P88, P90, P91 Hsu, A. – P150
Glick, S. – P93 Hanna, M. – P61 Hu, X. – P81
Gober, L.M. – P255 Hanson, I.C. – P107, P212 Hudes, G. – P106, P140
Goebel, M. – P41 Hanson, J. – 62 Humphrey, A.L. – 42
Gogna, M. – P148 Harada, L. – P252 Hwangpo, T. – P207
Goldberg, B.J. – P247 Harris, R. – P54 Imaoka, M. – P44
Gomez, R.A. – P244, P245 Harte, L. – P69 Imperato, G. – P202
Gong, A. – 19 Hartman, H.N. – P5, P224 Imran , M. – P19
Gonzalez de Alfonzo, R. – P87 Hartz, M. – P170 Indinnimeo, L. – P278
Gonzalez Díaz, S. N. – P16 Hasan, S. – P283 Irizarry Alvardo, J. – 3
Gonzalez Flores, S. – P53, P130, Hauk, M. – P279 Ishmael, F. – P20
P322
Heimall, J. – 64, P9 Iwanaga, T. – P44
Gonzalez ibarra, M. – P313
Helfner, L. – P112 Jacobs, J. – P32
Gonzalez-Estrada, A. – 17, P10,
P121 Helfner, L. – P86 Jacobs, R. – P305

Gonzalez-Flores, S. – P7, P178, P318 Henao, M.P. – P67, P280 Jain, V. – P110

Gordienko, A.I. – P234 Henrickson, S.E. – 64, P239 Janakiram, M. – P106

Gourgy-Hacohen, O. – P32 Henry, T. – 63 Jara, D.A. – 11

Graber, J. – P140 Hernandez Robles, M. – P16 Jesena, A. – P108

Grant, A. – P116 Hernandez-Ramirez, C. – P79 Jiang, N. – P35

Green, T. – 50 Hernandez-Sanchez, H. – P16 Jiao, J. – P129

Greenbaum, J. – P276 Hershey, G.K. – P38 Jin, J. – 36

Greos, L. – P57, P62, P295 Herzog, R. – P185, P237 Joglekar, A.V. – 26

Guha, K. – P174 Higgins, V. – P58 Johnson, C. – 63

Gundling, K. – P133 Hill, J.L. – P165 Johnson, K.E. – P71

Gupta Louis, A. – P85 Hilton, R.P. – 59 Joks, R. – P31, P39, P309

Gupta, M. – 29, P144 Hintermeyer, M. – P224 Jongco, A.M. – P86, P112, P216,
P273
Gupta, R. – 44, P135, P252 Hirsch, A. – 45
Jorge , Y. – 25
Gupta, S. – P85 Hirsch, D. – P159
Joseph, M. – P145
Gurung, P. – P173 Ho, S. – 1
Joshi, A.Y. – 35, 36, P170, P238
Gutiérrez-Ceniceros, M. – P100 Hoban, M.D. – 26
Joshi, N.P. – P110
Gutta, R. – P314 Hobsbawn, B. – P34
Joychan, S. – P13
Haaland, D.A. – P149 Hogan, M. – P282
Jyonouchi, S. – 64, P239
Hall, P. – P29 Holcombe, J.M. – 20, P268
Jyothirmayi, G. – P319

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SPEAKER DISCLOSURES

Kachru, R. – 40 King, E. – 33 LeMasters, G.K. – P38

Kagen, S. – P36 Kishikawa, R. – P44 Lemiere, C. – 61
Kalinina, N.A. – P236 Klaustermeyer, W.B. – P124 Leonard, S. – P253
Kamili, Q. – 18, P283, P321, P324 Kleva, A. – P216 Leonardi, L. – 47
Kankirawatana, S. – P1 Koatz, A.M. – P59 Levy, D. – P314
Kannan, J. – P184 Kobrynski, L. – P217 Li, J. – P195
Kapila, A. – P174 Kohn, D.B. – 26 Li, M. – P126, P138, P139
Kaplan, B. – P188 Koterba, A. – P211 Li, Z. – P206
Kaplan, M. – P258 Kreiner, R. – P208 Liacouras, C.A. – P255
Kappagoda, S. – P150 Kremenska, L.V. – 12, P237 Lin, C.K. – P103, P247
Karam, M. – P111 Kremer, C. – 63 Lin, S.K. – P119
Karikari, K. – P292 Kreuz, W. – P274 Linauskiene, K. – P18
Karpel, J. – P288 Krishna, N.K. – 53 Lindgren, K. – P153
Katayeva, I. – P93 Krishnaswamy, G. – P26 Lippo de Becemberg, I. – P87
Katial, R. – P117 Kristofek, L. – P209 Littlefield, M. – 27
Katta, A. – P193 Kubiak, C.D. – P214 Liu, A. Y. – P24, P150, P151
Katta, R. – P321, P324 Kumar, A. – P190 Logsdon, S. – P104
Kau, A.L. – P129 Kumar, K. – 46 Lomas, J.M. – P15, P136
Kaygusuz, S. – P52 Kumar, R. – 56 Looney, R.J. – P15, P136, P231
Kearns, S. – P209 Kuo, C.Y. – 26 Love, T. – P22
Kelbel, T. – P20 Kurchenko, A. – P89 Lucas, R. – 23
Kelly, B.T. – 24 Kurmaeva, N. – P78 Lundberg, C. – P105
Kelly, K.J. – 24 Kurz, J. – P155 Luster, S. – P306
Kempe, E.E. – P272 Kwong, J. – P166 Maccia, C. – P169
Kern, J. – P306 LaBarba, S. – P202, P203 Mack, D.P. – P61
Kerstjens, H.A. – P294 Lanford, E. – P155 Maddox, D. – P11
Khaliq, A. – P4 Lang, D.M. – 17 Maglione, P.J. – 30
Khan, D.A. – P154, P179 Lanser, B.J. – P2 Maik, J. – P290
Kharod, N. – P12 Leal Villarreal, L. – P16 Makris, C.M. – P1
Khoiny, N. – P258 Lecompte, N. – 28, P65 Maldonado Ríos, V.A. – P251
Khojah, A. – P92 Lee, B. – 62 Maleeva, A. – 12
Khokhar, A. – P202 Lee, D. – P303 Malinow, I. – P312
Kiehm, J. – P188 Lee, J. – P255, P303 Mangi, M. – 7
Kim, A.B. – P325, P327 Lee, J.X. – P124 Maples, K.M. – 53
Kim, J.K. – P179 Lee, T. – P162 Marchisotto, M. – P252
Kim, K. – P285 Lee-Kim, C. – P101 Marshall, G.D. – P229
Kim, S.J. – P247 Leiding, J.W. – P214, P218 Martinez, J. – P19

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SPEAKER DISCLOSURES

Martinez-Saguer, I. – P274 Morales, M.B. – P60 Nugent, M. – 24

Maskatia, Z. – P283 Morgal, N.F. – P108 Nunez, M. – 60
Maspero, J. – 61 Moroni-Zentgraf, P. – P294 Nursoy, M. – P52, P127
Mathew, A. – P31 Mortezavi, M. – P15, P136, P231 Nwaobasi-Iwuh, E. – P171
Mathur, A. – P95 Motosue , M.S. – P186 Nyalwidhe, J.O. – 53
Mawhirt, S.L. – P196 Motruk, I.I. – 12, P237 Nyrimanov, K.R. – P235
May, S.M. – P170 Mourad, A.A. – P8 Obase, Y. – P44
Mayer, M. – P299 Mueller, J. – P173 O'Brien, C. – 61
Mazzina, O. – 2, P248 Murphy, H. – 62, P49, P69 Ocampo, T. – P164
McCracken, J. – P183 Murray, D. – 36 Occasi, F. – 47
McDonald, M. – 51 Musatova, K.V. – 12, P237 Ochoa, A. – P137
McGoey, B.A. – P279 Mutnick, J.L. – P271 Ogbogu, P.U. – 49
McGrath, K. – P175 Mygal, L.A. – P236 Olsen, J. – P72
McMorris, M. – P111, P113 Nagar, S. – 56 Omana, V. – 55
McNeil, D. – 8 Nagarajan, S. – P40, P281 Onyango, N. – P292
Mehta, R.S. – 1 Naik, P. – P152 Orson, F. – P262
Mehto, U. – 56 Nakahiro, R. – 19 Ortega-Gonzalez, A. – P79
Melendez, S. – P75 Nasir, H. – P114 Ott, N.L. – P170
Melengu, T. – P278 Navarrete , E. – P75 Ownby, D.R. – 58
Melethil, S. – 1 Navetta, B. – P246 Oza, P. – P21
Mellado Abrego, J. – P311, P313 Nayak, D. – P23, P181 Pacheco, F. – 52
Mendez, J.A. – P14, P312 Nayak, R. – P193 Palacios, T.V. – P182
Meng, Q. – P40, P281 Nayima, V. – P242 Palamarchuk, O. – 12, P37
Metz, C. – 29 Nazari , R. – 25 Paltarackiene, V. – P18
Michelis, M. – P279 Nazario, S. – P14, P312, P330 Paris, K. – P326
Miller, L. – P110 Nebbioso, M. – 47 Parker, J. – P69
Miller, V. – P155 Netterville, A.C. – P137 Parrish, C. – P126, P138, P139
Mills, J. – 36 Nguyen, A.P. – P63 Partida , A. – P223
Minto, H. – 53 Nguyen, H. – P38 Pasha, M. – P206
Moallem, J. – 34, P93 Nguyen, Q.L. – P321, P324 Patel, R. – P48, P319
Modeste, R. – P48 Nichols, K. – 51 Patel, B. – P238
Mohiuddin, A. – P166 Nickels, A.S. – 54, P238 Patel, G. – P155
Molina Macip , M. – P251, P269 Noroski, L.M. – P283 Patel, K. – 33, P133
Montalvo Stanton , E. – 21 North, M.L. – 55 Patel, P.J. – 21
Montandon, S. – 50 Nsouli, S.T. – 41, P260, P286 Patel, S. – P101, P165, P171
Moore, L.E. – P241 Nsouli, S. – P304 Patrimonio, M. – P108
Moorthy, L.N. – P166, P169 Nsouli, T.M. – 41, P260 Paul, R.S. – P167

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SPEAKER DISCLOSURES

Paull, K. – P212 Pratt, R. – P276 Rivero Yeverino, D. – P269

Pavlov, K. – P88 Price, R. – P211 Rivkina, V. – 44
Pavon Romero, G.F. – P251, P263, Prikhodko, A. – 12 Roberts, R. – P232
P269, P270
Prince, B. – P17, P200 Robertson, D.M. – P219
Pavord, I.D. – P66
Pun, T. – P110 Rodenas, M. – P42
Pazheri, F. – 17, P125
Qamar, N. – P188 Rodinkova, V.V. – 12, P37
Pelz, B. – P200
Quezada-Chalita, C. – P100 Rodrigues, E. – 3
Peng, T. – P166, P169
Quirt, J.A. – P149 Rodrigues, J.M. – P193
Pepose, J. – 51
Rabinovitch, N. – P2 Rodríguez Gaspar, J.I. – P263
Perez Estrella , Z. – P251
Radojicic, C. – P98 Rodriguez, I. – P270
Perkins, A.M. – 53, P60
Rael, E. – P64, P67, P68, P280 Rodríguez-Roa, M. – P312, P330
Perlov, O. – P149
Rafi, A. – P124, P167 Rogers, S. – 37
Persaud, Y.K. – P134
Ramanava, I. – P91 Rohr, A. – P298
Peterburgskiy, V.F. – P236
Ramírez Jiménez, F. – P251, P263, Rojo-Gutierrez, M. – P311, P313
Peters, A. – P17, P175 P269
Romanova, A. – P276
Petrov, A. – P249 Ramirez Rojo, P. – P311
Rosa, J.S. – P150, P151
Petrovic, A. – P214 Ramirez, F. – P270
Rosenbaum, R. – P208
Petz, Z. – P308 Ramos, C. – P312
Rosenstreich, D.L. – P222
Phillips, E. – 63 Rampur, L. – P180
Rosenthal, D.W. – P128
Pichardo , Y. – 25 Randolph, C.C. – P94
Rosner, G. – P128
Pike, J. – P58 Rans, T. – 13, P164
Rossen, R. – P262
Pimentel , C.M. – P312 Raphael, G. – P73, P74
Routes, J. – P224
Piper, K. – 63 Raschal, S. P. – 20, P268
Roy, T. – P174
Pirani, Z. – P147 Rascon-Pacheco, A. – 60
Rubinstein, A. – P161, P180, P208,
Pityn, P. – 9 Rashid, Q. – P116 P240
Placeres-Uray, F.A. – P87 Rassbach, W.M. – P250 Ruffner, M.A. – P254
Platts-Mills, T.A. – 43, 49 Ravi, A. – P11 Ruiz Morales, R.D. – P251
Polanco , P. – 25 Reddy, M. – 42, 62, P49, P69, P191 Rumelhart, S. – 63
Pollard, S. – P29 Reddy, V. – P99 Ryan, P.H. – P38
Ponda, P. – P172, P202, P203 Regan, J. – P168 Saadia, T.A. – P309
Pongdee, T. – 3 Rehuretska, R. – P89 Saifi, M. – P115
Poowuttikul, P. – 31, P220 Reiss, A. – 27 Salapatek, A. – P48
Poroshina, T.V. – P235, P236 Ren, Z. – P180 Saltoun, C. – P23, P181
Porta, D. – P278 Reponen, T. – P38 Salvatore, S. – P248
Portnoy, J.M. – 11, P257 Riccardi, C. – P248 Sanchez Borja, M. – 28
Potter, L. – 37 Richler, A.L. – 25 Sanchez de la Vega Reynoso, P. –
P251
Potthast, J.K. – P214 Ringwala, S. – P102, P109, P114
Sandoval, E. – P100
Prasad, R. – 56 Rishi, R. – P102, P109, P114

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SPEAKER DISCLOSURES

Sands, M. – P12 Sherr, J. – P24 Strothman, K. – P120, P272

Sangidorj, B. – P316 Shih, J. – P147 Stukus, D. – 50, P272
Saucedo , O. – P223 Shimoda, T. – P44 Subramanian, A. – P10
Savchenko, V.S. – P235, P236 Shroba, J. – 42 Sudano, D. – P165
Schaefer, D. – 32 Shtessel, M. – P140 Sundaresan, A. – 45
Schatz, M. – 19 Shuker, M.M. – P255 Sur, S. – P183
Scherr, R. – P282 Shum, M. – P309 Swann, J. – P71
Scherzer, R. – P120, P272 Sidhu, M. – P110 Ta, V. – P110
Schlegel, C. – P183 Simpson, P. – 24 Taborga, M. – P323
Schmidt, H. – P294 Sindher, S.B. – 4, P9 Tallar, M. – P224
Schmidt, J. – P321 Singh, K. – 56 Tamuz, M. – P273
Schneider, L. – P104 Sivaprasad, U. – P38 Tan, J. – P41
Schroer, B. – P125 Slack, M. – 49 Tartibi, H.M. – P215
Schussler, E. – P199 Slavin, R. – P193 Ten-Boquera, R. – P133
Schwartz, B. – 45 Slavyanskaya , T. – P316 Tentler , A. – 21
Scierski, W. – P307 Small, M. – 17, P10, P58 Teran Juarez , L.M. – P251, P263,
P269, P270
Scott, L. – P126, P138, P139 Snyder, M. – 36
Thethi, A. – 3
Scotten, M. – P160 Solanki, M. – 29
Thiele, J. – 55
Secord, E. – 31, P220 Soliman, M. – 55
Thobani, S. – P126, P138, P139
Segal, M. – P96, P135 Son, H. – P83
Thompson, J.C. – P6
Seidu, L. – P209 Sonza, S. – P108
Tingen, M.S. – 58
Sejour, R. – P273 Soti, L. – P308
Titov, L. – P88
Serban, N. – 59, P71 Speck, A. – P113
Toh, J. – P240
Shaduro, D.V. – P234 Specks, U. – 36
Travis, R. – 21
Shah, A. – 46 Spergel, J.M. – P255
Tripathi, A. – 43
Shah, D. – P177 Spriet, S. – P22
Trotter, J.R. – P214
Shah, H. – P141 Sran, S. – P323
Truong, T. – P177
Shah, N.N. – P326 Steacy, L.M. – P34
Trzil, J. – P82
Shah, S. – P155 Steele, R. – 27, P152
Tsybulkin, N. – P78
Shams, M.R. – P30, P217 Stein , B. – P168
Tsybulkina, V. – P78
Shankar, T. – P249 Stein, M. – P211
Tuano, K. – P107, P283
Shaw, G. – P174 Stepanova, N. – P233
Tucker, M.H. – P244
Sheikh, F. – P4 Steven, G. – P275, P277
Tuer, W. – P211
Sheikh, J. – 19, P258 Stevens, M. – P47, P72
Tupas, M. – P108
Shen, L. – P84 Stevens, W. – P168
Turbyville, J. – P29
Sher, J. – P196 Stokes, J. – P47
Uong, P. – P122, P157, P158
Sher, M. – P218 Storm, M. – 45
Uzuner, S. – P52

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SPEAKER DISCLOSURES

Vargas, P. – 24 Warrier, M. – P192 Wu, S. – P212, P283

Vargas-Becerra, M. – 60, P70 Wedner, H.J. – P146 Wysocki, C. – P179
Vartabedian, B.S. – P212 Weis, E. – P231 Xue, X. – 29
Vaughn, M.P. – 16 Weiss, P.F. – P166 Yanez Perez, I.V. – P16
Velasco-Medina, A. – P7, P53, P130, Weissmann, D. – P166 Yang, A. – P173
P178, P318, P322
Welch, K. – P226 Yanovitch, O. – P88
Velazquez-Samano, G. – P7, P53,
P130, P178, P318, P322 Weller, A. – P169 Yao, L. – P95

Verbsky, J. – P224 Wells, H.D. – P6 Yates, A. B. – P241

Verma, R. – P255 Wen, L. – P35 Yin, J. – P35

Vernon , N. – P142 White, A. – P245 Young, R.M. – P123

Vidal-Guzman, J. – P79 White, K.M. – P244, P245 Yu, B. – P153, P303

Visbal, L. – 28, P65 Wild, L. – P156 Yu, M. – P84

Vitale, J. – P192 Williams, D. – 62, P49 Yuksel , M. – P127

Volcheck, G. – 54, P238 Willis, L.K. – 53 Yusin, J.S. – P124, P167

Voloshyna, I. – 27 Willits, E. – 35 Zafra, H.T. – 24, P131

Vutikullird, A.B. – P55 Wilson, N. – P282 Zangrilli, J. – 61

Wada, K.J. – 50 Winkler, K. – 34 Zaragoza , J.R. – P142

Waldram, J.D. – P256 Woessner, K.M. – P110, P256 Zell, K. – 17

Walker, T.J. – P34 Wolf, R. A. – 5 Zgherea, Y. – P19

Wall, L. – P141 Wolff, A. – P171 Zhao, W. – P190

Waller, J.L. – 58 Wolverton, J. – P49 Zheng, Y. – 59

Walton, T. – 32 Wong, A.K. – P126, P138, P139 Zhou, L. – P229, P241

Wang, J. – P250 Wong, D. – P157 Zibert, J.M. – P160

Wang, X. – 17 Wong, P.H. – 13, P244 Zicari, A. – 47

Waqar, S. – P194 Wonnaparhown, A. – P282 Zicari, A. – 47

Ward, B. – P190 Workman, L.J. – 43

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INDEX OF ORAL AND POSTER ABSTRACT AUTHORS
A Atkinson, P. P242
Abghari, P. 31*
Abiteboul, K. P265
Abou Baker, N. 21
Abraham, J.T. P189*
Abramowitz Saadia, T. 34
Acantilado, C. P14
Achar, K. 25, P222*
Acharya, S. P188
Adelman, B. P289
Adkins, C. P1*, P3
Agarwal, P. 22*
Agrawal, S. P85
Akande, T. P134
Akbar, S. P273
Akl, E. P190*
Al Gazlan, S. P4*
Al Jiffri, O.H. P43*
Al Otaibi, T. P4
Al-Kawas, F.H. 41
Aleem, S. 63*
Alfonzo, M. P87
Alhashim, S. P4
Ali, A. P96*
Alkhatib, F. P219*
Allen, C. P3
Allen, N. 23
Allenbrand, R. 52
Alpan, O. P92
Altrich, M. P6*
Amar, N.J. 14, P305
Ambrus, J.L. P84
Amin, A. P287*
Amin, R. P4
Amistani, Y. P264
An, W. 24
Anand, R. P84*
Anderson, J.J. 9*
Anderson, J. P3
Anderson, J.T. P207
Anderson, L. P167
Andreae, D.A. P213*
Andujar-DeLaCruz, J. P166
Angeles-Garay, U. 60, P79
Anghel, S. 33
Ansary, F.F. P163*
Anthony, K. P156*
Antonevich, N. P90
Antonova, E. 57, P80, P317
Antonova, J. P46, P320
Anyane-Yeboa, K. P201
Aquino, M. 27, 39, P152, P196
Arakali, S. P197
Arias Cruz, A. P16
Arora, R. P29
Arroyo-Cruz, M.E. P7, P53,
P130, P178, P318, P322
Asawa, A. P143*
Ashton, V.L. P66
Assa’ad, A. P195
AUTHOR INDEX
Borja-Aburto, V.H. 60, P70 Casper, R. P122
Avila, P. P168 Bork, K. P225 Castillo Narvaez, G. P311,
Aygören-Pürsün, E. P225 Bornstein, L. P185*, P237 P313
Bose, S. P181* Cavero Chavez, V. P228*
Bouillet, L. P225 Celestin, J. P206
B Bour, L.J. P295 Cervantes, M. P270
Bozoghlanian, V. P314* Cervantes Malagon, M.E. P263
Bachove, I.R. P204* Brady, S.P. P146* Challa, S. 33*
Baghian, S. P134 Braunstein, M.Z. P39* Chang, C. P82
Bahna, S.L. P8, P215 Brensilver, J. 33 Chang, E. P80, P317
Baik, J. P327* Breslin, M. P232 Chase, J. P258
Bajpai, S. P48 Broder, M. P80, P317* Chatterjee, P. 29
Baker, J. 8 Brooks, J. P132* Chau, A.S. P112*
Baldwin, J. P111 Brown, K.R. P195* Chaudhry, S. P273
Banerji, D. P284 Brown-Whitehorn, T.F. P255 Chefitz, D. P166
Banks, T. P22, P105 Bruner, K.E. P245* Chekan, V. P90
Bansal, V. 7 Buatti Small, M. P48, P66 Chen, H. P45
Bantz, S. P42 Buddiga, P. P176* Chen, M. P64*
Barbir, A. 6* Buelow, B.J. P131* Chiarella, S.E. P23*
Bardelas, J.A. 15 Buenfil Lopez, J.A. P16 Chipps, B.E. P50*, P51*
Barnes, C.S. 11, 52* Bukhari, A. P92 Chokshi, N. P283
Barth, R. P31 Bundy, V. 40* Chong, M.H. 39*, P196*
Bauer, C. 24 Burch, T.C. 53 Chotikanatis, K. P31*, P93,
Bayer, D. P283 Burden, A. P66 P309
Beattie, E. 48 Burke-Mcgovern, S. P198* Chowdhary, A. 22
Becerril-Angeles, M. P70*, Bush, J.S. 58* Christine, K. P157
P79, 60 Chumpitazi, B.P. P212
Busse, P. P162, P199
Bellanti, J.A. 41, P260 Chyung, Y. P289*
Buterleviciute, N. P18
Bellucci, F. 2 Ciaccio, C. 42, 52
Buyantseva, L. P221*
Beloglazov, V. P77, P234 Cianferoni, A. P255
Bygum, A. P225
Bensch, G. P57*, P288, P294 Cicardi, M. P225, P291
Byrd, R. P174
Berger, W.E. P294, P301*, Cicero, C. P223
P305* Ciesielska, M. 61
Bergerson, J. P200* C Ciminera, P. P123
Berkes, E. P328, P329 Clay, K.G. P63
Berman, G. P259 Caballero, T. P225 Cohn, L.A. P82
Bernstein, D.I. 14, P38, P41*, CaJacob, A. P3* Collins, C. P24*
P266
Cakir, E. P52, P127 Columbo, M. P298*
Bernstein, J.A. 10*, P184*, Calais, C.J. 38*
Commins, S.P. 43
P225, P300* Calderon, L.I. P223*
Conboy, E. 36
Bewtra, A. P47 Calderon, M.A. 15
Conner, K. P153
Bhatti, H. P220* Caldwell, J.W. P25
Cook, K. P243*
Biagini Myers, J.M. P38 Camacho, J.M. P230*
Corren, J. P62
Biedenkapp, J. P289 Camacho Ordonez, N. P251
Corrente, S. 5, P248
Bielory, B.P. 51* Campbell, A. P285
Corrigan, C.J. P66
Bielory, L. 33, 51, P40*, P281, Campbell, J.D. P66
P290, P306 Coscia, G. P201*
Cancian, M. P225 Coyne, T. P27, P28
Bilaver, L. P252
Capitle, E. P197 Craig, T.J. P99, P163, P221,
Bird, J.A. P115
Capitle MD, E. P319 P225*, P292
Bisyuk, Y. P77
Capriati, T. 2 Craig, V. P166
Bjermer, L. 61
Carino Cartagena, D.A. P7, Crandall, L. 24
Blaziene, A. P18 P53, P130, P178*, P318,
Crans Yoon, A. 19*
Bleecker, E.R. P66 P322
Crawford, W. 19
Blessing-Moore, J. P300 Carlton, B.G. 20*, P268*
Creticos, P. 14*
Blumenstock, J. P252 Carr, T.F. P165
Crisp, H.C. 13
Boccon-Gibod, I. P225 Carr, W.W. P295
Cristiano, L.M. P25*, P26*
Bodner, S. P273* Caruthers, C. P192*
Cron, R.Q. P166
Bolgar, B. P209 Casale, T. P295*
Cuervo-Pardo, L. 17, P121*
Bollard, C.M. P212 Casciano, J. P48*
Cuff, C. P285
Bonagura, V.R. 29, P112, P159 Casillas, A. 18
Cunningham-Rundles, C. 30,
Bonds, R. P143 Casper, J. P224
P100, P187, P213, P230
Borish, L. P182
VOLUME 113, NOVEMBER, 2014 A133
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A134
AUTHOR INDEX
Cunnion, K.M. 53
Curtiss, M.L. P207*
Cyr, M. P276
Czecior, E. P307
D Eisen, D. P195
D’Addio, A. P299*
Dahdah, L. 2*, P248
Dara, J. P161*, P240
Dass, K. P13, P331*
DaVeiga, S.P. 4, P144
Davidovich, G. P91
Davis, C.M. 41
Davis-Lorton, M. 27, 39, P196
de Vos, G. 25
Dees, J. 23
DeFelice, M. P97
Del Rio, B.E. P75, P223
Del Río, J. P75
Demirdag, Y. P201
Dennerlein, J. 6
Deol, S. P154*, P179
DePietro, M. P50, P51
Derkach, V. P316
DeSantiago-Cardenas, L. 44
Descartes, M. P3
Devillier, P. P267
DeWaters, A. P67*
Dhar, M. 11
Di Coste, A. P278
Di Giorgi, B.K. P312
Diamanti, A. 2
Diaz, J.M. 29*
Diliberto, N.Z. 41, P260
Dillard, K. P107
DiMaio, C. P280*
Ditto, A. P331
Dodam, J. P82
Donnenfeld, E. 51
Doshi, A. P253*
Dotiwala, Z. P48
Draikiwicz, S. P197*
Drannik, G.N. P235, P236
Drannik, G. P89, P233
Dreyfus, D.H. P94
Driyanska, V. P233
Du, Q. P296, P297
Dubovyi, A. P77
DuBuske, L.M. 12*, P18*,
P37*, P77*, P78*, P88*,
P89*, P90*, P91*, P233*,
P234*, P235*, P236*,
P307*, P308*
Duff, C.M. P218*
Duncan, E. P27, P28
Durham, S. P257
Duse, M. 47*, P278*
Dutmer, C. P118*
Duzh, E. P91
A134 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
E Furcha, R. P287
Ebeling, M. P261
Egan, M. P187*
Egea, E. 28, P65*
Egea, G.E. 28*, P65
Eisner, M.D. P45
Ellis, A.K. 55*, P34
Enciso-Pelaez, S. P100
Ender, K. P201
Engel, M. P288, P294, P295
Engl, W. P227
Erwin, E.A. 43, 49
Escamilla, J. P65
Esquivel, B. P210*
Estrada-Aguilar, J.L. P70
Ettinger, A. P169
F Gawlik, R. P307
Fajt, M. P249
Fang, L. 28, P65
Farkas, H. 8, P225
Farri, F. P134*
Farzan, S. P194
Fasano, M. 63, P47
Fatteh, S. P102, P109, P114
Faucette, R. P289
Fausnight, T.B. P119
Fenny, N. P23, P175*
Ferastraoaru, D. P106*, P140,
P222
Ferguson, P. 63
Fernandez, D. P10
Fernández de Córdova-
Aguirre, J.C. P7, P53*,
P121, P130*, P178,
P189, P318*, P322*
Ferreira, M.B. P225
Festic, E. 7
Feuille, E.J. P205*
Fiedler, J. P254
Fineman, S.M. P30, P63
Finkas, L. P117*
Fiocchi, A. 2, 5, P248*
Firestone, L.E. P260
Fitzpatrick, A. 18
Flores Ruvalcaba, C.N. P311*,
P313
Foca, M. P201
Fonacier, L. 27, 39, P152,
P196
Forastiere, G. P278
Ford, L. P288
Foster, P. P72
Franklin, K.B. P296, P297
Franxman, T. P111
Freiler, J. P245
Frieri, M. P103, P323
Fuleihan, R. P200
G Greenbaum, J. P276
Gaisenyuk, F. P233
Galowitz, S. P97*
Ganim, R. P173
Garcia, E. 18*
Garcia, M. P270
Garcia Buheis, M. P283
García Cruz, M.D. P251
García Cruz, M.H. P269, P263
Garcia-Lloret, M. 40, P232
Gard, L. 52
Garner, L. P261
Gasataya, V. P108
Gaur, S. 22
Gavino, A.C. 18, P283*
Gawchik, S. P302
Gedik, A. P52, P127
Gedrich, R.W. P82
Geh, E. 10
Gelfand, E. P118
Geng, B. 32*, 40, P232*
George, E. P58*, P84
Gever, L. P58*, P299, P300,
P301
Ghably, J.G. P174*
Ghaffari, G. P132, P142
Gharib, A. P85*
Ghosh, B. 17
Ghosh, D. 10
Giacinto Lawrence, J. P172*
Gierer, S. P19, P160
Gillespie, M. P55
Gimenez, L. 24, P5
Gipson, K. P141
Glancy, E. P10, P98*
Gleeson, P.K. P68*
Glick, S. P93
Gober, L.M. P255
Goebel, M. P41
Gogna, M. P148*
Goldberg, B.J. P247
Golden, D.B. P265*
Gomez, R.A. P244, P245
Gong, A. 19
Gonzalez de Alfonzo, R. P87
Gonzalez Díaz, S.N. P16
Gonzalez ibarra, M. P313
Gonzalez-Estrada, A. 17*, P10,
P121
Gonzalez-Flores, S. P53, P130,
P178, P318, PP322
González-Flores, S. P7
Gopalan, G.H. P66
Gordienko, A.I. P234
Gourgy-Hacohen, O. P32*
Graber, J. P140
Grant, A. P116
Grant, J.A. P227
Green, T. 50
Greos, L. P57, P62*, P295
Grier, T.J. P27*, P28*
Guha, K. P174
Guilarte, M. P225
Gundling, K. P133
Gupta, M. 29, P144*
Gupta, R. P135*, 44*, P252*
Gupta, S. P85, P227
Gupta Louis, A. P85
Gurung, P. P173
Gutiérrez-Ceniceros, M. P100
Gutta, R. P314
H
Haaland, D.A. P149
Hadari, Y. P82
Hall, D. P27, P28
Hall, P. P29
Hamad, A. P315*
Hamadani, S. P126*
Hamilton, R. 43
Hampel, F. P302
Hamzavi Abedi, Y. P60*
Hancharou, A. P88, P90, P91
Hanna, M. P61*
Hanson, I.C. P107, P212
Hanson, J. 62*
Harada, L. P252
Harris, R. P54*
Harrow, B. P58
Harte, L. P69
Hartman, H.N. P5*, P224
Hartz, M. P170
Hasan, S. P283
Haselkorn, T. P45
Hauk, M. P279
Heimall, J. 64, P9
Helfner, L. P86*, P112
Henao, M.P. P67
Henao, P. P280
Hendershot, R.W. 23
Hendrickson, B. P285
Henrickson, S.E. 64*, P239*
Henry, T. 63
Henson, M. P328, P329
Hernandez Robles, M. P16
Hernandez-Ramirez, C. P79*
Hernandez-Sanchez, H. P16*
Hershey, G.K. P38
Herzog, R. P185, P237*
Higgins, V. P58
Hill, J.L. P165*
Hilton, R.P. 59
Hintermeyer, M. P224
Hirsch, A. 45
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A135

AUTHOR INDEX

Hirsch, D. P159* K Krishna, N.K. 53 Longhurst, H. P225

Ho, S. 1 Krishnan, J. P48 Looney, R.J. P15, P136, P231
Hoban, M.D. 26 Kachru, R. 40 Krishnaswamy, G. P26 Love, T. P22
Hobsbawn, B. P34 Kagen, S. P36* Kristofek, L. P209 Lubeski, C. P82
Hogan, M. P282 Kalinina, N.A. P236 Kubiak, C.D. P214* Lucas, R. 23*
Holcombe, J.M. 20, P268 Kamili, Q. 18*, P283, P321*, Kulich, K. P284 Lundberg, C. P105*
Holland, S. P150 P324* Kumar, A. P190 Luster, S. P306
Hopp, R. P72 Kankirawatana, S. P1 Kumar, K. 46*
Horak, F. P266 Kannan, J. P184 Kumar, R. 56*
Horner, C.C. P129 Kapila, A. P174 Kuo, C.Y. 26* M
Howarth, P. 48 Kaplan, A. 57* Kurchenko, A. P89
Kaplan, B. P188 Kurmaeva, N. P78 Maccia, C. P169
Hsu, A. P150
Kaplan, M. P258 Mack, D.P. P61
Hu, X. P81* Kurz, J. P155
Kappagoda, S. P150 Kwong, J. P166 Maddox, D. P11
Hudes, G. P106, P140
Karafilidis, J. P57, P62 Magerl, M. P225
Hulsey, T. P261
Karam, M. P111* Maglione, P.J. 30*
Humphrey, A.L. 42*
Karikari, K. P292 L Maik, J. P290*
Hwangpo, T. P207
Karpel, J. P288 Makris, C.M. P1
Katayeva, I. P93* LaBarba, S. P202, P203* Maldonado Ríos, V.A. P251
I Katial, R. P117 LaForce, C. P73* Maleeva, A. 12
Katta, A. P193 Lanford, E. P155 Malinow, I. P312
Iarrobino, R. P289 Katta, R. P321, P324 Lang, D.M. 17 Maloney, J. 14, 15, P257,
Imaoka, M. P44 Kau, A.L. P129 Lanier, B.Q. P259 P259*, P266
Imperato, G. P202* Kaur, A. 14, 15, P257, P259 Lanser, B.J. P2* Mandel, E.M. P82*
Imran, M. P19* Kaygusuz, S. P52 LaVallee, T. P82 Mangi, M. 7*
Indinnimeo, L. P278 Kearns, S. P209* Lawrence, M. P182 Maples, K.M. 53*
Iribarren, C. P45 Kelbel, T. P20* Leal Villarreal, L. P16 Marchisotto, M. P252
Irizarry Alvardo, J. 3 Kelly, B.T. 24* Lecompte, N. 28, P65 Marshall, G.D. P229
Ishmael, F. P20 Kelly, K.J. 24 Lee, B. 62 Martinez, J. P19
Iverson, H. P56, P73, P74, P76 Kempe, E.E. P272* Lee, D. P303 Martinez-Saguer, I. P225,
Iwanaga, T. P44 Lee, J. P303 P274*
Kenniston, J. P289
Lee, J.X. P124* Maskatia, Z. P283
Kern, J. P306*
Lee, J. P255* Maspero, J. 61*
Kerstjens, H. P288
J Lee, T. P162* Mathew, A. P31
Kerstjens, H.A. P294, P295
Lee-Kim, C. P101* Mathur, A. P95*
Khalil, S. 57
Jacobs, J. P32 Leibl, H. P227 Mawhirt, S.L. P196
Khaliq, A. P4
Jacobs, R. P305 Leiding, J. P218 May, S.M. P170*
Khan, D.A. P179, P154
Jain, N. P158 Leiding, J.W. P214 Mayer, M. P299
Kharod, N. P12*
Jain, V. P110 LeMasters, G.K. P38 Mazzina, O. 2, 5, P248
Khoiny, N. P258*
Janakiram, M. P106 Lemell, P. P266 McCracken, J. P183*
Khojah, A. P92*
Janelli, M. 6 Lemiere, C. 61 McDonald, M. 51
Khokhar, A. P202
Jara, D.A. 11* Leonard, S. P253 McGoey, B.A. P279
Kiehm, J. P188*
Javoronok, S. P88 Leonardi, L. 47 McGrath, K. P175
Kim, A. P325*
Jesena, A. P108 Levy, D. P314 McMorris, M. P111, P113
Kim, A.B. P327
Jiang, N. P35* Li, C. P48 McNeil, D. 8
Kim, J.K. P179*
Jiao, J. P129* Li, H. 8* Mehta, R.S. 1
Kim, K. P285
Jin, J. 36* Li, J. P305, P195 Mehto, U. 56
Kim, S.J. P247*
Joglekar, A.V. 26 Li, M. P126, P138, P139 Meier, E.J. P293*
King, E. 33
Johnson, C. 63 Li, Z. P206*, 14, P257, P266 Melamed, I. P227
Kishikawa, R. P44
Johnson, K.E. P71* Liacouras, C.A. P255 Melendez, S. P75*
Klaustermeyer, W.B. P124
Joks, R. P31, P39, P309 Lin, C.K. P247 Melengu, T. P278
Kleva, A. P216*
Jongco, A.M. P86, P112, P216, Lin, C. P103* Melethil, S. 1*
Koatz, A.M. P59*
P273 Lin, M. 6 Mellado Abrego, J. P311, P313
Kobrynski, L. P217, P227
Jorge, Y. 25 Lin, S.K. P119* Meltzer, E.O. P299
Koch, G. P257
Joseph, M. P145* Linauskiene, K. P18 Meltzer, S. P300
Kohn, D.B. 26
Joshi, A.Y. 35, 36, P170, P238 Lindgren, K. P153* Mendez, J.A. P14*
Koterba, A. P211*,
Joshi, N.P. P110* Lippo de Becemberg, I. P87 Méndez, J. P312
Kreiner, R. P208*
Joychan, S. P13* Littlefield, M. 27 Meng, Q. P40, P281*
Kremenska, L.V. 12, P37
Jyonouchi, S. 64, P239 Liu, A.Y. P24, P150, P151 Metz, C. 29
Kremer, C. 63
Jyothirmayi PA-C, G. P319 Logsdon, S. P104* Michelis, M. P279*
Kreuz, W. P274
Lomas, J.M. P15, P136* Miller, D.P. P45
Krier, J. P328, P329

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ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A136
AUTHOR INDEX
Miller, D. P73, P74, P76
Miller, L. P110
Miller, R. P285
Miller, V. P155*
Mills, J. 36
Minto, H. 53
Mire, B. P33
Moallem, J. 34, P93
Modeste, R. 48
Mohiuddin, A. P166
Moldovan, D. P291
Molina Macip, M. P251, P269*
Monsul, N. P328, P329
Montalvo Stanton, E. 21
Montandon, S. 50
Moore, L.E. P241*
Moorthy, L.N. P166, P169
Morales, M.B. P60
Morgal, N.F. P108*
Moroni-Zentgraf, P. P288,
P294, P295
Mortezavi, M. P15*, P136,
P231*
Motosue, M.S. P186*
Motruk, I. 12
Motruk, I.I. P37
Mourad, A.A. P8*
Mueller, J. P173
Murphy, H. 62, P49*, P69*
Murphy, K. P294*
Murray, D. 36
Musatova, K.V. 12, P37
Mutnick, J.L. P271*
Mygal, L.A. P236
N P
Nagar, S. 56
Nagarajan, S. P40*, P281
Naik, P. P152*
Nakahiro, R. 19
Naples, A. P261
Nasir, H. P114
Navarrete, E. P75
Navetta, B. P246*
Nayak, D. P23, P181
Nayak, R. P193
Nayima, V. P242*
Nazari, R. 25
Nazario, S. P14, P312, P330
Nebbioso, M. 47
Nelson, H.S. 15*, P266
Netterville, A.C. P137*
Ney, J. 32
Nguyen, A.P. P63*
Nguyen, H. P38*
Nguyen, Q.L. P321, P324
Nichols, K. 51
Nickels, A.S. 54*, P238
A136 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Nolte, H. 14, 15, P257*, P259, Pavon Romero, G. P251, P263, Ramanava, I. P91
P266* P269 Ramirez, F. P270
Nordenfelt, P. P225 Pavord, I.D. P66 Ramírez Jimenez, F. P251,
Noroski, L.M. P283 Pazheri, F. 17, P125* P263, P269
North, M.L. 55 Pearlman, D. P56 Ramirez Rojo, P. P311
Nsouli, S. P286*, P304* Pelz, B. P200 Ramos, C. P312
Nsouli, S.T. 41, P260 Peng, T. P166*, P169* Rampur, L. P180
Nsouli, T.M. 41*, P260* Pepose, J. 51 Randolph, C.C. P94*
Nugent, M. 24 Perez Estrella, Z. P251 Rans, T.S. 13, P164
Nunez, M. 60* Perkins, A.M. 53, P60 Raphael, G. P73, P74*
Nursoy, M. P52*, P127* Perlov, O. P149 Raschal, S.P. 20, P268
Nwaobasi-Iwuh, E. P171 Persaud, Y.K. P134 Rascon-Pacheco, A. 60
Nyalwidhe, J.O. 53 Peterburgskiy, V.F. P236 Rashid, Q. P116*
Nyrimanov, K.R. P235 Peters, A. P17, P175 Rassbach, W.M. P250*
Petrov, A. P249 Ratner, P. P301
Petrovic, A. P214 Ravi, A. P11*
O Petz, Z. P308 Reddy, M. 42, 62, P49, P69
Phillips, E. 63 Reddy, M.B. P191*
O’Brien, C. 61, P73, P74 Pichardo, Y. 25 Reddy, V. P99*
Obase, Y. P44 Pike, J. P58 Regan, J. P168*
Ocampo, T. P164* Pimentel, C.M. P312 Rehuretska, R. P89
Occasi, F. 47 Piper, K. 63 Reinero, C.R. P82
Ochoa, A. P137 Pirani, MD, Z. P147* Reiss, A. 27
Ogbogu, P.U. 49 Pityn, P. 9 Relan, A. 8, P291
Olsen, J. P72* Placeres-Uray, F.A. P87* Ren, Z. P180*
Omachi, T.A. 57, P45*, P320 Platts-Mills, T.A. 49, 43 Reponen, T. P38
Omana, V. 55 Plunkett, G. P33* Reshef, A. 8, P225
Onyango, N. P292* Polanco, P. 25 Reynolds, R. 23
Orson, F. 18 Pollard, S. P29 Rhodes, B. 23
Ortega-Gonzalez, A. P79 Ponda, P. P172, P202, P203 Riccardi, C. 5, P248
Ostrom, N. P56* Pongdee, T. 3 Richler, A.L. 25*
Ott, N.L. P170 Poowuttikul, P. 31, P220 Riedl, M. P291*
Ownby, D.R. 58 Porebski, G. 8 Rigazio, A. P66
Oza, P. P21* Poroshina, T.V. P235, P236 Ringwala, S. P102, P109*,
Porta, D. P278 P114
Portnoy, J.M. 11, P257 Rishi, R. P102*, P109, P114*
Potter, L. 37 Rivero Yeverino, D. P269
Potthast, J.K. P214 Rivkina, V. 44
Pacheco, F. 52
Prasad, R. 56 Roberts, R. P232
Palacios, T.V. P182*
Pratt, R. P276* Robertson, D.M. P219
Palamarchuk, O.O. 12, P37
Rodenas, M. P42*
Price, D.B. P58, P66*
Paltarackiene, V. P18
Price, R. P211 Rodinkova, V.V. 12, P37
Paolozzi, L. P264
Prikhodko, A. 12 Rodrigues, E. 3
Paris, K. P326
Prince, B. P17*, P200 Rodrigues, J.M. P193*
Parker, J. P69
Pun, T. P110 Rodriguez, I. P270*
Parrish, C. P126, P138*, P139
Rodríguez Gaspar, J.I. P263*
Partida, A. P223
Rodríguez-Roa, M. P312*,
Pasha, M. P206 Q P330*
Patel, B. P238* Rogers, S. 37*
Patel, G. P155 Qamar, N. P188 Rohr, A. P298
Patel, K. P133*, 33 Quezada-Chalita, C. P100 Rojo-Gutierrez, M.I. P311,
Patel, M.K. P296, P297* Quirt, J.A. P149* P313*
Patel, P.J. 21* Romanova, A. P276
Patel, R. 48* Rosa, J.S. P150*, P151*
Patel, S. P171*, P165, P101 R Rosenbaum, R. P208
Patel MD, R. P319* Rosenstreich, D.L. P222
Patrimonio, M. P108 Rabinovitch, N. P2
Rosenthal, D.W. P128
Paul, R.S. P167 Radojicic, C. P98
Rosner, G. P128*
Paull, K. P212 Rael, E. P64, P67, P68, P280
Rossen, R. 18
Pavlov, K. P88 Rafi, A. P124, P167
Routes, J. P224
Pavon, G. P270 Raimundo, K. 57, P46, P317,
Roux, M. P267*
P320*
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A137
Roy, T. P174 Shaw, G. P174
Rubinstein, A. P161, P180, Sheikh, F. P4
P208, P240 Sheikh, J. 19, P258
Ruffner, M.A. P254* Shen, L. P84
Ruiz, N. P57, P62, P299, P300, Sher, J. P196
P301, P302 Sher, M. P218
Ruiz Morales, R.D. P251* Sherr, J. P24
Rumelhart, S. 63 Shih, MD, J. P147
Ryan, P.H. P38 Shimoda, T. P44*
Shroba, J. 42
Shtessel, M. P140*
S Shuker, M.M. P255
Shum, M. P309*
Saadia, T.A. P309
Sidhu, M. P110
Saifi, M. P115*
Sigmund, R. P288
Salapatek, A. 48
Simpson, P. 24
Saltoun, C. P23, P181
Sindher, S.B. 4*, P9*
Salvatore, S. 5, P248
Singh, K. 56
Sanchez Borja, M. 28
Sivaprasad, U. P38
Sanchez de la Vega Reynoso, P.
Skoner, D. P259
P251
Sandoval, E. P100* Slack, M. 49*
Slavin, R. P193
Sands, M. P12
Sangidorj, B. P316 Slavyanskaya, T. P316*
Small, C. P305
Saucedo, O. P223
Small, M. P58
Savchenko, V.S. P235, P236
Smith, M.A. 17, P10*
Schaefer, D. 32
Snyder, M. 36
Schaffer, F.M. P261*
Solanki, M. 29
Schatz, M. 19
Solari, P. P46*, P80, P320
Scherr, R. P282*
Soliman, M. 55
Scherzer, R. P120, P272
Song, S. P55
Schiff, R.I. P227
Sonza, S. P108
Schlegel, C. P183
Soteres, D. P301
Schmidt, H. P294
Soti, L. P308
Schmidt, J. P321
Schneider, L. P104 Speck, A. P113*
Specks, U. 36
Schroer, B. P125
Spergel, J.M. P255
Schussler, E. P199*
Schwartz, B. 45 Spriet, S. P22*
Sran, S. P323*
Schwartz, S.A. P228
Scierski, W. P307 Stanaland, B. P302*
Steacy, L.M. P34
Scott, L. P126, P138, P139
Scotten, M. P160 Steele, R. 27*, P152
Stein, B. P168
Seare, J. 5
Secord, E. 31, P220 Stein, M. P211, P227
Steinfeld, J. P55*
Segal, M. P96, P135
Seidu, L. P209 Stepanova, N. P233
Sejour, R. P273 Steven, G. P275*, P277*
Serban, N. 18, 59, P71 Stevens, M. P47*, P72
Stevens, W. P168
Settipane, R. P302
Sexton, D. P289 Stobiecki, M. P225, P291
Stokes, J. P47
Shaduro, D.V. P234
Shah, A. 46 Storm, M. 45
Strothman, K. P120*, P272
Shah, D. P177*
Stukus, D. 50, P272
Shah, H. P141*
Subhadra, B. P328*, P329*
Shah, M. P45
Subramanian, A. P10
Shah, N.N. P326*
Sudano, D. P165
Shah, S. P155
Sun, G. P80, P317
Shams, M.R. P30*, P217*
Shankar, T. P249* Sundaresan, A. 45*
Shastri, S. P328 Sur, S. P183
Swann, J. 18, P71
AUTHOR INDEX
T Verbsky, J. P224
Verma, R. P255
Ta, V. P310* Vernon, N. P142
Taborga, M. P323 Vidal-Guzman, J. P79
Tallar, M. P224* Visbal, L. 28, P65
Tamuz, M. P273 Vitale, J. P192
Tan, J. P41* Volcheck, G.W. 54, P238
Tantry, S. P305 Voloshyna, I. 27
Tartibi, H.M. P215* von Ziegenweidt, J. P66
Tashkin, D.P. P50, P51 Vutikullird, A.B. P55
Taveras, H. P56, P73, P74, P76
Ten-Boquera, R. P133
TenHoor, C. P289 W
Tentler, A. 21
Wada, K.J. 50*
Teran, L. P270
Wahn, U. P264
Teran Juarez, L.M. P251,
Waldram, J.D. P256*
P263, P269
Walker, T.J. P34*
Thethi, A. 3*
Wall, L. P141
Thiele, J. 55
Waller, J.L. 58
Thobani, S. P126, P138, P139
Walton, T. 32
Thompson, J.C. P6
Tian, X. P296, P297 Wang, J. P250
Wang, X. 17
Tingen, M.S. 58
Tiplady, B. P284* Waqar, S. P194*
Ward, B. P190
Titov, L. P88
Warrier, M. P192
Toh, J. P240*
Wasserman, R.L. P227
Travis, R. 21
Wayne, D. P76
Tripathi, A. 43*
Weber, R. 14
Tripp, C. P285*
Wedner, H.J. P146, P291
Trotter, J.R. P214
Weis, E. P231
Trudo, F. P50, P51
Weiss, P.F. P166
Truong, T. P177
Weissmann, D. P166
Trzaskoma, B. 57, P46, P320
Welch, K. P226*
Trzil, J. P82
Weller, A. P169
Tsybulkin, N. P78
Tsybulkina, V. P78 Wells, H.D. P6
Wen, L. P35
Tuano, K. P283, P107*
White, A. P245
Tucker, M.H. P244
Tuer, W. P211 White, K.M. P244, P245
Wild, L. P156
Tupas, M. P108
Turbyville, J. P29* Williams, D. 62, P49
Willis, L.K. 53
Willits, E. 35*
U Wilson, N. P282
Winkler, K. 34*
Uong, P. P122*, P157*, P158* Woessner, K.M. P256, P310
Urdaneta, E.R. P296*, P297 Wolf, R.A. 6
Uzuner, S. P52 Wolff, A. P171
Wolverton, J. P49
Wong, A.K. P126, P138, P139*
V
Wong, D. P157
Wong, P.H. 13*, P244*
Vandewalker, M.L. P288*
Wonnaparhown, A. P282
Vargas, P. 24
Workman, L.J. 43
Vargas-Becerra, M. 60, P70
Wu, C. P285
Vartabedian, B.S. P212
Wu, M. P296, P297
Vaughn, M.P. 16*
Wu, S. P212*, P283
Velasco-Medina, A.A. P7, P53,
Wysocki, C. P179
P130, P178, P318, P322
Velazquez-Samano, G. P7,
P53, P130, P178, P318,
P322
VOLUME 113, NOVEMBER, 2014 A137
ACAAIAbstractAnnals14v4_ACAAI Abstract Book 9/25/14 9:29 AM Page A138

AUTHOR INDEX

X
Xue, X. 29

Y
Yanez Perez, I.V. P16
Yang, A. P173*
Yang, W.H. P267, P291
Yanovitch, O. P88
Yao, L. P95
Yates, A.B. P241
Yel, L. P227*
Yin, J. P35
Young, R.M. P123*
Yu, B. P153, P303*
Yu, M. P84
Yuksel, M. P127
Yusin, J.S. P124, P167*

Z
Zafra, H. 24
Zafra, H.T. P131
Zangrilli, J. 61
Zanichelli, A. 8
Zaragoza, J.R. P142*
Zazzali, J. 57, P46, P80*, P320
Zeldin, R.K. P264*, P265,
P267
Zell, K. 17
Zgherea, Y. P19
Zhao, W. P190
Zheng, Y. 59*
Zhou, L. P229*, P241
Zibert, J.M. P160*
Zicari, A. 47, 47
Zieglmayer, P. P266
Zieglmayer, R. P266
Zuraw, B. P225

A138 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY