Allergy Grand Rounds

Allergy Grand Rounds
By:Sarbjit S. Saini, M.D.
JHAAC

Chief complaint
* 13 yr old male referred in June 2004 for evaluation of severe chronic urticaria
* Referred by pediatric allergist in VA
* Significant illnesses:
o include Type I DM for 2.5 yrs
o ADHD
o mood disorder

History of Present Illness-I
History of Present Illness-II
History of Present Illness-III
Other atopic history
* No history of eczema or food allergy
* Allergic rhinitis symptoms
* Exercise-related asthma age 9 treated with prn albuterol prior to activity
* Reported qhs cough, but denied wheezing
Medications
* Zoloft, 50 mg qd**
* Oxcadazepine (Trileptal) 300 mg/600 mg **
* Adderall 30 mg bid
* Quetiapine (Seroquel) 200 mg qd
* Fexofenadine 180 mg qd ( off 1 wk)
* Cetirizine 10 mg qd ( off 1 week)
* Cyclosporine 100 mg bid (off 1 wk)
* Humulin 7 U/4 U, Humulin R 5 U/ 4 U
* Epipen, Albuterol

Past Medical History
* Type I DM for 2.5 yrs
* ADHD
* Mood disorder, possible bipolar
o exacerbated by steroids
o suicidal ideation due to urticaria
* Chicken pox as child
* Salivary gland surgery
* Normal birth history, negative history of other infections
Family History
* Younger Sister with eczema
* PGM with asthma
* Paternal cousins with asthma
Environmental Hx
* Apt dweller x 5 yrs
* Dog since 1999
* 3 hamsters

Social Hx
* 7th grader
* Lives with mom and sister
Physical Exam
* T-99.7, HR-121, BP-109/75, HT-5, WT-125,RR-22
* General: no obvious pubertal signs,central obesity, moon facies
* HEENT: “allergic shiners”,erythematous nasal mucosa, prominent turbinates
o Normal TMs, oropharynx, neck
* Resp: CTA, normal I:E ratio, CV: nl S1, S2 tachy
* Abdomen: benign Ext: no joint swelling
* Skin: urticaria on face, arms, feet, back, chest; no pigmentation

Recent labs
* CBC-WBC 7.3 HCT-41.2, Plts-331
* HbA1C-8.6 (4-6) Jan 2004
* Negative studies: ANA, H. Pylori Ab,anti-thyroid peroxidase antibodies, WESR
* Normal C3, C4, CH50; TSH, thyroxine, T3 and T4
* RASTS- negative for crab, lobster, fish garlic and insulin

Cyclosporine related labs
* Jan 2004 reduced Hct-12.1 HB- 37.2
o CsA: 37 ng/ml trough
* March 2004 Normal studies
* June 2004
o CsA: 46 ng/ml trough
o CBC, Mg, Cr, K normal
Impression/ Recommendations
* Severe CIU/angioedema h/o significant steroids requirements
o No clear drug (insulin), food or systemic etiology
o Avoiding NSAIDs
* Consider alternate diagnoses:
o Hx of autoimmunity with Type I DM
o Rheumatologic?-joint symptoms, bruising
o Obtain a skin Biopsy to verify urticaria vs. other
+ Consider immunofluorescence

Follow-up on Recommendations
* Rheum evaluation: Repeated ANA, RF, dsDNA, ANCA, Urine and SPEP- all normal
o showed IgA of < 20, no other etiology for joints
* October 04 -Csa 100 mg qd and fexofenadine with good control
* Prednisone used only single day since 6/2004
* No skin biopsy to date- attempted
* Glucose under better control
CU in children : association with thyroid autoimmunity
* 187 CU pts (6- 18 yr) followed 7.5 yrs
* Tests: CBC, sed, Chem, Antibodies to Hep B, HSV, EBV,CMV, mycoplasma, ASO, ANA, C3, C4, Thyroid function and antibodies,Ua, chest and sinus X-rays, food skin tests, ice cube test
* Results: 8/187 antithyroid Ab (4.3%), all girls
o 3x -1.27% rate seen in pediatric population
o Much less than 14 to 33% range in adults
o 5 +ANA, 4 + family Hx of autoimmunity
Cyclosporine in Urticaria
* CBC, Mg, K, renal function q 2 wks for first 3 months, CsA levels
* Gingival hypertrophy
* BP monitoring
* Dose: 2-6 mg/kg/d similar to RA and psoriasis (2.5 mg/kg/day)
* Tx dose 8 mg/kg/d; trough levels 100 ng/ml

CsA and Urticaria-RDBCT
* 30 subjects, severe CIU unresponsive to H1 tx and positive ASST ( +HRA)
o 4mg/kg CsA (n=20) or placebo (n=10) for 4 wks
o All subjects followed for up to 20 wks, all on daily 20 mg cetirizine
* Outcome: +< 25% of baseline UAS, relapse > 75% of UAS
* Results: 8/19 + at week 4, 6 relapse wk 6
o Noted reductions in HRA and ASST

CsA in CIU:Adults
* Open trial in 35 CIU with 3(0-3)
o Low dose CsA 3 mos, 68% response (13/19) with few SEs1
* DB trial :40 pts CsA 5 mg/kg x 8 wks, then 4 mg/kg x 8 wks vs. cetirizine 10 mg/d2
o All cetirizine crossed to active CsA
o 3 pts reduced CsA for Cr rise
o On tx- 22 had relapse, 10 resolved spon 12 with H1
o Off tx- 16/40 in remission at 9 mos

Immunosuppression in Adolescents: Cyclosporin
* 80% of liver, kidney, cardiac Tx > 5 yr survivors on CsA
* Nephrotoxicity: 4-5 % in cardiac and liver
o 10% in RA dosed > 4 mg/kg avg 19 mos
* HTN (20-30%)
* Hyperlipedemia (10% of cardiac)
* Post-tx lymphoproliferative disease:5-17%
* Cosmetic-Gingival hyperplasia, hirsutism

Allergy Grand Rounds.ppt