Case 1

1
Case 1

• A 30 year old diesel fitter was referred with the
  following history
• 2 years ago, 20 minutes after taking ibuprofen
  for a headache, he suffered from wheeze lasting
  for 2 hours.
• More recently, after taking some naproxen for a
  painful hand, he noted the onset of
  breathlessness, wheeze with constriction of the
  throat, leading to loss of consciousness. He
  subsequently required ventilation in the ITU.
• He had previously taken paracetamol without any
  difficulty. He complained of constant hay
  fever-like symptoms and was considered to have
  asthma (with mainly nocturnal wheeze). Current
  medications were salbutamol inhaler,
  beclomethasone nasal spray and an oral
  antihistamine (cetirizine). He kept a dog.
• Examination showed large nasal polyps on both
  sides.
• What is the diagnosis and the significance of the
  nasal polyps?
• Would any tests or investigations be useful?
• What treatment(s) could be considered?
• What advice should the patient be given?

2
Case 1

• What is the diagnosis and the significance of
  polyps?
• The diagnosis is hypersensitivity to
  non-steroidal anti-inflammatory drugs often
  associated with non-allergic rhinitis/asthma.
• Polyps are much more strongly associated with
  non-allergic than allergic rhinitis.
• Would any tests or investigations be useful?
• There are no tests for NSAID hypersensitivity,
  other than exposing the patient to the drug(s).
  These reactions are not IgE-mediated, but due to
  pharmacological hypersensitivity to
  cyclooxygenase inhibitors.
• However, these reactions occurred against a
  background of chronic rhinitis, and so testing
  for sensitisation to common aero-allergens might
  be useful this patient had a strongly positive
  skin test to grass pollens, with significantly
  elevated circulating pollen-specific IgE
  (negative to house dust mite, cat and dog). He
  had never noted any seasonal variation to his
  symptoms, so the significance of these findings
  is unclear.
• What treatment(s) could be considered?
• Nasal polyps are often very steroid-sensitive.
  This patient was given Betnesol drops, reverting
  to an aqueous steroid spray after 3 weeks. He
  gained only transient benefit and was referred
  for polypectomy. Post-surgery, he should maintain
  low-dose topical steroid treatment to avoid
  recurrence.
• What advice should be given?
• Avoid NSAIDs

3
Case 2

• A 42 year old woman was referred with a 4 year
  history of hay fever, with symptoms of rhinitis
  and asthma starting in March or April of each
  year. She had also begun to notice a sensation of
  tingling around the lips and mouth, throat
  congestion and wheeze when eating peaches, pears,
  apples, hazel nuts, carrots or celery.
• What is the diagnosis?
• Would any tests or investigations be useful?
• What treatment(s) could be considered?
• What advice should the patient be given?

4
Case 2

• What is the diagnosis?
• This is an example of allergic rhinitis with
  oral allergy syndrome, due to allergy to birch
  pollen causing symptoms on exposure to
  cross-reacting allergens in a variety of fruits,
  particularly peach, pear, apple and plum. Other
  plant-derived foods are sometimes involved, as in
  this case.
• Would any tests or investigations be useful?
• Skin prick testing showed a very strong response
  to birch pollen. Strong responses were also
  obtained to hazel nut, almond, carrot and celery.
  Extracts of the relevant fruits gave negative
  results. IgE results as follows
• total 52.4
• birch pollen 22.3
• apple 1.01
• carrot 1.3
• celery 0.8 (peach, pear and plum were negative)
• What treatment(s) could be considered?
• Because of the severity of symptoms and the
  possibility of accidental exposure, inhaled and
  injectable adrenaline were prescribed, as well as
  a supply of oral antihistamine.
• What advice should be given?
• Avoidance of allergens.

5
Case 3

• A 32 year old prison officer was referred with
  the following history
• While drinking from a can, he was stung on the
  lip by an insect. Although he said this was a
  wasp, he also said he had had to remove the
  sting.
• He rapidly developed symptoms of facial
  angioedema, itching, tightness of the throat with
  difficulty breathing, progressing to loss of
  consciousness and double incontinence within
  about 15 minutes.
• He regained consciousness in an ambulance and,
  on arrival in A/E, he was treated with
  adrenaline, hydrocortisone, chlorpheniramine and
  salbutamol. One hour later, he required further
  adrenaline for hypotension.
• He was kept in hospital for a further 5 days
  because of atrial fibrillation.
• Past medical history included anxiety attacks,
  for which he was taking propranolol.
• Investigation revealed
• Weals of 1.5 and 3 mm to wasp venom 1mm to bee
  venom
• Specific IgE of 3.37 to wasp and 54.3 to bee.
• What is the diagnosis?
• Why was his reaction so severe and prolonged?
• How should this patient be managed?

6
Case 3

• What is the diagnosis?
• Probably bee allergy
• Why was his reaction so severe and prolonged?
• reaction was severe because of his regular
  treatment with propanolol
• How should this patient be managed?
• avoidance, emergency treatment plan,
  antihistamine and epipen
• consider immunotherapy

7
Case 4

• A 42 year old childminder was referred with the
  following history
• While having dinner in a hotel, she noticed
  tingling of her lips while eating a starter of
  salmon, tomatoes, garlic and avocado (she had
  never eaten the latter before). She took an
  antihistamine and finished the rest of the meal
  which included chicken, mixed nuts and wine. On
  returning to her room, she experienced
  generalised itch and developed angioedema,
  followed by loss of consciousness. She regained
  consciousness after being given adrenaline, but
  took several days to recover completely.
• She was an atopic subject, known to suffer from
  hayfever and eczema. There was a past history of
  anaphylaxis of unknown cause, and she had
  previously experienced lip swelling after blowing
  up balloons. She itched when she wore rubber
  gloves.
• What is the diagnosis, and the link between the
  current episode and her previous history?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

8
Case 4

• What is the diagnosis?
• This history suggests food allergy. Foods not
  eaten before are always likely candidates and, in
  this case, the past medical history of probable
  allergy to natural rubber latex provides a
  diagnostic clue, since latex cross-reacts with a
  number of dietary antigens, including avocado
  (notably, kiwi fruit and banana).
• Are any further tests or investigations needed?
• The patient had positive skin prick tests to
  latex and avocado.
• Specific IgE to latex was raised at 10.2
• What treatment(s) could be considered?
• There is an argument for adrenaline and
  antihistamines to be available to this patient.
• What advice should be given?
• Avoid contact with rubber latex and avocado.
  Ensure the message is communicated to relevant
  health care workers consider a MedicAlert
  bracelet.

9
Case 5

• A 14 year old schoolboy was referred with the
  following history
• At the age of 7, he was seen to develop swelling
  of the face, blotchiness of the skin and severe
  breathing difficulty within 1 hour of eating a
  small piece of brazilnut. He had avoided these
  since that time.
• He was aware that he could eat peanuts,
  hazelnuts, almonds, cashews and pistachios
  without any difficulty, and is keen to know if it
  is now OK to eat brazilnuts again.
• He had previously experienced a skin rash while
  taking penicillin, and sneezing and wheeze on
  exposure to (some) dogs. He thought he had mild
  hay fever and he suffered from mild hand eczema.
• Blood tests showed
• total IgE 68.8
• IgE to peanut lt0.35
• IgE to hazelnut lt0.35
• IgE to brazilnut lt0.35
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

10
Case 5

• What is the diagnosis?
• The history is highly suggestive of allergy to
  brazilnut.
• Are any further tests or investigations needed?
• In view of the history, skin prick tests were
  performed these showed a very strong positive
  response to brazilnut and a weak positive to
  hazelnut (negative to other nuts). There were
  additional positive responses to cat, dog, house
  dust mite and grass pollen allergens.
• What treatment(s) could be considered?
• Assuming the patient wishes it, he should have a
  supply of adrenaline for self-administration in
  the event of further anaphylactic attacks. He
  should also keep an oral antihistamine. A
  MedicAlert bracelet was recommended.
• What advice should be given?
• Avoidance of all nuts is the safest advice, but
  many patients will reach their own conclusions
  about what they can and cant eat.

11
Case 6

• A 36 year old education inspector was referred
  with the following history
• Earlier in the year, she bought a chicken, cheese
  and mushroom dish from the supermarket. The
  instant the food touched her lips, she
  experienced burning of her hands and feet,
  generalised itching, swelling of the face, tongue
  and throat and vomiting. At A/E, she was noted to
  be hypotensive and was given steroid and
  antihistamine.
• 20 minutes before the onset of symptoms, she had
  given some amoxicillin suspension to her young
  daughter, and had licked the spoon afterwards.
• There was a past history of eczema and
  pre-eclampsia.
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

12
Case 6

• What is the diagnosis?
• Food allergy is unlikely as the onset of systemic
  symptoms occurred too soon after contact (in less
  time that it would take for antigen to
  circulate!) However, the earlier exposure to a
  penicillin is suspicious.
• Are any further tests or investigations needed?
• The patient had a strongly positive skin prick
  tests to amoxicillin (negative to penicillin and
  its major and minor determinants).
• Specific IgE to the amoxicilloyl moiety was
  raised at 1.63 (total IgE 48.5)
• What treatment(s) could be considered?
• Although the patient had already been prescribed
  a supply of adrenaline, this was not renewed as
  accidental exposure was considered to be
  unlikely. However, a MedicAlert bracelet should
  be considered.
• What advice can be given for the future?
• All penicillins should be avoided in future, as
  should cephalosporins previous estimates of the
  frequency of cross-reaction of about 15 were
  probably underestimates as they included
  non-IgE-mediated reactions. Where the mechanism
  of penicillin allergy is genuinely anaphylactic,
  cross-reaction rates are likely to be much higher.

13
Case 7

• A 39 year old man was referred with a 1 year
  history of asthmatic symptoms, sometimes with
  quite marked exacerbations. As a child, he was
  said to have been allergic to cats. However,
  although he had recently bought a cat, his
  symptoms preceded this by several months. For the
  last 34 years, he had also experienced hay fever
  symptoms.
• In the clinic, his peak expiratory flow rate was
  400 l/min., which was low for his age and height.
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

14
Case 7

• What is the diagnosis?
• Asthma.
• Are any further tests or investigations needed?
• The patient had positive skin prick tests to
  grass pollen, alternaria, cat and dog.
• IgE tests showed
• total IgE 109
• cat 26.3
• dog 3.33
• alternaria 3.99
• grass pollen 4.49
• What treatment(s) could be considered?
• The patient was treated as for asthma, with
  inhaled steroid and salbutamol, to which
  salmeterol was later added.
• What advice should be given?
• In view of the significance of his symptoms, and
  the fact that he was clearly sensitised to cat
  allergen, this patient was advised to find
  another home for the family cat.

15
Case 8

• A 17 year old girl was referred with a history of
  longstanding severe eczema. She was aware of
  itching within 2 hours or so of eating a number
  of foods (pork, citrus fruits, jams and foods
  containing benzoates or other preservatives). In
  the past, it was thought that she might be
  allergic to eggs, wheat and nuts, but she was
  unsure about this. She had undergone trials of
  dietary exclusion under the care of the
  dermatologists, but without success.
• What is the role of food allergy in atopic
  eczema?
• What further tests or investigations needed, if
  any?
• What advice should the patient be given?

16
Case 8

• What is the role of food allergy in atopic
  eczema?
• There is no consensus that eczema is
  aetiologically related to dietary allergy.
• Are any further tests or investigations needed?
• Allergy testing was considered only because of
  the historical suggestion of immediate-type
  symptoms.
• The patients eczema was too severe to perform
  skin prick tests.
• IgE tests showed
• total IgE 1,872
• house dust mite gt100 cod lt0.35
• grass pollens 35 peanut 7.22
• wheat 4.78 orange 1.31
• milk 6.62 lemon 1.8
• egg 0.38 pork 2.12
• As is frequently the case in eczema, specific IgE
  testing gave results which were virtually
  impossible to interpret. For example, she knew
  that she was able to drink milk without any
  difficulty. Allergy testing is a very poor guide
  to the management of eczema as these patients
  often have positive skin tests and circulating
  IgE to substances which they can tolerate.
  Similarly, whether the other symptoms she
  reported are actually due to type I
  hypersensitivity to food antigens is a moot point
  oral challenge testing would be the only way to
  establish this. This is rarely necessary, as
  these patients have usually decided for
  themselves what they can or cannot tolerate.
  However, it may be indicated in cases where the
  diet is being seriously restricted or where foods
  which have been avoided are being reintroduced.
• What advice should be given?
• Eat as normal a diet as possible, avoiding those
  foods which reliably cause symptoms.

17
Case 9

• A 47 year old woman, a production worker in a
  cake factory, was referred with the following
  history
• 7 months ago, she woke up in the middle of the
  night with gross facial angioedema. Since then,
  there had been 3 further episodes with
  involvement of the tongue and/or lips when she
  had difficulty talking/breathing. The onset of
  symptoms was entirely unpredictable.
• She had suffered from spontaneous coughing fits
  for a long time.
• She was a hypertensive, on enalapril for the last
  8 years, with the recent addition of a diuretic.
• What is the diagnosis?
• Would any tests or investigations be useful?
• What treatment(s) could be considered?
• What advice should the patient be given?

18
Case 9

• What is the diagnosis?
• This is non-allergic angioedema, which can be
  exacerbated or even caused, by ACE inhibitors a
  phenomenon which is, unfortunately, not as
  well-known as it is well-documented in the
  literature! This symptom can appear for the first
  time even after prolonged therapy. Dry cough is
  also a common side-effect of this group of drugs.
• Would any tests or investigations be useful?
• One can debate whether any further investigations
  are necessary, but it would seem reasonable to
  withold further investigations until the symptoms
  have been seen not to have resolved after
  stopping ACE inhibitor treatment.
• What treatment(s) could be considered?
• The patient should not be given any ACE inhibitor
  again. Substitution of an angiotensin II receptor
  antagonist seems reasonable, but it should be
  borne in mind that even these are occasionally
  associated with angioedema (although it is
  difficult to propose by what mechanism).
• What advice should be given?
• Avoidance of ACE inhibitors.

19
Case 10

• A 38 year old male chef was referred with the
  following history
• For several months, he had experienced daily
  episodes of urticaria, which had become
  progressively worse and were increasingly
  accompanied by marked swelling around the lips
  and eyes.
• On a number of occasions, he had experienced
  tightness of the throat with difficulty
  breathing, and had been admitted overnight from
  casualty for observation. On the most recent
  occasion, he was artificially ventilated.
• Symptomatic episodes were entirely unpredictable
  and unrelated to any discernable trigger.
• He was a diet-controlled diabetic and had a
  previous history of Prinzmetals angina.
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?

20
Case 10

• What is the diagnosis?
• This is idiopathic urticaria/angioedema/anaphylaxi
  s. This case was at the more severe end of the
  spectrum of this condition.
• Are any further tests or investigations needed?
• Investigations are characteristically negative,
  although evidence of infection (including dental
  infection) should be sought. If angioedema is
  unaccompanied by urticaria, hereditary or
  acquired C1 inhibitor deficiency should be
  excluded (complement component C4 will almost
  always be very low).
• What treatment(s) could be considered?
• A typical therapeutic progression would be
• H1 anagonist
• double dose
• add H2 antagonist (or dothiepin)
• tranexamic acid
• A supply of adrenaline was given and used
  successfully on a number of occasions.

21
Case 11

• A 31 year old woman was referred with the a 7
  year history of episodic abdominal pain which had
  been said to be of hysterical origin. Episodes of
  cramping pain were entirely unpredictable and
  lasted for up to several days before resolving
  spontaneously.
• Her father and a paternal aunt had died suddenly
  in middle age and from no obvious cause.
• Her two young daughters had been noted to have
  episodes of swelling of the face or limbs and
  were being treated with antihistamines for this.
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

22
Case 11

• What is the diagnosis?
• This history is very suggestive of hereditary
  angioedema. This is due to a deficiency of C1
  inhibitor, and is inherited in an autosomal
  dominant fashion. Although externally apparent
  angioedema is common, patients can have
  predominantly internal symptoms, e.g. with
  mucosal oedema of the gut, as in this case.
  Sudden death from respiratory obstruction is well
  documented and is the most disastrous consequence
  of non-diagnosis.
• Are any further tests or investigations needed?
• One of the few occasions in which tests done by
  the diagnostic immunology lab. are absolutely
  diagnostic(!)
• C4 lt0.1 (0.20.5)
• C1 inh. 0.03 (0.080.26)
• What treatment(s) could be considered?
• Treatment is virtually mandatory, and all
  patients with this condition should be under
  long-term follow up by a clinical allergist or
  immunologist. C1 inh. levels can be increased by
  treating with low-dose androgens (danazol,
  stanozolol). These are contraindicated in
  pregnancy, when tranexamic acid is used.
• What advice can be given for the future?
• Patients should avoid unnecessary physical trauma
  and seek early medical attention for severe
  attacks. A MedicAlert bracelet should be
  considered.

23
Case 12

• A 51 year old woman was referred with the
  following history
• For many years, she had experienced a variety of
  symptom on exposure to chlorinated water,
  hydrocarbon gases (methane, propane and butane),
  various odours/scents, and some foods.
  Immediately following exposure, she would
  experience shakiness and dizziness followed, the
  next day, by headache, vomiting, vertigo and
  fluid retention. She could not even bathe in
  normal tap water and distilled all her own water
  at home.
• She had previously seen a private allergy
  specialist who had offered desensitisation
  therapy to chlorine and other substances, with
  transient benefit.
• She had undergone a diagnostic test for food
  allergy/intolerance at a health food shop and was
  advised to avoid wheat, milk, eggs and potatoes.
• Examination suggested a pleasant individual who
  was rather underweight and frail-looking and
  whose personal hygiene was in doubt.
• What is the diagnosis?
• Are any further tests or investigations needed?
• What treatment(s) could be considered?
• What advice should the patient be given?

24
Case 12

• What is the diagnosis?
• The patient is in thrall to an irrational belief
  system centred on allergy.
• Are any further tests or investigations needed?
• No. Negative skin prick tests to the foods she
  had been told to avoid failed to convince this
  patient that she was not suffering from food
  allergy.
• What treatment(s) could be considered?
• There is no physical treatment from which this
  patient is likely to benefit. She was unwilling
  to countenance the possibility that her
  perception of ill health was mainly (if not
  entirely) phsychosocial in aetiology, and so
  would have been unwilling to seek appropriate
  treatment (even if it were available!).
• What advice should be given?
• She was advised to eat a normal diet but
  subsequently wrote to the consultant to say that
  this had made her feel awful. She was
  discharged from the clinic and told that she
  could not be helped in the context of an orthodox
  allergy practice.