An emergency kit should be envisaged for all children having an IgE-mediated food allergy. The contents should be personalized and adapted to the risk of anaphylaxis. Kits should contain only the essential drugs and should be ready at all times. Absolute indications for the prescription of adrenaline auto-injectors in the food allergy emergency kit are as follows: a history of food anaphylaxis, food allergy (except pollen-food syndrome) and diagnosed asthma. Oral antihistamines and inhaled short-acting action bron-chodilators constitute second- or even third-line treatments for anaphylaxis. Oral corticosteroids are of no use in treating the symptoms of anaphylaxis and no scientific studies have proven their efficacy in such settings; as such, except in certain specific cases, they should not be included in emergency kits. (C) 2020 Elsevier Masson SAS. All rights reserved.

L’immunothérapie spécifique par voie orale (ITO) déjà documentée pour les allergies au lait et à l’œuf est considérée actuellement pour l’arachide. Les auteurs rapportent la mise en place de l’immunothérapie orale à l’arachide dans un service hospitalier selon une démarche devant assurer une sécurité maximale et fixant les paramètres biologiques nécessaires pour la décision et pour la surveillance de l’évolution. Le matériel est l’arachide grillée. Les procédures de l’immunothérapie orale spécifique reposent sur l’administration de doses croissantes à domicile. Trois protocoles de durée variable (17, 36, 60semaines) sont adaptés à la sévérité des cas. Cette revue détaille les conditions d’achat, de stockage, de préparation de la poudre, du conditionnement des doses, et de leur envoi postal, les textes explicatifs de l’allergie à l’arachide et de l’immunothérapie spécifique, les bénéfices et risques attendus, les consentements éclairés écrits pour les tests cutanés, biologiques, le test de provocation oral et l’ITO, les conditions de mise en œuvre du protocole à domicile, les adaptations en cas d’événement intercurrent, les contrôles hospitaliers reposant à intervalles de 12semaines sur les prick-tests au même matériel et le dosage des IgE et IgG4 spécifiques des trois allergènes majeurs recombinants, le choix et la quantité quotidienne des aliments industriels choisis pour la maintenance. Les tâches et responsabilités des personnels paramédicaux et des allergologues sont détaillées. La revue des questions en suspens conduit à recommander la mise en place de l’ITO à l’arachide par des services hospitaliers, mais une progression régulière des doses à domicile est possible sous condition d’évaluation régulière à intervalles de 12semaines.

Specific oral immunotherapy (OTT) has been described for allergy to milk and to egg and is now being considered as treatment for peanut allergy. The authors describe the initiation of a course of peanut-specific OIT in a hospital allergy department using a procedure designed to ensure maximum safety and which includes the laboratory assays necessary for decision-making and monitoring of the evolution of the therapy. The material used in this OTT is grilled peanut. The practice of OTT we use is based on taking increasing doses of the allergen at home. Based on the severity of the cases, three protocols of different durations (17, 36, 60 weeks) are available. This review details the conditions of the purchase, the preparation and storage of the powdered allergen, packaging of the doses and of sending them through the mail; it includes texts explaining peanut allergy and OTT, the expected benefits and risks, written informed consent forms for skin and laboratory tests, for the oral provocation test and for OTT, as well as the conditions for Conducting the protocol at home, changes when necessary due to intercurrent events, the 12-weekly hospital consultations for prick-tests with the same material and assays for peanut-specific IgE and IgG4 using the three major recombinant peanut allergens; and the choice and the daily quantity of the industrial foodstuffs chosen for the patient's maintenance diet. The responsibilities of the allergists and paramedical personnel are described in detail. This review of some important questions, which may need further discussion, ends by recommending that hospital-based allergy departments set up peanut-specific OIT, with regular progression of doses at home and with regular evaluation at the hospital at 12-week intervals. (C) 2014 Elsevier Masson SAS. All rights reserved.

Il existe peu de données cliniques sur la diminution de la pression thérapeutique encore appelé step-down. Selon les recommandations, devant un patient ayant un asthme contrôlé, il faut envisager de diminuer la pression thérapeutique et trouver ainsi la dose thérapeutique minimale mais efficace sur les symptômes et la fonction respiratoire. Selon les recommandations GINA 2012, le rythme recommandé de diminution du traitement de fond est d’environ trois mois.There is little clinical data on the reduction of inhalation therapy, now known as step-down therapy. Present guidelines for a patient with well-controlled asthma recommend that inhalation therapy be decreased until the minimal therapeutic dose which effectively provides control of asthma symptoms and lung function is reached. According to GINA 2012, the recommended rhythm of dose reduction should cover about three months.

We report a case of chronic glossitis in a 4-year-old boy due to scurvy. The boy showed up in our department with a patchy depapillated tongue. A detailed dietary history revealed an unbalanced diet without any fruit or vegetable. The biological investigations showed a low serum ascorbic acid. The boy was treated by oral ascorbic acid during 15 days. The glossitis improved within one week and serum levels of vitamin C returned to the normal range. In industrial countries, scurvy became a rare disease in healthy children. However, since a few years, cases are reported in children and teenagers with unbalanced diet coming from economically favoured families. These extreme cases are one of the signs of a more general deterioration of dietary habits in paediatric populations in our societies. This emphasizes the importance of effective nutritional education programs aimed towards both parents and children.

La caractérisation de l’IgE-réactivité, essentielle au diagnostic a fait appel aux sources allergéniques puis aux allergènes majeurs purifiés. Les réactivités croisées (RC) très fréquentes liées aux déterminants carbohydrates des végétaux et des insectes ont été abolies par l’utilisation d’allergènes recombinants. Les RC liées à l’homologie des séquences d’acides aminés, larges ou limitées, offrent la notion d’allergènes spécifiques et d’allergènes croisants. Le concept de la puce ISAC basé sur 103 allergènes purifiés ou recombinants, permet un diagnostic de sensibilisation par analyse des composants. Les indications actuelles sont explorées. L’utilité de ce test pour affirmer/infirmer le diagnostic de choc anaphylactique idiopathique est présenté à partir de huit cas. Les polysensibilisations sont confirmées dans les dermatites atopiques sévères de l’enfant, selon des profils différents de ceux de l’adulte. L’exploration des oesophagites à éosinophiles montre l’importance des sensibilisations aux aéro-allergènes et trophallergènes. Une aide au choix d’une immunothérapie est envisagée dans le cas de l’allergie à différents pollens et acariens. Les restrictions actuelles d’utilisation concernent les RC non cliniquement relevantes (famille PR-10 et tropomyosines), les allergènes inopérants ou insuffisants (Ana c 2, allergènes du blé, Ana o 3) et l’absence de sources allergéniques alimentaires (moutarde, lupin, lentilles, noix, amande, sarrasin). Les applications du test ISAC à la recherche sont des études épidémiologiques et le suivi des immunothérapies par l’apparition d’IgG4 spécifiques. Le test ISAC devrait prochainement se développer par l’adjonction de nouveaux allergènes. L’aide au diagnostic et à la prédiction de persistance et de sévérité de l’allergie rendra nécessaire le traitement des données grâce à des systèmes experts d’informations.

Peanut allergy is one of the most prevalent food allergies. The possibility of a lethal accidental exposure and the persistence of the disease make it a public health problem. Evaluating the intensity of symptoms is accomplished with a double blind placebo-controlled food challenge (DBPCFC), which scores the severity of reactions and measures the dose of peanut that elicits the first reaction. Since DBPCFC can result in life-threatening responses, we propose an alternate procedure with the long-term goal of replacing invasive allergy tests. Discriminant analyses of DBPCFC score, the eliciting dose and the first accidental exposure score were performed in 76 allergic patients using 6 immunoassays and 28 skin prick tests. A multiple factorial analysis was performed to assign equal weights to both groups of variables, and predictive models were built by cross-validation with linear discriminant analysis, k-nearest neighbours, classification and regression trees, penalized support vector machine, stepwise logistic regression and AdaBoost methods. We developed an algorithm for simultaneously clustering eliciting dose values and selecting discriminant variables. Our main conclusion is that antibody measurements offer information on the allergy severity, especially those directed against rAra-h1 and rAra-h3. Further independent validation of these results and the use of new predictors will help extend this study to clinical practices.

Background: Foods containing flaxseed proteins rich in polyunsaturated fatty acids are new on the market. Objectives: In a population of patients attending the allergology department, we evaluated the frequency of sensitization to flaxseed, characterized allergens and looked for modifications related to industrial processing. Methods: Natural, heated and extruded flaxseeds were tested using prick-in-prick tests (PIP using the fresh seed), SDS PAGE, immunoblots, immunoblot inhibition and Fourier Transform Infrared (FTIR) spectroscopy. Results: PIP tests to natural flaxseed were positive in 5.8% of the 1,317 patients. 73 of 77 PIP-positive patients were atopic. There was cross-reactivity with five seeds: peanut, soybean, rapeseed, lupine and wheat, and with rape pollen. Immunoblot inhibition by bromelain confirmed the presence of specific IgE to cross-reactive carbohydrate determinants (CCD). 0.15% of this population presented with food allergy to flaxseed and positive PIP to heated and extruded flaxseed. Two sera showed that clinically relevant allergens in industrial products had MW between 25 and 38 kDa. Sensitization to processed flaxseed characterized only the allergic subjects. FTIR spectroscopy showed major modifications in beta and a structures following industrial processing. Conclusion: Positive prick tests to natural flaxseed were mainly due to cross-reactions. Flaxseed allergy is rare and could be detected by PIP to heated extruded flaxseed. Increasing consumption calls for monitoring of clinical risk.

Background: Double-blind placebo-controlled food challenge (DBPCFC) is currently considered the gold standard for peanut allergy diagnosis. However, this procedure that requires the hospitalization of patients, mostly children, in specialized centers for oral exposure to allergens may cause severe reactions requiring emergency measures. Thus, a simpler and safer diagnosis procedure is needed. The aim of this study was to evaluate the diagnostic performance of a new set of in vitro blood tests for peanut allergy. Methods: The levels of IgE directed towards peanut extract and recombinant peanut allergens Ara h 1, Ara h 2, Ara h 3, Ara h 6, Ara h 7, and Ara h 8 were measured in 3 groups of patients enrolled at 2 independent centers: patients with proven peanut allergy (n = 166); pollen-sensitized subjects without peanut allergy (n = 61), and control subjects without allergic disease (n = 10). Results: Seventy-nine percent of the pollen-sensitized patients showed IgE binding to peanut, despite their tolerance to peanut. In contrast, combining the results of specific IgE to peanut extract and to recombinant Ara h 2 and Ara h 6 yielded a peanut allergy diagnosis with a 98% sensitivity and an 85% specificity at a positivity threshold of 0.10 kU/l. Use of a threshold of 0.23 kU/l for recombinant Ara h 2 increased specificity (96%) at the cost of sensitivity (93%). Conclusion: A simple blood test can be used to diagnose peanut allergy with a high level of precision. However, DBPCFC will remain useful for the few cases where immunological and clinical observations yield conflicting results.

Background. - Peanut allergy (PA) is persistent and severe, so that therapeutical trials using oral immunotherapy (OIT) are in the spotlight. The primary objective of this pilot study conducted from 2007 to 2009 is the evaluation of the efficiency and the safety of this procedure.Methods. - Fifty-one subjects aged 2 to 20 years with persistent PA documented by DBPCFC are enrolled. Doses of roasted peanut powder are weighted in the hospital. The duration of the escalation phase is 17 or 34 weeks according to the severity of PA and the threshold of reactivity. The final dose is 12 grams per week. Controls at specified times are carried out by prick-test and specific IgE to peanut. Adverse reactions (AR) are studied and risk factors are searched out.Results. - Forty-eight subjects completed the escalation phase. The duration was extended in two cases. 18 patients have been controlled after six months of the maintenance phase. The global efficiency is estimated at 92.1%. A decrease of prick-tests and an increase of specific IgEs are observed at the end of the escalation phase and evolve conversely six months later. AR occur during both phases, benign in 84% of cases, serious in 16%. They characterize 36.8% patients of group 1, 53.1% of patients in group 2 (0.26% and 0.48% of doses respectively). The relationship of RI with a lower basal threshold is confirmed: 763 +/- 363 mg versus 1988 +/- 1995 mg (p < 0.05). Risk factors are aspirin, exercise sunbathe, viral gastroenteritis, pollinosis, discontinuation of daily doses, intake in decubitus. Eighty-eight percent of RI remain still unpredictable.Conclusions. - These results show a benefit of OIT and lead to propose further trials. The duration of the daily dose maintenance and the optimal dose have to be monitored by the immunological profile of IgEs and IgG4s to recombinant peanut major allergens. (C) 2010 Elsevier Masson SAS. All rights reserved.

BACKGROUND:Foods containing flaxseed proteins rich inpolyunsaturatedfatty acids are new on the market.OBJECTIVES:In a population of patients attending the allergology department, we evaluated the frequency of sensitization to flaxseed, characterized allergens and looked for modifications related to industrial processing.METHODS:Natural, heated and extruded flaxseeds were tested using prick-in-prick tests (PIP using the fresh seed), SDS PAGE, immunoblots, immunoblot inhibition and Fourier Transform Infrared (FTIR) spectroscopy.RESULTS:PIP tests to natural flaxseed were positive in 5.8% of the 1317 patients. 73 of 77 PIP-positive patients were atopic. There was cross-reactivity with five seeds. peanut, soybean, rapeseed, lupine and wheat, and with rape pollen. Immunoblot inhibition by bromelain confirmed the presence of specific IgE to cross-reactive carbohydrate determinants (CCD). 0.15% of this population presented with food allergy to flaxseed and positive PIP to heated and extruded flaxseed. Two sera showed that clinically relevant allergens in industrial products had MW between 25 and 38 kDa. Sensitization to processed flaxseed characterized only the allergic subjects. FTIR spectroscopy showed major modifications in 3 and alpha structures following industrial processing.CONCLUSION:Positive prick tests to natural flaxseed were mainly due to cross-reactions. Flaxseed allergy is rare and could be detected by PIP to heated extruded flaxseed. Increasing consumption callsfor monitoring of clinical risk.

Asthma and rhinitis are both expressions of food allergy (FA). When they are not associated with other allergic symptoms, their importance in FA is sometimes underrated, although the literature shows that most cases of fatal food-induced anaphylaxis begin with the sudden onset of a respiratory distress syndrome. Moreover, recent analyses of fatal asthma among children and young adults have shown the essential place of allergy to peanut and tree nuts. To optimize the basic treatment of asthma is therefore an indispensible corollary of the management of FA. Laryngeal edema is another mode of expression of food-induced anaphylaxis. Investigation of nasosinusoidal dysfunction and anomalies of kinin metabolism are part of the new diagnostic and therapeutic strategies. (C) 2009 Elsevier Masson SAS. All rights reserved.

Background: In vitro testing for food allergy may yield clinically irrelevant results due to cross-reactive carbohydrate determinants (CCD) specific immunoglobulin E (sIgE) induced by pollen exposure. The performances of 2 in vitro methods were evaluated for peanut sIgE measurement in patients allergic to grass pollen with or without subsequent allergy to peanuts. The correlation between clinically irrelevant peanut sIgE and the presence of CCD sIgE was investigated. Methods: In vitro measurement of peanut sIgE was performed using the Pharmacia ImmunoCap™ system Radio Immuno Assay (RIA) and the Immulite ® 2000 3gAllergy™ system. Discrepancies between in vitro results and peanut allergy diagnosis were evaluated by measurement of CCD sIgE using bromelain and ascorbic acid oxydase (AAO). Results: The sensitivity was 100% with both systems for the diagnosis of allergy to peanut (58 patients), nevertheless the specificity obtained with Immulite (73%) was better than that obtained using ImmunoCap (46%) in patients who were not allergic to peanuts, but who had a grass pollen allergy (n = 41). In 22 out of 41 patients who presented clinically irrelevant peanut sIgE results using ImmunoCAP, CCD sIgE was detected in 72% of the cases by bromelain and in 86% by AAO. In 11 patients out of 41 who presented irrelevant peanut sIgE results using Immulite, CCD sIgE was detected in 81% of the cases by bromelain and in 100% by AAO. Conclusion: The Immulite 2000 system had better specificity than the ImmunoCap system for accurate diagnosis of peanut allergy in patients allergic to grass pollen. CCD sIgE was identified in most of the false-positive peanut sIgE results.

To date, neither in vitro nor in vivo tests can establish with reliability the diagnosis of food allergy. The availability of recombinant allergens (RA) has led to improvement in the standardization of allergenic extracts and enrichment of natural extracts, resulting in more sensitive screening tests. These biotechnological advances facilitate the diagnostic approach which now rests on an individual reaction profile (component resolved diagnosis) with well-characterized allergens classified on a molecular basis. Development of diagnostic tests using RA or peptides expressing some distinctive epitopes of interest may improve the prediction of severe and/or persistent food allergies and guide the choice of the therapeutic measures that follow. (C) 2008 Elsevier Masson SAS. Tous droits reserves.

Background: The prevalence of severe anaphylaxis, between 1 and 3 per 10 000, has increased sharply over recent years, with a rate of lethality of 1%. The economic burden is unknown.Objective: The aim of this study was to estimate the economic costs of anaphylaxis, including direct costs of treatment, hospitalization, preventive and long‐care measures, and the indirect cost: absenteeism.Methods: Analysis of 402 patients of anaphylaxis declared by 384 allergists was reported to the Allergy Vigilance Network. The global cost was estimated from the national data of hospital admissions: ICD‐10 coding available for 2003, 2004 and 2005.Results: Three work/classroom days were lost per patient. Diagnosis required oral challenge with hospitalization in 18% of cases. The estimated mean total cost was 1895€ for food‐ and drug‐related anaphylaxis (5610€ for the most severe), and 4053€ for Hymenoptera anaphylaxis. National statistics recorded 2575 patients in 2005; 22% more than in 2003. The estimated annual cost was 4 789 500 €. The possible reasons for this being an under‐estimate include: data coming only from hospitalized patients, poor identification by medical teams unfamiliar with ICD‐10 codes, peri‐operative anaphylaxis being insufficiently declared, rush‐immunotherapy and maintenance treatments for Hymenoptera anaphylaxis. Similarly, the extra cost of cow milk substitutes, as well as insurance costs where deaths are followed by litigation were not taken into account.Conclusions: The mean cost of anaphylaxis was 1895–5610€ in nonfatal patients. The prevalence was under‐estimated because of many biases, leading to under‐estimation of the national cost. Further studies would be necessary to evaluate the value of preventive strategies.