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Latex allergy

Latex allergy

Presented by Pairach Supsongserm, MD.

March5, 2021

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Latex allergy

  1. 1. Pairach Supsongserm Fellow in Training Allergy and Clinical Immunology King Chulalongkorn Memorial Hospital 5 March 2021
  2. 2.  Introduction  Epidemiology  Latex allergens  Clinical syndromes  Diagnosis and investigation  Management  Prevention  Quiz
  3. 3.  Latex (Spanish word) = milk  White milky sap synthesized by the specialized laticifer cells of a tree and secreted from the wounded trunk  1600 BC > Castilla elastica tree (Panama or Mexican rubber tree) Mixed with… > The juice from a morning glory vine (Ipomoea alba) Raulf M.The Latex Story. Chem Immunol Allergy 2014.
  4. 4.  Nowadays, Hevea brasiliensis is the source of commercially produced natural rubber latex (NRL)  Most H. brasiliensis trees grow commercially in a number of tropical countries (Thailand, Malaysia and India)  In 1840, Charles Goodyear and Nathaniel Hayward discovered the process of vulcanization  This method enabled the manufacture of suitable and flexible NRL materials (Medical and household devices) Raulf M.The Latex Story. Chem Immunol Allergy 2014.
  5. 5. EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  6. 6. Wu M, et al. Current prevalence rate of latex allergy:Why it remains a problem? J Occup Health 2016.
  7. 7.  Immediate-type latex allergy > In 1927 >> Urticaria and laryngeal edema (Rubber dental prosthesis) >> Inhalation of NRL particles from a warmed electric wire isolated by rubber > In 1980s >> Intraoperative anaphylaxis in nurses (Latex gloves) >> Intraoperative anaphylaxis (Children with spina bifida and a history of urticarial after exposure to rubber products)  Contact dermatitis Raulf M.The Latex Story. Chem Immunol Allergy 2014.
  8. 8. Raulf M.The Latex Story. Chem Immunol Allergy 2014.
  9. 9.  Many theories have been proposed to explain the sudden increase in the number of persons affected by latex allergy > Increasing recognition of latex allergy > Increasing concern about AIDS and STDs (Increased latex gloves using) > Increased allergen content of gloves > Selective growth of higher latex-yielding trees RD, et al. A history of latex allergy. J ALLERGY CLIN IMMUNOL 2002.
  10. 10.  General populations > Sensitization to latex 1% (0.7-1.1%)  Health care workers (HCWs) > Sensitization to latex 17% > Respiratory asthma like symptoms 50% > Irritant or contact hand dermatitis (Increased risk of latex allergy 11 times)  Spina bifida > Sensitization to latex 70% Kelly KJ, et al. Latex Allergy:Where Are We Now and How Did We Get There? J ALLERGY CLIN IMMUNOL PRACT 2017.
  11. 11.  Urologic, neurologic defects, or multiple surgeries > Cloacal anomalies > Esophageal atresia, gastroschisis, omphalocoele > Cerebral palsy, spinal cord injuries  Type 1 DM > Rubber-topped insulin bottles (Punctured repetitively) Kelly KJ, et al. Latex Allergy:Where Are We Now and How Did We Get There? J ALLERGY CLIN IMMUNOL PRACT 2017.
  12. 12. Wu M, et al. Current prevalence rate of latex allergy:Why it remains a problem? J Occup Health 2016.
  13. 13. Wu M, et al. Current prevalence rate of latex allergy:Why it remains a problem? J Occup Health 2016.
  14. 14. Wu M, et al. Current prevalence rate of latex allergy:Why it remains a problem? J Occup Health 2016.
  15. 15.  The main constituent of Hevea latex is the polymeric hydrocarbon 1,4 cis-poly- isoprene (1-2% of the fresh milky sap is made up of proteins)  The proteins are heterogeneously distributed in the latex sap  They are involved in the biosynthesis of the polyisoprene, associated with the coagulation of latex and in the defense of the plant against various diseases EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  16. 16.  After ultra-centrifugation of the fresh latex sap > Rubber phase >> Rubber particles >> Insoluble proteins (Hev b 1 and 3) > C-serum >> Water-soluble proteins > B-serum >> Water-soluble proteins >> 200 polypeptides (Rubber biosynthesis enzymes) EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  17. 17. EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  18. 18. Blanco C. Latex–Fruit Syndrome. Current Allergy and Asthma Reports 2003. Spina Bifida (Hev b 1 and 3) Health Care Workers (Hev b 5 and 6) Latex-Fruit Syndrome (Hev b 6.02 and 7) Panallergens (Hev b 8, 11 and 12))
  19. 19. MP, et al. A Review of Natural-Rubber Latex Allergy in Health Care Workers.Clinical Infectious Diseases 2004.
  20. 20.  The most frequent manifestation  Eczema and xeroderma are nonspecific symptoms  Urticaria is more highly correlated with sensitization to latex than isolated pruritus  Contact with the mucosa induces angioedema  The most common cause of occupational contact urticaria Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  21. 21.  Exposed via inhalation  Powdered gloves are the main source of reactions to environmental latex  Occupational asthma in HCWs 2.5-10%  Eosinophilic bronchitis (Rare) Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  22. 22.  The second cause of intraoperative anaphylaxis after muscle relaxants (12.1- 22.3%)  Cardiovascular collapse is the most common form of presentation in anesthetized patients +/- skin rash or bronchospasm  Reactions to latex normally occur during the maintenance phase of anesthesia  Abdominal, gynecological, and orthopedic operations present the greatest risk  Risks > Atopy > Higher levels of exposure (HCWs and multiple operations or tests) Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  23. 23.  Cross-reactivity between inhaled and food allergens  Anaphylaxis to both latex and foods is common  The association between latex allergy and fruit allergy 21-58%  The frequency of sensitization to foods without symptoms is very high  The foods most frequently involved are chestnut, avocado, banana, and kiwi  Anaphylactic reactions caused by foods 5-50%  Class I chitinases (Hev b 6) have been considered responsible for latex-fruit allergy syndrome Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  24. 24. EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  25. 25. Blanco C. Latex–Fruit Syndrome. Current Allergy and Asthma Reports 2003.
  26. 26. Blanco C. Latex–Fruit Syndrome. Current Allergy and Asthma Reports 2003.
  27. 27.  A 34-year-old Thai female nurse presented with chest discomfort, cough, dyspnea, facial angioedema and urticaria 15 minutes after ingestion of ten pieces of dried jackfruit  Physical examination revealed facial angioedema, urticaria on both hands and wheezing  The diagnosis of anaphylaxis was made and she was treated with adrenaline, antihistamine and corticosteroid parenterally, and was admitted to the hospital
  28. 28.  For one year, the patient had been having pruritic rashes at both hands whenever they came in contact with latex  Later, the rash developed into chronic eczema  She had underlying long-term allergic rhinitis and atopic dermatitis  Skin prick test was positive for house dust mite
  29. 29.  Skin prick tests were positive for dried jackfruit (4+), fresh jackfruit (4+), papaya (3+), kiwi (2+), latex glove brand #1 (1-2+) and latex glove brand #2 (4+) and were negative for banana, sterile and vinyl gloves  The patient was advised to avoid exposure of any latex products, jackfruit, papaya, and kiwi  The patient was transferred from the inpatient ward to the patient relationship unit
  30. 30. Wongrakpanich S, et al. Jackfruit anaphylaxis in a latex allergic patient. Asian Pac J Allergy Immunol 2015.
  31. 31.  A 52 year old Thai woman was admitted at the emergency unit as a result of oral pruritus, generalized urticaria, nausea, vomiting and breathlessness ending in syncope shortly after eating a persimmon  Treatment consisted of epinephrine, corticosteroids and antihistamines injections, and salbutamol inhalation  A few days later she developed similar symptoms but without syncope following intake of bananas
  32. 32.  A past Cesarean section over two decades ago, chronic urticaria, asthma and rhinitis (Sensitized to house dust, mites and Alternaria)  She recalled the first symptom of oral pruritus and swelling, from jackfruit intake and blowing balloons  Total IgE was 778 kU/L  Specific IgE for persimmon was not available
  33. 33. Pradubpongsa P,et al. Latex-Fruit Anaphylaxis from Persimmon.J Clin Exp Dermatol Res 2016.
  34. 34. Pradubpongsa P,et al. Latex-Fruit Anaphylaxis from Persimmon.J Clin Exp Dermatol Res 2016.
  35. 35.  The fundamental risk factor is the number of operations  Other factors > Elevated IgE titers > Presence of a ventriculoperitoneal shunt during the first days of life > Atopy  Exposure routes: mucosa, blood vessels, and inhalation  The most frequent manifestation is urticaria-angioedema  The most relevant allergen appears to be Hev b 1 Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  36. 36. Konz KR, et al. Comparison of latex hypersensitivity among patients with neurologic defects. J ALLERGY CLIN IMMUNOL 1994.
  37. 37. Diagnosis and Investigation
  38. 38.  Diagnosis of latex allergy is based on clinical suspicion  The sensitivity and specificity of a good clinical history taken by an allergologist are very high Hamilton RG, et al. Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy. J ALLERGY CLIN IMMUNOL 2002. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  39. 39.  History > Atopy > Previous operations or medical procedures involving latex products > High risk groups > Acute episodes of anaphylaxis or urticaria with no known cause > Reactions induced by contact with or ingestion of fruit (Kiwi, chestnut, avocado, and banana) Warshaw EM, et al. Latex allergy. Journal of the American Academy of Dermatology 1998. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  40. 40. Binkley HM, et al. Latex Allergies: A Review of Recognition, Evaluation, Management, Prevention, Education, and Alternative Product Use. Journal of Athletic Training 2003.
  41. 41.  The method of choice to confirm or rule out latex allergy  Allergen extracts > Commercial extracts (Ammoniated and non-ammoniated) >> Standardized extracts: sensitivity 93%, specificity 100% > Glove extracts >> Gloves soaked in diluent: possible false negative results  Safe  Intradermal tests are not recommended Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  42. 42. Hamilton RG, et al. Natural rubber latex skin testing reagents: Safety and diagnostic accuracy of nonammoniated latex, ammoniated latex, and latex rubber glove extracts. J ALLERGY CLIN IMMUNOL 1996. Gabriel MF, et al. Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests. Investig Allergol Clin Immunol 2013.
  43. 43.  Used in suspected delayed-type hypersensitivity reactions  Most of which are not attributable to latex but to additives > Mercaptobenzothiazole > N-I-paraphenylenediamine  Latex patches without additives are not recommended Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  44. 44.  CAP (Phadia)/AlaSTAT (Diagnostics Products Corporation) > Positive cutoff point >0.35 kUA/L > Sensitivity >> CAP 97% >> AlaSTAT 100% > Specificity >> CAP 83% >> AlaSTAT 33%  ImmunoCAP ISAC (CRD 112) (Phadia) > Semiquantitative test > rHev b 1, rHev b 3, rHev b 5, rHev b 6.01, rHev b 8 Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  45. 45. EAACI MOLECULAR ALLERGOLOGY USER’S GUIDE 2016.
  46. 46.  Proven efficient in the diagnosis of latex allergy  Sensitivity >93% and specificity 91.7%  Not widely used Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  47. 47.  Indicated when the clinical history is suggestive and complementary diagnostic tests are negative or contradictory  Used to rule out latex allergy in asymptomatic sensitized patients  Tests > Rubbing test > Glove use test > Specific bronchial challenge test Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  48. 48.  False positives  Not standardized  Low diagnostic yield  Not used Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  49. 49.  Establish the diagnosis of type I-latex allergy  Considerable disparity exists between glove use protocols, with exposure times ranging from 15 minutes to 2 hours  Methods > Place a fingertip of the glove on a dampened finger > If negative, put on complete powdered glove > A vinyl or nitrile glove is used on the other hand as a negative control > Positive test if contact causes erythema,pruritus, blisters, or respiratory symptoms  Limitations > The difficulty in blinding (False positives) > Patients who have avoided latex for a long time (False negatives) Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  50. 50.  Using different methods > Aqueous latex extract with a nebulizer or in a chamber with aerosolized glove extract > Handling or shaking gloves to generate a dust aerosol  Conjunctival challenge and nasal challenge have also been used Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  51. 51. NUCERA E, et al. CHALLENGE TESTS IN THE DIAGNOSIS OF LATE X ALLERGY. INTERNATIONAL JOURNAL OF IMMUNOPATHOLOGY AND PHARMACOLOGY 2010.
  52. 52. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  53. 53. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  54. 54.  Goals > Treatment of the present reaction >> Standard treatment (Depending on severity) > Prevention of future reactions >> Patient education >> Avoidance of contact with latex objects >>> Alternatives to latex for the manufacture of gloves and other medical products >>> Avoidance of foods with cross-reactivity to latex >> Specific immunotherapy Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  55. 55.  Understanding the importance of identifying themselves as allergic to latex and knowing where latex may be present and how to avoid it  If a patient is admitted to hospital, latex allergy should be stated clearly  Unequivocally in the clinical history, the nursing notes, the surgical report and at the head of the patient’s bed  Wearing a medical bracelet warning of the danger Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  56. 56. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  57. 57.  Alternatives to latex > Neoprene > Polyvinyl chloride > Silicone > Polyurethane > Vinyl  For surgical procedures, synthetic polymers such as neoprene (polychloroprene), polyisoprene, butadiene, and elastiprene are recommended Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  58. 58. Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.  Patients with latex-fruit syndrome should be advised to avoid the fruits involved  No consensus has been reached on the avoidance of the 4 highest-risk foods (chestnut, avocado, banana, and kiwi), although no previous reactions to these foods have been reported, not even in the presence of subclinical sensitization or specific IgE against the main allergens causing this reactivity
  59. 59.  Immunotherapy with latex has only been analyzed in 7 published studies using the parenteral or sublingual route  All conclude that while the clinical sensitivity of patients can be reduced, the incidence of important adverse reactions is too high to recommend its habitual use, except under very controlled conditions and in very specific cases Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  60. 60.  Regulations regarding the presence of latex in objects  Labeling > In order to facilitate immediate identification and enable the individual to avoid contact  Primary prevention > Used gloves only when necessary > Avoided powdered latex gloves > Used synthetic gloves with allergic patients  Secondary prevention > Sensitized and allergic patients: avoidance > HCWs: used unpowdered gloves and gloves with a low latex protein Cabañes N, et al. Latex Allergy: Position Paper. J Investig Allergol Clin Immunol 2012.
  61. 61.  Which is main latex allergen in health care workers? > Profillin > Proheavin > Lipid transfer protein > Esterase
  62. 62.  A 23-year old man with spina bifida has a history of shortness of breath and hypotension after exposure to latex products.What food allergen should he avoid? > Wheat > Shrimp > Kiwi > Peanut
  63. 63.  Which food most frequently causes clinical allergy symptoms in a latex-allergic person? > Apple > Mango > Melon > Potato
  64. 64. Finish…

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