latex allergy

Natural latex rubberAllergy

Anchalee Senavonge MD.

3 February 2017

Pediatric allergy and immunology department

Chulalongkorn University

Case consultation

• Boy 5 yr old

• U/d tracheobronchomalacia, chronic lung disease s/p tracheostomy, d-TGA s/p arterial switch operation, PDA s/p ligation, GERD s/p PEG

• Admit for bronchoscopy- patient developed wheal and flare on his chest and neck 30 minutes after the procedure, required IV one dose of antihistamine

Past history

• 1 year PTA urticaria on glove contact area and erythema skin around PEG area (foley catheter as a replacement for gastrostomy tube)

• Never have banana, giwi, avocado (on Blenderized diet)

• Specific IgE (k82) 3.59 kUA/L class 3

• Skin prick test (soaked glove extract): pending

Case consultation

History

• In 1927, 2 cases reported in Germany • First-urticaria and laryngeal edema caused by a ‘caoutchouc' (rubber) dental

prosthesis

• Second- after inhalation of NRL particles

• During the late 1980s and early 1990s, NRL allergy become important

• particularly among healthcare workers (HCW) and medical doctors and in dental clinics

Chem Immunol Allergy 2014, the latex story

History

Chem Immunol Allergy 2014, the latex story

Allergen sources

• Hevea brasiliensis -tree of the family Euphorbiacieae (“rubber tree”)

• Source: process called “rubber tapping,” latex is collected from the milky sap

• 33% rubber, cis-1,4-polyisoprene, 2% resin, 65% water, and proteins

• Hevea brasiliensis grows commercially in tropical countries (Thailand, Indochina, Malaysia, India)

Pediatric Allergy and Immunology 2016: EAACI molecular allergologyNatural rubber latex allergy. Disease-a-month 2016

• After ultracentrifugation of the fresh latex sap basically three main fractions [rubber phase, the C serum and the bottom fraction (B-serum)]

• rubber phase: rubber particles and 2 insoluble proteins

• C and B-serum proteins are water-soluble

Allergen sources

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

Medical setting Non-medical setting

• Dipped (also known as soft) • gloves

• higher content of latex proteins and greater allergic potential

• Moulded (also known as hard or dry) such as• medication vial stoppers

• contain denatured latex proteins; therefore, less antigenic

Types of latex products

การใชประโยชนและการแปรรป

• แบงเปน 2 กลม ไดแก

1. ยางแหง (ยางแผนรมควน ยางแทง ยางเครพ ยางแผนผงแหง และยางสกม)2. ยางน า (น ายางขน หรอยางลาเทกซ) กอนจะน าไปแปรรปในขนตอไปซงจะเปนผลตภณฑทเราพบไดใน

ชวตประจ าวน ยกตวอยางเชน ยางส าหรบประกอบยานพาหนะ ยางยดและยางรดของ ถงมอยางทางการแพทย รองเทาและอปกรณกฬา สายพานล าเลยง ผลตภณฑฟองน า เปนตน

• prevalence of latex allergy

• 9.7% healthcare workers

• 7.2% susceptible patients

• 4.3% general population

Prevalence worldwide

Epidermiology

Allergy

• general population 0% to 2.3%

• children with spina bifida ranges between 25% and 72%

• healthcare workers 0–30%

Sensitization

• 5.4% to 7.6%

• adult blood donors showing latex-specific IgE antibodies 6%

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

• Nurses, Srinagarind Hospital, Khon Kaen 2006• NRL glove allergic symptoms 24%, sensitization 2%

• Dental students, Faculty of Dentistry, Chulalongkorn University 2011• NRL glove-related symptoms 5.0% (hand pruritus 64.5%, hand eczema 19.4%,

contact urticaria 16.1%)

• Risk: AD, >18 hr, > 3 pairs

• Sensitization 14.2%

• Hatyai, Yala and Thammasart 2013• Self-report symptom 18%

Prevalence in Thailand

Current prevalence rate of latex allergy, J Occup Health 2016

Allergens

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

Major allergens

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

ไทรยอยใบแหลม

papaya and kiwi (around 60%) banana, avocado, and chestnut (close to 90%)

Allergens

EAACI 2016 Position paperJACI 2012

Middleton 8th ed

Spina bifida 1,3,5,6.01 1,3 1,3,7

HCW major 5,6.01 5,6 2,5,6,13

HCW minor 1,3 2,4,7,13 -

Latex-fruit 2,6.02,7,8,12 6.02,78,11,12 (pan)

2,7,8,12

Clinical syndrome

Clinical presentation

• Most frequent

• Most common cause of occupational urticaria

• Type I hypersensitivity

• Direct contact or inhalation of airborne allergens

• erythematous, pruritic patches, hives within minutes

Contact urticaria

Position paper, JACI 2012Natural rubber latex allergy. Disease-a-month 2016

Contact urticaria after wearing latex gloves for 3 minutes

• Type IV

• Acute ACD: pruritic, erythematous, scaly plaques with vesicles and crusting on the dorsal hands and wrists 24–48 h after contact

• Chronic ACD: lichenified, erythematous, scaly plaques

Allergic contact dermatitis

Position paper, JACI 2012

Natural rubber latex allergy. Disease-a-month 2016

• exposed via inhalation• health care professionals and workers who use protective gloves

• considered to be an occupational asthma

• Prevalence 2.5-10%

Allergic rhinitis and asthma

Position paper, JACI 2012

• 2nd cause of intra-operative anaphylaxis (1st muscle relaxants)• Occur maintenance phase of anesthesia (muscle relaxants and opiates-

induction phase)

• Abdominal, gynecological, and orthopedic operations

• Risk in children

1. Under 5 yr old

2. Atopic

3. Multiple exposures (> 8 surgical procedures )

Systemic reaction

Position paper, JACI 2012

Natural rubber latex allergy. Disease-a-month 2016

Case report-anaphylaxis

• 4.5-year old Caucasian child, scheduled for congenital strabismus sursoadductorius of the left eye surgery

• No history of allergy, no known medical condition

• After surgery 25 minutes, hypotension, TV drop, desaturation

• IgE levels 835 IU/ml

• natural latex rubber (k82) 11.30 kU/l, CAP-class 3

Malsy et al. BMC Research Notes 2015

• 51-year-old nurse (obstetrics head nurse)

• Contact dermatitis 4 yr ago->better• fear for the loss of her job, not report skin problem

• Gynecological examination->anaphylactic reaction• IV chloropyramine chloride (Synopen) and soon she felt better

• positive prick test reaction to latex

Case report-anaphylaxis

• 21% to 58%

• Most involved: chestnut, avocado, banana, kiwi

• Other infrequent foods: papaya, tomato, potatoes

• anaphylactic reactions caused by foods ranges from 50% to <5%

Latex-fruit syndrome

Position paper, JACI 2012

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

• Man, 37 years old, developed urticaria with skin redness, itching, dyspnea and tachycardia 5 min after drinking a glass of apple juice supplemented with acerola (Malpighia glabra; Barbados cherry)

• no allergy to apple and apple juice was well tolerated

• significant contact urticaria induced by natural rubber latex products

• OAS after ingesting avocado, celery, walnut

Case report-latex fruit syndrome

J Allergy Clin Immunol 2002: 109: 715–6.

• SPT +ve to grass pollen mixture, latex, rye, acerola-containing apple juice; apple juice without acerola negative

• specific IgE • Latex 24.7 kU/L (class 4)

• grass pollen (class 3)

• tomato, soy bean (class 2)

• banana, green apple,

herbal mixture (class 1)

Latex–acerola cross-reactivity based on Hev b6.01/Hev b 6.02

J Allergy Clin Immunol 2002: 109: 715–6.

• 28 years old woman, surgical instrumentalist in the operating theatre

• frequently dry skin of the hands, itching, redness and irritated skin of the fingers -> diagnosed as AD (FH eczema)

• immediately after eating a banana - rash, tickling, throat perturbation

• 1.5 year later, kiwi consumption –rash, hypotension

Case report-latex fruit syndrome

UNIVERSI Journal. December 2015

• IgE to latex (16.5 KU/L), banana (27 KIU / L) and kiwi (35.6 KIU / L)

• Avoid NRL product and avocados, bananas, cherries, figs, kiwis, grapes, melons, nectarines, papayas, pineapples, strawberries, tomatoes, celery, plums

• Clinical improved

UNIVERSI Journal. December 2015

Spina bifida

• Higher prevalence

• Risk factors• number of operations

• elevated IgE titers

• presence of a VP shunt during the first days of life

• atopy

• Exposure via mucosa, blood vessels, inhalation routes

• Most frequent manifestation is urticaria, angioedema

• Allergen most relevant: Hev b 1

Position paper, JACI 2012

Health care workers

• Latex allergy 4.32% (4.01% to 4.63%) in HCWs and 1.37% (0.43% to 2.31%) of general population [3 to 3.5 times]

• Latex-positive skin prick test 6.9% to 7.8% for the HCWs, 2.1% to 3.7% in general population

• Risk factors • hand dermatitis (OR 2.46)

• asthma or wheezing (OR, 1.55)

• rhinoconjunctivitis (OR, 2.73; 95%)

• at least one generic symptom (OR, 1.27)

NRL allergy among HCW. Sys review. JACI 2006

• Dental students, Faculty of Dentistry, Chulalongkorn University 2011• NRL glove-related symptoms 5.0% (hand pruritus 64.5%, hand eczema 19.4%,

contact urticaria 16.1%)

• The risk factors for latex - glove allergy were

1. history of allergic diseases(atopic dermatitis, urticaria, pruritus and rubber allergy)

2. Duration of using gloves(more than 18 hours per week)

3. more than 3 pairs of gloves used per day and the timing of glove exposure

16/383 sensitization (4.2%)8/16 symptoms: 4 dermal only, 2 respiratory only and 2 both

Diagnosis

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

cross-reactive carbohydrate determinants' (CCD)

component-resolved diagnosis (CRD)

horseradish peroxidase (HRP)

Specific IgE

Pediatric Allergy and Immunology 2016: EAACI molecular allergology

False –ve: missing allergenFalse +ve: IgE binding to N-glycans and/or O-glycans which are often part of allergens of plant origin--> use cross-reactive carbohydrate determinants (CCD) to clarify

• positive cutoff point is established at >0.35 kUA/L

• CAP (Phadia) or AlaSTAT (Diagnostics Products Corporation) • similar sensitivity (97% ,100%)

• specificity of 83% CAP, 33% AlaSTAT

• ImmunoCAP ISAC (CRD 112)

Specific IgE

Position paper, JACI 2012

Skin prick test

• Standardized extracts can provide a sensitivity of 93% with a specificity of 100%

• ammoniated, non-ammoniated commercial extracts, glove extracts

• Many allergists create a homemade extract from gloves soaked in diluent-possible false negative

Position paper, JACI 2012

• Alk-Abelló

• Allergopharma

• Bial-Aristegui

• Leti

• Lofarma

• Q-Pharma

• Stallergènes

SPT extract reagents

Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests, JACI 2013

SPT extract reagents

Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests, JACI 2013

• Considered safe, although isolated cases of anaphylaxis have been reported

• Intradermal tests are not recommended

Position paper, JACI 2012

Skin prick test

• 39-year-old housewife U/d AD+long standing asthma• Reaction while painting her house, facial and periocular swelling

requiring systemic corticosteroids+ antihistamine• SPT with 100 HEP Hevea brasiliensis ALK Abello (UK) ->Less than 3 min

complained of dizziness, difficulty breathing, wheezing and tachypnea• NRL prick test site 6-mm Wheal reaction (histamine 4 mm)• RAST for latex IgE 2.87 km/L (0–0.34 km/ L), total IgE 1047.0 km/L (0–

122 km/L)

Patch test

• in suspected delayed-type hypersensitivity reactions

• not attributable to latex but to additives

• it is advisable to test mixtures of substances (carba mix, paraphenylenediamine mix, and thiuram mix) instead of each additive separately, except mercaptobenzothiazole and N-I-para-phenylenediamine

Position paper, JACI 2012

Glove use test

• Considerable disparity exists between glove use protocols, with exposure times ranging from 15 minutes to 2 hours

• Place a fingertip of the glove on a dampened finger

• if –ve, put on complete powdered glove

• A vinyl or nitrile glove is used on the other hand as a negative control

• Positive if contact causes erythema, pruritus, blisters, or respiratory symptoms

Position paper, JACI 2012

Natural rubber latex allergy. Disease-a-month 2016

Other types of provocation test

• measurement of pulmonary function by spirometry after the inhalation of aqueous surgical glove extract

• use of a “hooded exposure chamber” that permits progressive latex aeroallergen exposure to a patient's airway and conjunctiva

Natural rubber latex allergy. Disease-a-month 2016

Position paper, JACI 2012

Treatment

Avoidance of latex objects

Position paper, JACI 2012

Alternative products

• neoprene, polyvinyl chloride, silicone, polyurethane, and vinyl• Polyvinyl chloride (or simply vinyl) do not have the same barrier effect as

latex, not a valid alternative as infection protection

• Nitrile (acrylonitrile butadiene) provide protection comparable to latex, similar permeability against cytotoxic agents

• For surgical procedures, synthetic polymers such as neoprene(polychloroprene), polyisoprene, butadiene, and elastiprene are recommended, given their biomechanical and barrier properties

Position paper, JACI 2012

Avoidance of foods with cross-reactivity to latex

Position paper, JACI 2012

Operating Room Patient Care

• Use non-latex gloves

• Use non-latex tourniquets or polyvinyl chloride tubing

• Draw medication directly from opened multidose vials (remove stoppers) if medications are not available in ampoules

• Draw up medications immediately prior to the beginning of the case or their administration.

• The rubber allergen could leach out of the plunger of the syringe causing a reaction. The intensity appears to increase over time.

• Utilize latex-free or glass syringes, stopcocks to inject drugs rather than latex ports.

• Place clear and readily visible signs on the doors

Airway Equipment

• Use Silicone Masks

• Use PVC ET tubes

• Use clear plastic oropharyngeal airways

• There is NO latex in the LMA

• Signs and Symptoms usually occur within 30 minutes following anesthesia induction; however, can range from 10-290 minutes

Products in KCMH

Not made with natural rubber latex

J

Tracheostomy

Endotracheal tube

MallinckrodtLatex free

Gastrostomy

Fortune® Silicone GastrostomyCatheterLatex/DEHP free

Norta urine catheterLatex silicon

Urine catheter

Suction set

MeditekLatex gloveSuction tube- no latex

Feeding tube

TerumoNo Latex ?

Gloves

Megaglove, SempermedLatex glove

Nitrile Gloves (Butadiene-acrylonitrile) มความทนทานตอสารเคมสง

Vinyl Gloves (Polyvinyl Chloride หรอ PVC) คณสมบตการปองกนทตา และไมยดหยน

Neoprene Gloves (Polychloroprene) เปนทางเลอกสาหรบผ ทแพถงมอยาง Latex เนองจาก มคณสมบตปองกนไดดเยยม รวมทงใหความรสกและสมผสทด แตไมยดหยนและเหนยวเทยบเทาถงมอยางแบบ Latex

BSI Group (Thailand) Co., Ltd

Nitrile Disposable Gloves

AMMEX Nitrile Exam GlovesTextured/Micro-roughenedBeaded CuffPolymer CoatedLatex FreeAmbidextrous

Case consultation

• Specific IgE (k82) 3.59 kUA/L class3

• Skin prick test (soaked glove extract): pending

• Diagnosis: suspected NRL allergy (contact urticaria)

• Management• advise latex-free medical product

• identification on medical record

• notify allergy clinic before each procedure

Thank you