Download - Latex allergy
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Natural latex rubberAllergy
Anchalee Senavonge MD.
3 February 2017
Pediatric allergy and immunology department
Chulalongkorn University
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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
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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
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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
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History
Chem Immunol Allergy 2014, the latex story
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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
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• 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
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Pediatric Allergy and Immunology 2016: EAACI molecular allergology
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Medical setting Non-medical setting
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• 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
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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
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• prevalence of latex allergy
• 9.7% healthcare workers
• 7.2% susceptible patients
• 4.3% general population
Prevalence worldwide
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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
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• 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
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Current prevalence rate of latex allergy, J Occup Health 2016
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Allergens
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Pediatric Allergy and Immunology 2016: EAACI molecular allergology
Major allergens
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Pediatric Allergy and Immunology 2016: EAACI molecular allergology
ไทรยอยใบแหลม
papaya and kiwi (around 60%) banana, avocado, and chestnut (close to 90%)
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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
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Clinical syndrome
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Clinical presentation
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• 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
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• 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
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• 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
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• 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
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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
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• 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
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• 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
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• 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.
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• 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.
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• 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
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• 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
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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
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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
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• 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
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16/383 sensitization (4.2%)8/16 symptoms: 4 dermal only, 2 respiratory only and 2 both
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Diagnosis
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Pediatric Allergy and Immunology 2016: EAACI molecular allergology
cross-reactive carbohydrate determinants' (CCD)
component-resolved diagnosis (CRD)
horseradish peroxidase (HRP)
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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
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• 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
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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
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• 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
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SPT extract reagents
Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests, JACI 2013
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• 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)
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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
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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
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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
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Treatment
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Avoidance of latex objects
Position paper, JACI 2012
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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
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Avoidance of foods with cross-reactivity to latex
Position paper, JACI 2012
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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
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Airway Equipment
• Use Silicone Masks
• Use PVC ET tubes
• Use clear plastic oropharyngeal airways
• There is NO latex in the LMA
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• Signs and Symptoms usually occur within 30 minutes following anesthesia induction; however, can range from 10-290 minutes
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Products in KCMH
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Not made with natural rubber latex
J
Tracheostomy
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Endotracheal tube
MallinckrodtLatex free
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Gastrostomy
Fortune® Silicone GastrostomyCatheterLatex/DEHP free
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Norta urine catheterLatex silicon
Urine catheter
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Suction set
MeditekLatex gloveSuction tube- no latex
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Feeding tube
TerumoNo Latex ?
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Gloves
Megaglove, SempermedLatex glove
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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
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Nitrile Disposable Gloves
AMMEX Nitrile Exam GlovesTextured/Micro-roughenedBeaded CuffPolymer CoatedLatex FreeAmbidextrous
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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
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Thank you