Correspondence

The natural history of large local reactions from stinging insects To the Editor:

I read with great interest the article by Mauriello et al.’ regarding the natural history of large local reactions from stinging insects. These reactions are common events that require decision making and recommendations from both primary care physicians and allergists regarding referral, testing, and possible treatments. It appears to me that the authors analyzed their data to support their conclusion, i.e., risks are low, and referral, testing, and treatment (hyposen- sitization) are all unnecessary. My viewpoint and recom- mendations have always been the same. However, in review- ing their data, it is apparent that one out of the 18 subjects (5.6%) with a large local reaction and a positive RAST, who was not treated with immunotherapy and was restung, had a systemic reaction. The 5.6% risk is much different than the 0.77% risk of all subjects and appears to be a more relevant figure in identifying an individual subject’s risk. Even this 5.6% figure may be low since an unknown number of the restings may have been from another stinging insect to which the subject was not sensitive, as the authors stated.

Therefore, perhaps we should be trying to identify which patients with large local reactions have venom-specific IgE and therefore may have a 5% to 6% risk of having a systemic reaction to a subsequent sting. This would allow the family to make an informed decision based on the subject’s true risk, and physician and patient could then choose the most appropriate form of therapy.

Gerald L. Goldstein, M.D. Kansas City Allergy and Asthma Associates, P.A. 4601 W. 109th St. Overland Park, KS 6621 I

REFERENCE

1. Mauriello PM, Barde SH, Georgitis JW, Reisman RE: Natural history of large local reactions from stinging insects. J ALLERGY CLIN 1MMUNOL 74:494, 1984

Seafood allergy To the Editor:

The misconception that allergy to iodine in seafood (and particularly shellfish) predisposes to systemic reactions to radiocontrast media persists despite our best efforts to put it to rest. I have heard of this association of phenomena from Radiographers and Physicians, I have read of it in a medical advice column in my local newspaper, and I have had to comment on it to the courts. I have, however, been unable to iind when the concept originated, and I have never seen it stated in a textbook.

If any readers have historical information on this subject, I would very much like to hear from them, and I will share all information with those who might be interested.

Lawrence Preuss, M.D. 4870 Clark Rd. Ypsilanti, MI 48197

The pharmacology and therapeutic use of theophylline

To the Editor: In reference to the article “The Pharmacology and Ther-

apeutic Use of Theophylline” by Miles Weinberger (J AL- LERGY CLIN IMMUNOL 73:525, 1984), we would like to state that this is a well-written manuscript discussing the pharmacokinetics of theophylline. There are, however, sev- eral points that are misleading in the area of bronchodila- tation therapeutics.

1. Dr. Weinberger correctly states that the theophylline range of 10 to 20 mcglml in serum is necessary for efficacy in severe asthma as portrayed in cited papers by Tumer- Warwick,’ and Jenne et al.2 Equal space should be noted for studies published by our group and others that have demonstrated a much lower dose of theophylline required for clinical response in children with asthma who are not in a tertiary center.‘.’ The difference may be that the former articles dealt only with severe asthma and acutely or chron- ically ill hospitalized patients, whereas the latter articles deal with the asthmatic subject in the everyday situation as an outpatient. It is clear from these latter studies that low- dose theophylline is better than placebo, resulting in im- provement both by objective pulmonary function as well as clinical symptoms.6 Thus, it is not always necessary to strive toward 10 to 20 mcg in the serum as a usual therapeutic dose.

2. The section on formulation is also well written, but statements like “There is no rationale, however, for choos- ing these preparations over unadulterated theophylline for oral administration” is controversial. For example, there are many patients who cannot tolerate oral theophylline, even in sustained-release forms, primarily because of gas- trointestinal side effects. This condition occurs as well in low dosages, but the same patient can often tolerate a “salt” of theophylline without gastrointestinal side effects. Perhaps there are reasons for this intolerance unrelated to our current knowledge.

3. Another area misleading the reader regards the use of pharmacokinetic studies of a single dose theophylline to calculate the results of slow-release theophylline formula- tion. It is apparent that this method may suggest a poor correlation between the product release of theophylline and the absorption of theophylline from the gastrointestinal tract.

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