- Latex - 10/20/05 re: Prevention of latex allergy reactions in the OR I am the Clinical Director of an outpatient surgery center located in Florida. We are trying to formulate a policy that would direct the care or patients experiencing a latex allergy. During our preoperative interview we find that a number of our patients state that they are allergic to latex. When we question them further we find numerous inconsistencies on whether or not they are truly allergic to latex. Our policy thus far has been that if a patient states that they are allergic to latex, regardless of the reaction, their case is canceled and they are referred to an allergist for a definitive diagnosis. If allergy testing determines that they are indeed allergic to latex than we do not schedule them at our center and instead their case is scheduled at the hospital. In reviewing the literature on latex allergies it was difficult to determine what if any changes to our policy should be made. Can patients with latex allergies be treated safely in an outpatient setting and is it enough to do the procedure with a latex free cart and as the first patient of the day? Several of our physicians thought that we should bring patients with a questionable latex allergy into the center prior to surgery and have a piece of a known latex product taped to their skin by the anesthesiologist. The product could then be removed after twenty four hours and the results documented. If the skin reacted than the test was positive and they would be scheduled at the hospital and if negative they could be done at our facility. Other physicians thought this was better left to an allergist. We were also confused as to the degree of sensitivity, if any, we should allow. Can skin sensitive patients' safely be done in an outpatient setting that is not completely latex-free? Extensive investigation by latex allergy experts such as Drs. Kevin Kelly and John Yunginger have shown that the major sources of latex allergen in health care settings are powdered latex gloves of the usual type. Use of non-powdered, low allergen-content latex gloves (now readily available) markedly reduces the amount of latex allergen disseminated in the ambient air of the operating room (OR) settings. As a result there is much less sensitization of health care personnel and much less respiratory symptoms in already latex-sensitive subjects. However, in patients already very sensitive to latex, there is still potential for inducing a systemic allergic reaction when latex allergen elutes from the surface of latex gloves and is absorbed through mucosal surfaces such as the peritoneum even if the patient's history of latex allergy is limited to skin manifestations. Therefore, it is important to identify those individuals who are truly very latex-allergic. The usual initial screening test for latex allergy is an ELISA blood test. However, as performed in usual clinical labs, this test is only about 80% sensitive for detecting latex allergy. A latex skin test, when done properly, is more sensitive but may occasionally induce a systemic allergic reaction. Therefore such testing should be carried out by physicians with considerable experience in this testing, such as a certified allergist. The same comment applies to the informal challenge test suggested by one of your surgeons. The usual recommended challenge is not to put a piece of latex glove material loosely on the skin but to cut off a finger length from a latex glove, put it snugly on the patient's finger, remove after about 1-2 hours and then observe for 6-8 hours for signs of local skin reaction (hives or starting contact dermatitis type reactions). However, there have been occasional cases where a systemic allergic reaction has been reported with such challenges. Thus, the patient should be kept under observation in a facility with experience in treating acute systemic allergic reactions, again that of a certified allergist. I have enclosed below FYI abstracts of review articles by Dr. Kelly and another group experienced in latex allergy. Methods. 2002 May;27(1):15-21. Related Articles, Links Natural rubber latex allergy in the occupational setting. Charous BL, Tarlo SM, Charous MA, Kelly K. Milwaukee Medical Clinic, Allergy and Respiratory Care Center, Advanced Healthcare, SC, 3003 West Good Hope Road, Milwaukee, WI 53209, USA. Over the last decade, the prevalence of natural rubber latex (NRL) allergy has reached epidemic proportions among workers who use or who are exposed to powdered latex products. NRL-associated occupational asthma is confined largely to those exposed to powdered latex glove use or other latex aerosols. The most frequent presenting symptom of NRL allergy is contact urticaria; inhalation may cause symptoms of allergic rhinitis and asthma. Skin prick testing is the most accurate tool for diagnosis of NRL allergy. The cornerstone of management is cessation of exposure; substitution with non-NRL or non-powdered NRL gloves results in predictable rapid disappearance of latex aeroallergen. Copyright 2002 Elsevier Science (USA). Clin Infect Dis. 2004 Jan 15;38(2):252-6. Epub 2003 Dec 19. A review of natural-rubber latex allergy in health care workers. Ranta PM, Ownby DR. Department of Pediatrics, Medical College of Georgia, Augusta, Georgia 30912, USA. This brief review of natural-rubber latex (NRL) allergy in health care workers (HCWs) includes the definition of NRL allergy and data on its epidemiology, pathogenesis, diagnostic algorithm, management, long-term outcomes, economic impact, cost-effectiveness of changing facilities to a latex-free environment, and prevention. The data presented suggest that an individual with type I or type IV hypersensitivity to NRL should be able to continue to work in the workplace with careful evaluation and reasonable accommodations. Reducing exposure to latex is a safe and more economical alternative to complete removal of the individual from the place of employment. The use of low-allergen, non-powdered NRL gloves substantially reduces airborne exposure to latex in most health care settings. 10/13/05 re: Availability of non-latex T Tubes I am a general surgeon. I had a recent latex allergic patient who needed a laparoscopic cholecystectomy. In checking our latex free cart we had no latex free T tubes. I checked with multiple manufactures and surfed the latex free lists and could find no latex free alternatives. This caused me concern as I am used to having these available should a patient require a common bile duct exploration. I realize that these procedures are much less common in the era of laparoscopic intervention and ERCP, however we have patients who come to an open common bile duct exploration at least once a year. Placing a known latex rubber T-tube in a common bile duct of a confirmed latex allergic patient is totally unacceptable. Do you have any suggestions in this situation? To respond to your question, I obtained input from Dr. Kevin Kelly, an expert in latex allergy. His prompt response is enclosed below, including a generous offer to contact a company with offices in Atlanta that may be able to make a T-Tube coated to reduce the chance of latex allergen eluting from the tube. A significant problem with this approach mentioned by Dr. Kelly are the liability issues dealing with a device not approved by the FDA. So making a special product may involve some legal issues. If you wish Dr. Kelly to make an inquiry in your behalf, please submit such a request to our AADMC website "Ask the Expert" program. Dr Kelly's comments: I agree with the surgeon that it is unacceptable to place such a tube but he identified the reason that there are none. i.e...There is no market for them. I suggest that the usual manufacturers of T tubes forcholecystectomy be asked to make a custom one with clearance from the FDA. My hopes are slim to none unfortunately. There is some suggestion from latex glove extraction process by researchers that coated latex will not emit allergen readily. A company such as Regent Medical is familiar with such technology and might be willing to help coat a t-tube with indemnification of liability. My contact there is Mr. Milt Hinsch in Atlanta. I certainly would be willing to contact Milt if the surgeon wishes my help. 9/23/05 re: Latex packaging notice We are working at reducing all latex in our environment to create latex safe environment for all patients. We recently obtained “Pediatric” Band-aids by Johnson and Johnson and 3M that have Latex in the package only. What is the recommendation about using a product that is labeled latex in package only? To respond to your question, I obtained input from Dr. Kevin Kelly, an expert in latex allergy. His response is enclosed below. Dr. Kelly also suggested that you contact the consumer telephone hotline of the manufacturer. If this is not helpful, contact the American Latex Allergy Association ( www.latexallergyresources.org/ ), a patient support group that actively investigates sources of latex in commercial products. You can submit questions such as yours to their Web site. Dr. Kelly's comments: I believe that the labeling means the following: The box that contains multiple band-aids has no latex content itself. The individually wrapped band-aids contain latex but their packing isolates them from any other contents of the box and the box itself. PLEASE REALIZE THAT I AM INTERPRETING. THIS IS A DANGEROUS INTERPRETATION AND THAT THE COMPANY CONSUMER LINE SHOULD BE ABLE TO CLARIFY THIS. 9/22/05 re: Latex eluted on organ for transplant I am a preoperative nurse educator in a very busy operating room. Our institution was one of the first in the area to have a latex allergy standard of care that allowed us to achieve positive outcomes for our patients during surgical interventions that have a known or suspected allergy to latex. Question; an organ harvested for transplant (kidney) while wearing latex gloves, is subsequently transplanted in a latex allergic recipient. Is there any evidence that enough of the latex residue is present that it could trigger an allergic response in the recipient ? I know of no situation that has occurred with the circumstances described by you. I also found no literature reference to such a situation. However, I would suspect that most if not all of any latex antigens which might elute from latex gloves onto an organ removed for transplant should be readily removed by immediate thorough irrigation of the organ with the usual irrigating fluid. After all, there is not the potential for absorption into the non-vascularized organ tissues as would occur if latex allergens eluted from the surgeon's gloves onto the mucosal/serosal surfaces of a living patient. Of course, the individuals removing organs for potential transplantation should be strongly encouraged to use non-latex gloves with adequate barrier function. 8/10/05 re: Adhesive sensitivity - latex allergy? I work in the OR and we see pts who claim they have a latex allergy because band-aids cause a rash. We have also had pts with the same band-aid issue and nurses are labeling them as latex allergic even though they are able to wear latex gloves. How can we differentiate between the two without allergy testing? To help respond to your question, I obtained input from Dr. Kevin Kelly of the Medical College of Wisconsin, an expert in latex allergy. He kindly responded very promptly. His response is enclosed below. Dr. Kelly's response This is a difficult question to answer. Clearly, many adhesives contain latex. However, they contain many other chemicals that can cause contact dermatitis. In our original article on anaphylaxis to latex in spina bifida patients, one of the risk factors for predicting skin test positive reactions to latex and anaphylaxis was a history of rash to tape. The reference is below: Kelly KJ, Pearson ML, Kurup VP et al: Anaphylactic reactions in patients with spina bifida during general anesthesia: epidemiologic features, risk factors, and latex hypersensitivity. J Allergy Clin Immunol 1994; 94(1): 53-61. So what does this mean? The correlation of this is relatively low but raises suspicion only. Given the state of testing in the US, people need to ask other questions (urticarial rash?, angioedema?, onset of rash relative to contact with the adhesive? etc...) Then, a judgement needs to be made. I believe it would be unwise (in the face of no testing) to ignore a patient complaint just prior to surgery of latex allergy. Latex precautions should be used for the immediate case at hand, but the caveat is the following. ALL OF THESE PATIENTS NEED AN ALLERGY/IMMUNOLOGY SPECIALIST TO DO A HISTORY, PHYSICAL EXAM, AND APPROPRIATE TESTING TO CONFIRM OR RULE OUT THE DIAGNOSIS BEFORE ANOTHER PROCEDURE. If the allergists is not comfortable with patch testing, then a dermatologist could also be consulted. This post procedure activity is often the step that is skipped and patients keep coming back to the OR saying the same thing. I certainly agree with the frustration of the questioner, but the statistics only give relative risks and judgment and referral for specialty help is necessary. 6/16/05 re: Evaluation for latex allergy I am a family practic doctor who developed a latex allergy about 4 years ago. I was sick for about 6 weeks straight with a sore throat, sinus congestion and dry, tight cough. It was significantly better by the end of a 3 day weekend and gone after 5 days off of work, only to return. It never hit when I first got to work, it was after about 3 hours that the symptoms started and progressed as the day went on. Allergy and other treatments did nothing. I eliminated latex from the office and all my symptoms completely resolved. A serum IgE was positive for latex (low positive). Everything was fine until a month ago. My symptoms are back but different. I have sinus symptoms, but less. I have the dry cough and sore throat but it is more a sore/swollen tongue, particularly at the back of the tongue. Again, usual treatments for respiratory symptoms haven't helped and the symptoms are persisting too long--the only other time I have been sick this long was with the latex allergy onset. So I am suspicious of latex again and think it is a nonoccupational exposure--probably some handlebar tape on my bicycle that I had overlooked. I am in the process of replacing it and am avoiding it altogether in the meantime. My question is regarding the serum IgE tests--will repeating it in the midst of symptoms be helpful in confirming active latex allergy? Will a higher titer be present during active exposure and reaction than when the allergy is quiescent? Obtaining another in vitro test for anti-latex IgE antibodies can be helpful in that a stronger positive result would give more convincing evidence that you are latex-sensitive. However, there is not a close association between the titer of such antibodies and the severity of latex-induced symptoms. Therefore, it is not helpful to use such antibody levels to monitor the course of the disease. Some individuals who have low titer or even negative in vitro antibody tests will exhibit a positive skin test response to latex extract (see enclosed abstract). Unfortunately an approved, standardized latex skin test reagent is not yet available If there is evidence of a contact dermatitis or contact urticaria, then a patch test with the suspect material is indicated. I should mention some other things about latex allergy that may be relevant to your case. It is very unusual to manifest respiratory tractions to latex without preceding/accompanying skin manifestations unless one inhales the latex-containing material. In such cases, the offending material is usually latex coated on the powder which is released into the local air during donning or removal of powdered natural rubber latex gloves. If latex contained in the handlebar tape were the cause I would expect there to be some reaction in the skin in contact with the tape. Another possible cause of symptoms you described is a reaction to certain foods with which there is a cross-sensitivity in some latex- sensitive individuals (see enclosed abstract). I would add chestnut to the list of foods in the abstract. Such cross-sensitivity could lead to reactions in the tongue after eating the suspect food. Dermatol Ther. 2004;17(4):289-301. Related Articles, Links Latex allergy: diagnosis and management. Taylor JS, Erkek E. Department of Dermatology, Cleveland Clinic Foundation, OH 44195-5032, USA. Latex allergy is an IgE-mediated immediate hypersensitivity response to natural rubber latex (NRL) protein with a variety of clinical signs ranging from contact urticaria, angioedema, asthma, and anaphylaxis. Major allergens include dipped latex products such as gloves and balloons. In highest risk for NRL allergy are patients with spina bifida, but health care workers and others who wear latex gloves are also at risk. NRL allergic patients may also react to fruits/foods, especially banana, kiwi, and avocado. Diagnosis is made by a positive latex RAST and/or skin prick test or challenge test to NRL. Allergen avoidance and substitution and the use of latex-safe devices including synthetic gloves (vinyl, synthetic polyisoprene, neoprene, nitrile, block polymers, or polyurethane) are essential for the affected patient. Accommodation in the workplace may include the use of powder-free, low-allergen NRL gloves or synthetic gloves. These preventive measures have significantly reduced the prevalence of reported reactions to NRL. Hyposensitization is not yet feasib Dermatitis. 2004 Dec;15(4):192-6. Related Articles, Links Clinical presentations of patients sensitive to natural rubber latex. Guin JD. BACKGROUND: Eczematous reactions to natural rubber latex (NRL) have been associated with both immediate and delayed hypersensitivity. OBJECTIVE: To determine clinical cases that might require testing for immediate sensitivity or patch testing for delayed hypersensitivity to latex fabric. METHODS: Patients with suspected sensitivity to NRL were given in vitro testing by radioallergosorbent test (RAST) or ImmunoCAP test and if negative, were prick-tested. If prick-test results were negative and the patients were still available, patch testing was done with latex glove fabric. Case histories of persons with positive results on RASTs, ImmunoCAP tests, prick tests, and patch tests were reviewed for clinical presentation and relevance. RESULTS: Of 92 persons with positive responses, 26 had positive RAST results, 26 had positive ImmunoCAP test results, 33 had positive prick-test results, and 7 had a positive patch-test result. Presentations included hand urticaria or eczema (46 patients), eyelid dermatitis (14), shoe dermatitis (10), atopic eczema (6), waistband dermatitis (5), clothing dermatitis (3), contact eczema to elastic in a mask (2), urticaria to a phlebotomy tourniquet, and eczema over the elbows and from an elastic bandage used for occlusive dressing therapy. Several other presentations were less likely to be relevant. CONCLUSION: Persons with putative contact dermatitis in areas that may come into contact with NRL deserve not only to be patch-tested with rubber chemicals but also to be tested for immediate sensitivity and, if results are negative, to be patch-tested with NRL. 4/28/05 re: Allergy to nitrile gloves I noticed the most recent inquiry on the website regarding potential nitrile allergies is from 9/04. I frequently use nitrile gloves in my job, and I've started developing contact dermititis/eczema on my hands. The onset is typically correlated to my wearing these gloves. I've been looking for other possible causes, but I haven't yet come up with another possibility. Has any information regarding nitrile allergies recently become available? Since my response in 9/04 to the Ask the Expert question about nitrile glove sensitivity (to which you referred), I have come across an occasional mention of presumed sensitization to nitrile gloves. You sound convinced that your contact dermatitis is due to the nitrile gloves and not other agents used on your hands. This relationship can be confirmed by doing a patch test with a small piece of a nitrile glove appended to the skin of your inner arm with a non-irritating adhesive tape such as the Magic Tape by the 3 M company. The nitrile patch is removed after 48 hours and the site is examined over the succeeding 48 hours for persistent redness and possible small blistering.You did not mention why you have used nitrile gloves instead of natural rubber latex (NRL) gloves. Powder-free, low- protein NRL gloves are much less likely to sensitize than regular NRL gloves. If you are already sensitive to NRL and wish to avoid both NRL and nitrile gloves you may wish to consider using non-latex neoprene (polychloroprene) gloves (see enclosed abstract). J Biomed Mater Res B Appl Biomater. 2004 Jan 15;68(1):81-7. Abrasion resistance of medical glove materials. Walsh DL, Schwerin MR, Kisielewski RW, Kotz RM, Chaput MP, Varney GW, To TM. Office of Science and Technology (HFZ-150), Center for Devices and Radiological Health, Food and Drug Administration, 9200 Corporate Boulevard, Rockville, Maryland 20852, USA. Due to the increasing demand for nonlatex medical gloves in the health-care community, there is a need to assess the durability of alternative glove materials. This study examines durability characteristics of various glove materials by abrasion resistance testing. Natural rubber latex (latex), polyvinyl chloride (vinyl), acrylonitrile butadiene (nitrile), polychloroprene (neoprene), and a styrene- ethylene/butylene-styrene block copolymer (SEBS) were tested. All test specimens, with the exception of the vinyl, were obtained from surgical gloves. Unaged out-of-the-box specimens as well as those subjected to various degrees of artificial aging were included in the study. After the abrasion sequence, the barrier integrity of the material was assessed through the use of a static leak test. Other traditional tests performed on these materials were viral penetration to validate the abrasion data and tear testing for comparative purposes. The results indicate that specific glove-material performance is dependent upon the particular test under consideration. Most notably, abrasion, even in controlled nonsevere conditions, may compromise to varying degrees the barrier integrity of latex, vinyl, SEBS, nitrile, and neoprene glove materials. However, as evidenced by the results of testing three brands of neoprene gloves, the abrasion resistance of any one glove material may be significantly affected by variations in production processes. 4/27/05 re: Latex sensitivity as a cause of clinical syndrome I'm writing about myself- I've invested incredible amounts of time money and testing and all doc's including me are at a bit of a loss but all agree that I'm atopic( me too) allergic to latex and who knows what else-In the event something meaningful is in "events" ( maybe not) I'll give you all we know to date.I suspect there is more than 1 problem therefore the confusion.Also... Is anyone in the states doing latex desensitization? Is it recommended? I've all but stopped all hospital work due to the allergy as I get sick each time I go but my reactions are not always the same.... Childhood- mumps- 2 months-couldn't wear "rubber pants "or clothes with exposed elastic- hives- chronic cough and chronic fever's of unknown origin to 106 multiple times until age 2 when it was decided to remove my tonsils to see if that would help- they were a little big- all my mom remembers- post operative breathing complications? they told my mom that they should always be wary of anesthesia??? at the Army base in Tacoma Wa 1965- no records available- the fevers did go away- Mycoplasma pneumonia age 10- treated successfully- complicated by asthmatic symptoms; was a swimmer and had problems with hives and local rash from some swimsuits, goggles and swiwmcaps.age 3 to present Chronic night cough -forever until...(age.2-16-) (1979)water skiied all day had a HA took 2 excedrin( ASA and Tylenol) ( my mom could not recall ever having given me asprin or Tylenol ever before nor can I recall having taken it before that time- it was a sample pack that came in the mail- they were homeopathic nuts) and went to bed awoke 2 hours later blue, couldn't talk and all swollen- broke the lamp for help- taken by ambulance and treated for anyphlaxis and intubated for status asthmatic us for 2 days- treatment complicated by at. fib with RVR from epi- tx'd with cardio version x 3; officially diagnosed with asthma- inhalers stopped night cough Freshman year of college-ran cross counry- got bronchitis and treated with Keflex within 24 hrs I had full blown erythema multiforme with asthma, hypotension and GI upset- Keflex DC'd and put on steroids for several months; then erythema multiforme 2-3 times per year- no one knew why-never got it when at home only when living in the dorms usually right after they sprayed for roaches???( psychosomatic?) 1st year medical school- within 1 month horrible EM-sickest I'd ever been with swollen joints, angioedema- on 60mg prednisone the whole year- anything lower I would relapse- used inhalers for asthma tid. Was able to wean off in 2 weeks after going home for summer break. ( We had anatomy lab with latex gloves????)Major workup done then with ECHO- I had an asx prolapsed mitral valve, a gastric ulcer from all the steroids ( and felt generally better with Tagamet- not the stomach-all over) skin testing positive for anything and everything RAST + for everything- eosinophilia and very high histamine levels in urine...2 nd year lived in same spot- no problems- 3rd year my hands burned intensely as soon as I put on gloves- then rash-went to non powdered- still got an intense rash and EM- went to non powdered hypo allergenic gloves and developed severe Raynaud's causing vascular ulcers on hand and feet with loss of some nails- ring surgical rotations-umultiple treatments unsuccsessful- only happened when in clinics- never out running, at home, on break or vacation- really bad after getting yearly PAPsmears which was always followed with vaginitis-that passed in 2 weeks- married- allergic to condoms-that didn't take long to learn- started BCP's to prevent pregnancy did fine.1991- in residency- rash with nonsterile gloves- but not sick- pregnant, Father's Day got a dog- treated dog for fleas with pyrethrin's developed EM the last 2 months of pregnancy (no latex precautions taken during pregnancy or delivery- no one seemed interested that I couldn't wear latex gloves) on steroids- EM passed after 1 month- ended up with C section due to ear first- unrelated- all fine. each time dog or cat treated with pour on pyrethrins for fleas- I'd get EM- on steroids off and on through residency5-6 times per year- occasional asthma problems- hypotensive when assiting in surgeries- 2nd child 1992- no EM no problems- my OB developed latex glove allergy-1993-4 no problems; 1995 severe EM the same time my cat lost all it's fur- we had just sprayed our home for termites-(we'd quit pyrethrins as I thought I might have a contact dermatitis to them) well they sprayed with pyrethrins- we fortunately had sprayed for termites as we were preparing to move and the EM stopped 2 weeks after moving out- my usual EM symptoms are I'll awaken feeling ill-generally-aching all over,itch severely, stiff joints and be hypotensive but usually can remain upright (barely) short of breath, diarrhea and typical EM target lesions all over usually palms, soles and mouth and extensor surfaces the most- but sometimes everywhere sometimes just a few; usually my joints are super sore and stiff but not boggy- there is mild angioedema with this. My dermatologist biopsied some in the past and it could be hives or EM they couldn't tell??? Sometime in here I developed cold uticaria- lasts 1-2 hours and passes- no biggie- Treated with Allegra, Tagamet and Benadryl and steroids and gradually resolved; occasional EM after helping my spouse with the cows- pyrethrins again then in 2000bad EM after using DEET to go fishing-(within an hour - it burned spraying it on- I'd never had that before)2001 case of EM in Oregon- called and found hotel room had been sprayed for bugs the day we checked in- we stayed 1 night- lost 2 toenails)Could think of no other knowable reason??? Nov. 2003 I developed unusual bleeding and underwent a polypectomy, D&C and endometrial ablation and am still sick- immediately after discharge(30 min.) I was hypotensive, nauseated and never hurt so bad in my life- I developed a generalized itchy macular rash, SOB, urinating Bright red blood for 3 hours then no urine for 3 days- I 3rd spaced everywhere and swelled up like a toad- I was still on Singulair (which totally stops my Raynaud's- go figure) Allegra 180 and Tagamet which I've taken chronically for asthma and allergies- I was given Zofran for the nausea and developed dyskinesias- within 48 hours all mucous membranes sloughed off my mouth and vaginal membranes continue to slough every 48-72 hours except if on high dose steroids then they slough every 7 days-( took steroids for 6 months) usually several small ulcers are left following the slough this was biopsied and thought to be lichen planus or EM- ( spongiosis, parakeratosis, subepithelial inflammatory infiltrate) I had an EGD- and other than things being a little generally friable- it was normal- blood work has been normal but no testing for Histamine levels, latex allergens and the like have been done or serum trypton- I still have dermatographia, no energy, intermittent angioedema, burning eyes. My corner of the office is latex free-the whole building is not- we are trying to get everyone to go to powder free gloves and 90% have- 2 doc's have refused. I've discovered the joy of latex free tape and bandaids- the hospitals are not- latex free- when I go to see a consult or to the neurodiagnostic lab I travel in the nonpatient care areas as much as possible ;36- 48 hours later I will develop severe hypotension, angioedema esp. periorbital and perioral, mild asthma symptoms, and a non descript itchy rash who knows where but also typically on my chin and chest- also forearms- shins, thigh, back- it's been a number of places this rash is scaly itchy and bumpy and takes months to go away.I will usually not urinate for 2-3 days in spite of generous fluid intake and 2-3 days later will diurese like crazy- and usually have diarrhea as well. epi pens help the SOB and hypotension- it usually requires 4-5 pens per episode to remain upright and thinking- I stopped the steroids as I feel bad on them and they didn't totally stop the sloughing- I'm tired of a sore mouth and vagina- they burn and feel swollen and of course slough and leave little painful ulcers-not apthous- they ruled that out- I'd like to be able to resume my normal medical practice and be able to go into my doctor's office without getting sick I've taken 2 -2 week vacations (after about 10 days I start to feel better) then I feel great for 8-10 days no membranes slough- no itchy rashes- normal energy etc..I'm looking for any answers as I don't get typical anaphylaxis but have this chronic other problem- I dread an ER visit- I kept thinking it was in my head but a trip to the doctor's lounge for lunch makes me ill later as does going to med records to sign a chart- and these are nowhere near patient care areas-I know the molecules are in the air- is there a set level that is safe? Can I have it tested? If so how- who? what do they look for? It'd have to be out of my pocket- I just don't consider going on disability an option as 2 doctor's have suggested. Can I get desensitized? Do you think I have 2 different things or as my dermatologist/allergist say have this chronic allergic reaction with flare ups??? Do you have a listing of latex free hositals- It's been suggested I go to Mayo's etc.. but I'm like great -I go alone and get exposed to more latex and possibly die- and get sicker or just stay status quo and epi pens are ridiculously expensive!!!! ( my mouth my buccal mucosa sloughs and sometimes the side of my tongue and hard palate ( all 3 will get ulcers) and I just finished an 8 week rash from the corner of my lip to my chin which was scaly and peeling with 2 little ulcers that looked like a picked pimple- but wasn't- I treated them with topical steroid- clobestalol- and a vacation- I thought they'd never heal and go away- a 7 day vacation got it gone-)I gave up banana's ( 3 months) and all- avocado etc.. no change- I fasted a week without change- and I eat as usual when on vacation and get better so I doubt a food allergy- I am allergic to soap' and poison ivy , perfumes, red dye- rash and get hayfever esp. to trees and grasses and am worst when the sap goes up and comes down but those symptoms are nothing and Allegra and Singulair and Tagamet control it well and the like- I keep with my good old unscented dove and changed my toothpaste and toothbrush ( still doesn't explain the vaginal) without benefit- and again I take my toothpaste and all with me and use it on vacation- the dog too- I exercise and it doesn't seem at all exercise related. I've taken vitamins, stopped vitamins, stopped caffeine, soda, artificial sweetners etc, to no avail- no one seems to have any ideas on what to do or where to go next- all rheumatolgic testing is normal- infectious disease neg. I've been to- OB/GYN, GI, INt Med, Allergy Immunology, General Surgery, Infectious Disease, Dermatology, Rheumatology, Dentist, Oral Surgeon all by referral from my PCP- I've put her on hold as we've gotten nowhere- everyone has been kind and attentive and sympathetic but I've had enough tests and blood draws- except for the ones I probably need but no one here does latex allergy or knows anyone who does and also this is weird- I've had mucositis for 18 months and 1 episode of hairy leukoplakia on my tongue- so ideas? The clinical picture you describe is obviously quite complex with the real possibility that more than one disorder is responsible for the different symptoms you describe. One thought that comes to my mind is that you have the unusual presentation of recurrent E. Multiforme with elements of the Stevens-Johnson Syndrome (SJS) to possibly explain your skin, oral and vaginal manifestations (see enclosed abstracts). As noted in the enclosed abstract, the majority of such cases of recurrent EM appear to be associated with/triggered by herpes virus infections. There is a beneficial response to acyclovir is a sizable percentage of such cases. You raised the question of whether latex sensitivity could be causing your chronic/recurrent symptoms. I have obtained input from Dr. Kevin Kelley of the Medical College of Wisconsin, an expert in latex sensitivity. Dr. Kelley's comments are enclosed below. As he stated, the first step is to get a reliable assay for serum IgE anti-latex antibodies. One of the best I know of is the DACI labs in Johns Hopkins Medical Institutions, supervised by Robert Hamilton, PhD. You can contact Dr. Hamilton by E mail (rhamilto@jhmi.edu) to find out the logistics and billing arrangements to have this latex-IgE antibody assay done. If the serum assay is negative, perhaps you can find someone near you to do the latex skin test (occasionally positive when the serum test is negative. However, the skin test is not done if the serum test is strongly positive). Dr. Kelley suggested Dr. Jay Portnoy in Kansas City (jportnoy@cmh.edu). I hope that this information is of assistance. Br J Dermatol. 1993 May;128(5):542-5.Recurrent erythema multiforme: clinical features and treatment in a large series of patients. Schofield JK, Tatnall FM, Leigh IM. Department of Dermatology, Royal London Hospital, U.K. Recurrent erythema multiforme is an uncommon disorder. We have reviewed the clinical features and treatment of 65 patients with this condition. The mean number of attacks per year was six (range 2-24), and the mean duration of the disease was 9.5 years (range 2- 36) reflecting its chronicity. The majority of patients had oral mucous membrane involvement (69%). In 46 patients (71%) the condition was precipitated by a preceding herpes simplex virus infection. Acyclovir was found to be the most useful first-line treatment, with 55% of patients deriving benefit from either continuous oral acyclovir or a patient-initiated 5-day oral course at the onset of herpes simplex virus infection. Of those failing to respond to acyclovir, a small proportion responded to dapsone. The most resistant patients (11) were treated with azathioprine, with complete disease suppression in all cases. Dermatol Clin. 2003 Jan;21(1):195-205.Oral manifestations of erythema multiforme. Ayangco L, Rogers RS 3rd.Division of Periodontics, Department of Dental Specialties, Mayo Clinic, 200 First Street SW Rochester, MN 55905, USA. Erythema multiforme is a reactive mucocutaneous disorder in a disease spectrum that comprises a self-limited, mild, exanthematic, cutaneous variant with minimal oral involvement (EM minor) to a progressive, fulminating, severe variant with extensive mucocutaneous epithelial necrosis (SJS and TEN). Significant differences exist among EM minor, EM major, SJS, and TEN with regards to severity and clinical expression; however, all variants share two common features: typical or less typical cutaneous target lesions and satellite-cell or more widespread necrosis of the epithelium. These features are considered to be sequelae of a cytotoxic immunologic attack on keratinocytes expressing non- self-antigens. These antigens are primarily microbial (viruses) or drugs and in rare instances histocompatibility antigens [5]. Although the precise pathogenesis is unknown, there is a tendency to consider EM both minor and major as part of one spectrum that is most often triggered by viral infections, and SJS and TEN as a separate one most often elicited by drugs with EM major and SJS representing a bridge in the continuum of EM. The oral manifestations of the spectrum of EM range from tender superficial erythematous and hyperkeratotic plaques to painful deep hemorrhagic bullae and erosions. Other mucosal surfaces including ocular, nasal, pharyngeal, laryngeal, upper respiratory, and anogenital may be involved. Scarring sequelae from ocular and pharyngeal involvement cause morbidity. The oral EM variant is an underrecognized form of EM. Most patients have chronic or recurrent oral lesions only, but one third have oral and lip lesions and one quarter have oral, lip, and skin lesions. This variant is a reaction pattern similar to EM minor, EM major, SJS, and TEN. The diagnosis of oral EM is one of exclusion. Careful clinical evaluation for other chronic mucocutaneous diseases, such as pemphigus, paraneoplastic pemphigus, mucous membrane pemphigoid, and lichen planus, is a necessary component of the diagnosis. The value of a biopsy specimen studied by both routine histopathologic and immunopathologic methods is fundamental to excluding the other causes for this variant of EM. Dr. Kelley's comments With regards to the physician patient, I have read her complaints multiple times. I believe there are two things going on. I agree that she has latex allergy historically but I would like to see her tests (serum results). She is close to Jay Portnoy in KC who might be of help clinically. The vaginitis she experienced may be due to latex. We have a biopsy proven case of vaginitis published in the literature associated with latex glove contact. Franklin Adkinson MD has as IND for desensitization at Johns Hopkins. He reported two cases at AAAAI this year. Steve McGeady in your town also has tried many years ago but no longer does it. No one at Mayo does this anymore. Mark Swanson from Mayo does air sampling with reliability. The air samples are unnecessary though. If powder gloves in prepackaged kits, gloves or surgical gloves are being used in the area she contacts, there is allergen in the air. I believe that some of the angioedema and EM are likely to be autoimmune in nature. I am unaware of EM being reported from latex. Some patients have more than one disease. In light of the tongue findings, nail loss/change, and buccal mucosal issues, the chronic mucocutaneous candidasis syndromes with autoimmune issues might be involved? Sounds like a immunologic review of T cell disease and neutrophils may be needed. I actually see an adult with CMCC that has many similar mucosal complaint as well as the skin papule complaints. 4/19/05 re: Latex sensitivity in spina bifida patients I am a Respiratory therapist and work with peds from time to time. I have noticed a strong relationship to spina bifida and development of latex allergies. Is this just because of a higher presence of IgE antibodies and if so does this develop in direct response to the lack of closure of the neural tube? I am pondering if the timing of the neural tube closure is at the same time of a specific immunological development in the fetus and the defects are related to this stage of development or lack of rather, in these situations.Thank you for your help in answering my questions. You raise a provocative question whether there is a particular inherent disposition of spina bifida (SB) patients to develop latex allergy (LA). Most investigators have concluded that the frequent development of LA in SB patients is related to the multiple surgeries with latex exposure and indwelling catheters that SB patients undergo (see enclosed abstracts). For example, some groups have concluded that a risk factor for a SB patient developing LA is a history of having undergone at least 4-5 surgical procedures (see enclosed abstracts). In a more recent study, a major effort to reduce latex exposure during surgery and post-op care in SB patients has been followed by a marked reduction in the development of LA in such individuals.However, the picture may be more complex than just a matter of heavy latex exposure in SB patients. One group has reported that spinal cord injury patients with a similar number of surgeries as their SB patients did not develop LA while LA occurred commonly in the SB patients (see enclosed abstract). However, it is not clear when the amount of latex exposure was similar in the two patient groups.Therefore, it is conceivable that some host factor in SB patients could also pre-dispose to developing LA. One would expect that an inherent abnormality in SB patients leading to LA would also be manifest by strong IgE responses to other aeroallergens such as pollens or dust mites. However, I am not aware of any generalized alteration in immune responsiveness of SB patients unless the patient develops kidney failure (which can depress immune responsiveness). Therefore, the major effort at this time has been to reduce exposure to latex in SB patients. Clin Exp Allergy. 1998 Feb;28(2):175-80. Related Articles, Links Molecular analysis of DRB and DQB1 alleles in German spina bifida patients with and without IgE responsiveness to the latex major allergen Hev b 1. Rihs HP, Cremer R, Chen Z, Baur X. Institute for Occupational Medicine (BGFA), Ruhr-University Bochum, Germany .BACKGROUND AND OBJECTIVE: Spina bifida patients are at a high risk of developing latex allergy. Recently, we found a relationship between the IgE responsiveness to latex allergen hevein and human leucocyte antigen (HLA) alleles DRB1*04(DR4) as well as DQB1*0302(DQ8). This study was carried out to investigate the association between HLA class II alleles and the specific IgE response to latex allergen Hev b 1 in spina bifida patients. METHODS: Blood samples from 103 unrelated German spina bifida patients exposed to latex products and from 90 unsensitized controls were examined. Genomic DNA isolation followed by HLA-D-specifc polymerase chain reaction (PCR) amplification was used to perform HLA typing of allelic polymorphisms in exon 2 of DQB1 and of DRB1,3,4,5 with sequence-specific oligonucleotide probes (SSOPs). RESULTS: Fifty-one out of 103 spina bifida patients were found to have anti-latex IgE antibodies; 40 had also anti-Hev b 1 antibodies. Further, we observed that 80% of the Hev b 1 responders underwent five or more surgeries whereas 55% of the Hev b 1 non-responders and 75% of the latex-non-responders underwent less than five surgical interventions. From the latex-sensitized group 33% showed an elevated phenotype frequency of DRB1*0701(DR7) when compared with unsensitized patients (12%, P = 0.0095, Pc = NS) and with controls (17%; P = 0.035, Pc = ns). Fifteen out of 40 Hev b 1 responders also exhibited an elevated DR7 frequency when compared with latex-sensitive but Hev b 1-negative patients (38% vs 18%, P = NS) or with unsensitized controls (38% vs 17%, P = 0.013, Pc = NS). CONCLUSIONS: Although we found that the DRB1*0701 (DR7) phenotype frequency was elevated in SB patients with latex- as well as with Hev b 1-IgE responsiveness, the analyses of the other class II alleles clearly demonstrate that the HLA-D region does not play a major role in the pathogenetic way of sensitization to Hev b. Eur J Pediatr Surg. 2002 Dec;12 Suppl 1:S19-21. Related Articles, Links Reduction of latex sensitisation in spina bifida patients by a primary prophylaxis programme (five years experience). Cremer R, Kleine-Diepenbruck U, Hering F, Holschneider AM. Children's Hospital, Paediatric Clinic, Cologne, Germany. reinhold.cremer@t-online.de Spina bifida patients represent a group with the highest risk for latex sensitisation and allergy with life-threatening symptoms mostly during surgery. At the end of 1995 we initiated a primary latex prophylaxis around and during surgery and anaesthesia of all spina bifida patients. The aim of our study was to investigate the prevalence of latex sensitisation in the spina bifida patients born during the five years after establishing latex prophylaxis in the Cologne Children's Hospital in December 1995. We investigated 34 serum samples of 27 spina bifida patients (mean age 2.4 years) for specific IgE antibodies against latex allergens (CAP system) and compared these patients born after 1995 with 38 spina bifida patients up to 5 years of age (mean 3.1 years) born before. In the prophylaxis group two of 27 patients (7 %), one of them with two operations outside the Children's Hospital, had low specific IgE against latex (</= 0.9 kU/l, 3 and 5 operations). The other patients in this group were not sensitised despite up to 8 operations (min. 1, mean 3.1). In contrast, before introducing the prophylaxis, 16 of 38 patients (42 %) were latex IgE-positive after multiple operations (min. 2, max. 11, mean 4.7) with values of specific IgE up to > 100 kU/l (mean 22.6 kU/l, min 0.4 kU/l). Sera of 22 patients remained negative for latex IgE (min. 1, max. 19, mean 4.3 operations). By primary latex prophylaxis during surgery, anaesthesia and in paediatric wards the prevalence of latex sensitisation can be significantly reduced even in the high risk group of spina bifida patients. Problems can arise by the need for surgery in hospitals not experienced in the treatment of spina bifida patients, where latex prophylaxis is neglected Allergol Immunopathol (Madr). 2002 Jan-Feb;30(1):5-13. Related Articles, Links Risk factors for latex sensitization in children with spina bifida. Pires G, Morais-Almeida M, Gaspar A, Godinho N, Calado E, Abreu-Nogueira J, Rosado-Pinto J. Immunoallergy Department, Dona Estefania Hospital, Lisbon, Portugal. BACKGROUND: Children with spina bifida represent the major risk group for latex sensitization.Purpose: To determine the prevalence of latex sensitization in these children and to identify risk factors. MATERIAL AND METHODS: We studied 57 patients with spina bifida. The mean age was 5.6 years and the male/female ratio was 0.8/1. In all patients a questionnaire, skin prick test (SPT) with latex (UCB-Stallergenes, Lofarma and ALK-Abello), common aeroallergens and fruits (UCB-Stallergenes) and serum determination of total IgE (AlaSTAT) were performed. RESULTS: The prevalence of latex sensitization was 30 %; only two sensitized children (12 %) had symptoms after exposure. Risk factors for latex sensitization were age >/= 5 years (p = 0.008; OR = 6.0; 95 % CI = 1.7-22.1), having at least four previous surgical interventions (p < 0.0001; OR = 18.5; 95 % CI = 3.6-94.8), having undergone surgery in the first 3 months of life (p = 0.008; OR = 5.4; 95 % CI = 0.7-29.2) and total serum IgE >/= 44 IU/ml (p = 0.03; OR = 3.8; 95 %CI = 1.1- 13.1). Multiple logistic regression analysis showed that only a history of four or more surgical interventions (p < 0.0001; OR = 26.3; 95 %CI = 2.9-234.2) and total serum IgE >/= 44 IU/ml (p = 0.02; OR = 8.6; 95 % CI = 1.4-53.4) were independently associated with latex sensitization. Sex, family and personal allergic history, hydrocephalus with ventriculoperitoneal shunt, cystourethrograms, intermittent bladder catheterization and atopy were not related to latex sensitization. CONCLUSIONS: In children with spina bifida, significant and independent risk factors identified for latex sensitization were multiple interventions and higher levels of total serum IgE. A prospective study will clarify the clinical evolution of asymptomatic children sensitized to latex. 2/4/05 re: Latex sensitivity from masks As a Cardiac Surgeon and Director of the Pacemaker services of my hospital for 30 years, part of my activities included an average of 300 to 350 surgical procedures per year. I have also used surgical gloves in hundreds of medical events a year. Since 1991, during the Gulf War, I started to suffer of Bronchial Asthma. Due to that, I am very interested in the Latex Allergy concept developed in the last decades. Born at 1937, I have NEVER suffered of Asthma or any allergic illness till 1991 nor allergy to surgical gloves. When the Gulf War started at January 15.91, all the Israeli citizens were advised to protect themselves by using antigas masks produced of latex. Each time the duration was between half to three hours, at least twice a day. After 10 days of intermittent use, at 1.24.91 I suffered an acute episode of respiratory distress (bronchoconstriction) and was hospitalized with a suspected diagnosis of asthma? (first time in my life) or a pulmonary embolus. At the ICCU the diagnosis was confirmed as Acute Bronchial Asthma and treated with i/v corticoids medication. After discharged, maintained treatment for about 2 months and the ASTHMA diagnosis was suspected but not confirmed. A year later, after a second acute episode of respiratory distress (bronchoconstriction) I was medicated and started an ASTHMA treatment with a combination of drugs that I maintain since then. I was advised to avoid exposing myself to airborne irritants and/or to latex devices. The diagnosis of Asthma triggered by allergy to airborne irritants as latex and other Non-Allergic Asthma Triggers was accepted, but discussed by others, due to a negative anti-NRL IgE antibody test (3.3.98). However is known that: First: the normal total IgE level does not exclude the diagnosis of an allergic disorder and Second: values for atopic and normal individuals can overlap. To support the latex allergy pathogenic diagnosis I want to mention that during an intercurrent eye-cataract surgery at 12.16.99, by mistake a latex mask and tubing for O2 were used instead of the silicones as indicated. I immediately complained of a sense of itching and irritation in my throat and dispnea, which almost induced a provocative challenge testing. It was avoided when the mask and tubing were immediately supplanted by silicone units. The concentration of NRL (natural rubber latex) proteins have been found in the air of medical, dental practice buildings and ambulances, but I have no data when using OR or antigas latex masks. By extension, exposure to these airborne proteins may be a health hazard for sensitized patients and EMT's (emergency medical technicians) working in the close area. Allergen exposure can produce allergic sensitization in susceptible persons, resulting in symptomatic asthma on re-exposure. I would be very obliged, if you would consider: a) discussing the case as Asthma related to latex allergy while using ANTIGAS LATEX MASK, its diagnostic and pathogenesis considerations, exposing your views and suggestions, b) perhaps there are other similar cases diagnosed as ASTHMA due or in relation to latex masks: O.R. or antigas. Most of the well-documented cases of allergy to natural rubber latex (NRL) have involved contact with dipped NRL products such as rubber gloves from which the NRL allergen spontaneously elutes onto the skin, particularly when there is perspiration under the gloves. These allergens bind to the cornstarch powder used as a glove lubricant and are dispersed into the surrounding air when gloves are put on or removed. Therefore, it is possible to become sensitized to NRL allergens by inhaling the air in the OR or in wash-up areas where rubber gloves are being put on or removed. It has been shown that such airborne levels of NRL allergens are markedly reduced in institutions which have switched to the use of powder-free, low allergen content rubber gloves. There have been documented cases where individuals have reacted to NRL allergens which have eluted from “soft” rubber products such as urinary catheters and drains (particularly with chronic use, as in spina bifida cases). The soft rubber connectors in some intravenous setups have also been thought to cause occasional latex-allergy reactions. However, I am not aware of such elution of NRL allergen from the harder NRL products used in face masks. The usual commercial tests for serum anti-NRL IgE antibodies are usually only about 80-85% sensitive. Therefore, a negative test of this sort does not completely rule out NRL allergy. The skin test with NRL extract is more sensitive. If there is still a question, a local challenge such as applying a cut off finger section of a powdered NRL glove to the patient's finger with subsequent careful observation in a medical facility may be indicated. I suggest that you consult Dr. Meir Shalit of the Hadassah Medical Center in Jerusalem for possible further evaluation. Dr. Shalit is a very experienced allergist with a special interest in NRL allergy. 12/22/04 re: Rubber mulch, latex allergy As a Registered Dietitian, I work with a number of children who are allergic to tree nuts (not specifically tested for allergies to chestnuts) and other food allergies. Our local elementary school has rubber mulch as the surfacing material, and I have been asked if the children with nut allergies should avoid playing in this. Would daily exposure to pieces of rubber mulch worsen their food allergies, or increase their likelihood of developing an allergy to latex? Latex allergy is induced by repeated exposure to products made with soft molded natural rubber, particularly surgical gloves and occasionally rubber tubing used in intravenous administration setups. The latex allergens (allergy-inducing compounds) actually leach out of these products under certain circumstances and can come in contact with the skin or be inhaled. In that way, allergy to natural rubber latex (usually called latex allergy) can be induced in some individuals after repeated exposures. Latex allergy has not been reported to be associated with exposure to "hard": rubber products, which would include the fragments of rubber tires. That is likely because the process of making hard rubber products (such as vulcanization in tire manufacture) alters or prevents leaching of latex allergens. Therefore, exposure to a mulch made of tire fragments should not present an increased risk for developing latex allergy. Incidentally, the term "latex" is used for other products, such as certain paints, which do not contain the natural rubber latex. Therefore, exposure to latex paints does not involve a risk for developing latex allergy. 10/1/04 re: Latex sensitivity I am a 31 year old physical therapist and owner of a PT clinic. I have been struggling with multiple food allergies for the past couple of years. My allergist recently tested me for latex allergy. I use latex thera-bands daily with my patients, and I have never had a rash or any other skin problem from touching them. So I have two questions: Is it possible that my food allergies have been made worse by my daily exposure to latex? And if the test for latex is positive, will simply removing the latex thera-bands from my clinic improve my tolerance to foods? IgE antibodies to latex appear to cross react with allergens in certain foods, mainly bananas, kiwi, avocado, chestnut (see enclosed abstract), but not all foods. As a result, about 30% of latex-sensitive individuals also exhibit allergic reactions to these foods. However, the situation in those who are primarily allergic to these foods is more complex in that there appears to be a lower incidence of subsequent sensitization to latex. To answer your questions: If you are clinically reactive to one of the cross-reacting foods noted above, it is conceivable that sensitization to latex, then contact with latex will enhance allergic reactivity to that food as well. However, since you do not appear to be latex-sensitive, it is unlikely that sensitization to these foods will increase (you can be more sure by being skin tested to latex). Likewise, it is unlikely that allergies to these foods will decrease by latex avoidance if you are not latex-sensitive. However, if you wish to take extra precautions, you can consider use of nitrile gloves. These do not contain the latex allergens yet appear to have the same barrier capacity against pathogenic viruses such as HIV and hepatitis B as the natural rubber latex (NRL) gloves. I do not know current prices but nitrile gloves were more expensive than NRL gloves. 1: Curr Allergy Asthma Rep. 2003 Jan;3(1):47-53. Latex-fruit syndrome. Blanco C. Servicio de Alergia, Hospital Universitario Dr. Negrin, c/Barrenco de la Ballena s/n, 35012 Las Palmas de Gran Canaria, Spain. Natural rubber latex immunoglobulin E-mediated hypersensitivity is probably one of the most relevant challenges that has been faced in the treatment of allergies during recent years. Additionally, allergen cross-reactivity has arisen as another very important problem, in the difficulty in diagnosing it and in its clinical implications. It is clear that some latex allergens cross-react with plant-derived food allergens, the so-called latex-fruit syndrome, with evident clinical consequences. Although the foods most frequently involved are banana, avocado, kiwi, and chestnut, several others are also implicated. Investigations point to a group of defense-related plant proteins, class I chitinases, which cross-react with a major latex allergen, hevein, as the panallergens responsible for the syndrome. This review focuses on our current understanding of the latex-fruit syndrome. 9/7/04 re: Nitrile allergy I am a clinical educator in a hospital. We are currently converting to a “latex safe” environment. We have recently converted from latex exam gloves to Nitrile powder free exam gloves. Have you ever heard of Nitrile allergy? I can't find any research or current literature on this subject. Although nitrile gloves are now used extensively because their barrier protection appears to be equal of that of natural rubber latex (NRL) gloves, I am not aware of any reports of allergic reactions to such nitrile gloves occurring with any frequency. However, there have been several reports of allergic reactions to a nitrile-containing chemical used in some cosmetics (see enclosed abstract). If there is a strong suspicion that an individual health care worker has had an adverse reaction to nitrile gloves, one may wish to consider use of a non-powdered, low-allergen NRL gloves. A recent report described a decrease of over 80% in the incidence of latex sensitivity in hospitals in Germany after a switch to predominant use of non-powdered, low-allergen NRL gloves (see enclosed my recent review of this report for the Current Literature section of this AADMC website). Contact Dermatitis. 2003 Mar;48(3):150-4. Methyldibromo glutaronitrile: clinical experience and exposure-based risk assessment. Zachariae C, Rastogi S, Devantier C, Menne T, Johansen JD. Department of Dermatology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. In the year 2000, the level of methyldibromo glutaronitrile (MDGN) allergy in dermatology clinics in Europe exceeded the level of allergies to all other preservatives, with a prevalence of 3.5%. In the present study, cases of primary sensitization and elicitation to MDGN due to cosmetic products were collected over an 8-month period at the Department of Dermatology, Gentofte University Hospital . The aim was to identify the products related to hand eczema, assess exposure to MDGN in these products and relate the findings to results from a newly developed updated risk assessment model for contact allergy. Out of 24 patients with a positive patch test to MDGN, 17 patients with hand eczema were identified. In 11 of these patients, cosmetic products used in relation to the onset of the disease were shown to contain MDGN (65%). In 8 of these 11 cases, primary sensitization was probable, 5 due to hand/body lotions and 3 due to lotions and/or liquid hand soap. Chemical analysis of 12 products showed that lotions contained 149-390 ppm of MDGN, liquid hand soap 144-399 ppm, a rinsing cream 293 ppm and shampoos 78-79 ppm. The shampoo exposure was not of certain relevance to the eczema. Applying the newly developed updated risk assessment model showed that the concentrations of MDGN in lotions of 149-390 ppm exceeded the calculated maximum acceptable exposure level for MDGN, which would be expected to lead to sensitization in consumers using such products, as seen in the current study. The present cases and updated exposure-based risk assessment process add to the evidence and need for re-defining safe-use concentrations of MDGN in cosmetic products.   Current Lit Item Declining incidence of latex sensitization Summary Background - The prevalence of allergic reactions to natural rubber latex (NRL) has to be increasing since the 1980's. particularly with the increasing use of NRL gloves by health care workers (HCW). Use of powder-free and gloves with low contents of NRL allergens have been recommended as measures to prevent NRL sensitization. Findings - Allmers et al determined the annual number reported of suspected cases of NRL-induced occupational allergies from 1996-2000 as well as the frequency of different types of gloves purchased by acute care hospitals in Germany from 1986-2000. The number of powder free, non-surgical gloves exceeded the number of powdered gloves by 1998, assuming an 88% market share by the year 2002. The frequency of non-powdered surgical gloves also exceeded the frequency of powdered surgical gloves by 2000 with a marked share of the former of 89% by year 2002. The incidence of contact urticaria in HCW attributed to NRL peaked in 1998, declining by 80% since then. Likewise, the incidence of occupational asthma attributed to NRL peaked in 1998, declining by 83% as of 2002. Conclusions - The reduced use of powdered NRL gloves is likely responsible for the sizable reduction in the frequency of NRL sensitization in HCW. Reference - J Allergy Clin Immnol 2004;114:347-51 Editor's Comments These findings provide encouraging supportive evidence that the incidence of NRL sensitization in HCW can be reduced markedly by the use of non-powdered gloves with lower content of NRL allergen. The question remains whether this reduced incidence of NRL sensitization in HCW will be accompanied by a similar reduction in NRL sensitization in patients coming in contact with the less allergenic NRL gloves now in use by HCW. 6/29/04 re: Evidence for "first case of the day" as a latex-avoidance approach I am the PACU Charge Nurse of an Endoscopy Center. We do approximately 250 cases a week with several patients that have a known or suspected latex sensitivity or allergy. I have made several requests that these types of patients be done as "the first case of the day." The problem is our Medical Director refuses to do this unless he is shown clinical studies that attest to this fact. Can you refer me to such so I can provide proof and establish some guidelines to the facility? Thank you in advance for your time and consideration. The approach you have suggested for scheduling latex-sensitive individuals as the first case of the day in an OR/procedure room had been recommended by some investigators about 10 years ago. However, there are now some other options that may keep the levels of latex allergen in OR/procedure rooms quite low throughout the day. I obtained input from Dr. Kevin Kelly of the Medical College of Wisconsin, an expert in latex allergy. His response is enclosed below: Dr. Kevin Kelly's response: The presumptive evidence for using the "first case of the day" as a latex avoidance approach came from an article in the 1990's by Mark Swanson, John Yunginger and Loren Hunt from the Mayo Clinic. Serial sampling of air in OR settings showed the lowest airborne levels occur first in the morning and after the weekend when no operative cases had occurred in a room for awhile. This is due to the fact that the particles of powder are relatively large and fall to the ground. Unless there was activity in the area, there was no aeroallergen detected. The reference is included below. Swanson MC. Bubak ME. Hunt LW. Yunginger JW. Warner MA. Reed CE. Quantification of occupational latex aeroallergens in a medical center. Journal of Allergy & Clinical Immunology. 94(3 Pt 1):445-51, 1994 Sep. The questioner should consider another opportunity here. The use of Powder- free, low- allergen gloves and non-latex materials would be preferable. A latex allergic subject must always have non-latex material used. The other subjects can use latex if it is powder free since there is little risk of airborne contamination with latex allergen that can be detected in this manner. This gets around the "first case of the day" problem which I can clearly identify with the scheduling nightmare this presents. Many settings like this require vigilance by the endoscopy staff so that surgeon gloves, exam gloves, pre-packaged kit gloves (e.g. bladder catheters or suction catheters) must all have powder free latex or non-latex gloves. 6/16/04 re: Systemic sensitivity in those with latex contact dermatitis I hope you can indulge one more question from me. I had written to you before to ask about latex rubber stoppers in vials. Thank you for your response. But I am about to give a small talk on latex allergy to my unit at the hospital where I work and I have one very basic question that will indeed come up: If during a nursing assessment the patient tells you that they are allergic to latex and through further questioning the patient describes skin rash only, whether it be irritant dermatitis or allergic contact dermatitis, do you treat them as an actual latex allergic patient? Most patients who describe their "allergy" this way have not been tested. Of all the articles I've read, everyone seems to avoid this question. And it is the most basic. There seems to be no hard evidence that skin rash will ultimately develop into actual latex allergy (type IV reaction) but many articles say this is possible and there is no way to tell if this will happen. There have been cases where patients who had only previously had a skin reaction to latex gloves have experienced anaphylaxis without warning on subsequent exposure. So, in summary, in your opinion, should a patient with type I or II reactions be labeled "latex allergic?" Your question addresses a subject in which published opinions have varied somewhat. To obtain additional input, I consulted Dr. Kevin Kelly of the Medical College of Wisconsin, a well-recognized expert in latex allergy and related avoidance measures. Dr. Kelly's response is enclosed below. The questioner is correct; everyone hedges on this. If one looks at the question of dermatitis, it is clear that about 90% of health care workers note hand dermatitis when they have latex allergy. However, dermatitis alone is a very non-specific indicator of IgE mediated disease. The chance of latex allergy (IgE mediated) is very low in such individuals with latex-related dermatitis if there are no symptoms of immediate hypersensitivity. The prevalence rate is not zero however. Some of this will depend on how much "defensive" medicine is being practiced. If one practices in a manner that one takes nearly 100% of the risk away, then complete latex precautions are indicated when someone states they have latex allergy. (An unfortunate way to practice medicine.) However, this is likely to be overkill for the vast majority of subjects with latex-related dermatitis. People with contact dermatitis to rubber alone (no IgE mediated disease) only need to be kept away from skin and mucous membrane contact. I'm afraid that if you ask 10 latex allergy experts about the question posed by the questioner, different opinions will emerge in their responses. Sorry to be non-committal on this. 5/18/04 re: Latex sensitivity and lung transplant Are there ways to protect a severely latex allergic patient who has cystic fibrosis and will be undergoing a lung transplant? For example, the transplant hospital will use latex-safe procedures, but the "harvesting" hospital can not be controlled and may use latex gloves. Is there a process of washing the organ to reduce latex? Should Xolair be used on a prophylactic basis until transplant and/or would there be any benefit in using Xolair “on call” which may only be 8-12 hours pre surgery? I realize that the group hoping to perform lung transplants often have little control about the harvesting of lungs obtained from fatal accident victims on short notice. However, I wonder whether it would be feasible to have listed in the request to the organ network that the individual harvesting the lung for use in your patient wear a pair of non-latex gloves over the latex gloves (so that protection against possible pathogen transmission is optimal without exposing the lung tissue to latex molecules). I realize that such an approach may not work, Therefore, I obtained input from Dr. Kevin Kelly of the Medical College of Wisconsin, an expert in latex allergy-related matters. His response is enclosed below. I should mention that I was also unable to find a cited report about Xolair treatment in latex sensitivity in my Medline search. Dr. Kelly's response The answer to the first question is unknown but it makes sense that washing the surface of the harvested organ is appropriate. There is no evidence that prophylactic treatment with Xolair is useful in latex allergy except by doctor to doctor anecdotes. I understand a clinical trial was worked on in France for such patients but have not seen any full text on this. However, I could have missed it. Prophylactic Xolair treatment of the recipient would need three months at least prior to transplant if I judge the clinical trial design and results correctly. More importantly, the half life of Xolair is very long and I am unaware of any studies on the use of this in transplant immune suppressed patients. Could this monoclonal antibody interfere with transplant immune suppression post transplant? I certainly don't know. These are great questions, but the reality is that they should wash the lung and deal with the problems if any arise. I assume that the harvesting team can communicate to the receiving team prior to such a dire operation or at least some info communicated to use latex safe precautions during the harvest. I may be naive here but that seems best.   5/8/04 re: Use of medications in contact with NRL stoppers I am a registered nurse working in an Endoscopy department. Our hospital is latex free for the most part but there are still a few things out there that contain latex. My question involves the rubber stoppers on vials and the rubber plunger ends in syringes that contain latex. I have read several articles that talk about this and have come away with differing opinions. One small study done at Johns Hopkins confirms that latex particles are indeed present in the medication found in rubber topped vials and that the level seems to increase after repeated puncture. A significant number of tested latex allergic subjects did in fact react to the allergen after the liquid in the vial was injected intradermally. I've also read that this “hard rubber” latex rarely if ever causes a problem. Some say not to use medicine from vials with NRL (natural rubber latex) or use prefilled med syringes that have NRL plunger ends. Others say it is not a problem. At our hospital, practice is inconsistent. Some nurses remove the metal seal and rubber stopper with Kelly's and then draw up the med in a latex free syringe in order to at least avoid the single puncture through the stopper. Others don't. The pharmacist told me that we really shouldn't use a medication in a prefilled syringe containing NRL on a latex allergic patient. But most do and without problem. It doesn't seem practical to try to separate the type IV's from the type I's as the vast majority of patient's who say they are allergic to latex have not had any type of testing (Does that matter anyway?). And even if they state symptoms associated with type IV (poison ivy type rash a day or 2 after wearing gloves) several articles say that anaphylaxis has occurred in patients with a history of skin rash only after exposure to latex. So I guess my question can be summarized: Is there any consensus or are there studies on whether the use of medication that has been in contact with NRL is safe to use on either type IV or type I latex allergy? Thank you in advance for your input. This has been a nagging question on our unit for a long time.   To help answer your questions, I have enclosed below the input I obtained from Dr. Kevin Kelly of the Medical College of Wisconsin in Milwaukee, a highly respected investigator of latex allergy. I believe that Dr. Kelly has a balanced view of what is still a somewhat contentious subject. However, before that I should respond to your comment questioning the value of testing for latex allergy. Although the in vitro tests for type I latex allergy (as performed by reputable labs) is still only about 80% sensitive in picking up all cases, latex skin testing may detect most of the other 20% of the cases. Hopefully, an FDA-approved skin test reagent will be available soon. Dr. Kelly's response: I understand that there are 2-3 reports of diabetics getting hypersensitivity reactions to medications from vials with latex caps, manifested as a hive at the injection site without systemic reactions. These are not large case report series so the diagnostics involved are limited. I assess this as a minimal risk but somewhere above zero risk. I understand that adverse reports to FDA suggest that the majority of reported reactions are to dipped rubber products. The clinical relevance of finding allergen in multiply punctured vials (in the Hopkins study) is unclear as a reaction in latex-sensitive individuals wasn't demonstrated. 12/10/03 re: Cross-sensitivity between usual latex and poinsettia We have a patient with severe latex allergy. What should be the guidelines for poinsettia plants in the ward? I am not aware of reports of studies showing the degree of symptomatic cross-reactivity between the usual latex component obtained from Hevea plants and that of pointsettia. Therefore, I consulted Dr. Kevin Kelly of the Medical College of Wisconsin, an expert in latex allergy. His response is shown below. Dr. Kelly's comments: Poinsettia is a lactifer (secretes latex) with similar proteins to Hevea Brasiliensis. Some our first testing was done with Poinsettia latex back in 1990 when we didn't have access to Hevea brasiliensis latex. Indeed, the patients can have reaction theoretically but in my estimation (no published literature) only with direct contact with the latex. If you are interested, break a leaf off of the end of a poinsettia and see the latex ooze out of the plant circulation system. I believe there will likely be no problem with plants in the hospital unless a patient comes in direct contact with the latex by the manner I mentioned above. Some hospitals have decided not to put these plants in their building. We have not taken that route but exclude them from latex allergic patient rooms and instruct the patients not to have contact. I know of no scientific immune cross-reactive data. Our work was unpublished as we were just getting started in the area 14 years ago. 10/6/03 re: Latex sensitivity in avocado-allergic patient I saw a 39 year old lady in our Allergy Clinic, who had a history of step I-II asthma, Allergic rhinitis and FOOD ALLERGY to mango, cantaloupe, and avocado. Of these foods, AVOCADO caused the worst reaction with actual trouble breathing and sensation of throat closing. She has had no clinical reactions to latex. I did a latex rast test and her score was 3009 which is 2+. Do you feel this increases her likelihood of future latex reactions? Despite the negative clinical history to latex, would you: advise pt. to avoid latex products? advise pt. to carry epipen and benadryl? Please advise. Thanks so much. I referred your question to Dr. Kevin Kelly , a leading clinical investigator of latex allergy. His response is enclosed below. Dr. Kelly has stressed that individuals such as you describe are likely at increased risk for clinical sensitivity to dipped latex products (e.g.- latex-containing gloves), not the hard rubber products that people are more likely to encounter in their usual activities. DR. KELLY'S RESPONSE: Previous reactions to Latex likely depend on past exposures to dipped rubber products. Thus, a number of patients with primary fruit allergic reactions with a positive RAST to latex (I assume that Dr. Block meant that the RAST was to latex and not the foods in question) may eventually become symptomatic. I believe that Carlos Blanco's article in the JACI addresses this. There is no harm in someone carrying injectable epinephrine. Such a precaution is indicated for a person with severe food allergy regardless of the history of no clinical reaction to latex. I would avoid dipped products of rubber (as opposed to all rubber products so as to not create a "phobia" in the patient). I believe that latex precautions (once again - a harmless procedure) for surgeries and medical procedures where latex is used are reasonable. 4/17/03 re: Evaluation of latex allergy in occupational setting I am an occupational physician in a hospital-based practice. Can you direct me to any evidence-based medical practice guidelines in the work-up of possible new onset latex allergy (due to occupational exposure)? I apologize for the slight delay in responding to your question. I can provide you with some information, based on the publications of Dr. Robert Hamilton of Johns Hopkins and Dr. Kevin Kelly of the Medical College of Wisconsin, leading experts in the evaluation of latex allergy (see enclosed abstracts). I have also enclosed FYI an abstract of a report concerning the program set up at Hopkins to reduce exposure to latex. 1. A carefully obtained history of the type of exposure and symptom pattern is an important first step. Almost all occupational latex sensitivity involves "dipped" rubber products such as natural rubber latex (NRL) gloves. There is little if any risk for reactions to hard rubber products such as stoppers. NRL-containing connectors and injection ports have generally been supplanted by synthetic materials in IV infusion sets but may still be present occasionally. There is no NRL in "latex paint". Individuals with latex sensitivity should be asked about reactions to ingestion of certain foods (bananas, kiwi, avocado, chestnut most common) 2. The currently available in vitro tests for latex-specific IgE antibodies are only about 75% sensitive (see enclosed abstract). The latex skin test recently developed is close to 100% sensitive (when compared to latex challenge tests) but has not yet been approved by the FDA for clinical use. If the history suggests a delayed contact skin reaction to NRL, then patch testing is indicated. 3. If the history strongly suggests latex sensitivity but the in vitro blood test is negative, one can consider a diagnostic challenge test, carried out cautiously under close observation in any one with a history of a prominent systemic reaction attributed to latex (see enclosed abstract). J Allergy Clin Immunol 2002 Aug; 110(2 Suppl):S47-56 Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy. Hamilton RG, Peterson EL, Ownby DR. Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. The accurate diagnosis of hypersensitivity to natural rubber latex is the initial step in the effective management of individuals with latex allergy and in ensuring the quality of epidemiologic studies. The diagnostic algorithm used in the evaluation of an individual with suspected latex allergy begins with a comprehensive clinical history during which risk factors (atopy, food allergies, hand dermatitis) and temporal relationships between symptoms and natural rubber product exposure are identified. If type IV hypersensitivity is suspected because of the delayed nature (hours to days) and confinement of symptoms to the skin-latex product contact areas, patch testing can be conducted to confirm the presence of activated T cells with specificity for rubber chemicals. If type I hypersensitivity is suspected because of ocular, upper and lower airway, and/or systemic symptoms that have rapid onset (minutes) after a definable latex exposure, a confirmatory skin or blood test for IgE antibody may be conducted to verify a state of sensitization within the individual. The definitive diagnosis would then be made only after consideration of the individual's clinical history and confirmatory in vivo and/or in vitro laboratory test results. If discordance remains between highly convincing latex-associated symptoms as identified in the history and repetitively negative confirmatory IgE antibody test results, then one of several types of in vivo provocation tests may be performed for adjudication. This overview examines the current state of the art in both in vivo and in vitro diagnostic methods for latex-specific IgE antibody detection in skin and blood. The performance, advantages, and limitations of each diagnostic method are compared. Methods 2002 May;27(1):22-31 Diagnosis of natural rubber latex allergy. Hamilton RG. Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. The accurate diagnosis of a latex-allergic individual begins with a comprehensive clinical history. Atopy, food allergies, hand dermatitis, and temporal relationships between allergic symptoms and natural rubber product exposure are risk factors that increase the suspicion of latex allergy. If symptoms are temporally delayed (hours-days) and confined to skin-latex product contact areas, Type IV hypersensitivity should be suspected and patch testing may be performed to identify activated T cells that are specific for selected rubber chemical additives. If ocular, upper and lower airway, and/or systemic allergic symptoms are observed with rapid onset (minutes) following a definable latex exposure, Type I hypersensitivity should be suspected. One or several confirmatory tests for latex-specific IgE antibody in the skin or blood may next be performed to verify a sensitized (IgE antibody positive) state. If the clinical history remains discordant with a skin test or blood test result, in vivo provocation tests may be cautiously considered for adjudication. Diagnostic methods for latex-specific IgE antibody detection in skin and blood are overviewed, with a focus on their performance, advantages, and limitations. Copyright 2002 Elsevier Science (USA). Methods 2002 May;27(1):15-21 Natural rubber latex allergy in the occupational setting. Charous BL, Tarlo SM, Charous MA, Kelly K. Milwaukee Medical Clinic, Allergy and Respiratory Care Center, Advanced Healthcare, SC, 3003 West Good Hope Road, Milwaukee, WI 53209, USA. Over the last decade, the prevalence of natural rubber latex (NRL) allergy has reached epidemic proportions among workers who use or who are exposed to powdered latex products. NRL-associated occupational asthma is confined largely to those exposed to powdered latex glove use or other latex aerosols. The most frequent presenting symptom of NRL allergy is contact urticaria; inhalation may cause symptoms of allergic rhinitis and asthma. Skin prick testing is the most accurate tool for diagnosis of NRL allergy. The cornerstone of management is cessation of exposure; substitution with non-NRL or nonpowdered NRL gloves results in predictable rapid disappearance of latex aeroallergen. Copyright 2002 Elsevier Science (USA). Methods 2002 May;27(1):22-31 Diagnosis of natural rubber latex allergy. Hamilton RG. Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. The accurate diagnosis of a latex-allergic individual begins with a comprehensive clinical history. Atopy, food allergies, hand dermatitis, and temporal relationships between allergic symptoms and natural rubber product exposure are risk factors that increase the suspicion of latex allergy. If symptoms are temporally delayed (hours-days) and confined to skin-latex product contact areas, Type IV hypersensitivity should be suspected and patch testing may be performed to identify activated T cells that are specific for selected rubber chemical additives. If ocular, upper and lower airway, and/or systemic allergic symptoms are observed with rapid onset (minutes) following a definable latex exposure, Type I hypersensitivity should be suspected. One or several confirmatory tests for latex-specific IgE antibody in the skin or blood may next be performed to verify a sensitized (IgE antibody positive) state. If the clinical history remains discordant with a skin test or blood test result, in vivo provocation tests may be cautiously considered for adjudication. Diagnostic methods for latex-specific IgE antibody detection in skin and blood are overviewed, with a focus on their performance, advantages, and limitations. Copyright 2002 Elsevier Science (USA). J Allergy Clin Immunol. 1999 May;103(5 Pt 1):925-30. Diagnostic performance of Food and Drug Administration-cleared serologic assays for natural rubber latex-specific IgE antibody. The Multi-Center Latex Skin Testing Study Task Force. Hamilton RG, Biagini RE, Krieg EF. Division of Allergy and Clinical Immunology, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA. BACKGROUND: In the absence of Food and Drug Administration-approved natural rubber latex skin testing reagents, latex-specific IgE antibody immunoassays are used in the diagnosis of latex allergy. Comparative diagnostic performance of these tests has not been definitively determined. OBJECTIVE: We sought to study the predictive value of available Food and Drug Administration (510K)-cleared latex-specific IgE antibody immunoassays in the diagnosis of latex allergy. METHODS: Subjects (n = 312) were classified as having a positive (n = 117) or a negative (n = 195) latex allergy history (Hx) or having a positive (n = 131) or a negative (n = 181) puncture skin test (PST) response (Greer reagent). The 14 subjects with a negative Hx and a positive PST response had negative responses to glove provocation testing and thus were considered sensitized but asymptomatic. Sera from 22 subjects were split to evaluate intra-assay variation. All 334 coded sera were analyzed for latex-specific IgE antibodies in the Diagnostic Products Corporation microplate AlaSTAT, Hycor HY-TEC EIA System, and Pharmacia-UpJohn CAP System. Variance and diagnostic performance parameters of each test were computed with 95% confidence intervals in relation to the subjects' Hx and PST status. RESULTS: Intra-assay concordance of split sera results was 96.0% for all 3 assays, with coefficients of variation of less than 25% and between-assay coefficients of variation of less than 21%. The diagnostic performance of the CAP and AlaSTAT assays were equivalent in comparison with PST results: sensitivity, CAP 76.3% and ALASTAT 73. 3% and specificity, CAP 96.7% and AlaSTAT 97.2% (P = NS). The HY-TEC assay was more sensitive (91.6%) and less specific (73.3%) than the CAP and AlaSTAT assays (P <.001). From 9% to 25% of the sera were discordant, being positive in at least 1, but not all 3, assays. CONCLUSION: The CAP and AlaSTAT assays produce 24% and 27% of false-negative results, respectively, whereas the HY-TEC produces 27% of false-positive results when compared with the PST. Jt Comm J Qual Saf 2003 Mar;29(3):113-23 How health care organizations can establish and conduct a program for a latex-safe environment. Brown RH, Hamilton RG, McAllister MA; Johns Hopkins Latex Task Force. Johns Hopkins Medical Institutions, Baltimore, USA. BACKGROUND: The advent of universal precautions brought about a dramatic increase in the use of natural rubber latex gloves, and reports of rubber latex allergies began appearing in the literature. In 1997 the Johns Hopkins Hospital created the interdisciplinary Latex Task Force to address the issue of creating, implementing, and evaluating a latex-safe environment. CONVERSION TO NONLATEX PRODUCTS AND EXAMINATION GLOVES: When suitable alternatives were available, allmedical products that contained latex were to be removed from the hospital and nonlatex alternatives substituted. Latex medical gloves, especially powdered latex examination gloves, which were used in all patient care areas, were replaced by vinyl gloves. Yet because of the ongoing concern about strike-through and the minimal level of acceptance of fit with the vinyl gloves, the search for alternatives to the vinyl gloves continued. The task force recommended switching to nitrile examination gloves throughout the hospital. To facilitate the transition to another examination glove, new educational pamphlets about the nitrile gloves were developed. POSTSCRIPT: The switch to nitrile examination gloves was successfully completed, but conversion to nonlatex surgical gloves was less successful, with costs being the overwhelming impediment. Monitoring of latex-containing products and ongoing evaluations of alternatives are crucial in ensuring patient and health care worker safety. We have just received a response, from Dr. Kevin Kelly, one of the experts cited by me in my response to you. I hope that this additional information will be of assistance to you. Dr. Kelly's response: In answer to the question, there are now a number of articles that point to evidence in the work up of latex allergy. The principals involved are those of any high molecular weight IgE mediated allergen. Multiple occupational medical texts address the appropriate algorithm for such a work up. These are based on sound clinical papers of occupational asthma. The difference of latex to the other situations is the lack of a FDA approved skin test reagent for diagnosis and the similar lack of a standardized specific allergen challenge. Thus the occupational physician is left with a medical history, physical exam, serological testing (with their own specific false negatives and false positive rates), methacholine testing, pulmonary function testing before and after occupational exposure. The epidemiology of the disease is part of the consideration in the occupational setting. Thus I have included a number of articles that are relevant for the questioner. References: Kelly KJ, Kurup VP, Zacharisen M, Resnick A, Fink JN: Skin and serologic testing in the diagnosis of latex allergy. J Allergy Clin Immunology 1993; 91:1140-5. Kelly KJ, Kurup VP, Reijula K, Fink JN: The diagnosis of natural rubber latex allergy. J Allergy Clin Immunol 1994; 93(5):813-6. Hamilton G, Adkinson F, Kelly KJ and the Multicenter Latex Skin Testing Study Task Force: Diagnosis of natural skin testing efficacy study. J Allergy Clin Immunol 1998;102 (3):482-90. Hamilton RG, Biagini RE, Krieg EF, Multi-Center Latex Skin Testing Study Task Force: Diagnostic performance of FDA-cleared serological assays for natural rubber latex-specific IgE antibody. J Allergy Clin Immunol 1999; 103:925-30. Charous BL, Tarlo SM, Charous MA, Kelly KJ: Natural rubber latex allergy in the occupational setting. Methods 2002; 27:15-21. Liss GM, Sussman GL, Deal K, Brown S, Cividino M, Siu S, et al. Latex allergy: epidemiological study of 1351 hospital workers. Occup Environ Med 1997; 54:335-342 Brown RH, Schauble JF, Hamilton RG. Prevalence of latex allergy among anesthesiologists. Anesthesiology 1998; 89(2):292-99. Allmers H, Brehler R, Chen Z, et al. Reduction of latex aeroallergens and latex-specific IgE antibodies in sensitized workers after removal of powdered natural rubber latex gloves in a hospital. J Allergy Clin Immunol 1998; 102(5):841-6. Vandenplas O, Delwiche JP, Evrared G, Aimont P, Van Der Brempt S, Jamart J, Delaunois L. Prevalence of occupational asthma due to latex among hospital personnel. Am J Respir Crit Care Med 1995; 151:54-60 Brugnami G, Marabini A, Siracuse A, Abbritti G. Work-related late asthmatic response induced by latex allergy. J Allergy Clin Immunol 1995; 96(4):457-64. Ownby DR, Ownby HE, McCullough J, Shafer AW. The prevalence of anti-latex IgE antibodies in 1000 volunteer blood donors. J Allergy Clin Immunol 1996; 97(6):1188-1192. Saxon A, Ownby D, Huard T, Parsad R, Roth D: Prevalence of IgE to natural rubber latex in unselected blood donors and performance characteristics of AlaSTAT testing. Annals of Allergy, Asthma & Immunology 2000; 84:199-206. Liss GM, Sussman GL: Latex Sensitization: Occupational versus general population prevalence rates. Am. J. Ind. Med 1999; 35: 196-200. Yunginger JW. Diagnostic skin testing for natural rubber latex allergy. J Allergy Clin Immunol 1998; 102:351-2.   3/24/03 re: Tingling a manifestation of latex allergy? I was hoping to gain your expertise in offering advice to a patient recently diagnosed with type 1 latex allergy. She is a 28 year old nurse who had an anaphylactic reaction whilst at the dentist over 2 months ago. All her clinical duties have been suspended at the hospital. However, she is currently experiencing tingling on her face and an itch in the inside lining of her nose. There are no specific areas within the hospital where this take place. The symptoms subside whilst away from the hospital environment. She is considering a change of career away from the hospital environment. My first question is; Do you think this tingling is due to the latex allergy? She frequently asks if her sensitivity will increase if she stays within the hospital setting as opposed to a non clinical area where the latex count would be less. My second question is; Is it common for patients with Type 1 allergy to become increasingly sensitised with increased exposure? Will the allergy get worse as she gets older? Finally, her lip has remained swollen since the event. Is this a common problem. I appreciate your expertise in finding the answers to these questions. The clinical picture you describe sounds very atypical for latex allergy. It would be very important to document whether or not the patient has a true IgE sensitivity to latex proteins. The serum latex-CAP test marketed by Pharmacia Labs (they should have branch laboratories in your country) is about 75% sensitive ? one looks for high levels of IgE antibodies in the serum. A latex skin test (available in certain centers in Europe and North America) is more sensitive but requires specialized training for performance and interpretation. It should be done, if feasiblr, if the serum latex-CAP test is negative. If there is still question one can do a cautious challenge in which the cut-off finger of a latex glove is appended to the patient's finger for a period of up to several hours under close observation. One looks for objective signs of reaction such as a rash (at application point or systemically), documented evidence of rhinitis or wheezing) not just tingling. Informed consent should be obtained from the patient in advance of any challenge test. To answer your other questions. 1) Latex sensitivity can increase after repeated latex exposures. However, tingling sensation by itself would not be an expected presentation of latex allergy. 2) Studies by a Mayo Clinic group have shown that, airborne levels of latex in most areas of a hospital are very low. The major at risk areas are where powdered latex gloves are used extensively (operating, procedure and post-op recovery rooms, Emergency Departments). If your patient has not been working in such areas and does not use powdered latex gloves her exposure to latex in other areas of the hospital is likely extremely low. Therefore, this would be further evidence against latex allergic reactions as a cause of her symptoms. I suggest that you refer the patient to a qualified specialist in Allergy & Immunology at a referral hospital for assistance in evaluation. 2/27/03 re: Tests for latex allergy What are the current most commonly used tests to assess latex allergy and how are they performed? There are several commonly used in vitro tests for levels of IgE antibodies against the major latex allergens (see enclosed abstracts). The diagnostic sensitivity of most in vitro tests such as these are 70-80% when compared to the "gold standard" challenge test such as the test where a cut-off finger of a latex glove is placed on the finger of the patient with suspected latex allergy for several hours. However, one has to proceed with considerable caution in carrying out such in vivo latex challenges in a patient with a reported previous serious systemic reaction attributed to latex allergy. There is not yet an FDA-approved latex prick skin test available although a number of investigators have used "home made" latex extracts for this purpose (see enclosed abstract). Some investigators have reported that the latex skin test is more sensitive than the latex in vitro antibody test. Again, one has to carry out such prick skin test with caution in patients with a reported serious systemic reaction attributed to latex allergy. I have enclosed below my review (for our Current Literature section) of a recent article describing the use of latex in vitro and skin tests in evaluating possible latex sensitivity in the workplace.   1: J Allergy Clin Immunol 2002 Aug;110(2 Suppl):S47-56 Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy. Hamilton RG, Peterson EL, Ownby DR. Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. The accurate diagnosis of hypersensitivity to natural rubber latex is the initial step in the effective management of individuals with latex allergy and in ensuring the quality of epidemiologic studies. The diagnostic algorithm used in the evaluation of an individual with suspected latex allergy begins with a comprehensive clinical history during which risk factors (atopy, food allergies, hand dermatitis) and temporal relationships between symptoms and natural rubber product exposure are identified. If type IV hypersensitivity is suspected because of the delayed nature (hours to days) and confinement of symptoms to the skin-latex product contact areas, patch testing can be conducted to confirm the presence of activated T cells with specificity for rubber chemicals. If type I hypersensitivity is suspected because of ocular, upper and lower airway, and/or systemic symptoms that have rapid onset (minutes) after a definable latex exposure, a confirmatory skin or blood test for IgE antibody may be conducted to verify a state of sensitization within the individual. The definitive diagnosis would then be made only after consideration of the individual's clinical history and confirmatory in vivo and/or in vitro laboratory test results. If discordance remains between highly convincing latex-associated symptoms as identified in the history and repetitively negative confirmatory IgE antibody test results, then one of several types of in vivo provocation tests may be performed for adjudication. This overview examines the current state of the art in both in vivo and in vitro diagnostic methods for latex-specific IgE antibody detection in skin and blood. The performance, advantages, and limitations of each diagnostic method are compared   J Allergy Clin Immunol 1999 May;103(5 Pt 1):925-30 Diagnostic performance of Food and Drug Administration-cleared serologic assays for natural rubber latex-specific IgE antibody. The Multi-Center Latex Skin Testing Study Task Force. Hamilton RG, Biagini RE, Krieg EF. Division of Allergy and Clinical Immunology, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA. BACKGROUND: In the absence of Food and Drug Administration-approved natural rubber latex skin testing reagents, latex-specific IgE antibody immunoassays are used in the diagnosis of latex allergy. Comparative diagnostic performance of these tests has not been definitively determined. OBJECTIVE: We sought to study the predictive value of available Food and Drug Administration (510K)-cleared latex-specific IgE antibody immunoassays in the diagnosis of latex allergy. METHODS: Subjects (n = 312) were classified as having a positive (n = 117) or a negative (n = 195) latex allergy history (Hx) or having a positive (n = 131) or a negative (n = 181) puncture skin test (PST) response (Greer reagent). The 14 subjects with a negative Hx and a positive PST response had negative responses to glove provocation testing and thus were considered sensitized but asymptomatic. Sera from 22 subjects were split to evaluate intra-assay variation. All 334 coded sera were analyzed for latex-specific IgE antibodies in the Diagnostic Products Corporation microplate AlaSTAT, Hycor HY-TEC EIA System, and Pharmacia-UpJohn CAP System. Variance and diagnostic performance parameters of each test were computed with 95% confidence intervals in relation to the subjects' Hx and PST status. RESULTS: Intra-assay concordance of split sera results was 96.0% for all 3 assays, with coefficients of variation of less than 25% and between-assay coefficients of variation of less than 21%. The diagnostic performance of the CAP and AlaSTAT assays were equivalent in comparison with PST results: sensitivity, CAP 76.3% and ALASTAT 73. 3% and specificity, CAP 96.7% and AlaSTAT 97.2% (P = NS). The HY-TEC assay was more sensitive (91.6%) and less specific (73.3%) than the CAP and AlaSTAT assays (P <.001). From 9% to 25% of the sera were discordant, being positive in at least 1, but not all 3, assays. CONCLUSION: The CAP and AlaSTAT assays produce 24% and 27% of false-negative results, respectively, whereas the HY-TEC produces 27% of false-positive results when compared with the PST   Current Literature: Latex allergy among construction workers Summary Occupation- related latex allergy (LA) has been considered mainly a problem in health care workers. However, Conde-Salazar et al of the University Hospital Ramon y Cajal in Madrid, Spain have uncovered evidence that LA may be a significant problem in construction workers as well. They studied 230 construction workers of whom 24% reported some intolerance to the wearing of rubber gloves or boots. They found that 16 workers (7%) had positive prick skin test (PST) reactions to latex of whom 14 individuals gave a history of contact urticaria to latex gloves/boots. Significant serum levels of IgE anti-latex antibodies were present in 15 of 16 individuals. All of these 14 workers had positive patch tests to a "True" patch test series, including positive reactions to rubber chemicals in 9 workers. The authors concluded that LA may be as common in some populations of construction workers as in health care workers. Many of the workers with IgE-mediated LA also ha