Wiparat Manuyakorn - Academia.edu (original) (raw)

Papers by Wiparat Manuyakorn

Research paper thumbnail of Needle length for epinephrine prefilled syringes in children and adolescents: Is it one inch?

Asian Pacific Journal of Allergy and Immunology, 2017

Background: Intramuscular epinephrine is the first line drug in the treatment of anaphylaxis. Thi... more Background: Intramuscular epinephrine is the first line drug in the treatment of anaphylaxis. This study was to identify the appropriateness of 1 inch needle length for epinephrine prefilled syringes in children. Methods: Children aged 1 month to 18 years were enrolled. Skin to muscle depth (STMD) and skin to bone depth (STBD) were measured using an ultrasonography at the mid-anterolateral thigh. A 1 inch needle was considered as being appropriate if the STBD was more than 1 inch and the STMD was less than 1 inch. Results: Seventy five infants, 75 preschool aged children, 75 school aged children and 147 adolescent were enrolled: 196 (52.7%) children were male. A 1 inch needle length was appropriate for 61% of the infants, for 88% of the preschool children, for 99% of the school aged children and for 95% of the adolescents. Thigh circumference ≥23 cm, BMI ≥16 kg/m 2 and BW ≥ 6 kg in infants provided the sensitivity of 74%-96% in predicting the appropriateness of 1 inch needle. In preschool group, thigh circumference ≥25 cm, BMI ≥13.5 kg/m 2 and BW ≥ 10 kg provided the sensitivity of 98.5-100% in predicting the appropriateness of 1 inch needle. Thigh circumference ≥ 49 cm in adolescents provided the sensitivity of 75% in predicting that a 1 inch needle was too short. Conclusion: One inch needle length may not be appropriated for intramuscular injection at thigh in all children. Thigh circumference, BMI and body weight are useful for predictor for using the 1 inch needle.

Research paper thumbnail of Spontaneous Pneumomediastinum in Non-Asthmatic Children with Exercise-Induced Bronchoconstriction

The American journal of case reports, 2015

BACKGROUND Subcutaneous emphysema can result from rupture of the respiratory or gastrointestinal ... more BACKGROUND Subcutaneous emphysema can result from rupture of the respiratory or gastrointestinal systems, commonly occurring after trauma or surgery, as well as from rupture of alveoli as pneumothorax or pneumomediastinum. Spontaneous pneumomediastinum with subcutaneous emphysema is rare in children without chest or neck trauma. Here, we report 2 cases of spontaneous pneumomediastinum with exercise-induced bronchoconstriction. CASE REPORT The first case is an 11-year-old boy who presented with neck pain after vigorous exercise. Radiography showed pneumomediastinum. The second case is a 15-year-old boy who presented with pleuritic chest pain and respiratory failure requiring intubation. We extensively investigated the possible causes of pneumomediastinum. Both patients had no history of trauma or asthma, and were diagnosed with exercise-induced bronchoconstriction. They were discharged after conservative treatment, without complication. CONCLUSIONS Early recognition and investigation...

Research paper thumbnail of A retrospective study on 158 Thai patients with juvenile idiopathic arthritis followed in a single center over a 15-year period

International Journal of Rheumatic Diseases, 2015

To determine the outcomes of juvenile idiopathic arthritis (JIA) in Thai children. A retrospectiv... more To determine the outcomes of juvenile idiopathic arthritis (JIA) in Thai children. A retrospective cohort study. All JIA patients in a rheumatology clinic, Ramathibodi Hospital, between July 1997 and December 2012 were enrolled. The patient data were reviewed from medical records. At the most recent follow-up visit, patient outcomes were assessed in three aspects: disease status, functional outcomes and structural damage. Of 168 patients, 158 (94.0%) were assessed in disease status and functional outcomes, with 114 patients (67.9%) assessed in three aspects over 4 years of disease. The most common JIA category was systemic JIA (SJIA) (33.8%), followed by enthesitis-related arthritis (ERA) (24.8%), oligoarthritis (18.5%), rheumatoid factor (RF)-negative polyarthritis (15.3%), RF-positive polyarthritis (7.6%) and one undifferentiated arthritis. SJIA had the highest remission rate due to early diagnosis and prompt treatment compared to other categories, whereas RF-positive polyarthritis carried the worst prognosis in three aspects, followed by ERA. Moreover, ERA patients had the highest failure rate in conventional therapy, half of whom had combined treatment with biologic agents and presence of human leukocyte antigen (HLA)-B27 was a predictor for biologic treatment in ERA patients. In addition, disease duration > 2 years or failure of conventional therapy was a predictor of structural bone damage. SJIA had the highest remission rate, whereas RF-positive polyarthritis had the worst outcome in three aspects. Prolonged disease duration or failure of conventional therapy was a predictor of structural bone damage, while HLA-B27 was a predictor for biologic treatment in ERA patients.

Research paper thumbnail of Airway remodelling in asthma and novel therapy

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand

Asthma is an airway inflammatory disease with functional and structural changes, leading to bronc... more Asthma is an airway inflammatory disease with functional and structural changes, leading to bronchial hyperresponsiveness (BHR) and airflow obstruction. Airway structural changes or airway remodelling consist of epithelial injury, goblet cell hyperplasia, subepithelial layer thickening, airway smooth muscle hyperplasia and angiogenesis. These changes were previously considered as a consequence of chronic airway inflammation. However, several studies have demonstrated that inflammation and remodelling can occur as separate but parallel aspects of the asthmatic process. As such there is increasing evidence for the role of mechanocompressive forces within the asthmatic airway contributing to airway structural changes. Furthermore, it is unclear what is the best treatment to modify remodelling and which component to target. There is also a need to identify asthma phenotype that might specifically respond to novel therapies such as anti-IL5, anti-IL13 and tyrosine kinase inhibitors.

Research paper thumbnail of Association analysis of CYP2C9*3 and phenytoin-induced severe cutaneous adverse reactions (SCARs) in Thai epilepsy children

Journal of Human Genetics, 2015

CYP2C9 is the key enzyme in aromatic antiepileptic drugs (AEDs) metabolism. CYP2C9*3 is a loss of... more CYP2C9 is the key enzyme in aromatic antiepileptic drugs (AEDs) metabolism. CYP2C9*3 is a loss of function polymorphism. This study was designed to investigate genetic association between CYP2C9*3 and aromatic AED-induced severe cutaneous adverse reactions (SCARs) in Thai children. The 37 aromatic AED-induced SCARs patients (20 phenobarbital and 17 phenytoin) and 35 tolerances (19 phenobarbital and 16 phenytoin) were enrolled. CYP2C9*3 was genotyped by allele-specific PCRs. The association between CYP2C9*3 with phenytoin-induced SCARs and phenobarbital-induced SCARs were analyzed in comparison with tolerances and healthy samples. Significant association between phenytoin-induced SCARs and CYP2C9*3 was discovered (odds ratio=14.52; 95% confidence interval (CI)=1.18-∞, P-value=0.044). CYP2C9*3 was not associated with phenobarbital-induced SCARs. This study is the first report of CYP2C9*3 association to phenytoin-induced SCARs in Thai epileptic children. The CYP2C9*3 is a reasonable predictive genetic marker to anticipate SCARs from phenytoin.Journal of Human Genetics advance online publication, 21 May 2015; doi:10.1038/jhg.2015.47.

Research paper thumbnail of In vitro cytokine changes after pediatric liver transplantation

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2015

Patients with chronic liver disease have been shown to have impaired immune statuses. Liver trans... more Patients with chronic liver disease have been shown to have impaired immune statuses. Liver transplantation (LT) is the standard treatment for end-stage liver disease patients and immunosuppressive drugs are commonly used to prevent graft rejection. There is an increasing evidence of de novo food allergies post LT. To investigate the cytokine response of peripheral blood mononuclear cells (PBMCs) of pediatric LT recipients before and six months after transplantation. PBMCs collected before and six months after LT were stimulated with phytohemagglutinin (PHA), beta-lactoglobulin (BLG), tacrolimus (Tac), dexamethasone (Dex), and a combination of BLG and Dex (B+D), BLG and Tac (B+T), BLG and Tac plus Dex (B+T+D). Culture supernatants were measured for IL-5, IFN-γ and IL-10. Blood for liver function tests, complete blood counts, total IgE and specific IgE (sIgE) to cow's milk were recorded. A total of five pediatric LT recipients were enrolled in the study. There were no food allerg...

Research paper thumbnail of The stability and sterility of epinephrine prefilled syringe

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2010

The commercially available auto-injector epinephrine is considerable expensive. Epinephrine prefi... more The commercially available auto-injector epinephrine is considerable expensive. Epinephrine prefilled syringe is an alternative treatment for anaphylaxis patients. The objective of the present study was to evaluate the stability and sterility of epinephrine prefilled syringe. Epinephrine prefilled syringe was kept in the pencil box to prevent from light exposure. The active ingredients, integrity and level of potency were measured by high-performance liquid chromatography (HPLC). The sterility was accessed by aerobic bacteria and fungi culture. The epinephrine concentration at 1, 2 and 3 months after the preparation was 101.36, 99.31 and 101.09%, respectively (acceptable range 90 - 110%). The pH was 3.17 - 3.23 (acceptable range 2.8 - 3.6). Nor-epinephrine was undetected. The cultures for bacteria and fungus were both negative. Consequently, epinephrine prefilled syringe was stable and sterile at least three month after preparation. Epinephrine prefilled syrine is an alternative low...

Research paper thumbnail of Serum TGF-beta1 in atopic asthma

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2008

Asthma is a chronic inflammatory disease of the airway. Pathological repair of chronic inflammati... more Asthma is a chronic inflammatory disease of the airway. Pathological repair of chronic inflammation leads to airway remodeling. Transforming growth factor-beta (TGF-beta), a profibrotic cytokine, plays an important role in promoting the structural changes of airway remodeling. TGF-beta effects on the proliferation, differentiation and extracellular matrix (ECM) metabolism of airway structural cells. This study assessed serum TGF-beta1 in different severity of atopic asthma compared to non-atopic controls. Thirty-one atopic asthmatic patients and 34 non-atopic controls, aged 7-18 years, were recruited as to the asthma severity: steroid naïve mild asthma, moderate asthma, and asthma in remission. Serum TGF-beta1 was measured by enzyme-linked immunosorbent assay. There was a significant difference between serum TGF-beta1 in asthmatic patients and that in control patients (39.59 ng/ml vs. 0.26 ng/ml, p < 0.001). Serum TGF-beta1 was highest in steroid naïve mild asthma group when comp...

Research paper thumbnail of Assessing the efficacy of a novel temperature and humidity control machine to minimize house dust mite allergen exposure and clinical symptoms in allergic rhinitis children sensitized to dust mites: a pilot study

Asian Pacific Journal of Allergy and Immunology, 2015

Background: House dust mite avoidance is advised in dust mite sensitized patients to decrease the... more Background: House dust mite avoidance is advised in dust mite sensitized patients to decrease the risk to develop allergic symptoms. Maintaining a relative humidity (RH) of less than 50% in households is recommended to prevent dust mite proliferation.

Research paper thumbnail of The Association of HLA-B* 5101 and Phenobarbital-Induced Severe Cutaneous Adverse Drug Reactions in Thai Children

Journal of Allergy and Clinical Immunology, 2015

Research paper thumbnail of Sensitivity of Turbutester and Accuhaler tester in asthmatic children and adolescents

Pediatrics International, 2010

Dry powder inhalers (DPI) are alternative devices for delivering medication for treatment of asth... more Dry powder inhalers (DPI) are alternative devices for delivering medication for treatment of asthma. The amount of drug delivery to the lungs is directly influenced by peak inspiratory flow rate (PIFR). A minimum PIFR of -30 L/min is needed for the Turbuhaler and Accuhaler. In order to evaluate the sensitivity of the Turbutester and Accuhaler tester in detecting the minimum and optimum PIFR for the Turbuhaler and Accuhaler in asthmatic children, PIFR was measured using the In-Check Dial through the internal resistance of the Turbuhaler and Accuhaler and compared according to the child&amp;amp;amp;amp;amp;amp;#39;s ability to make a whistle sound via both testers. A total of 259 asthmatic children were studied: 20 pre-school children, aged 5-6 years; 174 school-age children, aged 7-12 years; and 65 adolescents, aged 13-18 years. The sensitivity of the Turbutester and Accuhaler tester to detect optimum PIFR were 98.40% and 97.2%, respectively. In the comparison among age groups, the sensitivity of the Accuhaler tester to detect optimum or minimum PIFR for the Accuhaler was 95%, 97.7% and 95.4%, respectively. The sensitivity of the Turbutester to detect optimum PIFR for the Turbuhaler was 94.4%, 98.8% and 98.5%, respectively. The sensitivity of the Turbutester to detect minimum PIFR for the Turbuhaler was 94.7%, 100% and 100%, respectively. There were no significant differences in percentage of having optimum or minimum PIFR among asthma severity and current device usage in all age groups. Most children aged at least 5 years could generate enough PIFR to use dry powder inhaler devices. Both the Turbutester and Accuhaler tester were found to have high sensitivity in detecting optimum and minimum required PIFR.

Research paper thumbnail of Cow milk protein allergy presenting as feeding intolerance and eosinophilia: case reports of three preterm neonates

Paediatrics and International Child Health, 2014

Three preterm infants with cow milk protein allergy (CMPA) presented with feeding intolerance, se... more Three preterm infants with cow milk protein allergy (CMPA) presented with feeding intolerance, sepsis-like episodes and persistent moderate-to-severe eosinophilia. After eliminating cow milk, the clinical symptoms improved significantly. CMPA can cause common manifestations in sick preterm infants such as feeding intolerance and eosinophilia.

Research paper thumbnail of S32 Cyclical mechanical stretch enhances the pro-fibrotic responses of primary embryonic foetal fibroblasts, but not ADAM33 expression

Thorax, 2010

scaffold protein involved in the proteasomal processing of p105 into the p50 subunit. Inhibition ... more scaffold protein involved in the proteasomal processing of p105 into the p50 subunit. Inhibition of this process impairs the nuclear translocation of NF-kB and the consequent p65/p50 regulated gene transcription. Hence, TRUSS may be a novel target for modulating the inflammatory functions of TNFa-TNF-R1 signalling.

Research paper thumbnail of Peak inspiratory flow rate via incheck-dial ?? in children with asthma

World Allergy Organization Journal, 2007

Research paper thumbnail of Cytokine responses during exacerbation compared with stable phase in asthmatic children

World Allergy Organization Journal, 2007

Bronchial asthma is a chronic inflammatory disorder of the airways. Balancing in Th1 and Th2 resp... more Bronchial asthma is a chronic inflammatory disorder of the airways. Balancing in Th1 and Th2 response is a target in the treatment. Recent studies show that interleukin-10 (IL-10) has an important role in the regulation of Th2 and allergic responses and its amount was found to decrease in asthmatic patients. This study was to focus on cytokine responses, including interferon-gamma (IFN-γ), IL-4 and IL-10 in asthmatic children during acute exacerbation compared to stable period. Peripheral blood mononuclear cells (PBMCs) from fourteen asthmatic children during exacerbation and stable phase were stimulated with phytohemagglutinin (PHA) and mite allergen (Der p) for 72 hours. Levels of IFN-γ, IL-4 and IL-10 in cell culture supernatants were measured using enzyme-linked immunosorbent assay. The median level of IL-10 in PBMCs stimulated with PHA was significantly lower in acute asthma exacerbation compared with stable phase (464 vs. 859.5 pg/ml, p = 0.03). However, there was no difference in the level of IL-10 in PBMCs stimulated with Der p. The level of IFN-γ and IL-4 were not different between exacerbation and stable phase both in PHA and Der p-stimulated PBMCs. The decrease of IL-10 production in asthmatic children during acute exacerbation may emphasize the role of IL-10 in immune regulation in allergic disease.

Research paper thumbnail of Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing

Pediatric Pulmonology, 2005

The jet nebulizer is a common device used for administering aerosol medication in young children.... more The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.

Research paper thumbnail of Phenobarbital-induced severe cutaneous adverse drug reactions are associated with CYP2C19*2 in Thai children

Pediatric Allergy and Immunology, 2013

Aromatic anticonvulsant-induced severe cutaneous adverse drug reactions (SCARs), including Steven... more Aromatic anticonvulsant-induced severe cutaneous adverse drug reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrosis (TEN), and drug rash with eosinophilia and systemic symptoms (DRESS), are fatal immune-mediated adverse drug reactions. CYP2C19, a cytochrome P450 isoform, plays a role in metabolic rate of aromatic anticonvulsant. HLA-B*1502 has also been demonstrated to be associated with carbamazepine-induced SJS-TEN. Forty case patients who were diagnosed with SCARs after initiation of phenobarbital (PB), phenytoin (PHT), or carbamazepine (CBZ) for 1-8 wk and forty control patients who received PB, PHT, or CBZ at least 2 months with no adverse drug reactions were enrolled in the study. The genotypes of CYP2C19*1, CYP2C19*2, and HLA-B*1502 were analyzed using allele-specific polymerase chain reaction technique. Clinical characteristics of SCARs patients who used different drugs were also analyzed. There was no significant difference in sex, onset of symptoms, laboratory results, treatment, and length of stay among patients with SCARs due to PB, PHT, or CBZ. The patients with CYP2C19*2 variant had a trend to have a likelihood to develop SCARs more than the patients with CYP2C19 wild type (OR = 2.5, 95% CI (0.96-67.3) p = 0.06). In subgroup analysis, the patients with CYP2C19*2 variant were at four times increased risk of SCARs from phenobarbital more than the patients with CYP2C19 wild type (OR = 4.5, 95% CI (1.17-17.37) p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.03). There was no association between the HLA-B*1502 and aromatic anticonvulsant-induced severe cutaneous adverse reactions (SCARs). CYP2C19*2 variant may play a role in the genetic predisposition of SCARs from phenobarbital.

Research paper thumbnail of Proteome and Allergenome of Asian Wasp, Vespa affinis , Venom and IgE Reactivity of the Venom Components

Journal of Proteome Research, 2014

Vespa af f inis (Asian wasp, Thai banded tiger wasp, or local name: Tor Hua Seua) causes the most... more Vespa af f inis (Asian wasp, Thai banded tiger wasp, or local name: Tor Hua Seua) causes the most frequent incidence of medically important Hymenoptera sting in South and Southeast Asia. However, data on the venom components attributable to the sting derived-clinical manifestations (local reactions, IgE mediated-anaphylaxis, or systemic envenomation) are lacking. This study provides the first set information on V. af finis venom proteome, allergenome, and IgE reactivity of individual venom components. From 2DE-gel basedproteomics, the venom revealed 93 protein spots, of which proteins in 51 spots could be identified and classified into three groups: typical venom components and structural and housekeeping proteins. Venom proteins in 32 spots reacted with serum IgE of wasp allergic patients. Major allergenic proteins that reacted to IgE of >50% of the wasp allergic patients included PLA 1 (100%), arginine kinase (73%), heat shock 70 kDa protein (73.3%), venom allergen-5 (66.7%), enolase (66.7%), PLA 1 magnifin (60%), glyceraldehyde-3-phosphate dehydrogenase (60%), hyaluronidase (53.3%), and fructose-bisphosphate aldolase (53.3%). The venom minor allergens were GB17876 transcript (40%), GB17291 transcript (20%), malic enzyme (13.3%), aconitate hydratase (6.7%), and phosphoglucomutase (6.7%). The information has diagnostic and clinical implications for future improvement of case diagnostic sensitivity and specificity, component-resolve diagnosis, and design of specific Hymenoptera venom immunotherapy.

Research paper thumbnail of Nasal Challenge Test in Childhood Allergic Rhinitis with House Dust Mite Sensitization

Journal of Allergy and Clinical Immunology, 2009

RATIONALE: Different devices for percutaneous allergy skin testing have demonstrated statisticall... more RATIONALE: Different devices for percutaneous allergy skin testing have demonstrated statistically and clinically significant differences in performance characteristics. We compared two FDA-approved multi-head allergy skin testing devices: Multi-Test II (Lincoln Diagnostics) and ComforTen (Hollister-Stier Laboratories). METHODS: Skin tests with glycerinated histamine (6 mg/mL base) and glycerinated saline were applied to 30 adults using Multi-Test II on the volar surface of one forearm and ComforTen on the opposite forearm. RESULTS: Data were accumulated from 150 histamine sites and 90 negative control sites for each device. Using cutoff wheal sizes of 5 vs 3 mm inclusive to define a positive result, Multi-Test II sensitivity increased from 97% to 100%, and specificity decreased from 100% to 97%, whereas ComforTen sensitivity increased from 27% to 82%, and specificity decreased from 100% to 99%. For Multi-Test II vs ComforTen, histamine mean (SD) wheal sizes were 7.47 (1.72) vs 3.93 (1.59) mm (p 5 0.000), mean coefficients of variation were 23.0% vs 40.5%, and pooled estimates of variance were 1.42 vs 1.29. At different test head positions, there was no statistically significant variation in histamine wheal sizes with either Multi-Test II or ComforTen. CONCLUSIONS: Multi-Test II had notably greater wheal size and higher sensitivity, but similar specificity to ComforTen. Multi-Test II had superior performance at both 3 mm and 5 mm wheal cutoffs. Because ComforTen had a low sensitivity at the 3 mm and particularly the 5 mm wheal cutoff, skin testing with this device might result in underdiagnosis of allergy using either cutoff.

Research paper thumbnail of Rush Hymenoptera Venom Immunotherapy in Thai Children

Journal of Allergy and Clinical Immunology, 2009

RATIONALE: The rush hymenoptera venom immunotherapy (VIT) has been shown to be safe and effective... more RATIONALE: The rush hymenoptera venom immunotherapy (VIT) has been shown to be safe and effective, but it is not commonly practiced in Thailand. We examined the efficacy and safety of rush VIT and the risk factors in these patients. METHODS: A 3-year retrospective study was done which revealed 11 patients with history of severe systemic reaction after being stung by hymenoptera. Diagnosis was made on the basis of history and evidence of sensitization by positive skin testing and/or presence of specific IgE to honeybee, vespid or fire ant venom. They all received rush VIT regimen with a careful monitoring of adverse reaction in Ramathibodi hospital, a referral center for insect venom allergy. We evaluated risk factors for serious adverse reaction such as age, gender, atopic history, severity of insect sting reaction according to the H.L. Muller classification, and evidence of sensitization. RESULTS: There were 4 patients treated with honeybee, 5 with fire ant, one with mixed vespid and one with mixed vespid plus honeybee immunotherapy. All patients are male. Adverse reactions were observed in 4 patients (36%) with mild severity (1 with large local reaction, 3 with generalized urticaria but no other systemic reaction), and were not associated with age, type of hymenoptera allergen used, level of sensitization (either by skin testing or specific IgE) and atopic history. CONCLUSIONS: Rush hymenoptera venom immunotherapy is an alternative treatment for patients who are in active life styles especially children and adolescents. No serious adverse reaction with rush VITwas seen in our study. RATIONALE: Several case reports indicate a reduced efficacy of VIT in patients with SM. It is unclear whether the efficacy of VIT in patients with SM depends on the maintenance dose. METHODS: In a retrospective study 33 patients (54.5% male, 45.5% female) with SM and HVA were analysed. 4 patients (12.1%) were treated with honeybee venom (HBV), 21 (63.7%) with yellow jacket venom (YJV), and 8 (24.2%) with both venoms. Depending on the severity of the sting reaction, on the type of venom, and on additional risk factors, selected patients were treated with an increased maintenance dose. 200 mg venom were used for VIT in 9 of 29 treatment courses using YJV, and in 8 of 12 treatment courses using HBV. A challenge test with a living honeybee and/or yellow jacket was done 6 to 18 months after the beginning of VIT. At the challenge tests patients were between 29 and 75 years old (mean 48.4 6 11.9 years). RESULTS: All patients receiving 200 mg venom were protected at the challenge test. In contrast, 5 patients on VIT with 100 mg venom developed systemic symptoms upon sting challenge (1 patient upon honeybee sting and 4 patients upon yellow jacket sting). Treatment with an elevated maintenance dose was more effective than treatment with the standard dose (p < 0.05). CONCLUSIONS: An increased maintenance dose appears to be very effective to treat HVA in patients with SM. Therefore, we would recommend the use of elevated venom doses to treat patients with near fatal sting reactions and/or particular factors. . RATIONALE: Presently there are no reports in the literature that characterize the safety of subcutaneous immunotherapy (IT) with Imported Fire Ant (IFA) whole body extract. The goals of this study were to calculate a rate of systemic reactions (SR) to IT with IFA whole body extract and analyze a case-control sample of patients for putative SR risk factors. METHODS: A case-control study based on a 3 year retrospective chart review (2005)(2006)(2007)(2008) at a single institution was performed for patients receiving IFA IT. A control group received IFA IT over the same time period but did not have a SR. RESULTS: Seventy-seven patients (40 female, mean age 34 years, range 3-76 years) received 1,887 injections and 7 patients experienced 8 SRs for a rate of 0.4% per injection and 9.1% per patient. Sixteen patients experienced 20 large local reactions for a rate of 1.1% per injection and 20.7% per patient. Gender, age, phase (build up versus maintenance), asthma, angiotensin-converting enzyme inhibitor, large local reaction, concentration of positive skin test or SR to skin test did not increase the odds of a SR to IFA IT. SR organ involvement included 1 cardiovascular, 4 cutaneous, 1 gastrointestinal, 1 globus, 2 pulmonary, and 5 rhinoconjunctivitis. None required admission. Two SRs occurred after 30 minutes. CONCLUSIONS: This study is the first to characterize the safety of IT with IFA whole body extract. An overall low SR rate was observed and no specific risk factors were associated with SRs to IFA IT. BACKGROUND: Anaphylaxis following a hymenoptera sting has been reported in patients with mastocytosis, but few data exist regarding the disease's prevalence in patients with hymenoptera allergy. METHODS: Using bone marrow (BM) histology/cytology, flow cytometry (FC), and detection of KIT mutations, we assessed the prevalence of mastocytosis in patients with both systemic reactions to hymenoptera and increased serum tryptase (sBT). RESULTS: Forty-four out of 379 patients (11.6%) with systemic reactions to sting had increased sBT (>11.4 ng/mL, 95th percentile of normal subjects), and 70.5% of them had a history of sting-induced anaphylaxis. Thirty-four patients underwent a BM analysis. Histology fulfilled major WHO diagnostic criteria in 42.4% of cases. Abnormal mast cells (MCs) were identified by FC and cytology in 78.8% and 61.8% of patients, respectively. A codon 816 KIT mutation was detected in 58.1% of patients. The diagnosis was indolent systemic mastocytosis (ISM) in 61.7% of cases (11.8% with Urticaria Pigmentosa) and Monoclonal MC Activation Syndrome (MMAS) in 26.5%. In particular, 96.4% of patients with anaphylaxis were classified as ISM or MMAS. CONCLUSIONS: Based on the results of the approach utilized in our study, the concomitant presence of systemic reactions (especially anaphylaxis) following hymenoptera sting and raised sBT suggests that a BM examination is indicated in order to diagnose clonal MC disease.

Research paper thumbnail of Needle length for epinephrine prefilled syringes in children and adolescents: Is it one inch?

Asian Pacific Journal of Allergy and Immunology, 2017

Background: Intramuscular epinephrine is the first line drug in the treatment of anaphylaxis. Thi... more Background: Intramuscular epinephrine is the first line drug in the treatment of anaphylaxis. This study was to identify the appropriateness of 1 inch needle length for epinephrine prefilled syringes in children. Methods: Children aged 1 month to 18 years were enrolled. Skin to muscle depth (STMD) and skin to bone depth (STBD) were measured using an ultrasonography at the mid-anterolateral thigh. A 1 inch needle was considered as being appropriate if the STBD was more than 1 inch and the STMD was less than 1 inch. Results: Seventy five infants, 75 preschool aged children, 75 school aged children and 147 adolescent were enrolled: 196 (52.7%) children were male. A 1 inch needle length was appropriate for 61% of the infants, for 88% of the preschool children, for 99% of the school aged children and for 95% of the adolescents. Thigh circumference ≥23 cm, BMI ≥16 kg/m 2 and BW ≥ 6 kg in infants provided the sensitivity of 74%-96% in predicting the appropriateness of 1 inch needle. In preschool group, thigh circumference ≥25 cm, BMI ≥13.5 kg/m 2 and BW ≥ 10 kg provided the sensitivity of 98.5-100% in predicting the appropriateness of 1 inch needle. Thigh circumference ≥ 49 cm in adolescents provided the sensitivity of 75% in predicting that a 1 inch needle was too short. Conclusion: One inch needle length may not be appropriated for intramuscular injection at thigh in all children. Thigh circumference, BMI and body weight are useful for predictor for using the 1 inch needle.

Research paper thumbnail of Spontaneous Pneumomediastinum in Non-Asthmatic Children with Exercise-Induced Bronchoconstriction

The American journal of case reports, 2015

BACKGROUND Subcutaneous emphysema can result from rupture of the respiratory or gastrointestinal ... more BACKGROUND Subcutaneous emphysema can result from rupture of the respiratory or gastrointestinal systems, commonly occurring after trauma or surgery, as well as from rupture of alveoli as pneumothorax or pneumomediastinum. Spontaneous pneumomediastinum with subcutaneous emphysema is rare in children without chest or neck trauma. Here, we report 2 cases of spontaneous pneumomediastinum with exercise-induced bronchoconstriction. CASE REPORT The first case is an 11-year-old boy who presented with neck pain after vigorous exercise. Radiography showed pneumomediastinum. The second case is a 15-year-old boy who presented with pleuritic chest pain and respiratory failure requiring intubation. We extensively investigated the possible causes of pneumomediastinum. Both patients had no history of trauma or asthma, and were diagnosed with exercise-induced bronchoconstriction. They were discharged after conservative treatment, without complication. CONCLUSIONS Early recognition and investigation...

Research paper thumbnail of A retrospective study on 158 Thai patients with juvenile idiopathic arthritis followed in a single center over a 15-year period

International Journal of Rheumatic Diseases, 2015

To determine the outcomes of juvenile idiopathic arthritis (JIA) in Thai children. A retrospectiv... more To determine the outcomes of juvenile idiopathic arthritis (JIA) in Thai children. A retrospective cohort study. All JIA patients in a rheumatology clinic, Ramathibodi Hospital, between July 1997 and December 2012 were enrolled. The patient data were reviewed from medical records. At the most recent follow-up visit, patient outcomes were assessed in three aspects: disease status, functional outcomes and structural damage. Of 168 patients, 158 (94.0%) were assessed in disease status and functional outcomes, with 114 patients (67.9%) assessed in three aspects over 4 years of disease. The most common JIA category was systemic JIA (SJIA) (33.8%), followed by enthesitis-related arthritis (ERA) (24.8%), oligoarthritis (18.5%), rheumatoid factor (RF)-negative polyarthritis (15.3%), RF-positive polyarthritis (7.6%) and one undifferentiated arthritis. SJIA had the highest remission rate due to early diagnosis and prompt treatment compared to other categories, whereas RF-positive polyarthritis carried the worst prognosis in three aspects, followed by ERA. Moreover, ERA patients had the highest failure rate in conventional therapy, half of whom had combined treatment with biologic agents and presence of human leukocyte antigen (HLA)-B27 was a predictor for biologic treatment in ERA patients. In addition, disease duration &amp;amp;amp;amp;gt; 2 years or failure of conventional therapy was a predictor of structural bone damage. SJIA had the highest remission rate, whereas RF-positive polyarthritis had the worst outcome in three aspects. Prolonged disease duration or failure of conventional therapy was a predictor of structural bone damage, while HLA-B27 was a predictor for biologic treatment in ERA patients.

Research paper thumbnail of Airway remodelling in asthma and novel therapy

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand

Asthma is an airway inflammatory disease with functional and structural changes, leading to bronc... more Asthma is an airway inflammatory disease with functional and structural changes, leading to bronchial hyperresponsiveness (BHR) and airflow obstruction. Airway structural changes or airway remodelling consist of epithelial injury, goblet cell hyperplasia, subepithelial layer thickening, airway smooth muscle hyperplasia and angiogenesis. These changes were previously considered as a consequence of chronic airway inflammation. However, several studies have demonstrated that inflammation and remodelling can occur as separate but parallel aspects of the asthmatic process. As such there is increasing evidence for the role of mechanocompressive forces within the asthmatic airway contributing to airway structural changes. Furthermore, it is unclear what is the best treatment to modify remodelling and which component to target. There is also a need to identify asthma phenotype that might specifically respond to novel therapies such as anti-IL5, anti-IL13 and tyrosine kinase inhibitors.

Research paper thumbnail of Association analysis of CYP2C9*3 and phenytoin-induced severe cutaneous adverse reactions (SCARs) in Thai epilepsy children

Journal of Human Genetics, 2015

CYP2C9 is the key enzyme in aromatic antiepileptic drugs (AEDs) metabolism. CYP2C9*3 is a loss of... more CYP2C9 is the key enzyme in aromatic antiepileptic drugs (AEDs) metabolism. CYP2C9*3 is a loss of function polymorphism. This study was designed to investigate genetic association between CYP2C9*3 and aromatic AED-induced severe cutaneous adverse reactions (SCARs) in Thai children. The 37 aromatic AED-induced SCARs patients (20 phenobarbital and 17 phenytoin) and 35 tolerances (19 phenobarbital and 16 phenytoin) were enrolled. CYP2C9*3 was genotyped by allele-specific PCRs. The association between CYP2C9*3 with phenytoin-induced SCARs and phenobarbital-induced SCARs were analyzed in comparison with tolerances and healthy samples. Significant association between phenytoin-induced SCARs and CYP2C9*3 was discovered (odds ratio=14.52; 95% confidence interval (CI)=1.18-∞, P-value=0.044). CYP2C9*3 was not associated with phenobarbital-induced SCARs. This study is the first report of CYP2C9*3 association to phenytoin-induced SCARs in Thai epileptic children. The CYP2C9*3 is a reasonable predictive genetic marker to anticipate SCARs from phenytoin.Journal of Human Genetics advance online publication, 21 May 2015; doi:10.1038/jhg.2015.47.

Research paper thumbnail of In vitro cytokine changes after pediatric liver transplantation

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2015

Patients with chronic liver disease have been shown to have impaired immune statuses. Liver trans... more Patients with chronic liver disease have been shown to have impaired immune statuses. Liver transplantation (LT) is the standard treatment for end-stage liver disease patients and immunosuppressive drugs are commonly used to prevent graft rejection. There is an increasing evidence of de novo food allergies post LT. To investigate the cytokine response of peripheral blood mononuclear cells (PBMCs) of pediatric LT recipients before and six months after transplantation. PBMCs collected before and six months after LT were stimulated with phytohemagglutinin (PHA), beta-lactoglobulin (BLG), tacrolimus (Tac), dexamethasone (Dex), and a combination of BLG and Dex (B+D), BLG and Tac (B+T), BLG and Tac plus Dex (B+T+D). Culture supernatants were measured for IL-5, IFN-γ and IL-10. Blood for liver function tests, complete blood counts, total IgE and specific IgE (sIgE) to cow's milk were recorded. A total of five pediatric LT recipients were enrolled in the study. There were no food allerg...

Research paper thumbnail of The stability and sterility of epinephrine prefilled syringe

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2010

The commercially available auto-injector epinephrine is considerable expensive. Epinephrine prefi... more The commercially available auto-injector epinephrine is considerable expensive. Epinephrine prefilled syringe is an alternative treatment for anaphylaxis patients. The objective of the present study was to evaluate the stability and sterility of epinephrine prefilled syringe. Epinephrine prefilled syringe was kept in the pencil box to prevent from light exposure. The active ingredients, integrity and level of potency were measured by high-performance liquid chromatography (HPLC). The sterility was accessed by aerobic bacteria and fungi culture. The epinephrine concentration at 1, 2 and 3 months after the preparation was 101.36, 99.31 and 101.09%, respectively (acceptable range 90 - 110%). The pH was 3.17 - 3.23 (acceptable range 2.8 - 3.6). Nor-epinephrine was undetected. The cultures for bacteria and fungus were both negative. Consequently, epinephrine prefilled syringe was stable and sterile at least three month after preparation. Epinephrine prefilled syrine is an alternative low...

Research paper thumbnail of Serum TGF-beta1 in atopic asthma

Asian Pacific journal of allergy and immunology / launched by the Allergy and Immunology Society of Thailand, 2008

Asthma is a chronic inflammatory disease of the airway. Pathological repair of chronic inflammati... more Asthma is a chronic inflammatory disease of the airway. Pathological repair of chronic inflammation leads to airway remodeling. Transforming growth factor-beta (TGF-beta), a profibrotic cytokine, plays an important role in promoting the structural changes of airway remodeling. TGF-beta effects on the proliferation, differentiation and extracellular matrix (ECM) metabolism of airway structural cells. This study assessed serum TGF-beta1 in different severity of atopic asthma compared to non-atopic controls. Thirty-one atopic asthmatic patients and 34 non-atopic controls, aged 7-18 years, were recruited as to the asthma severity: steroid naïve mild asthma, moderate asthma, and asthma in remission. Serum TGF-beta1 was measured by enzyme-linked immunosorbent assay. There was a significant difference between serum TGF-beta1 in asthmatic patients and that in control patients (39.59 ng/ml vs. 0.26 ng/ml, p < 0.001). Serum TGF-beta1 was highest in steroid naïve mild asthma group when comp...

Research paper thumbnail of Assessing the efficacy of a novel temperature and humidity control machine to minimize house dust mite allergen exposure and clinical symptoms in allergic rhinitis children sensitized to dust mites: a pilot study

Asian Pacific Journal of Allergy and Immunology, 2015

Background: House dust mite avoidance is advised in dust mite sensitized patients to decrease the... more Background: House dust mite avoidance is advised in dust mite sensitized patients to decrease the risk to develop allergic symptoms. Maintaining a relative humidity (RH) of less than 50% in households is recommended to prevent dust mite proliferation.

Research paper thumbnail of The Association of HLA-B* 5101 and Phenobarbital-Induced Severe Cutaneous Adverse Drug Reactions in Thai Children

Journal of Allergy and Clinical Immunology, 2015

Research paper thumbnail of Sensitivity of Turbutester and Accuhaler tester in asthmatic children and adolescents

Pediatrics International, 2010

Dry powder inhalers (DPI) are alternative devices for delivering medication for treatment of asth... more Dry powder inhalers (DPI) are alternative devices for delivering medication for treatment of asthma. The amount of drug delivery to the lungs is directly influenced by peak inspiratory flow rate (PIFR). A minimum PIFR of -30 L/min is needed for the Turbuhaler and Accuhaler. In order to evaluate the sensitivity of the Turbutester and Accuhaler tester in detecting the minimum and optimum PIFR for the Turbuhaler and Accuhaler in asthmatic children, PIFR was measured using the In-Check Dial through the internal resistance of the Turbuhaler and Accuhaler and compared according to the child&amp;amp;amp;amp;amp;amp;#39;s ability to make a whistle sound via both testers. A total of 259 asthmatic children were studied: 20 pre-school children, aged 5-6 years; 174 school-age children, aged 7-12 years; and 65 adolescents, aged 13-18 years. The sensitivity of the Turbutester and Accuhaler tester to detect optimum PIFR were 98.40% and 97.2%, respectively. In the comparison among age groups, the sensitivity of the Accuhaler tester to detect optimum or minimum PIFR for the Accuhaler was 95%, 97.7% and 95.4%, respectively. The sensitivity of the Turbutester to detect optimum PIFR for the Turbuhaler was 94.4%, 98.8% and 98.5%, respectively. The sensitivity of the Turbutester to detect minimum PIFR for the Turbuhaler was 94.7%, 100% and 100%, respectively. There were no significant differences in percentage of having optimum or minimum PIFR among asthma severity and current device usage in all age groups. Most children aged at least 5 years could generate enough PIFR to use dry powder inhaler devices. Both the Turbutester and Accuhaler tester were found to have high sensitivity in detecting optimum and minimum required PIFR.

Research paper thumbnail of Cow milk protein allergy presenting as feeding intolerance and eosinophilia: case reports of three preterm neonates

Paediatrics and International Child Health, 2014

Three preterm infants with cow milk protein allergy (CMPA) presented with feeding intolerance, se... more Three preterm infants with cow milk protein allergy (CMPA) presented with feeding intolerance, sepsis-like episodes and persistent moderate-to-severe eosinophilia. After eliminating cow milk, the clinical symptoms improved significantly. CMPA can cause common manifestations in sick preterm infants such as feeding intolerance and eosinophilia.

Research paper thumbnail of S32 Cyclical mechanical stretch enhances the pro-fibrotic responses of primary embryonic foetal fibroblasts, but not ADAM33 expression

Thorax, 2010

scaffold protein involved in the proteasomal processing of p105 into the p50 subunit. Inhibition ... more scaffold protein involved in the proteasomal processing of p105 into the p50 subunit. Inhibition of this process impairs the nuclear translocation of NF-kB and the consequent p65/p50 regulated gene transcription. Hence, TRUSS may be a novel target for modulating the inflammatory functions of TNFa-TNF-R1 signalling.

Research paper thumbnail of Peak inspiratory flow rate via incheck-dial ?? in children with asthma

World Allergy Organization Journal, 2007

Research paper thumbnail of Cytokine responses during exacerbation compared with stable phase in asthmatic children

World Allergy Organization Journal, 2007

Bronchial asthma is a chronic inflammatory disorder of the airways. Balancing in Th1 and Th2 resp... more Bronchial asthma is a chronic inflammatory disorder of the airways. Balancing in Th1 and Th2 response is a target in the treatment. Recent studies show that interleukin-10 (IL-10) has an important role in the regulation of Th2 and allergic responses and its amount was found to decrease in asthmatic patients. This study was to focus on cytokine responses, including interferon-gamma (IFN-γ), IL-4 and IL-10 in asthmatic children during acute exacerbation compared to stable period. Peripheral blood mononuclear cells (PBMCs) from fourteen asthmatic children during exacerbation and stable phase were stimulated with phytohemagglutinin (PHA) and mite allergen (Der p) for 72 hours. Levels of IFN-γ, IL-4 and IL-10 in cell culture supernatants were measured using enzyme-linked immunosorbent assay. The median level of IL-10 in PBMCs stimulated with PHA was significantly lower in acute asthma exacerbation compared with stable phase (464 vs. 859.5 pg/ml, p = 0.03). However, there was no difference in the level of IL-10 in PBMCs stimulated with Der p. The level of IFN-γ and IL-4 were not different between exacerbation and stable phase both in PHA and Der p-stimulated PBMCs. The decrease of IL-10 production in asthmatic children during acute exacerbation may emphasize the role of IL-10 in immune regulation in allergic disease.

Research paper thumbnail of Randomized controlled trial of salbutamol aerosol therapy via metered dose inhaler-spacer vs. jet nebulizer in young children with wheezing

Pediatric Pulmonology, 2005

The jet nebulizer is a common device used for administering aerosol medication in young children.... more The jet nebulizer is a common device used for administering aerosol medication in young children. However, compared to a metered dose inhaler-spacer (MDI-spacer), it takes more time and personnel. This study aimed to compare the efficacy of salbutamol aerosol therapy given via these two devices in young wheezing children. A prospective randomized, double-blind, placebo-controlled trial was performed in children up to 5 years old who had acute wheezing and were admitted to the Department of Pediatrics, King Chulalongkorn Memorial Hospital. Patients were randomly divided into two groups. The first group received 2 puffs of placebo via MDI-spacer, followed by 0.15 mg/kg salbutamol respiratory solution via jet nebulizer. The second group received 2 puffs (100 microg/puff) of salbutamol via MDI-spacer, followed by placebo via jet nebulizer. Clinical scores and tidal breathing pulmonary function test were evaluated before and after treatment. Pulmonary function parameters included those derived from flow volume loops (volume to peak tidal expiratory flow over total expiratory volume, V(PTEF)/V(E); time to peak tidal expiratory flow over total expiratory time, T(PTEF)/T(E); and ratio of tidal expiratory flow at 25% remaining expiration to peak expiratory flow, 25/PF), compliance (Crs), and resistance (Rrs) of the respiratory system. The efficacy of both methods was compared by using analysis of covariance. Forty-seven wheezing children were studied (24 received salbutamol via MDI-spacer, and 23 received it via jet nebulizer). There was no statistical difference between the two groups regarding clinical scores and all pulmonary function parameters. However, heart rate was significantly increased after treatment in the jet nebulizer group when compared to those in the MDI-spacer group (P = 0.004). In conclusion, the efficacy of salbutamol aerosol therapy via MDI-spacer compared to jet nebulizer in young wheezing children was not different in terms of clinical score and postbronchodilator pulmonary function parameters. However, salbutamol aerosol therapy via jet nebulizer significantly increased the heart rate when compared to the MDI-spacer.

Research paper thumbnail of Phenobarbital-induced severe cutaneous adverse drug reactions are associated with CYP2C19*2 in Thai children

Pediatric Allergy and Immunology, 2013

Aromatic anticonvulsant-induced severe cutaneous adverse drug reactions (SCARs), including Steven... more Aromatic anticonvulsant-induced severe cutaneous adverse drug reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrosis (TEN), and drug rash with eosinophilia and systemic symptoms (DRESS), are fatal immune-mediated adverse drug reactions. CYP2C19, a cytochrome P450 isoform, plays a role in metabolic rate of aromatic anticonvulsant. HLA-B*1502 has also been demonstrated to be associated with carbamazepine-induced SJS-TEN. Forty case patients who were diagnosed with SCARs after initiation of phenobarbital (PB), phenytoin (PHT), or carbamazepine (CBZ) for 1-8 wk and forty control patients who received PB, PHT, or CBZ at least 2 months with no adverse drug reactions were enrolled in the study. The genotypes of CYP2C19*1, CYP2C19*2, and HLA-B*1502 were analyzed using allele-specific polymerase chain reaction technique. Clinical characteristics of SCARs patients who used different drugs were also analyzed. There was no significant difference in sex, onset of symptoms, laboratory results, treatment, and length of stay among patients with SCARs due to PB, PHT, or CBZ. The patients with CYP2C19*2 variant had a trend to have a likelihood to develop SCARs more than the patients with CYP2C19 wild type (OR = 2.5, 95% CI (0.96-67.3) p = 0.06). In subgroup analysis, the patients with CYP2C19*2 variant were at four times increased risk of SCARs from phenobarbital more than the patients with CYP2C19 wild type (OR = 4.5, 95% CI (1.17-17.37) p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.03). There was no association between the HLA-B*1502 and aromatic anticonvulsant-induced severe cutaneous adverse reactions (SCARs). CYP2C19*2 variant may play a role in the genetic predisposition of SCARs from phenobarbital.

Research paper thumbnail of Proteome and Allergenome of Asian Wasp, Vespa affinis , Venom and IgE Reactivity of the Venom Components

Journal of Proteome Research, 2014

Vespa af f inis (Asian wasp, Thai banded tiger wasp, or local name: Tor Hua Seua) causes the most... more Vespa af f inis (Asian wasp, Thai banded tiger wasp, or local name: Tor Hua Seua) causes the most frequent incidence of medically important Hymenoptera sting in South and Southeast Asia. However, data on the venom components attributable to the sting derived-clinical manifestations (local reactions, IgE mediated-anaphylaxis, or systemic envenomation) are lacking. This study provides the first set information on V. af finis venom proteome, allergenome, and IgE reactivity of individual venom components. From 2DE-gel basedproteomics, the venom revealed 93 protein spots, of which proteins in 51 spots could be identified and classified into three groups: typical venom components and structural and housekeeping proteins. Venom proteins in 32 spots reacted with serum IgE of wasp allergic patients. Major allergenic proteins that reacted to IgE of >50% of the wasp allergic patients included PLA 1 (100%), arginine kinase (73%), heat shock 70 kDa protein (73.3%), venom allergen-5 (66.7%), enolase (66.7%), PLA 1 magnifin (60%), glyceraldehyde-3-phosphate dehydrogenase (60%), hyaluronidase (53.3%), and fructose-bisphosphate aldolase (53.3%). The venom minor allergens were GB17876 transcript (40%), GB17291 transcript (20%), malic enzyme (13.3%), aconitate hydratase (6.7%), and phosphoglucomutase (6.7%). The information has diagnostic and clinical implications for future improvement of case diagnostic sensitivity and specificity, component-resolve diagnosis, and design of specific Hymenoptera venom immunotherapy.

Research paper thumbnail of Nasal Challenge Test in Childhood Allergic Rhinitis with House Dust Mite Sensitization

Journal of Allergy and Clinical Immunology, 2009

RATIONALE: Different devices for percutaneous allergy skin testing have demonstrated statisticall... more RATIONALE: Different devices for percutaneous allergy skin testing have demonstrated statistically and clinically significant differences in performance characteristics. We compared two FDA-approved multi-head allergy skin testing devices: Multi-Test II (Lincoln Diagnostics) and ComforTen (Hollister-Stier Laboratories). METHODS: Skin tests with glycerinated histamine (6 mg/mL base) and glycerinated saline were applied to 30 adults using Multi-Test II on the volar surface of one forearm and ComforTen on the opposite forearm. RESULTS: Data were accumulated from 150 histamine sites and 90 negative control sites for each device. Using cutoff wheal sizes of 5 vs 3 mm inclusive to define a positive result, Multi-Test II sensitivity increased from 97% to 100%, and specificity decreased from 100% to 97%, whereas ComforTen sensitivity increased from 27% to 82%, and specificity decreased from 100% to 99%. For Multi-Test II vs ComforTen, histamine mean (SD) wheal sizes were 7.47 (1.72) vs 3.93 (1.59) mm (p 5 0.000), mean coefficients of variation were 23.0% vs 40.5%, and pooled estimates of variance were 1.42 vs 1.29. At different test head positions, there was no statistically significant variation in histamine wheal sizes with either Multi-Test II or ComforTen. CONCLUSIONS: Multi-Test II had notably greater wheal size and higher sensitivity, but similar specificity to ComforTen. Multi-Test II had superior performance at both 3 mm and 5 mm wheal cutoffs. Because ComforTen had a low sensitivity at the 3 mm and particularly the 5 mm wheal cutoff, skin testing with this device might result in underdiagnosis of allergy using either cutoff.

Research paper thumbnail of Rush Hymenoptera Venom Immunotherapy in Thai Children

Journal of Allergy and Clinical Immunology, 2009

RATIONALE: The rush hymenoptera venom immunotherapy (VIT) has been shown to be safe and effective... more RATIONALE: The rush hymenoptera venom immunotherapy (VIT) has been shown to be safe and effective, but it is not commonly practiced in Thailand. We examined the efficacy and safety of rush VIT and the risk factors in these patients. METHODS: A 3-year retrospective study was done which revealed 11 patients with history of severe systemic reaction after being stung by hymenoptera. Diagnosis was made on the basis of history and evidence of sensitization by positive skin testing and/or presence of specific IgE to honeybee, vespid or fire ant venom. They all received rush VIT regimen with a careful monitoring of adverse reaction in Ramathibodi hospital, a referral center for insect venom allergy. We evaluated risk factors for serious adverse reaction such as age, gender, atopic history, severity of insect sting reaction according to the H.L. Muller classification, and evidence of sensitization. RESULTS: There were 4 patients treated with honeybee, 5 with fire ant, one with mixed vespid and one with mixed vespid plus honeybee immunotherapy. All patients are male. Adverse reactions were observed in 4 patients (36%) with mild severity (1 with large local reaction, 3 with generalized urticaria but no other systemic reaction), and were not associated with age, type of hymenoptera allergen used, level of sensitization (either by skin testing or specific IgE) and atopic history. CONCLUSIONS: Rush hymenoptera venom immunotherapy is an alternative treatment for patients who are in active life styles especially children and adolescents. No serious adverse reaction with rush VITwas seen in our study. RATIONALE: Several case reports indicate a reduced efficacy of VIT in patients with SM. It is unclear whether the efficacy of VIT in patients with SM depends on the maintenance dose. METHODS: In a retrospective study 33 patients (54.5% male, 45.5% female) with SM and HVA were analysed. 4 patients (12.1%) were treated with honeybee venom (HBV), 21 (63.7%) with yellow jacket venom (YJV), and 8 (24.2%) with both venoms. Depending on the severity of the sting reaction, on the type of venom, and on additional risk factors, selected patients were treated with an increased maintenance dose. 200 mg venom were used for VIT in 9 of 29 treatment courses using YJV, and in 8 of 12 treatment courses using HBV. A challenge test with a living honeybee and/or yellow jacket was done 6 to 18 months after the beginning of VIT. At the challenge tests patients were between 29 and 75 years old (mean 48.4 6 11.9 years). RESULTS: All patients receiving 200 mg venom were protected at the challenge test. In contrast, 5 patients on VIT with 100 mg venom developed systemic symptoms upon sting challenge (1 patient upon honeybee sting and 4 patients upon yellow jacket sting). Treatment with an elevated maintenance dose was more effective than treatment with the standard dose (p < 0.05). CONCLUSIONS: An increased maintenance dose appears to be very effective to treat HVA in patients with SM. Therefore, we would recommend the use of elevated venom doses to treat patients with near fatal sting reactions and/or particular factors. . RATIONALE: Presently there are no reports in the literature that characterize the safety of subcutaneous immunotherapy (IT) with Imported Fire Ant (IFA) whole body extract. The goals of this study were to calculate a rate of systemic reactions (SR) to IT with IFA whole body extract and analyze a case-control sample of patients for putative SR risk factors. METHODS: A case-control study based on a 3 year retrospective chart review (2005)(2006)(2007)(2008) at a single institution was performed for patients receiving IFA IT. A control group received IFA IT over the same time period but did not have a SR. RESULTS: Seventy-seven patients (40 female, mean age 34 years, range 3-76 years) received 1,887 injections and 7 patients experienced 8 SRs for a rate of 0.4% per injection and 9.1% per patient. Sixteen patients experienced 20 large local reactions for a rate of 1.1% per injection and 20.7% per patient. Gender, age, phase (build up versus maintenance), asthma, angiotensin-converting enzyme inhibitor, large local reaction, concentration of positive skin test or SR to skin test did not increase the odds of a SR to IFA IT. SR organ involvement included 1 cardiovascular, 4 cutaneous, 1 gastrointestinal, 1 globus, 2 pulmonary, and 5 rhinoconjunctivitis. None required admission. Two SRs occurred after 30 minutes. CONCLUSIONS: This study is the first to characterize the safety of IT with IFA whole body extract. An overall low SR rate was observed and no specific risk factors were associated with SRs to IFA IT. BACKGROUND: Anaphylaxis following a hymenoptera sting has been reported in patients with mastocytosis, but few data exist regarding the disease's prevalence in patients with hymenoptera allergy. METHODS: Using bone marrow (BM) histology/cytology, flow cytometry (FC), and detection of KIT mutations, we assessed the prevalence of mastocytosis in patients with both systemic reactions to hymenoptera and increased serum tryptase (sBT). RESULTS: Forty-four out of 379 patients (11.6%) with systemic reactions to sting had increased sBT (>11.4 ng/mL, 95th percentile of normal subjects), and 70.5% of them had a history of sting-induced anaphylaxis. Thirty-four patients underwent a BM analysis. Histology fulfilled major WHO diagnostic criteria in 42.4% of cases. Abnormal mast cells (MCs) were identified by FC and cytology in 78.8% and 61.8% of patients, respectively. A codon 816 KIT mutation was detected in 58.1% of patients. The diagnosis was indolent systemic mastocytosis (ISM) in 61.7% of cases (11.8% with Urticaria Pigmentosa) and Monoclonal MC Activation Syndrome (MMAS) in 26.5%. In particular, 96.4% of patients with anaphylaxis were classified as ISM or MMAS. CONCLUSIONS: Based on the results of the approach utilized in our study, the concomitant presence of systemic reactions (especially anaphylaxis) following hymenoptera sting and raised sBT suggests that a BM examination is indicated in order to diagnose clonal MC disease.