ORIGINAL ARTICLES
Prevalence of allergy to latex in the pediatric population
J. L. Eseverri, J. Botey, M. Cozzo, M. Pena and A. M. Marín
Servei d''Al.lergologia i Immunologia Clínica Pediàtrica. Hospital Universitari Materno Infantil "Vall d''Hebrón" Universitat Autònoma. Barcelona.
Correspondence:
Jaume Botey i Sala
Diagonal, 347 entl.
08037 Barcelona
SUMMARY
Latex is a substance that is extracted from the plant Hevea Brasiliensis, and world production is 6 million metric tons per year. After gathering it undergoes a series of processes in which ammonia, vulcanization-accelerating additives or anti-oxidants are added. All of this may constitute the antigenic load that latex contains.
It is used in medicine for gloves, drainage tubes, dental implants and a growing number of products from condoms to sport products or automobile components.
Over fifteen different allergenic bands have been described, with molecular weights of between 2 and 100 kDa. In a joint study, USA-Finland identified three antigenic bands that predominate according to the population type studied (2). In children with spina bifida, congenital urogenital abnormalities or those submitted to multiple surgical interventions, the band of 27 kDa is predominant. This antigen has not been detected in adult serum, which suggests that contact with the antigen is through the mucous membranes and the sensitization is triggered from here.
The incidence of allergy to latex in the general population is not known, but it seems to be lower than 1%. Turjanmaa (1) establishes a frequency of 0.125% (1/800) in patients submitted to general surgery.
The incidence of sensitization to latex varies according to the population studied. Among the population considered to be at risk are the workers of the health environment, where the incidence is between 2.6 and 16.9%, whereas in the general population the percentage is around 1%. Sensitivity to latex is of great importance in patients suffering from spina bifida, in whom an incidence of between 28 and 67% has been found.
We present our experience in a group of children attending our service for the first time for diverse reasons of supposed allergic etiology. The objective is to determine the incidence of sensitization to latex according to the diagnostic methodology [cutaneous test or by determination of specific IgE (CAP)]; according to the type of patient (atopic or non-atopic), the direct relationship with latex material and the role that can be played by a history of surgical intervention.
In our experience with 282 children studied in our pediatric allergology service using diverse methods, the incidence of allergy to latex is 3.19%. Nevertheless, if we analyze this percentage we observe that if the diagnosis is based exclusively on cutaneous tests, it is only 1.08%; if to establish a diagnosis we used exclusively the determination of specific IgE (CAP) we would label 7.2% of our children as allergic. Atopy is a factor that facilitates sensitization. In our sample, the incidence among the atopic population is 4.4%, though this percentage may vary between 1.69% and 9.5% depending on the methodology used.
There are several hypotheses for explaining these discrepancies in the diagnostic tests. Although there do not seem to be differences regarding the ammonia content of the different lots, it seems that the differential factor could lie in the type of extract and in whether it is commercial or a natural latex extract. It could be a consequence of the existence of a prophyllin, so it has not been ruled out that a part of the IgE is an antiprophyllin. The presence of different epitopes would mean that each of them has the ability to produce its own specific IgE, though the RAST/CAP was not able to differentiate them and identified them as whole.
The rate of allergy to latex in a group of children suffering from myelomeningocele is 80%.
At a paediatric level, sensitization to latex is influenced by the means of contact, the duration of the exposure to the antigen and the fact that the exposure occurs early, which in the case of children with myelomeningocele is associated with the immaturity of the defence mechanism of the mucous membranes.
Key words: Child latex allergy. Epidemiology.
RESUMEN
El látex es una sustancia que se extrae de la planta Hevea Brasiliensis; tras su recolección sufre una serie de procesos en los que se le adiciona amoniaco, aditivos aceleradores de la vulcanización o antioxidantes. Todo ello puede constituir la carga antigénica que contiene el látex.
Se han descrito más de 15 bandas alergénicas distintas, con pesos moleculares entre 2 y 100 kDa. En un estudio conjunto, USA-Finlandia se han identificado tres bandas antigénicas que predominan según sea el tipo de población estudiada (2). En niños con espina bífida, anormalías urogenitales congénitas o sometidos a múltiples intervenciones quirúrgicas predomina la banda de 27kDa, este antígeno no ha sido detectado en el suero de adultos, lo que sugiere que el contacto con el antígeno es por vía mucosa y a partir de esta vía se desencadena la sensibilización.
La incidencia de alergia al látex en la población general, se desconoce, pero parece ser menor al 1%. Turjanmaa (1) establece una frecuencia del 0,125% (1/800) en pacientes sometidos a cirugía general.
La incidencia varía en función de la población estudiada; entre la población considerada de riesgo como son los trabajadores del ámbito sanitario, esta incidencia se sitúa entre el 2,6 y el 16,9% mientras que en la población general el procentaje es alrededor del 1%. La sensibilidad al látex adquire una importancia capital en los pacientes afectos de espina bífida entre los que la sensibilidad al látex se ha establecido entre el 28 y el 67%.
Nuestra experiencia en 282 niños estudiados en nuestro servicio de alergología pediátrica, por diversos procesos, la incidencia de alergia al látex es del 3,19%. No obstante si analizamos este porcentaje observamos que si el diagnóstico lo fundamentamos exclusivamente en los tests cutáneos, tan sólo la cifraríamos en el 1,08%; si para establecer un diagnóstico utilizásemos exclusivamente la determinación de IgE específica (CAP) etiquetaríamos como alérgicos al 7,2% de nuestros niños. La atopia es un factor que facilita la sensibilización, en nuestra muestra, la incidencia entre la población atópica es del 4,4%, porcentaje este que puede variar entre el 1,69% y el 9,5% dependiendo de la metodología utilizada.
Diversas son las hipótesis que se barajan a la hora de explicar estas discrepancias que nos ofrecen los test diagnósticos. Si bien no parece existir diferencias por lo que respecta al contenido en amoniaco de los distintos lotes, si que parece que el hecho diferencial podría estar en el tipo de extracto sea este comercial o se trate de un extracto de látex natural. Podría ser consecuencia de la presencia de una profilina, por lo que una parte de la IgE no se descarta sea una antiprofilina. La presencia de distintos epítopes daría lugar a que cada uno de ellos tuviese la capacidad de producir su propia IgE específica y sin embargo el RAST/CAP no fuese capaz de diferenciarlas, identificándolas en un todo.
La alergia al látex en un grupo de niños afectos de mielomeningocele es del 80%.
A nivel pediátrico la sensibilización al látex se ve influenciada por la vía de contacto, la duración y la exposición temprana al antígeno, que en el caso de los niños con mielomeningocele se asocia a la inmadurez del mecanismo defensivo de las mucosas.
Palabras clave: Alergia al látex en niños. Epidemiología.
MATERIAL AND METHODS
Our prospective study was aimed at determining sensitivity to latex in a random population attending our service for the first time.
282 children of aged from 1 to 14 were selected: 145 boys and 137 girls. All were submitted to an allergological study that included cutaneous tests for pneumoallergens and trophoallergens, determination of specific IgE and provocation tests. The cutaneous tests with latex were performed in duplicate with two different commercial extracts with a low ammonia content.
Although all the patients were subjected to a complete study in order to establish their basic aetiology, sensitivity to latex was determined in 185 children by means of prick test, and in 97 children through the detection of specific IgE by means of CAP.
In order to assess the type of response, we included an independent group of 12 children who were specifically referred to us in order to rule out the existence of hypersensitivity to latex, either because the clinical history suggested this or because it was a high-risk population. This group was composed of two anaphylactic reactions in connection with latex material and 10 children suffering from myelomeningocele with a large number of surgical interventions (between 5 and 11). In this specific group the diagnosis for latex was established by means of prick test and specific IgE (CAP).
RESULTS
At the end of the study 181 (181/282) children were considered as atopic according to the different confirmation tests, that is to say 64.18%.
The results of the study to assess the prevalence of allergy to latex showed the presence of specific antibodies to latex in 9 children, regardless of the diagnostic technique. This shows a general incidence of 3.19% in the paediatric population that was the objective of the study.
Analyzing the different factors of risk, the presence of atopy was the most important. Of the nine children with sensitivity to latex, 8 were sensitive to other allergens. This represents an incidence of allergy to latex of 4.4% among the atopic population.
The prick test for latex was positive in two cases (2/185), both atopic children, which represents 1.08%. One of them suffered from severe atopic dermatitis and was polysensitized to dust mites, eggs and cereals; the second case was a 10 year-old girl suffering from urticaria/angioedema and sensitized to fruits (peach, apple) nuts and fish. Since in this group 118 children had another type of atopic manifestation, the prevalence of allergy to latex among the atopic population was 1.69%.
We detected specific IgE to latex in 7 children, which represents an incidence of 7.2% (7/97). Of these seven children, 6 were included among the atopic ones (6/63) so the incidence of allergy to latex among the atopic population was 9.5%. In only one non-atopic case (vasomotor rhinitis) a specific IgE to latex was obtained (1/34), that is to say 2.9%.
A more exhaustive interrogation aimed specifically at establishing a relationship with latex shows that 4 children had on some occasion presented small dermal manifestations with latex products (balloons, swimming goggles...) but the parents did not consider it relevant.
Another of the risk factors involved in sensitization to latex is a history of surgical intervention. This is an important factor, because 5 children (all them diagnosed as sensitive to latex by means of CAP) had previous surgical intervention. In two cases the interventions were orthopaedic, in one at an abdominal level (appendicectomy), the fourth had an adenoid operation and the fifth (not atopic but positive CAP) had been submitted to adenoidectomy and had the antecedent of meningococcic sepsis, which suggests a close contact with hospital products containing latex. The two children diagnosed by means of prick test, both atopic, had no history of surgical intervention.
The presence of cross-reactivity between latex and fruits is found in several studies. Also in our clinical experience this phenomenon was also found to be significant. Four children with hypersensitivity to latex were sensitized to certain fruits (banana, avocado, chestnut and kiwi).
If we analyze the group of children considered as high-risk, 10 children suffering from myelomeningocele, two were asymptomatic, two showed clinical symptoms after contact with balloons and the other six had diverse intraoperatory incidences (the number of interventions was between 5 and 11).
The two children with anaphylactic reactions after contact with latex material had a history of minor surgery.
The immuno-alergollogical study in all patients demonstrated a hypersensitivity to latex (in 8 myelomeningocele cases and 2 anaphylaxis cases) both by prick test and by determination of specific IgE; the study was negative precisely in the two children suffering from myelomeningocele, who were asymptomatic.
Regarding the existence of cross-reactivity with fruits, 4 of the myelomeningocele patients showed positive in both the prick test and the CAP to the fruits that are habitually involved.
CONCLUSIONS
The prevalence of allergy to latex differs considerably according to the diagnostic methodology. The differences that we observe are common to the other authors who have established its diagnosis either by cutaneous test or by determination of specific IgE.
In all the studies a personal history of atopy, surgical intervention, and a large number of interventions at an early age are established as risk factors.
In our sample of children attending an allergy service and subjected to a study for allergy to latex, we obtain different results if we use the cutaneous test or determination of specific IgE.
When they undergo cutaneous tests the incidence of sensitivity to latex in 1.08%, whereas if the diagnostic method is based on the determination of specific IgE following the same criteria the incidence is 7.2%.
We find a considerable difference in the two cases when we separate the atopic and the non-atopic population. While all the positive prick test cases are atopic children, which would represent a prevalence of allergy to latex of 1.69%, we found non-atopic children with a positive prick test for latex. In the population subjected to discrimination by means of CAP, 9.5% of atopic children showed sensitivity to latex against 2.9% of non-atopic children.
In the high-risk population the prevalence of allergy to latex is considerable. 80% of the children with spina bifida showed sensitivity (8/10), and the diagnosis was confirmed in both the children suspected of having anaphylactic conditions induced by latex (100%). In this very selective group we found no difference between the two diagnostic tests (cutaneous test-CAP), which showed complete agreement.
The surgical risk factor plays a major role in the mechanism that triggers sensitization. This is clearly shown in the high-risk group of children (myelomeningocele-anaphylaxis), since all of them (12/12) had been submitted to surgery (100%).
Surgical antecedents are present in 71.1% (5/7) of patients showing sensitization to latex by means of CAP. However, in the children with a positive prick test, this factor was only present in the boy suffering from atopic dermatitis, who was hospitalized in severe phases of exacerbation during which he was manipulated with latex gloves in the application of the topical treatment.
Finally, the existence of cross-reactivity with certain fruits should not be ignored, because its shows a high percentage. 66.6% (4/6) of patients with a positive CAP show a sensitization to these fruits, and 57.1% (4/7) of high-risk patients also show sensitization to fruits. No positive prick case showed cross-reactivity with these fruits, though they did with other fruits.
DISCUSSION
Latex is a substance that is extracted from the plant Hevea Brasiliensis; after being gathered it undergoes a series of processes in which ammonia, vulcanization-accelerating additives or anti-oxidants are added. All of this may constitute the antigenic load that latex contains.
Several proteins have been isolated from latex in pure state: phenyltranferase, rubber elongation factor, hevein and hevamine. Rubber elongation factor is one of the most important allergens involved in allergy to latex.
From the immunological point of view, different allergens from different sources have been identified in latex: in natural latex (that is not ammonia centrifuged), ammonia centrifuged latex or extracts of products manufactured with latex, in all of which reactivity with IgE antibodies in serums of patients with sensitivity to latex has been demonstrated.
The protein content of latex may vary according to the production method, and there are also variations between batches.
Over fifteen different allergenic bands have been described, with molecular weights of between 2 and 10 kDa. In a joint study, USA-Finland identified three antigenic bands that predominate according to the population type studied (2). In children with spina bifida, congenital urogenital abnormalities, or those submitted to multiple surgical interventions, the band of 27 kDa is predominant. This antigen has not been detected in adult serum, which suggests that contact with the antigen is through mucosa and the sensitization is triggered from here.
Allergy to latex can be considered as a "European" disease. The first case was described in 1927 by Stern in Germany. The "modern age" of the disease began in 1979, when Nutter (3) published a case of urticaria, and a great variety of clinical symptoms associated with latex began to be described: urticaria, angioedema, conjunctivitis, rhinitis, bronchospasm and anaphylactic shock occurring during surgical intervention.
In the USA, between 1988 and 1992 the FDA counted more than 1,000 systemic reactions induced by latex, 15 of which were fatal (4).
The clinical symptomatology for sensitivity of an immediate type (IgE-mediated) is characterized by urticaria, andioedema, conjunctivitis, rhinitis, asthma and anaphylaxis. Once the sensitization has been established, manifestations at a cutaneous level and in the mucous membranes are the most common, and respiratory manifestations are usually secondary to inhalation or latex particles in suspension in the environmental air.
The powder that is normally used to lubricate gloves facilitates the environmental dissemination of allergenic particles of latex. Epidemiological studies on sensitization to latex among health workers have demonstrated that it is closely linked to the workplace, to the amount of latex particles in the different hospital areas and to the use of latex gloves in these areas.
The use of latex gloves with a low protein content reduces the risk of asthmatic reactions considerably among sensitized individuals; it has not yet been determined whether the sensitizing power of this type of glove is lower than that of other gloves.
At a paediatric population, sensitization to latex is influenced by the means of contact, the duration and by the age of exposure to the antigen, which in the case of children with myelomeningocele is associated with the immaturity of the defence mechanism of the mucous membranes.
Sensitization to latex in adults is basically of an occupational nature and may affect the eyes or nose, or be produced by contact. Allergy to latex is a typical example of Maibach and Johnson''s Contact Urticaria Syndrome (5), which is divided into four states:
I) Urticaria in the contact zone.
II) Widespread urticaria and angioedema.
III) Urticaria with asthma, rhinoconjunctivitis and orapharyngeal and gastrointestinal syndromes.
IV) Urticaria with anaphylactic reaction.
Turjanmaa (1) reports that in 42 adults with allergy to latex, 2% showed no symptoms in the contact zone, and 10% showed exacerbations and pruritus of the eczema. If these patients are grouped according to Maibach and Johnson states, 40% would be in State I, 17% in State II, 21% in State III and 10% in State IV.
Kwittken et al (6) conclude in their study that there is a direct interrelation between sensitization to latex and the age of the first surgical intervention. In 33 of the 35 children studied, the surgical intervention took place during the first year of life.
These authors divide the severity of the clinical conditions into four degrees, and in 17 cases the symptoms occurred in the intraoperatory period. 31.4% of all reactions were considered as severe (degrees 3-4).
There seem to exist different patterns of IgE response according to the different allergens of latex and different groups of individuals. Children suffering from myelomeningocele do not have the same behaviour as individuals who are allergic to fruits, and this makes it necessary to identify the specific antigen that is responsible in each group of individuals.
In adults with cutaneous symptoms the antigen corresponding to the protein band of 20 kDa (77% of the serums studied) has been identified as responsible for the sensitization. An antigen whose molecular weight is located in the band of 14 kDa is found in children with spina bifida, which would suggest the hypothesis that the identified antigen of 27 kDa could correspond to a dimer from of that of 14 kDa. This hypothesis has not yet been demonstrated.
For the above reasons the existence of different reactivities according to the studied group could be explained. This behaviour is assumed to be the consequence of the convergence of diverse factors such as genetic predisposition, the different behaviour of the immune response and the different variables of presentation of the antigen.
When we study a patient suspected of suffering an adverse reaction to latex it is fundamental to bear in mind the variability of the reactivities of the antigens; this variability may be related to the lack of reactivity in up to 25% of the serums that are clinically sensitized.
Our data agree with those of the literature, both in the effective incidence and when the study populations divide the patients into atopic and non-atopic.
All the authors also include intense contact with latex (as occurs in surgical interventions) as a major risk factor, combined with surgical intervention at an early age and repeated surgical intervention.
Similar results were found, for example, by Porri et al (7) in 1997, in an allergological study to detect sensitivity to latex carried out by cutaneous tests or by determination of specific IgE (RAST/CAP). On a sample of 286 individuals these authors found 17 sensitive to latex, including those sensitive at the level of serum and at a cutaneous level. Indeed, 9 individuals were labelled as allergic to latex because they had a positive RAST test and 8 because they had a positive cutaneous test, however, none of them had both a tests positive, that is to say, the positive agreement between the prick test and RAST was 0.
Several hypotheses have been put forward to explain this difference in the diagnostic tests. Although there seem to be no differences in the ammonia content of the different batches, it seems that the differential fact could lie in the type of extract --whether it is commercial or a natural latex extract. It could be a consequence of the existence of a prophyllin, so it has not been ruled out that a part of the IgE is an antiprophyllin. The presence of different epitopes would mean that each of them has the ability to produce its own specific IgE, though the RAST/CAP was not able to differentiate them and identified them as a whole.
In health personnel Turjanmaa (8) found that 6.2% of operating theatre staff, 1.5% of laboratory staff and 7.4% of surgeons had positive tests to latex.
In a health personnel population of 273 individuals, Vanderplas et al (9) found 13 (4.7%) positive prick tests to latex. The allergological survey shows that all 13 showed contact urticaria, 12 rhinoconjunctivitis; 5 showed a clinical condition of asthma, all with a positive bronchial provocation test to latex.
A group of 596 patients studied by Moneret-Vautrin (10) were divided into four groups according to whether they had a history of atopy and whether they had been exposed to latex. In the non-atopic group that was not exposed to latex 0.37% were found to be sensitized to latex; in the non-atopic group that was exposed to latex the percentage of sensitization was 6.8%. In the atopic group that was not exposed to latex 9.5% showed sensitization; in the atopic group that was exposed to latex 36.4% showed sensitization. According fo these figures the presence of atopy multiplies the risk of sensitization by 25 in those that are not exposed to latex. Although frequent contact with latex and atopy are risk factors, they act sinergically.
38% of the children with spina bifida in the group studied by Tosi et al (11) showed a positive RAST to latex. In a similar population studied by Michael et al (12), 49% showed a positive RAST (80/165). When the sensitization was detected by cutaneous tests, 46% were positive (37/81).
The incidence of sensitization to latex varies according to the population studied. Among the high-risk population such as health workers, this incidence is between 2.6 and 16.9%, while in the general population it is around 1%. Sensitivity to latex is of great importance in patients suffering from spina bifida, among whom sensitivity to latex has been established as between 28 and 67%.
Most of the literature on this topic indicates a prevalence of atopic patients among those with hypersensitivity to latex.
In 1996 Liebke and Wahn (13) published a study on sensitization to latex in atopic and non-atopic children. By determining specific IgE (CAP), these authors found 1/303 (0.3%) children without a personal history of atopy to be sensitive to latex; in the group of atopic children this incidence was 20.8% (60/306). It was only possible to carry out a prick test for latex in 48 children, of whom 16 (16/48) showed positive cutaneous sensitivization when latex with a high concentration of ammonia was used; if an extract with a low ammonia content was used 17 children (17/48) showed positive. When a bronchial provocation test was carried out with latex, 12 of the 48 responded positively. 75% of these children had clinical conditions of atopic dermatitis; the 36 remaining children that showed positive in the prick test had shown no symptoms related to latex but did have a history of at least one surgical intervention.
According to these authors, the most important risk factor for developing sensitization to latex is a history of atopy, particularly if it corresponds to an atopic dermatitis. Other risk factors are a high specific IgE, a positive history to contact with latex, the number of surgical interventions and the age of the first intervention.
Using the determination of specific IgE as a diagnostic test in 200 serums of atopic patients (70.8% under 18 years), Reinheimer (14) established the prevalence of sensitivity to latex at 12% (24/200). All these serums showed a positive RAST inhibition.
In a population of 146 atopic adults, Hadjiliadis and Tarco (15) found the incidence of sensitization to latex by means of pricks test to be 7% (10/146). In a study of 1,288 individuals submitted to a prick test, Fuchs (20) found an incidence of sensitization to latex of 4.2% (54 individuals).
Reactions of secondary hypersensitivity to sensitization to latex have followed an upward tendency in recent years. It is not yet possible to determine the immunopathological mechanism because we do not have a precise knowledge of the relevant antigens of latex and because of the lack of purified and well standardized latex antigens.
The first step in the diagnosis is the clinical history, an assessment of the appearance of urticaria or contact eczema, rhinitis, angioedema or asthma related to the use of balloons, gloves or other medical or surgical objects or materials containing latex.
Immunological tests both in vivo and in vitro can be of great help, but there is a great variability in both their sensitivity and their specificity because the extracts that we use are not properly individualized.
We should be cautions in using these antigens because they can lead to serious adverse reactions, without excluding anaphylaxis.
Well purified and standardized allergens are useful for diagnosis, but we should bear in mind the variability of response according to the different study groups.
Although the allergens of latex are not yet well characterized, those available for prick tests are very reliable. Using extract of natural latex in 907 health workers Moneret-Vautrin et al (17) found a sensitivity of 100%: 18 positive test in 18 patients with suspected conditions. The specificity of the test was established as 99%.
The determination of specific IgE (RAST) gives a sensitivity of 89% according to Tosi (11); Michel (12) also finds a good agreement between prick tests and CAP.
In a series of 93 patients with spina bifida, Slater (18) finds a negative predictive value of 98% in RAST; only one of the 58 children showing a negative RAST showed clear symptoms in contact with latex.
Since the nineties authors have reported individuals with allergy to latex that show hypersensitivity reactions after ingesting banana, avocado, chestnut or kiwi.
In 1991 M''Raihi described the simultaneous appearance of allergy to banana for the first time in a patient with allergy to latex, which suggested to him the possibility of it being a cross-reaction. Since then, several articles have been published demonstrating the existence of a close relationship between latex and allergy to certain fruits.
Several theories have been put forward to explain the existence of this double sensitization to latex and fruit, including the existence of common antigens or antigens with cross-reactivity.
Since atopic patients have a genetic predisposition to develop hypersensitivity reactions, it is not surprising that regardless of the sensitization to latex they also acquire a predisposition to be sensitized to an undetermined number of vegetable antigens.
Prophyllin is an antigen that is present both in latex and in fruits. However, it is doubtful whether this is the common nexus that justifies the existence of a cross-reaction, since it is not possible to detect specific antibodies to prophyllin in most patients that are allergic to latex.
Lysozyme is an enzyme that plays an important role in the defence mechanism; it is present both in latex and in some fruits (pawpaw, avocado), so it has not been ruled out that it may play a certain role in producing a cross-reaction between latex and some fruits.
At the present time it is suggested that the cross-reactivity would not involve a single antigen but would be the result of the presence of multiple antigens. Some authors suggests that these patients could have a unique endowment of histocompatibility antigens.
Makinenen-Kiljunen (19) found that 83% of patients allergic to latex show a positive RAST test to banana. By immunoblotting they identify in latex eight allergens between 14 and 75 kDa that are inhibited by the antigen of the banana. They also identify in the banana thirteen bands whose molecular weights are between 14 and 150 kDa, of which 10 are inhibited by latex.
Blanco et al (20) report that 13 of a series of 25 patients allergic to latex showed 42 episodes of hypersensitivity to fruits (avocado, chestnut, banana, kiwi and pawpaw); 23 of these episodes were anaphylactic reactions. By RAST inhibition they demonstrate the existence of cross-reactions between latex, avocado, chestnut and banana.
In 1995 Lavaud (21) published a study demonstrating the existence of an antigenic band of 30 Kd that is common to latex, avocado and banana.
The American Academy of Allergy and Immunology has established a series of recommendations in order to avoid reactions of hypersensitivity to latex, which includes:
* Study the history of medical, surgical and dental methods involving exposure to latex.
* Avoid latex in risk populations.
* All health institutions should be able to deal with patients sensitized to latex and provide health workers (who are sensitive) with material that does not contain latex.
To replace latex, material containing synthetic latex (polychloroprene or carboxylated nitrile rubber) or obtained from other vegetable species such as Ficus elasticus and Parthenium argentatum have been recommended.
Finally, sensitized patients and/or those who have shown previous symptoms should be given premedication in the event of surgical intervention or high-risk medical care.
REFERENCES
1.Turjanmaa K, Mäkinen-Kiljunen S, Reunala T, Alenius H, Palosuo T. Natural rubber allergy. Immunology and Allergy Clinics of North America 1995;15:71-8.
2.Alenius H, Palosuo T, Kelly K, Kurup V, Reunala T, Mäkinen-Kiljunen S, et al. IgE reactivity to 1 kD and 27 kD natural rubber proteins in latex-allergic children with spina bifida and other congenital anomalies. Int Arch Allergy Immunol 1993;102:61-6.
3.Nutter AF. Contact urticaria to rubber. Br J Dermatol 1979; 101:597-8.
4.Slater J. Latex Allergy. J Allergy Clin Immunol 1994;94:139-49.
5.Maibach HI, Johnson HL. Contact urticaria syndrome. Arch Dermatol 1975;111:726.
6.Kwitten P, Sharon K, Caompbell DE, Pawoloski NA. Latex hypersensitivity in children: clinical presentation and detection of latex-specific immunoglobulin IgE. Pediatrics 1995; 95:693-9.
7.Porri F, Lemiere C, Birbaum J, Guilloux L, Lanteaume A, Didelot R, et al. Prevalence of latex sensitization in subjects attending health screening: implications for a perioperative screening. Clin Exp Allergy 1997;27:413-7.
8.Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987;17: 270-5.
9.Vanderpla O, Delwiche J-P, Evrard G, Aimont P, Van der Brempt X, Jamart J, et al. Prevalence of occupational asthma due to latex among hospital personnel. Am J Respir Crit Care Med 1995;151:54-60.
10.Moneret-Vautrin D, Beaudouin E, Widmer S, Mouton C, Kanny G, Prestat F, et al. Prospective study of risk factors in natural rubber latex hypersensitivity. J Allergy Clin Immunol 1993; 92:668-77.
11.Tosi L, Slater JE, Shaer C, Mostello LA. Latex allergy in spina bifida patients: prevalence and surgical implications. J Pediatr Orthop 1993;13:709-12.
12.Michael T, Niggemann B, Moers A, Seidel U, Whan U, Scheffner D. Risk factors for latex allergy in patients with spina bifida. Clin Exp Allergy 1996;26:934-9.
13.Liebke C, Niggemann B, Wahn V. Sensitivity and allergy to latex in atopic and non-atopic children pediatric allergy and immunology 1996;7:103-7.
14.Reinheimer G, Ownby DR. Prevalence of latex-specific IgE antibodies in patients being evaluated for allergy. Annals Allergy 1995;74:184-7.
15.Hadjiliadis D, Khiroon Khan RN, Tarco S. Skin test responses to latex in an allergy and asthma clinic. J Allergy Clin Immunol 1995;96:431-2.
16.Fuchs T. Latex allergy: correspondence to the editor. J Allergy Clin Immunol 1994;94:951-2.
17.Moneret-Vautrin D, Laxenaire MC. Routine testing for latex allergy in patients with spina bifida is not recommended. Anesthesiology 1991;74:391-2.
18.Slater JE, Mostello LA, Shaer C. Rubber specific IgE in children with spina bifida. J Urology 1991;146:578-9.
19.Mäkinen-Kiljunen S, Alenius H, Ahlroth M, Turjanmaa K, Palosuo T, Reunala T. Immunoblot inhibition detects several common allergens in rubber latex and banana. J Allergy Clin Immunol 1993; abstracts: 242.
20.Blanco C, Carrillo T, Castillo R, Quiralte J, Cuevas M. Latex allergy: clinical features and cross-reactivity with fruits. Ann Allergy 1994;73:309-14.
21.Lavaud F, Prevost A, Cossart C, Guerin L, Bernard J, Kochman S. Allergy to latex, avocado, chestnuts and banana: evidence for 30 kD antigen in immunoblotting. J Allergy Clin Immunol 1995;95:557-64.
