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What's new in allergy and immunology
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What's new in allergy and immunology

Disclosures: Anna M Feldweg, MD Nothing to disclose. Elizabeth TePas, MD, MS Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2015. | This topic last updated: Aug 27, 2015.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ASTHMA AND COPD

Soy isoflavone supplementation does not improve asthma control (June 2015)

Patients with asthma often request guidance on dietary alterations that might improve asthma control. Preliminary studies suggested that soy isoflavone supplementation might fill this role, possibly by a reduction in eosinophil leukotriene synthesis. However, in a 24-week multicenter trial that included 386 adults and children age 12 or older with poorly controlled asthma, isoflavone supplementation did not significantly improve pulmonary function, symptom scores, episodes of poor asthma control, or exhaled nitric oxide [1]. High-quality studies are essential to determining the efficacy of dietary adjustments; this study demonstrates that soy isoflavone supplements are not useful in poorly controlled asthma. (See "Alternative and experimental agents for the treatment of asthma", section on 'Dietary alterations'.)

Investigational agent shows promise in asthma (June 2015)

GATA3 is a transcription factor that is essential for Th2 lymphocyte differentiation and activation. An investigational synthetic DNA molecule (SB010) has been developed that uniquely binds to GATA3 messenger RNA and cleaves it. The effect of SB010 was assessed in 43 patients with mild allergic asthma who were randomly assigned to inhalation of SB010 or placebo once daily for 28 days [2]. The early and late asthmatic responses to allergen bronchoprovocation were significantly attenuated by SB010. The degree of suppression of the late response was similar to that of inhaled glucocorticoids. This study supports a potential role for disruption of GATA3 (and thus Th2 cytokines) in asthma. (See "Alternative and experimental agents for the treatment of asthma", section on 'GATA3-specific DNAzyme'.)

Warning about use of non-prescription asthma treatments (April 2015)

The US Food and Drug Administration (FDA) released a consumer warning about the potential health risks of over-the-counter (OTC) homeopathic products for asthma [3]. The efficacy and safety of OTC products are not evaluated by the FDA. In addition, there is evidence that some non-prescription therapies, such as racemic epinephrine inhaler (sold as Asthmanefrin) and systemic ephedrine (sold as Bronkaid and Primatene tablets), are less effective than standard therapies for asthma and have a higher rate of side effects. Thus, OTC products are not recommended for the routine care of asthma, particularly acute asthma symptoms. These warnings are an important reminder for clinicians to ask their patients about use of OTC products. (See "Asthma in children younger than 12 years: Rescue treatment for acute symptoms", section on 'Nonstandard therapies' and "Alternative and experimental agents for the treatment of asthma", section on 'Risks associated with inhaled epinephrine' and "Alternative and experimental agents for the treatment of asthma", section on 'Homeopathic agents' and "Homeopathy", section on 'Specific diseases'.)

Safety of inhaled long-acting beta agonist/glucocorticoid for asthma during pregnancy (February 2015)

An important clinical question for pregnant women with asthma is whether using a combination long-acting beta-agonist (LABA) plus inhaled glucocorticoid confers an increased risk for adverse fetal outcomes, compared with monotherapy using a higher dose of the inhaled glucocorticoid. In a study of 1302 pregnant women with asthma, the risk for a major congenital malformation was not increased when a LABA plus low dose inhaled glucocorticoid was compared with a medium dose inhaled glucocorticoid, or when a LABA plus medium-dose inhaled glucocorticoid was compared with a high-dose inhaled glucocorticoid [4]. (See "Management of asthma during pregnancy", section on 'Long-acting beta-adrenergic agents'.)

Safety of omalizumab for asthma during pregnancy (February 2015)

The safety of omalizumab exposure during pregnancy in humans has not been formally evaluated, but outcomes from an omalizumab registry have been published [5]. There were 169 pregnancies with known outcomes: 156 live births (160 infants), 1 fetal death/stillborn, and 11 spontaneous abortions. The rate of preterm birth was 14 percent, and 11 percent of infants were small for gestational age. Congenital anomalies were present in 13 percent, and 4 percent had a major anomaly. While the sample size is small, these results are similar to findings from other studies of pregnant women with asthma. Further data are needed to more fully characterize outcomes of omalizumab use in pregnancy. (See "Management of asthma during pregnancy", section on 'Anti-immunoglobulin E'.)

Novel glucocorticoid receptor agonist for asthma (February 2015)

The investigational agent AZD5423 is a nonsteroidal compound that binds to the glucocorticoid receptor in a different manner from that of traditional glucocorticoids. It suppresses production of proinflammatory proteins (like traditional glucocorticoids), but with reduced adverse effects in animal models. An inhaled dry powder formulation of AZD5423 was assessed in a trial that randomly assigned 20 subjects with mild allergic asthma to pretreatment with AZD5423, budesonide, or placebo for seven days followed by allergen-bronchoprovocation [6]. AZD5423 attenuated the fall in forced expiratory volume in one second (FEV1) during the late phase asthmatic response compared with budesonide or placebo, but did not affect the early decrease in FEV1. AZD5423 also decreased allergen-induced sputum eosinophilia and allergen-induced airway hyperresponsiveness at 24 hours and was well-tolerated. Additional studies are needed to determine the safety and efficacy of AZD5423 compared with inhaled glucocorticoids. (See "Alternative and experimental agents for the treatment of asthma", section on 'Novel glucocorticoid receptor agonist'.)

DRUG HYPERSENSITIVITY

Eosinophilia during prolonged antibiotic therapy (June 2015)

Eosinophilia is not uncommon in patients receiving prolonged intravenous (IV) antibiotics, but the prevalence and significance has not been extensively studied. In a prospective cohort study of 824 patients receiving prolonged intravenous antibiotic therapy, eosinophilia developed in 25 percent, appearing at a median of 15 days of therapy and peaking at a median absolute count of 726/mL (500 to 8610/mL) [7]. Although most patients with eosinophilia completed their courses without complications, one-third developed a hypersensitivity reaction involving rash or hepatic or renal involvement. Medication-associated eosinophilia does not mandate discontinuation of therapy but warrants close monitoring for evidence of hypersensitivity and consideration of alternative medications that could be substituted without compromising care. (See "Approach to the patient with unexplained eosinophilia", section on 'Medications and over the counter remedies'.)

Low allergic cross-reactivity between penicillins and carbapenems (May 2015)

Carbapenems (eg, imipenem, meropenem) share a common beta-lactam ring with penicillins and hence the potential for allergic cross-reactivity, and some drug information systems list penicillin allergy as a contraindication to the use of carbapenems (figure 1). In the largest study to date, 212 patients with allergy to penicillins, confirmed by skin testing, were then tested with carbapenems [8]. All subjects were negative to carbapenem skin testing and tolerated graded challenges to three different carbapenems. Based on this and other series, the rate of reactivity to carbapenems in patients with confirmed penicillin allergy is estimated at <1 percent. This supports our current recommendations on administration of carbapenems to patients reporting immediate-type penicillin allergy: Perform penicillin skin testing when available. If negative, patients may safely receive penicillins and carbapenems. If penicillin skin testing is positive or not available, carbapenems may be administered via a graded challenge. (See "Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams", section on 'Carbapenems'.)

Immediate infusion reactions to leucovorin (April 2015)

Infusion reactions to leucovorin are rarely reported, but they may be under recognized because leucovorin is often administered simultaneously with other chemotherapy agents that are well known to cause reactions, such as oxaliplatin. In a series of 44 patients who had an immediate infusion reaction while receiving a leucovorin-containing regimen for metastatic colorectal cancer, five appeared related to leucovorin and not the coadministered drug (oxaliplatin, irinotecan) [9]. Leucovorin skin tests were negative, but challenge with leucovorin reproduced the symptoms in all five patients, while separate challenge with the co-administered agents produced no symptoms. All patients also reacted to subsequent challenge with LEVOleucovorin, suggesting that the L-isomer cannot necessarily be substituted for the more commonly used racemic leucovorin unless the patient has been specifically challenged and found to tolerate it. If continued leucovorin therapy is needed, it can be accomplished using a desensitization protocol. (See "Infusion reactions to systemic chemotherapy", section on 'Leucovorin'.)

FOOD ALLERGY AND INTOLERANCE

Early introduction of peanuts in high-risk infants (March 2015)

Previous guidelines recommended delayed introduction of highly allergenic solid foods (eg, eggs, peanuts, tree nuts, dairy products other than cow's milk, fish, and shellfish) for the purpose of preventing allergic disease in high-risk infants. However, evidence from observational studies suggested this practice was not effective and may lead to an increased incidence of food allergies.

The Learning Early about Peanut Allergy (LEAP) trial is the first randomized trial to show benefit of early introduction of a major food allergen [10]. In this study, introduction of peanut at 4 to 11 months of age rather than avoidance until 60 months of age in children at high risk for peanut allergy due to severe eczema and/or egg allergy decreased the risk of developing peanut allergy. The rate of peanut allergy in the consumption group compared with the avoidance group was 1.9 versus 13.7 percent in children who were skin prick test-negative, and 10.6 versus 35.3 percent in children who were skin prick test-positive (wheal 1 to 4 mm). Exclusion criteria included a skin prick test wheal >4 mm or a positive baseline oral food challenge to peanut.

These findings indicate that past recommendations to delay introduction of highly allergenic foods were appropriately rescinded. Interim guidance regarding peanut introduction in infants with manifestations of atopic disease similar to those in the LEAP study is given in a consensus communication by an international group of allergy organizations [11]. (See "Introducing formula and solid foods to infants at risk for allergic disease", section on 'Introduction of solid foods to high-risk infants'.)

Oat cereal for thickening infant bottle feeds (February 2015)

For healthy infants with problematic gastroesophageal reflux who are bottle-fed, thickening feeds with infant cereal slightly improves symptoms. Although rice cereal has traditionally been used for this purpose, oat cereal is now preferred because of concerns about possible contamination of rice cereal with arsenic [12-14]. The US Food and Drug Administration (FDA) is investigating to determine if there are clinically significant traces of arsenic in rice cereal. (See "Gastroesophageal reflux in infants", section on 'Thickening feeds'.)

IMMUNODEFICIENCY

Pulmonary manifestations in adults with chronic granulomatous disease (June 2015)

Pulmonary complications remain the most common manifestation of chronic granulomatous disease (CGD) in adulthood. In a series of 67 adults with CGD, two-thirds had at least one infectious or noninfectious pulmonary event, and about half had manifestations involving the gastrointestinal tract or skin [15]. Most patients with invasive pulmonary fungal infections were on itraconazole prophylaxis, although serum azole concentrations were low in the majority of the patients tested. One-third of patients with pulmonary complications, including invasive fungal infections, were asymptomatic. Serial screening for elevated inflammatory markers, such as C-reactive protein (CRP), followed by imaging of the suspected organ(s) involved if levels are elevated, are suggested to monitor for and diagnose infection. (See "Chronic granulomatous disease: Pathogenesis, clinical manifestations, and diagnosis", section on 'Sites of infection' and "Chronic granulomatous disease: Pathogenesis, clinical manifestations, and diagnosis", section on 'Pulmonary' and "Chronic granulomatous disease: Treatment and prognosis", section on 'Antifungal prophylaxis' and "Pulmonary complications of primary immunodeficiencies", section on 'Chronic granulomatous disease' and "Chronic granulomatous disease: Treatment and prognosis", section on 'Monitoring and diagnosis'.)

Dedicator of cytokinesis 2 deficiency (June 2015)

Dedicator of cytokinesis 2 (DOCK2) deficiency is a newly recognized combined immunodeficiency (CID). Biallelic (homozygous or compound heterozygous) mutations in the DOCK2 gene were identified through whole-exome sequencing in a group of unrelated patients with early-onset invasive bacterial and viral infections, lymphopenia, and defective T, B, and NK cell responses [16]. DOCK2 deficiency results in impaired activation of RAC1 that leads to defects in actin polymerization, lymphocyte proliferation and migration, natural killer cell degranulation, and response to viral infections in fibroblasts and peripheral blood mononuclear cells. Other CIDs that are the result of defects in actin regulation include Wiskott-Aldrich syndrome and DOCK8 deficiency. (See "Combined immunodeficiencies", section on 'Dedicator of cytokinesis 2 deficiency'.)

URTICARIA AND ANGIOEDEMA

Effective long-term management of Schnitzler's syndrome with anakinra (March 2015)

Schnitzler's syndrome is a form of urticarial vasculitis associated with monoclonal gammopathy, primarily IgM, and other systemic manifestations including bone pain, skeletal hyperostosis, arthralgias, lymphadenopathy, and intermittent fevers. In the past, this condition has been shown to respond to therapy with interleukin-1 inhibition. The largest study to demonstrate the long-term effectiveness of interleukin-1 inhibition included 29 patients with Schnitzler's syndrome treated with anakinra, all of whom demonstrated sustained improvement in disease activity [17]. After a median follow-up of 36 months, 24 patients were in complete remission and 5 patients were in partial remission. Severe infections were observed in six patients, although no lymphoproliferative diseases occurred during the treatment. Thus, anakinra appears to be a effective long-term therapy for Schnitzler's syndrome, although the risk of infectious complications with long-term use requires further study. (See "Urticarial vasculitis", section on 'Differential diagnosis'.)

Sensitivity to nonsteroidal antiinflammatory drugs in children with chronic urticaria (February 2015)

In many patients with chronic spontaneous urticaria (CSU), nonsteroidal antiinflammatory drugs (NSAIDs) exacerbate symptoms. NSAID sensitivity has been demonstrated in 20 to 40 percent of adults with CSU and typically presents as an increase in urticaria lesions appearing one to four hours after ingestion. However, data in children have been limited. In a new study of 68 children with CSU and no history of previous reactions to NSAIDs, subjects underwent single-blind challenge with aspirin, and 10 to 24 percent developed increased symptoms, with the majority experiencing isolated lip angioedema [18]. Clinicians should inform patients with CSU (and their caretakers) about potential sensitivity to NSAIDs. (See "Chronic urticaria: Standard management and patient education", section on 'Avoidance of exacerbating factors'.)

VACCINES AND VACCINE HYPERSENSITIVITY

US ACIP recommendations for serogroup B meningococcal vaccination (June 2015)

In late 2014 and early 2015, the US Food and Drug Administration approved two serogroup B meningococcal vaccines (Trumenba, MenB-FHbp and Bexsero, MenB-4C). In June 2015, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for serogroup B meningococcal vaccine for high-risk individuals aged 10 years or older; these include individuals with persistent complement component deficiencies, individuals with anatomic or functional asplenia, microbiologists routinely exposed to N. meningitidis isolates, and individuals at increased risk because of a serogroup B meningococcal disease outbreak [19]. These indications overlap with those for the quadrivalent meningococcal conjugate vaccine and are summarized in the table (table 1). Among patients with none of the above risk factors, the ACIP advises discussion between doctors and patients regarding vaccination against serogroup B meningococcus; routine vaccination has not been recommended [20]. (See "Meningococcal vaccines", section on 'Use in United States'.)

Choice of influenza vaccine formulation in patients with egg allergy (March 2015)

Most influenza vaccines are produced in an egg-based system, which has been a concern in patients with egg allergy. A number of observational studies have shown that administration of injectable inactivated influenza vaccine (IIV) containing up to 0.7 mcg ovalbumin per 0.5 mL dose is safe in patients with egg allergy. Two new observational studies have demonstrated safe administration of the intranasal live attenuated influenza vaccine (LAIV) containing <0.24 mcg ovalbumin per 0.2 mL dose in patients with egg allergy [21,22]. Influenza vaccine ovalbumin content is shown in the table (table 2). About 40 percent of patients in these studies had a history of anaphylaxis to egg and around 60 to 70 percent had asthma.

Based upon these findings and accumulating unpublished clinical experience, we recommend that all patients with egg allergy ≥6 months of age, including those with a history of anaphylaxis, receive annual immunization with an influenza vaccine according to the indications for all other patients without egg allergy. We would administer any age-appropriate, approved influenza vaccine (table 2), including the LAIV, in these patients according to the indications and contraindications outlined in the tables (table 3 and table 4). The vaccine is administered in a single dose rather than in two or more doses as a graded challenge. A 30 minute observation period is still suggested for patients with egg allergy who receive an egg-based influenza vaccine. This observation period is not necessary for those receiving an egg-free influenza vaccine. (See "Influenza vaccination in individuals with egg allergy", section on 'Safety of vaccines in patients with egg allergy' and "Influenza vaccination in individuals with egg allergy", section on 'Our approach'.)

Pneumococcal conjugate vaccine in adults ≥65 years of age (September 2014, MODIFIED March 2015)

The CAPiTA trial, which is the largest trial to assess the efficacy of the 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13) in adults, compared PCV13 to placebo in approximately 85,000 immunocompetent adults ≥65 years of age in the Netherlands who had not received a pneumococcal vaccine previously [23]. The trial demonstrated 46 percent efficacy of PCV13 against vaccine-type pneumococcal pneumonia, 45 percent efficacy against vaccine-type nonbacteremic pneumococcal pneumonia, and 75 percent efficacy against vaccine-type invasive pneumococcal disease. Efficacy persisted for the duration of the trial (mean follow-up four years). However, some concern has been raised that since this trial began before PCV13 was used routinely in infants in the Netherlands, it might not answer the question of whether its use in adults is efficacious in countries that routinely vaccinate infants. (See "Pneumococcal vaccination in adults", section on 'Efficacy'.)

The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for many years in the United States for all adults ≥65 years of age. In September 2014, the United States Advisory Committee on Immunization Practices (ACIP) began also recommending PCV13 for all adults ≥65 years of age [24]. The ACIP revision was prompted by results from the CAPiTA trial. Current recommendations for individuals ≥65 years of age who have not previously received either PCV13 or PPSV23 are to administer PCV13 followed 6 to 12 months later by PPSV23 (algorithm 1). In June 2015, the ACIP voted to recommend that the interval between administration of PCV13 and PPSV23 for adults ≥65 years of age be changed to one year. Formal recommendations have not yet been released. In patients who have already received PPSV23, at least one year should elapse before they are given PCV13. (See "Pneumococcal vaccination in adults", section on 'Indications'.)

OTHER GENERAL ALLERGY AND IMMUNOLOGY

Stevens-Johnson syndrome outbreak associated with M. pneumoniae (August 2015)

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe blistering mucocutaneous reaction, most commonly triggered by medications, characterized by extensive necrosis and detachment of the epidermis and mucosa. Mycoplasma pneumoniae and cytomegalovirus infections are the next most common trigger of SJS/TEN, particularly in children. Between September and November 2013, an outbreak of eight pediatric cases of M. pneumoniae-associated SJS/TEN was reported in Colorado, likely related to high levels of M. pneumoniae infection in the region [25]. All children had severe oropharyngeal mucositis; the conjunctiva was involved in seven children and the genital mucosa in five. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Infection'.)

Predictors of the need for repeat epinephrine doses in anaphylaxis (August 2015)

Epinephrine is the first-line therapy for anaphylaxis, and retrospective studies suggest that up to one-third of patients may require a second dose. However, predictive factors for requiring more than one dose are not well defined. In a prospective cohort study of over 500 patients (all ages) treated for anaphylaxis in a tertiary care emergency department, 14 percent of those requiring any epinephrine required more than one dose [26]. Patients with a history of previous anaphylaxis, and those presenting with flushing, diaphoresis, or dyspnea, were more likely to require multiple doses of epinephrine to control symptoms. Anaphylaxis is an inherently unpredictable disorder, but this study provides some insight into predictors of a more complicated treatment course and may help clinicians managing such patients. (See "Anaphylaxis: Rapid recognition and treatment", section on 'Dosing and administration'.)

Ease of use of different epinephrine autoinjectors for anaphylaxis (July 2015)

Epinephrine autoinjectors can be life saving for patients with serious allergies, but even with specific training, many people have trouble using the various devices properly. A randomized trial of mothers of food-allergic children, tested in simulated anaphylaxis scenarios, suggested that the Auvi-Q device, a rectangular cassette that has audible instructions to guide the user through the injection process, was easier to use than non-audible pen devices [27]. When prescribing an epinephrine autoinjector, ease of use, cost, the need for multiple injectors, and patient facility with self-injection should all be considered. (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Ease of use'.)

Acute worsening of atopic dermatitis due to aeroallergen exposure (July 2015)

Environmental allergens are a trigger of atopic dermatitis (AD) in a small subset of children and adults. Patients who have environmental allergies as a trigger of AD have persistent disease with chronic exposure to an allergen in the environment. A small study of adults with AD demonstrated that exposure to grass pollen in an environmental challenge chamber for two consecutive days resulted in a significant worsening of AD on exposed skin for the five days after challenge compared with exposure to clean air (placebo) [28]. This study shows that an isolated exposure to an aeroallergen can cause an acute flare of AD in sensitized individuals. (See "Role of allergy in atopic dermatitis (eczema)", section on 'Aeroallergens'.)

Unclear association between atopic dermatitis and lymphoma (May 2015)

The association between atopic dermatitis and lymphoma is controversial. A 2015 systematic review and meta-analysis of four cohort studies and 18 case-control studies found a modest increase in the risk of lymphoma in patients with atopic dermatitis compared with the general population [29]. The risk increase was significant in the meta-analysis of the cohort studies but not in the case-control studies. However, the large heterogeneity of case-control studies in study design and diagnostic criteria does not allow any definite conclusion. In particular, due to overlapping clinical features, cases of cutaneous T cell lymphoma may have been initially misdiagnosed and treated as severe atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Risk of lymphoma'.)

Depression and anxiety disorders in patients with atopic dermatitis (April 2015)

Several lines of evidence suggest that the incidence of psychiatric comorbidities, including major depression and anxiety disorders, is increased among patients with atopic dermatitis and may be influenced by factors such as perceived disease severity and quality of life. A longitudinal cohort study evaluated the risk of developing major depression or anxiety disorders later in life among more than 8000 adolescents and adults with atopic dermatitis and age- and sex-matched controls [30]. Patients with atopic dermatitis had a six- and fourfold increased risk of developing major depression or anxiety disorders, respectively. These findings suggest that the identification and treatment of psychiatric comorbidities are important aspects of the management of patients with atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Depression and anxiety disorder'.)

Safety of calcineurin inhibitors for treatment of atopic dermatitis in children (February 2015)

Topical calcineurin inhibitors can be used as an alternative to topical corticosteroids for the treatment of mild to moderate atopic dermatitis. In 2005, based upon case reports, animal studies, and the known risks with systemic calcineurin inhibitors, the US Food and Drug Administration (FDA) issued boxed warnings about a possible link between the topical calcineurin inhibitors and cancer. An analysis of data from 7500 children enrolled between 2004 and 2014 in the Pediatric Eczema Elective Registry (PEER), an ongoing post-marketing cohort study, found a trend toward increased risk for lymphoma and leukemia that was not statistically significant compared with incidence in the general population based on the SEER database [31]. The small sample size and wide confidence intervals for these data may not exclude all risk. While awaiting data from a larger study, it seems prudent to use topical calcineurin inhibitors only as second-line therapy for the management of atopic dermatitis in areas at high risk for skin atrophy when treated with topical corticosteroids. (See "Treatment of atopic dermatitis (eczema)", section on 'Long-term safety concerns'.)

Caustic ingestions mimicking anaphylaxis in young children (February 2015)

Accidental ingestion of caustic liquids by young children may be mistaken for anaphylaxis because both may present with nausea, vomiting, difficulty swallowing, and swelling of the lips, tongue, or pharynx. In a report of two cases and review of the literature, clinical clues to the diagnosis of caustic ingestion include the lack of a history of food allergy or other allergic disease and failure to respond to treatment for anaphylaxis [32]. Caretakers may not have witnessed the ingestion, or may not report it for fear of reprisal. Careful visualization of the affected areas with endoscopy or microlaryngoscopy can distinguish caustic ingestion from anaphylaxis by identifying ulceration and mucosal damage to the upper airway and esophagus. Preparations should be in place to intubate, if necessary, when manipulating a compromised airway. (See "Differential diagnosis of anaphylaxis in children and adults", section on 'Caustic ingestion (young children)' and "Caustic esophageal injury in children".)

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