Proceedings of the Canadian Society of Allergy and Clinical Immunology Annual Scientific Meeting 2017

© The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Allergic Rhinitis/Asthma

quantification of specific IgE & IgG against pigeon allergens in the blood serum of asthmatic patients. Methods: A total of 200 asthmatic patients diagnosed as per GINA guideline (15-58 years old) were enrolled for the study. All subjects underwent routine investigations and skin prick testing against common aero-allergens and pigeon allergens. All patients underwent serum estimation of specific IgE and IgG against pigeon droppings and feathers with the help of ImmunoCAP100. Results: Out of the total 200 subjects (81 males and 119 females) history of exposure to pigeons was present in 108 patients (54%). Out of the 200 patients, 68 (34%) had positive SPT to ≤ 3 common aeroallergens and 40 (20%) SPT positive ≥ 3 common aeroallergens. In SPT positivity of pigeon allergens feathers and droppings, 4 patients (2%) and 14 (7%) patients were positive respectively. The mean value of specific IgE & IgG of SPT against droppings was 1.4 KUA/L and 28.12 MgA/L and feathers were 0.0075 KUA/L and 9.625 MgA/L respectively. Specific IgE of pigeon exposure against droppings and feather was higher in patients exposed to pigeon droppings and feathers with their mean values 0.31KUA/L (p = 0.013) and 0.093 KUA/L (p = 0.001) in comparison to non-exposed groups with their mean values droppings 0.15 KUA/L and feathers 0.041 KUA/L. Specific IgG of patients exposed group against droppings and feather was higher 25.52 MgA/L (p = 0.009) and 5.61 MgA/L (p = 0.064) in comparison to nonexposed groups dropping and feather 20.61MgA/L and 4.60 MgA/L respectively. Conclusions: Specific IgE and IgG against pigeon droppings and feathers exposed patients was high in comparison to non-exposed asthmatic patients.

A16
Assessing Canadian children's exposure to phthalates and polycyclic aromatic hydrocarbons (PAHs) Garthika Navaranjan 1 , Edem A. Afenu 2 , Miriam L. Diamond 1,3 , Jeffrey R. Background: Exposures to chemicals in the indoor environment, where children spend much of their early life, are important to examine in the development of childhood asthma and allergic disease. However, little has been done to characterize children's exposures to these chemicals, including phthalates and polycyclic aromatic hydrocarbons (PAHs), which have widespread use or release into the household environment. This analysis will quantify Canadian children's exposure to phthalates and PAHs as a first step in examining environmental triggers of childhood asthma and allergic disease onset. Methods: Infants were recruited in Vancouver as part of a pilot for the Canadian Healthy Infant Longitudinal Development study. The pilot involved in-home visits with questionnaires administered, and collection of infant urine, floor dust and surface wipes of window films from infant bedrooms and most used room (MUR). Concentrations of six phthalates and 16 PAHs were statistically analyzed for differences across room type using paired t test and correlations between dust and window wipes using Spearman's correlation. Results: Forty infants were recruited as part of the pilot. The highest concentration was observed for phthalates DEHP in dust (geometric mean (GM) dus t:146.74 ng/mg) and window films (GM window :837.61 ng/ wipe) and DiNP (GM dust :153.26 ng/mg; GM window :692.51 ng/wipe). Concentrations of PAHs were lower and ranged from 0.08 to 0.73 ng/ mg dust and 0.6 to 1.35 ng/wipe. GM concentrations of phthalates and PAHs appeared higher in bedrooms than MUR, but was only statistically significant for DEHP (p = 0.03) in dust, and BnBP (p = 0.02) and benzo [b] fluoranthene (p = 0.01) in window wipes. A significant positive correlation was only found between BzBP in dust and window wipes in bedroom (r = 0.34; p = 0.04) and MUR (r = 0.39; p = 0.02).
Background: Allergic rhinitis (AR) is a common disorder affecting 20-25% of Canadians. Intranasal corticosteroids (INCS) are a mainstay of AR treatment, and some are available over-the-counter (OTC). The aim of this review was to evaluate the efficacy and safety of intranasal corticosteroids approved for OTC use. Methods: A search using keywords allergic rhinitis, anti-allergic agents, intranasal administration, fluticasone, and triamcinolone was conducted on Ovid MEDLINE and Google Scholar. The search was limited to placebo-controlled studies published from 1991 to present. Studies were included which evaluated the efficacy of intranasal fluticasone propionate or triamcinolone acetonide, for the treatment of seasonal or perennial allergic rhinitis. Results: Six trials met the inclusion criteria, three evaluating fluticasone propionate intranasal spray (FPNS), and three evaluating triamcinolone acetonide intranasal spray (TANS), versus placebo. A total of 1218 and 747 subjects were enrolled in FPNS and TANS trials, respectively. The primary efficacy measure was reduction in nasal symptom scores (NS). FPNS demonstrated statistically significant reduction in nasal symptoms when compared to placebo (p < 0.01) and reduction in obstruction upon awakening (p < 0.01), indicating efficacy lasting 24 h. One study evaluating reduction in ocular symptoms (OS) showed FPNS significantly reduced OS when compared with placebo (p = 0.002). TANS also demonstrated significant reduction in NS when compared to placebo (p < 0.05) across all trials. Overall, safety evaluations indicated both FPNS and TANS were well tolerated. Conclusions: As more INCSs for AR become available OTC, the role of the health professional is pivotal in diagnosis, treatment selection, and education of patients with AR. The efficacy and safety of INCS is well established. ARIA and Canadian Guidelines recommend the use of INCS to manage mild persistent to moderate-severe allergic rhinitis. Health professionals should feel comfortable in recommending an INCS for use in these patients.

Background:
In Canada, it is estimated that asthma affects 8.5% of the total population. It is the leading cause of hospital admissions, the third leading cause of work loss, and results in 146,000 emergency room visits annually in the overall population. Omalizumab is indicated for the treatment of adults and adolescents with moderate to severe persistent allergic asthma whose symptoms are inadequately controlled despite optimized standard therapy. Real world effectiveness data assessing the HCU in the Canadian context is limited.
Objective: This study was a retrospective, pre-post cohort, observational study. The primary objective was to evaluate the health care utilization (HCU) following Omalizumab initiation as assessed by the reduction in number of hospitalizations, emergency room (ER) visits, and oral corticosteroid (OCS) use in patients covered in Ontario. The number of night awakenings was an exploratory endpoint. Results: 148 patients (mean age 57.6; female 62.2%) formed the study population. Omalizumab was associated with a 74.4% reduction in the number of hospitalization (pre vs post-Omalizumab's 12 month treatment period: 0.7 vs 0.2 p < 0.001). 89.9% of patients did not have any asthma related hospitalization. There was a reduction of 87.5% in ER visits (7.3 vs. 0.9 p < 0.001), 66.2% of patients did not have any emergency visit. A 74.7% reduction of the number of high dose OCS by (4.23 vs. 1.07 p < 0.001), 52.7% of patients did not need to take any courses of high dose OCS. The mean number of night awakenings/per week decreased from 6.1 (8.03) to 1.3 (2.79) following 12 month treatment with Omalizumab. Conclusions: There was an observed reduction in the number of hospitalizations, ER visits, and high-dose OCS courses post-Omalizumab use in patients with severe uncontrolled asthma in a real-world setting. The results are consistent with outcomes observed in previous large real-world trials such as the experience registry.

A27
Comparative analysis of total ocular and total rhinoconjunctivitis symptom profiles in the Environmental Exposure Unit versus the Nasal Allergen Challenge model Mark W. Tenn 1,2 , Lisa M. Steacy 2 , Jenny Thiele 1,2 , Daniel E. Adams 2 , Terry J. Walker 2 , Anne K. Ellis 1,2 1 Background: The Environmental Exposure Unit (EEU) and Nasal Allergen Challenge (NAC) are both experimental models of Allergic rhinitis (AR). They mimic the inflammatory processes and symptom manifestations associated with exposure to sensitized aeroallergens. Previous studies demonstrated a unique Total Nasal Symptom Score (TNSS) profile following allergen challenge in each model. As AR individuals also experience ocular symptoms, we sought to compare the Total Ocular Symptom Score (TOSS) profiles following allergen challenge in both the EEU and NAC models. Methods: 7 birch-allergic and 4 non-allergic individuals who participated in both an EEU study and a NAC study using birch pollen were included in the analysis. For both studies, TNSS, TOSS, and Total Rhinoconjunctivitis Symptom Scores (TRSS) were collected at baseline, 15 min (NAC only), 30 min, and hourly until 12 h post-challenge (every half hour during first 4 h for EEU). Data was analyzed using GraphPad Prism. Adjustments for multiplicity testing were not made. Results: Peak increases in TOSS were observed at 3 h and 30 min post-challenge in the EEU and NAC respectively. However, they were only significant in the EEU (p < 0.05). In contrast, TRSS peaked at 3 h (p < 0.05) and 15 min (p < 0.05) post-challenge in the EEU and NAC respectively. Overall, a significantly higher mean TRSS (p < 0.05), but not TOSS (p = 0.16), was observed in the EEU compared to the NAC. When comparing TOSS profiles from both models by time point, significant differences were observed at 30 min, 1, 3, 4, 5, 7, and 9 h (all p < 0.05). Conversely, significant differences in TRSS profiles were observed at 30 min, 1 through 9 and 12 h (all p < 0.05) following allergen challenge. Conclusions: Significant ocular symptoms in the EEU may be attributable to the prolonged pollen exposure period and contact with airborne pollen. Significant differences in TRSS within and between each model were primarily driven by differences in TNSS, not TOSS.

Background:
The 'atopic March' describes the progression from atopic dermatitis during infancy to asthma and allergic rhinitis in later childhood. In a Canadian birth cohort, we investigated whether concomitant allergic sensitization enhances subsequent development of these allergic diseases at age 3 years. Methods: At age 1, children completed skin prick testing. Children were considered sensitized if they produced a wheal 2 mm or greater than the negative control to any of ten inhalant or food allergens. Children were also assessed for atopic dermatitis using the diagnostic criteria of the UK Working Party. At age 3, children were assessed for asthma, allergic rhinitis, food allergy, and atopic dermatitis. Data from 2311 children were available. Results: Atopic dermatitis without allergic sensitization was not associated with an increased risk of asthma at age 3, after adjusting for common confounders (RR 0.46, 95% CI 0.11-1.93). Conversely, atopic dermatitis with allergic sensitization increased the risk of asthma over sevenfold (RR 7.04,. Atopic dermatitis and allergic sensitization had significant interactions on both the additive (RERI 5.06, 95% CI 1.33-11.04) and multiplicative (ratio of RRs, 5.80, 95% CI 1.20-27.83) scales in association with asthma risk. There was also a positive additive interaction between atopic dermatitis and allergic sensitization in their effects on food allergy risk (RERI 15.11,. Conclusions: Atopic dermatitis without allergic sensitization was not associated with an increased risk of asthma. In combination, atopic dermatitis and allergic sensitization had strong interactive effects on both asthma and food allergy risk at age 3. Background: In a post-marketing analysis last updated in July 2007, the FDA reported that an estimated 0.2% of patients suffered treatment related anaphylaxis and rare incidence of serum sickness. To substantiate this, the occurrence of treatment related anaphylaxis and serum sickness was assessed in one of the largest global allergy and asthma tertiary clinics. Methods: The original retrospective chart review of our database of Omalizumab administration was performed to collect data between 1998 and June 2014. This has been updated to include the recent data from July 2014 to June 2017. Data was collected on the number of patients receiving treatment, the number of injections received/ dose schedule of each patient, as well as the age and gender of each patient. Results: During clinical trials and with our post market experience, between 1998 and June 2017, over 50,000 injections of Omalizumab were administered to over 400 patients diagnosed with either severe allergic asthma or chronic idiopathic urticaria. No cases of anaphylaxis or serum sickness like symptoms were observed. Conclusions: Meticulous care was taken by our Omalizumab administration clinic to ensure optimal safety based on the emphasized warnings of anaphylaxis, as well as the indicated warnings and precautions for serum sickness. Data collected in this analysis observed no cases of anaphylaxis or serum sickness like symptoms in the treatment of patients with Omalizumab, during a period of 17.5 years, thus confirming the low incidence of both anaphylaxis and serum sickness.

Background:
We designed a written anaphylaxis plan called Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to assess the impact of the Kids' CAP on anaphylaxis recognition and treatment, and to determine its perceived usefulness. Methods: Prior to clinical validation, we assessed the readability and understandability metrics of the Kids' CAP using the Gunning Fog index (GFI), the Fry index, and the Patient Education Material Assessment Tool (PEMAT). During the clinical assessment phase, patients (12-17 years of age) and parents of patients (0-11 years of age) were taught and given the Kids' CAP during first visit with an allergist at two community clinics, or an anaphylaxis emergency department (ED) visit at a tertiary pediatric centre. The Newest Vital Sign tool was used to determine the baseline health literacy level of study participants. Three weeks later, we conducted a phone interview to assess their comprehension of anaphylaxis manifestations and management. We also used the Consumer Information Rating Form (CIRF) to measure the participants' perception of the usability, satisfaction, and usefulness of the Kids' CAP. Results: Two hundred participants completed the follow-up interview. The median age of patients was 3.95 years (IQR 1.4-9.2), and 104/200 (52%) were males. The written contents of the Kid's CAP matched grade 7 readability level. The mean CIRF score for usability and design quality were 23 (out of 25) (SD 2.6), and 25.1 (out of 30) (SD 2.5), respectively. The mean comprehension score was 11.2 (out of 14) (SD 1.7) with no significant difference between participants with and without previous experience with anaphylaxis, or high versus low literacy level. Conclusions: The implementation of the Kids' CAP can improve patient's comprehension of anaphylaxis manifestations and treatment, which are critical components of ED management of anaphylaxis. Background: The recent rise in food allergy prevalence has led to an increase in the number of parents concerned about accidental exposure of their children to allergenic food. Our goal was to investigate the role of the school environment on food allergy emergency room visits. Methods: Visits to Canadian emergency departments for food and environmental/drug allergic and anaphylactic reactions were obtained from the Canadian Institute for Health Information (CIHI), based on the 2013-2014 National Ambulatory Care Reporting System. Reactions were defined in accordance to the ICD-10-CA diagnostic codes. Data was provided grouped by approximate school attendance ages into 3-5 (pre-school), 6-12 (primary school) and 13-18 (secondary school) years. Data was divided into day (9-16:59) and night (17-0:59). Allergic reactions to Environmental and Drug triggers were analyzed as control. p < 0.05 was considered as statistically significant assuming equal distribution. Chi squared analysis and T-testing (STATA14) were performed. Numbers shown are normalized by age categories and represent mean per hour over the span of the 6 months with full school scheduling. Results: During the study period, 2758 food and 3398 environmental/ drug visits were recorded. Significantly fewer food allergic reactions were recorded during the day than at night for preschool (5.17 ± 2.16 vs. 9.83 ± 4.46), elementary (2.875 ± 1.13 vs. 5.98 ± 2.53), and secondary school (4.65 ± 1.89 vs. 7.06 ± 2.35) age groups. Fewer events were recorded among primary school ages during the day than both preschool and secondary ages, while this difference was not significant at night. Environmental/drug allergic reactions showed the opposite trend, with fewer reactions at night during the day, and no differences between age groups during day or night. Conclusions: A structured environment may protect primary school aged children from food allergic reactions during daytime. In general, school-aged children visit the emergency room more frequently after school, which could inform recruitment for allergy studies. Background: The risk of developing anaphylaxis has been reported in multiple population-based studies, with estimates and definitions being highly variable. The aim of this systematically review is to synthesize the incidence, etiologies, and definitions of anaphylaxis worldwide. Methods: Following established guidelines, systematic review of records in any language obtained from multiple database searches (MEDLINE, EMBASE, Cochrane Register) through May 25, 2017 for population-based studies reporting on the incidence and elicitors of anaphylaxis and methodology used to identify and validate cases. Risk of bias and assessment of the certainty of evidence will be rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results: Database searches yielded 1706 unique records, of which 245 were potentially relevant, and 91 are included for analysis. The range of reported incidence rates for anaphylaxis, stratified by geographic location, age, setting and definition will be reported. Methods of identification and validation of anaphylaxis will be reviewed, highlighting their relative merits and potential limitations. We anticipate that like most population-based research, the main limitation of these studies will be under ascertainment of events. If there is sufficient detail in reporting, we will synthesize the incidence and accuracy of specific causes of anaphylaxis, such as foods, drugs, insects, and idiopathic. Conclusions: The incidence of anaphylaxis through population-based research will be systematically reviewed, synthesized and assessed. These data, and a uniform case definition are critical to establish anaphylaxis risk estimates for patients and clinicians, as well as to inform future research and guidelines. Background: As the incidence of food allergies continues to rise, potential therapies are undergoing investigation. Oral immunotherapy (OIT) for food has been studied in the pediatric population in both phase 2 and ongoing phase 3 trials. Families are keenly interested in this approach of actively managing food allergy despite our lack of knowledge of long term outcomes. We sought to investigate the use of a novel suspension medium to desensitize patients with peanut and tree nut allergy. Methods: This is a retrospective review from 2014 to 2017 of OIT in a pediatric outpatient clinic. After initial evaluation, testing, detailed informed consent/assent and potential oral challenge, participants were given the opportunity to be desensitized to the foods of concern. This included peanuts, and multiple simultaneous tree nuts. Peanut and/or individual tree nut flours were suspended in Suspendit ™ medium and were given daily as sublingual/oral administration starting at 0.25 mg total nut protein and progressing up to 50 mg nut protein in suspension and then transitioned to actual weighed nut. Doses were increased in clinic on a biweekly basis. Results: Oral desensitization was successfully completed in a high majority of the 38 patients who initially enrolled ages 9 months to 17 years. The majority of individuals reported mild side effects. However, moderate to severe reactions were reported in several individuals during build up and maintenance requiring epinephrine use. Cofactors for reactions such as illness and compliance were identified. Side effects diminished with prolonged use. Skin prick testing decreased after being on maintenance therapy for 6-12 months. Conclusions: This is the first Canadian data to report on the safety and efficacy of pediatric oral immunotherapy in private practice for peanut and tree nut allergies. Suspendit ™ suspension medium allowed for safe and effective dosing titration of OIT for peanuts and tree nuts. Background: Cow's milk oral immunotherapy (OIT) is effective in attaining desensitization but its safety is not well established. We aimed to characterize adverse events (AE) in a pediatric cohort undergoing OIT at the Montreal Children's Hospital. Methods: Data was collected on AE occurring during OIT between 2013-2017. Anaphylaxis was defined as involvement of 2 organ systems and/or hypotension in response to a milk exposure. Non-anaphylactic AE was defined when only one organ system was affected as previously published. Descriptive statistics were used to represent demographics, clinical characteristics and co-morbidities. Poisson regression was performed to evaluate risk factors associated with anaphylaxis. Results: Among 29 children, the mean age at study entry was 11.9 years (SD 3.9) and the majority were male (58.6%). Co-morbidities included asthma (82.8%), seasonal allergy (48.3%) and eczema (27.6%).In total 8 children withdrew from OIT (27.6%). Among those, the mean number of anaphylactic reactions per patient was 14.1 (SD 18.2) versus 7.2 (SD 7.3) in non-withdrawals. On average, 0.6 (SD 0.9) reactions required epinephrine treatment in children maintained in the study versus 0.7 (SD 1.1) in withdrawals. Differences between both groups were statistically nonsignificant.Among 1060 AE, the majority were non-anaphylactic (75%). Of those, the majority occurred during the escalation phase (91.0%) and were categorized as mild (78.5%). Risk factors for anaphylaxis included older children at study entry [risk ratio: Background: Oral food challenges (OFCs) are considered the gold standard in food allergy diagnostic testing. Despite this, there is a lack of Canadian data regarding its implementation. We investigated how many allergists perform OFCs, number of OFCs performed, barriers that prevent more from being conducted, and possible solutions to these barriers. Methods: Surveys were sent to allergist members of the Canadian Society of Allergy and Clinical Immunology (CSACI). Questions included practice characteristics, number of OFCs conducted, barriers to conducting more OFCs, and solutions that would mitigate barriers. Results: Of the 205 CSACI allergists surveyed, 61 responded (response rate = 30%). Preliminary data showed 50 of the 61 respondents conducted OFCs (range = 1-60/month, median = 12/month, 66% perform 10 or more/month). There was no significant difference between number of OFCs performed and allergists' years of practice, or number of OFCs performed between allergists using a specific hospital OFC fee code and those using all other codes. Nearly all respondents agreed there was a need to conduct more OFCs, but barriers exist, with 74% of respondents choosing "lack of support staff", and 70% choosing "lack of time" as "moderately to extremely influential" barriers. The most influential solutions were "standard criteria for which challenges should be done in a hospital versus the community" chosen by 72% of respondents, and "patients agreeing to consume the food after a negative OFC", chosen by 70%. Conclusions: This is the first study to capture barriers and examine possible solutions to OFC implementation. Selection bias may be a limitation in this study since allergists who perform OFCs may be more likely to complete the survey. Results show that resources (support staff and time) to perform OFCs are lacking, and that standard OFC protocols and patient education around OFCs need to be explored as possible solutions to allow OFCs to be more accessible to Canadian patients. Background: Teens with food induced anaphylaxis (FIA) live with the unpredictable risk of reacting to, and potentially dying from something they eat. FIA results in considerable burden for teens, including stigma, marginalization, and the need for constant vigilance. Despite teen anaphylaxis rates in Canadian emergency rooms more than doubling in recent years, no published studies have focused exclusively on the teen experience living with FIA in Canada. At present, we lack the knowledge to recommend best practices in managing teens with FIA. Therefore, in this study we aim to create a detailed understanding of teens' lived experience of FIA in daily life. Methods: We combine van Manen's hermeneutic phenomenology with photovoice techniques to explore and interpret the lives of teens with FIA through their eyes, using their own words. Participants will include teens (age 12-19) living in Manitoba. Each teen will participate in 2 semi-structured interviews: the first will focus on lived experience, with photovoice images and techniques incorporated in the second interview. Interviews will be recorded and transcribed, and images retained for analysis. Both researchers will code and analyze data independently to identify meaning, relationships, and themes. Data collection and analysis will occur concurrently, informing the study as it progresses. Teens will be invited to join a Youth Advisory Committee (YAC) to discuss findings and inform knowledge translation efforts. Results: To be presented via traditional academic means (e.g. journal publications, conference presentations) and tailored education sessions for knowledge users, alongside initiatives determined in consultation with YAC members. Conclusions: This study fosters understanding, forming a base for future research to meet the healthcare needs of these teens and their families. Findings have potential to inform policy affecting teens with FIA, helping to focus change in priority areas and assist in health promotion for teens and families living with FIA. Background: Patient and caregiver knowledge of the symptoms and triggers of food allergy is key to successful management. To date, there have been no Canadian studies on this issue. We aimed to characterize patient and caregiver knowledge of food allergy in a Canadian setting. Methods: The Food Allergy Epinephrine Auto-Injector Study (FEAST) is an observational study on the dining experience of food allergic patients. Online surveys were administered to patients and caregivers in February 2015. Patients were identified from Food Allergy Canada's database. Among others, the survey contained questions on symptoms and triggers of food allergy. Results: There were 1165 respondents of the survey. 93.3% correctly identified the symptoms of an allergic reaction. Most knew that ingestion of small amounts of allergen could cause a reaction (92.6%). There was a high degree of understanding that removal of allergen from a plate is not sufficient to prevent reaction (93%). More respondents (48.8%) than not (45.5%) believed smell of peanut butter could cause a reaction. The majority correctly identified Health Canada's list of the ten most common food allergens: peanut (93.7%), treenuts (93.2%), shellfish and crustaceans (92.3%), egg (91.5%), milk (90.4%), wheat (84.1%), soy (81.2%), fish (77.3%), sesame (76.1%), mustard (57.3%), sulfites (not tested). There was a high degree of correct identification of uncommon causes of food allergy: apples (97.3%), chocolate (93.6%) coconut (94%), strawberry (77.4%), onion (98.6%), garlic (98.3%), pumpkin seed (98%). Conclusions: The Canadian respondents had high recognition of the symptoms of food allergy. Knowledge of the common and uncommon food allergens was also good. Understanding of cross contamination as a cause of allergic reaction was similarly high. Lower rate of correct identification of mustard and strawberry as common and uncommon allergens respectively were seen. There was also a notable amount of misunderstanding that smell could cause a reaction. Background: As the incidence of food allergies continues to rise, potential therapies are investigated. Oral immunotherapy (OIT) for food has been studied in the pediatric population for milk. We sought to investigate the use of oral milk immunotherapy to desensitize patients with milk allergy. Methods: This is a retrospective review from 2014 to 2016 of OIT in a pediatric outpatient clinic ages 5-13 years (mean 9.8). After initial evaluation, testing, detailed informed consent/assent and potential oral challenge, participants were given the opportunity to be desensitized to milk starting with 1 drop of 1:25 diluted milk in sterile water. Maintenance target dose was 250 mL of cow's milk. Doses were increased in clinic on a weekly-biweekly basis. A sublingual/oral immunotherapy approach was used. Those with asthma and prior severe reaction were not excluded.

Background:
In 2015, Allergy Consensus Guidelines began recommending peanut introduction before age 12 months for high-risk infants in countries with high peanut allergy prevalence. They suggested that these infants may benefit from an allergist's assessment before peanut introduction. We evaluated if peanut allergy prevalence was different among infants who had peanut introduced before assessment versus infants who had peanut introduced after assessment. Methods: We screened infants born in 2015 and 2016 who were referred to Pediatric Allergy Clinic before age 12 months, regardless of the reason for referral. Children at high risk for peanut allergy because of egg allergy and/or moderate-severe atopic dermatitis were included. We compared the prevalence of peanut allergy among infants who were first introduced to peanut before allergy assessment versus infants who were first introduced to peanut after assessment. Data were analyzed by Chi square and Kruskal-Wallis tests. Results: Of the 42 infants at high risk for peanut allergy, peanut introduction data were available for 34: 13 (38.2%) had peanut introduced before allergy assessment, 13 (38.2%) had peanut introduced after assessment, and 8 (23.5%) did not have peanut introduced. Baseline characteristics were similar among the three groups: egg allergy (76.9, 61.5, and 50.0%, p = 0.21), moderate-severe atopic dermatitis (46.2, 76.9, and 75.0%, p = 0.14), age at first visit (11.1, 9.0, and 10.8 months, p = 0.31) and peanut sensitization (38.5, 46.2, and 50.0%, p = 0.60). For infants who had peanut introduced before and after allergy assessment, median age of peanut introduction was 8.0 versus 11.0 months (p = 0.017), peanut was introduced before age 12 months in 92.3% versus 61.5% (p = 0.068), and peanut allergy prevalence was 38.5% versus 38.5% (p = 1.0). Conclusions: Children introduced to peanut after allergy assessment had peanut introduced later but were as likely to be introduced before age 12 months. Peanut allergy prevalence was similar among infants introduced before and after assessment. Background: In medical ethics, the justice principle holds that when allocating care, patients in similar situations should have access to the same care. The recent opening of a publicly funded oral immunotherapy (OIT) program at our center, raised ethical issues as the demand for treatment was expected to significantly exceed its capacity. Criteria for patient selection had to be determined that would respect the justice principle and have high acceptability from patients, clinicians and managers. Methods: Using a Delphi approach with 3 iterations, a panel of 25 experts were asked to propose and validate prioritization criteria for OIT, and establish their respective weights based on a fictive scenario. The consensual weights were used to determine prioritization ratios for patient subgroups and design a system that would adjust in realtime to the prevalence of these subgroups within the waiting list. This system was submitted to the expert for approval. Results: The 25 experts that agreed to participate to the Delphi included 8 representatives of patient groups, 10 allergists (4 with experience with OIT), 3 allergy nurses, 2 administrative agents with experience managing tertiary care allergy referrals and 2 managers. In addition to validating the admissibility criteria, the participants reached a consensus on 4 main prioritization criteria and their prioritization ratio (PR): • Allergy to multiple food groups (PR = 2.53).

Conclusions:
The system based on applying consensual PR to subgroup prevalence within waiting list was unanimously approved by a multidisciplinary expert group. The most frequently mentioned comment was that the PR system gave a real opportunity for less severe but admissible patients to benefit from the program, whereas traditional additive scoring system would de facto result in these patients never being seen, and were thus perceived as unfair.

Safety of daily food introduction in food allergic children with high reaction thresholds
Noémie Paradis 1 , Béatrice Paradis 1 , Louis Paradis 1,2 , Jonathan Lacombe 1 , Anne Des Roches 1 , Philippe Bégin 1,2 Background: To compare the rates, triggers, and management of anaphylaxis in adult emergency departments (ED) in Calgary and Montreal.
Methods: As part of the Cross-Canada Anaphylaxis Registry (C-CARE), anaphylaxis cases fulfilling the consensus definition were identified through chart review of adults presenting with anaphylaxis and allergy-related ICD-10 codes to a Calgary tertiary care ED in 2015.
These cases were compared with published data on similarly identified cases from a Montreal ED in 2011. Statistical analysis was done using the Wilcoxon matched-pairs signed rank test and a p-value less than 0.05 was considered significant. Results: An interim analysis showed a significant increase in 6 patients in the CD19 dim PD-L1 + CD38 + population at the end of escalation phase in 3 conditions: CpG-B/anti-IgM/IgG/anti-CD40, anti-CD40/IL4/ IL21, and anti-CD40/IL4/IL21 plus milk proteins. The median percentage difference between baseline and end of escalation phase was 8.35, 4.49, and 7.12% for the above conditions, respectively. The majority (89.16%, 95% CI 81.21-95.56%) of the CD19 dim PD-L1 + population in all conditions were CD38 + cells.

Results
Conclusions: PD-L + regulatory B cells increase during milk OIT and may be part of the mechanism of successful desensitization in children. This population of Bregs could play a role in other allergic diseases as well. Further assessment with a larger sample size is underway. Background: The barrier-derived cytokine Interleukin-33 (IL-33) is a critical regulator of pathological processes in atopic dermatitis. This alarmin signals through interleukin-1 receptor-like-1 (ST2) receptor resulting in a Th2 immune response. We examined the expression of IL-33 and ST2 in skin following an intradermal allergen challenge in patients with atopic dermatitis. Methods: Patients with moderate to severe atopic dermatitis who developed a late cutaneous response to intradermal challenge, with common airborne allergens were recruited. Patients withheld oral steroid (8 days) and other immunosuppressive medications (4 weeks) prior to challenge. Allergen and saline control were injected intradermally on the patient's back. At 24 h post-challenge, the size of the wheel and flare was measured and a punch biopsy was obtained. Biopsy tissue was formalin-fixed, paraffin embedded, and stained with antibodies to IL-33 and ST2 for immunofluorescence microscopy. Regions of interest (ROI) highlighting the epidermis and dermis were selected and images were obtained using an upright Nikon microscope. The thresholding tool in the NIS-element software was set to pick up the radius of 6 pixels from selected channels corresponding to the intensity value of these pixels. All pixels in the image of similar intensity value were highlighted. Data was exported to excel showing the number of objects and the mean intensity of each channel in the selected ROI. Results: Data are presented for 4 patients. When compared to saline, intradermal allergen increased the number of cells/mm 2 expressing IL-33 by approximately 30% in the dermis (p = 0.02) and epidermis + dermis (p = 0.03). In the epidermis, the number of cells/mm 2 expressing IL-33 increased in 3 of the 4 patients studied (p = 0.09). No significant changes in ST2 expression were observed, due to the small sample size. Conclusions: Our data supports the role of IL-33 in acute allergeninduced inflammatory processes in atopic dermatitis. Background: The anti-inflammatory role of many plant derivatives is not fully understood. There is evidence that a family of plant derivatives, the petasite sesquiterpenes, can regulate the immune system through dendritic cell (DC) targeting. DC activation induces their expression of class-II major histocompatibility complex (MHC) and co-stimulatory surface molecules, as well as migration into secondary lymphoid organs, where they activate naïve T-cells. To better understand the anti-inflammatory effects of petasite sesquiterpenes, we focused on their activation mechanism involving peroxisome proliferator activated receptor gamma (PPARγ). PPARγ is a transcription factor that inhibits inflammatory responses and induces DCs to acquire a mucosal phenotype. Since mucosal DCs are central in innate immune responses, we hypothesized that sesquiterpenes would inhibit DC maturation and activation via the PPARγ pathway.

Methods:
We generated mouse bone marrow-derived DC (BmDC) in media supplemented with GM-CSF+IL-4. BmDC were treated with bicyclic petasite sesquiterpenes in the presence or absence of PPARγ agonists, followed by overnight activation with LPS. BmDC were harvested and analyzed for surface expression of co-stimulatory molecules CD80 and CD86, by flow cytometry, and pro-inflammatory cytokine production, by commercial ELISA. Results: Bicyclic petasite sesquiterpenes downregulated the expression of the co-stimulatory molecules CD80 and CD86 and proinflammatory cytokines of LPS-activated DCs. We observed differences in the downregulation of CD80 and CD86, and in TNF, IL-6 and IL-12p70 release when LPS-activated DC were pretreated with petasite sesquiterpenes or combinations of petasite sesquiterpenes and PPARγ agonists. Conclusions: Bicyclic petasite sesquiterpenes inhibited the maturation and activation of DC, and this inhibitory activity was enhanced in the presence of PPARγ agonists. Studies are underway to determine the intermediary molecules involved in DC inhibition. Background: Breast milk feeding has many beneficial effects, including a reduced risk of food allergy. Cow's milk also contains several regulatory molecules, such as TGF-β and vitamin A, which could enhance oral tolerance. Toll-like receptor 2 (TLR2) activation by pathogen products or their analogues can lead to tolerance disruption. Soluble tolllike receptor 2 (sTLR2) acts as a decoy receptor and is found in both human and cow's milk; however, its role in oral tolerance is unknown. Hypothesis: We hypothesize that sTLR2 can block tolerance disruption by TLR2 ligands found in food or microbes. Methods: Oral tolerance was assessed in wild-type and TLR2-deficient mice through analysis of antigen-specific antibody responses after OVA feeding and a systemic antigen challenge. The ability of cow's milk to block the anti-tolerogenic effects of a TLR2 activator (PAM3CSK4) was assessed. Tolerance to OVA was also assessed in mice that were nursed by WT or TLR2 −/− dams. The impact of cow`s milk on development of antigen-specific Treg cells and tolerogenic dendritic cells was also determined. Results: Oral administration of antigens over 1 week induced the development of tolerance, independent of TLR2 expression. Tolerized mice produced 5.8-fold less allergen-specific IgE than controls (n = 15). Soluble TLR2 was detected in cow's milk and in commercial baby formulas (range 15-35 ng/mL). Interestingly, cross-fostering of pups by WT dams resulting better oral tolerance induction to OVA compared to pups nursed by TLR2 −/− dams. Furthermore, cow's milk feeding was also able to enhance the development of ovalbumin-specific Treg cells and tolerogenic-dendritic cells significantly in Peyer's patches and mesenteric lymph nodes of mice. Conclusions: Our results suggest an important role for cow's milkregulatory molecules and sTLR2 in the development of oral tolerance, which could inform both allergy prevention and treatment strategies. This work was supported by CIHR and Allergen N.C.E Background: Neuroinflammation is a specific immunological reaction in the central nerve system and is distinct from peripheral inflammatory responses. It is induced by microglia, which is a resident phagocyte in the brain. Neuroinflammatory response is a defense system against exogenous antigens, but chronic neuroinflammation is involved in various neurodegenerative disorders. Hesperetin is present in the peel of citrus as one of the flavonones. In previous studies, hesperetin has been shown to have anti-inflammation, anti-cancer and anti-oxidant effects. However, the anti-neuroinflammatory effect of hesperetin on microglia is not well known. Methods: BV-2 murine microglia cell line was used in this study. Cytotoxicity of heperitin on BV-2 was measured by MTT assay and NO production was evaluated by Griess assay. Expression of pro-inflammatory genes and signal transduction protein were determined by RT-PCR and western blot analysis, respectively. Cytokine release was determined by ELISA. Results: Heperetin reduced the LPS-induced no production at noncytotoxic concentration. Furthermore, hesperetin effectively inhibits mRNA expression of pro-inflammatory molecules including TNF-α, iNOS, and IL-6 and IL-1β, and cytokines, IL-6. Hesperetin inhibited the phophorylation of p38 and ERK in LPS-activated BV-2 microglia. Conclusions: These results suggest that hesperetin has an anti-neuroinflammatory effect on LPS-activated BV-2 murine microglia through the suppression of p38 and ERK phosphorylation. Background: The role of mast cells (MC) in host defences against influenza A virus (FluA) is incompletely understood. We found that MC were resistant to productive FluA infection and suppress viral propagation in airway epithelial cells (AEC) in co-culture systems. We hypothesized that MC interact with AEC to produce a factor(s) that enhances antiviral capabilities, therefore reducing viral replication and release of infectious particles and enhancing AEC survival. Methods: Our experimental model to investigate MC and AEC interaction during FluA infection involves a co-culture system with AEC (Calu-3) cultured on the membrane insert in the top chamber, and human MC (LAD2) in the bottom chamber. FluA infection was achieved by exposing AEC to A/PR/8/34 (H1N1; 0.04 MOI [multiplicity of infection]). Hemagglutination assay was used to assess viral propagation 3 days post infection. Supernatants of post-FluA experienced AEC-MC cocultures were collected for further investigation. Supernatants were treated to 65 and 100 °C for 30 min to investigate heat lability of antiviral activity. Fractionation of supernatants were performed using Centricon size exclusion filters (10 kDa). Ion exchange columns are used to further fractionate supernatant by molecular charge. Results: In the presence of MC, AEC were found to release 3-fold less FluA particles. Supernatant from a FluA experienced AEC-MC co-culture exhibits an antiviral effect against FluA in AEC. Heat treatment of the supernatant suggest that the antiviral effect is sensitive to 100 °C but not 65 °C. Fractionation approaches suggest that the antiviral effect is larger than 10 kDa. Preliminary data from ion exchange suggest that anti-viral activity has a high net positive charge. Conclusions: FluA experienced co-culture supernatant has antiviral activity mediated through a soluble factor(s) against FluA infection in AEC. Identification of the anti-viral factor(s) may foster novel approaches to enhancing FluA vaccination and therapeutic strategies. these cells in the pathogenesis of AD. This study aims to quantify EoP in the allergen induced late cutaneous response. Methods: Subjects with severe AD and a positive allergen prick test were recruited (n = 4). After 8 days of systemic steroid washout, intradermal challenge was performed with allergen and saline control. The late cutaneous response was measured at 24 h post challenge and biopsied. A 4 mm skin biopsy was formalin-fixed, paraffin embedded and stained with hematoxylin and eosin for eosinophils. Immunofluorescence staining was performed using fluorochrome linked antibodies to CD34-FITC, IL-5Rα-Cy5, and Von Willebrand factor-TRITC. Using Nikon Imagine Software Analysis, the papillary dermis was examined for EoP (CD34+/IL-5Rα+) cells that were Von Willebrand negative. A paired t-test was performed on the data.

Results:
We identified the presence of both CD34+/IL-5Rα+ cells and mature eosinophils in skin biopsies with perivascular organization. There was a significant increase in EoP (p < 0.05) and mature eosinophils (p < 0.05) 24 h post-allergen compared to diluent control. Conclusions: Intradermal allergen challenge induces an increase in eosinophil lineage-committed progenitor cells and mature eosinophils in atopic dermatitis skin. Local in situ maturation may play a role in development of tissue eosinophilia in patients with atopic dermatitis.
Background: Rituximab is a monoclonal antibody targeted at CD20. It is used in chemotherapeutic regimens in several malignancies, as well as in a variety of autoimmune diseases, given its effects on B cells. Often, if a patient develops allergy to rituximab there are no alternative treatments, or the alternative is not as effective. There are published protocols for rituximab desensitization available but we were not able to find any case reports of their use in Canada. Case presentation: Patient 1 is a 29 year old female with a longstanding history of systemic lupus erythematosus (SLE), complicated with hypertension and significant lupus nephritis. The patient had failed multiple therapeutics for SLE and was doing well on rituximab, until she developed Type 1 and Type III hypersensitivity to the drug. With pre and post-medications she was successfully desensitized to rituximab, using a 12-step protocol. Patient 2 is a 70 year old female who presented with urticaria and respiratory symptoms during rituximab infusion for management of eosinophilic granulomatosis with polyangiitis. The patient was successfully desensitized to rituximab, using a 12-step protocol. Both patients were managed in an Intermediate Care setting as inpatients. Discussion: In our patients, rapid desensitization to rituximab was well tolerated. The protocols were successfully completed. For one patient, desensitization was successful in preventing Type I and Type III hypersensitivity. For one patient, the first desensitization produced mild symptoms. Subsequent desensitizations have not produced any significant reactions. There are some challenges in arranging inpatient beds for these desensitizations, which has affected the timeliness of their drug dosing. A multidisciplinary approach was necessary to establish a protocol for our institution. Conclusions: Rituximab desensitization can be safely done in a monitored setting with close supervision by an allergist.

A63 An in depth look at the medical management of hereditary angioedema through a Canadian
Lisa Fu 1 , Amin Kanani 2 , Gina Lacuesta 3 , Susan Waserman 4 , Stephen Betschel 1 Allergy Asthma Clin Immunol 2018, 14(Suppl 1):18 Background: Hereditary angioedema (HAE) is a rare disease that has significant morbidity and may be potentially fatal due to airway obstruction. Our study aimed to determine how Canadian physicians diagnose and treat HAE. Methods: A survey was designed to determine HAE practice patterns amongst Canadian physicians. These physicians were identified by sending the survey to members of three physician organizations: the Canadian Hereditary Angioedema Network, the Canadian Society of Clinical Immunology and Allergy, and the Canadian Hematology Society. Results: Thirty-six physicians responded to the survey. Thirty-four physicians were included in the analysis. The majority of referrals to HAE treating physicians were from family and emergency room physicians. The most common sites of swelling reported by patients to physicians were facial, peripheral and abdominal. A mean of 53.9% of HAE-Type 1 and II patients and 53.4% of HAEnC1INH patients were on long term prophylaxis. A mean of 41.9, 19.4 and 93.5% of respondents had some patients on danazol, tranexamic acid and C1-inhibitor respectively. The majority of physicians felt severity and frequency of attacks were the most important determinants in deciding when to use prophylaxis. A mean of 88.2% of physicians used C1-inhibitor to treat acute attacks and 79.4% used icatibant. A mean of 91.4 and 94.3% of respondents felt very or extremely confident using C1-inhibitor for prophylaxis and for acute attacks respectively. A mean of 71.4% of physicians felt very or extremely confident in using icatibant. All respondents were aware of HAE guidelines. Respondents felt a further need for guidance when managing HAE in pregnancy, and pediatric patients. Conclusions: Physicians are using guidelines to support their practice, and using agents suggested by guidelines with confidence. C1-inhibitor is being used widely for prophylaxis, as well as acute treatment of attacks along with icatibant. However, certain special patient populations may require additional focus in future guidelines. Background: Macrolides are commonly used antibiotics in children, however there are no standardized skin tests available for diagnosis of allergy. While up to 3% of children report reactions to macrolides, it is not clear how many have a true allergy. Our aim was to assess the risk of macrolide allergy in patients through the use of a graded oral challenge. Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy were recruited for the LAACTAM study between March 2013 and 2017. A standardized survey with questions on treatment, symptoms, and associated factors was filled and an oral challenge (10 and 90% of the oral dose) was conducted at the clinic visit. The patients were contacted annually to query on subsequent antibiotic use and associated reactions. Multivariate logistic regression was used to estimate factors associated with a positive oral challenge. Results: Seventy-seven patients with a reported allergy to macrolide antibiotics were recruited, with 79.2% (95% CI, 71.4%, 88.5%) reporting a reaction to clarithromycin and 19.5% (95% CI, 11.7%, 28.7%) to azithromycin. The majority of the reactions were isolated to the skin and occurred within 3 days of starting treatment. Among 68 patients who underwent an oral challenge, 3 patients (4.4% [95% CI, 1.5%, 9.4%]) had a positive challenge, of which all were immediate reactions. A positive oral challenge to a macrolide antibiotic was associated with older age (OR 1.03 [95% CI, 1.01, 1.04]) while adjusting for sex, type of macrolide, history of known food allergy, drug allergy, and asthma. Among the 65 patients with negative oral challenge eligible for follow-up, 48 (73.8%) patients responded. Of the contacted patients, 15 (31.3%) reported macrolide antibiotic use and 1 patient (6.7% [95% CI, 0.3%, 34.0%]) reacted to subsequent treatment.

Conclusions:
Graded oral challenges can be used to safely diagnose macrolide antibiotic allergy. The risk of subsequent reaction among those with a negative challenge is almost 7%. Guidelines establishing the diagnosis of macrolide allergy are required to appropriately manage these patients.

A65
Cytokine profile of Th1 and Th2 cells following T cell polarization in high and low atopic risk umbilical cord blood mononuclear cell samples Mallory Gallant 1,2 , Mark W. Tenn 1,2 , Jenny Thiele 1,2 , and Anne K. Background: Individuals with atopic disorders tend to have a decreased ratio of Th1 to Th2 cells, known as a "Th2 shift". The dynamic balance between Th1 and Th2 cells in combination with their functionality in early life has not been thoroughly investigated, and may serve as an important predictor of atopic disease. We investigated this prospect by examining cytokine production of newly polarized Th1 and Th2 cells from umbilical cord blood mononuclear cell (CBMC) samples from mothers with and without self-reported allergic disease. Methods: CBMC samples were collected and cryo-preserved from consenting mothers with self-reported allergy (high atopic risk (HR) n = 4) or no allergy (low atopic risk (LR) n = 3). Non-adherent mononuclear cells were isolated from thawed samples and cultured for 7 days under Th1 (Interleukin (IL) 12, IL-2, and anti-IL4), Th2 (IL-4, IL-2, and anti-IL-12), and non-polarizing (IL-2, anti-IL-4 and anti-IL-12) conditions. Culture supernatants were extracted and cytokine concentrations were quantified via Bio-Plex Pro ™ Human Cytokine 17-plex Assay. Results: IL-1β, IL-7, IL-8, IL-12, IL-17, IFN-γ, and TNF-α were significantly increased in Th1 cultures when compared to the Th2 polarizing condition (all p < 0.05). Significantly elevated IL-5 and IL-13 levels were observed in Th2 supernatants versus Th1 supernatants (all p < 0.05). HR participants generated numerically higher levels of IL-8 and IL-10 (p = 0.58 and p = 0.21 respectively), and decreased levels of IFN-γ (p = 0.19) when compared to LR counterparts. Conclusion: The polarization culture conditions induced skewing towards a Th1 or Th2 cell phenotype with respect to cytokine concentrations. Given the small sample size of HR and LR participants, only weak trends for cytokine secretion were observed. Experiments with additional participants will improve power and confirm reproducibility of results in order to further address the potential of cytokine profiling in early life as a predictor of atopic disease.

A66
IVIG for recurrent pregnancy loss and recurrent implantation failure: experience at the MUHC Geneviève Genest 1 , Carl A. Laskin 2 , Phil Gold 1 pregnancy ensued, IVIg was given monthly until 32 weeks. We prospectively followed patients during pregnancy and 1 month after delivery to determine the efficacy and safety of IVIg. Results: 15 patients were included. 13/15 (86%) have delivered healthy offspring; 2/15 (13%) failed their ET. In the subgroup analysis, successful outcomes occurred in 7/9 (77%) patients with primary RIF, 2/2 (100%) with secondary RIF, 3/3 (100%) with primary PRL and 1/1 (100%) with secondary RPL. IVIg related side effects included 6/15 (40%) reports of mild post-infusion headaches; one patient developed hypotension and chills during her first IVIg infusion but tolerated scIg. IVIg was discontinued prematurely in 2 patients, one because of hospitalization for renal colic and another developed prolonged hypotension at needle insertion. Obstetrical complications were reported in 2 patients, one delivered prematurely at 34 6/7 weeks because of HELLP syndrome, another developed preterm labour at 27 weeks but delivered a healthy child at term. There was one fetal anomaly reported; one child was born with mild benign hydrocephalus.

Conclusions:
Our IVIg protocol appears to be safe and may be effective for patients with suspected IMRF undergoing IVF and our results justify the need for a properly designed RCT. Background: Primary immunodeficiency diseases (PIDs) represent a significant collection of immune system disorders that increase susceptibility to infection, which in some cases are serious or lifethreatening. Patients with PID often require immunoglobulin G (IgG, commonly referred to as Ig) replacement therapy to prevent infections and associated comorbidities. PID treatment, in addition to symptoms and associated social and emotional impacts, has a significant impact on patients' quality of life (QoL). Methods: The authors conducted a cross-sectional survey to measure health-related QoL in a cohort of patients with PID. Eligible participants were identified through the Canadian Immunodeficiencies Patient Organization (CIPO). The questionnaire consisted of 61 questions that covered patient-reported outcomes including diagnosis, QoL, treatment regimes, and communication. Results: Surveys were returned by 149 patients with PID. Participants conveyed significant impact on QoL including personal, occupational, financial, emotional, and social impacts as a result of PID symptoms, risks, and treatment logistics, limitations, and side effects. The most common diagnoses were related to B-Lymphocyte disorders (60.4%). Common treatments include intravenous immunoglobulin (IVIg; in hospital) and subcutaneous immunoglobulin (SCIg; at home), in addition to antibiotics and antifungals as required. Respondents reported feeling "average" before treatment on a scale of 0-10 (mean 5.46 ± 2.23) with increased health after treatment (mean 6.66 ± 2.32). Respondents felt current treatment was convenient (mean 8.22 ± 1.94) and were comfortable with self-infusions (mean 6.96 ± 3.46). Conclusions: Patients with PID are not uncommon in the Canadian community, and in these patients PID is associated with a significant impairment in QoL. Experiences range with regards to a particular treatment's advantages and disadvantages, cost, travel, and convenience. Respondents hope to achieve improved QoL through the following solutions: better treatment, improved infusions, gene modification, more research and clinical trials, a cure, and education and outreach. Improved financial, medical, and social supports were also requested. Background: Chronic idiopathic urticaria (CIU) is characterized by wheals and itching for at least 6 weeks with no identifiable cause. Previous studies have suggested a relationship between female gender, asthma and CIU, but little is known about the predictors of prognosis. The purpose of this study was to determine the predictors of disease outcome for patients with persistent CIU. Methods: This was a retrospective chart review of patients 18 years of age and older with persistent CIU (at least 3 clinic visits) seen in the Outpatient Allergy Clinic at Kingston Health Sciences Centre. Patients exhibiting symptoms of physical urticarias were excluded. Patients' demographics, clinic visits, disease duration and outcome, comorbidities, angioedema, triggers, allergies, medications used, and results of work up were recorded. A two-level disease outcome was used, where "controlled" was defined as urticaria-free patients, on or off medication. Those who relapsed after a period of remission or had persistent symptoms despite medications were considered "uncontrolled". Analyses included Chi square tests, independent samples t-tests, and a multivariable logistic regression. This study was approved by Queen's University Ethics Committee. Results: Of the 98 patients included, 83% (81/98) were females. The average age, duration of disease, and number of clinic visits were 51.18 ± 15.12 years, 45.13 ± 69.9 months, and 4.63 ± 2.61, respectively. There was a trend between age and disease outcome, as prognosis was worse in younger patients (p = 0.077). A greater proportion of males obtained control of their disease (82.4%) as compared to females (64.2%) (p = 0.147). Female patients used significantly more medications then males to control their symptoms (2.77 vs 2.0, p = 0.026). Patients with co-existing asthma experienced significantly worsened outcomes as compared to non-asthmatics (p = 0.04). Conclusions: In adults with persistent CIU, younger female asthmatics were less likely to gain control of disease. Physicians should have a lower threshold for escalating treatment strategies for this patient population. and efficient avenue for their re-introduction. Our objective is to propose a new classification for HSRs to mAbs and provide new insight into their management with desensitization. Methods: We reviewed the characteristics of the presentation of initial HSRs for 104 patients, skin testing, biomarkers and the outcomes of their management with 526 desensitizations. Results: The initial reaction phenotypes included type I (IgE/non IgE mast cell activation) in 65 (63%), cytokine-release in 14 (13%), mixed reactions (Type I/cytokine) in 22 (21%) and delayed type IV in 3 (3%) patients. Skin testing was performed for 10 mAbs in 58 patients. A positive skin test was associated with severe initial reaction (p-value 0.0088). IL-6 was elevated in 8 patients, correlated with cytokine storm phenotype. Tryptase was elevated in 1 patient. There were no HSR during 404 (76.8%) desensitizations; when reactions occured, they were type I in 39 (32%), cytokine storm in 64 (52.5%), mixed in 14 (11.5%) and delayed type IV in 5 (4%). All but one patient safely completed their desensitization and received their target dose. Conclusions: A new proposed classification for HSRs to mAbs is provided based on the presentation and includes 4 phenotypes; type I (IgE/non-IgE mast cells activation), cytokine storm, mixed (type I/ cytokine release) and delayed type IV reactions. Endotypes were confirmed by tryptase and IL-6. Skin testing is a valuable tool in assessing HSRs to mAbs. Management with desensitization provides safe and effective re-treatment options. Precision and personalized medicine should be applied to patients with HSR to mAbs. Background: Mast cells play a key role in asthma. The release of preformed mediators, generation of lipid mediators, and production of cytokines, such as GM-CSF, contribute to inflammation and bronchoconstriction. Asthma exacerbations are often associated with respiratory viral infections. Severe asthma is also associated with reduced production of type I and III interferons (IFNs). Human mast cells have been described as an excellent source of IFNs [1]. Therefore, this study investigated the impact of concurrent FcεRI-mediated activation and viral infection on mediator production by human cord blood-derived mast cells (CBMCs). Methods: CBMCs were sensitized with IL-4 (10 ng/mL) and IgE (2.5 µg/ mL), and then activated with 2 µg/mL anti-IgE (n = 3). In some experiments, sensitized CBMCs were infected with reovirus (5 MOI) prior to activation with anti-IgE (n = 2). FcεRI expression was measured by flow cytometry. Degranulation was assessed via a β-hexosaminidase assay. IFNA2, IFNL1 and GM-CSF mRNA expression were assessed by qPCR and normalized to the reference gene HPRT. Results: IgE-sensitized CBMCs exhibited increased FcεRI expression (51.5%) compared to unsensitized controls (0.2%), and activation with anti-IgE induced degranulation at 30 min (34.2% vs 10.5% in controls). GM-CSF mRNA expression at 24 h was enhanced 7.122-fold by FcεRI activation, 12.67-fold by reovirus infection, and 55.15-fold by concurrent activation of these pathways compared to non-activated controls. IFNA2 and IFNL1 expression was also induced by reovirus infection. However, substantial donor variation in IFN responses to combined viral and IgE-mediated activation was observed. Conclusion: Our preliminary data suggests that reovirus infection of IgE-activated human mast cells synergistically enhances FcεRI-induced GM-CSF gene expression, but may have a more donor-dependent effect on viral-induced IFN production. Background: Idiopathic angioedema (IA) is a form of angioedema in which no known cause can be found. Phenotypically it is divided into histaminergic angioedema which responds to antihistamines, whereas non-histaminergic does not. Studies on the natural history and long term outcomes of idiopathic angioedema are lacking. Methods: Charts of patients with angioedema from an allergist office were reviewed. Patients over age 19 with an initial presentation of IA were recruited to the study. Telephone surveys were conducted to obtain data including demographics, disease characteristics and treatment. Results: 29 patients participated in the survey. Median age of disease onset was 45 years. Most patients reported attacks lasting less than 24 h. Body parts affected include lips (72%), eyelids (69%), tongue (66%), other facial structures (59%), extremities (41%), airways (38%) and trunk (21%). 59% feel attacks have become less frequent, 45% less severe and 31% shorter over time. 2 patients developed urticaria. 24% of patients report having had a life threatening event. One required intubation. 66% of patients presented at least once to the ER. Antihistamines are the most commonly prescribed treatment in the ER (79%). 53% received epinephrine. 84% responded to treatment. 34% are taking prophylactic antihistamines and 41% take them as needed. 74% of patients find antihistamines effective. 7/29 patients have not had an attack in the last 12 months and do not currently take antihistamines. Patients report stress, viral illnesses, alcohol, NSAIDS, pressure, insect bites and food additives as potential triggers. Conclusions: Idiopathic angioedema is a chronic illness with variability in frequency and duration of attacks. Angioedema may affect any body part but most commonly affects facial structures. Only a minority of patients will enter remission (no attacks in 12 months) but most patients improve symptomatically over time. Patients perceive antihistamines to be effective prophylactically and as needed. Background: VHCs are medical devices that are recommended by Asthma and COPD guidelines to be used with pMDI as a delivery system. VHCs improve medication delivery and reduce oropharyngeal deposition of medication; this is reflected in the fine particles mass (FPM, 1.1-4.7 µm) that reaches the airways of the lungs. The significant role of the VHC in drug delivery was acknowledged by the European Medicines Agency (EMA) in their recommendation that pMDI manufacturers should nominate at least 1 named VHC during clinical safety and efficacy studies. It also recommends if a VHC is to be substituted by an alternative VHC, that appropriate in vitro methods be employed to demonstrate equivalence. Methods: Particle size measurements from the Inspirachamber, Optichamber Diamond, Space chamber, Vortex and Life Brand VHCs (test devices) were compared to the AeroChamber Plus* Flow-Vu* Antistatic Background: In Phase 3 studies, subcutaneous Omalizumab (150 or 300 mg every 4 weeks for 24 weeks) was safe and effective in treating symptoms associated with CIU/CSU. OPTIMA (NCT02161562) is a novel study addressing remaining gaps in knowledge of optimal CIU/ CSU treatment. Design: Patients with CIU/CSU and symptomatic despite H1-antagonists were randomized 4:3 to Omalizumab 150 or 300 mg for 24 weeks (1st dosing period). All well-controlled patients (UAS7 ≤ 6) were then subjected to treatment withdrawal for up to 8 weeks. The patients whose symptoms came back (UAS7 ≥ 16) within this timeframe were retreated at the same dose as in the 1st dosing period. The patients who did not achieve remission during the 1st dosing period were either (1) stepped-up (150-300 mg) if symptoms were not controlled after ≥ 8 and ≤ 24 weeks; or (2) had treatment extension if symptoms were not well-controlled with 300 mg at 24 weeks. The entire study was 53 weeks. To observe a sufficient number of relapses after initial dosing with 150 or 300 mg, 314 patients were enrolled. Analysis: The primary endpoint was the proportion of patients who were clinically well controlled (UAS7 ≤ 6) after the initial dosing phase, relapsed (UAS7 ≥ 16) upon withdrawal, and who achieved a UAS7 score ≤ 6 at the end of the second dosing phase. Key secondary endpoints include: change in UAS7 score and proportion of patients UAS7 ≤ 6 in those who step-up from 150 to 300 mg; change in UAS7 score in patients who extend 300 mg treatment; time to relapse in both doses. Conclusions: This study helps identify appropriate Omalizumab treatment in CIU/CSU patients who relapse or are not well controlled after initial treatment. Background: Among patients who report a penicillin allergy, more than 80% have negative testing. Patients can be erroneously labeled with a penicillin allergy due to a misclassification of the suspected reaction. This study seeks to validate a questionnaire and assessment tool that will guide physicians in identifying penicillin allergy risk groups among pediatric patients.

Methods:
The questionnaire was developed by pediatric allergists to assess history of possible penicillin allergy. Subjects are recruited from referrals to the allergy clinic for penicillin allergy assessment. Pharmacists and allergists administer the questionnaire to participants during the visit. The questionnaire answers will be assessed for inter-rater reliability. The allergist assessment and outcome from the clinic visit will be compared with follow up clinical assessment and decision forms (completed by allergy and non-allergy physicians) to assess validity. Results: We report the results of a preliminary analysis from the first 24 patients recruited between November 2016 and March 2017. 46% were male and the median age was 7 years. 79% received amoxicillin. 71% subjects reported a maculopapular rash, 42% of subjects reported urticaria. Symptoms lasted > 48 h in 55% of cases. 96% of subjects had consulted medical advice. Skin testing was not indicated in 66%. 19 subjects received amoxicillin oral challenge, and none reacted. Of 24 subjects assessed, 22 (91%) were found not to be allergic, one was deemed allergic to penicillin and one was diagnosed with severe adverse drug reaction. Conclusions: Most patients received amoxicillin and presented with prolonged maculopapular rashes or urticaria. The majority of subjects referred were deemed not allergic after an allergist assessment. Most patients are not deemed allergic based on history alone and pass drug challenges, without need for skin testing. The availability of a clinical tool to guide physicians in assessing risk level for possible penicillin allergy would decrease risk of erroneous penicillin allergy labels.
Background: Common variable immunodeficiency (CVID) is associated with numerous non-infectious manifestations, including chronic liver disease. Nodular regenerative hyperplasia (NRH) has been identified as the most common form of liver pathology in CVID patients, with these patients being at risk of the attendant complications of hepatic dysfunction. We present a case of hepatopulmonary syndrome in a CVID patient with possible NRH. Case presentation: A 52-year-old male with CVID on immunoglobulin replacement for approximately 30 years presented with progressive dyspnea out of keeping of his known mild bronchiectasis. He had previously been investigated for liver disease based on elevated liver enzymes, splenomegaly, and thrombocytopenia; however, the liver biopsy showed only non-specific sinusoidal fibrosis without evidence of cirrhosis. Pulmonary function testing was notable for a DLCO of 50% predicted and an alveolar-arterial gradient of 50 mmHg. Lung perfusion imaging was positive for a right-to-left shunt and a contrast-enhanced transthoracic echocardiogram confirmed extracardiac shunting. There was also evidence of portal hypertension with esophageal varices and portal hypertensive gastropathy. Repeat liver biopsy showed sinusoidal dilatation and fibrosis with features of NRH but was non-diagnostic. Discussion: This case illustrates the possibility of complex, multiorgan dysfunction in CVID. A diagnosis of hepatopulmonary syndrome is made by demonstrating impaired oxygenation and intrapulmonary vascular dilatations in a patient with liver disease, and it should be considered in the evaluation of dyspnea in CVID patients when more common causes have been excluded. Liver transplant, the only treatment for hepatopulmonary syndrome, should not be withheld from CVID patients on the basis of their immunodeficiency given that longterm survival in CVID transplant recipients has been documented. Allergy Asthma Clin Immunol 2018, 14(Suppl 1):18 Background: Podophyllotoxin etoposide is a chemotherapeutic agent in use for over 30 years. Type I hypersensitivity reactions occur in 1-3% of patients receiving etoposide. We discuss two pediatric patients with etoposide hypersensitivities successfully treated with etoposide phosphate without the need for desensitization. Case study: Patient 1: A 14 year-old male with relapsed osteosarcoma status post right leg above the knee amputation and left thoracotomy with left lung wedge resection was initially treated with a chemotherapy regimen containing high dose methotrexate, cisplatin, and doxorubicin from 2012 to 2013. In 2016, a relapse in his lung was identified and he was started on ifosfamide and etoposide. Within 1 min of receiving his first etoposide dose, he developed respiratory distress and lip swelling. His infusion was stopped, diphenhydramine was administered, and vitals remained stable. The patient was started on etoposide phosphate and completed six cycles of therapy without any adverse reactions. Patient 2: A 13 year-old male with metastatic Ewing's sarcoma was treated with vincristine, doxorubicin, mesna, and cyclophosphamide, alternating with cycles of ifosfamide, mesna, and etoposide. Within 1 min of his first etoposide dose, he developed a cough, generalized pallor, facial edema, and had a large emesis. His oxygen saturation decreased to the 80 s and blood pressure dropped to 70 s systolic. Diphenhydramine and a saline bolus were administered with stabilization of his vitals and symptom resolution. The patient was started on etoposide phosphate and tolerated 14 cycles. Discussion: The mechanism by which etoposide causes a hypersensitivity reaction is suspected to be caused by the polysorbate 80 component. Neither oral etoposide, nor etoposide phosphate contain polysorbate 80 and are usually safe for administration. However, caution is needed as there are cases of etoposide phosphate hypersensitivity. Conclusion: Etoposide phosphate is a potentially safe alternative for pediatric patients with etoposide hypersensitivity.

Consent:
Informed consent has been obtained from the patients and next of kin reported in this abstract. Case study: Treatment with human immunoglobulin is indicated in various medical conditions including autoimmune diseases, infections and immunodeficiency syndromes. Serious cutaneous adverse reactions due to immunoglobulin therapy are rare and most often associated with patients with neurologic conditions who are receiving higher doses of intravenous immunoglobulin (IVIG) infusions. We report two cases of rash associated with patients receiving subcutaneous immunoglobulin (SCIG) therapy for IgG deficiency. One patient developed a painful erythematous inframammary rash soon after the initiation of SCIG therapy, persisting beyond the cessation of therapy. Trial of a different SCIG product also resulted in similar rash. The second patient developed a blistering erythematous rash on the legs after a few years of uneventful immunoglobulin therapy. The mechanism of these cutaneous reactions is not clear. There are a number of proposed theories in the literature for rash associated with immunoglobulin therapy, such as T cell mediated pathway, complement mediated immune complex deposition and IgE involvement. Although these cutaneous reactions were not life threatening, they resulted in the cessation of a beneficial therapy. Further analysis of similar cases may be helpful to understand the underlying pathophysiology of these reactions.

Consent:
Informed verbal consent to publish is obtained from both patients with written consent to follow. Background: Ginseng has become increasingly popular in North America due to its proposed medicinal effects. Although cases of anaphylaxis have been reported in adults in response to Korean ginseng, there are no reported cases of allergy to American ginseng, nor reported cases in pediatric patients. We present a unique case of anaphylaxis to American ginseng in a 6-year-old girl. Clinical case: A 6-year-old girl with a history of multiple IgE-mediated food allergies (peanuts, tree nuts and fish), atopic dermatitis, and a remote history of asthma was presented to the emergency department with urticaria, coughing, and wheezing. Symptoms began minutes after entering a store selling powdered American ginseng. On physical examination, she had wheezing bilaterally and diffuse urticaria. She was treated with salbutamol, dexamethasone and diphenhydramine. Symptoms resolved shortly after treatment, and she was referred for allergy testing. Skin prick testing (SPT) with American ginseng was positive with a 13x12 mm wheal. Spirometry was entirely normal (FEV1 107% predicted). A basophil activation test (BAT) showed a dose-dependent increase in expression of CD63 on basophils in response to American ginseng extract, but not to Korean ginseng extract. No changes were observed in a non-atopic control, and minimal changes were observed in an atopic control. It was concluded that this patient had an anaphylactic reaction to American ginseng. She was advised to strictly avoid all ginseng products and carry an epinephrine autoinjector at all times. Conclusion: We present a unique case of anaphylaxis with physician-confirmed respiratory symptoms and urticaria, with evidence of sensitization to ginseng on SPT and allergy on BAT. This is the first reported case of ginseng anaphylaxis in a pediatric patient, in addition to anaphylaxis to American ginseng. As ginseng exposure is becoming increasingly prevalent in North America, it is important to consider ginseng as a cause of allergic presentation in children. Allergy Asthma Clin Immunol 2018, 14(Suppl 1):18 monoclonal antibodies (mAb) therapy in the management of eosinophilic disorders. Case: We present a case of a 22-year old security officer with severe CRSwNP and aspirin associated respiratory disease (AERD). His medical history included asthma with ragweed pollen sensitization, elevated serum IgE (122), and peripheral eosinophilia (500/μL). Investigations for vasculitis, aspergillus sensitization, immunodeficiency, cystic fibrosis, and primary ciliary disorders were negative. Despite multiple endoscopic sinus surgeries and maximal medical therapy (saline and 0.5 mg budesonide irrigation, and aspirin 650 mg, twice daily), his symptoms persisted. Mucocele development and invasion into the ipsilateral orbit led to orbital abscess formation and visual compromise, necessitating urgent surgical decompression. Intra-operatively, the middle and superior turbinates were noted to have complete polypoid transformation. Based on his history of refractory CRSwNP, asthma, and peripheral eosinophilia, he was started on the anti-IL5 mAb mepolizumab. After three monthly 100 mg subcutaneous infusions, he had significant improvement in nasal obstruction and purulent rhinorrhea, and complete return of olfaction. His visual acuity and extra-ocular movements returned to baseline. Endoscopy revealed no evidence of polyp recurrence or ongoing inflammation. Conclusion: Several clinical trials have evaluated the safety and efficacy of biologics in CRSwNP. The anti-IgE monoclonal antibody omalizumab and anti-IL-4 receptor antibody dupilumab demonstrated efficacy in reducing polyp size and improving nasal symptoms as long term therapy. Anti-IL-5 therapy has only been studied as single dose treatment. Our case illustrates the potential therapeutic benefit of extended anti-IL-5 therapy to induce disease remission in patients with medically and surgically refractory CRSwNP.

Consent:
Written informed consent for the publication of these details was obtained from the patient. Background: Food allergy affects approximately 2% of adults. The most common adult triggers include fruits and vegetables; delayed sensitization may develop due to shared homologous proteins with airborne allergens (i.e., pollens). Mast cells are associated with allergic diseases, including asthma, atopic dermatitis, and medication hypersensitivity. In contrast, the association of adult onset food allergy with mast cell disorder has not been well described. Case study: We present a case of a 55-year-old man with a three-year history of recurrent syncope, associated with almond and yellow pepper ingestion. He also reported sporadic flushing and pruritus without eruption. Skin testing with fresh extracts of almonds and yellow pepper was positive. Baseline serum tryptase levels were elevated, with serial values of 29, 32, and 37 (normal < 11.4) ng/mL. Investigations included normal serum immunoglobulins, protein electrophoresis, and 24-h urine 5-hydroxyindoleacetic acid, vanillylmandelic acid and metanephrines. Liver and renal function were normal, with two abdominal ultrasounds confirming normal liver and spleen size and echotexture. Bone marrow analysis indicated normal tri-lineage hematopoiesis with normal maturation, and minimal infiltration by mast cells. Given his elevated tryptase, and diagnosis of an IgEdependent disease related mast cell disorder, the patient was maintained on cetirizine, and advised to avoid almonds and yellow pepper. He was prescribed epinephrine auto-injectors. To date, there is one case report of shellfish anaphylaxis associated with mast cell activation syndrome (MCAS). In contrast, there is an established association, and parameters for management, of mast cell disorders associated with venom allergy [stinging insect parameter]. In our patient, it is unclear whether the mast cell disorder was incidentally discovered and secondary to an IgE mediated allergy, or if mast cell dysfunction unmasked sub-clinical food sensitizations. MCAS can predispose to severe anaphylaxis reactions. In adults with newly discovered food allergy, clinicians should have a high suspicion for newly acquired or indolent mast cell disorders, particularly if there is a history of severe cardiovascular compromise.

Consent:
The patient provided written informed consent for publications of the details in this case report. Patient treated with high dose steroids but unable to reduce Prednisone to < 20 mg/day. Failed second line treatments included: Hydroxyurea 500 mg, Cyclophosphamide 50 mg. Imatinib mesylate 400 mg which caused retinal hemorrhage. Trial of Mepolizumab 100 mg subcutaneous injections q 4 weeks was initiated, pruritus improved after first dose and Imatinib discontinued. After 3 doses of Mepolizumab, itching stopped, Prednisone dose reduced to 4 mg daily. After 5 doses, Mepolizumab discontinued -patient still symptom free 4 months later with absolute eosinophil count 33 eos/mm 3 . Conclusion: There is no current treatment for HES patients not caused by M-HES or L-HES who have failed first and second line agents. Past trials with high dose mepolizumab 750 mg IV for idiopathic HES showed good response. We report use of Mepolizumab 100 mg subcutaneous q 4 weeks for 5 doses, with complete amelioration of symptoms.

Consent:
Written informed consent was obtained from the patient for publication of this abstract. A copy of the written consent is available for review by the editor of this journal. Introduction: Familial hemophagocytic lymphohistiocytosis (FHL) is a life-threatening disease characterized by fever, cytopenias and hepatosplenomegaly. Identifying FHL is crucial as definitive treatment is hemopoietic cell transplantation (HCT). FHL usually presents in toddlers, only few adult cases have been described. Most adult patients have hypomorphic mutation and residual or normal perforin level. Case presentation: At ages 5, 10 and 12, the patient was hospitalized for recurrent episodes of fever, cytopenias, hepatosplenomegaly and encephalitis. He was diagnosed with chronic EBV infection with central nervous system involvement. At age 26 and 35, he presented with cytopenias, fever and splenomegaly. Hemophagocytic lymphohistiocytosis was suspected both times but no macrophage activation was found. He was treated with steroids and IVIG. On flow cytometry, NK cells were low and perforin was absent. Molecular biology showed heterozygosity for the PFR1 gene with P39H and G149S missenses mutations. The patient was diagnosed with FHL type 2 with complete absence of perforin. At age 36, he underwent allogeneic HCT (unrelated donor) after a conditioning regimen including fludarabine, melphalan and alemtuzumab. As of day +217 after HCT there is no sign of relapse or graft-versus-host disease, despite mild neurologic sequelae. Discussion: To our knowledge, we describe the oldest patient with FHL without residual perforin activity. He survived 36 years with presumed complete absence of perforin, thought to be fatal in the first years of life, with a promising 6-month follow-up after HCT. This atypical case presented as a subacute perforinopathy without residual perforin level. Furthermore, missenses mutations are thought to have a milder impact than nonsense mutations on perforin level. The optimal conditioning regimen for HLH in adult is unknown, different regimens have been described. This case emphasizes the need for increasing awareness on the existence of FHL in adults.

Consent:
Informed written consent was obtained from the patient. Background: Hypereosinophilic syndrome (HES) is a rare condition that is characterized by peripheral eosinophilia (an absolute eosinophil count (AEC) of > 1.5 × 10 9 /L) for greater than 6 months and end-organ damage with the exclusion of other secondary causes. Eosinophilia with myositis (EWM) consists of peripheral eosinophilia (> 0.5 × 10 9 /L) and eosinophilic muscle infiltrates. We present the case of a patient with late-onset EWM and HES traits with symptoms that have been refractory to glucocorticoids. Case presentation: RM is an 82 year old male who experienced a 4 year history of progressive myopathy, arthralgias and weight loss in the setting of a climbing AEC. RM was referred to the neurology service, due to functional impairment, and was subsequently admitted to hospital to expedite management. Initially, RM had an elevated AEC which normalized with glucocorticoids. However, even with continued steroid use, RM still experiences myositis symptoms and a recent MRI showed active disease involving bilateral proximal thigh muscle groups. Although eosinophilic myositis remains high on the differential, CK levels have always been normal which is unusual in this disease process. Discussion: Investigations have been negative for a clear neurologic, rheumatologic, infectious or hematologic etiology. RM's IgE level was mildly elevated and a consultation to clinical immunology and allergy is pending. On bone marrow biopsy, a PDGFRa/CHIC2 deletion, a surrogate for the FIP1L1-PDGFRA mutation, was negative, therefore imatinib is likely to be of limited use. Hydroxyurea therapy was therefore initiated and RM will follow-up with the rheumatology service. If symptoms remain refractory, there could be consideration of mepolizumab therapy. Conclusion: The case describes symptoms concerning for eosinophilic myositis with a late age of presentation, and unusual biochemical markers. The case also emphasizes the importance of early recognition of eosinophilia related end-organ damage, and consideration of second-line therapies, in difficult-to-treat eosinophilia with myositis. Consent to publish: Written informed consent to publish was obtained from the patient.

A97
Wide complex rhythm following intravenous epinephrine injection for venom induced anaphylaxis: a case report Nazanin Montazeri, Samira Jeimy, Harold Kim Department of Clinical Immunology and Allergy, Western University, London, Ontario, Canada Correspondence: Nazanin Montazeri Allergy, Asthma & Clinical Immunology 2018, 14(Suppl 1):A97 Background: Epinephrine, the main treatment for anaphylaxis, exerts its effects through alpha and beta-adrenergic receptors. 1 The cardiac effects are tachycardia and enhanced myocardial contractility. These are mediated through beta-1 adrenergic receptors. 1 Despite its lifesaving effects, epinephrine has been associated with serious cardiac and non-cardiac adverse effects. 2 Case study: We report the case of a 25-year-old healthy male who was stung on the head by an insect. He developed local swelling, numbness of his lips, urticarial lesions on his wrists, and mild shortness of breath. He came into an emergency room. He was diagnosed with anaphylaxis and inadvertently treated with IV Epinephrine. He received 0.2 mg of 1:1000 Epinephrine pushed intravenously. Within minutes, he reported severe headache, feeling of doom and lightheadedness. The patient was placed on cardiac monitoring and a wide complex rhythm was identified and recorded. His blood pressure was measured at 200/130 mmHg. Within minutes, he spontaneously reverted to sinus rhythm and he clinically recovered. He was referred to an allergist and was treated for yellow-jacket allergy. Conclusion: Serious cardiac adverse effects due to epinephrine have been reported in the past. They include hypertension, ventricular arrhythmias, myocardial infarction and pulmonary edema. 2 However, to our knowledge this is the first case of a wide complex rhythm due to a very small dose of intravenous epinephrine injection for treatment of anaphylaxis recorded on a rhythm strip. Our case highlights a well-documented episode of a potentially deadly arrhythmia caused by a small dose of IV epinephrine. Consent to publish: Written informed consent to publish was obtained from the patient. Background: Anaphylaxis is a serious potentially life-threatening allergic reaction. However, recurrent anaphylaxis is a rare phenomenon since most life-threatening allergies can be avoided with strict allergen avoidance. Case report: A 44 year-old male with a known peanut allergy first presented to our clinic with symptoms of severe recurrent anaphylaxis, requiring epinephrine administration in the emergency room. These episodes had been associated with consumption of food (though he had fastidiously avoided any ingestion of peanuts) at lunchtime, and clinical history did not correspond with objective testing. The following year, he returned to us having experienced a number of recurrent episodes of anaphylaxis in association with the consumption of specific foods at lunchtime. At this point, the differential was broad but investigations did not clearly reveal any organic disease process. He was seen multiple times in the past 4 years concerning at least seven episodes of anaphylaxis. We discussed the possibility of contamination where the patient revealed to us that the police had suggested that his wife might have been contaminating his food. He discovered that his wife, who suffers from bipolar affective disorder, was sprinkling peanut dust on his lunches in an attempt to harm him. She subsequently was admitted to a psychiatric facility where she has remained. On this patient's most recent allergy testing, he was skin test negative and IgE negative to peanut. Conclusion: This is the first report of intentional poisoning with peanut allergen identified in a case of recurrent anaphylaxis. Since the most recent testing no longer revealed an allergy to peanuts, it is possible that this individual may have resolved his allergy from the repeated exposures. This unusual case reinforces the importance of taking an accurate history, the importance of trusting the results of objective testing, and of having a broad differential diagnosis for the cause of life threatening anaphylactic reactions. Intentional poisoning with food allergens should be considered in recurrent and unexplained anaphylaxis.

Consent to publish:
Written informed consent to publish was obtained from the patient. Background: DL is a healthy 32-year-old male with Cold Induced Urticaria (CIU) successfully treated with Omalizumab who experienced severe weight gain. A systematic review of the literature showed that there is only one other case of weight gain induced by Omalizumab in the treatment of severe asthma. Case: DL was started on monthly Omalizumab in August 2015 and gained 22 lb (235-257) over 4 months. The weight gain was gradual, averaging 7 lb per month. Mr. DL's thyroid, liver, renal function and complete blood count labs were normal. Due to weight gain, he discontinued Omalizumab between December and March 2015 and lost 4 lb (257-253). Due to uncontrolled CIU, he was restarted on Omalizumab every 6 weeks in March 2016 for 4 months. During this time, Mr. DL increased his physical activity and modified his diet, and lost 8 lb over 3 months . In September 2016, he was re-started on monthly Omalizumab for 7 months due to worsening CIU and experienced an 11-pound weight gain (244-255) despite continued intense exercise and a healthy diet. DL stopped Omalizumab between March and June 2017 and lost 17 lb (255-238) although he stopped exercising and dieting during this time. Results: We observed a trend towards weight loss when Omalizumab was stopped or decreased in frequency. Conclusion: Although there are no manufacturer disclosures regarding weight gain with Omalizumab, we suspect this is an underreported side effect. Our patient experienced severe weight gain while on treatment, which was reversible upon stopping the treatment for a few months. We suspect that Omalizumab may play a role in the endocrine axis of weight regulation in certain patients.

Consent:
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Background: Lupine (Lupinis albus) is a member of the legume family. In Europe, it is often used in baked goods as an alternative to wheat or soy flour [1]. Lupine is recognized as a priority allergen in the European Union because of its cross-reactivity with peanut. However, it has yet to reach the Canadian list, as it hasn't been present in most Canadian food products. Case presentation: We describe a 10-year old boy with confirmed peanut allergy, who developed anaphylaxis to lupine flour in May 2017. A few minutes after eating pancakes made with PC Blue Menu Buttermilk Protein Pancake Mix that didn't contain any of his known allergens (peanut, tree nuts), he developed a tingly mouth followed by throat tightness, severe stomach ache, lightheadedness, cough, hoarse throat, stuffy nose, sneezing, and fatigue. He refused EpiPen ® , but was given Reactine. The symptoms resolved after 3 h, but he was still unwell the following day. In a conversation between the mother and Dr. Chan, it was determined that lupine was likely the cause of the reaction. To confirm, he was brought into clinic for skin testing to lupine. Results were consistent with lupine allergy (pancake mix: 10 × 7 mm, lupine bean: 12 × 6 mm). The family has since reported this to the Canadian Food Inspection Agency, resulting in a consumer advisory bulletin and product recall. Conclusion: This is the first reported case of allergic reaction to lupine in Canada, and highlights the need for education of Canadian families with peanut allergy as well as allergists, regarding the possibility of cross-reactivity between peanut and lupine and its current presence in the Canadian food supply. In addition, a precautionary label for those with peanut allergy who purchase products containing lupine and addition of lupine to the list of priority allergens in Canada should be considered.

Consent to publish:
Written informed consent to publish was obtained from the patient's guardians. Background: We are writing about the possible correlation between NOD2 and/or NLRP3 mutations. Disorders in innate immune system are associated with a group of diseases, collectively called autoinflammatory diseases. A group of monogenetic defects were described in association with many of these diseases, such as: MEFV, MVK, TNFR1, NLRP3, NOD2, PSTPIP1 mutations with FMF (familial Mediterranean fever), HIDS (hyper IgD syndrome), TRAPS (Tumor necrosis factor receptor associated Periodic Syndrome), CAPS (Cryopyrin associated autoinflammatory syndromes), Blau syndrome and PAPA (Pyogenic arthritis pyoderma gangrenosum and acne) respectively. A considerable number of patients seen in allergy clinic for urticaria and/or angioedema have accompanying symptoms of nonspecific bone aches, subjective fever or a typical treatment resistant skin involvement.