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Dog allergy, unresponsive to immunotherapy?

Q. My patient is a 13 WF first diagnosed with dog allergy at age 6 and started on IT. The following is the time sequence for her treatment to date:

- 7/05 Dog 1:10w/v Hollister Stier 0.5 cc in a 5ml vial. Made to a maintenance dose 1:1, 0.3 cc on 3/07 and continued monthly until 4/09.

-2/07 Dog 1:10 w/v ALK/Abello 1.5 cc per 5 cc vial started in addition, worked up to 1:10, 0.4 cc on 8/08 and continued every 2-3 weeks until 2/09, then this vial stopped.

– 4/09 Started AP Dog 1:100, HS 1.1 cc in 5 ml vial. Worked up to 1:10, 0.45 cc on 12/10 with last dose on 3/12

At her most recent prick skin test on 7/12, her dog response had a 17mm wheal with interestingly, a wheal to horse of 30mm and cat of 7mm. She remains symptomatic with dog exposures, and unfortunately is regularly exposed to dogs in her home and in those of close family members. What should I do now?

A. The patient is probably sensiitve to Can f 2 (lipocalin) which cross reacts with horse, mouse, cat (Fel d 4), etc., for which there are common components. The overriding problem is that this allergen is very poorly represented in allergen extracts, particularly if the extract is first defatted. Lipocalins change their configuration and stability in the presence of other lipids. Since your patient demonstrates rather large skin test reactions, she is also probably sensitized to some other animal allergens such as Can f 1 and Can f 4 (again, lipocalins).

We allergists should push our extract makers for better and more representative products with which to treat our patients! The determination of component-specific IgE might be of value as she is probably allergic to a number of different animals, due to cross reactivity. However, at present other than avoidance, this knowledge might not make a difference. As a side note, as you may know, these allergens are very difficult to clean out of a home and she could expect exposures that are practically ubiquitous. These probably serve to maintain her sensitization over time. This patient will have to avoid animals, period. It would be interesting to see what would happen to her specific IgE concentrations if she did.

Another detail of potential future importance here is that Can f 4 is related to prostatic kallikrein from male semen. As individuals who are sensitized continue to have exposures, they expand their s-IgE repetoire to other allergens from the same source through bystander effects. This gives another possible reason for avoidance. In addition, there are some individuals who make responses to these lipocalins which can cross react with human tear lipocalins, precipitating ocular problems in some.

 
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