Latex allergy Presented by Kullapornpas Benyajirapach, MD. August31, 2018

1. Latex Allergy
KULLAPORNPAS BENYAJIRAPACH, M.D.
31ST AUGUST 2018

2. DEFINITION OF LATEX
Natural Rubber Latex (NRL) – milky sap produced by more than 2000 species of plants from
about 300 genera
Industrial use of NRL almost exclusively from the rubber tree Hevea brasiliensis
Synthetic rubber – produced by synthesis of polyisoprene or other polymers
Arch Intern Med 2001

3. DEFINITION OF LATEX
• Most Hevea brasiliensis grows in tropical countries: Thailand, Indochina, Malaysia and India
• Main constituent of Hevea latex
polymeric hydrocarbon 1,4 cis-poly-isoprene
1-2% of the fresh milky sap are proteins
Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

4. Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

5. PREVALENCE OF LATEX ALLERGY
• 9.7% healthcare workers
• 7.2% susceptible patients
• 4.3% general population
Journal of Occupational Health 2016

6. PREVALENCE OF LATEX ALLERGY
• 0-30% healthcare workers
• 25-72% children with spina bifida
• 0-2.3% general population
Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

7. LATEX ALLERGEN SOURCES
• After ultra-centrifugation of fresh latex sap:
3 main fractions
(rubber phase, C-serum and B-serum)
• Rubber phase: rubber particles and 2 main insoluble
proteins
• C-serum and B-serum proteins: water-soluble
Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

8. Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

9. Anchalee Senavonge M.D.

10. CLINICAL SYNDROME

11. CLINICAL SYNDROME
Contact Urticaria
• Most frequent manifestation
• Most common cause of occupational contact urticaria
• Immediate-type hypersensitivity (type I)
• Contact with mucosa induces
angioedema
Position Paper, JACI 2012

12. CLINICAL SYNDROME
Allergic Rhinitis and Asthma
• Exposed via inhalation
• Powdered gloves (mostly cornstarch) - main source of
reactions to environmental latex
• Latex caused occupational asthma, prevalence 2.5-10%
• Eosinophilic bronchitis (infrequent)
Position Paper, JACI 2012

13. CLINICAL SYNDROME
Systemic Reactions
• Latex - second cause of intraoperative anaphylaxis after muscle relaxants
• Cardiovascular collapse – most common, skin rash and bronchospasm
• Abdominal, gynecological, and orthopedic operations
• Anaphylactic reactions following anesthesia in children
• Aged under 5 years
• Atopic
• Higher levels of exposure eg. multiple operations or tests
Position Paper, JACI 2012

14. Sao Paolo Med J. 2017

15. CLINICAL SYNDROME
Latex-Fruit Syndrome
• Association between latex allergy and fruit allergy ranges 21-
58%
• Most frequently involved food: chestnut, avocado, banana,
and kiwi
• Wide spectrum of reactions: anaphylactic reactions to mild
local reactions
Position Paper, JACI 2012

16. CLINICAL SYNDROME
Latex-Fruit Syndrome
Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

17. CLINICAL SYNDROME
Latex-Fruit Syndrome
• Certain foods prone to induce severe reactions - fig, papaya, and tomato
• Potato - usually induce mild local reactions
Current Allergy and Asthma Reports 2003

18. CLINICAL SYNDROME
Latex-Fruit Syndrome
Current Allergy and Asthma Reports 2003

19. CASE REPORT LATEX-FRUIT SYNDROME
#1 - JACKFRUIT
• A 34-year-old Thai female nurse presented with chest discomfort, cough, dyspnea, facial
angioedema and urticaria 15 minutes after ingestion of ten pieces of dried jackfruit
• For one year, the patient having pruritic rashes both hands when contact with latex and
developed chronic eczema
• Underlying diseases: AR, AD
Asian Pac J Allergy Immunol. 2015

20. CASE REPORT LATEX-FRUIT SYNDROME
#1 - JACKFRUIT
• A 34-year-old Thai female nurse presented with chest discomfort, cough, dyspnea, facial
angioedema and urticaria 15 minutes after ingestion of ten pieces of dried jackfruit
• Skin prick tests positive: dried jackfruit (4+), fresh jackfruit (4+), papaya (3+), kiwi (2+), latex
glove brand #1 (1-2+) and latex glove brand #2 (4+)
• Skin prick tests negative: banana, sterile and vinyl gloves
Asian Pac J Allergy Immunol. 2015

21. Asian Pac J Allergy Immunol. 2015

22. CASE REPORT LATEX-FRUIT SYNDROME
#2 - PERSIMMON
• A 52 year old Thai woman with oral pruritus, generalized urticaria, nausea, vomiting and
breathlessness ending in syncope shortly after eating a persimmon
• A few days later she developed similar symptoms without syncope following intake of bananas
• Past history: Cesarean section over two decades ago, chronic urticaria, asthma and rhinitis
Exp Dermatol Res 2016

23. CASE REPORT LATEX-FRUIT SYNDROME
#2 - PERSIMMON
Exp Dermatol Res 2016

24. LATEX ALLERGY – SPINA BIFIDA
• Risk factor: number of operations, elevated IgE titers, presence of ventriculoperitoneal shunt
during first days of life, atopy
• Exposure to latex via several routes (mucosa, blood vessels, and inhalation)
• Most frequent – urticaria angioedema
• Most relevant allergen - Hev b 1
Position Paper, JACI 2012

25. DIAGNOSIS

26. Position Paper, JACI 2012

27. Pediatric Allergy and Immunology 2016: EAACI Molecular Allergology

28. SKIN PRICK TESTS
• Standardized extracts - sensitivity 93%, specificity 100%
• Intradermal tests not recommended
Position Paper, JACI 2012

29. J Investig Allergol Clin Immunol 2013

30. J Investig Allergol Clin Immunol 2013

31. PATCH TEST
• In suspected delayed-type hypersensitivity reactions
• Most not attributable to latex but to additives
• Except mercaptobenzothiazole and N-I-paraphenylenediamine, test mixtures of substances
(carba mix, paraphenylenediamine mix, and thiuram mix) instead of each additive separately
Position Paper, JACI 2012

32. GLOVE USE TEST
• Placing a fingertip of the glove on a dampened finger  if the result is negative  put on
complete powdered glove (exposure times ranging from 15 minutes to 2 hours)
• Vinyl or nitrile glove is used on the other hand - negative control
• Result positive if erythema, pruritus, blisters, or respiratory symptoms
Position Paper, JACI 2012

33. CHALLENGE TESTS
• Indicated when suggestive clinical history and complementary diagnostic tests (skin or
laboratory tests) - negative or contradictory
• Rule out latex allergy in asymptomatic sensitized patients
Position Paper, JACI 2012

34. SPECIFIC IgE
• Specific IgE against latex Sensitivity using CAP (Phadia) or AlaSTAT (Diagnostics Products
Corporation) is high
• With a positive cutoff point established at > 0.35 kUA/L, both techniques show similar
sensitivity (97% and 100%, respectively) with specificity of 83% for CAP and 33% for AlaSTA
• ImmunoCAP ISAC (CRD 112) (Phadia): antibodies from patient’s serum bind to the components
of the fixed purified allergens and detected using a fluorescent antibody with latex allergens
available: rHev b 1, rHev b 3, rHev b 5, rHev b 6.01, and rHev b 8
Position Paper, JACI 2012

35. FLOW CYTOMETRY
• Sensitivity greater than 93% and a specificity of 91.7%
• High cost
Position Paper, JACI 2012

36. TREATMENT

37. PATIENT EDUCATION
• Identifying themselves as allergic to latex
• Important in the health care setting
• Wear medical bracelet
Position Paper, JACI 2012

38. AVOIDANCE OF LATEX OBJECTS
Journal of Occupational Health 2016

39. ALTERNATIVES TO LATEX
• Neoprene
• Polyvinyl chloride
• Silicone
• Polyurethane
• Vinyl
Position Paper, JACI 2012
Nitrile gloves
Vinyl gloves

40. ALTERNATIVES TO LATEX
Position Paper, JACI 2012

41. AVOIDANCE OF FOOD
CROSS-REACT TO LATEX
• Patients with latex-fruit syndrome
should be advised to avoid the
fruits involved
Position Paper, JACI 2012

42. SPECIFIC IMMUNOTHERAPY
• Incidence of important adverse reactions too high to recommend its habitual use
Position Paper, JACI 2012

43. Ann Allergy Asthma Immunol 109 (2012)

44. Adv Dermatol Allergol 2018

45. Adv Dermatol Allergol 2018

46. Adv Dermatol Allergol 2018

47. PREVENTION

48. PREVENTION
Labeling
Primary Prevention
• use gloves when necessary
• avoid powdered latex gloves
• always use synthetic gloves with allergic patients
Secondary Prevention
•use of unpowdered gloves and gloves with a low latex protein content   patients with
symptoms and the concentrations of specific IgE
Position Paper, JACI 2012
Contains latex from natural rubber,
which may cause allergic reactions