Latex allergy

Natural latex rubber
Allergy
Anchalee Senavonge MD.
3 February 2017
Pediatric allergy and immunology department
Chulalongkorn University

Case consultation
• Boy 5 yr old
• U/d tracheobronchomalacia, chronic lung disease s/p tracheostomy,
d-TGA s/p arterial switch operation, PDA s/p ligation, GERD s/p PEG
• Admit for bronchoscopy- patient developed wheal and flare on his
chest and neck 30 minutes after the procedure, required IV one dose
of antihistamine

Past history
• 1 year PTA urticaria on glove contact area and erythema skin around
PEG area (foley catheter as a replacement for gastrostomy tube)
• Never have banana, giwi, avocado (on Blenderized diet)
• Specific IgE (k82) 3.59 kUA/L class 3
• Skin prick test (soaked glove extract): pending
Case consultation

History
• In 1927, 2 cases reported in Germany
• First-urticaria and laryngeal edema caused by a ‘caoutchouc' (rubber) dental
prosthesis
• Second- after inhalation of NRL particles
• During the late 1980s and early 1990s, NRL allergy become important
• particularly among healthcare workers (HCW) and medical doctors
and in dental clinics
Chem Immunol Allergy 2014, the latex story

History
Chem Immunol Allergy 2014, the latex story

Allergen sources
• Hevea brasiliensis -tree of the family
Euphorbiacieae (“rubber tree”)
• Source: process called “rubber tapping,”
latex is collected from the milky sap
• 33% rubber, cis-1,4-polyisoprene, 2%
resin, 65% water, and proteins
• Hevea brasiliensis grows commercially in
tropical countries (Thailand, Indochina,
Malaysia, India)
Pediatric Allergy and Immunology 2016: EAACI molecular allergology
Natural rubber latex allergy. Disease-a-month 2016

• After ultracentrifugation of the
fresh latex sap basically three
main fractions [rubber phase, the
C serum and the bottom fraction
(B-serum)]
• rubber phase: rubber particles
and 2 insoluble proteins
• C and B-serum proteins are
water-soluble
Allergen sources

Medical setting Non-medical setting

• Dipped (also known as soft)
• gloves
• higher content of latex proteins and greater allergic potential
• Moulded (also known as hard or dry) such as
• medication vial stoppers
• contain denatured latex proteins; therefore, less antigenic
Types of latex products

การใช้ประโยชน์และการแปรรูป
• แบ่งเป็น 2 กลุ่ม ได้แก่
1. ยางแห้ง (ย่างแผ่นรมควัน ยางแท่ง ยางเครพ ยางแผ่นผึ่งแห้ง และยางสกิม)
2. ยางน้า (น้ายางข้น หรือยางลาเท็กซ์) ก่อนจะนาไปแปรรูปในขั้นต่อไปซึ่งจะเป็นผลิตภัณฑ์ที่เราพบได้ใน
ชีวิตประจาวัน ยกตัวอย่างเช่น ยางสาหรับประกอบยานพาหนะ ยางยืดและยางรัดของ ถุงมือยางทาง
การแพทย์ รองเท้าและอุปกรณ์กีฬา สายพานลาเลียง ผลิตภัณฑ์ฟองน้า เป็นต้น

• prevalence of latex allergy
• 9.7% healthcare workers
• 7.2% susceptible patients
• 4.3% general population
Prevalence worldwide

Epidermiology
Allergy
• general population 0% to 2.3%
• children with spina bifida ranges
between 25% and 72%
• healthcare workers 0–30%
Sensitization
• 5.4% to 7.6%
• adult blood donors showing
latex-specific IgE antibodies 6%

• Nurses, Srinagarind Hospital, Khon Kaen 2006
• NRL glove allergic symptoms 24%, sensitization 2%
• Dental students, Faculty of Dentistry, Chulalongkorn University 2011
• NRL glove-related symptoms 5.0% (hand pruritus 64.5%, hand eczema 19.4%,
contact urticaria 16.1%)
• Risk: AD, >18 hr, > 3 pairs
• Sensitization 14.2%
• Hatyai, Yala and Thammasart 2013
• Self-report symptom 18%
Prevalence in Thailand

Current prevalence rate of latex allergy, J Occup Health 2016

Major allergens

ไทรย้อยใบแหลม
papaya and kiwi
(around 60%)
banana, avocado,
and chestnut
(close to 90%)

Allergens
EAACI 2016 Position paper
JACI 2012
Middleton 8th ed
Spina bifida 1,3,5,6.01 1,3 1,3,7
HCW major 5,6.01 5,6 2,5,6,13
HCW minor 1,3 2,4,7,13 -
Latex-fruit 2,6.02,7,8,12 6.02,7
8,11,12 (pan)
2,7,8,12

• Most frequent
• Most common cause of occupational
urticaria
• Type I hypersensitivity
• Direct contact or inhalation of airborne
allergens
• erythematous, pruritic patches, hives
within minutes
Contact urticaria
Position paper, JACI 2012
Contact urticaria after wearing
latex gloves for 3 minutes

• Type IV
• Acute ACD: pruritic,
erythematous, scaly plaques
with vesicles and crusting on
the dorsal hands and wrists
24–48 h after contact
• Chronic ACD: lichenified,
erythematous, scaly plaques
Allergic contact dermatitis

• exposed via inhalation
• health care professionals and workers who use protective gloves
• considered to be an occupational asthma
• Prevalence 2.5-10%
Allergic rhinitis and asthma

• 2nd cause of intra-operative anaphylaxis (1st muscle relaxants)
• Occur maintenance phase of anesthesia (muscle relaxants and opiates-
induction phase)
• Abdominal, gynecological, and orthopedic operations
• Risk in children
1. Under 5 yr old
2. Atopic
3. Multiple exposures (> 8 surgical procedures )
Systemic reaction

Case report-anaphylaxis
• 4.5-year old Caucasian child, scheduled for congenital strabismus
sursoadductorius of the left eye surgery
• No history of allergy, no known medical condition
• After surgery 25 minutes, hypotension, TV drop, desaturation
• IgE levels 835 IU/ml
• natural latex rubber (k82) 11.30 kU/l, CAP-class 3
Malsy et al. BMC Research Notes 2015

• 51-year-old nurse (obstetrics head nurse)
• Contact dermatitis 4 yr ago->better
• fear for the loss of her job, not report skin problem
• Gynecological examination->anaphylactic reaction
• IV chloropyramine chloride (Synopen) and soon she felt better
• positive prick test reaction to latex
Case report-anaphylaxis

• 21% to 58%
• Most involved: chestnut, avocado, banana, kiwi
• Other infrequent foods: papaya, tomato, potatoes
• anaphylactic reactions caused by foods ranges from 50% to <5%
Latex-fruit syndrome

• Man, 37 years old, developed urticaria with skin redness, itching,
dyspnea and tachycardia 5 min after drinking a glass of apple juice
supplemented with acerola (Malpighia glabra; Barbados cherry)
• no allergy to apple and apple juice was well tolerated
• significant contact urticaria induced by natural rubber latex products
• OAS after ingesting avocado, celery, walnut
Case report-latex fruit syndrome
J Allergy Clin Immunol 2002: 109: 715–6.

• SPT +ve to grass pollen mixture, latex, rye, acerola-containing apple
juice; apple juice without acerola negative
• specific IgE
• Latex 24.7 kU/L (class 4)
• grass pollen (class 3)
• tomato, soy bean (class 2)
• banana, green apple,
herbal mixture (class 1)
Latex–acerola cross-reactivity based on Hev b6.01/Hev b 6.02
J Allergy Clin Immunol 2002: 109: 715–6.

• 28 years old woman, surgical instrumentalist in the operating theatre
• frequently dry skin of the hands, itching, redness and irritated skin of the
fingers -> diagnosed as AD (FH eczema)
• immediately after eating a banana - rash, tickling, throat perturbation
• 1.5 year later, kiwi consumption –rash, hypotension
Case report-latex fruit syndrome
UNIVERSI Journal. December 2015

• IgE to latex (16.5 KU/L), banana (27 KIU / L) and kiwi (35.6 KIU / L)
• Avoid NRL product and avocados, bananas, cherries, figs, kiwis,
grapes, melons, nectarines, papayas, pineapples, strawberries,
tomatoes, celery, plums
• Clinical improved
UNIVERSI Journal. December 2015

Spina bifida
• Higher prevalence
• Risk factors
• number of operations
• elevated IgE titers
• presence of a VP shunt during the first days of life
• atopy
• Exposure via mucosa, blood vessels, inhalation routes
• Most frequent manifestation is urticaria, angioedema
• Allergen most relevant: Hev b 1

Health care workers
• Latex allergy 4.32% (4.01% to 4.63%) in HCWs and 1.37% (0.43% to
2.31%) of general population [3 to 3.5 times]
• Latex-positive skin prick test 6.9% to 7.8% for the HCWs, 2.1% to 3.7%
in general population
• Risk factors
• hand dermatitis (OR 2.46)
• asthma or wheezing (OR, 1.55)
• rhinoconjunctivitis (OR, 2.73; 95%)
• at least one generic symptom (OR, 1.27)
NRL allergy among HCW. Sys review. JACI 2006

• Dental students, Faculty of Dentistry, Chulalongkorn University 2011
• NRL glove-related symptoms 5.0% (hand pruritus 64.5%, hand eczema 19.4%,
contact urticaria 16.1%)
• The risk factors for latex - glove allergy were
1. history of allergic diseases(atopic dermatitis, urticaria, pruritus and rubber
allergy)
2. Duration of using gloves(more than 18 hours per week)
3. more than 3 pairs of gloves used per day and the timing of glove exposure

16/383 sensitization (4.2%)
8/16 symptoms: 4 dermal only, 2 respiratory only and 2 both

cross-reactive
carbohydrate
determinants' (CCD)
component-resolved
diagnosis (CRD)
horseradish
peroxidase
(HRP)

Specific IgE
False –ve: missing allergen
False +ve: IgE binding to N-glycans and/or O-glycans which are often part of allergens of
plant origin--> use cross-reactive carbohydrate determinants (CCD) to clarify

• positive cutoff point is established at >0.35 kUA/L
• CAP (Phadia) or AlaSTAT (Diagnostics Products Corporation)
• similar sensitivity (97% ,100%)
• specificity of 83% CAP, 33% AlaSTAT
• ImmunoCAP ISAC (CRD 112)
Specific IgE

Skin prick test
• Standardized extracts can provide a sensitivity of 93% with a
specificity of 100%
• ammoniated, non-ammoniated commercial extracts, glove extracts
• Many allergists create a homemade extract from gloves soaked in
diluent-possible false negative

• Alk-Abelló
• Allergopharma
• Bial-Aristegui
• Leti
• Lofarma
• Q-Pharma
• Stallergènes
SPT extract reagents
Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests, JACI 2013

SPT extract reagents
Evaluation and Comparison of Commercially Available Latex Extracts for Skin Prick Tests, JACI 2013

• Considered safe, although isolated cases of anaphylaxis have been
reported
• Intradermal tests are not recommended
Skin prick test
• 39-year-old housewife U/d AD+long standing asthma
• Reaction while painting her house, facial and periocular swelling
requiring systemic corticosteroids+ antihistamine
• SPT with 100 HEP Hevea brasiliensis ALK Abello (UK) ->Less than 3 min
complained of dizziness, difficulty breathing, wheezing and tachypnea
• NRL prick test site 6-mm Wheal reaction (histamine 4 mm)
• RAST for latex IgE 2.87 km/L (0–0.34 km/ L), total IgE 1047.0 km/L (0–
122 km/L)

Patch test
• in suspected delayed-type hypersensitivity reactions
• not attributable to latex but to additives
• it is advisable to test mixtures of substances (carba mix,
paraphenylenediamine mix, and thiuram mix) instead of each additive
separately, except mercaptobenzothiazole and N-I-para-
phenylenediamine

Glove use test
• Considerable disparity exists between glove use protocols, with
exposure times ranging from 15 minutes to 2 hours
• Place a fingertip of the glove on a dampened finger
• if –ve, put on complete powdered glove
• A vinyl or nitrile glove is used on the other hand as a negative control
• Positive if contact causes erythema, pruritus, blisters, or respiratory
symptoms

Other types of provocation test
• measurement of pulmonary function by spirometry after the
inhalation of aqueous surgical glove extract
• use of a “hooded exposure chamber” that permits progressive latex
aeroallergen exposure to a patient's airway and conjunctiva

Avoidance of latex objects

Alternative products
• neoprene, polyvinyl chloride, silicone, polyurethane, and vinyl
• Polyvinyl chloride (or simply vinyl) do not have the same barrier effect as
latex, not a valid alternative as infection protection
• Nitrile (acrylonitrile butadiene) provide protection comparable to latex,
similar permeability against cytotoxic agents
• For surgical procedures, synthetic polymers such as neoprene
(polychloroprene), polyisoprene, butadiene, and elastiprene are
recommended, given their biomechanical and barrier properties

Avoidance of foods with cross-reactivity to latex

Operating Room Patient Care
• Use non-latex gloves
• Use non-latex tourniquets or polyvinyl chloride tubing
• Draw medication directly from opened multidose vials (remove stoppers) if
medications are not available in ampoules
• Draw up medications immediately prior to the beginning of the case or their
administration.
• The rubber allergen could leach out of the plunger of the syringe causing a reaction. The
intensity appears to increase over time.
• Utilize latex-free or glass syringes, stopcocks to inject drugs rather than latex
ports.
• Place clear and readily visible signs on the doors

Airway Equipment
• Use Silicone Masks
• Use PVC ET tubes
• Use clear plastic oropharyngeal airways
• There is NO latex in the LMA

• Signs and Symptoms usually occur within 30 minutes following
anesthesia induction; however, can range from 10-290 minutes

Not made with natural rubber latex
J
Tracheostomy

Endotracheal tube
Mallinckrodt
Latex free

Gastrostomy
Fortune® Silicone Gastrostomy
Catheter
Latex/DEHP free

Norta urine catheter
Latex silicon
Urine catheter

Suction set
Meditek
Latex glove
Suction tube- no latex

Feeding tube
Terumo
No Latex ?

Gloves
Megaglove, Sempermed
Latex glove

Nitrile Gloves (Butadiene-acrylonitrile) มีความ
ทนทานต่อสารเคมีสูง
Vinyl Gloves (Polyvinyl Chloride หรือ PVC)
คุณสมบัติการป้ องกันที่ต่า และไม่ยืดหยุ่น
Neoprene Gloves (Polychloroprene) เป็นทางเลือกสาหรับผู้ที่
แพ้ถุงมือยาง Latex เนื่องจาก มีคุณสมบัติป้ องกันได้ดีเยี่ยม รวมทั้งให้
ความรู้สึกและสัมผัสที่ดี แต่ไม่ยืดหยุ่นและเหนียวเทียบเท่าถุงมือยางแบบ
Latex
BSI Group (Thailand) Co., Ltd

Nitrile Disposable Gloves
AMMEX Nitrile Exam Gloves
Textured/Micro-roughened
Beaded Cuff
Polymer Coated
Latex Free
Ambidextrous

Case consultation
• Specific IgE (k82) 3.59 kUA/L class3
• Skin prick test (soaked glove extract): pending
• Diagnosis: suspected NRL allergy (contact urticaria)
• Management
• advise latex-free medical product
• identification on medical record
• notify allergy clinic before each procedure

Latex allergy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Latex allergy

Similar to Latex allergy (20)

More from Chulalongkorn Allergy and Clinical Immunology Research Group

More from Chulalongkorn Allergy and Clinical Immunology Research Group (20)

Recently uploaded

Recently uploaded (20)

Latex allergy