Atopic dermatitis (AD) is one of the most common inflammatory skin diseases, with a prevalence of up to 15%-20% in children and 2%-10% in adults. Patients with AD have genetically determined risk factors that affect the barrier function of the skin and immune responses that interact with environmental factors. Recently, there has been increasing awareness of the importance of vitamin D, a potential factor, in the development and progression of atopic diseases including AD. Furthermore, some reports suggested that vitamin D deficiency impairs epithelial integrity, leading to increased and inappropriate mucosal exposure to antigens promoting sensitization. Even though numerous studies favor strong associations of vitamin D deficiency during pregnancy and infancy with allergies, high vitamin D intake might be harmful according to conflicting results of other trials. The growing body of the literature indicates an inverse relationship between the severity of AD and vitamin D levels. Animal studies, case reports, randomized clinical trials, and birth cohort studies have suggested that vitamin D may alleviate the symptoms of AD through immune-modulation of the innate and adaptive immune system. Moreover, some studies have shown that in individuals with AD with low vitamin D level, repletion of vitamin D results in decreased severity of diseases. However, all these results have prompted the question of which time, dose, duration, or mode of application of vitamin D might be appropriate in children with AD. Further large cohort studies and clinical trials are warranted to assess the role of vitamin D in the prevention and treatment of AD in children.

Purpose: Dysregulated cysteinyl leukotriene (CysLT) synthesis is prominent in exercise-induced bronchoconstriction (EIB). Secreted phospholipase A2 (sPLA2) plays a key regulatory role in the biosynthesis of CysLTs. We previously found that serum leptin levels correlate with (EIB) in children with asthma. The aim of this study was to address the relationship between plasma sPLA2/leptin levels and EIB. Methods: Sixty-seven prepubertal children between the ages of 6 and 10 years were included in the study. They were asthmatics with EIB (n=25), asthmatics without EIB (n=21), and healthy subjects (n=21). We measured the plasma sPLA2 and leptin levels. We also performed pulmonary function tests at baseline, after bronchodilator inhalation, and after exercise. Results: The sPLA2 and leptin levels were significantly higher in asthmatics with EIB than in those without and control subjects. In addition, sPLA2 levels were significantly correlated with body mass index (Speraman correlation coefficient r=0.343, P=0.023) and leptin levels (partial correlation coefficient r=318, P=0.033). The maximum decrease in % forced expiratory volume in 1 second after exercise was significantly correlated with both PLA2 levels (r=0.301, P=0.041) and leptin levels (r=0.346, P=0.018). Conclusion: The sPLA2 and leptin levels were significantly higher in asthmatics with EIB than in asthmatics without EIB and control subjects. In addition, sPLA2 levels were significantly correlated with leptin levels and EIB in asthmatic children.

Purpose: Chronic cough is one of the major symptoms of asthma and allergic sensitization and may appear prior to the onset of asthma. The object of this study was to investigate the risk of allergic sensitization in preschool children with chronic cough. Methods: We reviewed the medical records of 99 preschool children presenting with chronic cough but not with allergic rhinitis, atopic dermatitis, recurrent wheezing, or lower respiratory tract infection between November 2011 and July 2013. Results: Fifty-four children (55%) were sensitized at least one of the following inhalant allergens: Dermatophagoides pteronyssinus, Dermatophagoides farinae, cockroach, Alternaria alternata, dog dander, and cat epithelium. Children with allergic sensitization had a higher blood total IgE levels transformed by common logarithm (1.9±0.6 IU/mL vs. 1.3±0.5 IU/mL, P<0.001) and eosinophils (3.7%±2.5% vs. 2.7%±2.0%, P=0.043), more frequent parental history of allergy (68% vs. 48%, P=0.044) and less frequent history of breast milk feeding (68% vs. 86%, P=0.041) than those without. Conclusion: These results suggest that the ratio of allergic sensitization may be 50% or more in preschool children with chronic cough and that parental history of allergy and formula milk feeding may be associated with allergic sensitization.

Purpose: IgE is associated with allergic disease. However, insufficient research has been carried out regarding the levels of serum IgA in children with allergic disease. The purpose of this study was to evaluate the levels of serum immunoglobulin in Korean children with allergic disease and to identify significant correlations between such diseases and serum IgA levels. Methods: We evaluated 338 children who visited the Pediatric Allergy Clinic, CHA Bundang Medical Center from March 2007 to July 2013. We assessed factors, such as sex, age, and family history of allergic diseases. Laboratory tests, including serum IgG, A, and M, total IgE, and specific IgE, were carried out on all patients. In addition, we compared serum IgA levels in allergic Korean children with normal reference ranges. Results: The median (interquartile range) of serum IgA values was 31.1 mg/dL (14.3-50.6 mg/dL) in cases of food allergy and 44.3 mg/dL (25.7-94.2 mg/dL) in cases of atopic dermatitis. The serum IgA levels were lower in allergic Korean children aged 9-12 months and 25-72 months than in the normal mean reference values. Relationships between age and serum IgA levels were statistically significant in allergic children. Conclusion: Our study suggests that serum IgA levels might be lower in allergic children than in the normal mean reference values. In order to understand this mechanism, normal levels for IgA in Korean children must be determined.

Purpose: The characteristics of allergic rhinitis can be different among countries and areas because causative allergens and aggravating factors depend on the living environment. However, there have been few studies on the clinical feature of Korean children with allergic rhinitis, as well as on clinical characteristics in different age groups. The aim of this study was to investigate the clinical characteristics of Korean children with allergic rhinitis. Methods: The medical records of children under 12 years of age who had rhinitis symptoms were analyzed in terms of clinical symptoms and positive allergens. Subjects were classified into 2 groups: those with allergic rhinitis (AR group) and nonallergic rhinitis (NAR group). Both groups were subdivided into 3 categories: the 1-4 years, 5-8 years, and 9-12 age groups. Results: Among 516 children, 397 (76.94%) belonged to the AR group and 119 (23.06%) belonged to the NAR group. The male to female ratios were 2:1 in both groups. There were significant differences in sneezing and itching between the AR and NAR groups across different age subgroups. There were significant differences in nasal obstruction between the AR and NAR groups in the 9-12 age group. The incidence of AR was 77.8 % in chronic sinusitis patients. Sensitized allergens were house dust mites, animal hair, pollen, and mold in decreasing order in the AR group. Children who were sensitized to animal hair more frequently had sneezing than those who were not. Conclusion: Sneezing and itching strongly suggest allergic rhinitis in Korean children. Clinical characteristics of allergic rhinitis in Korean children would helpful in early diagnosis and adequate treatment of disease.

Purpose: Adverse cutaneous reactions to antituberculous drugs (ATD), such as maculopapular eruption (MPE), are the most common causes of discontinuation of scheduled treatment of tuberculosis. We previously reported that tumor necrosis factor (TNF)-α genetic polymorphism -308G/A is significantly associated with ATD-induced hepatitis. This study aimed to investigate associations between TNF-α -308G/A and ATD-induced MPE. Methods: Patients with ATD-induced MPE and controls without any adverse reactions to ATD were recruited from the database of the Adverse Drug Reaction Pharmacogenomic Research Group database of Korea. We compared the genotype frequency of TNF-α -308G/A between patients with ATD-induced MPE and ATD-tolerant controls. Results: A total of 69 patients with ATD-induced MPE and 229 control subjects were enrolled for this study. There were no significant differences in genotype frequency between the patients and the controls, suggesting lack of associations between TNF-α -308G/A and ATD-induced MPE. Conclusion: The TNF-α genetic polymorphism -308G/A may not be related to the development of ATD-induced MPE, in contrast to ATD-induced hepatitis. These findings suggest that associations between TNF-α -308G/A and ATD-induced adverse reactions can be phenotype-specific.

Purpose: Atopic dermatitis is one of the most common allergic diseases, and its prevalence has been increasing in recent decades. Social economic status is a well-known risk factor for allergic disease. This study was performed to investigate the relationship between social economic status and atopic dermatitis in Korean adults. Methods: Data were acquired from 18,066 men and women aged older than 19 years who participated in the Fifth Korea National Health and Nutrition Examination Surveys (KNHANES), which was conducted from 2010 to 2012. The presence of atopic dermatitis was based on self-reported physician diagnosis of atopic dermatitis in the Health Interview Surveys. Results: The prevalence of atopic dermatitis was 2.3%, which decreased with age. In univariate analysis, adults with atopic dermatitis were younger, well-educated, had higher monthly family income, had more household members, and lived in the urban area (P<0.05), whereas sex, residential type, or smoking status was not associated with the presence of atopic dermatitis. The prevalence of hypertension, diabetes mellitus, and obesity were lower in atopic dermatitis subjects, while asthma was higher (P<0.05). Binary logistic regression analysis showed that younger age and the presence of asthma were associated with higher prevalence of atopic dermatitis (P<0.01). Conclusion: The results of this study suggest that younger age and the prevalence of asthma may be important risk factors for the prevalence of atopic dermatitis in Korean adults. These results warrant future studies to explore mechanisms underlying the association between social economic status and atopic dermatitis.

PurposeGenetic modification technique is widely used in plants for improving crop yields and qualities, and reducing pesticide use. Zoysia japonica is one of the widely planted grasses for lawning. Pollenless herbicide-tolerant genetically modified (GM) grasses (JG21-MS1 and JG21-MS2) were developed under surveillance for possible biohazard. Grasses may cause allergic contact dermatitis with direct contact on human skin. Patch testing with allergens was adopted to compare the incidences of allergic contact dermatitis to GM grass leaves with those of wild-type grass.MethodsPatch testing with controls and leaves of wild-type and GM grasses was performed in individuals with informed consent.ResultsNinety-seven individuals (mean age, 32±8 years; 48% males) were enrolled. For nickel sulfate as a positive control, 38 subjects (39.2%) were positive. For GM grasses, 10 (10.3%) showed positive patch test results and 11 (11.3%), for wild-type grass, the proportions of which were similar among the tested grasses.ConclusionJG21-MS1 and JG21-MS2 are not more biohazardous than wild-type grass in the risk of allergic contact dermatitis.

Purpose: Cow's milk-specific IgE (CM-IgE) has been proposed as one of the valuable markers for diagnosis of clinical cow's milk (CM) allergy. In this study, we evaluated the additional usefulness of casein-specific IgE (casein-IgE) and IgG (casein-IgG) for the diagnosis of clinical CM allergy. Methods: Fifty-eight subjects, aged from 3 months to 154 months, were enrolled. Thirty-four patients showed immediate-type of clinical CM allergy, and 24 patients were atopic controls. The serum levels of CM-IgE, casein-IgE, and casein-IgG were measured. Patients were divided into 2 groups: those aged under 12 months and those aged 12 months or over. The diagnostic values of each antibody were analyzed and compared using the Mann-Whitney U-test and receiver operating characteristic curves. Results: CM allergy had significantly higher levels of CM-IgE and casein-IgE, and lower levels of casein-IgG/IgE ratio when compared to atopic controls in both age groups (P<0.05). CM-IgE and casein-IgE were shown to be better predictive markers for immediate-type CM allergy in patients under 12 months, while casein-IgG/IgE ratio was a more useful marker in those aged 12 months or over. Considering 100% positive predictive values, cutoff points were 1.04 kU/L for CM-IgE, 0.11 kU/L for casein-IgE, 19.5 for casein-IgG/IgE ratio in patients aged under 12 months, and 7.1 kU/L for CM-IgE, 1.41 kU/L for casein-IgE, 12.51 for casein-IgG/IgE ratio in those aged 12 months or over. Conclusion: CM-IgE, casein-IgE, and casein-IgG/IgE ratio are useful markers for predicting immediate-type CM allergy. Further studies are needed on diagnostic decision points for CM allergy using combination of cutoff values of these 3 markers.

Purpose: Pneumomediastinum is rare in children and adolescents, and its causes have not yet been clearly determined. We aimed to identify the causes, clinical manifestations and prognosis of noniatrogenic pneumomediastinum in children. Methods: From February 2007 to June 2014, we retrospectively investigated 121 patients with pneumomediastinum under 18 years of age in 2 hospitals. Eighteen patients with pneumomediastinum after thoracotomy and 35 patients with iatrogenic pneumomediastinum were excluded. Results: Sixty-eight patients were divided into 4 age groups: those under 1 year of age (n=9, 13.2%), those 1 to 5 years of age (n=9, 13.2%), those 6 to 10 years of age (n=17, 25.0%) and those over 11 years of age (n=33, 48.5%). Chest pain (n=43, 63.2%) was the most common initial complaint and subcutaneous emphysema was identified in 18 patients (26.5%). Chest x-ray was diagnostic in all except 9 patients (13.2%). Predisposing causes of pneumomediastinum were idiopathic (n=26, 38.2%), respiratory tract infection (n=23, 33.8%), asthma exacerbation (n=4, 5.9%), trauma (n=4, 5.9%), endobronchial foreign body (n=2, 2.9%), interstitial lung disease (n=5, 7.4%), and neonatal respiratory disease (n=4, 5.9%). Chest pain (P<0.001) and idiopathic cause (P=0.001) were shown to linearly increase with age. On the contrary, tachypnea (P<0.001), dyspnea (P=0.016), and interstitial lung disease (P=0.008) were shown to have a decreasing linear association with age. The length of hospital stay was significantly increased in patients with interstitial lung disease (P=0.042), those with pneumothorax (P=0.044), and those without chest pain (P=0.013). Conclusion: According to age groups, there were significant differences in causes and clinical manifestations. In particular, pneumomediastinum that developed in younger patients with interstitial lung disease showed unfavorable outcomes, such as dyspnea, pneumothorax, and increased length of hospital stay. Therefore, precise evaluation of predisposing causes and careful management are needed for children with pneumomediastinum.

Bee stings can cause severe adverse reactions. There have been no cases of acute lung injury induced by bee sting acupuncture. We report a case of a 52-year-old male who required high flow oxygen therapy because of acute lung injury by bee sting acupuncture. The patient had been treated with live bee sting acupuncture by himself for knee pain. After self-injections of live bee sting, he immediately presented with generalized urticaria that remitted within 3 hours after taking an oral antihistamine. Ten days later, he visited our emergency department due to dyspnea and dizziness. He was diagnosed with acute lung injury by bee sting acupuncture based upon a history of symptom onset after exposure to the allergen and clinical test results. This case emphasizes that practitioners should consider potential risks of delayed-onset adverse reactions induced by bee sting acupuncture.

Trimethoprim-sulfamethoxazole (TMP-SMX) is an antibiotic used for the treatment or prophylaxis of Pneumocystis pneumonia and other infectious conditions. Sulfonamide derivatives have been reported to cause delayed hypersensitivity reactions, resulting in switch to less effective second-line antibiotics. Although desensitization is traditionally known to be effective in patients with immediate hypersensitivity, it is also applied to the treatment of delayed hypersensitivity in recent years. A 66-year-old female who had a history of repeated TMP-SMX-induced delayed hypersensitivity presenting as whole body rashes needed to take prophylactic dose of TMP-SMX (80/400 mg daily) before initiation of chemotherapy for multiple myeloma. Intravenous rapid desensitization was performed by using a 11-step, 4-bottle protocol from 1:1,000 to 1:1 solution for 3 hours to reach the target dose for prophylaxis. After successful rapid desensitization of TMP-SMX, 1-month prophylaxis was completed without any complications until the patient recovered normal immunity. We herein reported a case of delayed hypersensitivity reaction to TMP-SMX in an about-to-be immunocompromised host with planned chemotherapy who successfully completed 1-month prophylaxis with the drug without any complications through rapid desensitization.

Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a rare systemic necrotizing vasculitis affecting small- to medium-sized vessels. EGPA is associated with severe asthma and eosinophilia. The most frequently involved organs are skin and peripheral nerves; however, EGPA may involve other organs, such as the gastrointestinal tract, kidney, and heart. Antineutrophil cytoplasm antibodies (ANCAs)-related abnormal immune reactions are known to be associated with EGPA, but only 30%-40% of patients have a positive marker of ANCA. ANCA-negative patients are at higher risk of cardiac involvement than ANCA-positive patients. Cardiac involvement is one of the leading causes of mortality and could be resistant to conventional treatment. Early treatment with steroid plus cyclophosphamide is important because it could give chances of restoration of cardiac function. For patients undergoing heart transplantation, we should consider the severity of cardiac disease and the presence of systemic diseases, including vasculitis. Here, we report a case of a 25-year-old EGPA patient with cardiac involvement who eventually received heart transplantation for progressive heart failure, although treated with systemic corticosteroid with cyclophosphamide. EGPA patients undergoing heart transplantion are rarely reported worldwide, and this is the first case report in Korea.