Sublingual Allergen Immunotherapy in a Child Sensitized to Pollens Responder and nonresponder in one – Case Report

Allergen immunotherapy is a well-established way of treatment in children with allergic rhinitis (AR). The therapy is the only method of changing the natural course of the disease and may prevent new sensitizations (1) (2).  Unfortunately, it is not possible to achieve this effect in all allergic patients. To implement the treatment, the following conditions have to occur:  no contraindications,  good cooperation with patient/parents,   correct diagnosis of AR, and access to a specific allergen for immunotherapy (3). Finding the specific allergen which causes allergic symptoms is not easy in some patients, moreover,  typical allergy tests, like specific IgE serum measurements or skin prick tests, are not always sufficient (4). Another problem is the similarity of some allergens of different origins, e.g. plant families, with high homology in the primary structure of the proteins or carbohydrates leading to IgE cross-reactivity (5), therefore, molecular diagnostics is often necessary and currently available. Finally, a positive result of a specific IgE measurement or skin prick test does not always mean that a patient is allergic to the tested substance (6) (7).   For verification purposes, we sometimes have to perform allergen provocation challenges on our patients (8).

To highlight the problem of the proper allergen selection for allergy immunotherapy we present the history of long-term diagnostics and immunotherapy in a child with AR and asthma.

We report a 14-year-old boy, one of the monozygotic twins of healthy parents. He was healthy up to the 4th year of his life. Then, in the spring of 2013, he developed mild ocular allergy symptoms which did not require medical treatment.   In July 2013 skin prick tests with common allergens showed positive results for grain and dog. Because of mild symptoms, the young age of the boy, and incompatibility between the symptoms and the test results (he had no contact with pets), we decided to refrain from pharmacological treatment.

In 2014 symptoms occurred in April,  with moderate ocular problems, sneezing, and stuffy and runny nose. He received desloratadine and nasal mometasone. In June, the effect was unsatisfactory, and we decided to add montelukast to achieve a good effect.

After the pollen season, we performed diagnostic tests again. We found serum sIgE (kU/l): birch 3.60, hazel 0.73, alder 0.58, grass 62.00, rye 6.20, and positive skin prick tests to trees, grass, and weeds (Table. 1)

Table 1: Results of the analysis performed in October 2014.