Sublingual Allergen Immunotherapy in a Child Sensitized to Pollens Responder and nonresponder in one – Case Report
Mikolajczyk Marek¹, Baj Zbigniew², Majewska Ewa²
1Allergology Department of the Voivodeship Rehabilitation Hospital for Children in Ameryka, Poland.
2Department of Pathophysiology and Clinical Immunology, Medical University of Lodz, Poland.
Marek Mikolajczyk, Allergology Department of the Voivodeship Rehabilitation Hospital for Children in Ameryka, Poland.
In the Polish climate, April is the peak time of birch pollen season and June is the peak time of grass pollen season. Due to the obtained results, we decided to initiate allergen immunotherapy to grass before the next season, i.e. in February 2015. Grass pollen seemed to be a better choice as the first allergen since the clinical symptoms were more intensive in June than in April.
The boy received Staloral 300® 762 5 grass/rye (Stallergenes) sublingual drops. At the end of February and at the beginning of March, the boy required budesonide nebulization (Pulmicort 0.25mg/ml twice a day) because of dry cough and breathing difficulties, with a good effect. We had to introduce the same, as a year before, intensive treatment during June. The clinical picture and treatment were similar in 2016 - with asthma symptoms in March and allergic rhinitis symptoms in June.
Following the pollen season, we decided to add birch pollen immunotherapy - Staloral 300® 615 birch 100% (Stallergenes) sublingual drops and applied it from December 2016 to May 2017 with no complications. We decided to change the allergen composition because of the poor effect of the implemented immunotherapy during the grass pollen season. The boy got Staloral 300® 688 5 grass 100% (Stallergenes) sublingual drops along with birch immunotherapy.
The clinical picture of the boy in spring 2017 and 2018 was better. We observed only mild ocular symptoms in April. Spring 2019 was free of symptoms, however, during all these three seasons we had to introduce the same intensive treatment during June.
Because of the poor effect of the grass pollen immunotherapy, the boy had to undergo diagnostic sensitization tests once again in October 2019. Molecular diagnostics was then available. We found serum sIgE to grass pollen and its chosen proteins (Table. 2)
Table 2: Results of the analysis performed in October 2019.
We performed nasal lavage sIgE measurement and we found nasal sIgE concentrations corresponding to the observed in serum (Table. 3)
The results confirmed the properness of the allergens chosen for immunotherapy. The results of the birch pollen allergy treatment were excellent, so we decided to continue the same treatment in the two following seasons. The effects of the treatment of grass pollen allergy were disappointing, so we decided to change the allergen vaccine again. The boy was administered Oralair® 688 5 grass 100% (Stallergens) sublingual tablets from March 5 to the end of August 2020. The spring of 2020 was without any symptoms. There were only mild ocular symptoms treated with olopatadine eye drops in June. Because of better results achieved during the grass pollen season this year, we decided to continue therapy with Oralair for the next three years. Since 2022 the boy is free of symptoms. The allergy diagnostics were performed once again in March 2023 (Table. 4)
Table 3: Results of the nasal fluid analysis performed in October 2019.
Table 4: Results of the analysis performed on March 2023.
Figure 1: The dynamics of changes in the severity of the symptoms and the need for pharmacological and immunological treatment during the last eight years.
It is difficult to explain the low efficacy of grass pollen treatment, however, most probably, it resulted from the unstandardized allergen extract composition. The number and composition of proteins in the available allergen vaccines are not known, which leads to the random effectiveness of allergens chosen for immunotherapy. Therefore, it is difficult to match adequate allergen proteins to an individual patient’s sensitizations, moreover, proper allergic protein compositions can be insufficient if the patient’s immune system cannot recognize different epitopes on the proper allergen (9). Over time, there has been incremental improvement in AR symptoms observed in the boy as a result of the grass pollen immunotherapy, which proves that each of the consecutive allergen vaccines matched the boy’s allergy better, giving more satisfactory results.