We report a case of accidental injection of adrenaline auto-injectors (EpiPen^®) in right thumb of a healthy 10-year-old boy. The boy went to play with an 8-year-old boyfriend who had been prescribed an EpiPen^®. The 8-year-old boy brought a backpack in which the EpiPen^® was put. The 10-year-old boy found the EpiPen^® in the backpack, and he took it out with interest. He misidentified it to be a “pen” for writing. When he removed its safety cap and pressed its needle cover, its needle accidentally stuck into his right thumb. He was not able to pull out the EpiPen^® for himself. After he got home, his mother removed the needle from his thumb and took him to our hospital one hour after the injection. During the examination, he had no tachycardia or hypertension. However, a part beneath the nail of his right thumb was pale. We followed-up without treatment. Seven hours after the accidental injection, the pale site was ameliorated ; 1 day after, the pale site disappeared, and the color became light blue. There were no complications, such as tissue necrosis and osteomyelitis. We assumed that EpiPen^® needle was stuck in his right thumb distal phalanx, and adrenaline affected the right dorsal finger artery causing vasoconstriction, leading to ischemia.

Background : Allergen-specific immunotherapy is the only therapy that can alter the natural course of allergic disease, and early childhood may offer favorable opportunities for early intervention with a higher chance to affect its natural history. However, in Japan, no study has reported on immunotherapy in early childhood. Here, we report the safety and efficacy of rush immunotherapy with house dust extract for Japanese young children. Methods : This was a non-interventional, retrospective study performed on young patients with allergic rhinitis (AR). We included patients aged 3-5 years at the beginning of subcutaneous immunotherapy, in the younger group (12 patients), and those aged 6-15 years in the older group (27 patients). The safety of the treatment was assessed by the rate of systemic reaction. The efficacy of treatment was assessed by the reduction rate of AR symptom-medication score over 12 months of therapy. Result : The baseline symptom-medication score of the older group was higher than that of the younger group. There were no significant differences between both the two groups with respect to the systemic reaction rate and reduction rate of AR symptom-medication score. Conclusion : This study found that rush immunotherapy with house dust extract had the same level of safety and efficacy among children in younger age group as among those in older age group.

Standardized cedar pollen extracts came to be available, the possibility of the radical cure is suggested for cedar pollen allergy which has been increasing in all ages of Japan. In this study, 19 pediatric severe cedar pollen allergy patients who have difficulty in control of the symptoms with any drugs (13 men, 6 women, 4 to 15 years of age) had received a rapid subcutaneous immunotherapy (SCIT) with Japanese cedar pollen extract, and the clinical efficacy and safety were examined. As a result, improvement of symptoms is recognized in all cases, 78% were considered to be markedly improved. Local reactions were observed in all cases, and systemic reactions including anaphylaxis (11%), general urticarial (11%) and cough (5%) were presented respectively. Anaphylactic reactions were mild so as not to need adrenaline injection. SCIT with Japanese cedar pollen extract is effective and safe as well as other extracts. In recent years, sublingual-immunotherapy (SLIT) is also noted, superiority of SCIT has been strongly suggested. SCIT should be recommended for pediatric severe cedar pollen allergy patients.

Background : Allergic rhinitis (AR) has been characterized by questionnaires based on the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines as well as the Practical Guideline for the Management of Allergic Rhinitis in Japan (PG-MARJ). However, many patients have been classified as experiencing moderate/severe AR according to the ARIA definition ; because PG-MARJ symptom scores represent the average daily count, defining counts accurately is challenging. Purpose : To evaluate the usefulness of the visual analog scale (VAS) for assessing AR severity and degree of nasal symptoms, as well as for general monitoring of pediatric AR cases. Subjects and Methods : We evaluated children with AR, and compared their VAS values with ARIA and PG-MARJ results. Results : Children with moderate/severe AR (defined by ARIA) had significantly higher VAS values than children with mild AR. The cut-off VAS value to distinguish between mild and moderate/severe AR was 26 mm. VAS values were significantly correlated with PG-MARJ symptom scores. In 57 children monitored for 1-2 months, changes in VAS values were significantly correlated with changes in symptom scores. Conclusion : VAS is a useful tool to assess AR severity and monitor the degree of symptoms in pediatric AR cases.

1 : Exhaled nitric oxide concentration (eNO) is measured by handle device with expiratory flow rate of 50 ml/s and eNO plateau of 3 seconds according to ATS/ERP recommendation for standardized procedures. 2 : eNO values can be affected by several factors, including sex, age, height and atopic status. ATS recommended the use of cut points rather than reference values classified into low, intermediate and high eNO in children and adults. 3 : In case of asthmatic children, high eNO predicts effectiveness of ICS therapy for clinical and spirometric improvement. On the other side, low eNO suggests non-eosinophilic inflammation and poor ICS responsiveness. 4 : Some asthma phenotypes, such as mild atopic asthma, atopic asthma with allergic rhinitis dominant and severe atopic asthma with small airway obstruction were defined by our studies using eNO, lung function test and total and specific IgE analysis in asthmatic children older than 12 years of age, 5 : eNO is one of the Th2 high biomakers and its measurement is not only simple and non-invasive but also can be playfully performed, so eNO may be one of most expecting Th2 high biomarkers for predicting responsiveness of biologic medications in near future.