Latex Allergy 2

8/8/2019 Latex Allergy 2

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RISK FACTOR forLATEX ALLERGYRISK FACTOR forLATEX ALLERGY

Haryani, SKp, M.KesHaryani, SKp, M.Kes


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IntroductionIntroduction Allergy to natural rubber latex is

increasingly common and serious in

children and adults.

Latex is the milky fluid derived from thelactiferous cells of the rubber tree, Heveabrasiliensis.

Contains a large variety of sugars, lipids,nucleic acids, and highly allergenicproteins.

Allergy to natural rubber latex isincreasingly common and serious in

children and adults.

Latex is the milky fluid derived from thelactiferous cells of the rubber tree, Heveabrasiliensis.

Contains a large variety of sugars, lipids,nucleic acids, and highly allergenicproteins.


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IntroductionIntroduction Latex is ubiquitous in modern society and particularly in

health care

In the late 1980s, however, latex gloves were widely

recommended to prevent transmission of blood-bornepathogens, including HIV

In the 1980s and 1990s, heightened demand for latex tomanufacture gloves and other objects resulted in hundredsof new, poorly regulated latex factories in tropicalcountries. The incidence of minor and serious allergicreactions to latex began to rise rapidly among patients and

health care workers (HCWs).

Latex is ubiquitous in modern society and particularly inhealth care

In the late 1980s, however, latex gloves were widely

recommended to prevent transmission of blood-bornepathogens, including HIV

In the 1980s and 1990s, heightened demand for latex tomanufacture gloves and other objects resulted in hundredsof new, poorly regulated latex factories in tropicalcountries. The incidence of minor and serious allergicreactions to latex began to rise rapidly among patients and

health care workers (HCWs).


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PathophysiologyPathophysiology

Latex exposure is associated with 3

clinical syndromes.

The first syndrome is irritant dermatitis.

It is a result of mechanical disruption of

the skin due to the rubbing of gloves. It

is not immune mediated, is notassociated with allergic complications

Latex exposure is associated with 3

clinical syndromes.

The first syndrome is irritant dermatitis.

It is a result of mechanical disruption of

the skin due to the rubbing of gloves. It

is not immune mediated, is notassociated with allergic complications


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PathophysiologyPathophysiology The second syndrome is a delayed (type IV)

hypersensitivity reaction, resulting in a typical

contact dermatitis. Symptoms usually developwithin 24-48 hours of cutaneous or mucousmembrane exposure to latex in a sensitized person

Langerhans cells process the antigens and present

them to cutaneous T cells Type IV hypersensitivity is more common in atopic

individuals. The dermatitis may predispose patientsto further sensitizations or infections.

The second syndrome is a delayed (type IV)hypersensitivity reaction, resulting in a typical

contact dermatitis. Symptoms usually developwithin 24-48 hours of cutaneous or mucousmembrane exposure to latex in a sensitized person

Langerhans cells process the antigens and present

them to cutaneous T cells Type IV hypersensitivity is more common in atopic

individuals. The dermatitis may predispose patientsto further sensitizations or infections.


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PathophysiologyPathophysiology The third, most serious, and least

common syndrome is immediate (type I)

hypersensitivity. It is mediated by animmunoglobulin E (IgE) responsespecific for latex proteins

IgE molecules on mast cell and basophil

cell membranes by latex proteinallergens triggers the release of histamine and other mediators of thesystemic allergic cascade in sensitizedindividuals.

The third, most serious, and leastcommon syndrome is immediate (type I)

hypersensitivity. It is mediated by animmunoglobulin E (IgE) responsespecific for latex proteins

IgE molecules on mast cell and basophil

cell membranes by latex proteinallergens triggers the release of histamine and other mediators of thesystemic allergic cascade in sensitizedindividuals.


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PathophysiologyPathophysiology Exposure can occur following skin,

mucous membrane, or

visceral/peritoneal contact. It also canfollow inhalation of latex-laden particlesor bloodstream exposure to soluble latexproteins following intravascular accessprocedures. Powdered latex examinationgloves have been the most frequentsource of sensitization in adults, causingcutaneous and inhalational exposures.

Exposure can occur following skin,mucous membrane, or

visceral/peritoneal contact. It also canfollow inhalation of latex-laden particlesor bloodstream exposure to soluble latexproteins following intravascular accessprocedures. Powdered latex examinationgloves have been the most frequentsource of sensitization in adults, causingcutaneous and inhalational exposures.


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PathophysiologyPathophysiology Sensitization is more common in atopic

individuals. Symptoms generally begin within

minutes of exposure. The spectrum of clinical manifestations includes

localized or generalized urticaria, rhinitis,conjunctivitis, bronchospasm, laryngospasm,

hypotension, and full-blown anaphylaxis. Type Iallergy has been implicated clearly inintraoperative and intraprocedure anaphylaxis,and it can be fatal without emergent treatment.

Sensitization is more common in atopicindividuals. Symptoms generally begin within

minutes of exposure. The spectrum of clinical manifestations includes

localized or generalized urticaria, rhinitis,conjunctivitis, bronchospasm, laryngospasm,

hypotension, and full-blown anaphylaxis. Type Iallergy has been implicated clearly inintraoperative and intraprocedure anaphylaxis,and it can be fatal without emergent treatment.


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PathophysiologyPathophysiology Latex is known to cause 2 of the 4 types ofhypersensitivity.

Type IThe most serious and rare form, type I is an immediateand potentially life-threatening reaction, not unlike the severereaction some people have to bee stings. Such reactionsaccount for a significant proportion ofperioperativeanaphylactic reaction, especially in children withmyelomeningocele. Synthetic latex products do not containthe proteins from the Hevea brasiliensis tree and will notcause this type of reaction.

Latex is known to cause 2 of the 4 types ofhypersensitivity.

Type IThe most serious and rare form, type I is an immediateand potentially life-threatening reaction, not unlike the severereaction some people have to bee stings. Such reactionsaccount for a significant proportion ofperioperativeanaphylactic reaction, especially in children withmyelomeningocele. Synthetic latex products do not containthe proteins from the Hevea brasiliensis tree and will notcause this type of reaction.


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PathophysiologyPathophysiology Some people who are allergic to latex are

also allergic to clothes, shoes, and other

things that contain natural rubber latex

for example elastic bands, rubbergloves, condoms, pacifiers and baby-bottle nipples, balloons, cars, andclothing containing natural rubber basedelastic. Synthetic elastic such aselastane or neoprene do not contain theproteins that trigger type I reactions.

Some people who are allergic to latex arealso allergic to clothes, shoes, and other

things that contain natural rubber latex

for example elastic bands, rubbergloves, condoms, pacifiers and baby-bottle nipples, balloons, cars, andclothing containing natural rubber basedelastic. Synthetic elastic such aselastane or neoprene do not contain theproteins that trigger type I reactions.


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PathophysiologyPathophysiology Type IV (allergic contact dermatitis)Also known as

allergiccontact dermatitis. This involves a delayed skin rashthat is similar to poison ivy with blistering and oozing of the

skin (see urushiol-induced contact dermatitis). This type iscaused by a naturally occurring latex protein.Type IV reactionsare caused by the chemicals used to process the rubber. Patchtesting needs to be done to verify which type of chemicaltriggers the reaction. Once the chemical is identified, then the

person can choose products that are not processed with thatchemical. Both natural rubber andsynthetic rubberproductsmay cause type IV reactions.

Type IV (allergic contact dermatitis)Also known asallergiccontact dermatitis. This involves a delayed skin rashthat is similar to poison ivy with blistering and oozing of the

skin (see urushiol-induced contact dermatitis). This type iscaused by a naturally occurring latex protein.Type IV reactionsare caused by the chemicals used to process the rubber. Patchtesting needs to be done to verify which type of chemicaltriggers the reaction. Once the chemical is identified, then the

person can choose products that are not processed with thatchemical. Both natural rubber andsynthetic rubberproductsmay cause type IV reactions.


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Those at greatest riskThose at greatest risk Children with myelomeningocele Spina bifida. Between 40% to

100% will have a reaction.

Industrialrubberworkers, exposed for long periods to highamounts of latex.About 10% have an allergic reaction.

Healthcare workers. Healthcare workers who frequently use latexgloves and other latex-containing medical supplies such as

physicians, nurses, aides, dentists, dental hygienists, operating

room employees, laboratory technicians, and hospitalhousekeeping personnel are at risk for developing latex allergy.

People who have had multiple surgical procedures, especially inchildhood

Children with myelomeningocele Spina bifida. Between 40% to100% will have a reaction.

Industrialrubberworkers, exposed for long periods to highamounts of latex.About 10% have an allergic reaction.

Healthcare workers. Healthcare workers who frequently use latexgloves and other latex-containing medical supplies such as

physicians, nurses, aides, dentists, dental hygienists, operating

room employees, laboratory technicians, and hospitalhousekeeping personnel are at risk for developing latex allergy.

People who have had multiple surgical procedures, especially inchildhood


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Frequency and Risk factorsFrequency and Risk factors

United States

Latex allergy is present in 1-5% of the general

population, with an increased prevalence in atopicindividuals. Latex allergy is increased inpopulations with chronic occupational exposure tolatex. It is found in 2-17% of HCWs and in at least

10% of rubber industry workers. The highest prevalence of latex allergy (20-68%) is

found in patients with spina bifida or congenitalurogenital abnormalities

United States

Latex allergy is present in 1-5% of the general

population, with an increased prevalence in atopicindividuals. Latex allergy is increased inpopulations with chronic occupational exposure tolatex. It is found in 2-17% of HCWs and in at least

10% of rubber industry workers. The highest prevalence of latex allergy (20-68%) is

found in patients with spina bifida or congenitalurogenital abnormalities


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Frequency andrisk factorFrequency andrisk factor Other patients with a history of multiple surgeries

or other latex-exposing procedures are also at

increased risk relative to the general population.Patients with cerebral palsy, mental retardation, orquadriplegia also appear to have increased risk oflatex allergy

Finally, the prevalence of latex allergy is increasedin persons with allergies to avocado, banana,mango, pineapple, strawberry, soy, chestnut, kiwi,papaya, peach, or nectarine. This is known as the

latex-fruit syndrome

Other patients with a history of multiple surgeriesor other latex-exposing procedures are also at

increased risk relative to the general population.Patients with cerebral palsy, mental retardation, orquadriplegia also appear to have increased risk oflatex allergy

Finally, the prevalence of latex allergy is increasedin persons with allergies to avocado, banana,mango, pineapple, strawberry, soy, chestnut, kiwi,papaya, peach, or nectarine. This is known as the

latex-fruit syndrome


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Frequency andrisk factorFrequency andrisk factor International

The risk patterns described above are similar in otherdeveloped countries. One study from Germany suggests

that the incidence of type I latex allergy has risen fasterrecently among HCWs than Type IV hypersensitivity

A recent meta-analysis of the French literature confirmedthat HCWs have an increased risk of sensitization andallergic symptoms to latex. Workers with occupationalexposure during harvesting and/or processing latex indeveloping countries where H brasiliensis is grown havean increased risk relative to the general populations.

International

The risk patterns described above are similar in otherdeveloped countries. One study from Germany suggests

that the incidence of type I latex allergy has risen fasterrecently among HCWs than Type IV hypersensitivity

A recent meta-analysis of the French literature confirmedthat HCWs have an increased risk of sensitization andallergic symptoms to latex. Workers with occupationalexposure during harvesting and/or processing latex indeveloping countries where H brasiliensis is grown havean increased risk relative to the general populations.


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Frequency andrisk factorFrequency andrisk factor Sex

Incidence in males and females is equal.

Age

Latex allergy probably is more common inchildren and in younger working adults

because of the increased medical and/oroccupational exposure over the past twodecades.

Sex

Incidence in males and females is equal.

Age

Latex allergy probably is more common inchildren and in younger working adults

because of the increased medical and/oroccupational exposure over the past twodecades.


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Mortality/

Morbidity

Mortality/

Morbidity

Patients with type I hypersensitivity are at risk of developinganaphylaxis and/or respiratory obstruction, which can be fatal.

Deaths have been reported following the intraoperative use of

latex rectal catheters. Latex anaphylaxis has occurred afterchildbirth, instrumentation, intravenous injection, balloonblowing, and condom use.

Although most patients can be treated effectively for type IVand type I reactions without clinical sequelae, major allergy

may prevent them from pursuing certain careers, using manyhousehold and workplace objects, and seeking timely medicalcare due to justified fear of latex exposure.

Patients with type I hypersensitivity are at risk of developinganaphylaxis and/or respiratory obstruction, which can be fatal.

Deaths have been reported following the intraoperative use of

latex rectal catheters. Latex anaphylaxis has occurred afterchildbirth, instrumentation, intravenous injection, balloonblowing, and condom use.

Although most patients can be treated effectively for type IVand type I reactions without clinical sequelae, major allergy

may prevent them from pursuing certain careers, using manyhousehold and workplace objects, and seeking timely medicalcare due to justified fear of latex exposure.


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CLINICAL

MANIFESTATION

CLINICAL

MANIFESTATIONA. History Symptoms of delayed (type IV) hypersensitivity usually

develop within 1-2 days of exposure. Immediate (type I)

hypersensitivity causes symptoms within minutes of exposure.

Symptoms may include the following:

Pruritus of exposed skin and mucous membranes

Edema of the skin, mucous membranes, or subcutaneoustissues

Hoarseness

Tearing

Rhinitis

A. History

Symptoms of delayed (type IV) hypersensitivity usuallydevelop within 1-2 days of exposure. Immediate (type I)

hypersensitivity causes symptoms within minutes of exposure.

Symptoms may include the following:

Pruritus of exposed skin and mucous membranes

Edema of the skin, mucous membranes, or subcutaneoustissues

Hoarseness

Tearing

Rhinitis


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CLINICAL

MANIFESTATION

CLINICAL

MANIFESTATION Dyspnea

Lightheadedness, syncope

Abdominal cramping

Nausea, vomiting Diarrhea

B. Physical Rash

Erythema, edema, papules, and vesicles in areas

of direct contact (type IV)

Erythema, thickening, and pigment changes withchronic exposure (type IV)

Urticaria, localized or generalized (type I)

Dyspnea

Lightheadedness, syncope

Abdominal cramping

Nausea, vomiting Diarrhea

B. Physical Rash

Erythema, edema, papules, and vesicles in areas

of direct contact (type IV)

Erythema, thickening, and pigment changes withchronic exposure (type IV)

Urticaria, localized or generalized (type I)


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CLINICAL

MANIFESTATION

CLINICAL

MANIFESTATION Conjunctivitis

Rhinitis

StridorWheezing

Hypotension, shock

Conjunctivitis

Rhinitis

StridorWheezing

Hypotension, shock


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Common Source of Latex

Exposure


Exposure

The source of latex exposure may be obvious or occult.

The history of latex allergy may be known or unknown.

Individuals may be exposed to latex through their skin,mucous membranes, or airway (ie, oral, nasal, or endotracheal tissue).

Medical procedures may cause reactions in sensitized

providers or patients. Inhalational exposure also may occur outside hospitals

from use of powder-lubricated latex products or even tireparticles in heavy traffic areas.

The source of latex exposure may be obvious or occult.

The history of latex allergy may be known or unknown.

Individuals may be exposed to latex through their skin,mucous membranes, or airway (ie, oral, nasal, or endotracheal tissue).

Medical procedures may cause reactions in sensitized

providers or patients. Inhalational exposure also may occur outside hospitals

from use of powder-lubricated latex products or even tireparticles in heavy traffic areas.


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Exposure


Exposure

Type I natural rubber latex allergy is caused from

IgE (immune) mediated reactions to proteins

found in the Hevea brasiliensis tree.

Synthetic latex products do not contain the

proteins from the Hevea brasiliensis tree

and will not cause this type of reaction.

Type I natural rubber latex allergy is caused from

IgE (immune) mediated reactions to proteins

found in the Hevea brasiliensis tree.

Synthetic latex products do not contain the

proteins from the Hevea brasiliensis tree

and will not cause this type of reaction.


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Exposure


Exposure

Type IV reactions are caused by the chemicals

used to process the rubber. Patch testing needs

to be done to verify which type of chemical

triggers the reaction. Once the chemical is

identified, then the person can choose products

that are not processed with that chemical. Both

natural rubber and synthetic rubber products

may cause type IV reactions.

Type IV reactions are caused by the chemicals

used to process the rubber. Patch testing needs

to be done to verify which type of chemical

triggers the reaction. Once the chemical is

identified, then the person can choose products

that are not processed with that chemical. Both

natural rubber and synthetic rubber products

may cause type IV reactions.


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Exposure


Exposure Gloves (eg, examination, surgical, household)

Tourniquets, blood pressure cuffs

Stethoscopes

Catheters Intravenous tubing ports, syringe plungers

Electrode pads

Goggles

Respirators

Wound drains and tubes Multidose vial tops

Dental dams

Tires

Gloves (eg, examination, surgical, household)

Tourniquets, blood pressure cuffs

Stethoscopes

Catheters Intravenous tubing ports, syringe plungers

Electrode pads

Goggles

Respirators

Wound drains and tubes Multidose vial tops

Dental dams

Tires


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Exposure


Exposure

Handgrips

Carpeting

Shoe soles, elastic in clothing Condoms, diaphragms

Balloons

Pacifiers, baby bottle nipples

Erasers, computer mouse pads, andrubber bands

Handgrips

Carpeting

Shoe soles, elastic in clothing Condoms, diaphragms

Balloons

Pacifiers, baby bottle nipples

Erasers, computer mouse pads, andrubber bands


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Laboratory StudiesLaboratory Studies Skin prick testing with latex extracts is sensitive, specific,

and rapid; however, it carries the risk of anaphylaxis.

Total serum IgE may be elevated in patients with type Iallergy, but it is neither sensitive nor specific.

Enzyme-linked assays of latex-specific IgE (ELISA)

Skin patch testing is useful in identifying specificallergens in patients with type IV hypersensitivity to latex

products.

Skin prick testing with latex extracts is sensitive, specific,and rapid; however, it carries the risk of anaphylaxis.

Total serum IgE may be elevated in patients with type Iallergy, but it is neither sensitive nor specific.

Enzyme-linked assays of latex-specific IgE (ELISA)

Skin patch testing is useful in identifying specificallergens in patients with type IV hypersensitivity to latex

products.


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Complications and

Prognosis

Complications and

Prognosis Complications

Respiratory compromise

Anaphylaxis

Prognosis

Most latex-allergic patients can function normally by avoidingsignificant latex exposure at home, at work, and in medical/dentalsituations.

Some patients will become more sensitized and have greaterdifficulty functioning.

A small percentage of patients with IgE-mediated allergy becomeso sensitized that inadvertent exposure to minute amounts oflatex, either by contact or inhalation, causes frequent life-threatening episodes.

Complications

Respiratory compromise

Anaphylaxis

Prognosis

Most latex-allergic patients can function normally by avoidingsignificant latex exposure at home, at work, and in medical/dentalsituations.

Some patients will become more sensitized and have greaterdifficulty functioning.

A small percentage of patients with IgE-mediated allergy becomeso sensitized that inadvertent exposure to minute amounts oflatex, either by contact or inhalation, causes frequent life-threatening episodes.


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TreatmentTreatment PrehospitalCare

Prehospital providers should be aware of the risk of latex allergy inpatients and providers.

Note the patient's history of relevant allergies to medical devices orfruits.

To rule out latex allergy that could worsen with further medicalexposure, review the patient's history of activities/exposuresimmediately preceding any systemic allergic reaction.

Use powder-free latex gloves or, ideally, high-quality nonlatexgloves to minimize risk to patients and providers. Latex-freeresuscitation and intravenous (IV) access equipment should beavailable for high-risk patients. Do not give medication fromrubber-topped multidose vials or through latex IV ports in latex-allergic patients.

PrehospitalCare

Prehospital providers should be aware of the risk of latex allergy inpatients and providers.

Note the patient's history of relevant allergies to medical devices orfruits.

To rule out latex allergy that could worsen with further medicalexposure, review the patient's history of activities/exposuresimmediately preceding any systemic allergic reaction.

Use powder-free latex gloves or, ideally, high-quality nonlatexgloves to minimize risk to patients and providers. Latex-freeresuscitation and intravenous (IV) access equipment should beavailable for high-risk patients. Do not give medication fromrubber-topped multidose vials or through latex IV ports in latex-allergic patients.


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TreatmentTreatment Emergency Department Care

- Patients with known or suspected latex allergy

must be kept within a latex-safe environment

- Patients presenting with frank symptoms of type Ilatex allergy are treated as any other patients withsystemic allergic reactions, except they must beprotected from further latex contact to avoidclinical deterioration.

Emergency Department Care

- Patients with known or suspected latex allergy

must be kept within a latex-safe environment

- Patients presenting with frank symptoms of type Ilatex allergy are treated as any other patients withsystemic allergic reactions, except they must beprotected from further latex contact to avoidclinical deterioration.


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TreatmentTreatment Latex-free resuscitation equipment must be available.

This frequently is accomplished with a mobile, latex-free cart carrying nonlatex intubation and ventilationequipment, IV tubing, syringes, tourniquets, electrode

pads, gloves, masks, and medication vials.

Routine care of high-risk patients should use nonlatexsupplies. Major reactions in sensitized patients have

been precipitated with pelvic and rectal exams usinglatex gloves, urinary catheterization with latexcatheters, IV medication given through latex ports,and inhalation of aerosolized latex glove powder.

Latex-free resuscitation equipment must be available.This frequently is accomplished with a mobile, latex-free cart carrying nonlatex intubation and ventilationequipment, IV tubing, syringes, tourniquets, electrode

pads, gloves, masks, and medication vials.

Routine care of high-risk patients should use nonlatexsupplies. Major reactions in sensitized patients have

been precipitated with pelvic and rectal exams usinglatex gloves, urinary catheterization with latexcatheters, IV medication given through latex ports,and inhalation of aerosolized latex glove powder.


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TreatmentTreatment Consultants must be aware of the need to

completely avoid latex exposure to the

patient during examinations and procedures.

Patients needing studies in other hospital

areas, such as radiology, must be transported

without risking latex exposure.

Identification of latex versus nonlatex

medical devices traditionally has required

laborious contacts with individual

manufacturers.

Consultants must be aware of the need to

completely avoid latex exposure to the

patient during examinations and procedures.

Patients needing studies in other hospital

areas, such as radiology, must be transported

without risking latex exposure.

Identification of latex versus nonlatex

medical devices traditionally has required

laborious contacts with individual

manufacturers.


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MedicationMedication Latex allergies are best treated with patient education to

avoid further exposure.

Type I reactions are treated as any other systemic allergicreaction. The cornerstones of treatment are epinephrine andH1 antihistamines. Systemic corticosteroids and H2

blockers may be useful. No specific immunotherapy hasbeen shown to be effective.

Type IV reactions (localized contact dermatitis) areunlikely to require ED treatment. They can be treated withtopical steroids and patient education to avoid furtherexposures.

Latex allergies are best treated with patient education toavoid further exposure.

Type I reactions are treated as any other systemic allergicreaction. The cornerstones of treatment are epinephrine andH1 antihistamines. Systemic corticosteroids and H2

blockers may be useful. No specific immunotherapy hasbeen shown to be effective.

Type IV reactions (localized contact dermatitis) areunlikely to require ED treatment. They can be treated withtopical steroids and patient education to avoid furtherexposures.


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Follow upFollow up Further Inpatient Care

Patients with major latex allergies who are admitted

for allergic complications or unrelated conditionsmust be moved to latex-safe rooms with clear warnings on doors and charts.

All examinations and care must be done without useof latex-containing devices or equipment.

All providers should be educated to avoid inadvertentexposure.

Known latex allergy or a history suggestive of majorlatex allergy should trigger the use of latex-freeoperating rooms and postoperative care.

Further Inpatient Care

Patients with major latex allergies who are admitted

for allergic complications or unrelated conditionsmust be moved to latex-safe rooms with clear warnings on doors and charts.

All examinations and care must be done without useof latex-containing devices or equipment.

All providers should be educated to avoid inadvertentexposure.

Known latex allergy or a history suggestive of majorlatex allergy should trigger the use of latex-freeoperating rooms and postoperative care.


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Follow upFollow up Further Outpatient Care

Patients and their families should be educated to identifyand avoid latex in home, work, and medical/dentalsettings.

Patients should be referred to an allergist or primary careprovider for follow-up.

Patients should be aware of the life-threateningcomplications of anaphylaxis, bronchospasm, andlaryngospasm.

Patients with type I hypersensitivity should carrysubcutaneous epinephrine kits at all times.

Patients should obtain and wear a MedicAlert-typebracelet identifying their allergy.

Patients should be aware of the risk of cross-reacting fruitallergies.

Further Outpatient Care

Patients and their families should be educated to identifyand avoid latex in home, work, and medical/dentalsettings.

Patients should be referred to an allergist or primary careprovider for follow-up.

Patients should be aware of the life-threateningcomplications of anaphylaxis, bronchospasm, andlaryngospasm.

Patients with type I hypersensitivity should carrysubcutaneous epinephrine kits at all times.

Patients should obtain and wear a MedicAlert-typebracelet identifying their allergy.

Patients should be aware of the risk of cross-reacting fruitallergies.

Latex Allergy 2

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