Contamination of nebulizer equipment with cockroach allergen: there's a bug in the system!

Background: Physicians often have anecdotal reports of patients describing increased asthma symptoms after the use of nebulizers; however, there are few published reports of nebulizer-associated exacerbations. Objective: To present 2 cases of asthmatic children who experienced a life-threatening exacerbation of their symptoms after nebulizer use. Methods: Case 2's nebulizer was tested for cockroach allergen by washing the medication reservoir with 2 mL of sterile filtered 1% phosphate-buffered saline, 0.05% bovine serum albumin, and Tween 20 overnight with rotation. The patient's sealed albuterol nebulizer medication was used as a control. The control albuterol and test solutions were analyzed for Blattella germanica I and 2 allergens using a monoclonal antibody-based immunoenzymetric assay. Results: The reservoir from case 2 was found to have measurable levels of both Bla g 1 and Bla g 2. The control albuterol solution had no measurable cockroach allergen. An insect found in the nebulizer box of case 2 was identified as an infantile German cockroach. Conclusions: Nebulizer use provides an opportunity for antigen exposure directly to small airways, which may lead to severe allergic reactions in patients using contaminated equipment.