Rituximab is a chimeric monoclonal antibody (mAb) against CD20 molecule which is expressed on human B cells. It has been used for the treatment of various lymphoid malignancies, lymphoproliferative diseases, and rheumatologic disorders. Rituximab is generally well tolerated. However, increased use of rituximab has been associated with hypersensitivity reactions (HSRs), which can be classified as infusion-related, cytokinerelease, type I (IgE/non-IgE), mixed, type III, and type IV reactions. Immediate infusionrelated reactions to rituximab are quite common and decrease in frequency with subsequent infusions. However, in about 10% of patients, severe infusion-related reactions develop, which prevent its use. Some of the immediate infusion reactions are due to a cytokine-release but some reactions raise concerns for type I (IgE/non-IgE) hypersensitivity. Recent studies have shown the presence of serum anti-rituximab antibodies, either represented by the IgG or IgE isotype. In some cases, clinical manifestations of IgE-mediated reactions and cytokine-release reactions partially overlap, which is called a mixed reaction. Classified as Type III reaction, rituximabinduced serum sickness reactions have been reported in patients with autoimmune diseases and hematological malignancies. The classic serum sickness triad (fever, rash, and arthralgia) has been observed in patients mainly with an underlying rheumatologic condition. Severe delayed type IV hypersensitivity reactions including non-severe maculopapular rash to severe reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis have been rarely reported following rituximab injection. Comprehensive reviews focused on rituximab-induced HSRs are scarce. We aimed to review clinical presentations, underlying mechanisms of rituximab hypersensitivity, as well as management including rapid drug desensitization.

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Due to the need for asthma diagnosis and surveillance, the bronchodilator reversibility test is commonly used. Yet, there are no complete, standardized guidelines for bronchodilator administration. Various methods are used to clean the Metered Dose Inhalers (MDIs), but some physicians may not even take sterility into account. We seek to determine what methods allergists use to administer bronchodilators and allergists' opinion of bronchodilator sterility of their practice. METHODS: A questionnaire was approved and distributed by the American Academy of Allergy, Asthma, and Immunology (AAAAI) to all member allergists in North America. Responses were tabulated after a three-week period. RESULTS: Of the 487 allergists who responded, 83.98% use MDIs for bronchodilator reversibility testing, with 59.34% using MDIs with a spacer and 24.64% using MDIs without a spacer. Several allergists, or 58.52%, use a nebulizer to administer the bronchodilator. With regards to sterility with MDI use, of 449 respondents, 9.13% wipe inhalers with a cleansing agent, 18.71% use a new inhaler between patients, and 38.75% use a new disposable attachment for a reused inhaler, respectively. Only 69.25% of allergists felt that their bronchodilator administration was sterile. Notably, 14.05% of allergists felt their bronchodilator administration was unsterile, and 16.70% of members were unsure of sterility. CONCLUSIONS: A significant number of allergists do not use sterile techniques when administering bronchodilators. This disregard for sterility can cause negative consequences for patients, such as the spread of infection. From this survey, it is evident that there is need for guidelines for sterile bronchodilator administration in allergy practices.