Recurrent Kounis syndrome - a life-threatening event after COVID-19 vaccine administration.

Kounis syndrome is an acute coronary syndrome occurring in the setting of a hypersensitivity reaction. It occurs as a consequence of mast-cell activation and degranulation causing coronary artery spasm, atherosclerotic plaque erosion, or stent thrombosis. We report the case of a man who presented to the emergency department with typical angina that started 20 minutes after coronavirus disease 2019 (COVID-19) vaccine administration. Electrocardiogram showed inferior ST-elevation myocardial infarction, and coronary angiography confirmed right coronary artery stent thrombosis. Five months before, he had an acute coronary syndrome after influenza vaccine administration. Both vaccines share a common excipient, polysorbate 80. Considering the reproducibility of the reaction and the temporal association between vaccine administration and coronary events, a hypersensitivity reaction to polysorbate 80 was admitted and the patient was instructed to further avoid drugs containing it. To our knowledge, this constitutes the first reported case of type 3 Kounis syndrome after COVID-19 vaccine administration. Kounis syndrome is an uncommon disease, often undiagnosed. Its recognition and proper management are crucial to prevent future events. .

Refractory chronic urticaria in adults: clinical characterization and predictors of severity.

BACKGROUND: Chronic urticaria (CU) is defined as recurrent urticaria lasting for more than 6 weeks. OBJECTIVES: We aimed to characterize the phenotypes of patients with CU refractory to standard dose anti-H1 antihistamine treatment and search for clinical predictors of poor disease control. METHODS: Retrospective collection of data regarding clinical characteristics, comorbidities, treatment, and disease control of all adult refractory CU patients presenting to the Allergy and Immunology Department during 1 year. RESULTS: Sixty-one adult patients were included, 74% females, average age 44.5 years (18 to 84 years old). Most patients (78.7%) had initiated CU less than 1 year before enrolment. Chronic spontaneous urticaria (CSU) accounted for 55.7% of the patients, CSU associated with chronic inducible urticaria (CIndU) as a comorbidity for 44.3%, and angioedema was present in 55.7%. Medically-confirmed psychiatric disorders were present in 78.7%. Complementary diagnostic tests were performed in cases with more severe presentation (UAS7 ≥ 28 and/or UCT < 12) or with longer evolution (> 1 year), corresponding to 42 tested patient. Evidence for autoimmunity (positive anti-thyroid peroxidase antibodies, anti-nuclear antibodies or autologous serum test) was found in 45.2% (n = 19/42), and high C-reactive protein was present in 14.3% (n = 6/42), half of these also had positive antinuclear antibodies. Forty-six patients (75.4%) had at least one significant exacerbation, requiring medical appointment, emergency room, hospitalization or job absenteeism. The number of exacerbations correlated with the presence of angioedema (p = 0.022), with a recent diagnosis (< 1 year), and with higher UAS7 severity (p = 0.006). Although ClndU was associated with poor symptom control (p = 0.022), it was also associated with less exacerbations requiring medical observation or hospitalization (p = 0.015). All patients were using antihistamines and 21.3% (n = 13) of them were also under treatment with omalizumab, ciclosporine or montelukast for disease control. CONCLUSIONS: Autoimmunity can affect about half of the patients with severe or long-term CU. UAS7 and angioedema are associated with disease exacerbations. UAS7 and UCT presented unequal accuracy, with UAS7 better associating with the occurrence of exacerbations and treatment doses. Patients with refractory CU frequently present psychiatric disorders. Accurate diagnostic tests, namely autoimmune parameters and inflammatory markers, should be recommended in some individual cases.

Beer: an uncommon cause of anaphylaxis.

Beer is one of the most consumed alcoholic beverages worldwide but allergic reactions to this beverage are uncommon. The authors present a case report of a 32-year-old male patient, sent to our Allergy and Immunology Department due to anaphylaxis minutes after Franziskaner beer ingestion. He tolerates all other alcoholic beverages. Prick tests to cereals were positive to wheat, corn and barley, as well as to peach. Prick-to-prick tests were performed with nine beer brands, all positive. Immunoglobulin (Ig)E to Pru p 3 was 14.8 kU/L. Sodium dodecyl sulfate polyacrylamide gel electrophoresis inhibition immunoblotting was performed with the Franziskaner beer extract in solid phase and both cereal extracts (wheat, barley and corn) and Pru p 3 as inhibitors. Extracts from wheat, barley and corn, and Pru p 3 purified protein were able to inhibit almost totally the IgE-binding to the Franziskaner beer extract. It seemed likely that the IgE-binding bands detected in the Franziskaner beer extract could be an LTP from cereals.

Gluten-free diet: a possible treatment for chronic diarrhoea in common variable immunodeficiency.

Gastrointestinal disorders are frequent in common variable immunodeficiency (CVID). Clinical symptoms and histological alterations in CIVD can resemble celiac disease. Usually, patients with chronic diarrhoea associated with CVID do not improve with a gluten-free diet. The authors present a case of a male patient who was diagnosed with CVID at age 33 and had chronic diarrhoea which resolved after initiating a gluten-free diet. Clinical relapse occurred after gluten reintroduction. The main objective of this case report is to alert clinicians to implement a gluten-free diet in patients with CVID with chronic diarrhoea.

Seroprevalence of vector-borne pathogens and molecular detection of Borrelia afzelii in military dogs from Portugal.

BACKGROUND: Canine vector-borne diseases (CVBDs) are increasingly being reported worldwide and represent a serious threat to both animal and public health. Military dogs may constitute a risk group for the agents causing these diseases, as they frequently work outdoors in different areas and are thus exposed to vector arthropods. In order to assess the risk of exposure of this type of dogs, a serological and molecular survey was conducted in military working dogs in Portugal. One hundred apparently healthy dogs were surveyed. Serum samples were tested for antigens of Angiostrongylus vasorum and Dirofilaria immitis; and for antibodies to A. vasorum, Anaplasma spp., Babesia spp., Ehrlichia canis, Leishmania infantum, Rickettsia spp. and Toscana virus. Serum was tested by polymerase chain reaction for Borrelia burgdorferi (sensu lato), with sequencing of the DNA products. RESULTS: Forty-nine per cent of the dogs were seropositive for antibodies against Rickettsia spp., 16 % for Anaplasma spp., 13 % for L. infantum, 7 % for E. canis, 5 % for A. vasorum (including 1 % positive for both antibodies and circulating antigens), 3 % for Babesia spp. and 1 % positive for Toscana virus. B. burgdorferi (s.l.) was detected in eight out of 94 dogs tested (8.5 %) and in three cases (3.2 %) nucleotide sequence analysis showed identity with the genospecies Borrelia afzelii. No positive cases were recorded for D. immitis. Overall, 66 % of the dogs were positive for at least one out of the eight tested CVBD agents, six of which are zoonotic (i.e. Anaplasma spp., Borrelia spp., E. canis, L. infantum, Rickettsia spp. and Toscana virus). Serological specific antibody detection against more than one CVBD agent (including molecular detection of Borrelia spp.) was recorded in 25 % of the dogs, comprising 19 % with positive reaction to two agents, 5 % to three agents and 1 % to four agents. CONCLUSIONS: These results reveal a high occurrence of CVBD agents in military working dogs in Portugal and highlight the need to maintain a comprehensive and regular prophylaxis to reduce the contact between working dogs and those pathogens. For the first time in Portugal, B. afzelii DNA was identified in dogs and a dog was found seropositive for antibodies against Toscana virus.