Vaccine hesitancy in patients presenting to a specialized allergy center: clinical relevant sensitizations, impact on mental health and vaccination rates.

Introduction: The COVID vaccination program with new types of vaccinations and early reports of allergic reactions to vaccines led to vaccination hesitancy in patients with allergies. In this study, we aimed to characterize patients who present at an allergy center with specific questions regarding risk assessment to COVID vaccines in comparison to regular allergy center patients. Methods: A total of 50 patient charts of patients with risk assessment for COVID vaccination (COV group) and 50 regular allergy center patients (ALL group) were assessed for documented allergies, comorbidities, total IgE, and tryptase levels and hospital anxiety and depression score (HADS). Skin prick testing (SPT) with additives of COVID vaccines [polyethylene glycol (PEG), polysorbate] were performed if indicated based on medical history. Results: Patients who presented for examination prior to a possible COVID vaccination were mostly female (86%) and had more frequently reported allergic reactions to drugs in the past, but only in a minor group (28%) were the reactions qualified as anaphylaxis. The group COV patients scored significantly higher in the HADS for anxiety and depression than the regular group ALL patients. The same trend was observed when data were corrected for gender. It is worth noting that patients without any prior contact to COVID vaccines scored comparable regarding anxiety to patients with prior reaction to COVID vaccinations, but significantly higher in the depression score. In 19 patients (38%) who met the indications for SPT for the suspicious contents PEG and Polysorbate 80, the tests did not show a positive result. Furthermore, 84% of patients underwent the prick test, but only 15% of patients who received consultation alone agreed to vaccination at our center. No vaccination-related event was documented in these patients. Discussion: In conclusion, vaccination hesitancy was frequently elicited by negative experiences with drugs and putative drug allergies. Female patients predominate in this patient group, and the anxiety and depression scores were significantly elevated. Allergological workup, including SPT, led to a high rate of subsequent vaccinations, whereas a discussion with the patients about risks and individualized advice for vaccination without testing only rarely resulted in documented vaccinations.

Case report: Severe chronic spontaneous urticaria successfully treated with omalizumab and dupilumab.

Urticaria is a disease triggered by mast cells and characterized by recurrent symptoms such as wheals and/or angioedema. Most patients benefit from treatment with antihistamines (AH) or, if not effective enough, from additional therapy with omalizumab, which leads to significant symptom relief. Here we present a patient with therapy-resistant chronic spontaneous urticaria treated with AH, omalizumab, and glucocorticosteroids. The subsequent recommended therapy according to the current guideline, cyclosporine A, was contraindicated in this patient. Therefore, therapy with dupilumab was initiated, resulting in a complete control of symptoms. In this case report, we present a case of successful dual therapy with omalizumab and dupilumab.

Therapy resistant urticaria as a long-term symptom of an incomplete Schnitzler syndrome.

BACKGROUND: Recurring therapy resistant hives, accompanied by IgM-gammopathy, fever and joint pain can indicate Schnitzler syndrome, a rare autoimmune disorder. There is currently no approved treatment, but complete remission of symptoms can be induced with IL-1 antagonists. CASE PRESENTATION: A patient with a history of chronic urticaria presented frequently at the outpatient clinic with severe hives and was treated unsuccessfully with antihistamines and omalizumab. After several years, additional symptoms such as joint pain, recurrent fever, and IgM-gammopathy developed. After the diagnostic criteria for Schnitzler syndrome were met, treatment with anakinra was initiated and resulted in an improvement of the symptoms. Shortly after the first injection, the patient developed large and painful erythematous lesions at the injection sites, leading to discontinuation of treatment and a rapid recurrence of symptoms. Subsequently, treatment with a longer-acting IL-1 antagonist (canakinumab) was initiated, resulting in a complete remission of symptoms. CONCLUSION: This case report demonstrates that patients with urticarial symptoms that are not relieved by typical treatments should prompt repeated reassessments of the diagnosis, even years later, because gammopathy and other diagnostic criteria for Schnitzler syndrome can occur with a delay.

Second-dose COVID-19 vaccines are well tolerated in patients with allergic reactions to the first dose - a single center experience.

COVID-19 vaccines contain additives such as Polyethylenglycol-2000 (PEG2000; mRNA vaccines) or Polysorbat 80 (vector vaccines), which have been described previously as culprits for anaphylactic events. This retrospective study included 46 individuals, who were referred to Comprehensive Allergy Center at the Department Dermatology and Venereology, Kepler University Hospital, Linz, Austria, with suspected allergic reactions to the first COVID-19 vaccine dose with either mRNA or vector-based vaccines. Patients underwent detailed anamnesis, clinical examination, and in most cases, skin prick testing using pure additive substances (PEG - different molecular weights, Polysorbate 80). Out of 46, 7 patients' reactions were classified as possibly anaphylactic and graded according to Ring & Messmer. Forty patients out of 46 were assessed with skin prick tests for potential allergens in COVID-19 vaccines. Only 1 patient showed an immediate positive prick test to PEG2000. Second-dose vaccination with mRNA or vector-based vaccines were tolerated well in all patients, including the individual with a positive skin prick test against PEG2000. The currently available COVID-19 vaccines have an overall low allergic potential and may be administered safely in patients with suspected allergic reactions to the first dose.

Human resident memory T cells exit the skin and mediate systemic Th2-driven inflammation.

Emigration of tissue-resident memory T cells (TRMs) was recently introduced in mouse models and may drive systemic inflammation. Skin TRMs of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) can coexist beside donor T cells, offering a unique human model system to study T cell migration. By genotyping, mathematical modeling, single-cell transcriptomics, and functional analysis of patient blood and skin T cells, we detected a small consistent population of circulating skin-derived T cells with a TRM phenotype (cTRMs) in the blood and unveil their skin origin and striking resemblance to skin TRMs. Blood from patients with active graft-versus-host disease (GVHD) contains elevated numbers of host cTRMs producing pro-inflammatory Th2/Th17 cytokines and mediating keratinocyte damage. Expression of gut-homing receptors and the occurrence of cTRMs in gastrointestinal GVHD lesions emphasize their potential to reseed and propagate inflammation in distant organs. Collectively, we describe a distinct circulating T cell population mirroring skin inflammation, which could serve as a biomarker or therapeutic target in GVHD.