Eficácia da midostaurina na mastocitose sistêmica ­ um relato de caso / Efficacy of midostaurin in systemic mastocytosis: a case report

Paciente do sexo feminino, com 63 anos de idade, portadora de mastocitose sistêmica há cerca de 20 anos, sendo agressiva há 10 anos. Crises quase diárias com manifestações do trato gastrointestinal e vasomotoras. Após diversas tentativas de tratamento, iniciou uso de midostaurina, um inibidor multiquinase. Depois de 6 meses de uso, observou-se bom controle dos sintomas, diminuição em quase 50% da triptase sérica e desaparecimento completo das lesões cutâneas.

A 63-year-old female presented with an approximately 20-year history of systemic mastocytosis, which had become aggressive over the past 10 years. She experienced almost daily episodes of gastrointestinal and vasomotor manifestations. After multiple treatment attempts, she was started on midostaurin, a multikinase inhibitor. At 6 months of therapy, satisfactory control of symptoms was achieved, with a nearly 50% reduction in serum tryptase and complete resolution of cutaneous lesions.

Dupilumab for Treatment of Food-Dependent, Exercise-Induced Anaphylaxis: Report of One Case / 中国医学科学杂志(英文版)

Food-dependent, exercise-induced anaphylaxis (FDEIA) is a potentially life-threatening disorder that often occurs with exercise, and patients typically have eaten a specific food within hours before disease onset. This disease is exceedingly rare, with a prevalence of 0.02%. No well-recognized prevention or treatment strategy has been available for FDEIA except avoiding triggers strictly. Here we report an 11-year-old boy with a history of recurrent anaphylaxis of unknown etiology more than 10 times within two years. As the anaphylactic symptoms had not been controlled after traditional treatments, the patient was given subcutaneous injection of dupilumab seven times within 33 weeks. During dupilumab treatments, the patient was exposed to culprit mushrooms plus exercises at least twice a month but without notable anaphylaxis. Thus, Dupilumab may improve the allergic reactions in FDEIA patients.

Precise diagnosis and management of anaphylaxis based on phenotypes and endotypes / 中华预防医学杂志

Anaphylaxis is the most severe allergic reaction, demanding immediate management by health care providers, which is currently underdiagnosed and undertreated in China. In addition to the classic IgE-mediated pathway, non-IgE dependent pathway has also been extensively studied in the pathogenesis of anaphylaxis. Recently, the atypical symptoms induced by widespread used monoclonal antibodies and biologics have been reported. The goal of this article is to recognize the phenotypes (triggers and presentation) and understand its characteristics through endotypes (mechanisms) of anaphylaxis. Ultimately, the aim is to help allergists and health care providers guide a precision approach to diagnose and manage of anaphylaxis.

Standardized diagnosis results of suspected local anesthetics allergy / 中华预防医学杂志

To review and investigate the diagnosis results of local anesthetics (LA) allergy and improve the understanding of LA allergy in clinician. From March 2017 to February 2022, a total of 24 patients were investigated in Allergy Center of West China Hospital,Sichuan University on suspicion of LA allergy. Clinical data and results of skin tests and drug provocation tests (DPT) with the suspected drugs were retrospectively evaluated. The value of standardized diagnostic protocol in the LA allergy were analyzed. The results showed that 24 patients (3 men/21 women) were included with age range from 20 to 74 years. Three cases (12.5%) were positive in previous LA skin tests and proved to be tolerated through standardized tests. Twenty-one patients were initially diagnosed as "LA allergy" because of adverse reactions after previous use of LA, including 20 cases of immediate-type reaction and 1 case of delayed-type reaction. Three cases were considered LA allergy through standardized diagnosis approaches, including skin tests and DPT. One patient was diagnosed with anaphylaxis caused by chlorhexidine. Of the remaining 17 patients, 7 were considered as psychosomatic reactions (29.1%), 3 of sympathetic nervous system conditions (12.5%), 1 of spontaneous urticaria (4.2%), 2 of vasovagal syncope (8.3%), drug side effects (8.3%), skin irritation (8.3%), respectively. In conclusion, true allergic reactions to LA are rare. Through standardized skin tests and DPT, allergy can be ruled out in the vast majority of patients who complain of "LA allergy". For patients who are highly suspected of LA inducing anaphylaxis, other local anesthetics that can be used as safe alternatives should be determined by diagnostic tests according to future needs.

Precise diagnosis and management of anaphylaxis based on phenotypes and endotypes / 中华预防医学杂志

Anaphylaxis is the most severe allergic reaction, demanding immediate management by health care providers, which is currently underdiagnosed and undertreated in China. In addition to the classic IgE-mediated pathway, non-IgE dependent pathway has also been extensively studied in the pathogenesis of anaphylaxis. Recently, the atypical symptoms induced by widespread used monoclonal antibodies and biologics have been reported. The goal of this article is to recognize the phenotypes (triggers and presentation) and understand its characteristics through endotypes (mechanisms) of anaphylaxis. Ultimately, the aim is to help allergists and health care providers guide a precision approach to diagnose and manage of anaphylaxis.

Standardized diagnosis results of suspected local anesthetics allergy / 中华预防医学杂志

To review and investigate the diagnosis results of local anesthetics (LA) allergy and improve the understanding of LA allergy in clinician. From March 2017 to February 2022, a total of 24 patients were investigated in Allergy Center of West China Hospital,Sichuan University on suspicion of LA allergy. Clinical data and results of skin tests and drug provocation tests (DPT) with the suspected drugs were retrospectively evaluated. The value of standardized diagnostic protocol in the LA allergy were analyzed. The results showed that 24 patients (3 men/21 women) were included with age range from 20 to 74 years. Three cases (12.5%) were positive in previous LA skin tests and proved to be tolerated through standardized tests. Twenty-one patients were initially diagnosed as "LA allergy" because of adverse reactions after previous use of LA, including 20 cases of immediate-type reaction and 1 case of delayed-type reaction. Three cases were considered LA allergy through standardized diagnosis approaches, including skin tests and DPT. One patient was diagnosed with anaphylaxis caused by chlorhexidine. Of the remaining 17 patients, 7 were considered as psychosomatic reactions (29.1%), 3 of sympathetic nervous system conditions (12.5%), 1 of spontaneous urticaria (4.2%), 2 of vasovagal syncope (8.3%), drug side effects (8.3%), skin irritation (8.3%), respectively. In conclusion, true allergic reactions to LA are rare. Through standardized skin tests and DPT, allergy can be ruled out in the vast majority of patients who complain of "LA allergy". For patients who are highly suspected of LA inducing anaphylaxis, other local anesthetics that can be used as safe alternatives should be determined by diagnostic tests according to future needs.

Natural history and risk factors of IgE-mediated cow's milk protein allergy in infants / 中华儿科杂志

Objective: To investigate the natural history and risk factors for continued allergy in infants with IgE-mediated cow's milk protein allergy (CMPA). Methods: This was a prospective cohort study that included 72 infants under 24 months of age diagnosed with IgE-mediated CMPA in the allergy clinic of the Children's Hospital, Capital Institute of Pediatrics from October 2019 to November 2020. General information, clinical manifestations, serum total IgE, cow's milk specific IgE, and cow's milk protein component specific IgE were collected. Follow-ups were conducted at 24 and 36 months of age, and the patients were divided into the persistent allergy group and the tolerance group based on whether they developed cow's milk tolerance at 36 months of age. Mann-Whitney U test, chi-square test, and binary Logistic regression were used for intergroup comparison and multivariate analysis. Results: Among the 72 CMPA children, there were 42 boys and 30 girls, with an age of 10 (7, 15) months at enrollment. Cow's milk protein tolerance was observed in 32 cases (44%) and 46 cases (64%) at 24 and 36 months of age, respectively. There were 26 cases in the persistent allergy group and 46 cases in the tolerance group. The proportion of respiratory symptoms, history of wheezing, positive specific IgE for α-lactalbumin and the total IgE level in the persistent allergy group were higher than that in the tolerance group (7 cases (27%) vs. 0, 6 cases (23%) vs. 2 cases (4%), 67% (14/21) vs. 26% (10/39), 225 (151, 616) vs. 48 (21, 185) kU/L, χ2=10.82, 4.16, 9.57, Z=4.07, all P<0.05). Multivariate Logistic regression analysis showed that anaphylaxis (OR=21.14, 95%CI 2.55-175.14, P=0.005), a history of allergic rhinitis (OR=5.94, 95%CI 1.54-22.86, P=0.005), elevated milk specific IgE (OR=1.04, 95%CI 1.01-1.08, P=0.024), and positive casein specific IgE (OR=6.64, 95%CI 1.39-31.69, P=0.018) were risk factors for continuous CMPA. Conclusions: Most infants with IgE-mediated CMPA can achieve tolerance within 3 years. Anaphylaxis, a history of allergic rhinitis, elevated milk specific IgE levels, and casein sensitization are risk factors for continuous allergy.

Guia prático de urticária aguda / Practical guide to acute urticaria

A urticária aguda é uma causa frequente de consulta com alergistas, caracterizada por urticas e/ou angioedema. Embora autolimitada e benigna, pode causar desconforto significativo e raramente representar uma doença sistêmica grave ou reação alérgica com risco de vida. Nesta revisão, elaborada pelo Departamento Científico de Urticária da Associação Brasileira de Alergia e Imunologia, foram abordadas as principais questões referentes ao tema para auxiliar o médico especialista e generalista.

Acute urticaria is a frequent cause of consultations with allergists, being characterized by wheals and/or angioedema. Although self-limited and benign, it may cause significant discomfort and uncommonly represent a serious systemic disease or life-threatening allergic reaction. In this review prepared by the Urticaria Scientific Department of the Brazilian Association of Allergy and Immunology, the main questions about this topic are addressed to help specialists and general practitioners.

Leguminosas como causa infrecuente de alergia alimentaria en Colombia: reporte de dos casos y revisión de la literatura / Legumes as an infrequent cause of food allergy in Colombia: report of two cases and review of the literature

La alergia alimentaria se ha venido incrementando a nivel mundial, afectando alrededor del 1,5 % a 2,5 % de los adultos y 6 % de los niños, y tiene un gran impacto en la calidad de vida de los pacientes y sus cuidadores, debido a las dietas de restricción. Los alérgenos más prevalentes son la leche, el huevo, el trigo, la soja, los frutos secos, el maní, el pescado y los mariscos. Las leguminosas mejor estudiadas son el maní y la soja; otras leguminosas como las lentejas, garbanzos y arvejas representan la quinta causa de alergia alimentaria en el área mediterránea, en Turquía y en la India, siendo menos prevalentes en otras áreas geográficas. La alergia a las leguminosas es una entidad infrecuente en Colombia, se desconoce la prevalencia en el país. Describimos los primeros dos casos de anafilaxia por lentejas reportados en el país. Ambos pacientes menores de 18 años, con reacciones adversas tras la ingesta de leguminosas, en las cuales se demuestra alergia mediada por IgE a las lentejas y además sensibilización en el primer caso a las arvejas y garbanzos, y en el segundo caso a los frijoles. Diferentes datos sobre la prevalencia se han descrito en varias áreas geográficas, siendo mayor en países con dietas mediterráneas. Las reacciones mediadas por IgE suelen aparecer incluso con el alimento altamente cocido, debido a la termo-estabilidad de las proteínas. La reactividad cruzada más frecuente se relaciona con los garbanzos y las arvejas

Food allergy has been increasing worldwide. Affects around 1.5% to 2.5% of adults and 6% of children, and has a great impact on the quality of life of patients and their caregivers, due to restricted diets. The most prevalent allergens are milk, egg, wheat, soy, tree nuts, peanuts, fish and shellfish. The best studied legumes are peanuts and soybeans; other legumes such as lentils, chickpeas and peas represent the fifth cause of food allergy in the Mediterranean area, Turkey and India, being less prevalent in other geographical areas. Allergy to legumes is not common in Colombia, the prevalence in the country is unknown. We describe the first two cases of legumes anaphylaxis reported in the country. Both patients were under 18 years of age, with adverse reactions after ingesting legumes, in which IgE-mediated allergy was demonstrated; in the first case to lentils, peas and chickpeas, and in the second case, to lentils and beans. Different data on prevalence have been described in various geographical areas, being higher in countries with Mediterranean diets. IgE-mediated reactions usually appear even with highly cooked food, due to the thermo-stability of proteins. The most frequent cross-reactivity is related to chickpeas and peas

Clinical characteristics of IgE-mediated cow's milk protein allergy in children / 中华儿科杂志

Objective: To analyze the clinical features of IgE-mediated cow's milk protein allergy (CMPA) in children aged 0-5 years. Methods: This cross-sectional study collected the data on children diagnosed with CMPA in the Department of Allergy at the Children's Hospital of the Capital Institute of Pediatrics from October 2019 to November 2020 and improved peripheral blood routine,total IgE defection, milk specific IgE (sIgE) defection,SPT and milk component defection,diagnosis of severe anaphylaxis based on clinical manifestations. Rank-sum test and chi-square test are used for statistical analysis of clinical characteristics between groups. Results: A total of 106 children (67 boys and 39 girls) were enrolled with the age of 15 (8, 34) months, including 42 cases (≤ 1 year of age), 39 cases (>1-<3 years of age) and 25 cases(≥3 years of age), the onset age of 6 (5, 8) months. Among them, 95 cases (89.6%) were reacted after consuming milk or its products, 42 cases (39.6%) had reaction due to skin contact and 11 cases (10.4%) reacted after exclusive breastfeeding. The onset time of milk product consumption was 45 (1, 120) min, skin contact pathway was 10 (5, 30) min and symptoms in breastfeeding pathway was 121 (61, 180) min. There was statistical difference among the time of symptoms (χ2=77.01, P<0.001).The cutaneous reaction was most common (100 cases, 94.3%), followed by digestive (20 cases, 18.9%) and respiratory (16 cases, 15.1%), and the nervous symptoms (1 case, 0.9%) were uncommon and 24 cases (22.6%) had at least one episode of anaphylaxis. There were 87 cases (82.1%) also diagnosed with other food allergies, 94 cases (88.7%) with previous eczema, 57 cases (53.8%) with history of rhinitis, and 23 cases (21.7%) with history of wheezing. The total IgE level was 191.01 (64.71, 506.80) kU/L, and the cow's milk sIgE level was 3.03 (1.11, 15.24) kU/L. The maximum diameter of the wheal in SPT was 8.2 (4.0, 12.0) mm. Component resolved diagnosis showed that 77 cases (81.9%) were sensitized to at least one out of 4 main components, including casein, α lactalbumin, β lactoglobulin and bovine serum albumin.The possibility of anaphylaxis in children with milk sIgE grade Ⅳ-Ⅵ was higher than that in children with grade 0-Ⅲ (57.7% (15/26) vs. 12.5% (10/80), OR=9.545, 95%CI 3.435-26.523). Children with milk SPT ≥+++ had a higher probability of anaphylaxis than those with milk SPT ≤++ (34.4% (11/32) vs. 11.5% (3/26), OR=4.016, 95%CI 0.983-16.400). Anaphylaxis were more common in α lactalbumin positive children than in negative children (34.3% (13/38) vs. 14.2% (8/56), χ2=1.23，P=0.042). Conclusions: CMPA in children has early onset and diversified clinical manifestations, which are mainly cutaneous symptoms. Most children are sensitized to at least one allergen component. Serum sIgE level, SPT reaction and allergen components play important roles in the diagnosis and evaluation of CMPA, and higher milk sIgE level may predict a higher risk of anaphylaxis.

Quiste hidatídico cervical primario / Primary cervical hydatid cyst

RESUMEN La hidatidosis cervical es una enfermedad poco frecuente aun en áreas endémicas. Suele presentarse como una lesión quística indolora de lenta evolución. Se presenta un caso clínico de una paciente femenina de 19 años con una lesión quística en el compartimento cervical central, inicialmente interpretada como un quiste tirogloso. El diagnóstico debe ser sospechado ante epidemiología compatible, el método de imágenes de elección es la ecografía. En localizaciones extrahepáticas los métodos serológicos tienen baja sensibilidad. El tratamiento de elección es la cirugía, realizando tratamiento perioperatorio con albendazol. Debe manipularse el quiste con cuidado para evitar su rotura y el derrame de contenido líquido, por riesgo de reacción anafiláctica, recurrencia e hidatidosis múltiple. En pacientes con alto riesgo quirúrgico puede optarse por realizar tratamiento médico con albendazol.

ABSTRACT Cervical echinococcosis is a rare disease, even in endemic areas. The lesions usually present as painless slow-growing cystic lesion. We report the case of a 19-year-old female patient with a cystic lesion in the central cervical region that was initially interpreted as a thyroglossal duct cyst. The diagnosis should be suspected when the epidemiology is consistent, and ultrasound is the imaging method of choice. The sensitivity of serologic tests is low in extrahepatic locations. Surgery is the treatment of choice and the administration of albendalzole before surgery is indicated. The cyst must be handled with care to avoid rupture and leakage of cyst contents, which can cause anaphylaxis, recurrence and multiple echinococcosis. In patients with high surgical risk, medical treatment alone may be the option.

Anaphylactic shock with pulmonary eosinophilic infiltration due to honeybee attack in a donkey: case report / [Choque anafilático com infiltração eosinófila pulmonar devido a ataque de abelhas em um burro: relato de caso]

A case of a donkey attacked by Africanized honeybee is reported here with clinical signs of agitation, dehydration, congestion of the ocular mucous membranes, tongue edema, tachycardia and inspiratory dyspnea, and progression to death. At necropsy, diffuse, severe subcutaneous edema at face and cervical regions and severe diffuse pulmonary hyperemia with abundant edema without parenchymal collapse were observed. Microscopically, marked, diffuse deep dermis and panniculus carnosus edema and marked diffuse alveolar edema, with moderate population of eosinophils predominantly around larger caliber vessels were noted. The final diagnosis of anaphylactic shock was supported by history, clinical signs, and anatomic pathology findings. This is the first report of a honeybee attack with pulmonary eosinophilic infiltration in a mammal.(AU)

Descreve-se um caso de ataque de abelha africanizada em um burro, com sinais clínicos de agitação, desidratação, mucosas oculares congestas, edema de língua, taquicardia e dispneia inspiratória, com progressão e morte. Na necropsia, foram verificados edema subcutâneo difuso grave nas regiões de face e cervical, hiperemia pulmonar difusa grave com edema abundante e sem colapso do parênquima. Microscopicamente, foram observados edema marcado difuso na derme profunda e panículo carnoso e edema alveolar difuso acentuado, com população moderada de eosinófilos predominantemente em torno de vasos de maior calibre. O diagnóstico de choque anafilático foi baseado no histórico, em sinais clínicos e em achados anatomopatológicos. Este é o primeiro relato de ataque de abelhas com infiltração eosinofílica pulmonar em um mamífero.(AU)

Anafilaxia no primeiro ano de vida: como diagnosticar / Anaphylaxis in the first year of life: how to diagnose

A anafilaxia é uma reação alérgica mais grave e potencialmente fatal. Apresenta-se quase sempre com manifestações cutâneas, acompanhadas por acometimento dos sistemas respiratório, gastrointestinal, nervoso e cardiovascular. Indivíduos de todas as faixas etárias podem manifestar anafilaxia, e seu diagnóstico no primeiro ano de vida é difícil por ser o lactente incapaz de expressar de modo claro as sensações vividas durante o episódio agudo. Nessa faixa etária os alimentos são os agentes desencadeantes mais envolvidos, embora medicamentos e veneno de himenópteros também o sejam. Em pacientes submetidos a várias cirurgias e procedimentos médicos a alergia ao látex pode ocorrer. A adrenalina intramuscular é a primeira linha de tratamento da anafilaxia na fase inicial, mas continua sendo subutilizada. Além disso, medidas de suporte, tais como decúbito supino, reposição de fluidos, vias aéreas pérvias e oxigenação, devem ser instituídas. Após a alta, o paciente deve ser encaminhado à avaliação e seguimento por especialista visando à identificação do agente desencadeante, assim como educar responsáveis/cuidadores destes pacientes sobre a prevenção de novos episódios. É importante que esse paciente tenha consigo algum tipo de identificação que o aponte como tendo tido episódio de anafilaxia, sobretudo se tiver sido recorrente. A oferta de um plano escrito de como proceder diante de um novo episódio é fundamental.

Anaphylaxis is a serious and potentially fatal allergic reaction. Most frequently, it features cutaneous manifestations accompanied by involvement of the respiratory, gastrointestinal, nervous, and/or cardiovascular systems. Individuals of all age groups may present with anaphylaxis, and its diagnosis in the first year of life is difficult because the infant is unable to clearly express the sensations experienced during the acute episode. In this age group, foods are the most common triggering agents, together with medications and Hymenoptera venom. In patients undergoing multiple surgeries and medical procedures, latex allergy may occur. Intramuscular epinephrine is the first line of treatment for early anaphylaxis, but it remains underutilized. In addition, supportive measures such as supine decubitus, fluid replacement, patent airways, and oxygenation should be instituted. After discharge, the patient should be referred for evaluation and follow-up by a specialist, with the purpose of identifying the triggering agent as well as educating the caregivers of these patients about the prevention of new episodes. This patient should always carry some type of identification that indicates that he/she has had any episode of anaphylaxis, especially if it has been recurrent. Providing a written plan of how to proceed in the face of a new episode is essential.

Anafilaxia em estudantes acima de sete anos nas escolas públicas de Imperatriz do Maranhão - MA / Anaphylaxis in public school students aged 7 years or older in Imperatriz do Maranhão, MA, Brazil

Introdução: Anafilaxia é uma reação de hipersensibilidade aguda, grave, potencialmente fatal, causada por mecanismos de hipersensibilidade. A prevalência da anafilaxia está crescendo, entretanto, pesquisas epidemiológicas sobre esta doença ainda são escassas no Brasil, o que motivou o presente estudo. Métodos: A pesquisa é observacional e com delineamento do tipo transversal, baseada na aplicação de questionário validado que sugere o diagnóstico de anafilaxia em crianças e adolescentes entre 7 a 18 anos em escolas públicas da cidade de Imperatriz, Maranhão, Brasil. Simultaneamente, outro questionário correlacionando características socioeconômicas e de saúde geral também foi aplicado. Foram sorteadas 30 escolas, e em cada uma delas foram sorteados 24 estudantes. Os questionários devolvidos foram processados, sendo que escores iguais ou acima de 28 foram identificados como sugestivos de anafilaxia. Dois grupos, sem e com anafilaxia, (respectivamente, A e B) foram comparados. Resultados: Dos 720 questionários entregues, 380 foram devolvidos e, destes, 294 foram considerados válidos e analisados. Destes 294, 144 (49%) alegaram já ter tido pelo menos uma crise de alergia e tiveram seus questionários tabulados. Dezessete entrevistados (5,78% dos 294) apresentaram escores iguais ou superiores a 28, o que sugere anafilaxia. Com relação ao segundo questionário, os grupos A e B apresentaram diferenças estatisticamente significativas quanto ao gênero, renda familiar, presença de tabagismo passivo e vacinação, sendo que o grupo B apresentou, respectivamente, predomínio do gênero feminino, maior renda familiar, maior índice de tabagismo passivo e vacinação completa. Conclusões: As taxas de prevalência de anafilaxia em pessoas suspeitas dessa doença em Imperatriz do Maranhão mostram-se significativas e comparáveis a outros locais já estudados no Brasil e no mundo. Mais estudos epidemiológicos são necessários para se ampliar o conhecimento dessa prevalência no país e sua correlação com dados socioeconômicos e de saúde geral.

Introduction: Anaphylaxis is a severe, potentially life-threatening hypersensitivity reaction, and its prevalence has been increasing. Despite the importance of this disease, there are few studies focusing on its epidemiological aspects in Brazil. Hence, the authors aimed to investigate the prevalence of anaphylaxis in Imperatriz, a city in Maranhão (MA) ­ a Northwest state in Brazil ­ as a contribution to the understanding of this issue. Methods: Thirty public schools were chosen at random, and in each one, 24 students were chosen randomly. A validated questionnaire to collect data on possible anaphylactic reactions was sent to them along with socioeconomic and general health questions. The answers were analyzed to identify who could have had an anaphylactic reaction. A score of 28 or higher indicated a possible anaphylactic reaction. The group with possible anaphylaxis was compared with the group without anaphylaxis. Results: Of 720 questionnaires sent to the students, 320 (52.8%) were returned and 294 were considered for analysis. Of 294, 144 (49%) students answered that they had had at least one episode of allergic reaction and, thus, had their answers tabulated. Seventeen students scored 28 or higher and were considered to have had an anaphylactic reaction. Therefore, the prevalence of anaphylaxis in this population was 5.78% (17/294). A comparison of the two groups, without anaphylaxis (A) and with possible anaphylaxis (B), showed that group B statistically differed in gender (more female), family income, second-hand smoking, and vaccination rate (higher indices in group B). Conclusion: Anaphylaxis is an important disease in Imperatriz (MA), and its prevalence is similar to that of other places in Brazil and in the world. More studies are necessary to better understand how anaphylaxis impacts the Brazilian population.

Anafilaxia ao ácido poli-L-láctico / Poly-L-lactic acid anaphylaxis

Paciente feminina, 47 anos, previamente hígida, apresentou reação anafilática associada ao uso do ácido poli-L-láctico (PLLA). Imediatamente após a administração do bioestimulador, a paciente referiu edema de face que evoluiu para urticária generalizada, edema em membros inferiores e tremores. Posteriormente, apresentou edema de língua e dificuldade para falar. Teste de puntura com extratos de PLLA na concentração pura 1:1 e testes intradérmicos na diluição 1:10 e 1:100 mostrou-se positivo. Paciente negou cofatores no dia do procedimento e alergias prévias. O presente artigo descreve o primeiro caso da literatura de anafilaxia ao PLLA, onde se discute aspectos da reação anafilática e exames usados para o diagnóstico.

A previously healthy 47-year-old woman had an anaphylactic reaction caused by poly-L-lactic acid (PLLA). Immediately after the administration of the biostimulating agent, the patient reported facial edema, which progressed to generalized urticaria, lower extremity edema, and tremors. Then she had tongue edema and difficulties to talk. A prick test with pure PLLA extracts (1:1) and intradermic tests (1:10 and 1:100 dilutions) were positive. The patient denied cofactors on procedure day as well as previous allergies. This is the first case report of anaphylaxis due to PLLA and includes a discussion of aspects of the anaphylactic reaction and tests that were used to provide the diagnosis.

Anafilaxia a alfa-gal: um relato de caso paraibano / Alpha-gal anaphylaxis: a case report from Paraíba, Brazil

O presente relato apresenta um caso de anafilaxia tardia ao carboidrato alfa-gal em um adolescente da cidade de Belém, na Paraíba, Brasil. O paciente desenvolveu reação tardia à ingesta de carne e vísceras de animais. Ele mora em fazenda e tem contato próximo com animais potencialmente contaminados por carrapatos. Essa causa de reação alérgica é nova, e estudos começaram a atribuí-la a casos antes ditos idiopáticos. A anafilaxia é uma reação potencialmente fatal, que deve ser prontamente diagnosticada e tratada. Sendo assim, a descoberta de seu fator desencadeante é um dos principais itens que direcionam o tratamento. No Brasil, nenhum caso de anafilaxia por alfa-gal foi antes descrito na literatura local.

This report presents a case of late anaphylaxis to alpha-gal carbohydrate in a teenager living in the city of Belém, Paraíba, Brazil. The patient developed a late reaction to eating meat and offal of animals; he lives on a farm and has close contact with animals potentially contaminated by ticks. This cause of allergic reaction is new, and studies have started to attribute it to cases previously said to be idiopathic. Anaphylaxis is a potentially fatal reaction that must be promptly diagnosed and treated. Thus, the discovery of its triggering factor is one of the main items that guide treatment. In Brazil, no case of alpha-gal anaphylaxis had been described in the local literature.

Should a patient with systemic mastocytosis be vaccinated against COVID-19? / Deve um doente com mastocitose sistêmica ser vacinado contra a COVID-19?

A 26-year-old woman was referred to the allergy department for two episodes of anaphylaxis after intake of non-steroidal antiinflammatory drugs. In both episodes she was evaluated at the emergency department, and her levels of tryptase were 141 ug/L and 117 ug/L, respectively. Baseline tryptase was 92 ug/L. Bone marrow biopsy, myelogram, and immunophenotypic study were performed, confirming systemic mastocytosis. In patients with mast cell disorders, the risk of anaphylaxis after mRNA vaccine against COVID-19 has been under debate. Considering the occupational risk of COVID-19, the risk of anaphylaxis upon exposure to the vaccine was discussed with the patient and, after consent, Pfizer/BioNTech® BNT162B2 was administered under allergist supervision. No premedication was administered and both vaccine inoculations occurred without eliciting mast cell symptoms.

Mulher de 26 anos enviada à consulta de imunoalergologia após dois episódios de anafilaxia no contexto de ingestão de antiinflamatórios. Em ambos os episódios foi observada no Serviço de Urgência. Os valores de triptase nos episódios foram 141 ug/L e 117 ug/L, respetivamente. A triptase basal 92 ug/L. Realizou biópsia de medula óssea, mielograma e estudo imunofenotípico que confirmaram mastocitose sistêmica. Nos doentes com doença mastocitária, o risco de anafilaxia após administração de vacinas mRNA contra a COVID-19 tem sido debatido. Considerando o risco de exposição à COVID-19, o risco de anafilaxia após administração da vacina foi discutido com a doente e, após consentimento, a vacina Pfizer/BioNTech® BNT162B2 foi administrada sob vigilância de um alergologista. Não foi administrada pré-medicação, e a doente recebeu as duas doses da vacina sem evidenciar sintomatologia relacionada com ativação mastocitária.

Identification of a thaumatin-like protein as a new allergen in persimmon (Diospyros kaki) with cross-reactivity with banana (Musa acuminata) / Identificação de uma proteína semelhante à taumatina como um novo alérgeno no caqui (Diospyros kaki) com reatividade cruzada com a banana (Musa acuminata)

Allergy to persimmon (Diospyros kaki ) has been only rarely reported. The antigenic composition of the fruit is not entirely known. Thaumatin-like proteins (TLPs) have been described as allergens in pollens and various fruits, such as kiwi and banana, but not in persimmon. We report the case of a 22-year-old man, with persistent moderate-to-severe allergic rhinitis, sensitized to house dust mites. The patient describes an episode of oral mucosa and ear canal pruritus, followed by diffuse urticaria, which rapidly evolved to dysphonia, dyspnea, and dizziness, after eating raw persimmon. A few months later he developed similar cutaneous symptoms accompanied by nausea, vomiting, abdominal colic, and hypotension immediately after the intake of banana. The prick-prick test with raw persimmon and banana were positive, as well as the serum specific IgE to the extract of these fruits. The ImmunoCAP ISAC_112i test demonstrated a positive specific IgE against Act d 2 (kiwi thaumatin), which is homologous to banana TLP (Mus a 4). Serum IgE inhibition test with "sponge" of Diospyros kaki ImmunoCAP (f301) showed partial inhibition (40%) of IgE to Act d 2. This raises the suspicion that a TLP is at least partially responsible for the referred sensitization. This patient is sensitized to Diospyros kaki and Musa acuminata. An anaphylactic reaction to consumed persimmon, presumably as a result from cross-allergy with banana thaumatin was diagnosed in our patient. Thaumatin has not been previously described as an allergen of persimmon with cross-reactivity with banana, and in vitro with Act d 2 (kiwi TLP).

A alergia ao caqui (Diospyros kaki ) tem sido raramente documentada, não sendo a composição antigênica da fruta totalmente conhecida. Proteínas semelhantes à taumatina (TLPs) foram descritas como alergênicos em pólens e várias frutas, como no kiwi e banana, mas não no caqui. Apresenta-se o caso de um doente de 22 anos, com rinite alérgica persistente moderadagrave, sensibilizado a ácaros do pó doméstico. O doente refere episódio de prurido na mucosa oral e canal auditivo, seguido de urticária generalizada, que rapidamente evoluiu para disfonia, dispneia e tontura, após ingestão de caqui. Poucos meses depois, desenvolveu sintomas cutâneos semelhantes, acompanhados de náuseas, vómitos, cólica abdominal e hipotensão imediatamente após ingestão de uma banana. O teste cutâneo por picada com caqui e banana em natureza foram positivos, bem como o doseamento de IgE específica. O teste ImmunoCAP ISAC_112i identificou a presença de IgE específica para Act d 2 (taumatina do kiwi), homóloga da TLP da banana (Mus a 4). O estudo de inibição ImmunoCAP ISAC com "esponja" de Diospyros kaki (f301) produziu uma inibição parcial (40%) da ligação de IgE a Act d 2, permitindo presumir que uma proteína semelhante à taumatina é, pelo menos, parcialmente responsável pela referida sensibilização. Este doente encontra-se sensibilizado a Diospyros kaki e Musa acuminata. Uma anafilaxia ao caqui ingerido, presumivelmente resultante de reatividade cruzada com a taumatina da banana foi diagnosticada. Não estão descritas na literatura TLPs como alergênicos do caqui com reatividade cruzada com a banana e com Act d 2 in vitro (TLP do kiwi).