Management of anaphylaxis due to COVID-19 vaccines in the elderly.

Older adults, especially men and/or those with diabetes, hypertension, and/or obesity, are prone to severe COVID-19. In some countries, older adults, particularly those residing in nursing homes, have been prioritized to receive COVID-19 vaccines due to high risk of death. In very rare instances, the COVID-19 vaccines can induce anaphylaxis, and the management of anaphylaxis in older people should be considered carefully. An ARIA-EAACI-EuGMS (Allergic Rhinitis and its Impact on Asthma, European Academy of Allergy and Clinical Immunology, and European Geriatric Medicine Society) Working Group has proposed some recommendations for older adults receiving the COVID-19 vaccines. Anaphylaxis to COVID-19 vaccines is extremely rare (from 1 per 100,000 to 5 per million injections). Symptoms are similar in younger and older adults but they tend to be more severe in the older patients. Adrenaline is the mainstay treatment and should be readily available. A flowchart is proposed to manage anaphylaxis in the older patients.

Contact Allergy Induced by Mango (Mangifera indica): A Relevant Topic?

INTRODUCTION: The most common clinical manifestation of mango allergy is contact dermatitis, which can be localized or systemic. The sensitising substances that have long been suspected are alk(en)yl catechols and/or alk(en)yl resorcinols. METHODS: We reviewed the original articles published on Pubmed, Embase and Cochrane Library before 15 September 2021, on the topic of contact allergy induced by mango and we synthesized the key data. RESULTS: We found 12 case reports and four case series, with a total of 37 patients. Only seven of these cases were reported in patients from mango-cultivating countries, the other 30 were from countries where mango cultivation does not occur, and 26 were also from countries where poison ivy/oak are commonly found. We found that contact dermatitis may occur on the first exposure to mango due to previous sensitisation to urushiol-containing plants. The diagnosis was confirmed by patch testing in some of the cases. There was great heterogeneity between the reagents used. CONCLUSION: Mango fruit is frequently consumed, but mango induced contact dermatitis, the main hypersensitivity reaction induced by mango, is rare. Further data is necessary for a better understanding of sensitising substances and, consecutively, standardization of patch test reagents.

Vitamin D Level and Immune Modulation in Children with Recurrent Wheezing.

INTRODUCTION AND AIM: A direct causal relationship between vitamin D (vit D) deficiency and recurrent wheezing has not been proven. The present study investigated the role of vit D in enhancing the risk of asthma or recurrent wheezing by modifying the intensity of the inflammatory process. MATERIAL AND METHOD: Forty children with wheezing presenting at the emergency service and sixteen healthy control subjects were included in the study. Children with wheezing were either in the first episode (20) or with recurrent wheezing (20). Children with chronic diseases, and other conditions that present with acute wheezing or that might influence the vit D level, were excluded. Blood samples were taken at presentation and 3-6 months later, to evaluate the serum levels of total IgE, vit D, IL-10 and IL-31. Statistical analysis was performed using the SPSS 25 program, with a significance level of p < 0.05. RESULTS AND CONCLUSION: The vit D level was lower in patients with recurrent wheezing compared with those with a single episode and with the control group, and this increased with time. IL-10 was significantly higher in children with wheezing than in the control group, with the highest values in those with an acute episode of wheezing. IL-31 was higher in children with recurrent wheezing than in those with a first episode only at the initial point, while at the final time point it was lower. Low levels of vit D appear to be detected more frequently in recurrent wheezing than in simple wheezing. Immune modulation, as measured by Th2 status reflected by IL-10 and IL-31 levels, appears to depend on the wheezing phenotype and on the general health status.

Integrating Artificial Intelligence in Pediatric Healthcare: Parental Perceptions and Ethical Implications.

BACKGROUND: Our study aimed to explore the way artificial intelligence (AI) utilization is perceived in pediatric medicine, examining its acceptance among patients (in this case represented by their adult parents), and identify the challenges it presents in order to understand the factors influencing its adoption in clinical settings. METHODS: A structured questionnaire was applied to caregivers (parents or grandparents) of children who presented in tertiary pediatric clinics. RESULTS: The most significant differentiations were identified in relation to the level of education (e.g., aversion to AI involvement was 22.2% among those with postgraduate degrees, 43.9% among those with university degrees, and 54.5% among those who only completed high school). The greatest fear among respondents regarding the medical use of AI was related to the possibility of errors occurring (70.1%). CONCLUSIONS: The general attitude toward the use of AI can be considered positive, provided that it remains human-supervised, and that the technology used is explained in detail by the physician. However, there were large differences among groups (mainly defined by education level) in the way AI is perceived and accepted.

Diagnostic Challenges in Hemophagocytic Lymphohistiocytosis, a Rare, Potentially Fatal Disease: Two Case Studies.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, and potentially fatal, syndrome, characterized by immune system dysregulation, with excessive activation of the macrophages and cytotoxic T cells. It can be classified into primary (genetic) and secondary (acquired) forms. HLH presents with fever, hepatosplenomegaly, cytopenia, and hyperferritinemia, with involvement of various organs. The initial symptoms of HLH are non-specific, but as, if untreated, it can progress rapidly to multiorgan failure, timely diagnosis is essential. We present here two cases of HLH in infants that illustrate the importance of early diagnosis and appropriate treatment, along with a short review of HLH.

Case Report: Food Protein-Induced Protein Losing Enteropathy (FPIPLE) in Infancy.

Food-protein induced protein-losing enteropathy (FPIPLE) is a mixed IgE and non-IgE food allergy in infants along with eosinophilic gastrointestinal (GI) diseases (EGID). It is characterized by poor weight gain, edema, due to hypoproteinemia/hypoalbuminemia by enteral loss of proteins, anemia, eosinophilia, raised fecal α1-antitrypsin (α1AT), and specific-IgE and allergy skin prick test (SPT) positive for offending foods. Here, we describe 4 cases with the same clinical pattern (edema due to hypoproteinemia/hypoalbuminemia from enteral loss of proteins, confirmed by high α1AT in the stools and no other pathological findings explaining the hypoproteinemia including normal kidney and liver function parameters), and propose the term "food-protein induced protein-losing enteropathy" (FPIPLE) to define this clinical entity. We also propose diagnostic criteria and an empirical algorithm of a practical approach to the diagnosis and management for children suspected to have FPIPLE. These infants can be managed successfully with dietary modification. In our 4 cases, initially, an empirical elimination diet was applied, comprising the foods that had benn introduced in the infant's diet during the last month and, an extensively hydrolyzed or elemental formula was given. In a second approach, after evaluation by a pediatric allergist, an allergy test-directed dietary elimination alimentation was implemented, for mother and/or infant. It has yet to be demonstrated whether patients with FPIPLE are a subset of patients with EGID, and whether early intervention modifies the natural course.

Alternative Fish Species for Nutritional Management of Children with Fish-FPIES-A Clinical Approach.

In the Mediterranean region, fish is a common cause of food protein-induced enterocolitis syndrome (FPIES) in children. No laboratory tests specific to FPIES are available, and oral food challenge (OFC) is the gold standard for its diagnosis and testing for achievement of tolerance. Children with FPIES to fish are usually advised to avoid all fish, regardless of the species. Fish are typically classified into bony and cartilaginous, which are phylogenetically distant species and therefore contain less cross-reacting allergens. The protein ß-parvalbumin, considered a pan-allergenic, is found in bony fish, while the non-allergenic α-parvalbumin is commonly found in cartilaginous fish. Based on this difference, as a first step in the therapeutic process of children with FPIES caused by a certain fish in the bony fish category (i.e., hake, cod, perch, sardine, gilthead sea bream, red mullet, sole, megrim, sea bass, anchovy, tuna, swordfish, trout, etc.), an OFC to an alternative from the category of cartilaginous fish is suggested (i.e., blue shark, tope shark, dogfish, monkfish, skate, and ray) and vice versa. Regarding the increased mercury content in some sharks and other large species, the maximum limit imposed by the European Food Safety Authority (EFSA) for weekly mercury intake must be considered. An algorithm for the management of fish-FPIES, including alternative fish species, is proposed.

Breastfeeding and COVID-19: From Nutrition to Immunity.

Breastfeeding not only provides the optimum source of nutrients for the neonate and its first strong shield against infection but also lays the foundation for somatic and psychological bonding between the mother and child. During the current COVID-19 pandemic, although the guidelines of the relevant international and national agencies recommend breastfeeding by SARS-CoV-2-infected mothers, considerable insecurity persists in daily clinical practice regarding the safety of the infants and the perceived advantages and disadvantages of discontinuation of breastfeeding. This is a systematic review of the currently available information regarding the transmissibility of SARS-CoV-2 through or while breastfeeding and the protection against infection that breast milk might provide. The accumulated body of knowledge regarding the role of breast milk in the development of the neonatal immune system and protection against infection by other respiratory viruses is discussed, with a focus on the anti-inflammatory role of the antibodies, microbes, and viruses provided to the infant in breast milk and its relevance to the case of SARS-CoV-2.

The Challenging Diagnosis of Pediatric Multisystem Inflammatory Syndrome Associated with Sars-Cov-2 Infection-Two Case Reports and Literature Review.

Severe acute respiratory coronavirus 2 (SARS-CoV-2) is a novel coronavirus discovered in 2019 that caused the coronavirus disease 2019 (COVID19). During the last year, over 70 million people were infected and more than 1.5 million people died. Despite the tremendous number of people infected, children were less affected and presented milder forms of the disease. A short time after the pandemic was declared, a new hyperinflammatory syndrome resembling Kawasaki disease (KD) was described in children with confirmed or suspected SARS-CoV-2 infection named multisystem inflammatory syndrome in children (MIS-C). The incidence of MIS-C is low and it has a polymorphous clinical presentation, making the diagnosis difficult. Although the incidence is reduced, there is a high risk of cardiovascular complications. In order to raise awareness, we present the cases of two pediatric patients diagnosed with MIS-C in our clinic.

Clinical Experience with Anti-IgE Monoclonal Antibody (Omalizumab) in Pediatric Severe Allergic Asthma-A Romanian Perspective.

BACKGROUND: Asthma is the most common chronic disease affecting children, with a negative impact on their quality of life. Asthma is often associated with comorbid allergic diseases, and its severity may be modulated by immunoglobulin E (IgE)-mediated allergen sensitization. Omalizumab is a humanized monoclonal anti-IgE antibody, the first biological therapy approved to treat patients aged ≥6 years with severe allergic asthma. The primary objective of our study was to investigate the efficacy and safety of Omalizumab in Romanian children with severe allergic asthma. METHODS: In this observational real-life study, 12 children and adolescents aged 6 to 18 years (mean 12.4 years) with severe allergic asthma received Omalizumab as an add-on treatment. Asthma control, exacerbations, lung function, and adverse events were evaluated at baseline and after the first year of treatment. RESULTS: We observed general improvement in total asthma symptom scores and reduction in the rate of exacerbation of severe asthma. Omalizumab treatment was associated with improvement in the measures of lung function, and no serious adverse reactions were reported. FEV1 improved significantly after one year of treatment with Omalizumab [ΔFEV1 (% pred.) = 18.3], and [similarly, ΔMEF50 (%) = 25.8]. The mean severe exacerbation rate of asthma decreased from 4.1 ± 2.8 to 1.15 ± 0.78 (p < 0.0001) during the year of treatment with Omalizumab. CONCLUSIONS: This study showed that Omalizumab can be an effective and safe therapeutic option for Romanian children and adolescents with severe allergic asthma, providing clinically relevant information on asthma control and exacerbation rate in children and adolescents. The results demonstrated the positive effect of Omalizumab in young patients with asthma, starting from the first year of treatment.

Pulse Wave Velocity as a Marker of Vascular Dysfunction and Its Correlation with Cardiac Disease in Children with End-Stage Renal Disease (ESRD).

One of the main markers of arterial stiffness is pulse wave velocity (PWV). This parameter is well studied as a marker for end-organ damage in the adult population, being considered a strong predictor of major cardiovascular events. This study assessed PWV in children with chronic kidney disease (CKD) as a marker of cardiovascular risk. We conducted a prospective observational single-center cohort study of 42 consecutively pediatric patients (9-18 years old) with terminal CKD and dialysis, at the Hemodialysis Department of the "M. S. Curie" Hospital, Bucharest. We measured PWV by echocardiography in the ascending aorta (AscAo) and the descending aorta (DescAo), and we correlated them with left ventricular hypertrophy (LVH). Fifteen patients (35.7%) presented vascular dysfunction defined as PWV above the 95th percentile of normal values in the AscAo and/or DescAo. Cardiac disease (LVH/LV remodeling) was discovered in 32 patients (76.2%). All patients with vascular damage also had cardiac disease. Cardiac damage was already present in all patients with vascular disease, and the DescAo is more frequently affected than the AscAo (86.6% vs. 46.9%). Elevated PWV could represent an important parameter for identifying children with CKD and high cardiovascular risk.

Myopericarditis Associated with COVID-19 in a Pediatric Patient with Kidney Failure Receiving Hemodialysis.

The outbreak of COVID-19 can be associated with cardiac and pulmonary involvement and is emerging as one of the most significant and life-threatening complications in patients with kidney failure receiving hemodialysis. Here, we report a critically ill case of a 13-year-old female patient with acute pericarditis and bilateral pleurisy, screened positive for SARS-CoV-2 RT-PCR, presented with high fever, frequent dry cough, and dyspnea with tachypnea. COVID-19-induced myopericarditis has been noted to be a complication in patients with concomitant kidney failure with replacement therapy (KFRT). This article brings information in the light of our case experience, suggesting that the direct effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on cardiac tissue was a significant contributor to myopericarditis in our patient. Further studies in this direction are required, as such associations have thus far been reported.

The Impact of SARS-CoV-2 Pandemic on the New Cases of T1DM in Children. A Single-Centre Cohort Study.

Type 1 diabetes mellitus (T1DM) represents one of the most frequent chronic illnesses affecting children. The early diagnosis of this disease is crucial, as it plays a key role in preventing the development of a life-threatening acute complication: diabetic ketoacidosis. The etiopathogenetic role of viral infections has long been suggested and emerging data are pointing towards a complex bidirectional relationship between diabetes and COVID-19. The aim of this study is to assess the impact of the COVID-19 pandemic on the incidence and severity of new T1DM cases in children in Romania. We analyzed the differences between a group of 312 patients diagnosed with T1DM in the period 2003-2019 and a group of 147 children diagnosed during the pandemic. The data were investigated using statistical analysis of a series of relevant variables. The total number of newly diagnosed T1DM increased by 30.08% in the period March 2020-February 2021 compared to the previous years. The patients in the pandemic group had a higher mean age at the onset of T1DM, were less frequently living in an urban area, and presented a higher mean value of HbA1c. Diabetic ketoacidosis at the onset of T1DM was 67.40% more frequent, and a higher percentage of these patients presented with a severe form. The duration of T1DM symptoms did not differ significantly between the two groups. A number of 8 patients associated SARS-CoV-2 infection at the time of T1DM diagnosis.

Management problems in severe chronic inducible urticaria: Two case reports.

Chronic inducible urticaria (CIndU) is a subgroup of chronic urticaria which can cause severe quality of life impairment by their refractory forms. The recommended treatment approach in CindU is the same as that for chronic spontaneous urticaria (CSU). However, CIndU seem to be more resistant to standard doses of H1 antihistamines (AHs) and higher doses of AHs are required for symptom control. Omalizumab, a recombinant anti-IgE antibody, effectively treats CSU. Nevertheless, there is not enough evidence in patients with CIndU, especially in AHs resistant cases. This study analyzed 2 severe cases of CIndU (cold urticaria and symptomatic dermographism) with completely different response to omalizumab. We describe 2 patients with 2 subtypes of CIndU: one with severe cold urticaria (including anaphylaxis) and the other with severe extensive symptomatic dermographysm. In both cases, we performed complete positive and differential diagnostic work-up. Management strategies included first line and second line symptomatic therapy, but with no success in either case. Avoidance of eliciting triggers was difficult to achieve (occupational reasons). We decided to start omalizumab treatment, 300 mg every 4 weeks for 6 months. The cold urticaria patient gained complete symptom relief 10 days after the first dose of omalizumab; the quality of life improved substantially with no side effects of the treatment. The urticaria factitia patient showed no benefit of the add-on 5 months treatment with omalizumab. He refused the 6th dose of omalizumab due to the lack of response, and also cyclosporine, but he showed some benefits of oral corticosteroids. Although many clinical studies support the use of omalizumab in the treatment of patients with CIndU, we certainly need more data for prediction of a good clinical response.

Correlation Between Idiopathic Nephrotic Syndrome and Atopy in Children - Short Review.

The idiopathic nephrotic syndrome is a common chronic kidney diseases in children defined by the association of massive proteinuria and hypoalbuminemia in a relapsing/remission course, with histological aspect of minimal changes (also called minimal change disease) in the majority of the cases, but its pathogenesis remains not very well known. Clinical and immunological studies have consistently shown a relationship between atopic diathesis, immunoglobulin E and cytokines involved in immunoglobulin E synthesis and idiopathic nephrotic syndrome. Additional research is necessary to clarify this relationship and to explore the contribution of allergic disease to the development of nephrotic syndrome and to identify potential new strategies of diagnosis and treatment.

[Adverse reaction with immune mechanism induced by antituberculous drugs]. / Reactii adverse cu mecanism imunologic induse de medicamentele antituberculoase.

In every day medical practice, adverse immune reactions induced by antituberculous agents occur less frequently compared to toxic reactions. The risk of their appearance is significantly greater during individualized regimens. They include severe and potentially fatal reactions such as: anaphylaxis, toxic epidermal necrolysis, severe immune cytopenia, which must be rapidly recognized and monitored in intensive care. Reintroducing the therapeutic agent after suppressing the reaction can prove the causal relationship with an inductor. This diagnostic test (challenge test) is contraindicated for severe adverse drug reactions. The suspicion of an immune reaction during the treatment with antituberculous agents should be followed by the withdrawal of the suspected drug and pharmacological management according to the type and severity of the reaction; lately the antituberculous regimen will be reassessed.