Aeroallergen immunotherapy associated with reduced risk of severe COVID-19 in 1095 allergic patients.

Introduction: Allergen immunotherapy (AIT) brings along changes in the immune system, restoring dendritic cell function, reducing T2 inflammation and augmenting the regulatory cell activation. Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, interferes with the immune system causing immune suppression during the first phase and over-activation in more advanced disease. We decided to explore the interaction of both in a real-world observational trial. Methods: We registered COVID-19 outcomes in patients with allergic disorders in Latin America, treated with and without AIT. The registry was conducted during the first 1.3 years of the pandemic, with most of the data collected before COVID-19 vaccination was concluded in most countries. Data collection was anonymous via a web-based instrument. Ten countries participated. Results: 630/1095 (57.6%) of the included patients received AIT. Compared to patients without AIT, those treated with AIT had a reduced risk ratio (RR) for COVID-19 lower respiratory symptoms (RR 0.78, 95% CI: 0.6703-0.9024; p = 0.001662) and need for oxygen therapy (RR 0.65, 95% CI: 0.4217-0.9992; p = 0.048). In adherent patients on maintenance sublingual immunotherapy/subcutaneous immunotherapy (SLIT/SCIT) the RR reduction was larger [RR = 0.6136 (95% CI 0.4623-0.8143; p < 0.001) and RR: 0.3495 (95% CI 0.1822-0.6701; p < 0.005), respectively]. SLIT was slightly more effective (NS). We excluded age, comorbidities, level of health care attendance, and type of allergic disorder as confounders, although asthma was related to a higher frequency of severe disease. When analyzing patients with allergic asthma (n = 503) the RR reduction favoring AIT was more pronounced with 30% for lower respiratory symptoms or worse (RR 0.6914, 95% CI 0.5264 to 0.9081, p = 0.0087) and 51% for need of oxygen therapy or worse (RR 0.4868, 95% CI 0.2829-0.8376, p = 0.0082). Among severe allergic patients treated with biologics (n = 24) only 2/24 needed oxygen therapy. There were no critical cases among them. Conclusion: In our registry AIT was associated with reduced COVID-19 severity.

Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines.

BACKGROUND: Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. METHODS: Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following. RESULTS: Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. CONCLUSIONS: Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.

[GUIMIT 2019, Mexican Guideline on Immunotherapy. Guideline on the diagnosis of IgE-mediated allergic disease and immunotherapy following the ADAPTE approach]. / GUIMIT 2019, Guía Mexicana de Inmunoterapia. Guía de diagnóstico de alergia mediada por IgE e inmunoterapia aplicando el método ADAPTE.

BACKGROUND: In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019). METHOD: With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document. RESULTS: GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached. CONCLUSIONS: A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.

Antecedentes: En México, la inmunoterapia con alérgenos (ITA) y con veneno de himenópteros (VIT) se practica tradicionalmente combinando criterios de las escuelas europea y estadounidense; los dos tipos de extractos están comercialmente disponibles en México. Para una ITA adecuada es crucial un diagnóstico oportuno. Objetivo: Presentar GUIMIT 2019, Guía Mexicana de Inmunoterapia 2019, de base amplia, actualizada, que abarca temas de diagnóstico, indicaciones, dosificación, mecanismos, efectos adversos de la ITA y expectativas con esta modalidad de tratamiento. Método: Con la participación de múltiples grupos mexicanos de alergólogos, que incluían los centros formadores universitarios en alergia e inmunología, se desarrolló el documento de la guía según la metodología ADAPTE. Las guías de inmunoterapia de la European Academy of Allergy and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology, German Society for Allergology and Clinical Immunology y del American College of Allergy, Asthma, and Immunology se seleccionaron como guías fuente, ya que recibieron la puntuación AGREE-II más alta entre las guías internacionales disponibles; su evidencia conforma la base científica de GUIMIT 2019. Resultados: En GUIMIT 2019 se emiten recomendaciones fuertes o débiles (sugerencias) acerca de temas directamente relacionados con el diagnóstico in vivo o in vitro de las enfermedades alérgicas mediadas por IgE, la preparación y aplicación de ITA o VIT y sus efectos adversos; se incluye la revisión de las modalidades de ITA para el futuro. Todos los argumentos que se exponen fueron discutidos y votados con > 80 % de aprobación. Conclusión: Un grupo amplio y diverso de expertos en ITA y VIT emitió recomendaciones transculturizadas basadas en evidencia, que alcanzaron consenso; con ellas se pretende mejorar y homologar la práctica de la inmunoterapia en México.

[Risk factors for uncontrolled asthma in adults]. / Factores de riesgo para mal control de asma en adultos.

BACKGROUND: Many studies in children had identified risk factors associated with partly or uncontrolled asthma. In adults, factors related to asthma control were not well defined. OBJECTIVE: To find the factors related to partly or uncontrolled asthma in adults. METHODS: Asthmatic adults who had severity at least in the mild persistent level, were recruited. The asthma control levels were classified as controlled, partly controlled and uncontrolled according to the Global Initiative for Asthma guideline. Risk factors were compared between the patients with controlled and partly controlled/ uncontrolled asthma groups. RESULTS: Two hundred (75.5 % females) were included. The mean age was 38.4 ± 11.93 years old. There were 100 patients (50 %) in the controlled and 100 patients (50 %) in partly controlled and uncontrolled asthma group. For asthma severity, 35 patients (88.2 %) were in mild persistent, 14 patients (10 %) in moderate persistent and 97 patients (1.8 %) in severe persistent groups. The absence of stress yielded an OR = 0.41 (95 % CI = 0.23-0.75), p = 0.03. While active smoking, OR = 4.23 (95 % CI = 1.35-13.2), p = 0.007. Patients who have no contact with stuffed animals or rugs have OR = 0.4 (IC 95 % = 0.2-0.79). It was important the result of the patients that if they correctly use their inhalers OR = 0.36 (IC 95 % = 0.13-0.97), p = 0.031. CONCLUSIONS: Current and active smoking and atopic dermatitis are risk factors. As a protective factor to the normal levels of eosinophils in blood, correct use of inhalers, FEV1 > 80 %, the absence of stress and the absence of contact with carpets and stuffed animals.

Antecedentes: Estudios en niños han identificado factores asociados con la falta de control del asma. En adultos no están bien definidos. Objetivo: Identificar los factores relacionados con la falta de control del asma en adultos. Métodos: Se incluyeron adultos con asma clasificados como controlados, parcialmente controlados y no controlados según los criterios de la Global Initiative for Asthma. Resultados: Se incluyeron 200 pacientes (75.5 % mujeres), edad promedio de 38.4 ± 11.93 años. Cien pacientes con asma controlada y 100 con asma no controlada y parcialmente controlada; 35 (88.2 %) con persistencia leve, 14 (10 %) con persistencia moderada y 97 (1.8 %) con persistencia grave; en estrés se encontró RM = 0.41 (IC 95 % = 0.23-0.75), p = 0.03; en tabaquismo actual y activo, RM = 4.23 (IC 95 % = 1.35-13.2), p = 0.007; y en uso correcto de inhaladores, RM = 0.36 (IC 95 % = 0.13-0.97), p = 0.031. Los pacientes no tuvieron contacto con peluches ni alfombras. Conclusiones: Se observó asociación con tabaquismo actual activo y dermatitis atópica. Como factores de protección se identificó niveles normales de eosinófilos en sangre, uso correcto de inhaladores, VEF1 > 80 %, ausencia de estrés y de contacto con alfombras y peluches.

[DRESS syndrome or reaction to drugs with eosinophilia and systemic symptoms associated to anti-tuberculosis drugs]. / Síndrome DRESS o reacción a fármacos con eosinofilia y síntomas sistémicos asociada con el consumo de fármacos antituberculosos.

Tuberculosis has increased all over the world. This paper reports the case of a male patient with tuberculous meningitis, spinal tuberculosis (Pott's disease) and severe adverse reactions to antituberculosis drugs. He had skin rash, hepatitis, eosinophilia and fever; all these signs make the diagnosis of DRESS syndrome. This syndrome is caused by a severe hypersensitivity reaction to different drugs. It is usually caused by anticonvulsants, sulfonamides and some antiviral drugs, among other drugs. Anti-tuberculosis drugs can also cause this potentially fatal syndrome. The importance of surveillance for early detection and treatment of adverse drug reactions is emphasized.

La tuberculosis se ha incrementado en todo el mundo. Comunicamos el caso de un paciente con meningoencefalitis tuberculosa y tuberculosis de hueso (mal de Pott), que sufrió una reacción adversa grave a los fármacos antituberculosos. Inició con farmacodermia, hepatitis, leucocitosis, eosinofilia y fiebre, que constituyen el síndrome DRESS. Este síndrome es una reacción grave de hipersensibilidad a diferentes fármacos. Suele ser producido por anticonvulsivos, sulfonamidas y algunos fármacos antivirales, entre otros. Los fármacos antituberculosos también pueden producir este síndrome potencialmente fatal. Se destaca la importancia de la farmacovigilancia para su detección y tratamiento tempranos.

[Allergic bronchopulmonary aspergillosis]. / Aspergilosis broncopulmonar alérgica.

Allergic bronchopulmonary aspergillosis is a slowly progressive disease, caused by the fungus Aspergillus fumigatus hypersensitivity when it is found in the airway. It usually affects asthmatics and patients with cystic fibrosis. We report the case of a 20-year-old male patient, student, farmer and rancher with chronic respiratory disease. The diagnosis of allergic bronchopulmonary aspergillosis was made on the basis of the clinical symptoms and complementary studies.

La aspergilosis broncopulmonar alérgica es una enfermedad de progresión lenta, producida por la hipersensibilidad al hongo Aspergillus fumigatus cuando invade la vía aérea. Por lo general afecta a pacientes asmáticos y con fibrosis quística. Comunicamos el caso de un paciente de 20 años de edad, estudiante, ganadero y agricultor, con un cuadro respiratorio crónico. Luego del análisis de sus síntomas y de estudios complementarios, llegamos al diagnóstico de aspergilosis broncopulmonar alérgica.