Levels of Immunoglobulin E Sensitization Drive Symptom Thresholds in Allergic Rhinitis.

BACKGROUND: Allergic rhinitis (AR) is a common respiratory disease encompassing a variety of phenotypes. Patients can be sensitized to one or more allergens. There are indications that polysensitization is associated with more severe disease. However, the extent to which the level of sensitization is associated to clinical disease variability, underlying the distinct nature of AR from AR+ conjunctivitis or AR+ asthma, is not known. OBJECTIVE: The aim of this study was to evaluate phenotypical differences between mono- and poly-sensitized patients with AR and to quantify their symptomatic variability. METHODS: 565 patients with a confirmed diagnosis of AR were included in this cross-sectional study. 155 were mono-sensitized and 410 poly-sensitized. Interactions between sensitization levels and reporting of different symptoms of AR and co-morbidities, disease duration and impact, were assessed. Furthermore, patients were stratified into mono- oligo- and poly-sensitized to assess whether the effect of sensitization on phenotype was ranked. RESULTS: Poly-sensitized patients reported significantly more often itchy eyes (p=0.001) and had higher number of ocular (p=0.005), itch-related (p=0.036) and total symptoms (p=0.007) than mono-sensitized patients. In addition, polysensitized adults and children more often reported wheeze (p=0.015) and throat-clearing (p=0.04), respectively. Polysensitization was associated with more burdensome AR according to VAS (p=0.005). Increasing sensitization level was reflected in more itchy eyes, number of ocular, itch-related and total number of symptoms, as well as disease burden. CONCLUSION: With increasing number of sensitizations, AR patients experience an increased diversity of symptoms. Multimorbidity-related symptoms increase with sensitization rank, suggesting organ-specific thresholds.

Impact of Presumed Tree Nut and Peanut Allergy on Quality of Life at Different Ages.

Tree nut and/or peanut allergy impairs patients' quality of life, but data on the impact of age and the type of nut or peanut on the quality of life are lacking. To evaluate the impact at different ages, age-appropriate survey questionnaires accompanied by FAQLQ and FAIM were distributed to patients with suspected tree nut and/or peanut allergy who presented at the allergy departments of three hospitals in Athens. Out of 200 questionnaires distributed, 106 met the inclusion criteria (46 children, 26 teenagers, 34 adults). The median score of each age group for FAQLQ was 4.6 (3.3-5.1), 4.7 (3.9-5.5), and 3.9 (3.2-5.1) and for FAIM was 3.7 (3.0-4.0), 3.4 (2.8-4.0), and 3.2 (2.7-4.1), respectively. FAQLQ and FAIM scores were correlated with the reported probability of using the rescue anaphylaxis set upon reaction (15.4%, p = 0.04 and 17.8%, p = 0.02, respectively) and pistachio allergy (FAQLQ: 4.8 vs. 4.0, p = 0.04; FAIM: 3.5 vs. 3.2, p = 0.03). Patients with additional food allergies reported worse FAQLQ scores (4.6 vs. 3.8, p = 0.05). Worse FAIM scores were associated with younger age (-18.2%, p = 0.01) and the number of life-threatening allergic reactions (25.3%, p < 0.001). The overall impact of tree nut and/or peanut allergy on patients' quality of life is moderate but differs with age, the type of nut, the use of adrenaline, and the number of previous reactions. The aspects of life affected and contributed factors also vary across age groups.

Administration of the Second Dose of mRNA COVID-19 Vaccine to a Woman With Immediate Reaction to the First Dose.

Vaccines constitute the most effective public health intervention as they prevent the spread of infectious diseases and reduce disease severity and mortality. Allergic reactions can occur during vaccination. Systemic anaphylaxis is a severe, life-threatening allergic reaction which can rarely occur after vaccination. There is limited data suggesting that the majority of the patients with immediate and potentially allergic reactions after the first dose of coronavirus disease 2019 (COVID-19) can receive the second dose. A 39-year-old woman was admitted to our department after presenting anaphylactic reaction following the first dose of mRNA COVID-19 vaccine (BNT162b2). A few days later, she contacted our department and was admitted for an allergy work-up on mRNA COVID-19 vaccine and its compound polyethylene glycol (PEG). Thereafter, she completed the vaccination procedure having received pretreatment under our guidance. Confirmed allergic reactions to vaccines are customarily attributed to the inactive ingredients, or excipients like PEG and polysorbate. The latest are used to improve water-solubility in vaccines. PEG itself has not been previously used in a vaccine but polysorbate has been identified as a rare cause of allergic reactions to vaccines. It has been reported that the interaction of the immune system with lipidic nanoparticle therapeutics could result in hypersensitivity reactions (HSRs), referred to as complement activation related pseudoallergy (CARPA), which is classified as non-IgE-mediated pseudoallergy caused by the activation of the complement system.

Co-occurrence between hereditary angioedema and multiple sclerosis: Therapeutic management of both diseases with fingolimod.

BACKGROUND: Hereditary angioedema (HAE) related to C1 esterase-inhibitor deficiency activates the classic complement pathway and results to edematous crises. Although HAE is usually associated with multiple immunoregulatory disorders, neurologic manifestations are rare. CASE REPORT: We report on the case study of a 33-year-old man diagnosed with HAE (SERPIN1G gene mutation) and multiple sclerosis (MS), followed up for at least 6 years. After a first clinical attack of HEA with scrotal edema, MS disease exacerbation was observed. Treatment with glatiramer acetate could not prevent either MS or HAE clinical attacks with recurrent exacerbations been observed. Remission of MS and significant amelioration of HAE attacks were achieved under fingolimod treatment. CONCLUSIONS: Herein we provide long term evaluation of an extremely rare case of concomitant existence of HAE and MS and present the effects of MS current disease-modifying therapies in HAE attacks. Our case highlights the possible effect of fingolimod in immunoregulatory-mechanisms implicated in both diseases.

Safety and Efficacy of a Progressively Prolonged Maintenance Interval of Venom Immunotherapy.

BACKGROUND: The long-term protection provided by venom immunotherapy (VIT) is related to the dose administered and to its long duration; the latter, however, becomes inconvenient for patients in countries like Greece, with many islanders or inhabitants of distant mountainous areas. Maintenance interval prolongation reduces the number of office visits - saving time and money - and as a consequence contributes to the patients' compliance. The aim of this prospective study was to evaluate the safety and efficacy of VIT on a progressively prolonged maintenance interval (PPMI). METHOD: 450 venom-allergic patients were reviewed for participation in our study; all of them were initially treated with a modified rush or an ultrarush protocol using freshly reconstituted, pure venoms. Upon reaching the maintenance dose, the VIT interval was scheduled to be gradually prolonged - by 1 week each time - aiming at a maximal interval of 26 weeks. RESULTS: 267/450 patients consented to participate in our VIT PPMI protocol: 98 were treated with vespid(s) venom, 142 with honeybee venom, and 27 with both. The mean duration of patient follow-up was 9.1 ± 4.2 years. The majority of systemic reactions due to VIT injections occurred up to the 8-weeks PPMI; few additional reactions were documented in a small fraction (2.9%) of our patient population beyond 9 weeks and up to 16 weeks; all were caused by honeybee VIT. No reactions were observed during VIT administration at the 26-week interval. Ninety-six patients reported 204 field sting occurrences by the culprit insect. Ten systemic reactions (8 mild and 2 moderate in severity) were registered between the 9- and 18-week PPMI; the honeybee was the culprit insect in all cases. 108 field stings by the offending insect were sustained beyond the 20- and up to the 26-week PPMI; there were no reactions at all. CONCLUSIONS: Progressively prolonging the VIT maintenance interval up to 26 weeks appears to be safe and efficacious.

Bee pollen sensitivity in airborne pollen allergic individuals.

BACKGROUND: Physicians who practice alternative medicine often prescribe bee pollen as a food supplement and a treatment for various ailments. OBJECTIVES: To determine the qualitative and quantitative composition of bee pollen and to investigate the cutaneous reactivity of atopic patients to bee pollen extracts. METHODS: The absolute number of pollen grains per gram of bee pollen was calculated, and morphologic identification of the botanical family was performed. Five extracts of bee pollen were prepared for skin prick testing, according to standard methods. Two hundred two volunteers participated in the study; 145 were atopic patients with respiratory allergy. The remaining 57 were healthy volunteers or nonatopic patients and served as a control group. All participants underwent skin prick testing with a standard battery of 6 aeroallergens (olive, grasses mix, Parietaria, mugwort, Dermatophagoides pteronyssinus, and Dermatophagoides farinae) and with all homemade bee pollen extracts. RESULTS: All samples of bee pollen contained Oleaceae pollen in high concentrations. Small amounts of anemophilous pollen (Compositeae, Chenopodiaceae) were detected in various samples. A strong positive correlation was observed between cutaneous reactivity to bee pollen extracts and olive, grasses, and mugwort. CONCLUSIONS: Bee pollen contains a large amount of pollen, which belongs to various allergenic families of plants. Bee pollen retains its allergenic potential as demonstrated by strong cutaneous responses to bee pollen extracts observed in atopic patients in contrast to nonatopic subjects. Regarding pollen allergic individuals, further studies are needed to evaluate the safety of ingesting large amounts of bee pollen.

Allergic reactions due to mizolastine.

BACKGROUND: An IgE-mediated allergic reaction to an antihistamine sounds like a paradox and is rare. OBJECTIVE: To describe 2 patients with anaphylaxis caused by mizolastine. In one patient, differential diagnosis from food allergy was necessary, whereas in the other patient, the history was clear. METHODS: History and in vivo skin testing were used for diagnosis. A challenge test to mizolastine was also proposed, but both patients refused to give consent. RESULTS: Skin test results were positive to mizolastine, whereas tests to the inert ingredients of the mizolastine tablets and to other H1 and H2 blockers had negative results. CONCLUSIONS: In vivo tests are highly sensitive, and they confirmed the diagnosis of the uncommon antihistamine allergy.

Efficacy and safety of mometasone furoate vs nedocromil sodium as prophylactic treatment for moderate/severe seasonal allergic rhinitis.

BACKGROUND: The preventive use of medications has been proposed to be effective in the treatment of seasonal rhinitis. OBJECTIVE: To evaluate the efficacy and safety of mometasone furoate and nedocromil sodium nasal sprays as prophylactic treatment for moderate to severe seasonal allergic rhinitis (SAR). PATIENTS: Sixty-one patients were recruited from 3 referral allergy centers. Inclusion criteria were history of SAR for 2 years or longer, sensitization to relevant local pollen (grasses, Parietaria, and olive), and age older than 12 years. METHODS: An open-label, randomized, parallel-group, "real-life" study design was used. Patients received mometasone furoate nasal spray once daily or nedocromil sodium nasal spray 3 times daily starting 2 to 4 weeks before the pollen season and continuing for up to 4 months. Instructions regarding the use of additional medications were given. Diary cards recording symptoms, use of medication, and adverse events were kept by the patients. RESULTS: All 61 patients completed the study. The prophylactic use of mometasone furoate vs nedocromil sodium led to significantly more days without symptoms (75.1% vs 54.5%; P < .001). The mometasone furoate group also had lower nasal symptom scores (mean, 1.4 vs 2.9; median, 0 vs 2; P < .001) and was more satisfied (93.1% vs 43.5%; P < .001). No serious adverse event was recorded, and there was no difference between the treatments in any adverse event. CONCLUSIONS: Prophylactic administration of mometasone furoate before the pollen season is safe and may lead to improved control of SAR compared with the use of nedocromil sodium.

Multiple physical urticarias: report of three cases and review of the literature.

The appearance of more than one physical urticaria (PU) in the same patient has been documented; cold urticaria or dermatographism in association with some other type of PU are encountered more frequently. Three female patients exhibiting multiple PUs simultaneously are presented. In one female patient four different forms of PU could be shown with the appropriate challenge tests; the other two female patients exhibited five different types. The longest postdiagnosis follow-up, with objective evaluation and persistence of all PUs, was 6 years in one subject. The co-occurrence of two, three, or four PU types has been published in the relative literature; no cases of five PUs have been reported previously.