[Drug allergy: Fundamental aspects in diagnosis and treatment.] / Alergia a medicamentos: aspectos fundamentales en el diagnóstico y tratamiento. Reporte de grupo del Colegio Mexicano de Inmunología Clínica y Alergia.

BACKGROUND: Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms. OBJECTIVES: To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis. METHODS: A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups. RESULTS: This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events. CONCLUSION: ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.

ANTECEDENTES: Cualquier sustancia prescrita en el tratamiento de algún padecimiento es capaz de producir eventos dañinos o desagradables, y se denominan reacciones adversas a medicamentos. Estas reacciones se originan por mecanismos inmunológicos y no inmunológicos. OBJECTIVOS: Describir los mecanismos inmunológicos de las reacciones de hipersensibilidad a medicamentos, epidemiologia, factores de riesgo, clasificación, manifestaciones clínicas, diagnóstico, tratamiento y pronóstico. MÉTODOS: Se revisó la bibliografía actualizada, en inglés y español, asociada con reacciones de hipersensibilidad a medicamentos en las principales bases de datos. RESULTADOS: Se describen los términos para definir las reacciones adversas y de hipersensibilidad a medicamentos, su clasificación y manifestaciones clínicas, métodos diagnósticos actuales y en estudio, algoritmos de tratamiento y pronóstico de los medicamentos más frecuentemente prescritos y con mayor prevalencia de eventos adversos reportados. CONCLUSIÓN: Las reacciones adversas a medicamentos representan un reto, con una fisiopatología compleja y no del todo comprendida. Su abordaje requiere un enfoque cuidadoso, porque no todos los fármacos cuentan con pruebas validadas para establecer el diagnóstico y tratamiento específico. Antes de indicar cualquier medicamento debe considerarse la gravedad de la enfermedad, disponibilidad de otros tratamientos y riesgos potenciales de sufrir eventos adversos.

Coronavirus disease 2019, allergic diseases, and allergen immunotherapy: Possible favorable mechanisms of interaction.

Background: Both, allergen immunotherapy (AIT) and SARS-COV-2 infection cause a set of immunologic changes that respectively vary during the course of the treatment or the disease. Objective: To review immune changes brought along by each of these entities and how they might interrelate. Methods: We start presenting a brief review of the structure of the new coronavirus and how it alters the functioning of the human immune system. Subsequently, we describe the immune changes induced by AIT and how these changes could be favorable or unfavorable in the allergic patient infected with SARS-CoV-2 at a particular point of time during the evolving infection. Results: We describe how a healthy immune response against SARS-CoV-2 develops, versus an immune response that is initially suppressed by the virus, but ultimately overactivated, leading to an excessive production of cytokines (cytokine-storm-like). These changes are then linked to the clinical manifestations and outcomes of the patient. Reviewing the immune changes secondary to AIT, it becomes clear how AIT is capable of restoring a healthy innate immunity. Investigators have previously shown that the frequency of respiratory infections is reduced in allergic patients treated with AIT. On the other hand it also increases immunoregulation. Conclusion: As there are many variables involved, it is hard to predict how AIT could influence the allergic patient's reaction to a SARS-CoV-2 infection. In any case, AIT is likely to be beneficial for the patient with allergic rhinitis and/or allergic asthma in the context of the SARS-CoV-2 pandemic as controlling allergic diseases leads to a reduced need for contact with healthcare professionals. The authors remind the reader that everything in this article is still theoretical, since at the moment, there are no published clinical trials on the outcome of COVID-19 in allergic patients under AIT.

Cutaneous Manifestations Related to COVID-19 Immune Dysregulation in the Pediatric Age Group.

PURPOSE OF REVIEW: At the juncture of the COVID-19 pandemic, the world is currently in an early phase of collecting clinical data and reports of its skin manifestations, and its pathophysiology is still highly conjectural. We reviewed cutaneous manifestations associated with COVID-19 in the pediatric age group. RECENT FINDINGS: Children infected by SARS-CoV-2 usually develop milder respiratory symptoms, but cutaneous manifestations seem a little more prevalent than in adults. These skin features of infection by the coronavirus can be similar to those produced by other common viruses, but there are also reports of cases with more heterogeneous clinical pictures, which have made their classification difficult. To date, the more frequently reported skin variants featured in pediatric cases are purpuric (pseudo-chilblain, necrotic-acral ischemia, hemorrhagic macules, and/or cutaneous necrosis), morbilliform/maculopapular, erythema multiforme, urticarial, vesicular, Kawasaki-like, and miscellaneous (highly variable in both frequency and severity). Their pathophysiological mechanism is still elusive and is likely to be the result of the complex involvement of one or more mechanisms, like direct virus-induced skin damage, vasculitis-like reactions, and/or indirect injury as a consequence of a systemic inflammatory reaction. In this review, we presented and discussed clinical cases as examples of different cutaneous responses reported in some children with SARS-CoV-2 infection, differential diagnosis considerations, and a preliminary conceptual approach to some of their probable associated pathologic mechanisms.

Enhancing innate immunity against virus in times of COVID-19: Trying to untangle facts from fictions.

INTRODUCTION: In light of the current COVID-19 pandemic, during which the world is confronted with a new, highly contagious virus that suppresses innate immunity as one of its initial virulence mechanisms, thus escaping from first-line human defense mechanisms, enhancing innate immunity seems a good preventive strategy. METHODS: Without the intention to write an official systematic review, but more to give an overview of possible strategies, in this review article we discuss several interventions that might stimulate innate immunity and thus our defense against (viral) respiratory tract infections. Some of these interventions can also stimulate the adaptive T- and B-cell responses, but our main focus is on the innate part of immunity. We divide the reviewed interventions into: 1) lifestyle related (exercise, >7 h sleep, forest walking, meditation/mindfulness, vitamin supplementation); 2) Non-specific immune stimulants (letting fever advance, bacterial vaccines, probiotics, dialyzable leukocyte extract, pidotimod), and 3) specific vaccines with heterologous effect (BCG vaccine, mumps-measles-rubeola vaccine, etc). RESULTS: For each of these interventions we briefly comment on their definition, possible mechanisms and evidence of clinical efficacy or lack of it, especially focusing on respiratory tract infections, viral infections, and eventually a reduced mortality in severe respiratory infections in the intensive care unit. At the end, a summary table demonstrates the best trials supporting (or not) clinical evidence. CONCLUSION: Several interventions have some degree of evidence for enhancing the innate immune response and thus conveying possible benefit, but specific trials in COVID-19 should be conducted to support solid recommendations.

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.

Chronic urticaria and thyroid pathology.

Urticaria is defined as the sudden appearance of erythematous, itchy wheals of variable size, with or without angioedema (AE) (swelling of the deeper layers of the skin). Its classification depends on time course of symptoms and the presence of eliciting factors. When it lasts less than 6 weeks it is classified as acute urticaria (AU), and if the symptoms persist for more than 6 weeks, it is classified as chronic urticaria (CU). Current International Guidelines also classify CU as chronic spontaneous urticaria (CSU) and inducible urticarial, according to the absence or presence of environmental triggering factors. CSU is defined as urticaria and/or angioedema in which there is no evidence of a specific eliciting factor. CSU is associated with autoimmunity in 30-45% of the cases, sharing some immunological mechanisms with other autoimmune diseases, and is associated with autoimmune thyroid disease (ATD) in about 4.3%-57.4% patients. Several studies suggest that adequate therapy with anti-thyroid drugs or levothyroxine in early stages of ATD and CSU, may help to remit the latter; but there is still a lack of double-blind, placebo-controlled studies that support this hypothesis in patients without abnormal thyroid hormone levels. The objective of this review is to describe the pathophysiology of chronic spontaneous urticaria and its association with autoimmune thyroid disease.

[Clinical Practice Guide for Anaphylaxis in Latin America (Galaxia-Latam)]. / Guía de Actuación en Anafilaxia en Latinoamérica. Galaxia-Latam.

Anaphylaxis is a severe allergic reaction with a rapid onset and it is potentially life-threatening. Its clinical manifestations are varied; they may affect the skin, the cardiovascular system, the respiratory system, and the digestive system, among others. The treatment of choice, which is an intra-muscular injection of epinephrine (adrenaline), must be applied promptly. Therefore, being prepared to recognize it properly is of crucial importance. The objective of this clinical practice guide is to improve the knowledge of health professionals about anaphylaxis and, consequently, to optimize the treatment and long-term management of this reaction. This guide is adapted to the peculiarities of Latin America; especially in matters regarding the treatment. The need to introduce epinephrine auto-injectors in countries that don't have them yet is highlighted.

La anafilaxia es una reacción alérgica grave de instauración rápida y potencialmente mortal. Sus manifestaciones clínicas son muy variadas, pudiendo afectar la piel, el sistema cardiovascular, el aparato respiratorio y el digestivo, entre otros. El tratamiento de elección, mediante la inyección intramuscular de adrenalina, debe ser precoz. Por lo anterior, es vital estar preparados para reconocerla adecuadamente. El objetivo de la presente guía de actuación clínica es mejorar el conocimiento de los profesionales sanitarios sobre anafilaxia y, consecuentemente, optimizar el tratamiento y manejo a largo plazo de esta entidad. La guía está adaptada a las peculiaridades de América Latina, especialmente en los aspectos relativos al tratamiento. Se destaca la necesidad de introducir los autoinyectores de adrenalina en los países que no dispongan de ellos.

[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.

Adverse immune reactions and non-immune medications for perioperative use. / Reacciones adversas inmunitarias y no inmunitarias a fármacos de uso perioperatorio.

Reactions to medications can occur through a mechanism mediated by immunoglobulin or otherwise, not both. Drug allergy is a type of adverse reaction to the drug and comprises a range of hypersensitivity reactions mediated by different immunological mechanisms with diverse clinical manifestations. A rate of 3.2 fatal cases of anaphylaxis associated with drugs per 100,000 inhabitants per year is estimated, which seems to be approximately 10 times higher in hospitalized patients. The incidence of perioperative anaphylactic reactions is estimated at 1 in 10,000-20,000 anesthetic procedures. The diagnosis is based on a careful clinical history and physical examination. In some cases, skin tests, progressive challenges and methods to induce tolerance to the medication may be required. In hospitalized patients and at perioperative intervals, muscle relaxants, neuroleptics and morphinomimetics are frequently used and adverse reactions may occur to these drugs. This review shows a general description of the reactions of these medications, emphasizes allergic reactions and analyzes strategies for the diagnosis and treatment of these reactions.

Las reacciones a medicamentos pueden ocurrir por mecanismos mediados o no por imunoglobulina E. La alergia a fármacos es un tipo de interacción adversa y comprende una gama de reacciones de hipersensibilidad mediadas por distintos mecanismos inmunológicos con diversas manifestaciones clínicas. Se estima una tasa anual de 3.2 casos fatales de anafilaxia asociados con los fármacos por cada 100 000 habitantes, que parece ser aproximadamente 10 veces mayor en los pacientes hospitalizados. La incidencia de reacciones anafilácticas perioperatorias se estima en uno de cada 10 000-20 000 procedimientos anestésicos. El diagnóstico se basa en una cuidadosa historia clínica y en el examen físico. En algunos casos pueden requerirse pruebas cutáneas, pruebas de retos progresivos y procedimientos de inducción de tolerancia al medicamento. En los pacientes hospitalizados y en el intervalo perioperatorio frecuentemente se emplean relajantes musculares, neurolépticos y morfinomiméticos, por lo que pueden presentarse respuestas adversas a estos fármacos. En esta revisión se hace énfasis en las reacciones alérgicas a los medicamentos y se abordan estrategias para su diagnóstico y manejo.

[Quality of life in chronic urticaria and its relationship with economic impact and disease control in patients attended to at the University Hospital of Monterrey, Mexico]. / Calidad de vida en urticaria crónica y su relación con el impacto económico y control de la enfermedad en pacientes atendidos en el Hospital Universitario de Monterrey, México.

BACKGROUND: Chronic urticaria (CU) manifests itself with hives and sometimes angioedema. Physical and social discomfort worsens patient quality of life. CU has an important impact on patients' economy. OBJECTIVE: To evaluate the relationship of quality of life (QoL) with economic burden and chronic urticaria control of in patients treated at our center. METHODS: Cross-sectional, descriptive, observational study. We included CU-diagnosed adult patients. The CU-Q2oL and UCT questionnaires in Spanish and the economic burden and comorbidities questionnaire developed by our center were applied. A sample size of 36 patients was calculated. RESULTS: 36 patients were included, out of which 58.3% were females. Mean age was 39.9 ± 15.6 years. Regarding QoL, 66.7% of patients reported being "A little" affected, 25% "Somewhat" and 8.3% "A lot", and its relationship with monthly income yielded a p-value of 0.017. 38.9% of patients reported having a monthly income of less than $ 5000 pesos. When disease control was compared with the CU-Q2oL, a significant difference was obtained for questions concerning itching. CONCLUSION: There was association between the quality of life of patients with chronic urticaria and monthly income, the lower the income, the more will the quality of life be affected. Furthermore, greater CU control was observed to reduce the negative effects on quality of life caused by itching.

Antecedentes: La urticaria crónica se manifiesta con erupciones y ocasionalmente con angioedema. La molestia física y social empeora la calidad de vida de los pacientes, quienes, además, enfrentan importantes gastos. Objetivo: Evaluar la relación de la calidad de vida con la carga económica y el control de la urticaria crónica. Métodos: Estudio transversal, descriptivo y observacional. Se incluyeron adultos con diagnóstico de urticaria crónica. Se aplicaron los cuestionarios CU-Q2oL y UCT en español y un cuestionario sobre carga económica y enfermedades coexistentes. Se calculó un tamaño de muestra de 36 pacientes. Resultados: Se incluyeron 36 pacientes, 58.3 % fue del sexo femenino. La edad fue de 39.9 años ± 15.6. Respecto a la calidad de vida, 66.7 % reportó poca afectación, 25 % bastante y 8.3 % mucha; la relación con el ingreso económico mensual obtuvo p = 0.017; 38.9 % refirió ingresos mensuales menores a $5000. Al comparar el control de la enfermedad con el CU-Q2oL se obtuvo diferencia significativa para las preguntas referentes a prurito. Conclusiones: Existió asociación entre calidad de vida de los pacientes con urticaria crónica e ingreso familiar mensual: a menor ingreso, más afectación de la calidad de vida. A mayor control de la enfermedad, menor afectación.

[Evaluation of vitamin D serum levels in asthmatic adults and their relationship with asthma control].

BACKGROUND: Decreased levels of vitamin D influence on the control and severity of asthma. OBJECTIVE: To evaluate the relationship between vitamin D serum levels and asthma control, as well as nutritional status, quality of life and patient comorbidities. METHODS: Cross-sectional, observational, descriptive study of 43 asthmatic patients older than 18 years of age. Multiple logistic and multiple linear regression multivariate analyses of variance were performed; a p-value ≤ 0.05 was considered to be statistically significant. RESULTS: Insufficient vitamin D levels were determined in 83.7 % of patients; 93 % had at least one asthma exacerbation in the previous year. There was no relationship between vitamin D serum levels and asthma control as measured by ACT and FEV1. There was a significant association between body mass index and vitamin D levels (p = 0.013). With a quality of life questionnaire for asthmatic adults, 76.7 % were recorded to have a poor quality of life. CONCLUSIONS: No relationship was observed between vitamin D serum levels and asthma control in the patients. Most patients had insufficient vitamin D serum levels, uncontrolled asthma, and poor quality of life. Overweight and grade I obesity were associated with vitamin D insufficient levels.

Antecedentes: Los niveles disminuidos de vitamina D influyen en el control y la gravedad del asma. Objetivo: Evaluar la relación entre niveles séricos de vitamina D y control del asma, así como estado nutricional, calidad de vida y comorbilidades del paciente. Métodos: Estudio transversal, observacional y descriptivo de 43 pacientes asmáticos mayores de 18 años. Se realizó análisis de varianza multivariados de regresión logística múltiple y lineal múltiples; se consideró estadísticamente significativa una p ≤ 0.05. Resultados: Se determinaron niveles insuficientes de vitamina D en 83.7 % de los pacientes; 93 % presentó al menos una exacerbación asmática en el último año. No se evidenció relación entre los niveles séricos de vitamina D y control del asma medido por el Asthma Control Test (ACT) y el volumen espiratorio forzado el primer segundo (FEV1). Se obtuvo asociación significativa entre el índice de masa corporal y niveles de vitamina D (p = 0.013). Con un cuestionario de calidad de vida en adultos asmáticos se registró que 76.7 % tenía mala calidad de vida. Conclusiones: No se observó relación entre los niveles séricos de vitamina D y el control del asma en los pacientes. La mayoría de los pacientes tenía niveles séricos de vitamina D insuficientes, asma descontrolada y mala calidad de vida. El sobrepeso y la obesidad grado I se asociaron con niveles insuficientes de vitamina D.

[Evaluation of functional capacity by 6-minute walk test in children with asthma]. / Evaluación de la capacidad funcional mediante prueba de marcha de 6 minutos en niños con asma.

BACKGROUND: Asthma patients show lower exercise tolerance. OBJECTIVE: Assessment of functional capacity in children with asthma. METHODS: Girls and boys from 6 to 17 years old were included in two groups: asthmatic patients and healthy subjects. PSPQ was applied and vital signs, peak expiratory flow and Modified Borg Dyspnea Scale were measured at the beginning and the end of 6MWD. RESULTS: Participants included 58 subjects, including 32 asthmatic patients, and 55.2 % male subjects. Mean age: 10.6 years ± 3.1. Asthmatic group: mean distance covered in meters 456.04 ± 54.05, meters covered by gender 456.31 ± 48.73 male and 455.74 ± 61.29 female (p = 0.28). Control group: the mean was 468.28 ± 54.52 meters, meters covered by gender 465.98 ± 58.04 male, 471.44 ± 51.95 female (p = 0.35). The difference between asthmatic group and control group was 12.24 meters in favor of control group (p = 0.378). There was no association between body mass index (BMI) and distance covered (p = 0.53), but a Pearson correlation p = -0.445. In the male gender, CF was positively associated with self-perception in CAF variables: physical condition, physical attractiveness, strength (p = 0.04) and physical self-concept in general (p = 0.02). CONCLUSIONS: There was no significant difference in the distance covered between the two groups. The main impact factor was the body mass index with an inverse relation to the distance. Males had better physical self-perception, which is positively associated with CF.

Antecedentes: los pacientes con asma muestran menor tolerancia al ejercicio. Objetivo: evaluar la capacidad funcional en niños con asma. Métodos: se incluyeron pacientes con asma de 6 a 17 años y un grupo control sano. Se registraron signos vitales, flujometría, escala de disnea y fatiga de Borg antes y después de prueba de marcha de seis minutos; se aplicó el Cuestionario de Autopercepción Física. Resultados: participaron 58 sujetos, 32 con asma, 55.2 % del sexo masculino. La edad fue de 10.6 años ± 3.1 años. En el grupo con asma, la distancia media recorrida fue de 456.04 ± 54.05 m; en los hombres de 456.31 ± 48.73 m y en las mujeres de 455.74 ± 61.29 m (p = 0.28). En el grupo control, la distancia media fue de 468.28 ± 54.52 m; en niños de 465.98 ± 58.04 m y en las niñas de 471.44 ± 51.95 m (p = 0.35). La diferencia entre los grupos con asma y control fue de 12.24 m, a favor del control (p = 0.378). No hubo asociación entre el índice de masa corporal y la distancia recorrida (p = 0.53). En el sexo masculino, la capacidad funcional se asoció positivamente con la condición física, atractivo físico, fuerza (p = 0.04) y autoconcepto físico en general (p = 0.02) del Cuestionario. Conclusiones: no hubo diferencia significativa entre los grupos en la distancia recorrida. El principal factor de impacto fue el índice de masa corporal, con una relación inversa a la distancia recorrida. El sexo masculino tuvo mejor autopercepción física, asociada positivamente con la capacidad funcional.

Psychoneuroimmunoendocrinology: clinical implications.

Psychoneuroimmunoendocrinology, which was first described in 1936, is the study of the interactions between the psyche, neural and endocrine functions and immune responses. The aim of psychoneuroimmunoendocrinology is to apply medical knowledge to the treatment of different allergic, immune, autoimmune, rheumatic, neoplastic, endocrine, cardiovascular and dental pathologies, among other disorders. Epigenetic factors and major stresses from different types of stimuli acting through distinct pathways and neurotransmitters are highly involved in altering the psychoneuroimmunoendocrine axis, resulting in the emergence of disease. The main purpose of this report is to expand the understanding of psychoneuroimmunoendocrinology and to demonstrate the importance of the above-mentioned interactions in the etiology of multiple pathologies. In this review, a search of the medical literature using PubMed (free access search engine for the Medline database of the National Library of Medicine of the United States) over the years 1936 to 2016 was conducted, and descriptive and experimental studies and reviews of the scientific literature were included.

[Management of anaphylaxis in Latin America: current situation]. / Manejo de la anafilaxia en América Latina: situación actual.

BACKGROUND: Anaphylaxis is a systemic and severe allergic reaction, which can be fatal. The first-line treatment of choice, according to international guidelines, is intramuscular adrenaline. However, different studies show that the performance of health professionals managing anaphylaxis is often inadequate. OBJECTIVE: To assess the current resources available in Latin American countries for the diagnosis and treatment of anaphylaxis. METHODS: Online survey promoted by the Latin American Society of Allergy and Immunology to representatives of the national allergy societies of Latin American countries. RESULTS: Responses were received from 10 countries out of the 14 countries invited to participate. Only five of the countries have clinical practice guidelines in anaphylaxis. Adrenaline autoinjectors are available only in two countries, Argentina and Brazil, but are not subsidized by public health systems. In all countries, adrenaline is available in ampoules, which is the presentation usually prescribed to patients for self-administration. The use of adrenaline was estimated to be less than 50 % of cases in five countries, while antihistamines and corticosteroids are almost always used. The determination of serum tryptase is possible in some health centers, often private, in five of the countries surveyed. CONCLUSION: It is necessary to improve resources related to the diagnosis and management of anaphylaxis in Latin American countries.

Antecedentes: La anafilaxia es una reacción alérgica sistémica y grave que puede resultar fatal. El tratamiento de elección de primera línea, según las guías internacionales, es la adrenalina intramuscular. No obstante, diferentes estudios muestran que las acciones de los profesionales sanitarios ante un cuadro de anafilaxia frecuentemente son inadecuadas. Objetivo: Analizar los recursos actuales disponibles en los países de América Latina para el diagnóstico y tratamiento de la anafilaxia. Métodos: Encuesta en línea promovida por la Sociedad Latinoamericana de Alergia e Inmunología y realizada a representantes de las sociedades nacionales de alergia de los países de América Latina. Resultados: Se recibieron respuestas de 10 países de los 14 a los que se invitó. Solo en 5 se disponía de guías de práctica clínica en anafilaxia y en 2, Argentina y Brasil, de autoinyectores de adrenalina, no subvencionados por el sistema público de atención a la salud. En todos los países se dispone de adrenalina en ampolletas, que suele prescribirse a los pacientes para autoadministración. Se estimó que la utilización de adrenalina se emplea en menos de 50 % de los casos en 5 países, mientras que los antihistamínicos y los corticoides se utilizan casi siempre. En 5 países, la determinación de triptasa sérica fue posible en algunos centros sanitarios, muchas veces privados. Conclusión: Es necesario mejorar los recursos relacionados con el diagnóstico y tratamiento de la anafilaxia en los países latinoamericanos.

[Cross-reactivity in allergic fungal sinusitis. Case report]. / Reactividad cruzada en sinusitis alérgica fúngica. Reporte de caso.

BACKGROUND: The presence of allergic mucin in allergic fungal sinusitis (AFS) is a manifestation that identifies it as a hypersensitivity process. AFS has a phenomenon of cross-reactivity to IgE-bound proteins having at least two shared epitopes. CLINICAL REPORT: A 13-year-old male with nasal obstructive symptoms of three years of evolution. An obstructive mass was identified in the sinuses through physical examination and CT. In endoscopic surgery, the left nostril polyp was identified with the macroscopic appearance of allergic mucin; the polyp was resected. Final histopathological examination using periodic acid-Schiff and Grocott's methenamine silver staining indicated Aspergillus. Two weeks after surgery, percutaneous tests showed sensitization to Alternaria, Helminthosporium sativum, and Deramatophagoides farianae with negativity to Aspergillus fumigatus. CONCLUSIONS: The absence of significant titers of specific IgE antibodies to Aspergillus fumigatus was the evidence that the hypersensitivity response was triggered by a pathogen other than that isolated in histopathological study, which coupled with positive tests for other fungi may be explained by the cross-reactivity phenomenon in a phenomenon of likely hypersensitivity.

Antecedentes: La presencia de mucina alérgica en la rinosinusitis alérgica fúngica (RAF) es una manifestación que la identifica como un proceso de hipersensibilidad. En la RAF existe un fenómeno de reactividad cruzada entre proteínas unidas a IgE que tienen al menos dos epítopes compartidos. Caso clínico: Varón de 13 años de edad con síntomas obstructivos nasales de tres años de evolución. Por exploración física y tomografía se identificó masa obstructiva en los senos paranasales. En la cirugía endoscópica, en la fosa nasal izquierda se identificó pólipo con aspecto macroscópico de mucina alérgica; el pólipo fue resecado. El examen histopatológico final mediante tinciones con ácido peryódico de Schiff y metenamina plata de Grocott indicó Aspergillus. Dos semanas después de la cirugía, las pruebas percutáneas mostraron sensibilización a Alternaria alternata, Helminthosporium sativum y Deramatophagoides farianae, con negatividad a Aspergillus fumigatus. Conclusiones: La ausencia de títulos significativos de anticuerpos IgE específicos para Aspergillus fumigatus constituyó la evidencia de que la respuesta de hipersensibilidad fue desencadenada por un patógeno distinto del aislado en el estudio histopatológico, que aunada a las pruebas positivas para otros hongos puede explicarse por el fenómeno de reactividad cruzada en un probable fenómeno de hipersensibilidad.

[Prevalence of sensitization to fungi in patients with respiratory allergy]. / Prevalencia de sensibilización a hongos en pacientes con alergia respiratoria.

BACKGROUND: As part of the etiology of respiratory allergy we have genetics, prenatal factors and sensitivity to various airborne allergens, between these fungi are found. Relationship has been found between sensitization to fungal in skin tests and allergy pathogenesis and aggravation. There is a few literature in Mexico and in the north of the country it is lacking regarding this problem. OBJECTIVE: Assess the prevalence of sensitization to fungi in patients with respiratory allergy in skin tests to airborne allergens; determine the most prevalent fungus and prevalence of sensitization to each species of fungus per year, to assess the prevalence of sensitization to fungi by years. MATERIAL AND METHOD: Cross-sectional, observational and descriptive study conducted from 1 January 2010 to 31 December 2014 in patients treated at the Regional Center of Allergy and Clinical Immunology (Monterrey, Mexico) where we reviewed a database with patients whom performed skin tests, sensitization to 6 species of fungi were evaluated. We performed tables of data capture and statistical analysis. RESULTS: 4880 patients had respiratory allergy, a 17.1% prevalence of sensitization to fungal skin tests was determined. The fungus specie most prevalent was Alternaria alternata with 5.5%. The year range with the highest prevalence of sensitization was 0-10 years with a 6.7. CONCLUSIONS: The prevalence of fungi sensitization was higher than the global prevalence found, but lower than the prevalence found in other researches in Mexico.

Antecedentes: la prevalencia de rinosinusitis crónica en pacientes adultos con inmunodeficiencia común variable (IDCV) es de 52%. Los pacientes con esta enfermedad tienen mayor frecuencia de rinosinusitis crónica, enfermedad inflamatoria que afecta a la mucosa de uno o más senos paranasales y la cavidad nasal. Objetivo: identificar los microorganismos de secreción del meato medio obtenida por endoscopia asociados con rinosinusitis crónica en pacientes adultos con inmunodeficiencia común variable (IDCV). Material y método: estudio descriptivo, transversal, que incluyó a pacientes adultos con inmunodeficiencia común variable, de quienes se obtuvo una muestra vía endoscópica de secreción del meato medio de ambas fosas nasales, que se envió a cultivo para bacterias aerobias, anaerobias y hongos. Se obtuvo consentimiento informado de todos los pacientes. Resultados: se estudiaron 29 pacientes: 18 mujeres y 11 hombres, con edad promedio de 40±13 años. Los resultados obtenidos fueron: 2 muestras de pacientes no tuvieron desarrollo microbiano, 24 tuvieron desarrollo de bacterias aerobias, en 3 casos hubo crecimiento fúngico sin desarrollo de bacterias anaerobias. Conclusiones: nuestros resultados muestran que los microorganismos asociados con rinosinusitis crónica en pacientes adultos con inmunodeficiencia común variable más comunes son: Moraxella catarrhalis, Staphylococcus, Sphingomonas paucimobilis y Citrobacter koseri; los agentes micóticos asociados fueron: Candida albicans y Aspergillus fumigatus.

Drug-Induced Anaphylaxis in Latin American Countries.

BACKGROUND: Information regarding the clinical features and management of drug-induced anaphylaxis (DIA) in Latin America is lacking. OBJECTIVE: The objective of this study was to assess implicated medications, demographics, and treatments received for DIA in Latin American patients referred to national specialty centers for evaluation. METHOD: A database previously used to compile information on drug-induced allergic reactions in 11 Latin American countries was used to identify and characterize patients presenting specifically with a clinical diagnosis of DIA. Information regarding clinical presentation, causative agent(s), diagnostic studies performed, treatment, and contributing factors associated with increased reaction severity was analyzed. RESULTS: There were 1005 patients evaluated for possible drug hypersensitivity reactions during the study interval, and 264 (26.3%) met criteria for DIA. DIA was more frequent in adults and in elderly females (N = 129 [76.6%] and N = 30 [75%], respectively) compared with children and/or adolescents (N = 21 [42.9%], P < .01). Severe DIA was less frequent with underlying asthma (N = 22 vs 35 [38.6% vs 61.4%], P < .05) or atopy (N = 62 vs 71 [43% vs 59% ], P < .01). Nonsteroidal anti-inflammatory drugs (NSAIDs) (N = 178 [57.8%]), beta-lactam antibiotics (N = 44 [14.3%]), and other antibiotics (N = 16 [5.2%]) were the most frequently implicated drug classes. Anaphylaxis was rated as severe in N = 133 (50.4%) and anaphylactic shock (AS) was present in N = 90 (34.1%). Epinephrine was only used in N = 73 (27.6%) overall, but in N = 70 (77.8%) of patients with AS. CONCLUSION: In Latin American patients referred for evaluation of DIA, NSAIDs and antibiotics were implicated in approximately 80% of cases. Most of these reactions were treated in the emergency department. Epinephrine was administered in only 27.6% of all cases, although more frequently for anaphylactic shock. Dissemination of anaphylaxis guidelines among emergency department physicians should be encouraged to improve management of DIA.

[Profile of sensitization to allergens in children with atopic dermatitis assisting to Allergology Service of University Hospital, Nuevo Leon, Mexico]. / Perfil de sensibilización a alergenos en niños con dermatitis atópica atendidos en el Servicio de Alergología del Hospital Universitario de la Universidad Autónoma de Nuevo León, México.

BACKGROUND: Sensitization to allergens in atopic dermatitis patients is a risk factor for developing asthma and allergic rhinitis in the future,as well as an aggravating factor in the course of the disease. Recent studies have attributed the activity of the proteases of some antigens to cause a grater defect in the epithelial barrier and a more severe disease. OBJECTIVE: To know the sensitization to allergens pattern in children with atopic dermatitis attended at Allergology Service of University Hospital of UANL, Mexico, and to know if these children have higher sensitization to antigens with proteolytic activity. MATERIAL AND METHOD: A retrospective study was done reviewing the skin prick test reports done in our service to children ranging from 5 months to 16 years old, diagnosed with atopic dermatitis during a period of 2 years, from January 2012 to January 2014. The frequency of sensitization to aeroallergens and food were analyzed as well as the weal size (≥6mm) on the skin in response to each particular allergen in the case of food skin prick test. RESULTS: Reports of skin tests of 66 children, 30 boys and 36 girls, were included; 37 of children were sensitized to more than one allergen,18/66 had asthma and/or allergic rhinitis, 40/66 60% skin prick tests were positive to high activity protease aeroallergens (Dermatophagoides pteronyssinus/Dermatophagoides farinae). Regarding food, sensitization was seen in 38 children; fruits and vegetables were the two most common foods. Only seven children had skin prick weal bigger than 6 mm, mainly to egg, fish and cow's milk. CONCLUSIONS: Children with atopic dermatitis are often sensitized to high protease activity aeroallergens, polysensitization is very common and the association with airway allergy is seen early in life. Sensitization to food is also common in these patients, but only a small percentage showed a response large enough to be associated with disease severity.

Antecedentes: la sensibilización a alergenos observada en la dermatitis atópica aumenta el riesgo del niño a padecer rinitis alérgica y asma. Los estudios recientes indican que entre mayor actividad de proteasas haya en los alergenos a los que se está sensibilizado, hay mayor defecto en la barrera cutánea y mayor gravedad de la enfermedad. Objetivos: conocer el patrón de sensibilización a los alergenos en niños con dermatitis atópica atendidos en el Servicio de Alergología del Hospital Universitario de la Universidad Autónoma de Nuevo León y conocer si estos niños tienen mayor sensibilización a los antígenos con actividad proteolítica. Material y método: estudio retrospectivo en el que revisamos los reportes de las pruebas cutáneas por punción realizadas en nuestro servicio a niños de 5 meses a 16 años de edad, con diagnóstico de dermatitis atópica, de enero de 2012 a enero de 2014. Evaluamos la frecuencia de sensibilización a aeroalergenos y alimentos, así como el tamaño de la roncha en la respuesta cutánea para cada alergeno en particular. Resultados: se incluyeron los reportes de pruebas cutáneas de 66 niños, 30 hombres y 36 mujeres. Cuarenta y seis pacientes estaban sensibilizados a aeroalergenos y 38 a alimentos. Los ácaros del polvo de casa (Dermatophagoides pteronyssinus/Dermatophagoides farinae) fueron los alergenos con mayor frecuencia de respuesta positiva en las pruebas cutáneas. De los niños con sensibilización a alimentos, sólo los niños sensibilizados a la leche de vaca, al huevo y al pescado tuvieron una roncha mayor de 6 mm de diámetro. CONCLUSIÓN: en los niños con dermatitis atópica es común la sensibilización a aeroalergenos con alta actividad de proteasas y la polisensibilización es muy común. La sensibilización a alimentos es común en estos pacientes, pero sólo un pequeño porcentaje de ellos muestra respuestas cutáneas lo suficientemente grandes para relacionarlas con gravedad de la enfermedad.