Ricardo Cardona

Asthma and other allergic conditions in Colombia: a study in 6 cities

BACKGROUND No detailed information is available on the burden and impact of allergic diseases simultaneously for adults and children in Colombia and most Latin American countries. OBJECTIVES To investigate the prevalence of asthma, allergic rhinitis, and atopic dermatitis symptoms in 6 cities in Colombia; to measure patient expenses and school days and workdays lost; to describe disease severity; and to determine levels of total and specific IgE in asthmatic subjects. METHODS A multistage stratified random sample selection of schools with subjects aged 5 to 18 years in each city was used. Guardian subjects selected were contacted, and home visits were arranged. Subjects aged 1 to 4 years and older than 19 years were also selected randomly by systematic sampling based on the addresses of the subjects aged 5 to 18 years. Subjects with asthma symptoms were invited to provide a blood sample. RESULTS Information was obtained from 6,507 subjects. The prevalence of asthma, rhinitis, and atopic dermatitis symptoms in the past 12 months was 10.4% (95% confidence interval [CI], 9.7%-11.1%), 22.6% (95% CI, 21.6%-23.6%), and 3.9% (95% CI, 3.4%-4.4%), respectively. Thirty-eight percent of asthmatic subjects had visited the emergency department or have been hospitalized, and 50% reported lost school days and workdays. Seventy-six percent of sampled asthmatic patients were considered to be atopic. CONCLUSIONS The burden of disease and societal consequences of allergic entities in urban settings in countries such as Colombia are of concern but are largely ignored, perhaps because of the misconception that these diseases are of public health importance only in industrialized nations.

Omalizumab beyond asthma

INTRODUCTION Omalizumab has been demonstrated to be a successful therapy in the management of asthma through reduction of patients symptoms and use of inhaled corticosteroids. The effect of omalizumab is achieved by immunoglobulin E (IgE) blockage and other secondary mechanisms resulting from this blockage. Because other diseases have an important IgE mediation in their physiopathology, the question arises as to if omalizumab would be useful in the treatment of other IgE-mediated diseases. OBJECTIVE We present an overview of the experimental studies and clinical reports evaluating the use of omalizumab in diseases different to asthma including atopic dermatitis, urticaria, eosinophilic gastrointestinal disorders, idiopathic anaphylaxis, latex allergy, hymenoptera venom allergy, and other IgE diseases. METHODS We reviewed the literature using PUBMED, EMBASE, and LILACS for publications which used omalizumab in the treatment of patients with allergic diseases or any other diseases. Complete articles published in English, Spanish or Portuguese were included. CONCLUSION There is not enough evidence to support the regular use of omalizumab in IgE diseases other than asthma. However, some experimental and clinical investigations indicate that omalizumab could be a therapeutic option in several allergic diseases like atopic dermatitis, urticaria, and eosinophilic gastrointestinal disorders. More control studies are needed in each IgE disease to evaluate the efficacy and safety of omalizumab in IgE mediated diseases.

Omalizumab. An option in vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a severe ocular disease with immediate and delayed hypersensitivity reactions which can produce loss of visual acuity and blindness. In its physiopathology a Th1 and Th2 response is present and the therapeutic approach is very difficult because the use of local immunosuppressive therapy such as topical corticosteroids for a long time could produce severe adverse effects. As with other allergy conditions, allergens can induce an immune response mediated through expression of IgE antibodies. Omalizumab is a monoclonal anti-IgE antibody indicated in severe asthma, but in recent years has demonstrated its usefulness in other allergic diseases as atopic dermatitis. We present a 16-year-old male patient with VKC with no response to conventional therapy but with important improvement in clinical symptoms after beginning omalizumab. The patient began at two years of age with moderate atopic dermatitis and at four years of age with rhinitis and asthma. At the age of eight he presented severe ocular bilateral symptoms with red eyes, marked burning and itchy sensations, moderate photophobia, pseudogerontoxon, lacrimation, stringy discharge, papillae arranged in cobble stone and heaviness of eyelids. He received topical cyclosporine and corticosteroids in cycles for a long time without control. At the age of 13 he presented keratoconus in both eyes and required bilateral cornea transplant and permanent topical cyclosporine as immunosuppressive therapy for the transplant. At the moment it is his first visit to our allergy service. The patient had moderate atopic dermatitis with regular control with topical corticosteroids, lubricants and tacrolimus 0.1%; persistent moderate/severe rhinitis controlled with nasal corticosteroids and non-controlled asthma. We began tacrolimus 0.03% ointment for VKC and a combination of inhaled corticosteroids/B2 agonist for severe asthma with regular response for both therapies. The patient had total IgE 340 UI/L and sensitisation to house dust mites (Der f, Der p) and we began immunotherapy but this was suspended after six months because of poor treatment adherence (Fig. 1). At age of 15 we decided to start omalizumab 300 mg each two weeks for non-controlled asthma and VKC, ophthalmic and systemic immunosuppressive therapy was completely suspended and we only left tacrolimus 0.03%. After six weeks the patient presented an important improvement in ocular symptoms. After nine months he had a reduction of papillae. Other allergic conditions had an important improvement such as complete asthma control after six doses and atopic dermatitis after six months (Table 1). Ocular allergies are categorised in seasonal or perennial conjunctivitis and vernal or atopic keratoconjunctivitis. Ocular symptoms normally run with asthma and rhinitis. Some articles describe ocular symptomatic changes in these patients following omalizumab treatment. Sotohi et al. observed a significant improvement in a group of seasonal rhinoconjunctivitis patients after a four-month period and one year after re-treatment. The same investigation group observed in a controlled study that the omalizumab patients group had less symptoms compared with suplast tosilate group. Additionally to conjunctivitis typical symptoms, atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) make conjunctiva and corneal damage which can lead to blindness. These diseases management is usually complicated and their pathophysiology is not totally clear but a Th2 and Th1 immunological response seems to be

Frecuencia de sensibilización a animales en un área tropical

Background : Pet avoidance is commonly recommended to allergic pa tients, even if an IgE-mediated sensitization has not been demonstrated. This management is difficult to accomplish by patients with emotional attachment to their pets and the effectiveness is controversial. Objective : To assess the sensitization to different animals among patients with asthma, rhinitis, conjunctivitis and/or dermatitis. Patients and method : A retrospective study was performed with 300 previously reported patients with asthma, rhinitis, conjunctivitis and/ or dermatitis; we organized two groups: Group 1 included patients who were tested skin sensitization to both dog and cat. Group 2 was comprised of all patients with skin testing droppings or feathers of birds (canary, parrot, pigeon or hen). Results : Sensitization to cat and especially to dog was high (7% and 47%, respectively). The co-sensitization to dog was high among patients sensitized to cat (85%). Sensitization to other epithelia (horse, hamster, rabbit, cow) was low. About birds, there was a greater sensitization to proteins contained in the feces than in the feathers, pigeon sensitization was the most frequent. We observed no differences in the pattern of sen s itization among patients according to age, gender or allergic symptoms. Conclusions : The frequency of co-sensitization with cat and dog was high, which may be explained by shared proteins between the two spe cies as lipocalins. About birds, the proteins in pigeon droppings were the main cause of sensitization; however, it does not seem to share cross-reactivity with other birds and the frequency was relatively low compared with epithelia allergens.

Checklist for a complete chronic urticaria medical history: an easy tool

BackgroundExisting guidelines do not offer a quick, efficient alternative to the patient’s recollection of relevant clinical features during anamnesis and physical examination for chronic urticaria (CU). This study aimed to identify specific items reflecting the main characteristics of CU that should be included in a comprehensive medical history for patients with CU. We also aimed to clarify possible eliciting factors for CU to support accurate diagnosis of the disease.MethodsA panel of postgraduate dermatologists conducted a literature search for relevant studies on CU using Medline, the Cochrane database, and PubMed.ResultsWe identified82 articles from which we drew a collection of items to inform development of an easy-to-use checklist and collection of items that should be included in a correct medical history. The final version of the checklist included42 items across two areas: essential clues for anamnesis and diagnosis of CU; and typical symptoms/parameters or characteristics according to subtype, etiology, and laboratory findings. Items included time of disease onset; duration, shape, size, color, and distribution of wheals; associated angioedema; atopy; and triggering factors.ConclusionsOur guide provides an easy-to-use tool to support clinicians to focus, orient themselves, and save time in medical consultations for CU, allowing better diagnosis and management of this disease.

Síndrome Frey en la consulta de alergología

BACKGROUND Freys syndrome is a group of symptoms that include unilateral sweating with malar region and external ear reddening after eating or drinking some food. It is a lesion of the auriculotemporal nerve that is secondary to surgery, parotid gland infection or facial trauma. CLINICAL CASES Three children between 4 and two and a half years of age: two girls and one boy. They had self-limiting unilateral erythematous facial macules that reached the external ear, without rash, itching, angioedema and gastrointestinal or respiratory symptoms; its onset was associated with the consumption of acid and some sweet foods. Symptom reproduction of was observed in the path of the auriculotemporal nerve. Their histories included cesarean section delivery owing to cephalopelvic disproportion (case 1), birth by operative vaginal delivery with forceps (case 2) and cesarean delivery owing to preeclampsia (case 3). CONCLUSIONS Freys syndrome is often mistaken with food allergy, leading to unnecessary dietary restrictions. Sweating is often absent in children owing to possible eccrine glands immaturity.

Oral Allergy Syndrome: Rethinking Concepts

This chapter reviews current concepts in our understanding of oral allergy syndrome. As allergen-detecting technology has improved, a much more accurate profiling of individuals with food allergy is now possible to achieve, resulting in more precise diagnosis and leading to the question whether the term “oral allergy syndrome” is still valid.

Dietary Habits in Patients with Chronic Spontaneous Urticaria: Evaluation of Food as Trigger of Symptoms Exacerbation

Background Many patients with chronic spontaneous urticaria (CSU) identify different foods as triggers of their symptoms and frequently make dietary restrictions without enough information. Objective To explore the diet habits of CSU patients and estimate the clinical impact of the foods most frequently reported to be suspect. Methodology Patients were interrogated about their clinical history of urticaria. Skin prick test and sIgE serum were done for most frequently reported foods by patients. Food challenge test was also performed. A group of healthy subjects was included to compare the dietary habits and the results of the diagnostic tests. Results Patients with CSU (n 245) and healthy (n 127) subjects were included. 164 (66%) subjects from CSU group and 31 (24%) from the control group reported at least one adverse reaction with foods. Food IgE sensitization was similar in both groups (17.5% versus 16.5%, respectively). 410 food challenge tests in 164 CSU patients and 38 in 38 control subjects were performed. 1.2% in CSU group and 0.7% in control group had a positive oral challenge test. Conclusion Despite the high frequency of self-report by patients, foods are uncommon triggers of CSU. Nevertheless, food challenge tests have to be offered early during medical evaluation to avoid unnecessary restrictions.

[Milk and egg allergy: diagnosis, management and implications for Latin America].

Sensitization to food allergens, as well as the development of food allergies, is increasing worldwide, and cows milk and hens eggs are the main implicated foods. In most Latin American countries there are no management guidelines on the aforementioned topics; at their creation, such guidelines should be adapted to the conditions of the population in each region. This paper presents a review of the management of food allergy to milk and eggs useful for health personnel at all levels and some considerations of the factors found in Latin American developing countries.

[Cold urticaria: case series and literature review].

Cold urticaria is one of the five most common causes of chronic urticaria and is grouped as a physical urticaria. It can occur after exposure to cold, either through solid objects, air or liquids. Patients may have symptoms of urticaria, angioedema, respiratory distress and even anaphylaxis when the skin is exposed to a cold environment, such as handling refrigerated objects, swimming in cold water or entering an air-conditioned room. Five cases of cold urticaria are presented, followed by a brief literature review.