CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 34, No 3 September 2021
- ALLERGY IN AFRICA
- Parental knowledge of food allergy
- The many faces of NSAID reactions
- Cold urticaria in a child: a case report
- A review of food protein-induced enterocolitis syndrome
- Approaching COVID-19 vaccination and anaphylaxis from two directions
- Atypical presentation of COVID-19 in an adolescent renal transplant recipient
INFORMATION OUT OF THE AFRICAN CONTEXT
Authors: Claudia Gray
Abstract: Although it was penned more than 30 years ago, this statement rings true at a time of excess opinion that overwhelms contextualised scientific reasoning. This issue of the journal focuses on providing just that – hard scientific facts and reasoning. At the same time, it includes its
usual varied range of articles that explore allergy in an array of African.
APPROACHING COVID-19 VACCINATION AND ANAPHYLAXIS FROM TWO DIRECTIONS
Authors: Cascia Day & Jonny Peter
Abstract: The SARS-COV-2 infection has already claimed the lives of more than 150 000 South Africans. In order to combat ongoing infections and fatalities, South Africa has commenced its largest adult mass vaccination roll-out ever. Roll-out commences against a backdrop of emerging science, increased anti-vaccine sentiments and much public anxiety about vaccine safety. Vaccine anaphylaxis is a serious adverse event known to occur in ~1 in a million doses with current registered vaccines. We discuss briefly the known epidemiology, diagnosis and common offending parts of vaccines that cause hypersensitivity. Similar to registered vaccines, anaphylaxis has been attributed to several COVID-19 vaccines, including a possible higher incidence up to ~8 in a million doses with the use of the novel mRNA COVID-19 vaccines. It is important that allergists approach both the risks and the management of COVID-19 vaccine-related anaphylaxis soundly. We present two recent cases to highlight our approach (i) to safe COVID-19 vaccination for patients with prior vaccinerelated anaphylaxis, multiple-drug hypersensitivity syndrome or clonal mast-cell disorders; and (ii) to allergy work-up and the management of patients with COVID-19 vaccine-related allergy or anaphylaxis. In particular, we discuss administering a safe second dose if required for vaccine efficacy.
Keywords: COVID-19 vaccine anaphylaxis, polysorbate-80, polyethylene glycol (PEG) 2000, mRNA vaccine, adenovirus vaccine, COVID-19
THE MANY FACES OF NSAID REACTIONS
Authors: Cascia Day and Jonathan Peter
Abstract: Nonsteroidal anti-inflammatory drugs (NSAIDs) are a large group of common over-the-counter and prescription medications. As a group, NSAIDs are a common cause of drug hypersensitivity. However, the challenge is that the spectrum of hypersensitivity reactions to NSAIDs is varied, including classic IgE- and non-IgE-mediated reactions to individual NSAIDs, intolerance to all cyclooxygenase-1 inhibitors (COX-1 inhibitors) and delayed T-cell reactions to single or multiple NSAIDs. Allergy work-up and management differ based on understanding the phenotype and mechanism. In this case series we describe three different reactions to an individual NSAID – diclofenac. This highlights the clinical presentation, work-up and distinct management necessitated by each case.
Keywords: nonsteroidal anti-inflammatory drugs, NSAIDs, drug hypersensitivity
ATYPICAL PRESENTATION OF COVID-19 IN AN ADOLESCENT RENAL TRANSPLANT RECIPIENT
Authors: Tamara Jaye, Nonhlanhla Mbenenge, Selwyn Schwartz, Jennifer Geel, Jason Parry, Daniella Marques, Beauty Sangweni, Tholang Khumalo and Cecil Levy
Abstract: Towards the end of 2019, a new coronavirus (CoV) was described emerging from Wuhan, China. Given its phylogenetic similarity to SARS-CoV, the new coronavirus was named severe-acute respiratory syndrome virus-2 and the disease it caused was named coronavirus disease of 2019 (COVID-19). There are few reports of paediatric renal transplant recipients infected with SARS-CoV-2 and, although guidelines for the management of solid-organ transplant recipients exposed to SAR-CoV-2 have been published, there are few paediatric-specific guidelines. We present a case of an unusual presentation of COVID-19 in an adolescent transplant recipient who presented with transient facial angioedema and a non-specific skin rash. She developed acute kidney injury, which resolved without any intervention. We suggest that, in future, an international registry of paediatric transplant recipients infected with COVID-19 be established to delineate more clearly the presenting features, clinical course and challenges encountered in treating these patients.
Keywords: COVID-19, Coronavirus, SARS-CoV-2, kidney transplant, children, adolescent, angioedema, skin rash, arthralgia, acute kidney injury
A REVIEW OF FOOD PROTEIN-INDUCED ENTEROCOLITIS SYNDROME
Authors: Kate Browde and Candice Royal
Abstract: Non-IgE-mediated food allergy represents a group of varied allergic disorders, characterised by a delayed onset of symptoms. These disorders typically present with gastrointestinal symptoms. Diagnosis may be delayed or missed due to the less obvious temporal association with allergen ingestion and a lack of confirmatory investigations. Food proteininduced enterocolitis syndrome (FPIES) is a type of non-IgE-mediated food allergy that can present as acute or chronic in nature depending on the amount and frequency of allergen consumption. There is also an atypical sub-type where there is IgE sensitisation to the trigger food. The pathophysiology is incompletely understood, and the prevalence is thought to be underestimated because of a lack of physician awareness. Little African and South African data exists, but with the large burden of diarrhoeal disease in this context, it is important to be aware of FPIES as a possible differential diagnosis. The recently published Consensus Guidelines provide an important tool to assist in recognition, diagnosis and management of FPIES.
Keywords: non-IgE-mediated food allergy, food protein-induced enterocolitis syndrome
PARENTAL KNOWLEDGE OF FOOD ALLERGY
Authors: Kate Browde and Candice Royal
Background: Studies in Western countries and some parts of Africa indicate that food allergy prevalence is increasing globally. For allergen-induced illness, avoiding the triggers is the mainstay of treatment and prevention. Unnecessarily withdrawing suspected protein-rich foods from children’s diets may lead to malnutrition and related complications. The aim of this study was to assess the knowledge and misconceptions about food allergy among parents.
Methods: This was a descriptive, mixed cross-sectional study and the design was explanatory sequential. Self-administered questionnaires and focus-group discussions were used to collect quantitative and qualitative data respectively.
Results: The majority of parents had poor knowledge scores, with an average of 49.14%. There were misconceptions about the aetiological mechanisms of food allergy, risk factors and the effects on the affected children’s diets. Thedemographic factors of parents were not associated with knowledge scores.
Conclusion: Most parents had poor knowledge irrespective of their level of education, age, gender and having a child with a food allergy.
Keywords: parental knowledge, food allergy, children, Kenya
COLD URTICARIA IN A CHILD: A CASE REPORT
Authors: Evelyn Ng’ang’a
Background: Over a one-month period, a 2½-year-old child presented with a recurrent history of an itchy rash involving the limbs, feet, lip and tongue swelling ten minutes after eating an ice lolly. A diagnosis of cold urticaria was made, responsive to antihistamines. She now tolerates cold foods.
Keywords: cold urticaria, angioedema, antihistamines, temp test, ice-cube test
CONSENSUS STATEMENT OF THE MANAGEMENT OF SEVERE, DIFFICULT-TO-TREAT ATOPIC DERMATITIS IN ADULTS AND ADOLESCENTS IN SOUTH AFRICA AND THE ROLE OF BIOLOGICS
Authors: Susanna M Kannenberg, Sarah J Karabus, Michael Levin, Tshegofatso Mabelane, Ahmed I Manjra, Lushen Pillay, Noufal Raboobee, Rajendrakumar Singh, André van Niekerk, Robert Weiss, Willem I Visser
Abstract: The first biological agent for treatment of moderate-to-severe atopic dermatitis (AD), dupilumab, has recently been introduced to South Africa and guidance is required as to its place in therapy. Consequently, an expert panel was convened to reach consensus on 14 statements relevant to contemporary management of AD and the use of dupilumab. In summary, the objectives of therapy are to reduce skin inflammation and pruritus, restore skin-barrier function, avoid flares, and improve quality of life. Useful comprehensive scoring tools to assess severity of AD and guide decisions to step up from topical to systemic therapy (including to a biologic agent), include SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI) and Dermatology Life Quality Index (DLQI). In addition, a photographic record of pre-treatment and follow-up assessments is helpful. When systemic therapy is required, options include cyclosporin, which should be limited to short-term use, and off-label use of methotrexate. Systemic corticosteroids should be considered only in short courses for rescue therapy in the event of flares. New classes of medication for the treatment of moderateto-severe AD are in various stages of development. The two most prominent classes of new therapies are biologics and small molecules. Dupilumab is the first fully humanised monoclonal antibody (MAB) biologic approved for the treatment of moderate-to-severe AD. It is an effective and well-tolerated, long-term treatment and has a favourable safety profile.
Keywords: atopic dermatitis, severe, biologics, adults, dupilumab
MISINFORMATION IN THE COVID-19 ERA
Authors: Sharon Kling
Abstract: Misinformation in the digital era has the potential to undermine the efforts of health authorities and professionals to keep the public informed. This is evident in the slew of misinformation around COVID-19 prevention, treatments and vaccines. Mis- and disinformation in the field of allergies is also prevalent. The consequences include harm to the public and increased healthcare costs.
Keywords: COVID-19, misinformation
ALLERGIES IN THE WORKPLACE
OCCUPATIONAL SKIN DISEASE IN HEALTH WORKERS, WITH A FOCUS ON CLEANING AGENTS – A REVIEW OF THE LITERATURE
Authors: Zahida Sonday, Amy Burdzik, Mohamed F Jeebhay
Abstract: Occupational skin disease is an important cause of morbidity in the global workforce; however, it is often under-diagnosed and under-reported. Health workers are a high-risk occupational group for work-related skin symptoms and conditions when compared to the general working population. Causative agents include both irritants and allergens. While most substances are potential irritants, important risk factors for occupational irritant contact dermatitis in health workers include wet working conditions and cleaning agent ingredients. These include disinfectants such as quaternary ammonium compounds present in surface cleaners and detergent foaming agents such as sodium lauryl sulphate in hand cleansers. With the substitution of less allergenic natural-rubber latex alternatives used in gloves over time, the incidence of latex allergy has declined. Common allergens associated with allergic contact dermatitis in health workers and occasionally implicated in Type-I immediate hypersensitivity reactions include cleaning agents (iNstrument disinfectants such as glutaraldehyde and ortho-phthalaldehyde, and hand hygiene disinfectants such as chlorhexidine) and glove-related rubber chemicals (especially thiuram). Preservatives and excipients in cleaning agents are also implicated in allergic contact dermatitis.
Keywords: occupational skin disease, occupational dermatoses, health workers, risk factors, cleaning agents, disinfectants, aldehydes, ortho-phthalaldehyde, glutaraldehyde, chlorhexidine, personal protective equipment, rubber accelerators