CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 34, No 4 December 2021
- AN UPDATE ON ASTHMA
- SARS-CoV-2 and patients with asthma
- Life-threatening asthma in children
- Chronic management of asthma – a paradigm shift
- New developments in the manufacture of low-cost modified bottle spacers
AN UPDATE ON ASTHMA
Authors: Professor Debbie A White
Abstract: It is both a singular honour and a privilege to bring you this fourth edition of our Current Allergy and Clinical Immunology Journal for 2021. Our theme for this issue is ‘An Update on Asthma’. I thank Prof Eugene Weinberg and Dr Di Hawarden for inviting me to guest edit this issue; it has been a pleasure to do so, and to collaborate with them and also with Mrs Robyn Marais, the journal’s production manager. Special thanks must go to her for her patience and support in putting this issue of the journal together.
SARS-COV-2 AND PATIENTS WITH ASTHMA
Author: Abdullah E Laher
Abstract: The current coronavirus disease 2019 (COVID-19) pandemic has had far-reaching health, economic and political consequences worldwide. Asthma is a non-communicable lung disease that affects approximately 300 million people globally. Since the pathophysiology of both of these conditions is centred on the respiratory tract, there was initial concern that individuals with asthma may be at higher risk of developing severe disease with poorer outcomes. In this article, several aspects pertaining to asthma and COVID-19, including the associated risk and outcomes, the use of nebulisers and the role of adjunctive anti-asthma/anti-allergy medications, are discussed.
Keywords: SARS-CoV-2, COVID-19, asthma, adjunctive anti-asthma medication, anti-allergy medications
NEW DEVELOPMENTS IN THE MANUFACTURE OF LOW-COST MODIFIED BOTTLE SPACERS
Author: Michael Levin
Abstract: Metered dose inhalers (MDIs) are the devices most commonly used to deliver aerosols to the lungs. With optimal technique, lung deposition averages below 10% rising to approximately 15% if a spacer is used. Optimal hand–breath coordination is required when using MDIs directly in the mouth as actuation one second before inhalation reduces drug delivery by 90%.1 Spacers and valved holding chambers provide an additional volume in which medication is dispersed before it is breathed into the lungs. Because particles are breathed in after dispersing within the chamber, both aerosol velocity and particle size are reduced as larger particles adhere to the sides of the chamber. These factors prevent most of the deposition on the oropharynx and improve lung deposition by approximately 6% (from 8.8% to 14.8%).2 Despite the widespread misconception that nebulisers work better than MDIs even with spacers, metered dose inhalers can achieve equivalent, or even better clinical effect than nebulisers, simply by increasing the number of puffs to deliver the same dose. Cochrane reviews show an equivalent risk of hospital admission for adults whether treated with nebuliser or MDI but a 35% reduction in risk of admission for children when treated with MDIs.3 In children, the length of stay in emergency departments is significantly shorter when an MDI and spacer is used with a mean difference of almost 30 minutes.
Keywords: low-cost modified bottle spacers, metered dose inhalers
CHRONIC MANAGEMENT OF ASTHMA – A PARADIGM SHIFT
Author: Ismail S Kalla
Abstract: Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In the genetically susceptible individual this inflammation causes recurrent episodes of wheezing, breathlessness and cough, particularly at night and in the early morning. The number of disability-adjusted life years (DALYs) lost due to asthma worldwide has been estimated to be 15 million per year. South Africa has the fourth-highest asthma mortality in the general population (1.5 per 100 000) and the fifth-highest asthma mortality among 5–35-year-old asthmatics (18.5 per 100 000). The goals of asthma therapy have been revised with latest publication of the 2021 Global Initiative for Asthma (GINA) guidelines. Asthma is now understood to be a heterogeneous condition that is characterised by frequent acute episodic exacerbations. These frequent exacerbations against the background of chronic persistent inflammation have led to a change in our goal of asthma therapy. Previously, we used an objective measure such as documenting spirometric improvement as being the main therapeutic yardstick; however, the goal is now one of achieving ‘total asthma control’ which encompasses sustained symptomatic and spirometric improvement. With our better understanding of the different pathophysiological mechanisms underlying the asthmatic phenotype, several newer medications have been synthesised to target the specific immunological pathway-driving inflammation in asthma. Furthermore, with the latest evidence from the maintenance and reliver therapy (MART) trials there has been a major change to the asthma management paradigm within the mild asthmatic population – an often-neglected population group. This article focuses on the new guidelines for mild asthmatic patients and expounds on the biologicals therapies available to treat patients with refractory asthma and their specific targets within the asthma endotypes.
Keywords: asthma, chronic inflammatory disorder, chronic management
LIFE-THREATENING ASTHMA IN CHILDREN: A REVIEW
Authors: Debbie A White, William A White and Sharon Kling
Summary: We present a case of a child presenting with well-described but poorly recognised symptoms of life-threatening asthma that were initially missed. We present a management protocol for life-threatening asthma, for which evidence in the literature is lacking.
Keywords: life-threatening asthma, acute hysteria, management protocol
ABC OF ALLERGY
MORE ABOUT THE MAST CELL: DEGRANULATION
Authors: Shaunagh Emanuel and Di Hawarden
Abstract: Mast cells and basophils are key players in allergic disease. We are familiar with the immunoglobulin E-mediated, immediate, type 1 hypersensitivity reaction that results in rapid degranulation of mast cells.
MANAGEMENT OF CHILDREN WITH FOOD ALLERGIES IN SOUTH AFRICA: KNOWLEDGE AND PRACTICE OF PARENTS REGARDING PRECAUTIONARY ALLERGEN LABELLING – A CROSS-SECTIONAL SURVEY
Authors: Tharien Bezuidenhout, Harris Steinman, Daniel G Nel and Evette van Niekerk
Background: The prevalence of precautionary allergen labelling (PAL) on food products is estimated at 65%, but PAL is inconsistently applied. Consumers believe that PAL is well regulated, but their knowledge and practice of PAL is unsound, which is inconsistent with their apparent lack of trust in PAL statements. PAL should be clearly visible, easily understandable, reliable and precise in indicating ‘real risk’.
Objectives: The primary objective was to determine the knowledge and practice (including adherence) of South African parents and/or caregivers regarding PAL in managing immune-mediated food allergies in children. Methods: This study was a descriptive cross-sectional investigation with an analytical component. The study population consisted of parents and/or caregivers of children (birth to ten years) with an immune-mediated food allergy in South Africa. An online self-administered questionnaire was the instrument used for data collection
Results: Of the 140 participants included in the study, 98% were aware that there is a special statement on food labels indicating food allergens. The majority (84%) considered the phrase ‘contains’ to indicate a real risk of allergen contamination, 64% for ‘may contain’, 56% for ‘made with the same equipment’ and 40% for ‘made in the same factory’. Only 29% indicated that they would read the food label every time before using a food product. Non-adherence to the PAL statement ‘made with the same equipment as (the allergen-containing food)’ was associated with a life-threatening reaction (p = 0.007) or a visit to an emergency unit (p = 0.033)
Conclusion: This research shows that parents of children with food allergies either do not understand PAL fully or do not implement PAL statements effectively. It is vital to standardise PAL locally and globally to indicate ‘real risk’ or ‘no risk’ in order for consumers to recognise best practice in eliminating the risk of being exposed to allergen-containing food products.
Keywords: precautionary allergen labelling, knowledge, management, children, food allergies
AUTONOMY IN ASTHMA MANAGEMENT
Author: S Kling
Abstract: The principle of autonomy is one of the pillars of the four principles approach to medical ethics. Autonomous patients should be respected and have the right and the freedom to make their own decisions regarding their healthcare. This individualistic view of autonomy is particularly prevalent in Western cultures and clinical practice; a relational type of autonomy prevails in cultures which are communitarian in their approach. Autonomy and shared decision making are important concepts in managing asthma.
Keywords: autonomy, asthma, management
DR SPUR’S MY STERY CASE
THE MYSTERY CASE OF AN ALLERGIC PATIENT NOT RESPONDING TO THERAPY
Authors: Sylvia van den Berg, Cathy van Rooyen and Robin J Green
Abstract: Dear Dr Bruno. Thank you for referring this delightful young lady to my practice. Her quality of life is definitely hampered by the recurrent episodes of sinusitis and by her feeling generally unwell. It is important to get to the bottom of this before permanent structural damage occurs. I requested baseline Streptococcus pneumoniae serotypespecific antibodies and subsequently vaccinated her with a polysaccharide vaccine, Pneumovax 23®. I repeated the S pneumoniae serotype-specific antibodies four weeks later. She responded with a twofold increase to only three of the serotypes.
ECTHYMA GANGRENOSUM AS THE PRESENTING CLINICAL FEATURE OF X-LINKED AGAMMAGLOBULINAEMIA: REPORT OF THREE CASES AND A REVIEW OF LITERATURE
Authors: Intan Hakimah Ismail, Mohd Azri Zainal Abidin, Farah Syuhada Mohd Radzi, Saidatul Saadah Ramlan, Julia Adam and Adiratna Mat Ripen
Background: Children with X-linked agammaglobulinaemia (XLA) usually present with pneumonia and otitis media caused by pyogenic bacteria. Rarely, ecthyma gangrenosum (EG), a known cutaneous manifestation of Pseudomonas septicaemia present in XLA as the first presenting features. We report three cases of EG caused by P. aeruginosa in previously healthy boys, leading to the diagnosis of XLA. In addition, we provide a brief literature review on those cases of EG where an underlying XLA was eventually diagnosed.
Methods: Three paediatric cases admitted to the intensive care unit with P. aeruginosa septicaemia associated with ecthyma gangrenosum were reviewed retrospectively. Laboratory workup consisted of microbiological, haematological and immunological investigations were analysed.
Results: The ages of the three patients were: one year and six months, three years and five months, and five years and six months. All patients had septic shock and required mechanical ventilation. P. aeruginosa was isolated in the blood and/or skin lesions of all patients. Underlying hypogammaglobulinaemia and neutropaenia were detected in all patients. Treatment consisted of combined antipseudomonal antimicrobial therapy and surgical debridement. All patients survived. Subsequent B-cell measurement and Brutonʼs tyrosine kinase (BTK) protein and genetic analysis confirmed the diagnosis of XLA. Twelve other similar reported cases were reviewed and analysed based on their clinical presentation, diagnosis and treatment.
Conclusion: P. aeruginosa sepsis should be treated as early as possible. The most common risk factor for ecthyma gangrenosum in XLA patients is neutropaenia. In previously healthy children presenting with EG, immunological evaluation is important to rule out an underlying immunodeficiency.
Keywords: Ecthyma gangrenosum, Pseudomonas aeruginosa, X-linked agammaglobulinaemia, XLA, neutropaenia