CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 37, No 4 December 2024
- ALLERGIES IN THE EMERGENCY DEPARTMENT
- An overview of serious allergic conditions
- Managing paediatric urticaria and angioedema
- Dermatological disorders
- Latex and chlorhexidine allergy
- Adult patients with inborn errors of immunity
- Unravelling a frightening issue
- Hypersensitivity pneumonitis
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GUEST EDITORIAL
Author: Tamara Kerbelker
Abstract: Welcome to the fourth issue for 2024 of Current Allergy and Clinical Immunology. I was invited to guest edit this edition in August 2023 and had decided to combine my two areas of interest for the review articles – allergy and emergencies – reflecting on the type of patients that I have seen over the years presenting at the emergency centre at the Red Cross War Memorial Children’s Hospital. However, this issue coincidentally became the ‘congress’ number after the plan for a joint-society congress in February 2025 did not materialise.
REVIEW ARTICLE
AN OVERVIEW OF SERIOUS ALLERGIC CONDITIONS PRESENTING TO THE EMERGENCY DEPARTMENT
Authors: Abdullah E Laher, Feroza Motara, Muhammed Moolla
Abstract: Allergic conditions place a significant burden on the Emergency Department. Inadequate management of allergic conditions in the department are associated with adverse patient outcomes and high rates of re-presentation to the department. In this article we review the presentation and management of the anaphylactic patient presenting in extremis, acute angioedema and atopic dermatitis to the Emergency Department.
Keywords: allergic conditions, emergency department, extremis, acute angioedema, atopic dermatitis
Review article
MANAGING PAEDIATRIC URTICARIA AND ANGIOEDEMA IN THE EMERGENCY DEPARTMENT
Author: Pieter de Waal
Abstract: Urticaria and angioedema are common in children who present to the Emergency Department. Given the broad range of possible diagnoses and the lack of immediate results from specialised tests in an acute setting, diagnosis depends largely on a thorough clinical history and careful physical examination. These patients may also present with life-threatening airway compromise or anaphylaxis, requiring immediate intervention and pharmacological treatment. Fortunately, in most cases, acute urticaria in children – though distressing to parents – is typically triggered by an infection and requires symptomatic treatment and reassurance. On the other hand, the cause of chronic urticaria often remains unknown. Angioedema may occur on its own and can be hereditary. In such cases, antihistamines and systemic corticosteroids are ineffective and treatment with fresh frozen plasma or newer on-demand therapies is recommended. If uncertain about the diagnosis, choice of special investigations or treatment, emergency physicians should promptly consult a specialist to ensure optimal management and follow-up care.
Keywords: urticaria, angioedema, anaphylaxis, hereditary angioedema, physical urticaria
Review article
DERMATOLOGICAL DISORDERS IN AN EMERGENCY CARE SETTING
Author: Joh-Nell van der Westhuizen, Nonhlanhla Lunjani, Tamara Kerbelker, Carol Hlela
Abstract: Dermatological disorders are frequently seen in an emergency care setting. Data suggest that up to 8% of emergency department cases are dermatology-related and may or may not be life-threatening.1 This review focuses on non-IgE- mediated life-threatening mucocutaneous hypersensitivity reactions. Dermatology emergencies that involve severe or life-threatening disease include Steven-Johnson syndrome or toxic epidermal necrolysis (SJS/TEN), a drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalised exanthematous pustulosis (AGEP), which are collectively referred to as severe cutaneous adverse reactions (SCARs). Erythroderma is also discussed in this review article as it represents skin failure that requires prompt management.
Keywords: dermatological disorders, life-threatening mucocutaneous hypersensitivity reactions, dermatology emergencies
Review article
LATEX AND CHLORHEXIDINE ALLERGY AMONG HEALTHCARE WORKERS IN EMERGENCY CENTRES IN AFRICAN SETTINGS: A REVIEW
Authors: Hussein H Mwanga, Khadija A Shebe
Abstract: Natural rubber latex (NRL) and chlorhexidine are important causes of occupational allergy in healthcare settings. A significant reduction in NRL allergy has been reported in countries that have adopted latex-avoidance measures. However, healthcare workers (HCWs) in many developing countries continue to use powdered NRL gloves, increasing their risk of developing an allergy to NRL. Chlorhexidine is commonly used for hand hygiene and disinfecting patients’ surfaces or wounds in emergency centres. However, only a few cases of occupational allergy to chlorhexidine have been reported among HCWs. Both NRL and chlorhexidine can induce IgE-mediated allergic reactions and irritant contact dermatitis. Unlike NRL, chlorhexidine can cause cell-mediated hypersensitivity. Allergic contact dermatitis resulting from wearing NRL gloves is due to rubber additives and not NRL allergens. Testing for allergic sensitisation is a crucial step in the clinical evaluation of these allergies. Avoiding exposure to the source of the problem remains the most effective method of managing these allergies. Powdered NRL gloves should be replaced with powder-free, low-protein or low-allergen NRL gloves or non-NRL alternatives. For chlorhexidine allergy, alternative products should be made available to sensitised HCWs. Adequate information about these allergies should be provided to all HCWs. In addition, the lowest effective concentration of chlorhexidine should be used and all chlorhexidine-containing products should be clearly labelled.
Keywords: natural rubber latex, chlorhexidine, occupational allergy, emergency centre, healthcare workers
Review article
ADULT PATIENTS WITH INBORN ERRORS OF IMMUNITY PRESENTING TO THE EMERGENCY DEPARTMENT
Authors: Mimi Deetlefs, Tamara Kerbelker, Di Hawarden
Abstract: Inborn errors of immunity (IEI) are becoming increasingly common and to date more than 480 disorders have been identified. The most common presentation is usually an infective complication, but patients may also present with atopy, autoimmune diseases, lymphoproliferation and malignancies. When considering the patient with IEI presenting to the Emergency Department (ED), two patient categories need to be considered: first, the patient with a potential undiagnosed IEI; and, second, the patient known to have an IEI presenting to the ED with an acute medical complication. Emergency physicians need to be able to identify and consider the needs of both of these patients in order to ensure the best possible outcome for patients with IEI.
Keywords: inborn error of immunity, IEI, primary immunodeficiency, secondary immunodeficiency, infectious manifestations, non-infectious manifestations
Case Report
UNRAVELLING A FRIGHTENING ISSUE: A COMMON MISTAKE UNVEILED IN THE ALLERGY CLINIC
Authors: Sydney Borg, Ejaz Yousef
Abstract: A ten-year-old male with known IgE-mediated rhinitis and mild intermittent asthma presented with an episode of epistaxis and bleeding from the right eye following his weekly allergen immunotherapy injection. Patient education about the correct intranasal spray technique is crucial to preventing epistaxis and nasal irritation. ‘Nasal pinching’ can unintentionally result in increased nasal cavity pressure with retrograde flow, causing haemolacria.
Keywords: allergy, epistaxis, haemolacria, immunotherapy
Allergies in the Workplace
HYPERSENSITIVITY PNEUMONITIS: IMPACT OF SECONDARY EXPOSURE TO PIGEON ANTIGENS FROM RESIDENTIAL SMALL-SCALE ANIMAL HUSBANDRY
Authors: Munyadziwa Muvhali, Anita Graham, Edith Ratshikhopha, Tanusha Singh
Abstract: Hypersensitivity pneumonitis (HP) caused by avian antigens is one of the most prevalent forms of HP, with pigeon antigens being the most common culprits. While the health effects on pigeon breeders are well documented, there is limited information on the impact that pigeon breeding has on the health of family members and individuals living near breeding pigeons. This case study describes the condition of a 56-year-old housewife who was referred to an academic hospital’s respiratory outpatient department with a principal complaint of six years of progressively worsening dyspnoea and intermittent dry cough. Comprehensive evaluations included a physical examination, chest X-rays (CXR), high- resolution computed tomography (HRCT) and lung-function testing. Her blood was analysed for specific immunoglobulin G (sIgG) to avian antigens due to the patient’s husband breeding birds at their residence for racing. The clinical work-up suggested an HP diagnosis supported by the laboratory analysis of elevated sIgG antibodies to pigeon mix Ge 91 (pigeon serum proteins, feathers and droppings) and Ge 93 (pigeon serum proteins). These results enabled a confirmatory diagnosis of HP to secondary pigeon exposure. The findings underscore the importance of incorporating sIgG testing to support an HP diagnosis, which is critical to effective disease and exposure management. This case emphasises the necessity of establishing national reference ranges for IgG against common antigens to improve the utility of sIgG antigen testing in the HP diagnostic framework. In addition, it highlights the importance of monitoring exposures in rapidly growing cottage industries in South Africa to reduce the risk of exposure to people, animals and the environment.
Keywords: hypersensitivity pneumonitis, bird antigen sensitisation, bird fanciers disease, avian antigens
Ethics article
COLLEGIALITY – THE ‘FORGOTTEN PILLAR OF MEDICAL PROFESSIONALISM’
Author: Sharon Kling
Abstract: Professionalism refers to the conduct and qualities of a group of persons with specialised knowledge and skills who practise a calling and regulate themselves. Health professionals undertake to put their patients’ welfare first, even if it is to their own detriment. Collegiality has been termed the ‘forgotten pillar’ of medical professionalism: it requires respectful behaviour and relationships, trust and empathy among the members of the healthcare team and in a healthcare organisation, with resultant excellence in patient care.
Keywords: collegiality, respectful behaviour, trust, empathy
ABC of Allergy
Itch
Authors: Shaunagh Emanuel, Di Hawarden
Introduction: Dr Do-a-lot presents a case of a 26-year-old pre-school teacher who came to see her about her itchy skin condition. There was no obvious rash and the generalised symptoms had been present for more than three months. She had been tested for various systemic conditions, including liver, kidney and thyroid disease, but she was found to be systemically well. Her GP had considered sending her for psychiatric evaluation but requested an allergy assessment first.
DR SPUR’S MYSTERY CASE
HSV – can it be a clue to an underlying inborn error of immunity
Authors: Miguel Jose Teixeira, Lizelle Nagel, Sylvia van den Berg
Introduction: Viral infections are exceptionally common and a frequent reason for healthcare consultations. It is expected that preschool children will experience six to ten viral infections in the upper respiratory tract a year, while adults will experience an average of two to five common colds annually. Susceptibility to viral infections and disease severity can certainly vary from one individual to the next, as you pointed out.