Polythylene glycol severe allergy and SARS-CoV-2 vaccines: usefulness of testing with PEG 1500 extract

Summary

Background. Polyethylene glycol (PEG) is being used for first time as an excipient for mRNA anti-SARS-CoV-2 vaccines containing PEG 2000, highlighting it as a potential cause of anaphylaxis. Methods. We evaluated 126 patients with moderate-high risk of allergy to SARS-CoV-2 vaccines referred to our department from March-December 2021. Skin tests were performed with PEG 1500 extract (Roxall), using a stepwise approach, with readings at 30 minutes: prick tests with 0.1%, 1% and 10% concentrations; if negative, intradermal tests with 0.0001%, 0.001% and 0.01% concentrations. The same protocol was applied to 5 healthy controls Results. Six patients had positive immediate intradermal tests with PEG 1500, all with severe PEG allergy: one with a near-fatal anaphylaxis after glucocorticoid injection containing PEG 3350 and five with systemic allergic reactions after mRNA vaccines containing PEG 2000 (Pfizer-BioNTech or Moderna). One patient developed anaphylaxis during intradermal test. These six patients were negative to polysorbate 80. The remaining 120 patients had negative tests to PEG 1500; seven had positive tests to polysorbate 80. All controls had negative tests. Conclusions. To our knowledge this is the first study describing the allergy work-up testing with PEG 1500 commercial extract in the scope of SARS-CoV-2 vaccination. The algorithm designed for skin tests revealed to be a useful tool. Severe PEG allergy was diagnosed in 5% of patients, contraindicating PEG-containing vaccines. PEG allergy was excluded in one hundred patients that afterwards took SARS-CoV-2 vaccines containing PEG 2000. Investigation should be conducted in specialized drug allergy centers..

Tree Nuts Anaphylaxis in Preschool Age Children

Summary

Introduction. The incidence of food-induced anaphylaxis (FIA) is increasing in young children. Although the commonest culprits are cow's milk and egg, FIA to tree nuts (TNs) have been increasing. Objective. Characterization of children referred to our allergy department due to TNs-induced anaphylaxis (TNs-FIA) during preschool age. Materials and methods. We have retrospectively included 25 children with clinical history of preschool TNs-FIA, proven by allergological work-up. TNs sensitization was assessed by skin prick tests and/or specific IgE. Results. The mean age of the first anaphylactic episode was 3.1±1.2 years. The majority (92%) had an allergic disease (52% asthma). The implicated TNs were cashew (11 children), walnut (8), pine nut (5), hazelnut (2) and almond (1). The reaction occurred after the first known ingestion in 68%. In 92%, symptoms appeared within 30 minutes after exposure. The most frequent clinical symptoms were mucocutaneous (96%), respiratory (80%) and gastrointestinal (52%). Twenty-one children were admitted to the emergency department, although only 48% were treated with epinephrine. An underneath IgE-mediated mechanism was proven in all cases. Immunologic cross-reactivity with other TNs was identified in 84%, and with peanut in 36%. Overall, in our center, TNs-FIA represents 18% of all causes of FIA. Conclusions. In preschool age children with TNs-FIA, cashew and walnut were the commonest implicated nuts. Most reactions occurred briefly after exposure to minimal amounts of TNs, demonstrating the high potency of these allergens. About one-third also had peanut sensitization. Potentially life-threatening TNs allergy can occur early in childhood and adequate management should be undertaken.

Lower airway flow influences peak nasal inspiratory flow in school-aged children

BACKGROUND

Rhinitis and asthma frequently coexist. Peak nasal inspiratory flow (PNIF) objectively evaluates nasal obstruction. Lower airway flow's impact on PNIF has seldom been analysed in children. We aimed to study the associations between PNIF and: 1)forced expiratory volume in one second (FEV1) and peak expiratory flow (PEF) in children with allergic rhinitis and asthma and healthy controls; 2)allergic rhinitis and asthma control subjective evaluation.

METHODS

Sequential assessments of PNIF before and after nasal decongestion and spirometry with bronchodilation test were performed in 65 children (6-12 years) with allergic rhinitis and asthma, and 24 gender, age-matched healthy controls. The Control of Allergic Rhinitis and Asthma Test in children (CARATkids) was used for control assessment. Associations were investigated by multiple linear regression models.

RESULTS

Baseline and decongested PNIF correlated with baseline and post-bronchodilation FEV1 and PEF, observed independently of rhinitis and asthma diagnosis. The best model for PNIF included PEF, age and gender. No association was found between PNIF and CARATkids scores, except for nasal obstruction self-report.

CONCLUSION

In school-aged children, besides age and gender, PEF values should ideally be known to interpret PNIF values. PNIF can be complementary to subjective control assessment in children with allergic rhinitis and asthma.

Regulatory T and B Cells in Asthmatic Women: Variations From Pregnancy to Postpartum

BACKGROUND AND OBJECTIVE

Allergic asthma and rhinitis are common in pregnancy. The immune mechanisms underlying the effects of asthma on pregnancy and vice versa are not completely understood. The aim of this study was to investigate changes in regulatory T and B cells in asthmatic women from late pregnancy to postpartum.

METHODS

Four groups of women were enrolled for this study: asthmatic (n=23) and healthy (n=43) third trimester-pregnant women and asthmatic (n=33) and healthy (n=35) nonpregnant women. Pregnant women were also evaluated postpartum (>6 weeks after delivery). Blood samples were taken from each woman and flow cytometry was used to characterize circulating regulatory T cells (Tregs) and regulatory B cells (Bregs). Foxp3 expression was assessed in CD4DimCD25Hi Tregs.

RESULTS

Tregs did not vary significantly from pregnancy to postpartum in asthmatic or healthy women, but CD24HiCD38Hi Bregs decreased in pregnancy and increased significantly postpartum. Foxp3 expression in Tregs was also impaired during pregnancy in both asthmatic and healthy women, but recovered postpartum. Asthmatic pregnant women had higher Foxp3 expression levels than healthy pregnant women (P=.007), probably due to the use of control medication.

CONCLUSIONS

Women with controlled asthma showed variations in regulatory cell subsets during pregnancy and postpartum. A similar pattern was observed for Foxp3 expression and CD24HiCD38Hi Bregs during this period, corroborating the interaction between Tregs and Bregs in immune responses. Considering the immunomodulatory potential of these immune mediators, more studies are needed to evaluate their relationship with asthma and rhinitis complications in pregnancy.

One-year survey of paediatric anaphylaxis in an allergy department

AIM

To determine the frequency of anaphylaxis in an allergy outpatient department, allowing a better understanding regarding aetiology, clinical manifestations and management, in children and adolescents.

METHODS

From among 3646 patients up to 18 years old observed during one-year period, we included those with history of anaphylaxis reported by allergists.

RESULTS

Sixty-four children had history of anaphylaxis (prevalence of 1.8%), with mean age 8.1±5.5 years, 61% being male. Median age of the first anaphylactic episode was 3 years (1 month-17 years). The majority of patients had food-induced anaphylaxis (84%): milk 22, egg 7, peanut 6, tree nuts 6, fresh fruits 6, crustaceans 4, fish 4 and wheat 2. Food-associated exercise-induced anaphylaxis was reported in 2 adolescents. Drug-induced anaphylaxis occurred in 8%: 4 non-steroidal anti-inflammatory drugs and 1 amoxicillin. Three children had cold-induced anaphylaxis, one adolescent had anaphylaxis to latex and one child had anaphylaxis to insect sting. The majority (73%) had no previous diagnosis of the etiologic factor. Symptoms reported were mainly mucocutaneous (94%) and respiratory (84%), followed by gastrointestinal (42%) and cardiovascular (25%). Fifty-one patients were admitted to the emergency department, although only 33% were treated with epinephrine. Recurrence of anaphylaxis occurred in 26 patients (3 or more episodes in 14).

CONCLUSIONS

In our paediatric population, the main triggering agent of anaphylaxis was IgE-mediated food allergy. Epinephrine is underused, as reported by others. Often, children have several episodes before being assessed by an allergist. We stress the importance of systematic notification and improvement of educational programmes in order to achieve a better preventive and therapeutic management of this life-threatening entity.

EAACI food allergy and anaphylaxis guidelines: managing patients with food allergy in the community

The European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines, managing patients with food allergy (FA) in the community, intend to provide guidance to reduce the risk of accidental allergic reactions to foods in the community. This document is intended to meet the needs of early-childhood and school settings as well as providers of non-prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast-food outlets) and targets the audience of individuals with FA, their families, patient organizations, the general public, policymakers, and allergists. Food allergy is the most common trigger of anaphylaxis in the community. Providing children and caregivers with comprehensive information on food allergen avoidance and prompt recognition and management of allergic reactions are of the utmost importance. Provision of adrenaline auto-injector devices and education on how and when to use these are essential components of a comprehensive management plan. Managing patients at risk of anaphylaxis raises many challenges, which are specific to the community. This includes the need to interact with third parties providing food (e.g., school teachers and restaurant staff) to avoid accidental exposure and to help individuals with FA to make safe and appropriate food choices. Education of individuals at risk and their families, their peers, school nurses and teachers as well as restaurant and other food retail staff can reduce the risk of severe/fatal reactions. Increased awareness among policymakers may improve decision-making on legislation at local and national level.

Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology

Rhinitis is a common problem in childhood and adolescence and impacts negatively on physical, social and psychological well-being. This position paper, prepared by the European Academy of Allergy and Clinical Immunology Taskforce on Rhinitis in Children, aims to provide evidence-based recommendations for the diagnosis and therapy of paediatric rhinitis. Rhinitis is characterized by at least two nasal symptoms: rhinorrhoea, blockage, sneezing or itching. It is classified as allergic rhinitis, infectious rhinitis and nonallergic, noninfectious rhinitis. Similar symptoms may occur with other conditions such as adenoidal hypertrophy, septal deviation and nasal polyps. Examination by anterior rhinoscopy and allergy tests may help to substantiate a diagnosis of allergic rhinitis. Avoidance of relevant allergens may be helpful for allergic rhinitis (AR). Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first-line AR treatment although the latter are more effective. Once-daily forms of corticosteroids are preferred given their improved safety profile. Potentially useful add-on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics. Allergen-specific immunotherapy is helpful in IgE-mediated AR and may prevent the progression of allergic disease. There are still a number of areas that need to be clarified in the management of rhinitis in children and adolescents.

The management of the allergic child at school: EAACI/GA2LEN Task Force on the allergic child at school

Allergy affects at least one-quarter of European schoolchildren, it reduces quality of life and may impair school performance; there is a risk of severe reactions and, in rare cases, death. Allergy is a multi-system disorder, and children often have several co-existing diseases, i.e. allergic rhinitis, asthma, eczema and food allergy. Severe food allergy reactions may occur for the first time at school, and overall 20% of food allergy reactions occur in schools. Up to two-thirds of schools have at least one child at risk of anaphylaxis but many are poorly prepared. A cooperative partnership between doctors, community and school nurses, school staff, parents and the child is necessary to ensure allergic children are protected. Schools and doctors should adopt a comprehensive approach to allergy training, ensuring that all staff can prevent, recognize and initiate treatment of allergic reactions.

Regulatory cells, cytokine pattern and clinical risk factors for asthma in infants and young children with recurrent wheeze

BACKGROUND

Several risk factors for asthma have been identified in infants and young children with recurrent wheeze. However, published literature has reported contradictory findings regarding the underlying immunological mechanisms.

OBJECTIVES

This study was designed to assess and compare the immunological status during the first 2 years in steroid-naive young children with >or= three episodes of physician-confirmed wheeze (n=50), with and without clinical risk factors for developing subsequent asthma (i.e. parental asthma or a personal history of eczema and/or two of the following: wheezing without colds, a personal history of allergic rhinitis and peripheral blood eosinophilia >4%), with age-matched healthy controls (n=30).

METHODS

Peripheral blood CD4(+)CD25(+) and CD4(+)CD25(high) T cells and their cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), GITR and Foxp3 expression were analysed by flow cytometry. Cytokine (IFN-gamma, TGF-beta and IL-10), CTLA-4 and Foxp3 mRNA expression were evaluated (real-time PCR) after peripheral blood mononuclear cell stimulation with phorbol 12-myristate 13-acetate (PMA) (24 h) and house dust mite (HDM) extracts (7th day).

RESULTS

Flow cytometry results showed a significant reduction in the absolute number of CD4(+)CD25(high) and the absolute and percentage numbers of CD4(+)CD25(+)CTLA-4(+) in wheezy children compared with healthy controls. Wheezy children at a high risk of developing asthma had a significantly lower absolute number of CD4(+)CD25(+) (P=0.01) and CD4(+)CD25(high) (P=0.04), compared with those at a low risk. After PMA stimulation, CTLA-4 (P=0.03) and Foxp3 (P=0.02) expression was diminished in wheezy children compared with the healthy children. After HDM stimulation, CTLA-4 (P=0.03) and IFN-gamma (P=0.04) expression was diminished in wheezy children compared with healthy children. High-risk children had lower expression of IFN-gamma (P=0.03) compared with low-risk and healthy children and lower expression of CTLA-4 (P=0.01) compared with healthy children.

CONCLUSIONS

Although our findings suggest that some immunological parameters are impaired in children with recurrent wheeze, particularly with a high risk for asthma, further studies are needed in order to assess their potential as surrogate predictor factors for asthma in early life.

Lung function and clinical risk factors for asthma in infants and young children with recurrent wheeze

BACKGROUND

Although several risk factors for asthma have been identified in infants and young children with recurrent wheeze, the relevance of assessing lung function in this group remains unclear. Whether lung function is reduced during the first 2 years in recurrently wheezy children, with and without clinical risk factors for developing subsequent asthma (ie, parental asthma, personal history of allergic rhinitis, wheezing without colds and/or eosinophil level >4%) compared with healthy controls was assessed in this study.

METHODS

Forced expiratory flows and volumes in steroid naïve young children with >or=3 episodes of physician confirmed wheeze and healthy controls, aged 8-20 months, were measured using the tidal and raised volume rapid thoracoabdominal compression manoeuvres.

RESULTS

Technically acceptable results were obtained in 50 wheezy children and 30 controls using tidal rapid thoracoabdominal compression, and 44 wheezy children and 29 controls with the raised volume technique. After adjustment for sex, age, body length at test and maternal smoking, significant reductions in z scores for forced expiratory volume at 0.5 s (mean difference (95% CI) -1.0 (-1.5 to -0.5)), forced expired flow after 75% forced vital capacity (FVC) has been exhaled (FEF(25)) (-0.6 (-1.0 to -0.2)) and average forced expired flow over the mid 50% of FVC (FEF(25-75)) (-0.8 (-1.2 to -0.4)) were observed in those with recurrent wheeze compared with controls. Wheezy children with risk factors for asthma (n = 15) had significantly lower z scores for FVC (-0.7 (-1.4 to -0.04)) and FEF(25-75) (-0.6 (-1.2 to -0.1)) than those without such risk factors (n = 29).

CONCLUSIONS

Compared with healthy controls, airway function is reduced in young children with recurrent wheeze, particularly those at risk for subsequent asthma. These findings provide further evidence for associations between clinical risk factors and impaired respiratory function in early life.

Prevalence of asthma in a Portuguese countryside town: repercussions on absenteeism and self-concept

BACKGROUND

Childhood asthma represents an increasing health problem and is the leading cause of hospital admission and absenteeism in children with chronic disease. It also compromises quality of life, eventually contributing to disturbances in self-concept. Self-concept is a recent and global perspective of "the self" and relates to skills, self-image and self-esteem. Little information is available on this topic and there are no data from Portuguese countryside towns.

OBJECTIVE

The aim of this study was to determine the prevalence of asthma among all school children in the 5th and 6th grades in a Portuguese countryside town and to establish its possible correlation with absenteeism and self-concept.

METHODS

In April 2002, two questionnaires were administered in the presence of the researcher to a group of 950 children attending different schools. The children completed the internationally renowned questionnaires: ISAAC and the Self-Concept Scale by Susan Harter.

RESULTS

Our sample (n = 818) had a mean age of 11 years (10-15 years) and a male-to-female ratio of 1/1. The cumulative prevalence of asthma was 11.9 % and that of active asthma was 8.8 %; 63.9 % of asthmatics were male and 36.1 % were female. The mean age of asthmatics was 11.34 years and 74 % had active symptoms. Comparison of this group of 97 asthmatic children with the remaining children revealed a statistically significant correlation between the presence of asthma and school absenteeism (global: p = 0.04; gymnastics: 0.05). Regarding the Self-Concept Scale a statistically significant association was found between the presence of asthma and school achievement (p = 0.027), physical appearance (p = 0.015), behavior (p < 0.000) and self-esteem (p < 0.000). No statistically significant correlations were found in social acceptance (p = 0.289) or athletic competence (p = 0.085). Asthmatic boys had higher self-concept scores than girls, except in the domain of behavior.

CONCLUSIONS

Twelve percent of the population studied was asthmatic. In asthmatic children, absenteeism was higher and self-concept was lower for almost all domains, except social acceptance and athletic achievement, probably due to overprotection.