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   Table of Contents - Current issue
July-December 2021
Volume 35 | Issue 2
Page Nos. 37-107

Online since Friday, July 8, 2022

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Pollen-food allergy syndrome and lipid transfer protein syndrome: Clinical relevance p. 37
PC Kathuria, Manisha Rai
The role of an allergist in recognizing the pollen-food allergy syndrome (PFAS) and lipid transfer protein syndrome (LTPS) is essential. LTPS differs from PFAS by having a different family of panallergens and clinical characteristics. Both are complex syndromes posing diagnostic and therapeutic challenges. Many cross-reactive allergen components are involved, such as plant panallergens profilins, PR-10 proteins (Bet v 1 homologous), and lipid transfer proteins (LTP). PFAS results from cross-reactivity between pollen-specific immunoglobulin E (IgE) and homologous proteins found in fruits and vegetables. In most cases, grass pollen is responsible for profilin hypersensitivity. But, tree and weed pollen may also act as primary sensitizers, depending on geographical differences. Nonspecific LTP (nsLTP) is ubiquitous in terrestrial plants and can induce systemic allergic severe reactions. Peach (Pru P 3) is the primary sensitizer for LTP-driven allergy, and its clinical relevance is considered the prototypic marker for LTPS. nsLTPs have been identified as a major allergen in tree and weed plants. A second critical point is the diagnosis of LTPS associated with cofactors such as exercise, alcohol, antacids, and NSAIDS, that can promote severe reactions. Skin Prick Test (SPT) with Peach extracts that have been highly enriched for Pru p 3 with very low content of other allergens for LTPS, is suggestive of LTPS. For PFAS, positive SPT with profilin-enriched date palm pollen and watermelon extract shows sensitivity and specificity that is very close to that of the recombinant grass pollen profilin. The present review address differences between the PFAS from LTP syndrome with particular attention to the clinical impact on cross-reactivity or cross-sensitization to pollens.
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Sulphites in food & drinks in asthmatic adults & children: What we need to know p. 43
Mukesh Kumar Gupta, GV Basavaraj
Sulfites are commonly used preservatives and additives in the food and pharmaceutical industries. Many people develop adverse reactions to them which may vary from mild skin rash to life-threatening anaphylactic reactions. However, asthma exacerbation is the most commonly linked problem. The possibility of sulfite sensitivity should be considered when individuals demonstrate asthma symptoms following the consumption of sulfite-containing foods (such as dried fruits and wines in adults and packaged food in children such as biscuits, chips, and packaged drinks) or adverse skin reactions following the use of cosmetics or medicated creams. In fact, many of the mild-to-moderate asthma cases in children can be cured by just avoiding the packaged/preserved/processed food and beverages. Food that has no additives at all is to be preferred particularly if it is to be consumed by children. It is best to eat a preservative-free diet if at all possible by adults as well if required natural food preservatives should be used.
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Expert opinion on montelukast and acebrophylline combination in the management of asthma Highly accessed article p. 48
NH Krishna, Amita Nene, Mahavir Modi, Tanvir Reza, Ashwin Songara, Vikrant Deshmukh
Asthma control is highly inadequate in India, with worse outcomes and poor adherence to inhaled corticosteroids (ICSs). As per the Global Initiative for Asthma guidelines, leukotriene receptor antagonist (LTRA) can be added when a low-to-moderate dose of ICS does not provide sufficient disease control. The combination of montelukast with its anti-inflammatory action and acebrophylline with its mild bronchodilator, anti-inflammatory, and mucolytic actions may be beneficial in patients with asthma. This manuscript aims to present an expert opinion to discuss the role of montelukast and acebrophylline combination in the management of asthma. An expert panel comprising nine specialists in respiratory medicine took part in a roundtable discussion to review the role of montelukast–acebrophylline combination in the management of asthma. A qualitative question-and-answer-based format was used to help facilitate the discussion. It was concurred that the montelukast and acebrophylline combination may be used if asthma symptoms remain uncontrolled with ICS and long-acting β2-agonists. This combination can also be preferred in patients with severe pulmonary obstruction along with allergic bronchopulmonary aspergillosis, in patients with asthma–chronic obstructive pulmonary disease overlap syndrome, and in patients with a history of smoking. There is adequate evidence for the role of montelukast and acebrophylline as individual drugs in asthma. However, evidence related to their combination therapy is lacking. The panel has reiterated the need for studies to evaluate the safety and efficacy of montelukast and acebrophylline combination in patients with asthma and its variants.
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Qualitative analysis of protein antigen in bird exposed asthma patients by high-performance liquid chromatography method p. 55
Anil Kumar Mavi, Sonam Spalgais, Manoj Kumar, Kamal Singh, Priya , Raj Kumar
BACKGROUND: Asthma is a chronic disease that affects large number of people worldwide. In urban areas, asthmatic people are getting exposed to pigeon antigen (droppings and feathers) around the workplace and domestic areas. The present study was conducted to the determination of MUC1 protein in the blood of pigeon-exposed asthmatic patients by the high-performance liquid chromatography (HPLC) method. MATERIALS AND METHODS: This was a prospective study of 108 pigeon-exposed asthma patients. We enrolled 17 asthmatic patients for detection of MUC1 expression in their serum sample who were atopic and skin prick testing positive for pigeon antigens (droppings and feathers). The MUC1 analysis was done with HPLC method. RESULTS: A total of 17 asthmatic patients were enrolled on the basis of the history of pigeon exposure and positive skin prick test for pigeon's feather and dropping allergens including 9 males and 8 females, the average age of the study candidates was 28.8 ± 10.1 years. MUC1 concentration was raised in all of the asthmatic patients exposed to pigeons. The MUC1 was upregulated in 15 and downregulated in 2 patients. A higher concentration of MUC1 was seen in younger patients. CONCLUSION: Pigeon droppings and feathers allergen exposed and sensitivity showed the higher MUC1 expression in serum in asthma patients. The concentration of MUC1 was higher in the younger age group. The HPLC method was easier and economical for the detection of MUC1.
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Clinicodemographic and patch testing profile of patients with lower leg and feet eczema at a tertiary care center in South India p. 61
Ann Shaji Nisha, Navakumar Manickam, Kannan Gopalan, Seethalakshmi Ganga Vellaisamy
BACKGROUND: Lower legs and feet eczema may be due to exogenous causes such as allergic contact dermatitis (ACD) or endogenous cause such as atopy. Currently, patch testing is the only scientific proof of contact allergy. AIMS: The aim was to study the clinicodemographic profile and to evaluate the role of patch testing in lower leg and feet eczema. MATERIALS AND METHODS: This was a cross-sectional study conducted among 60 patients with lower leg and feet eczema. They were subjected to patch testing with Indian standard series and readings were interpreted according to the International Contact Dermatitis Research Group scoring system. RESULTS: Our study included 32 (53.3%) males and 28 (46.7%) females (M: F = 1.1:1). The mean age was 42.61 ± 13.40 years corresponding to occupationally active age group. Construction workers (10 [31.25%]) were the most common occupational group affected among males (P = 0.007). Among females, most commonly affected were housewives (10 [35.71%]) (P = 0.0002). The most common pattern of eczema seen was ACD (22 [36.7%]). Positive patch test response was recorded in 17 (28.3%) patients and the most common allergen found to be positive was potassium dichromate (6 [35.3%]). Correlating the morphology with patch test results, ACD (13 [59.1%]) was significantly positive when compared to other eczemas (4 [10.53%]) (P = 0.000). CONCLUSION: Patch testing is a valuable diagnostic aid in lower leg and feet eczema. It plays a pivotal role in identifying causative allergens associated with ACD from which allergen avoidance can be advised for a better clinical outcome and quality of life.
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Clinical profile of drug sensitivity test in patients with a previous history of allergy as part of preanesthetic evaluation p. 67
Krishnan Sabhapathy, Shweta Krishnan
OBJECTIVE: Retrospective study looking at the profile of patients undergoing drug sensitivity tests (DST) and its utility in preventing hypersensitivity in the perioperative period. MATERIALS AND METHODS: Adult patients who had a previous history of drug allergy and or other forms of allergies were enrolled in the study. These were patients referred to our center before procedures requiring anesthesia. DST was done by the Skin prick method and supplemented by intradermal in few patients. Drugs chosen for testing was based on patient's allergic history and referring doctors request, usually anesthetics, antibiotics, and analgesics. RESULTS: Of 110 patients included in study, 84 were female. Eighty-eight had a history of drug allergy, either documented or presumed. Twenty-one had other forms of allergy, of whom 11 had food allergy, eight had allergic rhinitis with or without asthma, and three had allergic dermatitis or urticaria. The DST was positive in 65 patients, negative in 45. Drugs that showed positive reactions were ciprofloxacin in 21 patients, diclofenac in 20, atracurim, and ondansetron in 11, paracetamol, amoxicillin clavulanate, pentazocine in five each. CONCLUSION: DST in preanesthetic evaluation would prevent potential hypersensitivity reaction in the perioperative period. Sixty percent of patients showed sensitivity; ten percent of them had food allergy, allergic rhinitis, skin allergy without a history of drug allergy. Antibiotics and analgesics showed more sensitivity than anesthetics. All patients underwent their anesthetic procedures without any drug hypersensitivity reaction.
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In silico prediction of B-cell and T-cell epitope of Ves g 5 and Vesp m 5 allergens p. 72
Kuldeepkumar Singh, Tushar T Khandagale, Akshita Puri, Sangeeta Sinha
BACKGROUND: Hymenoptera venom allergy is one of the leading insect allergies in which allergens that promote IgE-mediated immune responses cause mild-to-severe reactions. Vespula germanica has a high spread rate and invades many regions of the world, while Vespa mandarinia has caused many fatalities in Asian countries including India. Ves g 5 and Vesp m 5 are important allergens of V. germanica and V. mandarinia, respectively, which cause allergenic reactions. AIM: This study aimed to predict the B- and T-cell epitopes of allergens Ves g 5 and Vesp m 5 using computational tools. MATERIALS AND METHODS: ProtParam, Jalview, and Swiss-Model analyzed the physiochemical, allergen sequence and 3D model. BepiPred-2.0, ABCPred, and ElliPro predicted B-cell epitopes, while Immune Epitope Database major histocompatibility complex-II binding prediction tool and CD4+ T-cell immunogenicity prediction tool were used to predict and confirm immunogenic T-cell epitopes RESULTS: Nine linear and four discontinuous B-cell epitopes were predicted for the Ves g 5 allergen and ten linear and five discontinuous B-cell epitopes were predicted for the Vesp m 5 allergen. Four and three T-cell epitopes were predicted for the allergens Ves g 5 and Vesp m 5, showing efficient binding and immunogenicity, respectively. CONCLUSION: Venom immunotherapy used as a treatment for HVA shows few fatal reactions and side effects, hence epitope-based vaccines or therapies are necessary. These results can be further used in the process of better immunotherapy and peptide-based vaccine design as well as to understand the etiology of Ves g 5 and Vesp m 5 allergens.
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Self-reported food allergy and its clinical significance in adult bronchial asthma patients:– A prospective study p. 82
Priya Sharma, Bharath Janapati, Rachna Rohatgi, Anil Kumar Jain
BACKGROUND: Self-reported food allergy is very common in asthmatics and hence these food items are frequently avoided by the patients. Food allergy is defined as an adverse immunological response to a dietary protein. Skin prick test (SPT) is a sensitive tool for identifying the presence of specific immunoglobulin E antibodies that can be associated with acute allergic reactions. However, sensitization often exists without clinical consequences, and at the same time, self-reported food allergens are frequently negative on SPT. The purpose of our study was to assess the clinical relevance of self-reported food allergy and the role of SPT in identifying food allergies in patients with bronchial asthma. METHODOLOGY: One hundred bronchial asthma patients were screened for this study, and skin prick testing for 22 food allergens frequently consumed in India, particularly Northern India was performed. RESULTS: A total of 36 subjects reported perceiving precipitation or an increase in severity of the asthmatic symptoms by one or more food items, and the most common food items mentioned in history were curd in 24%, rice in 19%, citrus fruits such as lemon in 14%, orange in 14%, banana in 8%, cold drinks in 16%, and ice creams in 16%. There were 68 patients negative for food allergens by SPT (food allergen negative [FAN] group) and 32 patients were positive (Food allergen Positive [FAP] group). Out of 36 asthmatics with self-reported food allergy, none was found to be SPT positive to the reported food allergens. However, 50% of patients with self-reported and only 21.9% with no history of food allergy were positive to one or more food allergens. Further, FAP group patients were tolerating these foods without any trouble or exacerbation of symptoms. Among the FAP group, 96.9% of patients had positive SPT for one or more other allergens also such as insects, pollens, fungi, or other aeroallergens. Only one patient had isolated food allergy by SPT. It implies that isolated food allergy is very rare in asthmatic patients. Common food allergens found positive by SPT were black gram in 12%, followed by red gram 9% and bengal gram, rice, and Baker's yeast 7% each. CONCLUSION: We concluded that the prevalence of food allergy in India among asthmatic adults though high, has a very poor correlation between patient's history of food allergens that is perceived as a precipitating or exaggerating factor for symptoms and actual sensitization as elicited by SPT. At the same time, there is high nonspecific food sensitization in self-reported patients as compared to those with no history of any perceived food allergy.
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An open-labeled, single-centered, interventional, prospective study to determine the efficacy of autologous serum therapy in chronic spontaneous urticaria p. 88
Khushboo Arvind Minni, GK Tharini
BACKGROUND: Chronic spontaneous urticaria (CSU) poses a therapeutic challenge by dermatologists and patients alike. OBJECTIVES: This study aimed to find the prevalence of functional autoantibodies among patients using autologous serum skin test (ASST) and to evaluate the efficacy of autologous serum therapy (AST) as an adjuvant in CSU. MATERIALS AND METHODS: An open-labeled, single-centered, prospective, interventional study of 1 year was performed after institutional ethical approval among 55 consenting patients of CSU. ASST was performed to find the prevalence of functional autoantibodies and those positive were given weekly intramuscular AST for the next 9 weeks. For clinical outcome, weekly urticaria activity score (UAS7) was recorded at baseline and at week 10. Any adverse effects were recorded. Wilcoxon sign-ranked test and Fisher's exact test were used to demonstrate equal variance. Results: Fifty-five CSU patients consented to participate in the study; 41 were ASST+ and six were dropped out; hence, the prevalence of autoreactivity was 74.54%. Four of seven who presented with angioedema were ASST+. Thus, the prevalence of angioedema in ASST+ patients of CSU was 11.4%. At the end of 10th week, on comparing individual components of UAS7, there was a statistical significant difference (P < 0.05) in the number of wheals (P = 0.00001), pruritus (P = 0.00001), frequency of wheals (P = 0.00001), as well as the overall UAS7 (P = 0.0001) scores. The effect size is 1.23 (Cohen's d). On grading the improvement at week 10, marked (>75%), good (50%–74%), satisfactory (25%–49%), and poor (<25%) improvement were observed in 8 (22.9%), 12 (34.3%), 11 (31.4%), and 4 (11.4%) patients, respectively. CONCLUSION: AST is effective in significantly reducing wheals and pruritus and improves quality of life. It can be tried as an adjuvant before switching patient to other immunosuppressants or expensive biologicals in this current COVID-19 pandemic. Large long-term prospective randomized controlled trials with follow-up are required to conclusively ascertain the efficacy of AST as an adjuvant in CSU.
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Successful treatment with a combination of bee venom immunotherapy and omalizumab for recurrent anaphylaxis after honey bee sting p. 94
PC Kathuria, Manisha Rai, Ghulam Hassan
Hymenoptera venom hypersensitivity reaction affects about 3% of the general population and a higher percentage (14%–43%) in beekeepers. Bee venom immunotherapy (bVIT) is effective in reducing subsequent severe systemic reactions and has a significant beneficial effect on disease-specific quality of life in both children and adults. In patients with a history of recurrent systemic anaphylactic reaction with bee venom, successful bVIT is difficult to achieve and can often lead to withdrawal of treatment. The combination of bVIT and omalizumab is a good option for these patients. Omalizumab is a humanized nonanaphylactogenic monoclonal anti-immunoglobulin (Ig) E antibody against the Cε3 domain of IgE to reduce the allergenicity, if combined with bVIT. We describe a successful treatment with combined omalizumab and bVIT in a case of recurrent anaphylaxis by honey bee sting hypersensitivity. Herein, subcutaneous omalizumab 150 mg was started 15 days before the initiation of bVIT and subsequently once a month for 30 months along with cluster doses of bVIT till the cumulative dose of 100 μg was achieved successfully.
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A rare and interesting case of wandering unilateral edema like a wave p. 99
Navgeet Mathur, Medha Mathur
This case report is about a 55-year-old female who presented with wandering unilateral edema in the sequence of the left breast (for 7 days) followed by left upper limb (for 1 month), followed by the left nape of the neck (for 1 day), followed by left scalp (for 1 day), followed by left-sided face (for 3 days), followed by right-sided face (for 2 days). Edema progressed from one site to another site in the above sequence with the overlapping period of only 12–24 h and later subsided completely from its previous site. In the patient's language edema was moving from site to site like a slow wave moving forward. The patient took multiple consultations but could not get any relief. The patient was evaluated according. Serum total eosinophil count found 3100/cumm (30.1% of total leucocyte count) and diagnosed with angioedema. The patient was completely recovered by steroid and antihistaminic. To the best of our knowledge, this is the first case reporting wandering unilateral edema like a wave.
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A case report of urticaria as a rare side effect of favipiravir in a patient with COVID-19 p. 103
Amit Kumar, Ankita Gupta
COVID-19 pandemic has been caused by severe acute respiratory syndrome coronavirus 2 which has caused worldwide health concerns. A 48-year-old female suffering from COVID-19 was started on favipiravir (FPV) along with other drugs. Within 12 h of initiation of FPV, the patient developed urticaria all over the body. She was given stat dose of injection dexamethasone and injection avil. Symptoms resolved within 3 days. Urticaria is a rare side effect of FPV but requires vigilant monitoring in the treatment of COVID-19 patients.
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Purpuric autologous serum skin test in urticaria: Is it mere a chance occurrence or a marker of strong autoimmunity p. 106
Seema Rani, Aastha Agarwal
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