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Barman P, Cv G, Sarkar R, Shenoy M, Jindal AK, Dogra S. Deciphering the landscape of hereditary angioedema in India: Perspective for Indian dermatologists. Indian J Dermatol Venereol Leprol 2024; 0:1-5. [PMID: 39152814 DOI: 10.25259/ijdvl_1002_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/12/2024] [Indexed: 08/19/2024]
Affiliation(s)
- Prabal Barman
- Department of Paediatrics, Advanced Paediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gayathri Cv
- Department of Paediatrics, Advanced Paediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashmi Sarkar
- Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| | - Manjunath Shenoy
- Department of Dermatology, Venerology and Leprology, Yenepoya Medical College, Mangalore, Yenepoya University Campus, Deralakatte, Mangalore, Karnataka, India
| | - Ankur Kumar Jindal
- Department of Paediatrics, Advanced Paediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venerology and Leprology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
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Mak HWF, So SWM, Longhurst HJ, Maurer M, Peter J, Riedl M, Li PH. Disparities in geography and race in hereditary angioedema: Analysis of 64 trials and 4354 patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00683-4. [PMID: 38969098 DOI: 10.1016/j.jaip.2024.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/12/2024] [Accepted: 06/25/2024] [Indexed: 07/07/2024]
Affiliation(s)
- Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Sophia W M So
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Hilary J Longhurst
- Department of Immunology, Auckland City Hospital, Grafton, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcus Maurer
- Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Immunology and Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Marc Riedl
- Division of Rheumatology, Allergy, and Immunology, University of California, San Diego, La Jolla, Calif
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
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Jindal AK, Chiang V, Barman P, Sil A, Chawla S, Au EY, Rawat A, Li PH. Screening for type II hereditary angioedema-the "poor man's c1-inhibitor function". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100179. [PMID: 38026504 PMCID: PMC10661124 DOI: 10.1016/j.jacig.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/31/2023] [Accepted: 09/10/2023] [Indexed: 12/01/2023]
Abstract
Background Hereditary angioedema (HAE) is a rare genetic disease. Patients with type II HAE have normal or elevated C1-inhibitor (C1-INH) levels but C1-INH protein is dysfunctional. C1-INH function requires careful sample handling and technical expertise and may account for the lack of diagnosed patients with type II HAE in resource-limited countries. Objective We sought to assess the diagnostic performance of elevated C1-INH levels in diagnosing type II HAE. Methods All patients with confirmed type II HAE in Hong Kong and India were analyzed. Diagnosis was confirmed by persistent low C1-INH function and/or pathogenic SERPING1 gene mutations. Their C1-INH levels were compared with those of matched controls. Results A total of 31 (14 Chinese, 17 Indian) patients with type II HAE and 31 matched controls were analyzed. Overall, 77.4% (24/31) of patients with type II HAE had elevated C1-INH levels compared with 38.7% (12 of 31) of controls (odds ratio, 2.00; 95% CI, 1.34-2.98; P = .017). C1-INH levels in patients with type II HAE were significantly higher than in controls (52.2 ± 20.0 mg/dL vs 29.1 ±3.6 mg/dL; P < .001). Findings were consistent when C1-INH values in the Chinese and Indian subgroups were analyzed separately. Receiver-operating characteristic curve demonstrated excellent performance for elevated C1-INH levels to diagnose patients with type II HAE with an area under the curve of 0.953 (95% CI, 0.941-0.992; P < .001). Positive and negative predictive values of both a low C4 and an elevated C1-INH level for patients with type II HAE were 100% and 82.9%, respectively. Conclusions Low C4 and elevated C1-INH levels may be considered as a screening tool for type II HAE, especially in countries where C1-INH function testing is not readily available.
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Affiliation(s)
- Ankur Kumar Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Pokfulam, Hong Kong
| | - Prabal Barman
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Archan Sil
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanchi Chawla
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Elaine Y.L. Au
- Division of Clinical Immunology, Department of Pathology, Pokfulam, Hong Kong
| | - Amit Rawat
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
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Mak HWF, Ho SY, Wong JCY, Chiang V, Lee E, Yim JSH, Wong BYH, Li PH. Clinical utility of and correlation between Sniffin' Sticks and TIB smell identification test (TIBSIT) among Hong Kong Chinese with or without chronic rhinosinusitis. FRONTIERS IN ALLERGY 2024; 5:1292342. [PMID: 38332895 PMCID: PMC10847303 DOI: 10.3389/falgy.2024.1292342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024] Open
Abstract
Introduction Olfactory dysfunction (OD) is common among patients with chronic rhinosinusitis (CRS). Validated and culturally specific tests, such as the "Sniffin' Sticks" test (SST) and the TIB Smell Identification Test (TIBSIT), are crucial for the diagnosis and monitoring of OD. However, they have not been utilised in Hong Kong Chinese and their correlations are unknown. Methods Twelve CRS patients and twenty healthy volunteers were prospectively recruited from a joint allergy-otorhinolaryngology clinic in Hong Kong and performed both SST and TIBSIT. Demographics, baseline characteristics and all test results were compared and analysed. Results Patients with CRS demonstrated significantly lower test scores than healthy controls (all p < 0.001). Significant and strong correlations were observed between all composite and subtest scores, particularly between the composite SST and TIBSIT scores (ρ = 0.789, p < 0.001). Multivariate analysis demonstrated that the presence of CRS and increasing age were significantly associated with OD. Conclusion Both SST and TIBSIT are useful olfactory tests and are strongly correlated among Hong Kong Chinese. We advocate that either test can be used for measuring OD among CRS patients.
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Affiliation(s)
- Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Shi Yeung Ho
- Department of Ear, Nose and Throat, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Elaine Lee
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jackie S H Yim
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Birgitta Y H Wong
- Department of Ear, Nose and Throat, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Honda D, Li PH, Jindal AK, Katelaris CH, Zhi YX, Thong BYH, Longhurst HJ. Uncovering the true burden of hereditary angioedema due to C1-inhibitor deficiency: A focus on the Asia-Pacific region. J Allergy Clin Immunol 2024; 153:42-54. [PMID: 37898409 DOI: 10.1016/j.jaci.2023.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/28/2023] [Indexed: 10/30/2023]
Abstract
Hereditary angioedema (HAE) due to C1-inhibitor deficiency or dysfunction is a rare genetic disorder that causes recurrent episodes of swelling in various parts of the body. Treatment goals of HAE aim to "normalize" life for all patients; however, lack of diagnostic facilities and limited access to effective treatment options in developing nations cause delays in diagnosis and place a significant burden on patients. In this review, we aim to highlight the burden of disease caused by C1-inhibitor HAE across the Asia-Pacific region, considering its epidemiology, morbidity and mortality, and socioeconomic and psychological impact. We also review the availability of guideline-recommended diagnostic facilities and treatments, and how patients are currently managed. Data were collected from published literature and HAE experts in the region, who provided information regarding diagnosis and management in their countries. Current practice was reviewed against international guidelines, as well as local guidelines/consensus used in Australia, Japan, and China. Suggestions are provided for improving the time to diagnosis in the region, increasing access to guideline-recommended treatments, and providing support to reduce the burden on patients and caregivers. There is an urgent need to improve HAE services and provide access to life-saving treatment in developing countries, and efforts should be made to increase awareness of guideline recommendations in high-income economies that do not currently provide long-term prophylactic treatments.
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Affiliation(s)
- Daisuke Honda
- Department of Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Ankur Kumar Jindal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Constance H Katelaris
- Immunology and Allergy Unit, Department of Medicine, Campbelltown Hospital and Western Sydney University, Campbelltown, Sydney, Australia
| | - Yu-Xiang Zhi
- Department of Allergy and Clinical Immunology, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, China
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Hilary J Longhurst
- Department of Immunology, Auckland City Hospital, Grafton, Auckland, New Zealand; Department of Medicine, University of Auckland, Auckland, New Zealand.
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Li PH, Au EYL, Cheong SL, Chung L, Fan KI, Ho MHK, Leung ASY, Chung MMH, Wong JCY, Coelho R. Hong Kong-Macau Severe Hives and Angioedema Referral Pathway. FRONTIERS IN ALLERGY 2023; 4:1290021. [PMID: 38125294 PMCID: PMC10731021 DOI: 10.3389/falgy.2023.1290021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background Urticaria (defined as the presence of hives, angioedema, or both) can be caused by a variety of etiologies ranging from more common conditions such as chronic spontaneous urticaria (CSU) to rarer conditions such as hereditary angioedema (HAE). Specialist referral may be necessary in cases of severe urticaria or HAE, but access to specialist services remains limited in certain regions, such as the Greater Bay Area (GBA) of China. To address this, the Hong Kong-Macau Severe Hives and Angioedema Referral Pathway (SHARP) was initiated by the Hong Kong Institute of Allergy and Macau Society of Dermatology to promote multidisciplinary collaboration and regional exchange of expertise in the diagnosis and management of severe urticaria. Methods A nominated task force of dermatologists and immunologists who manage patients with severe urticaria formulated the consensus statements (CS) using the Delphi method. The consensus was defined a priori as an agreement of ≥80%. Results A total of 24 CS were formulated, including four statements on classifications and definitions, seven statements on diagnosis, and 13 statements on management and referral. The definitions for acute/chronic urticaria and severe CSU were stated. Unnecessary investigations and inappropriate medications were discouraged. The characteristics and recommended approach to suspected bradykinergic angioedema were specified. Stepwise treatment options using second-generation antihistamines, omalizumab, or cyclosporin for patients with CSU were addressed, and the importance of access to HAE-specific medications was emphasized. Furthermore, an integrated referral pathway for patients with severe hives and angioedema was constructed. Conclusion The SHARP provides guidance for the management and specialist referral of patients with severe hives and angioedema in Hong Kong and Macau.
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Affiliation(s)
- Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Elaine Y. L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Si-Leong Cheong
- Department of Dermatology, Centro Hospitalar Conde de São Januário, Macau, Macao SAR, China
| | - Ling Chung
- Department of Dermatology, Centro Hospitalar Conde de São Januário, Macau, Macao SAR, China
| | - Ka I. Fan
- Department of Dermatology, Centro Hospitalar Conde de São Januário, Macau, Macao SAR, China
| | - Marco H. K. Ho
- Lee Tak Hong Allergy Centre, Hong Kong Sanatorium & Hospital, Hong Kong, Hong Kong SAR, China
| | - Agnes S. Y. Leung
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Martin M. H. Chung
- Division of Dermatology, Department of Medicine, Queen Mary Hospital, Hong Kong, Hong Kong SAR, China
| | - Jane C. Y. Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ricardo Coelho
- Department of Dermatology, Centro Hospitalar Conde de São Januário, Macau, Macao SAR, China
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Wong JC, Chiang V, Lam DL, Lee E, Lam K, Au EY, Li PH. Long-term prophylaxis for hereditary angioedema: Initial experiences with garadacimab and lanadelumab. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100166. [PMID: 38024849 PMCID: PMC10679768 DOI: 10.1016/j.jacig.2023.100166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 12/01/2023]
Abstract
Background With no approved long-term prophylaxis (LTP) for the prevention of hereditary angioedema (HAE) attacks in Hong Kong, patients rely on compassionate use programs and drug trials. Moreover, studies regarding the use and efficacy of LTP in Asia are lacking. Objectives Our aim was to assess 2 LTP medications for HAE in Hong Kong: lanadelumab and garadacimab. Methods A prospective study was performed. Adult patients with a diagnosis of type I or type II HAE with 1 or more expert-confirmed attacks per month were consecutively recruited. The patients had been receiving treatment for at least 6 months. Clinical data were obtained, and questionnaires were administered before treatment periodically for at least 6 months following initiation of LTP. Results Almost one-third of the patients with HAE experienced frequent attacks and began receiving LTP (8 of the 11 received garadacimab and 3 of the 11 received lanadelumab). At baseline, the time-normalized number of HAE attacks was 2.5 plus or minus 1.3 per month. At month 6, there was an overall reduction of time-normalized number of attacks per month of -2.4 attacks per month (95% CI = -3.3 to -1.5. [P < .01]). The time-normalized number of HAE attacks at month 6 was 0.1 plus or minus 0.1 per month. More than 70% of the patients (8 of 11) were completely attack-free during the 6-month period while receiving LTP, and no patients required hospitalization. LTP improved patients' scores of the Angioedema Quality-of-Life Questionnaire (P < .001) and reduced activity impairment due to health (P = .008). Patients experienced significant improvement across all dimensions of the Treatment Satisfaction for Medication Questionnaire (54.5%-76.8% [P = .002]), and no adverse events were reported. Conclusion The patients receiving LTP with garadacimab and lanadelumab experienced a significant reduction in number of HAE attacks and improvement in quality of life, and they were satisfied with treatment.
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Affiliation(s)
- Jane C.Y. Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Dorothy L.Y. Lam
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Elaine Lee
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
| | - Ki Lam
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Elaine Y.L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, The University of Hong Kong, Hong Kong
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Christiansen SC, Zuraw BL. Hereditary Angioedema: A Test of Our Progress. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3211-3212. [PMID: 37805224 DOI: 10.1016/j.jaip.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 10/09/2023]
Affiliation(s)
| | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, La Jolla, Calif; Medicine Service, Veterans Administration Healthcare, San Diego, Calif.
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Nieto S, Madrigal I, Contreras F, Vargas ME. Real-world experience of hereditary angioedema (HAE) in Mexico: A mixed-methods approach to describe epidemiology, diagnosis, and treatment patterns. World Allergy Organ J 2023; 16:100812. [PMID: 37727628 PMCID: PMC10506135 DOI: 10.1016/j.waojou.2023.100812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/03/2023] [Accepted: 08/17/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction and objectives Due to the lack of structured and systematic information available, the aim of this study was to describe the epidemiology, diagnosis, healthcare processes, and treatment patterns of hereditary angioedema (HAE) in Mexico. To achieve this, different data sources were consulted regarding medical literature, structured health system databases, and angioedema-specialized physicians (AEP) opinion regarding HAE. Material and methods A mixed methods approach was conducted in 4 phases: I) systematic literature review (SLR) and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; II) review of national health system (NHS) databases and systematic reports; III) physician survey; and IV) an epidemiologic model. ICD 10 D84.1 encoded records from the NHS were used to estimate the number of patients with HAE attended and treated during 2019. A survey was implemented to increase understanding of the clinical profile and treatments used. Results A prevalence rate of 0.9/50 000 inhabitants was estimated for 2019. In the same year, an estimated 317 HAE type 1 patients were recorded in the NHS, aged ≥11 years old. The most frequent clinical symptoms were cutaneous edema (67.5%) and abdominal pain (47.9%). A severe episode with laryngeal edema appeared in 27.5% of cases. Acute episodes were mainly moderate to severe (77.0%), with an annual per capita frequency of emergency visits of 7.6 patient-year (range 1-12/patient-year). The main reasons for hospitalization corresponded to laryngeal facial, tongue, and abdominal edemas, representing 73.3% of annual ICD 10 D84.1 reported hospitalizations. The main treatments that patients with HAE received were fresh frozen plasma for acute attacks and danazol for short-term prophylaxis (STP). Conclusions Despite efforts to make HAE visible, according to this study, cases recognized and treated in the NHS represent only 16.6% of the estimated prevalence.
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Affiliation(s)
- Sandra Nieto
- Specialty in Pediatrics and Pediatric Hematology. Genetics of Nutrition Unit, Instituto Nacional de Pediatría, CDMX, Mexico
| | - Ileana Madrigal
- Specialty in Allergy and Immunology. High Specialty Medical Unit (UMAE), Centro Médico Nacional de Occidente, IMSS, Guadalajara, Mexico
| | - Francisco Contreras
- Specialty in Pediatrics and Allergy and Clinical Immunology. Allergy and Immunology Department, Instituto Nacional de Pediatría, CDMX, Mexico
| | - María Eugenia Vargas
- Specialty in Internal Medicine, Allergy and Clinical Immunology Master's Degree in History. Allergy and Immunology Department, Centro Médico Nacional 20 de Noviembre, ISSSTE, CDMX, Mexico
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