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Norelli F, Gueli V, Bonadonna P. Hymenoptera venom allergy in children and adolescents. Curr Opin Allergy Clin Immunol 2024; 24:322-329. [PMID: 39133153 DOI: 10.1097/aci.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
PURPOSE OF REVIEW This review will identify and summarize the published existing data pertaining specifically to Hymenoptera venom allergy in children and adolescents, highlighting the major studies currently available on venom immunotherapy (VIT) and its prognosis in children. RECENT FINDINGS The current review covers the incidence and prevalence of Hymenoptera venom allergy (HVA) in children, factors influencing occurrence and severity of reactions (age, sex, comorbidities, etc.), indications to perform diagnostic tests and start VIT in children, different existing VIT protocols and their safety and efficacy. SUMMARY Hymenoptera venom allergy is the second most common cause of anaphylaxis in children and it considerably affects quality of life. Cutaneous reactions are the most prevalent clinical presentation in children who usually have a more favourable prognosis than adult patients. However, studies on HVA in children and adolescents are still limited. Currently VIT is the only treatment able to modify the natural history of HVA in adults as well as in children, and to protect patients from systemic reactions after subsequent stings.
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Affiliation(s)
| | | | - Patrizia Bonadonna
- Allergy Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
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Worm M, Cichocka-Jarosz E, Ruëff F, Spindler T, Köhli A, Trück J, Lange L, Hartmann K, Hawranek T, Nemat K, Pföhler C, Bilò MB, Sabouraud-Leclerc D, Wagner N, Papadopoulos N, Hämmerling S, Ensina LF, Dölle-Bierke S, Höfer V. Age- and Elicitor-Dependent Characterization of Hymenoptera Venom-Induced Anaphylaxis in Children and Adolescents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00855-9. [PMID: 39209067 DOI: 10.1016/j.jaip.2024.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Hymenoptera venom is one of the most frequent causes of anaphylaxis. Studies from adults indicate the clinical profiles and risk factors of Hymenoptera venom-induced anaphylaxis (VIA). Much less is known about pediatric VIA. OBJECTIVE To understand elicitor- and age-related factors determining pediatric VIA by analyzing data from the anaphylaxis registry. METHODS We selected pediatric VIA, pediatric food-induced anaphylaxis (FIA), and adult VIA cohorts from the anaphylaxis registry and performed a comparative data analysis regarding elicitors, symptoms, and management. RESULTS We identified 725 pediatric patients with VIA, 3,149 with pediatric FIA, and 5,534 with adult VIA. In pediatric VIA, boys were more frequently affected, atopy was not increased, and the onset of the reaction after exposure was fast (≤30 min; 91%) compared with pediatric FIA. Symptoms in pediatric VIA were age dependent, and although respiratory symptoms occurred most frequently besides skin symptoms in both pediatric patients with VIA and FIA, cardiovascular symptoms were more frequently reported in pediatric patients with VIA than pediatric patients with FIA. The analysis of pediatric versus adult VIA revealed clear differences in the frequency of involved organ systems (skin: 93% vs 78%; respiratory: 77% vs 64%; and cardiovascular: 61% vs 85%). For both pediatric and adult VIA, the rates of adrenaline application by a professional were low (29% vs 31%) but hospitalization rates were higher in children than in adults (61% vs 42%). Venom immunotherapy was frequently initiated regardless of age (78% each). CONCLUSIONS Pediatric VIA is more frequent in boys, symptoms are age dependent, and hospitalization is often required. Adrenaline should be applied according to current guidelines. Venom immunotherapy is an important treatment option in pediatric VIA and should be considered in severely affected children.
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Affiliation(s)
- Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venereology, and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Ewa Cichocka-Jarosz
- Department of Paediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Franziska Ruëff
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Spindler
- Outpatient Clinic for Pediatric Allergology and Pulmonology, Medizin Campus Bodensee, Friedrichshafen, Germany
| | - Alice Köhli
- Division of Allergology, University Children's Hospital Zurich, Zürich, Switzerland; Division of Paediatric Allergology, Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Johannes Trück
- Divisions of Allergy and Immunology, University Children's Hospital and Children's Research Center, University of Zurich, Zurich, Switzerland
| | - Lars Lange
- Department of Paediatrics, St Marien-Hospital, Bonn, Germany
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas Hawranek
- University Clinic for Dermatology and Allergology, Paracelsus Medical Private University Salzburg, Salzburg, Austria
| | - Katja Nemat
- Dresden-Friedrichstadt Children's Center, Dresden, Germany
| | - Claudia Pföhler
- Clinic for Dermatology, Venerology, and Allergology, Saarland University Hospital and Medical Faculty of Saarland University, Homburg, Germany
| | - Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | | | - Nicola Wagner
- Department of Dermatology, Uniklinikum Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | | | - Susanne Hämmerling
- Division of Paediatric Pulmonology and Allergology, University Children`s Hospital Heidelberg, Heidelberg, Germany
| | - Luis Felipe Ensina
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Sabine Dölle-Bierke
- Division of Allergy and Immunology, Department of Dermatology, Venereology, and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Veronika Höfer
- Division of Allergy and Immunology, Department of Dermatology, Venereology, and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Bilò MB, Golden DBK, Braschi MC, Martini M. Should Patients With a Large Local Reaction be Offered Venom Immunotherapy? A Pro-Con Debate. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00685-8. [PMID: 38972507 DOI: 10.1016/j.jaip.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/09/2024]
Abstract
Insect stings can cause large local reactions (LLRs) that are IgE-mediated and associated with considerable morbidity. A risk for systemic reactions including anaphylaxis to subsequent stings has been reported and is often noted by patients and health care providers. Guidelines do not recommend venom immunotherapy (VIT) for LLRs based on the relatively low risk of anaphylaxis, but this is debated in this review. On the pro side: the risk of anaphylaxis may be higher than reported in the limited literature, especially in patients who had only 1 LLR; new species with more potent stings are spreading into new areas; the quality of life can be markedly impaired by LLRs; and VIT is generally safe and highly effective. On the con side: LLRs are benign, stings occur infrequently, VIT has significant cost, systemic reactions occur more often to VIT than to stings in patients with LLRs, and Food and Drug Administration approval and published guidelines do not recommend VIT for LLRs. In practice, shared decision-making is appropriate to incorporate knowledge of the natural history and known high-risk factors in the context of the patient's personal values and preferences.
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Affiliation(s)
- M Beatrice Bilò
- Allergy Unit, Department of Internal Medicine, University Hospital AOU delle Marche, Ancona, Italy; Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
| | - David B K Golden
- Division of Allergy-Clinical Immunology, Johns Hopkins School of Medicine, Baltimore, Md.
| | - M Chiara Braschi
- Allergy Unit, Department of Internal Medicine, University Hospital AOU delle Marche, Ancona, Italy
| | - Matteo Martini
- Allergy Unit, Department of Internal Medicine, University Hospital AOU delle Marche, Ancona, Italy; Department of Clinical and Molecular Sciences, Marche Polytechnic University, Ancona, Italy
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Perčič S, Košnik M, Zaletel Kragelj L, Bojanić L, Kukec A. Risk Factors Associated with Severe Systemic Allergic Reaction after Wasp Sting in Subjects with a History of European Hornet Sting Allergy. Zdr Varst 2024; 63:66-72. [PMID: 38517021 PMCID: PMC10954242 DOI: 10.2478/sjph-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/05/2023] [Indexed: 03/23/2024] Open
Abstract
Aim To make the treatment approach in patients suffering a European hornet sting allergy reaction more personalized, preparing them also for possible future risks. Methods In Slovenia an extended retrospective observational cohort epidemiological study about the natural history of Hymenoptera venom sensitivity is in progress. The study is based on data from the healthcare records of the University Clinic Golnik (UCG) and data collected by a questionnaire sent to patients from May 2019 to April 2021. For a pilot study, we selected patients who were referred to UCG because of an allergic reaction to European hornet sting and had been re-stung later by a wasp (n=68). The association between severe systemic allergic reactions (SSAR) after wasp sting and potential risk factors in subjects with a history of hornet sting allergy was assessed univariately using the likelihood ratio test. Results Among 68 European hornet allergic patients 27 reacted with an SSAR and 41 reacted with a mild SAR. Among 27 patients with SSAR, 4 reacted with an SSAR also to a subsequent wasp sting. Among 41 patients with a mild European hornet sting SAR nobody reacted with an SSAR to a subsequent wasp sting. The association between the severity of the wasp SAR reaction in European hornet allergic patients was statistically significant (p=0.022). Conclusion Our results suggest that patients with severe European hornet SAR should be considered for wasp venom immunotherapy or prophylactic prescription of epinephrine auto-injector as they are at risk for an SSAR also after wasp string.
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Affiliation(s)
- Simona Perčič
- University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000Ljubljana, Slovenia
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204Golnik, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Internal Medicine, Zaloška cesta 7, 1000Ljubljana, Slovenia
| | - Lijana Zaletel Kragelj
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000Ljubljana, Slovenia
| | - Lidija Bojanić
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204Golnik, Slovenia
| | - Andreja Kukec
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000Ljubljana, Slovenia
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Cichocka-Jarosz E, Brzyski P, Jedynak-Wąsowicz U, Mól N, Klasa B, Mazurek-Durlak Z, Lis G, Nowak-Węgrzyn A. Skin prick tests are not useful for the qualification for venom immunotherapy in children. World Allergy Organ J 2023; 16:100775. [PMID: 37351272 PMCID: PMC10282561 DOI: 10.1016/j.waojou.2023.100775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 06/24/2023] Open
Abstract
Background The basis for qualification for venom immunotherapy (VIT) is the fulfilment of both the clinical and immunological criteria. Diagnostic tests that confirm the immunological criterion of an IgE-mediated sensitization include skin prick tests (SPT), intradermal tests (IDT), and serum specific IgE (sIgE) for the culprit venom. Objective This study aimed to assess the usefulness of SPT as the immunological marker in the diagnosis of insect venom sensitization in children with history of systemic reaction (SR) to insect sting evaluated by means of I-IV-grades Mueller's scale. There are no such studies in children. Methods This cross-sectional study sample consisted of 416 children aged 3-18 years (mean age 10.6 ± 3.8), 76% males, all with the history of a systemic reaction (SR) after a Hymenoptera sting (48% of grade III/IV according to Mueller scale), diagnosed between 1999 and 2019 in the tertiary referral centre. The standard diagnostic tests were used. Specificity, sensitivity, and positive and negative predictive values were computed to assess the diagnostic properties of the clinical tests to distinguish between mild and severe SR. To assess the relative value of an individual test in predicting the qualification to VIT we incorporated the Shapley value (SV). Results Positive SPT results were found in up to no more than 3% of children; among them less than 1% had only positive SPT and were negative for sIgE and IDT. Approximately 85% of the children had detectable venom sIgE, followed by positive IDT (75%). Almost 70% of children had positive both sIgE and IDT results. In children with grade III/IV reaction, about 80% of children had positive results of both of these tests. sIgE and IDT had sensitivity >0.80, whereas SPT had high specificity (>0.97) in differentiating between mild and severe SR. Relative value of diagnostic tests in predicting qualification to VIT varied between venoms. Bee venom IDT had higher SV (0.052) than sIgE (0.041). In contrast, wasp venom sIgE had higher SV (0.075) than IDT (0.035). Conclusion SPTs are not an useful immunological marker of venom sensitization in children, and eliminating SPT does not result in a loss of diagnostic accuracy. Limiting diagnostics to venom sIgE and IDT would shorten the procedure and reduce costs. Future studies are needed to determine if venom sIgE as the first line diagnostic test, with IDT added only if the venom sIgE is undetectable, is an optimal diagnostic process.
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Affiliation(s)
- Ewa Cichocka-Jarosz
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | | | - Urszula Jedynak-Wąsowicz
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | - Nina Mól
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | - Barbara Klasa
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | - Zofia Mazurek-Durlak
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | - Grzegorz Lis
- Department of Paediatrics, Jagiellonian University Medical College, 265 Wielicka St, 30-663 Krakow, Poland
| | - Anna Nowak-Węgrzyn
- Department of Pediatrics at NYU Grossman School of Medicine, New York, USA
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6
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Höfer V, Martini M, Dölle-Bierke S, Worm M, Bilò MB. Health-related quality of life in food and venom induced anaphylaxis and role of influencing factors. Clin Exp Allergy 2023; 53:295-306. [PMID: 36565032 DOI: 10.1111/cea.14268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 12/25/2022]
Abstract
The impact on health-related quality of life (HRQL) plays a key role for patients suffering from allergies and anaphylaxis. In this narrative review we review the HRQL in allergic patients suffering from food and venom allergy, both being the most frequent elicitors of severe allergic, potential life-threatening reactions and provide an overview on the current knowledge and identified gaps. The data show that for food and venom allergy standardized assessment tools to measure HRQL are available and have been successfully applied. Our analysis shows that multiple factors can modulate HRQL in these patient groups. These include sociodemographic data like patients' age and sex, fear of accidental reactions but also external factors like the social environment and the appreciation of the seriousness of the condition by others. External factors may have a significant impact on HRQL and should be considered in patient-related outcome assessments to avoid biased measurements possibly affecting the results. The assessment of the quality of life in the context of specific immunotherapy should consider lifestyle factors and ideally, the individual change in HRQL should be measured. Although there are many data indicating a negative impact on HRQL in food allergic children and their caregivers, limited data are existing from adults with food allergy and venom allergic patients from all age groups. Also, the use of standardized questionnaires should be extended to allow for a better comparability of results between studies. Therefore, translation to additional languages is necessary. Taken together, the eliciting allergen, the severity of the allergic disease but moreover multiple external factors impact the outcome in HRQL and should be considered in HRQL assessment.
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Affiliation(s)
- Veronika Höfer
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Matteo Martini
- Allergy Unit, Ospedali Riuniti Marche Nord, Fano, Italy.,Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Sabine Dölle-Bierke
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy
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7
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Dramburg S, Hilger C, Santos AF, de Las Vecillas L, Aalberse RC, Acevedo N, Aglas L, Altmann F, Arruda KL, Asero R, Ballmer-Weber B, Barber D, Beyer K, Biedermann T, Bilo MB, Blank S, Bosshard PP, Breiteneder H, Brough HA, Bublin M, Campbell D, Caraballo L, Caubet JC, Celi G, Chapman MD, Chruszcz M, Custovic A, Czolk R, Davies J, Douladiris N, Eberlein B, Ebisawa M, Ehlers A, Eigenmann P, Gadermaier G, Giovannini M, Gomez F, Grohman R, Guillet C, Hafner C, Hamilton RG, Hauser M, Hawranek T, Hoffmann HJ, Holzhauser T, Iizuka T, Jacquet A, Jakob T, Janssen-Weets B, Jappe U, Jutel M, Kalic T, Kamath S, Kespohl S, Kleine-Tebbe J, Knol E, Knulst A, Konradsen JR, Korošec P, Kuehn A, Lack G, Le TM, Lopata A, Luengo O, Mäkelä M, Marra AM, Mills C, Morisset M, Muraro A, Nowak-Wegrzyn A, Nugraha R, Ollert M, Palosuo K, Pastorello EA, Patil SU, Platts-Mills T, Pomés A, Poncet P, Potapova E, Poulsen LK, Radauer C, Radulovic S, Raulf M, Rougé P, Sastre J, Sato S, Scala E, Schmid JM, Schmid-Grendelmeier P, Schrama D, Sénéchal H, Traidl-Hoffmann C, Valverde-Monge M, van Hage M, van Ree R, Verhoeckx K, Vieths S, Wickman M, Zakzuk J, Matricardi PM, Hoffmann-Sommergruber K. EAACI Molecular Allergology User's Guide 2.0. Pediatr Allergy Immunol 2023; 34 Suppl 28:e13854. [PMID: 37186333 DOI: 10.1111/pai.13854] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 05/17/2023]
Abstract
Since the discovery of immunoglobulin E (IgE) as a mediator of allergic diseases in 1967, our knowledge about the immunological mechanisms of IgE-mediated allergies has remarkably increased. In addition to understanding the immune response and clinical symptoms, allergy diagnosis and management depend strongly on the precise identification of the elicitors of the IgE-mediated allergic reaction. In the past four decades, innovations in bioscience and technology have facilitated the identification and production of well-defined, highly pure molecules for component-resolved diagnosis (CRD), allowing a personalized diagnosis and management of the allergic disease for individual patients. The first edition of the "EAACI Molecular Allergology User's Guide" (MAUG) in 2016 rapidly became a key reference for clinicians, scientists, and interested readers with a background in allergology, immunology, biology, and medicine. Nevertheless, the field of molecular allergology is moving fast, and after 6 years, a new EAACI Taskforce was established to provide an updated document. The Molecular Allergology User's Guide 2.0 summarizes state-of-the-art information on allergen molecules, their clinical relevance, and their application in diagnostic algorithms for clinical practice. It is designed for both, clinicians and scientists, guiding health care professionals through the overwhelming list of different allergen molecules available for testing. Further, it provides diagnostic algorithms on the clinical relevance of allergenic molecules and gives an overview of their biology, the basic mechanisms of test formats, and the application of tests to measure allergen exposure.
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Affiliation(s)
- Stephanie Dramburg
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christiane Hilger
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom
| | | | - Rob C Aalberse
- Sanquin Research, Dept Immunopathology, University of Amsterdam, Amsterdam, The Netherlands
- Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie Acevedo
- Institute for Immunological Research, University of Cartagena, Cartagena de Indias, Colombia, Colombia
| | - Lorenz Aglas
- Department of Biosciences and Medical Biology, Paris Lodron University Salzburg, Salzburg, Austria
| | - Friedrich Altmann
- Department of Chemistry, University of Natural Resources and Life Sciences, Vienna, Austria
| | - Karla L Arruda
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brasil, Brazil
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano, Italy
| | - Barbara Ballmer-Weber
- Klinik für Dermatologie und Allergologie, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Domingo Barber
- Institute of Applied Molecular Medicine Nemesio Diez (IMMAND), Department of Basic Medical Sciences, Facultad de Medicina, Universidad San Pablo CEU, CEU Universities, Madrid, Spain
- RETIC ARADyAL and RICORS Enfermedades Inflamatorias (REI), Madrid, Spain
| | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - Maria Beatrice Bilo
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
- Allergy Unit Department of Internal Medicine, University Hospital Ospedali Riuniti di Ancona, Torrette, Italy
| | - Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Munich, Germany
| | - Philipp P Bosshard
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Heimo Breiteneder
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
| | - Helen A Brough
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Merima Bublin
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
| | - Dianne Campbell
- Department of Allergy and Immunology, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
- Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena, Cartagena de Indias, Colombia, Colombia
| | - Jean Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Giorgio Celi
- Centro DH Allergologia e Immunologia Clinica ASST- MANTOVA (MN), Mantova, Italy
| | | | - Maksymilian Chruszcz
- Department of Chemistry and Biochemistry, University of South Carolina, Columbia, South Carolina, USA
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rebecca Czolk
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
- Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Janet Davies
- Queensland University of Technology, Centre for Immunology and Infection Control, School of Biomedical Sciences, Herston, Queensland, Australia
- Metro North Hospital and Health Service, Emergency Operations Centre, Herston, Queensland, Australia
| | - Nikolaos Douladiris
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Bernadette Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University Munich, Munich, Germany
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Anna Ehlers
- Chemical Biology and Drug Discovery, Utrecht University, Utrecht, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Immunology and Dermatology/ Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Philippe Eigenmann
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Gabriele Gadermaier
- Department of Biosciences and Medical Biology, Paris Lodron University Salzburg, Salzburg, Austria
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francisca Gomez
- Allergy Unit IBIMA-Hospital Regional Universitario de Malaga, Malaga, Spain
- Spanish Network for Allergy research RETIC ARADyAL, Malaga, Spain
| | - Rebecca Grohman
- NYU Langone Health, Department of Internal Medicine, New York, New York, USA
| | - Carole Guillet
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Christine Hafner
- Department of Dermatology, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, St. Poelten, Austria
| | - Robert G Hamilton
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Hauser
- Department of Biosciences and Medical Biology, Paris Lodron University Salzburg, Salzburg, Austria
| | - Thomas Hawranek
- Department of Dermatology and Allergology, Paracelsus Private Medical University, Salzburg, Austria
| | - Hans Jürgen Hoffmann
- Institute for Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Tomona Iizuka
- Laboratory of Protein Science, Graduate School of Life Science, Hokkaido University, Sapporo, Japan
| | - Alain Jacquet
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center, Justus Liebig University Gießen, Gießen, Germany
| | - Bente Janssen-Weets
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
- Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Uta Jappe
- Division of Clinical and Molecular Allergology, Priority Research Area Asthma and Allergy, Research Center Borstel, Borstel, Germany
- Leibniz Lung Center, Airway Research Center North (ARCN), Member of the German Center for Lung Research, Germany
- Interdisciplinary Allergy Outpatient Clinic, Dept. of Pneumology, University of Lübeck, Lübeck, Germany
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
| | - Tanja Kalic
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
- Department of Dermatology, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, St. Poelten, Austria
| | - Sandip Kamath
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Molecular Allergy Research Laboratory, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Sabine Kespohl
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr- Universität Bochum, Bochum, Germany
| | - Jörg Kleine-Tebbe
- Allergy & Asthma Center Westend, Outpatient Clinic and Clinical Research Center, Berlin, Germany
| | - Edward Knol
- Department of Immunology and Dermatology/ Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - André Knulst
- Department of Immunology and Dermatology/ Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Korošec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Annette Kuehn
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Thuy-My Le
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Immunology and Dermatology/ Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andreas Lopata
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Molecular Allergy Research Laboratory, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Olga Luengo
- RETIC ARADyAL and RICORS Enfermedades Inflamatorias (REI), Madrid, Spain
- Allergy Section, Internal Medicine Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mika Mäkelä
- Division of Allergy, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Pediatric Department, Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
| | | | - Antonella Muraro
- Food Allergy Referral Centre, Department of Woman and Child Health, Padua University Hospital, Padua, Italy
| | - Anna Nowak-Wegrzyn
- Division of Pediatric Allergy and Immunology, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Roni Nugraha
- Molecular Allergy Research Laboratory, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
- Department of Aquatic Product Technology, Faculty of Fisheries and Marine Science, IPB University, Bogor, Indonesia
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
- Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Kati Palosuo
- Department of Allergology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Sarita Ulhas Patil
- Division of Rheumatology, Allergy and Immunology, Departments of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Allergy and Immunology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas Platts-Mills
- Division of Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Pascal Poncet
- Institut Pasteur, Immunology Department, Paris, France
- Allergy & Environment Research Team Armand Trousseau Children Hospital, APHP, Paris, France
| | - Ekaterina Potapova
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lars K Poulsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Christian Radauer
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Monika Raulf
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr- Universität Bochum, Bochum, Germany
| | - Pierre Rougé
- UMR 152 PharmaDev, IRD, Université Paul Sabatier, Faculté de Pharmacie, Toulouse, France
| | - Joaquin Sastre
- Allergy Service, Fundación Jiménez Díaz; CIBER de Enfermedades Respiratorias (CIBERES); Faculty of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Sakura Sato
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Enrico Scala
- Clinical and Laboratory Molecular Allergy Unit - IDI- IRCCS, Fondazione L M Monti Rome, Rome, Italy
| | - Johannes M Schmid
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Schmid-Grendelmeier
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Christine Kühne Center for Allergy Research and Education CK-CARE, Davos, Switzerland
| | - Denise Schrama
- Centre of Marine Sciences (CCMAR), Universidade do Algarve, Faro, Portugal
| | - Hélène Sénéchal
- Allergy & Environment Research Team Armand Trousseau Children Hospital, APHP, Paris, France
| | - Claudia Traidl-Hoffmann
- Christine Kühne Center for Allergy Research and Education CK-CARE, Davos, Switzerland
- Department of Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Marcela Valverde-Monge
- Allergy Service, Fundación Jiménez Díaz; CIBER de Enfermedades Respiratorias (CIBERES); Faculty of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Marianne van Hage
- Department of Medicine Solna, Division of Immunology and Allergy, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ronald van Ree
- Department of Experimental Immunology and Department of Otorhinolaryngology, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Kitty Verhoeckx
- Department of Immunology and Dermatology/ Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Stefan Vieths
- Division of Allergology, Paul-Ehrlich-Institut, Langen, Germany
| | - Magnus Wickman
- Department of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Josefina Zakzuk
- Institute for Immunological Research, University of Cartagena, Cartagena de Indias, Colombia, Colombia
| | - Paolo M Matricardi
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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8
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Gschwend A, Helbling A. Allergic Reactions to Stinging and Biting Insects. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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9
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Poziomkowska-Gęsicka I. Idiopathic Anaphylaxis? Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16716. [PMID: 36554595 PMCID: PMC9779638 DOI: 10.3390/ijerph192416716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
The most common causes of anaphylaxis, according to various authors and depending on the age of the studied groups, are: Hymenoptera venom, food, and medications. Unfortunately, we are not always able to indicate the cause of anaphylaxis. There are data in the literature where as many as 41% of all cases are idiopathic anaphylaxis. Since the introduction of new diagnostic methods such as molecular diagnostics (MD) in our centre, the percentage of idiopathic anaphylaxis in the Anaphylaxis Register has significantly decreased. The purpose of this study was to identify possible causes of idiopathic anaphylaxis in patients with a history of moderate to severe anaphylactic reactions. After using MD, the causative agent was found in another 29 people. The proportion of people with idiopathic anaphylaxis in the Registry decreased from 9.2% to 3.5%. There were no significant differences in the incidence, although men appear to be slightly more common in primary idiopathic anaphylaxis. The mean age of primary idiopathic anaphylaxis was 40 years, but this was as high as 51 for anaphylaxis with alpha-gal allergy. Exercise may or may not be present as a cofactor despite its established role, e.g., in wheat-dependent exercise-induced anaphylaxis (WDEIA). In most of the analyzed cases, i.e., 70%, the reaction took place within an hour. The longest time interval from exposure to the development of symptoms is in the case of alpha-gal allergy; in this analysis, it was at least 5 h after ingestion of the so-called "red meat". Patients are not aware of the disease, or further attacks cannot be prevented. As many as 80% had idiopathic anaphylaxis prior to visiting the centre, and 80% developed anaphylaxis after visiting the centre, which emphasizes the need to not stop the medical team in their search for the causes. As many as 93% of cases required medical intervention, of which adrenaline was used only in 34.5%, antihistamines in 86%, systemic glucocorticosteroids (sCS) in 75%, and fluids in 62% of cases. A total of 83% of patients received an emergency kit for self-administration. Idiopathic anaphylaxis can be resolved as known-cause anaphylaxis after a thorough medical history and, if possible, without exposing the patient after using appropriate, modern in vitro diagnostic methods, including molecular diagnostics. The diagnosis of idiopathic anaphylaxis should extend the diagnosis to include alpha-gal syndrome, LTP syndrome and WDEIA.
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Affiliation(s)
- Iwona Poziomkowska-Gęsicka
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, 70-111 Szczecin, Poland
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10
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Abstract
PURPOSE OF REVIEW Anaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management. RECENT FINDINGS Data from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data. SUMMARY The most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.
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Affiliation(s)
- Maria Teresa Ventura
- Unit of Geriatric Immunoallergology, University of Bari Medical School, Bari, Italy
| | - Elisa Boni
- Allergologia e Autoimmunità LUM, Maggiore Hospital, AUSL Bologna, Italy
| | - Luis Taborda-Barata
- UBIAir – Clinical & Experimental Lung Centre, University of Beira Interior, Covilhã and CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
- Department of Immunoallergology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - Hubert Blain
- Department of Geriatrics, Montpellier University Hospital, MUSE, Montpellier, France
| | - Jean Bousquet
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- University Hospital Montpellier, France
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11
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Risikofaktoren bei Bienen- und Wespengiftallergie: aktuelle Bewertung. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-021-4938-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Muraro A, Worm M, Alviani C, Cardona V, DunnGalvin A, Garvey LH, Riggioni C, de Silva D, Angier E, Arasi S, Bellou A, Beyer K, Bijlhout D, Bilò MB, Bindslev-Jensen C, Brockow K, Fernandez-Rivas M, Halken S, Jensen B, Khaleva E, Michaelis LJ, Oude Elberink HNG, Regent L, Sanchez A, Vlieg-Boerstra BJ, Roberts G. EAACI guidelines: Anaphylaxis (2021 update). Allergy 2022; 77:357-377. [PMID: 34343358 DOI: 10.1111/all.15032] [Citation(s) in RCA: 178] [Impact Index Per Article: 89.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/31/2021] [Indexed: 12/11/2022]
Abstract
Anaphylaxis is a clinical emergency which all healthcare professionals need to be able to recognize and manage. The European Academy of Allergy and Clinical Immunology Anaphylaxis multidisciplinary Task Force has updated the 2014 guideline. The guideline was developed using the AGREE II framework and the GRADE approach. The evidence was systematically reviewed and recommendations were created by weighing up benefits and harms. The guideline was peer-reviewed by external experts and reviewed in a public consultation. The use of clinical criteria to identify anaphylaxis is suggested with blood sampling for the later measurement of tryptase. The prompt use of intramuscular adrenaline as first-line management is recommended with the availability of adrenaline autoinjectors to patients in the community. Pharmacokinetic data should be provided for adrenaline autoinjector devices. Structured, comprehensive training for people at risk of anaphylaxis is recommended. Simulation training and visual prompts for healthcare professionals are suggested to improve the management of anaphylaxis. It is suggested that school policies reflect anaphylaxis guidelines. The evidence for the management of anaphylaxis remains mostly at a very low level. There is an urgent need to prioritize clinical trials with the potential to improve the management of patients at risk of anaphylaxis.
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Affiliation(s)
- Antonella Muraro
- Food Allergy Referral Centre Veneto Region, Department of Women and Child Health, Padua General University Hospital, Padua, Italy
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité Universitätsmedizin Berlin, Germany
| | - Cherry Alviani
- Clinical and Experimental Sciences and Human Development in Health, Faculty of Medicine, University of Southampton, UK
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron & ARADyAL Research Network, Barcelona, Spain
| | - Audrey DunnGalvin
- University College Cork, Cork, Ireland
- Sechnov University Moscow, Moscow, Russia
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and allergy, Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Carmen Riggioni
- Allergy, Immunology and Rheumatology Division, Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | | | - Elizabeth Angier
- Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Stefania Arasi
- Allergy Unit - Area of Translational Research in Pediatric Specialities, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Abdelouahab Bellou
- European Society for Emergency Medicine, Brussels, Belgium
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
- University of Rennes 1, Rennes, France
| | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Diola Bijlhout
- Association for Teacher Education in Europe (ATEE, Brussels, Belgium
| | - Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
- Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Montserrat Fernandez-Rivas
- Allergy Department, Hospital Clinico San Carlos, Facultad Medicina Universidad Complutense, IdISSC, ARADyAL, Madrid, Spain
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Britt Jensen
- Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Ekaterina Khaleva
- Clinical and Experimental Sciences and Human Development in Health, Faculty of Medicine, University of Southampton, UK
| | - Louise J Michaelis
- Department of Paediatric Immunology, Allergy, and Infectious Diseases, Great North Children's Hospital, Newcastle upon Tyne, UK
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hanneke N G Oude Elberink
- Department of Allergology, University Medical Center Groningen, University of Groningen, and Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | | | - Angel Sanchez
- AEPNAA Spanish Association for People with Food and Latex Allergy, Madrid, Spain
| | | | - Graham Roberts
- Clinical and Experimental Sciences and Human Development in Health, Faculty of Medicine, University of Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
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13
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Bousquet J, Agache I, Blain H, Jutel M, Ventura MT, Worm M, Del Giacco S, Benetos A, Bilo MB, Czarlewski W, Abdul Latiff AH, Al-Ahmad M, Angier E, Annesi-Maesano I, Atanaskovic-Markovic M, Bachert C, Barbaud A, Bedbrook A, Bennoor KS, Berghea EC, Bindslev-Jensen C, Bonini S, Bosnic-Anticevich S, Brockow K, Brussino L, Camargos P, Canonica GW, Cardona V, Carreiro-Martins P, Carriazo A, Casale T, Caubet JC, Cecchi L, Cherubini A, Christoff G, Chu DK, Cruz AA, Dokic D, El-Gamal Y, Ebisawa M, Eberlein B, Farrell J, Fernandez-Rivas M, Fokkens WJ, Fonseca JA, Gao Y, Gavazzi G, Gawlik R, Gelincik A, Gemicioğlu B, Gotua M, Guérin O, Haahtela T, Hoffmann-Sommergruber K, Hoffmann HJ, Hofmann M, Hrubisko M, lenaIllario M, Irani C, Ispayeva Z, Ivancevich JC, Julge K, Kaidashev I, Khaitov M, Knol E, Kraxner H, Kuna P, Kvedariene V, Lauerma A, Le LT, Le Moing V, Levin M, Louis R, Lourenco O, Mahler V, Martin FC, Matucci A, Milenkovic B, Miot S, Montella E, Morais-Almeida M, Mortz CG, Mullol J, Namazova-Baranova L, Neffen H, Nekam K, Niedoszytko M, Odemyr M, O'Hehir RE, Okamoto Y, Ollert M, Palomares O, Papadopoulos NG, Panzner P, Passalacqua G, Patella V, Petrovic M, Pfaar O, Pham-Thi N, Plavec D, Popov TA, Recto MT, Regateiro FS, Reynes J, Roller-Winsberger RE, Rolland Y, Romano A, Rondon C, Rottem M, Rouadi PW, Salles N, Samolinski B, Santos AF, Serpa FS, Sastre J, Schols JMGA, Scichilone N, Sediva A, Shamji MH, Sheikh A, Skypala I, Smolinska S, Sokolowska M, Sousa-Pinto B, Sova M, Stelmach R, Sturm G, Suppli Ulrik C, Todo-Bom AM, Toppila-Salmi S, Tsiligianni I, Torres M, Untersmayr E, Urrutia Pereira M, Valiulis A, Vitte J, Vultaggio A, Wallace D, Walusiak-Skorupa J, Wang DY, Waserman S, Yorgancioglu A, Yusuf OM, Zernotti M, Zidarn M, Chivato T, Akdis CA, Zuberbier T, Klimek L. Management of anaphylaxis due to COVID-19 vaccines in the elderly. Allergy 2021; 76:2952-2964. [PMID: 33811358 PMCID: PMC8251336 DOI: 10.1111/all.14838] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
Older adults, especially men and/or those with diabetes, hypertension, and/or obesity, are prone to severe COVID‐19. In some countries, older adults, particularly those residing in nursing homes, have been prioritized to receive COVID‐19 vaccines due to high risk of death. In very rare instances, the COVID‐19 vaccines can induce anaphylaxis, and the management of anaphylaxis in older people should be considered carefully. An ARIA‐EAACI‐EuGMS (Allergic Rhinitis and its Impact on Asthma, European Academy of Allergy and Clinical Immunology, and European Geriatric Medicine Society) Working Group has proposed some recommendations for older adults receiving the COVID‐19 vaccines. Anaphylaxis to COVID‐19 vaccines is extremely rare (from 1 per 100,000 to 5 per million injections). Symptoms are similar in younger and older adults but they tend to be more severe in the older patients. Adrenaline is the mainstay treatment and should be readily available. A flowchart is proposed to manage anaphylaxis in the older patients.
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Affiliation(s)
- Jean Bousquet
- Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center, Department of Dermatology and Allergy, Berlin, Germany.,University Hospital Montpellier, France.,MACVIA-France, Montpellier, France
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Hubert Blain
- Department of Geriatrics, Montpellier University Hospital, Montpellier, France
| | - Marek Jutel
- Department of Clinical Immunology, Wrocław Medical University, Wroclaw, and ALL-MED Medical Research Institute, Wrocław, Poland
| | - Maria Teresa Ventura
- University of Bari Medical School, Unit of Geriatric Immunoallergology, Bari, Italy
| | - Margitta Worm
- Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center, Department of Dermatology and Allergy, Berlin, Germany
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital "Duilio Casula", University of Cagliari, Cagliari, Italy
| | - Athanasios Benetos
- Department of Geriatrics, CHRU de Nancy and Inserm DCAC, Université de Lorraine, Nancy, France
| | - M Beatrice Bilo
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche - Allergy Unit - Department of Internal Medicine, University Hospital, Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Amir Hamzah Abdul Latiff
- Allergy & Immunology Centre, Pantai Hospital, Department of Pediatrics, Universiti Putra Malaysia Teaching Hospital,, Kuala Lumpur, Malaysia
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University and Department of Allergy, Al-Rashed Allergy Center, Kuwait
| | - Elizabeth Angier
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Isabella Annesi-Maesano
- Institut Desbrest d'Epidémiologie et Santé Publique (IDESP), INSERM et Université de Montpellier, Montpellier, France
| | | | - Claus Bachert
- Upper Airways Research Laboratory, ENT Dept, Ghent University Hospital, Ghent, Belgium.,Sun Yat-sen University, International Airway Research Center, First Affiliated Hospital Guangzou, China.,Division of ENT Diseases, CLINTEC, Karolinska Institutet, Stockholm and Department of ENT Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Annick Barbaud
- Division of Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France & Division of Equipe PEPITES, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Anna Bedbrook
- Allergy & Immunology Centre, Pantai Hospital, Department of Pediatrics, Universiti Putra Malaysia Teaching Hospital,, Kuala Lumpur, Malaysia
| | - Kazi S Bennoor
- Department of Respiratory Medicine, National Institute of Diseases of the Chest and Hospital, Dhaka, Bangladesh
| | - Elena Camelia Berghea
- Allergology and Clinical Immunology, Carol Davila University of Medicine and Pharmacy, Bucharest, and Clinical Emergency Hospital for Children MS Curie, Bucharest, Romania
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense Research Center for Anaphylaxis (ORCA), Odense, Denmark
| | - Sergio Bonini
- Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney and Woolcock Emphysema Centre and Sydney Local Health District, Glebe, NSW, Australia
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Luisa Brussino
- Department of Medical Sciences, Allergy and Clinical Immunology Unit, University of Torino & Mauriziano Hospital, Torino, Italy
| | - Paulo Camargos
- Federal University of Minas Gerais, Medical School, Department of Pediatrics, Belo Horizonte, Brazil
| | - G Walter Canonica
- Personalized Medicine Asthma, & Allergy Clinic-Humanitas University & Research Hospital, IRCCS-Milano, Italy
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron & ARADyAL research network, Barcelona, Spain
| | - Pedro Carreiro-Martins
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal; CEDOC, Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Carriazo
- Regional Ministry of Health of Andalusia, Seville, Spain
| | - Thomas Casale
- Division of Allergy/Immunology, University of South Florida, Tampa, Fl, USA
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
| | - Lorenzo Cecchi
- SOS Allergology and Clinical Immunology, USL Toscana Centro, Prato, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | | | - Derek K Chu
- Department of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alvaro A Cruz
- Fundação ProAR, Federal University of Bahia and GARD/WHO Planning Group, Salvador, Bahia, Brazil
| | - Dejan Dokic
- University Clinic of Pulmology and Allergy, Medical Faculty Skopje, Republic of Macedonia
| | - Yehia El-Gamal
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Sagamihara, Japan
| | - Bernadette Eberlein
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - John Farrell
- LANUA International Healthcare Consultancy, Down, UK
| | | | - Wytske J Fokkens
- Department of Otorhinolaryngology, Academic Medical Centers, AMC, Amsterdam, The Netherland, and EUFOREA, Brussels, Belgium
| | - Joao A Fonseca
- CINTESIS, Center for Health Technology and Services Research, Faculdade de Medicina, Universidade do Porto, Porto, Portugal ; Allergy Unit, CUF Porto, Porto, Portugal
| | - Yadong Gao
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Gaëtan Gavazzi
- Service Gériatrie Clinique, Centre Hospitalo-Universitaire Grenoble-Alpes, GREPI (TIMC-IMAG, CNRS 5525), Université Grenoble-Alpes, Grenoble, France
| | - Radolslaw Gawlik
- Dept of Internal Medicine, Allergy and Clin Immunology, Silesian University of Medicine, Katowice, Poland
| | - Asli Gelincik
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bilun Gemicioğlu
- Department of Pulmonary Diseases, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Maia Gotua
- Center of Allergy and Immunology, Georgian Association of Allergology and Clinical Immunology, Tbilisi, Georgia
| | | | - Tari Haahtela
- Skin and Allergy Hospital, Helsinki University Hospital, and University of Helsinki University, Helsinki, Finland
| | - Karin Hoffmann-Sommergruber
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Hans Jürgen Hoffmann
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus & Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maja Hofmann
- Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center, Department of Dermatology and Allergy, Berlin, Germany
| | - Martin Hrubisko
- Department of Clinical Immunology and Allergy, Oncology Institute of St Elisabeth, Heydukova, Bratislava, Slovakia
| | - Madda lenaIllario
- Federico II University & Hospital, Department of Public Health and Research and Development Unit Naples, Italy
| | - Carla Irani
- Department of Internal Medicine and Infectious Diseases, St Joseph University, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Zhanat Ispayeva
- President of Kazakhstan Association of Allergology and Clinical Immunology, Department of Allergology and clinical immunology of the Kazakh National Medical University, Kazakhstan
| | | | - Kaja Julge
- Tartu University Institute of Clinical Medicine, Children's Clinic, Tartu, Estonia
| | - Igor Kaidashev
- Ukrainina Medical Stomatological Academy, Poltava, Ukraine
| | - Musa Khaitov
- National Research Center, Institute of Immunology, Federal Medicobiological Agency, Laboratory of Molecular Immunology, Moscow, Russia
| | - Edward Knol
- Departments of Immunology and Dermatology/Allergology, University Medical Center Utrecht, The Netherlands
| | - Helga Kraxner
- Department of Otorhinolaryngology, Head and Neck Surgery, Semmelweis University, Budapest, Hungary
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Poland
| | - Violeta Kvedariene
- Institute of Biomedical Sciences, Department of Pathology, Faculty of Medicine, Vilnius University and Institute of Clinical Medicine, Clinic of Chest diseases and Allergology, faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Antti Lauerma
- Department of Dermatology and Allergology, University of Helsinki and Helsinki University, Meilahdentie Helsinki, Finland
| | - Lan Tt Le
- University of Medicine and Pharmacy, Hochiminh City, Vietnam
| | - Vincent Le Moing
- Department of Infectiology, Montpellier University Hospital, France
| | - Michael Levin
- Division Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Renaud Louis
- Department of Pulmonary Medicine, CHU Sart-Tilman, and GIGA I3 research group, Liege, Belgium
| | - Olga Lourenco
- Faculty of Health Sciences and CICS - UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal
| | | | - Finbarr C Martin
- Emeritus Geriatrician and Professor of Medical Gerontology Population Health Sciences I, King's College London, UK
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Branislava Milenkovic
- Clinic for Pulmonary Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Serbian Association for Asthma and COPD, Belgrade, Serbia
| | - Stéphanie Miot
- Department of Geriatrics, Montpellier University Hospital, Montpellier, France
| | - Emma Montella
- Federico II University & Hospital, Department of Public Health and Research and Development Unit, Naples, Italy
| | | | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Centre for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic; Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, University of Barcelona,, Spain
| | - Leyla Namazova-Baranova
- Pediatrics and Child Health Research Institute, Central Clinical Hospital of the Russian Academy of Sciences, Russian National Research Medical University, Moscow, Russia
| | - Hugo Neffen
- Director of Center of Allergy, Immunology and Respiratory Diseases, Santa Fe, Argentina
| | - Kristof Nekam
- Hospital of the Hospitaller Brothers in Buda, Budapest, Hungary
| | - Marek Niedoszytko
- Medical University of Gdańsk, Department of Allergology, Gdańsk, Poland
| | - Mikaëla Odemyr
- EFA European Federation of Allergy and Airways Diseases Patients' Associations, Brussels, Belgium
| | - Robyn E O'Hehir
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, and Alfred Health, Melbourne, Victoria, Australia
| | - Yoshitaka Okamoto
- Dept of Otorhinolaryngology, Chiba University Hospital, Chiba, Japan
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg & Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis,, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology, School of Chemistry, Complutense University of Madrid, Madrid, Spain
| | - Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, Athens General Children's Hospital "P&A Kyriakou, University of Athens, Athens, Greece
| | - Petr Panzner
- Department of Immunology and Allergology, Faculty of Medicine and Faculty Hospital in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Gianni Passalacqua
- Allergy and Respiratory Diseases, Ospedale Policlino San Martino -University of Genoa, Genoa, Italy
| | - Vincenzo Patella
- Division of Allergy and Clinical Immunology, Department of Medicine, Agency of Health ASL Salerno, "Santa Maria della Speranza" Hospital, Battipaglia Salerno, Italy
| | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics, Section of Geriatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Nhân Pham-Thi
- Ecole polytechnique Palaiseau, IRBA (Institut de Recherche bio-Médicale des Armées), Bretigny, France
| | - Davor Plavec
- Children's Hospital Srebrnjak, Zagreb, School of Medicine, University J.J. Strossmayer, Osijek, Croatia
| | - Todor A Popov
- University Hospital 'Sv Ivan Rilski'", Sofia, Bulgaria
| | | | - Frederico S Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra and Institute of Immunology, Faculty of Medicine, University of Coimbra, and ICBR - Coimbra Institute for Clinical and Biomedical Research, CIBB, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Jacques Reynes
- Department of Infectiology, Montpellier University Hospital, France
| | | | - Yves Rolland
- Gérontopôle de Toulouse, INSERM 1027, Toulouse, France
| | - Antonino Romano
- Oasi Research Institute-IRCCS, Troina, Italy; bFondazione Mediterranea GB Morgagni, Catania, Italy
| | - Carmen Rondon
- Allergy Unit, Hospital Regional Universitario de Malaga, Malaga, & Allergy Research Group, Instituto de Investigación Biomedica de Malaga-IBIMA and ARADyAL, Malaga, Spain
| | - Menachem Rottem
- Division of Allergy Asthma and Clinical Immunology, Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Philip W Rouadi
- Department of Otolaryngology-Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
| | - Nathalie Salles
- Société Française de Gériatrie et Gérontologie, Paris, France
| | - Boleslaw Samolinski
- Department of Prevention of Environmental Hazards and Allergology, Medical University of Warsaw, Poland
| | - Alexandra F Santos
- Department of Women and Children's Health (Paediatric Allergy, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London and Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London,and Children's Allergy Service, Evelina London Children's Hospital Guy'sand St Thomas' Hospital, London, Asthma UK Centre for Allergic Mechanisms in Asthma, London, UK
| | - Faradiba Sarquis Serpa
- Asthma Reference Center - School of Medicine of Santa Casa de Misericórdia of Vitória, Espírito Santo, Brazil
| | - Joaquin Sastre
- Fundacion Jimenez Diaz, CIBERES, Faculty of Medicine, Autonoma University of Madrid, Spain
| | - Jos M G A Schols
- Department of Health Services Research and Department of Family Medicine Caphri - Care and Public Health Research Institute, Maastricht University, Maastrich, Netherlands
| | | | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Mohamed H Shamji
- Immunomodulation and Tolerance Group, Imperial College London, and Allergy and Clinical Immunology, Imperial College London, London, UK
| | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Isabel Skypala
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sylwia Smolinska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, & "ALL-MED" Medical Research Institute, Wroclaw, Poland
| | - Milena Sokolowska
- Christine Kühne - Center for Allergy Research and Education (CK-CARE, Davos, Switzerland
| | - Bernardo Sousa-Pinto
- CINTESIS, Center for Health Technology and Services Research, Faculdade de Medicina, Universidade do Porto, Porto, Portugal ; Allergy Unit, CUF Porto, Porto, Portugal.,MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences; Faculty of Medicine, University of Porto, Portugal
| | - Milan Sova
- Department of Respiratory Medicine, University Hospital Olomouc, Czech Republic
| | - Rafael Stelmach
- Pulmonary Division, Heart Institute (InCor), Hospital da Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gunter Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria Outpatient Allergy Clinic Reumannplatz, Vienna, Austria
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, and Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Ana Maria Todo-Bom
- Imunoalergologia, Centro Hospitalar Universitário de Coimbra and Faculty of Medicine, University of Coimbra, Portugal
| | - Sanna Toppila-Salmi
- Skin and Allergy Hospital, Helsinki University Hospital, and University of Helsinki University, Helsinki, Finland
| | - Ioanna Tsiligianni
- Health Planning Unit, Department of Social Medicine, Faculty of Medicine, University of Crete, Greece and International Primary Care Respiratory Group IPCRG, Aberdeen, Scotland
| | - Maria Torres
- Allergy Unit, Málaga Regional University Hospital-IBIMA, Málaga, Spain
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | | | - Arunas Valiulis
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine & Institute of Health Sciences, Vilnius, Lithuania; European Academy of Paediatrics (EAP/UEMS-SP), Brussels, Belgium
| | - Joana Vitte
- Aix-Marseille University, IRD, APHM, MEPHI, Marseille& IHU Méditerranée Infection, Marseille and IDESP, INSERM, University of Montpellier,, Montpellier, France
| | | | - Dana Wallace
- Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Diseases and Environmental Health, Nofer Institute of Occupational Medicine, Lodz, Poland
| | - De-Yun Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Susan Waserman
- Department of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Arzu Yorgancioglu
- Department of Pulmonary Diseases, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Osman M Yusuf
- The Allergy and Asthma Institute, Islamabad, Pakistan
| | - Mario Zernotti
- Universidad Católica de Córdoba, Universidad Nacional de Villa Maria, Villa Maria, Argentina
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Tomas Chivato
- School of Medicine, University CEU San Pablo, Madrid, Spain
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Torsten Zuberbier
- Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center, Department of Dermatology and Allergy, Berlin, Germany
| | - Ludger Klimek
- Department of Otolaryngology, Head and Neck Surgery, Universitätsmedizin Mainz, Mainz, and Center for Rhinology and Allergology, Wiesbaden, Germany
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14
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Zanotti R, Tanasi I, Bernardelli A, Orsolini G, Bonadonna P. Bone Marrow Mastocytosis: A Diagnostic Challenge. J Clin Med 2021; 10:1420. [PMID: 33915965 PMCID: PMC8037514 DOI: 10.3390/jcm10071420] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 12/12/2022] Open
Abstract
Bone marrow mastocytosis (BMM) represents a provisional, indolent subvariant of systemic mastocytosis (SM). Utilizing WHO criteria, BMM requires bone marrow (BM) involvement and the absence of mastocytosis skin lesions. BMM is characterized by male sex prevalence, a slight increase of serum tryptase levels, low BM mast cells (MC) burden, and an indolent clinical course. BMM shows a strong correlation with severe anaphylaxis, mainly due to an IgE-mediated allergy to bee or wasp venom and, less frequently, to unexplained (idiopathic) anaphylaxis. Furthermore, BMM is often associated with osteoporosis which could be the only presenting symptom of the disease. BMM is an undervalued disease as serum tryptase levels are not routinely measured in the presence of unexplained osteoporosis or anaphylaxis. Moreover, BMM patients are often symptom-free except for severe allergic reactions. These factors, along with typical low BM MCs infiltration, may contribute to physicians overlooking BMM diagnosis, especially in medical centers that lack appropriately sensitive diagnostic techniques. This review highlights the need for a correct diagnostic pathway to diagnose BMM in patients with suspected symptoms but lacking typical skin lesions, even in the case of normal serum tryptase levels. Early diagnosis may prevent potential life-threatening anaphylaxis or severe skeletal complications.
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Affiliation(s)
- Roberta Zanotti
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Ilaria Tanasi
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Andrea Bernardelli
- Hematology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (I.T.); (A.B.)
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
| | - Giovanni Orsolini
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Reumathology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
| | - Patrizia Bonadonna
- Gruppo Interdisciplinare per lo Studio della Mastocitosi (GISM), Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.O.); (P.B.)
- Allergy Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy
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15
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Lange M, Hartmann K, Carter MC, Siebenhaar F, Alvarez-Twose I, Torrado I, Brockow K, Renke J, Irga-Jaworska N, Plata-Nazar K, Ługowska-Umer H, Czarny J, Belloni Fortina A, Caroppo F, Nowicki RJ, Nedoszytko B, Niedoszytko M, Valent P. Molecular Background, Clinical Features and Management of Pediatric Mastocytosis: Status 2021. Int J Mol Sci 2021; 22:2586. [PMID: 33806685 PMCID: PMC7961542 DOI: 10.3390/ijms22052586] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 12/12/2022] Open
Abstract
Pediatric mastocytosis is a heterogeneous disease characterized by accumulation of mast cells in the skin and less frequently in other organs. Somatic or germline mutations in the KIT proto-oncogene are detected in most patients. Cutaneous mastocytosis is the most common form of the disease in children. In the majority of cases, skin lesions regress spontaneously around puberty. However, in few patients, mastocytosis is not a self-limiting disease, but persists into adulthood and can show signs of systemic involvement, especially when skin lesions are small-sized and monomorphic. Children with mastocytosis often suffer from mast cell mediator-related symptoms. Severe hypersensitivity reactions can also occur, mostly in patients with extensive skin lesions and blistering. In a substantial number of these cases, the triggering factor of anaphylaxis remains unidentified. Management of pediatric mastocytosis is mainly based on strict avoidance of triggers, treatment with H1 and H2 histamine receptor blockers, and equipment of patients and their families with epinephrine auto-injectors for use in severe anaphylactic reactions. Advanced systemic mastocytosis occurs occasionally. All children with mastocytosis require follow-up examinations. A bone marrow investigation is performed when advanced systemic mastocytosis is suspected and has an impact on therapy or when cutaneous disease persists into adulthood.
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Affiliation(s)
- Magdalena Lange
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, 4031 Basel, Switzerland;
- Department of Biomedicine, University Hospital Basel and University of Basel, 4031 Basel, Switzerland
| | - Melody C. Carter
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Frank Siebenhaar
- Dermatological Allergology, Department of Dermatology and Allergy, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany;
| | - Ivan Alvarez-Twose
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)—Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle—Complejo Hospitalario de Toledo, 45071 Toledo, Spain; (I.A.-T.); (I.T.)
| | - Inés Torrado
- Instituto de Estudios de Mastocitosis de Castilla-La Mancha (CLMast)—Spanish Reference Center for Mastocytosis, Hospital Virgen del Valle—Complejo Hospitalario de Toledo, 45071 Toledo, Spain; (I.A.-T.); (I.T.)
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, 80802 Munich, Germany;
| | - Joanna Renke
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (J.R.); (N.I.-J.)
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (J.R.); (N.I.-J.)
| | - Katarzyna Plata-Nazar
- Department of Pediatrics, Pediatric Gastroenterology, Allergology and Nutrition, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Hanna Ługowska-Umer
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Justyna Czarny
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy; (A.B.F.); (F.C.)
| | - Francesca Caroppo
- Pediatric Dermatology Unit, Department of Medicine DIMED, University of Padua, 35128 Padua, Italy; (A.B.F.); (F.C.)
| | - Roman J. Nowicki
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Bogusław Nedoszytko
- Department of Dermatology, Venereology and Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland; (H.Ł.-U.); (J.C.); (R.J.N.); (B.N.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Peter Valent
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
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16
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Schoeben LS, Mohr N, Bubak C, Schmieder A, Schaarschmidt ML. Effects of a 90-min educational intervention for patients with insect venom allergy: a prospective controlled pilot study. Allergy Asthma Clin Immunol 2021; 17:22. [PMID: 33632327 PMCID: PMC7905619 DOI: 10.1186/s13223-021-00524-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/08/2021] [Indexed: 11/22/2022] Open
Abstract
Background Anaphylactic sting reactions need a prompt management. A structured educational intervention for patients with insect sting allergy has not been implemented so far. The purpose of this study was to analyze the effects of a structured 90-min educational intervention for patients with insect sting allergy. Methods Patients with an insect venom allergy were offered to participate in a structured 90-min group education (intervention group (IG)) or to attend a control group (CG). The patients’ subjective self-assurance in using the emergency medication, the willingness to always carry the emergency medication, the mental health status, absolute one-time willingness-to-pay (WTP) for complete cure, a disease knowledge assessment and a simulation test to examine the ability to manage an acute sting reaction were estimated at baseline (t0) and at follow-up (t1) as outcome parameters. Results 55 patients participated in the IG (n = 25, 52.0% female, mean age 55.9 years) or the CG (n = 30, 56.7% female, mean age 52.0 years). Both arms showed a significant gain in self-assurance in using the emergency medication (IG: 6.1 at t0 vs. 8.6 at t1, p < 0.0001 and CG: 7.1 vs. 8.0, p = 0.0062) and ability to manage an acute sting reaction (IG: 6.7 vs. 11.4, p < 0.0001 and CG: 9.0 vs. 10.5, p = 0.0002) at t1. However, trained participants showed a significantly higher gain in the respective parameters. There were no significant changes regarding the remaining examined outcome parameters. Conclusions Patients who are willing to invest 90 min in a patient education intervention benefit significantly by an increased subjective and objective empowerment to manage an acute sting reaction.
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Affiliation(s)
- Lisa-Sophie Schoeben
- Department of Dermatology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - Nicole Mohr
- Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bubak
- Department of Dermatology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - Astrid Schmieder
- Department of Dermatology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - Marthe-Lisa Schaarschmidt
- Department of Dermatology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Heller A, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Leitlinie zu Akuttherapie und Management der Anaphylaxie - Update 2021. ALLERGO JOURNAL 2021; 30:20-49. [PMID: 33612982 PMCID: PMC7878028 DOI: 10.1007/s15007-020-4750-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Johannes Ring
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Kirsten Beyer
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie, Biedersteiner Str. 29, 80802 München, Germany
| | - Andreas Bircher
- Universitätskliniken Basel, Petersgraben 4, 4031 Basel, Schweiz
| | - Matthias Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und, ALB FILS Kliniken Göppingen,, Göppingen, Germany
| | - Axel Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Isidor Huttegger
- Klinik für Pädiatrie, Universitätsklinikum Salzburg, Salzburg, Österreich
| | - Thilo Jakob
- Klinik für Dermatologie, Venerologie und Allergologie, Gaffkystraße 14, 35392 Gießen, Germany
| | - Ludger Klimek
- Zentrum f. Rhinologie und Allergologie, An den Quellen 10, 65183 Wiesbaden, Germany
| | | | - Claudia Kugler
- TU München, Biedersteiner Straße 29, 80802 München, Germany
| | - Lars Lange
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Oliver Pfaar
- Sektion für Rhinologie und Allergologie, Baldingerstraße, 35043 Marburg, Germany
| | - Ernst Rietschel
- Pädiatrische Pneumologie u. Allergologie, Klinikum der Univ. Köln, Kerpener Str. 62, 50924 Köln, Germany
| | - Franziska Rueff
- Dermatologische Klinik u. Poliklinik der LMU, Frauenlobstr. 9-11, 80337 München, Germany
| | - Sabine Schnadt
- Deutscher Allergie- und Asthmabund (DAAB), An der Eickesmühle 15 - 19, 41238 Mönchengladbach, Germany
| | - Roland Seifert
- Institut für Pharmakologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Britta Stöcker
- Kinderpneumologie u. Allergologie, Robert-Koch-Str. 1, 53115 Bonn, China
| | - Regina Treudler
- Universitätsklinikum Leipzig, Philipp-Rosenthal-Str. 23, 4103 Leipzig, Germany
| | | | - Thomas Werfel
- Klinik für Dermatologie, Allergologie und Venerologie, Carl-Neuberg-Str. 1, 30449 Hannover, Germany
| | - Margitta Worm
- Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Helmut Sitter
- Klinik für Dermatologie und Allergologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Knut Brockow
- Klinik f. Dermatologie und Allergologie am Biederstein, Biedersteiner Str. 29, 80802 München, Germany
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller A, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). ALLERGO JOURNAL INTERNATIONAL 2021; 30:1-25. [PMID: 33527068 PMCID: PMC7841027 DOI: 10.1007/s40629-020-00158-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Johannes Ring
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Andreas Bircher
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Matthias Fischer
- Clinic for Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, University Hospital Göttingen, Göttingen, Germany
| | - Axel Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Dr. von Hauner Children’s Hospital, Ludwig Maximilians University, Munich, Germany
| | - Isidor Huttegger
- Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Kugler
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | | | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Ernst Rietschel
- Department of Pediatrics, University Hospital Cologne, Cologne, Germany
| | - Franziska Rueff
- Department of Dermatology and Allergology, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Britta Stöcker
- Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital Leipzig, Leipzig, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thomas Werfel
- Immunodermatology and Experimental Allergology Unit, Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Berlin, Germany
| | - Helmut Sitter
- Institute for Surgical Research, Philipps-University Marburg, Marburg, Germany
| | - Knut Brockow
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
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Benefits and limitations of sting challenge in hymenoptera venom allergy. Allergol Select 2021; 5:45-50. [PMID: 33490858 PMCID: PMC7814776 DOI: 10.5414/alx02148e] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 01/13/2021] [Indexed: 11/29/2022] Open
Abstract
The prevalence of systemic reactions to hymenoptera stings is up to 7.5%. Venom-specific immunotherapy (VIT) is an established treatment for insect venom allergy. In order to monitor the allergic status and thus the success of the therapy, controlled sting challenge under VIT continues to be the gold standard. This review deals not only with useful indications and therapeutic consequences but also with critical aspects that should be considered when performing sting challenge.
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20
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Blank S, Grosch J, Ollert M, Bilò MB. Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes. Front Immunol 2020; 11:579409. [PMID: 33193378 PMCID: PMC7643016 DOI: 10.3389/fimmu.2020.579409] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.
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Affiliation(s)
- Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Johannes Grosch
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
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21
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Abstract
PURPOSE OF REVIEW Information on the natural history of hypersensitivity reactions is helpful for deciding which patient urgently needs a venom immunotherapy (VIT). RECENT FINDINGS The frequency of self-reported systemic allergic reactions (SAR) to Hymenoptera stings is approximately 3-7% in the Northern Hemisphere. About 25% of SAR are severe (anaphylactic shock). Fatal sting reactions are very rare. The most important risk factor for severe insect sting anaphylaxis is mast cell disease. Other risk factors are higher age, vespid venom allergy (in contrast to honeybee venom allergy), repeated stings, male sex, and treatment with ACE inhibitors. Preceding large local reactions seem not to play a risk factor for subsequent SAR. SUMMARY The majority of risk factors for severe anaphylaxis are not modifiable. For patients presenting with well defined risk factors for a very severe or even fatal anaphylaxis, VIT is of utmost importance, and they should be performed for the rest of their life. Sting challenge tests are required to identify patients in whom treatment was ineffective. Those patients, who did not receive VIT although presenting with a firm indication, or in whom VIT was stopped, require yearly monitoring to teach preventive measures and to renew the emergency kit.
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22
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Honeybee Stings in the Era of Killer Bees: Anaphylaxis and Toxic Envenomation. Am J Med 2020; 133:621-626. [PMID: 31715166 DOI: 10.1016/j.amjmed.2019.10.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Twenty-six years after the arrival of "killer bees" in Arizona, the entire state with the exception of high elevations in the north is populated with this bee variety and 11 people have died at the scene of massive bee attacks. METHODS Because of the aggressive behavior of these bees we studied bee stings reported to the Arizona Poison and Drug Information Center. The center received 399 calls regarding 312 victims of bee stings from January 2017 to June 2019. Calls originated from private residences and emergency centers. RESULTS Stings occurred at victims' home residences in 272 (84.7%) of cases and 24 (7.5%) in public areas; 251 people suffered 1 sting; 42 individuals, 2-10 stings, 4 had 11-49 stings, and 13 individuals had >50 stings (so-called massive stinging). Three individuals were admitted to intensive care units (ICU) and one 35-year-old man died of anaphylaxis after 1 sting; moderate clinical effects occurred in 32 individuals including 6 admitted to the hospital but not in the intensive care unit. Anaphylaxis occurred in 30 (9.6%) of individuals, 16 receiving 1 sting. Toxic effects, tachycardia, elevated creatinine, or rhabdomyolysis occurred in 13 (4.2%) individuals. CONCLUSIONS In the past, individuals stung more than 50 times were beekeepers working with European honeybees, whereas, in the current era, single as well as massive stings are the result of feral "killer bees." This change in epidemiology requires a new approach to sting victims: those with massive stinging should be evaluated and observed for anaphylaxis and serial laboratory values obtained for days to detect the toxic effects of envenomation.
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23
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Venom immunotherapy in patients with mastocytosis. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-2514-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bilò MB, Corsi A, Pravettoni V, Bignardi D, Bonadonna P, Quercia O, Mauro M, Novembre E, Micheletti R, Papa R. Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators. Clin Transl Allergy 2020; 10:8. [PMID: 32158533 PMCID: PMC7055031 DOI: 10.1186/s13601-020-00312-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/24/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Hymenoptera venom allergy (HVA) is an underestimated condition representing an important cause of morbidity and mortality worldwide. Preventing future allergic reactions in patients who have already developed a systemic reaction is based on the correct management of the acute phase of the reaction followed by a correct diagnosis and, where indicated, prescription of adrenaline autoinjectors and VIT. A possible strategy to optimize care processes and to improve outcomes is the implementation of a Diagnostic and Therapeutic Care Pathways, also known as Integrated Care Pathways or Clinical Pathways (CPWs). The aim of the care pathway is to enhance the quality of care by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To our knowledge, currently in Italy as well as in Europe, there is no CPWs codified for the management of HVA patients. This paper describes the development of the clinical content of a care pathway for the management of HVA. METHODS The methodology applied is based on the eight step method to build the clinical content of an evidence-based care pathway suggested by Lodewijckx et al. RESULTS Three hundred and seventeen different clinical activities were extracted from the selected literature. The expert panel was involved in their evaluation, expressing a judgment of relevance through the Delphi study. As a result, 126 clinical activities were appraised to be valid and feasible. The final recommendations (126) were translated into 123 key interventions. Six indicators were produced by the clinical activities. CONCLUSION A set of 123 key interventions and of six process indicators were found to be appropriate for the development and standardization of the clinical content of the Hymenoptera venom allergy care pathway.
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Affiliation(s)
- Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
- Department of Internal Medicine, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy
| | - Alice Corsi
- Postgraduate School of Allergy and Clinical Immunology, Università Politecnica delle Marche, Ancona, Italy
| | - Valerio Pravettoni
- U.O.C. General Medicine-Immunology and Allergology, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Patrizia Bonadonna
- U.S.D. Allergology Integrated University-Hospital of Verona, Verona, Italy
| | - Oliviero Quercia
- High Specialization Unit of Allergology, Hospital of Faenza, AUSL (Local Health Unit) of Romagna, Romagna, Italy
| | | | - Elio Novembre
- Complex Organizational Unit of Allergology, University-Hospital A. Meyer, Florence, Italy
| | - Rebecca Micheletti
- Postgraduate School of Hygiene and Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberto Papa
- S.O. Hospital Medical Management, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy
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Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JN, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy 2020; 75:535-545. [PMID: 31194889 DOI: 10.1111/all.13945] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/16/2019] [Accepted: 06/07/2019] [Indexed: 01/06/2023]
Abstract
Hymenoptera venom allergy ranks among the top three causes of anaphylaxis worldwide, and approximately one-quarter of sting-induced reactions are classified as severe. Fatal sting reactions are exceedingly rare, but certain factors may entail a considerably higher risk. Delayed administration of epinephrine and upright posture are situational risk factors which may determine an unfavorable outcome of the acute anaphylactic episode and should be addressed during individual patient education. Systemic mastocytosis and senior age are major, unmodifiable long-term risk factors and thus reinforce the indication for venom immunotherapy. Vespid venom allergy and male sex likewise augment the risk of severe or even fatal reactions. Further studies are required to assess the impact of specific cardiovascular comorbidities. Available data regarding potential effects of beta-blockers and/or ACE inhibitors in coexisting venom allergy are inconclusive and do not justify recommendations to discontinue guideline-directed antihypertensive treatment. The absence of urticaria/angioedema during sting-induced anaphylaxis is indicative of a severe reaction, serum tryptase elevation, and mast cell clonality. Determination of basal serum tryptase levels is an established diagnostic tool for risk assessment in Hymenoptera venom-allergic patients. Measurement of platelet-activating factor acetylhydrolase activity represents a complementary approach but is not available for routine diagnostic use.
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Affiliation(s)
- Johanna Stoevesandt
- Department of Dermatology, Venereology and Allergy & Allergy Center Mainfranken University Hospital Würzburg Würzburg Germany
| | - Gunter J. Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplatz Vienna Austria
| | - Patrizia Bonadonna
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic Azienda Ospedaliera Universitaria Integrata of Verona Verona Italy
| | - Joanna N.G. Oude Elberink
- Department of Allergology & GRIAC Research Institute University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Axel Trautmann
- Department of Dermatology, Venereology and Allergy & Allergy Center Mainfranken University Hospital Würzburg Würzburg Germany
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Venom immunotherapy in Europe and the United States. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-0747-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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27
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Bilò MB, Martini M, Pravettoni V, Bignardi D, Bonadonna P, Cortellini G, Kosinska M, Macchia D, Mauro M, Meucci E, Nittner‐Marszalska M, Patella V, Pio R, Quercia O, Reccardini F, Ridolo E, Rudenko M, Severino M. Large local reactions to Hymenoptera stings: Outcome of re-stings in real life. Allergy 2019; 74:1969-1976. [PMID: 31074868 DOI: 10.1111/all.13863] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Large local reaction to Hymenoptera stings is usually defined as a swelling >10 cm which lasts longer than 24 hours, sometimes associated with erythema, pruritus and blisters. Currently, the risk of subsequent systemic reactions after re-stings is considered low (2%-15%). Therefore, a diagnostic workup in case of large local reaction is often judged unnecessary, as well as adrenaline auto-injector and venom immunotherapy prescription. The aim of this study was to prospectively evaluate the outcome of re-stings in a real-world setting, in patients with a history of one previous large local reaction. METHODS We consecutively enrolled patients who experienced their first large local reaction (as per EAACI definition), treated with antihistamine and steroids. They were followed for field re-stings and assessed for risk of subsequent systemic reactions. RESULTS We enrolled 662 patients. Out of the 225 re-stung subjects, 24% did not experience reactions, 52% reported a second large local reaction and 24% had systemic reactions. The risk of subsequent systemic reactions was higher in case of skin test reactivity to Apis mellifera or Vespula species (OR 2.1 and 3.8, respectively), in particular if positive at 0.001 µg/mL concentration (OR 13.4 and 16.5, respectively). CONCLUSIONS Systemic reactions, after a previous large local reaction, occur more frequently than that reported by literature. After analysing the predictive role of large local reactions for systemic reactions, we demonstrated that an accurate diagnostic workup may be considered, particularly skin tests. Further studies in different countries are needed to confirm these results and large local reaction management.
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Affiliation(s)
- Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences Università Politecnica delle Marche Ancona Italy
| | - Matteo Martini
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Valerio Pravettoni
- General Medicine, Immunology and Allergy Unit ‐ IRCCS Foudation Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | | | - Patrizia Bonadonna
- U.S.D. Allergology Integrated University‐Hospital of Verona Verona Italy
| | - Gabriele Cortellini
- Allergy Unit, Internal Medicine Department, Rimini Hospital Local Health Unit of Romagna Rimini Italy
| | - Magdalena Kosinska
- Department of Internal Diseases and Allergology Medical University of Wroclaw Wroclaw Poland
| | | | - Marina Mauro
- UOS Allergology ASST Lariana Sant'Anna Hospital Como Italy
| | - Elisa Meucci
- Allergy Unit, Hospital S. Giovanni di Dio Florence Italy
| | | | - Vincenzo Patella
- Division Allergy and Clinical Immunology, Department of Medicine ASL Salerno "Santa Maria della Speranza" Hospital Salerno Italy
| | - Roberta Pio
- A.O.U San Giovanni di Dio e Ruggi d'Aragona Salerno Italy
| | - Oliviero Quercia
- High Specialization Unit of Allergology, Hospital of Faenza AUSL (Local Health Unit) of Romagna Faenza Italy
| | - Federico Reccardini
- SOC Pneumologia‐Fisiopatologia Respiratoria, Azienda Sanitaria Universitaria Integrata di Udine Udine Italy
| | - Erminia Ridolo
- Allergologia e Immunologia Clinica, Dipartimento di Medicina e Chirurgia Università degli studi di Parma Parma Italy
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29
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Sahiner UM, Durham SR. Hymenoptera Venom Allergy: How Does Venom Immunotherapy Prevent Anaphylaxis From Bee and Wasp Stings? Front Immunol 2019; 10:1959. [PMID: 31497015 PMCID: PMC6712168 DOI: 10.3389/fimmu.2019.01959] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Hymenoptera stings may cause both local and systemic allergic reactions and even life threatening anaphylaxis. Along with pharmaceutical drugs and foods, hymenoptera venom is one of the most common causes of anaphylaxis in humans. To date, no parameter has been identified that may predict which sensitized people will have a future systemic sting reaction (SSR), however some risk factors, such as mastocytosis and age >40 years are known. Venom immunotherapy (VIT) is the most effective method of treatment for people who had SSR, which is shown to be effective even after discontinuation of the therapy. Development of peripheral tolerance is the main mechanism during immunotherapy. It is mediated by the production of blocking IgG/IgG4 antibodies that may inhibit IgE dependent reactions through both high affinity (FcεRI) and low affinity (FcεRII) IgE receptors on mast cells, basophils and B cells. The generation of antigen specific regulatory T cells produces IL-10 and suppresses Th2 immunity and the immune responses shift toward a Th1-type response. B regulatory cells are also involved in the production of IL-10 and the development of long term immune tolerance. During VIT the number of effector cells in target organs also decreases, such as mast cells, basophils, innate type 2 lymphocytes and eosinophils. Several meta-analyses and randomized controlled studies have proved that VIT is effective for preventing SSR to a sting and improves the quality of life. In this review, the risk of SSR in venom allergy and how VIT changed this risk are discussed.
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Affiliation(s)
- Umit Murat Sahiner
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Pediatric Allergy Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
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Cichocka-Jarosz E, Stobiecki M, Nittner-Marszalska M, Jedynak-Wąsowicz U, Brzyski P. Venom allergy treatment practices in Poland in comparison to guidelines: next edition of the national audit. Postepy Dermatol Alergol 2019; 36:346-353. [PMID: 31333352 PMCID: PMC6640023 DOI: 10.5114/ada.2019.85642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/01/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Venom immunotherapy treatment (VIT) is the only causal treatment of hymenoptera venom anaphylaxis, which aims to provide long-lasting immunoprotection against severe reactions to subsequent stings. AIM To reassess the compliance of VIT procedures in the Polish allergy centres with the European guidelines. MATERIAL AND METHODS A structured questionnaire survey conducted in all 33 VIT-centres. The response rate was 94%. RESULTS The ultrarush initial protocol was the most common protocol (71%, n = 22), usually lasting for 3.5 h (50%, n = 7). The most frequent (36%, n = 11) time interval from the initial to the first maintenance dose (MD) was 14 days, ranging from 7 to 35 days. All centres used an MD of 100 μg. The most frequent time interval between subsequent MDs was 4 weeks (58%, n = 18). Five years' of VIT was declared by 71% (n = 22). Before the termination of treatment, more than half of the centres (58%, n = 18) performed sIgE and almost half (42%, n = 13) performed skin tests. To confirm VIT efficacy, few centres (26%, n = 8) conducted the sting challenge. About half of centres provided the patients with an adrenalin auto-injector both at the time of initial diagnostics and at the end of treatment. More than half (55%, n = 17) used antihistamines in all patients. Almost half (45%, n = 14) declared to stop treatment with β-blockers and almost one fourth (23%, n = 7) discontinued angiotensin-converting-enzyme inhibitors. CONCLUSIONS In the most important procedures, there is a very high compliance with the guidelines. In the areas where the guidelines are not precise, we observed a large spread of results.
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Affiliation(s)
- Ewa Cichocka-Jarosz
- Department of Paediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
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Helbling A, Müller UR. Allergic Reactions to Stinging and Biting Insects. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Adib-Tezer H, Bayerl C. Honeybee and wasp venom allergy: Sensitization and immunotherapy. J Dtsch Dermatol Ges 2018; 16:1228-1247. [PMID: 30300499 DOI: 10.1111/ddg.13670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/06/2018] [Indexed: 11/28/2022]
Abstract
Hymenoptera venom allergy is the most common cause of anaphylactic reactions in adults. In children, it is the second most common cause after food-related anaphylaxis. Such reactions are primarily due to stings by honeybees (Apis) and certain social wasps (Vespula vulgaris and Vespula germanica in particular). Especially in adults, stings are frequently associated with severe anaphylaxis. Established diagnostic methods including molecular tests allow for greater success rates in terms of determining the insect actually responsible for triggering the anaphylactic reaction. Sensitization to both venoms, or a history of systemic sting reaction without any evidence of sensitization, complicate the decision regarding treatment. Venom immunotherapy (VIT) is a safe and effective causal treatment.
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Affiliation(s)
- Hanan Adib-Tezer
- Department of Dermatology and Allergology, Skin Cancer Center Wiesbaden, Helios Dr. Horst Schmidt Clinics, Wiesbaden, Germany
| | - Christiane Bayerl
- Department of Dermatology and Allergology, Skin Cancer Center Wiesbaden, Helios Dr. Horst Schmidt Clinics, Wiesbaden, Germany
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Adib-Tezer H, Bayerl C. Bienen- und Wespengiftallergie: Sensibilisierung und spezifische Immuntherapie. J Dtsch Dermatol Ges 2018; 16:1228-1248. [DOI: 10.1111/ddg.13670_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Hanan Adib-Tezer
- Klinik für Dermatologie und Allergologie; Hauttumorzentrum Wiesbaden; Helios Dr. Horst-Schmidt-Kliniken Wiesbaden
| | - Christiane Bayerl
- Klinik für Dermatologie und Allergologie; Hauttumorzentrum Wiesbaden; Helios Dr. Horst-Schmidt-Kliniken Wiesbaden
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Bonadonna P, Scaffidi L. Hymenoptera Anaphylaxis as a Clonal Mast Cell Disorder. Immunol Allergy Clin North Am 2018; 38:455-468. [DOI: 10.1016/j.iac.2018.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Oberhofer E. [Not Available]. MMW Fortschr Med 2018; 160:14. [PMID: 29754365 DOI: 10.1007/s15006-018-0508-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, Antolín-Amérigo D, Cichocka-Jarosz E, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Ollert M, Oude Elberink JNG, Pfaar O, Pitsios C, Pravettoni V, Ruëff F, Sin BA, Agache I, Angier E, Arasi S, Calderón MA, Fernandez-Rivas M, Halken S, Jutel M, Lau S, Pajno GB, van Ree R, Ryan D, Spranger O, van Wijk RG, Dhami S, Zaman H, Sheikh A, Muraro A. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy 2018; 73:744-764. [PMID: 28748641 DOI: 10.1111/all.13262] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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Grabenhenrich LB, Dölle S, Ruëff F, Renaudin JM, Scherer K, Pföhler C, Treudler R, Koehli A, Mahler V, Spindler T, Lange L, Bilò MB, Papadopoulos NG, Hourihane JOB, Lang R, Fernández-Rivas M, Christoff G, Cichocka-Jarosz E, Worm M. Epinephrine in Severe Allergic Reactions: The European Anaphylaxis Register. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1898-1906.e1. [PMID: 29606638 DOI: 10.1016/j.jaip.2018.02.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/19/2018] [Accepted: 02/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Current guidelines recommend intramuscular administration of epinephrine as the first-line drug for the emergency treatment of severe allergic reactions (anaphylaxis), but no randomized trial evidence supports this consensus. OBJECTIVE We aimed to assess anaphylaxis treatment practices over 10 years, covering several European regions, all allergen sources, and all age groups. METHODS The European Anaphylaxis Register tracks elicitors, symptoms, emergency treatment, diagnostic workups, and long-term counseling for anaphylaxis incidents through web-based data entry from tertiary allergy specialists, covering information from the emergency respondent, patient, tertiary referral, and laboratory/clinical test results. RESULTS We analyzed 10,184 anaphylaxis incidents. In total, 27.1% of patients treated by a health professional received epinephrine and, in total, 10.5% received a second dose. Successful administration was less frequent in German-speaking countries (minimum 19.6%) than in Greece, France, and Spain (maximum 66.7%). Over the last decade, epinephrine administration from a health professional almost doubled to reach 30.6% in 2015-2017, half of which was applied intramuscularly. A total of 14.7% of lay- or self-treated cases were treated with an autoinjector. Of those without treatment, 22.4% carried a device for administration. No change in successful administration by lay emergency respondents was found over the last 10 years. Of the reaction and patient characteristics analyzed, only clinical severity considerably influenced the likelihood of receiving epinephrine, with 66.9% of successful administrations in near-fatal (grade IV) reactions. CONCLUSIONS Despite clear recommendations, only a small proportion of anaphylaxis incidents are treated with epinephrine. We demonstrated a slight increase in treated patients when handled by professionals, but stagnation in lay- or self-treated anaphylaxis. The reaction circumstances, the respondent's professional background, and patient characteristics did not explain which reactions were treated.
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Affiliation(s)
- Linus B Grabenhenrich
- Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany
| | - Sabine Dölle
- Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany
| | - Franziska Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilian Universität München, Munich, Germany
| | | | - Kathrin Scherer
- Department of Dermatology, Universitätsspital Basel, Basel, Switzerland
| | - Claudia Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, Universitätsmedizin Leipzig, Leipzig, Germany
| | - Alice Koehli
- Division of Allergology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Vera Mahler
- Division of Allergology, Paul-Ehrlich-Institut, Langen, Germany
| | - Thomas Spindler
- Klinik für Pädiatrische Pneumologie und Allergologie, Lungenzentrum Süd-West, Wangen im Allgäu, Germany
| | - Lars Lange
- Department of Pediatrics, St. Marien-Hospital, Bonn, Germany
| | - Maria Beatrice Bilò
- Department of Internal Medicine/Allergy Unit, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Nikolaos G Papadopoulos
- 2nd Pediatric Clinic, Allergy Department, University of Athens, Athens, Greece; Division of Infection, Immunity and Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | | | - Roland Lang
- Universitätsklinik für Dermatologie SALK, Paracelsus medizinische Privatuniversität Salzburg, Salzburg, Austria
| | | | - George Christoff
- Allergy Outpatient Clinic, Tokuda Medical Centre Sofia, Sofia, Bulgaria
| | - Ewa Cichocka-Jarosz
- Department of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Margitta Worm
- Department of Infectious Disease Epidemiology, Robert Koch-Institut, Berlin, Germany.
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Abstract
Introductions The efficiency of venom immunotherapy (VIT) has been well documented by many studies. However, the most important for VIT is safety, particularly for a pregnant woman and a fetus. Aim To establish the influence of continuation of VIT on pregnant women and offspring. Material and methods The 6 women became pregnant during a specific immunotherapy. We retrospectively analyzed the influence of the immunotherapy on any complications for the pregnant women and their infants. Results Of the 6 patients who participated in this study, four had hyperemesis gravidarum, nausea, and heartburn, and two of them had gestational diabetes mellitus symptoms, typical of pregnancy. The observation indicated that VIT was safe for the pregnant women and their offspring. Conclusions The VIT is an appropriate therapeutic method for most patients with severe anaphylactic reactions after a hymenoptera sting. The observation indicated that VIT is safe for pregnant women and for their infants.
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Anaphylaxis in the Workplace. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Aktuelle Entwicklungen rund um die Anaphylaxie. ALLERGO JOURNAL 2017. [DOI: 10.1007/s15007-017-1496-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Worm M, Sturm G, Kleine-Tebbe J, Cichocka-Jarosz E, Cardona V, Maris I, Dölle S. New trends in anaphylaxis. ALLERGO JOURNAL INTERNATIONAL 2017; 26:295-300. [PMID: 29214141 PMCID: PMC5705757 DOI: 10.1007/s40629-017-0042-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/26/2017] [Indexed: 11/04/2022]
Abstract
This review presents the current trends in anaphylaxis management discussed at the fourth International Network for Online-Registration of Anaphylaxis (NORA) conference held in Berlin in April 2017. Current data from the anaphylaxis registry show that Hymenoptera venom, foods, and pharmaceutical drugs are still among the most frequent triggers of anaphylaxis. Rare triggers include chicory, cardamom, asparagus, and goji berries. A meta-analysis on recent trends in insect venom anaphylaxis demonstrated for the first time that, although data on the efficacy of insect venom immunotherapy is limited, the occurrence of severe reactions upon repeated sting events can be prevented and patients' quality of life improved. Molecular diagnostics of insect venom anaphylaxis have significantly improved diagnostic sensitivity and specificity. Self-treatment of anaphylaxis is of great importance. Recent data from the anaphylaxis registry show an increase (from 23% in 2012 to 29% in 2016) in the use of adrenaline as recommended in the guidelines. A survey on the implementation of guidelines conducted among the centers reporting to the anaphylaxis registry highlights the extent to which the guideline has been perceived and implemented. Reports on a variety of cases in the anaphylaxis registry illustrate the diversity of this potentially life-threatening reaction. Component-resolved diagnostics can help to specify sensitization profiles in anaphylaxis, particularly in terms of the risk for severe reactions. Recent studies on anaphylaxis awareness show that training methods are effective; nevertheless, target groups and learning methods need to undergo further scientific investigation in coming years.
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Affiliation(s)
- Margitta Worm
- Department of Dermatology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gunter Sturm
- University Department of Dermatology and Venereology, Medical University Graz, Graz, Austria
| | - Jörg Kleine-Tebbe
- Hanf, Ackermann and Kleine-Tebbe Allergy Practice, Allergy and Asthma Center Westend, Berlin, Germany
| | - Ewa Cichocka-Jarosz
- Department of Pediatrics, Pulmonology, Allergology, and Dermatology Division, Institute of Pediatrics, Jagiellonian University Medical College, Krakau, Poland
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Ioana Maris
- Department of Paediatrics and ChildHealth, University College Cork, Cork, Ireland
| | - Sabine Dölle
- Department of Dermatology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Klimek L, Dippold N, Sperl A. [Insect venom allergies : Update 2016 for otorhinolaryngologists]. HNO 2017; 64:927-942. [PMID: 27787580 DOI: 10.1007/s00106-016-0274-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Due to the increasing incidence of hymenoptera venom allergies and the potentially life-threatening reactions, it is important for otolaryngologists working in allergology to have an understanding of modern diagnostic and treatment standards for this allergic disease. Molecular diagnosis with recombinant single allergens from bee and wasp venom components improves the diagnostics of insect venom allergies, particularly in patients with double-positive extract-based test results. Detection of specific sensitizations to bee or wasp venom enables double sensitizations to be better distinguished from cross-reactivity. Based on patient history and test results, the patient is initially advised on avoidance strategies and prescribed an emergency medication kit. Then, the indication for allergen-specific immunotherapy (AIT) is evaluated. The dose-increase phase can be performed using conventional, cluster, rush, or ultra-rush schedules, whereby rapid desensitization (rush AIT) performed in the clinic seems to be particularly effective as initial treatment.
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Affiliation(s)
- L Klimek
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, 65183, Wiesbaden, Deutschland. .,Universitäts-HNO-Klinik Mannheim, Mannheim, Deutschland.
| | - N Dippold
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, 65183, Wiesbaden, Deutschland
| | - A Sperl
- Zentrum für Rhinologie und Allergologie, An den Quellen 10, 65183, Wiesbaden, Deutschland
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Dhami S, Zaman H, Varga EM, Sturm GJ, Muraro A, Akdis CA, Antolín-Amérigo D, Bilò MB, Bokanovic D, Calderon MA, Cichocka-Jarosz E, Oude Elberink JNG, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Mosbech H, Ollert M, Pfaar O, Pitsios C, Pravettoni V, Roberts G, Ruëff F, Sin BA, Asaria M, Netuveli G, Sheikh A. Allergen immunotherapy for insect venom allergy: a systematic review and meta-analysis. Allergy 2017; 72:342-365. [PMID: 28120424 DOI: 10.1111/all.13077] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines on Allergen Immunotherapy (AIT) for the management of insect venom allergy. To inform this process, we sought to assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy. METHODS We undertook a systematic review, which involved searching 15 international biomedical databases for published and unpublished evidence. Studies were independently screened and critically appraised using established instruments. Data were descriptively summarized and, where possible, meta-analysed. RESULTS Our searches identified a total of 16 950 potentially eligible studies; of which, 17 satisfied our inclusion criteria. The available evidence was limited both in volume and in quality, but suggested that venom immunotherapy (VIT) could substantially reduce the risk of subsequent severe systemic sting reactions (OR = 0.08, 95% CI 0.03-0.26); meta-analysis showed that it also improved disease-specific quality of life (risk difference = 1.41, 95% CI 1.04-1.79). Adverse effects were experienced in both the build-up and maintenance phases, but most were mild with no fatalities being reported. The very limited evidence found on modelling cost-effectiveness suggested that VIT was likely to be cost-effective in those at high risk of repeated systemic sting reactions and/or impaired quality of life. CONCLUSIONS The limited available evidence suggested that VIT is effective in reducing severe subsequent systemic sting reactions and in improving disease-specific quality of life. VIT proved to be safe and no fatalities were recorded in the studies included in this review. The cost-effectiveness of VIT needs to be established.
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Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - H. Zaman
- School of Pharmacy; University of Bradford; Bradford UK
| | - E.-M. Varga
- Department of Pediatric and Adolescent Medicine; Respiratory and Allergic Disease Division; Medical University of Graz; Graz Austria
| | - G. J. Sturm
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
- Outpatient Allergy Clinic Reumannplatz; Vienna Austria
| | - A. Muraro
- Department of Women and Child Health; Food Allergy Referral Centre Veneto Region; Padua General University Hospital; Padua Italy
| | - C. A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); Switzerland Servicio de Enfermedades del Sistema Inmune-Alergia; University of Zurich; Zurich Switzerland
- Departamento de Medicina y Especialidades Médicas; Hospital Universitario Príncipe de Asturias; Madrid Spain
| | | | - M. B. Bilò
- Allergy Unit; Department of Internal Medicine; University Hospital of Ancona; Ancona Italy
| | - D. Bokanovic
- Department of Dermatology and Venerology; Medical University of Graz; Graz Austria
| | - M. A. Calderon
- Section of Allergy and Clinical Immunology; Imperial College London; National Heart and Lung Institute; Royal Brompton Hospital; London UK
| | - E. Cichocka-Jarosz
- Department of Pediatrics; Jagiellonian University Medical College; Krakow Poland
| | - J. N. G. Oude Elberink
- Department of Allergology and Internal Medicine; University of Groningen; University Medical Hospital Groningen; Groningen The Netherlands
- Groningen Research Center for Asthma and COPD (GRIAC); Groningen The Netherlands
| | - R. Gawlik
- Department of Internal Medicine, Allergy and Clinical Immunology; Medical University of Silesia; Katowice Poland
| | - T. Jakob
- Department of Dermatology and Allergology; University Medical Center Gießen and Marburg (UKGM); Justus Liebig University Gießen; Gießen Germany
| | - M. Kosnik
- Medical Faculty Ljubljana; University Clinic of Respiratory and Allergic Diseases Golnik; Golnik Slovenia
| | - J. Lange
- Department of Pediatric Pneumonology and Allergy; Medical University of Warsaw; Warsaw Poland
| | - E. Mingomataj
- Department of Allergology and Clinical Immunology; Mother Theresa School of Medicine; Tirana Albania
- Department of Paraclinical Disciplines; Faculty of Technical Medical Sciences; Medicine University of Tirana; Tirana Albania
| | - D. I. Mitsias
- Department of Allergy and Clinical Immunology; 2nd Pediatric Clinic; University of Athens; Athens Greece
| | - H. Mosbech
- Allergy Clinic; Copenhagen University Hospital Gentofte; Gentofte Denmark
| | - M. Ollert
- Department of Infection and Immunity; Luxembourg Institute of Health (LIH); Strassen Luxembourg
| | - O. Pfaar
- Department of Otorhinolaryngology; Head and Neck Surgery; Universitätsmedizin Mannheim; Mannheim Germany
- Medical Faculty Mannheim; Heidelberg University; Heidelberg Germany
- Center for Rhinology Allergology; Wiesbaden Germany
| | - C. Pitsios
- Medical School; University of Cyprus; Nicosia Cyprus
| | - V. Pravettoni
- UOC Clinical Allergy and Immunology; IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport Isle of Wight UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; University of Southampton; Southampton UK
| | - F. Ruëff
- Klinik und Poliklinik für Dermatologie und Allergologie; Klinikum der Universität München; Munich Germany
| | - B. A. Sin
- Department of Pulmonary Diseases; Division of Immunology and Allergy; Faculty of Medicine; Ankara University; Ankara Turkey
| | - M. Asaria
- Research Fellow Centre for Health Economics; University of York; UK
| | - G. Netuveli
- Institute for Health and Human Development; University of East London; London UK
| | - A. Sheikh
- Allergy and Respiratory Research Group; The University of Edinburgh; Edinburgh UK
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