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Understanding Vernal Keratoconjunctivitis: Beyond Allergic Mechanisms. Life (Basel) 2021; 11:life11101012. [PMID: 34685384 PMCID: PMC8541022 DOI: 10.3390/life11101012] [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: 07/30/2021] [Revised: 09/18/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022] Open
Abstract
Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, inflammatory disease of the cornea and conjunctiva mostly affecting boys in prepubertal age. VKC recurrence is characterized by intense symptoms of itching, redness, and photophobia associated with corneal damage, impairment of visual function, and quality of life. The pathogenesis of VKC has not yet been completely understood, and it is still controversial. In fact, VKC is considered an ocular allergic disease due to the involvement of immunoglobulin E, eosinophils, and mast cells, and of a lymphocyte T-helper type 2 reaction. However, approximately half of VKC patients have negative allergological history and testing, suggesting that other pathogenic mechanisms participate in VKC development and severity. Specifically, evidence suggests that genetic, endocrine, neuronal factors and an imbalance of innate immunity are involved in the pathogenesis of VKC. The purpose of this review is to summarize evidence on the pathogenic role of innate immunity, neuroimmune reaction, and hormonal changes in VKC. Increasing understanding of the pathogenic mechanisms behind VKC may lead to the identification of novel biomarkers for diagnosis and/or potential therapeutic targets in order to improve the management of this challenging condition.
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Sruthi V, Reddy RN, Sowmini K, Grace NS. To evaluate the efficacy and safety of olopatadine 0.1% ophthalmic solution and bepotastine 1.5% ophthalmic solution in patients with vernal keratoconjunctivitis in a tertiary care hospital. Indian J Pharmacol 2021; 52:476-481. [PMID: 33666188 PMCID: PMC8092179 DOI: 10.4103/ijp.ijp_174_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Vernal conjunctivitis comprises 0.5% of allergic eye diseases. The study is intended to collate the effectiveness of drugs by observing the reduction in signs and symptoms. OBJECTIVES The objective of the study is to evaluate the effectiveness and safety of olopatadine 0.1% ophthalmic drops with bepotastine besilate 1.5% ophthalmic drops in patients with vernal keratoconjunctivitis (VKC). MATERIALS AND METHODS A randomized, open-label, comparative study conducted in Sarojini Devi Eye Hospital, Telangana. The study included 50 patients diagnosed with VKC, of which Group A and Group B were given olopatadine 0.1% ophthalmic drops and bepotastine besilate 1.5% ophthalmic drops, respectively, twice a day for 8 weeks. The reduction in signs and symptoms in both groups was compared. The observations and results were tabulated accordingly, and data were analyzed using the SPSS. The unpaired t-test is used as the test of significance in between two groups. P value is statistically significant when it is less than 0.05. RESULTS Overall, 50 cases were included in the study, 72% of total patients were in the age group of 5-10 years, and 28% were in the age group of 11-15 years. There were 39 males and 11 females. After 8 weeks of follow-up, the mean reduction in the scoring of symptoms and signs provided better and quicker relief of watering, ocular discomfort, and conjunctival hyperemia with bepotastine 1.5% eye drops. Olopatadine 0.1% eye drops provided faster improvement in papillary hypertrophy. Both drugs were equally effective in reducing itching. Laboratory findings of absolute eosinophil count had no statistical significance in between the two groups. CONCLUSIONS In this study, based on the evaluation of therapeutic performance, bepotastine eye drops proved quicker relief of symptoms and signs compared to olopatadine eye drops but was not statistically significant which would prove beneficial for the patients.
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Affiliation(s)
- Vadlakonda Sruthi
- Department of Pharmacology, Osmania Medical College, Hyderabad, Telangana, India
| | - Resu Neha Reddy
- Department of Pharmacology, Osmania Medical College, Hyderabad, Telangana, India
| | - K Sowmini
- Department of Pharmacology, Osmania Medical College, Hyderabad, Telangana, India
| | - Nagur Sharone Grace
- Department of Pharmacology, Osmania Medical College, Hyderabad, Telangana, India
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Sithole HL. Understanding vernal keratoconjunctivitis in children. AFRICAN VISION AND EYE HEALTH 2020. [DOI: 10.4102/aveh.v79i1.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Vernal keratoconjunctivitis (VKC) is a public health problem that mostly affects children in warm subtropical climates. Unfortunately, the causative factors of the disease are not clearly defined, thus posing a serious management challenge to healthcare providers. It is therefore argued that understanding the pathogenesis of the disease and how various inflammatory cells affect the conjunctiva and the cornea may assist in the management of the disease.Aim: As visual impairment and avoidable blindness are indicated, it is advisable for optometrists to understand the clinical presentation of this chronic condition in order to initiate appropriate interventions and/or immediate referrals where necessary.Methods: A thorough literature search was conducted on peer-reviewed publications on VKC and children. All material obtained were then studied and the information extracted was used to document relevant information required for understanding VKC amongst children.Results: The results in the studied material revealed that VKC was prevalent amongst children aged 2 to 18 years, affecting mostly male children of African and Indian origins. Different strategies of management of the disease have been proposed, including but not limited to explaining to parents the nature of the disease, environmental strategies and preventive measures as well as possible surgical intervention.Conclusion: In view of the nature of this disease, healthcare providers should therefore seek to understand the history of the patient better when such patients present for their first consultation in order to develop a comprehensive management approach.
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Ghiglioni DG, Martino PA, Bruschi G, Vitali D, Osnaghi S, Corti MG, Beretta G. Stability and Safety Traits of Novel Cyclosporine A and Tacrolimus Ophthalmic Galenic Formulations Involved in Vernal Keratoconjunctivitis Treatment by a High-Resolution Mass Spectrometry Approach. Pharmaceutics 2020; 12:pharmaceutics12040378. [PMID: 32326044 PMCID: PMC7238033 DOI: 10.3390/pharmaceutics12040378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022] Open
Abstract
In this study, a sensitive quantitative method based on high performance liquid chromatography combined with high-resolution mass spectrometry, Q ExactiveTM-Orbitrap® was set up and applied for the determination of the immunosuppressor agents cyclosporine A and tacrolimus in novel ethanol-free ophthalmic formulations for the treatment of Vernal keratoconjunctivitis. Different storage parameters in terms of storage temperatures and practical usage conditions were investigated to assess the stability of all formulations during shelf life simulating the real conditions as well to confirm the feasibility of use of ethanol-free products. The methodology was linear (r2 = 0.995) over the concentration range 0–200 ng/mL, and its selectivity, precision, accuracy and recovery were all within the required limits. Under different conditions (storage period 0–90 days, 5–25 °C, unopened/usage simulated conditions), our results revealed that both active pharmaceutical ingredients (API) show satisfactory stability up to 30 days of storage/usage, with a significant and consistent concentration decline of cyclosporine A after this time point when its hydroalcoholic formulation was kept at 25 °C.
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Affiliation(s)
- Daniele Giovanni Ghiglioni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 28, 20122 Milan (MI), Italy; (D.G.G.); (S.O.); (M.G.C.)
| | - Piera Anna Martino
- Department of Veterinary Medicine, Università Degli Studi di Milano, Via Celoria 10, 20133 Milan (MI), Italy;
| | - Gaia Bruschi
- Department of Clinical and Community Sciences, University of Milan, Via della Commenda, 19, 20122 Milan (MI), Italy
- Correspondence:
| | - Davide Vitali
- Bruttomesso Pharmacy, Galenic Laboratory, Piazza Guglielmo Marconi, 20, 26013 Crema (CR), Italy;
| | - Silvia Osnaghi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 28, 20122 Milan (MI), Italy; (D.G.G.); (S.O.); (M.G.C.)
| | - Maria Grazia Corti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Via Francesco Sforza, 28, 20122 Milan (MI), Italy; (D.G.G.); (S.O.); (M.G.C.)
| | - Giangiacomo Beretta
- Department of Environmental Science and Policy, Università degli Studi di Milano, Via Mangiagalli 25, 20133 Milan (MI), Italy;
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Zicari AM, Capata G, Nebbioso M, De Castro G, Midulla F, Leonardi L, Loffredo L, Spalice A, Perri L, Duse M. Vernal Keratoconjunctivitis: an update focused on clinical grading system. Ital J Pediatr 2019; 45:64. [PMID: 31113464 PMCID: PMC6528205 DOI: 10.1186/s13052-019-0656-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/05/2019] [Indexed: 12/04/2022] Open
Abstract
Introduction Vernal keratoconjunctivitis (VKC) is a severe disease with a prevalence of < 1 case out of 10,000 in Europe, which occurs mainly in pediatric age and is characterized by a severe and often bilateral chronic inflammation of the ocular surface. The diagnosis is generally confirmed by the finding at the ocular examination of conjunctival hyperemia, papillary hypertrophy in the tarsal conjunctiva, giant papillae, papillae in the limbus region. Objective Aim of this review is to provide an updated overview on the disease focused on clinical grading system, searching papers published in the last decade on VKC in scientific databases. Results Currently there are no standardized criteria for diagnosis of VKC and there is no uniformity to define disease severity, which makes difficult to diagnose and treat the disease. Conclusions Given the wide overlap of the symptoms of VKC with the allergic conjunctivitis, criteria of probable, possible or improbable diagnosis are needed, providing pediatricians with parameters useful for deciding whether to drive the patient to the ophthalmologist for diagnostic confirmation.
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Affiliation(s)
- A M Zicari
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
| | - G Capata
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy.
| | - M Nebbioso
- Department of Sense Organs, "Sapienza" University of Rome, Rome, Italy
| | - G De Castro
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
| | - F Midulla
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
| | - L Leonardi
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
| | - L Loffredo
- Department of Internal Medicine and Medical Specialities, "Sapienza" University of Rome, Rome, Italy
| | - A Spalice
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
| | - L Perri
- Department of Internal Medicine and Medical Specialities, "Sapienza" University of Rome, Rome, Italy
| | - M Duse
- Department of Pediatrics, "Sapienza" University of Rome, Viale Regina Elena 324, Rome, Italy
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Chen YH, Lin CL, Bau DT, Hung YC. Risk of allergic conjunctivitis in patients with type 1 diabetes mellitus: a population-based retrospective cohort study. BMJ Open 2017; 7:e015795. [PMID: 28630085 PMCID: PMC5541456 DOI: 10.1136/bmjopen-2016-015795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE In accordance with the dichotomy between T helper type 1(Th1) and T helper type 2 (Th2) responses, the occurrence of allergic conjunctivitis (AC) and type 1 diabetes mellitus (T1DM) is, in theory, inversely related in the individual. However, recent studies investigating the association between the two diseases are controversial. DESIGN Population-based cohort study. SETTING We used claims data of the National Health Insurance Research Database of Taiwan. PARTICIPANTS We identified 4160 patients aged 1-30 years with newly diagnosed T1DM and no history of AC at baseline. For each patient with T1DM, four non-T1DM controls (n=16,640) were matched by sex. The mean follow-up time was 6 years. PRIMARY AND SECONDARY OUTCOME MEASURES Multivariate Cox proportional hazards regression analysis was used to evaluate the risk of AC. We additionally evaluated the association between risk of AC and T1DM progression by examining Diabetes Complications Severity Index (aDCSI) changes from the date of diagnosis until the end of follow-up. RESULTS The overall incidence of allergic conjunctivitis (AC) was higher in the type 1 diabetes mellitus (T1DM) cohort than in the control cohort (23.0 vs 13.5 per 1000 person-years, adjusted incidence rate ratio (aIRR): 1.59, 95% CI 1.47 to 1.71). Relative to that in patients with mildly progressive T1DM, the risk of AC increased as the adapted Diabetes Complications Severity Index (aDCSI) increased (aIRR: 1.68, 3.78 and 18.8, with yearly changes in aDCSI score: 0.51 to 1.00, 1.01 to 2.00, and >2.00 vs <0.51, respectively; for trend <0.001). CONCLUSION Patients with T1DM are at an elevated risk of developing AC; this risk increases with T1DM progression. The T helper type 1/T helper type 2 hypothesis is an overly simplistic explanation for this association.
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Affiliation(s)
- Yin-Huei Chen
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Da-Tian Bau
- Terry Fox Cancer Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Chih Hung
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
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Yeh JH, Kuo HT, Chen HJ, Chen YK, Chiu HC, Kao CH. Higher risk of myasthenia gravis in patients with thyroid and allergic diseases: a national population-based study. Medicine (Baltimore) 2015; 94:e835. [PMID: 26020387 PMCID: PMC4616403 DOI: 10.1097/md.0000000000000835] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to determine the risk of myasthenia gravis (MG) in patients with allergic or autoimmune thyroid disease in a large cohort representing 99% of the population in Taiwan. Data from the Taiwan National Health Insurance Database were used to conduct retrospective analyses. The study comprised 1689 adult patients with MG who were 4-fold frequency matched to those without MG by sex, age, and assigned the same index year. Multivariate logistic regression models were used to calculate the odds ratios and 95% confidence intervals for the association between allergic or autoimmune thyroid disease and MG. An increased subsequent risk of MG was observed in the patients with allergic conjunctivitis (AC), allergic rhinitis, Hashimoto thyroiditis, and Graves disease. The adjusted odds ratios (aORs) were 1.93 (1.71-2.18), 1.26 (1.09-1.45), 2.87 (1.18-6.97), and 3.97 (2.71-5.83), respectively. The aORs increased from 1.63 (1.43-1.85) in a patient with only 1 allergic or autoimmune thyroid disease to 2.09 (1.75-2.49) in a patient with 2 thyroid or allergic diseases to 2.82 (2.19-3.64) in a patient with ≥3 thyroid or allergic diseases. MG was associated with the cumulative effect of concurrent allergic and autoimmune thyroid disease with combined AC and Hashimoto thyroiditis representing the highest risk (aOR = 15.62 [2.88-87.71]). This population-based case-control study demonstrates the association between allergic or autoimmune thyroid disease and the risk of MG. The highest risk of subsequent MG was associated with combined AC and Hashimoto thyroiditis.
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Affiliation(s)
- Jiann-Horng Yeh
- From the Department of Neurology (J-HY, H-CC); Department of Nuclear Medicine and PET Center, Shin Kong Wu Ho-Su Memorial Hospital, Taipei (Y-KC); Fu Jen Catholic University, New Taipei City (J-HY, Y-KC, H-CC); School of Medicine, China Medical University (H-TK); Department of Developmental and Behavioral Pediatrics, Children's Hospital of China Medical University (H-TK); Management Office for Health Data, China Medical University Hospital (H-JC); College of Medicine (H-JC); Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University (C-HK); and Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan (C-HK)
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Zicari AM, Zicari A, Nebbioso M, Mari E, Celani C, Lollobrigida V, Cesoni Marcelli A, Occasi F, Duse M. High-mobility group box-1 (HMGB-1) and serum soluble receptor for advanced glycation end products (sRAGE) in children affected by vernal keratoconjunctivitis. Pediatr Allergy Immunol 2014; 25:57-63. [PMID: 24236762 DOI: 10.1111/pai.12142] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vernal keratoconjunctivitis (VKC) is a chronic disease affecting conjunctiva even though the immunopathogenetic mechanisms underlying this inflammation are unclear. The aim of our study is to investigate serum levels of HMGB1 and circulating sRAGE in children affected by VKC before and after treatment with cyclosporine A (CsA) eye drops and in a group of healthy children. METHODS Twenty-four children affected by VKC aged between 5 and 12 yrs of life were enrolled at the Department of Pediatrics, Division of Allergy and Immunology, 'Sapienza' University of Rome. Twenty-four healthy children without atopy, ocular, and systemic disease, cross-matched for sex and age to patients affected by VKC, represented the controls. All children affected by VKC were treated with CsA 1% eye drops for 4 wks, and blood samples were collected before and 2 wks after the end of treatment while the controls underwent to a single blood sample at the time of enrollment. RESULTS Serum basal levels of HMGB1 and sRAGE were higher in children with VKC when compared with controls while, in patients affected by VKC, no difference was detected between atopic and non-atopic, and between ANA-positive and ANA-negative children. A significant reduction in serum HMGB1 and sRAGE levels was detected after the therapy while CsA serum levels were negative. CONCLUSIONS Our study gives a support to the definition of VKC as a systemic inflammation in which HMGB1 and its soluble receptors could play a role.
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Affiliation(s)
- Anna Maria Zicari
- Department of Pediatrics, 'Sapienza' University of Rome, Rome, Italy
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Stagi S, Pucci N, Di Grande L, de Libero C, Caputo R, Pantano S, Mattei I, Mori F, de Martino M, Novembre E. Increased incidence of thyroid dysfunction and autoimmunity in patients with vernal keratoconjunctivitis. Int J Endocrinol 2014; 2014:804870. [PMID: 25140177 PMCID: PMC4130298 DOI: 10.1155/2014/804870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/06/2014] [Indexed: 11/29/2022] Open
Abstract
Hormones may play a role in the pathophysiology of vernal keratoconjunctivitis (VKC). An increased incidence of thyroid autoantibodies was recently observed in VKC, although there were no data on thyroid function. Two hundred and eighty-eight patients (202 males, 86 females; range 5.5 to 16.9 years) with VKC were evaluated and compared with 188 normal age- and sex-matched subjects. In all subjects, serum concentrations of free T4, TSH, thyroperoxidase, thyroglobulin, and TSHr autoantibodies were evaluated. In VKC, the family history of thyroid diseases showed no significant differences compared to the controls (9.4 versus 8.6%), whereas the family history of autoimmune diseases was significantly higher (13.2% versus 6.3%; P<0.05). Subclinical hypothyroidism was diagnosed in 6.6% (versus 1.6% of the controls; P<0.05) and overt hypothyroidism in 0.7% (versus 0.0% of the controls; P = NS). Finally, 5.2% of patients were positive for thyroid autoantibodies, which were significantly higher with respect to the controls (0.5%, P<0.05). In the patients positive for thyroid autoantibodies, 80% showed a sonography pattern that suggested autoimmune thyroiditis. Thyroid function and autoimmunity abnormalities are frequently present in children with VKC. Children with VKC should be screened for thyroid function and evaluated for thyroid autoimmunity.
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Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Neri Pucci
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- *Neri Pucci:
| | - Laura Di Grande
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Cinzia de Libero
- Clinical Ophthalmology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Roberto Caputo
- Clinical Ophthalmology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Stefano Pantano
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Ivan Mattei
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Francesca Mori
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
| | - Elio Novembre
- Department of Health Sciences, University of Florence, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
- Paediatric Allergology Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139 Florence, Italy
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