Hypersensibilité au vaccin anti-COVID ? analyses de 1000 avis allergologiques

Introduction (contexte de la recherche)

Les services d’allergologie ont été fortement sollicités en raison de l’appréhension vis-à-vis du risque allergique des vaccins contre la COVID-19.

Objectif

Nous rapportons les 1000 premières prises en charge proposées et le résultat des investigations allergologiques réalisées.

Méthodes

Nous avons mis en place un système d’avis-COVID par mail à l’aide d’un questionnaire. Ceci nous a permis de colliger, de façon rétrospective les données démographiques des patients, les conduites à tenir proposées, en fonction des données cliniques fournies et des recommandations de la SFA. Pour certains, des tests cutanés ont été nécessaires : prick-test aux PEGs 3500/1500 et polysorbate 80 avec des concentrations maximales respectives de 100 mg/mL et 1000 mg/mL. Lorsque des fonds de flacon de vaccin étaient disponibles, nous avons réalisé : prick-test et IDR jusqu’à leur concentration pure. Certaines vaccinations jugées à risque ont été réalisées dans le service.

Résultats

Du 20 janvier au 24 novembre 2021, 1000 avis allergologiques ont été donnés par mail en dehors des heures de consultation. Il s’agissait de 773 avis pré-vaccinaux et 227 post-vaccinaux. L’âge moyen des patients était de 55 ans, avec une majorité de femmes. Nous avons levé la contre-indication allergologique à la vaccination dans 99,4 % des cas. Elle a été recommandée en centre de vaccination conventionnel pour 44 % sans précaution particulière, 31 % sous antihistaminique, 30 % avec 30 minutes de surveillance. 31 patients ont été vaccinés dans notre service sans réaction. L’indication de tests cutanés a été retenue dans 6,9 % des cas. Nous avons mis en évidence une sensibilisation aux excipients et aux vaccins chez 4 patients du groupe pré-vaccinal et chez une patiente du groupe post-vaccinal qui a bénéficié d’une désensibilisation avec succès.

Conclusions

La gestion par mail des avis-COVID a permis de limiter les consultations dédiées en présentiel et de maintenir l’intégralité des activités du service. Nous avons proposé une réponse rapide avec traçabilité écrite, souvent exigée. Seuls 4 patients restent à ce jour contre-indiqués à la vaccination en raison d’une allergie aux PEGs.

Impact de la pandémie Covid 19 sur les adolescents asthmatiques en Alsace, durant le premier confinement

Introduction

L’Alsace a été particulièrement impactée par la première vague épidémique liée au Covid 19. Nous avons évalué l’impact de cette crise sanitaire sur des adolescents asthmatiques.

Méthodes

Au 1^er déconfinement, au cours d’une consultation, nous avons proposé un questionnaire à des adolescents asthmatiques suivis au CHR Haguenau ou au CHRU de Strasbourg. Nous avons recueilli les données concernant une possible infection par le SARS-COV2, le contrôle de l’asthme, des allergies, l’observance, les activités physiques, l’adhésion aux gestes barrière, et leurs attitudes et craintes envers la reprise de l’école.

Résultats

Vingt trois adolescents, âgés de 11 à 17 ans ont été inclus. Un seul rapportait une symptomatologie compatible avec la COVID19, et 7 un cas familial. Dans l’ensemble, distanciation sociale et lavage des mains semblaient respectés, mais pas le port de masque. Vingt patients avaient un traitement de fond, qu’ils ont maintenu. Dans la majorité des cas l’asthme est resté contrôlé. Seul un patient a nécessité une corticothérapie orale. Les activités sportives ont été poursuivies durant le confinement par 50 % des patients et 96 % s’aéraient régulièrement. 74 % étaient allergiques, dont 65 % aux pollens. Seuls 27 % décrivaient une majoration des symptômes par rapport aux années précédentes. 2 adolescents allergiques aux allergènes d’environnement intérieur étaient plus gênés pendant cette période. Le vécu du confinement a été évalué en moyenne à 6,47/10. En ce qui concerne la reprise des cours, 56 % y étaient favorables, 26 % y étaient opposés.

Conclusion

Pendant le premier confinement lié à la pandémie Covid19, dans notre région particulièrement impactée, l’asthme des adolescents est resté bien contrôlé. L’observance thérapeutique n’a pas été altérée malgré les premières rumeurs concernant la corticothérapie inhalée. La majorité des asthmatiques avec allergies associées ne présentait pas d’aggravation. Les adolescents tenaient à respecter les gestes barrières pour retourner à l’école ou pratiquer une activité physique collective. Alertés, par le manque de masque, et soutenus par la fondation Gregory Pariente, nous avons pu équiper ces adolescents.

[Is celecoxib a safe alternative for the Fernand Widal syndrome?]

The Fernand Widal syndrome is a set of associations between asthma, nasal polyposis and aspirin sensitivity. Selective cyclo-oxygenase 2 (COX 2) inhibitors are recognized as being a therapeutic alternative in cases needing analgesic or anti-inflammatory treatment. In a retrospective study, we have compiled data concerning oral provocation tests (OPT) undertaken with celecoxib, one of most the selective COX 2 inhibitors, in eight patients with the Fernand Widal syndrome. They were compared with twenty-seven control patients with sensitivity to aspirin or non-steroidal anti-inflammatories, manifesting as asthma, urticaria or rhino-conjunctivitis. Four patients with the Fernand Widal syndrome developed bronchospasm after taking the usually recommended daily dose of celecoxib while all the control patients tolerated it. The Fernand Widal patients who reacted during the OPT had a lower threshold of reactivity to aspirin, a more severe reaction with aspirin, and/or more severe asthma. In patients with the Fernand Widal syndrome, celecoxib is not always a possible alternative to non-steroidal anti-inflammatory drugs. Its introduction must be carried out in a hospital environment under medical supervision.

Diagnosis of primary ciliary dyskinesia: When and how?

INTRODUCTION

Primary ciliary dyskinesia (PCD) is a rare congenital disorder involving permanent ubiquitous structural and/or functional ciliary abnormalities.

METHODS

A single-center retrospective study included 56 cases of PCD (respiratory form) out of a cohort of 280 patients with suspected PCD. The main features of history-taking and clinical examination were analyzed, to formulate a pragmatic diagnostic procedure, easy to implement in clinical practice.

RESULTS

Chronic respiratory tract infectious symptoms are sensitive but non-specific for the diagnosis of PCD. Nasal brushing for phase-contrast microscopy study of ciliary morphology and activity proved to be a fast, easy, non-invasive, cost-effective and age-independent diagnostic method. In doubtful cases, depending on local availability, further tests are indicated: nasal nitric oxide level, electronic microscopy, genetic study and cell culture.

CONCLUSIONS

In suspected PCD, there being no gold standard method of screening and early diagnosis, nasal brushing with ciliary study is contributive, alongside numerous other complementary tests, on condition that the clinician is experienced and results are interpreted in the light of clinical examination and history-taking.

Anaphylaxis to diclofenac: nine cases reported to the Allergy Vigilance Network in France

Nine cases of diclofenac hypersensitivity recorded by the Allergy Vigilance Network in France from 2002 to 2012 were studied. Data from history, symptoms, skin tests, basophil activation tests, and oral challenge (OC) were recorded. Grade 3 severe anaphylactic reactions occurred in seven cases of nine. IgE-dependent anaphylaxis was confirmed in six cases: positive intradermal tests (n = 4), a syndromic reaction during skin tests (n = 1), and one case with grade 1 reaction and negative skin tests had an anaphylactic shock to the OC. A nonimmune reaction was suspected in one case. An IgE-dependent mechanism may be the predominant cause of adverse reactions to diclofenac. Allergy skin tests must be carried out sequentially at the recommended concentrations. BATs may be helpful because they can support the diagnosis of anaphylaxis. Given the risks of a direct challenge to diclofenac, OC to aspirin should be performed first to exclude a nonimmunologic hypersensitivity to NSAIDs. Tests for specific IgEs to most frequently used NSAIDs such as diclofenac and ibuprofen are urgently needed.

Identification of enolases and aldolases as important fish allergens in cod, salmon and tuna: component resolved diagnosis using parvalbumin and the new allergens

BACKGROUND

The majority of fish-allergic patients are sensitized to parvalbumin, known to be the cause of important IgE cross-reactivity among fish species. Little is known about the importance of fish allergens other than parvalbumin.

OBJECTIVE

The aim of this study was to characterize hitherto undefined fish allergens in three commonly consumed fish species, cod, salmon and tuna, and to evaluate their importance for in vitro IgE-diagnosis in addition to parvalbumin and fish gelatin.

METHODS

Sixty-two patients were diagnosed by clinical history, skin prick tests and specific IgE to fish extracts. Two new fish allergens from cod, salmon and tuna were identified by microsequencing. These proteins were characterized by immunoblot, ELISA and mediator release assay. Purified parvalbumin, enolase, aldolase and fish gelatin were used for quantification of specific IgE in ELISA.

RESULTS

Parvalbumin and two other allergens of 50 and 40 kDa were detected in IgE-immunoblots of cod, salmon and tuna extracts by most patient sera. The 50 and 40 kDa proteins were identified as beta-enolase and fructose-bisphosphate aldolase A respectively. Both purified enzymes showed allergenic activity in the mediator release assay. Indeed, 72.6% of the patients were sensitized to parvalbumin, 20% of these had specific IgE to salmon parvalbumin only. IgE to enolases were found in 62.9% (0.5-95.0 kUA /L), to aldolases in 50.0% (0.4-26.0 kUA /L) and to fish gelatin in 19.3% (0.4-20.0 kUA /L) of the patients. Inter-species cross-reactivity, even though limited, was found for enolases and aldolases by IgE-inhibition ELISA.

CONCLUSIONS AND CLINICAL RELEVANCE

Fish enolase and aldolase have been identified as important new fish allergens. In fish allergy diagnosis, IgE to enolase and aldolase are especially relevant when IgE to parvalbumin are absent.

[Hypersensitivity pneumonitis related to Penicillium chrysogenum and mesophilic Streptomyces: the usefulness of the Medical Indoor Environment Councelor (MIEC)]

Hypersensitivity pneumonitis (HP) occurred after organic antigens inhalation at home is rare and the diagnosis is very often difficult. We report the case of a 55-year male patient with allergic asthma since childhood, well controlled with inhaled corticosteroids, twice hospitalized for respiratory distresses. The patient presented fever (39°C), dry cough, rapidly progressive dyspnea, chest pain and crackles. Blood gas analysis found a hypoxemia of 52 mmHg, and CT-scan showed ground glass images in the upper lobes. Respiratory function tests showed severe obstructive syndrome and a decrease of diffusion test. HP was suspected because the symptoms were triggered by domestic environmental. The Medical Indoor Environment Councelor (MIEC) visited the patient's house and camper and performed air and dust samples. Moldy walnuts were found in the camper. The identification of microorganisms present in the air and on the surfaces in the camper was used for serum precipitins research by double diffusion (DD) and electrosyneresis (E) methods. From the 14 antigens tested, serological tests were considered significant for mesophilic Streptomyces (five arcs DD, six arcs E) and Penicillium chrysogenum (one arc DD, four arcs E). After removal from the camper of the objects suspected to be contaminated, the patient's symptoms regressed. This is a typical case of domestic HP to mesophilic Streptomyces and P. chrysogenum. The MIEC's intervention was useful in both diagnosis and treatment.

Identification of enolases and aldolases as important fish allergens in cod, salmon and tuna: component resolved diagnosis using parvalbumin and the new allergens

BACKGROUND

The majority of fish-allergic patients are sensitized to parvalbumin, known to be the cause of important IgE cross-reactivity among fish species. Little is known about the importance of fish allergens other than parvalbumin.

OBJECTIVE

The aim of this study was to characterize hitherto undefined fish allergens in three commonly consumed fish species, cod, salmon and tuna, and to evaluate their importance for in vitro IgE-diagnosis in addition to parvalbumin and fish gelatin.

METHODS

Sixty-two patients were diagnosed by clinical history, skin prick tests and specific IgE to fish extracts. Two new fish allergens from cod, salmon and tuna were identified by microsequencing. These proteins were characterized by immunoblot, ELISA and mediator release assay. Purified parvalbumin, enolase, aldolase and fish gelatin were used for quantification of specific IgE in ELISA.

RESULTS

Parvalbumin and two other allergens of 50 and 40 kDa were detected in IgE-immunoblots of cod, salmon and tuna extracts by most patient sera. The 50 and 40 kDa proteins were identified as beta-enolase and fructose-bisphosphate aldolase A respectively. Both purified enzymes showed allergenic activity in the mediator release assay. Indeed, 72.6% of the patients were sensitized to parvalbumin, 20% of these had specific IgE to salmon parvalbumin only. IgE to enolases were found in 62.9% (0.5-95.0 kUA /L), to aldolases in 50.0% (0.4-26.0 kUA /L) and to fish gelatin in 19.3% (0.4-20.0 kUA /L) of the patients. Inter-species cross-reactivity, even though limited, was found for enolases and aldolases by IgE-inhibition ELISA.

CONCLUSIONS AND CLINICAL RELEVANCE

Fish enolase and aldolase have been identified as important new fish allergens. In fish allergy diagnosis, IgE to enolase and aldolase are especially relevant when IgE to parvalbumin are absent.

[Cross reactions between pollens and vegetable food allergens]

INTRODUCTION

The association of food allergies and pollinosis are numerous, implicating tree, grass and weed pollens on one hand and on the other, several plant foods which after ingestion can induce an oral syndrome or more severe reactions such as urticaria, Quincke's edema, asthma and even anaphylactic shock.

BACKGROUND

The molecular basis of cross reactions between pollens and vegetable food allergens is increasingly understood. The principal allergens involved are those of the Bet v 1 family, and profilins found in all pollens as well as in many fruits and vegetables; these two groups of allergens are denatured by high temperatures and by gastric enzymes, in contrast to LTP, which is only found in weeds and some tree pollens. Other molecules can be involved in cross reactions such as Bet v 6 (an isoflavone reductase), 1 beta glucanases and thaumatine-like proteins. Inhibition experiments confirmed that the epitopes responsible for primary sensitization come mainly from pollen allergens; the cross-reactive molecular allergen is related to the geographic environment of the patients.

CONCLUSIONS

The practical aspects of managing these patients are underlined: explanations of co-sensitization, explanations for the lack of efficacy of some extracts, usefulness of a molecular diagnosis obtained either by CAP or microarray, prediction of severe clinical reactions induced by specific molecular allergens and the effectiveness of pollen immunotherapy on the cross-related food allergy.

Molecular allergology in practice: an unusual case of LTP allergy

The authors describe an unusual case of LTP allergy. A 35 years old patient presented repeated episodes of angiooedema after food intake and complained 10 years ago of contact urticaria and rhinoconjunctivitis when exposed to cannabis leaves and to marijuana smoke. The suspected responsible foods, such as wheat flour in bread, are known to contain LTR Oral syndrome occurred after ingestion of walnuts. Cutaneous tests confirmed immediate responses to several flours and nuts and also to cannabis leaf and flower. A few months later he had similar accidents following peach ingestion and drinking of beer and several wines which all induced positive skin tests. Serological investigations using ImmunoCAP and ISAC microarray confirmed IgE positivity for n Pru p3, r Cor a 8 and n Art v3. It was assumed that sensitization to LTP, the major allergen of cannabis, was responsible of the primary sensitization and induced further LTP food allergies.

Tropomyosin or not tropomyosin, what is the relevant allergen in house dust mite and snail cross allergies?

Since tropomyosin is cross reactive in many arthropods, it was assumed that this highly conserved protein could be responsible for cross reactions in house dust mite (HDM) allergic patients who experienced adverse reactions after crustacean and mollusc ingestion. Here we report two clinical cases where the role of tropomyosin is a matter of debate. In the first case, the clinical history, as well as the results of in vivo and in vitro investigations, are in favour of a shrimp allergy without any snail allergy in a patient sensitized to HDM. In the second, the clinical history and the cutaneous tests are in favour of an allergy to snails without any allergy to shrimps in a patient suffering from HDM allergies. The clinical presentation is different in shrimp and snail allergies. In shrimp allergy, symptoms are mainly urticaria or angio-oedema. In snail allergies, adverse reactions are especially severe asthma. Shrimp tropomyosin is a dominant allergen in crustaceans whereas has a much less prominent role in HDM sensitization. Cross reactivities between HDM and snails have been confirmed by inhibition experiments. However, tropomyosin appears to be a minor allergen or even is not involved in snail allergy. It is necessary to clarify the allergens shared between HDMI and snails. The effects of HDM immunotherapy in snail allergy are questioned. Knowledge of taxonomy can contribute to more precise evaluation of cross reactivities between crustaceans and molluscs.

Poor association between allergen-specific serum immunoglobulin E levels, skin sensitivity and basophil degranulation: a study with recombinant birch pollen allergen Bet v 1 and an immunoglobulin E detection system measuring immunoglobulin E capable of binding to Fc epsilon RI

BACKGROUND

Results from several studies indicate that the magnitude of immediate symptoms of type I allergy caused by allergen-induced cross-linking of high-affinity Fc epsilon receptors on effector cells (mast cells and basophils) is not always associated with allergen-specific IgE levels.

OBJECTIVE

To investigate the association of results from intradermal skin testing, basophil histamine release and allergen-specific IgE, IgG1-4, IgA and IgM antibody levels in a clinical study performed in birch pollen-allergic patients (n = 18).

METHODS

rBet v 1-specific IgEs were measured by quantitative CAP measurements and by using purified Fc epsilon RI-derived alpha-chain to quantify IgE capable of binding to effector cells. Bet v 1-specific IgG subclasses, IgA and IgM levels were measured by ELISA, and basophil histamine release was determined in whole blood samples. Intradermal skin testing was performed with the end-point titration method.

RESULTS

Our study demonstrates on the molecular level that the concentrations of allergen-specific IgE antibodies capable of binding to Fc epsilon RI and biological sensitivities are not necessarily associated. A moderate association was found between cutaneous and basophil sensitivity.

CONCLUSION

Our results highlight the quantitative discrepancies and limitations of the present diagnostic tools in allergy, even when using a single allergenic molecule. The quantity of allergen-specific serum IgE is only one component of far more complex cellular systems (i.e. basophil-based tests, skin tests) used as indirect diagnostic tests for IgE-mediated allergic sensitivity.

Les marqueurs d’exposition au tabagisme passif

INTRODUCTION

Tobacco smoke is one of the most common air pollutants found in the indoor environment. Passive smoking is defined as the involuntary inhalation of tobacco smoke present in the air. This article examines the advantages and limitations of the methods that are available to measure environmental tobacco smoke exposure.

STATE OF THE ART

Passive smoking can be assessed either by measuring tobacco smoke pollutants found in the air directly or by using biomarker assays, an indirect measure of exposure.

CONCLUSION

As far as the direct measurement of air pollutants is concerned, nicotine and 3-Ethenylpyridine levels seem most suitable because of their specificity. Four specific biological markers of tobacco smoke exposure are available: nicotine, cotinine, thiocyanates, and protein or DNA adducts. Only urinary cotinine assay can be retained as a reliable marker of exposure to tobacco smoke. It has been used as a reference in most epidemiological studies but only reflects tobacco exposure over the preceding 48 hours. The measurement of nicotine and cotinine levels in the appendages of the skin (hair and nails) reflects exposure to tobacco over the previous three months and could become a better reference marker in epidemiological and toxicological studies.