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Vanijcharoenkarn K, Lee F, Kalangara M. COVID-19 VACCINE ADMINISTRATION IN PATIENTS WITH FIRST-DOSE ADVERSE REACTIONS OR HISTORY OF SEVERE ALLERGIC REACTION. Ann Allergy Asthma Immunol 2022. [PMCID: PMC9646429 DOI: 10.1016/j.anai.2022.08.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction The COVID-19 pandemic has claimed over 6 million lives from 2020 onward. Vaccines against SARS-CoV-2 are one of our best tools in preventing severe illness and mortality. There have been multiple reactions reported to the SARS-CoV-2 vaccine that initially precluded further revaccinations, making protection against the virus incomplete. Our study aimed to identify true SARS-CoV-2 vaccine reactions, underlying patient risk factors, and to confirm the safety of our vaccine challenge protocol for revaccination. Methods Patients with reported adverse first-dose SARS-CoV-2 vaccine reactions precluding second dose, or those with history of severe allergic reaction were given a graded vaccine challenge of an initial 10% dose, observed for 30 minutes, with advancement to the 90% dose if no concerning reaction. Results Of the 50 patients enrolled, 49/50 (98%) were able to obtain the full vaccine dose. 8 (16%) of patients had a first dose reaction concerning for delayed hypersensitivity, and 7/8 of those patients tolerated the full repeat vaccine dose. 42 (84%) patients had history of immediate reaction to the first dose of the vaccine and all tolerated the full dose via challenge protocol. 1/50 patients needed epinephrine, but was able to fully obtain the dose with outpatient treatment during the course, and subsequent revaccination. Conclusion In a monitored setting, this challenge protocol is safe and effective for patients with history of adverse reaction to the vaccine or an underlying history of severe allergic reaction that would traditionally preclude repeat vaccination. The mechanism and pathophysiology of these reactions need to be elucidated through further research.
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Kalangara JP, Vanijcharoenkarn K, Chisolm S, Kuruvilla ME. Neuropathic pain and itch: mechanisms in allergic conjunctivitis. Curr Opin Allergy Clin Immunol 2022; 22:298-303. [PMID: 35916592 DOI: 10.1097/aci.0000000000000843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Allergic conjunctivitis is highly prevalent and affects up to one third of the general population. The current understanding of the pathophysiology and therapeutic strategies center around the type 2 inflammatory pathway. However, there is an increasing body of evidence that suggests neurogenic mechanisms also play a role in allergic inflammation, with a substantial proportion of allergic conjunctivitis patients experiencing both ocular itch and pain. RECENT FINDINGS Unmyelinated C fibres on the ocular surface transmit histaminergic itch and can be directly activated by mast cell mediators. The conjunctival mucosa also contains TRPV1+ (histamine-dependent) and TRPA1+ (histamine-independent) neurons that enhance ocular pain and itch in allergic conjunctivitis. Allergen-complexed IgE also binds directly to FcεRI expressed on peripheral neurons. Environmental aeroallergens can also directly stimulate neuronal nociceptors to release inflammatory substances. Allergic inflammation thus stimulates nerve terminals to release vasoactive and inflammatory neuropeptides, leading to a cyclical neuronal dysregulation that augments mast cell activity. These repetitive cycles lead to both peripheral and central sensitization and neuronal plasticity, resulting in decreased itch/pain thresholds and a heightened itch/pain response. SUMMARY Neurogenic mechanisms including peripheral and central sensitization may drive chronic ocular itch and pain secondary to allergic inflammation. Research into these pathways may help to identify therapeutic targets in allergic conjunctivitis patients with refractory symptoms.
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Affiliation(s)
| | | | - Sarah Chisolm
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
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Vanijcharoenkarn K, Lee FEH, Martin L, Shih J, Sexton ME, Kuruvilla ME. Immediate reactions following the first dose of the SARS-CoV2 mRNA vaccines do not preclude second dose administration. Clin Infect Dis 2021; 73:2108-2111. [PMID: 33989390 PMCID: PMC8194535 DOI: 10.1093/cid/ciab448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Indexed: 11/21/2022] Open
Abstract
Addressing coronavirus disease 2019 (COVID-19) vaccine hesitancy and minimizing potential vaccine contraindications are critical to combatting the pandemic. We describe a practical approach to immediate adverse events after the first dose of messenger RNA vaccines for severe acute respiratory syndrome coronavirus 2, focusing on diagnosis and management of allergic reactions.
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Affiliation(s)
- Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Frances Eun-Hyung Lee
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Lindsay Martin
- Department of Employee Health, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Jennifer Shih
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Mary Elizabeth Sexton
- Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Merin Elizabeth Kuruvilla
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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Kalangara J, Vanijcharoenkarn K, Lynde GC, McIntosh N, Kuruvilla M. Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management. Curr Allergy Asthma Rep 2021; 21:4. [PMID: 33409706 DOI: 10.1007/s11882-020-00980-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation. RECENT FINDINGS Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.
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Affiliation(s)
- Jerry Kalangara
- Division of Pain Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Health Care System, Decatur, GA, USA
| | - Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nichole McIntosh
- Atlanta VA Health Care System, Decatur, GA, USA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Merin Kuruvilla
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA.
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Rodrigues J, Kuruvilla ME, Vanijcharoenkarn K, Patel N, Hom MM, Wallace DV. The spectrum of allergic ocular diseases. Ann Allergy Asthma Immunol 2020; 126:240-254. [PMID: 33276116 DOI: 10.1016/j.anai.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The purpose of this article is to review the pathophysiologic mechanisms, differential diagnosis, evaluation, and treatment of the various manifestations of ocular allergy, with an especial focus on immunoglobulin E (IgE)-mediated disease. DATA SOURCES A PubMed search was performed to include articles, using the search terms ocular allergy and allergic conjunctivitis. STUDY SELECTIONS Recent and relevant human studies in the English language pertaining to our topic of study were selected. Animal studies pertaining to pathophysiology of ocular allergy were also reviewed. We focused on clinical trials, practice guidelines, reviews, and systematic reviews. In addition, case reports were reviewed if they described rare clinical presentations, disease mechanisms, or novel therapies. RESULTS Ocular allergy encompasses both IgE- and non-IgE-mediated disease, and the clinical severity may range from mild to sight-threatening inflammation. A comprehensive treatment regimen including education, lifestyle measures, topical therapies, and even systemic interventions may be necessary for the effective management of ocular allergies, tailored according to symptom severity. CONCLUSION Ocular allergy is frequently encountered by allergists and eye-care specialists, and despite progressively increasing incidence, it often remains underdiagnosed and, hence, untreated.
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Affiliation(s)
- Jonathan Rodrigues
- Allergy & Immunology, Sanford Health, Bismarck, North Dakota; Department of Internal Medicine and Department of Pediatrics, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.
| | - Merin E Kuruvilla
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nikki Patel
- Allergy & Immunology, Sanford Health, Sioux Falls, South Dakota
| | | | - Dana V Wallace
- Allergy and Immunology, Nova Southeastern University, Davie, Florida
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Kuruvilla ME, Vanijcharoenkarn K, Levy JM. The Role of Mast Cells in Aspirin-Exacerbated Respiratory Disease (AERD) Pathogenesis: Implications for Future Therapeutics. J Asthma Allergy 2020; 13:463-470. [PMID: 33116654 PMCID: PMC7569245 DOI: 10.2147/jaa.s237463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/23/2020] [Indexed: 12/31/2022] Open
Abstract
Mast cells (MC) have recently been demonstrated to play an integral role in the pathogenesis of aspirin-exacerbated respiratory disease (AERD). When activated, MCs release pre-formed granules of many pro-inflammatory mediators, including histamine, serotonin, and various chemokines and cytokines including tumor necrosis factor (TNF)-α, interferon ɣ (IFN ɣ), macrophage inhibitory factor, transforming growth factor, interleukin (IL) 1, 3–6, 9, 10, 13 and 16. These mediators promote inflammation in AERD by recruiting or activating a network of cells involved in acute and chronic inflammatory pathways, such as endothelial, epithelial, stromal, and other immune cells. Several studies have implicated multifactorial pathways for MC activation in AERD beyond classical IgE mediated mechanisms. The elucidation of these complex networks therefore represents important targets for innovative patient therapeutics. This review summarizes classic and alternative pathways of MC activation in AERD with a special focus in relation to new and emerging treatment strategies.
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Affiliation(s)
- Merin E Kuruvilla
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Joshua M Levy
- Department of Otolaryngology - Head & Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Vanijcharoenkarn K, Sharp W, Vickery B. Food Aversion After Negative Food Allergy Evaluation. J Allergy Clin Immunol 2020. [DOI: 10.1016/j.jaci.2019.12.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Edwards-Salmon S, Vanijcharoenkarn K, Patrawala M, Kuruvilla M, Shih J. M003 SUCCESSFUL DESENSITIZATION TO FLORINEF AFTER ANAPHYLAXIS IN A PATIENT WITH POSTURAL ORTHOSTATIC HYPOTENSION (POTS) DISEASE. Ann Allergy Asthma Immunol 2019. [DOI: 10.1016/j.anai.2019.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Vanijcharoenkarn K, Shih JA. Screening for Food Allergy-Related Anxiety in an Outpatient Allergy Clinic Setting: A Quality Improvement Project. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kuruvilla ME, Vanijcharoenkarn K, Shih JA, Lee FEH. Epidemiology and risk factors for asthma. Respir Med 2019; 149:16-22. [PMID: 30885424 DOI: 10.1016/j.rmed.2019.01.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/13/2019] [Accepted: 01/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Merin E Kuruvilla
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University, USA.
| | | | - Jennifer A Shih
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University, USA
| | - Frances Eun-Hyung Lee
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University, USA
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Vanijcharoenkarn K, Lee G. ERRONEOUS DIAGNOSIS OF PENICILLIN ALLERGY BASED ON MOLD HYPERSENSITIVITY TESTING COMPLICATING TREATMENT OF RHEUMATIC FEVER. Ann Allergy Asthma Immunol 2018. [DOI: 10.1016/j.anai.2018.09.413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Allergy and atopic asthma have continued to become more prevalent in modern society despite the advent of new treatments, representing a major global health problem. Common medications such as antihistamines and steroids can have undesirable long-term side-effects and lack efficacy in some resistant patients. Biologic medications are increasingly given to treatment-resistant patients, but they can represent high costs, complex dosing and management, and are not widely available around the world. The field needs new, cheap, and convenient treatment options in order to bring better symptom relief to patients. Beyond continued research and development of new drugs, a focus on drug repurposing could alleviate this problem by repositioning effective and safe small-molecule drugs from other fields of medicine and applying them toward the treatment for asthma and allergy. Herein, preclinical models, case reports, and clinical trials of drug repurposing efficacy in allergic disease are reviewed. Novel drugs are also proposed for repositioning based on their mechanism of action to treat asthma and allergy. Overall, drug repurposing could become increasingly important as a way of advancing allergy and atopic asthma therapy, filling a need in treatment of patients today.
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Affiliation(s)
- R. L. Kruse
- Medical Scientist Training Program; Baylor College of Medicine; Houston TX USA
| | - K. Vanijcharoenkarn
- Division of Allergy & Immunology; Department of Pediatrics; Emory University School of Medicine; Atlanta GA USA
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Kuruvilla M, Vanijcharoenkarn K, Wan J, Pereira N, Chung P. Exogenous progesterone hypersensitivity associated with recurrent pregnancy loss. J Allergy Clin Immunol Pract 2018; 6:1412-1413. [PMID: 29339132 DOI: 10.1016/j.jaip.2017.11.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Merin Kuruvilla
- Department of Allergy/Immunology, Emory University, Atlanta, Ga.
| | | | - Justin Wan
- Cornell Center for Reproductive Medicine, New York, NY
| | - Nigel Pereira
- Cornell Center for Reproductive Medicine, New York, NY
| | - Pak Chung
- Cornell Center for Reproductive Medicine, New York, NY
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Vanijcharoenkarn K, Patel K. Absence of IgE-Mediated Food Allergy Transmission in Solitary Kidney Transplant. J Allergy Clin Immunol 2017. [DOI: 10.1016/j.jaci.2016.12.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Zakas P, Vanijcharoenkarn K, Markovitz R, Meeks S, Doering C. Expanding the ortholog approach for hemophilia treatment complicated by factor VIII inhibitors. J Thromb Haemost 2015; 13:72-81. [PMID: 25315236 PMCID: PMC4295011 DOI: 10.1111/jth.12755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/26/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND The formation of neutralizing antibodies (inhibitors) directed against human coagulation factor VIII (hFVIII) is a life-threatening pathogenic response that occurs in 20-30% of severe congenital hemophilia A patients and 0.00015% of the remaining population (i.e. acquired hemophilia A). Interspecies amino acid sequence disparity among FVIII orthologs represents a promising strategy to mask FVIII from existing inhibitors while retaining procoagulant function. Evidence for the effectiveness of this approach exists in clinical data obtained for porcine FVIII (pFVIII) products, which have demonstrated efficacy in the setting of congenital and acquired hemophilia. OBJECTIVES In the current study, recombinant (r) ovine FVIII (oFVIII) was evaluated for antigenicity and procoagulant activity in the context of human patient-derived and murine model-generated FVIII inhibitors. METHODS The antigenicity of roFVIII was assessed using (i) inhibitor patient plasma samples, (ii) murine anti-FVIII MAbs, (iii) immunized murine hemophilia A plasmas and (iv) an in vivo model of acquired hemophilia A. RESULTS Overall, roFVIII demonstrated reduced reactivity to, and inhibition by, anti-hFVIII immunoglobulin in patient plasmas. Additionally, several hFVIII epitopes were predicted and empirically shown not to exist within roFVIII. In a murine hemophilia A model designed to mimic clinical inhibitor formation, it was demonstrated that inhibitor titers to roFVIII were significantly reduced when compared with the orthologous immunogens, rhFVIII or rpFVIII. Furthermore, in a murine model of acquired hemophilia A, roFVIII administration conferred protection from bleeding following tail transection. CONCLUSION These data support the investigation of FVIII orthologs as treatment modalities in both the congenital and acquired FVIII inhibitor settings.
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Affiliation(s)
- P.M. Zakas
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA
| | | | - R.C. Markovitz
- Graduate Program in Immunology and Molecular Pathogenesis, Laney Graduate School, Emory University, Atlanta, GA
| | - S.L. Meeks
- Aflac Cancer and Blood Disorders Center, Emory University/Children’s Healthcare of Atlanta, Atlanta, GA
| | - C.B. Doering
- Aflac Cancer and Blood Disorders Center, Emory University/Children’s Healthcare of Atlanta, Atlanta, GA
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