Qatar Medical Journal - Volume 2022, Issue 2 - First allergy conference in Qatar

Allergic diseases are common medical conditions that now show an increasing trend globally and contributes to poor quality of life of the affected individual. Allergies can be fatal in a few instances such as anaphylaxis, severe asthma, and hereditary angioedema if the symptoms are not recognized and treated correctly. (1, 2) The first Allergy Conference in Qatar aimed to highlight the burden of allergic diseases in Qatar and globally with a special focus on educating both the physicians and the community. The preparation for this conference over the past three years threw up a few challenges, mainly owing to the coronavirus disease 2019 (COVID-19) pandemic that affected all forms of face-to-face interactions and social gatherings. Therefore, our conference was held virtually on February 05, 2022, which was more than two years from the first planned date. The conference was sponsored by the Hamad Medical Corporation in partnership with the Qatar Allergy and Immunology Society. In our scientific program, the scientific committees selected topics related to 3 major areas in allergy practice (systemic, respiratory, and skin allergy disorders). Abstract submissions were encouraged in areas related to audits, case reports, service development, and clinical and basic research in the field of allergy. Additional topics were included related to the current COVID-19 pandemic and COVID-19 vaccinations. We received 34 abstracts and accepted 28 for poster abstracts. Among them, 6 received approval for oral presentations; and 6 (21.4%) had the term COVID-19 or SARS-CoV-2 in their title, which supported the burden related to COVID-19 in our community and association between this new pandemic and our allergy practice and disorders.

Background: It is a well-known fact that patients with chronic urticaria (CU) are not at a higher risk for a serious allergic reaction such as anaphylaxis from medications. However, there is a fear and some misconceptions regarding allergic reactions to the COVID-19 vaccine among patients and physicians, which might result in resistance to vaccination. Data about the incidence and severity of COVID-19 vaccine reactions in the CU population are scarce. In this study, we aimed to evaluate the real-world (Qatar) experience of the effects of COVID-19 vaccination on patients with CU and analyze the rates of vaccine-associated reactions and risk factors associated.

Methods: This is a cross-sectional questionnaire-based study conducted as a part of COVAC-CU international under the GALEN UCARE program. Adult patients with CU who received one or more doses of COVID-19 vaccination were administered a questionnaire regarding their demographic characteristics and any potential unfavorable effect of the vaccination from the November 03 to December 31, 2021.

Results: These are preliminary results from an ongoing study. The data were collected from 91 patients with CU, of whom 79.12% had chronic spontaneous urticaria, 15.3% had chronic inducible urticaria, and the remaining had both. Of these patients, 74.7% were women. The average age of the patients was 39.3 (range 15–68) years. The majority (84.6%) of them received 2 vaccine doses, 13.1% received 3 doses, and the remaining received 1 dose. Most (70.3%) of these patients did not experience any worsening in CU after vaccination. A total of 62.6% patients reported some type of side effects to the vaccine (16.4% had CU exacerbation and 46.1% other types of reactions, such as fever and muscle pain). None of the patients reported anaphylaxis. Two patients reported improvement in their symptoms.

Conclusion: Our local data suggest that patients with CU in Qatar can safely take the COVID-19 vaccine. Most patients with CU did not experience any worsening in symptoms, and there were no reports of a severe reaction (anaphylaxis). We recommend maximizing symptom control prior to vaccination to minimize the risk of worsening urticarial symptoms.

Omalizumab (XOLAIR®) is a recombinant DNA-derived humanized IgG1κ monoclonal antibody that binds to IgE and was first introduced in Qatar in 2009. Omalizumab is used to treat moderate-to-severe allergic asthma (SAA), chronic idiopathic urticaria (CIU), and chronic rhinosinusitis with nasal polyposis (CRSwNP). In this study, we have described a proposal to investigate the outcomes and impact of the clinical use of omalizumab for the labeled indications (SAA, CIU, and CRSwNP) and other off-label indications (food allergy, dermatitis, and others) in clinical practice in Qatar. This is a mixed-design study in which the first stage included a chart review of all the patients from the Allergy and Immunology Division registry who received omalizumab since May 2009. The second stage was a cross-sectional questionnaire to review all (previous and current) patients and identify their current health status and treatment outcomes. The third stage was a proof of concept and consisted of selecting a cohort to investigate the omalizumab mechanism for patients before and after administration. Patients with a physician diagnosis of asthma and/or urticaria fulfilling the diagnostic criteria for omalizumab administration and patients with off-label indications were recruited. Expected outcomes included identifying the real-life effectiveness and the experience of using omalizumab in Qatar and reporting all potential adverse effects that might have been missed during early trials or other published studies. This study was essential to observe Qatar’s local clinical practice regarding the use of omalizumab; and in addition, we could gather data about the risk factors contributing to disease recovery or progression and those resulting in favorable or unfavorable outcomes. We expect the results to augment the current knowledge about understanding diseases and the global experience on the use of omalizumab.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) cause different types of allergic and pseudo allergic reactions. This results in difficulties in clinical practice. Most cases of NSAID hypersensitivity are mediated by the inhibition of cyclooxygenase-1 enzyme (COX-1), which results in depletion of the protective prostaglandin E2, and promotes the unrestrained synthesis of inflammatory mediators from mast cells. Selective COX-2 inhibitors are considered safe alternatives in patients with NSAID allergy, although hypersensitivity reactions to COX-2 inhibitors have also been reported. Our study aimed to report the experience in Qatar for using COX2 inhibitors as an alternative treatment for nonselective NSAID allergy.

Methods: Data of patients who underwent open challenge with a single dose of oral celecoxib 200 mg were retrieved from the procedure log of the Allergy and immunology Division in Hamad medical corporation, Doha, Qatar, from 2013 to 2022. The challenge was considered positive if the patient developed cutaneous or respiratory symptoms.

Results: A total of 31 patients were identified; 4 with a history of celecoxib allergy. The remaining 27 (23 females and 4 males); with mean ( ± SD, range) age of 42 ( ± 12, 20–65) years had hypersensitivity to one (n = 11) or more than one (n = 16) nonselective NSAID, manifested as cutaneous, respiratory, or anaphylactic symptoms. Those 4 patients with celecoxib allergy were challenged and only one with a historical reaction of anaphylaxis developed anaphylaxis during the challenge. Celecoxib was well tolerated in all 27 patients with hypersensitivity reactions to nonselective NSAIDs. Also, patients were contacted by telephone call at 24 hours and after 1 week with no evidence of delayed reactions.

Conclusions: Selective COX-2 and nonselective NSAIDs have similar overall efficacy as analgesic, anti-inflammatory, and antipyretic agents. Hypersensitivity reaction to COX-2 inhibitors has been reported; however, it is rare. So, it is safer to challenge the patients with COX-2 inhibitors before prescribing them as alternative medication in patients with Nonselective NSAID allergies. We plan to conduct a single-/double-blind placebo-controlled study for more patients, especially using graded challenges for high-risk profile candidates. Also, it may be of significance to test more than one type of selective COX-2 to avoid drug-specific reactions.

Background: Chronic urticaria (CU) is a common and complex disorder that occurs without any identifiable provoking factor. The mechanisms underlying CU pathogenesis are still not fully understood. The autoimmune theory of IgG autoantibodies to IgE/high-affinity receptor of IgE on mast cells and mast cell activation and autoallergy (IgE-mediated disease) might contribute to CU pathogenesis. Extracellular vesicles (EVs) are membranous vesicles released from apoptotic or activated cells of different types. Elevated circulating levels of EVs in allergic diseases were associated with inflammation and disease progression. In this study, we aimed to investigate circulating EVs as potential biomarkers in patients with CU compared with that in healthy controls. Methods: We studied 15 patients with CU and 16 healthy controls. Circulatory EVs (plasma) were characterized by the presence of externalized phosphatidylserine (annexin V staining). Endothelial cells, platelets, T and B cells, macrophages, granulocytes, PECAM 2 1, and tissue factors were investigated. An unpaired t-test was used, and P <  0.05 was considered statistically significant. Results: We did not find significant differences in the total number of EVs in patients with CU. A significant decrease in the levels of T-cells (CD3) and endothelial cells (CD146) (P < 0.05) in these patients than in controls was found. No significant differences were observed between patients with CU and healthy controls in terms of platelets, macrophages, PECAM-1, B cells, and tissue factors. Conclusion: Endothelial cells have been shown to contribute to the pathogenesis of CU and are also targeted by mediators released by mast cells and other cellular infiltrates. We identified that circulatory endothelial and T-cell EVs might play an important role in CU pathogenesis. In addition, our study highlights the importance of EVs as future therapeutic targets to be investigated.

Chronic granulomatous disease (CGD) is a known Primary immunodeficiency disease that results in recurrent, life-threatening bacterial, fungal infections and granuloma formation which requires lifelong antibacterial and antifungal prophylaxis. Sulphamethoxazole-trimethoprim (TMP-SMX/Septrin) is the prophylactic antibacterial drug of choice.¹ Adverse drug reactions, including Fixed Drug Eruption (FDE) to TMP-SMX in CGD patients, are challenging as it may result in serious complications and difficulties in management.

A seventeen-year-old Qatari female diagnosed with CGD was maintained on prophylactic TMP-SMX and itraconazole since childhood. She developed bullous skin lesions involving the face, neck, and trunk sparing the limbs. The skin lesion was confirmed to be FDE by skin biopsy. TMP-SMX was discontinued as it was suspected to be the causative agent. Atovaquone 1500 mg and clarithromycin 250 mg daily were started as an alternative, but the patient could not tolerate them. TMP-SMX slow graded challenge and desensitization were performed; however, the patient developed similar lesions in the previous affected areas on day 3 of desensitization, which responded well to discontinuation of TMP-SMX along with administration of steroid. FDE to TMP-SMX as the causative agent was confirmed. An MDT meeting was conducted to evaluate other available options for treatment. Also, the case was discussed with international immunology colleagues. The recommendation was to go for bone marrow transplantation to treat the primary disease. Six years post transplants, the patient is doing well and is not on any medications apart from the hormonal replacement therapy patch.

CGD predisposes to several gram-positive, gram-negative bacterial (Staphylococcus aureus, Burkholderia cepacia complex, Serratia marcescens, Nocardia species) and fungal infections.² TMP-SMX is an ideal antibiotic as it is relatively cheap with good coverage and orally available. In the medical literature, desensitization can be tried in FDE, especially if there is no alternative for the needed drug. FDE signs should be observed when administered TMP-SMX.

Specialist nurses have a crucial role within the allergy and immunology specialty that reflects their competence in an increasingly complex area of work and ability to use advanced diagnostic testing and therapeutic modalities. A specialist nurse in Qatar follows the local Hamad Medical Cooperation (HMC) guidelines and the competency published by the British Society for Allergy and Clinical Immunology (BSACI).

Specialist Allergy Nurses

Learning domain: Learn and review the written standard operating procedure (SOP) and protocols for all diagnostic and therapeutic allergy procedures, including skin prick testing (inhaled, food, and others), intradermal testing, skin patch testing, penicillin testing, food and drug challenges, different desensitization protocols, and biologics and other medication administration. In addition, learn the protocol for immunotherapy administration and maintain an updated knowledge of trends and developments in the field by reading relevant articles, journals, and related material and attending seminars and conferences, as needed.

Maintain a safe work environment: Perform all the above procedures and medication administration with a high grade of competency under physician supervision. Apply quality measures to ensure safety. Furthermore, perform stocktaking by regularly checking procedure requirements, availability of items and consumables, date of expiry of items, and medications. Monitor the patients closely during drug and food allergy challenge procedures and record and report patients’ vitals and reactions to treating physicians. Ensure that a patient stays the required observation time after injection(s).

General care: Assess patient needs and suggest solutions to patient care problems. Provide education and resources for the patient and family support as needed. React appropriately and on time during patient reaction situations to mitigate early adverse reactions. Maintain patient, employee, and clinic confidentiality.

Specialist Immunology Nurses

1. • Develop specialist knowledge and experience in immunology.
2. •Develop nurse-led clinics for administering immunoglobulin replacement therapy safely and effectively based on patients’ preferences (IV vs. SC and in-hospital vs. home programs).
3. •Coordinate communication between members of the multidisciplinary team to facilitate the appropriate delivery of care.
4. •Provide education and resources for the patient and family support (insurance issues, resources for vaccination recommendations, concerns regarding traveling and vacations, pregnancy, and any other lifecycle changes).

Background: Allergic rhinitis and asthma exacerbation are strongly linked to respiratory viral and bacterial infections. COVID-19 pandemic has raised concerns about the risk of infection and the severity of COVID-19 infection in patients with asthma and allergic rhinitis. However, increasing evidence suggests that atopic disease protects against severe COVID-19 illness owing to the underlying type 2 inflammatory process. Many studies have reported the impact of asthma on COVID-19 disease; however, data on allergic rhinitis are scarce. In this study, we aimed to investigate the severity and outcome of COVID-19 disease in adult patients with allergic rhinitis in Qatar during the first pandemic wave.

Methods: We conducted a retrospective chart review of adult patients with a confirmed diagnosis of asthma and/or allergic rhinitis who had a positive COVID-19 RT-PCR between February 01, 2020, and December 01, 2020. Parameters evaluated included the WHO classification of COVID-19 disease severity as mild, moderate, severe, and critical; COVID-19 disease outcome; and mortality. Patients with allergic rhinitis were defined as those with typical allergic rhinitis symptoms and positive skin prick test or specific IgE to perennial or seasonal inhaled allergens. Only data about patients with allergic rhinitis has been presented in this report.

Results: We screened 97 EMR Cerner records of patients who had the diagnosis code for allergic rhinitis. Nine patients met the inclusion criteria of allergic rhinitis diagnosis; the remaining either had no allergy testing or had negative allergy tests. Seven (77.7%) patients had mild COVID-19, whereas only one (11.1%) patient each had moderate and severe disease. The length of hospital stays for 6 patients ranged from 5–13 days, and the remaining 3 patients were quarantined at home. No reports of critical cases or death were identified. All the patients recovered from COVID-19 with a favorable outcome.

Conclusion: This preliminary data showed that most patients with allergic rhinitis had mild COVID-19 disease. Furthermore, all of them recovered well, similar to the available data from previous studies. A limitation of this study is the small population size.

Background: Skin prick test (SPT) and intradermal test (IDT) are standard procedures in the allergy practice that are safe when performed. Individuals with a history of allergic reaction to the COVID-19 vaccine can undergo allergy skin testing for polyethylene glycol and polysorbate 80 to determine their eligibility for the same vaccine or a safe alternative.

Hypopigmentation is an infrequent adverse effect of corticosteroids, including triamcinolone acetonide, following local and intralesional treatment. Exposure to high potency corticosteroids for a long duration and the intradermal injection route are risk factors for hypopigmentation.

In this case report, we describe the development of hypopigmentation following triamcinolone ID testing.

Case report: A 29-year-old lady with a history of immediate severe allergic reaction following the first dose of mRNA COVID-19 vaccine (Pfizer) underwent SPT and IDT for polysorbate 80 and polyethylene glycol. Triamcinolone acetonide and Prevnar 13 were used as an indicator of polysorbate 80. Following a negative SPT, IDT for triamcinolone acetonide was negative at 1:10 of 40 mg/mL and positive at 1:1 of 40 mg/mL. A few days later, she noticed hypopigmented lesions at the site of the intradermal skin test for both concentrations of triamcinolone. The lesions have increased in size since then (see image). The patient was diagnosed with steroid-induced hypopigmentation secondary to triamcinolone IDT injection.

Conclusion: Skin hypopigmentation following intraarticular and intralesional triamcinolone injection has been reported previously. However, to the best of our knowledge, this is the first reported case of steroid-induced hypopigmentation following intradermal skin testing. Furthermore, this report highlights that even a low dose of local triamcinolone can cause hypopigmentation. We believe that this case report regarding the rare adverse event will alert clinicians to the potential complication of corticosteroid IDT and help them counsel the patients and provide a thorough explanation before any procedure.

Background: Unverified penicillin allergy has been linked to adverse patient events and increased healthcare expenditure owing to the usage of broad-spectrum, expensive antibiotics. Penicillin allergy test is the gold standard to diagnose penicillin allergy; and in this study, we present data from Qatar which have not been published before.

Methods: Patients with a history of penicillin allergy who underwent penicillin allergy testing between January 2015 and December 2020 at the Allergy Division of the Hamad General Hospital were retrospectively reviewed from the division registry. Benzylpenicilloyl-polylysine (PPL) and minor determinant mixture (MDM) kit DAP-penicillin (0.04 mg +0.5 mg)/vial) (penicillin G, amoxicillin (20 mg/vial), and lately clavulanic acid (20 mg/vial) (DAP, Diater, Madrid, Spain) were used for skin and intradermal testing according to published guidelines. Patients with negative skin tests were administered direct oral challenge with amoxicillin/clavulanate (500/125 mg) and observed for 2 hours.

Results: Of the 189 charts reviewed, 183 patients had a complete data set for analysis. Patients were predominantly women (n = 132, 72%) with an average age of 42 years. Of these patients, 149 (81.4%) had a history of an immediate allergic reaction to penicillin, 10 had a history of delayed reactions, and 24 had other or undefined reactions. A total of 39 (21.3%) patients were diagnosed with penicillin allergy (30 patients with positive skin test results and 9 using a direct oral challenge).

Of the 30 patients with positive skin testing, 5 reacted to PPL, 8 to MDM, 13 to amoxicillin, and 4 to clavulanic acid.

Conclusion: Previous studies indicate that 90% patients with a history of penicillin allergy were able to tolerate the drug (10% were truly allergic). Our data showed that 21% were truly allergic to penicillin. This high positive rate can be attributed to the high pretest probability based on the detailed history obtained before the test, which led to the exclusion of patients with symptoms incompatible with penicillin allergy from the test.

Background: Severe COVID-19 is thought to be caused by immune overdrive and cytokine storm. One of the cytokine storm syndromes frequently induced by infections is secondary hemophagocytic lymphohistiocytosis (HLH) which can be assessed using H-score. In this study, we aimed to evaluate the rate of patients with COVID-19 who meet HLH criteria based on H-score and the association of H-score with poor outcomes.

Methods: In a prospective cohort study of 19 patients with COVID-19 requiring ICU stay from March to May, 2020, we collected demographic and clinical data that focused on H-score's variables and COVID-19 outcomes. H-score ≥ 169 was used to determine the percentage of patients who met the HLH criteria. Mann-Whitney, Kruskal-Wallis, and Spearman rho tests and multiple regression analyses were carried out to evaluate the associated factors. The optimal H-score cut-off to predict poor COVID-19 outcome (need for intubation ± ECMO) was determined using receiver operating characteristic (ROC) analysis.

Results: In 669 patients with severe COVID-19 with a mean ± SD age of 50.3 ± 12.8 years, which comprised 95% men; 66% required intubation, 4% ECMO, and 16% died. Only 2% had an H-score ≥ 169. Patients with poor outcomes had a higher mean (SD) H-score than those without; intubation (96.0 [50.0] vs 75.0 [35.0], p < 0.01), ECMO (113.0 [25.0] vs 93.0 [50.0], p < 0.01) and death (98.0 [62.0] vs 93.0 [48.0], p < 0.01). Factors associated with H-score were diabetes (β coeff = − 10.4, p < 0.01), abdominal pain (β coeff = 19.1, p < 0.01), duration of COVID-19 symptoms (β coeff = − 0.7, p = 0.049), and days before ICU admission (β coeff = − 1.2, p = 0.01). H-score showed a fair ability to discriminate COVID-19 outcomes (AUC 0.61, 95% CI 0.54–0.67). An H-score of 85 was the optimal cut-off with a sensitivity 69% and 1-specificity 53%.

Conclusion: Despite its association with severity in COVID-19, H-score's ability to predict poor outcomes was only fair, indicating differences in the cytokine storm faced in COVID-19 compared with that during secondary HLH.

Background: Qatar has culturally diverse health professionals; and therefore, the care provided may vary according to their background, resulting in variations in care. To bridge this gap, the Ministry of Public Health (MOPH) has established the National Clinical Guidelines (NCG) Program, which aims to reduce variation in care delivery, improve value-add from the healthcare system, adopt international best practices to local context, and enable insurers and providers to access the most currently reviewed evidence-based practice in diagnosis and management of diseases.

The NCG for “Diagnosis and Management of Asthma in Adults” was developed in collaboration between Strategic Planning and Performance Department and Subject Matter Experts (SMEs) who are practicing healthcare professionals representing different healthcare organizations in Qatar.

The NCG aims to standardize the management and treatment received by adult patients with asthma across the healthcare system and adapt the best practice recommendations in the management of asthma to the culture, customs, practice, and formulary of Qatar.

Methods: This NCG has been developed through a rigorous process that aligns with international best practices and localized to the context of Qatar, involving:

1. • Extensive literature search for reputed published evidence specific to NCGs.
2. • Critical appraisal of the literature.
3. • Development of a baseline draft guideline.
4. • Review of the baseline draft by SMEs and patients.
5. • Review of the guidelines by the National Clinical Guidelines and Pathways Committee (NCGPC) from stakeholder organizations across Qatar.

Results: The first edition of the NCG was published on the MOPH website on December 14, 2016; and it was updated and republished on August 22, 2019. A Patient Information Leaflet (PIL) was prepared from the NCG using simple language for use by the patients. The NCG is currently under an updation process based on new evidence since August 22, 2019. A live demo was developed on how to access the NCG and its relevant pathways from the MOPH website and navigate each section of the guidelines.

Conclusion: These NCGs will improve the quality of care for patients with asthma and advocate for the best clinical practice strategies on the management of asthma in adults.

Background: The world is ceaselessly adapting to the ever-changing circumstances surrounding the COVID-19 pandemic, and face masks have become a part of our daily routine. Considering the fact that face masks are here to stay, there are challenges people experience regarding wearing them. In this descriptive study, we aimed to investigate the frequent outcomes of long-term use of face masks in the general population.

Methods: Twenty-five nursing students who attended the university wearing face masks owing to the current pandemic were selected. The data were collected using semi-structured interviews. The interviews were transcribed verbatim and analyzed according to the qualitative content analysis according to the Graneheim and Lundman method.

Results: The mean current age of the students was 20 (standard deviation [SD] = 2.5) years, and 60% of the students were women. The two main themes that emerged during data analysis were:

1. Physical health related problems, which included 3 categories; a) skin reactions, b) respiratory consequences, and c) visual complaints

2. Socioeconomic problems, including the 3 categories of; a) communication failure, b) personal style and appearance, and c) economic factors.

Conclusion: We support the necessity of face masks for a safe reopening of communities. Considering their advantages, some basic measurements are necessary to reduce the abovementioned concerns.

Background: Aspirin-exacerbated respiratory disease (AERD) is a chronic disease characterized by chronic rhinosinusitis, nasal polyposis, asthma, and intolerance to nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin challenge is considered the gold standard for diagnosing AERD. Many patients with AERD have reported clinical benefits when desensitized to aspirin and maintained on daily aspirin therapy. In this study, we have summarized aspirin challenges and aspirin desensitization in our division during the past ten years.

Methods: We reviewed aspirin challenges and desensitization procedures performed in the Allergy and Immunology Division at the Hamad Medical Corporation, Doha, Qatar, between 2010 and 2020 from our procedures log registry and reported the results of the procedures.

Results: The procedures were performed for patients with chronic rhinosinusitis, nasal polyposis, and bronchial asthma with a historical reaction to NSAIDs or those never exposed to NSAIDs. The challenge and desensitization procedure protocol is outlined in table.1. Of the 45 procedures performed, 36 (80%) patients reacted during aspirin desensitization; and their characteristics, historical reaction to NSAIDs, provoking dose, length of desensitization, and types of reactions were reviewed. Of the reactors, 32 (88%) patients completed aspirin desensitization successfully. The mean ( ± SD) age of patients was 46 ( ± 11.6) years, and 51% were women. The historical symptoms were asthma symptoms (56%) and naso-ocular (21%). The common (71%) reaction during the procedure was asthma symptoms, and 29% had naso-ocular symptoms. The provoking dose was 50–75 mg in most patients. The desensitization procedure was carried out over 2 days in most patients; however, 29% of the patients needed more than 2 days to complete the desensitization. None of the reactors needed emergency epinephrine use or hospital admission.

Conclusion: In our review, desensitization was successful in all the patients who reacted to aspirin, and it was the only therapeutic choice for patients with AERD before the era of biologics. The procedure was well tolerated in most patients. Aspirin challenge was positive in 80% of our patients with suspected AERD, and this has an important diagnostic value that may help in choosing the proper biologic, such as dupilumab, for these patients.

The chain of events that leads to the sensitization of the immune system to environmental antigens, resulting in the onset of allergic disease, has been studied in great detail over the past 30 years. However, during this time, the rate of allergic diseases has increased exponentially, indicating the need to concentrate our studies on host-environmental factors that contribute to the onset of disease. Monocyte-derived dendritic cells (DCs) play a key role in driving localized and systemic immune responses. In this study, we developed a platform for screening the molecular signature and phenotypic profile of DCs activated by allergenic stimuli, including TSLP, IL-25, IL-33, IL-1a, Vit-D3 (1α,25-Dihydroxyvitamin D3), PAR1-AP Peptide, Papain, and recombinant human DerP1 protein to induce a type II associated inflammatory signature. Following activation with allergenic stimuli, modulated DCs are subjected to deep phenotyping via flow cytometry for surface and intracellular markers to detect and/or validate immunomodulatory properties. RNA sequencing is further used to compare the gene expression profiles of DCs responding to either allergenic or microbial stimuli, including the TLR3 agonist dsRNA Poly I:C and TLR4 agonist LPS. In our study, we aimed to identify key molecular signatures of DCs involved in the development of asthma and allergy based on their comparative activation with this broad panel of allergens. We expect to determine central control modules of transcription factors in DCs associated with Th2 induction.

Background: Adverse reactions to local anesthetics (LA) are relatively common; however, true IgE-mediated allergy is extremely rare, estimated to occur in less than 1%. Investigating patients with suspected allergy to LA should begin with a detailed history to exclude other more common operation theater related culprit medications, followed by skin testing. The subcutaneous challenge is considered the gold standard for confirming true IgE-mediated allergy to LA. In this study, we have described the skin prick test results of patients with suspected lidocaine allergy who had historical reaction symptoms typical to IgE-mediated allergic reactions.

Methods: The data were retrieved from the allergy procedure log registry for patients who were referred to the allergy clinic with a suspected allergic reaction to lidocaine at the Hamad Medical Corporation between 2016 and 2020. These patients’ symptoms of historical reactions to lidocaine were compared to their skin test results.

Result: A total of 7 patients were identified. The skin test result for lidocaine was positive in only 1 patient; his historical reaction was anaphylaxis (urticaria/angioedema and shortness of breath). The remaining 6 patients had a negative result for skin and challenge tests. Of these 6 patients with negative results, 4 had only urticaria/angioedema as historical reactions; 1 had systematic manifestation (tachycardia) along with urticaria/angioedema, and 1 experienced systemic symptoms (shortness of breath, chest pain, and palpitation) with no skin or mucous membrane involvement (Table 1).

Conclusion: Negative skin test and subcutaneous challenge with a history of generalized cutaneous symptoms and/or systemic symptoms during the reaction to LA can be attributed to many causes, such as an IgE-mediated reaction against a component other than lidocaine (e.g., latex), medication side effects (adrenaline in combined preparations), and/or symptoms of primary disease (chronic spontaneous urticaria/angioedema).

Allergic diseases constitute significant health and economic issues in both developed and developing nations, with epidemiological studies demonstrating a rapid increase in the global prevalence of food allergy among the pediatric population. Cow milk protein allergy (CMPA), one of the most common forms of food allergies observed in early childhood, affects between 2%–6% of infants and children under 3 years of age. CMPA can present as either an IgE-mediated atopic allergy or a non-IgE mediated allergic response. Antigen-specific T cells play a pivotal role in directing the type of inflammatory immune response that occurs as well as in the formation of immunological memory. IgE-mediated CMPA is thought to develop because of an abnormal expansion of allergen-specific type-2 helper T (Th2) cells and a corresponding deficiency in immune regulation by regulatory T cells (Tregs), thereby altering the Th2/Treg balance. The gut microbiota, established very early during childhood through host-microbe interactions, can influence the incidence of allergic diseases. In this study, we aimed to analyze both the microbiome composition and CD4+T cell differentiation patterns in pediatric patients with and without cow milk allergy to establish the association between these factors. Using 16S rRNA sequencing, we analyzed the microbiome composition in stool samples of allergic and non-allergic pediatric patients aged between 1–4 years and identified the microbial species abundant in IgE and non-IgE mediated cow milk allergies. To assess the CD4+T cell differentiation patterns, peripheral blood mononuclear cells (PBMCs) from these patients were re-stimulated with cow milk antigen, and T cell subsets were assessed using flow cytometry. Antigen-specific CD4+T cells were identified and sorted for high throughput sequencing and subsequent gene expression analysis. The CD4+T cell differentiation patterns of the total and antigen-specific T cells were analyzed and statistically compared with controls. The identification of the correlation between the CD4+T cell differentiation patterns and species-specific microbial abundance in IgE and non-IgE mediated cow milk allergies can help in determining how the gut microbiome influences the CD4+T cell immune compartment development, ultimately leading to the development of cow milk allergy in pediatric patients.

Background: Patients undergoing hemodialysis are exposed to various potential allergens from medication, dialysis catheters, topical antiseptics, and different adhesive dressings. Many patients develop a local allergic reaction and get itchy rashes, which may get infected, leading to significant morbidity and preventable health cost. In this study, we aimed to report the incidence of contact dermatitis (CD) and its potential complications in hemodialysis (HD) patients at the Al Wakra Hospital Dialysis unit.

Methods: We performed a retrospective chart review of documented local allergic reactions at vascular access sites for the HD patients at the Al Wakra Hospital.

Results: Currently, 102 patients are getting maintenance HD through catheters or arteriovenous (AV) fistula. Twelve (14.4%) patients developed CD (7 [58%] had cuffed jugular dialysis catheter, and 5 [42%] had an AV fistula). Most patients (75%) developed CD in the early period of dialysis initiation, and 25% developed it later in the course. Most patients responded to removing adhesive plasters and dressing the vascular access site using gauze only and topical steroids (hydrocortisone 1% cream/mometasone 0.1% cream). Two (16.6%) of the 12 patients developed vascular access site infection, of whom 1 had an AV fistula and developed a severe rash with cellulitis leading to sepsis and 2 admissions, although blood cultures remained negative. The patient responded to IV antibiotics and local mometasone 0.1% cream. Complete removal of all adhesive tapes helped prevent recurrence of the rash. Later, dressing of the AV fistula site was performed only with a cotton gauze. The second patient had a jugular catheter and developed an allergic rash leading to cellulitis and tunnel infection. Swab culture showed Staphylococcus aureus from the exit site sensitive to cloxacillin/cefazolin. The patient improved after local and oral antibiotics and removal of adhesive tapes. The catheter was not removed, and the patient did well.

Conclusion: The incidence of CD at our dialysis unit is 14.4%. Previously published reports from other dialysis units showed a lower incidence of 1.25%. Early identification and diagnosis of allergic rash at the vascular access site and avoidance of adhesive plasters and other potential allergens prevent complications like infection and loss of precious vascular accesses in these patients.

Background: The diagnosis of typical cold urticaria (ColdU) relies on whealing in response to local cold stimulation testing (CST). It can also manifest with cold-induced anaphylaxis (ColdA). Till date, it is largely unclear how often patients with ColdU receive adrenaline treatment and are provided with an adrenaline autoinjector (AAI). Methods: An international, cross-sectional study, COLD-CE (i.e., comprehensive evaluation of ColdU and other cold-induced reactions), was carried out at 32 UCAREs. Detailed histories were taken and CST with an ice cube and/or TempTest^® performed. ColdA was defined as an acute cold-induced (i.e., by cold water, air, or surfaces) involvement of the skin and/or visible mucosal tissue and at least one of the symptoms (cardiovascular manifestations, difficulty breathing, or gastrointestinal symptoms). Results: Of the 551 ColdU patients, 75% (n = 412) had a positive CST. Of them, concomitant chronic spontaneous urticaria was diagnosed in 10%. Of 372 patients with stand-alone ColdU, 69% were women and 91% adults. Their median age was 36 (IQR 26 − 48) years. Patients were also categorized into residents of countries with a tropical (n = 33), temperate (n = 264), or cold (n = 75) climate (Table 1: R13C1, R17C1, R21C1). AAI was more often prescribed to residents of temperate than tropical countries (30% vs. 12%, p = .038; Table 1: R31C1), although the frequency of ColdA did not significantly differ between these countries (44% vs. 42%, p = 1.000; R29C2). Residents of tropical countries had a higher frequency of ColdA induced by cold air than residents of temperate (36% vs. 12%, p = .001; R29C4) or cold (36% vs. 12%, p = .007; R25C4) countries. Cardiovascular manifestations induced by cold air were diagnosed in 33% (n = 11) of residents of tropical countries, but only 18% (n = 2) and 36% (n = 4) of them had received adrenaline and AAI, respectively (R13 − 15C7). Furthermore, hypotension and/or loss of consciousness induced by cold air occurred in 18% (n = 6) of patients, but only 17% (n = 1) received adrenaline (R13 − 14C10). ColdA was induced by complete cold water immersion in 9% (n = 3) of patients, and none of them received adrenaline treatment nor AAI (R13 − 15C3). Conclusion: Our findings suggest that ColdA is undertreated and call for changes in ColdU management. Acknowledgement: This work benefited from the support of the GA²LEN UCARE network (www.ga2len-ucare.com), and the results reported here were presented at the First Qatar Allergy Conference and published in Allergy, the European Journal of Allergy and Clinical Immunology.

The hesitancy in taking COVID-19 vaccines is a complex process influenced by several factors, including individual, social, and cultural. Health literacy and community awareness around mRNA COVID-19 vaccines are critical for successfully combating the pandemic. Healthcare professionals, including family physicians and nurses, can help increase community awareness and mitigate some misconceptions and hesitancy regarding mRNA COVID-19 vaccines in people's attitudes. Therefore, in this study, we aimed to explore how the interaction between an individual's social identities such as gender, ethnicity, culture, knowledge, and belief impact their hesitancy and attitudes toward mRNA COVID-19 vaccines. We aimed to describe our experience in dealing with people residing in Qatar from the perspective of healthcare practitioners from the Qatar University Health Center during the period when mRNA COVID-19 vaccines was introduced in a time frame of 6 months (April to October, 2021).

We identified several factors associated with the reluctance to receive mRNA COVID-19 vaccines once vaccination services were available, affordable, and accessible to everyone in Qatar (Table 1). Most individuals were hesitant and refused to take mRNA COVID-19 vaccines owing to the unjustified myths and fear about potential side effects of vaccines in general and unknown long-term effects of vaccination, especially among women who were uneducated. We believe we have been able to put forth a fair, unbiased, and balanced argument between an individual's right to take or refuse the vaccine and the overall benefits to the public and community health in terms of the overall community immunity when the vast majority of the population will be vaccinated. Our experience could assist in developing culturally sensitive and tailored community outreach programs to increase community awareness as it is the cornerstone on which public health can fight the irrational myths, fear, misconceptions, vaccine hesitancy, and improve vaccination coverages. Moreover, our shared experiences might be able to better prepare future launching of pandemic vaccination campaigns in order to minimize vaccine hesitancy.