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

Background: Atopic dermatitis (AD) is a common chronic inflammatory skin disorder that affects up to 3% of adults and 15%-20% of children across the world. Although the mainstay of treatment is topical corticosteroids and/or calcineurin inhibitors, a majority of patients will not achieve a control of their condition and will need systemic treatment with steroids and immunosuppressants (1). Omalizumab is a humanized anti-IgE antibody licensed by the European Medical Agency for treatment of severe allergic asthma and spontaneous chronic urticaria in children older than 6 and 12 years, respectively; and a promising efficacy of omalizumab in the treatment of severe refractory AD has been shown by the ADAPT randomized clinical trial (2).

Case report: A 6-year-old male patient being treated and followed at a pediatric dermatology clinic for a diagnosis of AD since the age of 3 years, showed unresponsive disease to different topical treatment options and non-pharmacological measures. The patient was referred to our clinic for systemic treatment when his SCORAD index was 70/103. At our immunology clinic, we did an extensive workup to unveil a comorbid or underlying disease. His labs showed high IgE levels at 2500 IU/mL, hypereosinophilia, and normal IgA, IgM, and lymphocyte subsets. We started him on different lines of immunosuppressants, including cyclosporine, prednisolone, tacrolimus, and intensive topical treatment; however, the patient did not show any noticeable response for 2 years. We then started him on omalizumab 300 mg twice weekly, and the SCORAD index dropped to 57 at 12 weeks and 55 at 18 weeks. The drug is still well tolerated, and we were able to stop systemic steroids at 15 weeks of treatment.

Conclusion: Off-label use of omalizumab in a 6-year-old child with refractory severe AD was effective and safe in controlling the disease even though conventional systemic immunosuppressants proved ineffective.

Background: Cow's milk allergy is a common type of allergy in infants that is caused by the immune response to proteins in cow's milk. Digestive manifestations, atopic dermatitis, and respiratory discomfort are some of the clinical manifestations that appear; however, none of them are objective criteria to confirm the diagnosis, which may result in misdiagnosis, treatment hindrance, and parental concerns. Therefore, new methodologies for an accurate and immediate diagnosis is essential.

Methods: In this descriptive study, infants referred to the pediatric health center in Sulaymaniah were selected during a period of 1 year. The data were collected using a demographic questionnaire and the Cow's Milk Related Symptom Score (CoMiSS). Chi-squared and independent t tests were used to analyze the data.

Results: The findings of the present study indicated that among 250 infants (117 boys, 133 girls), with a mean ±  SD age of 2.9 ± 1.6 years, 21% were breastfed, 39% were fed both cow's milk and breast milk, and 60% were fed only cow's milk. The contingency of cow's milk allergy was positive in 35% of infants. According to this questionnaire, 18% of the participants got a score of 0–5, 47% scored 6–11, and 35% scored ≥ 12. A significant relationship was found between cow's milk allergy and the participants’ diet (p < 0.001). A significant association was also found between age-dependent growth index (weight p = 0.04, height p = 0.01, and head circumstance p = 0.02) and cow's milk allergy.

Conclusion: Although common problems in infancy such as colic and reflux may interfere with an accurate diagnosis of cow's milk allergy, give false-positive results, and decrease the reliability of CoMiSS; there is a need for non-invasive and easy methods for early diagnosis and improving awareness to encourage parents to take preventive measures.

Background: Foreign body (FB) aspirations in adults are relatively uncommon. The most commonly aspirated FBs in adults are organic, especially vegetable matter, peanuts, and fragments of bones. We report a rare case of a FB discovered in the left main bronchus of an adult male admitted to the intensive care unit. Case report: A 52-year-old male smoker with COPD presented to the emergency department with a two-day history of increasing dyspnea and cough. He was hypoxic and febrile with a temperature of 38°C. Auscultation revealed decreased breath sounds over the left lung and a few rhonchi on the right side. Chest x-ray showed left lung collapse. His condition rapidly worsened, and he was immediately intubated for acute respiratory failure. CT chest identified a large endobronchial mass obstructing the left main bronchus. Flexible bronchoscopy confirmed a soft and mobile brownish lesion in the left main bronchus. The histological appearance of the specimen retrieved was consistent with an organic foreign body. This was later identified as a melon chunk. It was removed successfully via flexible bronchoscopy by cutting it into smaller pieces to aid retrieval. Conclusion: FB aspiration can occur in all age groups but is less common in adults accounting for only 0.16%–0.33% of adult bronchoscopic procedures. Early detection of an aspirated FB is essential to avoid significant complications, morbidity, and mortality.

In this report, we have described a child suffering from Mendelian susceptibility to mycobacterial disease (MSMD) owing to an autosomal recessive, complete T-bet deficiency, which impairs IFN-γ production by innate and innate-like adaptive, but not mycobacterial-reactive purely adaptive lymphocytes. In this study, we explored the persistent upper airway inflammation (UAI) and blood eosinophilia in this patient. Unlike the wild-type (WT) T-bet, the mutant form of T-bet from this patient did not inhibit the production of T helper 2 (Th2) cytokines, including IL-4, IL-5, IL-9, and IL-13, when overexpressed in Th2 cells. Moreover, Herpesvirus saimiri immortalized T cells from the patient produced abnormally large amounts of Th2 cytokines, and the patient had markedly high plasma IL-5 and IL-13 concentrations. Finally, the patient’s CD4⁺ αβ T cells produced most of the Th2 cytokines in response to chronic stimulation, regardless of their antigen specificities, a phenotype reversed by the expression of WT T-bet. T-bet deficiency thus underlies the excessive production of Th2 cytokines, particularly IL-5 and IL-13, by CD4⁺ αβ T cells, causing blood eosinophilia and UAI. The MSMD of this patient results from defective IFN-γ production by innate and innate-like adaptive lymphocytes, whereas the UAI and eosinophilia result from excessive Th2 cytokine production by adaptive CD4⁺ αβ T lymphocytes.

Background: Penicillin (PNC) allergy is a major healthcare concern that necessitates antibiotic substitution which is associated with increased costs, worse clinical outcomes, and increased risks of antimicrobial resistance. Many patients are labeled as PNC allergic; however, this has been rarely confirmed. In this audit, we aimed to determine the characteristics of PNC allergy labeling.

Methods: A list of all the patients labeled with PNC allergy who presented to the Hamad General Hospital (HGH) for any medical reason from January to December 2021 was generated from pharmacy system. Of those, 30% were randomly selected for audit review. Electronic health records of the selected patients were retrospectively reviewed to identify the allergy labeling characteristics and whether the patients had recently received an antibiotic within the PNC class without developing any allergic reaction.

Results: Of the 464 patients identified with labelled PNC allergy, 139 patients were randomly selected and reviewed. Of the reviewed patients, 82 (59%) were women with an average ( ± SD) age of 46 ( ± 16.5) years. Forty-six patients were categorized to have a mild PNC allergy, and only 18 were categorized as severe with the remaining patients categorized as having a moderate PNC allergy. Despite documentation of severity, an accurate description of the allergic reaction event was significantly lacking with only 30/139 (21.5%) patients having clear documentation of the event description. Twenty (14.4%) patients labeled as PNC allergic received at least one antibiotic within the PNC class (e.g., piperacillin-tazobactam, ampicillin-sulbactam, or amoxicillin-clavulanic acid) safely without any documented reactions. Interestingly, of those 20 patients, 4 were categorized as being severely allergic to PNC. However, as more than 80 patients presented to the hospital for reasons not requiring antibiotics; experiences with PNC could not be assessed effectively.

Conclusion: Poor documentation of the details of allergic reactions may falsely affect future antibiotic decisions. The results of this audit highlight the need for standardizing the documentation process of medication allergy. In addition, reviewing the patient's experience with other drugs within the PNC class can guide healthcare providers during the PNC allergy evaluation.

Background: Prior to pulmonary function testing (PFT), local and international recommendations advise pre-procedural screening. Pulmonary function tests generate aerosol droplets containing millions of viruses, significantly increasing the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission not only to the individuals in and around the PFT office, but also to subsequent patients who undergo the test later in the same room.

Methods: This clinical audit was carried out to establish the rate of positive pre-procedural SARS-CoV-2 PCR testing before a PFT. The data were obtained over a 6-week period from our ATS accredited pulmonary function laboratory at the Hamad General Hospital, Qatar (December 01, 2021, to January 10, 2022). The PFT laboratory was closed from January 10, 2022, till the date of this report (January 27, 2022) owing to an increase in COVID cases in the community in Qatar during the fourth wave.

Results: All the patients scheduled for PFT were asymptomatic of COVID-19. A total of 331 individuals were scheduled for PFT, and 221 PFTs were performed. There were 109 no-shows for both the PCR and the PFT. Between weeks 1 and 4, all the pre-procedural SARS-CoV-2 PCR tests were negative. The weekly average number of COVID-19 cases in Qatar increased from 157 per 100,000 population in week 1 to 2,918 in week 6.² There was a similar trend in the pre-procedural SARS-CoV-2 PCR tests that increased and resulted in identifying 9 cases with positive SARS-CoV-2 PCR test over weeks 5 and 6 (Figure 1).

Conclusion: As the number of documented positive SARS-CoV-2 PCR tests in the community grew, so did the pre-procedural COVID-19 PCR positivity and the number of no-shows. The large number of no-shows may indicate greater worry or concern about contracting COVID-19 when visiting the hospital amid peak community cases. Our findings further call into question the utility of routinely performing pre-procedural PCR screening in asymptomatic cases when the prevalence of COVID-19 is low in the local population. Perhaps, it is time to consider replacing this with on-the-spot quick antigen testing for more effective use of resources.

Background: Honey is a natural product; and in terms of phytochemical composition, it contains a high number of flavonoids and polyphenols such as quercetin, kaempferol, chrysin, and apigenin. Flavonoids found in honey mitigate the inflammatory processes, thereby exhibiting the anti-inflammatory potential of honey. Besides their anti-oxidant activities, flavonoids have the ability to inhibit pro-inflammatory enzymes such as LOX, COX, iNOS, and pro-inflammatory mediators, including cytokines, nitric oxide, and chemokines. Furthermore, flavonoids modulate transcriptional factors such as NF-?B, thereby controlling the expression of several inflammatory mediators.

Methods: Clinical uses of natural raw honey have been studied at our Umm Ghuwailina Health Center, Doha, Qatar, with daily application under occlusion with promising results, in various patients with multiple conditions, including eczema, seborrheic dermatitis, and psoriasis. A layer of honey was applied to the lesion site, covered with a transparent securement dressing, and washed off for 7 consecutive days for patients with atopic dermatitis and psoriasis. The Three Item Severity (TIS) score, which includes erythema, edema/papulation, and excoriation on a scale from 0 to 3, was used for atopic dermatitis. For psoriasis, the primary outcome measure was the intensity component of the validated Psoriasis Area and Severity Index (PASI) and the Visual Analogue Score (VAS). Participants who were allergic to honey or receiving any corticosteroid within the last one month were excluded.

Results: Twelve patients with atopic dermatitis had a significant improvement from a TIS score of 6 to 1 noticed in the honey-treated lesion 1 week later. With regard to psoriatic lesions, 6 patients were studied. There was a significant overall improvement in their psoriatic lesions, reaching a PASI score of 80 even one month after stopping the topical honey application. The vast majority of patients showed a significant improvement and no side effects.

Conclusion: Raw natural honey might be a promising efficacious and cost-effective alternative to advanced anti-inflammatory products. However, well-designed double-blind placebo-controlled clinical trials are needed to confirm the benefits of honey from different botanical sources.

Knowledge about diurnal, seasonal, and annual fluctuations in airborne pollen and fungal spores in any geographical area is essential for effective diagnosis and treatment of allergies. Aerobiological analysis enables the detection of airborne pollen and spores, thus providing information on plant phenology, plant distribution, related diseases, and the risks for some species in terms of allergies. Although pollen and fungal spores have been widely studied as aeroallergens throughout the world, not much is known about the biological aerosols in countries with a desert environment; and these could be present in much higher concentrations than expected. Arid desert regions (including the region surrounding the Arab Gulf), characterized by hot weather, poor soils, and low biological productivity, have typically been neglected when building ambitious biomonitoring networks for the large-scale monitoring of biological particles; however, few studies in Kuwait, Saudi Arabia, and recently Qatar have aimed to delineate the various botanical families that contribute to inhalant allergens in this region.

Understanding the aerobiological features of countries with hot and desert climates may better prepare healthcare providers to assist patients with allergic rhinitis. It may be argued that one of the reasons why aerobiologists have only recently turned their attention to the state of Qatar investigating how pollen and fungal spore records could contribute to evaluating the correlation between different pollen conditions and allergy symptoms.

The first aerobiological network of Qatar was monitoring (2017–2020) the atmospheric pollen concentrations of Doha and Al Khor to determine the association between the possible risk of respiratory allergies and the distribution of certain species throughout the region. In the Qatari database, more than 25 native taxa have been recorded, up to 50% of which can be considered allergenic. This includes Amaranthaceae and Poaceae pollen among the major aeroallergens causing allergy symptoms in Qatar. Our study has confirmed a statistically significant association between Amaranthaceae and asthma and allergic rhinitis. To summarize, it is worth considering aerobiological monitoring in desert climate regions when assessing the effectiveness of pollen allergy therapy and planning prevention methods for patients.

Background: Intravenous immunoglobulin (IVIG) therapy has been used as antibody replacement therapy in primary immunodeficiency diseases (PID) for more than 50 years. In this study, we aimed to define IVIG usage and adverse reactions and complications in PID and explain how subcutaneous immunoglobulin (SCIG) replacement therapy is an alternative that improves the patient experience. In addition, the additional nursing responsibilities associated with this service were also identified.

Methods: Data and service satisfaction surveys for the last 10 years were reviewed from the Allergy and Immunology Division log registry for those on IVIG and SCIG.

Results: IVIG practice: Most patients currently on IVIG in our unit have PID. Adverse reactions occur during the initial 30 to 60 minutes of the infusion and are mild and self-limited. Infusion reactions are more likely to occur in patients receiving IVIG for the first time. Infusion-related complications included pyrogenic reactions, allergic reactions, and vasomotor symptoms. Complications reported in the literature such as the transmission of blood-borne pathogens and other serious complications, including thrombotic events, renal adverse events, and aseptic meningitis were never reported. Pyrogenic reactions occurred at a rate ≥ 100 mL/hr in at least 3 patients, and a slower infusion rate of ≤ 75 mL/hr mitigated this rate-related complication.

SCIG program: This program started in Qatar in 2017. Usually, the clinician assesses and evaluates several factors to help select candidates for this therapy, including the perceptions of inconvenience and/or pain of IV infusions, presence of difficult vein access, and other relevant clinical and social factors. Once training in the appropriate techniques has been accomplished (3–6 sessions), it is most often self-administered in the home setting by the patient or a parent for a child. Table 1 summarizes patients on SCIG.

Additional nursing responsibilities: The nursing role in subcutaneous IgG administration is primarily that of an educator and to help the patient/family become independent. This can be achieved by the assessment of appropriate patient selection for self-administration. Determining which patients are suitable include adequate patient education with return demonstration of the necessary skill set, monitoring parameters, educating patients about their medication, and providing educational resources and support.

Conclusion: SCIG administration can be a convenient alternative for patients with PID receiving long-term IVIG.