Qatar Medical Journal - 2 - Second Qatar Allergy Conference, April 2023

The 2^nd Qatar Allergy and Immunology Conference was organized by the Adult Allergy and Immunology Division of Hamad Medical Corporation (HMC) over two days as a hybrid conference on the 10^th and 11^th of February 2023 at ITQAN Clinical Simulation and Innovation Centre. The conference was preceded by two pre-conference workshops directed toward physicians and nurses on the 9^th of February, 2023. The workshops aimed to promote awareness about allergic and immunologic diseases among physicians and nurses.

The 2^nd Qatar Allergy and Immunology Conference represented a great learning platform for healthcare professionals and opportunities to update knowledge, present research, and meet professionals since allergy and immunology practice is a rapidly evolving science focusing on allergic and immunologic conditions and their advanced treatment options. The conference’s scientific program focused on the following topics: airway allergy and asthma, skin allergies, diagnosis and management of primary immunodeficiency diseases, and novel therapeutics for allergic diseases.

One of the significant achievements of this year’s conference is conducting a focused research symposium that provides a flagship platform for medical students and faculty scholars to present their research experiences and up-to-date health topics and to share their experiments and research findings with a broader community. It aimed to gather scientists and physicians from across Qatar and internationally with recent updates regarding the role of precision medicine in allergy and immunology science and practice.

HMC supported the event in partnership with the Qatar Allergy and Immunology Society (QAIS) (a chapter of the Qatar Medical Association). It was accredited for 21.25 CPD Category 1 as defined by the Ministry of Public Health’s Department of Healthcare Professions.

The conference hosted many expert speakers from Qatar, the Gulf region, and internationally. The total number of participants was 1082, comprised of physicians, nurses, and scientists. We received 34 abstracts, 32 were accepted for poster presentations, and the best six were selected for the oral presentation session.

Another achievement of our conference is advocating the Arabic language. One lecture and one oral abstract were presented in Arabic to demonstrate the importance and simplicity of using the Arabic language in medical education and science.

Background: Allergic respiratory diseases (allergic rhinitis and asthma) are major health problems with high prevalence causing significant patient morbidity as well as an economic burden (1). Sensitization to inhaled allergens is a major factor in the pathogenesis of allergic respiratory diseases (2). This study aims to determine the commonest aeroallergen sensitization in patients with allergic symptoms who attended an Adult Allergy Clinic in Qatar.

Methods: This retrospective study reviewed the skin prick test results database of 20 aeroallergens performed between January 1^st to December 31^st, 2022, at an Adult Allergy clinic in Qatar. Based on skin test results, the most prevalent aeroallergens were determined.

Results: A total of 554 patients (43% males, 57% females), aged between 12-87 years, 36±13.8 (mean ± SD), underwent skin prick test, of which 378 patients (68%) had positive results. There were no significant sex differences in the frequency of atopy (males: 60% versus females: 65% p= .076). Of the total 554 patients, 62% were diagnosed with Allergic rhinitis, 19% with non-allergic rhinitis, 32% with asthma, 6.7% with chronic urticaria, and 6.5% with atopic dermatitis. The frequency of sensitivity to aeroallergens was Dermatophagoides pteronyssinus 49.5%, Dermatophagoides farina 38.6%, Cat 37.3%, American Cockroach 25.9%, Russian thistle 24%, German cockroach 20%, Rough pigweed 19%, Bermuda grass 11%, and 8% to seven grass mix. 61 % were sensitized to indoor aeroallergens and 31% to different pollens (outdoor). Of the 378 patients who were sensitized, 145 patients (38%) were monosensitized, and 233 (62%) were polysensitized (≥ 2 allergens). There were no significant differences in the frequency of polysensitization between males and females (M:F: 1:1, p=0.938).

Conclusion: Insects (house dust mites and cockroaches) and animal protein (cat hair) were the most prevalent positive aeroallergen by skin tests. However, weed, tree pollens (Russian thistle, Rough pigweed, Mesquite tree), and grass pollens (Bermuda and seven grass mix) were also positive for a minority of patients. 62% of patients were polysensitized to aeroallergens.

Introduction: Subcutaneous immunoglobulin (SCIG) and intravenous immunoglobulin (IVIG) are used for the treatment of primary immunodeficiency (PIDD). SCIG is as effective as IVIG in preventing infections.¹ However, SCIG has advantages over IVIG as it causes fewer systemic reactions and can be infused at home by the patient leading to improved quality of life.²

Methods: We retrospectively analyzed adult patients with PIDD who received SCIG in an Adult Allergy Clinic in Qatar. Patients who received IVIG before SCIG and are naïve to IgG replacement were included. We compared Serum IgG levels, the number of antibiotic courses received, and the number of hospital admissions one year before and one year after starting SCIG. SF36 score was used to compare health-related quality of life scores before SCIG and after one year of SCIG.

Results: Twenty patients were included in the study, of which 17 were on prior IVIG replacement, and three were naive to replacement. SCIG replacement resulted in the maintenance of serum IgG levels in those who received IVIG prior. SCIG resulted in a statistically significant reduction in the number of antibiotics prescribed and hospitalization in the naïve subgroup but no substantial change in the prior IVIG group. 6/20 patients developed side effects like injection site pain, swelling, and headache. No patients developed significant systemic side effects. 10/20 patients discontinued the SCIG therapy, four patients due to side effects, and others due to noncompliance and financial reasons. SF36 Score was compared for the five patients in IVIG prior group and showed no significant improvement in individual score but improvement in the overall score (p=0.003)

Conclusions: In our experience, SCIG therapy effectively prevents recurrent infection in PIDD patients, and patients did not experience any significant systemic side effects. There is a substantial improvement in the quality of life. However, compliance continues to be a problem.

Background: Patch testing is the primary diagnostic approach for contact dermatitis,¹ an inflammatory skin reaction caused by exposure to external irritants. The pathophysiology of contact dermatitis may entail an immunological response (hypersensitivity type IV), a non-immunological response (irritant contact dermatitis), or a mix of the two. The diagnosis of contact dermatitis requires a correlation between a positive patch test and clinical relevance.² This study aims to determine the prevalence of allergy sensitization among adults in Qatar and the allergens most frequently associated with positive patch test findings.

Methods: Retrospective analysis used patch testing data from 2015 to 2022.

Results: Of the 87 patients tested, 43 had at least one positive reaction (mean age 41.7; range 19–68). Females were 33 of the total patients (76.7%). Thirteen (30%) patients had two or more positive reactions. The most common allergen groups associated with positive patch test reactions were nickel sulfate no. 12 (27.9%), and all reactants were female. followed by gold sodium thiosulfate no. 10 (23.3%, F:M = 2.3), p-phenylenediamine no. 10 (23.3%, F:M = 1.5), and p-tert-butylphenol formaldehyde resin no. 7 (16.2%, F:M = 6). Twenty-six reactants had one or more allergic disorders (allergic rhinitis, asthma, drug allergy, insect bite allergy, or chronic idiopathic urticaria), and 11 had atopic dermatitis.

Conclusion: Triggering agents for contact dermatitis vary among geographic regions and populations. This study gives an idea of the allergens that are the most common sensitizers among the contact dermatitis population in the adult allergy clinic in Qatar.

Introduction: Acquired cold-induced urticaria is a form of physical urticaria that is usually spontaneous. However, reports have shown that bees, wasps, or jellyfish stings can trigger it. We report the first case of cold-induced urticaria following black ant bite-induced anaphylaxis.

Case Report: A 41-year-old lady with no chronic illness with a known black ant bite allergy history. Three years ago, she sustained a black ant bite that required an emergency room visit to treat anaphylaxis. A few days later, she developed attacks of generalized hives on exposure to cold air and objects. She was started on desloratadine tablets which controlled her symptoms. The patient was given EpiPen and instructed to avoid black ants’ approach and exposure to cold. She was then followed up in our clinic.

Discussions and Conclusions: Acquired cold-induced urticaria is a form of physical chronic inducible urticaria. Physical urticarias account for 25 % of chronic urticarias. The patient can have wheals, angioedema, or both in response to the cold exposure. Symptoms can be mild or severe, limiting the patient’s quality of life. Acquired cold urticaria is idiopathic; however, cases have been reported after different triggers, such as insect stings (bees, wasps, and jellyfish). The black Samsum ant is a recognized trigger of allergic reactions in Qatar and the Gulf region. In a study done in Qatar, 23.5% of anaphylaxis cases were due to black ant stings. There are no validated or standardized skin tests or immunotherapy for the black Samsum ant, which necessitates physicians to be careful in assessing such patients and focus on taking a detailed history. The limitation of testing and immune therapy makes history the tool for diagnosis, and avoidance is the mainstay of treatment.

Introduction: The pathophysiology of chronic spontaneous urticaria (CSU) is not yet fully understood; however, increasing evidence supports the association between CSU and autoimmunity.

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder. MG management relies on using immunosuppressants and avoiding certain medications that can precipitate an MG crisis.

The coexistence of CSU and MG was described in the literature on elderly patients. Herein we present a challenging case regarding the management of CSU in a young female with MG.

Case report: A 22-year-old lady known to have Myasthenia gravis post thymectomy, with a history of multiple MG crises, presented to the Allergy Clinic with recurrent itchy hives typical for urticaria without associated angioedema. Despite being on Azathioprine and low-dose steroids for MG treatment, she had an active CSU disease, UAS7:32, UCT: 5. The neurologist advised against the use of regular oral antihistamines because they might exacerbate MG. Although we do not have serum autologous skin testing, basophil activation test, or IgG autoantibodies for a definitive definition of autoimmune CSU (aiCSU), the patient has some features supporting the diagnosis of aiCSU (see Table 1). In addition, she has a normal total IgE level, normal C3, C4, negative RF, ANA, ANCA, anti-TPO, and anti-thyroglobulin antibodies.

After the discussion with the neurologist, we started her on Omalizumab 300 mg every four weeks, which was increased to 450 mg every two weeks with partial control of CSU. She was started on rituximab to treat MG with improvement in CSU.

Conclusion: To the best of our knowledge, limited data describing the association between MG and CSU in young patients. Moreover, there is insufficient data on the safety of antihistamines in patients with MG, which are the first line of treatment for CSU.

There are clinical and laboratory biomarkers that help in identifying CSU endotypes. Recognition of aiCSU endotype is essential as it helps predict disease course and response to treatment. Moreover, careful therapeutic interventions in patients with CSU and coexistent autoimmune diseases are warranted to achieve efficacy and reduce drug interactions and adverse effects.

Background: Acute urticaria is urticaria with or without angioedema that is present for less than six weeks, while chronic urticaria is present for more than six weeks.

Pityriasis lichenoides (PL) is a benign cutaneous inflammatory disease of unknown etiology. Acute PL typically resolves within a few weeks, while chronic PL lasts several months. The skin rash of PL may resemble the rash of other conditions, so the distinction is essential and depends on history and physical examination and is confirmed by skin biopsy.

Case report: A 64-year-old gentleman presented with seven days history of generalized itchy skin (hives). Individual lesions last 24-48 hours and do not leave pigmentation or scarring. No systemic involvement. No specific triggers, with two previous similar episodes 30 years and 20 years ago. Levocetirizine, 5 mg tablet, was prescribed, and he was instructed to increase the dose to 4 tablets daily if needed. On reassessing the patient after ten days, he did not respond well. The rash was different from the initial one, with individual lesions lasting for five days or more, so he was referred to a dermatologist for a skin biopsy. Basic investigations were normal. Performing skin biopsy is needed to exclude other pathologies. Skin biopsy showed pathological changes of lichenoid dermatitis compatible with pityriasis lichenoides et varioliformis acuta (PLEVA). He has been treated with azithromycin 250 mg daily for three weeks with rapid and complete resolution without scaring.

Conclusion: Urticarial rash may mimic the skin rash of other conditions. Detailed serial history and physical examination are warranted to exclude other diagnoses. Skin biopsy is needed when diagnosing conditions other than urticaria are suspected.

Introduction: Food allergy incidence is increasing, and reactions can be life-threatening. Food allergies significantly impact patients’ and families’ quality of life (QoL).

Here, we describe two cases with adult-onset IgE-mediated food allergy impacting their physical and psychological health and affecting their quality of life.

Case Report: Patient 1: A 29-year-old lady, previously healthy, presented with a history of sneezing, shortness of breath, and eye and lip swelling shortly after drinking cow milk at the age of 28 years. She had multiple episodes of similar symptoms after consumption of dairy products. A positive blood test confirmed Cow’s Milk allergy (Table 1). She was very anxious and concerned about accidental exposure and even avoided serving milk to her children. She scored 5.2/7 on the Food Allergy Quality of Life Questionnaire-Adult Form (FAQLQ-AF). The patient currently avoids dairy products and carries Adrenaline auto-injectable (AAI), with no reported anaphylaxis.

Patient 2: A 46-year-old man with a history of type 2 DM was evaluated for recurrent urticaria. Further history revealed recurrent episodes of urticaria and angioedema for the past few years one to two hours after wheat intake; the most recent episode was typical for anaphylaxis, and he denied any exercise or presence of other co-factors. Allergy testing confirmed wheat allergy (Table 1). He scored 4.9/7 on FAQLQ-AF. He was concerned about having another anaphylaxis. He was instructed to avoid wheat and to carry AAI, after which no further attacks were reported.

Intervention: Identifying the food allergens for both patients alleviates some of their anxiety. Moreover, having an AAI on hand and training on how and when to use it led to increased safety feeling, although initially, they were hesitant to carry AAI. Continuous assessment will be carried out during clinic visits to ensure improved QoL.

Conclusion: Several factors affect the extent of food allergy’s impact on patients’ QoL, like age, type, and number of food allergens.

Physicians must be aware of the psychological burdens faced by adults with food allergies and implement strategies to address and improve patients’ QoL through counseling, proper education, and psychotherapy if needed.

Introduction: Severe combined immunodeficiency disease (SCID) is a rare primary immunodeficiency disease, usually manifest in the first six months of life with failure to thrive, oral thrush, recurrent respiratory infection, and chronic diarrhea.

Case presentation: In three male patients, we describe an unusual presentation of SCID. They are an outcome of consanguineous marriage; all received the BCG vaccine at birth. All three cases presented with regional lymphadenopathy at three months, progressing to generalized lymphadenopathy treated with anti-tuberculous. The first and second cases were twins. The first had an uneventful history until 33 months when he developed multiple Suppurative Tuberculous lymphadenitis confirmed by biopsy. The second and the third cases were diagnosed with Disseminated Tuberculosis at 24 months as they developed fever, anemia, weight loss, tuberculous peritonitis, and lymphadenopathy confirmed by biopsy. After investigations, the first case was diagnosed as CD4, CD16 lymphopenic SCID, the second one as CD4, CD8, CD19, CD16 lymphopenic SCID with hypogammaglobulinemia and the third case as CD3, CD4, CD8 lymphopenic SCID with hypogammaglobulinemia. They received anti-Tuberculous medications, prophylactic Trimethoprim/Sulfamethoxazole, and Immunoglobulin infusion. When writing this abstract, the patients were alive and had no other bacterial, viral, or fungal infections. The twins are three years old, and the third case is 30 months old.

Conclusion: SCID may not exhibit the classical manifestation of recurrent infections. It may present only as a complication of the BCG vaccine, alarming to maintain high susceptibility in such patients, especially in a developing country, specifically in Sudan, where the BCG vaccine is usually given at birth.

Background: The pandemic coronavirus disease 2019 (COVID-19) has been associated with substantial mortality worldwide. Efforts have continued to find an effective treatment for COVID-19. In vitro activity of interferon (IFN) subtypes has been shown against the SARS-CoV and MERS-CoV. Furthermore, the superiority of IFN-β over IFN-α2b and IFN-α2a has been demonstrated in MERS treatment. Early studies showed a low plasma level of IFNs in the peripheral blood or lungs of patients with severe COVID-19. This study assessed the effects of IFN-alpha-2a and -beta-1a on the prognosis of patients with covid-19 infection.

Methods: We conducted a triple-blind randomized clinical trial on adult patients with moderate to severe COVID-19 from April 2021 to June 2021. The patients were diagnosed based on clinical and laboratory findings and randomly assigned into four groups (A, B, C, and D) using the envelope allocation method. Patients in group A received IFN β-1a; group B received IFN β-1a placebo; group C received IFN α-2a, and group D was treated with IFN α-2a placebo. All patients concomitantly received the national protocol medications as well.

Results: A total of 95 eligible patients were randomly assigned into groups. National Early Warning Score 2 (NEWS2) index showed significant differences between groups only on the first day of admission (p-value = 0.001). CT scan scores on the first and tenth days slightly improved, although they were not statistically significant. Duration of hospitalization and hospital discharge did not significantly differ among all treated groups (Table 1). Mortality rates showed no significant statistical difference between the groups. However, viral clearance significantly accelerated in the patients receiving IFN β-1a or IFN α-2a (p < 0.05).

Conclusion: It seems that IFN α-2a and IFN β-1a are ineffective in treating COVID-19 patients. Further randomized clinical trials with large sample sizes are needed to estimate the effects of IFN α-2a or IFN β-1a on the outcomes of COVID-19 disease.

Atopic Dermatitis (AD) is a high-burden disease that affects approximately 2–5% of adults. AD patients experience intense pruritus and often report sleep and mental health disturbances accompanied by a diminished quality of life. The patients’ perceptions of their treatment benefits are becoming increasingly important in the benefit/risk assessment of therapeutics such as the gold standard in AD therapy, Dupilumab. A survey questionnaire (ADCT) has been recently developed to assess the control of AD symptoms using subjective patient-based reporting only. This study aimed to investigate the self-reported efficacy of Dupilumab in Qatari patients with severe AD using the new ADCT evaluation tool.

Methods: 30 patients completed a baseline survey before starting Dupilumab, and ADCT was assessed at four weeks post-therapy initiation. ADCT evaluates six AD symptoms in a severity grading from 0 to 3 (max. 24 points). The impact is assessed over the past week, including overall severity of symptoms, days with intense episodes of itching, the intensity of bother, problems with sleep, impact on daily activities, and impact on mood or emotions. In addition, itch severity was also assessed using a numeric rating scale (NRS11) ranging from 0 to 10.

Results: The overall mean ADCT score at baseline was 17.6, and at week 4, it was reduced to 4.1. Patients reported a dramatic change in the overall symptoms already in this early phase. The parried t-test showed a significant difference in ADCT Score before and after therapy. There was a substantial decline in experiencing the associated AD symptoms: overall severity of symptoms (mean baseline =3.1, Dupilumab week 4 =0.9 (3.1/0.9), days with intense episodes of itching (3.2/0.7), the intensity of bother (3.2/0.8), the problem with sleep (2.7/0.4), impact on daily activities (2.5/0.6), and impact on mood or emotions (2.9/0.6). The itch score also reduced from 8/10 at baseline to 0-3 at week 4.

Conclusion: Treatment of adult Asian/Arabic patients with severe AD treated with Dupilumab with or without topical steroids was highly effective and significantly improved overall well-being and pruritus as early as after 4 weeks of treatment.

Background: The ‘GeriDerm’ (geriatric dermatology) clinic, is a new dermatology-based service at Hamad Medical Corporation (HMC), accommodating the needs of our elderly population living in the State of Qatar. Due to the global demographic transition towards an elderly population (≥65 years of age), incidences of chronic diseases, including dermatologic conditions, rise in parallel. Patients of older age are at higher risk of using multiple medications, seeing multiple care providers, often receiving multiple diverging pieces of information, and feeling lost within the system. Taking into consideration the elderly unique characteristics, the Geriatric Dermatology telemedicine clinic is a novel approach to meeting the many challenges our elderly patients face via providing quick, accurate assessments of cognition, functional status, frailty screening, and assessment for polypharmacy.

Methods: Data of 1080 elderly patients with various skin disorders from June 2020 to July 2021 was received from the Dermatology Geriatric clinic, and then reviewed.

Results: There were 521(48.2%) new cases and 559(51.8%) follow-up cases who attended the clinic either virtually or face to face consultation. A total of 587(54.4%) female and 493(45.6%) male elderly patients attended the clinic. The mean age was 74.6, with a minimum age of 60 and a maximum age of 106 years. 57.9%(625) of GeriDerm patients were Qatari, followed by Palestinian 75(6.9%), Syrian 51(4.7%), Egyptian 46(4.3%), and Indian 44(4.1%); while other nationalities constituted 239(22.1%). The majority of the cases were Contact Dermatitis 146(13%), Bullous Pemphigoid 107 (10%), and Pruritis 101(9.4%).

Conclusion: The ‘GeriDerm’ service at HMC aimed to achieve the best healthcare standards for the elderly population of Qatar during COVID-19 pandemic, and is now established as a continuous advanced technology-based framework facilitating caring for older patients with skin disease via providing a clear pathway for adequate triaging, identification of severe conditions (red flag) requiring in-person clinic visits, while managing non-life threatening dermatoses via a tele-dermatology based approach.

Introduction: Multiple sclerosis (MS) is a disabling neurological disease with an unknown etiology, where the recombinant interferon beta (rIFNβ) is the most established treatment. However, the development of anti-IFNβ antibodies has posed a significant therapeutic drawback. In this study, the interaction between anti-IFNβ antibodies and macrophages was investigated to assess the effects on the immune system.

Methodology: Using magnetic beads, anti-IFNβ antibodies were extracted from MS patients’ sera positive for anti-IFNβ antibodies. A negative control (antibody-negative situation) and a baseline control were obtained in parallel. Bead or extracted bead-antibody complexes were then incubated vitro with monocyte-derived human macrophages. After incubation, macrophage cultures were tested for 91 immunologically relevant gene expressions by RT-PCR.

Results and Discussions: A Gene expression difference between antibody positive and negative situations was hypothesized to reflect the direct effects between antibodies and macrophages. Thus, 37-39 genes were either up-regulated or down-regulated due to this direct interaction. Of these, only 2-4 genes were up-regulated, and the rest were down-regulated. These observations suggest that anti-IFNβ antibodies have an overall suppressive effect on immunologically relevant gene activity when antibodies interact with macrophages.

Conclusion: The fate and effects of circulating anti-IFNβ antibodies are mainly unknown. With the observations obtained at in vitro level, such effects, especially from an immunological point of view, are suppressive on immunocompetent cells such as macrophages. However, in vivo verification is necessary.

Introduction: Health apps play an increasing role in everyday healthcare, especially for chronic diseases. The Chronic Urticaria Self Evaluation (CRUSE) is a new mobile health app for chronic spontaneous urticaria (CSU) patients, which replaces disease tracking via paper and pen, thus making disease monitoring more convenient, increasing tracking compliance, and improving data quality and access.

Methods: CRUSE enables patients to complete patient-reported outcome measures on their smartphone and send the results, along with current medication and pictures, to their treating physician via email. CRUSE captures the urticaria (UAS) and angioedema activity (AAS) scores and the urticaria and angioedema control tests (UCT and AECT). In this work, a descriptive analysis of CRUSE users and reported days was performed. The global network of Urticaria Centers of Reference and Excellence (UCARE) provides the app and its data.

Results: CRUSE is now available in Germany, Switzerland, Austria, the UK, Italy, Spain, France, and Turkey. Of 620 newly registered users (from July 1^st until November 18^th of 2022), 72 % were female, and the mean age was 36.6 years (17 - 78 years). The average daily UAS and AAS value (mean ± standard deviation) were 2.1 ± 1.9 and 7.2 ± 3.3, respectively. Most CRUSE patients had poorly controlled disease, with mean UCT values of 7.0 ± 4.4 and mean AECT values of 8.1 ± 4.5.

Conclusion: The first days of patients with CSU using CRUSE confirm the high need for an app that helps to monitor disease activity, impact, and control. The first results indicate low levels of disease control in most CRUSE users, with low UCT and AECT values. Future analyses will assess follow-up documentation data and evaluate the effects of treatment changes on CSU activity, impact, and control.

Objective: A frequent condition known as chronic urticaria (CU) is characterized by the appearance of wheals, angioedema, or both. CU lowers the quality of life and may also result in psychological discomfort. The literature survey revealed few studies dealing with depression and anxiety in these patients. Hence, Hamilton scores for depression and anxiety were used in this study to evaluate the incidence of depression and anxiety in chronic urticaria patients.

Methodology: To evaluate CU patients’ levels of depression and anxiety, the Hamilton Rating Scale for Depression (HDRS) and the Hamilton Anxiety Rating Scale (HAMA) were applied. Moreover, in a control group of thirty healthy volunteers, thirty CU patients were included in this study. It was essential to observe the patients’ urticaria activity score, medications, age, gender, comorbidities, employment status, and income. When it came to levels of depression and anxiety, a comparison was made between the case group and the healthy group.

Results: In the CU patients’ group, the mean age was 26.9 years. The questionnaires showed that 14 (46%) subjects in the patient group had moderate to severe signs of anxiety, and 21 (70%) had moderate to severe symptoms of depression. Besides, in the control group,7 (23.3%) had moderate to severe signs of anxiety, and 8 (26.7%) had severe depression.

Conclusion: According to the study, individuals with CU exhibit depression and anxiety symptoms more frequently than the control group. Therefore, the possibility of mental comorbidities should be considered when treating individuals with CU.

Introduction: Anaphylaxis is a fatal condition that can be easily managed if discovered early. Only a few examples of anaphylaxis-like reactions caused by heparin have been documented, and immediate-type hypersensitivity reactions to heparin are extremely uncommon.

Case Presentation: We report a case of a 53-year-old gentleman known to have an End Stage Renal Disease (ESRD) on Hemodialysis for two years, who went to the dialysis facility in his usual state of health. After two hours of dialysis, a new lock of taurolidine/heparin was installed; one minute later, the patient started to vomit and became restless, blood pressure dropped to 60/47 mmHg, and urticarial hives and a reddish rash developed on his skin, covering his trunk and limbs. He was immediately given three doses of epinephrine intramuscularly, which he did not respond to. Therefore, an epinephrine infusion was started. IV hydrocortisone and diphenhydramine were given for symptomatic relief. The patient was shifted to the emergency department, where he became vitally stable and returned to baseline. Heparin-induced anaphylaxis was assumed based on the quick response to the above medications.

Conclusion: This case can be added to the growing literature regarding this rare reaction, and more studies should be done to understand the nature of the reaction better. We recommend that the healthcare team becomes vigilant of heparin as a possible cause of anaphylaxis.

Background: Timely access to accurate, up-to-date drug allergy information is critical to avoid potentially life-threatening adverse drug reactions (ADRs). However, the completeness and accuracy of allergy documentation remain a challenge. Inappropriate allergy documentation usually necessitates alternative treatments, increases costs, and may negatively impact patients’ outcomes.

Objectives: Review medication allergy labeling documentation, identify the most reported medication class, and describe allergic reactions based on the reported severity.

Methods: A retrospective cross-sectional audit including all medication allergy labeling documentation for patients admitted to Hamad General Hospital (HGH) from January-December 2022 was conducted. A list of patients with medication allergies was generated from the pharmacy system, which included patients’ demographics, medication names, documented allergy severity, and any other comments. The list was reviewed, and medications were categorized into different classes.

Results: 2856 allergy documentation for 2431 unique patients were identified and included in the analyses. The mean age of included patients was 43 years old, with 73.2% (1780) being females. Among the reported allergic reactions, 11.8% (336) were documented as severe allergic reactions, 51.1% (1457) were moderate, and 37.1% (1060) were mild. Antibiotics were the most common documented allergens, representing 42.1% of all reported allergies, followed by non-steroidal anti-inflammatory drugs (20.7%, n=591), and paracetamol (5.3%, n=151). Of all the reported allergies, only 6 (0.21%) cases had documented confirmatory allergy tests done. Further analysis of the reported allergies revealed that 1.2% (34) of the allergies had documentation to counteract the allergy labeling through either revised patient history or re-challenging. Despite such, allergy labeling was kept in the medical profile without proper de-labeling.

Conclusion: Allergy labeling documentation is a key to safe medication prescribing. However, standardized allergy documentation should be implemented to include a brief description and onset of the symptoms. Additionally, a safe de-labeling pathway should be adopted. Most of the allergy documentation was based on patients’ or family/parents’ reports, while actual allergies observed by a healthcare provider were limited.

Background: The role of breastfeeding in the primary prevention of allergic diseases remains controversial, with hardly any reported studies from developing countries.

Objective: To evaluate the association between breastfeeding and the presence of allergies. Specifically, we aimed to demonstrate the association between the exclusivity of breastfeeding and the prevalence of allergies, including asthma, eczema, allergic rhinitis, and food allergy. Secondly, to ascertain the impact of feeding cow milk as complimentary feeding on the prevalence of atopy. Finally, we intended to substantiate the association between maternal education and breastfeeding awareness.

Materials and Methods: A cross-sectional study was conducted; 182 participants were enrolled. A confidential, anonymous questionnaire was administered to the participants’ mothers (those attending Academy Charity Teaching Hospital with children aged six months to 10 years). Crude associations between exclusive or non-exclusive breastfeeding and atopic diseases were evaluated using Chi-Square Test by computing crude odds ratios (OR) and corresponding 95% Confidence Interval (CI) with α level of 0.05. Multiple logistic regression models were used to estimate the effect of exclusive breastfeeding on allergic diseases. The sample was adjusted for confounding factors such as gender, family history, number of siblings, and paternal and/or maternal smoking habits.

Results: Of the 182 participants included in this study, 95(52.2%) were not exclusively breastfed, and 87(47.8%) were exclusively breastfed. The prevalence of allergic diseases in the children who received non-exclusive breastfeeding compared with those with exclusive breastfeeding showed a significantly higher prevalence of atopy [OR =3.6 95%CI: 1.87-6.94] with a p-value <0.001, even more, significant when the sample was adjusted for family history [OR =4.59 95%CI: 1.96-10.75] with a p-value <0.001. Moreover, milk administration as a complementary feeding type was not significantly associated with the development of atopy [OR =1.65 95%CI: 0.87-3.14] with a p-value of 0.14.

Conclusion: There is evidence that exclusive breastfeeding is protective against atopy. Mothers should breastfeed mainly for the first six months of child age and continue with partial breastfeeding beyond that age.

Background: Chronic Urticaria (CU) is a complex skin disease that appears as recurrent raised itchy rash/angioedema or both for more than six weeks. The pathophysiology of CU is complex and has yet to be understood entirely. It is predominantly a mast cell-driven disease with the possible involvement of type 2 inflammation. Current evidence largely favors mast cell activation by an IgE-mediated autoallergic mechanism or an autoimmune mechanism by IgG autoantibodies to IgE/ high-affinity receptor of IgE. MicroRNAs (miRNA) are small coding RNAs regulating gene expression at the post-transcription level. This study aimed to investigate the circulating miRNA as potential biomarkers in CU patients compared to healthy controls.

Methods: The miRNA gene expression was done in seven patients with CU and seven healthy controls. The expression of miRNA is done using TaqMan openArray human advanced miRNA Panel. ExpressionSuite Software (Thermo Fischer Scientific, Waltham, MA, USA) is used for data analysis to quantify the miRNA expressions. P<0.05 is considered to be statistically significant.

Results: A significant upregulation (p<0.05) in the miR-451a, miR-9-5p, miR-150-5p, miR-296-5p, and miR-182-5p was observed in CU compared to controls. Dysregulation of miR-451a is identified as an early biomarker in allergic diseases. Functional enrichment analysis with the KEGG pathway and disease ontology databases showed that these miRNAs were associated with skin diseases and inflammation. The differentially expressed miRNAs contribute to determining the genes regulated in CU. miRNA-based therapies that target different genes in a given pathway might be a potential candidate for treating CU.

Conclusion: miRNA field has grown steadily over the past few years, but the role of circulating miRNAs in CU remains relatively unexplored.

This study showed that the upregulated circulating miRNA might play an essential role in CU pathogenesis and inflammation. Also, our study highlights the importance of miRNAs as a future biomarker and potential therapeutic target to be investigated.

Objectives: Propolis has an anti-inflammatory effect induced by inhibiting cyclooxygenase, subsequent inhibition of prostaglandin and nitric oxide synthesis, reduction of inflammatory cytokines, and eventually immunosuppressive activity [1-3]. This study aims to evaluate the impact of propolis on clinical features and specific IgE levels against salsola in perennial allergic rhinitis patients.

Methods: Thirty patients diagnosed with perennial allergic rhinitis with salsola-positive skin prick test were enrolled in this randomized controlled clinical trial and divided into two groups. The intervention group received the propolis (200 mg per day), and the control group received a placebo for four months, besides intranasal corticosteroids. At baseline and the end of the intervention, the level of Salsola-specific IgE was measured by the RAST method. To assess the propolis effect on the quality of life and disease severity, miniRQLQ and SNOT22 questionnaires were completed by patients before and after the intervention.

Results: According to Table 1, Serum IgE level showed decreasing changes (-0.057) despite increasing changes in the control group (1.039). However, these differences were not statistically significant (P = 0.967). Based on the miniRQLQ questionnaire, quality of life improved in both groups without any significant difference (P = 0.930). According to the SNOT-22 questionnaire, both groups’ nasal and sinus problems decreased significantly. However, the intervention type did not affect this decrease and was observed over time in both groups (P> 0.05).

Conclusion: Propolis supplementation did not significantly affect various laboratory parameters, clinical symptoms, and quality of life of patients with allergic rhinitis.

Background: The prevalence of asthma is 9% among adults in Qatar, and its severity can be attributed to intrinsic and extrinsic factors such as environmental changes. As part of the project to investigate the association between air pollution and asthma severity, the rate of exacerbations in adult patients with asthma has been studied in Qatar.

Methods: Retrospective data of patients with asthma (16-70 years) from January 2019 to December 2021 was retrieved from Cerner medical records. Frequencies of exacerbations in inpatient and outpatient departments were analyzed using means ± SD and median (IQR) for descriptive data and frequency and percentage for categorical data. Exacerbations were divided into single, double, and more than double for each quarter of the year (January 2019-December 2021) using SPSS and Minitab statistical packages.

Results: A total of 6977 exacerbations visits (representing 6558 patients) were identified during the study period. The mean ± SD age was 41±14.3 years, with a female: male ratio of almost 1:1. The patients from the MENA region, including Qataris, presented 67% compared to 33% from the Indian subcontinent and other countries. The number of patient visits for hospitalization due to exacerbations showed a distinctive pattern during the three years. The highest record of asthmatics with exacerbations was observed in 2019 (42.7%) compared to half the rate in 2020 and 2021 (28.5%, 28.8%), respectively. The single exacerbation group was almost five times higher than 2 or >2 exacerbation groups in all years (2019-2021).

Conclusion: This preliminary overview provides the rate of exacerbation episodes in patients with asthma in Qatar. One cause of these exacerbations can be attributed to air quality changes. The drop in the exacerbation rate observed in 2020-2021 could be explained by COVID-19 lockdown regulations or patients’ adherence to prescribed meds. We aim to propose preventive and therapeutic strategies to alleviate asthmatics’ symptoms and improve their quality of life.

Objective: Common variable immunodeficiency (CVID) is a complex inborn error of humoral immunity with complications of both infectious and non-infectious origins. Classifications of CVID patients provide a clearer understanding of the pathogenesis, prediction, and management of non-infectious complications. This study aims to classify Moroccan CVID patients based on the European classification (EUROclass).

Materials and Methods: We recruited 20 CVID patients meeting standard diagnostic criteria (5-6). After collecting clinical and demographic data, we used flow cytometry to analyze B-cell subsets and group patients and assess the relation of each group with clinical manifestations.

Results: 90% of the patients in our cohort study had a history of respiratory infections. The non-infectious manifestations included splenomegaly, autoimmunity, lymphadenopathy, and granulomatous diseases diagnosed in 50%, 45%, 40%, and 25% of patients, respectively. We observed significant co-occurrence of splenomegaly with autoimmunity and granulomatous diseases to a lesser extent. Patients had a significant reduction in total, switched memory, marginal zone-like, plasma blasts, and a substantial increase in the percentage of activated B cells, suggesting a defect in the late phases of B-cell differentiation. This condition was linked with an increased occurrence of splenomegaly and granulomatous affections. Besides, patients also had an expansion of CD21^low B-cells, which was strongly associated with splenomegaly.

Conclusion: The classification of the first Moroccan cohort of CVID patients showed agreement with previous results. It suggests the possibility of adopting this approach on a global scale for better diagnosis and follow-up of CVID patients.

Background and Aim: Chronic giardia infection can lead to non-erosive gastrointestinal disorders, including protein-losing enteropathy (PLE). This report describes non-diarrheal PLE in chronic giardiasis in children with defective humoral immunity.

Methods: The retrospective report is related to 2 children known to have a monogenic inborn error of immunity. The first patient is a 13-year-old boy with X-linked agammaglobulinemia (Patient-1), and the second is a 5-year-old boy with NF-kB inducing kinase (NIK) deficiency infection. Frequency, growth status, and serum immunoglobulin-G (IgG) trough and albumin levels were monitored (Patient-2).

Results: Patient-1 had more frequency of pneumonia but reported no symptoms of gastrointestinal disease, including alteration of bowel habits, change in stool consistency, nausea, vomiting, fatigue, bloating, and abdominal pain. No clinical oedema on examination. His weight remains static at 19-20 kg for about 1.5 years. Simultaneously, hypoproteinaemia was noted (Figure-1).

A trial of increasing IVIG (0.7 – 1 g/kg) and the use of subcutaneous immunoglobulin (0.2 g/kg) did not reverse the biochemical and clinical situation. Hypoproteinaemia workup revealed normal liver and kidney functions, normal cardiac function, and no proteinuria. Interestingly, his upper endoscopy showed mild duodenitis and the presence of giardia lamblia at the luminal surface (Figure-2).

Following this, a 2-week course of oral metronidazole (7.5 mg/kg/dose BID) resulted in a restoration of therapeutic serum IgG trough and albumin levels. Additionally, the child’s nutritional status improved, and the frequency of respiratory infections dropped. In Patient-2, progressive hypoproteinaemia was noted over nine months. Similarly, no gastrointestinal complaints; however, the family reported foul-smelling semisolid stools with regular consistency. His IgG trough level was 2 g/l, and his albumin level was 20 g/l. Despite maximizing IVIG, he developed two episodes of pneumonia and once otitis media. An empiric oral metronidazole course resulted in the amelioration of symptoms and restoration of proteinemia. Meanwhile, faeces microscopy confirmed the presence of Giardia lamblia.

Conclusions: Progressive hypoproteinaemia in children with humoral immunodeficiency is a clinical concern. Routine stool microscopy can identify giardia infection despite the ambiguity of gastrointestinal symptoms in such patients. However, a trial of empiric metronidazole therapy should be considered.

The constant progress of genomics and the establishment of new functional tests have paved the way for identifying monogenic defects conferring a selective predisposition to infections by certain microbes as a new type of inborn errors of immunity (IEIs). Mendelian susceptibility to mycobacterial diseases (MSMD) is the most characterized of these IEIs, with 36 different disorders found in 20 distinct genes (IFNGR1, IFNGR2, IFNG, IL12RB1, IL12RB2, IL23R, IL12B, ISG15, USP18, ZNFX1, TBX21, STAT1, TYK2, IRF8, IRF1, CYBB, JAK1, RORC, NEMO, and SPPL2A) over the last 20 years. MSMD confers a selective susceptibility to infections with weakly virulent mycobacteria, including the M. bovis Bacille Calmette-Guérin (BCG) vaccines and various environmental mycobacteria in patients, primarily children, without classical immune defects. These patients may also present severe forms of tuberculosis, and about half of them might develop non-typhoidal salmonellosis. In some cases, patients also suffer from chronic mucocutaneous candidiasis (CMC), while in others, patients also present severe viral, parasitic, fungal, and/or bacterial diseases. Despite this clinical and genetic heterogeneity, almost all genetic etiologies of MSMD alter the interferon-gamma (IFN-γ)-mediated immunity by impairing or abolishing IFN-γ production or the response to this cytokine. It was proven that the human IFN-γ level is a quantitative trait that defines the outcome of mycobacterial infection. The study of these monogenic defects contributes to understanding the molecular mechanism of mycobacterial diseases in humans and to the development of new diagnostic and therapeutic approaches to improve care and prognosis. For example, MSMD patients with impaired production of IFN-γ may benefit from injections of human recombinant IFN-γ, while for patients with abolished response to this cytokine, hematopoietic stem cell transplantation (HSCT) and promising gene therapy are the only current therapeutic options. These discoveries also bridge the gap between simple Mendelian inheritance and complex human genetics.

Introduction: Anti-centromere antibodies (ACAs) are a variety of anti-nuclear autoantibodies (ANA) directed against different kinetochore proteins. They are sought on HEp2 substrates by indirect immunofluorescence technique (IFI), where they appear in the form of about forty fine nuclear punctuations attached to the chromosomes during their different cell cycle phases. They are encountered in several autoimmune diseases (AID), frequently in scleroderma. This work aims to retrospectively analyze serum samples containing anti-centromere antibodies and the associated pathologies.

Materials and methods: Eleven serum positive for ACAs were studied among 821 requests for ANA analyses sent to the Immunology Department, Central Laboratory for Medical Analyzes, CHU Hassan II-Fez for three years. Two techniques were used: indirect immunofluorescence for the ANA research and ELISA or Immunodot for identifying antigenic specificities according to the suppliers’ recommendations (D-Tek).

Results: The mean age of patients was 50 ± 18 years. A female predominance (81.8%) was observed, with a sex ratio F/M of 4.5. The research of Anti-nuclear antibodies was positive in immunofluorescence in all cases. With a centromeric appearance in 9 cases and a speckled appearance in 2 cases, the titer varied between 160 and 1280. Antigenic identification by Immunodot showed that anti-CENP A and CENP B were found in 7 cases, and anti-CENP B was identified in 4 cases. The results by pathology show a significant association of ACAs with the clinical suspicion of systemic sclerosis (45%).

Conclusion: The presence of ACAs can be associated with several AIDs, mainly scleroderma. These autoantibodies represent an important diagnostic and prognostic tool by defining immuno-clinical forms of the disease.

Introduction: Soluble anti-antigen antibodies (Anti-ENA) represent a specificity of anti-nuclear autoantibodies (ANA), which are directed against nuclear particles composed of small RNA (Ribonucleic acid) and proteins. They are found during certain autoimmune diseases (ADs), most frequently during systemic lupus erythematosus (SLE) and Gougerot syndrome. The aim of this study is to retrospectively analyze the positive serum for Anti-ENA antibodies and associated pathologies.

Materials and methods: This study was carried out at the Immunology Department, Central Laboratory of Medical Analysis, University Hospital Hassan II - Fez, Morocco, for a period of 2 years. 821 serum samples were included. The indirect immunofluorescence method (IFI) was used to search the ANAs in the serums. In the case of a positive result, an identification of the antigenic targets was performed by the Immunodot technique according to the supplier’s recommendations (D-Tek).

Results: Eighty-eight serums were found positive for anti-ENA antibodies. The mean age in our series was 41 ±15.5 years. There were 80 women and 8 men with a sex ratio F/M of 10. The results by associated pathologies show a strong association of the anti-ENA antibodies’ positivity with lupus and Gougerot syndrome.

Conclusion: Anti-ENA antibodies are important immunological markers for lupus and Gougerot syndrome diagnosis.

Background: Obstructive sleep apnea (OSA) affects 1% to 5% of all children, with the most significant prevalence between ages 2 and 8. Correlations between OSA and Adenoid hypertrophy (AH) have been well-demonstrated in children. If untreated, OSA can cause growth impairment, neuro-cognitive and behavioral problems, and cardiovascular complications. Allergy was reported to be a vital risk factor for AH, among other inflammatory processes mentioned.

Objectives:

1. To demonstrate that the combination of nasal steroids and ani leukotriene reduces the number of adenectomies in children with OSA and adenoid hypertrophy in Saudi children.
2. To demonstrate the positive Correlation between allergic sensitization and OSA caused by adenoid hypertrophy

Methods: This retrospective study included 60 children with moderate/severe OSA attending a Pediatric Allergy Clinic in Saudi Arabia diagnosed using Sleep-Related Breathing Disorder Scale (pediatrics-related items). We had children with adenoid hypertrophy confirmed by soft neck tissue x-ray or both; children who suffer from obesity were excluded. Sensitization was defined as positive specific IgE and/or skin prick for food and/or inhaled allergens; allergic comorbidities were enumerated.

Results: Combination of nasal steroid and anti-leukotriene reduces adenectomy by 58.3 % in children with OSA caused by AH. 71.7% of Them were sensitized to inhaled food or both allergens.

Conclusion: Anti-inflammatory treatment with a combination of nasal steroids and anti-leukotriene remarkably reduces the adenectomy rate in children with OSA caused by AH. Our findings suggest that allergic sensitization, regardless of the allergen, increases children’s susceptibility to AH through the inflammatory process. This may be why nasonex and montelukast are effective treatments for OSA in children with AH.

Background: Every year, 14 million babies are born with low birth weight (LBW) and/or intrauterine growth restriction (IUGR) in developing countries. In Sudan, 15-25% of all newborns are born with LBW, with half being Term-LBW. The importance of nutrition in the first 1000 days of life has been well demonstrated. Evidence links IUGR to various health and developmental disorders, and intrauterine programming of the hypothalamic-pituitary-adrenal (HPA) axis has been strongly suggested as a possible mechanism. Sudan has been listed among the lowest four countries regarding food security which has a massive impact on maternal and infant health.

Hypothesis: We hypothesize that infants who suffer from intrauterine growth retardation will have exaggerated physiological and behavioural responses to physical stressors.

Objectives: To compare T-LBW with T-NBW on (a) Salivary cortisol level at rest and after a physical stressor and (b) Behavioural response to physical stressors.

Methods: Hospital-based matched case-control study. Cases were 65 T-LBW neonates, and controls were 67 T-NBW neonates matched for age 4-6 hours, gestational age, and mode of delivery—measurements: Anthropometry, salivary samples for cortisol before and after heel prick, and behavioural ratings.

Results: Compared with controls, the IUGR neonates were lighter, shorter, and thinner (p <0.0001) and had lower basal cortisol levels (p <0.03). Following stressors, IUGR neonates had lower (p >0.0001) and inhibited cortisol response (p <0.02), and cried less vigorously (p <0.0001). All anthropometric measures were significantly and positively correlated with behavioural responses and pre- and post-stress cortisol levels. Stunting was more strongly associated with behavioural inhibition than wasting.

Conclusion: The severity of intrauterine growth retardation correlated with behavioral and physiological inhibition, which can lead to the development of mismatch diseases such as allergies, autoimmune diseases, and conjunctive disorders.

Introduction: The periodic fever syndrome Familial Mediterranean Fever (FMF) is caused by mutations in MEFV, which promote inflammation and present with uncontrolled systemic and organ-specific inflammation that can resemble infectious conditions. It is diagnosed based on clinical criteria, including frequent symptoms such as abdominal and thoracic pain, family history, and response to treatment with colchicine, which is confirmed by genetic assessment. Herein, we present a case of FMF with a relatively uncommon presentation.

Case presentation: A 22-month-old female was referred to the allergy and clinical immunology clinic with eczematoid skin rashes. She was admitted to the hospital several times since the 2^nd day of life with different complaints like fever, seizure, and restlessness, and treated with the diagnosis of septicemia. Endoscopy and colonoscopy were done at the age of 6 months due to poor weight gain and bloody diarrhea, which revealed active crypt-destructive colitis with foci of erosion in favor of infectious or allergic colitis. The colon biopsy was negative for Cytomegalovirus (CMV). Regarding family history, she was the second child of the first cousin’s parents and had a healthy 12-year-old sister. There was a history of death for unknown reasons of her cousin, whose parents were related. The immunologic evaluation was done, which showed a relatively normal immunoglobulin level, antibody response, flow cytometry, and lymphocyte transformation test. Nonetheless, a genetic study was done, which showed a homozygote mutation in exon 10 of the MEFV gene in the patient and a heterozygote mutation in both her parents.

Conclusion: The periodic fever syndrome Familial Mediterranean Fever (FMF) is caused by mutations in MEFV, which promote inflammation and present with uncontrolled systemic and organ-specific inflammation that can resemble infectious conditions. The patient was diagnosed with FMF, and treatment was started using colchicine, which successfully controlled the patient’s symptoms and prevented the recurrence of fever and other inflammatory manifestations.