Peanut‐induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

Background Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. Methods Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. Results 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). Conclusions The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition

Erweiterung der pulmologischen Diagnostik in der Nuklearmedizin

Kombinierte Ventilations- und Inhalationsszintigraphie Während konventionelle Lungenfunktionsparameter zur Bestimmung ventilatorisch und atemmechanisch bedingten Verteilungsstörungen nur eine funktionelle Beurteilung erlauben, ermöglichen die Methoden der Ventilations- und Inhalationsszintigraphie eine regional funktionelle Zuordnung. Bei obstruktiven Lungenerkrankungen kann durch den Einsatz von Aerosolen gezielt eine Verteilungsstörung nachgewiesen werden, die um so ausgeprägter ist, je weniger sich im Szintigramm (regional) die Lungenperipherie darstellen läßt. Mit einer gleichzeitig durchgeführten Xenon-133-Ventilation kann differenziert werden, ob es sich um eine obstruktionsbedingte Minderbelüftung handelt ( Ventilations-Inhalations-Mismatch), oder ob die Belüftung bestimmter Lungenareale funktionell ausgefallen ist ( Ventilations-Inhalations-Match). Ziel unserer Untersuchung war es herauszufinden, in welcher Beziehung die regionale Darstellung der Ventilations-Inhalations-Konstellationen zu konventionellen Inhomogenitätsparametern der Lungenfunktion bei Patienten mit COPD steht und inwieweit Informationen über die Lungenfunktion hinaus erlangt werden können. Patienten: Wir untersuchten 32 Patienten mit chronisch obstruktiver Lungenkrankheit (COPD) im Alter zwischen 17 und 68 Jahren. Die Untersuchung der Patienten wurde in einem möglichst beschwerdefreien Intervall unter klinischer Fragestellung durchgeführt. Methodik: Die Patienten wurden mittels folgender Methoden untersucht:1. Lungenfunktionsdiagnostik: Fluß-Volumen-Kurve, Bodyplethysmographie, FRC-Rebreathing, Diffusionsmessung und Impulsoszillometrie. 2. Szintigraphische Untersuchung: Alle Patienten wurden zur Darstellung der belüfteten Lungenabschnitte einer Xenon-133-Ventilationsszintigraphie und im Anschluß daran einer Technetium-99m-DTPA-Inhalationsszintigraphie unterzogen. Xenon-133 wurde im single-breath Verfahren mit 10 Sekunden Atemanhaltezeit verabreicht. Die Inhalation von Technetium markierten Aerosolpartikeln erfolgte mittels eines Verneblersystems. Die Patienten atmeten das Aerosol 7 Minuten langsam und ruhig ein. Die quantitative Auswertung erfolgte mittels interessierender Regionen (ROI) und eines Scores. Statische Szintigramme wurden nach einem Score in 4 Gruppen entsprechen verschiedener Ventilations-Inhalations-Konstellationstypen ( Mismatch, Match) eingeteilt. Ergebnisse: Bei Patienten mit COPD wurden nuklearmedizinisch 3 Schweregrade von Ventilationsstörungen unterschieden: geringgradiges Ventilations-Inhalations-Mismatch, ausgeprägtes Ventilations-Inhalations-Match, pathologisches Ventilations-Inhalations-Match. Im Vergleich der Schweregradeinteilung der Verteilungsstörungen durch Methoden der konventionellen Lungenfunktionsdiagnostik und der Nuklearmedizin ergibt sich eine hochsignifikante Korrelation. Von den 22 Patienten, die pathologische Lungenfunktionswerte aufwiesen, ergaben sich auch zu 95 % Veränderungen in der Szintigraphie, währenddessen zeigten von den 28 Patienten mit pathologischer nuklearmedizinischer Bewertung nur 75% pathologische Inhomogenitätsparameter. Die Methode der Ventilations- und Inhalationsszintigraphie erwies sich somit als sensitiver.Combination of ventilation and inhalation scintigraphy While conventional parameters to determine the ventilatory and respiratory-mechanical distribution disturbances allow a functional assessment only, the methods of ventilation and inhalation scintigraphy enable a regional functional categorization. With obstructive pulmonary diseases, a disturbance of distribution can be traced with the help of aerosols, the disturbance of distribution being the more severe the less the regional periphery of the lung can be imaged in the scintigram. A simultaneous xenon-133-ventiation, which is performed in selected cases, allows to differentiate between an obstructive underventilation (ventilation-inhalation mismatch) and the functional failure of ventilation of definite areas of the lung (ventilation-inhalation match). It was the aim of our investigation to find out the relation between the regional demonstration of the different ventilation-inhalation patterns and conventional parameters of inhomogeneity in patients with COPD. Is it possible to get more informations by scitigraphic methods and is there perhaps a parameter in conventional pulmonary function that reflects the degree of the disturbance of nuclear medical measures best? Patients: We examined 32 patients with chronic obstructive pulmonary disease (COPD) between 17 and 68 years of age. The patients were examined during a complaint-free period, so it was possible. Methodology: The following methods were applied to examine the patients: 1. Pulmonary function: flow-volume curves, bodyplethysmography, FRC-rebreathing, diffusion measuring and impulse oscillometry. 2. Scintigraphic examination: For imaging the ventilated parts of the lung, all patients underwent a xenon-133-ventilation scintigraphy followed by a technetium-99m-DTPA-inhalation scitigraphy with 10 seconds of breath-holding. The inhalation of technetium-marked particles of aerosol was enabled by mechanical atomising system. The patients inhale the aerosol for 7 minutes slowly and calmly. Quantitative evaluation was based on the regions of interest (ROI) and score. Static scitigrams were devided into 4 groups according to a score and to the different types of ventilation-inhalation patterns (match, mismatch). Results: In patients with COPD three degrees of severity of ventilation disturbances are defined by nuclear medical examinations: low-grade ventilation-inhalation mismatch, moderate ventilation-inhalation mismatch, pathological ventilation-inhalation match. A comparison of the classification of severity of distribution disturbances according to conventional pulmonary function diagnosis and nuclear medicine results in a highly significant correlation. Of the 22 patients with pathological values of pulmonary function, 95% showed pathological changes in the scintigram, whereas in the 28 patients who underwent nuclear medical examinations pathological inhomogeneity parameters were found in only 75%. Hence it follows that the method of ventilation and inhalation scintigraphy is the more sensitive one

Diagnosis and treatment of Hymenoptera venom allergy: S2k Guideline of the German Society of Allergology and Clinical Immunology (DGAKI) in collaboration with the Arbeitsgemeinschaft fur Berufs- und Umweltdermatologie e.V. (ABD), the Medical Association of German Allergologists (AeDA), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNOKC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Allergy and Environmental Medicine (GPA), German Respiratory Society (DGP), and the Austrian Society for Allergy and Immunology (OGAI)

Rueff F, Bauer A, Becker S, et al. Diagnosis and treatment of Hymenoptera venom allergy: S2k Guideline of the German Society of Allergology and Clinical Immunology (DGAKI) in collaboration with the Arbeitsgemeinschaft fur Berufs- und Umweltdermatologie e.V. (ABD), the Medical Association of German Allergologists (AeDA), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNOKC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Allergy and Environmental Medicine (GPA), German Respiratory Society (DGP), and the Austrian Society for Allergy and Immunology (OGAI). Allergologie Select . 2023;7(1):154-190.Hymenoptera venom (HV) is injected into the skin during a sting by Hymenoptera such as bees or wasps. Some components of HV are potential allergens and can cause large local and/or systemic allergic reactions (SAR) in sensitized individuals. During their lifetime, ~3% of the general population will develop SAR following a Hymenoptera sting. This guideline presents the diagnostic and therapeutic approach to SAR following Hymenoptera stings. Symptomatic therapy is usually required after a severe local reaction, but specific diagnosis or allergen immunotherapy (AIT) with HV (VIT) is not necessary. When taking a patient's medical history after SAR, clinicians should discuss possible risk factors for more frequent stings and more severe anaphylactic reactions. The most important risk factors for more severe SAR are mast cell disease and, especially in children, uncontrolled asthma. Therefore, if the SAR extends beyond the skin (according to the Ring and Messmer classification: grade >I), the baseline serum tryptase concentration shall be measured and the skin shall be examined for possible mastocytosis. The medical history should also include questions specific to asthma symptoms. To demonstrate sensitization to HV, allergists shall determine concentrations of specific IgE antibodies (sIgE) to bee and/or vespid venoms, their constituents and other venoms as appropriate. If the results are negative less than 2weeks after the sting, the tests shall be repeated (at least 4-6 weeks after the sting). If only sIgE to the total venom extracts have been determined, if there is double sensitization, or if the results are implausible, allergists shall determine sIgE to the different venom components. Skin testing may be omitted if in-vitro methods have provided a definitive diagnosis. If neither laboratory diagnosis nor skin testing has led to conclusive results, additional cellular testing can be performed. Therapy for HV allergy includes prophylaxis of reexposure, patient self treatment measures (including use of rescue medication) in the event of re-stings, and VIT. Following a grade I SAR and in the absence of other risk factors for repeated sting exposure or more severe anaphylaxis, it is not necessary to prescribe an adrenaline auto-injector (AAI) or to administer VIT. Under certain conditions, VIT can be administered even in the presence of previous grade I anaphylaxis, e.g., if there are additional risk factors or if quality of life would be reduced without VIT. Physicians should be aware of the contraindications to VIT, although they can be overridden in justified individual cases after weighing benefits and risks. The use of beta-blockers and ACE inhibitors is not a contraindication to VIT. Patients should be informed about possible interactions. For VIT, the venom extract shall be used that, according to the patient's history and the results of the allergy diagnostics, was the trigger of the disease. If, in the case of double sensitization and an unclear history regarding the trigger, it is not possible to determine the culprit venom even with additional diagnostic procedures, VIT shall be performed with both venom extracts. The standard maintenance dose of VIT is 100g HV. In adult patients with bee venom allergy and an increased risk of sting exposure or particularly severe anaphylaxis, a maintenance dose of 200 g can be considered from the start of VIT. Administration of a non-sedating H1-blocking antihistamine can be considered to reduce side effects. The maintenance dose should be given at 4-weekly intervals during the first year and, following the manufacturer's instructions, every 5-6 weeks from the second year, depending on the preparation used; if a depot preparation is used, the interval can be extended to 8weeks from the third year onwards. If significant recurrent systemic reactions occur during VIT, clinicians shall identify and as possible eliminate co-factors that promote these reactions. If this is not possible or if there are no such co-factors, if prophylactic administration of an H1-blocking antihistamine is not effective, and if a higher dose of VIT has not led to tolerability of VIT, physicians should should consider additional treatment with an anti IgE antibody such as omalizumab as off lable use. For practical reasons, only a small number of patients are able to undergo sting challenge tests to check the success of the therapy, which requires in-hospital monitoring and emergency standby. To perform such a provocation test, patients must have tolerated VIT at the planned maintenance dose. In the event of treatment failure while on treatment with an ACE inhibitor, physicians should consider discontinuing the ACE inhibitor. In the absence of tolerance induction, physicians shall increase the maintenance dose (200g to a maximum of 400g in adults, maximum of 200g HV in children). If increasing the maintenance dose does not provide adequate protection and there are risk factors for a severe anaphylactic reaction, physicians should consider a co-medication based on an anti-IgE antibody (omalizumab; off-label use) during the insect flight season. In patients without specific risk factors, VIT can be discontinued after 3-5 years if maintenance therapy has been tolerated without recurrent anaphylactic events. Prolonged or permanent VIT can be considered in patients with mastocytosis, a history of cardiovascular or respiratory arrest due to Hymenoptera sting (severity grade IV), or other specific constellations associated with an increased individual risk of recurrent and/or severe SAR (e.g., hereditary alpha-tryptasemia). In cases of strongly increased, unavoidable insect exposure, adults may receive VIT until the end of intense contact. The prescription of an AAI can be omitted in patients with a history of SAR grade I and II when the maintenance dose of VIT has been reached and tolerated, provided that there are no additional risk factors. The same holds true once the VIT has been terminated after the regular treatment period. Patients with a history of SAR grade ≥ III reaction, or grade II reaction combined with additional factors that increase the risk of non response or repeated severe sting reactions, should carry an emergency kit, including an AAI, during VIT and after regular termination of the VIT. © Dustri-Verlag Dr. K. Feistle