A clinical case of intricate tracheal disease and asthma

Context: Asthma is the most common inflammatory disease of the airways in children. The term problematic asthma is used to describe children with chronic symptoms or acute severe exacerbations, or both, not responding to standard asthma therapy. Case Presentation: We describe the case of a 5 years old girl with a history of recurrent respiratory infections and asthma since the first months of life, with a poor response to conventional therapies (antibiotics, high dose corticosteroids combined with long-acting β2 agonists and oral leukotriene-receptor antagonists). In some cases she needed hospitalization for the important respiratory engagement and radiological findings of pulmonary consolidations, predominantly localized to the right lung. Computed tomography angiography (CTA), described a mild tracheobronchomalacia caused by the right innominate artery compression and a dense tissue mediastinal extrinsic compression of the main bronchus of the middle lobe, defined a Middle Lobe Syndrome (MLS). Evidence Acquisition: MLS is defined as a recurrent or chronic collapse or infection of the middle lobe of the right lung. There is often a history of multiple treatments with antibiotics and anti-asthmatic drugs for ‘‘recurrent pneumonia’’ or ‘‘asthma’’, as in our patient. Chest X-ray is the first-line diagnostic tool, especially on the lateral view. CT-scan and bronchoscopy are considered useful for diagnosis or treatment. Treatment depends on etiology of MLS. Conclusion: In case of severe asthma symptoms co-morbidities must be evaluated. MLS is frequently unrecognized in children and thinking of it is a prerequisite for diagnosis, especially when recurrent respiratory infections or asthma symptoms are predominantly localized to the right lung

A case of fetal hydrops: prenatal diagnosis and neonatal management

Hydrops fetalis (HF) is a serious fetal condition defined as an abnormal fluid accumulation in fetal extravascular compartments and body cavities caused by either immune or non immune conditions. Immune hydrops is caused by fetal hemolysis medi¬ated by circulating maternal antibodies to fetal red blood cell antigens. Its most common determinant is rhesus incompatibility. Systemic Lupus Eritematosus (SLE) is another rare cause of immune fetal hydrops, when the pregnancy is complicated by the presence of a third degree congenital heart block (CHB). The Neonatal Lupus Syndrome occurs with a prevalence of 2%. We reported the case of severe fetal hydrops in a 31 weeks pregnant woman affected by mild maternal D alloimmunization and SLE. Despite fetal hydrops and a mild positive indirect Coombs’ test, the flow-rate study with the Systolic Peak Velocity (PSV) of the MCA excluded a fetal anemia. At birth, blood gas showed a condition of severe metabolic and respiratory acidosis (pH 6.43, pO2 9.9 mmHg, pCO2 206 mmHg, Base Excess (BE) -35 mmol/l, HCO3- 2.7 mmol/l) and a mild anemia (Hemoglobin 10.3 g/dl). ECG revealed a normal sinus rhythm and a CHB was excluded. Despite the critical clinical condition, no cardiorespiratory or neurological adverse outcomes occurred in the newbor

“Whole” vs. “fragmented” approach to EAACI pollen season definitions: A multicenter study in six Southern European cities

Background: The adequate definition of pollen seasons is essential to facilitate a correct diagnosis, treatment choice, and outcome assessment in patients with seasonal allergic rhinitis. A position paper by the European Academy of Allergy and Clinical Immunology (EAACI) proposed season definitions for Northern and Middle Europe. Objective: To test the pollen season definitions proposed by EAACI in six Mediterranean cities for seven pollen taxa. Methods: As part of the @IT.2020 multi-center study, pollen counts for Poaceae, Oleaceae, Fagales, Cupressaceae, Urticaceae (Parietaria spp.), and Compositae (Ambrosia spp., Artemisia spp.) were collected from January 1 to December 31, 2018. Based on these data, pollen seasons were identified according to EAACI criteria. A unified monitoring period for patients in AIT trials was created and assessed for feasibility. Results: The analysis revealed a great heterogeneity between the different locations in terms of pattern and length of the examined pollen seasons. Further, we found a fragmentation of pollen seasons in several segments (max. 8) separated by periods of low pollen counts (intercurrent periods). Potential monitoring periods included often many recording days with low pollen exposure (max. 341 days). Conclusion: The Mediterranean climate leads to challenging pollen exposure times. Monitoring periods for AIT trials based on existing definitions may include many intermittent days with low pollen concentrations. Therefore, it is necessary to find an adapted pollen season definition as individual solution for each pollen and geographical area

Heterogeneity of pollen food allergy syndrome in seven Southern European countries: The @IT.2020 multicenter study

Background Pollen food allergy syndrome (PFAS) is a frequently underdiagnosed disease due to diverse triggers, clinical presentations, and test results. This is especially relevant in geographic areas with a broad spectrum of pollen sensitization, such as Southern Europe. Objectives To elucidate similarities and differences of PFAS in nine Southern European centers and identify associated characteristics and unique markers of PFAS. Methods As part of the @IT.2020 Multicenter Study, 815 patients with seasonal allergic rhinitis (SAR), aged 10-60 years, were recruited in seven countries. They completed questionnaires regarding SAR, comorbidities, family history, and PFAS, and underwent skin prick testing (SPT) and serum IgE testing. Results Of the 815 patients, 167 (20.5%) reported PFAS reactions. Most commonly, eliciting foods were kiwi (58, 34.7%), peach (43, 25.7%), and melon (26, 15.6%). Reported reactions were mostly local (216/319, 67.7%), occurring within 5 min of contact with elicitors (209/319, 65.5%). Associated characteristics included positive IgE to at least one panallergen (profilin, PR-10, or nsLTP) (p = 0.007), maternal PFAS (OR: 3.716, p = 0.026), and asthma (OR: 1.752, p = 0.073). Between centers, heterogeneity in prevalence (Marseille: 7.5% vs. Rome: 41.4%, p < 0.001) and of clinical characteristics was apparent. Cypress played a limited role, with only 1/22 SPT mono-sensitized patients reporting a food reaction (p < 0.073). Conclusions PFAS is a frequent comorbidity in Southern European SAR patients. Significant heterogeneity of clinical characteristics in PFAS patients among the centers was observed and may be related to the different pollen sensitization patterns in each geographic area. IgE to panallergen(s), maternal PFAS, and asthma could be PFAS-associated characteristics

Omalizumab in children with severe allergic disease: a case series

Abstract Background Currently, severe allergic asthma and food allergy in children represent an important public health problem with medical, psychosocial and economic impacts. Omalizumab is a humanized monoclonal anti-IgE antibody, approved for refractory allergic asthma and chronic urticaria. It has been widely used in clinical practice as add-on therapy in patients with severe uncontrolled allergic asthma. In recent years there has seen the emergence of an allergic epidemic with increasing food allergy, which represents the main cause of anaphylaxis in children. The standard of care for food allergy is strictly dietary allergen avoidance and emergency treatment, but recent clinical trials have suggested that omalizumab may have a role to play as an adjuvant to oral immunotherapy (OIT). We present a case series of patients treated at our institution with omalizumab for severe allergic asthma and food allergy. Methods Patients received omalizumab according to a standard reference nomogram after failing standard therapies. In children with comorbid severe food allergy, omalizumab was administered in conjunction with an oral immunotherapy protocol. Results Omalizumab was effective in controlling symptoms of allergic asthma, allergic rhinitis and rhinosinusitis, but not eosinophilic esophagitis, while aiding successful oral desensitization of comorbid severe food allergies. Conclusions Omalizumab appears to be an excellent therapeutic option in children with inadequately controlled severe allergic asthma, allergic rhinitis and rhinosinusitis, with or without food allergy

Allergen immunotherapy in atopic dermatitis: Light and shadow in children

Atopic dermatitis (AD) is a chronic remitting-relapsing inflammatory skin disorder. Due to the multifactorial pathogenesis, there are numerous therapeutic management approaches, mainly based on symptomatic treatments. In recent years, allergen immunotherapy (AIT) has been progressively advanced as targeted disease-modifying treatment of allergic disease. The most recent guideline from the American Academy of Dermatology concludes that data available do not support its use in AD. The Joint Task Force and The European Academy of Dermatology suggest that clinicians can consider AIT treatment in selected patients characterized by aeroallergen sensitization, prevalently HDM, severe AD, and clinical exacerbation after exposure to the causative allergen. Nevertheless, its role in AD is still under debate, especially in children

Safety of allergen-specific immunotherapy in children

Allergic respiratory diseases, such as asthma and allergic rhinitis, are global health issues and have had an increasing prevalence in the last decades. Allergen-specific immunotherapy (AIT) is the only curative treatment for allergic rhinitis and asthma, as it has a disease-modifying effect. AIT is generally administered by two routes: subcutaneous (SCIT) and sublingual immunotherapy (SLIT). Local side effects are common, but usually well-tolerated and self-limited. However, systemic side effects are rare, and associated with uncontrolled asthma and bronchial obstruction, or related to errors in administration. Physicians should constantly assess potential risk factors for not only reporting systemic reactions and fatalities but also implementing other therapies to improve AIT safety. This paper highlights recent evidence on local and systemic reactions related to SCIT and SLIT in children

Recognizing the Emergent and Submerged Iceberg of the Celiac Disease: ITAMA Project—Global Strategy Protocol

Coeliac disease (CD) is frequently underdiagnosed with a consequent heavy burden in terms of morbidity and health care costs. Diagnosis of CD is based on the evaluation of symptoms and anti-transglutaminase antibodies IgA (TGA-IgA) levels, with values above a tenfold increase being the basis of the biopsy-free diagnostic approach suggested by present guidelines. This study showcased the largest screening project for CD carried out to date in school children (n=20,000) aimed at assessing the diagnostic accuracy of minimally invasive finger prick point-of-care tests (POCT) which, combined with conventional celiac serology and the aid of an artificial intelligence-based system, may eliminate the need for intestinal biopsy. Moreover, this study delves deeper into the “coeliac iceberg” in an attempt to identify people with disorders who may benefit from a gluten-free diet, even in the absence of gastrointestinal symptoms, abnormal serology and histology. This was achieved by looking for TGA-IgA mucosal deposits in duodenal biopsy. This large European multidisciplinary health project paves the way to an improved quality of life for patients by reducing the costs for diagnosis due to delayed findings of CD and to offer business opportunities in terms of diagnostic tools and support