Um caso clínico

Publisher Copyright: © 2021, Sociedade Portuguesa de Alergologia e Imunologia Clinica. All rights reserved.The increasing use of ophthalmic medication has led to the emergence of a greater number of hypersensitivity reactions (HR) associated with it. These are mostly type IV HR and, rarely, immediate. The agents involved are diverse, from active substances such as mydriatic eye drops (CM) to inactive substances (preservatives). We report the case of a patient with suspected immediate and non-immediate HR to ophthalmic medication (tropicamide 10mg/ml, phenylephrine 100mg/ml and cyclopentolate 10mg/ml), whose investigation included skin prick tests (SPT) and patch tests (PT) with the mentioned drugs. SPT were positive for cyclopentolate, with immediate reaction, and for phenylephrine at 48 and 96 hours. The PT were positive at 48 and 96 hours for phenylephrine. According to these results, we assumed allergy to phenylephrine and cyclopentolate and an ocular provocation test was performed with tropicamide which was tolerated by the patient.publishersversionpublishe

Obstrução e inflamação das vias aéreas na asma em idade pré-escolar

RESUMO: A asma brônquica é uma das doenças crónicas mais frequentes na criança, sendo causa de elevada morbilidade, de recurso comum aos serviços de saúde e de um enorme impacto familiar, social e económico. Trata-se de uma doença heterogénea, cujos fenótipos dependentes da idade, necessitam de melhor caracterização. Com início habitualmente precoce, o controlo da asma em idade pré-escolar impõe vários desafios aos clínicos. Com este projecto pretendeu-se responder às questões sobre o papel da obstrução brônquica, da resposta ao broncodilatador (BD) e da inflamação das vias aéreas na ausência do controlo da asma, no período entre crises, nesta faixa etária. Relativamente à inovação do estudo, destaca-se a metodologia utilizada na avaliação do controlo desta patologia, nomeadamente o uso do questionário “Test for Respiratory and Asthma Control in Kids (TRACK)”, a avaliação funcional respiratória por espirometria e oscilometria de impulso (IOS) e a medição dos biomarcadores de inflamação do ar exalado. Quanto às lacunas de conhecimento, decidimos focar-nos na identificação dos factores de risco associados à ausência do controlo da asma, na confirmação de que a ausência de controlo da asma se deve à presença de obstrução, hiperreactividade e inflamação das vias aéreas e na caracterização dos fenótipos da asma. Foram definidos os seguintes objectivos do estudo da asma em idade pré-escolar: 1) validação do questionário TRACK para uso na nossa população; 2) estudo da relação entre o nível de controlo da asma com parâmetros clínicos, funcionais, tais como a presença de obstrução das vias aéreas e resposta ao BD; 3) estudo da relação entre o nível de controlo da asma e os biomarcadores; 4) identificação de fenótipos de asma. Desenvolveu-se um estudo observacional, controlado e transversal, em que se incluíram 121 crianças entre os 3 e os 5 anos de idade, 107 com diagnóstico clínico de asma, a quem o médico tinha solicitado testes de função pulmonar, e 14 controlos saudáveis. As crianças foram avaliadas no máximo de duas visitas com um intervalo até sete dias, para completarem a realização de todos os exames. Procedeu-se à caracterização da asma, avaliação do nível de controlo da mesma pelo médico e pelos pais, incluindo o preenchimento por estes últimos da versão adaptada ao contexto português do questionário TRACK. Os exames realizados foram a espirometria e a IOS com prova de broncodilatação, medição da temperatura do ar exalado, medição de FENO e, numa subamostra de crianças, o estudo do pH do condensado brônquico do ar exalado. Para a validação das características psicométricas do questionário TRACK realizou-se um outro estudo, prospectivo, no qual foram incluídas 141 crianças com asma, tendo este estudo compreendido a realização de duas visitas separadas entre si por duas a seis semanas. Esta versão do questionário TRACK revelou ter boas características psicométricas, nomeadamente em termos de consistência interna e fiabilidade, assim como aceitável acuidade discriminativa, identificando correctamente o nível de controlo da asma em cerca de 80% das crianças asmáticas. Utilizaram-se os critérios GINA (Global INitiative for Asthma) como padrão para definir os níveis de asma: “controlado” e “não controlado”. Não se encontrou associação entre os níveis de obstrução das vias aéreas e os vários marcadores de inflamação, dependentes do nível de controlo da asma. Esta conclusão pode dever-se ao facto de cerca de 73% das crianças com asma não controlada versus 27% das que têm a asma controlada estarem medicadas com corticóides inalados, atenuando deste modo as potenciais diferenças.No entanto, a asma não controlada associou-se a uma maior reversibilidade do FEV1 e do FVC na resposta à prova de broncodilatação e encontrou-se uma associação significativa entre vários parâmetros espirométricos e oscilométricos. Na análise multivariável realizada, as variáveis associadas a um risco aumentado de asma não controlada foram as seguintes: “Mais de 3 crises nos últimos 12 meses”, “Rinite moderada a grave”, “Variação relativa na FVC e FEV1 após-broncodilatador”. As AUC dos modelos finais, que incluíram a variação da FVC ou FEV1, foram de 0,82 e 0,81, respectivamente. Em termos de fenótipos identificaram-se duas classes latentes de asma, nomeadamente “Não atópica, mãe fumadora” e “Atópica, mãe não fumadora”, numa proporção de 1 para 4, em que cerca de metade dos casos de ambos os grupos, tinham a sua doença não controlada. Em conclusão, para este grupo etário, este projecto permitiu: 1) validar uma nova versão do questionário TRACK para uso nacional; 2) criar um modelo preditivo da ausência de controlo da asma, que incluiu parâmetros objectivos clínicos e funcionais, para utilização em complemento ao reporte dos sintomas pelos pais; 3) mostrar que quer a obstrução brônquica, quer a inflamação eosinofílica se associam à presença de asma, mesmo quando esta se encontra controlada; 4) c,onfirmou a heterogeneidade de fenótipos da asma. Entende-se que são ainda necessários mais estudos para confirmar, neste grupo etário, o papel dos modelos preditivos descritos, da oscilometria de impulso e dos biomarcadores na monitorização do controlo da asma em contexto clínico.ABSTRACT: Bronchial asthma is one of the most common chronic diseases in children, with high morbidity, emergency health service use, and an enormous family, social and economic impact. It is a heterogeneous disease whose age-dependent phenotypes need to be better characterized. Usually, asthma control at preschool age is very challenging for clinicians. This project aimed to answer the question about the role of bronchial obstruction, bronchodilator (BD) responsiveness, and airway inflammation in non controlled asthma, inter-crisis. Regarding innovation, the methodology used to evaluate the control of this pathology stands out, namely the use of the questionnaire “Test for Respiratory and Asthma Control in Kids (TRACK)”, the respiratory functional evaluation by spirometry and impulse oscillometry (IOS), and the assessment of inflammatory biomarkers in the exhaled air. Concerning knowledge gaps, we decided to focus on identifying the risk factors associated with the lack of asthma control, verifying that uncontrolled asthma is associated with the presence of airway obstruction, BD hyperresponsiveness, and inflammation, and on the characterization of the asthma phenotypes. The objectives of the study concerning preschool asthma were: 1) to validate the TRACK questionnaire for use in our population 2) to study the relationship between the level of asthma control and clinical, functional parameters, such as the presence of airway obstruction and BD responsiveness 3) to analyze the relationship between the level of asthma control and biomarkers 4) to identify possible asthma phenotypes.An observational, cross-sectional study was carried out, including 121 children between 3 and 5 years of age, 107 with a clinical diagnosis of asthma and to whom the doctor requested pulmonary function tests, and 14 controls. Children were evaluated at most of two visits, with an interval of up to 7 days, to complete all tests. The data about the characterization of asthma, assessment of asthma level control by the doctor, and parents, with the last ones filling in the TRACK questionnaire, were collected. Spirometry and IOS with bronchodilation test, and exhaled air temperature and FENO measurements and, in a sub-sample of children, the study of the pH of the exhaled bronchial condensate, were performed. For the validation of the psychometric characteristics of the TRACK questionnaire, another prospective study was carried out, including 141 children with asthma, comprising two visits, separated between them, for two to six weeks. This version of the TRACK questionnaire was found to have good psychometric characteristics, namely in terms of internal consistency, reliability, as well as acceptable discriminative acuity, to correctly identifying the level of asthma control in about 80% of asthmatic children. The GINA (Global INitiative for Asthma) criteria were used as a standard to define the levels of asthma as controlled and uncontrolled. No association was found between the levels of airway obstruction or the various inflammation markers, depending on the level of asthma control, which may be due to 73% of children with uncontrolled asthma, versus 27% of those having controlled asthma were taking inhaled corticosteroids, mitigating possible potential differences.However, uncontrolled asthma was associated with greater variability in FEV1 and FVC in response to the bronchodilation test. Also, significant associations were found between various spirometric and oscillometric parameters. In the multivariable analysis, the variables associated with increased risk of uncontrolled asthma were: “More than 3 crises in the last 12 months”, “Moderate to severe rhinitis”, “Relative variation in FVC and FEV1 after bronchodilator”. The AUC of the final models that included the FVC or FEV1 variation were 0.82 and 0.81, respectively. About phenotypes, two latent classes of asthma were identified, namely “Non-atopic, smoking mother” and “Atopic, non-smoking mother” in a ratio of 1 to 4. About half of the cases in both groups had their illness uncontrolled. In conclusion, this project allowed: 1) to validate a new version of the TRACK questionnaire for national use 2) to create a predictive model of the absence of asthma control, which included objective clinical and functional parameters, for use in addition to the reporting of symptoms by parents 3) to show that bronchial obstruction and eosinophilic airway inflammation were associated with the presence of asthma, even when controlled 4) to confirm the heterogeneity of phenotypes. Further studies are needed to confirm the role of the described predictive models, impulse oscillometry, and biomarkers for monitoring asthma control in a clinical context in this age group

Cisatracurium – A “safe” neuromuscular blocking agent?

Anesthetic agents are an important cause of drug anaphylaxis, with neuromuscular blocking agents (NMBA) being a common cause of intraoperative anaphylaxis. Cisatracurium, a stereoisomer of atracurium, is the most recent NMBA, which was believed to have no histamine-releasing potential, and therefore, cause less allergic reactions than other NMBA. Although there have been several cases of severe anaphylactic reactions to cisatracurium reported worldwide, there are no known published cases in Portugal, to the best of our knowledge. The authors present two cases of severe perioperative anaphylaxis (grade 4 according to Ring & Messmer Classification) with cardiorespiratory arrest. In the allergological work-up, a positive intradermal skin test for cisatracurium (1: 100) was found in both patients. It is important to emphasize that this NMBA is not exempt of allergenic potential as previously thought. Thus, it should be taken into account when assessing an allergic reaction that occurred during anesthetic induction.publishersversionepub_ahead_of_prin

Ventilatory defects and treatable traits in very elderly patients

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was supported by AstraZeneca – Projecto OLDER (CEDOC/2015/59) and Finnee Project (PTDC/CCI-BIO/29702/2017).Though the approach used to classify chronic respiratory diseases is changing to a treatable-traits (TT) approach, data regarding very elderly patients is lacking. The objectives of this study were to assess TT frequency in very elderly patients and to study the link between extrapulmonary TT and ventilatory defects. Individuals (≥75 years) residing in elderly care centres answered a standardised questionnaire, underwent spirometry, atopy and fractional exhaled nitric oxide assessments and had their blood pressure and peripheral pulse oximetry measured. Pulmonary, extrapulmonary and behavioural TT were evaluated. Outcome variables were an airflow limitation (post-bronchodilator z-score FEV1/FVC<-1.64) and a restrictive spirometry pattern (z-score FEV1/FVC ≥ +1.64 and z-score FVC<-1.64). Seventy-two percent of the individuals who took part in the study (n = 234) were women, and the median age of participants was 86 (IQR: 7.4). At least one pulmonary TT was identified in 105 (44.9%) individuals. The most frequent extrapulmonary TTs were: persistent systemic inflammation (47.0%), anaemia (34.4%), depression (32.5%) and obesity (27.4). Airflow limitation was exclusively associated with smoking (OR 5.03; 95% CI 1.56-16.22). A restrictive spirometry pattern was associated with cognitive impairment (OR: 3.89; 95% CI: 1.55-9.79). A high frequency of various TTs was found. The novel association between a restrictive spirometry pattern and cognitive impairment highlights the urgency of clinical research on this vulnerable age group.publishersversionpublishe

ALERGIA A FÁRMACOS COM MANIFESTAÇÕES CUTÂNEAS - ABORDAGEM DIAGNÓSTICA

Adverse drug reactions constitute a major health problem in clinical practice. Drug allergy is defined as an immunologically mediated hypersensitivity reaction and represents 6-10% of all adverse drug reactions. Cli- nically, drug-induced allergic reactions can be classified as immediate (type I) and non-immediate (heterogeneous clinical manifestations, mostly related to type IV reactions). Several issues are considered in this revision, particularly immunopathologic mechanisms, cross-reactivity and the most relevant cutaneous reactions (maculopapular exanthe- ma, fixed drug eruption, acute generalized exanthematic pustulosis, drug hypersensitivity syndrome, also referred as drug rash with eosinophilia and systemic symptoms – DRESS, Stevens-Johnson syndrome and toxic epidermal necrolysis). The role of skin tests (epicutaneous or intradermal with late reading) in the diagnostic approach of non- -immediate reactions is also analysed. The most important causes of hypersensitivity reactions are antibiotics, parti- cularly beta-lactams. This group poses significant diagnostic and management difficulties and deserves, therefore, a more thorough attention, with particular attention to cross-reactivity patterns. Induction of drug tolerance should be considered in selected cases, especially when no safe or effective drug alternatives are available.KEYWORDS – Drug hypersensitivity; Beta-Lactams; Cross reactions; Skin Tests.As reacções adversas a fármacos (RAF) representam um problema frequente na prática clínica. A alergia a fármacos resulta de mecanismos de hipersensibilidade imunológica e representa 6-10% do total de RAF. Clinica- mente, as reacções alérgicas a fármacos podem ser classificadas como imediatas (tipo I) ou não-imediatas (com manifestações clínicas diversas e associadas sobretudo a reacções de tipo IV). Neste artigo são abordados aspectos gerais, nomeadamente os mecanismos imunopatogénicos implicados na alergia a fármacos e reactividade cruzada mas também as manifestações cutâneas mais relevantes, nomeadamente exantemas máculo-papulares, eritema fixo a fármacos (EFF), pustulose exantemática aguda generalizada (PEAG), síndrome de hipersensibilidade a fármacos (DRESS – drug rash with eosinophilia and systemic symptoms), síndrome de Stevens-Johnson/necrólise epidérmica tóxica (SSJ/NET). O papel dos testes cutâneos (epicutâneos ou intradérmicos de leitura tardia) na abordagem de reacções não-imediatas é também revisto. Os beta-lactâmicos (BL) são o grupo farmacológico mais frequentemente envolvido em reacções de hipersensibilidade imunológica e que mais dificuldades coloca na prática clínica diária, nomeadamente devido aos riscos de reactividade cruzada, pelo que é analisado em maior detalhe ao longo da revisão. A indução de tolerância a fármacos poderá ser considerada em casos selecionados, sobretudo quando na ausência de alternativas terapêuticas igualmente eficazes ou seguras.PALAVRAS-CHAVE – Hipersensibilidade a fármacos; Beta-Lactâmicos; Reactividade cruzada; Testes cutâneos

Beta-lactams anaphylaxis – When tolerance doesn’t exclude allergy

Publisher Copyright: © 2022, Sociedade Portuguesa de Alergologia e Imunologia Clinica. All rights reserved.Beta-lactams are a major cause of anaphylaxis in adults. We describe two cases of patients with symptoms of anaphyla-xis after taking beta-lactams that after the resolution of the initial reaction were able to keep the drug and tolerated a com-pleted treatment period. During the investigation, the skin tests were positive for the suspected beta-lactam and the patients underwent a drug provocation test, which identified an alternative beta-lactam. We suggest that anaphylaxis led to a con-sumption of mediators of the allergic inflammation, allowing a temporary tolerance of mast cells and basophils to the drugs in question, which was maintained by continuous exposure. We intent to alert to the possibility that tolerance after an allergic reaction to drugs may be misleading. Thus, the importance of carrying out allergic investigation in situations of tolerance im-mediately after anaphylaxis, which will allow to exclude/confirm the existence of hypersensitivity and reduce the risk of recurrence of potentially fatal conditions.publishersversionpublishe

A propósito de um caso clínico

Publisher Copyright: © 2021 Sociedade Portuguesa de Alergologia e Imunologia Clínica. Published by Publicações Ciência & Vida.Anaphylaxis triggered by ingestion of dust mite contaminated flour, namely wheat flour (WF), is a rare entity. We describe the case of a twelve-year-old male patient with a previous history of allergic rhinitis and suspicion of non-steroidal anti-inflam-matory drugs hypersensitivity, who developed two anaphylactic reactions to an unidentified trigger. Both episodes took place after ingestion of food that was subsequently tolerated. We performed cutaneous skin prick tests to aeroallergens and to the food ingested previously to the reactions, with positive results to numerous mite species and WF from the implicated package and with negative results to commercial extracts of wheat, gliadin, WF with/without baker’s yeast from new packages. We assumed the diagnosis of “pancake syndrome” and confirmed the ibuprofen hypersensitivity with a positive drug provocation test. We present this case because identifying this syndrome requires a high level of suspicion and it should be considered in the differential diagnoses of anaphylaxis of unknown cause.publishersversionpublishe

Chronic respiratory diseases and quality of life in elderly nursing home residents

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Fundação para a Ciência e Tecnologia–GERIA Project PTDC/SAU-SAP/ 116563/2010.Few studies have assessed the quality of life (QOL) related to chronic respiratory diseases in the elderly. In the framework of the geriatric study on the health effects of air quality in elderly care centers (GERIA) study, a questionnaire was completed by elderly subjects from 53 selected nursing homes. It included various sections in order to assess respiratory complaints, QOL (World Health Organization QOL (WHOQOL)-BREF), and the cognitive and depression status. The outcome variables were the presence of a score lower than 50 (publishersversionpublishe

Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.(SFRH/BPD/115169/2016) funded by Fundação para a Ciência e Tecnologia (FCT); ERDF (European Regional Development Fund) through the operations: POCI-01-0145-FEDER-029130 ('mINSPIRERS—mHealth to measure and improve adherence to medication in chronic obstructive respiratory diseases—generalisation and evaluation of gamification, peer support and advanced image processing technologies') cofunded by the COMPETE2020 (Programa Operacional Competitividade e Internacionalização), Portugal 2020 and by Portuguese Funds through FCT (Fundação para a Ciência e a Tecnologia).info:eu-repo/semantics/publishedVersio

Morphological and Postural changes in the foot during pregnancy and puerperium : a longitudinal study

The aim of this study is to observe the morphological and postural changes to the foot that take place during pregnancy and the puerperium. Method: In this descriptive, observational, longitudinal study, we analysed 23 pregnant women, with particular attention to morphological and postural aspects of the foot, at three time points during and after pregnancy: in weeks 9-13 of gestation, weeks 32-35 of gestation and weeks 4-6 after delivery. The parameters considered were changes in foot length, the Foot Posture Index (FPI) and the Hernández Corvo Index, which were analysed using a pedigraph and taking into account the Body Mass Index (BMI). The same procedure was conducted in each review. Results: The statistical analyses obtained for each foot did not differ significantly between the three measurement times. A pronator-type footprint was most frequently observed during the third trimester of pregnancy; it was predominantly neutral during the postpartum period. Statistically significant differences between the measurement times were obtained in the right foot for cavus vs. neutral foot type (between the first and third trimesters and also between the first trimester and the puerperium) (in both cases, p < 0.0001). Conclusions: Foot length increases in the third trimester and returns to normal in the puerperium. According to FPI findings, the third trimester of pregnancy is characterised by pronation, while the posture returns to neutrality during the postpartum period. During pregnancy, the plantar arch flattens, and this persists during the puerperium. The incidence of cavus foot increases significantly in the third trimester and in the puerperium