Introdução: A alergia à carne de frango é rara. Consoante a via de sensibilização, existem dois tipos de alergia: primária e secundária. Por regra, a reação cruzada entre carnes de aves é comum. Caso clínico: Mulher de 36 anos, sem antecedentes pessoais relevantes, com história de três episódios de prurido e urticária aguda generalizada e angioedema palpebral, minutos após ingestão de carne de frango assado sem temperos/conservantes. Desde o terceiro episódio que mantém evicção de todo o tipo de carne de aves, tolerando a ingestão de ovo. Foi referenciada a consulta de alergia alimentar, onde realizou testes cutâneos picada-picada com carne de frango e de peru, que foram positivos, ausência de IgE especificas séricas e provas de provocação oral a peru e pato negativas. Conclusão: Este caso revela a importância da confirmação da alergia e avaliação da reatividade cruzada entre alimentos para evitar restrições alimentares desnecessárias por parte dos doentes.

A 43-year-old male presented with pruritic nodular lesions in the red dye area of his leg tattoo, which developed 4 weeks after its application. Patch tests were performed using a standard series, and the inks used by the tattooist were tested semi-open. Tests identified a sensitization to 2 inks containing an azo-organic dye (Pigment Red 170), diketopyrrolopyrrole (Pigment Red 254), and copper phthalocyanine (Pigment Blue 15). Histopathological findings suggested a pseudolymphoid reaction, likely driven by T-cell hypersensitivity to the red pigments. Although the utility of patch testing in the assessment of tattoo reactions is not consensual, it can be useful in identifying the offending inks, helping to guide future tattoo choices and prevent recurrences. Patch testing including the suspected ink should not be disregarded from the diagnostic workup.

Background: Dust mites are the leading cause of respiratory allergic diseases worldwide. Allergy to storage mites (SMs) has mostly been related to occupational exposures. However, recent studies have shown that sensitisation to SM, such as Lepidoglyphus destructor (Lep d), is of considerable importance also in urban populations, with high prevalence in dust samples of domestic environments. Co-sensitisation between house dust mites (HDMs) and SM is now regarded as very frequent in some regions, and cross-reactivity between them seems to be narrow. Therefore, SM allergenic capacity is increasingly a subject of study. The nasal provocation test (NPT), as an in vivo technique, could be considered the gold standard for the clinical relevance assessment of an allergen, in polysensitised rhinitis patients. Objective: The objective of this study was to analyse the clinical relevance of the SM Lep d, by assessing the relationship between in vivo sensitisation and expression of allergic respiratory disease in an urban setting. Patients and Methods: In our study, we enrolled a total of 32 allergic patients with rhinitis (with or without asthma) with proven sensitisation by skin prick test (SPT) and specific IgE (sIgE) to HDMs and/or SM. Patients underwent NPT with Lep d using subjective (Lebel Symptom Score Scale) and objective measurements (peak nasal inspiratory flow [PNIF]) for assessment of nasal response. Results: Most of the patients with positive SPT and sIgE to Lep d had a positive NPT (24/27; 89%). True Lep d allergy, assessed by a positive NPT, could be predicted by a SPT wheal size >9.7 mm and a sIgE >0.42 kUA/L, with 100%/95.7% sensitivity and 75.0%/83.3% specificity, respectively. Co-sensitisation between Lep d and Der p was high, 75.0%. Asthma was more frequent in the positive Lep d NPT group (54 vs. 12%, p < 0.05). Significantly more patients from this group reported physical exercise, nonspecific irritants, and respiratory infections as relevant triggers of respiratory symptoms (p < 0.01–p < 0.05). Conclusions: To our knowledge, this is the first study to show that sensitisation to Lep d may have clinical relevance in a non-occupational setting. In this group, there seems to be a relationship between allergy to Lep d and severity of respiratory disease, with more bronchial inflammation, when comparing with mite-allergic patients sensitised only to HDM. Therefore, the authors consider that sensitisation to Lep d should be considered when assessing and treating allergic respiratory disease in urban environments.

Background. The aim of the study was to learn about perception of drug allergy by general practitioners (GP) from continental Portugal, identify difficulties and educational needs for its management. Methods. A total of 372 answers were obtained. A questionnaire was addressed to GPs. Results. The most commonly identified drugs were antibiotics for 65.3% of the GPs and skin was the most commonly affected organ for 65.8%. Drug allergy was considered as very important in clinical practice by 73.7%, but difficulties in recognizing it were stated by 70.2%. Further education in this field wouldbe welcome by 97.8% of the doctors. The collaboration of Immunoallergology centers was considered non satisfactory by 39.8% of GPs and 45.7% of them stated that two-thirds of the suspected reactions were not investigated. Conclusions. These points deserve consideration in future health educational and organizational strategies.

Clinical Implications•Skin testing (prick test and intradermal test) can be performed with the Pfizer-BioNtech severe acute respiratory syndrome coronavirus 2 vaccine, up to the undiluted form, without the risk of eliciting an immediate irritant reaction. This finding can help the evaluation of patients with an immediate reaction to the first dose of the vaccine or with a suspected immediate reaction to a component of the vaccine and who require vaccination due to the coronavirus pandemic. •Skin testing (prick test and intradermal test) can be performed with the Pfizer-BioNtech severe acute respiratory syndrome coronavirus 2 vaccine, up to the undiluted form, without the risk of eliciting an immediate irritant reaction. This finding can help the evaluation of patients with an immediate reaction to the first dose of the vaccine or with a suspected immediate reaction to a component of the vaccine and who require vaccination due to the coronavirus pandemic. The importance of vaccination to the coronavirus disease 2019 pandemic cannot be understated. However, reports of anaphylaxis associated with the Pfizer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine are emerging with the beginning of large-scale vaccination.1Castells M.C. Phillips E.J. Maintaining safety with SARS-CoV-2 vaccines.N Engl J Med. 2021; 384: 643-649Crossref PubMed Scopus (320) Google Scholar Preliminary data suggest an incidence of anaphylaxis of approximately 1 in 100,000 injections, 10 times greater than the incidence of traditional vaccines. Hypersensitivity to the vaccine, or to one of its components, has generally been established as a contraindication to the vaccine administration.1Castells M.C. Phillips E.J. Maintaining safety with SARS-CoV-2 vaccines.N Engl J Med. 2021; 384: 643-649Crossref PubMed Scopus (320) Google Scholar Concerning the observed anaphylactic reactions, the pathophysiology remains to be determined. An IgE-mediated pathway must be considered. Polyethylene glycol (PEG) 2000, used as a stabilizer of the lipid-based nanoparticle carrier system of the Pfizer SARS-CoV-2 vaccine, has been pointed as a possible culprit, and its role in inducing IgE-mediated anaphylaxis is well documented.1Castells M.C. Phillips E.J. Maintaining safety with SARS-CoV-2 vaccines.N Engl J Med. 2021; 384: 643-649Crossref PubMed Scopus (320) Google Scholar,2Wenande E. Garvey L.H. Immediate-type hypersensitivity to polyethylene glycols: a review.Clin Exp Allergy. 2016; 46: 907-922Crossref PubMed Scopus (266) Google Scholar Therefore, skin testing with the vaccine may prove a valuable method to evaluate patients who experienced immediate reactions with the first dose of the vaccine, as well as to identify people with allergy to the vaccine or its components and who should avoid it. The biggest problems in using the vaccine is the lack of information concerning the adequate (nonirritant) concentration for the skin tests,3Brockow K. Garvey L.H. Aberer W. Atanaskovic-Markovic M. Barbaud A. Bilo M.B. et al.Skin test concentrations for systemically administered drugs—an ENDA/EAACI Drug Allergy Interest Group position paper.Allergy. 2013; 68: 702-712Crossref PubMed Scopus (699) Google Scholar and the need for additional vaccine to perform the tests, especially considering the need for a quick worldwide vaccination and the consequent scarcity of the vaccine. Pfizer's specifications regarding the vaccine use state that each vial contains enough for 5 doses with a 6-hour viability before inoculation. In some settings, health care professionals have used the surplus in each vial for an additional sixth dose. Even in these cases, each vial still contains a small quantity of vaccine, which can be used to perform skin tests. Taking advantage of this fact, we evaluated 55 health care professionals to determine nonirritant concentrations for skin testing with SARS-CoV-2 mRNA vaccine. All participants were selected from a group of health care professionals being vaccinated with the Pfizer SARS-CoV-2 vaccine, as part of the Portuguese National Vaccination Plan. Participants were inoculated with the first dose of the vaccine, and if they remained asymptomatic for 30 minutes, they were considered eligible for skin testing. Participants were excluded if they took antihistamines or drugs with antihistamine properties in the 5 previous days. All participants signed an informed consent. Patients were questioned on their atopic history and, specifically, drug allergy. Additional information from their clinical files was added retrospectively. Each person underwent skin prick and intradermal tests with the undiluted vaccine and with a dilution of 1/10 with saline. The tests were performed in accordance with the literature.4Brockow K. Romano A. Blanca M. Ring J. Pichler W. Demoly P. General considerations for skin test procedures in the diagnosis of drug hypersensitivity.Allergy. 2002; 57: 45-51Crossref PubMed Scopus (741) Google Scholar A positive control with histamine (10 mg/mL) and a negative control with saline, performed by the prick test, were also carried out. Readings were made after 15 and 30 minutes for every test. Seventy-five percent of the patients were women, with an average age of 42 ± 12 years (between 23 and 67 years of age). Atopic history is detailed in Table I. None of the patients had a history suggestive of PEG allergy, or allergy to other vaccines. Three of the participants presented a history of anaphylaxis: one selective to indomethacin (with no previous evaluation by an allergologist, but with a very suggestive story), another to Pru p 3 (previously confirmed by an allergologist), and the last had IgE-mediated allergy to penicillin and nonsteroidal anti-inflammatory drug–induced asthma and urticaria (previously confirmed by an allergologist).Table IAtopic history of the participantsAtopic historyNo. of patients (n = 55)Allergic rhinitis confirmed by allergic testing11Nonallergic rhinitis confirmed by allergic testing1Rhinitis-like symptoms with no previous evaluation by allergology6Allergic asthma confirmed by allergic testing10Nonallergic asthma confirmed by allergic testing1Asthma-like symptoms with no previous evaluation by allergology2Food allergy confirmed by allergic testing2∗One case of anaphylaxis related to Pru p 3, and 1 case of oral allergy syndrome related to nuts.Food allergy with no previous evaluation by allergology0Drug allergy confirmed by allergic testing1†Urticaria with beta-lactam antibiotics, with positive skin tests and/or oral provocation tests and NSAID-induced asthma and urticaria.Drug allergy with no previous evaluation by allergology6‡Two cases of urticarial-like symptoms with amoxicillin, 1 case of urticarial-like symptoms with metoclopramide, 1 case of urticarial-like symptoms with oral acetylcysteine, 1 case of face angioedema with aspirin (tolerating other NSAIDs), and 1 case of anaphylaxis with indomethacin (consistent history on 2 separate occasions, tolerating other NSAIDs).NSAID, Nonsteroidal anti-inflammatory drug.∗ One case of anaphylaxis related to Pru p 3, and 1 case of oral allergy syndrome related to nuts.† Urticaria with beta-lactam antibiotics, with positive skin tests and/or oral provocation tests and NSAID-induced asthma and urticaria.‡ Two cases of urticarial-like symptoms with amoxicillin, 1 case of urticarial-like symptoms with metoclopramide, 1 case of urticarial-like symptoms with oral acetylcysteine, 1 case of face angioedema with aspirin (tolerating other NSAIDs), and 1 case of anaphylaxis with indomethacin (consistent history on 2 separate occasions, tolerating other NSAIDs). Open table in a new tab NSAID, Nonsteroidal anti-inflammatory drug. All the skin prick tests with histamine were positive (wheals between 4 × 4 mm and 9 × 8 mm). All negative control prick tests were negative with the exception of a patient with symptomatic dermographism (wheal of 5 × 5 mm). In 53 patients (96%), the vaccine prick and intradermal tests were negative. One patient showed erythema without pruritus or increase in diameter of the intradermal wheal in both the undiluted and 1/10 dilution. Another participant, with symptomatic dermographism, showed a positive reaction to the skin prick and intradermal tests, including the skin prick test with saline. No participant developed symptoms suggestive of an allergic reaction within 24 hours of the first inoculation. In conclusion, skin prick testing and intradermal testing can be performed with the Pfizer-BioNtech SARS-CoV-2 vaccine with its undiluted form. An open question remains about the exact positive predictive value these tests may have. These findings cannot be generalized to other vaccine preparations and do not address delayed reactions or adverse effects.

Introduction: The impact of air pollution on respiratory diseases, particularly in asthma, has been the subject of several studies. The impact of pollution on the daily symptoms of patients with asthma has been less studied. The aim of this study is to assess the association between the intensity of asthma symptoms and the variation of pollution levels. Material and Methods: Patients with a diagnosis of asthma were instructed to record the intensity of their respiratory symptoms daily, expressed on a scale from 0 to 5, in the months of March and April 2018. The website of the Portuguese Environment Agency was consulted in order to obtain the daily levels of pollutants measured by the two local monitoring stations during the same period of time. Data was analyzed using a temporal causal model to study the association between pollutant levels - particulate matter, ozone, nitrogen dioxide and carbon monoxide - and the intensity of respiratory symptoms. Results: From the 135 schedules delivered, 35 were correctly filled out and returned. The patient median age was 47.0 years, 18 being females. The best statistical model obtained identified ozone as the most relevant 'Granger cause' of asthma symptoms. Particulate matter, carbon monoxide and nitrogen also appeared as lower impact factors. The quality of the model was expressed by an R-2 of 0.92. The correlation between ozone values and asthma symptoms was more significant after five days. For the other identified factors there was a lag of four to five days. Discussion: Our results support the existence of a daily variation of asthma symptoms that is associated with the pollution levels, even if these are within acceptable limits according to national and international standards. Regretfully, the small number of participants was a limitation in term of the conclusions that could be drawn and did not allow the analysis of clinical or other factors that are potentially involved. Conclusion: In the place and period studied the air pollutants behaved as factors of variation in the intensity of asthma symptoms. The ozone level was the best predictive factor of symptom variation. Levels of particulate matter, carbon monoxide and nitrogen were identified as secondary markers. The time lag between the variables with the best correlation suggests there could be a delayed effect of pollutants on respiratory symptoms.

To the editor The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has rapidly become one of the biggest health threats the world has faced. The importance of controlling the disease and its worldwide spread cannot be understated. Vaccination arises as the cornerstone of this fight against coronavirus disease 2019 (COVID-19), though new challenges have emerged with it. Anaphylactic reactions to vaccines are very rare, occurring at a rate of 1.31 per million doses administered [1]. Reports on the new mRNA Pfizer-BioNTech SARS-CoV-2 vaccine show a higher rate of anaphylactic reactions: 4.7 cases/million doses administered [2]. There is great uncertainty about which patients might be at risk of developing an anaphylactic reaction to the vaccine. Current recommendations state that the vaccine should not be administrated if subjects have hypersensitivity to COVID-19 vaccines or any of its components [3]. The Pfizer-BioNTech SARS-CoV-2 vaccine is an mRNA vaccine that uses a lipid-based nanoparticle carrier system, stabilized by polyethylene glycol (PEG) 2000. Although evidence on the pathogenesis of severe immediate reactions to the SARS-CoV-2 vaccine is lacking, the PEG molecule has been proposed as a possible culprit for these reactions due to existing evidence of its ability to cause immunoglobulin E (IgE)-mediated anaphylaxis [456]. Assuming the reactions to the Pfizer-BioNTech vaccine resulted from IgE-mediated mechanisms, skin testing might prove a valuable method to identify patients with allergy to the vaccine or its components. Published data by Marcelino et al. [7] showed that skin prick (SP) and intradermal (ID) testing with the Pfizer-BioNTech SARS-CoV-2 vaccine in its undiluted form can be performed and are not irritant. However, multicentric data on the usefulness and validity of skin testing with the SARS-CoV-2 vaccine is still lacking. Our aim is to evaluate skin test positivity to the Pfizer-BioNTech SARS-CoV-2 vaccine and its association with PEG 2000 skin tests and with allergic reactions to the vaccine. As part of our national COVID-19 vaccination program, 2,755 healthcare workers were vaccinated at our Hospital. A total of 115 performed skin tests with the Pfizer-BioNTech SARS-CoV-2 vaccine (83% women, mean age of 44±12 years). Fifty-five of them were control subjects, who had tolerated the vaccine, and confirmed the nonirritant test concentrations (Marcelino et al. [7]). Sixty reported a previous history of drug anaphylaxis and underwent skin testing prior to the vaccination. SP and ID tests were performed for each person with the undiluted vaccine and a 1/10 dilution with saline solution. Readings were performed after 15 and 30 minutes. Four subjects had positive results to the ID tests, detailed on Table 1. The positive reactions were as follows: (1) 1 of the 4 developed a systemic urticaria within 10 minutes of performing the ID test with the undiluted vaccine, (2) 2 others had a positive ID test with the vaccine at a 1/10 dilution, (3) the last one had a positive ID test with the undiluted vaccine.Table 1: Patients with a positive skin test to Pfizer-BioNTech SARS-CoV-2 vaccine and their reported allergic historyAll 4 were then tested with PEG 2000 (BioUltra, SIGMA-ALDRICH Co., St. Louis, MO, USA) diluted in saline solution with SP tests (0.1 mg/mL and 1 mg/mL) and ID test (0.001 mg/mL, 0.01 mg/mL, and 0.1 mg/mL). Readings were performed after 30 minutes. There were no positive reactions to the prick tests. Only one tested positive to the ID tests at the 0.001-mg/mL dilution. This patient reported a history of anaphylaxis with nimesulide tablets, which contained macrogol 6000 (PEG 6000). One of the subjects with a positive ID test to the vaccine but no positive tests to PEG 2000 proceeded to vaccination with the Pfizer-BioNTech vaccine, premedicated with 20 mg of cetirizine. Inoculation was fractioned into 2 doses. Immediately after one-third of the vaccine's total dose was administered, the healthcare worker developed a sudden onset generalized urticaria. The other 3 subjects did not receive the Pfizer-BioNTech vaccine, one due to a systemic reaction with the ID test, the other 2 due to safety concerns. The AstraZeneca COVID-19 vaccine has not been associated with a higher incidence of anaphylaxis, does not contain PEG 2000, and there is no evidence suggesting that hypersensitivity to the Pfizer-BioNTech vaccine would increase the risk of reaction to the AstraZeneca COVID-19 vaccine [5]. For the prementioned reasons, 2 of the 4 subjects were later inoculated with the AstraZeneca COVID-19 vaccine, with no immediate reactions (Table 1). A third subject awaits vaccination with a non-mRNA vaccine (AstraZeneca or Johnson & Johnson's Janssen COVID-19 vaccine). A fourth subject refused vaccination with a COVID-19 vaccine. The 111 healthcare workers with negative tests were vaccinated with the Pfizer-BioNTech vaccine without any immediate reaction. None of the remaining 2,640 healthcare professionals reacted to the Pfizer-BioNTech vaccine. In conclusion, SP and ID testing using the Pfizer-BioNTech SARS-CoV-2 vaccine (undiluted and 1/10 dilution) was proved nonirritant. Skin test positivity to the vaccine was associated to a systemic reaction in 2 of 4 subjects. Although the dimension of our data is limited and does not allow definitive conclusions, it suggests that skin tests with the vaccine may prove useful to predict immediate reactions to the Pfizer-BioNTech vaccine. Only 1 of the 4 skin tests to PEG 2000 had a positive result. This suggests a role of PEG in some immediate reactions to the Pfizer-BioNTech SARS-CoV-2 vaccine, but it also points out that there may be non-PEG related immediate reactions to the vaccine. This study was approved by the Institutional Review Board of Centro Hospitalar de Setúbal E.P.E. (approval number: PI-008/2021). Conflict of Interest: The authors have no financial conflicts of interest. Author Contributions: Conceptualization: Elza Tomaz, João Marcelino, Fátima Ferreira. Formal analysis: João Vieira, Rita Silva, Miguel Proença. Investigation: João Vieira, João Marcelino, Fátima Ferreira, Sofia Farinha, Rita Silva, Miguel Proença, Elza Tomaz. Methodology: Elza Tomaz, João Marcelino, Sofia Farinha. Project administration: Elza Tomaz, João Marcelino. Writing - original draft: João Vieira, João Marcelino, Fátima Ferreira. Writing - review & editing: João Vieira, João Marcelino, Elza Tomaz.

Background: Adherence to therapy in bronchial asthma is essential for the control of the disease. Several studies show that non -adherence seems to be the result of different factors and barriers associated with the patient, but also with the prescriber. The most important are the psychological, economic and social aspects. In clinical practice, there are few resources that allow the physician to objectify the degree of compliance of his prescription. The aim of this study was to analyze the degree of adherence to therapy in asthmatic patients followed in a Hospital Immunoallergology Department. Methods: The clinical trials of 63 asthmatic patients followed at the Immunoallergology Department from January to December of 2016 (T0) and from January to December of 2017 (T1) were retrospectively studied. The number of packs prescribed to the patients by the attending physician and the number of packs actually purchased in pharmacies were analyzed in T0 and T1 by means of Electronic Medicines Prescriptions (PEM) records for the following drugs: bronchodilators (BD), inhaled corticosteroids isolated or in combination with bronchodilators (OUT), oral antihistamines (AH), leukotriene antagonists (LCRA), nasal corticosteroids (CN) and oral corticosteroids (CO). The following demographic and clinical variables were analyzed: age, sex, clinical diagnosis, atopy, allergen sensitization and specif ic immunotherapy treatment (ITE). Results: We found a compliance of 64.76% to the prescription. The drugs which the patients most adhere were oral corticosteroids (73%), followed by leukotriene antagonists and antihistamines (70%). When analysing associations between variables, it was observed that patients who were not under ITE had greater adhesion to the inhalers (BD and CI) (p <0.05). The asthmatic group had a positive association with adherence to the LCRA (p <0.05) and in the analysis by age, we found that the infant population had a positive association with adherence to AH (p <0.05). Conclusions: To improve adherence to therapy in asthma, it is important to address and know patient’s compliance. The study of each patient’s adherence based on computerized drug prescription and retrieval systems in pharmacies allows prescribing physicians to introduce this variable into the analysis of asthma control.

A gentamicina, antibiótico aminoglicosídeo, é muitas vezes utilizada como antibioterapia profilática em cirurgia ortopédica.As reações adversas aos aminoglicosídeos são maioritariamente tóxicas, sendo a ototoxicidade e a nefrotoxicidade as mais comuns.No que respeita a reações de hipersensibilidade, são mais frequentes as reações tardias, tipo IV, relacionadas com o uso de preparações oftálmicas ou cimento ósseo contendo gentamicina.No entanto, apesar de raras, estão descritas reações de hipersensibilidade imediata à gentamicina

Podemos melhorar o olfato na rinite alérgica?Can we improve olfaction in allergic rhinitis?