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COVID-19 and allergy: How to take care of allergic patients during a pandemic?

COVID-19 and allergy: How to take care of allergic patients during a pandemic?

By | Selected articles

Antonella Cianferoni, Martina Votto

Pediatr Allergy Immunol. 2020 Nov;31 Suppl 26:96-101. doi: 10.1111/pai.13367.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease, also known as COVID-19, constitutes a new threat for everybody due to its high infection rate and morbidity and mortality in vulnerable populations. People with allergic rhinitis need continuity of care by allergists during the pandemic. Allergists face the challenge of protecting themselves from becoming infected and providing care to people with allergic rhinitis. They need to be ready to work safely with adequate changes in their practice until either a universal vaccine or herd immunity is achieved. Some of the diseases under the attention of allergists are not considered risk factors but have symptoms such as cough and sneezing in differential diagnosis with COVID-19.

Below is a summary of how to treat specific conditions in the allergy office:

  • Skin testing can be delayed as often information is not essential for the patient’s immediate treatment.
  • Food challenges may be delayed except for peanut challenge in infants or for introducing a food critical for appropriate nutrition to avoid intervention such as a G tube or NG tube placement.
  • Patients on immunotherapy, the administration can be spaced to up to 6 weeks to reduced visits during the pandemic, with the possibility of dose adjustment until the regular schedule is resumed. However, the initiation of immunotherapy should be avoided.
  • Spirometry may cause aerosolization. Therefore, people with COVID-19 or flu-like symptoms should not be tested. All routine testing should be postponed during the pandemic phase.
  • Asthma is a risk factor for severe disease in the case of coronavirus 2 infections. Nevertheless, current recommendations are to continue to follow guidelines of treatment.
  • Patients with allergic rhinitis should continue their treatment. There is no evidence that these patients are at risk of severe complications during a COVID-19 infection. Allergic rhinitis may be evaluated via remote medicine, or telephone and evaluation of allergy may be postponed.

Any suggestions may change rapidly based on the evolving situation of each territory. Limiting in-person visit may have significant financial consequences, and also, at a certain point, delay of procedure may represent a more substantial risk for the patient than the potential risk of being exposed to COVID-19 and should be take under consideration.

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asma alergia y covid

ACE2 expression in allergic airway disease may decrease the risk and severity of COVID-19

By | Artículos seleccionados, Selected articles

Sunita Chhapola Shukla

Eur Arch Otorhinolaryngol. 2020 Oct 6;1-4. doi: 10.1007/s00405-020-06408-7. Online ahead of print.

At the start of the COVID-19 pandemic, allergic rhinitis, allergy, asthma, and chronic obstructive pulmonary disease were considered risk factors because they tend to aggravate during respiratory viral infections and upper respiratory tract symptoms viral infections, allergic rhinitis, and influenza overlap during COVID-19 early stages. This review aimed to revise recent studies published that do not prove that allergy and asthma are risk factors or increase severity for COVID-19.

Recent literature has not shown that airways allergic diseases are a high-risk factor or increase the severity of COVID-19. The reason is that there is a reduction in angiotensin-converting enzyme 2 (ACE2) gene expression in the nose and bronchial cells of allergic airway diseases.

Low ACE2 expression in airway cells of individuals with allergic rhinitis and allergic asthma decreases their susceptibility to COVID-19 and may not be a risk factor for severe infection. However, this is not true for the nonatopic asthma phenotype. More studies are needed to understand the impact of respiratory allergic diseases and T2 inflammatory response on COVID-19 severity and susceptibility. It is essential to continue asthma and allergic rhinitis treatments with inhaled corticosteroids, biologics, and allergen immunotherapy during the COVID-19 pandemic.

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urticaria and covid

Management of urticaria in COVID-19 patients: A systematic review

By | Artículos seleccionados, Selected articles

Eyad Abuelgasim, Ann Christine Modaragamage Dona, Rajan Singh Sondh, Amer Harky

Dermatol Ther. 2020 Sep 28;e14328. doi: 10.1111/dth.14328. Online ahead of print.

The COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), has resulted in an increased healthcare burden, with different symptoms manifesting in other patients. The evidence of skin manifestations similar to urticaria is also growing. The objective of this systematic revision was to review the current literature on urticaria in COVID-19 patients.

According to PRISMA guidelines, investigators carried out an extensive literature search in Medline, EMBASE, Scopus, Cochrane, and Google Scholar, using “COVID-19”, “Coronavirus”, “SARS-CoV-2”, “urticaria”, “angioedema” and “skin rash” until August 2020. Articles related to urticaria and/or angioedema due to COVID-19 and its management and outcome were included.

From the 169 articles returned by the search, 25 of them met the inclusion criteria. These articles were case reports, which related 26 patients infected with SARS-CoV-2 with symptoms such as urticaria and/or angioedema. Most patients (69%, n = 16) were over 50 years old. Treatment with antihistamines and/or steroids resolved the symptoms in different time frames, from less than 24 hours to up to 2 weeks. There was no report of recurrent cases of urticaria or non-responsiveness to treatment.

Patients infected with SARS-CoV-2 who develop urticaria symptoms should be managed with antihistamines. The use of a low prednisolone dose should be evaluated according to each patient in the shortest duration possible until symptoms are controlled.

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rinitis alérgica y covid-19

Clinical presentation at the onset of COVID-19 and allergic rhinoconjunctivitis

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Fabio Ferreli, Francesca Gaino, Elena Russo, Matteo Di Bari, Francesca Pirola, Andrea Costantino, Luca Malvezzi, Armando De Virgilio, Giovanni Colombo, Giovanni Paoletti, Emanuela Morenghi, Giorgio Walter Canonica, Giuseppe Spriano, Enrico Heffler, Giuseppe Mercante

J Allergy Clin Immunol Pract . 2020 Aug 18;S2213-2198(20)30823-0. doi: 10.1016/j.jaip.2020.08.009. Online ahead of print.

COVID-19 is characterized by various clinical conditions, from mild symptoms to pneumonia and death. Mild symptoms, such as nasal and ocular manifestations, can be confused with allergic rhinoconjunctivitis at the onset. This article describes the differences that let one distinguish COVID-19 and allergic rhinoconjunctivitis.

This study included 204 patients that were infected with coronavirus were included. They were retrospectively studied via telephone interview, where they were requested to complete a validated questionnaire, The Mini Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ), which evaluated a series of 14 signs and symptoms on a scale from 0 to 6, indicating “not troubled” and “extremely troubled”, respectively. Patients were also asked to compare the manifestations of their last allergic symptomatic period with COVID-19 manifestations and to evaluate their sense of taste and/or smell.

Among all 204 participants, 22 were also affected by allergic rhinoconjunctivitis. Clinical manifestations of allergic rhinoconjunctivitis compared with those at the onset of COVID-19 were defined as “completely different” by 15 patients (68,2%), “different” by 3 (13.6%), and “similar” by 4 (18,2%). The two clinical presentations were never reported as “identical”.

Although COVID-19 may present some overlap in symptoms with seasonal allergies, the MiniRQLQ scored significantly different between allergic rhinoconjunctivitis and COVID-19. Also, in this study, there were no differences in taste and smell dysfunction reported. Patients with allergic rhinoconjunctivitis are familiar with its symptoms and were able to distinguish them from COVID-19 rhinoconjunctival manifestations.

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Urticaria (angioedema) and COVID- 19 infection

Urticaria (angioedema) and COVID- 19 infection

By | Selected articles

Mojgan Najafzadeh, Fanila Shahzad, Nader Ghaderi, Kaveh Ansari, Badie Jacob, Andrew Wright

J Eur Acad Dermatol Venereol . 2020 Jun 11;10.1111/jdv.16721. doi:10.1111/jdv.16721. Online ahead of print.

The relationship between urticaria and COVID-19 infection has rarely been reported, however, it has been reported that in addition to the conventional respiratory symptoms, some COVID-19 patients also have skin manifestations, such as urticaria and angioedema.

This is a case study of an elderly man who first presented with generalised pruritic hives with a diameter of 1,5 to 8,0 cm, general malaise, fatigue, temperature and sore throat. He was negative for parasitic and bacterial infections, however presented low white blood cells and lymphopenia. The CT chest showed pneumonia with bilateral and subpleural areas of ground-glass opacification, consolidation affecting the lower lobes, thus confirming the diagnosis of COVID-19.

Although the relationship between urticaria and infection has rarely been reported, literature suggests that urticaria and angioedema can be induced by viral and bacterial infections. Urticaria has been associated before with Cytomegalovirus, Herpesvirus and Epstein-Barr virus. It was also found that once the viral infection was controlled, urticaria manifestations cleared up.

One study with 88 COVID-19 patients that analysed the cutaneous involvement found that 20,4 % presented with cutaneous manifestation, 8 of them developed it at disease onset, while 10 of the, developed it after hospitalisation. The cutaneous manifestations were erythematous rash, widespread urticaria and chickenpox-like vesicles.

Urticarial skin manifestations may be used as a possible diagnostic indicator in early COVID-19 stages.

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COVID-19: organization of an allergy clinic – an EAACI/ARIA Position Paper.

COVID-19 pandemic: Practical considerations on the organization of an allergy clinic – an EAACI/ARIA Position Paper

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Pfaar O, Klimek L, Jutel M, Akdis CA4, Bousquet J, Breiteneder H et al.

Allergy. 2020 Jun 12;10.1111/all.14453. doi: 10.1111/all.14453. Online ahead of print..

Earlier in March 2020, the World Health Organization (WHO) declared the “corona virus disease 2019 (COVID-19)” a pandemic viral disease, transmitted by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). Since the first cases were reported in China, the number of infected patients and fatalities have been increasing worldwide. Typical symptoms of COVID-19 include general malaise, fever, respiratory problems, and especially cough and shortness of breath. Specialists in the field of allergies and associated airways diseases have been in the front line, taking care of patients.

Coronaviruses may be associated with aggravation of asthma exacerbations and allergic diseases (allergic rhinitis, atopic dermatitis, urticaria and drug hypersensitivity).

This review identified studies that reported allergic diseases as co-morbidities of COVID-19 patients compared to non-allergic patients. A panel of experts have developed recommendations for the optimal management of allergic clinics during the pandemic to ensure necessary safety.

Allergic patients diagnosed with or suspect to have COVID-19 should follow the local area treatment and quarantine guidance. In general, most medications should be continued. For those unable to attend clinics, have examinations and/or receive prescriptions, e-health and telemedicine can assess the value of specialized treatments, provide educations for self-management without the risk of infection and triage patients for urgent consultations, such as diagnostic testing in drug allergy or application of medication. When biologicals are used, the decision to continue a treatment should be made on a case basis since the safety and efficacy of the mentioned biologics in COVID-19 patients are unknown. Psychological care for allergic patients during the pandemic is also essential.

Patients with allergic rhinitis and other allergies should be informed accordingly when new evidence is available, making it possible to adapt to new therapies.

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