Current Allergy & Clinical Immunology - Volume 27, Issue 3, September 2014

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On behalf of the Allergy Society of South Africa it is my pleasure, as congress convenor, to welcome you to our 23rd congress held in the beautiful city of Durban. The theme of this year's congress is "Frontiers in Allergy". We aim to bring to you the latest advances in the field of allergy and also allow international and local researchers to share their knowledge and experience with us.

Only recently recognised, mast cell activation syndrome (MCAS) is a large, prevalent collection of illnesses resulting from mast cells (MCs) which are inappropriately activated but which, in contrast to the (collectively rare) forms of mastocytosis, are not significantly proliferating. Due to the diversity of direct and indirect, local and remote effects of the menagerie of mediators released by MCs, likely due to highly heterogeneous sets of mutations in MC regulatory elements, MCAS typically presents as chronic, persistent or recurrent, waxing/waning or slowly progressive, generally inflammatory multisystem polymorbidity. Initial manifestations often occur in childhood but are non-specific; in fact, virtually all of the syndrome's manifestations are non-specific, leading to decades of mysterious illness complicated by incorrect or superficial diagnoses often poorly responsive to empiric therapies. Diagnosis is further challenged in detecting specific biomarkers of MC activation other than serum tryptase levels, which usually are elevated in systemic mastocytosis but normal in MCAS. MCAS therapy aims to inhibit mediator production/release and block/ameliorate mediator action. Although patient-specific optimal therapy is not presently predictable, a methodical, persistent, trial-and-error approach usually finds helpful therapy. Lifespan with MCAS approximates normal, but quality of life can be significantly impaired without correct diagnosis and effective treatment.

This article reviews the recent advances and current state of equipoise in the use of immunotherapy for IgE-mediated food allergy. It examines the various methods currently under evaluation for induction of desensitisation and tolerance in food allergy and encompasses permissive diets which allow for inclusion of extensively heated food allergens, specific oral tolerance induction (SOTI), the use of adjuvants for specific tolerance induction and novel pharmacotherapies.

The prevalence of food allergies has increased in the past 2 decades particularly in developed countries, but with recent evidence of an increase in developing countries too. Despite this change in prevalence, the most common allergenic foods remain cow's milk, hen's egg, wheat, soya, fish, shellfish, peanut and tree nuts.

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Food allergy prevalence studies are thwart with inherent difficulties, and using self-report or sensitisation patterns is an inaccurate measure of food allergy prevalence. Food challenge testing is the optimal way of proving food allergy, albeit labour and cost-intensive. Large population studies and meta-analyses of studies, using food challenges, have shown a wide variation in food allergy prevalence, ranging from 1% to over 10%, depending on the age of the child and the region studied. The prevalence of food allergy in South Africa is currently unknown, though thought to be on the increase. This is currently being investigated in a large population based study in the Western Cape. Risk factors for food allergy are both genetic and environmental, such as diet and microbial diversity. Children with eczema are at particular risk of food allergy because of cutaneous exposure to allergens.

The inactivated Influenza vaccine is manufactured via propagation of the virus in hen's egg, hence there is a potential for the vaccine to contain residual egg protein. As such, there has been much confusion about the use and safety of the influenza vaccine in egg allergic patients. Egg allergic patients are at increased risk of co-morbid atopic conditions such as asthma, which is a common indication for the influenza vaccine. This short report presents an illustrative case of a child with egg allergy requiring an influenza vaccine, and describes the latest indications and guidelines for the influenza vaccine in egg allergic patients.

Background : The goal of asthma management is to attain optimal control of symptoms with minimal treatment-related side effects. Several factors contribute to poor asthma control: such as poor adherence to medications, or inappropriate inhaler technique, in addition to home circumstances that trigger asthma attacks.

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Objective : To determine the level of asthma control and any home circumstances that may contribute toward poor asthma control in children seen at the Asthma and Allergy clinic at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH).

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Methods : A prospective cross sectional study was conducted in 115 asthmatic children, aged between 5 and 18 years, from July to October 2012. Children >12 years filled in the asthma control test, while those <12 years filled in the childhood asthma control test. A questionnaire on home circumstances was filled in by the parent or legal guardian or the patient. Adherence to medications was assessed and inhaler technique observed. All study participants underwent a full medical examination relevant to allergy and asthma, followed by the performance of a lung function test.

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Results : A total of 115 patients were enrolled of which 59 (51.3%) patients were male. Ninety nine (86.1%) patients were black and 55.7% of the patients had controlled asthma (ACT or C-ACT > 19). None of the home circumstances were found to be associated with poor asthma control. Good adherence to medications was found to be associated with good asthma control; however good inhaler technique did not contribute to the overall level of control.

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Conclusion : Taking the time to educate our asthma patients about the importance of adherence to medications is the most effective measure to achieve optimal asthma control. Home circumstances did not contribute to the overall level of asthma control.

Repeated inhalation of organic antigens is a main cause of hypersensitivity pneumonitis (HP). We reported three patients with mould-induced HP from one family residing in a wet environment. Measures to minimise antigen exposure resulted in regression of HP. This highlights the association between HP and domestic environment, and emphasises the importance of environmental control in HP treatment.

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Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis (EAA), is a diffuse inflammatory lung disease caused by repeated inhalation of various antigens derived from fungi, bacteria, and animal and plant proteins or reactive inorganic compounds in sensitised individuals. Fungi represent a large source of antigens capable of causing HP, which is often related to the patient's occupation or domestic environment. Three patients diagnosed with HP from one family, residing in a wet environment, were reported here.

Recently a colleague telephoned to ask me for advice: interns had posted photographs of paediatric patients they had examined, together with the patients' diagnosis, on their Facebook pages, but they did not see anything wrong with this. Their comments related to how cute the children were, and were not demeaning in any way, and they were sharing with friends, so how could it be wrong? Since then I have seen examples of colleagues posting derogatory and profane comments regarding their on-call experiences on their Facebook pages. One example lamented the inability of the medical profession to keep the female cervix closed in the middle of the night (in language I cannot repeat). Another alluded to repeated Caesarean sections in a 3-hour period and then the birth of a tiny preterm baby in the early hours of the morning in a named suburb. Imagine if a patient or a patient's family member read these postings.

Rubber contact dermatitis in the form of latex protein allergies has been well described but the incidence of occupational sensitisation to rubber additives used in the manufacture of natural and synthetic rubber is increasing. A variety of chemicals are used in the manufacture of rubber that can be converted to new allergens or, with time, become exposed in fully cured products. These chemicals come into contact with the skin and may cause hypersensitivity reactions. Rubber based products are ubiquitous and are not easily avoided thus potentially adversely impacting quality of life. This article discusses the additives used in the manufacture of synthetic rubber, the mechanism and diagnosis of rubber additive contact dermatitis as well as prevention and management strategies.

Dr Do-A-lot explains that eczema is a relapsing, inflammatory condition of the skin that results in a defective skin barrier.

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This results in a loss of moisture from the skin and allows for easy access by microbes, especially Staphylococcus Aureus.

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Importantly, affected skin is always itchy.

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In atopic eczema genetic factors play a role, and the inflammatory process is mediated by immunoglobulin-E (IgE) in response to exposure to environmental allergens which might include foods or inhaled allergens like house dust mite (HDM), pollens or animal dander.

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It typically affects infants and young children with a family history of atopy or a personal history of allergic disease like food allergy or asthma.

Transplant-acquired allergy (TAA), previously described as transplant-acquired food allergy (TAFA), is an infrequent but potentially serious complication of organ transplantation. It has been described mainly after liver transplantation, but also after bone marrow, intestinal, lung and heart transplantations. The onset of the allergic symptoms starts many months after the transplant and ranges from symptomatic eosinophilic gastrointestinal inflammation to life threatening anaphylaxis. The pathogenesis is still not understood but appears to be a complex interplay between multiple factors including donor and recipient factors, the type of organ transplanted as well as the type of post-transplant immunosuppressive therapy protocol. We report on an 8 year old girl who developed de novo severe multiple food allergies, debilitating eczema and anaphylaxis 18 months after undergoing a liver transplant. She responded well to supportive management and a targeted elimination diet.

Allergy is a hypersensitivity reaction initiated by immunological mechanisms. Allergy can be antibody- or cell-mediated. In the majority of cases the antibody typically responsible for an allergic reaction belongs to the IgE isotype, and these individuals may be referred to as suffering from an IgE-mediated allergy.

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Welcome to our Congress issue of the Journal and I really hope you are reading this Report at the Durban Congress. It is a true pleasure to welcome you to Durban and to another ALLSA Congress.

Congress abstracts of the 2014 ALLSA Congress