Allergic disorders in Mauritius with. stress on urticaria - angioedema
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1 Allergic disorders in Mauritius with stress on urticaria - angioedema
2 Mauritius
3
4 Climate Tropical maritime 20 S 58E Summer Hot, humid November- April Winter Cool, humid May October South Easterly winds
5 Le Morne
6 Mauritius, Le Morne
7 Original inhabitant
8 Multiracial Population 1.3 M European Africa Indian subcontinent Chinese
9 Famous tourists
10 More famous tourists
11 ALLSA ambassador
12 Pillars of Society
13 Personal evolution Adult physician- respiratory diseases and internal medicine Involvement with paediatric respiratory diseases Parental questions about allergy- skin prick tests Contented patient listing me on internet as doing tests for allergy Big influx of patients with urticarial, angioedema and? Food allergy
14 South African influences Prof Cas Motala Prof Paul Potter
15 Allergic diseases in Mauritius- personal perspective Asthma Rhinosinusitis Urticaria and angioedema
16 ISAAC all centres
17 ISAAC phase 3, yr olds
18 More ISAAC phase 3 data
19 Asthma Early 1990s : asthma phobia especially young women Inhaler phobia Nebulisers unknown Patient education improved Inhaler acceptance Systemic Steroid phobia transferred to inhaled steroids
20 Asthma Realisation that asthma IS common in children Often misdiagnosed as chronic bronchitis > 90 % aeroallergen + ve Big fear of parents is that inhalers will be for life Proper parent explanation and reassurance with MDI/spacer coaching will control > 90 % asthma patients
21 Allergic rhinitis Coexists with asthma in > 90 % patients Often not reported since chest symptoms dominate Strange sunshine /glare induced symptoms and cold nose > 90 % SPT + ve to a common aeroallergen Rarely associated with chronic sinusitis Excellent response to inhaled steroids
22 Allergic rhinitis
23 Allergic rhinitis
24 Nasal crease and black eyes
25 Weinberg s MAC syndrome
26 Allergy testing Aeroallergens SPT at SSRMC at UOM by P.K. Wan Man Chung as part of BSc Medical Sciences project SPTs by me from 1996 Blood tests ( Phadiatop and Fx 5 ) at Central Lab Victoria Hospital, Dr N. Joonas
27
28
29
30 Blood tests for allergy Dr N. Joonas Central Laboratory Victoria Hospital
31 Total Ig E Screening Tests carried out PHADIATOP Screening test for 16 inhaled allergens : Grasses/trees/animals/weeds/mites/moulds FX5- PAEDIATRIC FOOD SCREEN Tests for 6 most common foods Egg white Peanut Milk Soya Wheat Fish
32 Tests Done Between September 2015 and March 2016 Number of tests Total IgE>120 Phadiatop +VE Fx5 +VE % Positive Number of tests House Dust mites (d 201) Dust Mix ( Hx2) No of Positive % Positive wheat
33 My SPT results Total tested (year) Total 257 ( 1996 ) DP DF Blo Dog Cat Grasses Moulds Cockroa ch 166 ( 65 ) 158 ( 61 ) 128 ( 50 ) 11( 4.3) 16( 6.2 ) 44 (17 ) 44 ( 17 ) 55 ( 21 ) 303 ( 2015 ) 144 ( 48 ) 125 ( 41 ) 106 ( 35 ) 10 (3 ) 16 ( 3 ) 36 ( 12 ) 50 ( 17) 39( 13) 319 ( 2017 ) 138 ( 43 ) 126 ( 39 ) 123 ( 39 ) 16 ( 5) 24 ( 7.5 ) 18 ( 5.6 ) 14 ( 4.4 ) 34 ( 11 )
34 Plant pollens Allergy symptoms exacerbated at seasonal change Windy weather Thunderstorms All suggesting a role for plant pollens
35 Sugarcane
36 ?? Bottlebrush
37 Bird grass vaulting
38 Mango tree
39 Suspected food allergy Very often in context of chronic urticarial +/- angioedema Presumed Gluten allergy increasingly common Peanut allergy rare OAS from fruit not uncommon
40 Full face angioedema Diclofenac 1 hr 3 days after
41 Urticaria / Angioedema IgE mediated Foods, Medication, Insect stings, Infectious agents Physical agents- pressure, solar, cold, exercise, cholinergic Neoplasms Emotional stress Chronic urticaria mostly IDIOPATHIC ACE inhibitors- Nil
42 Full face angioedema Diclofenac 1 hr 3 days after
43 Cefuroxime urticaria
44 Cefuroxime urticaria
45 Chronic Idiopathic Urticaria /Angioedema
46 The young schoolgirl
47 16 yr schoolgirl 8 months : often awakens with uncomfortable lumps / swelling Lips always and the after waking other body parts mainly limbs Partial response to cetirizine Has restricted herself to a rice and water diet Nil systemic enquiry and clinically only angioedema
48 Angioedema lips
49 Angioedema forearms and hands
50 Angioedema above knee
51 Angioedema knee
52 Angioedema forearm
53 16 yr old schoolgirl Much improved on triple dose bilastin Patient and parents deny stress but admit tension Was due to sit A levels After passing exams ( flying colours ) successfully weaned off
54 Periorbital angioedema and chemosis
55 Mr Goji berry
56 Goji berry
57 Urticaria and angioedema Grandstand view of acute angioedema in Glasgow The irate senior registrar and the traumatized staff nurse Sudden massive localised swelling on the forearm and facial urticaria It happens when I m upset
58 Chronic idiopathic urticaria and angioedema About 40 patients seen since April 2017 Practically all have psychiatric morbidity antedating CIU /AE Underlying worries only revealed as from visit 3 Many are only partly responsive to even HD Gen 2 antihistamines Short course benzos and long term SSRIs and TALK induce remission
59 Typical scenarios Mostly female : mainly adolescents and middle age Exam stress Family trouble : Misbehaving kids, partner, in laws Men : housebuilding or work trouble
60 CNS Skin interactions- neurogenic inflammation
61 Axon reflex
62 Axon reflex, wheal and flare
63 Inflammatory molecules in skin
64 Role of CRF in mast cell degranulation Corticotrophin releasing factor receptor subtype 1 is a critical regulator of mast cell degranulation and stress induced pathophysiology Ayyedura S, Gibson A J et al : J Leuko Biology July our results revealed a prominent role for CRF signalling in mast cells as a positive modulator of stimuli induced degranulation and in vivo patholophysiogic responses to immunologic and psychologic stress.
65 PTSD and chronic idiopathic urticarial- an unrecognised comorbidity Gupta M A, Gupta A H Clinics in dermatology 2012 vol30, 3, The role of psychological stress in Urticaria pathogenesis known for 100 yrs Urticaria also dubbed emotional allergy Fascinating description of patients with CIU who on expert psychiatric assessment were found to have sufferedrecent PTSD that unlocked previous severe psychological trauma
66 PTSD and chronic idiopathic urticarial- an unrecognised comorbidity Skin has equivalent of HPA axis including local expression of CRF receptors Acute stress increases skin CRF which can trigger mast cell degranulation and histamine release This may play a role in stress mediated onset of urticaria
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