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

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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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