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Food allergy is a potentially life-threatening medical condition and a significant public health concern worldwide. The current management consists of strict avoidance of the culprit food and treating any adverse reactions from unintended food ingestion. The increasing prevalence of food allergy encouraged research and clinical trials in the field of specific allergen immunotherapy (AIT) which represents an appealing approach, especially in pediatric age. AIT consists of the gradual administration of growing amounts of the offending allergen in order to induce food desensitization, which is an increase in the threshold for reactivity while continuing on regular exposure to the allergen. AIT can be administered through oral, sublingual, epicutaneous, and subcutaneous routes. Reports on oral immunotherapy (OIT) thus far have been more extensive. The desirable goal is to achieve "post desensitization effectiveness", that is the ability to introduce food without reaction even after a period of discontinuation of the offending food. Other therapeutic approaches are being studied alongside immunotherapy such as modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines.

The COVID-19 pandemic has surprised the entire population. The world has had to face an unprecedented pandemic. Only, Spanish flu had similar disastrous consequences. As a result, drastic measures (lockdown) have been adopted worldwide. Healthcare service has been overwhelmed by the extraordinary influx of patients, often requiring high intensity of care. Mortality has been associated with severe comorbidities, including chronic diseases. Patients with frailty were, therefore, the victim of the SARS-COV-2 infection. Allergy and asthma are the most prevalent chronic disorders in children and adolescents, so they need careful attention and, if necessary, an adaptation of their regular treatment plans. Fortunately, at present, young people are less suffering from COVID-19, both as incidence and severity. However, any age, including infancy, could be affected by the pandemic.Based on this background, the Italian Society of Pediatric Allergy and Immunology has felt it necessary to provide a Consensus Statement. This expert panel consensus document offers a rationale to help guide decision-making in the management of children and adolescents with allergic or immunologic diseases.

Urticaria is a mast cell-driven disease presenting with wheals, angioedema, or both. Acute urticaria (AU) lasts < 6 weeks. AU is a not common condition in newborns and infants since they are showing an immune system functionally insufficient. In newborns and infants, AU is typically generalized and featured by large, annular, or geographic plaques, often slightly raised. The clinical features of the disease depend on the peculiar structure of neonatal and infant skin. A careful morphological examination of the lesions is essential to differentiate AU from other skin eruptions that may have overlapping features and to treat it adequately. The second-generation antihistamines are the first-line treatment of AU; however, only antihistamines with proven efficacy and safety should be used in newborns and infants. Corticosteroids may be added in severe cases.

Oral food challenges remain the gold standard for the diagnosis of food allergy. Nevertheless, the allergy workup is based on the presence of a clinical history, which is evocative of an immune-allergic reaction, and the first assessment is usually the performance of skin prick tests. Based on these results, allergists are used to evaluate the presence of serum-specific IgE, which are today the most commonly prescribed in vitro test for the evaluation of a possible food allergy. Other in vitro tests include the basophil activation test, that is becoming more and more employed by clinicians and not only by researchers, and the evaluation of serum IgG4, which is still an issue of debate in the allergy community. The present paper reviews the use of these in vitro tests for the diagnosis of food allergy.

Tuberculosis is one of the most common infectious diseases and infectious causes of death worldwide. Over the last decades, significant research effort has been directed towards defining the understanding of the pathogenesis of tuberculosis to improve diagnosis and therapeutic options. Emerging scientific evidence indicates a possible role of the human microbiota in the pathophysiology of tuberculosis, response to therapy, clinical outcomes, and post-treatment outcomes. Although human studies on the role of the microbiota in tuberculosis are limited, published data in recent years, both from experimental and clinical studies, suggest that a better understanding of the gut–lung microbiome axis and microbiome–immune crosstalk could shed light on the specific pathogenetic mechanisms of Mycobacterium tuberculosis infection and identify new therapeutic targets. In this review, we address the current knowledge of the host immune responses against Mycobacterium tuberculosis infection, the emerging evidence on how gut and lung microbiota can modulate susceptibility to tuberculosis, the available studies on the possible use of probiotic–antibiotic combination therapy for the treatment of tuberculosis, and the knowledge gaps and future research priorities in this field.

Background Currently, severe allergic asthma and food allergy in children represent an important public health problem with medical, psychosocial and economic impacts. Omalizumab is a humanized monoclonal anti-IgE antibody, approved for refractory allergic asthma and chronic urticaria. It has been widely used in clinical practice as add-on therapy in patients with severe uncontrolled allergic asthma. In recent years there has seen the emergence of an allergic epidemic with increasing food allergy, which represents the main cause of anaphylaxis in children. The standard of care for food allergy is strictly dietary allergen avoidance and emergency treatment, but recent clinical trials have suggested that omalizumab may have a role to play as an adjuvant to oral immunotherapy (OIT). We present a case series of patients treated at our institution with omalizumab for severe allergic asthma and food allergy. Methods Patients received omalizumab according to a standard reference nomogram after failing standard therapies. In children with comorbid severe food allergy, omalizumab was administered in conjunction with an oral immunotherapy protocol. Results Omalizumab was effective in controlling symptoms of allergic asthma, allergic rhinitis and rhinosinusitis, but not eosinophilic esophagitis, while aiding successful oral desensitization of comorbid severe food allergies. Conclusions Omalizumab appears to be an excellent therapeutic option in children with inadequately controlled severe allergic asthma, allergic rhinitis and rhinosinusitis, with or without food allergy.

A Doença de Chagas ainda é prevalente em paí­ses da América do Sul, em especial na forma gastrointestinal. A doença desencadeia alterações fisiológicas e anatômicas no órgão acometido. Um dos tratamentos em casos avançados de megaesôfago é a esofagectomia, cujas complicações mais frequentes são as pleuropulmonares e fí­stula anastomótica. Apresentamos o caso de paciente com disfagia progressiva após dois procedimentos prévios sobre o esfí­ncter inferior do esôfago. Pelo diagnóstico de megaesôfago avançado foi realizada esofagectomia transhiatal e reconstrução com tubo gástrico. O paciente evoluiu no pós-operatório precoce com fí­stula cervical secundária í necrose do estômago interposto, pneumonia e mediastinite. Foi tratado então com retirada do enxerto e toracotomias de demanda para drenagem de coleções torácicas. Apresentou boa evolução sendo posteriormente submetido í esofagocoloplastia. Mediastinite e necrose do estômago interposto são complicações graves da esofagectomia. O diagnóstico precoce e a rápida intervenção são essenciais no tratamento do paciente.Descritores: Doença de Chagas, Acalasia esofágica, Esofagectomia, Esofagoplastia, Mediastinite, Endocardite

Background: Eosinophilic esophagitis (EoE) has been defined as "asthma of the esophagus" for the large number of similarities between the two diseases. Omalizumab is an anti-Immunoglobulin E (IgE) antibody currently approved only in allergic IgE-mediated severe persistent uncontrolled asthma and in chronic spontaneous urticaria unresponsive to antihistamines, but it has been tried in other diseases, too. Case presentation: We present herein the case of a 13-year-old boy, affected from preschool age by severe chronic allergic asthma poorly controlled despite a generous long-term therapy, and, since he was 8 years old, by eosinophilic esophagitis, responsive to courses of strict elimination diet and semi-elemental diet, even if very burdensome for his quality of life. At the age of 11.5 years, for inadequate asthma control, he started to receive therapy with omalizumab. After the first month and for the entire duration (18 months) of omalizumab treatment, asthma was well controlled, long-term conventional therapy was gradually withdrawn and lung- function improved. Concerning EoE, after an initial clinical but not histological remission during the first few months of treatment with omalizumab, the patient experienced an exacerbation of gastrointestinal symptoms. Therefore, he started treatment with topical steroids which was effective to improve gastrointestinal symptoms. However, EoE is still steroid-dependent. Currently, he continues both treatments: omalizumab for asthma and topical steroid for EoE. Conclusions: This case report confirms that omalizumab is an effective treatment in patients with severe persistent, uncontrolled asthma. On the other hand, in our patient it did not produce persistent improvement neither on symptoms nor on biopsy findings of EoE. The outcome of this case might indicate different pathogenic mechanism(s) of the two diseases.

BACKGROUND Oral immunotherapy (OIT) for food allergy is gaining interest due to the favorable clinical results reported with cow's milk, hen egg and peanut. The safety of the procedure remains a critical aspect that can limit the introduction of OIT in clinical practice. OBJECTIVE We described herein, in detail, the occurrence and characteristics of adverse events (AE) with OIT in children who participated in controlled trials at our unit. METHODS The clinical records of 68 children who received active treatment (40 for cow's milk and 28 for hen egg) were carefully reviewed. The inclusion and exclusion criteria, and the grading of AEs were the same across the trials. Of the 68 children involved, 6 (9%) had to discontinue the OIT procedure due to severe AEs. Fifty percent of the children underwent the buildup and maintenance phases without AEs. Mild-to-moderate AEs were documented in 28 patients, who could complete the desensitization. The majority of reactions were mild or moderate, occurred during an acute intercurrent illness and required only symptomatic treatment. CONCLUSION A careful review of the patients who received food OIT in controlled trials confirmed that AEs were not rare but that ∼90% of children could achieve an effective desensitization. The procedure remains investigational and should be performed only by trained physicians, especially in the pediatric setting.

Recent epidemiological studies estimated that more than 30% of European suffer from allergic rhinitis or conjunctivitis, while up to 20% suffer from asthma and 15% from allergic skin conditions, while for many other regions the prevalence is increasing. Allergen immunotherapy represents the only available treatment that can modify the allergic disease process, and thus is worth considering as a treatment in affected individuals. A beneficial effect of allergen immunotherapy has been shown in both adults and children affected by allergic rhinitis, allergic conjunctivitis, allergic asthma and hymenoptera venom allergy. The present study represents an overview on allergen immunotherapy, focusing on the principal aspects of the use of immunotherapy in the past, its recent clinical applications and future outlook.

E S D A Y 842 Successful Specific Oral Tolerance Induction with Hake in an Allergic Child Detecting Fish in Cooking Steam Carmen M. Damelio, MD; Departament of Allergy Clinica Universidad de Navarra, PAMPLONA, Spain. RATIONALE: To describe a specific oral tolerance induction (SOTI) protocol with hake in a child suffering urticaria/angioedema upon fish cooking steam exposure. METHODS: A 6-year old girl who presented at 9 month of age acute urticaria after eating different types of fish (i.e. hake, sole). Skin prick test rendered positive results and since then she avoided fish. Subsequently she suffered several acute urticaria episodes after accidental intakes and even when exposed to tuna fish cooking steam. Comorbidities: mild and controlled atopic dermatitis, no bronchial asthma. A SOTI protocol was decided to apply. Sensitization was evaluated by Prick-to-prick (T1), specific IgE (sIgE) and IgG4 (sIgG4) to hake during the induction phase (T2) and when finalized (T3). SOTI to hake was performed using frozen hake loin, starting with lyophilized hake and when 20gr. were tolerated, we used cooked hake until reaching 40gr. RESULTS: The induction phase of the SOTI lasted 11 months until 40gr of hake were reached suffering one anaphylaxis, related to an infectious process and 5 episodes of abdominal pain requiring antihistamines in only 2 of them. After one month in maintenance-phase, eating 40gr of hake daily without reactions, she tolerated 50gr of bass, 50gr. of tuna, 50gr. of monkfish uneventfully. No atopic dermatitis exacerbation was observed. sIgE against hake (T1:3.31kUA/L; T2: 3.98kUA/L; T3: 2.02kUA/L) and wheal size for hake prick-to-prick (T1: 13x11mm; T2: 10x6mm; T3: 7x5mm) decreased during induction phase whereas hake sIgG4 levels increased (T2: 12.7kU/L, T3: 39.2kU/L). CONCLUSIONS: In our case, SOTI with hake induces tolerance to bass, tuna and monkfish.

Background Oral immunotherapy (OIT) may be an effective treatment for food allergy in children. It is not clear if the OIT-induced effect is achieved by desensitization (transient state dependent on regular antigen exposure), or by tolerance (persistent condition where the ability to consume the food is retained even after a period of withdrawal). Objective The aim of this study was to investigate the efficacy of OIT-egg desensitization in a double-blind placebo-controlled study, and to evaluate if, after desensitization, tolerance can be maintained. Methods Children with egg allergy were randomized to OIT or placebo for 4 months. At the end of the controlled phase, a double-blind food challenge was repeated to confirm the achieved desensitization. Those subjects found to be desensitized were placed on an egg-containing diet for 6 months, followed by an egg avoidance phase for 3 months, when the food challenge was repeated to determine the maintained tolerance. Results A total of 31 children were randomized to OIT with dehydrated egg white (n = 17) or placebo (n = 14). Of the 17 active patients (1 dropout), 16 achieved desensitization and started the 6-month egg-containing diet. After 3-month of egg avoidance, 31% remained tolerant. In the control group, only 1 passed the final food challenge. Egg-specific IgG4 increased only in the active group. Five active OIT patients had side effects. Conclusion Egg OIT results in desensitization in almost all subjects, although tolerance was maintained in only 1/3 of them after a 3-month period of withdrawal. Side effects were encountered, but the procedure appeared safe. In hen egg allergy, OIT is effective for desensitization.