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Antecedentes: Existen lineamientos para el diagnóstico de las enfermedades alérgicas y la aplicación de inmunoterapia con alérgenos (ITA).Objetivo: Describir cómo los alergólogos mexicanos diagnostican y tratan con ITA las alergias alimentaria y respiratoria.Métodos: Se encuestó a 227 alergólogos que acudieron a un simposio de inmunoterapia; se indagaron prácticas cotidianas en el diagnóstico de las alergias respiratoria y alimentaria, así como en la forma de aplicar la ITA.Resultados: Los alergólogos utilizan las pruebas cutáneas por punción para el diagnóstico de las alergias respiratorias y alimentarias en 100 y 87.7 % de los casos de una y otra; diagnóstico in vitro mediante determinación de IgE alérgeno-específica en 55.5 y 63 %; y diagnóstico molecular por componentes en 14.1 y 13.2 %. Para los aeroalérgenos, 81 % emplea ITA subcutánea; 77.9 %, ITA sublingual líquida; 1.8 %, ITSL en tabletas; 45 % indicó que estaba dispuesto a emplear tabletas en el futuro. Para los alérgenos de alimentos, la mayoría no utilizaba ITA, aunque 55 % se interesa en la ITA oral y 59 %, en la ITA sublingual.Conclusiones: En términos generales, el diagnóstico y tratamiento de las enfermedades alérgicas se realizan conforme los lineamientos internacionales, además, los alergólogos encuestados mostraron flexibilidad para adoptar nuevos esquemas.

Background:Both, allergen immunotherapy (AIT) and SARS-COV-2 infection cause a set of immunologic changes that respectively vary during the course of the treatment or the disease.Objective:To review immune changes brought along by each of these entities and how they might interrelate.Methods:We start presenting a brief review of the structure of the new coronavirus and how it alters the functioning of the human immune system. Subsequently, we describe the immune changes induced by AIT and how these changes could be favorable or unfavorable in the allergic patient infected with SARS-CoV-2 at a particular point of time during the evolving infection.Results:We describe how a healthy immune response against SARS-CoV-2 develops, versus an immune response that is initially suppressed by the virus, but ultimately overactivated, leading to an excessive production of cytokines (cytokine-storm-like). These changes are then linked to the clinical manifestations and outcomes of the patient. Reviewing the immune changes secondary to AIT, it becomes clear how AIT is capable of restoring a healthy innate immunity. Investigators have previously shown that the frequency of respiratory infections is reduced in allergic patients treated with AIT. On the other hand it also increases immunoregulation.Conclusion:As there are many variables involved, it is hard to predict how AIT could influence the allergic patient's reaction to a SARS-CoV-2 infection. In any case, AIT is likely to be beneficial for the patient with allergic rhinitis and/or allergic asthma in the context of the SARS-CoV-2 pandemic as controlling allergic diseases leads to a reduced need for contact with healthcare professionals. The authors remind the reader that everything in this article is still theoretical, since at the moment, there are no published clinical trials on the outcome of COVID-19 in allergic patients under AIT.

Purpose of Review At the juncture of the COVID-19 pandemic, the world is currently in an early phase of collecting clinical data and reports of its skin manifestations, and its pathophysiology is still highly conjectural. We reviewed cutaneous manifestations associated with COVID-19 in the pediatric age group. Recent Findings Children infected by SARS-CoV-2 usually develop milder respiratory symptoms, but cutaneous manifestations seem a little more prevalent than in adults. These skin features of infection by the coronavirus can be similar to those produced by other common viruses, but there are also reports of cases with more heterogeneous clinical pictures, which have made their classification difficult. To date, the more frequently reported skin variants featured in pediatric cases are purpuric (pseudo-chilblain, necrotic-acral ischemia, hemorrhagic macules, and/or cutaneous necrosis), morbilliform/maculopapular, erythema multiforme, urticarial, vesicular, Kawasaki-like, and miscellaneous (highly variable in both frequency and severity). Their pathophysiological mechanism is still elusive and is likely to be the result of the complex involvement of one or more mechanisms, like direct virus-induced skin damage, vasculitis-like reactions, and/or indirect injury as a consequence of a systemic inflammatory reaction. Summary In this review, we presented and discussed clinical cases as examples of different cutaneous responses reported in some children with SARS-CoV-2 infection, differential diagnosis considerations, and a preliminary conceptual approach to some of their probable associated pathologic mechanisms.

Background The International Study of Asthma and Allergies in Childhood (ISAAC) showed a wide variability in prevalence and severity of allergic rhinitis (AR) and rhinoconjunctivitis (ARC), in addition to other atopic diseases (Asher et al, 2006). 1 The Global Asthma Network (GAN) has continued to study these conditions. Objective To estimate the prevalence of AR and ARC in children and adolescents in Mexico and to assess their association with different risk factors. Methods GAN Phase I is a cross-sectional, multicentre survey carried out in 15 centres corresponding to 14 Mexican cities throughout 2016–2019 using the validated Spanish language version of the GAN Phase I questionnaires. The questionnaires were completed by 35 780 parents of 6–7 year old primary school pupils (children) and by 41 399 adolescents, 13–14 years old. Results The current and cumulative prevalence of AR was higher in the adolescents (26.2–37.5%, respectively) in comparison to the children (17.9–24.9%, respectively), especially in female participants. This tendency was also observed in the current prevalence of ARC, where 15.1% of female adolescents reported nasal symptoms accompanied with itchy-watery eyes in the past year. The most important risk factors for AR and ARC were the presence of wheezing in the past 12 months, wheezing in the first year of life, the previous diagnosis of asthma and eczema symptoms. Furthermore, allergic symptoms had a negative tendency concerning altitude. Conclusion This is the largest AR epidemiological study ever conducted in Mexico. It shows an increase in AR prevalence, as well as significant associations with modifiable risk factors, which could help to establish recommendations to reduce the burden of this condition.

Introduction In light of the current COVID-19 pandemic, during which the world is confronted with a new, highly contagious virus that suppresses innate immunity as one of its initial virulence mechanisms, thus escaping from first-line human defense mechanisms, enhancing innate immunity seems a good preventive strategy. Methods Without the intention to write an official systematic review, but more to give an overview of possible strategies, in this review article we discuss several interventions that might stimulate innate immunity and thus our defense against (viral) respiratory tract infections. Some of these interventions can also stimulate the adaptive T- and B-cell responses, but our main focus is on the innate part of immunity. We divide the reviewed interventions into: 1) lifestyle related (exercise, >7 h sleep, forest walking, meditation/mindfulness, vitamin supplementation); 2) Non-specific immune stimulants (letting fever advance, bacterial vaccines, probiotics, dialyzable leukocyte extract, pidotimod), and 3) specific vaccines with heterologous effect (BCG vaccine, mumps-measles-rubeola vaccine, etc). Results For each of these interventions we briefly comment on their definition, possible mechanisms and evidence of clinical efficacy or lack of it, especially focusing on respiratory tract infections, viral infections, and eventually a reduced mortality in severe respiratory infections in the intensive care unit. At the end, a summary table demonstrates the best trials supporting (or not) clinical evidence. Conclusion Several interventions have some degree of evidence for enhancing the innate immune response and thus conveying possible benefit, but specific trials in COVID-19 should be conducted to support solid recommendations.

There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs.To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach.The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part.Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma.For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

Background There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs. Objective To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach. Methods The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part. Results Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma. Conclusion For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

BackgroundTwo different allergic rhinitis (AR) symptom phenotype classifications exist. Treatment recommendations are based on intermittent–persistent (INT-PER) cataloging, but clinical trials still use the former seasonal AR–perennial AR (SAR-PAR) classification. This study was designed to describe how INT-PER, mild–moderate/severe and SAR-PAR of patients seen by allergists are distributed over the different climate zones in a (subtropical country and how these phenotypes relate to allergen sensitization patterns.MethodsSix climate zones throughout Mexico were determined, based on National Geographic Institute (Instituto Nacional de Estadística y Geografía) data. Subsequent AR patients (2–68 years old) underwent a blinded, standardized skin-prick test and filled out a validated questionnaire phenotyping AR.ResultsFive hundred twenty-nine subjects participated in this study. In the tropical zone with 87% house-dust mite sensitization, INT (80.9%; p < 0.001) and PAR (91%; p = 0.04) were more frequent than in the subtropics. In the central high-pollen areas, there was less moderate/severe AR (65.5%; p < 0.005). Frequency of comorbid asthma showed a clear no -south gradient, from 25% in the dry north to 59% in the tropics (p < 0.005). No differences exist in AR cataloging among patients with different sensitization patterns, with two minor exceptions (more PER in tree sensitized and more PAR in mold positives; p < 0.05).ConclusionIn a (sub)tropical country the SAR-PAR classification seems of limited value and bears poor relation with the INT-PER classification. INT is more frequent in the tropical zone. Because PER has been shown to relate to AR severity, clinical trials should select patients based on INT-PER combined with the severity cataloging because these make for a better treatment guide than SAR-PAR.

Several international guidelines on immunotherapy exist, but they only apply partially in Mexico. The Mexican guideline of immunotherapy dates from 1998.To establish clinical recommendations and suggestions for Allergy residents and specialists for skin testing and allergen immunotherapy based on evidence and Mexican expert opinion, according to the GRADE system.The guidelines were developed following the methodology of a guideline for clinical practice starting with the formulation of clinical questions, in the context of Mexican environmental conditions and morbidity, with the participation of allergists from all regions of the country. External validation was obtained. Its development followed three steps: 1. formulation of 24 clinical questions. 2. Search for consensus on the answers among members of the Regional chapters of both Mexican Colleges of Allergists (CMICA and COMPEDIA) during regional meetings. 3. Literature search for articles related to the questions and grading of its quality according to GRADE.Based on the regional consensus, 116 articles and the safety, patient acceptance/ comfort and cost clinical recommendations and suggestions were developed on basic aspects of skin testing, subcutaneous and sublingual immunotherapy (patient preparation, vial preparation and application schedules) and the treatment of eventual adverse reactions.A clinical guideline was developed respecting particular methodology, validated by CMICA and COMPEDIA for its implementation among Mexican allergists. Several aspects deserve further study to improve scientific evidence.Allergen immunotherapy, subcutaneous immunotherapy, sublingual immunotherapy, skin testing, allergy diagnosis, rhinitis, asthma, atopic dermatitis, house dust mite, pollens, anaphylaxis, adrenaline, Mexico.

The most important allergen manufacturers are based in Europe and in the US. In some countries local products are also sold. No comparison between European, US and local products has been made until now.To determine total protein content and total specific IgE binding capacity or major allergen content of diagnostic extracts from European, US and Mexican origins relative to the CBER/FDA reference extracts for Dermatophagoides pteronyssinus (Dpt), Bermuda grass and cat (10,000(B) AU/mL).Diagnostic extracts were purchased from various manufacturers, blinded and shipped to the analysing laboratory, where the following assays were conducted: total protein concentration (Bradford), specific IgE competition ELISA (Dpt and Bermuda grass) and determination of Fel d 1 U/mL. When available, CBER/FDA recommended tests and reagents were used.Total protein content of US reference extracts was higher than all other extracts. Relative potency of European and US-bought Dpt extracts 3,300-4,400 AU/mL, Bermuda grass 800-2,500 BAU/mL and cat 2.1-4.4 Fel d IU/mL (Ref. 19 U/mL), with one exception. Locally produced Mexican products were almost all below 1,000 (B)AU/mL.Three diagnostic extracts from European manufacturers and from Mexican providers which obtain extracts in US have a50% relative potency compared to 10,000 (B)AU/mL US extracts. Locally produced Mexican extracts have much lower total protein content and specific IgE binding capacity. These in vitro results must be complemented with other in vitro and in vivo skin prick tests to obtain a more complete picture of comparison of potency. Nevertheless results are quite consistent for the allergens tested here.

Rhinitis is the most frequent respiratory disease in most countries of the world. It is estimated that 600 million people suffer this condition. Allergic rhinitis is a public health problem at global level. Patients who suffer allergic rhinitis have from mild to annoying nasal symptoms which affect quality of life, cause sleep disorders, scholar and workplace absenteeism, and health expenditure. Rhinitis is frequently associated to co-morbidities such as sinusitis, otitis media, and especially asthma. Rhinitis is under-diagnosed and under-treated worldwide and also in Latin American countries. ARIA is the very first evidence-based guideline for the diagnosis and treatment of rhinitis with focus in its co-morbidities (2001), especially asthma published in 2001. In 2008 an update was published. ARIA recommends an integrative approach for management; including anti-histamines (second generation), intra-nasal corticosteroids, anti-leukotrienes and immunotherapy. It also provides a questionnaire to evaluate asthma and its severity in those patients suffering rhinitis. The prevalence of allergic rhinitis is quite high in Latin American countries and in recent years a great insight on the burden of this condition has been gained.

Immunotherapy is the only curative treatment recommended for allergic rhinoconjunctivitis and asthma, in which small amounts of allergen are administered sublingually or subcutaneously until the maximum tolerated dose has been reached. However, local or systemic adverse reactions (AR) -rarely even fatal- an occur. In Mexico there is no nationwide data on adverse reactions.To document the frequency of adverse reactions secondary to skin tests (ST) or immunotherapy (IT) in the allergist's office in Mexico, paying special attention to fatal and near fatal allergic reactions.We mailed a survey to all members of the Mexican Colleges of Allergy (CMICA) and Pediatric Allergy (CoMPedIA).A response rate of 59 (16%) for the adverse reactions part of the questionnaire was obtained from the College members. We found a near fatal reaction rate of 0.005 cases per year per allergy practice for skin testing and the same number -0.005 cases- for immunotherapy. This can be extrapolated to a total of 1.5 cases per year in the whole country of Mexico. No fatalities were reported.In Mexico the frequency of severe or near fatal adverse reactions to immunotherapy or skin tests is low and no fatal case has been reported till today.

Background Several studies have demonstrated the efficacy and safety of sublingual immunotherapy in the treatment of respiratory allergy. Objective To determine the frequency of systemic adverse reactions in patients treated with standardized extracts of sublingual immunotherapy. Methods Allergic patients with rhinitis with or without asthma and sensitized to at least 1 allergen were included. Increasing doses of standardized allergens were administered until reaching an average dose accumulated of 7,200 U after 26 weeks of treatment. Adverse events were graded according to the European Academy of Allergy and Clinical Immunology immunotherapy position paper. Results Forty-three patients with a median age of 11 years (interquartile range, 8-20 years) were included. All the patients had allergic rhinitis, and 63% had asthma; they were sensitized mostly to Dermatophagoides pteronyssinus and Dermatophagoides farinae . Four patients (9%) presented with an immediate and 1 (2%) with a late systemic reaction. In total, 7 systemic reactions occurred in 23,154 doses, and all were associated with wheezing or worsening of nasal symptoms (grade 2); in addition, 1 patient had angioedema and urticaria (grade 3). Conclusions In this group, systemic reaction frequency was 11.6%, and all were classified as grade 2 or 3. Further assessments in larger samples of patients are required in the context of randomized controlled trials.

It has been demonstrated that specific immunotherapy, in addition to its preventive properties, is an effective and safe therapeutic resource for allergic asthma, allergic rhinitis and allergy to insect's venom; however, its use in patients younger than five years has been limited due to the risk of systemic reactions.To know the frequency and severity of systemic reactions in children younger than five years and to know if a greater risk of systemic reactions in this group of age is real.We included 239 patients from one to five years of age with diagnosis of allergic disease and verified its specific sensitivity with skin tests or RAST and were treated with specific immunotherapy. A detailed registry of the application of specific immunotherapy was kept from every patient, with special attention to any symptom present during the first 30 minutes post application of specific immunotherapy or skin test.From January 1996 to June 2005, 6,689 injections were applied to 239 patients. Only one patient of 36 months of age presented with a delayed systemic reactions characterized by generalized hives, itching, runny nose, water eyes, 90 minutes post injection. The patient was under treatment with Dermatophagoides farinae and pteronissinus (house dust mites) with a dose of 1AU for allergic rhinitis. The systemic reactions were treated easily and without complications with a single dose of intramuscular epinephrine (0.15cc, 1:1000) and oral antihistamine.Patients younger than five years are not in greater risk of systemic reactions from specific immunotherapy or skin tests than the older children or adults and the treatment of those systemic reactions does not imply greater difficulty. Because of its preventive properties, safety and effectiveness in lowering the severity of symptoms of allergic diseases, we concluded that specific immunotherapy should be considered at early age, prescribed and administered only by specialist in pediatric allergy and in optimal conditions of safety.

The frequency and severity of systemic reaction (SR) from skin test (ST) and specific immunotherapy (SIT) in Mexico, have not been published before. In order to know that frequency and severity, a prospective study was performed in the Allergy Clinic at General Hospital of Matamoros from August, 1991 to July, 1996. SR from ST and SIT were monitored. Symptoms were recorded with respect to the time of onset, involvement of respiratory tract or skin and presence of hypotension.65,397 injections were given to 1,149 patients; there were 25 SR in 20 patients (1:2,615 injections or 1:57 patients). Time of onset was between 10 and 30 minutes. SR were present more frequently during maintenance. There was a 3:1 rate in female patients and a predominance in the 15 to 24 age group.In Matamoros, Tamps., Mexico, frequency and severity of SR from ST and SIT is not different from published data. Small children are not in higher risk. Immunotherapy is a safe therapeutic procedure on expert hands.

Background Allergen exposure leads to allergen sensitization in susceptible individuals and this might influence allergic rhinitis (AR) phenotype expression. We investigated whether sensitization patterns vary in a country with subtropical and tropical regions and if sensitization patterns relate to AR phenotypes or age. Methods In a national, cross-sectional study AR patients (2-70 y) seen by allergists underwent blinded skin prick testing with a panel of 18 allergens and completed a validated questionnaire on AR phenotypes. Results 628 patients were recruited. The major sensitizing allergen was house dust mite (HDM) (56%), followed by Bermuda grass (26%), ash (24%), oak (23%) and mesquite (21%) pollen, cat (22%) and cockroach (21%). Patients living in the tropical region were almost exclusively sensitized to HDM (87%). In the central agricultural zones sensitization is primarily to grass and tree pollen. Nationwide, most study subjects had perennial (82.2%), intermittent (56.5%) and moderate-severe (84.7%) AR. Sensitization was not related to the intermittent-persistent AR classification or to AR severity; seasonal AR was associated with tree (p

Background Several international guidelines exist on allergen immunotherapy (AIT) –eg American, European, British, Spanish, Italian- but local conditions that reign in each country limit their applicability. We present the steps we followed to develop a National Guideline on AIT, taking into account local legislation, extracts available, costs and patient preference. Methods Firstly a Nation-wide survey on the practice of skin testing and AIT was undertaken among all members of Mexican Allergist Societies. Secondly, based on the replies obtained with the survey clinical questions were formulated on critical points and issues susceptible for improvement, as diagnosed by the survey. Thirdly, all 6 Regional Allergist Societies were visited to obtain the opinion of their members on the clinical questions concerning how immunotherapy could best be practiced under local Mexican conditions. This led to the Consensed experience. Fourthly, 6 experts looked for the replies to the clinical questions reviewing the literature and assigning quality of evidence to the articles on the specific issues treated by each clinical question. Results To develop the final document the GRADE approach was used. For each clinical question both, knowledge from the local consensed experience and the evidence-based replies were taken into account, as well as cost, patient preference and safety to make a set of recommendations and suggestions on the most crucial aspects of skin testing and AIT. Forming centers of allergists in Mexico corrected the final draft. The final document came out as the January issue of Revista Mexicana Alergia and was presented by the authors in a National Course on Immunotherapy (May 2011), with—apart from the lectures—a more workshop-like part to allow for practical exercising and discussion. The updated questions on allergen immunotherapy for the final board exam are based on the Guideline. Allergy-residents developed a slide-show. In 2012 Regional Allergist Societies shall be visited again. Conclusions We present a democratic way of how a National Guideline can be developed, supported by evidence-based medicine and local experience in a country where little is legislated on this respect and quality improvement has to be stimulated by the professional community. We show how implementation can be enhanced.