Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Foto
1:
Prueba
cutnea:
(+)
control
de
histamina,
(-)
control
negativo
(solucin
salina),
las
ppulas
indican
que
el
paciente
tiene
reaccin
positiva
a
Pa
y
Df.
Foto
2:
Inflamacin
de
la
regin
nasal
anterior
derecha.
Este
paciente
fue
positivo
a
la
prueba
cutnea
del
caro
del
polvo
(Dp).
Resultados:
38
ninos
aceptaron
someterse
a
la
prueba
de
puncion
cutanea
previa
autorizacin
y
firma
del
consentimiento
informado
por
parte
de
los
padres
de
familia.
El
promedio
de
edad
fue
de
6.6
aos.
17
eran
mujeres
(M:F
1:0.8).
Dos
nios
fueron
excluidos
de
los
resultados:
un
nio
no
toler
culminar
la
prueba
cutnea,
y
otro
nio
se
present
negativo
a
la
prueba
de
control
positivo
de
histamina
(posiblemente
debido
al
reciente
uso
de
antihistamnicos),
lo
cual
invalidaron
sus
resultados.
De
las
36
pacientes
incluidos
,
8
fueron
positivos
(ver
grfico
1).
6
de
estos
nios
haban
sido
diagnosticados
previamente
de
alergia
y
haban
recibido
prescripcin
de
antihistamnicos
orales.
Seis
nios
tuvieron
test
positivo
a
HDM
y
dos
nios
positivo
a
la
cucaracha
(vase
el
grfico
1).
Grfico
2.
Frecuencia
de
positividad
a
la
prueba
cutnea
con
la
presentacin
de
sntomas
y
signos
clnicos.
Grfico
3.
Incidencia
of
positividad
a
la
prueba
cutnea
frente
a
la
prescripcin
de
antihistamnicos.
Discusin:
Mientras
que
la
alergia
se
ha
convertido
cada
vez
ms
frecuente
en
las
poblaciones
de
Europa
y
Amrica
del
Norte,
tambin
est
afectando
a
los
nios
en
el
Per,
y
nuestro
estudio
muestra
que
existe
alergia
respiratoria,
incluso
en
las
zonas
ms
pobres
donde
la
poblacin
tiene
poco
acceso
a
los
alerglogos
peditricos.
En
nuestras
consultas
clinicas
y
como
se
ha
reportado
aqu,
muchos
nios
estn
diagnosticados
con
alergia
y
estan
recibiendo
medicacion
(en
la
mayora
de
los
casos
potencialmente
sedantes
como
clorfenamina,
en
2
casos
los
esteroides
orales)
innecesariamente
y
sin
una
prueba
de
alergia.
En
nuestra
cohorte,
los
sntomas
por
s
no
eran
tiles
para
ayudar
al
diagnstico
de
alergia,
aunque
el
signo
clnico
de
la
inflamacin
de
los
cornetes
nasales
en
el
examen
dio
una
alta
tasa
de
pruebas
cutneas
positivas
a
pesar
de
que
este
signo
slo
se
observ
en
7
pacientes.
Por
lo
tanto,
aconsejamos
el
uso
ms
frecuente
de
las
pruebas
de
alergia,
como
las
pruebas
cutneas
para
ayudar
al
diagnstico
y
evitar
la
medicacin
a
ciegas
con
prescripcin
de
medicamentos
anti-alrgicos
ya
que
este
estudio
muestra
que
la
mayora
de
pacientes
que
se
pensaba
que
tenan
alergia
tuvieron
prueba
cutnea
negativa.
Es
posible
que
la
prueba
cutnea
que
se
realizo
en
este
estudio
no
ha
reconocido
otro
tipo
de
alergia
como:
alergia
al
polen,
hongos,
pelo
de
animales,
estos
no
son
muy
frecuentes
en
climas
ridos
como
la
ciudad
de
Ica,
adems
los
nios
en
este
estudio
presentan
sntomas
perennes
haciendo
la
alergia
al
polen
menos
probable.
Aunque
en
Per
es
muy
frecuente
tener
animales
como
mascotas
en
la
casa,
se
observo
que
solo
en
un
caso
negativo
en
este
estudio,
la
mascota
fue
considerada
como
causa
de
los
sntomas
presentes
en
este
nio
(basado
en
la
historia).
Cucaracha
y
el
acaro
ha
sido
reportado
como
causante
de
rinitis
alrgica
en
otras
partes
de
Sur
Amrica
7
por
lo
que
se
pens
que
seria
apropiado
usar
estos
alergenos
en
la
prueba
cutnea
en
este
estudio.
Un
aspecto
importante
de
nuestro
estudio
es
mostrar
que
las
pruebas
cutneas
en
estos
tipos
de
atencin
clnica
puede
ser
una
realidad
muy
prctica.
Las
pruebas
cutneas
toman
aproximadamente
2-3
minutos
para
llevarse
a
cabo
y
los
resultados
se
pueden
leer
en
20
minutos.
Este
estudio
demuestra
que
se
puede
llevar
a
cabo
en
consultorio
externo,
incluso
en
los
estratos
socio
econmicos
ms
bajos
y
entornos
con
menos
infraestructura
mdica.
De
hecho,
sugerimos
que
las
pruebas
de
puncin
cutnea
son
las
ms
prcticas
de
todas
las
pruebas
de
alergia
para
este
tipo
de
consultas
ya
que
las
consulta
de
seguimiento
son
generalmente
poco
atendidas
y
los
pacientes
a
menudo
no
asisten
al
sus
citas
de
control
y/o
seguimiento
de
resultados
de
las
investigaciones.
Es
evidente
que
el
principal
problema
de
nuestro
informe
es
el
nmero
de
participantes
involucrados,
el
cual
es
demasiado
bajo
como
para
extraer
conclusiones
estadsticamente
significativas
lo
cual
es
la
principal
desventaja
de
nuestro
estudio.
Sin
embargo,
dada
la
clara
tendencia
en
los
resultados,
creemos
que
esto
no
invalida
las
dos
principales
conclusiones
de
nuestro
estudio,
podemos
decir
que
el
sobre-diagnstico
de
alergia
respiratoria
y
la
utilidad
prctica
de
las
pruebas
cutneas
en
esta
poblacin
mejoran
la
precisin
diagnstica.
No
pretendemos
que
las
pruebas
de
puncin
cutnea
debe
sustituir
la
toma
de
una
buena
historia
o
el
examen
clnico
(de
hecho,
firmemente
afirmamos
lo
contrario),
pero
es
interesante
sealar
la
baja
incidencia
de
resultados
positivos
de
la
prueba
cutnea
en
relacin
a
los
sntomas
principales.
Notamos
la
incidencia
relativamente
alta
de
resultados
positivos
en
presencia
de
inflamacin
nasal
y
sugerimos
que
este
signo
sea
buscado
activamente
durante
la
evaluacin
clnica
de
los
nios
con
posible
alergia
respiratoria.
Declaracin:
Los
autores
declaran
que
no
han
recibido
ningn
apoyo
econmico
y
no
hay
intereses
de
por
medio
al
realizar
este
estudio
y
en
la
produccin
de
este
informe.
Estamos
agradecidos
a
Stallergenes
(del
Reino
Unido)
por
la
donacin
(estrictamente
del
equipo)
de
las
pruebas
cutneas
utilizadas
en
el
estudio
y
que
no
hay
ganancia
financiera
que
se
haya
hecho
a
partir
de
esta
obra.
Tambin
agradecen
al
equipo
de
MedICA
por
su
apoyo
y
el
Rotary
Club
Internacional
de
Ica
por
la
invitacin
a
su
campana
mdica.
Referencias:
1. Byorksten B et al. Worldwide time trends for symptoms of rhinitis and
conjunctivitis: Phase III of the International Study of Asthma and Allergies in
Childhood. Pediatr Allergy Immunol 2008: 19: 110124.
2. Greiner AN et al. Allergic Rhinitis. Lancet. 2011. 378 (9809): 2112-22.
Introduction
Chronic respiratory symptoms are a common childhood complaint and children
complaining of symptoms of rhinitis have been found to be as high as 44% in Lima,
Peru1. Rhinorrhea, cough & wheeze are most often seen in the context of acute
viral symptoms but (in the absence of underlying lung pathology) when chronic
they are more commonly attributable to long term exposure to respiratory irritants
which may be physical, chemical or allergic in aetiology. Physical & chemical
triggers (eg dust, environmental pollutants) can only be avoided through public
health initiatives involving political and legal processes generally beyond the
capabilities of Paediatricians and medical personnel attending these children on a
day to day basis. Allergic processes are more readily treated by acute physicians
(and therefore attractive as a diagnostic option) as oral antihistamines are cheap
and readily available while corticosteroid inhalers and nasal sprays have been
shown to be very effective in the treatment of asthma and allergic rhinitis2.
However, the ease of prescribing theses medications does not mean that they
should be blindly used as side effects do occur. Older generation anti-histamines
are generally not recommended as they may be sedating in children3 and may
have long term effects on school performance. Poor technique in the use of inhaled
and nasal corticosteroids has been shown to lead to systemic absorption and
consequent steroid induced side effects of poor growth and impaired adrenal
cortical action4. Hence the use of anti-allergic medication should be considered
completely inappropriate in the absence of convincing evidence that a childs
symptoms are attributable to an allergic process.
Local audit of children attending outreach volunteer run clinics in the city of Ica,
Peru, over a 4 year period indicated that up to 70% (unpublished data) of children
seen were being prescribed antihistamines for respiratory symptoms. We therefore
set out to confirm how many of these children actually have allergy as the cause of
their symptoms and consequently for whom anti-histamines might be considered
appropriate treatment. In this paper we present the results of allergy investigations
in two clinic settings carried out in December 2012.
The allergy assessments included both a directed questionnaire and a
standardised allergy test (skin prick tests) used by Allergists worldwide for the
diagnosis of IgE mediated allergy. Skin prick tests (SPTs) were chosen (as
opposed to blood-specific IgE tests) as they are relatively inexpensive and give an
accurate result within minutes without the delay of sending to a laboratory. Skin
prick tests are widely regarded as the gold standard in the diagnosis of allergic
rhinitis5. These factors make them practical for application in the context of low
income settings such as the poorer neighbourhoods of the city of Ica, Southern
Peru. A Medline search of published literature revealed no studies of Paediatric
allergy in the coastal regions of Peru and to the best of our knowledge this is the
first such study to have been conducted in the region of Ica.
Methods
The study was carried out in two clinic settings. The first was a newly formed clinic
in the neighbourhood of Manzanilla, Ica (run by an NGO, MedICA). This is an inner
city area with a high level of social deprivation as well as economic poverty.
Chronic gastrointestinal infections such as giardiasis are endemic and there is a
high incidence of tuberculosis6.The second clinic setting was in the outskirts of the
district of Parcona, Ica with logistical support from the Rotary Club International,
Ica. Parcona is a poor outlying area of the city and the area of the clinic setting is of
poor dwellings made of corrugated plastic and thatch with poor levels of sanitation
and medical care.
Two doctors (the authors) trained in the accurate use of skin prick tests conducted
the study. The study was carried out in the context of general Paediatric clinics
where all patients were offered the opportunity to have skin prick tests to house
dust mite and cockroach if their parents chose to do so. Exclusion criteria included
age <2 years or >16 years, being acutely unwell at the time of consultation or
having taken antihistamines within 48 hours of consultation. Informed written
consent was taken and a directed questionnaire was completed on the following
questions:
1. Are your symptoms seasonal or perennial?
2. Does your child cough?
a. At night?
b. During the day?
3. Does your child have rhinorrhea?
4. Does your child have asthma?
5. Has your child been prescribed medication for allergy in the past?
6. Which medications?
7. Is your child currently taking anti-allergy medications?
Physical examination was completed and if the child was clinically well and had not
received anti-histamine in the last 48 hours, proceeded to skin prick test with 5
potential allergens. These were 2 species of house dust mite: D. pteronyssinus
(Dp), D. farinae (Df) and 3 species of cockroach: Blomia tropicalis (Bt), Periplaneta
americana (Pa) and Blatella germanica (Bg). Although patterns of respiratory
allergy vary considerably between geographical regions throughout the world, the
authors considered these species the most likely to be causal in the city of Ica (in
the absence of any known epidemiological studies in the area) which is an arid
area unlikely to have high levels of moulds. Allergy to animals was not tested but
was questioned where skin prick tests were negative. Allergy to pollens was not
tested as unlikely to be causal if symptoms are all year round. The authors
considered that a balance needed to be struck between a reasonable number of
tests that would be tolerated by children and a reasonable chance of achieving a
positive result. Given the uncertainty of which type of HDM or cockroach species
might cause allergy, it was considered best to test for all commercially available
species.
Skin prick tests are generally well tolerated by children as they involve only small
needles introducing allergen into the epidermis without piercing the full thickness of
the skin or drawing blood so avoiding pain in a large degree. In addition to the
allergens tested, each child had a positive control (purified liquid histamine) and
negative control (0.9% saline solution) to ensure reliability of results. A positive
result was considered to be a weal of 3mm or more in the presence of a negative
saline control result and a positive histamine control reaction.
Where patients had a positive reaction, clinical advice was given to the parents
regarding:
1. Reduction in allergen exposure ie:
a. house dust mite: regular cleaning of bed linen, exposing furniture (in
particular mattresses and pillows) to direct sunlight for periods of over 1 hour,
regular vacuum cleaning
b. cockroach: regular cleaning of the house and avoidance of leaving food
exposed, use of pesticides
2. Medical therapy: for symptoms of allergic rhinitis the use of a corticosteroid
nasal spray and oral non-sedating antihistamines are recommended as second line
therapy. Immunotherapy is an alternative not available currently in Peru. While less
effective 7 than steroids, ease of availability and lower cost makes antihistamines a
more practical therapy for this population of poor economic resources.
Results
38 children agreed to undergo complete skin prick testing. Average age was 6
years and 8 months. 17 were female (male:female ratio of 1:0.8).Two children were
excluded from our results: one child did not tolerate complete testing and one child
had a negative positive histamine control test (possibly due to recent anti-histamine
use) invalidating his results. Of the 36 completed tests, 8 were positive (see graph
1). 6 of these children had been previously diagnosed as having allergy and been
prescribed oral antihistamines. Six children tested positive to HDM and two
children tested positive to cockroach (see graph 1).
Clinical symptoms/signs:
As regards clinical symptoms and signs, the most likely predictive factor for
positive skin prick tests was inflammation of the nasal turbinates (see picture 2). 5
of the 7 children with visible inflammation tested positive for allergy to either HDM
or cockroach (see graph 2). Of the 25 children who reported symptoms of chronic
rhinorrhea, 5 (20%) had positive SPTs. Cough by day or night was also a poor
predictor of positive skin prick test (7 and 21% respectively). Urticaria was
commonly reported but only 4 of 12 had positive skin prick tests.
Medication:
Of the 19 children who had been prescribed one or more antihistamines for their
symptoms only 5 (26%) were skin prick positive. 2 of 15 who had not received
antihistamines were found to be skin prick positive even though the parents did not
think their children had allergy (they both had significant nasal inflammation and in
one case significant snoring at night).
16 children had been prescribed
chlorphenamine, 7 children cetirizine, 4 loratadine, 2 desloratadine and 2
prednisalone for their syptoms. None of those prescribed more than one
medication was skin prick positive. 4 patients were using salbutamol inhalers
regularly but none of these was skin prick positive.
Discussion
While allergy has become increasingly prevalent in populations of Europe and
North America, it is also affecting children in Peru and our study shows that there is
respiratory allergy even in poorer areas where the population has little access to
Paediatric Allergists. In this health setting, and as found in the cohort here
reported, many children are being diagnosed with allergy and being prescribed
medication (in most cases potentially sedating chlorphenamine, in 2 cases oral
steroids had been used) without formal allergy testing. In our cohort, symptoms
alone were not useful in aiding the diagnosis of allergy although the clinical sign of
inferior turbinate inflammation (found in 7 patients) on examination did yield a high
rate of positive skin prick tests. We would therefore advise the more frequent use
of allergy tests such as skin prick tests to aid diagnosis rather than blind
prescription of anti allergic medication as this report shows that the majority of
patients who thought they had allergy were actually negative on testing.
While it is possible that the skin prick tests performed in this cohort missed other
allergic causes, such as pollen, fungus or animal dander, these are not frequently
found in arid climates such as that of Ica and the children in this study have
perennial symptoms making pollen allergy less likely. Although animals are
commonly kept as pets in Peru, in only one negative case in this cohort was pets
considered a plausible cause of the childs symptoms based on history. Both
cockroach and house dust mite have been reported as causing allergic rhinitis
elsewhere in South America7 and these allergens were thought most appropriate
for skin prick testing in this study.
An important aspect of our report is showing that allergy testing in these settings
can be made a practical reality. Skin prick tests take approximately 2-3 minutes to
perform and results can be read at 20 minutes. It is here demonstrated that they
can be performed in the context of outpatient clinics even in the lowest of economic
settings and least equipped clinic environments. Indeed the authors suggest that
skin prick tests are the most practical of all allergy tests for these type of clinics as
follow-up is generally very poor and patients often fail to attend follow-up for results
of investigations.
Clearly the numbers involved in this report are too low to draw statistically
significant conclusions regarding predictive values of symptoms/signs and this is
the main drawback of our report. However, given the clear trend in the results we
believe that this does not invalidate the two main conclusions of our study, namely
the overdiagnosis or respiratory allergy and the practical usefulness of skin prick
tests in this population to improve diagnostic accuracy. We would not claim that
skin prick tests should replace good history taking or examination (indeed the
authors are firmly of the opposite opinion) but it is interesting to note the low
incidence of positive test results in relation to key symptoms. The authors take note
of the relatively higher incidence of positive tests in the presence of nasal
inflammation and would suggest that this sign is actively looked for during clinical
assessment of children with possible respiratory allergy.
Declaration:
The authors declare that they have received no financial gain or had any conflict of interest in
production of this report. They are grateful to Stallergenes UK for the donation of the skin prick tests
used in the study but this was wholly limited to the donation of equipment alone. They also thank
MedICA and The Rotary Club International for their support.