Aeroallergen sensitisation and prevalence of asthma, allergic rhinitis and eczema in children with Vernal Keratoconjunctivitis

attending Red Cross War Memorial Children’s Hospital

Naidoo , S ; Levin ME ; Tinley C ; Pollock T

Background • Vernal Keratoconjunctivitis (VKC) is a severe

inflammatory disease of the conjunctiva, with

complex inflammatory pathways involving IgE and

non IgE mechanisms. (1, 2)

• There is a typical clinical picture w.r.t age , sex and

phenotype which distinguishes VKC from the more

common types of Ig E mediated allergic

conjunctivitis.

• Severe symptoms ,difficult to control , corneal damage visual acuity

(1) Friedlaender MH. Ocular allergy. Curr Opin Allergy Clin Immunol 2011 Oct;11(5):477-482. (2) Kumar S. Vernal keratoconjunctivitis: a major review. Acta Ophthalmol 2009 Mar;87(2):133-147.

VKC (1)Palpebral (2)Limbal

(3) Mixed

VKC • Ethnicity has a marked influence on the type of VKC

• VKC and atopy ?

• VKC , atopy & ethnicity ?

Previous African studies have suggested that there are

marked differences in the clinical expression of VKC in Africa , with far less atopy than in European and Asian cohorts. (3, 4)

Europe , South America and Asia : 30% to 51 % of VKC patients

are atopic

African studies generally <10 % VKC patients are atopic (

Nigeria 2000 , 19.8% physician diagnosed atopic disease) (4)

(3) Dahan E, Appel R. Vernal keratoconjunctivitis in the black child and its response to therapy. Br J Ophthalmol 1983 Oct;67(10):688-692. (4) Ukponmwan CU. Vernal keratoconjunctivitis in Nigerians: 109 consecutive cases. Trop Doct 2003 Oct;33(4):242-245. (5) Tuft SJ, Dart JK, Kemeny M. Limbal vernal keratoconjunctivitis: clinical characteristics and immunoglobulin E expression compared with palpebral vernal. Eye (Lond) 1989;3 ( Pt 4)(Pt 4):420-427

Aim Describe the prevalence of allergic sensitisation to

common aeroallergens as well as the prevalence of

asthma, allergic rhinitis, and eczema in a cohort of

children attending Red Cross Children’s Hospital,

Cape Town, South Africa

Method A cross sectional descriptive study where patients under 13

years had

a diagnosis of VKC confirmed by an ophthalmologist

completed a questionnaire regarding atopic diseases and

symptoms

a physical examination ( general and opthalmological)

sensitisation evaluated by skin prick testing (SPT) to common

aeroallergens

Results • n = 214 , age : 14 months to 12 years , 10 months

• gender : M 160(74.7%) ,ethnicity: Black 151(70.56 % )

• Co-morbid atopic disease

No %

Active eczema 17 7.9

Chronic eczema 27 12.6

Non specific wheeze 79 36

Previous asthma diagnosis

38 17

ISAAC data : Allergic rhinitis

1995 ( Cape Town) 2002 (Polokwane)

Rhinitis ever 1944 (37.6) 2466 (49)

Rhinitis last 12 months

1569 (30.4) 1939 (38.5)

Rhinoconjunctivitis in last 12 months

910 (17.6) 1223 (24.3)

(6) Zar HJ, Ehrlich RI, Workman L, Weinberg EG. The changing prevalence of asthma, allergic rhinitis and atopic eczema in African adolescents from 1995 to 2002. Pediatr Allergy Immunol 2007 Nov;18(7):560-565. (7)Green RJ, Hockman M, Friedman R, Davis M, McDonald M, Seedat R, et al. Chronic rhinitis in South Africa: update 2013. S Afr Med J 2013 Apr 30;103(6):419-422.

Allergic rhinitis

No %

Previous diagnosis of of allergic rhinitis

47

21

Allergic Rhinitis 122 * 57%

ISAAC study Phase II (2003) : prevalence of Allergic rhinitis was 38.5%. (6)

(7)Green RJ, Hockman M, Friedman R, Davis M, McDonald M, Seedat R, et al. Chronic rhinitis in South Africa: update 2013. S Afr Med J 2013 Apr 30;103(6):419-422.

Clinical rhinitis on day of enrolment

Results • Aeroallergen spread ( n= 213 )

>3mm wheal

HDM 123 57.7%

Grass 74 34.7%

Cockroach 40 18.77%

Cat 24 11.26%

Dog 30 14%

Tree pollens 17 7.98%

Mould 8 3.75 %

(8) Levin ME, Muloiwa R, Motala C. Associations between asthma and bronchial hyper-responsiveness with allergy and atopy phenotypes in urban black South African teenagers. S Afr Med J 2011 Jun 27;101(7):472-476.

Study Conclusions 1 • Higher incidence of allergic sensitisation and atopic

disease in our cohort of 214 children than in previous

African studies.

• Our cohort more closely resembles the quoted VKC data

from Europe and Asia than the earlier African studies.

• The prevalence of asthma and eczema found in this

study is similar to non selected South African subjects

• The prevalence of allergic rhinitis is striking, much higher

than in a non selected SA population.

• The major aeroallergens are HDM, grass and cockroach

with some of the highest levels of sensitisation found as

yet in an African study.

Study Conclusion 2 • Service Implications

• There is currently a well defined management

pathway for VKC from primary/secondary to the

tertiary Opthalmology Clinic at Red Cross.

• Children with VKC in Cape Town are atopic and

have co-morbid atopic diseases which require care notably allergic rhinitis .

• Challenge : How to access care and maintain

treatment for co-morbid atopic diseases within the

current structures when chronic paediatric care

needs are already underserviced ?

Acknowledgements • ALLSA Research Grant 2013 / School of Child and

Adolescent Health ( UCT ) Research funding

• Sr Heidi Thomas : Study nurse , data capturer

• Eye Clinic : Co-investigators Drs Tinley and Pollock ,

Sr Y Jacobs and Eye Clinic staff

• Prof ME Levin : Supervisor , HOD of Paediatric Allergy

Further references • Bonini S, Bonini S, Lambiase A, Marchi S, Pasqualetti P, Zuccaro O, et al. Vernal keratoconjunctivitis revisited: a case series of

195 patients with long-term followup. Ophthalmology 2000 Jun;107(6):1157-1163.

• Katelaris CH. Ocular allergy in the Asia Pacific region. Asia Pac Allergy 2011 Oct;1(3):108-114.

• Kumar S, Gupta N, Vivian AJ. Modern approach to managing vernal keratoconjunctivitis. Curr Allergy Asthma Rep 2010 May;10(3):155-162.

• Sacchetti M, Lambiase A, Mantelli F, Deligianni V, Leonardi A, Bonini S. Tailored approach to the treatment of vernal keratoconjunctivitis. Ophthalmology 2010 Jul;117(7):1294-1299.

• Montan PG, Ekstrom K, Hedlin G, van Hage-Hamsten M, Hjern A, Herrmann B. Vernal keratoconjunctivitis in a Stockholm ophthalmic centre--epidemiological, functional, and immunologic investigations. Acta Ophthalmol Scand 1999 Oct;77(5):559-563.

• Lambiase A, Minchiotti S, Leonardi A, Secchi AG, Rolando M, Calabria G, et al. Prospective, multicenter demographic and epidemiological study on vernal keratoconjunctivitis: a glimpse of ocular surface in Italian population. Ophthalmic Epidemiol 2009 Jan-Feb;16(1):38-41.

• Bonini S, Lambiase A, Sgrulletta R, Bonini S. Allergic chronic inflammation of the ocular surface in vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2003 Oct;3(5):381-387.

• Ellwood P, Asher MI, Beasley R, Clayton TO, Stewart AW, ISAAC Steering Committee. The international study of asthma and allergies in childhood (ISAAC): phase three rationale and methods. Int J Tuberc Lung Dis 2005 Jan;9(1):10-16.

• McMoli TE, Assonganyi T. Limbal vernal kerato-conjunctivitis in Yaounde, Cameroon. A clinico-immunology study. Rev Int Trach Pathol Ocul Trop Subtrop Sante Publique 1991;68:157-170.

• Kawuma M. The clinical picture of vernal kerato-conjunctivitis in Uganda. Community Eye Health 2001;14(40):66-67.

• Ajaiyeoba AI. Prevalence of atopic diseases in Nigerian children with vernal kerato-conjunctivitis. West Afr J Med 2003 Jan-Mar;22(1):15-17.

• Choi H, Lee SB. Nonseasonal allergic conjunctivitis in the tropics: experience in a tertiary care institution. Ocul Immunol Inflamm 2008 Jul-Aug;16(4):141-145.

• Marback PM, de Freitas D, Paranhos Junior A, Belfort Junior R. Epidemiological and clinical features of allergic conjunctivitis in a reference center. Arq Bras Oftalmol 2007 Mar-Apr;70(2):312-316.

• Tuft SJ, Dart JK, Kemeny M. Limbal vernal keratoconjunctivitis: clinical characteristics and immunoglobulin E expression compared with palpebral vernal. Eye (Lond) 1989;3 ( Pt 4)(Pt 4):420-427.

• Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2007 Oct;7(5):436-441.

• Morris A. Allsa position statement : allergen skin-prick testing : review article. Current Allergy & Clinical Immunology 2006 Mar;19(1):22-25.