Allergology and Clinical Immunology
Allergology and Clinical Immunology
The Allergology Unit of the Department of Medicine provides a 24 hour referral service for complex allergic diseases, from the Groote Schuur hospitals, the day hospitals and from regional clinics, Victoria-, Somerset- and the maternity hospitals.
Patients are seen in E16 outpatient clinics, the Groote Schuur Hospital wards and at Red Cross Children’s Hospital on Wednesday afternoons, by Prof Paul Potter, Dr Di Hawarden and by Dr Jonny Peter who has a special interest in immunological diseases.
In addition to allergic disorders, the Allergology clinics also care for adult patients with Primary Immunodeficiencies such as complement C6 and C5 deficiency using long term penicillin prophylaxis for patients with meningococcal meningitis and for a large group of patients with hereditary angioedema, who are treated prophylactically with attenuated androgens and also treated as emergencies whey they have life threatening attacks of angioedema. The clinical service is linked to clinical services provided by the UCT Lung Institute Allergology Service which provides nursing staff for certain procedures and the administrators of the UCT component of the South African Primary Immunodeficiency Register.
A significant part of the clinical work done includes the investigation of patients with food allergies, angioedemas, drug allergies, occupational allergies (e.g. latex) and novel African indigenous allergies.
Protocols for diagnostic food allergy challenges and drug allergy testing and aero allergen and drug allergy desensitisation are available. We also provide a telephonic service to doctors throughout southern Africa. We have also established new protocols for specialised allergy procedures.
DIAGNOSTIC LABORATORY SERVICES
The Allergology Unit has a diagnostic as well as a research laboratory. The diagnostic laboratory is housed at the UCT Lung Institute and provides allergy diagnostic tests for uncommon or unusual allergens for the NHLS and for the private sector.
These include sulphido leukotriene release tests, mast cell tryptases, micro arrays, Western blot specific IgE tests and allergen extract preparation for skin prick or oral challenges.
The research laboratory in H47 focusses on the identification and characterization of new (novel) African allergens using polyacrylamide gels, Western blotting and ELISA techniques. This research has been supported by the NRF. In recent years several interesting new African allergens have been identified and partially characterised, including Mopane worm, Marula nut, African penguin, African pear, Porcupine and Wildebeest. The laboratory work is conducted by Mrs Bartha Fenemore and Mrs Sumayah Salie.
The unit is also involved in clinical trials in immunotherapy, asthma, rhinitis, eczema/dermatitis, urticaria and hereditary angioedema.
The Allergy Unit also supports a National Research Funded (NRF) aerobiology research project, current collating aerobiological data collected over the past 30 years, with an emphasis on defining the local aerobiological spectrum in the Western Cape, defining pollen seasons in the region and identifying changes compatible with Global warming. The aerobiology service provides weekly pollen and mould counts for the region. This service is provided by Mrs Dilys Berman.
TEACHING AND POST GRADUATE TRAINING
Formal lectures in Allergy are given to the 3rd and 5th year medical students. In addition the unit participates in the SSM (Specialised Student Module) programs for 3rd year medial students. Post-graduate teaching includes training candidates for the Diploma in Allergy exam of the CMSA, paediatric registrar training, lectures to Pharmacology fellows, nurses, MSc and PhD students. The unit has also started a MPhil Allergology programme for sub-specialists in Allergology.
The unit is an accredited unit for subspeciality training in Allergology and is currently involved with the training of one adult allergology and 3 paediatric allergology subspecialists.
The unit has several ongoing basic research programs studying immunological mechanisms underlying sublingual immunotherapy, complement deficiency (C5 & C6), latex allergy (using recombinant component allergy testing) and novel African allergen identification.
The Allergy and Immunology Division of the Department of Medicine is headed by Prof Paul Potter. Administrative support is provided by Mrs Lindi Foot of the UCT Lung Institute Allergy Unit, as well as the secretaries of the Department of Medicine for research grants. Services of the Allergology Unit at the Lung Institute, complement those provided in E16 (i.e. nursing and secretarial and medical officer support) and there is a pressing need for UCT/Provincial secretarial and technical support for the Division to expand. Administration includes provision salaries, management of NRF & MRC Funds, preparation of research papers and staff support.
EXCITING ASPECTS OF OUR RESEARCH IN THE UNIT
In view of our state of the art laboratory capabilities, our unit has the unique capability on the continent to investigate and identify novel African allergens and over 20 new African allergies have been identified over the past 20 years by our laboratory, several reported in international journals. These include the following: Kikuyu grass pollen, Buffalo grass pollen, Eragrostis pollen, Acacia species, Rhodesian Flame Lily, Abalone (Haliotis Midae), Mopane worm, Marula nuts, African pear, Mogwagwa wild fruit, Locusta Migratoria, Cobra venom (Rinkhals), Wildebeest, African penguin and African porcupine allergens. Several of these cases were referred from neighbouring countries, e.g. Botswana (Dr Shiang-Ju) and Namibia (Dr C Buys).
We have also over the years investigated and published unique African aspects of global allergens such as house dust mite allergy, alien trees (Oaks and Plane), fungal spore allergens, Verbena hybrida, cockroach and Imbuia wood allergy.
The aerobiology service and its unique 30 year database and weekly aeroallergen reporting is also unique in the region.
On the clinical side we have made exciting discoveries on the high prevalence of complement C6 & C5 deficiencies in the Western Cape in collaboration with Dr Ann Orren (visiting scientist) We have ongoing complement research supported by the MRC. We have also been able to provide cutting edge novel treatment to hospital patients with Hereditary Angioedema through clinical trials we have been involved in at the UCT Lung Institute.
The most challenging aspects of our work include the investigation and management of patients with complex drug allergies and anaphylaxis (especially intra operative). Laboratory tests have limited value and often direct skin testing or clinical challenges with all the inherent clinical risks are necessary. Recommending safe ongoing medications for patients with complex and chronic diseases is always a challenge and our unit needs dedicated emergency facilities on site at Groote Schuur hospital to expand this service.
HIGHLIGHTS OF OUR WORK
A major highlight of our work in the Allergology unit was the recognition of Allergology as a sub-speciality in 2011. This followed 30 years of development of our diagnostic & clinical expertise at Groote Schuur Adult Allergy and Red Cross Paediatric Allergy Clinics.
Identification of the interesting novel African allergies (listed above) using our accumulated laboratory and clinical expertise is the most interesting aspect of our work and generates great excitement among the staff, referring doctors and the patients. This facility is unique on the African continent and has resulted in several international publications.
The identification of over 50 patients with hereditary angioedema and our 80 patients with complement deficiency is also unique in Africa and a highlight of our achievements. The extended identification of the genetic defects, frequencies and prevalence and prophylaxis, in collaboration with laboratories in Cardiff and UCT Chemical Pathology (Dr Tricia Owen and Dr Felicity Leisegang) is also globally unique and has made us world leaders in this area of primary immunodeficiency. Through our connections with the Allergy Society and the World Allergy Organization our unit has also contributed extensively to national and global position statements on the diagnosis and management of allergic diseases such as asthma, allergic rhinitis, chronic urticaria, atopic dermatitis and in the field of sublingual immunotherapy.
Since Allergology is a recognised subspeciality and the GSH/RXH Allergology Unit is accredited as a teaching unit for future allergology sub-specialists, it is important to create posts for future specialists to train in this field for the future since training numbers have been allocated by the HPCSA. This is a priority for succession and expansion of our clinical and laboratory services.
Patients who have been diagnosed with rare primary immunodeficiencies such as C6 complement deficiency need ongoing care and recombinant, genetic and vaccine therapy needs to be explored in the future, to prevent recurrent meningitis.
There is an urgent need for the state to provide better emergency treatments for treatment and prevention of attacks of hereditary angioedema (e.g. Bradykinin antagonists, Berinert [C1 inhibitor concentrates] and for patient with asthma [anti IgE treatments] and other allergies [immunotherapy vaccine programmes and cytokine therapies]).
The state needs to take cognition of the fact that allergology is an accredited medical field and to budget appropriate funds and infrastructure for this field to grow and to offer world class therapies in the future for the 20% of our population who suffer from allergic diseases. Since some of our key staff members are approaching retirement and since most of our activities have been funded by short term grants in the past, a commitment is required by the University and the state to create permanent posts for enough staff to run the unique laboratory and clinical service we have built up over the past 30 years.
RECENT PUBLICATIONS (2014-2015)
Articles in Peer Reviewed Journals
1. Gray C, Levin M, Zar H, Potter PC, Khumalo N, Volkwyn L, Fenemore B, Du Toit G. Food allergy in South African children with atopic dermatitis. Paediatric Allergy & Immunology, 2014; 25: 572-579.
2. Peter J, Ress S, Gray C. Guest Editorial: Immunology as a medical discipline in South Africa: Why, how and what form? SAMJ, November 2014; 104(11): 785-786.
3. Peter JG, Heckmann JM, Novitzky N. Recommendations for the use of immunoglobulin therapy for immunomodulation and antibody replacement. SAMJ, November 2014; 104(11): 796.
4. Owen E, Leisegang F, Whitelaw A, Simpson J, Würzner R, Morgan B, Potter PC, Orren A. A complement C5 gene mutation, c.754G>A:p.A252T, is common in the Western Cape, South Africa and found to be homozygous in seven percent of Black African meningococcal disease cases. Molecular Immunology, 2015; 64: 170-176.
5. Potter PC, Baker S, Fenemore B, Nurse B. Clinical and cytokine responses to house dust mite sublingual immunotherapy. Ann Allergy Asthma Immunol, 2015. (published online February 2015) doi:10.1016/j.anai.2014.12.015
6. Potter PC, Ehrlich R, Van Rooyen C, Fenemore B. Occupational sensitization to the African penguin serum and mucus proteins. Annals of Allergy, 2015. (published online February 2015) http://dx.doi.org/10.1016/j.anai.2014.12.023
IN PRESS OR SUBMITTED
1. Potter P, Mitha E, Mezei G, Santamaria E, Izquierdo I, Maurer M. Rupatadine effective in the treatment of chronic spontaneous urticaria in children aged 2-11 years: a randomized, double blind, placebo and desloratadine controlled study. Pediatric Allergy and Immunology, 2015 (submitted March 2015)
Articles Published in CME Journals
1. Hawarden D. Consensus Document: Guideline for diagnostic testing in allergy – Update 2014. Current Allergy & Clinical Immunology, 2014; September, 27(3): 216-222.
2. Potter PC. Unique South African Allergens. Current Allergy & Clinical Immunology, 2014; December, 27(4): 252-254.
3. Green R, Hockman M, Friedman R, Hawarden D, Potter PC et al. On behalf of the South African Allergic Rhinitis Working Group (SAARWG). Allergic Rhinitis in South Africa: Update 2014. Consensus document. Current Allergy & Clinical Immunology, 2014; December, 27(4): 302-309.
4. Berman D. Aerobiology studies in South Africa. Current Allergy & Clinical Immunology, 2014; December, 27(4): 255-258.
5. Weinberg E. Guest Editorial: Allergology in South Africa. Current Allergy & Clinical Immunology, 2014; December, 27(4): 244-247.
ABC OF ALLERGY (NURSES’ EDUCATION):
1. Emanuel S, Hawarden D. ABC of Allergy: Setting up an allergy and asthma clinic. Current Allergy & Clinical Immunology, 2014; March, 27(1): 48-51.
2. Emanuel S, Hawarden D. ABC of Allergy: The management of chronic asthma. Current Allergy & Clinical Immunology, 2014; June, 27(1): 125-129.
3. Emanuel S, Hawarden D. ABC of Allergy: Atopic eczema. Current Allergy & Clinical Immunology, 2014; September, 27(3): 207-210.
4. Emanuel S, Hawarden D. ABC of Allergy: Primary Management of Acute Asthma. Current Allergy & Clinical Immunology, 2014; December, 27(4): 328-330.
5. Emanuel S, Hawarden D. ABC of Allergy: Learning through stories and pictures. Current Allergy & Clinical Immunology, 2014; December, 27(4): 300-301.
6. Emanuel S, Hawarden D. ABC of Allergy: Allergy testing. Current Allergy & Clinical Immunology, 2015; March, 28(1).
1. Orren A, Owen T, Leisegang F, Würzner R, Rizkallah P, Potter P. The C5 genetic polymorphism A252T found homozygous in five (8%) unrelated Black South African children with meningococcal disease. Poster Session I, Pg. 55, Abstract No.: 129. XXV International Complement Workshop, 14-18 September 2014, Rio de Janeiro, Brazil.
2. Orren A, Owen T, Leisegang F, Würzner R, Rizkallah P, Potter P. A pathogenic genetic polymorphism of the C5 segregates in the Western Cape and is found homozygous in 8% of Black patients presenting with Meningococcal Disease (MD). Department of Medicine 41st Annual Research Day, 9 October 2014.