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 | Alimentatie | Asistenta sociala | Frumusete | Medicina | Medicina veterinara | Retete |
Studiu - alergia alimentara
-metoda utilizata
-studiul propriu-zis
- discutia rezultatelor
Studiul nostru asupra alergiilor alimentare cu manifestari cutanate s-a desfasurat in perioada 1 IANUARIE 2009 -1 IULIE 2009 in Clinica de Dermatologie a Spitalului "Colentina".
Metoda de identificare a bolnavilor alergici a fost, in prima faza, studierea registrului de consultatii de la camera de garda a clinicii de dermatologie si studierea registrului de internari de la serviciul de internari.Au fost, deci, retinuti in studiu, numai bolnavii care au necesitat internarea, neputand fi tratati in ambulator.
In completare, am studiat foile de observatie ale bolnavilor, de unde am cules date interesante cu privire la analizele de laborator efectuate in spital.
In cazurile mai dificile, am colaborat atat cu medicii de pe sectie, cat si cu bolnavii in cauza. Pe perioada respectiva au fost diagnosticati si internati 104 de bolnavi, cu manifestari cutanate de natura alergica, la care agentul etiologic s-a dovedit a fi un trofoalergen.
Din observarea sumara a periodicitatii cu care s-au prezentat la spital bolnavii, s- a putut observa o explozie de cazuri in luna mai, luna cu o importanta zi de sarbatoare.
Explicatia simpla a acestui fapt este
gasita in excesele alimentare ce se asociaza, in general,
sarbatorii amintite, excese care sunt facute chiar de alergicii
ce se stiu bolnavi, dar care lasa prudenta la o parte in astfel
de situatii. Din
totalul de alergii cu manifestari cutanate, 104 cazuri sunt alergii de
etiologie alimentara, 110 cazuri sunt alergii de etiologie neprecizata
si 107 cazuri sunt alergii de etiologie medicamentoasa.
GRAFICUL I
Din totalul de pacienti internati in clinica cu alergii alimentare cu manifestari cutanate, 10 bolnavi au fost internati in luna Ianuarie, 13 in Februarie, 25 in Martie, 7 in Aprilie, 26 in Mai, 23 in Iunie
GRAFICUL II
Din totalul celor 104 de bolnavi, 6 din ei au necesitat tratament de urgenta (cazuri foarte grave), iar restul de 98 de bolnavi nu au necesitat tratament de urgenta.
GRAFICUL III
GRAFICUL IV
DISTIBUTIA PE SEXE A PACIENTILOR
Din graficul IV, reiese ca majoritatea bolnavilor internati cu diferite forme de alergii alimentare sunt femei.Repartitia pe grupe de varsta este cea reprezentata in graficul V.
De aici reiese faptul ca numarul cel mai mare de boli alergice a fost semnalat la grupa de varsta 31-35 de ani (16%), urmata indeaproape de grupele de varsta:36-40(12%), 26-30(11%), 46-50 (11%).
GRAFICUL V
Se observa ca numarul scazut de cazuri pentru grupele de varsta extreme (0-5 ani, peste 75 ani). Odata cu inaintarea in varsta, reactivitatea imunologica scade, deci si numarul de alergii se reduce drastic peste 75 ani (2%) in studiul nostru.
In privinta, numarului crescut de cazuri la grupele de varsta mentionate, se poate spune ca odata cu cresterea industrializarii, odata cu aparitia in supermarketuri a cat mai multor alimente cu conservanti, aditivi alimentari a crescut si numarul de alergii. Aceasta constatare este facuta si de cateva studii efectuate in aceasta privinta.
GRAFICUL VI
Din graficul VI, reiese
ca majoritatea bolnavilor cu alergii alimentare provin din mediul urban.
Din totalul pacientilor internati doar o parte au locul de munca
in mediul alergizant (7 % din pacienti). Insa
numarul lor poate fi mai mare, deoarece in fisele pacientilor
pensionari nu a fost mentionata profesiunea pe care au avut-o.
GRAFICUL VII
GRAFICUL /III
Din cei 104 bolnavi, 34% (35 bolnavi) nu sunt la prima problema de alergie cutanata, prezentand un trecut bogat in consultatii si chiar internari in serviciul de dermatologie, pentru aceeasi afectiune ca in prezent, sau pentru o alta afectiune cutanata, dar tot de natura alergica.
In continuare am remarcat ca 18 bolnavi (17%) au mai prezentat si alte alergii decat cele pentru care au venit acum la spital, fie in sfera digestiva, fie, in sfera respiratorie, ca de exemplu rinite alergice, astm bronsic (vezi graficul X). Ei sunt in general bolnavi atopici cu stigmatele atopiei, inteleasa ca o predispozitie spre boli alergice, inclusiv alimentare.Se stie deja ca o mare parte din reactiile de tip imediat ca de exemplu urticaria, angioedemul, dermatita atopica-se valideaza in prezenta terenului atopic. (vezi graficul IX).
GRAFICUL IX
GRAFICUL X
Din bolnavii internati, 27% (28) au rude de gradul I -parinti, frati, bunici, unchi, care au avut la un moment dat macar o afectiune de etiologie dovedita alergica.Se stie de altfel ca un copil cu un parinte alergic are un risc de 20-30%sa fie si el alergic. Daca un copil are ambii parinti alergici, riscul creste la 70-80%.
GRAFICUL XI
Dupa cum am aratat si la subcapitolul "Factori de risc pentru alergia alimentara" un factor de risc important, dovedit si de autori romani (Dumitrascu si colab., 1977) il constituie afectiunile digestive asociate, prezentate de bolnavi.
GRAFICUL XII
Din cazurile noastre 18%
(-19) din bonavi acuza afectiuni digestive, dovedite printr-un
diagnostic anterior pus de un medic de specialitate.
Nu am luat in consideratie acuzele
nesustinute de un diagnostic medical clar. (veziXII-grafic).
Din bolnavii afectati in sfera gastro-intestinala, avem:
GRAFICUL XIII-A
- 7 bolnavi cu ulcer (24% din cei bolnavi digestiv)
- 6 bolnavi cu constipatie (19%)
- 5 bolnavi cu colecistita (16%)
- 5 bolnavi cu hepatita cronica (16%)
- 3 bolnavi cu enterocolite (10%)
- 2 bolnavi cu litiaza (6%)
- 2 bolnavi cu parazitoze (6%)
- 1 bolnav cu colon iritabil (3%)
Din cei 19 bolnavi alergici cu afectiuni digestive asociate, 6 din ei (24%) din toti alergicii-au chiar doua afectiuni digestive diagnosticate.
ULCER+CONSTIPATIE- 2 cazuri
GRAFICUL XIII-B
COLECISTITA+CONSTIPATIE-1caz
COLECISTITA+LITIAZA-1caz
ULCER +COLECISTITA-1caz
CONSTIPATIE+
GRAFICULX I/
Examenul coproparazitologic la cei 104 de pacienti este pentru majoritatea negativ. Doar 2 pacienti din 104 au avut examenul coproparazitologic pozitiv.
GRAFICUL X/
In ceea ce priveste diagnosticul dermatologic al afectiunilor, el nu a prezentat dificultati pentru medicii clinicii, anamneza si examenul clinic fiind suficiente pentru a diagnostica afectiunea prezenta. In nici unul din cele 104 de cazuri, nu s-a folosit biopsia cutanata pentru a trasa diagnostice diferentiale.
In general, semnele si simptomele alergiilor cutanate sunt foarte caracteristice, nepretand la confuzii.
A rezultat urmatoarea repartitie a bolnavilor pe entitati patologice:
|
TIPURI DE ALERGII DIAGNOSTICATE |
urticarie | |
|
eczeme | ||
|
dermatita atopica | ||
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prurigo | ||
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Din cei 104 de bolnavi, 83 din ei au prezentat urticarie si / sau angioedem. Din acestia, 29% (24) de bolnavi sunt atopici cunoscuti si anterior diagnosticati, nefiind la prima confruntare cu medicul dermatolog. GRAFICUL XVII
20% (17) din bolnavii cu urticarie si angioedem au rude de gradul intai cu diferite alergii: cutanate sau respiratorii (rinite, astm)(vezi graficul X/III). GRAFICUL XVIII
10% (8) din bolnavi prezinta si alte alergii, in afara de cea prezentata. In general este vorba de rinite alergice, conjunctivite si blefarite, eczeme de contact, astm bronsic,etc-
4 bolnavi din 104 de pacienti au prezentat PRURIGO ACUT., ei fiind toti la primul consult dermatologic GRAFICUL XX
Dintre ei, 50% au rude de gradul intai alergice. GRAFICUL XXI
75% (3) din pacientii cu prurigo acut prezinta si alte alergii in afara de prurigo. GRAFICUL XXII
6 dintre 104 de pacienti (6%) au fost diagnosticati cu DERMATITA ATOPICA.Dintre acestia 83% (5) au apelat si cu alte ocazii la medicul dermatolog. GRAFICUL XXIII
33% (2) din pacientii cu dermatita atopica au rude alergice.
GRAFICUL xxv
83% (5) prezinta si alte alergii in afara de dermatita atopica (in general atopii respiratorii). 11% (11 bolnavi) au prezentat manifestari exematiforme. Din acesti 11 bolnavi, 73% (8) sunt la prima internare si doar 27% (3) au avut nevoie si in trecut de un tratament dermatologic pentru eczeme sau eczematide. GRAFICUL XX/I
64% (7) din ei au si rude de gradul intai cu diferite manifestari alergice. GRAFICUL XXVII
- 18% (2) prezinta si alte manifestari alergice in afara de cea actuala. GRAFICUL XX/III
GRAFICUL XXIX
Daca tratamentul dermatologic s-a dovedit, in general simplu, diagnosticul alergologic a fost ceva laborios, necesitand anamneza, examenul clinic, regimuri de eliminare empirica si testare cutanata. In 34% cunoscuti din cazuri, anamneza a fost suficienta pentru a stabili agentul cauzator al afectiunii. Aceste cazuri au fost reprezentate de alergicii cunoscuti, cu frecvente apeluri la serviciile medicale, pentru diferite manifestari alergice. In 60% din cazuri anamneza nu a fost suficienta si s-au aplicat teste de eliminare empirica. Este vorba despre cazurile in care anamneza trimitea la un numar mic de alimente care ar fi putut provoca alergia. In 6%din cazuri, a fost necesar sa se efectueze de la inceput testul cutanat. Aceste cazuri au fost cele in care anamneza a fost extrem de neclara si ar fi fost extrem de dificil, daca nu chiar imposibil de efectuat eliminarea empirica. Aceste rezultate sunt centralizate in graficul de mai jos. GRAFICUL XXX
De mentionat ca in toate cazurile, dupa determinarea mai mult sau mai putin precisa a trofoalergenului, s-au aplicat dietele de eliminare empirica. Corectitudinea lor a fost confirmata de remisiunea simptomelor. Indiferent de calea folosita pentru identificarea trofoalergenului, la toti pacientii s-au facut, in cursul internarii, teste cutanate la trofoalergenii uzuali si la cei indicati de anamneza si de dietele de eliminare empirica. Testele au fost pozitive la 100 de bolnavi si doar la 4 dintre ei nu au fost concludente. Deci in urma studiului nostru testele cutanate se dovedesc a fi indiscutabil valoroase in diagnosticul alergiilor alimentare. Ne-am oprit la 10 bolnavi care au mai venit si alta data la dermatolog pentru o simpomatologie similara. In cazul lor, testele cutanate au fost pozitive la toti bolnavii. Din acestia 6 bolnavi au avut teste pozitive la alergeni la care se stiau sensibili, iar4 bonavi au prezentat sensibilizari la alergene noi. Acesti 4 bolnavi sunt polisensibili la 3, 5, respectiv 8 alergeni. GRAFICUL XXXI
Etiologia polisensibilizarilor identificate Trei alergeni----- ----- ----------amestec de cereale (POLEN), pui, rosii-1 bolnav cinci alergeni ----- ----- --------- ----- -------amestec de cereale (POLEN), peste de apa dulce, cartof, porc, rosii. ----1 bolnav cinci alergeni ----- ----- --------- ----- ------- amestec de cereale (POLEN), peste de apa dulce, rosii, ou intreg, porc----1 bolnav opt alergeni----- ----- ----- ----- ----amestec de cereale (POLEN), peste de apa dulce, ou intreg, cartof, porc, pui, rosii, cacao----1 bolnav Se observa ca un procent important de bolnavi cu alergii cutanate de etiologie alimentara au tendinta, in timp, de a dezvolta polisensibilizari. Cei 4 polisensibilizati au varstele ani, 31 ani, 58 ani, 12 ani si sunt persoane cu nenumarate apeluri la dermatolog sau la alergolog in antecedente. CONCLUZII 1. Din totalul de alergii cu manifestari cutanate diagnosticate in aceasta clinica- pe primul loc se situeaza alergiile cu manifestari cutanate de etiologie neprecizata -cu 110 cazuri, apoi urmeaza alergiile cu manifestari cutanate de etologie. Medicamentoasa-cu 107 cazuri si locul trei este ocupat de alergiile alimentare cu manifestari cutanate - cu 104 cazuri. 2. Cele mai multe cazuri de alergii alimentare s-au remarcat in luna mai, luna in carea fost o importanta zi de sarbatoare. Explicatia simpla a acestui fapt este gasita in excesele alimentare ce se asociaza, in general, sarbatorii amintite, excese care sunt facute chiar de alergicii se stiu bolnavi, dar care lasa prudenta la o parte in astfel de situatii 3. S-a constatat in urma acestui studiu ca din 104 pacienti, 6% au prezentat forme foarte grave. 4. Din studiul efectuat s-a putut observa ca cei mai multi pacienti internati - sunt de sex feminin (63%). 5. Manifestarile alergice s-au intalnit mai frecvent la persoanele cu varsta cuprinsa intre - 31-35 de ani (16%) 6. Cele mai multe cazuri apartin pacientilor care provin din mediul Urban 69%. 7. Foarte multi bolnavi sunt la prima internare ( ,) restul de 34% avand trecut dermatologic 7. Unii bolnavii alergici (27%) au un teren genetic favorizant fenomenelor alergice (teren atopic) -sunt bolnavi cu rude alergice. 8. Doar 7% dintre bolnavi alergici lucreaza in mediu alergizant. 9.Pacientii care au alergii mutiple reprezinta 3%. 10. Sensibilizarea la trofoalergene pare a fi favorizata de coexistenta unor afectiuni digestive-18% dintre bolnavi, 24%reprezentand doar cazurile cu ulcer (gastric sau duodenal). Din cei 18%bolnavi 6%au afectiuni digestive asociate, cea mai frecventa asociere (2%) fiind : ulcer+constipatie. 11. Cele mai frecvente alergii cutanate sunt - urticaria si angioedemul-79%, urmata de eczeme 11%, dermatita atopica 6%, prurigo 4%-. 12. Din studiul efectuat se observa ca un procent important de bolnavi cu alergii cutanate de etiologie alimentara au tendinta, in timp, de a dezvolta polisensibilizari. Test pozitivla un alergen nou s-a evidentiat la 40% din bolnavi, iar pentru restul 60%test pozitiv la alergeni cunoscuti De asemenea se remarca - polenul- ca fiind unul dintre alergenii importanti incriminati. 13. 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