GCC Nurse — Allergy & Immunology Guide

Gell & Coombs Hypersensitivity Classification

Type	Mechanism	Mediators	Onset	Examples
Type I IgE-mediated	IgE bound to mast cells; allergen cross-links IgE → degranulation	Histamine, tryptase, leukotrienes, prostaglandins	Minutes (immediate)	Anaphylaxis, allergic rhinitis, food allergy, urticaria
Type II Cytotoxic	IgG/IgM binds cell-surface antigen → complement/ADCC lysis	Complement, NK cells	Hours	Haemolytic anaemia (penicillin), transfusion reaction, Goodpasture's
Type III Immune-complex	Antigen-antibody complexes deposit in tissues → complement activation	Complement, neutrophils	Hours–days	Serum sickness, SLE, Farmer's lung, post-strep GN
Type IV Delayed (T-cell)	Sensitised T-cells release cytokines/cause cytotoxicity	IFN-γ, IL-2, TNF	24–72 h	Contact dermatitis, TB skin test, transplant rejection, Stevens-Johnson

Type I IgE-Mediated Mechanism

Sensitisation Phase

First allergen exposure → antigen-presenting cells process allergen
Th2 cytokines (IL-4, IL-13) drive B-cell class switching to IgE production
IgE binds high-affinity FcεRI receptors on mast cells and basophils
No clinical symptoms during sensitisation — patient is "primed"

Elicitation Phase

Re-exposure to allergen → cross-links IgE molecules on mast cells
Mast cell degranulation releases pre-formed mediators (histamine, tryptase, heparin)
Arachidonic acid cascade → leukotrienes (LTC4/D4/E4), prostaglandin D2
Late-phase reaction (4–8 h) — eosinophil and basophil infiltration

        Mast Cell Degranulation — Clinical Effects
        Histamine H1: pruritus, bronchoconstriction, vasodilation, urticaria
Histamine H2: gastric acid, cardiac tachycardia
Leukotrienes: prolonged bronchoconstriction, mucus secretion
Tryptase: rises within 15–60 min, peaks at 1–2 h — diagnostic marker for mast cell activation
PAF: platelet aggregation, bronchoconstriction

      

Common Allergens

Food Allergens (Big-9)

Milk, eggs, peanuts, tree nuts
Fish, shellfish, wheat, soy
Sesame (added 2023, USA)

Drug Allergens

Beta-lactams (penicillin, cephalosporins)
NSAIDs, aspirin (COX-1 inhibition)
Contrast media, muscle relaxants
Biologics (hypersensitivity infusion reactions)

Insect Venom

Honeybee (Apis mellifera)
Yellow jacket / wasp (Vespula)
Fire ant (common in some GCC areas)

Latex

Hevea brasiliensis proteins (Hev b 1–13)
Cross-reacts with banana, avocado, kiwi, chestnut

GCC-Specific Allergens

Desert & Arid Environment Allergens

Date Palm Pollen (Phoenix dactylifera): Major sensitiser in GCC — high season Feb–April; cross-reacts with grass pollens; responsible for much of "Ramadan rhinitis" in some years
Desert Dust / Sand Storms (Haboob): Particulate matter <10µm; carries mould spores, pollen fragments, endotoxin; exacerbates asthma and rhinitis
Aspergillus flavus / fumigatus: Thrives in irrigated areas, construction sites; allergic bronchopulmonary aspergillosis (ABPA) reported in GCC asthma patients
Salsola kali (Russian thistle): Dominant weed pollen in arid zones; cross-reacts with Chenopodium
Bermuda grass (Cynodon dactylon): Dominant grass pollen in GCC lawns and parks

Animal Allergens

Camel dander (Cam d 1): Occupational exposure — camel farms, racing events, Ramadan markets; serum-specific IgE available
Goat, sheep, horse dander — pastoral workers
Cockroach (Blattella germanica) — high sensitisation in older GCC urban housing
House dust mite — lower in desert but significant in coastal cities (Dubai, Abu Dhabi, Bahrain, Jeddah)

Food — Region-Specific

Sesame (Sesamum indicum) — very high consumption in Gulf cuisine (tahini, hummus)
Lupin flour — used in some artisanal breads
Camel milk — emerging food allergen, cross-reactivity with cow's milk debated

⚠ FIRST-LINE TREATMENT: ADRENALINE (EPINEPHRINE)

Antihistamines and corticosteroids are ADJUNCTS only. Adrenaline is the ONLY life-saving drug in anaphylaxis. Do NOT delay it.

Adults: Adrenaline 1:1000 — 0.5 mg (0.5 mL) IM into outer mid-thigh (anterolateral)

Children <12 years: 0.01 mg/kg IM (max 0.5 mg) — see paediatric calculator below

Repeat every 5 minutes if no improvement. Auto-injector: EpiPen 0.3 mg (adult), EpiPen Jr 0.15 mg (child)

WAO/EAACI Diagnostic Criteria for Anaphylaxis

Anaphylaxis is highly likely when ANY ONE of the following three criteria is met:

Criterion 1 — Acute onset, skin/mucosal involvement PLUS at least one of:

Respiratory compromise (dyspnoea, wheeze, stridor, reduced PEF, hypoxia)
Reduced BP or associated symptoms (hypotonia, syncope, incontinence)

Criterion 2 — Two or more of the following after likely allergen exposure:

Skin/mucosal involvement (urticaria, angioedema, flushing, pruritus)
Respiratory compromise
Reduced BP or associated symptoms
Persistent GI symptoms (cramping, vomiting)

Criterion 3 — Reduced BP after exposure to a KNOWN allergen:

Adults: systolic BP <90 mmHg or >30% drop from baseline
Infants & children: age-specific low systolic BP

Emergency Management Protocol

Step	Action	Detail
1	Call for help	Activate emergency team; GCC emergency: Saudi 911 / UAE 999 / Qatar 999 / Kuwait 112 / Bahrain 999 / Oman 9999
2	Adrenaline IM	0.5 mg (0.5 mL of 1:1000) anterolateral mid-thigh. Repeat q5 min PRN
3	Position	Supine + legs elevated (unless respiratory distress → semi-recumbent). Lateral position if vomiting. Do NOT allow patient to stand/sit upright — risk of "empty ventricle" death
4	Oxygen	High-flow O₂ 10–15 L/min via non-rebreather mask; target SpO₂ >95%
5	IV access	Large-bore IV (×2); bloods: FBC, U&E, serum tryptase (within 1–2 h of reaction, and repeat at 24 h)
6	IV fluids	0.9% NaCl 500–1000 mL bolus IV (adults); 20 mL/kg in children. Repeat PRN for hypotension
7	Antihistamine	Chlorphenamine 10 mg IV/IM (adult) — for skin symptoms ONLY, does NOT treat hypotension/bronchospasm
8	Corticosteroid	Hydrocortisone 200 mg IV (adult) — may reduce late-phase reaction; NOT first-line
9	Bronchospasm	Salbutamol 2.5–5 mg nebulised + adrenaline IM repeated
10	Refractory shock	IV adrenaline infusion (specialist); glucagon 1–2 mg IV if on beta-blockers

Biphasic Reaction Risk

Second wave of anaphylaxis occurs 8–12 hours after initial reaction (range 1–72 h) in 3–20% of cases. Observe ALL anaphylaxis patients for minimum 4–6 hours (8–12 h if severe/biphasic risk factors).

Biphasic risk factors: unknown trigger, large allergen dose, delayed adrenaline, severe initial reaction, previous biphasic reactions.

Discharge Criteria & Auto-Injector Training

Safe Discharge Requires ALL of:

Symptom-free for minimum observation period (4–6 h minimum)
Vital signs stable, no recurrence of symptoms
Allergen identified or follow-up with allergist arranged
2 × adrenaline auto-injectors prescribed and demonstrated
Written anaphylaxis action plan provided
Medical alert bracelet recommended
Allergy clinic referral arranged (SCIT/avoidance counselling)

Auto-Injector Instructions (EpiPen)

Remove blue safety cap
Hold orange tip toward outer mid-thigh (can inject through clothing)
Press firmly until click heard — hold 10 seconds
Remove, massage injection site 10 seconds
Go to nearest Emergency Department immediately — call ambulance
Second injection can be given 5–15 minutes later if no improvement

Skin Prick Testing (SPT)

Principle

Standardised allergen extracts placed on forearm skin → single lancet prick through drop → IgE on dermal mast cells cross-linked → local wheal-and-flare if sensitised.

Procedure

Antihistamines withheld 3–7 days prior (depends on generation); beta-blockers noted (relative contraindication — impairs adrenaline response if systemic reaction occurs)
Patient positioned comfortably; forearm cleaned with alcohol, dried
Allergen drops placed 2–3 cm apart on volar forearm
Positive control: histamine (10 mg/mL) — confirms mast cell reactivity
Negative control: saline (diluent) — confirms no dermatographism
Single-use lancet through each drop at 90° — do not wipe
Read at 15–20 minutes: measure largest wheal diameter in mm

        Interpretation
        Positive: Wheal ≥3 mm greater than negative control AND >50% of positive control wheal
Histamine control must be ≥3 mm — if not, test invalid (suppression by drugs)
Saline wheal ≥3 mm → dermatographism; test unreliable
SPT sensitivity ~85%, specificity ~77% for food allergens
A positive SPT = sensitisation, NOT necessarily clinical allergy — correlate with history

      

Contraindications

Severe eczema at test site, active urticaria
Anaphylaxis within past 2 weeks (unstable mast cells)
Pregnancy (relative — avoid in first trimester)
Severe or poorly controlled asthma (FEV1 <70% predicted)

Intradermal Testing (IDT)

More sensitive but less specific than SPT. Used when SPT negative but clinical suspicion high (drug allergy, venom allergy).

0.02–0.05 mL allergen injected intradermally → raised bleb 3 mm
Positive: wheal growth ≥3 mm at 15–20 minutes
More risk of systemic reaction — performed only in specialist setting with resuscitation available
Not used for food allergens (high false-positive rate)

Patch Testing — Contact Dermatitis

Assesses Type IV delayed hypersensitivity. Used for suspected allergic contact dermatitis (ACD).

Standard European/North American Baseline Series applied to upper back (Finn chambers or TRUE Test)
Patches removed at 48 hours — first reading
Second reading at 72–96 hours (some reactions peak at 96 h)
Grading: Negative (–), Doubtful (?+), Weak positive (+), Strong positive (++), Extreme (+++), Irritant reaction (IR)

Common culprits in GCC healthcare workers: Nickel (jewellery, buckles), fragrance mix, rubber accelerators (latex gloves), preservatives (methylisothiazolinone in hand sanitisers), chromate (cement).

Specific IgE Testing (RAST / ImmunoCAP)

Class	kU/L (ImmunoCAP)	Interpretation
0	<0.35	No detectable IgE — negative
1	0.35–0.70	Very low — equivocal
2	0.71–3.50	Low sensitisation
3	3.51–17.5	Moderate sensitisation
4	17.6–50	High sensitisation
5	50.1–100	Very high
6	>100	Extremely high

Component-Resolved Diagnostics (CRD)

Identifies specific allergenic molecules — important for risk stratification:

Peanut: Ara h 2 (storage protein) = high risk for severe reactions; Ara h 8 (PR-10) = cross-reactive, usually mild oral allergy syndrome
Date palm: Pho d 2 (profilin), Pho d 3 (polcalcin) — cross-reactive with other pollens
Cat: Fel d 1 — major allergen; Fel d 4 (lipocalin) — relevant for systemic reactions
HDM: Der p 1, Der p 2 — major allergens, predictive of immunotherapy response

Subcutaneous Immunotherapy (SCIT)

Mechanism

Repeated escalating doses of allergen → immune tolerance via: increased Treg cells (IL-10, TGF-β), IgG4 "blocking antibodies", reduced Th2 response, mast cell and basophil hypo-responsiveness.

Build-Up Phase

Duration: 3–6 months (conventional) or 6–8 weeks (cluster/rush protocols in specialised centres)
Injections given 1–2× per week with increasing allergen concentration
Starting dose typically 1:1,000,000 weight/volume, escalating to maintenance
Nurse role: verify injection schedule, document lot numbers, administer and monitor

Maintenance Phase

Monthly injections for 3–5 years once maintenance dose reached
Efficacy persists 3–7 years after completion
Indications: moderate-severe allergic rhinitis/conjunctivitis, allergic asthma (controlled), insect venom allergy

30-Minute Observation Rule

ALL patients MUST remain in clinic for 30 minutes post-injection. Systemic reactions peak within 20–30 minutes. Never allow early departure. Resuscitation equipment including adrenaline MUST be immediately available.

Pre-Injection Assessment (WITHHELD if ANY present)

Asthma exacerbation, wheeze, PEF <80% predicted
Active infection / fever
Large local reaction at previous injection site
New beta-blocker prescription (impairs adrenaline rescue)
Pregnancy (new — maintenance doses may continue)
Recent vaccination within 48 h

Sublingual Immunotherapy (SLIT)

Daily sublingual drops or tablets; home-administered. First dose given in clinic with 30-min observation.

Licensed tablets: Grazax® (grass pollen), Acarizax® (HDM), Ragwitek® (ragweed)
Hold under tongue 1–2 minutes, then swallow
Fewer systemic reactions than SCIT; local oral pruritus common initially
Patient compliance critical — daily use for 3 years
Nurse education: when to stop (acute illness, oral surgery, ulcers), store refrigerated

Systemic Reaction Management During SCIT

Grade	Presentation	Action
1 — Local	Wheal >25 mm at injection site; local pruritus	Monitor; oral antihistamine; reduce next dose
2 — Mild systemic	Generalised urticaria, rhinitis	Antihistamine IM + consider adrenaline; withold next injection
3 — Moderate systemic	Urticaria + bronchospasm or mild hypotension	Adrenaline 0.5 mg IM immediately; IV access; monitor 1 h+
4 — Anaphylaxis	Severe bronchospasm, hypotension, loss of consciousness	Full anaphylaxis protocol; emergency services; ICU

After any systemic reaction: reduce dose by 50% when re-starting; allergist review required.

Food Immunotherapy & Biologics

Oral Immunotherapy (OIT) — Food Allergy

Increasing doses of food protein orally (peanut, milk, egg) to achieve desensitisation
Palforzia® (peanut OIT) — FDA/EMA approved for ages 4–17
Nurse role: observe 30 min post-dose escalation; recognise and treat reactions
Goal: partial desensitisation/tolerance — does not "cure" food allergy

Biologic Adjuncts

Omalizumab (Xolair®): Anti-IgE; approved for severe allergic asthma, chronic spontaneous urticaria, food allergy (2024 FDA approval as adjunct to OIT); reduces systemic reaction risk during immunotherapy build-up
Dupilumab (Dupixent®): Anti-IL-4Rα; approved for atopic dermatitis, eosinophilic asthma, allergic rhinitis with nasal polyps, EoE

Allergic Rhinitis — ARIA Classification & Step Therapy

ARIA Category	Duration	Severity	First-Line Treatment
Intermittent Mild	<4 days/wk OR <4 wks	No sleep/activity impairment	Oral or intranasal antihistamine PRN
Intermittent Moderate/Severe	<4 days/wk OR <4 wks	Sleep/activity impaired	Intranasal corticosteroid (INS) + antihistamine
Persistent Mild	≥4 days/wk AND ≥4 wks	No impairment	INS or antihistamine
Persistent Moderate/Severe	≥4 days/wk AND ≥4 wks	Impaired sleep/activities	INS (first-line) ± antihistamine; consider SCIT

Intranasal corticosteroids (INS): Mometasone, fluticasone furoate — most effective monotherapy. Teach correct technique: tilt head forward, aim away from nasal septum to prevent epistaxis.

Allergen immunotherapy (SCIT/SLIT): Modifies disease — consider in patients not controlled with pharmacotherapy, or those wishing to reduce long-term medication burden.

Allergic Asthma — GINA Step Therapy

GINA Step	Controller Therapy	Reliever
Step 1 (Mild intermittent)	As-needed low-dose ICS-formoterol	ICS-formoterol PRN
Step 2 (Mild persistent)	Low-dose ICS daily OR as-needed ICS-formoterol	ICS-formoterol PRN
Step 3 (Moderate)	Low-dose ICS-LABA	ICS-formoterol PRN
Step 4 (Severe)	Medium/high-dose ICS-LABA	ICS-formoterol PRN
Step 5 (Very severe)	Step 4 + biologic (Omalizumab, Mepolizumab, Dupilumab) ± OCS	ICS-formoterol PRN

Note: SABA-only treatment (old Step 1) is no longer recommended by GINA 2023 — ICS should accompany every reliever.

Atopic Dermatitis — SCORAD Assessment

SCORAD Components

A — Extent (0–100): Body surface area affected using rule of nines — score /5
B — Intensity (0–18): Six signs scored 0–3: erythema, oedema/papulation, oozing/crusting, excoriation, lichenification, dryness
C — Subjective (0–20): Pruritus (0–10) + sleep disturbance (0–10) — last 3 days/nights
Formula: SCORAD = A/5 + 7×B/2 + C
Mild: <25 | Moderate: 25–50 | Severe: >50

Nursing Management

Emollients: apply liberally ≥2× daily, within 3 minutes of bathing (soak and smear)
Topical corticosteroids (TCS): lowest effective potency; fingertip unit (FTU) guidance
Topical calcineurin inhibitors (tacrolimus, pimecrolimus): steroid-sparing, especially face/neck
Dupilumab: for moderate-severe atopic dermatitis not controlled with topicals; subcutaneous injection every 2 weeks
Trigger identification: sweat, wool, detergents, food (in young children), stress

Food Allergy — Anaphylaxis vs Intolerance vs Coeliac

Feature	IgE-Mediated Food Allergy	Food Intolerance	Coeliac Disease
Mechanism	IgE / mast cell	Non-immunological (enzyme deficiency, FODMAP, etc.)	Autoimmune (anti-TTG IgA, HLA-DQ2/DQ8)
Onset after exposure	Minutes–2 hours	Hours–days	Days–years (chronic)
Dose dependence	Small doses can trigger	Often dose-dependent	All gluten must be avoided
Life-threatening	Yes — anaphylaxis	No	Yes if untreated (lymphoma, malnutrition)
Diagnosis	SPT, specific IgE, OFC	Exclusion diet/food diary	Anti-TTG IgA, duodenal biopsy (Marsh grading)

Drug Allergy

Penicillin Allergy

~10% of patients label themselves "penicillin allergic" — >90% can tolerate penicillin on formal testing
Cross-reactivity with cephalosporins: ~1–2% (previously overestimated at 10%)
Shared R1 side-chain similarity more important than beta-lactam ring in predicting cross-reactivity
Penicillin allergy delabelling (skin testing + oral challenge) recommended for low-risk labels

NSAID Hypersensitivity (AERD)

Aspirin-Exacerbated Respiratory Disease (AERD/Samter's triad): Asthma + nasal polyps + NSAID sensitivity
Mechanism: COX-1 inhibition → shunts arachidonic acid to leukotriene pathway
Management: NSAID/aspirin avoidance; aspirin desensitisation in specialist centres; montelukast; zileuton
Selective COX-2 inhibitors (celecoxib) generally tolerated in AERD patients

Drug Allergy Documentation — GCC Requirements

Document: drug name (generic + brand), reaction type, date, severity, investigation results
UAE (DHA/DOH): allergy field mandatory in Salama/NABIDH/Malaffi systems
Saudi Arabia (MOH): allergy documented in SEHA/SIHF unified record
Qatar (PHCC/HMC): CERNER allergy fields; "Allergy Review" flag alerts prescribers
Always distinguish true allergy from intolerance/side-effect in documentation

Urticaria & Angioedema

Urticaria Classification

Acute spontaneous: <6 weeks; often IgE-mediated (food, drug, infection)
Chronic spontaneous (CSU): >6 weeks; autoimmune (anti-FcεRI/IgE antibodies) in ~40%
Physical urticarias: dermographism, cold, pressure, solar, aquagenic, cholinergic
UAS7 score: Urticaria Activity Score over 7 days — monitor disease control (0–42; ≥28 = uncontrolled)

CSU Treatment Ladder

2nd-generation antihistamine (cetirizine, loratadine) regular dose
Up-dose antihistamine ×4 (off-label but guideline-supported)
Add omalizumab 300 mg SC monthly
Cyclosporine (specialist use)

Angioedema

Allergic (histaminergic): urticaria + angioedema; responds to antihistamines/adrenaline
Hereditary Angioedema (HAE): C1-inhibitor deficiency; bradykinin-mediated; does NOT respond to antihistamines/adrenaline
ACE-inhibitor angioedema: Bradykinin accumulation; onset months–years after starting drug; tongue/larynx commonly involved — life-threatening

Laryngeal Angioedema

Stridor + voice change + throat tightness = impending airway obstruction. Give adrenaline 0.5 mg IM immediately. Prepare for intubation/surgical airway. HAE: icatibant 30 mg SC or C1-INH concentrate.

Epidemiology & Prevalence in the GCC

Atopy prevalence in GCC adults 30–45%; allergic rhinitis affects ~30% of population in Saudi Arabia, UAE, Kuwait
Asthma prevalence ~13–15% (higher than global average of ~8%)
Rapid urbanisation, air conditioning, hygiene hypothesis, diesel particulates = rising atopy
Haboob (sandstorm) season (March–June) dramatically increases ER attendances for asthma/rhinitis; fine particles carry endotoxin, fungal spores, metals
Aspergillus sensitisation higher in GCC than temperate climates — ABPA should be excluded in difficult-to-control asthma
High humidity in coastal cities (Dubai, Manama, Doha, Muscat) drives indoor HDM and mould sensitisation year-round

Latex Allergy in GCC Healthcare Settings

Occupational Risk — Surgical & Theatre Nurses

Repeated exposure to natural rubber latex (NRL) gloves → sensitisation, progressing from contact urticaria → rhinitis → anaphylaxis
Prevalence in healthcare workers: 8–17% sensitisation; higher in atopic individuals
Powdered gloves greatly increase airborne latex allergen exposure — WHO recommends phase-out
GCC hospitals increasingly latex-safe: use nitrile/vinyl gloves, latex-free environments
Known latex allergy: first on operating list (when environment cleanest), latex-free OR, latex-free IV equipment, alert bracelet
Cross-reactive foods: banana, avocado, kiwi, chestnut, papaya — advise avoidance

Drug Allergy Documentation — MOH / DHA / SCHS

Authority	System	Key Fields	Nurse Responsibility
Saudi MOH	HESN / Nphies / SIHF	Drug name, reaction type (allergy/ADR/contraindication), severity, date, status (active/inactive)	Verify allergy status before administration; document new reactions within same shift
UAE DHA (Dubai)	Salama EMR / Malaffi HIE	Allergen, reaction description, category, certainty	Flag unverified or self-reported allergies for pharmacist review
UAE DOH (Abu Dhabi)	NABIDH / Shafafiya	Allergy type, reaction, onset, evidence type	Mandatory allergy documentation before prescribing through system
Qatar MOPH (HMC/PHCC)	Cerner / HAYAT	Allergy name, reaction, severity, status	Allergy reconciliation at admission and discharge
SCHS (Saudi private)	Varies by hospital group	Follow facility SOPs; CBAHI accreditation standards require allergy field	Allergy band on patient wrist; documented in nursing admission assessment

Halal / Haram Considerations in Allergy Medications

        Key Medications to Verify
        Gelatin capsules: Most standard capsules contain porcine gelatin — check with pharmacist for halal-certified alternatives or tab/liquid formulations; fatwa generally allows for medical necessity (“darura”)
Vaccines with porcine-derived materials: Some seasonal flu vaccines (cell-culture grown) use porcine trypsin — GCC Islamic authorities generally permit for medical need; discuss with patient
Alcohol-based oral solutions (antihistamines): Some liquid antihistamines contain ethanol as excipient; prefer tablet/syrup form for patients who request alcohol-free
Omalizumab (Xolair): Chinese hamster ovary cell derived — generally considered permissible; no porcine material
Heparin (used in some allergy testing buffers): May be porcine-derived — bovine heparin alternatives exist; clarify for strict observance
Nurse role: Never assume; consult hospital pharmacist; respect patient autonomy; document discussion; Islamic jurisprudence generally supports medical necessity principle

      

Leading GCC Allergy & Immunology Centres

Country	Centre	Speciality
Saudi Arabia	King Fahad Medical City (Riyadh) — Allergy & Immunology Dept	Comprehensive adult & paediatric allergy; SCIT programs
Saudi Arabia	King Faisal Specialist Hospital & Research Centre (Riyadh)	Primary immunodeficiency, severe asthma, transplant
Saudi Arabia	King Abdulaziz University Hospital (Jeddah)	Academic centre; allergy research; coastal allergen profiling
UAE	Cleveland Clinic Abu Dhabi — Allergy & Immunology	Full allergy workup, immunotherapy, biologic therapies
UAE	American Hospital Dubai — Allergy Dept	Private sector; food allergy OIT protocols
UAE	Al Jalila Children’s Specialty Hospital (Dubai)	Paediatric allergy, eczema, food allergy, primary immunodeficiency
Qatar	Hamad Medical Corporation — Allergy & Immunology	National referral; severe allergic asthma; immunodeficiency
Kuwait	Al-Razi Hospital (Kuwait City) — Allergy Unit	Pollen allergy profiling; SCIT
Bahrain	Salmaniya Medical Complex	Government allergy services; drug allergy evaluation
Oman	Sultan Qaboos University Hospital (Muscat)	Academic; allergy & clinical immunology research

⚡ Paediatric Adrenaline Dose Calculator

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1. A patient develops urticaria, wheeze and hypotension 10 minutes after penicillin IV. What is the MOST appropriate IMMEDIATE action?

Adrenaline 0.5 mg IM is the first-line life-saving treatment. Antihistamines and corticosteroids are adjuncts only and must never precede or replace adrenaline.

2. Which immunoglobulin class mediates Type I hypersensitivity reactions?

IgE binds to high-affinity FcεRI receptors on mast cells and basophils. Cross-linking of IgE by allergen triggers immediate degranulation — the hallmark of Type I hypersensitivity.

3. A nurse administers SCIT. How long must the patient be observed post-injection?

All SCIT patients must remain in clinic for 30 minutes post-injection. The majority of systemic reactions occur within 20–30 minutes, making this the internationally recommended minimum observation period.

4. During skin prick testing, the histamine positive control produces a 1 mm wheal. What does this indicate?

The positive control (histamine) must produce a wheal ≥3 mm. A subthreshold response indicates mast cell suppression, usually from recent antihistamine use. The entire test must be considered invalid and repeated when medications are withheld.

5. Which GCC-specific allergen is a major cause of seasonal rhinitis due to pollination in February–April?

Date palm (Phoenix dactylifera) pollinates predominantly from February to April and is a major regional sensitiser in GCC countries. It cross-reacts with grass pollens. HDM is more relevant in humid coastal cities; Timothy grass and birch are temperate-region pollens.

6. A patient on long-term ACE inhibitor develops sudden tongue swelling without urticaria. Which medication is LEAST likely to be effective?

ACE inhibitor-induced angioedema is bradykinin-mediated, NOT histamine-mediated. Antihistamines are ineffective. Treatment options include stopping the ACE inhibitor, icatibant (bradykinin B2 antagonist), C1-inhibitor concentrate, or FFP. Adrenaline may help with airway oedema temporarily.

7. Patch testing is used to diagnose which type of hypersensitivity reaction?

Patch testing diagnoses Type IV (delayed) hypersensitivity — allergic contact dermatitis. Patches are read at 48 and 72–96 hours because T-cell mediated reactions develop over 24–72 hours, in contrast to immediate IgE reactions.

8. What is the recommended minimum observation period for a patient who has had anaphylaxis to assess for biphasic reaction?

Biphasic reactions occur in 3–20% of anaphylaxis cases, most commonly at 8–12 hours. Minimum observation is 4–6 hours for uncomplicated cases, extended to 8–12 hours for severe reactions, unknown triggers, delayed adrenaline, or history of previous biphasic reactions.

9. A nurse is about to give a SCIT injection and the patient says they have had a fever of 38.5°C since yesterday. What should the nurse do?

Active infection/fever is an absolute reason to withhold SCIT. Fever and infection increase the risk of systemic reactions to immunotherapy. The injection should be postponed until the patient is well, and this should be documented clearly in the notes.

10. Which component-resolved diagnosis (CRD) result for peanut allergy indicates the HIGHEST risk for a severe systemic reaction?

Ara h 2 is a heat-stable, digestion-resistant 2S albumin storage protein and is the most clinically significant peanut allergen associated with severe systemic reactions and anaphylaxis. Ara h 8 is a labile PR-10 protein cross-reactive with birch pollen, typically causing only oral allergy syndrome.

Allergy & Immunology — GCC Nursing Guide