Artemisia vulgaris) is the important representative of the Asteraceae family. In India, mugwort pollen flowers appear in late summer and autumn. It is a coarse perennial herb, often reddish, angled stems, having dark green above, and white woolly beneath [1]. The main allergen in mugwort is 80% glycoprotein with a defensive-like domain (Art V1) and has 60% non-specific lipid transfer protein (Ns LTP-Art V3). This Ns LTP has cross-reactivity with peanut, soybean, wheat, and sunflower seeds. In Mugwort-Mustard Allergy Syndrome (MMAS), individuals sensitized to mugwort may develop an allergic reaction (urticaria, angioedema, and anaphylaxis) to mustard [2]. Mugwort pollen may represent the primary allergen source for Ns LTP sensitization. The pathogenesis of Lipid Transfer Protein Syndrome (LTPS) is linked to cross-reactivity between pollens (A. vulgaris, etc.) and homologous epitopes contained in food protein (wheat, peanut, etc.). In one study, it was found that 20% of patients allergic to grass and mugwort pollen are suffering from PFAS with symptoms of urticaria, nasal symptoms, angioedema, abdominal symptoms, and even anaphylaxis [3]. We herein describe four cases of mugwort (A. vulgaris), peanut, and wheat association confirmed by positive skin prick test (SPT) with positive specific immunoglobulin E (IgE) antibodies (Immunocap system) for mugwort, peanut, and wheat which has not been reported so far to our knowledge. Ns LTPs have a role in the transport of hydrophobic molecules. Nuts group (walnut, hazelnut, and peanut) and cereal (wheat, maize, and rice) have been described as foods eliciting a reaction not only like oral allergy syndrome (OAS) but also severe systemic reaction (anaphylaxis) in LTP-sensitized patients [4,5]. CASE SERIES Case 1 A 20-year-old male presented with a history of recurrent anaphylactic reactions (urticaria with itching, angioedema, swelling of the tongue, choking sensation, vomiting, and hypotension) after ingestion of peanuts, pizza, and spicy food. There was a history of persistent signs and symptoms of rhinoconjunctivitis in the past (watery nasal discharge, sneezing, lacrimation, itching in the eyelids, and redness in the eyes). The patient was otherwise healthy except during episodes of anaphylaxis. His vitals were within the normal range. Blood tests revealed an elevated level of serum IgE: Total IgE-612.0 IU/ml (normal range <87.0 IU/ml) and 25-hydroxyvitamin Dtotal was low-7.3 ng/ml (normal range 30.0-100.0 ng/ml). SPT was positive to mugwort (Artemisia vulgaris)-8 mm, mesquite (Prosopis juliflora)-6 mm, wheat-7 mm, peanut-4 mm, and shrimp-6 mm (Table 1). Serum-specific IgE was positive for mugwort (A. vulgaris)-0.62 kua/L, wheat-1.60 Kua/l, peanut-0.11 kua/l, Dermatophagoides farinae-0.78 kua/l, Dermatophagoides pteronyssinus-0.70 kua/l, cockroach-0.67 kua/l, and Bermuda grass-0.44 kua/l. He was recommended the elimination of wheat and peanut from the diet along with allergen immunotherapy (AIT) and Inj Omalizumab (Anti IgE) for A. vulgaris with supportive therapy (emergen...

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Allergen immunotherapy (AIT) is a well-recognized treatment for altering the natural course of respiratory allergy which builds immune tolerance and prevents progression of allergic diseases. In our five cases of house dust mite (HDM)-driven allergic rhinitis and asthma, combined HDM Subcutaneous Immunotherapy (HDM-SCIT) for 2 years with omalizumab for more than 12 months has achieved disease remission in four cases and disease control in one case along with long-term effect for 3 years after discontinuation of AIT. We hypothesize that combining HDM-SCIT and omalizumab is a promising strategy as it is effective, safe, and synergistic having immune-modifying activity in cases of HDM-driven Allergic Rhinitis and Asthma.

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Chronic spontaneous urticaria (CSU) is a heterogeneous disorder with recurrent pruritic wheals and/or angioedema. The anti-immunoglobulin E (omalizumab) is used in CSU patients resistant to four-fold second-generation anti-histamines. Most clinical trials have experienced relapse after stopping omalizumab treatment. Here, we present a case series of five cases of chronic atopic urticarial concomitant allergic rhinitis and asthma which have shown immunologically significant positivity to Dermatophagoides pteronyssinus and Dermatophagoides farinae. Disease control was achieved (Urticaria Activity Score 7 <6) in four cases by combination therapy of omalizumab with house dust mite (HDM) Allergen Immunotherapy (AIT) and remained sustained for three years on follow-up even after discontinuation of AIT for one year. We hypothesize that this combined therapy may contribute to enhanced clinical efficacy, safety, and faster achievement of disease control in CSU.