Occupational asthma in a latex doll manufacturing plant.

BACKGROUND: Occupational asthma caused by latex has been reported in health care workers and workers in glove manufacturing plants. OBJECTIVE: We report occupational asthma from latex in a newly identified occupational setting, a latex doll manufacturing plant. METHODS: We evaluated an index case of asthma associated with work in a latex doll manufacturing plant by performing a workplace challenge and evaluating the work environment. We then performed an occupational survey and skin testing of 22 workers in the doll manufacturing plant. RESULTS: The patient, a 21-year-old woman, had severe immediate bronchospasm within minutes of beginning a workplace challenge where sanding of latex parts was performed. Two of 22 workers surveyed (including the patient) reported flushing, rhinoconjunctivitis, and wheezing on exposure to sanded doll parts. These two workers were the only subjects surveyed to have a history of atopy and positive immediate-type skin test responses to a raw latex extract and to common aeroallergens. CONCLUSIONS: Sanding or grinding of solid latex during the manufacturing process may result in a significant incidence of occupational asthma and rhinoconjunctivitis from latex sensitization. Atopic workers appear to be most susceptible to developing latex sensitivity in this setting.

Angioedema and C1 inhibitor deficiency.

Deficiency of C1 inhibitor resulting in episodes of angioedema causes significant morbidity and mortality in affected patients, yet often goes undiagnosed for years. As biochemical understanding of the disorder has improved, competing theories for the pathophysiologic mechanism of angioedema have emerged. Further, existing therapeutic interventions have been refined by experience and newer modalities currently available in Europe may soon become available in the United States.

Prolonged nausea and vomiting associated with buprenorphine.

We conducted a trial to evaluate the histamine-releasing characteristics of morphine, meperidine, and buprenorphine when administered intravenously to 20 healthy adults without pain. Substantially more nausea and vomiting occurred with buprenorphine than with the other compounds, and was more intense on ambulation. High-affinity receptor binding may play a role in the long duration of nausea and vomiting after a single dose of this agent.

Ontogeny of the antibody response to cow milk proteins.

Twenty-nine infants were followed prospectively for the development of immunoglobulin G (IgG) and IgE antibodies to the cow milk proteins (CMPs) alpha-lactalbumin, alpha-casein, and beta-lactoglobulin. Thirteen infants were fed formula, eight were exclusively breast fed, and eight were breast fed with formula supplementation. By 4 months of life, infants fed formula or breast milk with formula supplementation had elevated IgE and IgG antibody levels to CMPs, when compared with values before 1 month of age. Further, breast-fed infants demonstrated significantly lower levels of IgE and IgG antibodies to CMPs than infants who received formula or breast milk with formula supplementation. Clinical symptoms of cow milk allergy were more common in infants fed formula or breast fed with supplementation, but were not significantly related to the presence of specific antibody. Our data suggest that the formation of CMP antibodies may reflect a normal humoral response following exposure to CMP antigens in this age group.

Cathepsin D-like activity in neutrophils and monocytes.

Monocytes-macrophages and polymorphonuclear leukocytes contain an acid proteolytic enzyme that cleaves tritiated hemoglobin. The monocyte-macrophage-derived enzymatic activity was completely inhibited by pepstatin A, a property of cathepsin D. Monocyte-derived macrophages developed detectable cathepsin D-like activity after 5 days in culture, and this activity coincided with the appearance of other known indicators of macrophage maturation. The cathepsin D activity further increased significantly with time after day 5 of culture. The proteinase activity extracted from neutrophils was only partially inhibitable by pepstatin A, which indicates that this activity is contributed by more than one proteolytic enzyme, including cathepsin D. Cathepsin D activity demonstrated in neutrophils and macrophages may be an important marker of phagocyte function.

Indirect enzyme-linked immunosorbent assay for measurement of human immunoglobulins E and G to purified cow's milk proteins: application in diagnosis of cow's milk allergy.

An indirect double-antibody enzyme-linked immunosorbent assay (ELISA) was developed for the measurement of human immunoglobulin E (IgE) and IgG to the cow's milk proteins (CMP) alpha-casein, alpha-lactalbumin, and beta-lactoglobulin. Human serum albumin was used as the negative-antigen control. Rabbit anti-human IgE or IgG served as the primary antibody, and horseradish peroxidase-conjugated swine anti-rabbit immunoglobulin served as the secondary antibody. Positive control sera were obtained from patients with well-documented histories of cow's milk allergy, while negative control sera were obtained from cord bloods of healthy full-term infants and from normal adult volunteers without known milk allergy. Test sera were obtained from 41 children (ages, 3 months to 13 years; average age, 2.6 years) with suspected cow's milk allergy and clinical manifestations that included wheezing, rhinitis, atopic dermatitis, urticaria, or gastrointestinal disturbances. The patients were simultaneously evaluated by prick skin testing with scratch test antigen to whole CMP. Although only 13 (32%) of the 41 patients were positive by the prick skin test, 25 (61%) were positive by the IgE ELISA. Of the 25 IgE ELISA-positive patients, 20 were also positive by the IgG ELISA. There was concordance of positive results between skin testing and the IgE ELISA in only 9 patients (22%), and there was concordance of negative results in 12 patients (29%). Discordant results were observed in 20 patients (49%). These results indicate that the ELISA is more sensitive than prick skin testing in the identification of individuals with elevated levels of IgE to CMP.

Recurrent infections and staphylococcal liver abscess in a child with C1r deficiency.

Complete absence of the C1r portion of the first component of complement was found in a 2 1/2-year-old boy of Puerto Rican origin who presented with a staphylococcal liver abscess. His medical history also included two episodes of pneumonia complicated by a pneumatocele and empyema, purulent staphylococcal lymphadenitis, recurrent otitis media, and pneumococcal bacteremia. The C1s component of complement was 50% of normal, and C4 was elevated. Other immunologic tests, including nitroblue tetrazolium test, and IgE were normal. This is the tenth patient reported with C1r deficiency. The patient differs from other reported patients with C1r deficiency in that he presented with a liver abscess, an infection that has not been reported in patients with complement deficiencies, and in that he has an apparent susceptibility to staphylococcal infection.

Effects of human serum on cathepsin D activity.

The proteolytic activity of bovine splenic cathepsin D was evaluated by using the digestion of tritiated hemoglobin. Acid-denatured human serum was an enhancer of cathepsin D activity. Concentrated serum sources showed decreased activity because of competition of serum albumin with tritiated hemoglobin for cathepsin D. The enhancing activity of serum did not separate with any isolated protein as assessed by Sephadex G-50-80 chromatography or protein electrophoresis. The extraction of serum with ethanol-ether and chloroform-methanol showed that the enhancing activity separated with the phospholipid fraction, which had 2.6 times as much activity as the total lipid fraction. The activity was stable to heat at 56 degrees C for 30 minutes and to freeze-thawing, and was not dependent on metal ions.

The use of theophylline clearance in pediatric status asthmaticus. I. Interpatient and intrapatient theophylline clearance variability.

A group of 167 pediatric asthmatics were followed up over four years, and their theophylline clearance values were recorded when they were admitted for status asthmaticus. A slow and gradual decrease of the clearance value was noted in all age groups. The clearance did not change significantly between the ages of 2 and 9 years. Longitudinal intrapatient clearance changes achieved statistical significance after the age of 9 years. When the patient groups were studied according to their initial clearance values, it became evident that only the patients with clearance values of 80 mL/kg/h showed significant changes of this value. In our patient group, obesity did not play a significant role in effecting a change in theophylline clearance.

The use of theophylline clearance in pediatric status asthmaticus. II. The choice of appropriate dose for the intravenous theophylline infusion.

We developed an individualized approach for determining the intravenous rate of theophylline infusion for the treatment of status asthmaticus in children. The method is based on the individual's theophylline clearance rate as determined at previous admissions. We compared the method with two standard recommended approaches used currently in clinical pediatrics--the American Academy of Pediatrics and the Food and Drug Administration guidelines.

Asthma mortality in children: a 16-years experience at Children's Hospital of Philadelphia.

Over the 16-year period from August 1969 to August 1985, 15 children aged 9 to 19 years, well-known to physicians in the Allergy Section of the Children's Hospital of Philadelphia died unexpectedly of asthma outside the hospital. There were no deaths in hospitalized asthmatics during this time. Over half the deaths occurred since 1979, the same period in which significant increases in asthma deaths and hospitalizations were noted nationwide. The 15 children all had certain features in common and then subdivided into three subgroups. From analysis of the data five maxims for management of high-risk, chronic asthmatics were developed.

Fibronectin and complement secretion by monocytes and peritoneal macrophages in vitro from patients undergoing continuous ambulatory peritoneal dialysis.

We investigated the role of the opsonic glycoprotein fibronectin in the host defense of the peritoneum in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Fibronectin concentration in peritoneal dialysate from high infection rate CAPD patients (greater than 1.50 episodes peritonitis per year) was significantly less than from low infection rate CAPD patients (less than 0.55 episodes peritonitis per year). In vitro secretion of fibronectin by cultured peritoneal macrophages from patients with high infection rate was less than from low infection rate patients (P less than 0.05) and controls (P less than 0.01). In vitro secretion of the second component of complement, however, was similar in both high and low infection rate patients. Plasma fibronectin concentration and in vitro fibronectin secretion by cultured peripheral blood monocytes was not different between high infection rate patients and low infection rate patients, but was less than normals. Decreased fibronectin secretion by peritoneal macrophages is associated with a higher incidence of peritonitis among CAPD patients.

Unexpected death in childhood asthma. A review of 13 deaths in ambulatory patients.

Between January 1969 and January 1984, there were 13 deaths in ambulatory chronic asthmatics aged 9 to 19 years who had been followed up by physicians of the Allergy Section, Children's Hospital of Philadelphia. During this period, 5,686 children had been admitted to this institution for treatment of acute asthma and all had survived. Three possible causes for these deaths are suggested from a detailed review of each case. One cause may be medication-related, as exemplified by patient abuse of inhaled adrenergic drugs with concomitant erratic use of theophylline and corticosteroid drugs, or by physician failure to appreciate the need for corticosteroids. Serious behavioral disturbances account for some cases of medication misuse. A second cause of death may be an unsuspected pulmonary pathologic lesion, as revealed at autopsy, and a third cause may be sudden, intense airway narrowing, as has been reported in near deaths in hospitalized asthmatics.

Compliance with oral theophylline therapy in asthmatic children.

Serum theophylline levels were obtained from 111 children on continuous theophylline therapy when seen in the emergency department for acute episodes of wheezing. Sixty-six percent of patients were at least partially compliant and only 34% were noncompliant in medication taking on the basis of a serum theophylline level of less than 5 micrograms/mL. The main factors associated with compliance were type of primary care source, whether the patient had difficulty keeping appointments, and the relationship of the caretaker to the patient.