Referral pattern to the allergist for hay fever in a health-care system with open access to specialists.

Little is known about referral patterns to the allergist for hay fever. In a system with open access to the specialist, we investigated the reasons for consulting an allergist in 126 patients who completed a questionnaire on their first visit. Both sexes were equally represented, the median age was 29 years, the duration of the disease and the duration of seasonal symptoms were 9 years and 10 weeks (median), respectively, and 54% of patients reported a history suggestive of asthma. The symptoms were highly variable; on average, 5.6 on a 10-cm visual analog scale. Most of the patients (94%) had been treated for hay fever before. Only 30% were referred by another physician, the rest being self-referred. The reasons for referral were investigated. The overall motivation to consult was related to symptom severity in 63% of the patients; 37% consulted for other reasons, including an expectation of greater "know-how" on the part of the allergist concerning specific diagnosis, treatment, and advice or counseling. The stimulus triggering the consultation was clearly not related to symptoms or disease in 25% of the cases. We conclude from these data that many patients are clearly interested in benefiting from the professional skill of a fully trained allergist.

The breakthrough phenomenon during alpha-interferon therapy of chronic hepatitis C: incidence, management, and outcome.

OBJECTIVES: Some patients treated with alpha-interferon (alpha-IFN) for chronic hepatitis C (CHC) initially respond with normalization of ALT only to encounter a rise in ALT while still on the drug. This phenomenon is called breakthrough (BT). We reviewed our experience with BT to clarify its incidence, pathogenesis, management, and outcome. METHODS: Charts from 71 consecutive patients with CHC treated with alpha-IFN were reviewed. Forty of these patients were part of a study of 1-yr escalating dose alpha-IFN, initiated at 2 million units (MU) 3 times per week. Endpoints that were evaluated were: reachievement of normal ALT, complete response (CR) (defined as normal ALT at the end of therapy), and sustained CR maintained for 6 months after therapy. RESULTS: Twenty-one (29.5%) patients sustained 28 BT events. Thirteen (46.4%) BT events occurred during the first 6 months of a course of alpha-IFN therapy, and 15 (53.6%) occurred during months 7 through 12. Of patients experiencing BT, six (28.6%) completed their course of therapy with a CR, of which two (9.5%) were sustained. By comparison, of 22 patients who normalized ALT without BT, all completed their course with a CR by definition (p < 0.0001), and nine (40.9%, p < 0.05) had a sustained CR. Of 28 BT events, 13 (46.4%) were followed by reattainment of normal ALT. Of 16 BT events managed with continuation of the same dose of alpha-IFN, normal ALT was reachieved in seven (43.8%). Of 12 BT events managed with an escalation in alpha-IFN dose, six (50%) reachieved normal ALT. A full sequential series of hepatitis C virus RNA PCR from periods of elevated, normal, and again elevated ALT was available for 12 BT events. The pattern was +/+/+ in six, +/-/+ in five, and +/-/- in one. In one additional patient, an apparent BT was attributable to alpha-IFN-induced autoimmune hepatitis. CONCLUSIONS: BT is a common event that may occur at any point during alpha-IFN therapy of CHC. This may limit the benefits of maintenance strategies. After a BT event, normal ALT can be reestablished in about 50% of cases, although the chance of a sustained CR falls to less than 10%. No advantage was demonstrated for escalating the alpha-IFN dose after a BT event. Therefore, we recommend continuation of the same dose as the initial approach. We suspect that BT relates to nonspecific ALT fluctuation in some patients and to emergence of resistant hepatitis C virus strains in others. Other causes of ALT elevation must also be considered in patients with apparent BT.

Anaphylactoid purpura like vasculitis following fibrinolytic therapy: role of the immune response to streptokinase.

We report the case of a patient who presented with a clinical picture of serum sickness with some characteristics of anaphylactoid purpura (Henoch-Schönlein purpura) five days after receiving streptokinase as a treatment for myocardial infarction. The appearance of Henoch-Schönlein like vasculitis after streptokinase treatment was particularly intriguing in view of the common association of streptococcus infection with this type of vasculitis. The production of streptokinase specific IgG and IgA antibodies was studied in the patient and compared with six controls treated with identical doses of streptokinase without adverse effects. A more rapid increase of streptokinase specific IgA was detected in the patient, with a significant higher amount of streptokinase specific IgA and IgG after six days of treatment. These results suggest that different kinetics could induce a precipitation of the immune complexes responsible for vasculitis. However, we cannot exclude that the IgA found in the vessel walls was only an "innocent bystander" deposited as a secondary event.

Comparison of two in vitro assays, RAST and CAP, when applied to the diagnosis of anaphylactic reactions to honeybee or yellow jacket venoms. Correlation with history and skin tests.

We compared the results obtained with a new specific IgE assay (Pharmacia CAP system) to those of RAST and intradermal skin tests (ST) performed in 87 patients with a history of generalized reaction to honeybee or yellow jacket venom. When CAP and RAST were compared with positive ST performed with honeybee venom, CAP sensitivity was not significantly higher (98%) than that of RAST (95%). When yellow jacket venom was tested, CAP sensitivity (93%) was clearly superior to that of RAST (40%). When we compared the specificities of RAST and CAP to bee venom, RAST was positive in 21% of the 24 subjects with negative ST, and CAP in 42%. Among the 29 patients with negative ST to yellow jacket venom, RAST was positive in 17% and CAP in 28%. These results do not reflect a lower specificity of CAP, because CAP positivities could be inhibited in vitro, and because, in three patients with a history of anaphylactic reaction (one to honeybee, two to yellow jacket), CAP was the only positive test confirming the clinical observation. Among the 53 patients who were able to identify the offending insect (honeybee, 31; yellow jacket, 22), the cause of the anaphylactic reaction was usually confirmed by ST and CAP: honeybee venom 97% for both ST and CAP; yellow jacket venom 82% for ST, 86% for CAP. This was not the case for RAST, which confirmed honeybee venom hypersensitivity in 87% and yellow jacket venom hypersensitivity in only 41%. Thus, CAP is both more sensitive and more rapid than RAST, without losing specificity.

[Temporal arteritis: diagnostic and therapeutic approach. What is new?]. / Artérite temporale: approches diagnostiques et thérapeutiques. Quoi de neuf?

In giant cell arteritis, a common vasculitic disease of elderly patients, the biopsy of the temporal artery has been considered an important part of the diagnostic procedure. The necessity to perform this biopsy has recently been questioned. It has also been proposed to substantially reduce the high doses of steroids usually given.

[Systemic lupus erythematosus associated with homozygous C2 deficiency. Apropos of a case report and literature review]. / Lupus érythémateux systémique associé à un déficit homozygote en C2. A propos d'un cas et revue de la littérature.

Inherited deficiencies of classical pathway complement components are rare and associated with autoimmune diseases and with increased susceptibility to bacterial infections. We report the clinical evolution and studies of the complement system in a 17-year-old female patient of Swiss origin presenting with systemic lupus erythematosus (malar rash, photosensitivity, leukopenia and antinuclear antibodies), in whom the hemolytically active second complement component (C2) was less than 10% of the normal value and antigenic C2 was not detectable. Linkage studies showed that the patient is HLA-A25, B18 positive and has the slow factor B allotype BfS. Further immunological assessment revealed low IgG4 concentrations in the patient, who had the G2M(23) allotype. The asymptomatic first degree family members had half-normal C2 levels compatible with a heterozygous state of C2 deficiency. Therapy with hydroxychloroquine for 17 months and topical sunscreen preparations produced marked clinical improvement. During the 4 years of follow-up, the patient has been well and shown only an abnormal titer of antinuclear antibodies. No infections were observed. To the best of our knowledge, 99 cases of homozygous C2 deficiency have been described so far and are discussed here.

Serological diagnosis of HIV infection: incidence, outcome and significance of partial reactions found in western blot analysis.

Between May 1986 and April 1987 routine screening for anti-HIV antibody was performed by enzyme immunoassay (EIA) on 3344 serum samples. The 1160 samples found positive or borderline were further analysed in Western blot (Wb). We analysed the frequency of different patterns of 'intermediate' Wb reactions (1-3 'specific' bands) and tried to determine their significance by searching for possible modifications of the pattern of reaction a few months later. Of 1160 Wb, 461 were clearly positive, 489 negative and 210 'intermediate'. The latter consisted of: 92 sera with anti-p24 (associated or not), 23 with anti-gp 120 and 160, 16 with anti-p55, 12 with anti-p41, 10 with anti-p65, eight with anti-p17 and four with anti-p31. A non-specific pattern was observed in the remaining 45. Of these sera, 46% were obtained from high risk subjects, 38% from persons without risk and in 16% no reliable information was available. In 30 subjects (24 with p24 and 6 with p41), a second sample was obtained about three months later. The reaction persisted in nine, was replaced by another in five, and disappeared in 15. One subject with anti-p41 in the first sample became clearly positive. In one of the 15 samples with disappearance of the reaction, the antigen p24 was present as the only sign of HIV infection. Later samples of this subject showed clear seroconversion. In many subjects with and without risk of exposure to HIV, the Wb gives an intermediate pattern of reactions (1-3 specific bands), that does not permit definitive conclusion on one single sample. Later controls are therefore necessary. Most of these reactions do not correspond to HIV infection.

Screening for anti-HTLV-III/LAV antibody in high-risk subjects: sensitivity and specificity of commercial tests.

1,834 serum samples from high-risk subjects were tested for anti-HTLV-III/LAV antibody by using the enzyme immuno assay (EIA) of Abbott (A), or the EIA of Abbott and Pasteur (P), or those two EIA plus Western blot analysis (WB). 983 samples were negative in A, 766 were strongly positive when tested in duplicate with both A and P, and 85 were slightly positive in A (23 samples) or discordant (62 samples) when tested further in P and WB. Of 62 discordant samples, 38 were reproducible. The pattern A+P-WB- was by far the most frequently encountered (26 samples) and interpreted as reflecting the higher incidence of positive results in the assay A. If one assumes that WB results are correct, the specificities of A and P are 93 and 100%, respectively (p less than 0.01), whereas the sensitivities are similar (98 and 99%).