Drug allergy and asthma.

The prevalence of drug induced asthma in a series of 347 patients with drug induced adverse effects has been evaluated corresponding to 10% of drug adverse effects always due to NSAIDS.

The asthma rhinitis link.

The reports and similarities between rhinitis and asthma are presented--common triggers, common inflammatory mechanisms and incidence of association of both diseases are analysed. Personal data on the frequency of asthma in rhinitis and of rhinitis in asthma are presented. The effect of nasal provocations tests in peak expiratory flow in patients with and without rhinitis is compared being greater in presence of nasal allergy. Finally the ARIA recommendations are discussed.

Drug allergy and pollinosis. A short report.

2 series of patients with pollinosis and drug allergy studied 10 years apart and comprising 115 cases are presented. In both series grass pollens and parietaria are as usual the most common cause of pollinosis but Parietaria was more common in the first series. Beta-lactams were the major cause of drug allergy in the first group, supersed by NSAID in the second group. Rhinitis was the more frequent symptom on pollinosis and urticaria/angioedema on drug allergy.

"In vivo" and "in vitro" tests in the diagnosis of Beta-lactams allergy.

The results of "in vivo" and "in vitro" diagnostic tests in 114 patients reporting an allergic reaction to Beta-lactams are presented. Skin test gave an overall positivity of 85% and determination of specific IgE of 42%. Skin tests have a greater sensitivity but "in vitro" tests are an useful associated diagnostic method.

Alpha-1-antitrypsin deficiency asthma and allergy.

The biochemistry, genetics and pathology of alpha-1-anti-trypsin deficiency are reviewed. The geographical distribution in Europe of more current phenotypes M, SZ is discussed. Two cases of alpha-1- anti-trypsin are presented one homozygotic ZZ non-smoker without any respiratory pathology and one heterozygotic SZ heavy smoker with a severe chronic obstructive pulmonary disease and reversibility to Beta-2-mimetics suggesting asthma. The relationship between alpha-1-antitrypsin and asthma is discussed and general measures of treatment or prevention suggested.

"In vivo" and "in vitro": tests in the diagnosis of trichophyton allergy.

A group of 100 patients with Trichophyton allergy and a control of group of 100 without fungal allergy have been compared in order to evaluate the diagnostic value of skin prick and intradermal tests and assay of Trichophyton specific IgE. The evaluation of sensitivity, specificity efficacy, positive and negative predictive values suggests that skin tests in two steps, prick and intradermal and research of specific IgE must be used to a better diagnostic approach. In cases were allergy is not cleared by antifungal therapy specific immunotherapy is worthwhile to be tried with a great percentage of success.

Clinical efficacy and safety of preseasonal sublingual immunotherapy with grass pollen carbamylated allergoid in rhinitic patients. A double-blind, placebo-controlled study.

BACKGROUND: The aim of this study was to confirm the clinical efficacy and safety of a preseasonal sublingual immunotherapy (SLIT) in a group of allergic patients with seasonal rhinoconjunctivitis with or without mild intermittent or mild persistent asthma. The immunotherapy was administered through the oral mucosa with a monomeric carbamylated allergoid (allergoid SLIT) for grass pollens. A secondary endpoint was to evaluate the effect of the allergoid SLIT on nasal reactivity. METHODS AND RESULTS: A single-center, randomized, double-blind, placebo-controlled study was performed. Patients were selected and randomly allocated to two groups: one group received active treatment (allergoid SLIT) for 2 years and the other received placebo. Both groups received the necessary drug treatment throughout the trial. Thirty-three outpatients (20 men and 13 women, mean age: 30 years; range: 19-43) attending our center were enrolled in the study. Symptoms and medications were scored on diary cards during the pollen season. An allergen nasal challenge was performed at baseline and after 2 years of SLIT to evaluate nasal reactivity. Because the clinical scores were non-normally distributed, the Mann-Whitney and the Chi-square tests for intergroup comparisons and the Wilcoxon test for intragroup comparisons were used. The results were evaluated after 1 and 2 years of treatment. Between the first and second years of treatment, no changes in the scores for the placebo group were found, while for the active vaccine group significant decreases were found in rhinorrhea (p < 0.03), sneezing (p < 0.03), and conjunctivitis (p < 0.02). Symptom scores after nasal challenge decreased (p < 0.03) after 2 years' treatment. Nasal steroid use significantly decreased in the active treatment group during May and June in both the years of treatment (p < 0.02). Only two mild local adverse events were reported in the active group and none was reported in the placebo group. CONCLUSIONS: The results of this study show that the allergoid SLIT is safe and effective in decreasing symptom scores and drug use in rhinitic patients allergic to grass pollen.

Prevalence of drug allergy in an out-patient population.

The prevalence of drug allergy in an out-patient population has been studied, 448 cases were diagnosed mainly to NSAIDS and beta-lactams and local anesthetics, sulfa drugs, quinolones and others. Clinical history and skin tests are sufficient to diagnose most cases of drug allergy.

Trichophyton allergy: review of 89 cases.

A serie of 89 cases (55 men 34 women) of Tricophyton allergy is presented. All the patients had a clinical history and in 86 out of 89 lesions of dermatophytosis urticaria/angioedema was present in 57, eczema in 8, rhinitis in 12, conjunctivitis in 1 and asthma in 12. Skin prick tests to Tricophyton were positive in 53 (59,6%) of the patients and intradermal test in all. Specific IgE was found in 45 (69,3%) out of 70 patients. Antifungal treatment was effective at mean term in 18 cases. Specific immunotherapy was evaluated in 54 with good or very good results in 41 (83,3%). Tricophyton dermatophytosis must be looked for in all the cases of urticaria/angioedema and most cases of respiratory allergy without clear allergy to inhalants.

Skin tests in NSAIDS hypersensitivity.

Prick tests are more specific but less sensitive than ID which can give false positive results. 3 NSAIDS groups can be considered: Aspirin, diclofenac and metamizol with a higher percentage of positivity. For others NSAIDS including the newer coxibs positivity around 50%. Nimesulid and acetaminophen with a lower of positivity. Skin tests can be used in NSAIDS hypersensitivity to confirm clinical history but also to choose, case by case, a drug less prone to give hypersentivity reactions.

Monoid sublingual immunotherapy.

Sublingual monoid immunotherapy with monomeric allergoids has been largely used in Europe in the last few years. An open trial of allergoid in tablets has been done in rhinitic patients allergic to house dust mites, grass pollens and Parietaria with clear improvement in clinics and drug consumption scores. In a second phase a double blind placebo controlled trial of grass pollens allergoids have been done in hay fever patients with significant decrease on the scores of rhinorrea, sneezing and conjunctivitis nasal steroid consumption and clinical score after serial nasal challenges. Monomeric allergoids are an efficace and safe immunotherapy in allergic rhinitis.

Immunoblot studies in allergic patients to hymenoptera venom before and during immunotherapy.

BACKGROUND: Hymenoptera venom immunotherapy (VIT) is immunologically effective in patients with systemic allergic reactions after hymenoptera stings. OBJECTIVE: To evaluate the effect of VIT on specific IgE and IgG4 immunoblotting bands in VIT-treated patients. MATERIAL AND METHODS: Specific IgE and IgG4 immunoblotting bands for hymenoptera venom were performed with ALABLOT in sera of 17 patients (8 allergic to honeybee venom, 8 to wasp and 1 to polistes venom) before and during successful VIT (1 and 3 years). Before immunotherapy, all patients had experienced moderate/severe systemic reactions to a hymenoptera sting, with positive skin tests and venom-specific IgE. During immunotherapy all patients suffered field stings, without any systemic reaction. RESULTS: Before VIT we detected several immunoglobulin-binding bands in different regions, with different individual patterns. After VIT, we observed in some patients (5/8 for honeybee venom, 6/8 for wasp and 1/1 for polistes) complete disappearance of some IgE-binding bands, mainly the 15 kDa region (honeybee) and 23 and 44 kDa regions (wasp and polistes). All patients showed decreased intensity of IgE-binding bands, most pronounced in regions 16, 44 and 52 kDa (honeybee); 44 and 35 kDa bands (wasp) and 23 kDa (polistes). Some patients showed de novo appearance of IgG4-binding bands (4/8 for honeybee and 8/8 for wasp venom), mainly in 52 kDa (honeybee) and in 23 and 44 kDa regions (wasp). All patients showed increased intensity of IgG4 bands that were already present before VIT, more pronounced in 52 and 44 kDa (honeybee) and in 44 and 35 kDa regions (wasp). CONCLUSIONS: During successful VIT there are changes in intensity and number of IgE and IgG4 binding bands, which could reflect the immunological improvement induced by VIT. These changes are more pronounced/frequent in wasp VIT, a fact that could explain the best results usually seen in these patients.

Allergy to sunflower seeds.

A case of oral syndrome after eating sunflower seeds is reported. Sensitization has been probably through inhalant route when using these seeds to feed birds. Skin prick tests with a fresh macerate of sunflower seeds has been clearly positive (greater than histamine control) but commercial extracts have given borderline positivity and specific IgE to sunflower was strongly positive.

"Minor" hemoglobinopathies: a risk factor for asthma.

BACKGROUND: Thalassemia, sickle cell disease and other hemoglobinopathies are not rare in Portugal and European Mediterranean area. Homozygotic patients present major hematological disease but heterozygotic minor assymptomatic forms are frequent, mainly thalassemia minor and sickle cell trait. In these cases mycrocytosis with decrease or red cell volume and mean corpuscular volume or abnormal rigid erythrocytes are found and can lead to hemorheologic disturbances. The purpose of this study is to evaluate the incidence of asthma in hemoglobinopatic patients allergic to house dust mites. METHOD: From 4.000 patients seen in the last 5 years in an out-patient allergy clinic, 63 cases of hemoglobinopathies have been confirmed by red cell count, hemoglobin electrophoresis, assays of hemoglobin A2, Fc, and S, and sickle cell test. All these patients had allergic disease characterized by clinical history, skin prick test to aeroallergens total and specific IgE (RAST-CAP-FEIA) and respiratory function evaluation. RESULTS: 66 Hemoglobinopathies: Betathalassemia 61 cases, Betadelta thalassemia 2, sickle cell trait 2, Hemoglobin C, 1.57 patients have respiratory allergy, rhinitis in 14 cases of thalassemia and 1 of hemoglobin C, asthma with or without rhinitis in 41 cases of thalassemia and 1 case of sickle cell trait, the other 6 cutaneous allergy. Therefore asthma was present in 75.0% of the respiratory allergic patients and rhinitis only in 25.0%. In contrast in a control group of 491 respiratory allergic patients wihout hemoglobinopathies, 57% has asthma and 43% only rhinitis. CONCLUSION: The prevalence of asthma is higher in thalassemia minor and sickle cell trait (p<0.05 Square chi test). Hemorheological changes probably a greater rigidity of red blood cells in capillary bed can contribute to changes in bronchial circulation and bronchial hypereactivity. Detection of hemoglobinopathies must be done in asthmatic patients with slight anemia or mycrocytosis.

Chronic urticaria and thyroid auto-immunity.

Purpose was to evaluate thyroid auto-immunity and thyroid function in chronic urticaria (CU). Evaluation of antibodies Ab to thyroglobulin (TG) thyroid peroxidase (TPO) and of TSH, FT3, FT4, and of intra-dermal self test with patients own serum in 56 patients presenting chronic idiopathic urticaria and in a matched control group of 56 subjects without CU. Ab to TG positive in 13 (22.2%) to TPO in 15 (26.8%). Overall thyroid antibodies 28.5%. Thyroid function normal in 52 patients, TSH increased in 2, FT3 decreased in 1, TG and TPO Abs and thyroid function results always normal in control group. Self test positive in 4 out of 56 patients. Therapy with thyroid extract was effective in 2 out of 5 cases. CU is associated with thyroid autoimmunity in most cases. Thyroid Ab and function must be evaluated in all the cases of chronic urticaria.

Efficacy and safety of specific immunotherapy with a modified mite extract.

BACKGROUND: In specific immunotherapy (SIT), modified extracts have been used to allow safe administration of higher allergen doses. Schedules reaching maintenance doses in approximately 1 month, which may have greater efficacy, have even been proposed. AIMS: To assess the safety and efficacy of SIT with modified (depigmented and polymerized) Dermatophagoides pteronyssinus extract in the treatment of allergic rhinitis. MATERIAL AND METHODS: Fifty patients with moderate-to-severe persistent allergic rhinitis and who were monosensitized to Dermatophagoides were included in this controlled, pragmatic, 1-year open study. The patients were randomly allocated to receive treatment with a Dermatophagoides pteronyssinus 100 % modified allergen vaccine (active group, n = 25) or pharmacological treatment only (control group, n = 25). All SIT-related adverse reactions were recorded. Efficacy was assessed primarily through the results of nasal allergen challenges, through visual analog scale (VAS) and symptom scores. RESULTS: In SIT-treated patients, significant improvements were found in symptom scores (mean reduction > 40 %), VAS scores (mean improvement > 20 %) and nasal challenges (mean increase in allergen concentration threshold > 500 %). For symptom and VAS scores, statistically significant differences between control and SIT-treated patients were recorded at 12 months. In nasal challenges statistically significant differences were observed as early as at 6 months. Control patients showed no significant differences during the study period. Local reactions were observed in 28 % of SIT-treated patients (total 24 reactions). There was only one immediate grade I systemic reaction, which was successfully treated with an antihistamine. CONCLUSIONS: SIT with this modified extract appears to be a relatively safe treatment, which can rapidly improve nasal allergenic tolerance, reduce symptom scores and improve subjective self-evaluation measured through VAS, reflecting a general improvement in patients' well-being.

Solar urticaria and porphyrias.

The importance of disturbances of porphyrin metabolism in solar urticaria is discussed. 15 cases of porphyrias with sun sensitivity are presented comprising 5 cases of erythropoietic protoporhyria, 8 cases of coproporphyria hereditaria and 2 cases of porphyria variegata, 9 out of these 10 patients presented neuroabdominal symptoms and in 4 cases contraceptive pills have triggered the disease. Due to the risk of severe forms of disease sometimes drugs induced porphyrias must be considered in all cases of solar urticaria and a correct laboratory study done in the suspected cases.

Candida and human disease.

A general review on candida and human disease emphasizing Candida Species, clinical manifestations, immune response NK failure and immunotherapy.

Latex and chickpea (Cicer arietinum) allergy: first description of a new association.

In this paper we describe the existence of cross-reactivity between allergens from latex and chickpea, a food from the Leguminosae family, which is common in the Mediterranean diet. We present the case report of a spina bifida boy with a clinical relevant food allergy to chickpea (oral syndrome + dysphonia), developing after the appearance of latex allergy symptoms (lip angioedema + intraoperative anaphylaxis). Specific IgE to latex and chickpea was demonstrated by skin prick tests, measurement of patient's serum specific IgE and IgE-immunoblotting. Cross-reactivity was studied by means of EAST-inhibition and western blotting-inhibition. A strong inhibition was observed in several IgE-binding bands when latex extract was used in solid phase and patient serum was preincubated with chickpea extract (chickpea extract as inhibitor phase). As far as we know, this is the first report of cross-reactivity between latex and chickpea, a food which should therefore be added to the extensive list of latex cross-reactive foods.

Kinetics and dynamic evaluation of specific immunotherapy.

UNLABELLED: Specific immunotherapy (SIT) is frequently used in the treatment of allergic diseases. However, the mechanisms by which SIT achieves clinical improvement remained unclear. We decided to study the in vivo kinetics of this therapy, using a nuclear medicine approach (leukocytes labelled with 99mTc-HMPAO) in patients on maintenance doses of specific immunotherapy with confirmed clinical efficacy. MATERIAL AND METHODS: We studied 13 allergic patients grouped according to different treatment schedules: subcutaneous aqueous allergenic extract (3 latex and 2 hymenoptera venom), subcutaneous depot extract (2 house dust mite and 2 pollens), subcutaneous modified allergens (2 pollens), sublingual extract (2 house dust mites). The control group included two allergic patients submitted to subcutaneous injections of bacterial extract (1 patient--positive control), and aqueous solution (1 patient). At the same time that the therapeutic allergen was administered subcutaneously, the autologous labelled white cells were injected intravenously in a peripheral vein in the contralateral arm. A thoracic dynamic acquisition of 60 mins, 64x64 matrix, 2 frame/min, in anterior view was performed. Static acquisition for 256x256 matrix, during 5 mins each at 60, 90, 120, 180, 240, 300 and 360 mins after the administration of the radiolabelled leukocytes, in thoracic (anterior and posterior), and abdominal view were performed. During the examination, the local erythema was monitored. A similar procedure was undertaken for Sublingual administration of immunotherapy. RESULTS: The inflammatory activity at the site of SIT injection (aqueous depot extract) started in the first hour and the increase was time related. For modified allergen extract and sublingual SIT the activity was present since the beginning of the administration. The ascendant lymphatic drainage, which was directed to the homolateral axillary region, to the lymphoid tissue of the upper mediastinum and to the anterior region of the neck began earlier. Thoracic focalisations were present for all the patients, whereas bowel focalisations were only observed for the subcutaneous route of administration. Sublingual SIT did not induce axillary or intestinal inflammatory focalisations, even though the patients had swallowed the allergenic extract. The uptake coefficient in individualized areas corrected to the uptake coefficient background was also studied. CONCLUSIONS: For the subcutaneous route of administration, except for glutaraldehyde-modified allergen, the local inflammatory activity at the allergenic injection site was significantly higher in depth and was time dependent, maintaining activity even after complete disappearance of the erythema and/or wheal. These results express a prompt inflammatory involvement of the immune system with this allergenic therapy, which was unexpected until now. We also observed differences concerning allergic diseases, the type of allergenic extracts and routes of administration.