Prevention of new sensitizations in monosensitized subjects submitted to specific immunotherapy or not. A retrospective study.

BACKGROUND: Specific immunotherapy is the only currently available allergen-orientated treatment able to modify the natural history of respiratory allergic diseases. Safety and clinical efficacy of this treatment are well documented, but evidence about the ability to reduce new sensitizations is still poor. OBJECTIVE: We report a retrospective study conducted in order to assess the prevention of new sensitizations in monosensitized subjects treated with specific immunotherapy vs. monosensitized patients treated with anti-allergic drugs. METHODS: 8396 monosensitized patients with respiratory symptoms were selected according to an open, retrospective design. Group A included 7182 patients submitted to specific immunotherapy (and anti-allergic drugs when needed) for 4 years and then treated with drugs for at least 3 years. Group B included 1214 patients treated only with drugs for at least 7 years. All patients underwent prick test with a standard panel of allergens and total and specific IgE determination before and after 4 years of treatment and again 3 years later. RESULTS: Groups were well balanced. Polysensitized subjects were 23.75% in Group A and 68.03% in Group B after 4 years (P < 0.0001) and 26.95% and 76.77%, respectively, after 7 years (P < 0.0001). Asthmatic subjects were more prone to develop polysensitization in comparison to subjects suffering only from rhinitis (32.14% instead of 27.29% after 4 years, 36.5% instead of 31.33% after 7 years; P < 0.0001). Specific IgE decreased by 24.11% in Group A and increased by 23.87% in Group B (P < 0.0001). Total IgE decreased by 17.53% in Group A and increased by 13.71% in Group B (P < 0.0001). CONCLUSIONS: Specific immunotherapy was observed retrospectively to reduce new sensitizations in monosensitized subjects suffering from respiratory allergic diseases.

Measurement of inflammatory mediators of mast cells and eosinophils in native nasal lavage fluid in nasal polyposis.

BACKGROUND: Nasal polyposis (NP) often coexists with asthma, rhinitis and sinusitis. Polyp histology typically shows chronic, eosinophilic inflammation. The inflammatory cell infiltrate generally includes eosinophils, lymphocytes, plasma cells and mast cells. OBJECTIVE: To gain insight into the natural history of NP, we analysed mediator levels and leukocyte values in nasal fluids and eosinophil cationic protein (ECP), total IgE levels and eosinophils in the blood in several groups of both allergic and non-allergic patients with nasal polyps and in patients with allergic rhinitis (AR). METHODS: Thirty-two patients with nasal polyps entered the study. As a control group, we studied 55 patients with AR, i.e. 20 patients with seasonal AR to grass pollen, 24 with AR sensitive to Parietaria and 11 with AR sensitive to house dust mite (HDM). Eighteen patients with nasal polyps were also allergic patients (8 were sensitive to Parietaria and 10 were sensitive to HDM), whereas 14 were non-allergic patients. Tryptase and histamine values were assayed in nasal fluids, whereas total IgE was determined in serum. ECP values were assayed both in nasal fluids and serum. Eosinophils were quantified both in the blood and nasal fluids. RESULTS: Tryptase levels were significantly higher in the nasal lavages from patients with NP than in those from patients without NP (4.7 vs. 3.5 U/l, p < 0.001) and correlated with symptom scores (r(s) = 0.42, p < 0.0001). The median levels of histamine in nasal fluids from patients with NP were also significantly higher than those observed in patients without NP (50.0 vs. 21.3 ng/ml, p < 0.001), but did not correlate with symptom scores. Finally, the median levels of ECP in nasal fluids from patients with NP were significantly higher than those observed in patients without NP (38.1 vs. 16.1 ng/ml, p < 0.001) and correlated with symptom scores (r(s) = 0.38, p < 0.001). Analysis of variance showed that, among the variables studied, the presence of nasal polyps was the factor responsible for the higher levels of tryptase, histamine and ECP in nasal fluids. With regard to leukocyte counts in nasal fluids, no significant differences were observed between rhinitis patients with NP and those without NP. With regard to serum ECP and serum total IgE, no significant differences were detected between the two groups under study. Blood eosinophil levels in patients with NP were significantly higher than those observed in patients without NP (5.8 vs. 5.6, p = 0.002). Analysis of variance showed that both the presence of nasal polyps and the type of sensitisation were important. Considering the total symptom scores, no significant differences were observed between rhinitis patients with NP and those without NP. CONCLUSIONS: The present findings are consistent with the view that chronic eosinophil mucosal inflammatory disease in NP involves a self-sustaining mechanism, i.e. local release of inflammatory mediators, independent of allergen stimulation of nasal mucosa. Increased release of inflammatory mediators contributes to the development of nasal polyps, determining oedema and an increased recruitment of inflammatory cells. Besides eosinophils, mast cells also play a key role in this process.

Immediate reaction to clarithromycin.

We present the case of bronchospastic reaction to clarithromycin had during a drug challenge test. Personal allergic history was negative for respiratory allergies and positive for adverse drug reactions to general and regional anesthesia and to ceftriaxone. After the administration of 1/4 of therapeutic dose of clarithromycin the patient showed dyspnea, cough and bronchospasm in all the lung fields. The positivity of the test was confirmed by the negativity to the administration of placebo. The quickness and the clinical characteristic of the adverse reaction suggest a pathogenic mechanism of immediate-type hypersensitivity. On reviewing the literature we have found no reports of bronchospastic reaction to clarithromycin. Macrolides are a class of antibiotics mainly used in the last years in place of beta-lactams because of a broad spectrum of action and a low allergic power. In fact, there are few reports on allergic reactions to these molecules. Clarithromycin is one of the latest macrolides, characterised by the presence of a 14-carbon-atom lactone ring as erythromycin, active on a wide spectrum of pathogens.

Immediate reaction to clarithromycin

We present the case of bronchospastic reaction to clarithromycin had during a drug challenge test. Personal allergic history was negative for respiratory allergies and positive for adverse drug reactions to general and regional anesthesia and to ceftriaxone. After the administration of 1/4 of therapeutic dose of clarithromycin the patient showed dyspnea, cough and bronchospasm in all the lung fields. The positivity of the test was confirmed by the negativity to the administration of placebo. The quickness and the clinical characteristic of the adverse reaction suggest a pathogenic mechanism of immediate-type hypersensitivity. On reviewing the literature we have found no reports of bronchospastic reaction to clarithromycin. Macrolides are a class of antibiotics mainly used in the last years in place of b-lactams because of a broad spectrum of action and a low allergic power. In fact, there are few reports on allergic reactions to these molecules. Clarithromycin is one of the latest macrolides, characterised by the presence of a 14-carbon-atom lactone ring as erythromycin, active on a wide spectrum of pathogens (AU)

Presentamos un caso de reacción broncospástica a claritromicina que tuvo lugar durante la prueba de provocación con el fármaco. La historia alérgica personal fue negativa para alergias respiratorias y positiva para reacciones farmacológicas adversas a la anestesia general y regional y a la ceftriaxona. Después de la administración de un cuarto de la dosis terapéutica de claritromicina, el paciente presentó disnea, tos y broncospasmo en todos los campos pulmonares. La prueba se confirmó mediante la negatividad de la respuesta frente a la administración de placebo. La rapidez y características clínicas de la reacción adversa sugieren un mecanismo patogénico de hipersensibilidad de tipo inmediato. En la revisión de los estudios publicados no identificamos ninguna descripción de reacción broncospástica a claritromicina (AU)

Effect of fluticasone propionate on soluble CD30 release in patients with severe allergic asthma.

Previous studies have demonstrated improvements in health-related quality of life in asthmatic patients after treatment with fluticasone propionate. CD30 is a marker of Th2 lymphocytes, which are key cells in the pathogenesis of allergic inflammation. There is also a soluble form of CD30 (sCD30) released by CD30+ cells. Since serum sCD30 levels are high in allergic patients, in our study we examined the possible role of fluticasone propionate in modulating sCD30 release in patients with severe allergic asthma. In addition, we evaluated a possible correlation between sCD30 and FEV1 in these patients. To this end two groups of subjects were enrolled: 20 healthy nonatopic control subjects (group A) and 20 atopic patients with severe bronchial asthma receiving fluticasone propionate at the total dosage of 1 mg/day for 8 weeks (group B). Serum samples were examined before and after the treatment period. sCD30 serum levels were determined by the commercial ELISA-kit (Dako). The limit of detection of the assay was 1 U/ml. Our data show that sCD30 basal serum levels were significantly (p <0.05) higher in patients of group B respect to group A subjects (8.35+/-4.88 vs. <1 IU/ml, respectively). In addition, we found that sCD30 serum levels were undetectable in patients of group B after fluticasone propionate therapy. In group B a positive correlation between serum sCD30 levels and FEV1 values before fluticasone propionate treatment was noted (Rho = -0.644, p <0.005). The fluticasone propionate inhibition of sCD30 release may partly explain how fluticasone propionate exerts its antiinflammatory activity, through the modulation of Th2 cells.

Bronchial hyperresponsiveness in subjects with gastroesophageal reflux.

BACKGROUND: The relationship between gastroesophageal reflux (GER) and asthma has been widely studied in the last years. GER may interfere with airway reactivity and aggravate or even induce asthma. OBJECTIVE: To assess the prevalence of bronchial hyperresponsiveness (BHR) in patients with GER disease with a view to judging the potential influence of GER on BHR. METHODS: 30 patients with GER disease and no clinical evidence of asthma and 30 normal subjects underwent a methacholine bronchial challenge. The methacholine concentration that caused a 20% fall in the FEV(1) (PC20) was used to assess bronchial responsiveness. RESULTS: In the GER group 11 subjects of the 30 studied showed a PC20 methacholine equal to or less than 8 mg/ml while in the control group only 2 subjects had a PC20 methacholine equal to or less than 8 mg/ml (p < 0.01; ANOVA test). CONCLUSIONS: Subjects with GER had a greater increase in airway reactivity when inhaling methacholine compared to disease-free normal subjects.

Burning mouth syndrome due to cadmium in a denture wearer.

We report the case of a female denture wearer who was referred to our service due to burning of the lips and tongue but with no visible oral lesions. Her biochemical data, complete blood cell count, sedimentation rate, thyroid and sex hormones were normal. Tongue culture was negative. Patch tests, performed with a panel of 20 potential denture allergens, gave positive results (+++) only to a 2% petrolatum cadmium sulfate, which was present in the denture. Removal of the denture led to the clearing up of oral symptoms in 3 days. In light of these findings, carrying out patch tests with the allergens related to denture materials should be considered in these cases.

Incidence of sensitivity to Anisakis simplex in a risk population of fishermen/fishmongers.

BACKGROUND: Anisakis simplex, a fish and cephalopodes parasite, can cause either gastrointestinal symptoms or allergic reactions in humans on eating/handling contaminated fish. OBJECTIVE: The aim of our study was to determine the capacity of Anisakis simplex to induce specific IgE production and allergic reactions following eating and handling fish in a population at risk. METHODS: We determined the levels of total IgE, specific IgE, and eosinophil count in 28 fishermen/fishmongers (group A) and 15 healthy donors (group B). A skin prick test (SPT) with extracts from Anisakis and the most common species of fish in our country, were also carried out. RESULTS: Specific IgE to Anisakis were found in 14 subjects of group A (13 of them had a positive SPT to the same extract) and none of group B (only one subject had a positive SPT). The SPT with fish extracts was positive in 4 patients of group A but in none of group B. Subjects in group A with specific IgE to Anisakis showed higher total IgE levels and eosinophil counts compared with either other individuals of the same group or to those of group B. CONCLUSIONS: These results indicate that fishermen/fishmongers are a population at risk for Anisakis simplex sensitization and suggest that this kind of sensitization should also be investigated not only in subjects like fishermen/fishmongers who live in countries where fish is likely to be contaminated with Anisakis simplex parasites, but also in those who handle fish for other reasons.

Clinical study on Alternaria spores sensitization.

BACKGROUND: sensitization to fungi spores is often associated with sensitization to other allergens and so it is difficult to estabilish the exact cause of illness. OBJECTIVE: the aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization. METHODS: 37 subjects who were monosensitized to Alternaria (prick-test positive), according to a previous epidemiological study were evaluated. Clinical symptoms and the period of their occurrence were taken into consideration as well as immunological parameters (RAST). RESULTS: 20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23. CONCLUSIONS: Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. Prick test is preferable to and more reliable than RAST as a diagnostic test.

Aluminium allergy in a patient with occupational contact dermatitis.

Case of a 57-year-old hospital attendant with hand eczema. Patch tests were read at 2 and 3 days using the 1+ to 3+ scoring system recommended by the Contact Dermatitis Research Group.

Clinical study on Alternaria spores sensitization

Background: sensitization to fungi spores is often associated with sensitization to other allergens and so it is difficult to estabilish the exact cause of illness. Objective: the aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization. Methods: 37 subjects who were monosensitized to Alternaria (prick-test positive), according to a previous epidemiological study were evaluated. Clinical symptoms and the period of their occurrence were taken into consideration as well as immunological parameters (RAST). Results: 20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23. Conclusions: Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. Prick test is preferable to and more reliable than RAST as a diagnostic test (AU)

Introducción: la sensibilización a esporas de hongos se asocia frecuentemente con la sensibilización a otros alergenos, con lo que es difícil establecer la causa exacta de la enfermedad. Objetivo: la finalidad del estudio fue evaluar a grupos de pacientes monosensibilizados a Alternaria y establecer la prevalencia, periodicidad y perfil clínico de esta clase de sensibilización. Métodos: se estudiaron 37 pacientes monosensibilizados a Alternaria (prick test positivo) seleccionados en un estudio epidemiológico previo. También se consideraron los síntomas clínicos y su frecuencia, así como algunos parámetros inmunológicos (RAST). Resultado: 20 pacientes (por encima del 50 por ciento) padecían asma asociada con otros síntomas alérgicos y 22 pacientes (60 por ciento) presentaban síntomas perennes. El RAST llevado a cabo en 34 pacientes monosensibilizados, fue positivo en 11 y negativo en 23. Conclusiones: la sensibilización a Alternaria se caracterizó por ser perenne, cursar con síntomas respiratorios graves (asma) y tener lugar principalmente en niños. Es preferible y más fiable como test diagnóstico el test cutáneo que el RAST. (AU)

Aluminium allergy in a patient with occupational contact dermatitis

Case of a 57-year-old hospital attendant with hand eczema. Patch tests were read at 2 and 3 days using the 1+ to 3+ scoring system recommended by the Contact Dermatitis Research Group (AU)

Caso de un ayudante sanitario de 57 años con eczema en las manos. Se realizan pruebas cutáneas evaluadas a los dos o tres días utilizando el sistema de puntuación 1+ a 3+ recomendado por el Contact Dermatitis Research Group (AU)

Unusual polyarthritis as a unique clinical manifestation of coeliac disease.

This report describes a patient who presented with an unusual polyarthritis accompanied by myalgia, fever and anxiety. After extensive clinical and serological evaluation, duodenal biopsy and serological tests provided evidence for the diagnosis of coeliac disease (CD). The patient was promptly put on a gluten-free diet, which led to an improvement in the clinical abnormalities.

Effect of inhaled glutathione on airway response to 'Fog' challenge in asthmatic patients.

OBJECTIVE: We report on the effect of glutathione, an antioxidant compound on the airway response to the ultrasonically nebulised distilled water (UNDW, 'fog') challenge. METHODS: 12 subjects with mild-to-moderate bronchial asthma underwent double-blind, cross-over pretreatment, administered 30 min earlier, in a randomised order with inhaled glutathione (G) (600 mg), sodium cromoglycate (SCG) (20 mg) and placebo (P), followed by the challenge. RESULTS: After P pretreatment UNDW challenge caused a mean 20.41% decrease in FEV-1 (p < 0.05), after G, a mean 6.04% fall in FEV-1 (p = n.s.), and after SCG a mean 5.99% fall in FEV-1 (p = n.s.). CONCLUSIONS: G significantly attenuated 'fog'-induced falls in FEV-1 (p < 0.001 compared with P) and showed a protective effect on UNDW-induced bronchoconstriction.

Sublingual immunotherapy: a double-blind, placebo-controlled trial with Parietaria judaica extract standardized in mass units in patients with rhinoconjunctivitis, asthma, or both.

BACKGROUND: New routes of administering immunotherapy in respiratory allergy are being studied as an alternative to conventional injective immunotherapy. We carried out a study to evaluate the clinical efficacy and effects of sublingual immunotherapy in patients with Parietaria judaica-induced respiratory allergy. METHODS: A double-blind, placebo-controlled design was followed. Thirty patients with P. judaica rhinoconjunctivitis, mild asthma, or both were randomly chosen for sublingual immunotherapy (14 patients) or placebo treatment (16 patients). The patients underwent preseasonal rush induction treatment followed by coseasonal maintenance treatment during the Parietaria pollen season. Symptom and drug scores, as well as specific IgE and specific IgG4, were recorded. RESULTS: Significantly lower symptom and drug scores were found (P=0.04), especially during the Parietaria pollination period, in the immunotherapy group. No significant difference in specific IgE and specific IgG4 was detected between the active and placebo groups; a statistically significant increase of specific IgE was detected in both groups (P=0.05). No patient undergoing active sublingual immunotherapy reported local or systemic side-effects. CONCLUSIONS: Our data suggest that sublingual immunotherapy is both clinically effective and safe in treating patients with Parietaria-induced rhinoconjunctivitis and mild asthma.

Effect of fluticasone propionate on interleukin-12 and interferon-gamma production in patients affected by allergic bronchial asthma.

Fluticasone propionate is a very effective topical treatment for asthma. Interleukin-12, which is produced by monocyte-macrophage and B lymphocytic cell lines, plays an important role in the induction of Th1 cells; whereas interferon-gamma (IFN-gamma), mainly produced by Th1 cells, exhibits a crucial effect on macrophage and natural killer cell activation. Since previous studies have demonstrated a reduced production of IL-12 and IFN-gamma in patients with allergic asthma, we examined whether fluticasone propionate therapy could influence the release of these cytokines in asthma. We selected two groups of subjects (15 per group): nonatopic healthy donors (group A) and asthmatic patients (group B). Cytokine release was assessed in sera as well as in supernatants of whole blood cultures after IFN-gamma priming and lipopolysaccharide stimulation. Venous blood and spirometric tests from patients in group B were obtained before and after treatment. Fluticasone propionate therapy significantly increased interleukin-12 levels in both supernatants of blood cultures (1,152.12 +/- 225.57 vs. 540.87 +/- 130.07 pg/ml; p < 0.05) or in sera (72.24 +/- 15.76 vs. 10.83 +/- 2.70 pg/ml; p < 0.05). Patients treated with fluticasone propionate also displayed increased levels of IFN-gamma in either blood culture supernatants (59.12 +/- 16.88 vs. 18.87 +/- 7.53 IU/ml; p < 0.05) or in sera (5.60 +/- 2.87 vs. < 1 IU/ml; p < 0.05). In addition, we observed a significant increase in FEV1 values in asthmatic patients after fluticasone propionate therapy (51.86 +/- 5.31 vs. 71.46 +/- 10.37% predicted). We propose that fluticasone propionate may exert at least in part of its antiinflammatory activity through the modulation of the cytokine output.

A controlled study on the effectiveness of loratadine in combination with flunisolide in the treatment of nonallergic rhinitis with eosinophilia (NARES).

BACKGROUND: Nonallergic rhinitis with eosinophilia (NARES), accounting for some 15% of perennial rhinitis, is a nasal disorder whose main features are eosinophil counts in nasal smear higher than 10% and negative IgE tests. The mainstay of treatment is topical corticosteroids. OBJECTIVE: To evaluate the adjunctive effect of loratadine, a non-sedating antihistamine with anti-allergic activity, on nasal symptoms and eosinophil counts in nasal secretions in patients with NARES. METHODS: Thirty patients with NARES were divided in two groups, half receiving flunisolide two 25 microg puffs per nostril morning and night plus loratadine 10 mg u.i.d. and half the same doses of flunisolide plus placebo, according to a double-blind fashion, for 3 weeks. The effectiveness of the treatment in the two groups was evaluated by comparing symptom scores and eosinophil counts, and safety was assessed by comparing the adverse effects. RESULTS: The loratadine treated group had better results both in nasal symptoms, with a decrease in sneezing (P < 0.000001) and rhinorrhoea (P < 0.006), respectively, corresponding with 73.4% and 66.7% with respect to 46.6% and 26.7% in the control group, and in eosinophil counts which decreased by 20% compared with 14.3% in patients treated with placebo and flunisolide. As to safety, only nasal irritation in two patients, one in each group, was reported. CONCLUSION: Loratadine improves the effectiveness of flunisolide in treatment of NARES with no change in safety, and with no sedation.