Hypersensitivity pneumonitis secondary to lovebirds: a new cause of bird fancier's disease.

Hypersensitivity pneumonitis (HP) is an immunologically mediated lung disease due to the repetitive inhalation of antigens. Most new cases arise from residential exposures, notably to birds, and are thus more difficult to recognise. The present authors report a 59-yr-old male who complained of dyspnoea and cough while being treated with amiodarone. Pulmonary function tests revealed restriction and obstruction with low diffusing lung capacity for carbon monoxide and partial pressure of oxygen. A high-resolution computed tomography chest scan and bronchoalveolar lavage showed diffuse bilateral ground-glass attenuation and lymphocytic alveolitis, respectively. Initial diagnosis was amiodarone pulmonary toxicity, but because of a rapidly favourable evolution, this diagnosis was questioned. A careful environmental history revealed a close contact with lovebirds shortly before the onset of symptoms. Precipitins were strongly positive against lovebird droppings, but were negative against other avian antigens. The patient was diagnosed with hypersensitivity pneumonitis to lovebirds. Avoidance of lovebirds and steroid treatment led to rapid improvement. The present observation identifies a new causative agent for hypersensitivity pneumonitis and highlights the importance of a thorough environmental history and of searching for precipitins against antigens directly extracted from the patient's environment. These two procedures should allow a more precise classification of some cases of pneumonitis, and thus might avoid progression of active undiagnosed hypersensitivity pneumonitis to irreversible fibrosis or emphysema.

Idiopathic pulmonary fibrosis/cryptogenic fibrosing alveolitis.

Idiopathic pulmonary fibrosis (IPF), synonymous with cryptogenic fibrosing alveolitis (CFA), is a progressive and usually fatal disease of unknown cause characterized by sequential acute lung injury with subsequent scarring and end-stage lung disease. Historically, IPF/CFA encompassed a heterogeneous group of different histological and clinical entities arising in an idiopathic setting. Recently, the American Thoracic Society (ATS) and European Respiratory Society (ERS) core committee has redefined diagnostic criteria for both IPF/CFAand idiopathic interstitial pneumonias confining the term IPF/CFA to patients with a histological pattern of usual interstitial pneumonia on lung biopsy. This review attempts to refine the clinico-radiological-pathological features that together define IPF/CFA as it is understood today, and to summarize the rationale of new therapeutic approaches based on the current understanding of the pathogenetic mechanisms.

[Muckle-Wells syndrome: 4 cases in three generations]. / Syndrome de Muckle-Wells: description de 4 cas sur trois générations.

BACKGROUND: Muckle-Wells syndrome is a hereditary condition with variable penetrance. The main manifestations are urticarial rash, malaise in the evening, joint pain, perception deafness and renal amylosis. CASE REPORT: We describe a family with 4 affected members in 3 successive generations. Clinical expression was variable. DISCUSSION: Despite the absence of renal amylosis in our patients, this family presented the syndrome described by Muckle and Wells in 1962. As for other cases reported in the literature, the clinical course was favorable with low-dose corticosteroid therapy.

Comparison of the effects of terfenadine with fexofenadine on nasal provocation tests with allergen.

BACKGROUND: Fexofenadine, the hydrochloride salt of terfenadine active metabolite, is a nonsedative, noncardiotoxic antihistamine derivative for the treatment of allergic rhinitis. OBJECTIVE: We sought to compare the effects of terfenadine and fexofenadine on nasal provocation tests with allergen. METHODS: A preliminary provocation test (screening phase) was performed in 25 patients with a history of seasonal allergic rhinitis to grass pollen to determine the combined nasal reaction threshold, which was defined as 2 of the 3 following criteria: (1) at least a 40% decrease in peak nasal inspiratory flow and/or a 30% decrease in minimal cross-sectional area as measured by acoustic rhinometry, nasal secretions of 0.5 g, and 5 to 10 sneezes per minute. Patients were then included into a double-blind, randomized, 2-way crossover study to receive terfenadine or fexofenadine 120 mg 2 hours before provocation. Rhinorrhea, sneezing, peak nasal flow, and minimal nasal cross-sectional area, as well as symptom scores for nasal congestion and itchiness, were recorded at each allergen concentration up to the reaction threshold. The whole study was performed out of allergy season. RESULTS: Fexofenadine was as potent as terfenadine in limiting pruritus and nasal congestion. Rhinorrhea and sneezing were better controlled by fexofenadine than by terfenadine. Overall, the allergen concentration necessary to reach the combined reaction threshold was increased after treatment with both drugs. Comparison between screening and each treatment phase indicated that the shift in allergen concentration to reach the reaction threshold was significantly greater after fexofenadine than after terfenadine (P =. 033). CONCLUSION: After oral administration, fexofenadine provided better protection than terfenadine against the immediate allergic reaction.

[The anti-leukotrienes: a new class of drugs to integrate into the therapeutic strategy of asthma]. / Les antileucotriènes: une nouvelle classe de médicaments à intégrer dans la stratégie thérapeutique de l'asthme.

Leukotrienes play an important role in the pathogenesis of asthma, a chronic inflammatory disease. They are potent bronchoconstrictors and chemoattractants; furthermore, they increase vascular permeability and mucus secretion. Early treatment of bronchial inflammation has become an essential element of the therapeutic approach of asthma and relies mainly on inhaled corticosteroids. However, known adverse effects of inhaled corticosteroids raise important long-term questions on their local and systemic tolerance. These safety aspects have encouraged the development of other anti-inflammatory drugs. Antileukotrienes (specific antagonist of receptors and inhibitors of 5-lipoxygenase) display a beta 2-agonist additive effect, confer an effective protection in bronchial provocations, improve both clinical and functional asthma scores and also allow a decreasing in short-acting beta 2-agonist use. They are intended for patients suffering from persistent mild-to-moderate asthma. However, further studies are still required to determine both their long-term efficacity and tolerance, to define their place in the strategy of asthma management and finally to clarify their application in other allergic diseases.

[Inhaled steroids effect on bones]. / Effects osseux des stéroïdes inhalés.

Inhaled corticosteroids (ICS) are the mainstay of asthma treatment, when an antiinflammatory agent is warranted. The development of the ICS has permitted to diminish the adverse effects associated with oral steroids and with equipotent doses there are less adverse effects with ICS on bone metabolism compared to oral steroids. There is now reassuring evidence that doses of < or = 400 micrograms for children and < or = 1000 micrograms for adults are safe and do not appear to have clinically significant adverse effect on bone density or bone growth. When exceeding the recommended thresholds for more than 3 months, osteoporosis prevention would be appropriate. Furthermore a mineral bone density measurement might be done in this context in order to identify those persons who are at risk of developing or worsening preexisting osteoporosis. Growth monitoring is justified in any child taking ICS. Biochemical markers of bone formation and resorption might give complementary information to the mineral bone density measurement. The addition of a leukotriene receptor antagonist and or of a chromone may allow a reduction in the requirement for ICS in mild to moderate asthma. Finally the achievement of an increased glucocorticoid potency combined with an improved airway selectivity and a shorter plasmatic half-life of the ICS will further contribute to diminish their effects on bone metabolism.