Duration of allergen immunotherapy in respiratory allergy: when is enough, enough?

OBJECTIVES

To investigate the duration of effective inhalant subcutaneous immunotherapy (SCIT) reported in the published literature and to determine if any specific biomarkers or clinical predictors exist that may identify patients who will remain in long-term remission after discontinuing treatment.

DATA SOURCES

Articles were selected from a search of the PubMed database from 1976 to 2006 using the search terms immunotherapy and allergen immunotherapy in combination with venom, allergic rhinitis, asthma, mechanism, efficacy, and duration, as well as articles known to the authors and referenced in review articles.

STUDY SELECTION

Articles were selected if evaluation of efficacy of the primary allergic disease treated after discontinuation of SCIT was stated as one of the objectives of the study.

RESULTS

The rate of relapse after discontinuing SCIT ranges from 0% to 55% of patients in the studies reviewed in this article. The length of the specific allergen immunotherapy and allergen type (ie, perennial vs seasonal) may be variables that affect the duration of clinical remission after cessation of SCIT. One study found the duration of SCIT efficacy after discontinuation depended on duration of treatment and correlated with decrease in skin test reactivity.

CONCLUSION

Until specific tests or clinical markers are identified that will clearly distinguish between patients who will relapse from those who will remain in long-term clinical remission after discontinuing effective allergen immunotherapy, the decision to continue or stop immunotherapy must be individualized.

Prevention of pneumococcal infection in a patient with normal immunoglobulin levels but impaired polysaccharide antibody production

BACKGROUND

Patients with normal immunoglobulin levels may have an impaired response to immunization with pneumococcal vaccine and increased susceptibility to infection with encapsulated organisms. In children, but not adults, immunoglobulin replacement has been shown to be effective in reducing the infection rate.

OBJECTIVE

To reduce the incidence of infection in an adult with impaired response to pneumococcal vaccine but normal serum IgG levels.

METHODS

Intravenous IgG, 350 mg/kg, was given every 4 weeks.

RESULTS

The patient, who was hospitalized 3 times in 3 years with respiratory tract infections and who had documented infection with Streptococcus pneumoniae and Haemophilus influenzae, did not require antibiotic therapy for more than 15 months while undergoing intravenous immunoglobulin replacement therapy.

CONCLUSION

Adults with impaired response to vaccination with polyvalent pneumococcal vaccine and normal IgG levels may benefit from replacement therapy.

Lack of cross-reactivity between 5-aminosalicylic acid-based drugs: a case report and review of the literature

BACKGROUND

5-Aminosalicylic acid (5-ASA)-containing drugs are the mainstay of therapy in inflammatory bowel disease, but adverse reactions to these medications are relatively common. Because there may be a lack of cross-reactivity among the various 5-ASA formulations, treatment with alternative preparations is sometimes possible even after an apparent allergic reaction to a 5-ASA product.

OBJECTIVE

To describe a patient with a possible allergy to 2 different 5-ASA drugs who tolerated a third.

METHODS

A 27-year-old man with Crohn disease developed a rash while taking mesalamine (Pentasa and Asacol). Treatment with 5-ASA products was discontinued, and 6-mercaptopurine and prednisone were prescribed. He then experienced multiorgan failure secondary to herpes simplex infection, which required discontinuation of the immunosuppressive therapy. After recovery from the acute infection, he underwent successful graded challenge with balsalazide.

RESULTS

The patient continued treatment with balsalazide for 9 months, with good control of his inflammatory bowel disease and no adverse effects.

CONCLUSIONS

Adverse reactions to 1 or more 5-ASA medications do not necessarily preclude the use of others in the same class. A treatment algorithm for patients with adverse reactions to 5-ASA is outlined based on the case report and review of the literature.

Response of asthma-related voice dysfunction to allergen immunotherapy: a case report of confirmation by methacholine challenge

Professional singers and other serious voice users are particularly susceptible to alterations in their vocal apparatus. As the support for vocalization, lung function is an essential element of the production of speech and song. Patients have been described who presented with voice complaints along with minimal or no abnormalities on spirometry, but responded to conventional bronchodilator and other asthma therapy. It was proposed that this represented an exercise-induced asthmalike condition, brought on by the hyperventilation associated with performing. The objective of this study was to establish whether improvement in vocalization while performing correlated with a decrease in non-specific bronchial reactivity. We concluded that resolution of vocal complaints in conjunction with a decrease in methacholine reactivity supports the hypothesis that these patients do have an exercise-induced asthmalike condition brought on by airway drying. As with other patients with asthma, it appears to respond to allergy-directed therapy.

Differential regulation of a family of apyrase genes from Medicago truncatula

Four putative apyrase genes were identified from the model legume Medicago truncatula. Two of the genes identified from M. truncatula (Mtapy1 and Mtapy4) are expressed in roots and are inducible within 3 h after inoculation with Sinorhizobium meliloti. The level of mRNA expression of the other two putative apyrases, Mtapy2 and Mtapy3, was unaffected by rhizobial inoculation. Screening of a bacterial artificial chromosome library of M. truncatula genomic DNA showed that Mtapy1, Mtapy3, and Mtapy4 are present on a single bacterial artificial chromosome clone. This apyrase cluster was mapped to linkage group seven. A syntenic region on soybean linkage group J was found to contain at least two apyrase genes. Screening of nodulation deficient mutants of M. truncatula revealed that two such mutants do not express apyrases to any detectable level. The data suggest a role for apyrases early in the nodulation response before the involvement of root cortical cell division leading to the nodule structure.

False positive perfusion lung scintiscans in tetraplegic patients: a case series

An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from either inappropriate therapy or failure to institute anticoagulation. The diagnosis of pulmonary embolism in tetraplegic spinal cord injury patients is complicated by frequent inability to perform the ventilation portion of the ventilation-perfusion scintiscan (V/Q scan) and by controversy regarding classification of defects on perfusion-only scans, as well as by coexisting pulmonary disease, systemic illness, related injuries, and the tendency for tetraplegic patients to have unexplained fever. This report describes three tetraplegic ventilator-dependent patients with hypoxic respiratory failure and normal chest radiographs who had large defects on perfusion-only lung scans. Ventilation scintiscans were not performed because the patients were ventilator-dependent with tracheostomies. Pulmonary angiography findings were normal in all patients, and all three responded to aggressive pulmonary toilet. Even large defects on perfusion-only scans despite normal chest radiographs should not be used to establish a diagnosis of pulmonary embolism in tetraplegic patients, and further diagnostic imaging is warranted.

Airway reactivity induced reversible voice dysfunction in singers

As the power source for vocalization, the lower respiratory tract plays a key role in voice production. This is particularly true with sustained singing, where continued high ventilatory demands are present. Changes in pulmonary function that are insignificant with normal speech have been shown to lead to performance impairment. The purpose of this study was to examine and characterize this problem in a large group of singers. Systematic evaluation of a defined population, along with inhalational and singing challenge, was the design. The demographic characteristics, history, pulmonary function, and response to treatment were evaluated in 20 professional or serious amateur singers with voice problems, who did not have causal laryngeal pathology, whose history and evaluation suggested increased airway reactivity, and who responded to anti-asthma therapy. An additional patient was challenged by the exercise of singing in the office, with pulmonary function measurements before and after. This group of serious singers demonstrated vocalization complaints referable to bronchodilator responsive airway obstruction. They responded to treatment for asthma, with improvement in their performance-related difficulties. An additional subject demonstrated a small decline in expiratory flow rates with only 20 minutes of singing in the office. This was readily reversed by an inhaled bronchodilator. Singers who present with complaints of impaired vocalization, such as vocal fatigue, decreased control, and excessive muscular tension, should be evaluated for increased airway reactivity as a possible cause of their complaints.

Cooperative action of lipo-chitin nodulation signals on the induction of the early nodulin, ENOD2, in soybean roots

Various lipo-chitin molecules were tested for their ability to induce the expression of the early nodulin, ENOD2, in Glycine soja roots. When inoculated separately onto G. soja roots, LCO-V (C18:1 delta 11,Mefuc), LCO-V (C18:1 delta 9,Mefuc), LCO-V (C16:0,Mefuc), and LCO-IV (C16:0) were unable to induce ENOD2 expression, even though these compounds had previously been shown to induce root hair curling, the formation of nodule-like primordia, and induction of the early nodulin, ENOD40. ENOD2 expression, however, was induced when any two of these molecules were inoculated in combination. Thus, the lipo-chitin nodulation signals appear to act cooperatively to induce ENOD2 expression. B. japonicum strains USDA110 and USDA135 and B. elkanii strain USDA61, all symbionts of soybean, were found to produce at least two distinct nod signals ([i.e., NodBj-V[C18:1,Mefuc] and NodBj-V[C16:0,Mefuc]). These two compounds were mixed in various ratios and tested for their ability to induce ENOD2 expression. The results indicate that the former compound must be present in equivalent or excess amount in order to obtain maximum ENOD2 expression. Additional nonspecific LCOs (e.g., LCO-IV[C16:2 delta 2,9; SO3]), incapable of inducing root hair curling or cortical cell division, were tested in combination with the four active LCOs listed above. It was found that any combination of one active LCO with a nonspecific LCO was sufficient to induce ENOD2 mRNA expression. The ENOD2 mRNA expression pattern detected by in situ hybridization closely resembled that found in bacterial-induced nodules with expression detected in cortical cells between primary and secondary meristems and around the vascular strands. These data demonstrate that the cooperative action of at least two LCO nodulation signals leads to a greater progression of nodule ontogeny as demonstrated by the expression of ENOD2, a marker gene for the differentiation of nodule parenchyma.

Expression of the early nodulin, ENOD40, in soybean roots in response to various lipo-chitin signal molecules

The lipo-chitin (LCO) nodulation signal (nod signal) purified from Bradyrhizobium japonicum induced nodule primordia on soybean (i.e. Glycine soja) roots. These primordia were characterized by a bifurcated vascular connection, cortical cell division, and the accumulation of mRNA of the early nodulin gene, ENOD40. A chemically synthesized LCO identical in structure to the Nod signal purified from B. japonicum cultures showed the same activity when inoculated on to soybean roots. Surprisingly, synthetic LCO or chitin pentamer, inactive in inducing root hair curling (HAD) or cortical cell division (NOI) in G. soja, induced the transient accumulation of ENOD40 mRNA. In roots inoculated with such LCO, ENOD40 mRNA was abundant at 40 h after inoculation but decreased to the background levels 6 days after inoculation. In contrast, nod signals active in inducing HAD and NOI induced high levels of ENOD40 accumulation at 40 h and 6 days after inoculation. In situ hybridization analysis showed that ENOD40 mRNA accumulated in the pericycle of the vascular bundle at 24 h after root inoculation with nod signal. At 6 days post-inoculation with nod signal, ENOD40 expression was seen in dividing subepidermal cortical cells. These results provide morphological and molecular evidence that nodule induction in soybean in response to purified or synthetic nod signal is similar, if not identical, to nodule formation induced by bacterial inoculation. Surprisingly, ENOD40 mRNA accumulation occurs in response to non-specific chitin signals. This suggests that, in the case of ENOD40, nodulation specificity is not determined at the level of initial gene expression.

Respiratory and glottal efficiency measures in normal classically trained singers

Respiratory and glottal efficiency measures were collected from a pool of 40 classically trained singers with normal larynges. All singers had > or = 3 years of formal classical voice training and were active professional solo classical singers. Mean flow rates were obtained from all subjects to assess glottal efficiency. Additionally, maximum phonation times and phonation quotients were obtained from a subset of the singers. Pulmonary function test data on forced expiratory volume, forced vital capacity, and forced expiratory flow were obtained for all subjects. Results were compared with published normal values, not specifically derived from trained singers, used commonly in voice laboratories. Differences were found, suggesting the need for separate normative data to be used for evaluation of the vocal athlete.

The value of ultrasound-guided fiberoptic bronchoscopy

Flexible fiberoptic bronchoscopy is the procedure of choice for the diagnosis of endobronchial neoplasm. Because of technical limitations of fiberoptic bronchoscopy, the use of ultrasound assistance was initiated and evaluated. This article reviews the technique, study design, and clinical results of ultrasound-assisted fiberoptic bronchoscopy.

Vocal disorders and the professional voice user: the allergist's role

BACKGROUND

As the modulating and power source for the voice, the upper and lower respiratory tracts play a key role in management of voice production. Allergic respiratory disease can impair vocalization, which can be a particular problem in the professional voice user.

OBJECTIVE

The goal of this review is to facilitate the evaluation and management of professional voice users who have allergic respiratory problems contributing to their vocal dysfunction. This article discusses the anatomy and physiology of voice production, laryngeal pathology, and special diagnostic and therapeutic considerations relative to the allergist's role in treatment of these patients.

METHODS

Mechanisms of voice production are reviewed, as well as common laryngeal pathology effecting voice production. Allergic respiratory diseases are summarized, with particular attention to those aspects of management that are altered in professional voice users.

RESULTS

Professional voice users require modification in their management to optimize vocal function and minimize abnormalities of the vocal tract. This includes avoidance of medications that produce drying of the airway, as well as avoidance of inhaled corticosteroids. Subtle changes in respiratory function, which may be of no consequence to other individuals, may adversely affect performance ability, and need aggressive management. Allergen immunotherapy, because of its lack of adverse effects on the vocal apparatus, is particularly well suited for treatment of professional voice users.

CONCLUSIONS

Allergists have an important role to play in management of the professional voice user. With careful attention to the unique requirements of these highly trained individuals, the allergist can enhance their performance ability while minimizing side effects from treatment.

US-assisted bronchoscopy with use of miniature transducer-containing catheters

PURPOSE

To demonstrate the value of ultrasound (US) guidance during flexible bronchoscopic procedures in a series of patients with known or suspected pulmonary neoplasms.

MATERIALS AND METHODS

US-guided bronchoscopy was carried out as an adjunct to conventional bronchoscopy for the diagnosis of mediastinal, hilar, or parenchymal neoplasms in 25 patients with masses previously detected with chest radiography or computed tomography. Miniature transducer-containing catheters were inserted through the biopsy port of the flexible bronchoscope, and cross-sectional real-time US scans of tumors, lymph nodes, and blood vessels were obtained.

RESULTS

Among six cases of peripheral masses and 19 cases of central masses, additional information was provided in 18 cases (72%). This information was used to choose the optimal site for transmural biopsy.

CONCLUSION

These preliminary results suggest that this US procedure may become an important diagnostic tool during bronchoscopy, due to the ability to identify structures beyond the lumen of the tracheobronchial tree.

Determinants of patient compliance with allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIM) has been demonstrated to be safe and effective in the treatment of allergic respiratory disease. Although it requires considerable patient commitment, little attention has been paid to the factors that contribute to patient compliance.

METHODS

Patients in a practice based at an urban university hospital, who discontinued AIM, were contacted to determine their reasons for stopping treatment. Results were correlated with demographic and disease data obtained from the patient charts.

RESULTS

Review of practice records identified 217 patients on AIM. One hundred forty-eight had allergic rhinitis, (R), 66 had allergic rhinitis and asthma (RA), and 3 had allergic asthma without evidence of rhinitis (A). Seventy-four (50%) of the patients in the R group, 32 (48%) of the patients in the RA group, and three (100%) of those in the A group discontinued treatment. The groups differed in that 55% of the patients in the R group discontinued treatment because of inconvenience, compared with only 22% of the patients in the RA group (p < 0.01). By contrast, 25% of the patients in the RA group stopped because they thought that they were "better" with medication, compared with none of the patients in the R group (p < 0.001). All of the patients in the RA group who stopped because they were better completed at least the first four-vial treatment series.

CONCLUSIONS

Inconvenience is the major contributing factor in noncompliance with AIM. Regulations designed to protect patients from adverse reactions should balance the potential risk of reactions against the benefits of treatment and the effect of more stringent guidelines on patient compliance.