Mannitol versus hypertonic saline

Eosinophilic asthma phenotype predicts good response to corticosteroids and associates to asthmatic exacerbations. Sputum induction by hypertonic saline (HS) inhalation is technically demanding. Bronchial hyperresponsiveness (BHR) to osmotic agents indirectly mirrors active airway inflammation. We compared the safety and ability of HS and mannitol to induce sputum and measure BHR. We evaluated the stability of inflammatory phenotypes. We studied 35 non-smoking asthmatics randomized to undergo HS and mannitol challenges on 2 days 1 week apart. Sputum was sampled for cell analysis and phenotyped as eosinophilic (≥3% eosinophils) and non-eosinophilic (<3%) asthma. Nineteen subjects had BHR to mannitol and nine of them also had BHR to HS. Drops in forced expiratory volume in 1 s were higher from HS challenge than from mannitol challenge. Adequate sputum samples were obtained from 80% subjects (68% mannitol and 71% HS). Eosinophils and macrophages from both challenges correlated. Neutrophils were higher in sputum from HS. Ninety percent samples were equally phenotyped with HS and mannitol. Fractional exhaled nitric oxide, sputum eosinophils and BHR correlated in both challenges. HS and mannitol showed similar capacity to produce valuable sputum samples. BHR to both osmotic stimuli partially resembled airway eosinophilic inflammation but mannitol was more sensitive than HS to assess BHR. Eosinophilic phenotype remained stable in most patients with both stimuli.

Phenotypes and endotypes of uncontrolled severe asthma: new treatments

Severe asthma is a heterogeneous disease that affects only 5%-10% of asthmatic patients, although it accounts for a significant percentage of the consumption of health care resources. Severe asthma is characterized by the need for treatment with high doses of inhaled corticosteroids and includes several clinical and pathophysiological phenotypes. To a large extent, this heterogeneity restricts characterization of the disease and, in most cases, hinders the selection of appropriate treatment. In recent years, therefore, emphasis has been placed on improving our understanding of the various phenotypes of severe asthma and the identification of biomarkers for each of these phenotypes. Likewise, the concept of the endotype has been gaining acceptance with regard to the various subtypes of the disease, which are classified according to their unique functional or pathophysiological mechanism. This review discusses the most relevant aspects of the clinical and inflammatory phenotypes of severe asthma, including severe childhood asthma and the various endotypes of severe asthma. The main therapeutic options available for patients with uncontrolled severe asthma will also be reviewed.

Consensus document on the diagnosis of severe uncontrolled asthma

BACKGROUND

The concepts of asthma severity, control, and exacerbation are important in the evaluation of patients and their response to treatment. However, terminology is not standardized, and terms are often used interchangeably. Patients with uncontrolled severe asthma pose a major health care problem. Over the last decade, it has become increasingly clear that, in order to facilitate the development of novel targeted therapies, patients must be further characterized and classified.

OBJECTIVE

To draft a consensus statement on the diagnosis, management, and treatment of severe uncontrolled asthma. The statement is meant to serve as a guideline for health professionals and clinical researchers.

METHODS

The consensus was led by the Severe Asthma Working Group of the Spanish Society of Allergology and Clinical ImmunologyAsthma Committee. A review was conducted of the best available scientific evidence (until December 2011) on severe asthma in adults and children.

RESULTS

Definitions for severe asthma, level of control, and exacerbation are developed. Different phenotypes and endophenotypes of severe uncontrolled asthma and new specific therapeutic interventions are presented. A systematic algorithm for the evaluation of patients presenting with severe persistent asthma symptoms is proposed.

CONCLUSIONS

A consensus statement on the diagnosis, management, and treatment of severe uncontrolled asthma is presented.

Respiratory allergy to peach leaves and lipid-transfer proteins

BACKGROUND

Several lipid-transfer proteins (LTPs) have been identified as important food allergens, especially in fruits of the Rosaceae family. The major peach (Prunus persica) allergen has been identified, sequenced and designated Pru p 3.

OBJECTIVE

To present Pru p 3 as an aeroallergen able to induce occupational asthma.

METHODS

A thorough investigation was performed in a fruit grower with occupational asthma. Skin prick-prick tests with peach leaves and prick tests with perennial respiratory allergens and pollens, fruits and peach leaf extracts were done. Serum-specific IgE was tested for peach leaf, peach fruit, peach skin and respiratory allergens that were positive in skin prick tests. Specific bronchial provocation tests (BPTs) with extracts of peach leaf were also done. Before and 24 h after the BPT, BPTs with methacholine and sputum induction were done. The IgE reactivity pattern to peach leaf and fruit extracts and to Pru p 3 was identified by using SDS-PAGE and immunoblotting. Blotting inhibition of peach leaf extract by Pru p 3 was also performed. The putative allergen was quantified in leaf and fruit skin extracts with ELISA based on an anti-Pru p 3 antibody.

RESULTS

Skin tests were positive for peach leaf and fruit. The BPT was positive, with immediate and delayed response. This test induced a decrease in PD20 (dose of agonist that induces a 20% fall in FEV1) methacholine and an increase in eosinophils and eosinophil cationic protein in sputum. Peach leaf extract contained concentrations of Pru p 3 similar to those found in peach skin. Specific IgE immunodetection showed that patient's sera reacted with Pru p 3, and with a single major band from the peach leaf extract fully inhibited by Pru p 3.

CONCLUSION

Pru p 3 from peach leaves can act as a respiratory allergen and cause occupational rhinoconjunctivitis and asthma.

Diversity of asparagus allergy: clinical and immunological features

BACKGROUND

Asparagus (Asparagus officinalis) is an extensively grown and consumed vegetable. To a lesser extent than other Liliaceae vegetables, allergic contact dermatitis (ACD) due to asparagus has been reported. However, only a few case reports of asparagus IgE-mediated allergy have been published. In a previous study, we demonstrated that two lipid transfer proteins (LTPs) (Aspa o 1.01 and Aspa o 1.02) were relevant allergens of asparagus.

OBJECTIVE

We retrospectively analysed the 27 patients diagnosed with asparagus allergy during the last 5 years. All of them reported adverse symptoms after either asparagus ingestion or handling. We describe their clinical features and evaluate whether they were associated to immunological findings (immunoblot pattern and skin reactivity to LTPs).

METHODS

Patients underwent skin prick and patch tests with standard panels of vegetables and aeroallergens. Besides crude asparagus extract, two purified LTPs were prick and patch tested. Total and specific IgE measurements and asparagus extract IgE immunoblotting were performed. Patients reporting asthma symptoms underwent specific inhalation challenge to asparagus.

RESULTS

Of the 27 subjects, eight had ACD, 17 had IgE-mediated allergy and two had both ACD- and IgE-mediated allergy. Positive patch tests with the crude asparagus extract but not with LTPs were observed in subjects with ACD (n=10). Of 19 patients with IgE-mediated disease, 10 had contact urticaria after asparagus handling. Of them, five subjects and five others without skin allergy showed respiratory symptoms; of them, eight were diagnosed with occupational asthma confirmed by positive asparagus inhalation challenge, whereas the remaining two had isolated rhinitis. Four patients suffered from immediate allergic reactions related to asparagus ingestion (food allergy); three of them reported anaphylaxis whereas the other had oral allergic syndrome. Positive IgE immunoblotting (bands of 15 and 45-70 kDa) was observed in 10 subjects. Of 10 subjects with positive prick test to LTPs, six showed bands at 15 kDa. Either IgE-binding bands or positive prick tests to LTPs were observed in asthma (62%) and anaphylaxis (67%).

CONCLUSION

Asparagus is a relevant source of occupational allergy inducing ACD and also IgE-mediated reactions. Severe disease (anaphylaxis or asthma) is common and LTPs seem to play a major role. The clinical relevance of LTP sensitization among patients with mild disease or symptom-free subjects should be addressed in prospective studies.

Occupational asthma from natural rubber latex. Specific inhalation challenge test and evolution

BACKGROUND

Natural rubber latex (NRL) is the most frequent cause of occupational respiratory problems in hospital workers.

OBJECTIVE

To describe the diagnostic methodology, including the specific inhalation challenge (SIC), used on patients diagnosed as having occupational asthma due to NRL in our Allergy Department during a 6-year period from 1989 to 1995.

METHODS

In 19 patients diagnosed as having occupational asthma due to NRL, clinical severity was assessed with a combined score for symptoms and medication use. Skin prick tests with aeroallergens, latex, papain, kiwi and chestnut, total IgE, serum-specific latex IgE, respiratory function study, methacholine test, specific conjunctival test, and SIC test with latex were done.

RESULTS

All but three patients worked in hospitals. All presented urticaria and rhinoconjunctivitis, and six also suffered anaphylaxis, usually preceded by asthma. Clinical fruit allergy was present in eight patients. The latency period was variable (0.25-27 years). The intensity of symptoms was low to moderate. Specific IgE, skin prick, and conjunctival tests to latex were positive in all cases. SICs were done in 12 patients. All of them presented isolated immediate reactions. No adverse reactions were observed. Duration of follow-up ranged from 1 to 7 years. Twenty-six percent of the patients kept their job, 26% changed jobs but remained in health care, and 48% switched to jobs unrelated to health care. Only 16% were free of symptoms without treatment, while 32% needed bronchodilators and 52% needed inhaled steroids. The specific bronchial challenge test was safe, but it did not predict the course of the illness. Duration of exposure and intensity of symptoms did correlate with prognosis, however.

CONCLUSIONS

NRL acts as a common aerollergen. Minor symptoms often precede occupational asthma. The SIC test was safe in the hands of trained technicians. Occupational asthma due to NRL seems to have a poor prognosis.

Liposome-entrapped D. pteronyssinus vaccination in mild asthma patients: effect of 1-year double-blind, placebo-controlled trial on inflammation, bronchial hyperresponsiveness and immediate and late bronchial responses to the allergen

BACKGROUND

Allergen vaccination is effective in mite-allergic asthma. Liposomes are immunological adjuvants that can act as allergen carriers.

OBJECTIVE

To evaluate the immunological and functional effects of a liposome-entrapped D. pteronyssinus vaccine on mite monosensitive, mild asthma patients.

METHODS

A double-blind, placebo-controlled trial was conducted on 26 asthma patients who randomly received vaccination or placebo for 1 year. The levels of exposure to Der p 1 allergen were constant during the study. Allergen bronchial challenge was made at the beginning (T0) and after 1 year of treatment (T12). The day before and 24 h after the allergen provocation, patients were challenged with methacholine (Mth) (until FEV1 fell by 40%) and blood and sputum samples were obtained. Dose-response curves to Mth were evaluated in terms of Mth-PD20 (dose of Mth that induced 20% drop in FEV1), slope (Mth-DRS) and level of plateau. Blood and sputum eosinophils and serum levels of eosinophil cationic protein (ECP) and intercellular adhesion molecule-1 (ICAM-1) were measured.

RESULTS

Groups were comparable at the start of the trial. At TI2, previous to the allergen challenge, the active group showed higher values of both FEV1 and Mth-PD20 and lower values of Mth-DRS. The number of patients presenting a level of plateau increased in the active group (from two to four) and decreased in the placebo group (from two to one). At T12, before the allergen challenge, serum ECP levels increased in the placebo group and blood eosinophils showed a trend towards lower numbers in the active one. The immediate response and the changes in Mth-DRS values, sputum eosinophils and serum ECP levels following the allergen challenge were attenuated in the active group.

CONCLUSION

Liposome-entrapped D. Pteronyssinus vaccination: (i) protects mild asthma patients from the worsening of asthma due to sustained mite exposure; and (ii) reduces the functional and inflammatory changes induced by allergen bronchial provocation.

Tolerance of immunotherapy with a standardized extract of Alternaria tenuis in patients with rhinitis and bronchial asthma

We studied the safety of immunotherapy with an Alternaria extract in patients with rhinitis and bronchial asthma. The few studies that have investigated immunotherapy with mold allergens suggest that they cause adverse reactions more frequently than do other extracts. All treatments prescribed by our allergology service with Alternaria immunotherapy between 1988 and 1996 were recorded and analyzed. In all cases a biologically standardized depot extract of Alternaria tenuis containing 5 BU/ml was used according to a conventional immunotherapy schedule. During the study period 129 patients received immunotherapy with Alternaria extract. Of the 3,892 doses given, 1.95% led to adverse reactions, which occurred in 39.5% of the patients. Most of the adverse reactions were systemic and mild, and reproduced the underlying disease. The risk of adverse reactions was significantly higher in children, patients with asthma, and during the initial phase of treatment. Patients who suffered from adverse reactions had a significantly higher level of total and specific IgE. It was concluded that tolerance of Alternaria mold extract was worse than for other allergenic extracts, although most reactions recorded were mild. The risk of adverse reactions was greater in children and patients with asthma, and during the initial phase of immunotherapy.

Comparison of allergen-induced changes in bronchial hyperresponsiveness and airway inflammation between mildly allergic asthma patients and allergic rhinitis patients

Bronchial eosinophilic inflammation and bronchial hyperresponsiveness (BHR) are the main features of allergic asthma (AA), but they have also been demonstrated in allergic rhinitis (AR), suggesting a continuity between both diseases. In spite of not fully reproducing natural allergenic exposure, the allergen bronchial provocation test (A-BPT) has provided important knowledge of the pathophysiology of AA. Our aim was to verify the existence of a behavior of AA and AR airways different from the allergen bronchial challenge-induced airway eosinophilic inflammation and BHR changes. We studied a group of 31 mild and short-evolution AA and 15 AR patients, sensitized to Dermatophagoides pteronyssinus. The A-BPT was performed with a partially biologically standardized D. pteronyssinus extract, and known quantities of Der p 1 were inhaled. Peripheral blood (eosinophils and ECP) and induced sputum (percentage cell counts, ECP, albumin, tryptase, and interleukin [IL]-5) were analyzed, before and 24 h after A-BPT. Methacholine BHR, assessed before and 32 h after the A-BPT, was defined by M-PD20 values and, when possible, by maximal response plateau (MRP). The A-BPT was well tolerated by all the patients. AA presented a lower Der p 1 PD20 and a higher occurrence of late-phase responses (LPR). M-PD20 values decreased in AA, but not in AR, patients. MRP values increased in both groups. Eosinophils numbers and ECP levels increased in blood and sputum from both AA and AR, but only the absolute increment of sputum ECP levels was higher in AA than AR patients (P = 0.025). The A-BPT induced no change in sputum albumin, tryptase, or IL-5 values. We conclude as follows: 1) In spite of presenting a lower degree of bronchial sensitivity to allergen, AR patients responded to allergen inhalation with an eosinophilic inflammation enhancement very similar to that observed among AA. 2) MRP levels increased in both AA and AR patients after allergen challenge; however, M-PD20 values significantly changed only in the AA group, suggesting that the components of the airway response to methacholine were controlled by different mechanisms. 3) It is possible that the differences between AR and AA lie only in the quantitative bronchial response to allergen inhalation.

Airway inflammation in asthma and perennial allergic rhinitis. Relationship with nonspecific bronchial responsiveness and maximal airway narrowing

BACKGROUND

Eosinophilic airway inflammation is the hallmark of asthma, but it has also been reported in other conditions such as allergic rhinitis. We have tested whether the analysis of cells and chemicals in sputum can distinguish between patients with mild allergic asthma, those with allergic rhinitis, and healthy controls. The relationship between inflammation markers in sputum and nonspecific bronchial hyperresponsiveness to methacholine (BHR) (PD20 and maximal response plateau [MRP] values) was also evaluated.

METHODS

We selected 31 mild asthmatics and 15 rhinitis patients sensitized to house-dust mite. As a control group, we studied 10 healthy subjects. Every subject underwent the methacholine bronchial provocation test (M-BPT) and sputum induction. Blood eosinophils and serum ECP levels were measured. Sputum cell differentials were assessed, and eosinophil cationic protein (ECP), tryptase, albumin, and interleukin (IL)-5 levels were measured in the entire sputum supernatant.

RESULTS

Blood eosinophils and serum ECP levels were higher in asthma patients and rhinitis than in healthy controls, but no difference between asthma patients and rhinitis patients was found. Asthmatics had higher eosinophil counts and higher ECP and tryptase levels in sputum than rhinitis patients or control subjects. Sputum albumin levels were higher in asthmatics than in controls. Rhinitis patients exhibited higher sputum eosinophils than healthy controls. An association between sputum eosinophil numbers and MPR values (r= -0.57) was detected, and a trend toward correlation between sputum ECP levels and PD20 values (r= -0.47) was found in the rhinitis group, but not in asthmatics. No correlation between blood eosinophilic inflammation and lung functional indices was found.

CONCLUSIONS

Induced sputum is an accurate method to study bronchial inflammation, allowing one to distinguish between rhinitis patients and mildly asthmatic patients. The fact that no relationship was detected between sputum inflammation and BHR suggests that other factors, such as airway remodeling, may be at least partly responsible for BHR in asthma.

Effect of current exposure to Der p 1 on asthma symptoms, airway inflammation, and bronchial hyperresponsiveness in mite-allergic asthmatics

The existence of a dose-response relationship between indoor allergen exposure and sensitization has been widely described, but the effect of allergen exposure on asthma activity (symptoms, bronchial hyperresponsiveness [BHR], and inflammation) is not clear. Our aim was to determine the existence of an association among current exposure to mite allergens and symptoms, BHR, and airway inflammation assessed in blood and sputum from asthmatic patients sensitized to Dermatophagoides pteronyssinus. We selected 31 mild and recently diagnosed (12-24 months) asthma patients sensitized to D. pteronyssinus. Allergenic exposure (Der p 1, Der 2) was assessed by a commercial assay based on monoclonal antibodies (mAb), carried out on the dust samples collected from patients' beds in a standardized way. Patients completed an asthma symptom questionnaire and underwent skin tests, methacholine bronchial challenge, and sputum induction. Sputum cell profile was analyzed and eosinophil cationic protein (ECP), tryptase, albumin, and interleukin(IL)-5 levels were quantified in sputum supernatant. Total eosinophil numbers and ECP levels were measured in blood samples. Most patients were exposed to Der p 1 levels under 2 microg/g of dust. Der p 1 exposure was higher among the subjects with positive sputum tryptase detection (P = 0.020). Der p 1 levels showed a trend toward correlation with asthma symptoms (P = 0.066, r = 0.36) and correlated with sputum tryptase levels (P = 0.032, r = 0.42). No relationship between BHR, eosinophilic inflammation, and allergenic exposure was found. Our results suggest that asthma symptoms and lung mast-cell activation are at least partially dependent on current allergen exposure. The lack of correlation between mite exposure, eosinophilic inflammation, and BHR supports the role of other factors that enhance the immunologic response initiated by allergen, increasing the activity of asthma.

Eosinophilic gastroenteritis and Anisakis

BACKGROUND

The differential diagnosis of eosinophilic gastroenteritis (EG) includes, among other diseases, parasitic infections such as anisakiasis, which has acquired worldwide importance.

METHODS

We reviewed all patients referred to our allergy service who had been diagnosed as having primary EG to determine the possible role of Anisakis simplex in the etiopathology of the disease. All patients (n = 10) were studied and diagnosed as having primary EG between 1989 and 1996, inclusive. Two different groups of subjects were used as controls: group A (149 subjects without digestive disorder) and group B (10 subjects with digestive disorder different from EG). Cutaneous prick tests were performed with the main foods, aeroallergens, and commercial extract of A. simplex. Total and specific serum IgE was measured in all patients. Gastric or gut histologic specimens were re-examined in five cases.

RESULTS

Peripheral eosinophilia was detected in 40% of the patients with EG, and sensitization to A. simplex was detected in 80% of these. In both control groups, the rate of sensitization to A. simplex was 10%. Sensitization to A. simplex in EG patients with respect to control groups A and B showed odds ratios (OR) of 36 and 40, respectively. In one case, serialization of the histologic section allowed us to observe a whole Anisakis larva.

CONCLUSIONS

Immunologic methods to detect specific antibodies against Anisakis should be used routinely before diagnosing EG as primary disorder. Preventive measures are of capital importance.

Occupational asthma and food allergy due to carmine

Carmine (E120), a natural red dye extracted from the dried females of the insect Dactylopius coccus var. Costa (cochineal), has been reported to cause hypersensitivity reactions. We report a case of occupational asthma and food allergy due to carmine in a worker not engaged in dye manufacturing. A 35-year-old nonatopic man, who had worked for 4 years in a spice warehouse, reported asthma and rhinoconjunctivitis for 5 months, related to carmine handling in his work. Two weeks before the visit, he reported one similar episode after the ingestion of a red-colored sweet containing carmine. Peak flow showed drops higher than 25% related to carmine exposure. Prick tests with the cochineal insect and carmine were positive, but negative to common aeroallergens, several mites, foods, and spices. The methacholine test was positive. Specific bronchial challenge test with a cochineal extract was positive with a dual pattern (20% and 24% fall in FEV1). Double-blind oral challenge with E120 was positive. The patient's sera contained specific IgE for various high-molecular-weight proteins from the cochineal extract, as shown by immunoblotting. Carmine proteins can induce IgE-mediated food allergy and occupational asthma in workers using products where its presence could be easily overlooked, as well as in dye manufacture workers.

Indoor allergens and dwelling characteristics in two cities in Spain

BACKGROUND

Indoor allergens are common causes of sensitization and asthma. Climatic and home conditions can modify their levels.

OBJECTIVE

We studied the influence of climatic conditions and home characteristics on the exposure to indoor allergens of mite allergic asthmatic subjects in two Spanish cities with different climates (Las Palmas and Pamplona).

METHODS

We included 65 subjects diagnosed with asthma caused by Dermatophagoides pteronyssinus. A questionnaire about their dwellings was completed. Home dust samples were collected. Mite (Der p1, Der f1, Der 2) and cat (Fel d1) allergens were measured by a monoclonal-antibodies based ELISA.

RESULTS

Characteristics of dwellings were similar in both areas. Der p1 was the main allergen (0-44 micrograms/g). Der p1, Der f1 and Der 2 levels were higher in the homes in Las Palmas (p < 0.001, p < 0.01 and p < 0.001, respectively). Damp homes in Pamplona had higher Der p1 levels, similar to those detected in homes in Las Palmas. Fel d1 levels (0-78.90 micrograms/g) were only related to the presence of cats in the dwelling (p < 0.001).

CONCLUSIONS

D. pteronyssinus allergen exposure was influenced by climatic conditions and dampness in homes in temperate regions. Humidity in homes can generate an ideal environment for mite growth despite unfavorable outdoor climatic conditions. Fel d1 levels were only related to the presence of a cat in the house.

Immunotherapy with standardized extract of Dermatophagoides pteronyssinus in bronchial asthma: a dose-titration study

According to the maximum tolerated dose (MTD) achieved, we assessed the changes in clinical and laboratory parameters, induced by specific immunotherapy (SIT), in a group of 43 asthmatic patients sensitized to Dermatophagoides pteronyssinus, over a period of 18 months. A standardized extract (100 Bu/ml; 40 micrograms/ml of Der p 1; 20 micrograms/ml of Der p 2) was used. The patients were divided into two groups: the high-dose immunotherapy (HDI) group (MTD > or = 4 micrograms Der p I) and the conventional immunotherapy (CI) group (MTD < 4 micrograms Der p 1). Changes in clinical severity index, medication, and symptom scores; in cutaneous and conjunctival reactivity; and in the levels of specific IgE, IgG, IgG1, and IgG4 to D. pteronyssinus (Der p 1 and Der p 2) were measured (ELISA monoclonal antibodies). Safety was monitored according to the EAACI guidelines. The range of the MTD was 0.8-16 micrograms of Der p 1. Ninety percent of the patients tolerated a dose of 3.2 micrograms, but only 18% of the patients reached a maintenance dose of 16 micrograms. The medians of the accumulated dose were 197 micrograms of Der p 1 for the HDI group, and 50 micrograms for the CI group. Conjunctival and cutaneous reactivity was significantly lowered (P < 0.001) after SIT, as were the clinical severity score and medication score in both groups, without significant differences between the groups, except for cutaneous reactivity. Levels of specific IgE decreased significantly (P < 0.01) in both groups, again without significant differences between the groups. The range of the increase in medians of specific IgG, IgG1, and IgG4 was 4.4-120-fold for the HDI group and 3-24-fold for the CI group (P < 0.01). The increase in the levels of Der p 1 and Der p 2 IgG4 were correlated to the changes in cutaneous and conjunctival reactivity (P < 0.01). These results show that a maintenance dose of 3.2 micrograms Der p 1 (8 BU) can induce pronounced clinical and immunologic changes with an excellent safety profile.

Airborne contact dermatitis from Frullania

7 subjects, each giving a history of scaly or vesicular dermatitis in light-exposed areas after going for strolls to the park, the forest or the country during warm weather, were evaluated. Patch testing was carried out with Frullania dilatata and Frullania tamarisci as well as with 2 common members of the Compositae and to alantolactone and the sesquiterpene lactone mix. All the patients were positive to F. dilatata, 3 reacted to F. tamarisci as well, and 2 to florists' chrysanthemum. All of them except 1 gave positive responses to the sesquiterpene lactone mix, but only 3 reacted to alantolactone. Airborne contact dermatitis from these species of Frullania was considered to be the cause of their eczema. Patch testing with the sesquiterpene lactone mix seems to be a good screen for Frullania sensitivity; however, a variable pattern of response to these sesquiterpene-lactone-containing materials was observed, suggesting individual immunologic responses to them.

Occupational asthma and immunologic responses induced by inhaled carmine among employees at a factory making natural dyes

Carmine is a natural red dye widely used as a food coloring agent and for cosmetic manufacture. It is extracted from the dried females of the insect Dactylopius coccus var. Costa (cochineal). Although it has been reported that inhalation of carmine may give rise to occupational asthma and extrinsic allergic alveolitis, there is little evidence of its immunogenic capacity. We studied nine current employees at a factory making natural dyes and one former employee who had left this plant after occupational asthma developed. A current employee had work-related symptoms of rhinitis and asthma that were confirmed by bronchial provocation tests, and another worker had rhinitis. Immunologic sensitization to carmine and cochineal was evaluated by means of skin testing and determination of serum-specific IgE and IgG subclass antibodies by RAST and ELISA, respectively. The specificity of the RAST assay was investigated by RAST inhibition with different fractions of carmine. The three workers with respiratory symptoms had positive skin prick test reactions to both carmine and cochineal. An immediate response to the bronchial provocation test with carmine and cochineal was observed in the current employee with asthma. Specific IgE antibodies against carmine and cochineal were found only in this worker. RAST inhibition studies indicated that the main allergen had a molecular weight between 10 and 30 kd. Specific IgG antibodies against carmine and cochineal, mainly the subclasses IgG1, IgG3, and IgG4, were found in the 10 subjects surveyed. These findings suggest that carmine may induce immunologic responses, most likely IgE mediated in workers with symptoms of occupational asthma.