Aspirin-sensitive rhinosinusitis/asthma: spectrum of adverse reactions to aspirin

In order to determine the types of respiratory responses observed during aspirin-induced reactions, 50 consecutive asthmatic patients with a history of aspirin sensitivity underwent prospective oral aspirin challenges between 1979 and 1981. Oral aspirin challenges produced 36 asthmatic responses (33 combined with rhinitis and three purely asthmatic) and six acute rhinoconjunctivitis responses (three combined with mild asthma and three purely rhinoconjunctivitis) but failed to stimulate any reaction in eight patients. The results produced by these challenges were then compared with results recorded during additional aspirin challenges in 28 of these patients, performed after the index challenge in 1979-1981 in 26 patients and in the case of two patients before 1979. The type of respiratory response to aspirin varied significantly in 11 (39%) of the 28 patients and included disappearance of aspirin reactivity in four patients.

Aspirin-sensitive rhinosinusitis: the clinical syndrome and effects of aspirin administration

Nineteen aspirin sensitive adult patients were identified who experienced naso-ocular responses without associated bronchospasm during standardized oral aspirin challenge. These 19 patients exhibited the characteristics of the aspirin triad except asthma. These included hypertrophic rhinitis with or without associated nasal polyps, abnormal sinus roentgenograms, nasal eosinophilia, aspirin-provoked responses of the upper airway identical to those observed in aspirin-sensitive asthmatics, capacity of the upper airway to be desensitized to aspirin, and cross-reactivity and/or cross-desensitization of the upper airway to indomethacin. Of the 17 patients who were treated with daily aspirin after desensitization, 77% experienced improvement in their nasal symptoms.

Aspirin desensitization in aspirin-sensitive asthmatic patients: clinical manifestations and characterization of the refractory period

Thirty aspirin-sensitive asthmatic patients underwent incremental, oral aspirin challenge until a "positive reaction" (delta FEV1 greater than or equal to 25%) occurred. After this reaction, aspirin was readministered in an attempt to achieve "desensitization." This was defined as the ability of the patient to ingest 650 mg of aspirin without experiencing upper or lower respiratory-tract symptoms or a decrease in lung function. To determine the "refractory period" following aspirin desensitization, patients were rechallenged after various intervals (days) without aspirin until a positive reaction recurred. All 30 aspirin-sensitive asthmatic patients were successfully desensitized to aspirin. Individual patient refractory periods ranged from less than 2 days to greater than 5 days, with most patients gradually returning to sensitivity between 2 to 4 days. Cross-densensitization with indomethacin and other nonsteroidal anti-inflammatory drugs was also demonstrated. These studies show that aspirin desensitization can be safely achieved in aspirin-sensitive asthmatic patients; however, this desensitization will gradually disappear over several days when additional aspirin is withheld.

Increased peripheral blood monocytes with Fc receptors for IgE in patients with severe allergic disorders

Peripheral blood monocytes, defined as latex bead-ingesting mononuclear cells, from 15 healthy nonallergic donors and 22 patients with allergic disorders were analyzed for Fc receptors for IgE (Fc epsilon) by a rosette assay employing ox erythrocytes coated with IgE. The patients were divided into 3 groups. Group I: 12 patients with mild to moderate atopic disease and serum IgE levels up to 2300 IU/ml. Group II: 6 patients with severe generalized atopic dermatitis, allergic rhinitis, and asthma, of which 5 had IgE serum levels of 8000 to 77,500 IU/ml. Group III: 4 severely atopic patients with IgE levels greater than 10,000 IU/ml and receiving oral corticosteroids. The numbers of monocytes were similar in healthy donors and patients. In contrast, severely atopic patients (Group II) had significantly more (p less than 0.01) Fc epsilon + monocytes (107 +/- 42/mm3) than healthy donors (20 +/- 14/mm3) or patients of Group I (31 +/- 14/mm3). Patients of Group III had significantly fewer (p less than 0.05) Fc epsilon + monocytes (12 +/- 16/mm3) than controls and patients of Groups I and II. We conclude that patients with severe allergic disorders have a significant increase of peripheral blood monocytes with Fc receptors for IgE, which suggests that these cells may participate in the pathophysiology of atopic disease.

Increased peripheral blood monocytes with Fc receptors for IgE in patients with severe allergic disorders

Peripheral blood monocytes, defined as latex bead-ingesting mononuclear cells, from 15 healthy nonallergic donors and 22 patients with allergic disorders were analyzed for Fc receptors for IgE (Fc epsilon) by a rosette assay employing ox erythrocytes coated with IgE. The patients were divided into 3 groups. Group I: 12 patients with mild to moderate atopic disease and serum IgE levels up to 2300 IU/ml. Group II: 6 patients with severe generalized atopic dermatitis, allergic rhinitis, and asthma, of which 5 had IgE serum levels of 8000 to 77,500 IU/ml. Group III: 4 severely atopic patients with IgE levels greater than 10,000 IU/ml and receiving oral corticosteroids. The numbers of monocytes were similar in healthy donors and patients. In contrast, severely atopic patients (Group II) had significantly more (p less than 0.01) Fc epsilon + monocytes (107 +/- 42/mm3) than healthy donors (20 +/- 14/mm3) or patients of Group I (31 +/- 14/mm3). Patients of Group III had significantly fewer (p less than 0.05) Fc epsilon + monocytes (12 +/- 16/mm3) than controls and patients of Groups I and II. We conclude that patients with severe allergic disorders have a significant increase of peripheral blood monocytes with Fc receptors for IgE, which suggests that these cells may participate in the pathophysiology of atopic disease.

Increased IgE-dependent cytotoxicity by blood mononuclear cells of allergic patients

Peripheral blood mononuclear cells from 14 healthy donors and 22 allergic patients were incubated with 51Cr-labelled chicken erythrocytes coated with an IgE myeloma protein or rabbit IgG antibodies. Mononuclear cells from patients with severe atopic disorders released a significantly greater percentage of 51Cr (P less than 0.001) from IgE-coated target cells than mononuclear cells from healthy controls, patients with mild atopic disease, or patients with severe atopic disease taking oral prednisone. Specific 51Cr-release from IgE-coated target cells was directly correlated to the percentage of monocytes (latex-ingesting cells) with Fc receptors for IgE (r = 0.87, P less than 0.01) as detected by a rosette assay employing ox erythrocytes coated with IgE. Mononuclear cells from patients and normals released similar amounts of 51Cr from IgG-sensitized target cells. Depletion of monocytes from mononuclear cell preparations from two severe atopic patients decreased 51Cr-release from IgE-coated target cells to levels seen in healthy donors or patients with mild allergic disease. These results demonstrate that mononuclear cells from severely allergic patients have a significantly increased cytotoxicity toward IgE-coated targets coated target cells and that this cytotoxicity correlates highly with the percentage of monocytes with Fc receptors for IgE in these mononuclear preparations.

Efficacy of troleandomycin in outpatients with severe, corticosteroid-dependent asthma

Sixteen severe, corticosteroid-dependent yet resistant outpatient asthmatics were treated with troleandomycin (TAO), a macrolide antibiotic, in an attempt to both induce a clinical remission and reduce methylprednisolone requirements. Within the first 2 wk of initiating TAO therapy, 50% of the patients experienced a greater than 20% increase in forced expiratory volume in 1 sec (FEV1) and 80% noted a greater than 20% increase in forced vital capacity between 25% and 75% (FVC 25%-75%). Maximal increases in FEV1 and FVC 25%-75% were noted in all patients within the first 6 wk on TAO and methylprednisolone. There was a concomitant clinical improvement in all patients. Corticosteroid-induced side effects, gastrointestinal tract discomfort, and elevated serum glutamic pyruvic transaminase (SGPT) were common yet generally transient during TAO and methylprednisolone therapy. After a 4- to 18-mo follow-up 15/16 patients were well-controlled on TAO and methylprednisolone. Methylprednisolone requirements were reduced at least four- to fivefold in most patients during TAO therapy. Normal morning serum cortisol levels were documented after varying intervals in most patients when both TAO (250 mg) and methylprednisolone (4 to 16 mg) could be reduced to alternate-day administration. Only one patient was forced to discontinue therapy due to side effects. The present study extends the effectiveness of TAO therapy to ambulatory asthmatics, establishes a clinical strategy that maximizes benefit/risk factors, and provides practical guidelines for the long-term use of TAO and methylprednisolone.

Complement-dependent histaminase release from human granulocytes

The role of particle-bound complement proteins in the induction of noncytotoxic enzyme release from human granulocytes was investigated with the use of sera genetically deficient in complement and highly purified complement components. Release of histaminase, one of two important histamine catabolizing enzymes, and beta-glucuronidase from polymorphonuclear leukocytes was solely dependent on particle-bound C3b (the larger cleavage product of the third component of complement) when fluid-phase complement was excluded. The extent of enzyme release was a function of particle-bound C3b input, was reduced by exposing the particles to C3b inactivator, and was blocked by fluid-phase C3b. Phagocytosis of the C3b-coated particles was not required for enzyme release from neutrophils. In contrast, phagocytosis of "opsonized" particles was required for noncytotoxic release of histaminase and arylsulfatase from eosinophils; other proteins, as well as C3b, were able to opsonize particles for induction of enzyme release from eosinophils. These studies suggest a dual role for complement (particularly C3) in modulating vascular permeability phenomena, i.e., release of vasoactive mediators by the action of C3a and C5a, and release of the corresponding enzymes that inactivate the mediators by C3b.

Delayed cold-induced urticaria: a dominantly inherited disorder

A delayed cutaneous response to cold, characterized by areas of erythematous, edematous deep swelling at 9 to 18 hr after experimental ice challenge, was recognized in a 10-yr-old boy and several members of his family. Biopsy of the cold-induced lesion showed edema and an infiltrate of mononuclear cells; mast cells were normal, and immunoglobulins, complement factors, and fibrin were not detected by immunofluorescence techniques. Local cold challenge did not release histamine or induce alterations in the complement system or the enzymes, histaminase, and histamine methyl transferase. The delayed cutaneous response to cold could not be passively transferred with serum or tissue extracts to monkey skin. Family studies suggested an autosomal-dominant mode of inheritance.

Histaminase release from human eosinophils

Phagocytosis of opsonized zymosan by human eosinophils results in a dose-dependent noncytotoxic release of histaminase as well as arylsulfatase and beta-glucuronidase. The calcium ionophore A23187 also stimulates release of eosinophil histaminase at concentrations of ionophore which barely release arylsulfatase and beta-glucuronidase. Zymosan-induced histaminase release from eosinophils but not from neutrophils was abolished or markedly reduced in the presence of cytochalasin B, suggesting a difference in the mechanisms of histaminase release from the two granulocyte cell types.

Histaminase release from human granulocytes

Histaminase (EC-1.4.3.6), one of the two catabolic enzymes for histamine, is contained in human granulocytes. Opsonized zymosan or the calcium ionophore A-23187 induce a dose-dependent release of histaminase from human granulocytes in vitro. Release is completed within 30 min, is temperature dependent, and requires divalent cations. Opsonized zymosan-induced histaminase release was maximal in the presence of both calcium and magnesium, whereas ionophore release was magnesium independent. The total cellular content of histaminase could be released by both opsonized zymosan and ionophore. In contrast, only 25% of the cellular beta glucuronidase, a lysosomal enzyme, was released after maximal stimulation with opsonized zymosan; there was minimal release of beta glucuronidase with ionophore. Zymosan- and ionophore-induced histaminase release was inhibited by agents that are presumed to interfere with cell metabolism and disrupt microtubules. Human granulocytes therefore may modulate the effect of histamine by releasing histaminase at a site of inflammation. Studies of granulocyte histaminase release in vitro may also provide a new model to explore granulocyte function and secretion.

Histamine metabolism. II. Cellular and subcellular localization of the catabolic enzymes, histaminase and histamine methyl transferase, in human leukocytes

Histaminase (EC 1.4.3.6) activity has been demonstrated in human eosinophils and neutrophils, but not in mononuclear cells, with the use of a new and specific thin-layer radiochromatographic enzyme assay. Leukocyte histaminase was physicochemically and functionally similar to histaminase isolated from human placenta and was principally localized to the 27,000-g granule-rich fraction of eosinophil and neutrophil homogenates. Histamine methyl transferase (EC 2.1.1.8), on the other hand, was detected in monocytes but not in granulocytes, eosinophils, lymphocytes, or platelets, and was localized solely to the 100,000-g cell sap supernatant fraction. These data suggest a role of human leukocytes in the catabolism of histamine and therefore in the modulation of histamine-mediated inflammatory reactions.

Histamine metabolism. I. Thin-layer radiochromatographic assays for histaminase and histidine decarboxylase enzyme activities

Thin-layer radiochromatographic methods for the measurement of histaminase and histidine decarboxylase activities have been developed. The assays are specific for the respective enzymes, are sensitive and reproducible, and can be performed using commercially available substrates. The histaminase assay permits determination of enzyme activity from 2.5 mul of pregnancy sera, 1-2 X 10(6) human granulocytes, and microgram quantities of partially purified human placenta histaminase with an error of less than 5 per cent. The histidine decarboxylase assay permits measurement of nanogram quantities of newly formed histamine from as few as 2 X 10(4) rat peritoneal mast cells or rat basophilic leukemia cells with an error of less than 5 per cent.