Topical nasal sprays: treatment of allergic rhinitis

Topical nasal sprays, especially steroids, have regained favor as treatment for allergic rhinitis. Nasal steroids are widely used and are as safe and effective as antihistamines in controlling symptoms of rhinitis. However, if improperly used, steroids can have side effects. It is essential that patients learn correct techniques for administering nasal steroids and understand complications that can result from nasal steroid use. New steroid drugs, such as budesonide, tripedane and fluticasone, are being evaluated and will be available in the near future. Other topical drugs, such as cromolyn and ipratropium, are also effective. Over-the-counter decongestants are helpful in reducing nasal congestion and allowing other topical medicines to penetrate effectively into the nasal cavity, but their use should be limited to no more than three days. Prolonged use of topical nasal decongestants has no place in the treatment of allergic rhinitis and can be associated with significant side effects.

Suppression of an antibody to adenosine-deaminase (ADA) in an ADA-deficient patient receiving polyethylene glycol modified adenosine deaminase

An adenosine deaminase (ADA) deficient patient with severe combined immunodeficiency (SCID) developed resistance to therapeutic injections of bovine ADA conjugated to polyethylene glycol (PEG-ADA). This 18-year-old girl was diagnosed as having partial ADA deficiency at age 7 years, and was started on bovine conjugated PEG-ADA at age 15 years. The weekly dose of 15 U/kg led to clinical improvement with resolution of sinusitis and bronchitis within 2 months and normalization of some T cell functions. After 5 months, however, she developed an inhibitory antibody to ADA, became refractory to treatment with PEG-ADA, and clinically and immunologically deteriorated. This antibody was successfully suppressed over a 4-month period with a combination of prednisone (2 mg/kg/day), intravenous immunoglobulin (2 g/kg/dose), and discontinuing the PEG-ADA injections for 7 weeks. The PEG-ADA injections were then restarted at a higher dose (20 U/kg/dose, twice a week). With the suppression of the inhibitory antibody, her clinical and immunologic status improved to previously achieved level. She has subsequently continued treatment for over 36 months, receiving a single weekly dose of PEG-ADA (20 U/kg/week) with sustained clinical and immunologic improvement, including weakly positive antigen-specific T cell proliferative responses to tetanus and Candida.

Antibody responses to bacteriophage phi X174 in patients with adenosine deaminase deficiency

Adenosine deaminase (ADA) deficiency and its biochemical consequences cause severe combined immunodeficiency (SCID). Treatment strategies, designed to correct the biochemical abnormalities, include transplantation of matched bone marrow or haploidentical bone marrow stem cells, repeated partial exchange transfusions with frozen irradiated human red blood cells (RBC), or weekly injection of polyethylene glycol-modified bovine ADA (PEG-ADA). To evaluate the effect of these therapeutic options, we studied in vitro T-cell function and in vivo antibody responses to the T-cell-dependent neoantigen, bacteriophage phi X174, in 10 children with ADA-deficient SCID. In untreated patients, T-cell function was severely depressed, and only minute amounts of antibacteriophage antibody were produced. Transplantation of bone marrow from a matched sibling (one patient) or a phenotypically matched parent (one patient) resulted in a stable graft, normal T-cell function, and substantial but subnormal antibody titers to bacteriophage, with reduced memory and impaired switch from IgM to IgG. Patients receiving T-cell-depleted haploidentical bone marrow stem cells had markedly depressed antibody responses for as long as 3 years posttransplantation, despite rapidly improving T-cell function that became normal in two of four patients. Two methods of enzyme replacement were explored. During treatment with human RBC transfusions, antibody responses to bacteriophage were as severely depressed as in untreated ADA-deficient patients. Treatment with weekly injections of PEG-ADA resulted in normalization of T-cell numbers in all four patients, normal or near-normal T-cell function in two, and mildly but variably improved T-cell function in the other two patients. Quantitatively and qualitatively normal antibody responses to bacteriophage were observed in three of four patients. Assessment of antibody responses to immunization with bacteriophage phi X174 is a useful method to monitor humoral immune function in treated ADA-deficient patients and can be used to estimate when intravenous immunoglobulin (IVIG) prophylaxis may be safely discontinued.

Exercise-induced asthma

Exercise-induced asthma affects approximately 10 percent of the exercising population but often goes undiagnosed. Diagnosis is generally simple if the physician is aware of the subtle symptoms that may present during or after exercise. Preventive treatment, using a combination of exercise strategies and inhaled medications, is often successful. For patients with underlying chronic asthma that is exacerbated by exercise, long-term medication with preexercise doses is recommended.

Exercise-induced asthma, anaphylaxis, and urticaria

Exercise-induced asthma is a common but frequently undiagnosed problem. The patient may not wheeze, but rather have shortness of breath, chest tightening, and coughing. The coach and the physician must be particularly alert to the signs and symptoms of exercise-induced asthma to recognize this syndrome. Proper conditioning, warming up, inducing refractoriness, participating in sports less likely to provoke exercise-induced asthma, and the aggressive use of appropriate medications allow patients to enjoy sports and compete effectively. A rare but potentially fatal syndrome is exercise-induced anaphylaxis. Accurate diagnosis and differentiation from other exertion-related syndromes are critical, and appropriate precautions are necessary. A third clinical entity, exercise-induced cholinergic urticaria, although not life-threatening, can be quite annoying. Aggravating factors, such as increased heat, compound the problems. In summary, exercise-induced allergic phenomena are common and should be recognized by the practicing physician.

Home-based immunoglobulin infusion therapy: quality of life and patient health perceptions

Thirty-seven antibody-deficient patients who were participating in a multicenter trial evaluating home-based, self-administered IVIG therapy anonymously completed questionnaires regarding beliefs concerning health control, quality of life, and attitudes toward active participation in medical care. Their responses were compared with a group of 29 patients undergoing traditional IVIG therapy in a medical clinic setting. A subsample of the home-based group who later returned to clinic-based IVIG therapy allowed comparison of responses given by the same patients in both settings. Home-based therapy was preferred to clinic-based therapy. Independence, convenience, comfort, decreased disruption of activities, travel time, and costs were specific factors rated most favorably. On the Health Belief Questionnaires, patients preferred informed, self-involved medical care regardless of the setting for their IVIG treatments.

Home self-administration of intravenous immunoglobulin therapy in children

Twelve children with primary immunodeficiency, aged 2 to 17 years (mean +/- 1 SD = 9.8 +/- 5.3), were enrolled in a 9-month study to evaluate the feasibility and safety of home self-infusion of intravenous immunoglobulin (IVIg). An initial 2-month training and supervisory period was followed by a 6- to 7-month period during which the children or their parents infused IVIg in a home setting. Eight children received an average dose of 204 +/- 12 mg/kg every 2 weeks, two children received a dose of 400 mg/kg every month, and an additional two children received 240 to 250 mg/kg every 10 days. Peak and trough levels varied from 946 +/- 20 mg/dL and 627 +/- 16 mg/dL, respectively, in children receiving IVIg every 2 weeks. The peak-trough values for the children receiving IVIg every month were 1105 +/- 94 mg/dL and 457 +/- 78 mg/dL, while those of children receiving IVIg every 10 days were 840 +/- 24 mg/dL and 553 +/- 109 mg/dL. A total of 224 infusions were administered, with only two minor reactions occurring (reaction rate of 0.9%). There was no difference in the frequency of infections and antibiotic use during the study compared with the previous phase. The results demonstrate that home self-infusion of IVIg in children is safe and feasible.

Beclomethasone dipropionate aqueous nasal spray for seasonal allergic rhinitis in children

A 3-week double-blind, parallel group study comparing the effectiveness and safety of an aqueous formulation of beclomethasone dipropionate (BDP-AQ) versus placebo was undertaken in 101 patients. Children aged 5 to 13 years with a diagnosis of seasonal allergic rhinitis received one spray in each nostril twice daily of either BDP-AQ (42 micrograms/spray) or an identical placebo spray. Patient assessment at the end of treatment indicated statistically significant improvement in nasal symptoms for BDP-AQ patients. The physicians overall evaluation of treatment indicated that the BDP-AQ-treated patients experienced significantly greater (P = .012) improvement as compared with placebo-treated patients. There was no difference in the incidence of adverse events between the two treatments. The results demonstrate the effectiveness and safety of BDP-AQ nasal spray in the treatment of seasonal allergic rhinitis in children.

Interferon-gamma in a family with X-linked lymphoproliferative syndrome with acute Epstein-Barr virus infection

A 20-month-old male with fulminant infectious mononucleosis and the X-linked lymphoproliferative syndrome (XLP) was studied. Epstein-Barr virus (EBV)-determined nuclear antigen (EBNA) and EBV DNA were detected in various tissues. Despite a combined treatment with acyclovir, immunoglobulin, and methylprednisolone, the patient deteriorated rapidly. Following treatment with recombinant interferon-gamma (IFN-gamma), defervescence occurred and circulating EBNA-positive cells markedly decreased. IFN-gamma prior to treatment ranged from 10.8 to 24.5 U/ml in the patient's serum and increased linearly post exogenous IFN-gamma treatment. His natural killer (NK)-cell activity remained in the normal range throughout his illness but autologous EBV-infected cells were not killed in vitro by his peripheral blood lymphocytes (PBL). These results suggest that patients with the fatal infectious mononucleosis phenotype of XLP may produce endogenous IFN-gamma. Defective cytotoxic T cells against EBV-infected cells seem to be responsible for the fulminant infectious mononucleosis in this patient.

Treatment of adenosine deaminase deficiency with polyethylene glycol-modified adenosine deaminase

We treated two children who had adenosine deaminase deficiency and severe combined immunodeficiency disease by injecting bovine adenosine deaminase modified by conjugation with polyethylene glycol. The modified enzyme was rapidly absorbed after intramuscular injection and had a half-life in plasma of 48 to 72 hours. Weekly doses of approximately 15 U per kilogram of body weight maintained plasma adenosine deaminase activity at two to three times the level of erythrocyte adenosine deaminase activity in normal subjects. The principal biochemical consequences of adenosine deaminase deficiency were almost completely reversed. In erythrocytes, adenosine nucleotides increased and deoxyadenosine nucleotides decreased to less than 0.5 percent of total adenine nucleotides. The activity of S-adenosylhomocysteine hydrolase, which is inactivated by deoxyadenosine, increased to normal in red cells and nucleated marrow cells. Neither toxic effects nor hypersensitivity reactions were observed. In vitro tests of the cellular immune function of each patient showed marked improvement, along with an increase in circulating T lymphocytes. Clinical improvement was indicated by absence of infection and resumption of weight gain. We conclude that from the standpoints of efficacy, convenience, and safety, polyethylene glycol-modified adenosine deaminase is preferable to red-cell transfusion as a treatment for adenosine deaminase deficiency. Patients with other inherited metabolic diseases in which accumulated metabolites equilibrate with plasma could benefit from treatment with the appropriate polyethylene glycol-modified enzyme.

Circulating immune complexes in cystic fibrosis and their correlation to clinical parameters

Circulating immune complexes (CIC) have been found to be elevated in individuals with cystic fibrosis (CF). Previous investigators, using a variety of assays, have reported high levels of CIC in as many as 86% of these patients. Our study followed the progress of 25 patients with CF over a period of 10 months to determine which, if any, clinical parameters correlated with the occurrence and/or concentration of CIC. Immune complex determinations were performed using a coprecipitation method with equine rheumatoid-complement complex. One hundred percent of the CF patients had CIC elevated above normal levels, however, levels of CIC did not correlate with the severity of an individual's acute exacerbation. Clinical parameters including pulmonary function tests, vital signs, total serum IgG levels, and other laboratory studies, were obtained on each individual and analyzed with respect to their relationship to CIC. Only four of 38 parameters examined had p less than 0.05. Factors that showed significant correlation to elevated CIC's in the highly elevated portion of our CIC population were poor NIH score, increased patient age, low peak expiratory flow rate, and elevated total serum IgG. These clinical values are associated more with the measurement of chronic disease. These data suggest that CICs cannot be used as an indication of short-term prognosis or as a monitor to follow the course of acute severe lung infections in the CF patient. Of interest was the observation that all patients who died during the course of the investigation had CIC levels greater than 80 micrograms/ml.

Evaluation of a sustained-release theophylline tablet in young asthmatics

A sustained-release theophylline (SRT) tablet was evaluated in 15 children with moderately severe asthma between the ages of 3 and 5 years (4.2 +/- 0.83 years). They received a mean daily dose of 20.4 mg/kg given q12h for 3 or more weeks with daily symptom scores and twice daily peak flow rates (PFR) measured. Serum theophylline levels (STL) were then obtained at 0, 1, 2, 4, 6, 8, 10, and 12 hr (eight children had 24-hr samples obtained), along with PFRs every 3 hr. The mean peak STL (x +/- SD) was 16.6 +/- 4.4 and the trough was 5.9 +/- 2.8, with a peak-trough difference of 10.6 +/- 3.9. The average time to peak level was 3.9 hr. The mean +/- SD clearance was 1.42 +/- 0.63 ml/kg per min and the apparent T1/2 was 5.11 +/- 1.34 hr. The average weekly morning PFR for the 3-week period ranged from 116.8 +/- 41.2 to 127.4 +/- 37.4 L/min, and the evening PFT ranged from 126.5 +/- 38.4 to 137.0 +/- 40.9 L/min. In conclusion, the SRT tablet is effective in treating many young asthmatics on a 12-hr dosage schedule. For some children who experience excessive peak-trough differences, an 8-hr dosage schedule may be indicated.

Prostaglandin E1 therapy. Is it associated with a higher incidence of wound infection in the cyanotic neonate?

Prostaglandin (PGE1) may be used to maintain ductal patency in the infant with cyanotic congenital heart disease, but the risk of infection may be increased. Between October, 1976 and December, 1982, 38 neonates with complex cyanotic congenital heart disease required operations creating systemic-to-pulmonary artery shunts. Of 13 patients who did not receive PGE1 therapy, none developed a wound infection. Of 25 patients who did receive PGE1 therapy, four (16 percent) developed a significant wound infection. The two patient groups were similar when compared by age and weight at operation, by severity of heart disease and by the presence of other congenital anomalies. Pathogenic Staphylococcus epidermidis was recovered from all infected wounds, all of which responded favorably over a period of two to four weeks with a short course of antibiotics and wound debridement.

Serum theophylline levels in young children receiving a sustained-release theophylline tablet

This study indicates that a sustained-release tablet may be used in certain young children on an every-12-hr dosing schedule with acceptable serum theophylline fluctuation. Many young children are able to swallow the tablet and dosing increments are convenient.

Galactose inhibition of neonatal neutrophil function

To investigate possible causes for the significantly increased incidence of sepsis observed in galactosemic neonates, the in vitro effect of galactose on neutrophil function in healthy newborns was studied. Neutrophils from 25 normal newborns and 23 normal adult volunteers were incubated with 100 mg of glucose per dl, 300 mg of galactose per dl and 300 mg of galactose plus 100 mg of glucose per dl, respectively. Tests for neutrophil function included chemiluminescence (CL), chemotaxis (CTX) and adherence. Neutrophil CL (measure of bactericidal activity) was significantly depressed by galactose in both adults (30.2%) and newborns (59.5%); however, neonatal neutrophil function (CL) was depressed to a much greater extent than in adults. CTX was also significantly depressed by galactose in newborns but not in adults. Supplementing the galactose-containing medium with glucose restored both CL and CTX function to normal in adults. However, only CTX was restored in newborns, while CL remained markedly depressed. Neutrophil adhesion, a function which is not energy-dependent, was not affected by galactose in both adults and newborns. These findings indicate that depressed neutrophil function by galactose or its metabolites may contribute to the high incidence of sepsis in galactosemic neonates.