Incidence of systemic reactions during rush immunotherapy

Rush immunotherapy (RIT) was administered on an outpatient basis to 11 patients. Of these, nine had asthma and four were steroid-dependent. All patients received extracts containing a mixture of antigens to which they were prick-sensitive. FEV1s were greater than 80% predicted before starting RIT. Four patients each required a 1 week steroid "burst" to accomplish this. A series of 8 subcutaneous injections were given starting with 0.3 mL of 1:100,000 (wt/vol) and ending with 0.10 mL of 1:100 (wt/vol) 1.5 days later. A dose of 0.15 mL of 1:100 was given weekly after that. All patients but one completed the RIT. Four had sore arms, four had pruritus and/or sneezing, four developed wheezing, and one experienced anaphylaxis with hypotension. Systemic reactions tended to occur at the higher doses and usually more than 30 minutes after a previous injection. Subsequent weekly injections were tolerated without reactions by seven of the patients. Rush immunotherapy is an effective method for administering a high dose of allergen in a very short time period. Due to the risk of systemic reactions it needs to be given under carefully controlled conditions.

Methotrexate treatment of severe asthma in children

Seven children from 3 to 14 years old with chronic steroid-dependent asthma were treated with methotrexate (MTX). Asthma in all of the patients had been poorly controlled for at least 2 years despite the use of oral theophylline and inhaled corticosteroids, cromolyn and albuterol. All presented with significant side effects as a result of chronic systemic steroid therapy. Five patients were atopic and had been unable to tolerate immunotherapy because of systemic reactions. Forced expiratory volume in 1 second and forced expiratory flow, mid-expiratory phase, improved in four patients after 4 to 6 months of treatment with doses of MTX ranging from 7.5 to 17.5 mg/wk. Three patients were able to discontinue their systemic corticosteroids. Laboratory values including complete blood cell count with differential and liver enzymes remained at baseline in all except one patient, who had transient elevation in alanine aminotransferase and aspartate aminotransferase. One patient experienced side effects sufficient to require discontinuation of MTX. It is concluded that MTX is effective for reducing the need for systemic corticosteroids and for improving pulmonary functions in some individuals. The benefits of MTX in this group of severe asthmatics appear to justify the potential risks involved in its use.

Separation of Alternaria into protein and carbohydrate fractions with phenyl sepharose

To evaluate the contribution of high carbohydrate-containing fractions to the allergen content of Alternaria, samples of an Alternaria extract were bound to a phenyl Sepharose column and eluted with Tris buffer containing 4, 2, and 1 mol/L of NaCl and then distilled water. The fractions were dialyzed and lyophilized. The 4 mol/L fraction accounted for 79% of the dry weight and most of the carbohydrate content. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the fractions demonstrated significant interfraction differences with the largest number of silver-stained bands in the H2O fraction. Although individual differences in skin reactivity to the fractions were present, geometric means of histamine equivalent pricks were approximately the same with only a 0.5 log dilution higher potency for the 1 mol/L and H2O fractions. The 50% IgE ELISA-inhibition concentration was 100 micrograms/ml for the 1 mol/L and distilled water fractions and 10 micrograms/ml for the other fractions. Since the 4 mol/L fraction accounted for most of the dry weight and had the highest carbohydrate to protein ratio (5.8), purification of Alternaria extracts by removal of carbohydrate fractions may result in significant loss of allergenic material.

Restriction endonuclease patterns of herpes simplex virus DNA: subtyping of HSV-1 and HSV-2 strains from genital and nongenital lesions

Herpes simplex type 1 (HSV-1) and type 2 (HSV-2) isolates from genital and nongenital infections were submitted to restriction endonuclease analysis for possible genomic changes in relation with the adaptation of the virus to a new site on the body. HSV-1 and HSV-2 strains were successfully divided into two subgroups using the Hin c II restriction enzyme. No correlation was found, however, between the proposed genomic subtypes H1A, H1B, H2A and H2B, and the genital or nongenital origin of the HSV strains.

Affinity purification of a major Alternaria allergen using a monoclonal antibody

An extract of Alternaria (ALT) was passed through an affinity column containing a monoclonal antibody directed to ALT. After washing the column, a single glycoprotein was eluted using 0.1 M glycine (pH 3.0). This glycoprotein accounted for 13% of the dry weight of our ALT preparation and had a carbohydrate to protein ratio of 0.35 as compared with 3.2 for the whole ALT extract. Its molecular weight was 70 kD by SDS-PAGE and isoelectric point was 3.5 by IEF. Though individual sensitivities varied, 14/16 patients skin reactive to ALT were also reactive to this glycoprotein. Quantitative skin tests of extracts adjusted to the same dry weight per volume showed that it required about a four times greater concentration of the purified glycoprotein to give a wheal size equal to whole Alternaria. The ability to purify large amounts of this allergen with affinity chromatography should make its complete characterization possible.

Replacement of special enzyme immunoassay transport medium by a standard viral transport medium in the Herpcheck herpes simplex virus antigen detection test

A new direct herpes simplex virus antigen enzyme immunoassay (EIA) uses a special EIA transport medium (ETM) for transport of herpes simplex virus (HSV) specimens. As ETM lyses the virus precluding culture and typing, we evaluated the relative performance of this EIA when performed on specimens transported in either ETM or a standard viral transport medium (VTM). These EIA results were also compared to cell culture performed on specimens transported in VTM (VTM-CC) and direct rapid inoculation into cell culture (CC). Based on all confirmed positives, by any test, the sensitivities for CC was 97% (66/68), for VTM-CC 91% (62/68), for ETM-EIA 97% (66/68), and for VTM-EIA 93% (63/68). It appears that VTM may be a slightly less desirable substitute than ETM in the performance of EIA. However, VTM-EIA is certainly as sensitive as cell culture performed on VTM.

Diagnosis of herpes simplex virus infection in a clinical setting by a direct antigen detection enzyme immunoassay kit

A commercial 4-h direct herpes simplex virus (HSV) antigen detection enzyme immunoassay (EIA) kit (Du Pont Herpchek) was evaluated by using 273 clinical specimens obtained in a hospital-based infectious disease practice. The EIA was compared with a standard culture method in which WI38 cells were inoculated within 20 min of sample collection. Cultures were observed for 2 weeks, and positive findings were confirmed by fluorescein-labeled monoclonal antibody (FA) staining. The values for the overall HSV detection rate were 40.7% by the standard culture method and 41.4% by EIA. In eight cases, the EIA was positive, while the culture method was negative; however, clinical data and confirmatory blocking EIA suggested that a true HSV infection was present. For six FA-confirmed, culture-positive samples, the direct EIA was negative; however, an EIA performed on the supernatants of these cultures was positive, suggesting that the failure of the EIA to detect these samples was not due to lack of strain specificity of the test. After confirmatory tests of standard culture and EIA discrepant results, the overall sensitivity of the test was 95.0% (113 of 119) and the specificity was 100% (154 of 154).

One-year suppression of frequent recurrences of genital herpes with oral acyclovir

A double-blind, placebo-controlled study was undertaken to evaluate the long-term efficacy and safety of oral acyclovir suppressive therapy over a 1-year period. Results from the multicenter trials, based on a total of 261 patients with frequently recurring genital herpes, were analyzed. Of the patients enrolled in the study, 131 received oral acyclovir capsules (800 mg) daily and 130 received placebo capsules. Medication was taken twice daily. Analysis of data from patients who completed a full year of therapy demonstrated that only 5% of patients receiving placebo were free from recurrences, as compared with 46% of acyclovir recipients. The mean number of recurrences for patients on acyclovir therapy was 1.8, as compared with a rate of 8.7 recurrences for the placebo group over the course of the year. The mean time to the first recurrent herpes outbreaks was 19 days for the placebo group and 274 days for the acyclovir-treated patients. There were no significant differences between the two groups in laboratory data or in the frequency or nature of side effects reported. Daily administration of acyclovir capsules for 1 year is a safe and effective therapy for control of frequent recurrences of genital herpes.

Pilot study of recombinant interferon alpha-2a for treatment of infants with bronchiolitis induced by respiratory syncytial virus

Eleven children with bronchiolitis induced by respiratory syncytial virus received 10,000 to 70,000 U of recombinant interferon alpha-2a per kg of body weight per day. None developed signs of toxicity, and all but one developed an antiviral state following treatment. Interferon alpha-2a appears to be safe for infants with bronchiolitis. Its efficacy for the treatment of this condition remains to be determined.

Continuous terbutaline nebulization for the treatment of severe exacerbations of asthma in children

Twelve children with severe asthma were treated in an intensive care unit with continuously nebulized terbutaline at doses between 1.0 and 12.0 mg/hour. All patients showed improvement in blood gases, pulse, and respiratory rates. None experience significant side effects. The duration of therapy ranged from 1 to 24 hours (mean = 8.3 hours), and all were able to leave the intensive care unit within one day. The use of continuously nebulized terbutaline appears to be safe and effective for the treatment of severe asthma in children in this limited experience.

Efficacy and safety of foscarnet for recurrent orolabial herpes: a multicentre randomized double-blind study

Foscarnet sodium (trisodium phosphonoformate hexahydrate) has been shown to inhibit herpes simplex virus (HSV) in vitro and to be efficacious for topical treatment of experimental HSV infection in animals. To assess its clinical efficacy in the treatment of recurrent orolabial herpes a multicentre collaborative, double-blind, placebo-controlled trial was conducted. The study patients were randomly assigned to receive either 3% foscarnet cream (78 patients) or placebo (cream vehicle) (75 patients) and were asked to start treatment at the earliest indication of a recurrence. Efficacy was evaluated in 143 patients (74 in the foscarnet group and 69 in the placebo group). There was no significant difference in time to healing or duration of virus shedding between the two groups. However, in the subgroup of patients who started treatment before vesicles appeared, the duration of virus shedding was shorter in the foscarnet group than in the placebo group (p = 0.04), and the proportion of lesions that evolved to the vesicular stage was smaller (p = 0.03). No significant difference in the incidence of local or systemic adverse effects was noted between the two groups. We conclude that the beneficial effect of foscarnet was limited to a subgroup of patients who started treatment in the prevesicular stage.

Epicoccum allergy: skin reaction patterns and spore/mycelium disparities recognized by IgG and IgE ELISA inhibition

Comparable degrees of skin reactivity were observed towards spore and mycelium extracts from two isolates of Epicoccum and to one preparation of Alternaria in 35 rural and 120 university patients. The best experimental extracts detected Epicoccum sensitivity in 70% of the group tested while the commercial extract detected sensitivity in only 6%. Skin reaction correlations were greatest within isolates (eg, spore-A/mycelium-A), then for specific fungus parts (eg, spore-A/spore-B), then between isolates and parts (spore-A/mycelium-B). High correlations were found between individual IgG and IgE ELISA values for all antigens using serum from Epicoccum skin-reactive patients. ELISA inhibition results suggested that significant cross-reactivity exists between Epicoccum and Alternaria antigens recognized by IgG but not by IgE. ELISA inhibition cross-reaction patterns among Epicoccum antigens were comparable to skin reactions while IgG patterns showed little variability. Further characterization of spore/mycelium and interstrain recognition patterns among different immunoglobulin isotypes will be necessary before complete standardization of extracts from different parts of fungi will be possible. The use of spore material for skin testing and treatment of Epicoccum sensitivity appears to be both premature and unnecessary at this time.

False-positive results of confirmatory testing for antibody to HIV-I

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Specific stimulation of lymphocytes from patients with AIDS by herpes simplex virus antigens

Peripheral blood lymphocytes of patients with AIDS are generally anergic to stimulation by lectins or by alloantigens. We have succeeded in demonstrating that the lymphocytes of six AIDS patients, with histories of herpes simplex virus (HSV)-induced genital, anal and/or oral lesions, retained functional specificity with regard to HSV antigens. This was accomplished by treating patient lymphocytes with OKT8 monoclonal antibodies, in the presence of complement, to yield a cell population that was partially responsive to phytohaemagglutinin (PHA). Enhanced proliferation was obtained in the presence of exogenous interleukin-2, which was also employed to foster the growth of these cells over several generations. Lymphocytes derived from these AIDS patients, and maintained in vitro as described, were specifically stimulated in proliferation assays by a HSV antigen preparation in six of the ten cases studied.

Clinical course of recurrent genital herpes and treatment with foscarnet cream: results of a Canadian multicenter trial

Clinic-initiated topical treatment of recurrent genital herpes with foscarnet cream (concentration, 0.3% in men and 1% in women) was compared with a placebo in a Canadian multicenter trial involving 309 patients. Culture-positive episodes of herpes took significantly longer to heal than did the others. Lesions in men were larger and lasted longer but were less symptomatic than those in women. Foscarnet did not statistically improve the times to healing or the loss of symptoms overall but did result in a higher proportion of symptom-free individuals after one day of treatment. Foscarnet-treated patients had a reduced duration of shedding of virus, and this was significant for men. These clinical benefits do not, however, warrant general use of this agent for established lesions. Earlier, prodromal treatment might have been more effective, but patient-initiated studies include a greater proportion of culture-negative (shorter) episodes that often make results difficult to interpret.

Intractable sneezing with a specific psychogenic origin

A case of intractable sneezing due to a specific psychogenic cause is described. Identification of the cause led to resolution of the symptoms which had not otherwise responded to maximum pharmacologic intervention.