Prevalence of specific IgE to the storage mite, Aleuroglyphus ovatus

Aleuroglyphus ovatus (Ao) is a storage mite that has a worldwide distribution and has been found in stored bran, wheat, chicken meal, and dried fish products. Ao was isolated from a chicken meal sample, cultured on whole wheat flour at 75% relative humidity, and 1 gm of pure Ao bodies were extracted, 1:20 wt/vol, in 0.2 mol/L of ammonium bicarbonate. Der p I, major allergen of Dermatophagoides, pteronyssinus (Dp), or Der f I major allergen to Dermatophagoides farinae (Df), was not detected in extracts of Ao. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed 25 bands (6 to 110 kd), and thin-layer isoelectric focusing revealed 19 bands (isoelectric point, 3.5 to 9.3). Sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblots with six different sera identified nine IgE binding bands (16 to 100 kd). Thin-layer isoelectric focusing immunoblots identified 16 IgE binding bands (isoelectric point, 4.5 to 9.3). An aliquot of the Ao extract was diluted in bicarbonate buffer (pH 9.2) and adsorbed to plastic microtiter plates. RAST to Ao and Dp were performed with sera of 163 atopic individuals (88 with allergic rhinitis and 75 with allergic asthma with or without allergic rhinitis). All individuals had appropriately positive skin tests that correlated with a history of exacerbation secondary to allergen exposure. RAST results to Dp and Ao were analyzed by regression analysis (r = 0.64; p = 0.0001). Fifty-five individuals were RAST positive to Dp alone, 32 to Ao and Dp, and three to Ao alone; 73 individuals were negative to Ao and Dp. RAST inhibition demonstrated moderate cross-reactivity between Ao and Dp.

Environmental assay for cockroach allergens

A sandwich ELISA was developed to measure the concentration of cockroach allergen in the environment. The assay was based on a monospecific rabbit antibody preparation reactive with determinants shared by the important allergens, Per a I and Bla g I, from American and German cockroaches. The sensitivity was 0.2 ng Lowry protein of Per a I equivalents per milliliter, corresponding to 1 ng of Per a I equivalents per gram of dust (Per a I eq/gm). The assay did not react with noncockroach-allergen sources. Dust samples from 73 households in a cockroach-infested area were assayed. The concentration in these samples varied from below detection to 200,000 ng of Per a eq/gm of dust. Three commercial cockroach-allergen extracts all contained the allergen. The assay will be valuable for studies of the clinically relevant cockroach-allergen exposure levels and for assessment of efficacy of allergen-avoidance measures. Furthermore, the assay could be used for sanitary documentation in bakeries, restaurants, etc.

Caffeine, a naturally occurring acaricide

Since caffeine is a plant alkaloid that has been described as a naturally occurring insecticide, its acaricidal effect on Dermatophagoides pteronyssinus (Dp) was investigated. Twelve cultures were established by adding 30 Dp to 200 mg of Tetramin fish food and brewer's yeast (8:2 ratio); six cultures were treated with 20 mg of finely ground caffeine. All 12 cultures were incubated at 75% relative humidity, 25 degrees C, and observed during 8 weeks. Live mites were then counted under a stereoscope, cultures were extracted, and supernatants were analyzed for Der p I and Der f I allergen content with a two-site monoclonal RIA. Live mite counts in untreated cultures varied from 146 to 274 (215 +/- 47.1), and in caffeine-treated cultures from 0 to 3 (1 +/- 1.2; p less than or equal to 0.0001). Der p I concentrations in untreated cultures varied from 588 to 9000 ng/gm (3138.3 +/- 2990.8 ng/gm), and in caffeine-treated cultures from 52 to 117 ng/gm (78 +/- 23.8 ng/gm; p less than or equal to 0.01). Der p I was not detected in the food media or caffeine; Der f I was not detected in any of the cultures. Results demonstrate that caffeine inhibits mite growth and allergen production.

Identification and purification of an important cross-reactive allergen from American (Periplaneta americana) and German (Blattella germanica) cockroach

Aqueous whole body extracts from two major domiciliary cockroaches, the American, Periplaneta americana, and the German, Blattella germanica, were analyzed in crossed immunoelectrophoresis and immunoblotting. Forty-five antigens were found in P. americana and 29 in B. germanica. IgE-binding antigens were identified by crossed radioimmunoelectrophoresis with sera from 30 cockroach-allergic patients. Seven and three precipitates from P. americana and B. germanica bound significant amounts of IgE. A cross-reactive, apparently homologous allergen, from P. americana and B. germanica bound IgE from 100% and 70%, respectively, of the patients. These important allergens were tentatively named Per a I and Bla g I. The allergens were purified by sequential ion exchange, gel filtration, and isoelectric focusing. Both allergens had a molecular size of 33 to 37 kd in Sephadex G-75 gel filtration, and 28 kd in high-performance liquid chromatography gel filtration. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed a minor band at approximately 25 kd, and most of the protein at 6 kd. The isoelectric point of both allergens was found be to 3.5. In amino acid analysis, the allergens were highly similar. Skin test revealed the allergens to be important in vivo sensitizing agents. The allergens may be used for environmental assays for cockroach exposure in the homes of allergic subjects.

The Hymenoptera venom study. III: Safety of venom immunotherapy

One thousand four hundred ten (44%) of the 3236 subjects in the Hymenoptera venom study accepted venom immunotherapy (VIT). Time to maintenance averaged 95 days, and the largest number achieved maintenance (147 subjects, 10.4%) at day 56. Ninety-two percent of the treated subjects achieved maintenance, and 84% continued therapy, most subjects (91%) until the study was terminated. One hundred seventy-one subjects (12%) experienced 327 treatment systemic reactions (Srs). The incidence of pruritus and angioedema/urticaria was similar with mild, moderate, or severe SRs. The SR severity did not correlate with the severity of the most recent sting before entry into the Hymenoptera-venom study, the most severe historical sting SR, the most severe SR during venom skin tests, the total dose of venom, the degree of skin test reactivity, or the lowest concentration yielding a positive skin test. Most SRs occurred between 1 and 50 micrograms and at maintenance; honeybee or wasp venoms were most likely to produce SR. This study, the largest of its kind with the use of standardized extracts, demonstrates (1) that there was good compliance, (2) that various historical and diagnostic criteria did not predict SRs to VIT, (3) that SRs to VIT were most likely to occur between 1 and 50 micrograms and at maintenance, (4) that honeybee or wasp venoms were most likely to produce an SR, and (5) that VIT is relatively safe.

House dust mite allergy in Florida. Mite survey in households of mite-sensitive individuals in Tampa, Florida

This study evaluated the prevalence of positive house dust mite skin tests in a population of atopic individuals and identified the mite species present in mattress and house dust samples in homes of the Tampa Bay area. Four hundred consecutive individuals were evaluated for respiratory complaints and skin tested with standardized extracts of Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df). Two hundred forty individuals (60%) had a positive skin test to the mite extracts. Dust samples were collected in 40 homes of mite-allergic individuals and analyzed by light microscopy. Mite species were found in 53 of the 60 dust samples (20 mattresses and 40 carpets). Mite numbers ranged from 110-6200 mites/g of mattress dust and from 120-5500 mites/g of carpet dust. Eleven different mite species were identified and Blomia tropicalis (Bt), not previously identified in the United States, was found in 30% of the samples. Dp and Df wee the predominant species. These observations suggest that house dust mite allergy is common in the Tampa Bay area and that the house dust mite fauna comprises several mite species besides Dp and Df. Prospective studies in progress are designed to confirm the role of different mite species in house dust mite allergy.

Venom immunotherapy in the Hymenoptera-allergic pregnant patient

Natural or iatrogenic causes of anaphylaxis are significant risk factors in pregnancy. A 3% to 5% risk of sting anaphylaxis in any pregnant woman with insect-sting allergy untreated with venom immunotherapy (VIT) can be calculated. Insect-sting anaphylaxis has allegedly caused severe fetal abnormalities and is a potential cause of fetal loss and severe maternal morbidity and/or mortality. Hymenoptera anaphylaxis is a highly preventable cause of anaphylaxis, but VIT may itself carry a risk potential, with an appropriate 5% reaction during buildup and 1% reaction risk during maintenance VIT. To assess the safety of VIT in pregnancy, we have gathered data from 26 women with 43 pregnancies. All the women were receiving VIT. One woman was stung early in pregnancy with anaphylaxis resulting. Outcome of pregnancy was normal. Thirty-six of the pregnancies ended normally. There were two mild adverse reactions to VIT, neither of which required treatment. One child was born with multiple congenital abnormalities of unknown cause. Since congenital malformations may occur as frequently as one in 40 live births, these data do not suggest a significant increased risk from VIT during pregnancy.

Serum IgE and human immunodeficiency virus (HIV) infection

Human immunodeficiency virus infection is characterized by a progressive depletion of helper T-lymphocytes and, like allergic diseases, is associated with altered T cell regulation. Total serum IgE was measured in 67 infected male subjects, 27 uninfected heterosexual male subjects, and 18 uninfected homosexual male subjects. The mean IgE level (132 IU/ml) of infected subjects with a helper T-lymphocyte number less than or equal to 200/mm3 was significantly greater than mean IgE levels of the uninfected heterosexual (38 IU/ml) and homosexual (35 IU/ml) groups. IgE levels were inversely related to both helper T cell and suppressor/cytotoxic T cell numbers but not to IgG or IgA levels. The increase in IgE was not a reflection of an increased prevalence of atopic disease (allergic asthma, allergic rhinitis, or atopic dermatitis) in the infected subjects. The elevation of IgE may be related to a difference among the groups in T cell production of IgE regulatory lymphokines.

Local reactions to stinging insects (Hymenoptera)

Hymenoptera stings cause cutaneous nonallergic local reactions of limited size and duration in most individuals. Some subjects experience an allergic local reaction (large local reaction) to a sting that is greater than 10 cm in diameter and may last for up to 5 days. The nonallergic local reaction is a toxic response to venom constituents, while the large local reaction appears to be caused by an allergic reaction to venom proteins. The IgE-mediated late-phase reaction is probably responsible for most of these reactions; however, a cell-mediated mechanism, or a combination of the two, is possible. A diagnostic workup is not recommended for local reactions. However, skin testing with Hymenoptera venoms (bee, wasp, hornet, and yellowjacket) identifies most subjects with sting-induced large local reactions. Therapy of the local reactions is symptomatic. An oral glucocorticosteroid, H1 antagonist and possibly a H2 antagonist are indicated for treatment of large local reactions. Venom immunotherapy is effective in preventing recurrences of large local reactions in children but is not usually recommended for either adults or children.

The Hymenoptera venom study. II: Skin test results and safety of venom skin testing

Data are summarized in this Hymenoptera venom study (HVS) article on the safety of skin testing with venom extracts. Of the 3236 subjects studied, 89% had experienced an historical sting systemic reaction (SSR). Seventy-four percent of all subjects and 76% of subjects who had experienced an historical SSR had a positive skin test to at least one venom. More subjects tested positive to yellow jacket venom (51.8%) than to any other venom. There were no significant differences of the wheal and erythema sizes associated with different venoms or different historical sting reactions. Forty-five percent of subjects with positive venom skin tests (VST) were positive to wasp, and 89% of these subjects were also positive to at least one of the following venoms: yellow jacket, yellow hornet, or white-faced hornet. Sixty-four of the 3236 subjects studied (2%) had a systemic reaction (SR) during VST; 13 of the SRs (0.4%) were severe. Thirteen of 64 adverse reactions (20%) were possibly vasovagal, and six other subjects (9%) demonstrated no symptoms of immediate-type hypersensitivity. Thus, 45 (1.4%) of the 3236 subjects tested had an SR that was considered to be a reaction of hypersensitivity, of which eight reactions (0.25%) were severe. Allergic SRs are associated with VST but are unusual and are rarely severe.

Bahia grass pollen, a significant aeroallergen: evidence for the lack of clinical cross-reactivity with timothy grass pollen

Thirty-eight subjects were challenged (25 nasal, 13 bronchial) with Bahia grass, Paspalum notatum, pollen extract. A positive Bahia intradermal skin test predicted a positive challenge to Bahia in all (11/11) of the nasal challenges and 75% (6/8) of the bronchial challenges. All 19 subjects with negative Bahia intradermal skin tests had negative challenges with Bahia. Specific IgE antibodies to Bahia pollen were detected by conventional RAST (greater than or equal to 2+) in 82% (14/17) of subjects with positive challenges and in 5% (1/20) of subjects with negative challenges. Eight subjects had positive intradermal skin tests to either Bahia (three) or timothy, Phleum pratense (five). Seven of the eight subjects reacted exclusively to either Bahia or timothy nasal challenge as predicted by their skin tests. Bahia grass is a significant aeroallergen, which in some subjects can be demonstrated not to cross-react with timothy.

Multiple stings by imported fire ants (Solenopsis invicta), without systemic effects

This is the first case report of imported fire ants invading a building and aggressively attacking a human being, resulting in multiple stings. This case illustrates that, although the venom has a high LD50 in mice, it does not induce toxic systemic effects in humans when the venom is introduced intradermally.

Lack of effect of gold salts on acetylcholine or histamine contraction of canine tracheal and bronchial smooth muscle

In vitro gold salt incubation with proximal and distal canine airway smooth muscle was compared to untreated canine airway muscle with respect to histamine and acetylcholine-induced contraction. Gold chloride and gold sodium thiomalate had no effect on either proximal or distal canine airway smooth muscle agonist-induced contraction. Gold chloride in concentrations greater than 10(-5) M had a direct contractile effect. These results differ from previous studies which showed an inhibition of the histamine response of guinea-pig tracheal smooth muscle following in vitro preincubation with gold salts. This difference suggests that the mechanism(s) of the beneficial effects of long-term gold salt therapy on human asthma cannot be reliably studied with short-term in vitro animal preparations without first assessing species differences with respect to the effects of therapeutic agents. Human airway smooth muscle preparations would be the best means of addressing this question.

Allergens of the imported fire ant

A whole body extact (WBE) was prepared by saline extraction of ground imported fire ants (IFA). A serum pool from rabbits immunized with the WBE elicited 31 precipitates on crossed immunoelectrophoresis. Crossed radioimmunoelectrophoresis was performed with sera from 26 RAST IFA-positive subjects, 24 of whom were known for clinical hypersensitivity to IFA and two subjects, known to be hypersensitive to yellow jacket. Radiostaining was obtained to 14 precipitates, some of which were judged to be partially identical. Thus, six apparently different allergen groups could be identified. Two of these fulfilled arbitrary criteria of major allergens. Three of the IFA WBE allergens were easily identified in crossed immunoelectrophoresis of a commercially obtained IFA-venom preparation. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the IFA WBE demonstrated protein bands with molecular weight ranging from 10,000 to 200,000 daltons. An immunoblotting technique with nitrocellulose paper strips revealed binding of human IgE from hypersensitive subjects to four different bands (either single bands or clusters of proteins of similar molecular weight) with molecular weights ranging from 13,000 to 42,000 daltons. It is a notable finding that these insect allergens thus were of a similar size as important aeroallergens.

Histamine tachyphylaxis in young dog airway--compared with adult dog

The phenomenon of histamine tachyphylaxis in vitro previously observed in the airway smooth muscle from adult dogs was investigated in airway smooth muscle from young dogs (age 72-96 days; mean: 91 days). Tachyphylaxis was demonstrated by repetitive exposure to 10(-4) M histamine (4th contractile response was 53.0 +/- 4.9% of the initial histamine contraction; n = 6, P less than 0.01). This result was similar to that previously reported (Anderson et al., 1979) in adult canine tracheal smooth muscle. Tachyphylaxis to histamine was demonstrated also by repetitive exposure to histamine (10(-4) M) in the small airway smooth muscle (2 mm diameter), (4th contractile response was 59.6 +/- 7.2% of the initial histamine contraction; n = 6, P less than 0.01). This tachyphylaxic response is not present in the small airways from adult animals. The development of histamine tachyphylaxis in both tracheal and small airway smooth muscle could be prevented or reversed by preincubation of the tissue with indomethacin (2.8 x 10(-6) M). The composite information thus implicates prostaglandins as the most probable mediators of the process. These results suggest that the variable phenomenon of histamine tachyphylaxis is dependent on the maturity of the animal and on the size of the airway.

The Hymenoptera venom study I, 1979-1982: demographics and history-sting data

The Hymenoptera venom study, a study based on case histories, skin test results and adverse reactions, immunotherapy and adverse reactions, and treatment efficacy, for 3236 Hymenoptera-allergic subjects, was begun in 1979 after the Food and Drug Administration approval of Hymenoptera venoms. Eighty-four Fellows and Members of the American Academy of Allergy and Immunology participated in the study. All subjects had a history of an adverse reaction to one or more Hymenoptera insects. The mean age was 30 1/2 years (range 1 to 83 years). Male subjects accounted for 61.5% and female subjects, 38.5%; 3.1% were beekeepers and 32.3% were atopic. Demographic data were similar for subgroups. There was an average of 2.7 history stings per subject. At least one systemic reaction (SR) was reported by 2866 subjects (89%); 2219 (69%) experienced an SR after their most recent sting before entry into the study, and 70% had experienced only a single SR. Moderate to severe SRs were equally likely after stings of yellow jacket, white-faced hornet, and yellow hornet (65%), honeybee (67%), or wasp (70%), although historical SRs were reported more often after stings of yellow jacket, white-faced hornet, or yellow hornet (30%) than after honeybee (19%) or wasp (14%) stings. No association was noted between the number of stings per episode and severity of the SR. Fifty-one percent of SRs were reported as occurring within 10 minutes of sting; however, the onset of a moderate to severe SR sometimes occurred at 301 or more minutes after a sting episode. Of 2219 subjects with an SR after their most recent sting before entry into the study, 68% received epinephrine for treatment.

Rheumatic manifestations of human immunodeficiency virus infection

PURPOSE

The prevalence and characteristics of the rheumatic and extra-rheumatic manifestations of human immunodeficiency virus (HIV) infection were determined in a prospective manner.

PATIENTS AND METHODS

One hundred one patients with HIV infection were consecutively interviewed and examined. The prevalence of autoantibodies and their association with rheumatologic symptoms were also determined.

RESULTS

The musculoskeletal system was involved in 72 patients. Thirty-five patients had arthralgias, 10 had Reiter's syndrome, two had psoriatic arthritis, two had myositis, and one had vasculitis. Also found were two previously unreported syndromes. The first, occurring in 10 patients, consisted of severe intermittent pain involving less than four joints, without evidence of synovitis, of short duration (two to 24 hours), and requiring therapy (ranging from nonsteroidal antiinflammatory drugs to narcotics). The second, occurring in 12 patients, consisted of arthritis (oligoarticular in six patients, monoarticular in three patients, and polyarticular in three patients) involving the lower extremities and lasting from one week to six months. The synovial fluid of five patients (three with arthritis, one with Reiter's syndrome, and one with psoriatic arthritis) was sterile and inflammatory.

CONCLUSION

Musculoskeletal complications are common in advanced stages of HIV infection. Persons in a high-risk group for HIV infection who manifest oligoarthritis with or without any other extra-articular manifestation suggestive of Reiter's syndrome or other form of spondyloarthropathy should be tested for HIV.

Treatment of asthma with glucocorticosteroids

Glucocorticosteroids (GCS) are used to treat asthma that does not respond to accepted first-line therapy. Because they have potent anti-inflammatory properties, facilitate beta-adrenergic responsiveness, suppress the late-phase reaction and reduce secretion of mucus, GCS are indicated in the treatment of severe acute asthma and chronic asthma not responsive to beta-agonists and methylxanthines. They are also useful as a diagnostic tool to determine reversibility of airway obstruction in some patients with chronic obstructive pulmonary disease. Maximal antiasthmatic effect is achieved by prescribing daily divided doses of intermediate-acting systemic GCS and reducing the dosage to alternate days after the asthma has been controlled. Inhaled GCS have minimal systemic effects when used properly, and in selected cases may be as effective as the oral preparations. Improper use of these drugs may provoke side effects which are undesirable and dangerous. Proper patient education in the use of these drugs is necessary to avoid such severe adverse effects.

Effects of ketotifen on the responsiveness of peripheral blood lymphocyte beta-adrenergic receptors

The effects of ketotifen therapy on the responsiveness of lymphocyte beta-adrenergic receptors was evaluated by measuring cyclic AMP elevations caused by isoproterenol in cells isolated from patients treated with ketotifen for more than 1 year. Binding of 3H-dihydroalprenolol to beta-receptors was also evaluated. The isoproterenol-induced rise in cyclic AMP relative to each individual's baseline level was greater in patients on current ketotifen therapy than in other asthmatic patients or non-asthmatic subjects. Ketotifen therapy increased the apparent equilibrium dissociation constant for specific 3H-dihydroalprenolol binding to the receptors. Receptor numbers in symptomatic asthma patients on standard drug therapy were decreased. The results indicate that long term ketotifen therapy is associated with increased responsiveness of beta-receptors to stimulation by catecholamines and that this alteration may involve changes in the receptors themselves, their membrane environment, adenylate cyclase or components of the adenylate cyclase coupling system.

Sinusitis and asthma

Knowledge of the diagnosis and treatment of sinusitis is essential to the care of the patient with asthma. Interest in the association of this disease and bronchial asthma has been renewed during the past decade, although it had been recognized for years. Sinusitis is more common in subjects with asthma, especially those with the aspirin triad (aspirin intolerance, asthma, and nasal polyps). Proper treatment by medical and/or surgical means will frequently result in significant improvement of asthma.

Melkersson-Rosenthal syndrome

Two patients were referred to the University of South Florida College of Medicine Allergy and Immunology Clinic for evaluation of "angioedema." Patient 1 presented with intermittent severe lip edema, and patient 2 presented with lip and facial swelling together with facial palsy. Multiple symptomatic treatments had been ineffective. Both patients were ultimately found to have Melkersson-Rosenthal syndrome, a rare granulomatous disorder of undetermined cause that must be considered in a differential diagnosis of facial edema. The patients are presented in detail to call attention to the diagnosis of the condition in order that unnecessary treatment, with attendant side effects, may be avoided.

Australian pine (Casuarina equisetifolia) pollen as an aeroallergen

Sixty-seven nasal and bronchial provocation tests were performed with Australian pine pollen extract (APE) on 61 subjects. A positive nasal response was elicited in 10 of 14 (71%) subjects with allergic rhinitis and positive APE skin tests and in none of 23 control subjects with negative APE skin tests. A positive bronchial challenge was elicited in 5 of 10 (50%) extrinsic asthmatics with positive APE skin tests and in none of 20 control subjects with negative APE skin tests. Australian pine pollen-specific IgE was demonstrated by conventional RAST (greater than or equal to + 1) in 6 of 14 (42%) subjects with a positive nasal challenge, and in 4 of 5 (80%) subjects with a positive bronchial challenge. The Australian pine pollen is an aeroallergen.

Shellfish and fish poisoning related to the toxic dinoflagellates

At least four different species of the toxic dinoflagellates cause shellfish and fish poisoning in the United States: Ptychodiscus brevis, neurotoxic shellfish poisoning; Protogonyaulax catenella and P tamarensis, paralytic shellfish poisoning; and Gambierdiscus toxicus, ciguatera fish poisoning. These three disorders have similar clinical manifestations, primarily neurologic and alimentary. A complete history is essential; confirmation, while dependent on specific laboratory analysis, is usually based on a history of ingestion of fish or shellfish previously associated with these types of poisonings. The principal toxins affect sodium channels; Ptychodiscus brevis toxins and ciguatoxin by stimulating these channels and saxitoxin by blocking them. Since no antidote is known, treatment is symptomatic. Public health measures and public education are necessary to prevent this form of poisoning.

Fatalities from immunotherapy (IT) and skin testing (ST)

The Committee on Allergen Standardization of the American Academy of Allergy and Immunology obtained information about 46 fatalities that had occurred during immunotherapy (IT) or skin testing (ST) since 1945. Sufficient information for complete analysis was provided for 30 patients (six for ST and 24 for IT). Of the 30 fatalities, there were 15 male and 15 female fatalities ranging in age from 7 to 70 years (x = 33 years). Known errors of administration accounted for three and possibly an additional three fatalities. Ten fatalities occurred during seasonal exacerbation of the patient's disease, four in patients who had been symptomatic at the time of the injection, two of whom had been receiving beta-adrenergic blockers. Of the 24 fatalities associated with IT, four had experienced previous reactions, 11 manifested a high degree of sensitivity, and four had been injected with newly prepared extracts. Fifteen of the 30 fatalities had received pollen extracts as part of the fatal injection. Of the six fatalities associated with ST, five were due to intradermal testing without prior puncture testing. The signs and symptoms were variable and did not indicate that death was imminent nor predict the cause of death. The time to onset of the reaction was less than 30 minutes in 22/30, more than 30 minutes in 3/30, and not reported in 5/30. The cause of death in 14/16 patients with asthma was respiratory. Epinephrine had been administered to 18, not administered to three, and was either not recorded or unknown in the remaining nine patients. Since seven to 10 million allergen injections are administered yearly, the risk of a fatal reaction is low and may be lessened even further as additional precautions are taken in the selection and treatment of allergic patients and in improved treatment of the anaphylactic reactions.

The treatment of mild to severe chronic idiopathic urticaria with astemizole: double-blind and open trials

Astemizole is a new H1 histamine-receptor antagonist that has a long elimination half-life and high H1-receptor affinity. This double-blind study evaluated the safety and efficacy of astemizole in the treatment of chronic idiopathic urticaria (more than or equal to 3 months). Seventeen male and 34 female adult patients with chronic idiopathic urticaria entered the 2-month study. After a 48- to 72-hour washout, half the subjects were prerandomized to receive astemizole (10 mg), and the other half received placebo. Placebo-treated patients who were unable to complete the full 8 weeks because of uncontrolled chronic urticaria symptoms were entered into a 2-month open astemizole trial. Treatment with astemizole, as measured at the end point of each patient's treatment and compared to placebo, resulted in significant improvement of pruritus, erythema, number of wheals, frequency of urticarial attacks, and control of urticaria (p less than or equal to 0.03). The overall response to astemizole was significantly better than for placebo, according to both the investigator's and the patient's global evaluations (p less than 0.01) and as indicated by dropouts caused by treatment failure with placebo (p = 0.005). Six of 26 (24%) of the placebo-treated patients in the double-blind study had good to excellent results on the basis of global assessments. Thirteen of 16 patients with placebo-treatment failures who received astemizole in the open trial improved significantly from baseline symptoms of pruritus, erythema, and number of wheals (p less than or equal to 0.05). No significant side effects were reported except mild sedation in three astemizole-treated subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma improved by acetylsalicylic acid and other nonsteroidal anti-inflammatory agents

Acetylsalicylic acid (ASA) and other nonsteroidal anti-inflammatory drugs (NSAID) cause a variety of symptoms in patients sensitive to these drugs. These include wheezing, rhinorrhea, flushing, pruritus, urticaria, hypotension and loss of consciousness. Conversely, improvement of asthma with the use of these drugs in patients who do not have idiosyncratic reactions to ASA (ASA-nonsensitive) has also been observed both with respect to clinical symptoms and pulmonary function tests.

The mechanism of ergonovine-induced airway smooth muscle contraction

There have been three articles in the clinical literature of ergonovine maleate-induced bronchospasm. The effect of the alkaloid on isolated canine tracheal smooth muscle was analyzed to investigate the mechanism of ergonovine-induced airway smooth muscle contraction. Both ergonovine and 5-hydroxytryptamine (5HT, serotonin) contracted the smooth muscle preparations with EC50s of 1.35 X 10(-8) mol/L and 5.06 X 10(-7) mol/L, respectively. The maximal contractile response observed with ergonovine was approximately 30% less than that observed with 5HT. Methysergide competitively blocked both ergonovine and 5HT responses with similar calculated pKB values (8.33 against ergonovine and 8.46 against 5HT) and also similar pA2 values determined by Schild plots (8.50 and 8.45, respectively). The relative affinity and efficacy of ergonovine versus 5HT were determined by use of a concentration of the irreversible antagonist, phenoxybenzamine, which partially blocked receptor sites. The calculated affinity of ergonovine was about 16 times higher than that of 5HT. The relative efficacy at EC100 for ergonovine was 0.2, but at EC10 it was 41.9 (5HT efficacy = 1). Ergonovine 10(-9) or 10(-8) mol/L shifted the 5HT dose-response curve to the right without reducing the maximal response, but the shift was nonparallel. Blockade of muscarinic (atropine), alpha 1-adrenergic (prazosin), beta-adrenergic (propranolol), H1 (pyrilamine), or H2 (cimetidine) receptors did not alter ergonovine-induced contraction. These data indicate that ergonovine directly contracts canine tracheal smooth muscle as a result of its combination with 5HT receptors. This effect may result in precipitation of an asthmatic attack in susceptible individuals.

Effects of age on respiratory tract immunity in guinea pigs

This study examined cell-mediated immune responses of aged guinea pigs following intranasal sensitization with Bacillus Calmette Guérin (BCG). Young adult and aged guinea pigs, one and three years old, respectively, were inoculated intranasally with BCG. Changes in lung cell profile, production of migration inhibition factor (MIF) by lung derived lymphocytes and development of delayed hypersensitivity-skin (DHS) reaction to purified protein derivative (PPD) were evaluated at various time intervals. Normal lung lavage cell profiles were similar in both groups. Significant increases in total lung lavage cells occurred in both groups at 2 and 6 weeks following sensitization and corresponded with significant increases in the number of macrophages. The young adult group had significant increases in the total number of lymphocytes and rosette forming cells at 6 weeks compared to their preimmunization levels. Production of MIF was significantly greater in magnitude in the young adult group at 2 weeks compared to aged groups. The total number of animals mounting immune responses to BCG (MIF production) was also significantly lower in the aged group over the 6 week study period. DHS reaction to PPD was positive in all young adult animals, while only half of the aged guinea pigs were positive at 6 weeks. Data suggest that age adversely affects lung resistance to infection from intracellular microbial agents of the respiratory tract.

Bald cypress tree (Taxodium distichum) pollen, an allergen

Fifty-seven nasal and bronchial provocation tests were performed with bald cypress pollen extract (BCE) on 41 subjects. A positive nasal response was elicited in 12 of 17 (71%) subjects with allergic rhinitis and positive BCE skin tests, and in none of 16 control subjects. A positive bronchial challenge was elicited in two of ten extrinsic asthmatics with positive BCE skin tests, and in none of 14 control subjects. BCE-specific IgE was demonstrated by RAST in seven of the 12 (59%) subjects with a positive nasal challenge and in one of the two with a positive bronchial challenge. BC pollen is an aeroallergen.

Effects of ergometrine on airway smooth muscle contractile responses

A 26-year-old asthmatic female developed severe asthma within a few hours of receiving three oral doses of 0.4 mg ergometrine maleate for the control of postpartum haemorrhaging. This experience and two previous reports of bronchospasm in asthmatic subjects following ergometrine suggested that ergometrine altered airway smooth muscle tone. In the present investigation the effect of ergometrine was studied on canine tracheal smooth muscle strips. Ergometrine (10(-9) M-10(-4) M) induced contraction of canine tracheal smooth muscle. The concentration causing 50% of maximal contraction (EC50) was 4.73 X 10(-8) M. The acetylcholine EC50 was not altered by ergometrine (10(-9) M or 10(-8) M); however, acetylcholine (10(-4) M and 10(-3) M) induced contractions were enhanced by ergometrine (10(-8) M). The data suggest that ergometrine maleate may cause broncho-constriction in some patients with asthma.

The site of action of Ptychodiscus brevis toxin within the parasympathetic axonal sodium channel h gate in airway smooth muscle

The red tide toxin produced by Ptychodiscus brevis ( PBTX ) may cause cough, sneezing, and asthma. Previous in vitro studies with isolated canine tracheal smooth muscle demonstrated that PBTX stimulates sodium channels of parasympathetic nerve endings and thus causes a contractile response. The present study investigated the mechanism of the PBTX effect on canine tracheal smooth muscle. Repeated exposure of the muscle strip to PBTX (final concentration 46 micrograms/ml) followed by washout of the toxin resulted in reestablishment of baseline tension but a failure of contraction on further addition of PBTX . However, veratridine and scorpion toxin (SCT), which are voltage-sensitive sodium channel activators, still induced contraction. Furthermore, the contraction caused by veratridine was enhanced by a high dose of PBTX , whereas contraction caused by SCT was not. Responses to veratridine and SCT as well as PBTX (previously reported) were blocked by tetrodotoxin (a sodium channel blocker), while acetylcholine responsiveness remained intact. These results indicate that PBTX receptors in parasympathetic nerves influence Na+ flux at the h gate, that these receptors differ from the veratridine and SCT receptors, and that the conformational change in the receptors induced by PBTX affects the tissue response to veratridine.

Pharmacokinetics and bioavailability of three dyphylline preparations

The pharmacokinetics and bioavailability of 3 oral dyphylline preparations, solution (S), regular (R) and sustained release (SR), were studied in 8 healthy subjects (mean age 25 years). A single dose of each preparation, 20 mg X kg-1, was given at one week intervals and multiple serum samples obtained over 24 h. Drug levels were measured by high performance liquid chromatography. No adverse effects were found. The dyphylline half-life for the solution was 2.16 +/- 0.18 h and for the tablet 2.59 +/- 0.56 h. The mean clearance rate for S was 13.6 +/- 1.7 h-1 and volume of distribution 43.0 +/- 3.91. Peak concentration (Cmax, micrograms X ml-1), time of peak (Tmax, h), area under the curve (AUC, micrograms X ml-1 X h) and relative bioavailability (RB, %), were determined for three preparations: Cmax S, 33.7 +/- 3.7; R, 27.7 +/- 4.2; SR, 10.4 +/- 1.5 Tmax: S, 0.33 +/- 0.0; R, 0.66 +/- 0.0; SR, 2.13 +/- 1.1 AUC: S, 108.4 +/- 12.1; R, 113.9 +/- 25.2; SR, 104.0 +/- 30.8 RB: Reference Product R, 105.00 +/- 16.00; SR, 100.00 +/- 25.00 The data confirm the short half-life of dyphylline, demonstrate a lack of toxicity for the 20 mg X kg-1 dose and establish bioequivalence for the products studied.

Theophylline kinetics in a geriatric group

The influence of age, sex, and smoking on theophylline disposition was studied in 38 healthy subjects ranging in age from 26 to 81 yr. There were 8 young (less than 60 yr) and 30 geriatric (greater than 60 yr) subjects, including 28 men (8 smokers) and 10 women (3 smokers). A crossover experimental design was used. A single dose of theophylline elixir (5 mg/kg lean body weight [LBW]) was given as a reference product to all subjects. One week later a sustained-release (SR) theophylline tablet (8 and 6 mg/kg LBW) was given to the young and the geriatric subjects. Serum theophylline concentrations were determined by HPLC. Theophylline elimination (t1/2 beta) is shorter in the geriatric group (6.93 and 8.14 hr); total body theophylline clearance is greater in the geriatric group (44.39 and 32.97 ml/kg/hr), and the apparent volume of distribution is also greater in the geriatric group (26.29 and 22.97 l). Sex and smoking did not influence any of the parameters studied. In 93% of the geriatric subjects, serum theophylline levels of 8 to 20 micrograms/ml were reached at steady state with the SR tablet. Theophylline dose reduction based on an arbitrary age limit is not, therefore, invariably indicated.