Bee pollen: a dangerous food for allergic children. Identification of responsible allergens

BACKGROUND

Bee pollen has been proposed as a food supplement, but it can be a dangerous food for people with allergy. We study an allergic reaction after ingestion of bee pollen in a 4-year-old boy who had developed rhinitis in the last spring and autumn.

METHODS

We performed a prick-by-prick test with bee pollen and skin prick tests with the most important local pollens, house dust mites, common fungi, and animal danders. The levels of serum tryptase, serum total IgE and specific IgE against bee venom and local pollen extracts were determined. The composition of the bee pollen was analysed and SDS-PAGE immunoblotting and blotting-inhibition were carried out.

RESULTS

Prick tests were positive to bee pollen and all local pollens extracts and negative to any other allergen sources. The bee pollen sample contained pollens from Quercus genus, and Asteraceae (Compositae) and Rosaceae families. Total IgE was 435 kU/l. Serum specific IgE to bee pollen was 6 kU/l and greater than 0.35 kU/L against pollens from Artemisia vulgaris, Taraxacum officinalis, Cupressus arizonica, Olea europaea, Platanus acerifolia and Lolium perenne as well as to n Art v 1 and other pollen marker allergens. Tryptase level was 3.5 mcg/mL. SDS-PAGE immunoblotting-inhibition points to Asteraceae pollen as the possible cause of the allergic reaction.

CONCLUSION

Foods derived from bees can be dangerous to people with allergy to pollen.

Noninvasive methods for assessment of airway inflammation in occupational settings

The present document is a consensus statement reached by a panel of experts on noninvasive methods for assessment of airway inflammation in the investigation of occupational respiratory diseases, such as occupational rhinitis, occupational asthma, and nonasthmatic eosinophilic bronchitis. Both the upper and the lower airway inflammation have been reviewed and appraised reinforcing the concept of 'united airway disease' in the occupational settings. The most widely used noninvasive methods to assess bronchial inflammation are covered: induced sputum, fractional exhaled nitric oxide (FeNO) concentration, and exhaled breath condensate. Nasal inflammation may be assessed by noninvasive approaches such as nasal cytology and nasal lavage, which provide information on different aspects of inflammatory processes (cellular vs mediators). Key messages and suggestions on the use of noninvasive methods for assessment of airway inflammation in the investigation and diagnosis of occupational airway diseases are issued.

Measuring asthma control: a comparison of three classification systems

There are various ways to classify asthma control; however, no classification is universally accepted. This retrospective analysis compared asthma control as assessed by the Asthma Control Questionnaire (5-item version; ACQ-5), Global Initiative for Asthma (GINA) or Gaining Optimal Asthma Control (GOAL) study criteria. Pooled data at the final study week (n = 8,188) from three budesonide/formoterol maintenance and reliever therapy studies which measured ACQ-5 were stratified according to GINA or GOAL criteria and ACQ-5 score distribution. The percentages of patients with a controlled/partly controlled week (GINA), totally/well-controlled week (GOAL) and range of ACQ-5 cut-off points were compared. Patients with GINA controlled, partly controlled and uncontrolled asthma had mean ACQ-5 scores of 0.43, 0.75 and 1.62, respectively. Patients with GOAL totally controlled, well-controlled and uncontrolled asthma had ACQ-5 scores of 0.39, 0.78 and 1.63. The kappa measure of agreement was 0.80 for GINA and GOAL criteria, and 0.63 for GINA controlled/partly controlled and ACQ-5 <1.00. ACQ-5 detected clinically important improvements in 49% of patients who, according to GINA criteria, remained uncontrolled at the end of the study. Asthma control measured by GINA or GOAL criteria provides similar results. GINA Controlled/Partly Controlled and GOAL Totally Controlled/Well-Controlled correspond to ACQ-5 <1.00. The ACQ-5 is more responsive to change in a clinical trial setting than a categorical scale.

Use of the lymphocyte transformation test in the diagnosis of DRESS syndrome induced by ceftriaxone and piperacillin-tazobactam: two case reports

Drug-related rash with eosinophilia and systemic symptoms (DRESS) syndrome, or drug-induced hypersensitivity syndrome (DIHS), is a life-threatening multiorgan systemic reaction characterized by rash, fever, lymphadenopathy, hepatitis, and leukocytosis with eosinophilia. Aromatic anticonvulsant drugs and allopurinol have been reported to be the most frequent eliciting agents. Our search of the literature revealed only 2 cases induced by piperacillin and 1 case by ceftriaxone.We present 2 cases of DRESS syndrome induced by the beta-lactam drugs ceftriaxone and piperacillin-tazobactam. An allergological workup including skin prick test, intradermal tests, patch tests, and lymphocyte transformation test (LTT) was performed. LTT was shown to be a useful technique in both cases to help to identify the drugs involved.

Cleaning agents and asthma

Although cleaners represent a significant part of the working population worldwide, they remain a relatively understudied occupational group. Epidemiological studies have shown an association between cleaning work and asthma, but the risk factors are uncertain. Cleaning workers are exposed to a large variety of cleaning products containing both irritants and sensitizers, as well as to common indoor allergens and pollutants. Thus, the onset or aggravation of asthma in this group could be related to an irritant-induced mechanism or to specific sensitization. The main sensitizers contained in cleaning products are disinfectants, quaternary ammonium compounds (such as benzalkonium chloride), amine compounds, and fragrances.The strongest airway irritants in cleaning products are bleach (sodium hypochlorite), hydrochloric acid, and alkaline agents (ammonia and sodium hydroxide), which are commonly mixed together. Exposure to the ingredients of cleaning products may give rise to both new-onset asthma, with or without a latency period, and work-exacerbated asthma. High-level exposure to irritants may induce reactive airways dysfunction syndrome. Cleaning workers may also have a greater relative risk of developing asthma due to prolonged low-to-moderate exposure to respiratory irritants. In addition, asthma-like symptoms without confirmed asthma are also common after exposure to cleaning agents. In many cleaners, airway symptoms induced by chemicals and odors cannot be explained by allergic or asthmatic reactions. These patients may have increased sensitivity to inhaled capsaicin, which is known to reflect sensory reactivity, and this condition is termed airway sensory hyperreactivity.

Immunotherapy with a Phleum pratense allergen extract induces an immune response to a grass-mix allergen extract

BACKGROUND

Grass pollen allergy is one of the most common allergies worldwide, and patients often show sensitization to an array of phylogenetically related species.

OBJECTIVE

To determine the effect of specific immunotherapy (SIT) with Phleum pratense extract on induction of the immune response to a mixture composed of 5 grass pollen extracts.

METHODS

Forty-six adult patients suffering from rhinitis and sensitized to a mix of grass pollen allergen extracts were randomized 3:1 to receive a short course of SIT with P. pratense or to an open control group without SIT. At baseline and after 3-4 months, we evaluated levels of specific immunoglobulin (Ig) E and IgG4, as well as the immediate and delayed cutaneous responses to the grass mix and P. pratense. IgG4 to Lolium perenne was also determined.

RESULTS

Levels of IgE and IgG4 to grass mix and P. pratense increased significantly during treatment (P<.001). However, this increase was only significantly higher in the SIT group than in the control group for IgG4 (P<.001). The levels of IgG4 to Phl p 5 and Lol p 5 were highly correlated (r=0.99, P<.001). The immediate and delayed cutaneous responses were significantly diminished to both extracts after SIT (P<.001).

CONCLUSIONS

Patients with rhinoconjunctivitis diagnosed using skin prick testing with a grass mix allergen extract and treated with a short course of SIT based on a single species P. pratense allergen extract are able to develop an immune response that targets not only the immunizing species, but also the grass mix allergen extract.

Micro-arrayed wheat seed and grass pollen allergens for component-resolved diagnosis

BACKGROUND

Wheat is a potent allergen source and can cause baker's asthma, food and pollen allergy. The aim of the study was to develop an allergen micro-array for differential diagnosis of baker's asthma, wheat-induced food allergy and grass pollen allergy.

METHODS

We analysed the immunoglobulin-E reactivity profiles of patients suffering from baker's asthma, wheat-induced food allergy and grass pollen allergy to micro-arrayed recombinant wheat flour allergens and grass pollen allergens and compared these results with clinical results and diagnostic tests based on crude wheat flour, wheat pollen and grass pollen allergen extracts.

RESULTS

We identified recombinant wheat flour allergens, which are specifically recognized by patients suffering from baker's asthma, but not from patients with food allergy to wheat or pollen allergy. rPhl p 1 and rPhl p 5 were identified as marker allergens specific for grass pollen allergy. They can be used to replace grass pollen extracts for allergy diagnosis and to identify grass pollen allergic patients among patients suffering from baker's asthma and wheat-induced food allergy. Profilin was identified as a cross-reactive allergen recognized by patients suffering from baker's asthma, food and pollen allergy.

CONCLUSIONS

Our results indicate that it will be possible to design serological tests based on micro-arrayed recombinant wheat seed and grass pollen allergens for the discrimination of baker's asthma, wheat-induced food allergy and grass pollen allergy.

Recombinant lipid transfer protein Tri a 14: a novel heat and proteolytic resistant tool for the diagnosis of baker's asthma

BACKGROUND

Baker's asthma is an important occupational allergic disease. Wheat lipid transfer protein (LTP) Tri a 14 is a major allergen associated with wheat allergy. No panel of wheat recombinant allergens for component-resolved diagnosis of baker's asthma is currently available.

OBJECTIVE

To evaluate the potential role of recombinant Tri a 14 as a novel tool for the diagnosis of baker's asthma, and to test the heat and proteolytic resistance of the wheat LTP allergen.

METHODS

A cDNA encoding Tri a 14 was isolated and sequenced, the recombinant allergen produced in Pichia pastoris and purified by chromatographic methods. Physicochemical and immunological comparison of the natural and recombinant forms of Tri a 14 was carried out by N-terminal amino acid sequencing, matrix-assisted laser desorption/ionization mass spectrometry, circular dichroism (CD) analysis, IgE immunodetection, and specific IgE determination and ELISA-inhibition assays using a pool or individual sera from 26 patients with baker's asthma. Thermal denaturation and simulated gastrointestinal digestion of both Tri a 14 forms were checked by spectroscopic and electrophoretic methods, respectively, and biological activity by basophil activation test (BAT).

RESULTS

Natural and recombinant Tri a 14 were similarly folded, as indicated by their nearly identical CD spectra and heat denaturation profiles. A high interclass correlation coefficient (0.882) was found between specific IgE levels to both Tri a 14 proteins in individual sera from baker's asthma patients, but a slightly lower IgE-binding potency of rTri a 14 was detected by ELISA-inhibition assays. Natural and recombinant Tri a 14 elicited positive BAT in two and one out of three patients, respectively. Heat denaturation profiles and simulated gastrointestinal digestion assays indicated that Tri a 14 displayed a high heat and digestive proteolytic resistance, comparable to those of peach Pru p 3, the model food allergen of the LTP family.

CONCLUSIONS

Recombinant Tri a 14 is a potential tool for baker's asthma diagnosis, based on its physicochemical and immunological similarity with its natural counterpart. Wheat Tri a 14 shows a high thermal stability and resistance to gastrointestinal digestion.

Diagnosis of aspirin-induced asthma combining the bronchial and the oral challenge tests: a pilot study

BACKGROUND

We investigated the usefulness of the bronchial challenge (BC) with lysine-acetylsalicylate (L-ASA) in the diagnosis of aspirin-exacerbated respiratory disease (AERD) using a protocol that combined both the oral challenge (OC) and the BC tests.

METHODS

Adult asthmatic patients with suspected AERD who underwent BC with L-ASA were included in the study. If the BC result with L-ASA was negative, an OC was carried out to establish the diagnosis. AERD was ruled out if both the BC and the OC results were negative (nonresponders). Both responders and nonresponders were compared for age, gender, a personal or family history of atopy, underlying disease, current asthma treatment, and presence of nasal polyps. Six patients with asthma but no suggestive history of AERD were included as controls.

RESULTS

Twenty-two patients completed the study. Ten patients tested positive to the BC and/or OC (responders), whereas 12 did not (nonresponders). Seven out of the 10 responders had a positive BC result and 3 a positive OC result. After BC, 4 patients had an early asthmatic response, 1 had a dual response, and 2 had isolated late responses. No significant differences were observed in the aforementioned variables between responders and nonresponders. The results of both challenges were negative in the 6 controls.

CONCLUSIONS

The BC had a high positive predictive value, was safe, and when negative, the subsequent OC did not result in any severe adverse reactions. The BC elicited an isolated late asthmatic response that has not been previously described in the literature.

Asthma in Alergológica-2005

BACKGROUND

This study analyses the prevalence and the clinical and therapeutic data on asthma collected in consultations as part of Alergológica-2005.

MATERIAL AND METHODS

A cross-sectional, descriptive, observational, epidemiologic study was carried out.

RESULTS

The prevalence of asthma was 28%, lower than the 35% prevalence observed in the Alergológica-2002 study. The average age of the patients with asthma was 27 years (range 1 to 86). Those affected were children between 5 and 15 years of age and young adults. 55.4% were females. The classification of asthma according to severity was: 57.4% slight, 40.9% moderate and 1.7% serious. 79.8% of patients had extrinsic asthma, 18.7% intrinsic asthma and 1.2% occupational asthma. 43.8% of patients were sensitized to pollens, 41.4% to dust mites and 19.6% to animal epithelia. In comparison with the first phase of Alergológica, the prescription of immunotherapy fell from 54% to 30%, theophylline from 26% to 0.4%, chromones/ketotifen from 53% to 1.4% and inhaled corticosteroids from 40% to 31.7%. In contrast, combinations of inhaled corticosteroids and long-acting beta2-agonists and antileukotrienes, both of which were absent in the first phase of the study, made a great impact in this second phase of the study with figures of 38.5% and 24.4% respectively.

CONCLUSIONS

The prevalence of asthma in Alergológica-2005 has diminished in comparison with the first phase of the study. Changes in the therapeutic guidelines are clear such as a reduction in the use of immunotherapy and a notable increase in the prescription of combinations and antileukotrienes.

Occupational rhinitis

The present document is the result of a consensus reached by a panel of experts from European and nonEuropean countries on Occupational Rhinitis (OR), a disease of emerging relevance, which has received little attention in comparison to occupational asthma. The document covers the main items of OR including epidemiology, diagnosis, management, socio-economic impact, preventive strategies and medicolegal issues. An operational definition and classification of OR tailored to that of occupational asthma, as well as a diagnostic algorithm based on steps allowing different levels of diagnostic evidence, are proposed. The needs for future research are pointed out. Key messages are issued for each item.

Obesity and asthma

Asthma and obesity have a considerable impact on public health and their prevalence has increased in recent years. Numerous studies have linked these disorders. Most prospective studies show that obesity is a risk factor for asthma and have found a positive correlation between baseline body mass index and the subsequent development of asthma. Furthermore, several studies suggest that whereas weight gain increases the risk of asthma, weight loss improves the course of the illness. Different factors could explain this association. Obesity is capable of reducing pulmonary compliance, lung volumes, and the diameter of peripheral respiratory airways as well as affecting the volume of blood in the lungs and the ventilation-perfusion relationship. Furthermore, the increase in the normal functioning of adipose tissue in obese subjects leads to a systemic proinflammatory state, which produces a rise in the serum concentrations of several cytokines, the soluble fractions of their receptors, and chemokines. Many of these mediators are synthesized and secreted by cells from adipose tissue and receive the generic name of adipokines, including IL-6, IL-10, eotaxin, tumor necrosis factor-alpha, transforming growth factors-beta1, C-reactive protein, leptin, and adiponectin. Finally, specific regions of the human genome related to both asthma and obesity have been identified. Most studies point out that obesity is capable of increasing the prevalence and incidence of asthma, although this effect appears to be modest. The treatment of obese asthmatics must include a weight control program.

Coexistence of asthma and allergic rhinitis in adult patients attending allergy clinics: ONEAIR study

BACKGROUND

Several studies have shown links between the upper and lower airways in allergic patients.

OBJECTIVES

This study aimed to evaluate the prevalence of rhinitis in patients with allergic asthma attending allergy outpatient clinics and to examine the interrelationship between both conditions.

METHODS

An epidemiological prospective study was carried out during the period 2004-2005 and 170 allergists from all over the country participated. After obtaining written informed consent, we collected clinical and demographic data, a personal and family history of allergic diseases, and data on the duration and severity of asthma and rhinitis. These data were classified according to the criteria of the Global Initiative for Asthma and the Allergic Rhinitis and its Impact on Asthma guidelines, respectively.

RESULTS

A total of 968 subjects were screened and 942 were enrolled in the study. Mean (SD) age was 35.5 (14) years and 63% were female. Of these patients, 89.5% presented with allergic rhinitis. The duration of the disease was 12.6 (8.9) years for rhinitis and 11.4 (9.6) years for asthma (P < .0001). The severity of asthma was classified as intermittent (39%), mild persistent (30%), moderate persistent (27%), and severe persistent (4%). Rhinitis was classified as mild intermittent (24%), moderate/severe intermittent (22%), mild persistent (19%) and moderate/severe persistent (35%). A significant correlation was found (P < .0001) between the severity of rhinitis and asthma. The prevalence of allergic rhinitis was inversely correlated with the age of the patients (P < .0001) and the severity of asthma (P < .05).

CONCLUSION

This study reinforces the high prevalence of allergic rhinitis in patients with asthma, which can affect as many as 89.5%.

Increased prostaglandin E2 levels in the airway of patients with eosinophilic bronchitis

BACKGROUND

Eosinophilic bronchitis is a common cause of chronic cough, which like asthma is characterized by sputum eosinophilia, but unlike asthma there is no variable airflow obstruction or airway hyperresponsiveness. We tested the hypothesis that the different airway function in patients with eosinophilic bronchitis and asthma could be caused by an imbalance in the production of bronchoconstrictor (LTC(4)) and bronchoprotective (prostaglandin E(2); PGE(2)) lipid mediators.

METHODS

We measured cytokines levels, proinflammatory mediators and eicosanoids concentration in sputum from 13 subjects with nonasthmatic eosinophilic bronchitis, 13 subjects with asthma, and 11 healthy control subjects. Cytokines mRNA levels were measured by real time PCR, proinflammatory mediators, PGE(2), and LTC(4) were measured by enzyme immunoassays.

RESULTS

The median sputum eosinophil count was not statistically different in patients with asthma (7.95%) and eosinophilic bronchitis (15.29%). The levels of mRNA specific to interleukin-5 (IL-5), IL-4, IL-10, IL-13, interferon gamma (IFN-gamma), IL-2, vascular endothelial growth factor and transforming growth factor beta were similar in both conditions. In addition, no differences were found between asthma and eosinophilic bronchitis in proinflammatory cytokines, such as IL-8, IFN-gamma and tumor necrosis factor alpha (TNF-alpha) levels. Sputum cysteinyl-leukotrienes concentration was raised both in eosinophilic bronchitis and asthma patients. We found that induced sputum PGE(2) concentrations were significantly increased in subjects with eosinophilic bronchitis (838.3 +/- 612 pg/ml) when compared with asthmatic (7.54 +/- 2.14 pg/ml) and healthy subjects (4 +/- 1.3 pg/ml).

CONCLUSION

This data suggest that the difference in airway function observed in subjects with eosinophilic bronchitis and asthma could be due to differences in PGE(2) production in the airways.

Sensitization to human milk

BACKGROUND

Allergy to milk is one of the earliest manifestations of IgE-mediated allergies and affects about 2.5% of newborn children. Several reports indicate that milk-allergic patients may be sensitized also to human milk proteins.

OBJECTIVE

To analyse the specificity and possible biological relevance of IgE reactivity to human milk antigens in milk-allergic patients.

METHODS

The specificity of IgE reactivity to cow's milk and human milk antigens was analysed with sera from milk-allergic children and adults by IgE immunoblotting. IgE cross-reactivity between milk antigens was studied by immunoblot inhibition experiments. That IgE reactivity to human milk antigens is not due to alloreactivity or due to the transmission of foreign antigens into mother's milk was demonstrated through the analysis of milk samples from genetically unrelated mothers before and after intake of dietary milk products. The biological relevance of IgE reactivity to human milk was confirmed by skin testing. Results IgE antibodies to human milk were found in more than 80% of the tested milk-allergic patients. Cross-reactive IgE-reactive human antigens such as alpha-lactalbumin and non-cross-reactive human milk antigens were identified. Immediate-type skin reactions could be elicited with human milk samples in patients with IgE reactivity to human milk.

CONCLUSION

IgE reactivity to human milk in milk-allergic patients can be due to cross- sensitization and genuine sensitization to human milk and may cause allergic symptoms. IgE-mediated sensitization to human milk is common in milk-allergic patients and may require diagnostic testing and monitoring.

Occupational asthma in the developing and industrialised world: a review

Occupational asthma is the most common occupational lung disease in industrialised countries, and the second most common occupational lung disease reported after pneumoconioses in developing countries. The median proportion of adult cases of asthma attributable to occupational exposure is between 10% and 15%. The population attributable fraction appears to be similar in industrialised and developing countries characterised by rapid industrialisation (13-15%), but lower in less industrialised developing countries (6%). The high-risk occupations and industries associated with the development of occupational asthma vary depending on the dominant industrial sectors in a particular country. High-risk exposure to cleaning agents and pesticide exposure in developing countries appear to be as important as exposure to isocyanates, cereal flour/grain dust, welding fumes, wood dust and, more recently, hairdressing chemicals, commonly reported in industrialised countries. The reported mean annual incidence of occupational asthma in developing countries is less than 2 per 100 000 population, compared to very high rates of up to 18/100 000 in Scandinavian countries. While occupational asthma remains under-recognised, especially in developing countries, it remains poorly diagnosed and managed and inadequately compensated worldwide. Primary and secondary preventive strategies should be directed at controlling workplace exposures, accompanied by intense educational and managerial improvements. Appropriate treatment remains early removal from exposure to ensure that the worker has no further exposure to the causal agent, with preservation of income. However, up to one third of workers with occupational asthma continue to remain exposed to the causative agent or suffer prolonged work disruption, discrimination and risk of unemployment.

Bronchial responsiveness to bakery-derived allergens is strongly dependent on specific skin sensitivity

BACKGROUND

Quantitative relationships between immunological reactivity, non-specific bronchial responsiveness and bronchial responsiveness to allergens have scarcely been investigated in occupational asthma.

METHODS

We assessed the above relationships in 24 subjects with baker's asthma. The skin endpoint titration to bakery allergens as a measure of immunological reactivity, together with the methacholine PC20 and allergen PC20 during early asthmatic reaction were determined.

RESULTS

All patients had positive skin tests to some bakery allergens (wheat and rye flour, soybean flour, fungal enzymes and egg white proteins) and bronchial hyperresponsiveness to methacholine. Specific inhalation challenge (SIC) tests were performed with aqueous allergen extracts of cereal flour (n = 14), soybean (n = 8), baking enzymes (n = 12), and egg white proteins (n = 8) in sensitized workers. A positive asthmatic reaction was observed in 84% of the inhalation challenges. SIC elicited isolated early asthmatic reactions in 62%, dual reactions in 32% and isolated late reactions in 5%. Multiple linear regression analysis showed allergen PC20 as a function of skin sensitivity to allergen and methacholine PC20, yielding the following highly significant regression formula: log-allergen PC20 = 0.18 + 0.99 log(skin sensitivity) + 0.343 log(methacholine PC20) (r = 0.89, P < 0.001). This formula predicted allergen PC20 to within one double concentration in 67%, to within two double concentrations in 85% and within three double concentrations in 97%.

CONCLUSION

The main determinant of bronchial responsiveness to allergen in patients with baker's asthma is the degree of sensitization to occupational allergens as determined by skin reactivity, modulated to a lesser extent by non-specific bronchial hyperresponsiveness.

Occupational asthma in industry

Occupational or professional asthma is defined as adult asthma, i.e., an inflammatory respiratory disease characterized by the presence of variable airflow limitation or bronchial hyperreactivity secondary to conditions and causes associated with a given occupational or working environment - not with stimuli found outside the workplace. Depending on the physiopathological mechanism involved, a distinction is made between immune asthma (with or without IgE mediation) and non-immune asthma. It is difficult to establish the relationship among the symptoms of asthma, the patient's professional activity and the presence or absence of sensitization to certain agents in the working environment. Guided compilation of the case history and measurement of nonspecific bronchial hyperreactivity and bronchial inflammation are currently essential in the diagnostic approach to occupational asthma. Whenever possible, allergists should establish the cause-effect relationship in occupational asthma, as required by the medical-legal and social implications of the disease. Occupational asthma remains a minority diagnosis among occupational diseases in general. Adequate personnel training and the creation of diagnostic centers may help to ensure correct and rapid detection of this disease.

IgE reactivity to latex allergens among sensitized healthcare workers before and after immunotherapy with latex

BACKGROUND

New IgE sensitizations to proteins in allergen extracts have been shown to occur during allergen-specific immunotherapy (IT).

METHODS

Twenty-four healthcare workers (HCWs) -- patients included in a latex IT study -- were analysed, 16 in active treatment and eight in placebo. Sera were obtained at baseline and after 6 months of IT and analysed with immunoblotting and CAP System with eight single recombinant latex allergens (rHev b 1, 3, 5, 6.01, 8, 9, 10, 11, and a mix of rHev b1, 5, 6.01 and 8).

RESULTS

After IT with latex, three patients in the active treatment group had new IgE sensitizations, one to Hev b 5, one to Hev b 11 and another to Hev b 6.01. No other significant variation in mean of specific IgE to latex or recombinant allergens were observed in patients who received placebo or active treatment. A significant (P = 0.012) negative correlation (-0.72) was observed between maximal tolerated dose and specific IgE to Hev b 6.01 at baseline. After IT, immunoblot analysis demonstrated a significant increase in IgE binding in a band of approximately 22 kDa (P = 0.032) that may correspond to Hev b 6.01. New or more intense bands appeared in seven patients of the active group, while in three subjects a reduction was observed.

CONCLUSIONS

Hev b 6.01 seems to be the most relevant latex allergen in HCWs. New or more intense IgE binding to latex allergenic components occurs during latex immunotherapy. However, the levels of specific IgE against these new components are low and do not seem to have clinical relevance.

Occupational asthma due to piperazine citrate

BACKGROUND

Piperazine is a secondary heterocyclic amine that may give rise to occupational asthma of uncertain mechanism.

METHODS

We report on a 42-year-old woman, a process operator in a chemical factory, who developed work-related symptoms of rhinitis and asthma upon exposure to piperazine citrate. She remained symptom free during holidays and days off work.

RESULTS

Skin prick test with piperazine citrate was positive. Specific inhalation challenge with piperazine citrate at a concentration of 5 mg/m3 for 30 minutes elicited an isolated late asthmatic response. Airway hyperresponsiveness to methacholine significantly increased 3 hours after the piperazine challenge, preceding the late asthmatic response.

CONCLUSION

This patient had developed occupational asthma caused by piperazine, as confirmed by the specific inhalation challenge test, possibly due to an immunological mechanism.

Immunological studies in a case of hydrochlorothiazide-induced pulmonary edema

A case of acute onset non-cardiogenic pulmonary edema induced by hydrochlorothiazide (HCT) is presented. Rapid recovery was obtained with supportive therapy. Leukopenia was evident during the acute phase, with rapid recovery parallel to the clinical improvement, suggesting pulmonary sequestration of granulocytes. Immunological studies including lymphocyte stimulation test with HCT and measurement of specific IgG and IgE to HCT elicited negative results. The pathogenesis of this type of reaction remains to be elucidated.

Anaphylaxis caused by cauliflower

BACKGROUND

Cauliflower is a vegetable belonging to the family Cruciferae, genus Brassica, var. Botrytis.

METHODS

We report the case of a 70 year-old man who suffered an acute episode consisting of oropharyngeal itching, facial and hand swelling, dyspnea and severe bronchospasm within a few minutes after eating vegetable paella containing cauliflower, green beans, red and green pepper. Due to the severity of the reaction he needed treatment in the emergency room.

RESULTS

Skin prick tests with common aeroallergens were positive to Cupressus, Platanus and grass pollen. A strong skin prick test response was obtained with cauliflower and peach lipid transfer protein. Skin prick test with rice, green beans and pepper were negative. Specific IgE determinations were positive to cabbage and cauliflower, and negative to mustard.

CONCLUSIONS

The clinical history and the results of the allergologic work-up point out to this patient having experienced an IgE-mediated anaphylactic reaction to cauliflower. To the best of our knowledge, this is the first case report of anaphylaxis due to cauliflower.

Tolerance and effects on skin reactivity to latex of sublingual rush immunotherapy with a latex extract

BACKGROUND

Specific immunotherapy could be a therapeutic tool for the increasing problem of sensitisation to Natural Rubber Latex (NRL).

OBJECTIVE

To investigate the tolerability of SLIT for Latex and its effects on skin reactivity.

METHODS

Twenty-six patients (mean age 35.5 years) with an average history of 7.5 years of cutaneous symptoms plus respiratory symptoms (23/26) due to NRL were studied. All underwent rush sublingual therapy (4 days) with a standardized NRL extract followed by a 9-week maintenance treatment. Local and systemic adverse reactions were monitored throughout the treatment. Skin reactivity to NRL extract was evaluated before, during and at the end of the treatment by latex glove-use test, rubbing test and skin prick test.

RESULTS

All patients reached the maintenance dose. Out of 1044 administered doses, 257 (24.6%) produced adverse reactions from which 21.4% were local. Only 10.1% of cases required treatment, mainly with antihistamines alone (5.8%), with 2-agonists alone (0.8%) or associated to antihistamines and/or corticosteroids (2.7%). One patient was precautionary treated twice with adrenaline but completed the treatment without further problems. The glove-use test improved significantly after 5 days and 10 weeks of treatment (p = 0.003, p = 0.0004 respectively), whereas the rubbing test improved significantly only after 10 weeks of treatment. Doctor's assessments confirmed the results obtained with the glove-use test (p = 0.003 after 5 days, and p = 0.004 after 10 weeks) but not those obtained with the rubbing test. No change was detected for SPTs.

CONCLUSION

SLIT for NRL allergy is able to modify skin reactivity to NRL in days as assessed with methods reproducing HCWs normal exposure to the allergen. Tolerance of SLIT is better than tolerance reported for injective therapy with NRL, but the build up phase should be administered under medical surveillance until sufficient experience has been accumulated. The long-term effect of the treatment deserves further investigation.

Characterization of allergens of Anisakis simplex

BACKGROUND

Anisakis simplex is an intestinal parasite of sea mammals. The larvae infect crustaceans, cephalopods and fish. Humans may consume A. simplex third stage larvae (L3) when eating infected raw or under-cooked fish. Consumed larvae cause an inflammatory reaction when they penetrate the digestive mucosa. The larvae or their secretory/excretory products can sensitize humans and induce an immunoglobulin E (IgE)-mediated allergic reaction. This parasite is now being implicated in numerous cases of allergic reactions after eating fish. The purpose of this study was to evaluate the allergenicity of proteins present in an extract of the third stage larva.

METHODS

Rabbit antiserum raised to A. simplex somatic extract (L3) was reacted by crossed immunoelectrophoresis (CIE) with the same somatic extract. Crossed radioimmunoelectrophoresis (CRIE) was also performed by incubating CIE gels first in the sera of 13 individuals with positive immunoCAP to A. simplex and then in radiolabeled anti-human IgE.

RESULTS

Twelve to 16 antigen-antibody precipitin peaks were visualized on Coomassie blue stained CIE gels in which somatic extract was reacted with somatic-antiserum. Autoradiography of CRIE gels showed that 18 different proteins bound IgE in patient sera. Individual patients had serum IgE directed at two to 10 different allergens. Five of these allergens were recognized by >/=50% of the patients. No allergen was recognized by every patient and no patient had serum IgE directed at all 18 allergens.

CONCLUSION

Somatic extracts of A. simplex L3 larva contain a large number of allergenic molecules and there is significant variability between patients in their sensitivity and reactivity to these allergens.

Egg white proteins as inhalant allergens associated with baker's asthma

BACKGROUND

Bakery workers may develop IgE-mediated allergy to liquid and aerosolized hen's egg proteins that are commonly used in the baking and confectionery industries.

METHODS

We studied four bakery workers who had work-related allergic respiratory symptoms upon exposure to egg aerosols. The causative role of egg proteins in their respiratory symptoms was investigated by immunologic and specific inhalation challenge (SIC) tests.

RESULTS

Skin prick tests to egg white extract and to lysozyme gave positives responses in all the subjects, to ovalbumin in two, to ovomucoid in one and to egg yolk in two subjects. They were also sensitized to wheat, rye and barley flours. Specific IgE determinations to egg white were positive in all patients, to lysozyme in two, to ovalbumin in three, to ovomucoid in two and to egg yolk in two of them. Methacholine inhalation tests revealed bronchial hyperresponsiveness in all workers (PC20 < 16 mg/ml). SICs were performed with aqueous extracts of lysozyme (n = 4), ovalbumin (n = 2) and ovomucoid (n = 1), which elicited isolated early asthmatic reactions in all subjects. Double-blind, placebo-controlled, oral challenge tests with raw egg white were positive in three subjects.

CONCLUSIONS

These bakery workers had developed IgE-mediated occupational asthma to hen's egg white proteins.

[Asthmatic characteristics in smokers with advanced emphysema]

OBJECTIVES

Most pneumologists assume that chronic asthma and emphysema associated with smoking differ both in their etiology and type of inflammation. However, it is difficult to study subjects who have both diseases simultaneously. We designed a prospective study to determine whether or not some advanced emphysema patients who are smokers have an asthmatic profile suggesting the two diseases overlap.

PATIENTS AND METHOD

Twenty-three smokers with moderate to severe obstruction and radiologic signs of advanced emphysema were studied. The following signs of asthma were analyzed for all patients: positive acute response to bronchodilators, eosinophilia in peripheral blood, significant eosinophilia in sputum, significant total serum immunoglobulin E (IgE) and specific IgE positive for common allergens and fungi. An asthmatic profile was defined as the presence of 3 or more of the aforementioned signs. Statistical analysis was by calculation of the confidence interval on the total number of positive cases to estimate the population percentage.

RESULTS

Data on at least 4 characteristics were available for 21 of the 23 patients. Ten (48%) of the 21 had asthmatic profiles (3 or more of the aforementioned characteristics). This finding suggests that asthmatic characteristics are present in between 17.6 and 79.6% of the studied population with advanced emphysema, with a confidence interval of 99.9%.

CONCLUSIONS

We conclude that emphysema initially associated with smoking may mean that at least 17.6% of patients have a clear asthmatic profile, which indicates a high degree of overlap between asthma and emphysema in smokers. Thus, our findings are consistent with the Dutch theory that chronic obstructive diseases have a common origin in underlying allergic sensitization and bronchial hyperresponsiveness alongside various other influential factors such as tobacco smoking over the course of disease.