[The value of immunotherapy in treatment of IgE-induced allergic diseases]

Until today, immunotherapy is the only causal treatment of IgE-mediated allergic disease. Its efficacy has been demonstrated in controlled studies for rhinitis and bronchial asthma due to various pollens, house-dust mite and animal dander as well as for systemic allergic reactions following hymenoptera stings. This treatment is especially successful in younger patients with seasonal allergy of rather short duration and with sensitization only to few allergens. In order to avoid allergic side effects of this treatment, measures of precautions must be strictly observed. A close cooperation between patient, family practitioner and allergist is important for the success of this treatment.

Safety and efficacy of oral immunotherapy with standardized cat extract

Fifty-three subjects with positive skin prick test results to cat extract and rhinoconjunctival symptoms on exposure to cat dander were enrolled in a double-blind, placebo-controlled study of oral cat immunotherapy. Responses were assessed by development of symptoms and nasal blockage on exposure to an apartment contaminated with cat dander, by titrated skin prick tests, and by cat-specific IgG and IgE. A total cumulative dose of 2.5 x 10(6) allergy units or 436 U Fel d I were administered over a period of 3 months. Both groups of subjects had significantly fewer symptoms on exposure to cat dander during the course of the study, but there was no significant difference between active and placebo groups. There were no significant changes in either group in nasal blockage, skin prick test results, or specific IgG levels. Both groups had significant increases in cat-specific IgE, but there were no differences between groups. Subjects receiving active treatment had a slight excess of gastrointestinal complaints. Two subjects receiving active treatment experienced systemic symptoms: one had pulmonary edema, and the other had persistent asthma and urticaria, which may have represented reactions to the treatment. We conclude that oral cat immunotherapy with the preparation and doses used in this study is not effective.

[The procedures for using immunological study methods in different diseases]

The article deals with the basic principles of application of immunological methods for the diagnosis of the immune system disorders. A two-staged method of laboratory tests for the immune status evaluation was accompanied with a number of immunological methods which differed depending on the proper status of the immune system. The author stresses the clinical significance of the methods of the immune status evaluation and also gives the basic immunological criteria for the immunomodulatory therapy.

Safety and efficacy of a 12-week maintenance interval in patients treated with Hymenoptera venom immunotherapy

It is currently recommended to administer a maintenance dose of 100 micrograms of venom at 4-6 week intervals for Hymenoptera venom immunotherapy (VIT). Because the optimal duration of therapy is not known, we decided to progressively prolong the interval between maintenance injections instead of accepting the risk of anaphylactic reactions when VIT is discontinued after a predetermined period. We report here on the results of a first phase of this interval extension programme, covering the gradual increase of the interval from 1-12 weeks over 19 months in 178 patients. A 12-week interval maintenance VIT could be achieved in 117/128 (91%) of yellow jacket venom (YJV) and in 35/50 (70%) of honeybee venom (HBV) allergic patients. At the time of the interview these 152 patients had been treated with 12-weekly 100 microgram venom injections for an average period of 2 years without any untoward reaction to VIT. During this period 48 YJV allergy sufferers experienced 77 field re-stings without systemic reaction (SR), and 17 HBV allergic subjects were restung at least 213 times in total, with one patient developing a very large local reaction and one a mild systemic reaction. In 26 of the 178 patients the interval of 12 weeks was not reached for various reasons, with a higher failure rate among the HBV allergic patients. Most Hymenoptera venom allergic patients can thus be safely and effectively treated with 12-weekly injections of 100 micrograms venom.

Safety considerations in assessing the role of immunotherapy in allergic disorders

Specific immunotherapy (SIT) is accepted as an effective treatment of allergic diseases when high quality extracts are used. However, this form of treatment can cause untoward reactions among which systemic reactions are the most severe. Although life-threatening reactions are rare and deaths exceptionally reported, SIT should be prescribed by allergists to patients with well defined characteristics, and administered with care by (or under the close supervision of) physicians trained to deal rapidly with the reactions. Reactions with standardised extracts occur mostly during the dose increase phase but they can be prevented using adapted schedules and premedication. During maintenance injections or when vial batches are changed, standardised extracts of known shelf-life usually result in a low rate of systemic reactions. Patients with asthma are more prone to develop systemic reactions, and allergens should not be administered to patients with a forced expiratory volume in 1 second (FEV1) under 70% of predicted or in those who have unstable or symptomatic asthma. Systemic reactions may be observed with all allergens and allergenic preparations although it appears that high molecular weight extracts may be safer.

[Allergology in the year 2000]

As already today, the use of fully standardized allergens for specific allergen phenotyping will be essential also in the future. The determination of allergen-reactive patterns in patients will be performed with panels of tracer allergens being produced by molecular biology techniques. Such recombinant allergen proteins can in principal also be used for specific immunotherapy. Undesired biological properties of allergens can be removed by directed mutagenesis. Because recombinant allergens can bind IgE only selectively, T-cell activating fragments thereof may be employed. This may lead to fully artificial protein constructs consisting of immunogenic and allergy-suppressing parts. A different possible way is the therapeutic use of immunologically active proteins, such as monoclonal antibodies or soluble receptors, which suppress IL-4 and/or IgE synthesis. The accessibility of these proteins will lead to a better understanding of the mechanisms responsible for the development of allergy. At the end of this development one could conceive the construction of low molecular chemical agents, drugs in the classical sense, able to regulate IgE synthesis. Of highest significance will be the establishment of genetic markers for atopy and allergy. Such genes may not only indicate a genetic predisposition for the disease but also open an immense spectrum of new diagnostic and therapeutic applications in allergy.

Observation on the curative effect of acupuncture on type I allergic diseases

In a comparative study on treatment of type I allergic diseases, acupuncture and desensitization therapies were performed in 143 cases. The results showed that acupuncture therapy had an extensive and remarkable action against type I allergic reaction. The curative effect was higher in the acupuncture group than in the desensitization group in allergic asthma, allergic rhinitis and chronic urticaria.

House dust mite allergy: from T-cell epitopes to immunotherapy

CD4+ T-lymphocytes induce and regulate allergic inflammatory responses to common environmental aeroallergens derived from Dermatophagoides spp. (house dust mite, HDM), which cause clinical symptoms in approximately 10% of the population. Definition of the molecular structure of HDM proteins combined with the ability to isolate monoclonal populations of human CD4+ T-cells representative of the 'interleukin-4 (IL-4) dominant' functional phenotype, which support immunoglobulin E (IgE) synthesis, has allowed T-cell recognition of HDM to be examined in detail. The results of these investigations demonstrated extensive heterogeneity in both the antigen and HLA class II restriction specificity of the HDM reactive T-cell repertoire. Furthermore, long-lived clones of T-cells with oligoclonality in T-cell antigen receptor (TcR) usage, driven by chronic stimulation with HDM, have been identified in human peripheral blood. The presentation of specific peptides and superantigens under conditions that induce T-cell non-responsiveness has provided an in vitro model for analysing the mechanisms of CD4+ T-cell targeted immunotherapy. It appears that the mechanisms underlying T-cell anergy are accompanied by a transient downregulation of TcR and CD28 and mediated by a shift in the cytokine profile from that of the 'IL-4 dominant' to the 'interferon-gamma (IFN-gamma) dominant' functional phenotype of CD4+ T-cells. In parallel, using a murine model, it has been demonstrated that administration of an immunodominant peptide via the mucosal surfaces of the respiratory and alimentary tracts may tolerize an established response to intact HDM proteins. The potential application of these models in the development of novel approaches to immunotherapy is discussed.

Environmental control in the prevention and treatment of pediatric allergic disease

Allergen avoidance should be considered as a first line of defense for all types of allergic disease. For some allergens, such as the common pollens, significant avoidance may be difficult or even impossible to accomplish without major alterations in lifestyle. For others, however, particularly the common indoor allergens, avoidance is a very real option that can be achieved through practical environmental control measures. In addition to the inherent logic of allergen avoidance, there are substantial data to support its efficacy in the treatment of patients with atopic disease, particularly asthma. Further, there is an emerging body of evidence to support its role in the prevention of allergic disease in infants and children. In this article, recent research advances in the areas of indoor allergens, environmental control, and allergen avoidance are reviewed.

Allergic to the 20th century

Twentieth century allergy has caught the popular imagination. This article looks at the nature of the problem and whether it is in fact a true allergy. A practical approach to clinical assessment is made and advice as to management is offered.

Selection of Hymenoptera venoms for immunotherapy on the basis of patient's IgE antibody cross-reactivity

BACKGROUND

Positive skin test results to multiple venoms in patients with Hymenoptera venom allergy may result from IgE antibody cross-reactivity among venom proteins. To avoid treatment with unnecessary and costly venoms, we have developed a venom RAST inhibition test that identifies individuals in whom a positive venom IgE RAST result is due to cross-reactive venom-specific IgE antibody.

METHODS

Serum samples (n = 412) were collected over 5 years from patients with clinically characterized Hymenoptera venom allergy who had positive skin test results to more than one venom. Venom allergosorbent was added to serum containing IgE antivenin and buffer or 100 micrograms of homologous or heterologous venom. Bound IgE was detected with radiolabeled anti-human IgE. Intraassay variation less than 10% coefficient of variation and homologous venom inhibition greater than 80% were required for acceptance of data. A "cross-reactivity index" (CRI) was computed as a ratio of percent inhibition produced by heterologous versus homologous venom.

RESULTS

Of the 412 sera-venom combinations analyzed, 41 (10%) were excluded because of incomplete homologous venom inhibition. Of the 371 remaining sera, 82% (n = 305) were studied for IgE anti-Polistes wasp venom (PWV) cross-reactivity with yellow jacket venom (YJV) and the other 66 for other venom specificity cross-inhibitions. Of the serum samples tested, 36.4% (111 of 305) contained IgE anti-PWV venom of which the binding to solid-phase PWV was inhibited with soluble YJV to a level that produced CRIs greater than 95%. We believe that this constitutes complete inhibition and demonstrates exclusively YJV cross-reactive antibody in these samples. The remaining 63.6% had CRIs from 0% to 95%, indicating IgE specific for a spectrum of unique and cross-reactive PWV allergens. Only 4.3% (13 of 305) had CRIs less than 5%, which is consistent with IgE restricted to PWV unique allergens. The degree of the IgE anti-PWV inhibition to solid-phase PWV by YJV was independent of the IgE anti-PWV level.

CONCLUSIONS

This study shows that one third of patients with Hymenoptera venom allergy evaluated with positive YJV- and PWV-reactive IgE in the skin and/or serum were identified as candidates for exclusion of PWV from their immunotherapy regimen because their IgE anti-PWV was more than 95% cross-inhibitable with YJV. Cost analysis of the venom RAST inhibition test and a conventional 5-year Hymenoptera venom immunotherapy program indicates that this serologic evaluation is cost-effective.

Abrogation of facial seborrhoeic dermatitis with homoeopathic high dilutions of tobacco: a new visible model for Benveniste's theory of 'Memory of water'

The author describes the activity of homoeopathic high dilutions of tobacco to treat his familial facial seborrhoeic dermatitis induced by the hapten nicotine. A double-blind experiment against placebo and several treatments with continuous and single intakes of tobacco high dilutions led after a break to a late abrogation of dermatitis simulating a desensitization. These observations provide a new possible explanation for the placebo effect and facial seborrhoeic dermatitis is proposed as a new visible model for Benveniste's theory of 'Memory of water'.

Fungal extracts in clinical practice

Sensitivity to fungi is a common clinical problem. Although many commercial extracts for diagnosis and treatment of fungal sensitivity are available, there is a lack of standardized materials. New research into the isolation and purification of fungal allergens may improve upon this situation. Controlled immunotherapy trials with fungal extracts have identified selected populations who may benefit from this type of therapy.

Injection immunotherapy. British Society for Allergy and Clinical Immunology Working Party

A working party of the British Society for Allergy and Clinical Immunology has reviewed the role of specific allergen immunotherapy in the treatment of allergic disease and produced a position statement summarising the available evidence for efficacy and safety. The working party recommends specific allergen immunotherapy for treating summer hay fever uncontrolled by conventional medication and for wasp and bee venom hypersensitivity. It is not recommended for asthma or for allergic rhinitis due to other allergens. For the recommended indications the risk:benefit ratio is acceptable provided patients are carefully selected; in particular, patients with asthma should be excluded as they are especially vulnerable to adverse reactions. Injections should be given only by doctors experiences in this form of treatment in a clinic where full resuscitative facilities are immediately available. Provided patients remain symptom free a 60 minute observation period after injection is sufficient to detect all serious adverse reactions.

Heterogeneity of histamine releasing factors and IgE

Advances in our understanding of cytokines and their effects seem to occur almost on a daily basis. The first description of a cytokine causing histamine release was in 1979. Since that time several cellular products have been described which cause histamine release. The following is a general review of the literature concerning histamine releasing factors and their IgE interactions.