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Affiliation(s)
- J O Warner
- St Mary's and St Charles Hospitals, London
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Abstract
Local reactions from subcutaneous allergen immunotherapy are very common during the course of immunotherapy. These local reactions are not bothersome to patients. Local reactions from immunotherapy also do not predict future local or systemic reactions. This review discusses the studies that show that local reactions are not predictive of future reactions and that dose adjustments for local reactions from allergen immunotherapy are unnecessary. The article also focuses on factors that lead to patient noncompliance with immunotherapy and evaluates methods to prevent local reactions from subcutaneous allergen immunotherapy.
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Affiliation(s)
- Christopher A Coop
- Department of Allergy & Immunology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX, USA
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3
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Abstract
PURPOSE OF REVIEW After 100 years of experience with allergen-specific immunotherapy (SIT), an issue that is still unresolved is whether SIT can act as a trigger of, or as a risk factor for, autoimmune disease. We searched the literature for evidence on this topic. RECENT FINDINGS Several case reports of autoimmune disease development with plausible relation to SIT have been published. Vasculitis reactions accounted for the majority of case reports retrieved in our literature search. Whether the number of reported cases is higher or lower than what would be expected by chance is not possible to determine from existing data. There are no published data on autoimmune disease development in patients participating in randomized trials of the effects of SIT. One nonrandomized pharmacoepidemiological study did not detect an increased risk of autoimmune disease development during SIT as compared with the risk during conventional allergy treatment. SUMMARY In conclusion, development of autoimmune disease in allergic patients treated with SIT is rare. Nevertheless, as a principle of caution, it seems reasonable to carefully evaluate the indication for SIT, that is, risks versus benefits, in patients with established autoimmune disease or a strong family history of autoimmune disease.
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Zur G, White SD, Ihrke PJ, Kass PH, Toebe N. Canine atopic dermatitis: a retrospective study of 169 cases examined at the University of California, Davis, 1992-1998. Part II. Response to hyposensitization. Vet Dermatol 2002; 13:103-11. [PMID: 11972893 DOI: 10.1046/j.1365-3164.2002.00286.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
One hundred and sixty-nine dogs were diagnosed with atopic dermatitis, and treated with hyposensitization for at least 1 year based on the results of either intradermal skin tests (IDST) or enzyme-linked immunosorbant serum assays (ELISA). Excellent (i.e. hyposensitization alone controlled clinical signs), good (> 50% improvement), moderate (< 50% improvement) and no (clinical signs were unchanged) responses were seen in 19.5, 32.5, 20.1 and 27.8%, respectively. Age of onset, age when treatment was initiated or the duration of clinical signs had no influence on response to hyposensitization. Dogs having concurrent flea allergy dermatitis were statistically more likely to respond better than dogs with concurrent food allergies. Although not statistically significant, there were trends for Golden Retriever and male dogs to respond better than other breeds and female dogs, respectively. Dogs having more than 21 positive reactions in allergy tests and treated with more than 21 allergens had lower response scores, and a longer time course before achieving beneficial response. Lower response scores were seen in dogs having positive reactions to cultivated plants, grasses, trees or insects. There was no difference in response to hyposensitization whether based on IDST or ELISA results.
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Affiliation(s)
- Gila Zur
- Koret Veterinary Teaching Hospital, School of Veterinary Medicine, The Hebrew University of Jerusalem, PO Box 12 Rehovot 76100, Israel.
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5
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Lockey RF, Nicoara-Kasti GL, Theodoropoulos DS, Bukantz SC. Systemic reactions and fatalities associated with allergen immunotherapy. Ann Allergy Asthma Immunol 2001; 87:47-55. [PMID: 11476476 DOI: 10.1016/s1081-1206(10)62195-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The primary objective of this review is to discuss systemic allergic reactions and risk factors associated with the injection of allergen vaccines. DATA SOURCES A review of the literature on anaphylactic reaction, adverse effects, and fatalities associated with allergen immunotherapy (IT) was conducted. STUDY SELECTION The expert opinion of the author was used to select relevant data. RESULTS Systemic allergic reactions associated with the injection of allergen vaccines usually begin within 20 minutes. However, on occasion, they begin 20 to 30 minutes or longer after an injection. Such reactions can also occur after allergen skin testing. Most reactions associated with skin testing and allergen IT are mild and readily respond to appropriate treatment. However, severe and even fatal reactions have been reported with both skin testing and IT. CONCLUSIONS Risk factors for skin testing and allergen IT include: 1) patients, particularly asthmatic patients, suffering with seasonal exacerbation of their symptoms; 2) patients who demonstrate exquisite sensitivity to particular allergen(s); 3) patients on beta-blockers; 4) patients with asthma, especially if their asthma is unstable; 5) patients in whom rush IT is used; and 6) patients in whom high doses of potent standardized allergen vaccines are used. It is essential that strict attention be paid to the risk factors for systemic reactions, and that techniques and management be initiated both before and after skin testing or IT to minimize these risks. Done properly, the risk of skin testing and IT is minimal.
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Affiliation(s)
- R F Lockey
- Department of Internal Medicine, University of South Florida College of Medicine, and James A. Haley Veterans' Medical Center, Tampa 33612, USA.
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7
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ADVERSE EFFECTS OF ALLERGEN IMMUNOTHERAPY. Radiol Clin North Am 2000. [DOI: 10.1016/s0033-8389(22)00108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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8
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Branco-Ferreira M, Clode MH, Palma-Carlos AG. Distal digital vasculitis induced by specific immunotherapy. Allergy 1998; 53:102-3. [PMID: 9491238 DOI: 10.1111/j.1398-9995.1998.tb03783.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Quirce S, Fernandez Rivas M, Losada E, de la Hoz B, Fraj J, Alvarez Cuesta E. Recurrent pericarditis: a rare complication of allergen immunotherapy. Allergy 1992; 47:343-5. [PMID: 1443458 DOI: 10.1111/j.1398-9995.1992.tb02068.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report on a 29-year-old woman suffering from hay fever due to grass and olive tree pollens. She developed recurrent pericarditis during her first course of immunotherapy with an alum-adsorbed pollen extract. A causal relationship was established between the allergen injections and the acute pericarditis episodes on two consecutive occasions, which presented with blood eosinophilia. Blood cultures and serological tests for microorganisms were negative. There were no signs of autoimmune disease or systemic vasculitis. To the best of our knowledge, allergen immunotherapy-induced pericarditis has not been previously reported.
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Affiliation(s)
- S Quirce
- Servicio de Alergia, Hospital Ramón y Cajal, Madrid, Spain
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11
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Du Buske LM, Ling CJ, Sheffer AL. SPECIAL PROBLEMS REGARDING ALLERGEN IMMUNOTHERAPY. Immunol Allergy Clin North Am 1992. [DOI: 10.1016/s0889-8561(22)00097-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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12
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Scinto JD, Bernstein DI. IMMUNOTHERAPY WITH DUST MITE ALLERGENS. Immunol Allergy Clin North Am 1992. [DOI: 10.1016/s0889-8561(22)00091-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Taylor RJ. Hypersensitivity vasculitis occurring in a patient receiving immunotherapy. J Allergy Clin Immunol 1991; 87:889-90. [PMID: 1826508 DOI: 10.1016/0091-6749(91)90139-f] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- R J Taylor
- Southern Illinois University School of Medicine, Springfield
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14
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Poulsen LK, Søndergaard I, Weeke B. Improvement of specific immunotherapy by human IgG and modified allergens. Allergy 1989; 44:241-55. [PMID: 2660625 DOI: 10.1111/j.1398-9995.1989.tb01065.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- L K Poulsen
- Laboratory for Medical Allergology, Medical Department TTA, State University Hospital, Copenhagen, Denmark
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15
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Valovirta E, Viander M, Koivikko A, Vanto T, Lindström P, Wager O, Pekkola-Heino K, Ingeman L, Kekomäki R. Circulating immune complexes during immunotherapy in allergy to dog. Allergy 1989; 44:123-31. [PMID: 2785775 DOI: 10.1111/j.1398-9995.1989.tb02235.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Circulating immune complexes (CIC) were determined from dog-allergic asthmatic children (n = 35) receiving immunotherapy with dog dander and hair extract. The results from CIC are expressed in SDU (standard deviation units) and presented as follows: pretreatment results (n = 20), rush results (n = 11), mid-schedule results (n = 20), maintenance results (n = 15) and the results of the placebo-treated group (n = 12). The results of the placebo-treated group (n = 12) and those of the untreated atopic (n = 12) and non-atopic (n = 14) were controls. CIC levels were analysed by means of KgB-ELISA (conglutinin binding enzyme linked immunosorbent assay), C1qB-ELISA (C1q-binding enzyme linked immunososrbent assay), RFb-ELISA (rheumatoid factor binding enzyme linked immunosorbent assay) and by PIPA (platelet 125J-labelled staphylococcal protein-A test). The CIC level determined by KgB-ELISA in dog-allergic asthmatic children was higher than that of the atopic controls (P less than 0.05) already before the onset of the hyposensitization. During conventional hyposensitization with dog dander and hair the CIC level remained the same as before treatment. On day 5 of rush hyposensitization the mean level of CIC showed no increase when compared with the pretreatment values. A statistically significant correlation (P less than 0.01) was observed between the dog dander and hair-specific IgG antibodies and the CIC level measured by KgB-ELISA during the maintenance period of conventional immunotherapy. The samples of sera to measure this correlation were collected before the injection of allergen and after 2 weeks of injection during maintenance treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- E Valovirta
- Department of Pediatrics, University of Turku, Finland
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16
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Tipton WR. Immunotherapy by the Clinical Allergist. Immunol Allergy Clin North Am 1987. [DOI: 10.1016/s0889-8561(22)00185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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17
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Immunotherapy for Allergic Diseases. Prim Care 1987. [DOI: 10.1016/s0095-4543(21)01028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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18
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Ford AW, Platts-Mills TA. Standardized extracts, dust mite, and other arthropods (inhalants). CLINICAL REVIEWS IN ALLERGY 1987; 5:49-73. [PMID: 2435397 DOI: 10.1007/bf02802257] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Pradalier A, Dry J, Artigou C, Chateau M. [Dermatopolymyositis during desensitization with candidin]. Rev Med Interne 1985; 6:253-6. [PMID: 4048686 DOI: 10.1016/s0248-8663(85)80114-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A dermatopolymyositis observation is reported. An urticaria has preceded the dermatopolymyositis and has been treated by a desensitivity procedure. The possible connection between this treatment and the dermatopolymyositis occurring is debated. This observation gives the opportunity to point out the importance of a thorough knowledge of the phenomena involved by such a treatment.
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Dry J, Pradalier A, Artigou C. [A plea for specific desensitization]. Rev Med Interne 1985; 6:249-51. [PMID: 2413513 DOI: 10.1016/s0248-8663(85)80113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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22
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Yancey KB, Lawley TJ. Circulating immune complexes: their immunochemistry, biology, and detection in selected dermatologic and systemic diseases. J Am Acad Dermatol 1984; 10:711-31. [PMID: 6233339 DOI: 10.1016/s0190-9622(84)70087-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Circulating immune complexes (CICs) are a heterogeneous group of immunoreactants formed by the noncovalent union of antigen and antibody. Many factors influence the formation, immunochemistry, biology, and clearance of these soluble reactants. The recent development of sensitive assays for the detection of CICs and the capability to assess immune complex (IC) clearance mechanisms in humans in vivo have expanded our understanding of these mediators. CICs influence both the afferent and efferent limbs of the immune response and can mediate tissue damage in certain pathologic states. ICs probably play an important role in the pathogenesis of serum sickness, systemic lupus erythematosus, and cutaneous necrotizing vasculitis. Recent investigations have raised the possibility that CICs may be of significance in other types of vasculitis as well. In other instances, ICs may form in response to tissue injury and subsequently modify the immune response of the host. A review of this material with special emphasis on diseases of relevance to dermatologists is presented.
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23
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Nakagawa T, Yoshinoya S, Sakamoto Y, Ito K, Miyamoto T. Circulating immune complexes in patients with house-dust-mite-sensitive bronchial asthma. CLINICAL ALLERGY 1984; 14:129-38. [PMID: 6705179 DOI: 10.1111/j.1365-2222.1984.tb02643.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Sera from forty patients with house-dust-mite-sensitive bronchial asthma were examined for the presence of circulating immune complexes (CIC) by the sensitive and quantitative Clq solid-phase radioimmunoassay (Clq-SP) and a monoclonal rheumatoid factor solid-phase radioimmunoassay (mRF-SP). Compared to fifteen normal individuals, the asthmatic patients showed significantly higher mean values of Clq-reactive materials; however, there was no difference between the results from the patients treated by immunotherapy using Dermatophagoides farinae extract and those not so treated. Moreover, immune complexes in eight patients before and after immunotherapy showed that the amount of the complexes tend to decrease during immunotherapy. Furthermore, the presence of complexes had no relationship with the amounts of mite-specific IgG antibody. Similar results were also obtained in tests using mRF-SP. These data suggest that complexes in the sera of the house-dust-mite-sensitive asthmatic patients are not necessarily associated either with immunotherapy or with the mite-specific IgG antibodies.
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Stevens WJ, Bridts CH. IgG-containing and IgE-containing circulating immune complexes in patients with asthma and rhinitis. J Allergy Clin Immunol 1984; 73:276-82. [PMID: 6699311 DOI: 10.1016/s0091-6749(84)80020-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In looking for an additional mechanism that could cause inflammation and therefore be important in the pathogenesis of asthma and rhinitis, IgG- and IgE-CIC were determined in a number of patients that were suffering from asthma and/or rhinitis. Patients were further subdivided into allergic (type I allergy) and nonallergic patients on the basis of history, skin testing with common inhalant allergens, RAST, and, if necessary, allergen provocation. In addition, a control group and patients that were undergoing allergen-specific hyposensitization were studied also. The mean level and frequency of elevated IgG-CIC were significantly increased in all three patient groups as compared to controls. The frequency of IgE-CIC was only significantly elevated in both allergic groups, and the difference between allergic and nonallergic patients was highly significant. IgG- and IgE-CIC did not increase during long-term allergen hyposensitization. Since there was no significant increase of IgE-CIC 10 min after bronchial allergen challenge nor at the moment that symptoms such as urticaria, bronchial obstruction, or rhinorrhea appeared during rush hyposensitization in asthmatic patients, we think that CIC are not involved in classic type I allergic reactions. The possible role of IgG- and IgE-CIC in inducing inflammatory, mediator release from eosinophils and macrophages via binding of Fc receptors on these cells is discussed.
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27
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Zeiger RS, Schatz M. Immunotherapy of atopic disorders. Present state of the art and future perspectives. Med Clin North Am 1981; 65:987-1012. [PMID: 6457225 DOI: 10.1016/s0025-7125(16)31485-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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28
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Lawley TJ, Hall RP. Circulating immune complexes in dermatologic disease. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 1981; 4:221-40. [PMID: 7041299 DOI: 10.1007/bf01892179] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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29
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Stendardi L, Delespesse G, Debisschop MJ. Circulating immune complexes in bronchial asthma. CLINICAL ALLERGY 1980; 10:405-11. [PMID: 7449074 DOI: 10.1111/j.1365-2222.1980.tb02123.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Soluble immune complexes were detected by a sold phase Clq binding assay in forty-two out of 106 well studied asthmatic patients (39.6%) and in eleven out of 145 age-matched controls (8%; P < 0.01). Clinical significance of immune complexes has been evaluated by comparing the following parameters in patients with and without such complexes: age, sex, duration of disease, IgE-mediated allergy (RAST, skin test), precipitins (Aspergillus, Candida albicans, Thermoactinomycetes), corticodependency, lung function tests, associated symptoms (hivernal bronchitis, urticaria, eczema,...), desenstization treatment, serum concentration in immunoglobulin in G, A, M and E. Immune complexes were found more frequently in female than in male patients. The prevalence of immune complexes was higher in patients treated by hyposensitization therapy and in cases with precipitating antibodies against thermophilic actinomycetes and Aspergillus.
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Dorval G, Yang WH, Goodfriend L, Roy R, Espinoza LR, Hébert J. Circulating immune complexes may be associated with increased suppressor T-cell activity in atopic allergy. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1980; 16:245-53. [PMID: 6966558 DOI: 10.1016/0090-1229(80)90209-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Kemler BJ, Franklin WD, Alpert E, Bloch KJ. Failure to detect circulating immune complexes in allergic patients on injection therapy. CLINICAL ALLERGY 1979; 9:473-8. [PMID: 498490 DOI: 10.1111/j.1365-2222.1979.tb02511.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Injection therapy for allergic diseases may create an environment conducive to circulating immune complex formation. Therefore, we examined the sera of eleven patients receiving injection therapy for the presence of circulating immune complexes. A sensitive Raji cell radioimmune assay was used to examine the sera prior to and 4, 8 and 24 hours after allergenic injection. Levels measured in these sera were compared to values obtained from forty-two healthy controls. Ten of eleven allergic patients receiving injection therapy had values within the normal range prior to maintenance injection. These ten patients also had normal values for circulating immune complexes at each interval after maintenance injection. The data suggest that circulating immune complexes are not a routine consequence of injection therapy for allergic disease.
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Abstract
The causes of rhinitis are many. Allergic rhinitis is mediated by IgE, and immunotherapy in selected patients is very effective. Immunoglobulins do not seem to play a role in nonallergic rhinitis, and immunotherapy is ineffective. Correct diagnosis spares the patient needless expense, inconvenience, and eventual disappointment.
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