Bronchial asthma due to spiramycin and adipic acid

Occupational asthma in antibiotic manufacturing workers: case reports and systematic review

Background. The risks of occupational asthma (OA) from antibiotics are uncertain. We report 4 new cases and a systematic review of the literature. Methods. Cases were identified through a specialist clinic, each underwent specific provocation testing (SPT). We subsequently reviewed the published literature. Results. The patients were employed in the manufacture of antibiotics; penicillins were implicated in three cases, in the fourth erythromycin, not previously reported to cause OA. In two, there was evidence of specific IgE sensitisation. At SPT each developed a late asthmatic reaction and increased bronchial hyperresponsiveness. 36 case reports have been previously published, 26 (citing penicillins or cephalosporins). Seven cross-sectional workplace-based surveys found prevalences of 5-8%. Conclusions. OA in antibiotic manufacturers may be more common than is generally recognised. Its pathogenesis remains unclear; immunological tests are of uncertain value and potential cases require confirmation with SPT. Further study of its frequency, mechanisms, and diagnosis is required.

Veterinary pharmacovigilance. Part 4. Adverse reactions in humans to veterinary medicinal products

Although seemingly rare, adverse reactions to veterinary products do occur. These may arise from inadvertent exposure during use or as a result of occupational accidents. They are often mild in nature and include adverse effects such as minor skin reactions. However, more serious reactions may occur, and they are not restricted to the effects of the veterinary medicines themselves. For example, high-pressure injection injuries may occur as a result of accidents occurring during animal vaccination operations. This paper reviews some of these events, mentions where appropriate the regulatory actions taken, and describes some of the measures used to minimise such effects in the future, and serves to bring the issues discussed here to the attention of pharmacologists, pharmacoepidemiologists and others who train those who use veterinary medicinal products.

Toxicity of adipic acid

Adipic acid has very low acute toxicity in rats with an LD50 > 5000 mg/kg. Adipic acid produced mild to no skin irritation on intact guinea pig skin as a 50% concentration in propylene glycol; it was not a skin sensitizer. Adipic acid caused mild conjunctival irritation in washed rabbit eyes; in unwashed rabbit eyes, there was mild conjunctival irritation, minimal iritis, but no corneal effects. Adipic acid dust may irritate the mucous membranes of the lungs and nose. In a 2-year feeding study, rats fed adipic acid at concentrations up to 5% in the diet exhibited only weight loss. Adipic acid is not genetically active in a wide variety of assay systems. Adipic acid caused no developmental toxicity in mice, rats, rabbits, or hamsters when administered orally. Adipic acid is partially metabolized in humans; the balance is eliminated unchanged in the urine. Adipic acid is slightly to moderately toxic to fish, daphnia, and algae in acute tests.

Occupational airway sensitizers: an overview on the respective literature

BACKGROUND

Worldwide, there is rigorous scientific activity concerning the further development of work safety regulations involving airway-sensitizing substances. Technical directives on hazardous substances are enforced in several countries and are being continuously updated. The European Union has established a code for several occupational substances, now labeled R 42 ("may cause sensitization by inhalation").

METHODS

We present an overview of the literature dealing with allergic occupational asthma. The literature was selected according to criteria of study design and diagnostic test methods. Approximately 300 publications were reviewed including both epidemiological studies and individual case reports.

RESULTS

Airway sensitizers are systematically arranged and separately listed according to chemicals and their origin from animals, plants, and microorganisms. The clinical data as well as threshold limit values (TLV) and R 42 labeling of 250 airway-sensitizing substances are presented.

CONCLUSIONS

The most common sensitizing substances causing occupational asthma were dust of cereal flours, enzymes, natural rubber latex, laboratory animals as well as low molecular substances such as isocyanates and acid anhydrides.

Lymphocyte Transformation Tests in Workers with Occupational Exposure to Spiramycin

Pharmaceutical industry employees are exposed to drugs which can stimulate allergic reactions. Other authors have found that, in workers of pharmaceutical companies exposed to spiramycin, spiramycin-induced asthma can be diagnosed only on the basis of spiramycin inhalation tests, because IgE specific antibodies, as well as skin and patch tests, are often negative.

Since lymphocytes from humans sensitised to various agents undergo morphological transformation on exposure to sensitising antigen in culture, we used a lymphocyte transformation test (LTT) following in vitro exposure to spiramycin of cells collected from healthy workers occupationally exposed or not exposed to this antibiotic.

LTT was measured by [3H]-thymidine uptake into DNA of lymphocytes cultured for three days in medium containing 0-500μg/ml spiramycin. The number of lymphoblasts was also counted on cell smears. Lymphocytes from spiramycin-exposed subjects, incubated with spiramycin, demonstrated a statistically significant increase of [3H]-thymidine incorporation; the presence of lymphoblasts in the cultures was only slightly increased.

Although other experiments with lymphocytes obtained from patients with spiramycin-induced asthma need to be performed, this pilot study suggests that LTT may be able to be used to detect early immune response changes caused by chemical agents in occupationally exposed workers.

Occupational asthma in workers of a pharmaceutical company processing spiramycin

After investigation of one worker with occupational asthma, all 51 employees of a pharmaceutical company processing the macrolide antibiotic spiramycin were investigated to determine the frequency of the condition and the risk factors. The antibiotic was produced for short periods four to five times a year. The first part of the investigation, conducted before a production period, consisted of the following: questionnaire, skinprick tests, blood sample, spirometry, assessment of bronchial responsiveness to methacholine, and monitoring of peak expiratory flow rates (PEF). The second part of the survey was carried out in 48 of the 51 workers during the production period, and included the same assessments except for skin testing. No FEV1 values had changed by more than 9% or PEF by more than 19%. Inhalation challenge with spiramycin was performed in 12 of the 14 individuals who had a history of occupational asthma, a provocative concentration of methacholine (PC20) of 16 mg/ml or less, or a PC20 that fell by 2.5 fold or more during the production period (or a combination of these). Three subjects experienced immediate bronchoconstriction. All reported symptoms, and all had a fall in PC20 methacholine during the production period. It is concluded that the minimum frequency of occupational asthma in this company processing spiramycin is 4/51 (7.8%). The combination of a positive response to the questionnaire and a change in bronchial hyperresponsiveness during the production period appeared to be the best detector of individuals with occupational asthma, as confirmed by inhalation challenge with spiramycin.