Immunoblot studies in allergic patients to hymenoptera venom before and during immunotherapy

BACKGROUND

Hymenoptera venom immunotherapy (VIT) is immunologically effective in patients with systemic allergic reactions after hymenoptera stings.

OBJECTIVE

To evaluate the effect of VIT on specific IgE and IgG4 immunoblotting bands in VIT-treated patients.

MATERIAL AND METHODS

Specific IgE and IgG4 immunoblotting bands for hymenoptera venom were performed with ALABLOT in sera of 17 patients (8 allergic to honeybee venom, 8 to wasp and 1 to polistes venom) before and during successful VIT (1 and 3 years). Before immunotherapy, all patients had experienced moderate/severe systemic reactions to a hymenoptera sting, with positive skin tests and venom-specific IgE. During immunotherapy all patients suffered field stings, without any systemic reaction.

RESULTS

Before VIT we detected several immunoglobulin-binding bands in different regions, with different individual patterns. After VIT, we observed in some patients (5/8 for honeybee venom, 6/8 for wasp and 1/1 for polistes) complete disappearance of some IgE-binding bands, mainly the 15 kDa region (honeybee) and 23 and 44 kDa regions (wasp and polistes). All patients showed decreased intensity of IgE-binding bands, most pronounced in regions 16, 44 and 52 kDa (honeybee); 44 and 35 kDa bands (wasp) and 23 kDa (polistes). Some patients showed de novo appearance of IgG4-binding bands (4/8 for honeybee and 8/8 for wasp venom), mainly in 52 kDa (honeybee) and in 23 and 44 kDa regions (wasp). All patients showed increased intensity of IgG4 bands that were already present before VIT, more pronounced in 52 and 44 kDa (honeybee) and in 44 and 35 kDa regions (wasp).

CONCLUSIONS

During successful VIT there are changes in intensity and number of IgE and IgG4 binding bands, which could reflect the immunological improvement induced by VIT. These changes are more pronounced/frequent in wasp VIT, a fact that could explain the best results usually seen in these patients.

Efficacy and safety of specific immunotherapy with a modified mite extract

BACKGROUND

In specific immunotherapy (SIT), modified extracts have been used to allow safe administration of higher allergen doses. Schedules reaching maintenance doses in approximately 1 month, which may have greater efficacy, have even been proposed.

AIMS

To assess the safety and efficacy of SIT with modified (depigmented and polymerized) Dermatophagoides pteronyssinus extract in the treatment of allergic rhinitis.

MATERIAL AND METHODS

Fifty patients with moderate-to-severe persistent allergic rhinitis and who were monosensitized to Dermatophagoides were included in this controlled, pragmatic, 1-year open study. The patients were randomly allocated to receive treatment with a Dermatophagoides pteronyssinus 100 % modified allergen vaccine (active group, n = 25) or pharmacological treatment only (control group, n = 25). All SIT-related adverse reactions were recorded. Efficacy was assessed primarily through the results of nasal allergen challenges, through visual analog scale (VAS) and symptom scores.

RESULTS

In SIT-treated patients, significant improvements were found in symptom scores (mean reduction > 40 %), VAS scores (mean improvement > 20 %) and nasal challenges (mean increase in allergen concentration threshold > 500 %). For symptom and VAS scores, statistically significant differences between control and SIT-treated patients were recorded at 12 months. In nasal challenges statistically significant differences were observed as early as at 6 months. Control patients showed no significant differences during the study period. Local reactions were observed in 28 % of SIT-treated patients (total 24 reactions). There was only one immediate grade I systemic reaction, which was successfully treated with an antihistamine.

CONCLUSIONS

SIT with this modified extract appears to be a relatively safe treatment, which can rapidly improve nasal allergenic tolerance, reduce symptom scores and improve subjective self-evaluation measured through VAS, reflecting a general improvement in patients' well-being.

Nasal ECP patterns and specific immunotherapy in mite-allergic rhinitis patients

BACKGROUND

Specific immunotherapy (SIT) is an effective treatment in allergic rhinitis and it has been shown to decrease nasal ECP rise after allergen challenge.

AIMS

To evaluate if the kynetics of nasal ECP release after specific nasal challenge could be changed by SIT and if these changes were related to the dose of allergen administered.

MATERIAL AND METHODS

75 allergic rhinitis patients, monosensitized to house dust mites were included: 25 controls and 50 SIT-treated patients. These patients were divided in two groups: one receiving a high dose of the allergenic extract (Group 2) and other receiving a lower dose (Group 1). Nasal challenges were performed at the beginning of the study (T0), after 6 (T1) and after 12 months (T2). Nasal ECP values were measured in nasal lavages before challenge and one and four hours after obtaining a positive reaction. Patients were also asked in every visit to evaluate on a visual analog scale the intensity of their disease in the previous month.

RESULTS

SIT was effective in improving subjective (visual analog scale) and objective parameters (nasal allergenic reactivity). Both SIT groups had significant differences between T0 and T2 values and comparing with control patients. SIT reduced significantly mean post-provocation ECP values in both groups and reduced the number of patients that showed increase in nasal ECP > 100% of basal values in each of the SIT-treated groups. The changes in nasal ECP values and particularly in nasal ECP patterns were more pronounced in Group 2 than in Group 1 but the differences did not reach statistical significance.

CONCLUSIONS

SIT can inhibit nasal ECP increase after allergen challenge, frequently present in non SIT-treated patients. This effect is more pronounced and reaches statistical significance earlier in patients receiving higher doses of the allergenic extract used in SIT.

Latex and chickpea (Cicer arietinum) allergy: first description of a new association

In this paper we describe the existence of cross-reactivity between allergens from latex and chickpea, a food from the Leguminosae family, which is common in the Mediterranean diet. We present the case report of a spina bifida boy with a clinical relevant food allergy to chickpea (oral syndrome + dysphonia), developing after the appearance of latex allergy symptoms (lip angioedema + intraoperative anaphylaxis). Specific IgE to latex and chickpea was demonstrated by skin prick tests, measurement of patient's serum specific IgE and IgE-immunoblotting. Cross-reactivity was studied by means of EAST-inhibition and western blotting-inhibition. A strong inhibition was observed in several IgE-binding bands when latex extract was used in solid phase and patient serum was preincubated with chickpea extract (chickpea extract as inhibitor phase). As far as we know, this is the first report of cross-reactivity between latex and chickpea, a food which should therefore be added to the extensive list of latex cross-reactive foods.

Capillary leakage syndrome: a case report and a review

Capillary leakage Syndrome (CLS) is a rare clinical syndrome, that was first described in 1960, characterized by acute episodes of generalized edema, hemoconcentration, hypoproteinemia and monoclonal gammopathy, in the vast majority of cases. We describe a 39-year-old man with anasarca, bilateral pleural and pericardial effusions, ascites and diffuse alveolo-intersticial edema. Clinical and laboratory findings were consistent with an acute episode of CLS. Treatment with prednisone, furosemide and aminophylline was started, which lead to a gradual improvement in 48 hours. Pathophysiologically there is an increase in capillary permeability with the extravasation of fluid and plasmatic proteins to the extravascular space that can lead to hypovolaemic shock. In the second phase there is a reentry of the fluid overload leading to pulmonary edema. The etiology of this hyperpermeability still remains unclear. The role of cytokines has become central in the comprehension of pathophysiology of CLS. Adhesion molecules are probably also involved in the genesis of capillary leakage. CLS treatment remains empirical. However, at present it seems that the association of steroids with furosemide, aminophylline and terbutaline are capable of controlling the clinical manifestation of the acute episodes in most cases. To our knowledge no prophylatic therapy has clearly proven its efficacy. There are only a few series analyzing the long-term evolution of patients with CLS. Further studies are necessary with the objective to collect enough patients with CLS to observe natural history of the disease and evaluate the efficacy of empiric treatments.

Heat-shock proteins and atherosclerosis

In this review the authors focus on the possible role of heat-shock proteins (hsp) in the immune pathogenesis of the atherosclerotic process. The authors discuss evidence showing increased expression of these proteins in the vascular wall of stressed and atherosclerotic vessels and the immune mechanisms which could justify some of the inflammatory aspects that are now currently recognized in atherosclerosis, namely some of the possible hsp immune activating properties and also the possibility of hsp representing an innocent auto-antigen which could be the unwanted target of an immune response, initially directed against microbial heat-shock proteins. Epidemiological evidence linking atherosclerosis and cardiovascular diseases to soluble hsp levels as well as the intensity of anti-hsp immune response is also reviewed.

Laboratory diagnosis of hymenoptera venom allergy: comparative study between specific IgE, western blot and allergen leukocyte stimulation (CAST)

Allergy to hymenoptera venom is a classical IgE mediated disease with a potentially fatal course. Specific venom immunotherapy (SIT) is the most effective mean of treating this serious condition, after the diagnosis has been clearly established by a clinical history, in-vivo and in vitro tests. We have evaluated the usefulness of a cellular test (CAST) which is a recently developed ELISA method based on the evaluation of sulfidoleukotriene secretion by leukocytes stimulated with specific antigen. We also evaluated the correlation of CAST with skin tests, specific IgE (sIgE) and western blot for sIgE for hymenoptera venom sIgE. We have included in this study 14 patients, with a clinical history suggestive of hymenoptera venom allergy. None of them had previously been subjected to immunotherapy. A good correlation was obtained between skin tests, sIgE and western blot. However, there was no correlation between these methods and CAST. We conclude that the positivity of CAST method raises some questions about other mechanisms, which maybe non-IgE dependent. Although the number of patients in this study is quite small, the immunoblot analysis may be a valuable additional method in insect venom allergy.

Atopy and helminths

In this article, the authors review current and latest evidence linking helminth infections and the development of atopy. Although there is intense ongoing investigation and debate on this issue, the review of experimental, clinical and epidemiological data apparently shows that helminth infections can have beneficial aspects in regard to the pathogenesis of atopy and allergic diseases. Despite the fact that simplistic views are not recommended, it seems that polyclonal IgE production and mainly the stimulation of host immunoregulatory networks leading to synthesis of anti-inflammatory cytokines (IL-10, TGF-beta and others) can provide new insights into how mechanisms that helminths have developed throughout their evolution and that are useful for parasite evasion and persistence, could also be used in humans in order to provide new approaches in atopy prevention.

A 12-week, placebo-controlled study of the efficacy and safety of ebastine, 10 and 20 mg once daily, in the treatment of perennial allergic rhinitis. Multicentre Study Group

This double-blind, placebo-controlled, multicentre study investigated the ability of ebastine, 10 and 20 mg once daily, to control symptoms of perennial allergic rhinitis (PAR) over a 12-week period, and assessed additional benefits of the 20-mg dose. Following a 2-week baseline period, patients (12-63 years) were randomized to treatment with ebastine 10 mg (n=88) or 20 mg (n=102), or placebo (n=100). Patients scored symptom severity (0-3) twice daily, and mean changes from baseline scores showed ebastine to be significantly effective in week 1. Control of symptoms persisted over the 12 weeks, the average daily total nasal symptom score for nasal stuffiness plus nasal discharge plus sneezing plus itchy nose being reduced by both doses, with statistical significance at 20 mg (P=0.015 vs placebo) despite decreased usage of sodium cromoglycate rescue medications. Patient and clinician final opinions of treatment also significantly favoured ebastine, both 10 and 20 mg, over placebo. No serious adverse events occurred, and study treatments were well tolerated with a low incidence of central nervous system-related adverse events and headache. In conclusion, ebastine 10 or 20 mg once daily was rapidly effective in relieving symptoms of PAR in adult and adolescent patients; additional benefits of the 20-mg dose became apparent in the longer term.

Turbutest in the training of asthmatic Turbuhaler users

BACKGROUND

Correct utilization of inhalation devices is a key factor in asthma management. Objective assessment of the ability to use inhaler devices is therefore fundamental.

METHODS

The objective was to assess objectively the inhalation technique of Turbuhaler users who reported having no difficulty in using such a device. A total of 600 asthmatic patients of our allergology outpatient department, daily users of Turbuhaler devices, were evaluated with Turbutest. This is a simple portable apparatus which connects a Turbuhaler inhaler with an electronic device to allow semiquantitative assessment of inhalation technique, with a score ranging from 0 (worst) to 3 (best), readily visualized on the apparatus. Patients were allowed to practice with Turbutest, assisted by an allergologist, until they improved their scores. A second Turbutest assessment was performed at a 2-month follow-up visit.

RESULTS

On the first assessment, one-third of the patients had scores inadequate to allow a good inhalation, and only 20% achieved a score of 3. On the second assessment, significantly higher Turbutest scores were observed.

CONCLUSIONS

Turbutest is a valuable tool in asthmatic patients' training, allowing identification and improvement of an inadequate inhalation technique with Turbuhaler.