Immediate Hypersensitivity to Contrast Agents: The French 5-year CIRTACI Study

BACKGROUND

Iodinated and gadolinium-based contrast media (ICM; GBCM) induce immediate hypersensitivity (IH) reactions. Differentiating allergic from non-allergic IH is crucial; allergy contraindicates the culprit agent for life. We studied frequency of allergic IH among ICM or GBCM reactors.

METHODS

Patients were recruited in 31 hospitals between 2005 and 2009. Clinical symptoms, plasma histamine and tryptase concentrations and skin tests were recorded. Allergic IH was diagnosed by intradermal tests (IDT) with the culprit CM diluted 1:10, "potentially allergic" IH by positive IDT with pure CM, and non-allergic IH by negative IDT.

FINDINGS

Among 245 skin-tested patients (ICM = 209; GBCM = 36), allergic IH to ICM was identified in 41 (19.6%) and to GBCM in 10 (27.8%). Skin cross-reactivity was observed in 11 patients with ICM (26.8%) and 5 with GBCM (50%). Allergy frequency increased with clinical severity and histamine and tryptase concentrations (p < 0.0001). Cardiovascular signs were strongly associated with allergy. Non-allergic IH was observed in 152 patients (62%) (ICM:134; GBCM:18). Severity grade was lower (p < 0.0001) and reaction delay longer (11.6 vs 5.6 min; p < 0.001). Potentially allergic IH was diagnosed in 42 patients (17.1%) (ICM:34; GBCM:8). The delay, severity grade, and mediator release were intermediate between the two other groups.

INTERPRETATION

Allergic IH accounted for < 10% of cutaneous reactions, and > 50% of life-threatening ones. GBCM and ICM triggered comparable IH reactions in frequency and severity. Cross-reactivity was frequent, especially for GBCM. We propose considering skin testing with pure contrast agent, as it is more sensitive than the usual 1:10 dilution criteria.

[Safety of reintroducing platelet-inhibitory doses of aspirin in patients with urticaria or angioedema induced by anti-inflammatory doses]

BACKGROUND

Aspirin is one of the most widely prescribed drugs in the world on account of its analgesic, antipyretic, and anti-inflammatory properties. Its effect on platelet aggregation makes it the first choice for prophylaxis in cardiovascular, neurological and obstetric diseases. However, a history of aspirin-induced urticaria and/or angioedema is usually a contraindication for further prescription of the drug. The aim of this article was to demonstrate that patients presenting aspirin-induced cutaneous reactions at anti-inflammatory doses can safely benefit from aspirin reintroduction at platelet-inhibitory doses.

PATIENTS AND METHODS

Patients with a history of aspirin-induced urticaria and/or angioedema referred to our department between January 2000 and June 2008 for double-blind placebo-controlled reintroduction at platelet-inhibitory doses for a medical indication were enrolled in this study.

RESULTS

Seventy patients with aspirin hypersensitivity as well as a medical indication for this therapy were referred to our department. Of these, 38 (54.3%) had a history of aspirin-induced urticaria and/or angioedema, including three laryngeal oedemas (7.9%). All subjects received platelet-inhibitory doses of aspirin (maximal total dose: 400mg/day) in double-blind placebo-controlled fashion during a one-day hospitalization period. None of the patients presented an immediate hypersensitivity reaction. Only one patient, who had received a cumulative dose of 200mg/day, reported diffuse urticaria and facial angioedema of no clinical significance the following day. He had a history of chronic urticaria.

CONCLUSION

This article demonstrates the safety of reintroducing platelet-inhibitory doses of aspirin in patients in whom it is indicated and reporting aspirin-induced urticaria and/or angioedema with anti-inflammatory doses. However, patients with a history of chronic urticaria should undergo a challenge with the lowest platelet-inhibitory dose (75mg/day) in order to minimize the risk of aggravating their condition.

Sublingual-swallow immunotherapy with standardized 3-grass pollen extract: a double-blind, placebo-controlled study

BACKGROUND

Sublingual immunotherapy (SLIT) is accepted as a safe and effective route for the treatment of grass pollen allergy, but clarification of its clinical and biological efficacy requires more study.

OBJECTIVE

To evaluate the efficacy, safety, and compliance of SLIT with a standardized 3-grass pollen extract in patients with grass pollen seasonal allergic rhinoconjunctivitis, with or without mild asthma.

METHODS

This multicenter, randomized, double-blind study included 127 patients (aged 12-41 years; mean age, 24.9 years) with grass pollen seasonal allergic rhinoconjunctivitis, with or without mild asthma. They received either SLIT with a high-dose, standardized, 3-grass pollen extract or placebo for 10 months before and during the grass pollen season. The efficacy evaluation compared weekly clinical scores (defined as the sum of the symptom score and rescue medication score) to measure rhinoconjunctivitis and asthma for the first 8 weeks of the pollen season. We also evaluated safety and compliance and measured changes in anti-Dactylis specific IgG4 antibody levels.

RESULTS

There was a trend in favor of the study group in the mean adjusted clinical score. The groups were not comparable on inclusion (P = .02): the SLIT group included more subjects with asthma and had a higher mean IgG4 serum level. Additional exploration according to subgroups with and without asthma found that among the patients without asthma, the SLIT group had a significantly better clinical score (P = .045). Anti-Dactylis specific IgG4 levels increased significantly in the SLIT group.

CONCLUSION

SLIT with a standardized, high-dose, 3-grass pollen extract is safe and significantly improves the clinical score in patients with hay fever and without asthma during the pollen season.

Skin reactions to intradermal neuromuscular blocking agent injections: a randomized multicenter trial in healthy volunteers

BACKGROUND

Numerous reports confirm the performance of intradermal tests for the diagnosis of anaphylaxis during anesthesia; however, there is controversy over their diagnostic value regarding the newer neuromuscular blocking agents (NMBAs).

METHODS

One hundred eleven healthy volunteers were randomly assigned to receive intradermal injections of two NMBAs, at five increasing concentrations. A concentration was considered as a reactive concentration when it led to a positive reaction in more than 5% of the subjects. These concentrations were compared with the maximal concentration recommended for the diagnosis of sensitization to NMBAs.

RESULTS

The maximal nonreactive concentrations were 10 m for suxamethonium; 10 m for pancuronium, vecuronium, rocuronium, and cisatracurium; and 10 m for atracurium and mivacurium. Except for mivacurium, these nonreactive concentrations were close to the maximal concentrations used for the diagnosis of sensitization against NMBAs. For mivacurium, the nonreactive concentrations were higher than the maximal concentration currently recommended in clinical practice.

CONCLUSION

The aminosteroidal NMBAs pancuronium, vecuronium, and rocuronium and the benzylisoquinoline cisatracurium have a similar potency to induce a nonspecific skin reactivity. If the criteria for positivity and the maximal concentrations of the commercially available compounds recommended by French practice guidelines are used, the risk of false-positive results is limited, and only minor modifications of these recommendations could be suggested. A slight reduction in the maximal concentration used for rocuronium from 1:100 to 1:200 and an increase from 1:1,000 to 1:200 for mivacurium can be proposed.

Specific immunotherapy with standardized latex extract versus placebo in latex-allergic patients

BACKGROUND

Allergy to natural rubber latex proteins continues to be an important medical problem among health care professionals, but also in multioperated children. Clinical manifestations range from urticaria to angioedema, rhinoconjunctivitis, bronchial asthma and anaphylactic shock.

METHODS

The aim of this study was to investigate the efficacy and safety of a 12-month latex-specific immunotherapy in sensitized patients, most often health care workers. Twenty-three patients with latex rhinoconjunctivitis (20 of whom also had asthma) were included in this randomized, double-blind, placebo-controlled trial (11 in the active group, 12 in the placebo group). Treatment efficacy was assessed by means of symptom and medication scores. Conjunctival provocation tests and quantitative skin prick tests were also performed.

RESULTS

The clinical index (derived by combining changes from baseline of six efficacy variables during the treatment period) did not differ significantly between treatment groups. Change from baseline of rhinitis, conjunctivitis, skin symptoms, asthma symptoms, medication score and cutaneous reactivity were not significantly different between the two groups. A nonsignificant difference in conjunctival reactivity was observed in favor of the active group (p = 0.09). Systemic reactions were much higher in the specific immunotherapy than in the placebo group.

CONCLUSIONS

The present study failed to show a significant improvement of symptoms and medication scores, probably because of the low level of symptoms at baseline and the low maintenance dose of therapy, even if allergen-specific conjunctival reactivity decreased in the active group. Moreover, the incidence of systemic reactions was very high in the active group.

Prevention of latex sensitization in guinea pigs by a bacterial and viral filter used in anaesthesia

BACKGROUND

Preventing anaphylactic reactions as a result of natural rubber latex (NRL) proteins is an important concern in anaesthesia. The clinical relevance of a bacterial/viral filter (Pall BB25) in preventing sensitization to NRL by inhalation was tested in guinea pigs.

METHODS

Guinea pigs (n=8-10 in each group) were exposed to aerosolized NRL-contaminated cornstarch powder or to NRL in saline for 1 h every day for 2 weeks. The experiments were repeated with a Pall BB25 filter placed over the aerosol system. Control groups were exposed to non-contaminated cornstarch or to saline alone. Three weeks after the last exposure, specific bronchial challenge was performed and thromboxane (Tx) B2 levels in bronchoalveolar lavage fluid were measured.

RESULTS

After bronchial challenge, the animals exposed to NRL or NRL-contaminated cornstarch with the BB25 filter in place showed a level of bronchoconstriction (i.e. the variation of pulmonary insufflation pressure) not different from controls. Conversely, those exposed to NRL or NRL-contaminated cornstarch without the filter showed a higher level of bronchoconstriction (respectively, P<0.02 and P<0.001) than control. Elevated TxB2 levels were found in the lungs of the guinea pigs, which inhaled NRL or NRL-contaminated cornstarch in the absence of a filter. Animals treated with the filter showed comparable TxB2 levels with those of control.

CONCLUSION

The Pall BB25 filter efficiently protected the guinea pigs from sensitization to NRL. This filter can be used as a complementary measure for avoidance of NRL contact during surgical procedures particularly if the mechanical ventilator apparatus contain NRL devices.

Head and Neck Atopic Dermatitis and Malassezia-furfur-Specific IgE Antibodies

BACKGROUND

Atopic dermatitis of the head and neck (HNAD) has been recognized as a separate entity. Malassezia furfur, a lipophilic yeast, is considered to be a pathogenic allergen in this form of atopic dermatitis.

OBJECTIVE

The purpose of this study was to determine the level of IgE anti-M.-furfur antibodies and their relation to the severity of the disease.

METHODS

IgE anti-M.-furfur antibodies were assayed in 106 patients with HNAD. Controls included 25 patients with non-HNAD, 20 with nonatopic dermatitis and 16 with seborrheic dermatitis (including 4 with AIDS).

RESULTS

There was a highly significant correlation between the level of anti-M.-furfur IgE and clinical severity. Furthermore, there was a significant but smaller correlation between total IgE and clinical severity. In patients with HNAD, total IgE was higher amongst men.

CONCLUSION

IgE anti-M.-furfur antibodies are a good and specific marker for HNAD. IgE M. furfur levels are strongly correlated with the severity of the disease.

The effect of montelukast on rhinitis symptoms in patients with asthma and seasonal allergic rhinitis

OBJECTIVE

The objective of this study was to evaluate montelukast 10 mg daily as treatment for allergic rhinitis in patients with symptomatic allergic rhinitis and active asthma during the allergy season.

METHODS

This was a multicenter study of 831 patients (ages 15 years-85 years) with seasonal allergen sensitivity, active symptoms of seasonal allergic rhinitis, and active asthma. Following a single-blind, placebo run-in period of 3 days-5 days, patients were randomized to oral montelukast 10 mg (n = 415) or placebo (n = 416) daily during the 2-week, double-blind, active-treatment period.

MAIN OUTCOME MEASURES

The primary endpoint was Daily Rhinitis Symptoms score, average of Daytime Nasal Symptoms and Nighttime Symptoms, as self-rated by patients on a 0-3 scale on daily diaries.

RESULTS

Montelukast reduced the Daily Rhinitis Symptoms score: difference between montelukast and placebo in mean change from baseline was -0.12 [95% CI -0.18, -0.06; p < or = 0.001]. Similar improvements were seen in Daytime Nasal Symptoms (-0.14 [-0.21, -0.07; p < or = 0.001]) and Nighttime Symptoms (-0.10 [-0.16, -0.04; p < or = 0.001]). Improvements (p < 0.05) were seen in Daytime Eye Symptoms and in the secondary endpoints of Global Evaluations of AR by Patient and by Physician, and Rhinoconjunctivitis Quality of Life. In exploratory analyses, improvement in rhinitis symptoms was numerically (though not statistically) larger in patients with greater levels of asthma at study start. Montelukast provided benefit in the Global Evaluations of Asthma by Patient and by Physician: mean differences were -0.24 [-0.41, -0.06; p = 0.008] and -0.17 [-0.33, -0.01; p = 0.037]. Similarly, as-needed beta-agonist use (puffs/day) was reduced with montelukast (p < or = 0.005).

CONCLUSION

Montelukast provides significant relief from symptoms of seasonal allergic rhinitis, while also conferring a benefit for asthma, in patients with both allergic rhinitis and asthma.

The en 455-3 modified lowry assay does not yield a reliable estimate of the allergenicity level of latex gloves with low total protein content

BACKGROUND

Estimation of the allergenicity of latex gloves by measurement of total extractable protein content with the modified Lowry method is not satisfactory. Therefore, complementary methods that are accurate, sensitive, and clinically relevant are needed. The Competitive Immunoassay for Antigenic Latex Proteins (CIALP) method described in a previous study could be a reliable complementary method for estimating the allergenicity of latex gloves.

MATERIAL/METHODS

Extracts from 62 powdered or powder-free gloves (16 surgical and 46 examination) were tested by the EN 455-3 modified Lowry assay, IgE-inhibition, and CIALP. The results were compared with those from 36 glove extracts reported in a previous study.

RESULTS

Significant correlations were observed between CIALP, IgE-inhibition, and the Lowry assay for the 62 glove extracts (r between 0.79 and 0.87; p<0.001), mostly rich in proteins. After inclusion of results from the previous study, significant correlations between the three methods were again observed (r between 0.76 and 0.90; p<0.001). However, there was no correlation between CIALP or IgE-inhibition and results of the Lowry assay for gloves that had a total protein content <50 micro g/g of glove. Furthermore, 15/16 extracts with undetectable total proteins were positive in both the CIALP and IgE-inhibition methods.

CONCLUSIONS

The modified Lowry assay alone is useful for estimating the allergenicity of latex gloves when the total protein content is >/=50 micro g/g of glove. For gloves with a total protein content <50 micro g/g of glove, complementary methods such as CIALP are necessary.

Inhaled cornstarch glove powder increases latex-induced airway hyper-sensitivity in guinea-pigs

BACKGROUND

Breathing is one of the most important modes of sensitization to natural rubber latex (NRL) for health-care workers, a group most at risk. Cornstarch powder (CSp) from medical powdered NRL gloves is known to be an allergen carrier, and sensitization to NRL can occur by inhaling airborne particles from such gloves.

OBJECTIVE

The aim of this study was to demonstrate, using an experimental model, which CSp may act as an adjuvant in NRL-induced airway hyper-responsiveness.

METHODS

Guinea-pigs were exposed to aerosolized NRL-contaminated CSp or to NRL in saline solution for 1 h every day for 2 weeks. The control groups were exposed either to CSp or to saline alone. An additional group of guinea-pigs was exposed to aerosolized ovalbumin (OVA) in saline. Three weeks after the last exposure, specific bronchial challenges were performed. In addition, Specific IgG and IgG1 in sera and thromboxane (Tx) B(2) levels in bronchoalveolar lavage fluid (BALF) were measured.

RESULTS

The NRL challenge caused significant bronchospasm in the animals that had been exposed to NRL compared with those in the control groups (P<0.02). Guinea-pigs exposed to OVA also demonstrated a significant bronchospasm after OVA challenge (P<0.001). The guinea-pigs that had inhaled NRL-contaminated CSp had a significantly higher bronchoconstriction level than those that had inhaled NRL alone (P<0.02). Specific IgG and IgG1 were undetectable in sera from all groups, whereas significant amounts of TxB(2) (P<0.001) were found in the lungs of the guinea-pigs exposed to NRL or OVA.

CONCLUSION

Inhaling CSp increases the airway response to NRL. The fact that specific IgG and IgG1 were not detected might be the result of an immune response limited to the airways. This finding is supported by a significant increase of TxB(2) level in the BALF of sensitized guinea-pigs.

[Chronic urticaria, thyroiditis and autologous serum test]

INTRODUCTION

The autoimmune nature of certain forms of chronic urticaria remains debatable. Aim of the study. To find a correlation in terms of autoimmune pattern between chronic urticaria and thyroiditis using the autologous serum test and the search for anti-thyroid antibodies.

PATIENTS AND METHODS

Study in a single center of 59 patients having consulted for urticaria that had progressed for more than six weeks and without precise etiology. An autologous serum test was conducted and anti-thyroid autoantibodies were searched for in the serum stored after the test.

RESULTS

Out of 59 patients, 51 had an interpretable autologous serum test and 57 underwent research for anti-thyroid antibodies. Twelve patients out 57 (21 p.cent) exhibited one or more types of positive (n=10) or borderline (n=2) anti-thyroid antibodies, and eight out of 12 (66.6 p.cent) had a known thyroid disease before the onset of urticaria. The systematic blood test permitted the discovery of 4 cases of unknown anti-thyroid antibodies. The symptoms regressed in two of these patients without any specific treatment, one patient was treated with L thyroxin for hyperthyroidism without any improvement in the symptoms and one other patient had normal thyroid function. Among these 12 patients, 11 underwent autologous serum tests, but only 3 of them exhibited clearly positive results and one was doubtful.

CONCLUSIONS

Within the limits of this study, we found a 21 p.cent rate of patients with chronic urticaria exhibiting one or more anti-thyroid antibodies. The positivity of the autologous serum test does not appear to be related with autoimmune thyroid disorders.

Mizolastine in primary acquired cold urticaria

BACKGROUND

Treatment of primary acquired cold urticaria (CU) is quite difficult because of variable clinical effectiveness and side effects of classic antihistamines.

OBJECTIVE

The objective of the study was to assess the efficacy and safety of mizolastine, an antihistaminic with antiallergic properties, versus placebo in primary acquired CU.

METHODS

This study was a phase II, multicenter, randomized, double-blind, crossover, placebo-controlled study of mizolastine (10 mg, once daily) versus placebo in 28 patients with primary acquired CU. Efficacy was measured by the cold-stimulation time test, the wheal response, and pruritus intensity after an ice-cube test.

RESULTS

Mizolastine delayed the cold-induced wheal reaction, reduced wheal response at 3 and 10 minutes, and reduced pruritus intensity. Statistically significant differences were observed versus placebo for the cold-stimulation time test, wheal response at 3 and 10 minutes, and pruritus intensity (P =.006,.015,.009, and.005, respectively). No clinically relevant adverse events were reported.

CONCLUSIONS

Mizolastine (10 mg, once daily) was shown to be superior to placebo for both delaying and reducing the cold-induced wheal reaction without significant adverse events. Results suggest that mizolastine may be effective in the treatment of CU.

Immunoadjuvant properties of glove cornstarch powder in latex-induced hypersensitivity

BACKGROUND

Cornstarch powder present in medical gloves plays an important role in latex-induced hypersensitivity as allergen carrier either, by the inhalation route, by skin contact or by direct contact with mucous membranes.

OBJECTIVE

Our objective was to test the hypothesis that cornstarch could act as an immunoadjuvant in immediate type-I latex-induced hypersensitivity.

METHODS

Guinea-pigs were sensitized by intraperitoneal route with two different antigens (latex proteins and ovalbumin) with or without cornstarch powder. Airway responsiveness after specific bronchial provocation was evaluated and specific IgG and IgG1 levels were determined by enzyme-linked immunosorbent assay (ELISA). Controls were treated with cornstarch powder or saline alone.

RESULTS

Animals sensitized with latex proteins (n = 7 in each group) showed significant bronchoconstriction (P < 0.03) and higher anti-latex antibody levels than the controls (P < 0.005). Guinea-pigs sensitized with latex-contaminated cornstarch had higher levels of specific antibodies than those sensitized with latex alone (P < 0.05). Animals sensitized to latex mixed with cornstarch showed higher bronchospasm than those treated with latex alone (P < 0.003). Animals sensitized to ovalbumin mixed with cornstarch also showed higher antibody and bronchoconstriction levels (P < 0.05) than those immunized with ovalbumin alone but antibody titres were significantly lower than those of the animals treated with ovalbumin and Freund's complete adjuvant (P < 0.01; n = 5 in each group).

CONCLUSION

Our findings show that cornstarch powder increases antigen-induced bronchoconstriction and antibody production. This role of immunoadjuvant is not antigen-specific. The cornstarch powder used as donning agent in latex gloves is an allergen carrier and it can enhance latex-induced hypersensitivity.

Emerging principles for the design of promiscuous HLA-DR-restricted peptides: an example from the major bee venom allergen

Mechanisms underlying successful immunotherapy of allergic patients operate at the level of CD4+ helper T cells. T cell epitopes from allergens may thus constitute interesting molecules for immunotherapy, provided they are efficient for all patients and are not recognized by IgE. In an attempt to define such peptides for allergy to bee venom, we have investigated the capacity of peptides encompassing the sequence of the major bee venom allergen to stimulate PBMC from allergic patients and to react specifically with their IgE. The region 77-110 emerged as the most frequently T cell stimulating. We then analyzed the binding modes of the sequence 81-97 for ten different HLA-DR molecules and introduced punctual mutations to enhance the peptide affinity for these molecules. Six different modes have been identified on the sequence 81-97, one mode being common to eight HLA-DR molecules. Four HLA-DR molecules can bind the P85-97 peptide by two different modes with an equivalent affinity. The peptide N89L has a higher affinity for DRB1*0301 and DRB3*0101 and remains as active as the native peptide towards the other HLA-DR molecules.

Safety of various dosage regimens during induction of sublingual immunotherapy. A preliminary study

BACKGROUND

Sublingual immunotherapy (SLIT) has been demonstrated to be a viable alternative to injection immunotherapy. Administration of high doses of allergens to ensure efficacy has been shown to be well tolerated. The aim of the present study was the first step to address the issue of fast-induction regimens using various induction SLIT regimens in paediatric and adult patients.

METHODS

Sixty-four patients (age range 5-46 years) with grass pollen rhinoconjunctivitis were enrolled in an 8-month double-blind, placebo-controlled trial of SLIT. Sixty-three patients were randomized to four groups and evaluated at the end of the study. One group received placebo (n = 16) and the other three groups (n = 47) received five grass pollen extracts according to three different induction regimens: regimen 1 starting with 3 IR tablets (n = 15), regimen 2 starting with 10 IR (n = 16) and regimen 3 starting with 30 IR (n = 16). The maintenance phase was made with sublingual-swallow drops at the same concentration of 300 IR/ml for all the patients. Adverse events were recorded on diary cards.

RESULTS

During induction phase, 25/47 patients in the SLIT groups had adverse reactions in comparison to 2/16 patients in the placebo group (p < 0.05). The rate of adverse reactions was 33.3% (11.8-61.6) (95% CI) for regimen 1, 31.3% (11.0-58.7) for regimen 2, 43.8% (19.8-70.1) for regimen 3 and 12.5% (1.6-38.3) for placebo. Fifty-seven reactions were local reactions involving the oral region (54 SLIT, 3 placebo) and 13 were systemic reactions (all in the SLIT groups). 11/13 reactions were mild (gastrointestinal disorders, rhinoconjunctivitis), 1/13 consisted of moderate asthma and 1/13 consisted of severe abdominal pain. No urticaria, angioedema or life-threatening events were observed.

CONCLUSIONS

These preliminary data showed that various induction regimens for SLIT are generally well tolerated and could allow a fast build-up phase of SLIT.

Mizolastine provides effective symptom relief in patients suffering from perennial allergic rhinitis: a double-blind, placebo-controlled study versus loratadine

BACKGROUND

Mizolastine is a nonsedating H1 histamine receptor antagonist with additional antiallergic properties currently marketed in Europe for the treatment of seasonal and perennial allergic rhinitis (PAR) and urticaria.

OBJECTIVE

This multicenter, randomized, double-blind, parallel-group study was conducted to evaluate the efficacy and safety of mizolastine in PAR compared with loratadine and placebo.

METHODS

After a 1-week placebo run-in period, 428 adult PAR patients received placebo (146 of 428), mizolastine 10 mg (141 of 428), or loratadine 10 mg (141 of 428) once daily for 28 days. Symptoms were evaluated by patients and physicians using a total nasal score, evaluating itching, rhinorrhea, nasal blockade, and sneezing severity.

RESULTS

Mizolastine treatment resulted in a significantly greater decrease in patient-rated total nasal score than placebo after 2 weeks (D14; -42%, P < 0.001) and at the end of the treatment period (-46%, P = 0.01), and significantly greater than that observed with loratadine at D14 (P = 0.031). No significant difference in change in total nasal score was observed between loratadine and placebo at 2- and 4-week visits. The global safety was satisfactory and the incidence of adverse events was similar in the three treatment groups.

CONCLUSIONS

Mizolastine provides effective symptom relief in PAR together with a satisfactory safety profile. Improvement with mizolastine was significantly greater than placebo throughout the study despite a large placebo effect. Also mizolastine's effects were greater those observed with loratadine after 2 weeks of treatment.

Efficacy and safety of levocetirizine in seasonal allergic rhinitis

OBJECTIVE

Pharmacodynamic studies have demonstrated that levocetirizine is the active enantiomer of cetirizine. This first therapeutic trial of levocetirizine aimed at determining the dosage with the best benefit/risk ratio in patients with seasonal allergic rhinitis (SAR).

METHODS

Patients with seasonal allergic rhinitis were randomised in a placebo-controlled, double-blind, parallel-group multicentre study 2.5, 5, 10 mg levocetirizine or placebo once daily during 2 weeks. Patients filled in a diary evaluation card every evening before taking study medication using the classical (0-3) scale for assessment of severity of sneezing, rhinorrhea, nasal congestion, nasal pruritus and ocular pruritus over the preceding 24 hours. The Total Four-Symptom Score (T4SS) was calculated by adding the individual symptom scores, excluding nasal congestion.

RESULTS

470 patients were included and constituted the intent-to-treat population. All 3 doses of levocetirizine were significantly superior to placebo in reducing the mean T4SS over the 2 weeks (all P (0.001). Additionally, individual symptom severity scores for sneezing, rhinorrhea, itchy nose, and itchy eyes were also significantly decreased for all doses of levocetirizine. Levocetirizine was significantly superior to placebo in reducing symptom severity with an important global treatment effect (P = 0.0001), except for nasal congestion. Furthermore, there was simple linear relationship between levocetirizine dosages and reduction of T4SS (P = 0.001). All doses were well tolerated, somnolence was higher with 10 mg (10.2%) than 5 mg (1.7%) and other adverse events were more frequent with the highest dose.

CONCLUSION

Levocetirizine 5 mg once daily has an optimal benefit/risk ratio in the treatment of SAR.

Acetaminophen (paracetamol)-induced anaphylactic shock

Acetaminophen (paracetamol) is a widely prescribed analgesic-antipyretic drug. Adverse allergic reactions to this drug are rare. We report a case of anaphylactic shock due to acetaminophen. Results of skin prick tests and intradermal tests were negative. Oral rechallenge resulted in generalized urticaria associated with an increased plasma level of histamine. Acetaminophen should be added to the list of causes of anaphylaxis.

[Responsibility of food in exercise-induced anaphylaxis: 7 cases]

INTRODUCTION

Exercise induced-anaphylaxis is a rare allergic disease. In most cases, the ingestion of a specific food within a maximum of 4 hours preceding physical activity is necessary to develop the anaphylactic reaction.

CASE-REPORTS

We report 7 cases of food-dependant exercise induced-anaphylaxis. The responsible foods were wheat (2 cases), corn, barley, shrimp, apple, paprika and mustard. The discovery of the food allergen and its systematic eviction 4 hours before the beginning of a physical effort led to the disappearance of clinical symptoms in all cases.

DISCUSSION

The role of food in exercise-induced-anaphylaxis is essential. The food in cause varies but our study confirms the predominant role of cereal food which is a less sensitizer in adults, except in a context of effort. The responsibility of this type of food consumed daily can explain partially the frequent delay before diagnosis of this allergic disease.

[Anisakis simplex and immediate hypersensitivity reactions]

BACKGROUND

Anisakis simplex is one of the nematode worms that parasitize sea mammals. When its larvae are accidentally ingested by humans, they can infect the host, resulting in anisakiasis manifested by digestive symptoms, or they may cause an allergic reaction, which in some cases may be severe.

CASE REPORTS

We report three cases of acute urticaria associated with abdominal pain, and hypotension in two of them, starting two to six hours after ingestion of raw fish. The diagnosis of an allergic reaction caused by Anisakis simplex was based on the clinical histories and positive tests for anisakis-specific IgE.

DISCUSSION

In patients with acute urticaria associated with abdominal symptoms, a history of ingestion of raw fish in the preceeding hours is evocative of gastro-allergic anisakiasis. In association with symptomatic treatment, gastrointestinal endoscopy allows the larvae to be visualized and removed, which may relieve the symptoms and provide a diagnosis before the results of skin testing and serological assay are known.

Treatment of severe seasonal rhinoconjunctivitis by a combination of azelastine nasal spray and eye drops: a double-blind, double-placebo study

BACKGROUND

Evaluation of combined azelastine nasal spray and eye drops treatment in patients with severe rhinoconjunctivitis.

METHODS

Phase III, multicenter, randomized, double-blind study of patients with a history of grass pollen allergy, confirmed by skin testing/specific IgE, total symptom scores > or =6 (ocular) or > or =8 (nasal). Intent-to-treat analysis.

RESULTS

99 patients (azelastine = 53, placebo = 46) enrolled homogeneously from May to September 1997 in 7 venues in France. The efficacy of azelastine was significantly higher compared to placebo (49% vs. 28%, p = 0.04), considering response as a decrease of the total sum of ocular and nasal scores by at least 50% and no use of cetirizine by day 7. The decrease of total ocular and nasal scores by at least 50% at day 7, with cetirizine rescue <3 tablets was higher, but not significantly, in azelastine patients (43% vs. 30%). Cetirizine rescue was more frequent, from day 0 to 7, in the placebo patients (4.9 +/- 5.0 vs. 2.7 +/- 4.1, p = 0.02). Global efficacy was rated higher for azelastine by investigators (26% vs. 10%, p = 0.05) and patients (28% vs. 7%, p = 0.01). Adverse events were burning sensation, "red eyes," nasal irritation, bitter taste. No serious adverse events were reported. Tolerance of azelastine was "very good/good"/"satisfactory" in the majority (62%/82% assessed by investigators, or 55%/79% by patients, respectively).

CONCLUSIONS

Combining azelastine eye drops and nasal spray is a safe and effective treatment of severe seasonal rhinoconjunctivitis.

[Allergy in women]

Allergy affects without distinction both sexes. Nevertheless some allergens are responsible more frequently for contact dermatitis in females. The components of cosmetics and in first fragrance are indeed responsible for numerous contact dermatitis because of their increasing use. Nickel allergy is the most frequent contact allergy in women with a rate of 20-40% of female population and only 3-5% of male population. Specific female allergies such as allergy to seminal liquid or autoimmune progesterone dermatitis are on the other hand exceptional.

Immunotherapy with a calcium phosphate-adsorbed five-grass-pollen extract in seasonal rhinoconjunctivitis: a double-blind, placebo-controlled study

BACKGROUND

Calcium phosphate-adsorbed allergen extracts are used for subcutaneous immunotherapy to avoid the use of aluminium adjuvants.

OBJECTIVES

A double-blind, placebo-controlled study was performed in order to confirm the safety and assess the efficacy of a standardized five-grass-pollen extract adsorbed onto calcium phosphate for specific immunotherapy (IT).

METHODS

Twenty-nine patients with seasonal rhinoconjunctivitis were randomized to receive either the active preparation (16 patients) or placebo (13 patients), in a 1-year study. During the increasing dose phase, an extract ranging from 0.1 IR per ml to 50 IR per ml was administered at a rate of one subcutaneous injection per week until a maintenance dose was reached. The patients were assessed by symptom diary and rescue medications during seasonal exposure and specific nasal and skin reactivity before and after IT. Immunological parameters (specific IgE and IgG4 antibodies) were assessed before, during and after IT.

RESULTS

The overall symptoms score (mean AUC) was not significantly different between the IT group and the placebo group during grass-pollen exposure (49.6 vs. 56, respectively). The total medication score (mean AUC) was significantly lower in the IT group than in the placebo group (11 vs. 41, P < 0.01, Mann-Whitney U-test). The cumulative symptom/medication score was significantly lower in the IT group than in the placebo group (64.5 vs. 102.3, P < 0.05, U-test). A significant increase in nasal reactivity threshold was observed after IT in the IT group (21. 4 IR/mL before IT vs. 63.4 IR/mL after IT, P < 0.01, Wilcoxon), whereas no significant changes were observed in the placebo group (31.0 IR/mL before IT vs. 37.7 IR/mL after IT). IT induced a significant reduction in grass pollen cutaneous reactivity in the actively treated group (P < 0.001). A significant increase in serum-specific IgG4 antibody response was observed in the IT group (3.1% before IT vs. 10.1% after IT, P < 0.001). Nine patients in the IT group developed moderate immediate systemic reactions vs. two patients in the placebo group.

CONCLUSION

Specific immunotherapy with calcium phosphate-adsorbed standardized grass pollen extract was safe and effective for the treatment of patients with seasonal allergic rhinoconjunctivitis.

[Vibratory angioedema]

BACKGROUND

Vibratory angioedema is a rare form of physical urticaria. This entity can be an hereditary autosomal dominant disorder or an acquired sporadic disease. Immediate and delayed forms have been reported.

CASE-REPORT

A 34-year-old woman was referred to us for a vibratory angioedema induced by mountain biking. Despite her handicap, she could provoke a clinical tolerance with disappearance of pruritus but not of erythema and edema if she continued her physical effort. Diagnosis was confirmed with a vibratory stimulus using a Vortex for 5 minutes. The realization of a controlled vibratory stimuli among 20 volunteers induced a positive response in 7 cases (35 p. 100).

DISCUSSION

These results raise the problem of the specificity of the test but also point out the possible physiological response of the body to intense vibratory stimulations.

Retention of airborne latex particles by a bacterial and viral filter used in anaesthesia apparatus

We have developed a series of laboratory tests to evaluate the efficiency of a heat and moisture exchanger filter (Pall BB25) in retaining latex particles in order to protect allergic patients during anaesthesia. Latex particles were nebulised with cornstarch as a support and collected for assay in a flask, with or without the filter integrated into the experimental circuit. With the Pall BB25 filter in the circuit, no natural latex proteins were detected by measurement of either total protein or antigenic latex proteins. The Pall BB25 filter may represent a useful means of preventing inhalation of latex particles during anaesthesia in susceptible patients.