IgE antibody responses in young children with atopic dermatitis

In 2184 young children aged 13-24 months with atopic dermatitis (SCORAD 5-59) serum IgE antibodies to a standard panel of food and inhalant allergens were assayed. The frequency of positive IgE responses (>0.35 kU/l) increased with greater severity of skin disease. A significant minority of infants had levels of IgE antibody to foods to suggest they were at risk of acute reaction to those foods (7% to hen's egg, 3% to cow's milk, 4% to peanut). Our findings indicate that the frequency of positive IgE responses is related to disease severity and suggest that differences in the time course of the development of IgE responses to food, which are at maximum prevalence within the first year of life, while inhalant allergies, are still developing between 1 and 2 yr and beyond.

Corticosteroids (inhaled and/or intranasal) in the treatment of respiratory allergy in children: safety vs. efficacy

BACKGROUND

Topical administration of Corticosteroids (CS) can reduce the total dose of CS required to treat the patient and minimize side effects. Topical CS is extremely effective and has an excellent safety profile. Nonetheless, care must be taken when multiple sites such as lungs, nose and skin are being treated. CS mechanisms of action on the inflammatory process are complex. The aim of this study is to review such mechanisms and the adverse events secondary to it.

METHODS

Review English database (Embase, PubMed, Scielo) searching words: CS, adverse events, inhaled CS, intranasal CS, and children.

RESULTS

There is a classic mechanism involving a genomic effect of CS and a non-genomic effect, independently of gene transcription process. This mechanism acts by reducing mucosal blood flow in the asthmatic airways. Second-generation topical CS is the treatment of choice in allergic diseases control because of their good anti-inflammatory activity, poor absorption and first-pass hepatic metabolism. When comparing different CS, it is important to compare therapeutically equivalent doses. Although topical CS reduces systemic side effects, local and even systemic side effects can occur. Many factors affect the amount of drug that reaches the lung, including inhaler technique and inhaler type, fine particle dose and particle distribution.

CONCLUSION

Most patients with allergic diseases respond to CS treatment, but there is a small subset of them whose response is unsatisfactory even with high doses of CS. They are classified as corticosteroid-resistant asthmatics. Pro-inflammatory cytokines appear to up regulate the expression of GRb that has been associated with CS resistance.

Antibody response to pneumococcal capsular polysaccharide vaccine in Down syndrome patients

The majority of children with Down syndrome (DS) tend to have frequent bacterial infections including recurrent respiratory infections. Our objective was to evaluate the production of antibodies to pneumococcal polysaccharide antigens after active immunization in DS subjects. IgG antibodies to pneumococcal serotypes (1, 3, 6B, 9V, and 14) were measured before and 6 weeks after immunization with a 23-valent pneumococcal vaccine (Pneumo23, Pasteur-Merrieux) in 6- to 13-year-old DS children (N = 17) and in aged-matched normal controls (N = 30). An adequate response was defined as a 4-fold increase over baseline or a post-immunization level of specific pneumococcal serotype antibody > or = 1.3 microg/mL. After immunization, all DS children had an increase in post-immunization levels against all serotypes analyzed. A 4-fold or more increase was observed in all DS children concerning serotypes 1 and 14, in 90% of subjects for serotypes 3 and 9V, and in 65% for serotype 6B. Regarding this increase, 8 of the 17 DS children had an adequate response to all serotypes analyzed, 8/17 patients to 4 serotypes and 1/17 to 3 serotypes. However, when we compared post-immunization levels between DS children and controls, we observed lower levels in the former group (P < 0.05) for all serotypes except serotype 3. We conclude that pneumococcal polysaccharide immunization could be beneficial for these DS children.

Changes in the prevalence of asthma and allergic diseases among Brazilian schoolchildren (13-14 years old): comparison between ISAAC Phases One and Three

The present study is aimed to describe the changes in the prevalence of symptoms of asthma, rhinitis and eczema among Brazilian adolescents (AD, 13-14 years old) between Phases 1 and 3 of the International Study of Asthma and Allergies in Childhood (ISAAC). The prevalence of self-reported symptoms of asthma, rhinitis and eczema in AD from five Brazilian cities (Curitiba, Porto Alegre, Recife, Salvador and São Paulo), obtained during ISAAC Phase 1 (n = 15 419) and Phase 3 (n = 15 684), was compared to determine the trend of prevalence in a 7-year interval. There was a trend to reduction in the current prevalence of wheezing and increasing of nocturnal cough when averaging figures from the five cities. The prevalence of wheezing in the last 12 months was 27.7 vs. 19.9% (p < 0.01); asthma ever 14.9 vs. 14.7% (p > 0.05); severe episode of wheezing 5.2 vs. 5.2%; nocturnal cough 32.6 vs. 34.9% (p < 0.01); exercise wheezing 23.6 vs. 23.0% (p > 0.05) and awake with wheezing 11.8 vs. 11.2% (p > 0.05). Similar things were observed with the prevalence of current symptoms of rhinitis and eczema. In Brazil, there was a small but significant mean decrease in the prevalence of two asthma-related symptoms, wheezing and nocturnal cough, though this trend was not consistent in the surveyed cities. The prevalence of asthma symptoms in Brazil, despite its mean trend to a decrease, is still one of the highest in Latin America.

Prevalence of symptoms of asthma, rhinitis, and atopic eczema in Brazilian adolescents related to exposure to gaseous air pollutants and socioeconomic status

OBJECTIVES

To evaluate the relationship between exposure to gaseous air pollutants (ozone [O3], carbon monoxide [CO], nitrogen dioxide [NO2], and sulfur dioxide [SO2]) socioeconomic status and the prevalence of symptoms of asthma, rhinitis and atopic eczema in adolescents.

SUBJECTS AND METHODS

A sample of 16 209 adolescents from São Paulo West (SPW), São Paulo South (SPS), Santo André (SA), Curitiba (CR), and Porto Alegre (PoA) were enrolled. Data on air pollutants and socioeconomic status were compared to prevalence of symptoms with the Spearman correlation coefficient.

RESULTS

Socioeconomic status was quite similar in all cities. The levels of O3 in SPW, SPS, and SA, and of CO in SA were higher than the acceptable ones. In relation to O3 and CO exposures, adolescents from SPW and SA had a significant risk of current wheezing, whereas living in SPW was associated with a high risk of rhinoconjunctivitis, eczema, and flexural eczema and living in CR to rhinitis. Exposure to NO2 was associated with a high risk of current wheezing in SPW and SA, and of severe asthma in SPW and PoA. Exposure to SO2 was associated with a high risk of current wheezing in SPW and SA, severe asthma in SPW and PoA, and nighttime cough, eczema, flexural eczema and severe eczema in SPW. Living in SPW, CR, or PoA was associated with a high risk of rhinitis, rhinoconjunctivitis, and severe rhinitis.

CONCLUSIONS

Although we did not detect a characteristic pattern for all symptoms evaluated or a specific air pollutant, our data suggest a relationship between higher exposure to photochemical pollutants and high prevalence or risk of symptoms of asthma, rhinitis, and atopic eczema.

Childhood tuberculosis diagnosed and managed as asthma: case report

The worldwide incidence of tuberculosis (TB) has been increasing. Although its diagnosis is well established in adults, in children it is difficult due to its particular aspects. We report a 3 years and 8 month-old infant who experienced chronic wheezing, classified as moderate-to-severe asthma, had recurrent pneumonia, and was not responsive to management with beta adrenergic agents. Chest X-rays (CXR) showed heterogeneous condensation in medium lobe and the chest computerized-tomography scan (CCT) a heterogeneous increase in pulmonary transparency, like condensation in the same lobe. After four months of treatment with anti tuberculosis agents, a significant improvement in symptoms, normal CXR, absence of pulmonary medium lobe condensation, and persistence fibro-atelectatic band in lingula were observed.

Prevalence of rhinitis and related-symptoms in schoolchildren from different cities in Brazil

By using the standard written questionnaire (WQ), designed for the International Study of Asthma and Allergies in Childhood (ISAAC) we determined the prevalence of rhinitis and its related-symptoms, in Brazilian children and adolescents, living in different cities of the country. The WQ was answered by the parents of 11,403 children aged 6-7 years from five Brazilian cities: Porto Alegre (South, N = 2,846), São Paulo (Southeast, N = 3,005) Uberlândia (Southeast, N = 2,991), Itabira (Southeast, N = 1,151) and Recife (Northeast, N = 1,410). The WQ was also applied to 20,587 adolescents (13-14 years old) living in: Porto Alegre (South, N = 3,195), Curitiba (South, N = 3,004), São Paulo (Southeast, N = 3,008), Uberlândia (Southeast, N = 2,998), Itabira (Southeast, N = 2,134), Salvador (Northeast, N = 3,162) and Recife (Northeast, N = 3,086). The mean response rates were 75% and 95%, for the 6-7 year-old children and for the adolescents, respectively. The data was transcribed to a database (Epi-Info) and analyzed regarding the answers to questions of rhinitis module. The mean prevalence of rhinitis (affirmative response to question 2) was 26.6% and 34.2% in the groups of 6-7 and 13-14 year-old, respectively. Applying the criteria that evaluate the association between nasal and ocular symptoms (affirmative response to question 3) the mean prevalence of allergic rhinitis were 12.8% for the 6-7 year-old children and 18.0% for the adolescents. In conclusion, the prevalence of rhinitis and its related symptoms among children and adolescents living in different Brazilian cities was as high as the prevalence observed in other areas of the world.

Nasal provocation test (NPT) with isolated and associated dermatophagoides pteronyssinus (Dp) and endotoxin lipopolysaccharide (LPS) in children with allergic rhinitis (AR) and nonallergic controls

BACKGROUND

Inhalation of endotoxin may enhance inflammatory airway response in sensitized asthmatics persons after allergen(s) inhalation.

OBJECTIVE

To evaluate nasal response to intranasal instillation of Dermatophagoides pteronyssinus (Dp), endotoxin (LPS), and to Dp+LPS in children with perennial allergic rhinitis (PAR).

METHODS

10 PAR children (positive skin prick test to Dp) and 10 nonallergic controls (C) undergoing nasal provocation test (NPT), who were quantified by active anterior rhinomanometry and measurement of Total Nasal Resistance (TNR). The NPTs were initially performed with histamine (H; 0.03 to 16.0 mg/mL), and then, at least at weekly intervals, the NPTs were done with Dp (1/100,000 to 1/2.5), LPS (1 to 500 mg/mL) and to Dp+LPS. During NPT with Dp+LPS, Dp concentration was kept constant (1/100,000; 1/10,000; 1/1,000) and was combined with different concentrations of LPS (1, 5, 10, 20 mg/mL). The NPT was considered positive when TNR reached twice the basal TNR.

RESULTS

H and Dp NPTs were positive in all AR children. In group C, H NPT was positive in 60% and Dp NPT was negative in all children. NPT with LPS was positive only in 30% of the AR children. NPT with Dp+LPS was positive in 90% of the AR patients in Dp concentration of 1/1,000 and in LPS concentrations of 5, 10, and 20 mcg/ mL. This positive association was observed with Dp concentrations lower than those obtained during NPT with Dp in 60% of AR patients. There were no changes in pulmonary function tests in all children after NPT.

CONCLUSIONS

This study suggests that LPS enhances the effects of allergen challenges on nasal airflow. The daily inhalation of allergens plus endotoxin in AR patients does increase the nasal responsiveness.

IGF-I, IGF-BP3, and GH serum levels after stimulation tests in prepubertal allergic boys

The prevalence of short stature (SS, < 3rd percentile NCHS) among children with respiratory allergy (asthma and/or rhinitis) varies from 2% to 10%. In spite of several studies, the etiology of SS in those patients remains unknown. We evaluated growth hormone (GH) serum levels in response to two stimulating tests (standardized exercise and clonidine) in prepubertal boys (G1P1, Tanner; 8 years and 5 months to 14 years) with SS, 14 of them with respiratory allergy (A, positive skin prick test to D. pteronyssinus) and 5 nonallergic children (NA). Other causes of SS were excluded in both groups. Patients had mild asthma and/or rhinitis, and they had never received inhaled or systemic corticosteroid at any time. Tests were performed on different days, at least 1 week apart. [To prevent exercise-induced asthma, 30 min before the exercise test, allergic children inhaled disodium cromoglycate (2 mg)]. GH serum levels (Immunoassay, AIA-PACK HGH, Tosoh Co, Japan) were determined at the following times: exercise (E)--basal, 5, 15, and 30 min after exercising for 6 min; clonidine (C)--basal, 30, 60, and 90 min after clonidine (0.15 mg/m2 body surface) ingestion. A response was considered positive when GH serum levels reached the minimum of 10 ng/ml. Among (the allergic) A patients, four responded to both tests, five to C (clonidine) alone, four to E (exercise) alone and one had no response. Among NA, four had a positive response to both tests and one to C (clonidine) alone. The serum levels of insulin-like growth factor I (IGF-I) (DSL-5600 Active TM IGF-I Coated-Tube IRMA [DSL Lab Inc, USA]) and its binding protein (IGF-BP3) (DSL-6600 Active TM IGF-BP3 Coated-Tube IRMA [DSL Lab Inc, USA]) were within the normal range except for one A child. Bone age was delayed in relation to chronological age in all children, but adequate for height age. All children had delayed skeletal age in relation to chronological age, but bone age was normal for height. We concluded that in the children studied a deficiency of GH does not seem to be responsible for SS.

Asthma and respiratory disease mortality rates in the state of Sao Paulo, Brazil: 1970-1996

BACKGROUND

Asthma morbidity and mortality have been increasing. Data of asthma and respiratory mortality rates in Brazil are scarse.

METHODS

We studied asthma and respiratory disease mortality rates in the state of So Paulo (capital and country side) from 1970 to 1996, as its relation with sales of drugs usually used in asthma treatment.

RESULTS

Asthma mortality in the 5-34-year age group has doubled in the state of So Paulo (0.2 deaths/100,000 inhabitants in 1970 to 0.4 in 1996), mainly by its increase in the capital. The greatest increase was observed in the population of up to 15 years of age. The sales of inhaled anti-inflammatory drugs are proportionally very low and reflect a greater concern about the treatment of acute exacerbations.

CONCLUSION

We believe that the institution of a public health supply to the whole population could provide better conditions for the control of those indexes.

Cow's milk protein intolerance and chronic constipation in children

Cow's milk protein (CMP) allergy was investigated in 25 children (age-range 3 months to 11 years) with chronic constipation. A diagnosis of constipation was made on the basis of a history of painful elimination of hard stools for at least 1 month, whether or not associated with a reduced frequency of stools or soiling. The children were evaluated using clinical parameters and the following laboratory tests: total serum immunoglobulin E (IgE); specific IgE (radioallergosorbent test [RAST]) for whole cow's milk, alpha-lactoalbumin, beta-lactoglobulin, and a food group; and skin-prick tests with whole milk, alpha-lactoalbumin, beta-lactoglobulin, and casein. Following the evaluation, the children were submitted to a CMP-free diet for a period of 4 weeks. In seven patients (28%), constipation disappeared during the CMP-free diet and reappeared within 48-72 h following challenge with cow's milk. In two infants a rectal biopsy revealed allergic colitis and they therefore did not undergo the challenge. High serum levels of total IgE were observed in five of the children who showed a clinical improvement (71%), a positive skin-test in two (29%), and detectable specific IgE in two (29%). These results suggest that CMP allergy or intolerance should be considered as a cause of chronic refractory constipation in children, although the underlying mechanism still require further investigation.

Specific and non-specific nasal provocation tests in children with perennial allergic rhinitis

BACKGROUND

nasal provocation tests (NPT) have been extensively used in clinical practice to evaluate chronic rhinopathies, mainly allergic rhinitis (AR).

METHODS

we submitted 10 perennial AR children (aged from six to 15 years) to histamine (H), Dermatophagoides pteronyssinus (Dp) and Blomia tropicalis (Bt) NPT. All children were sensitized (positive skin prick test, mean wheal > 3 mm) to both mites. Dp and Bt specific NPT were realized in two occasions, apart one week, always preceeded 24 hours by H challenge. Increased concentrations were applied to the nasal mucosa during each NPT: H (0,03 to 16 mg/ml), Dp (1/100,000 to 1 /2.5) and Bt (1/125,000 to 1/10). NPT were evaluated by clinical and rhinomanometric parameters (total score, TS), and by lung function tests. NPT was considered positive, when total nasal resistance (TNR) doubled in relation to basal value.

RESULTS

H NPT was positive twice in 8/10 patients. Concordance between H concentration that induces a positive NPT measured by TNR or TS was observed. Regarding to specific NPT, 90 % of patients were positive to Dp and 60 % to Bt. There was no concordance between the allergen concentration that induces a positive SPT and a positive NPT, considering the different concentrations. There were no modification in lung function tests during both specific and non-specific provocation tests.

CONCLUSIONS

NPT with H is an objective and reproducible method which allow evaluate nasal reactivity. Specific NPT have restricted indications, mainly when there where doubts about AR's etiology.

Barriers to measuring and achieving optimal outcomes in pediatric asthma

To measure the effectiveness of any therapeutic endeavor, a set of defined outcome measurements must be performed, or the task of determining the effectiveness of any therapeutic step becomes difficult. With asthma, however, in which case it is difficult to establish the initial diagnosis, beginning a program of outcome measurements regarding any therapeutic interaction is nearly impossible. Conventional means are thwarted at the outset. One way of approaching the problem of obtaining reproducible outcomes data is to examine those areas in which measurements can be made and determine the barriers to obtaining the data. Establishing a good medical history is a critical step that, in general, is especially difficult with very young children, and tools that provide objective measurements that are used in the normal evaluation of older children are of little use in the very young child with asthma. Parts of the physical examination are difficult to perform in very young children, and findings associated with asthma can be found in other clinical states. In this age group, diary keeping suffers from the same problems and issues that are related to obtaining an accurate medical history. Barriers also exist to obtaining the best outcomes. The choice of medications for the very young child is limited; there are several typical adherence problems, and information about adverse effects is limited.

International Study of Asthma and Allergies in Childhood: validation of the rhinitis symptom questionnaire and prevalence of rhinitis in schoolchildren in São Paulo, Brazil

Written questionnaires (WQ) have been widely used in epidemiologic studies. In order to yield comparable results, they must be validated after translation to another language. The International Study of Asthma and Allergies in Childhood (ISAAC) WQ has been previously validated by a comprehensive study, but its validation in Brazil has not been performed. Our objectives were to validate the rhinitis component of the ISAAC's self-applicable WQ following its translation to Portuguese, and to determine the prevalence of rhinitis and related symptoms among Brazilian children living in the city of São Paulo. A group of 10 pediatricians and 10 pediatric allergists graded the questions from 0 to 2 and established a maximum score for each question. The WQ was answered by parents or guardians of children 6-7 years of age with rhinitis (R) (n = 27) and of control children of the same age without rhinitis (C) (n = 27). The WQ was also completed by adolescents 13-14 years of age with rhinitis (R) (n = 32) and without rhinitis (C) (n = 32). Half of these individuals answered the same WQ after 2-4 weeks, to ensure reproducibility. Cut-off scores of 4 and 3 were identified for the 6-7- and 13-14-year-old groups, respectively, as scores predictive of rhinitis. The prevalence of rhinitis was 28.8% in the group of 3005 children 6-7 years of age and 31.7% in the group of 3008 children 13-14 years of age, respectively. Using the global cut-off score, these prevalences were even higher, in the order of 34.7% and 40.7%, respectively. In conclusion, the rhinitis component of the ISAAC WQ was proven to be reproducible, adequate and able to discriminate children and adolescents with and without rhinitis, and revealed that the prevalence of rhinitis among Brazilian children living in the city of São Paulo was as high as the prevalence of rhinitis in other areas of the world.

Inhaled budesonide for the treatment of acute wheezing and dyspnea in children up to 24 months old receiving intravenous hydrocortisone

BACKGROUND

Inhaled corticosteroids are highly effective in the treatment of asthma at all ages, and their use in younger children is increasing. There are no data currently available on the treatment of infants with acute wheeze and dyspnea with nebulized budesonide.

OBJECTIVE

Our purpose was to assess the clinical effect of nebulized budesonide in infants with acute wheeze and dyspnea.

METHODS

A prospective study was performed comparing the addition of nebulized budesonide 0.25 mg every 6 hours (group A, n = 32) and nebulized ipratropium bromide 0.1 mg every 6 hours (group B, n = 39) with the normal treatment regimen with intravenous fluid, hydrocortisone, and nebulized fenoterol. A clinical score was made at admission and every 12 hours. The score included wheezing and costal retraction (0-6) and respiratory rate (counts per minute).

RESULTS

Seventy-one infants aged 3 to 24 months were studied (42 boys). A statistically significant reduction was seen in clinical score and respiratory rate in both groups 12 hours after admission. The children who received budesonide improved significantly faster than the children who received ipratropium bromide, and the hospitalization period was significantly lower in the budesonide group (66.4 hours) compared with the ipratropium bromide group (93 hours) (P <.01). Three patients from the budesonide group and 2 from the ipratropium bromide group were readmitted within the first 4 weeks.

CONCLUSION

Treatment of infants with acute wheeze with nebulized budesonide is associated with faster clinical improvement and reduction in hospital stay period.

Cockroach allergens and asthma in Brazil: identification of tropomyosin as a major allergen with potential cross-reactivity with mite and shrimp allergens

BACKGROUND

Cockroaches produce several proteins that induce IgE antibody responses. Although cockroaches are abundant in warm and humid areas, sensitization to cockroach allergens has not been investigated in Brazil.

OBJECTIVE

The aims of this study were to investigate the frequency of cockroach allergy among patients with asthma, rhinitis, or both in Brazil and to identify American cockroach allergens.

METHODS

Skin tests using cockroach extracts were performed on children and young adults with asthma, rhinitis, or both. A Periplaneta americana complementary (c)DNA library was screened by using IgE antibodies from Brazilian patients allergic to cockroaches. Reactivity of an mAb directed to Dermatophagoides pteronyssinus tropomyosin against cockroach tissue was examined by immunofluorescence.

RESULTS

Cockroach allergy was present in 55% and 79% of the patients, as determined by using skin prick tests alone or combined prick and intradermal tests, respectively. Five cDNA clones reacted with IgE antibody and contained the same sequence. A representative clone (1300 bp), pa 12, coded for a protein that reacted with 50% of the sera from patients allergic to cockroaches on plaque immunoassay and showed a high degree of homology to tropomyosins, particularly those from invertebrates. P americana tropomyosin showed 80%, 81%, and 82% sequence identity to tropomyosins from D pteronyssinus, D farinae, and shrimp, respectively, which have been previously defined as important allergens. An mAb directed against D pteronyssinus tropomyosin, which also recognizes shrimp tropomyosin, showed binding to cockroach striated muscle.

CONCLUSION

Our results support the recommendation that cockroach extracts should be routinely used for the evaluation of patients with asthma, rhinitis, or both in Brazil. The identification of P americana tropomyosin as an important allergen will make it possible to investigate cross-reactivity among cockroaches, mites, and food derived from invertebrates.

Pulse oximetry in the evaluation of the severity of acute asthma and/or wheezing in children

We evaluated 174 children with acute asthma and/or wheezing attending two different settings, the allergy clinic (AC) and the emergency room (ER), and compared clinical symptoms and spirometric findings with arterial oxygen saturation as measured by pulse oximetry (SpO2). Seventy-four children (4 months to 15 years old) seen at the AC and 100 children (2 months to 14 years old) seen at the ER for the treatment of acute asthma and/or wheezing were evaluated and a clinical score was attributed on the basis of their symptoms. In addition, the heart rate (HR) was recorded and SpO2 was measured. Among the children seen at the AC, 58 were able to perform pulmonary function tests, and the forced respiratory volume in 1 sec (FEV1) and forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75)) were determined. Children from both groups underwent treatment with a nebulized beta2-agonist (Fenoterol 0.5% solution, 0.08 mg/kg/dose, maximum 2.5 mg) and were re-evaluated after 30 min. Our results showed a significant correlation between decrease in clinical scores and increase of SpO2 following treatment with bronchodilator in both groups of children. SpO2 levels correlated positively with FEV1 and FEF(25-75) values, and negatively with clinical scores and heart rate. The data revealed that a clinical score greater than 3 and an SpO2 < 94% were associated with increased severity of the asthma attack. In addition, SpO2 levels < or = 92% were associated with a 6.3-fold greater relative risk for requiring additional treatment. We concluded that determination of oxygen saturation by pulse oximetry is helpful in monitoring the severity of an acute exacerbation of asthma and/or wheezing, and has a prognostic value.

Prevalence of asthma and related symptoms in school-age children in São Paulo, Brazil--International Study of Asthma and Allergies in Children (ISAAC)

We studied the prevalence of asthma and related symptoms using a standard written questionnaire designed for the International Study of Asthma and Allergies in Children (ISAAC). The written questionnaire (questions 1-8 related to asthma) was applied to 3005 children aged 6-7 years and to 3008 children aged 13-14 years. The parents of the 6-7-year-old children answered the questionnaire, whereas the 13-14-year-old children answered the questionnaire themselves. Response rates were 72% in the 6-7-year-old group and 94% in the 13-14-year-old group. There was a slight predominance of females in the population studied (male:female ratio 0.94). In the group of the 6-7-year-old children, the prevalence of diagnosed asthma was 7.3% for boys and 4.9% for girls, and in the group of the 13-14-year-old children, the prevalence was 9.8% and 10.2% for boys and girls, respectively. Asthma severity was similar for both age groups, and wheezing following exercise was more frequent among the adolescents. In keeping with studies in other parts of the world, comparison between reported symptoms and diagnosed asthma revealed significantly lower frequency of diagnosed asthma, suggesting that in the population we have studied, asthma is underdiagnosed. Using a global cut-off score to define asthma, we found a significantly higher prevalence of asthma among 6-7-year-old boys, as compared to girls (23.8% vs. 20.4%), and no significant differences among adolescent boys and girls (22.5% and 21.9%, respectively).

Protective effects of different doses of inhaled fenoterol on methacholine-induced bronchoconstriction in asthmatic children

OBJECTIVE

To evaluate the protective effect of different doses of inhaled fenoterol (F) on bronchoconstriction induced by methacholine (M).

DESIGN

Randomized double-blind study.

SETTING

Referrence center.

PARTICIPANTS

9 children (aged from 7 to 15 years old), with mild or moderate asthma and allergic to D. pteronyssinus.

INTERVENTION

On the first day, the M concentration necessary to induce a 20% fall in the forced expiratory volume in the first second (FEV1; PC20FEV1) was determined using closed circuit inhalation (De Vilbiss 646). On subsequent days, the children inhaled a dose of F (25 or 50 or 100 or 200 micrograms) through the same circuit and, after 15 minutes the FEV1 was measured, becoming the basal value. Bronchoprovocation was then initiated using the concentration prior to the PC20FEV1 of the first day and continuing until there was a 20% fall in the FEV1. This concentration was the "new" PC20FEV1.

RESULTS

F in a dose of 25 micrograms protected 2 of the 9 children, in a dose of 50 mg protected 4 of the 9 and in doses of 100 and 200 micrograms protected all children. We did not observe any relationship between the magnitude of the bronchodilation and bronchoprotection induced by the inhalation of F.

CONCLUSIONS

Our results suggest that a dose of 100 micrograms of F is capable of inducing bronchoprotection in children with mild/moderate asthma.

International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire: validation of the asthma component among Brazilian children

Written questionnaires have been widely used in epidemiological studies of asthma. However, when translated to another language, they must be validated. The International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire had been previously validated by a comprehensive study, but this had not been done in Brazil. Our objective was to validate the asthma component of the ISAAC self-applicable written questionnaire following its translation to Portuguese. A group of 10 pediatricians and 10 pediatric allergists graded the questions from 0 to 2, and established a maximum score for each question. The questionnaire was answered by parents or guardians of asthmatic children, aged 6 to 7 years old (n = 26) and of nonasthmatic control children of the same age (n = 26); and by asthmatic (n = 33) and nonasthmatic (n = 33) adolescents, aged 13 to 14 years. Half of these individuals responded to the same questionnaire after 2 to 4 weeks. This second response allowed the evaluation of the reproducibility of the ISAAC questionnaire. The maximum global score possible was 14, and cut-off levels of 5 and 6 were found for the groups of 6 to 7 and 13 to 14 year olds, respectively. There was significant agreement between the adolescents' responses to the questionnaire and those from their parents or guardians (74.3%); however, significant discordance was observed for individual questions including "wheezing with exercise." In both age periods the questionnaire was significantly reproducible (Kappa test) (6 to 7 year olds Kw = 1; 13 to 14 year olds Kw = 0.89). In conclusion, the asthma component of the ISAAC written questionnaire was proven to be reproducible, adequate and able to differentiate between asthmatics and controls. Adolescents answered the questionnaire appropriately, however the results suggest that adolescents' parents or guardians underestimate asthma symptoms which interfere little with the adolescent's daily activities.

Prevalence and characteristics of exercise-induced asthma in children

We have evaluated the prevalence and the characteristics of exercise-induced asthma (EIA) in a group of 71 patients with a prior history of mild, moderate or severe asthma (42 males and 29 females), aged 6-16 years-old. Measurements of the forced expiratory volume in 1 second (FEV1) were obtained before and at regular intervals up to 8 hours following exercise. As a control, the same patients were evaluated at similar time intervals on another day when they had not been submitted to an exercise challenge. Using pre-exercise FEV1 values as the reference, 32 patients (45.1%) had a positive exercise challenge, defined as a fall in FEV1 value equal to or greater than 15% from baseline following exercise. Among the patients with a positive exercise challenge, the majority (23/32, 71.8%) had an immediate response alone, with no significant changes in FEV1 within the 8-hour follow-up. However, a subgroup of patients (9/32, 28.1%) had both an immediate and a late-phase response to exercise. During the control day, no significant fall in FEV1 were observed. In keeping with previous investigations, no correlation was found between a history of EIA and a positive exercise challenge in the present study. Positive exercise challenges were found more frequently among patients with moderate and severe asthma than patients with mild asthma.

Metabolic and hematologic changes occurring after rapid intravenous infusion of gammaglobulin in patients with antibody deficiency syndromes

OBJECTIVE

We wished to investigate whether increased IgG infusion rates are associated with metabolic and hematologic changes in pediatric patients with antibody deficiency syndromes.

METHODS

We studied 7 patients (2-16 years old) with primary antibody deficiencies who had been on regular IgG replacement treatment, 350-600 mg/kg/dose every 3 weeks with a 3% IVIG preparation, for periods ranging from 6 months to 4 years. Initially, the IgG concentration of IVIG preparations was increased to 6, 9 and 12% in consecutive infusions at a constant IgG infusion rate of 4 mg/kg/min. Subsequently, the infusion rates were increased to 8, 12, and 16 mg/kg/min using the IVIG 12% preparation.

RESULTS

Clinically, all patients tolerated increases in IVIG concentrations while the infusion rate was 4 mg/kg/min. However, 3 patients presented side effects when the infusion rate was increased to 8 and 16 mg/kg/min.

CONCLUSION

We conclude that metabolic and hematologic sides effects occur with rapid infusion of IVIG even in patients who tolerate the increased infusion rate clinically. The advantages of using high infusion rates have to be re-evaluated.

[Asthma in children: classification and treatment]

OBJECTIVES: To review concepts, classification based on severity, and long term treatment for children with asthma. METHODS: To identify precipitating factors of acute asthma attacks and classify the disease in order to establish long term treatment. RESULTS: Different plans of management according to its classification: mild, moderate and severe asthma. Antiinflammatory therapy is reserved to moderate and severe asthma. CONCLUSIONS: The identification and control of the etiologic and precipitating factors are important tasks in the management of asthma. The inhalatory route is the most appropriate to treat patients suffering from asthma. The usual drugs indicated in asthma treatment are reviewed. Precocious treatment with inhaled glucocorticosteroids is recommended by several authors.

[Non-specific bronchoprovocation with metacholine in children before and during sugar cane burning in Catanduva-SP]

OBJECTIVE: Evaluate the influence of sugar cane burning on BHR of asthmatic and "normal" control children by metacholine bronchoprovocation tests; and verify if interferes in pulmonary function tests.METHODS: Twenty-two asthmatic children (A) aged from 7 to 14 years old, and twelve "normal" control children (C), aged from 8 to 13 years, were submitted to non-specific bronchoprovocation test with methacholine before and during the sugar cane burning. The metacholine concentrations used were 0.025; 0.25; 1.0; 2.5; 10.0; 25.0 mg/ml, and the results were expressed in PC(20) FEV1 (concentration of metacholine that induces a fall of 20% or more in the forced expiratory volume in the first second).RESULTS: The PC(20) average for asthmatic children was significantly lower than the control group, before (A= 3.68; C= 25.62 mg/ml) and during the burning (A= 4.11; C= 25.25 mg/ml) (p < 0.05). However, there were no significant differences, when compared in each group PC(20) values before and during burning. The same was observed regarding FEV1, forced vital capacity (FVC) and forced expiratory flux between 25 and 75% of FVC (FEF (25-75%)).CONCLUSIONS: It was not possible to demonstrate that cane plantation burning influences the BHR, and pulmonary functions tests of the studied children.

Evaluation of the potential cardiotoxicity of the antihistamines terfenadine, astemizole, loratadine, and cetirizine in atopic children

BACKGROUND

Adverse cardiac effects have been related to the use of H1-receptor antagonists terfenadine and astemizole.

OBJECTIVE

We have investigated the cardiac effects of the H1-receptor antagonists terfenadine, astemizole, loratadine and cetirizine, used in recommended doses, concomitantly or not with the antibiotic erythromycin.

METHODS

A group of 80 children aged 5 to 12 years was studied. All children had been diagnosed with perennial allergic rhinitis based on symptoms, clinical signs and a positive immediate skin test to Dermatophagoides pteronyssinus. The children had no personal history of cardiac disease or hepatic dysfunction, and they had a normal electrocardiogram (ECG) at the beginning of the study. Forty children had allergic rhinitis and sinusitis, and were assigned to subgroups of ten children who received terfenadine, astemizole, loratadine, or cetirizine, concomitantly with erythromycin, for 14 days. Erythromycin was started to treat presumed bacterial infection in children with complete radiologic opacification of the maxillary sinus(es). The remaining 40 children had no sinusitis, and were assigned to subgroups of 10 children who received terfenadine, astemizole, loratadine, or cetirizine for 14 days.

RESULTS

No significant changes in the QT interval and QTc (QT corrected by Bazzett's equation) were observed among children who received astemizole, loratadine or cetirizine, with or without erythromycin. Children who have received terfenadine and erythromycin showed significantly prolonged QT interval (mean pretreatment and posttreatment values 0.32s and 0.34s, respectively). Analysis of the QTc interval, however, showed no significant differences in the group treated with terfenadine and erythromycin (mean values 0.39s and 0.39s, respectively).

CONCLUSIONS

Our results show that H1-receptor antagonists terfenadine, astemizole, loratadine and cetirizine, administered with or without erythromycin, to atopic children in recommended doses, do not induce adverse cardiac effects. Although the association between terfenadine and erythromycin has caused a statistically significant increase in QT interval measurements, the magnitude of these changes was below levels considered cardiotoxic or clinically relevant.

Malnutrition and experimental lung allergy

BACKGROUND

Although it is commonly accepted that the immune response is affected by malnutrition there are very few data about its effect in allergic diseases.

OBJECTIVE

The aim of the present study was to investigate the effect of malnutrition in allergic lung inflammation.

METHODS

An anaphylactic reaction was induced in rat lungs and the increased vascular permeability was measured in the trachea, internal and external bronchi and parenchyma by the Evans blue extravasation method. These studies were conducted in two dietary groups: one fed a normoproteic diet (18%) and the other a hypoproteic diet (4.5%). When the animals were 60 days old the group fed the hypoproteic diet presented a reduction of 77.86% in bodyweight, 63.3% in food intake and 36% in plasma protein concentration characterizing a severe protein-calorie malnutrition.

RESULTS

The anaphylactic reaction in the lungs induced a significant increase in vascular permeability in the trachea and bronchi of both dietary groups. However, the intensity of this effect was significantly lower in the malnourished group. Analysis of immunoglobulin isotypes in the serum by ELISA showed that whereas IgG1 and IgG2a levels were similar in both groups, the levels of IgE were significantly lower in the malnourished animals. Moreover, the levels of antigen-specific IgG1, IgG2a and IgE were all significantly inhibited by the protein-calorie malnutrition. When antibodies were passively transfered to the malnourished rats, they developed a reaction as intense as the normoproteic group.

CONCLUSION

These results suggest that the capacity to release inflammatory mediators and the vascular response to these mediators is not affected by this type of malnutrition and, therefore, the diminished response of the airways reported here is probably due to the lower levels of anaphylactic antibodies produced by the malnourished rats.

Juvenile systemic lupus erythematosus. Neurological involvement

With the purpose of analyzing the neurological involvement due to systemic lupus erythematosus (SLE), we evaluated 17 female patients who were seen regularly at the hospital and had been diagnosed as having SLE according to classification criteria proposed by the American College of Rheumatology revised in 1982, before the age of 16. Neurological involvement was detected in 12 patients (71%): headache (35%), extrapyramidal syndrome (35%), epileptic syndrome (24%) pyramidal syndrome (24%), peripheral neuropathy (12%) and optic neuritis (6%). The findings of CT scan (58%) and cerebrospinal fluid (50%) were most closely correlated to clinical neurological involvement.

Endotoxin exposure and symptoms in asthmatic children

Endotoxins (ET) are pro-inflammatory substances present in house dust which may increase non-specific bronchial reactivity in asthmatic patients. Endotoxins (EU/g) and Der p 1 levels were compared in the homes of ten asthmatic and ten control children, aged 6-16 years, living in São Paulo, Brazil. The houses were visited once a month from February 1993 to February 1994 and dust samples were collected from the bedding and floor of each subject's house. No significant differences were observed in ET and Der p 1 levels in the homes of asthmatics and controls. The highest ET levels were detected in January and November, whereas the lowest levels were detected in April and August (p < 0.05), demonstrating a distinct seasonal distribution. The highest Der p 1 levels in bedding were observed in July and the lowest in February (p < 0.05), while Der p 1 levels in floor did not show significant differences throughout the year. Symptom and medication scores were evaluated monthly in the group of asthmatic children. There was a significant correlation (p < 0.05, r = 0.63) between clinical symptom scores and ET exposure, however no significant correlation was found for mite exposure (p > 0.05, r = 0.19). The results suggest that ET exposure exacerbates asthmatic symptoms in mite allergic, asthmatic children.

HLA antigens in asthmatic children

The purpose of the present study was to analyze the frequency of HLA-DR and DQ antigens in Brazilian asthmatic children with skin-test and RAST positivity to Dermatophagoides pteronyssinus. The comparison of HLA-DR and DQ antigenic frequencies between patients (n = 30) and controls disclosed a significantly higher HLA-DQ2 frequency in the patients (60% versus 34%, p = 0.013; R. R. = 2.8).

Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis

BACKGROUND

There appears to be an association between sinusitis and asthma. The effect on bronchial hyperresponsiveness of clinical therapy for sinusitis in children may help to decipher whether sinusitis and asthma are independent manifestations of the same disease.

OBJECTIVE

To evaluate the effect of clinical treatment for sinusitis in patients with rhinitis and/or asthma on symptoms and on bronchial hyperresponsiveness to methacholine.

METHODS

Open label, randomized, non-treatment control in a teaching hospital in São Paulo, Brazil. Forty-six atopic and 20 normal children were studied. The atopic children consisted of 18 with allergic rhinitis (12 without sinusitis and 6 with sinusitis), and 28 children with rhinitis with asthma (13 with normal sinus radiographs and 15 with complete opacification of the maxillary sinuses). Methacholine PC20 was determined before and 30 days after treatment with nasal saline, sulfamethoxazole-trimethoprim, antihistamine/decongestant, and five days of prednisone. Sinus radiographs were also repeated.

RESULTS

The only patients with increase in methacholine PC20 were patients with rhinitis and asthma with opacified maxillary sinuses at entry and who at 30 days had normal sinus radiographs (P < .05).

CONCLUSION

In this study, children with allergic rhinitis and sinusitis with asthma improved their bronchial hyperresponsiveness to methacholine and decreased their symptoms with appropriate response of their sinuses to clinical therapy.

IgE antibodies to aeroallergens in allergic children in São Paulo, Brazil

The sensitization to inhaled allergens was studied in 80 Brazilian children and 12 controls, aged 6 to 16 years. We performed skin tests with Alternaria alternata, cat, dog, Lolium perenne, grasses and the following domestic mites: Blomia tropicalis, Dermatophagoides pteronyssinus, Dermatophagoides farinae, Lepidoglyphus destructor, Chortoglyphus arcutus and Aleuroglyphus ovatus. The frequencies of positive skin tests (mean diameter > or = 23 mm) were respectively 15%, 11%, 11%, 6%, 7%, 95%, 92%, 88%, 76%, 75% and 71%. The mean diameter of the wheal to domestic mites was higher to D. pteronyssinus than to B. tropicalis, L. destructor, A. ovatus and C. arcuatus (p < 0.05). The skin test results to domestic mites by regression analysis revealed highly significant correlation (p < 0.0001), suggesting considerable cross-reactivity between them. Specific IgE to each mite was determined and the results expressed as the mean of the percentage of total counts bound (% TCB). We had the highest levels of % TCB to D. farinae, followed by D. pteronyssinus, E. maynei, B. tropicalis, C. arcuatus, L. destructor and A. ovatus. The Brazilian children with asthma had more positive skin tests to domestic mites than to other inhalant allergens, and based on previous studies performed in São Paulo that have shown D. pteronyssinus and B. tropicalis as the most prevalent mite species in house dust, we assumed that IgE Ab to D. farinae reflects cross-reactivity with D. pteronyssinus in most cases. The observed high levels of IgE Ab to domestic mites stress the importance of environmental avoidance measures, decreasing the rate of sensitization or perhaps the development of symptoms of asthma in genetically predisposed children.

[Risk factors and clinical evolution of asthma in children]

OBJECTIVE

The purpose of this study was to obtain data on the clinical evolution and risk factors related to asthma in children followed as outpatients in our Division of Allergy.

METHODS

The asthmatic group consisted of 165 children (107 boys, 58 girls), between the ages of 3 and 14 years. All children were atopic and had a positive skin prick test to D. pteronyssinus. The control group consisted of 40 healthy children (20 boys, 20 girls), within the same age range, without personal history of asthma or other atopic disease and with negative skin prick test to D. pteronyssinus. The mothers were interviewed to obtain data on: a) clinical evolution, b) family history of asthma or any other atopic disease, c) description of the house environment.

RESULTS

1) in approximately half of the cases symptoms started on the first year of life. Mothers were not informed of the condition at the time; 2) upper respiratory tract infections and bronchiolitis were responsible for triggering the first wheezing episode in most cases and remain the main precipitating factors in the first year of the disease whilst allergens, irritants, sinusitis, physical exertion and emotional factors were the main precipitating factors between the ages of 5 and 13; 3) changes in climatic conditions precipitated acute attacks throughout the evolution of the disease and; 4) asthma was not the only allergic manifestation, allergic rhinitis being the most frequent associated condition; 5) family history of atopy (Relative Risk (RR) = 2.40; 95% confidence interval (CI95%) = 1.60-3.50); maternal history of asthma (RR = 2.23; CI95% = 1.10-4.63) and the presence of smokers in the house (RR = 2.30; CI95% = 1.20-4.31) were the main risk factors for the manifestation of asthma.

CONCLUSIONS

a) there were no differences between boys and girls regarding the evolutionary aspects, b) asthma was underdiagnosed, c) family history of atopy, maternal history of asthma, and the presence of smokers in the house were risk factors for the manifestation of asthma.

Bronchoprovocation with methacholine in children under two years old: a follow-up study

Fifty-one wheezing babies (WB) under two years of age and 20 controls (C) within the same age range were submitted to a bronchial provocation test (BPT) with methacholine. The appearance of wheezing on pulmonary auscultation was used to determine PCW (provocative concentration of methacholine causing wheezing). For all tests, methacholine diluted in saline at increasing concentrations (0.025, 0.125, 0.25, 0.5, 1.0, 2.5, 5.0 and 10.0 mg/ml) was delivered with O2 (5 ml/min) via a face mask. Solution was inhaled through the mouth and nose during two minutes of quiet tidal breathing via a nebulizer containing a 2 ml volume. No collateral effects were observed, except for tachypnea and tachycardia. There was a statistically significant difference between the PCW for WB (2.3 mg/ml) and the PCW for C (9.2 mg/ml). A 5 mg/ml concentration of methacholine provides the clearest distinction between the WB and C groups. Indeed, we observed that 96% of WB and 25% of C demonstrated PCW below this concentration. In the WB group, those with mild symptoms had higher PCW values. When the BPT was repeated in 27 WB at an 8-month interval, statistically significant differences between the two PCV values were observed. The highest PCW values were evidenced in the second BPT. The use of BPT with methacholine could establish PCW as a parameter of bronchial hyperreactivity in infants.

Specific sensitization to Dermatophagoides pteronyssinus and cutaneous reactivity to histamine in Brazilian children

The immediate hypersensitivity cutaneous test is a recognized method for etiologic diagnosis of allergic diseases. It is easily conducted, painless and can be quickly interpreted, making it deal for use with children. However, its low positivity in infants limits its use this population. The purpose of our study was to evaluate the skin reactivity to atopic and non-atopic children of different ages to increasing concentrations of histamine and to an extract of Dermatophagoides pteronyssinus (Dpt). Atopic children (A, n = 217) and non-atopic children (C, n = 198), under 15 years of age were grouped by age and administered skin prick tests. Increasing concentrations of histamine (1, 9, 81 and 243 mg/ml) and Dpt (10,000 AU/ml) were applied to the forearm. Skin reactions were recorded after 15 minutes and expressed as the mean of the largest wheal and its midpoint perpendicular diameter. Cutaneous reactions were observed in the early phases of life with a progressive increase observed in both groups. Significant differences were noted between the two groups starting at 48 months of life. As the concentration of histamine was increased, we observed a higher level of cutaneous reactivity in younger children. Comparative analysis of cutaneous reactivity to the histamine solution (1 mg/ml) and the Dpt extract showed parallelism between them and wheals with diameters larger than 3 mm after 12 months of age. We concluded that the skin prick test with Dpt is reliable in atopic children after 1 year of age. Reactivity to higher concentrations of histamine was observed after 3 months of age for all children. However, considering all age groups, the skin reactivity in atopic children to histamine (1 mg/ml) was more precocious when compared to controls.

Comparative efficacy of inhaled furosemide and disodium cromoglycate in the treatment of exercise-induced asthma in children

BACKGROUND

Inhaled furosemide has been shown, in patients with asthma, to have prophylactic properties similar to those of disodium cromoglycate.

OBJECTIVE

The aim of this study was to evaluate the protective effect of these drugs in the treatment of exercise-induced asthma.

METHODS

Fifteen children with exercise-induced asthma (mean age, 10.8 years) underwent exercise challenge after a single dose of nebulized placebo, furosemide (20 mg/m7 body area), or disodium cromoglycate (20 mg), 2 days apart, in a single-blind crossover trial.

RESULTS

Both furosemide and disodium cromoglycate exerted significant protection against the bronchial response to exercise challenge, with a mean maximum percentage falls in FEV1 of 4.66% and 7.22%, respectively (p < 0.05). On the placebo day, the mean maximum percentage fall in FEV1 was 34.50% (p < 0.05).

CONCLUSION

The results of this study suggest that furosemide and disodium cromoglycate provide comparable efficacy in preventing exercise-induced asthma in children, with no side effects.

[Non specific bronchial hyperreactivity in infants]

OBJECTIVE

To evaluate the presence of bronchial hyperreactivity (BHR) in Wheezing Babies (WB) and Normal Control Infants (C) employing the methacholine (M) bronchoprovocation test (BPT).

METHODS

Fifty-one WB and 20 C, all under two years old and assisted at the Department of Pediatrics of UNIFESP-EPM, were submitted to BPT with M, having pulmonary auscultation as monitoring parameter to evaluate PCW (provocative concentration of M causing wheezing). For all tests, M diluted in saline at increasing concentrations of: 0.025, 0.125, 0.25, 0.5, 1.0, 2.5, 5.0, and 10.0 mg/ml was delivered with O2 (5 l/min) by a face mask. It was inhaled through the mouth and nose during 2 minutes of quiet tidal breathing via nebulizer with 2 ml of solution.

RESULTS

None collateral effects were observed, except for tachypnea and tachycardia. There was statistically significant differences between WB (2.3 mg/ml) PCW value and C (9.2 mg/ml) (p < 0.05). At the PCW value of 2.5 mg/ml, 41% of the WB had statistically positive response (p < 0.05). This was not observed in the group C, when a positive response only occurred at the concentration of 5 mg/ml (25%). At this concentration we observed a clear cut difference between WB and C (p< 0.05). According to the severity, the highest M concentration was observed within the group displaying mild symptoms.

CONCLUSIONS

We conclude that BPT utilizing PCW may be a good option for detecting BHR in young children. It is well tolerated by children, easy and safe to perform. Follow-up studies may clarify the real mean of the PCW.

Sensitization to Blomia tropicalis in patients with asthma and identification of allergen Blo t 5

In tropical and subtropical regions of the world, allergens produced by Blomia tropicalis are an important cause of IgE-mediated sensitization among patients with asthma. We compared the relative importance of sensitization to the two mite species among asthma patients from Florida, Puerto Rico, and Brazil (n = 83), who were concurrently exposed to B. tropicalis and D. pteronyssinus, with patients from the United States and from the United Kingdom (n = 56) exposed to D. pteronyssinus. In addition, molecular cloning techniques were used to clone and express a major B. tropicalis allergen. There were significant differences between IgE antibody responses to B. tropicalis and D. pteronyssinus that were related to exposure: only 22% of patients exposed to both species had a high ratio (> 10) of IgE D. pteronyssinus:B. tropicalis, whereas 68% of patients exposed only to D. pteronyssinus had a ratio of > 10 (p < 0.001). A major 14-kD allergen (Blo t 5), cloned from a B. tropicalis cDNA library, showed 43% sequence homology to D. pteronyssinus Der p 5. Recombinant Blo t 5 produced in E. coli reacted with 45 to 69% of sera from B. tropicalis-allergic asthmatics and induced positive immediate skin tests at 10(-3) to 1 microg/ml. In vivo and in vitro comparisons of IgE responses to B. tropicalis, D. pteronyssinus, rBlo t 5, and rDer p 5, showed that B. tropicalis has unique allergens that cause specific IgE responses. The results suggest that B. tropicalis is an independent cause of sensitization and that use of recombinant Blo t 5 should lead to a better understanding of the role of B. tropicalis in causing asthma in tropical environments.

Lysine-vasopressin in the evaluation of the hypothalamic-pituitary-adrenal axis in children with allergic rhinitis treated with intranasal beclomethasone dipropionate or oral prednisone

One of the complications of steroid therapy is the hypothalamic-pituitary-adrenal (HPA) axis' suppression, particularly in children where this can lead to growth suppression and other well known complications. Although there are a large number of studies on suppression of the HPA axis with the use of topical steroids, the subject is still controversial. We measured the HPA axis function in 3 groups of allergic children treated with: 1) intranasal beclomethasone dipropionate (BDP) 400 micrograms/day for 4 weeks or 2) BDP 800 micrograms/day for 4 weeks and 3) oral prednisone, 1 mg/kg/day for 2 weeks. The HPA response was obtained after lysine-vasopressin (LVP) stimulation. LVP acts on the pituitary or hypothalamus level, stimulating the whole axis. Peripheral blood samples through an intravenous line were obtained for serum cortisol measurement at zero, 30, 60, and 90 minutes after the intravenous injection of LVP, before and after the treatment period. Our results showed no suppression of the HPA axis in children medicated with BDP at either 400 micrograms/day or 800 micrograms/day. On the other hand, there was a suppression of the HPA axis after prednisone treatment (p < 0.05). During the LVP test some side effects, possibly due to systemic vasoconstriction, were noted such as abdominal pain, nausea and vomiting, and transient hypertension. In conclusion, intranasal BDP at the dose of 400 or 800 micrograms/day during 4 weeks did not induce HPA axis suppression. The LVP test is efficient to demonstrate HPA hypofunction or suppression and it produced only mild to moderate transient side effects. However, due to the side effects observed, a safer test such as urinary free cortisol (24 hours), should be used in the investigation of the HPA axis.

Short stature in children with respiratory allergy

We evaluated the prevalence of short stature (SS) among children with respiratory allergic disease followed up in a specialised centre. These patients (N = 617; 8 months to 16 years) with respiratory allergy (asthma and/or rhinitis) were evaluated for SS (stature shorter than the 3rd percentile, NCHS pattern). The possible links between SS and gender; current age; type, severity, and duration of the allergic disease, treatment with corticosteroid and birth weight were also studied. To assess the influence of the socioeconomic level on SS frequency among atopics, 120 of these patients were compared to their non-atopics siblings. The overall prevalence of SS was 7.9%. Relationship between SS and gender type and severity of the allergic disease and treatment with corticosteroids were not observed. A significant higher frequency of SS occurred among patients with longer period of disease and birth weight less than 2,500 gr. Analysis of the pairs of brothers showed significant higher frequency of SS between allergics (12.5% x 4.2%) showing influence of allergic disease per se. Longitudinal studies for long periods of time are required to properly establish the relation between atopic disease and SS.

[Intranasal azelastine in the treatment of perennial allergic rhinitis in children]

Twenty-five patients (5-15 years old) with perennial allergic rhinitis (PAR) for at least one year were treated with intranasal azelastine. The study was conducted in two separate occasions. In the first study, in a special prepared room, the patients underwent Active Anterior Rhinomanometry (AAR). Twenty minutes later, after 2 drops of saline installed in each nostril, the Total Nasal Resistance (TNR) and Total Nasal Conductance (TNC) were measured. This was followed by the intranasal application of azelastine (0.14 mg/nostril ) and the TNR and TNC were measured at 15,30,60,90 and 120 minutes. At the end of this period, a topical vasoconstrictor (fenoxazoline 0.05%) was instilled and TNR and TNC measured after 15 and 30 minutes. The patients were discharged with a prescription of intranasal azelastine, same dose, for 14 days, with diary cards. Clinical evaluation and clinical score were performed at days 3,7 and 14. There were no changes in TNR and TNC after the acute and prolonged (14 days) use of azelastine, which was observed after the use of fenoxazoline. Clinical scores (physician and patient), according to the diary card, were significant for itching and sneezing after 7 days of treatment. Intranasal azelastine is useful for the therapeutic management of PAR, mainly in those for whom nasal blockage is not important.

Non-specific nasal provocation in children with chronic allergic rhinitis

Twenty-three children with chronic allergic rhinitis (Group A) and eleven normal non-atopic subjects (group C) were submitted to non-specific nasal provocation tests with histamine (0.03; 0.06; 0.125; 0.25; 0.5; 1.0; 2.0 and 4.0 mg/ml), and one week later with methacholine (0.025; 0.1; 0.25, 0.5; 1.0; 2.5; 5.0 and 10.0 mg/ml). Measurements of total nasal resistance were performed by active anterior rhinomanometry (Berger, S.A.) and symptoms were recorded. Challenges were carried out in the morning with all children in an acclimatized room (25 degrees C/77 degrees F). Concentrations of the tested drugs were increasingly instilled, and after 5 min were followed by total nasal resistance, FEV, and FVC measurements. Considering as positive those tests in which total nasal resistance had a 100% increase, we observed that both histamine and methacholine caused an increase in total nasal resistance as instilled drug concentration rose; histamine provocations were significantly more positive among group A than group C patients (91% sensitivity, 80.8% positive predictive value). This was not observed with methacholine (55% sensitivity, 75% positive predictive value). In neither provocation was there correlation between the concentration that induced a positive response and symptoms. There were no changes in spirometric values during the tests. Nasal provocations with histamine and methacholine are safe and well tolerated. Histamine seems to be more adequate for differentiating children with allergic rhinitis from normal controls.

[Lupic nephropathy in childhood: morphologic analysis of 18 cases]

Serum IgE concentration was determined in 17 newborn and 171 children with ages between 1 and 12 months. In the first group, blood was taken from the umbilical cord, and in the second, we used a periferic blood sample. The selection implied the exclusion of children with any suspicion of atopic disease, family history of atopy and recent viral infection. The serum IgE concentration was determined by enzyme linked immunoabsorbent assay (PRIST). The sex, race ( white and non white) and age were analyzed in the children studied. During a follow-up period (24 months) seven children (3,7%) developed atopic symptoms. The serum IgE concentration of the groups studied was higher than in other studies. The mean IgE in each group was as follows : newborns = 0.24 IU/ml; 1-3 months = 1.57 IU/ml; 4-6 months = 7.72 IU/ml; 7-9 months 12.07 IU/ml; 10-12 months = 12.14 IU/ml.