Disodium cromoglycate, prednisolone, beclomethasone and salbutamol were administered prior to the cycle ergometer exercise task separately to different groups of children with exercise-induced dual asthmatic reaction. Pre-treatment with disodium cromoglycate of ten asthmatics totally inhibited the dual reaction. Prednisolone treatment of eleven asthmatics and beclomethasone treatment of five asthmatics did not inhibit the early response but only the late response. Salbutamol treatment of ten asthmatics mainly inhibited the early phase reaction. Changes in neutrophil chemotactic activity correlated with airflow limitation in the disodium cromoglycate and prednisolone study, however, there were some discrepancies between the changes in FEV1 and neutrophil chemotactic activity in the beclomethasone and salbutamol studies. These findings suggest that exercise-induced dual asthmatic reaction are modified by disodium cromoglycate, prednisolone, beclomethasone or salbutamol in a mechanism which may be different in each drug and that there are similarities in the inflammatory responses in antigen- and exercise-induced dual asthmatic responses.
Anaphylaxis, the most emergent manifestation of allergy, is best described by its clinical pathologic alterations. Sites of involvement include skin (urticaria), upper respiratory tract (laryngeal edema), lower respiratory tract (bronchospasm), and the cardiovascular system (severe hypotension). Ultrastructural analysis of skin biopsies obtained from individuals experiencing exercise-induced anaphylaxis prior to and immediately after exercise revealed changes indistinguishable from those observed following immunologic challenge of pulmonary mast cells. These alterations included enlargement of the mast cell granules, solubilization (discharge) of mast cell granule contents, merger of the granule membranes with adjacent granule membranes, as well as the mast cell membrane. The successful reversal of anaphylaxis requires the prompt recognition of symptoms and early institution of therapy for anaphylaxis. Patients suffering from exercise-induced anaphylaxis should avoid any foods, drinks, or pharmaceutical agents, particularly acetyl salicylic acid for four and preferably six hours prior to exercise.
Asthma in the elderly may present difficult management problems. We reviewed 46 elderly patients with corticosteroid dependent asthma who have been managed on our ambulatory service for an average of nine years. We present our therapeutic regimens which resulted in better control for the majority of patients. The goals of therapy were control of asthma to prevent status asthmaticus which is potentially fatal asthma. In those patients who did not improve, inability to comply with our regimens was a major factor.
Although a small part of the IgG4 subclass probably can bind to basophils (and mast cells), IgG4 antibodies usually do not behave as anaphylactic antibodies. Therefore, detection of IgG4 antibodies in serum is not a suitable in vitro assay for IgG-S-TS activity. Furthermore, differences between IgG4 and the other IgG subclasses with respect to antibody valency and interaction with the complement system, stress the point that IgG4 takes a special place in the humoral immune response.
The data obtained so far indicate that 1) presence of high titer of IgE antibodies was related with symptoms of egg hypersensitivity, 2) it seems unlikely that increased IgG4 antibody levels against egg white is a cause of egg hypersensitivity, and one should pay much attention to IgG1 antibodies, instead, 3) it is possible that increased IgG4 may reduce the effect of complement-fixing antibodies like IgG1 and/or interfere the action of IgE antibodies.
Inhalation challenge with methacholine is now a standardized procedure using a drug specifically approved for the purpose of determining the nature and extent of airways hyperreactivity. The methodology described involves the intermittent administration of graduated concentrations of methacholine by aerosol inhalation followed by routine spirometry after each incremental dose thereby enabling the construction of a dose response curve. The PD20FEV1, the provocation dose of agonist necessary for a 20% decrease in FEV1, is interpolated from the curve and is the accepted index of airways sensitivity. Clinically, the procedure has been widely used to implement the diagnosis of asthma in such atypical cases as when the physical exam and pulmonary function tests are equivocal. In such a setting, a positive test often justifies the use of therapeutic bronchodilators whereas a negative test would lead the examiner away from the alternative of hyperactive airways. Other applications include the evaluation of antigen sensitivity for diagnostic and research purposes including occupational asthma, epidemiology, and investigational drug trials.
Hymenoptera therapy with honeybee venoms has been practiced for the past ten years. A variety of studies have evaluated the short term effects of this therapy. This study focuses on the long term effects using venom specific IgE and IgG4 determinations. Results from the study indicate that after venom immunotherapy there is a rapid and prolonged rise in specific IgG4. This continues for several years, but after four or five years the specific IgG4 response seems to wane.
This manuscript has attempted to briefly outline the most important areas of clinical impedance audiometry. The author has emphasized the use of impedance audiometry in differentiating different types of middle ear pathology and utilizing the stapedial reflex in the determination of malingering as well as an overall test of the normal function of the auditory nervous system from the inner ear to brain stem. Finally, the use of Eustachian tube function can also be utilized by the trained audiologist in determining whether or not there is Eustachian tube dysfunction. It is important to again emphasize that impedance audiometry is objective and does not involve the cooperation of the patient. Thus in the autistic child and in the child who is uncooperative, it is of particular help to the clinical otologist and audiologist. In patients who are malingering the stapedial reflex may assist in determining a valid response in routine autiometry. Finally, with special types of tests which have not been discussed in this manuscript, such as stapedial reflex decay, one may be able to determine the presence of an early acoustic neurinoma.
IgG4 deficiency can be an isolated phenomenon, or it can occur in combination with deficiencies of IgG2, IgA, and/or IgG1 (in order of decreasing frequency). Isolated deficiency of IgG4 is associated with symptoms and signs which are similar to those associated with other IgG subclass deficiencies. The most common manifestation is an unusual frequency of pyogenic infections, most often of the respiratory tract. There is also an increased frequency of isolated serum IgG4 deficiency in subjects who have recurrent or chronic diarrhea, asthma, adverse reactions to foods, chronic candidiasis, pediatric AIDS, and autoimmune disorders. The mean and normal ranges of serum IgG4 in 400 subjects ages four months to 17 years are given. Diagnostic studies, unique features of IgG4, illustrative case reports and possible mechanisms are discussed.
The U.S. Olympic Team demonstrated a significant prevalence of Exercise-Induced Bronchospasm (EIB) among world-class athletes (11.2). Nearly all sports were involved but endurance events seemed to have the highest prevalence of team members with EIB. Resting pulmonary function studies were poor discriminators of athletes affected with EIB. The 67 athletes of the 597 member team were responsible for winning 41 Olympic medals including 15 golds and 21 silvers, clearly demonstrating their ability to compete and succeed in world-class competitive events. These results should send a strong message to young people that they can strive to excel in sports with proper medication and management.
Chronic nasal symptoms occur commonly in pregnant women. The most frequent causes of rhinitis during pregnancy are allergic rhinitis, bacterial rhinosinusitis and rhinitis medicamentosa. The appropriate diagnosis in the individual pregnant woman can usually be established on the basis of the history, physical examination and nasal cytology. Benefit-risk considerations in the management of gestational rhinitis are discussed in detail.
Following successful immunotherapy estimates of relapse rate ranged from 22% to 42%, depending on method of follow-up. The time to relapse varied with the method of follow-up, indicating that recall may play a major role in the perception of a relapse. How much of the continued well-being of most patients (58% of contacted patients) is due to immunotherapy or the natural history of the illness cannot be ascertained from this study.
A patient who received venom immunotherapy during pregnancy without complications delivered a healthy term infant. Venom-specific IgG antibodies were similar in the mother and infant at birth and then fell to undetectable levels by six months of age. Although the mother had elevated venom-specific IgE levels, they were not detectable in the infant at birth or six months of age. Therefore, venom immunotherapy during pregnancy did not lead to allergic sensitization of this child.
Our studies have revealed that patients with Cystic Fibrosis CF who are infected with P. aeruginosa have grossly elevated serum levels of IgG antibodies to the opsonic immunodeterminant, type-specific LPS. Second, this elevation is distributed among all four IgG subclasses, with a significant shift towards IgG3. Third, sera from colonized CF patients shows diminished opsonic capacity, although complement dependent human neutrophil phagocytosis is not notably impaired. Fourth, functional polyclonal or monoclonal antibody opsonins exhibit prozone inhibition of phagocytosis at high concentrations. Fifth, sera from uninfected CF patients have lower levels and proportions of IgG2 antibodies to P. aeruginosa LPS, and higher levels and proportions of IgG4 antibodies, than normal controls. Finally, levels of IgG4 antibodies, but not IgG1, 2, or 3, correlate inversely with opsonic capacity. We therefore make several speculations. High levels of IgG4 antibodies to opsonic immunodeterminants may inhibit normal pulmonary clearance of P. aeruginosa by alveolar macrophages in vivo. Second, high levels of opsonic antibodies may also contribute to the problem in vivo by the phenomenon of prozone inhibition. Third, reduced levels of IgG2 antibodies in uninfected CF patients raises the intriguing possibility of an wider polysaccharide antigen-related isotype-restricted immunodeficiency, with an attempted compensatory shift to IgG4 doomed to failure.
Eighty pregnancies in 73 gravidas with severe asthma who required inhaled and/or systemic corticosteroids were reported in an attempt to define the effects of asthma and its treatment on the outcome of pregnancy. No maternal deaths occurred. Infants delivered from gravidas who experienced at least one episode of status asthmaticus during gestation had decreased birth weights (p = 0.03) compared with infants delivered from gravidas who did not require emergency therapy or develop status asthmaticus. The data confirm the importance of maintaining gravidas with severe asthma as free from symptoms and signs of asthma as possible.
Exercise-induced anaphylaxis has been recognized with increasing frequency since its original description in 1980. Recent studies suggest food-induced reactions may occur frequently in this syndrome, which is a mast cell-dependent phenomenon. In this article, the clinical manifestations of exercise-induced anaphylaxis are reviewed, and food-related factors contributing to the disorder are considered.
Though exercise-induced asthma (EIA) has been recognized for centuries, its characteristics, standardized testing, and pharmacologic management have been clarified only in the last two decades. Controversy continues concerning etiology; whether or not cold air, hypertonic and hypotonic bronchial challenges involve the same mechanism(s); and the incidence and clinical significance of late phase reactions. Aerosolized adrenergic agents such as albuterol or terbutaline, when administered prior to exercise, are usually effective in preventing EIA. Theophylline varies in effectiveness from subject-to-subject as does cromolyn sodium. Other agents such as H-1 antihistamines, ipratropium bromide, calcium channel blockers and adrenocorticosteroids are less effective when used alone, but may be useful when used in association with the more potent drugs.
