George A. Sprecace M.D., J.D., F.A.C.P. and Allergy Associates of New London, P.C.




(Published in the Feb. 2008 volume, JACI)

  1. Dexamethasone (Decadron) is mentioned in Abstract #3.  This oral and injectible corticosteroid is important as the only such medication (since Celestone – Betamethasone – became unavailable for oral use) which is effective in patients who have become unresponsive (“steroid resistant”) to prednisone and methylprednisolone.  It is especially useful in some of our asthmatic patients. 
  2. The measurement of exhaled Nitric Oxide is finally approaching clinical availability in the evaluation of inflammation in bronchial asthma and chronic bronchitis – asthma variant.  It compares well with other measures of inflammation.  See Abstracts # 123, 292, 605, 612.
  3. Abstract 20 notes a positive correlation found between early onset asthma and adult respiratory status. 
  4. The subject of generalized reactions to allergy immunotherapy injections, although real, is often presented in overwrought fashion.  Abstract # 101 suggests pretreatment with anti-histamines…which I discourage as giving a possibly false sense of security.  Strict adherence to safe protocol results in very rare reactions.  Such reactions are discussed in Abstracts #481 and 549.
  5. Allergic reactions to foods are the subject of numerous abstracts: a) most reactions in children occur in school, not in buses - #106; b) RAST, puncture-prick, intradermal and patch testing are discussed in #400; c) casein-containing chalk may be the reason for increased asthma in milk-allergic children in school - #714; d) one can be allergic to goat and sheep milk without being allergic to cow’s milk - #716; e) the issue of histamine in wine is discussed in #’s 746, 908, and 910; f) cross-reactions between peanut (a legume) and nuts…in addition to the problem of manufacturing proximity…are discussed in #936; g) desentization for milk allergy is discussed in #’s 962 and 982; h) oral desensitization to peanut and milk is discussed in #’s 530,531.
  6. There is an increased risk of invasive pneumococcal disease in the presence of allergic disorders - #122.
  7. The  Atopic March” is alive and well: a) atopic dermatitis is often the firstr step, and its clearing may not alter the march to other allergic manifestations - #126; b) the use of probiotics in infancy seems to lower the occurrence of allergies - #129; c) the potential of Rituximab (anti-CD-20) is discussed in #138; d) exclusive breast feeding for four or more months is protective - #144.
  8. Omalizumab (Xolair) is the topic of several abstracts: a) possible use in insulin allergy - #150; b) in hyper-IgE Syndrome - #341; c) has no effect on T-cell responses - #446; d) reasons to discontinue - #537; e) improves quality of life in asthma - #592; f) is being used in patients with IgE over the currently stipulated maximum of 700 - #845.  This approach to dealing with the underlying cause of atopic allergies (IgE) continues to be a distant second to properly evaluated and implemented allergy immunotherapy.  But at least, finally, asthmatic patients of Pulmonologists are getting some attention to this basic matter. 
  9. Eosinophilic Esophagitis has been re-discovered: a) diagnosis is by biopsy, and correlates well with presenting symptoms = #;s 169, 177; b) dysphagia is a common presenting symptom, often secondary to major motor disturbance of small muscle function - #’s 271,273; c) it may present in various ways - #285; d) these patients should be tested for food sensitivities - #’s 399,400,402.
  10. Concomitant use of nasal decongestants and nasal steroids is discussed in #215.  I discourage this.
  11. Systemic reactions to percutaneous skin testing reportedly occurs in 3.5% of patients, for which the prompt administration of epinephrine is useful - #223.
  12. Subcutaneous IG is a more convenient and also effective mode of administration, as compared with  IVIG - #230.
  13. SSRI anti-depressants do not affect histamine wheal size – 234.
  14. Long-term use of inhaled nasal steroid (over 3-4 years) appears safe in children and adolescents - #235.
  15. Wheezing Rhinovirus infection in early childhood predisposed to later asthma - #’s 240,561.
  16. Known for many years, diesel exhaust exposure has both early and late effects, and increases the likelihood of asthma (think school buses!) - #’s 252,253.
  17. Abstract # 262 discusses protocols for desensitization to retuximab and other chemical agents. 
  18. Sublingual desensitization is experiencing a revival of interest, although I don’t believe it is yet ready for prime time – #’s267, 370, 493. 
  19. Allergy Immunotherapy is very useful in children, although I find it rarely necessary below the age of 5 years - #289.
  20. Genetics in Asthma occurrence and progression are discussed in #297.
  21. Positive ANA is correlated with lack of proper control in asthma - #298.
  22. The use of pulmonary function testing, which I find very useful in determining adequacy of actual – vs clinical – control – is discussed in #311.
  23. Immunodeficiency: a) this should include isolated IgA deficiency - #331; b) CVID is associated with recurrent purulent infections and reduced lung function - #339; c) a new IVIG (Privigen) is discussed in #’s 634,635.
  24. Peanut Sensitivity; a) efforts at rush desensitization (not recommended by me), #’s 370,371,375,528,529,532; b) “may outgrow”, #567; c) associated with increased risk of other food sensitivities, especially if the reactivity is severe - #’s932, 976.
  25. Hereditary Angioneurotic Edema can be treated with replacement of C1-esterase inhibitor (#380) and by use of fresh frozen plasma (#383).
  26. Chronic Urticaria:  a) when associated with autoimmune disease (#396), and b) may be treated with (Xolair), with which I have no experience (#’s 566, 872). 
  27. A form of Lactobacillus, another probiotic, may be useful in decreasing the asthma response - #’s 470,714.
  28. Therapy of asthma: a) remember Cardiac Asthma - #621; b) there is too much use of ICS /LABA therapy vs ICS mono-therapy, leading to increased mortality…a point with which I agree, given the propensity for the development of tolerance to excessive use of beta adrenergic therapy - #’s 551, 596; c) early screening and diagnosis is vital to effective asthma control - #609; d) s-Tryptase in induced sputum is correlated with increase in eosinophiles and with increased severity of asthma - #806; e) HSCRP may be a useful marker for persistent inflammation in asthma, although it does not correlate with exhaled Nitric Oxide of local eosinophile count - #760; f) staphylococcal enterotoxins may play a role in asthma severity - #765.
  29. As we have learned more pointedly in recent years Vitamin D plays an important role in many metabolic functions in addition to bone health.  This is all the more important given the fact that many if not most people are deficient in this vitamin. Abstracts # 555 and 752 note that low levels in patients with bronchial asthma contribute to increased exacerbations and to problems with bone health.
  30. The existence of a “naso-ocular reflex” prompts the use of nasal inhaled steroids for ocular symptoms - #582.
  31. Broncho-thermoplasty” is being studied as a possible treatment for asthma.  But its long-term effects remain unknown - #590.
  32. Inhaled Corticosteroids: a) no growth retardation in children younger than six years, but growth must still be monitored - #602; b) concentrated usage (2X, 4X) during exacerbations reduces symptoms and reduces need for oral steroids - #842; c) indications for reducing or eliminating ICS are discussed in # 844.
  33. Aspirin Sensitivity: a) # 613 describes bronchial and oral challenge tests; b) NSAID reactivity is becoming increasingly common - #727; c) aspirin desensitization is described in # 737; d) extra-respiratory reactions are discussed in #747.
  34. Regarding Pneumovax, pre-immunization antibody level reduces response, but does not eliminate it.
  35. Sarcoidosis: those patients with elevated IgE are improved on Xolair - #668, probably reflecting combined disease with bronchial asthma.
  36. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis are very serious systemic diseases, usually caused by drug reactions, especially anti-epileptic medications - #’s 724,733,743.
  37. For Penicillin testing, both major and minor determinant materials may be available from Kaiser-Permanente in California - #740.
  38. Abstract #750 suggests reasons for an OPD Allergy consultation.  Tell that especially to the pediatricians.
  39. Myelitis with atopic diathesis may be caused by infection with Toxicara - #782
  40. Cross-reaction among latex, tobacco and other related species is described in # 857.
  41. According to #’s 923 and 925, egg-allergic patients can tolerate influenza vaccine without ill effect, even when given in a single dose.  (?).


Xolair (omalizumab)
Hereditary angioedema



MARCH 3-7, 2006

2) "The high prevalence of sub-clinical asthma ... supports the soundness of recommendations to evaluate allergic rhinitis patients for asthma". It has been estimated that 40% of patients presenting with allergic rhinitis have or will develop bronchial asthma.

3) Asthmatic children are not well able to recognize reductions in lung function and therefore do not appropriately use Albuterol. Therefore, objective measures should be used in children, such as peak expiratory flow measurements.

4) Vascular Endothelial Growth Factor (VEGF) is highly expressed in the airway of asthmatic child patients and is responsible for increase bronchial hyper-reactivity.

13) Exercise-induced bronchospasm is found to a greater degree in obese adolescents.

32) Other abstracts provide evidence that omalizumab (Xolair) is effective in use in moderately to severely affected asthmatics. It is also reportedly useful as an add-on treatment to concurrent allergy immunotherapy. Approximately two thirds of patients respond to Xolair therapy.

40) However, anaphylaxis to Xolair can occur even after prolonged successful treatment has been in effect.

43) Adult height in children treated with inhaled Budesonide is reached markedly later than in healthy children. This has been noted before, namely that children using inhaled corticosteroid have a delay in their growth but no total reduction in their growth.

76) Anti-TNF agents have revolutionized the treatment of some arthritis. However, it can be associated with side effects including endocarditis. This has been found to more likely to occur in patients with preexisting high titer ANA.

91) Formaldehyde, a widespread domestic indoor pollutant, has been shown to increase the risk of childhood asthma through a significant increase in bronchial hyper-reactivity.

98) A form of occupational asthma caused by styrene in an auto body shop is reported.

99) Clarinettist's Cheilitis is reported due to allergic reaction to the cane reed.
118) Reports cases of lady bug hyper sensitivity among residence of homes infested with lady bugs.

127) Cross-reactivity was noted among almond, peanut and other tree nuts, possibly extending to sunflower, pine nut, walnut and pecan. Therefore, any patient allergic to peanut or to a tree nut should essentially eliminate intake of nuts in general, partly because of the common production facilities for packaging of these nuts and also peanuts. Peanut allergy associated with high household exposure to peanut in infancy is reported in abstract 140. The message here is to delay an infants exposure to peanut for a long time. However, no special effect of maternal consumption during pregnancy or lactation was observed.

145) We learn that sesame may be the "Middle Eastern peanut, since it is an essential nutrient of the Middle East diet and can be responsible for serious allergic reactions.

158) We learn that approximately 25% of children with cow's milk allergy tend to outgrow their allergy by the age of ten years.

166) We are reminded that most food anaphylactic reactions are due to "hidden" allergens. Milk is the most common allergen among children and can be encountered as casein in many foods.

183) Immediate allergic reactions after ingestion of cooked mushrooms correlate the finding of reaction between mushrooms and some molds, particularly alternaria.
190) Reports cases of scurvy associated with oral allergy syndrome resulting from elimination of the related important foods from the diet. Therefore, vitamin C supplementation is required.

222) Reports that patients with nasal and pulmonary allergic symptoms should be questioned about gastrointestinal symptoms, since there is an association in children with eosinophilic esophagitis .

239) Is important since it looks at the possible relationship of tumor necrosis factor and severe asthma. TNF-alpha can induce both accumulation and activation of neutrophiles and eosinophils. It has been found to be increased in the airways of severe asthma.

304) We are reminded that infantile eczema is a predictor of asthma in pre-school children. However, it is not associated with asthma severity.

330) We learn that breast feeding for at least twelve weeks and the absence of being overweight appeared to play synergistic roles in asthma protection.

33l) We learn that elevated body mass index at age three predicts wheezing at age five independent of wheezing earlier in life. Thus, the increasing evidence of relationship between obesity and asthma.

339) Early life exposure to maternal stress is associated with development of asthma.

Several abstracts discuss the affect of sublingual immunotherapy. The reports are conflicting; and generally this is not yet accepted.

350) We are reminded that close self monitoring of asthma symptoms with peak expiratory flow meter increases children's awareness of their disease status, leading to earlier intervention to avert asthma episodes.

371) Reminds us of a serious complication of chronic steroid treatment; that is, steroid myopathy. In the case presented, the manifestation was restrictive lung disease.

376) Reminds us that stable asthma should be associated with gradual reduction in inhaled corticosteroid use. This of course should be monitored with pulmonary function tests before and after bronchodilator, to unmask possible occult bronchospasm.

425) Reports the clinical syndrome of specific antibody deficiency (SAD) in children, an immune deficiency characterized by normal immunoglobulin levels and antibody responses to protein antigens, but impaired antibody responses to polysaccharide antigens. It is fairly commonwith a prevalence of 15% in children with recurrent infection without another defined immune deficiency. It is also associated with allergic disease, which suggests that it may be part of a more general disorder of immune regulation.

478) In abstract 478 we learn sulfasalazine medication, usually used for ulcerative colitis, is beneficial in the treatment of recalcitrant chronic idiopathic urticaria.

479) In abstract 479 we review hereditary angioedema. The typical symptoms include abdominal attack (occurring in 97% of the patients) and also skin swellings including extremity, facial, genital and trunk. Treatment for this condition continues to include long-term andrigen therapy, which appears to be safe.

489) We review mastocytosis syndrome, which can be localized cutaneous or progress to systemic forms.
508) We learn of adverse reactions to orthodontic appliances in nickel-allergic patients.

523) Reports delayed anaphylactic reaction to immunotherapy injection, delayed for over two hours and requiring abundant immediate epinephrine for resolution.

536) According to this abstract, there may be a direct association between RSV infection and patients with family or person history of atopy.

576) We find another use for Singular; namely, refractory vulvovaginal pain and itch. Singular significantly improved these symptoms.

602) Reports that a history of paternal asthma and allergy appears to confer an increased risk for allergic sensitization in pre-school children to a greater extent than similar maternal histories.

603) We learn that asthma symptoms under two years of age are much more common following birth Meconium Aspiration Syndrome.

647) We learn that nasal corticoid steroids reduce adenoidal size in children with allergic rhinitis.

756) Reports on the safety of continuous high dose nebulized levalbuterol in children with severe bronchial asthma. In this studv, potassium. glucose and heart rate were followed in comparison with racemic Albuterol.

800) Reports that in one per cent of patients receiving influenza vaccine. significant chest pain occurred as a side effect.

859) Is the first report in the English literature of a case of anaphylaxis to topical benzocaine.

866) Reports that the use of beta blockers does not affect the performance of penicillin skin testing. The issue of concomitant beta blocker use and skin testing and allergy immunotherapy is a relative contraindication and not a strong one in our experience.

884) Describes serum sickness-like reactions following placement of sirolimus-eluting stents.

885) Describes contact allergic reaction to inhaled budesonide, but not to other inhaled steroids.

919) Describes something that we have recognized for decades; that is, the classification between IgE and non IgE mediated atopic dermatitis. These are two separate conditions carrying the same name. They must be distinguished for proper diagnoses and treatment.

927) Describes contact dermatitis to lanolin masquerading as chronic dyshydrosis eczema.

957) Reports no.n-immediate reaction to iodine contrast media.

979) Gives more evidence for the important association between diesel fuel exposure and the development of allergy, since this exposure favors Th2 cell recruitment.  It will be recalled that the hygiene hypothesis, involving early exposure to infections and other endotoxin-containing agents, works to push Th2 cell reactions toward Thl cell reactions, thereby reducing the incidence of atopic allergy.

982) Describes the importance of cytokines in allergic inflammation, particularly IL-5 and IL-13.

986) Reports that IL-13 is particularly a critical mediator of allergic inflammation and therefore may be a target for therapeutic intervention.

1000) Reports on the issue of exposure to mercury in fish, in vaccines and possibly in dental amalgam, and its relationship to TH-2 driven autoimmune disorders.

1009) Benzalkonium chloride as a preservative in saline nasal sprays impairs nasal mucociliary clearance. "Due to development of modern delivery devices, it is obsolete to use this preservative in nasal solutions." We should remember this.

1021) We have some de ja vu wherein the report is that the immunologic effect of specific immunotherapy includes stimulation of the allergen-specific TH-1 response and induction of an allergen specific non-IgE antibody response, primarily characterized by IgG4. This is something that those of us who have been trained in the field have known for many decades.

1024) Reports on ths safety of allergic immunotherapy in systemic lupus erythematosus.

1062) Reports that children that undergo adenoidectomy and tonsillectomy are likely to experience a significant improvement in their asthma symptoms.

1068) Reports on the use of macrolide antibiotics in the management of asthma since these antibiotics have known anti inflammatory properties in addition to their known antimicrobial activity.

1137) Reports the positive impact of breast feeding for at least 8 months in protecting from and reducing the prevalence of allergic disorders.

1146) Reports a patient who developed allergic rhinitis and asthma due to manipulation of wax moths as part of sport fishing.

1147) Reports that the prevalence of atopy is higher in obstructive apnea syndrome in children.

1149) Reports paralytic shell fish poisoning caused by ingestion of associated toxins and algae the west coast of Florida, including red tide blooms. The differential diagnoses here includes pufferfish and organophosphate poisoning.

1163) Reports regarding oral allergy syndrome wherein isolated symptoms are most commonly due to melon.  However, systemic reactions are more commonly due to peach.

1164) Reports a high prevalence of sensitization to tomato although most sensitized subjects are asymptomatic. There are a number of abstracts involving eosinophil esophagitis.

1176) Reports on the relatively mediocre treatment of anaphylaxis in emergency rooms, mainly due to the under-use of epinephrine and epi-pens. In fact, abstract 1178 recommends the availability of two epi-pens to treat properly acute severe allergic reactions.

1182) Reports a priming mechanism with regard to the development of insect sting anaphylaxis, either associated with prior sting or with skin testing. There are a number of abstracts discussing venom immunotherapy.

1196) Reports bed bug bites as a basis for chronic urticaria.

More next year...


PEARLS from Abstracts of papers to be presented March 18-22, 2005 at the annual meeting of the American Academy of Allergy, Asthma and Immunology.
(Published in the Journal of Allergy and Clinical Immunology, Vol. 115, No. 2, Feb. 2005)

  1. Heparin inhalation inhibits mast cell activation and may be useful as low molecular weight heparin as add-on treatment for bronchial asthma.
  2. Astelin is clinically useful as a nasal spray, similar to intra-nasal steroids.
  3. Effective inhalation drug delivery for children: blow-by with extension tube is cimilar to close-full mask, and is better tolerated by young children.
  4. "Singular is better than theophyllin in asthma".  Maybe, but at least additive.
  5. There are patients with irreversible asthma despite all treatment.  Efforts are being made to identify this cohort of patients early.
  6. Cockroach allergy is very important, especially in urban communities.
  7. Some children fail to respond immunologically to Pneumovax.   ??
  8. IVIG preparations canbe given safely sub-cutaneously, with monitoring.  This is especially useful in patients who develop recurring troublesome reactions from the IV route.
  9. Job's Syndrome often includes also skeletal abnormalities.
  10. Mold contamination (especially toxic molds like stachybotyrum chartarum) is becoming ever-more important...not only in homes and in the work-place but also in autos.
  11. Latex allergy substantially reduces in an individual with avoidance.  Also, cutaneous latex allergy can evolve...sometimes suddenly...into serious asthma.
  12. Respiratory reactions have been detected from exposure to colophony and to the gasoline additive MBTS.
  13. Allergic reactions are reported to many agents (eg. hops, beer, wheat....)  Just assume that anything, including cortisone, can be allergenic.
  14. Allergy to the important drug methytrexate can be reduced with desensitization procedures.
  15. There is cross-reactivity between beta-methasone and dexamethasone.  So that's why dexa-methasone is a fair substitute for celestone in patients who are otherwise steroid-resistant.
  16. Alcohol-related eruptions from tacrolimus are reported.
  17. In "penicillin-allergics", there is a low risk of allergy reaction to 2nd generation cephalosporins like cefuroxime.
  18. Rapid desensitization is possible for allergy to TMP-SMX used for HIV infection.  "Easy and safe".
  19. Regarding the question of stinging insect venom immunotherapy in response to large local reactions, the authors report a 10% incidence of progression to generalized reaction.  ??
  20. The drug allergy history reported for hospitalized patients is often incomplete and innacurate.  Beware.
  21. Interferon alpha is being used in treatment of systemic mastocytosis.
  22. One interesting report suggests that the likelihood of later sensitivity to outdoor aero-allergens may be related to month of birth.  The observation suggests that contact with pollen allergens in the first six months of life may sensitize the infant.  In the Northeast, the tree pollen season extends from early April through May.  The grass season extends from later May through mid-July.  The ragweed season extends from later August through early October.  The mold season extends from March through November, with peaks between August and November.
  23. Even in a soy allergic person, soybean oil is reported to be not allergenic.
  24. Here's a peculiar one (abstract #388).  Researchers in San Francisco report a "Creative Syndrome": ..."artistically creative atopic individuals demonstrated more severe and more frequent Total IgE Deficiency (less than 21 IU/ml) compared to the control group of atopic non-creative patients".  From this they suggest extra-immunologic function for IgE.  ??
  25. One abstract found no correlation between the findings of clinical history and skin testing, one the one hand, and total and specific IgE.  The authors suggest that using the former parameters is enough.  Of course, that is what most of us do most of the time.
  26. Regarding peanut allergy: the sensitivity may not resolve; if it does resolve, it may recur; it is difficult to avoid completely exposure everywhere; Epi-pen should be carried at all times; roasting and boiling enhances the allergenic properties of peanuts.  Therefore, Beware!
  27. In abstract #560 we learn that there may be a connection between alopecia areata and very high eosinophile count; that eosinophiles are activated by necrotic epithelial cells; and that eosinophiles can be activated directly by aero-allergens.
  28. Sodium Hypochlorite solution (2.4%) is useful for cleaning moldy areas.
  29. In abstract #619 we learn that patients sensitive to anti-microbial sulfonamides can generally tolerate non-antimicrobial solfonamides like sulfonureas, diazide and loop diuretics, carbonic anhydrase inhibitors, celebrex and dapsone.
  30. NSAID sensitivity generally does not involve Cox-2 inhibitors like celebrex and vioxx.  However, there is cross-reactivity in 10% of cases.  Therefore, careful challenge testing is appropriate.
  31. There was found to be a 56% incidence of exercise-induced bronchospasm in recreational road-runners.  This seems quite high, but may be explained by the fact that EIB can be overcome often by "running through it".  Of course, that could be risky.  Thus the need for awareness, possible pre-medication, and the availability of a rescue inhaler (albuterol) in such individuals.
  32. The effect of paranasal sinus surgery on maxillary sinus mucosal function is slow and partial. Such surgery, including intra-nasal surgery, should generally follow - and often may be obviated by- proper allergy evaluation and comprehensive treatment.  This is true for children as well as for adults.
  33. See abstract #714 for a discussion of "Hyper-IgD Syndrome".
  34. Viteligo is an auto-immune process.
  35. In Stevens-Johnson Syndrome, IVIG may be useful.
  36. A new, potent, selective PDE4 inhibitor, Roflumilast, holds promise as another anti-inflamatory agent in the treatment of bronchial asthma (see abstracts #773,780,784,and 785).
  37. As part of the "Hygiene Theory", early life exposure to sources of endotoxin may protect against allergic later in life.  As noted in abstract #812, this appears to be true also for eczema (atopic dermatitis).
  38. There is ample evidence of under-utilization of Epi-Pen in appropriate circumstances by parents and teachers.  This is unfortunate and dangerous.
  39. It is suggested that gender-based Epi-Pens may have to be marketed, in view of the finding that the generally greater depth of sub-cutaneous tissue in women makes the desired intra-muscular administration of the epinephrine more difficult.
  40. IgE level tested shortly after an episode of anaphylaxis may be falsly deminished or negative.
  41. Swimming in lakes has produced anaphylaxis secondary to allergy to algae.
  42. Abstract #857 is an important report on "Idiopathic Anaphylaxis", a distressing and recurrent event for patient and physician alike.  One ray of hope: "Episodes decline over time in severity and frequency".
  43. Pectin used during barium enema procedure may produce anaphylaxis.
  44. Intra-operative anaphylaxis my rersult from latex sensitivity.
  45. Specialty care is more effecive and cost-effective than that provided by family physicians and pediatricians.
  46. Abstract #935 describes bi-phasic anaphylaxis, occurring in nearly 20% of cases, and within 10-38 hours.  In these patients, time to resolution of initial episode was significantly longer; and they generally received less epinephrine and corticosteroids. Thus, the issue of hospitalization should always be considered, as well as sufficient discharge instructions.
  47. Abstract #936 emphasizes the importance of the intra-muscular route for epinephrine in the treatment of anaphylaxis.
  48. "Promising" studies are underway of a sub-lingual epinephrine product.
  49. The occurrence of RS virus infection early in life increases both the incidence of asthma and of Th2 mediated allergic disorders later in life.
  50. A condition new to me is described in abstract #978:"Exercise Induced Laryngeal Prolapse in Elite Athletes - 'Curable Asthma'"
  51. Beta blockers may be used judiciously for congestive heart failure in patients with bronchial asthma or COPD.
  52. Beware sudden-onset near-fatal or fatal asthma.  Abstract #1048.  One circumstance where this can occur is in an aspirin-sensitive asthmatic.
  53. Cancer Chemotherapy anaphylaxis (or anaphylactoid reaction) is being reported with some increased frequency. Abstract #1131 notes that this reaction may not be IgE mediated and is not prevented by conventional prophylaxis.
  54. Abstract #1155 describes one approach to the vexing problem of "Multiple Drug Allergy Syndrome".
  55. Abstract # 1215 discusses the possible role of IgA in allergic airway disease.
  56. Abstract #1240 discusses the possible non-psychogenic, immunologic role of Lexapro in the treatment of atopic dermatitis.
  57. Abstract #1241 discusses the use of Efalizumab (a humanized monoclonal IgG1 antibody in moderate to severe plaque psoriasis.
In addition, both allergists and pulmonologists are beginning to use Xolair with somewhat greater frequency for bronchial asthma.  This is an especially positive development for asthmatics followed exclusively by those pulmonologists who through the decades have stubbornly refused to provide their patients with the clear benefits of allergy immunotherapy.   At least now their IgE mediated disease process will finally be addressed.


The latest pearls from Allergy Abstracts, 2003

The following are "pearls" extracted from the 2003 Year Book of Allergy, Asthma, And Clinical Immunology (Mosby), a yearly feature of this web site.  Please see also earlier year book offerings in this section.  These are the main themes for the last year.  Where appropriate, this information is augmented by the clinical experience of the undersigned, gleaned from over 46 years of medical practice...and counting.

The continuing message here, from yours truly, is to be evaluated and treated by a certified allergist for most of the above diseases.  Only in that way can you be sure of comprehensive evaluation and treatment.  It's not that complicated.  It's just that too many pediatricians, family practice physicians, general internists, and pulmonologists have for 40 years been unwilling or unable to learn the relevant facts and approaches. It is always better to work to interrupt causes than to try to modify effects.

The latest pearls from Allergy Abstracts, 2003,
The Journal of Allergy and Clinical Immunology, Vol. 111, No.2, February 2003.

This year's crop of Allergy Abstracts - and the forthcoming  research papers in the JACI - break some new ground and contain some clinically applicable advances to the treatment of allergies, bronchial asthma and related diseases.  The following are subject areas and brief pearls which will require a deeper dive to obtain real benefit regarding areas of personal interest.

In addition to the above, the following "pearls" are offered from further personal experience (over 40 years in practice in this field - and counting):
  1. The tablet forms of plain Robitussin - type mucolytics, such as Duratuss G (1,200 mg. twice a day) and Humibid LA (twice a day) are useful in the ancillary treatment of bronchitis, asthma and URI - sinusitis.
  2. Added to the many useful effects of Theophyllin agents (bronchodilator, mucolytic, cardiotonic, ciliary stimulant, diaphgramatic musculotonic) can now be added anti-inflamatory agent,  through now well-defined immunologic mechanisms.
  3. Eye drop use such as Ketotifen may now improve also nasal allergic symptoms, through the lachyrmal duct connection.
  4. Allergic Rhinitis and large-tonsil-associated Obstructive Sleep Apnea in children can be confused with ADHD, a very unhelpful error on several levels.
  5. Substantial chronic airway inflamation in the young (ie. chronic sinusitis even in the first few years of life) is now being increasingly recognized.
  6. Mast cell-derived chemicals like histamine are associated with late as well as early-phase inflamatory-allergic reactions.  Thus the importance of reducing and even eliminating the release of these chemicals in the first place by means of properly applied allergy immunotherapy.
  7. Serum Tryptase levels can be auseful marker for suspected allergic reactions.  In fact, elevated serum tryptase levels have been detected in infant deaths diagnosed as SIDS.


The above developments, expanded minute by minute throughout the scientific world, represent one of the reasons why some of us are “hooked” to our chosen field.  This also represents the reason why we call what we do the “Practice of Medicine”: we’re always practicing!



The following represent my “take” on the Year 2002 research and clinical offerings previewed for the March,  2002 annual meeting of the American Academy of Allergy, Asthma and Immunology  held in New York City.  These notes are derived from over 1,100 abstracts recently published in the Journal of Allergy amd Clinical Immunology, January 2002.

This seems to be a year of building upon previous break-throughs, with a few developments new to me.  The disease of the decade continues to be Bronchial Asthma, still the most underestimated and undertreated serious disease in America, except perhaps for high blood pressure.  This is a real shame, for there is no lack of scientific insights or of therapeutic modalities for both of these potential killers.  There is still an embarrassing and risky lack of implementation on the part of many physicians, and a devil-may-care attitude on the part of many people.

The numbers which accompany each personal commentary refer to the related abstract(s).  Many if not most of the abstracts will be published as complete articles during  the coming months in the Journal of Allergy and Clinical Immunology.

1)  Aspirin / NSAID-Induced Asthma (#50,220):

Contrary to decades - old clinical impressions, aspirin - induced asthma commonly is associated with underlying allergic (atopic) tendencies.  Such patients should thus be fully evaluated.  Potential reactions fall into two categories, although not totally separate: urticarial / angioedema reactions; and severe (or suddenly lethal) asthmatic reactions.  Aspirin desensitization under controlled circumstances is not only possible, but is also useful in achieving better control (through subsequent constant aspirin dosage) of both asthma and rhino-sinusitis.
2) Heparin (#65,66,430,431):
Heparin is an agent generally used as an anti-coagulant.  It has several other pharmacologic properties which may find clinical utility.  One of these is its anti-inflamatory property which, when applied by inhalation has been reported to reduce both early and late phase asthmatic reactions.  On the other hand, heparin is highly antigenic.  This, in addition to the well-known side-effect of thrombocytopenia,  it may produce acute allergic reactions.  Immediate and delayed-type skin testing may be useful in evaluating this problem.
3) Diesel Exhaust (#75,468):
It has been known for years that, in addition to being generally noxious, diesel fumes contain chemicals which increase the level of IgE (the allergic antibody) in humans.  Such exposure also favors the development of Th2 - type immune responses.  Both actions provide the conditions necessary to produce allergic reactions and may be an important reason for the epidemic of asthma in the western world during the last two decades.  In fact, the particular preponderance of bronchial asthma in children of inner cities may well be related to the inordinate amount of time school - age children spend on school buses with diesel engines running, estimated to be about 180 hours per year.  Local and state agencies are beginning to address the issue of school bus engine practices.
4) The Hygiene Theory (#80):
This theory is based upon numerous observations  noting  an inverse relationship between exposure to air pollutants and/or number of respiratory tract infections on the one hand, and the incidence of allergies.  The immunologic effect associated with this connection is the tendency for infections to stimulate the immune system from Th2 reactions (favoring allergic disorders) to Th1 activity.  Although the connection is very likely valid, a few reports have tended to confound the lessons to be learned from these experiments of Nature.  One study, referenced here, suggests that allergic tendencies might protect against respiratory tract infections.  Other studies suggest that having a pet in the house might be of benefit to allergic individuals.  Both of these suggestions fly in the face of broad clinical experience that relates allergies to increased frequency and severity of infections, and that associates prolonged exposure to dogs and cats in the home environment with almost inevitable sensitization and worsening of the allergic manifestations.  (If chronic urticaria is the bane of allergists’ existence, CATS especially are their cross.  Might CATS  really be the first aliens to arrive on this planet, preparing to take over the world??)  Indeed, the preponderance of evidence for the Hygiene Theory and related research seem to support the decades-long  use by some allergists - myself included - of  “stock bacterial vaccine”  especially in children as a useful adjunct to reducing asthmatic responses to respiratory tract infections.  It has always been suspected that its effectiveness was probably due to the endotoxin content of the vaccine (#96,104,580,611).  This product is no longer available because of “lack of proof of efficacy”.  Too bad...but that may change as this question is necessarily revisited by researchers and by the FDA.
5) Bronchial Asthma (#86,511,514,792,1099,1100):
Severe bronchial asthma, often steroid-resistant, is the subject of many studies.  The “Tenor Study”, as established, is positioned to provide much epidemiologic and longitudinal information, perhaps similar to the Framingham Study.  The Denver Study describes troublesome evidence that - despite all the therapeutic modalities in use - loss of lung function and often loss of steroid responsiveness continue, especially in asthma dating from childhood.  In my opinion, this unfortunate situation is due to at least three factors: a) the lack of compliance by most physicians - who should know better - with the numerous treatment protocols clearly established for the proper treatment of bronchial asthma; b) although controversial, developing evidence that prolonged use of inhaled steroids may actually contribute to “re-modeling” - scarring of lung tissue; c) the tendency of many people to underestimate the severity of their asthma; d) the continuing failure of most physicians, pulmonologists and even some timid allergists to implement the clear theoretical and abundant evidence-based knowledge supporting the use of immunomodulation - in the form of specific high-dose allergy immunotherapy - to eliminate the causes of the asthmatic disease process, rather than pursuing its effects.  The proper approach to bronchial asthma is a complete medical and allergy evaluation by a certified allergist (since no one else seems able or willing to do it right).  The proper treatment is comprehensive, including environmental control, absolute cessation of smoking, expert use of the multiple medications readily available and - where unavoidable allergenic agents are detected - allergy immunotherapy to reduce or eliminate the patient’s reactivity to such agents.  Using this approach, the vast majority of asthmatics (85%+)  can achieve at least stabilization and very often reversal of their disease process, with the ability to discontinue the immunotherapy after a few years.   This has been my experience over the last 40 years, dealing with a practice predominating in bronchial asthma, adult and pediatric.  The message here for patients is clear:
“Caveat emptor...Let the Buyer Beware!”
6)  Sick Building Syndrome - Related to Multiple Chemical Sensitivity Syndrome? (#105):
Nothing like adding an enigma to a puzzle.  But the author is probably right.  Both conditions exist and may be interrelated, despite our inability to clearly define their mechanisms.  That’s why we call this the “Practice of Medicine”...we never get it quite right!
7)  Indoor Air Quality and Vacuum Cleaners (#114, 121, 1118):
This appears to be a victory for HEPA - type air cleaners of adequate air-handling size over fancy vacuum cleaners, if one or the other must be chosen.
8)  Leukotriene Receptor Inhibitors (particularly Montelucast - Singulair) - Other Uses Besides in Bronchial Asthma (#131,281, 415, 472, 507, 738):
Although by no means as great a break-through as were the antihistamines which came on the scene around 1950, the anti-leukotrienes (Accolate, Singulair) are important.  They are agents which block the pro-inflamatory actions of leukotrienes, products of white blood cells involved in the defenses and immune mechanisms of the body.  Clinically, the best of the three appears to be singulair (montelukast); and it has found wide application in the comprehensive treatment of bronchial asthma.  Since this chemical also has bronchodilator properties, it is also under study as an intravenous medication for emergency use in acute asthma.
The above references describe other uses being studied for this class of medications:
  1. Reduction of pain and itching from local reactions to allergy limmunotherapy.  Rarely, a patient may experience recurrent delayed (12-24 hour) indurated local reactions which interfere with compliance and with progression of treatment.  Singulair, 10 mg., taken two hours before injections may be useful here.
  2. Treatment of nasal polyposis, an inflamatory condition often associated with, but distinct from,  nasal allergy.
  3. Treatment of “Samter Syndrome”: asthma, nasal polyposis and aspirin/NSAID intolerance.
  4. Pre-treatment for aspirin/NSAID intolerance manifesting as hives and angioedema.  This, however, is not to be tried (other than possibly in association with aspirin desensitization)  when the sensitivity has manifested as acute asthma.  Such a reaction can be quickly fatal.  (See item 1, above).
  5. Possible utility, not yet established, for atopic dermatitis (“infantile eczema”).
  6. Reduction of exercise-induced asthma.
9)  Other Allergies: What you don’t suspect can hurt you.  Ref.#197,425,430,431,432,435,438,639,650,661,714,929,952,954):
Copper, Hepatitis -B Vaccine, heparin, beta-methasone (celestone), omeprazole (prilosec), parabens (widely used preservatives), sesame and pistachio (often hidden in sauces), nicklel (possibly also in foods;eg. vegetables),  pine nut (often added to sauces and vegetables), gummi-bears, menthol - peppermint oil - mint (included in toothpastes). Epi-Pen should be part of the daily attire of any person (without high blood pressure) who has or strongly suspects food and/or medicine allergies.
10) Mastocytosis (Ref. #202):
This is a condition characterized by an excess number of mast cells in the body (in skin and/or in mast cell tumors), the major source of histamine and other chemicals that can produce allergic reactions or allergic-looking reactions.  It can be an occult cause of anaphylactic reaction.  It can be detected fairly easily with a blood and/or urine test, and occasionally with a biopsy.
11) The Allergic Rhinitis...Asthma Connection. (Ref. #239):
Numerous studies have shown that allergic rhinitis (hay fever with or without ”sinus trouble”) is often a precursor to the development of bronchial asthma, a sequence which can be avoided by treating the allergic rhinitis with specific allergy immunotherapy.
12) Allergy to Penicillin (Ref. #251,419,420):
Many more people carry a history of “allergy to penicillin” than are actually allergic to penicillin.  This is not to minimize in any way the central role of the medical history in making treatment decisions about the use of penicillin and related antibiotics.  However, where circumstances warrant  a more definitive diagnosis with direct effect on the choice among limited antibiotics, skin testing is very useful and dependable.  It can reduce the use of more high-tech antibiotics and thus reduce the development of resistance to these important agents, for which there are sometimes no substitutes.
13) GERD and Allergies: Not only an association, but also a causal relationship? (Ref.#269):
Dyspepsia may be just another manifestation, reflecting similar tissue changes, of allergic reactions in some patients.  Certainly, the frequency of such symptoms is increased over normal levels in patients with asthma as well as in those with allergic rhinitis and atopic dermatitis.  In any case, such symptoms should be treated aggressively, primarily with proton pump inhibitors (prilosec, prevacid, nexium, aciphex),  because lower esophageal acidity can produce reflex bronchospasm; and actual regurgitation can substantially complicate both upper and lower respiratory tract disease.
14) Steroid Oral And Nasal Inhalers: (Ref # 282, 543, 734, 770):
Budesonide (Pulmocort) has emerged as a prerferred agent.  Meanwhile, the side effects in children appear to be overestimated, leading to the under-use of budesonide and other inhaled steroids.  And the potential steroid side-effects in adults (such as osteoporosis and adrenal insufficiency) appear to be underestimated.
Prudent use is the message here.
15) Chronic Urticaria: The Pain and Bane Of  Allergists’ Existence.  (Ref.# 355, 357, 358, 360, 363, 365):
Here is another area where we constantly “practice” Medicine: we never get it right!
These articles again point out the frequent association between  “chronic” hives (6 or more months duration) and auto-immune diseases and auto-antibodies (expecially anti-thyroid and ANA antibodies).  Other associations discussed include insulin (definite) land H. pylori (uncertain).  The prolonged use of sulfadiazine (6 weeks) is also suggested  (#365) as a treatment for chronic urticaria of unknown cause.  This would be in line with the fact that “hives” can be the body’s response to allergens (eg. foods), infections (eg. urinary tract or dental infections, hepatitis, etc.), or to a malignancy.
16) ACE Inhibitors / Angioedema Connection. (Ref.#370, 428)

17) Acquired C1 Esterase Inhibitor Deficiency and  Underlying Lymphoma (Ref.#374)

18) Facial Edema can represent subcutaneous emphysema resulting from micro-perforation of the bowel during Colonoscopy!  (Ref. #375)

19) Tylenol Cross-Reactivity With Aspirin / NSAID Sensitivity.  (Ref.#412, 413, 416):

This is real, but the greater dangers  from tylenol  are overuse, leading liver toxicity, and deliberate overdosage - with likely fatal consequences if not treated promply.
20) Anti-IgE (Omalizumab)  (Ref.#458, 460):
This agent, still in clinical trials, will very likely be an effective addition to our  treatment modalities.  But, is this another “anti-”drug  rather than an effort to reverse  the underlying immunologic mechanism through specific immunotherapy?  I think so.
21) Tacrolimus (Protopic) (Ref.#470,471,1089):
This is the newest non-steroidal topical agent for moderate to severe eczema, and appears to be a real addition to available therapies.  If this doesn’t work,  the authors suggest a really big gun: cyclosporine.
22) IV-Ig:  The Black Box Of The 1990’s (Ref #555):
Intravenous gammaglobulin is used as replacement therapy in immunoglobulin deficiency states.  It has also been used in recent years to treat an increasing number of pathologic conditions of ill-defined cause through an ill-defined mechanism generally assumed to be immunomodulation.  And it works many times!
The treatment is, however, somewhat laborious to administer; and it carries a small risk of side effects, including the possibility of anaphylactic - type reaction.  The above reference describes the sub-cutaneous administration of Ig, avoiding the inconvenience and  the side-effects with reportedly better trough levels.  This is worth checking out if you are in that arena.
23) Latex Allergy (Ref.#785, 873,1033):
A little more information.
24) Epinephrine (Ref.#788):
We may soon have a sub-lingual epinephrine for use in acute allergic reactions, instead of the Epi-pen self injectors.  Stay tuned.
25) Gluten Intolerance (Celiac Syndrome) and Wheat Intolerance (Ref.#932,933):
Avoiding gluten in foods is more difficult than might be expected for patients so afflicted.  It is, of course, the entire basis for their treatment and is thus highly important.
26) Anti-Histamines and Skin Testing (Ref.#805):
Skin testing, (particularly intradermal skin testing, acknowledged as the gold standard), is very important, second only to a carefully taken medical and allergy history in the diagnosis of allergic, IgE mediated diseases.  The intake of anti-histamines suppresses and may negate the results, which depend on the release of histamine in the skin resulting from the antigen-antibody reaction being sought.  1st generation anti-histamines (Chlortrimeton, Benadryl) should no longer be used, except in an emergency, because of the sedative effects and also because of their reflex -  impairing activity (eg. in driving).  2nd generation anti-histamines generally lack these side effects.  But their effect on skin tests is of much longer duration.  This is true of claritin, allegra, zyrtec, and astelin; and it is especially true of clarinex, the newest arrival on the scene.  Based upon the latest reported evidence, none of these anti-histamines should be taken by a patient scheduled for skin testing for one week before the procedure.  Of course, the patient’s symptoms must be otherwise controlled during that period.   This can ordinarily be accomplished with inhalational or nasal steroid sprays - or in more complicated cases with a short course of oral steroids.


The following are summaries of the latest research in this field reported at the 57th annual meeting of the American Academy of Allergy, Asthma & Immunology, March 16 - 21, 2001.  Number references are made to abstracts published in the February 2001 edition of the Journal of Allergy and Clinical Immunology.

Physicians...dazzle your patients.  Patients...dazzle your physicians.

A)  Prevention:

  • Diesel fumes, toxic and  carcinogenic in many ways, also stimulate IgE, the allergy - producing antibody in everyone.  This problem is considered one important reason for the near - doubling of allergies in the general population in recent decades.  (#480)
  • Pregnancy and infancy are the times to put preventive measures into effect, including mother’s smoking, secondary smoke, pet avoidance and other environmental control measures, and also mother’s diet during  breast - feeding.  (#985, 766)
  • B) Diagnosis:
  • Skin tests, puncture - prick and especially intradermal, are the gold standard of allergy diagnosis and are far more useful and reliable than the “RAST” tests.  (#54)
  • Penicillin is the most common cause of medicinal allergic reactions.  Penicillin skin testing ( with both major and minor determinant agents) is only 70% effective in detecting penicillin sensitivity.  Thus, history is the most important diagnostic tool.  In the rare cases where there is no substitute for penicillin in a penicillin - allergic patient,  careful desensitization is available in expert hands.
  • Local anesthetic reaction is not uncommon, but true allergic reaction is rare.  A form of testing/rapid desensitization  is available, again in expert hands...since such approaches can carry a risk.
  • “Multiple Antibiotic Drug Allergy” (MADA) is a vexing syndrome of unclear causation -- but it is real.  (#40)
  • Eosinophilic Gastroenteritis is a particular ailment which can mimic GERD and other GI conditions.  After a positive diagnosis, Singulair may be helpful.  (#641, 99,643)
  • Anxiety/depression is reported to be more common in patients with allergic disorders.
  • Urticaria ( hives, acute and especially chronic)  continues to be a challenge for both physician and patient.  But much can be done.  (#178,180)
  • Latex allergy is a problem of increasing frequency, especially in health care workers.  It can be mild or severe and life-threatening; it can be obvious or obscure.  It is diagnosed by history, blood tests, and possibly skin tests.  Treatment ultimately consists of avoidance, since the sensitivity tends not to disappear.    There is also cross-reaction with a group of foods.  (#384,794)
  • Occupational diseases  include chronic beryllium poisoning.  In addition to pulmonary and skin involvement, there is reported an allergic contact reaction the gums from beryllium-containing dental implants.  (#420)
  • Soy protein sensitivity is not ruled out by tolerance to soy sauce.  Also, soy oil may cause problems.   (#464,623)
  • Chronic sinus disease, complicating fungus infection, the relation to bronchial asthma, and the potential utility of leukotriene inhibitors (eg. singulair) are  discussed.   (#536,537, 549,551)
  • Cat protein sensitivity, as manifested in skin testing, is the most common  allergen: fluffy, sticky, easily and persistently airborne, nearly impossible to get rid of, and easy to be exposed to on others’ clothing, is a bad actor.  (#564)
  • Oral Allergy Syndrome, involving allergic mouth symptoms on ingestion of certain foods (particularly certain fruits), may progress to generalized symptoms.  Thus, patients so afflicted should carry  an epi-pen or ana-kit for self-administration.  (#656)
  • Bumble Bee venom allergy can be yet another occupational illness, affecting workers in vegitable crop greenhouses that use bumble bees for pollenation.  In such cases, bumble bee venom and not honey bee venom should be used for immunotherapy.  (#727)
  • MSG (monosodium glutamate)  is well known for causing “Asian food syndrome”; but it is not considered to cause asthmatic reactions.
  • “Food-Dependent Exercise-Induced Anaphylaxis” can exist despite negative food skin tests and negative RAST tests.  (#877)  Thus, the history is all-important.
  • Grape allergy is rare but exists.  (#887)
  • Myasthenia Gravis is an immunologic disease which may at times benefit from treatment with IVIG, an important immunomodulator for many diseases with an immunologic base.
  •  “Graft-vs-Host Disease is another immunologic disease which can complicate treatment efforts which are associated with host immunodeficiency, either natural or acquired (eg. secondary to some treatments for cancers).  (#975)
  • Stachybotyris fungus toxicity/allergy  is an emerging causal agent in a variety of clinical syndromes occurring in the context of exposure to homes or buildings which have been water-damaged. This goes well beyond  well-known mold allergy found in similar circumstances.  (#1034)
  • C) Drug Reactions:
  • Bupropion (Welbutrin, Zyban), a psychotropic agent widely used and effective for smoking cessation, may rarely produce a serum sickness-like reaction (fever, rash, arthralgias) even days after beginning its use.  (#30)
  • Steroids, used topically, orally or by injection, may rarely produce allergic reactions, the precise problems for which they are ordinarily given.  This is true also for H1 (claritin, allegra, zyrtec, etc.) and H2 (zantac, pepcid, etc.) antihistamines.  (#31)   The moral of this story is that any medications or chemicals used for medical purposes can produce  allergic or ideocyncratic, as well as toxic, reactions.
  • Insulin, even human-derived (Humulin) can produce anaphylactic reactions, in addition to local and cutaneous allergy.  (#35)
  • NSAID’s (and aspirin) are well known to react allergically with sulfonamides (like bactrim, septra, gantricin, etc).  Cox-2 agents (vioxx, celebrex) may react in the same way, although to a lesser extent.  (#442,443)  The worst of the possible reactions is sudden, severe, sometimes fatal asthma.  This, like penicillin allergy, can kill you!
  • Singulair, a leukotriene-receptor inhibitor increasingly prescribed for lower and also upper respiratory allergic disorders, as well as for some other inflamatory disorders, may rarely cause a serious systemic condition called a “vasculitis”.  Although some reported “reactions” may really represent the unmasking of “Churg-Strauss Syndrome”,  patients should be given the benefit of the doubt by discontinuing Singulair.  (#866)
  • “Natural or Alternative” products  may themselves produce hypersensitivity and toxic reactions.  (#886)  This is really a “black box” which should be avoided until the FDA finds the political courage to subject that industry to its thorough oversight.  One exception may be the combination of Glucosamine and Chondroitin sulfate, which may have some place in the treatment of degenerative joint diseases.
  • D) Therapeutics:
    A  number of abstracts address the use of various medications in this field.  Of note are three issues:
    1) The unresolved controversy regarding whether to use “beta adrenergic” drugs only “as needed”, or on a maintenance basis (eg. proventil-albuterol, serevent-salmeterol).  (#338,339,365)   I try to avoid ahe maintenance use of these drugs, for both theoretical and practical reasons.
    2) Steroid  burst treatment (#448),  steroid withdrawal (#473), steroid resistance (#771)  and  the side effects of inhaled steroids (more prominent with fluticasone).
    3) Monoclonal anti-IgE antibody  under investigation for the treatment of allergic disorders.
    E) Immunotherapy:
  • The concomitant use of “beta-blockers” and/or ACE inhibitors may complicate the treatment of rare systemic reactions to allergy injection treatment; but they are not contraindicated.  The physician should have glucagon and ipatropium, in addition to adrenalin, benadryl, etc. available to use if needed.  (#236)
  • “Stock bacterial vaccine” is  a product used for the last fifty years by many, but not all, allergists and initially introduced by the pioneer Dr. Robert Cooke.   It has always been  suspected,  in the absence of confirmatory research but based upon decades of clinical experience,  to be effective in the reduction of “allergic” reactions to infectious agents, particularly in children (eg. recurrent acute asthmatic bronchitis). The mechanism has been thought to be its endotoxin content.  Now comes increasing evidence to support this,  including the “hygiene hypothesis”  and related studies of TH2/Th1 cell changes, and  “design-allergen for DNA -based desensitization.  (#310,313,747,749,1057)
  • GS

      Notes Taken from Articles Abstracted in the Yearbook of
      Allergy, Asthma, and Clinical Immunology 2000

      1. Many articles address the various functions of different interleukens in the pathogenesis of allergies.
      2. An article on page 17 demonstrates that Staphylococcal toxin, a type of super antigen, augments specific IgE responses by atopic patients exposed simultaneously to allergen.  The mechanism of this augmentation is defined.  This supports the long-known observation that developing certain respiratory tract infections in pollen seasons in an otherwise non-allergic individual may initiate the allergic response to those seasonal antigens.
      3. An article on page 23 describes the hyper-IgE (Job’s) syndrome characterized by very high levels of serum IgE together with chronic dermatitis and often severe infections of skin, paranasal sinuses, and lungs.
      4. The article on page 24 reviews further evidence that atopy and asthma have been on the rise in developed countries, while remaining uncommon in less developed countries, especially in rural areas.  The increase is most marked in urban groups.  Inverse relationships are reported between atopy and number of siblings and atopy and early entry into communal daycare.
      5. Another article on page 29 discusses this finding further, noting that infectious diseases produce TH1 type responses resulting in environments rich in interferon gamma which participates in the suppression of TH2 responses.
      6. An article on page 43 discusses the fact that polyaeromatic hydrocarbons associated with diesel exhaust particles favor IgE production, bronchial hyper-responsiveness, and airway inflammation.
      7. In two articles beginning on page 49, the observation is reported that there is substantial expression of Cox-2 in airway, epithelial, and inflammatory cell in the absence of evident airway inflammation.  This, in addition to the known importance of Cox inhibition precipitating asthma attacks in aspirin-sensitive individuals suggests the possibility that specific Cox-2 inhibition, with or without other leukotriene antagonists may have a role in treatment of this condition.
      8. An article on page 57 reports the contribution of IL4 in the development of allergy inflammation and asthma.  Conversely, it discusses the utility of soluble human IL4 receptor (Nevance) in reducing asthmatic inflammation.
      9. An article on page 60 describes the utility of anti-IgE in inhibiting mast cell activation, although without interfering with eosinophilic infiltration.  Thus treatment with anti-IgE is limited in its effectiveness to early phase response.  It was also found that concurrent treatment with anti-IL5 suppresses eosinophilic infiltration and interferes with the inflammatory response.
      10. An article on page 63 defines the pathophysiology of allergic asthma as involving TH2 cytokines including interleuken 4 and interleuken 5.
      11. An article on page 68 supports the evidence of discordance between suppression of inflammatory interleukens such as IL4 and IL5 and continued changes of remodeling in asthma.  Once again this increases the importance of avoiding the entire reaction in the first place with comprehensive treatment including allergy immunotherapy and environmental control.
      12. An article on page 72 points out that aerobic exercise, in this case swimming, raises exercise tolerance resulting in increased oxygen uptake and reduced ventilation requirement, thus allowing an individual with exercise-induced bronchospasm to exercise for a longer period before triggering EIB.  It is emphasized, however, that “working through” EIB is to be discouraged because it can produce severe reaction.
      13. An article on page 74 also addresses EIB noting that numerous medications are effective including Cromalin, Tilade, and Singulair.  One suggests the use of Salmeterol powder by Discus for 12-hour protection.
      14. An article on page 86 emphasizes that importance of introducing inhalational steroids early in the treatment of childhood asthma in order to avoid reduced responsiveness later, probably associated with airway remodeling.
      15. An article on page 90 describes the central role of eosinophils and eosinophilic cationic protein and major basic protein in the development and worsening of airway inflammation.  This appears to be true regardless of whether the underlying mechanism is allergic or otherwise.
      16. An article on page 93 reiterates the central role of RSV virus as a common respiratory tract infection in early childhood stimulating both asthmatic reactions and bronchiolitis.  It discusses the value of a safe and effective RSV vaccine when available.  In addition, the article on page 97 describes treatments other than the usual supportive care which may be appropriate in patients with serious underlying disorders.  Such treatments might include antiviral therapy, such as Ribavirin and RSV immunoglobulin.  It is generally thought, though not completely proven, that patients who have had acute bronchiolitis are much more likely to develop asthma subsequently.
      17. An article on page 101 notes a significant correlation between exhaled nitric oxide and sputum eosinophils as markers of airway inflammation in children with mild to moderate asthma.
      18. An article on page 102 once again suggests that some degree of airway inflammation persists despite inhaled leukocorticoid therapy and in the absence of symptoms.
      19. An article on page 105 notes that treatment with Singulair results in reduced levels of exhaled nitric oxide.
      20. An article on page 107 demonstrates that allergen avoidance is associated with fall exhaled nitric oxide supporting the importance of environmental control.
      21. Two articles on page 113 and 115 discuss vocal cord dysfunction in child as well as adults.  This problem is identified as a paradoxical adduction of the vocal cords during the respiratory cycle, usually on inspiration but also possibly on expiration.  This can imitate asthma and will not respond to anti-asthmatic treatment.  Once identified, it is best treated with respiratory phonation exercises, and perhaps psychotherapy.
      22. An article on page 125 discusses the occupational asthma involving red cedar and notes that the reactions to this antigen manifest late or biphasic asthmatic reactions to the plicatic antigen.
      23. An article on page 129 describes glucocorticoid insensitive asthma as being a problem which changes over time, so that individuals may vary between steroid-sensitive and steroid-insensitive situation.
      24. An article on page 136 describes airway hyper-responsiveness in the absence of asthma, noting that the development of asthma symptoms apparently involves both atopy and hereditary factors.  In addition, the presence of airway inflammation and remodeling in patients with asymptomatic AHR is confirmed.  It also notes that some of these asymptomatic patients go on to develop clinical asthma, those being uniformly atopic with positive family histories.  There is also a suggestion that a critical threshold in airway inflammation/remodeling must occur in asymptomatic AHR before the development of asthma.  This increases the importance of identifying patients with AHR even without asthma as in the case of patients with upper respiratory allergies without the development as yet of overt asthma.
      25. An article on page 138 describes IVIG as a glucocorticoid-sparing agent in patients with chronic severe asthma.  The mechanism is probably immunomodulation, so far not elucidated.
      26. An article on page 140, addressing recognition of early asthma, noted that at least 40 percent of all children with wheezing, lower respiratory illness during their first three years will still have wheezing episodes at six years of age when more specifically several major and minor criteria were identified in predicting persistent asthma.  Major criteria are hospitalization for bronchiolitis/wheezing, at least three wheezing lower respiratory illnesses during previous six months, parental history of asthma, and atopic dermatitis.  The minor criteria are rhinorrhea separate from colds, wheezing separate from colds, eosinophilia, and male sex.
      27. Further information from the University of Arizona group emphasizes the difficulty in identifying those wheezing infants who will or will not proceed to persistent asthma and also emphasizing the importance of initiating anti-inflammatory treatment in present and future asthmatics as early as possible; thus the need to give these infants the benefit of the doubt with anti-inflammatory treatment.
      28. On page 150, there is further evidence of the importance of the eosinophilic process in the pathophysiology of severe asthma.  The paper notes two distinct pathologic subtypes of severe asthma:  (1) the classic eosinophilic process with inflammation, (2) the other, eosinophil negative, with little evidence of classic asthmatic inflammation. The eosinophil-positive type was associated with greater inflammatory cell infiltrate and higher incidence of respiratory failure.
      29. On page 156, we find once again the importance of endotoxin, in this case inhaled endotoxin highly concentrated in organic dust.  This is a potent inflammatory agent likely to have a significant role in airway inflammation in patients with asthma.  This relates to our premise over many decades that the stock bacterial vaccine effectiveness is related at least in part to its endotoxin content.
      30. On page 161, we find a new name for exercise-induced bronchospasm, namely “thermally-induced asthma” by E. R. McFadden.  He holds that the severity of exercise-induced asthma depends largely on the rate of airway rewarming after the cessation of exercise.
      31. The article on page 163 addresses the issue of remissions of asthma.  It is noted that in adults, remissions are relatively rare and restricted to mild cases and elimination of cigarette smoke.  In children, however, variability is the defining characteristic.  The prognosis is largely unpredictable, although children will retain increase airway responsiveness and will remain at risk as they reach middle age.
      32. An important observation is noted on page 169, namely severe exacerbation of asthma occurring with the use of interferon A for the treatment of chronic hepatitis C.  The problem diminished with cessation of interferon therapy.  Reinstitution of interferon therapy produced severe asthma once again.
      33. The next article on page 170 finds that there is no evidence that long term asthma leads to the development of emphysema in non-smoking patients.  However, it is noted that non-reversible airflow obstruction is more likely to occur with highly variable airflow obstruction at baseline.  Thus, some patients with apparently stable asthma who have high bronchodilate reversibility may need more intense anti-asthma therapy to improve airway function and control inflammation.  However, in this ten-year longitudinal study, it was once again noted that individuals with moderate to severe asthma remain at risk for development of non-reversible airway obstruction despite treatment with inhaled leukocorticoids.  Thus, we should be more aggressive with anti-inflammatory treatment in patients with marked reversibility and we should treat them comprehensively including the use of allergy immunotherapy in appropriate cases to avoid the entire cascade toward chronic inflammation and airway remodeling.
      34. Articles on page 175 and 176 discuss the delayed-type relations to amino- penicillins, exploring diagnostic approaches.  These include patch testing and intradermal skin testing looking for delayed intradermal test results.  These latter tests were found to be a more sensitive diagnostic tool.
      35. The article on page 181 casts doubt on previously reported suggestions that MSG ingestion causes asthma.
      36. On page 188 an article reviews breast-feeding in allergic infants and emphasizes the desirability of initiating breast-feeding on atopic infants.
      37. The article on page 192 discusses the “latex-fruit syndrome” reflecting the now recognized cross-sensitization between latex and the growing list of fruits including chestnut, avocado, and banana.  Latex sensitivity may also exist without the concurrent fruit sensitivity.
      38. Another article on page 197 notes that the prevalence of occupational allergy to natural rubber latex is reported to be between 8 and 17 percent.  The incidents of latex-induced occupational asthma are between 2 and 6 percent.
      39. On page 199, the article addresses skin test safety and notes that in one large experience, there were only six systemic reactions and no deaths in more than 18,000 patients undergoing allergy skin tests.
      40. On page 207, we notice once again reference to superantigen involvement in T-cell stimulation, in this case complicating atopic dermatitis, probably as a result of Staph aureus skin infection.  There are a number of such articles addressing the contribution of bacterial superantigens to chronic inflammation and raising the old saw of Staph toxoid which we used to use in the 1960s when it was still available.
      41. On page 227, an article addressing the bane of the allergist’s existence, namely chronic urticaria, pointing out that often these cases have underlying autoimmune processes.  This is the first report of IgE antithyroid antibody in a patient with chronic urticaria.
      42. The next article is on page 234 through 236 relating to common variable immunodeficiency, clinical, and also pulmonary manifestations.  Also the article on page 243 regarding immunoglobulin replacement treatment by rapid subcutaneous infusion and page 244, renal insufficiency as a result.
      43. Also the pages 247 and 248 relate to Churg-Strauss Syndrome and condition.
      44. On page 251, the major cause of acquired heart disease in children is Kawasaki syndrome. The etiology is undetermined, but it appears to be an immune activation possibly by bacterial superantigens with antibodies attacking vascular endothelial cells.  IVIG has been shown to be an effective treatment modality.
      45. The article on page 255 discusses asthma morbidity and mortality, particularly in inner city children, and notes that the optimum results are obtained when these children are followed by a specialist.  Short of that, a major step involves the assignment of such children to a specific primary care physician for treatment and follow-up.
      46. The article on page 258 compares the use of nebulizer treatment and pressurized metered dose inhalant with holding chamber in children.  Sufficiency is approximately the same but total dose deliver is much higher with the nebulizer.  This is true also for inhalational steroids.
      47. The article on page 263 once again points out that many patients whose disease appears under clinical control still have airway hyper-responsiveness and airway inflammation, chronic abnormalities that may lead to airway remodeling, and a worse long-term outcome.  Thus the recommendation to treat patients with few symptoms, nearly normal lung function but severe airway hyperactivity with higher dose of inhaled steroids than a patient with similar symptoms baseline function but with mild airway hyperactivity.
      48. The article on page 265 describes the use of leukotriene receptor antagonists like Singulair for severe premenstrual asthma, a problem in up to 40 percent of women with asthma.
      49. We should add here that the article on page 248 regarding Churg-Strauss syndrome should also be reproduced as above.
      50. On page 268, the use of Heliox in a kid’s severe asthma is described favorably.  The study suggests that up to eight hours of Heliox therapy is not only safe, but also effective, easy to administer, and apparently free of adverse effects.  This of course is in addition to other therapies including IV beta-agonist, IV Theophylline, and IV magnesium.  This is for severe status asthmaticus.  The ratio of Heliox being 70 percent helium, 30 percent oxygen.
      51. The article on page 272 reports the effectiveness of monoclonal anti-IgE antibody in the treatment of both rhinitis and asthma.
      52. The article on page 274 discusses the use of menopausal estrogen and estrogen-progesterone replacement therapy and breast cancer risk.  The findings are that the addition of progesterone and estrogen may significantly increase the risk of breast carcinoma.  This is related to duration of use; the risk increased by 8 percent for each year of estrogen and progesterone therapy but only 1 percent for each year in which only estrogen was used. This use of course is for prevention of osteoporosis and importance indications.
      53. The article on 280 discusses corticosteroid resistance, well known in some cases of severe asthma but here described in occasional cases of mild asthma.  The question is whether the problem is a genetic trait or an exaggerated inflammatory response to allergen.
      54. The article on page 283 discusses the early emergency room use of intravenous corticosteroids in children in the ER or hospitalized for acute asthma.
      55. The article on page 295 is another discussing the benefits of high dose IVIG in patients with severe steroid-dependent asthma.  This major utility is in steroid-sparing effect and appears to be well tolerated, with headache as the most common adverse effect.  In addition, children and adolescents appear to respond more favorably to IVIG than adults.  The doses used in this study were not as high as those used by National Jewish Hospital, namely 2 gm/kg administered every four weeks.
      56. A comment on page 305 relates to the debate regarding the development of tolerance to Salmeterol over time.  In addition, as noted on page 207, another nagging question concerns whether “Salmeterol therapy may provide improved bronchodilatation at the expense of masking increasing airway inflammation.  On the other side of this question, there is the study on page 306 putting an anti-inflammatory effect of Salmeterol noted in reduction of airway eosinophils.  This issue is still unsettled.
      57. On page 313, the article provides evidence for the improved effectiveness of Levalbuterol (Xopenex).  “Recent studies have suggested that the summer may actually be deleterious”.
      58. On page 317 is another article discussing Salmeterol, this time as an inhalation steroid-sparing agent and suggesting the combined use the two.
      59. The articles on page 325 and 327 discuss allergy immunotherapy and its mechanism of action.

    The following are selected results of medical research recently reported at the annual meeting of the American Academy of Allergy, Asthma and Immunology.

    Abstracts of the actual papers may be found in the January 2000 Edition of the Journal of Allergy and Clinical Immunology, Volume 105, No.1, Part 2.

    No. 1: reinforcing the well-known relationship between allergies, allergic rhinitis, and bronchial asthma, abstract No. 3 reports that higher numbers of positive skin test are associated,  in patients with allergic rhinitis, with the diagnosis of asthma.

    No. 2: orally exhaled nitric oxide may move from the research laboratory to clinical use as yet another test reflecting the presence of pulmonary inflammation associated with asthma.  Abstract No. 7 found a strong correlation between levels of exhaled nitric oxide and serum IGE  levels,again supporting the important relationship between asthma and allergic predisposition.

    No. 3: in abstract No. 27  there is reported a decrease asthma mortality in Israel during the years 1991-1995 probably associated with the increased use of inhaled corticosteroids for asthma.  This use promises to be the easiest and best intervention to reverse the ongoing epidemic of morbidity and also deaths from asthma worldwide.

    No. 4: abstract No. 33 and several other abstracts report the correlation between regular use of inhaled corticosteroids  and reduced levels of exhaled nitric oxide, reflecting reduction in underlying pulmonary inflammation, the mechanism for ultimate lung scarring.

    No. 5: abstract 52 reports on the beneficial effects of high dose IVIG  administration as  a  steroid-sparing agent in the population of patients with severe steroid-dependent asthma.

     No. 6: several abstracts report on the continued reliance of many asthmatics, particularly in inner-cities,  on the emergency room for the care of their asthma.  The abstracts also show that, apart from the resolving the acute attack, emergency room treatment is poor with regard to establishing for the patient a comprehensive program of treatment.

    No. 6: increasing evidence suggests that levalbuteral (Xopenex)  is more effective for treatment of asthma than the usually used  albuteral for inhalation.  See abstract 66.

    No. 7: abstract 82 reports that in addition to  Wegener’s Granulomatosis, nasal mucosal necrolysis  septal  perforation may also result from cocaine abuse.

    No. 8: abstract No. 92 reports further evidence that  microbial infection early in life may have a protective efffect on the development of atopic disease.  This abstract also investigates the role  of endotoxin  in this immunomodulation,  an issue which may well be related to the effectiveness of stock bacterial vaccine, used by some allergens including myself,  as part of a program of Allergy Immunotherapy.  (See that section on this web-site).

    No. 9: abstract No. 220 emphasizes the importance of  gastro-esophageal reflux disease, not only in the evaluation and treatment of asthma,  but also in the evaluation of upper airway disease .

    No. 10: several abstracts emphasize the utility of the newer leucotriene receptor antagonists like Singulair  in treating asthma, with a reduction in need for other medications and with the reduction in overall cost of treatment.

    No. 11: several abstracts report on the impact  of  regular inhaled corticosteroid therapy on childhood asthma, noting its importance in treating established asthma and thereby avoiding permanent airway remodeling (scarring) that can occur even in childhood. See abstract No. 307.

    No. 12: abstract No. 371 emphasizes that fragrances frequently cause respiratory symptoms asthmatic individuals. Their use should be minimized both by asthmatics and by  individuals having close contact with asthmatics, as a courtesy.

    No. 13: abstract No. 384 reports that the increased use of  Lady-Bug  beetles as a natural means of insect pest control has led to increased allergic sensitization to these insects, producing  reactions including asthma, allergic rhinitis, and allergic conjunctivitis.

    No. 14: there are numerous reports regarding the increasing problem of latex sensitization. One report notes that reasonable precautions taken by affected health care personnel, notably elimination of contact with latex gloves, can often resulted in the individual of being able to maintain health-care employment.

    No. 15: although the clinical significance of this is often difficult to evaluate,  abstract 408 describes many foods containing varying levels of naturally occurring salicylates and reports that exposure to these foods may precipitate symptoms in aspirin-sensitive patients.   Such  foods include  almonds, Apples, apricots,  many types of berries, grapes, oranges, peaches, plums, prunes, cucumbers, pickles, and tomatoes.

    No. 16: abstract No. 415 reminds us that,  in addition to the ingestion  of a food allergen, occupational or home exposure to aerosolized food - as occurs during cooking -  can provoke asthma in children as well as in adults.  Three  common examples of this include egg, fish, and  peanut .

    No. 17: abstract number of 497 points out a marked difference in prescribing patterns for asthma between general practitioners, on the one hand, and allergists and pulmonologists on the other hand.    General practitioners have not yet learned and incorporated into their practice the comprehensive management of bronchial asthma.  This is a continuing problem with no excuse and with an easy solution: “when all else fails, please follow directions.”

    No. 18: abstract  566 discusses the potential future for patients with “oral allergy syndrome”. This is a condition usually describing localized  itching around the mouth and throat caused by some common foods.  The article points out that this syndrome can progress in the same individual to generalized anaphylaxis from one or more of these foods in future years. Thus, carrying epinephrine  is appropriate.

    No. 19: abstract No. 569 reports that “stress may trigger autonomic responses that result in bronchoconstriction in asthmatics”.  This relates to the perennial question regarding whether emotion can produce asthma.  The perennial answer it is that emotion can be a potent trigger; but  it requires the necessary ammunition (allergic sensitization).

    No. 20 abstract 570 addresses the problem of asthmatics who  do not realize how sick  they  are at times.   Substantial numbers of moderate to severe asthmatics were found to have poor perception of their air flow limitation, resulting in a much greater risk of sudden suffocation from an acute asthmatic attack.  This is a continuing problem for physicians, a problem which can only be resolved by careful objective  monitoring of the air flow  (peak expiratory flows) of all their asthmatic patients.

    No. 21 abstract No. 585 notes the importance of identifying  obstructiive sleep apnea in some asthmatic patients  and of treating that problem with nasal CPAP ( see our web-site section on that subject).

    No. 22 abstract No. 726 reflects the fact that latex allergies may present in early infancy as a diaper rash,  oral  eruptions, coughing and wheezing.

    No. 23 abstract 783 emphasizes that  “step-down therapy starting with high dose of inhaled steroids and short-term oral steroids is more effective in  gaining prompt control asthma and in reducing  the maintenance dose of inhaled steroids than step-up therapy starting with low dose of inhaled steroids in patients with moderate asthma”.

    No. 24 abstract 813 addresses the question whether inhalation of  epinephrin from a metered dose inhaler may be used as a substitute for injected  epinephrine as pre-hospital treatment for anaphylaxis.  The results of this study showed that most children were unable to inhale an adequate number of epinephrine  to produce comparable and necessary  blood levels.  Thus, injection  of epinephrine  remains the mainstay of  treatment of anaphylaxis.  The one exception may be allergic laryngospasm (or vocal cord swelling) with change in or loss of voice,  where inhaling epinephrine directly onto the affected cords may be life-saving. This is the only safe and indicated usefulness of Primitine Mist or of  Medihaler Epi.

    No. 25: abstract 904 reviews a partial differential diagnosis of “exercise-induced asthma and  adds to it to the occasional possibility of acute pulmonary emboli (blood clots  to the lung, a potentially life-threatening condition frequently missed in diagnosis).

    No. 26 abstract 915 reports that allergens imunotherapy   has “ well-documented clinical long-term efficacy,  but the underlying immunologic mechanisms are not entirely clear”.    The authors propose a unifying theory of the mechanism of action, based upon the role of “blocking IgG” in converting TH2 cells to TH1 cells and thus modulating the immune system away from  allergic reactivity.

    No. 27: abstract No. 939 describes the high incidence of  GERD in asthmatics and reports on the existence of  “silent GERD” in asthmatics.  Thus, special attention including possibly a trial of medicinal treatment would appear appropriate.

    No. 28 abstract 949  describes a study of the risk of  adenoidal hypertrophy in children with allergic rhinitis, and found that respiratory allergens,  especially dust mites and mold, together with exposure to smoking,  are highly related to adenoidal hypertrophy.


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