George A. Sprecace M.D.,
J.D., F.A.C.P. and Allergy Associates of New
OF ABSTRACTS PRESENTED
AT THE MEETING
AMERICAN ACADEMY OF ALLERGY, ASTHMA, AND
IMMUNOLOGY, MARCH 14-18, 2008
in the Feb. 2008 volume, JACI)
- 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.
- 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.
- Abstract 20 notes a positive correlation
found between early onset asthma and adult respiratory
- 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.
- 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.
- There is an increased risk of invasive
pneumococcal disease in the presence of allergic disorders -
- 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.
- 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.
- 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
- Concomitant use of nasal decongestants
and nasal steroids is discussed in #215. I
- Systemic reactions to percutaneous
skin testing reportedly occurs in 3.5% of patients, for which
the prompt administration of epinephrine is useful - #223.
- Subcutaneous IG is a more
convenient and also effective mode of administration, as compared with IVIG - #230.
- SSRI anti-depressants do not
affect histamine wheal size – 234.
- Long-term use of inhaled nasal steroid
(over 3-4 years) appears safe in children and adolescents - #235.
- Wheezing Rhinovirus infection in early
childhood predisposed to later asthma - #’s 240,561.
- 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.
- Abstract # 262 discusses protocols for desensitization
to retuximab and other chemical agents.
- Sublingual desensitization is
experiencing a revival of interest, although I don’t believe it is yet
ready for prime time – #’s267, 370, 493.
- Allergy Immunotherapy is very useful
in children, although I find it rarely necessary below the age
of 5 years - #289.
- Genetics in Asthma occurrence
and progression are discussed in #297.
- Positive ANA is correlated
with lack of proper control in asthma - #298.
- The use of pulmonary function testing,
which I find very useful in determining adequacy of actual – vs
clinical – control – is discussed in #311.
- 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.
- 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.
- Hereditary Angioneurotic Edema
can be treated with replacement of C1-esterase inhibitor (#380) and by
use of fresh frozen plasma (#383).
- 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).
- A form of Lactobacillus, another
probiotic, may be useful in decreasing the asthma response -
- 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.
- 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.
- The existence of a
“naso-ocular reflex” prompts the use of nasal inhaled
steroids for ocular symptoms - #582.
is being studied as a possible treatment for asthma.
But its long-term effects remain unknown - #590.
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.
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.
- Regarding Pneumovax,
pre-immunization antibody level reduces response, but does
not eliminate it.
those patients with elevated IgE are improved on Xolair -
#668, probably reflecting combined disease with bronchial asthma.
Syndrome and Toxic Epidermal Necrolysis are very serious systemic
diseases, usually caused by drug reactions, especially
anti-epileptic medications - #’s 724,733,743.
- For Penicillin
testing, both major and minor determinant materials may be
available from Kaiser-Permanente in California - #740.
- Abstract #750
suggests reasons for an OPD Allergy consultation. Tell that especially to the pediatricians.
with atopic diathesis may be caused by infection with Toxicara
among latex, tobacco and other related species is described in
- According to #’s
923 and 925, egg-allergic patients can tolerate
influenza vaccine without ill effect, even when given in a single dose. (?).
OF ABSTRACTS PRESENTED AT AMERICAN ACADEMY OF
ALLERGY, ASTHMA, AND IMMUNOLOGY, FEBRUARY 2007 MEETING
- Abstract 1 is the first case of a paradoxical severe and
near-fatal reaction to levalbuterol (Xopenex inhalation).
- Abstract 3. Discusses bronchial thermoplasty in refractory asthma
of a severe and persistent type. Three sessions were generally needed
and clinical and statistical improvement is noted at 22 weeks afterward.
- Found that levalbuterol solution is comparable with budesonide,
ipratropium, cromolyn, or acetylcysteine.
- The use of aminophylline remains controversial especially for
younger physicians, but continues to be usefuhas in this case for
children with acute asthma. It is still part of our armamentarium.
- Numerous abstracts report the favorable combination of Beta-2
agonist and Atrovent or Spiriva.
- Discontinuing Xolair treatment results in return of IgE toward
baseline within a few months.
- Abstract 832: Reports on Xolair therapy for allergic
bronchopulmonary aspergillosis despite the very high IgE levels.
- Abstract: Reports on continued efficacy of the Xolair despite
using extended dose Inhalation
- Item 967: Proceeds in the direction opposite from the recently
placed black box for Xolair, reporting the "Safety" of Home Therapy
with subcutaneous anti-IgE. (??)
- Abstract 1072: Suggests Xolair for treatment of resistant chronic
idiopathic urticaria and angioedema. It may or may not work in this
- Item 1201: Reports that upon discontinuation of Xolair therapy,
clinical symptoms reemerged and correlate well with reducing Xolair
concentrations. Thus, the reduction in Xolair dose after 6 months of
treatment cannot be recommended, and Xolair treatment is certainly not
a substitute for properly applied allergy immunotherapy, which
progressively reduces IgE which in the majority of patients leads to a
true desensitization and ultimate discontinuation of allergy
- Helicobacter pylori infection has been found to be a triggering
factor of attacks in patients with HAE, and treatment of this infection
causes the reduction in the frequency and severity of the reactions.
- In addition to hereditary angioedema, there is an acquired form
of angioedema due to C1 esterase inhibited deficiency, which has no
family history. One of its associations is with lymphoma.
- Abstract 1068: Reports that hereditary angioedema can precipitate
- Abstract 1070: Reports that fresh frozen plasma contain C1
esterase inhibitor and that it can be used for surgery during pregnancy
and for acute exacerbations of HAE without evidence of initiating an
attack or worsening a preexisting attack.
- Abstract 1087: Reports on prodromal signs and symptoms that can
occur in patients with hereditary angioedema that may precede an
exacerbation by hours or days. This can include rash, a flu-like
illness, and paresthesias.
- Human seminal plasma allergy in woman is rare but can be serious.
This study finds that the prostate specific antigen is the causative
- Abstract #68. Treatment of diabetic patients with insulin may
produce anti-insulin antibodies with several different effects. One
type includes typical allergic reactions; the other type has to do with
neutralizing antibodies, which can produce both hyperglycemia by
blocking insulin effect and also hypoglycemia by binding to insulin
acting as a reservoir and then releasing the insulin at inappropriate
times. When this problem is refractory to treatment with steroids, it
may be successfully treated with intravenous immunoglobulin
- Abstract #73. Sarcoidosis. It may present in many ways. Isolated
sarcoidosis of the bone marrow can present as lymphopenia, FUO, and
anemia without lymphadenopathy or abnormal chest imaging.
- Abstract #75. Reports a case of life-threatening multiorgan
thrombosis occurring acutely as part of catastrophic antiphospholipid
syndrome, and then becoming associated with autoimmune thyroiditis.
- A full spectrum of allergic respiratory reactions can occur from
exposure to marijuana and/or hashish.
- Abstract #82. Refers to multiple chemical sensitivity (MCS)
reportedly including reactions to pesticides, solvents, et cetera.
- Occupational asthma can occur after exposure to airborne enzyme
powder used in cheese production.
- Mycoplasma pneumonia infection can be considered a triggering
factor in acute exacerbations of asthma.
- Obesity results in increased severity of asthma.
- Involves another report of long-term effects of diesel exhaust
particles inhalation on airway inflammation and hyperresponsiveness.
- Sirolimus and Macrolide antibiotic use in organ transplant is
reported to cause angioedema.
- Severe or recurrent drug anaphylactic shock can be the first
presentation of a systemic mastocytosis.
- Superior vana cava syndrome can masquerade as anaphylaxis.
- For children with food-induced anaphylaxis, the second dose of
epinephrine is required in nearly half of the patients. Therefore, 2
EpiPen should be provided.
- Sensitization to egg can occur via inhalation of egg aerosol, as
for example in a laboratory setting, resulting in anaphylaxis.
- Protamine is a protein added to insulin and is also used to
reverse heparin-induced anticoagulation. This is a case of
protamine-induced anaphylactoid reaction, which was reversed by 100 mg
of intravenous methylene blue.
- Abstract #137. Describes a single day aspirin desensitization
- Frequency of aspirin hypersensitivity in atopic patient is 10
times higher than the average population.
- Stevens-Johnson syndrome is a systemic adverse reaction to drugs
with severe cutaneous manifestations. It involves particularly certain
classes of drugs such as NSAID, allopurinol, anticonvulsants,
antibacterial, and sulfonamides. This is a case of a carbonic anhydrase
inhibitor reaction, namely acetazolamide.
- Abstract 158. Reports a rare case of allergy to multiple local
anesthetics, that is to groups 1 and 2, possibly via an IgE mediated
- Article 165. Reports multiple troubles and adverse effects to
danazol use in a prophylactic treatment of hereditary or acquired C1
esterase inhibitor deficiency.
- Abstract 172. Reports profound lymphopenia in 2 immunocompetent
children with the finding of allergic fungal sinusitis. In
another interesting aspect, it was found that Aspergillus fumigatus
organisms induced mast cell degranulation in IgF independent manner
based upon contact.
- It was found that cigarette smoke, besides being an irritant,
activates human mast cells,thus potentiating airway inflammation.
- Abstract 216. Discusses rush desensitization and antileukotriene
prophylaxis to decrease anaphylaxis severity. The abstract does not
address the effect of this approach on IgE levels.
- 50% glycerinated extracts did not appear to correlate with local
or large local reaction rates.
- Another abstract reports that ocular symptoms of seasonal
allergic disease can be treated effectively with a steroid nasal spray,
in this case Nasonex.
- Abstract 265. Reports a case of frontal sinusitis complicated by
an epidural abscess and seizures. Lu.Sc`
- One abstract reported that 37% of children with cow's milk
allergy lose their allergy by the age of 12 years.
- Another abstract reports that atopic dermatitis was the most
common clinical presentation of egg allergy in children. About
half of egg allergic children developed tolerance by 5 years of age.
- Abstract 308. Reports that venom immunotherapy is effective in
reducing large local reaction to insect stings and may be indicated in
particularly troublesome situations.
- Abstract 318. Reports on the positive predictive power of
frequent exhaled nitric oxide measurements in patients with asthma who
are unstable and not well controlled.
- Abstract 326. Reports on adolescent asthmatics who frequently are
symptom'free but who can be shown to have obstruction of peripheral
airways with response to bronchodilator. This indicates underlying
inflammation, which should be treated.
- Abstract 374 is an Army study about Smallpox vaccination
program~reports on vaccinia-associated myopericarditis. The vast
majority of patients were
- Abstract: Reports that urticaria can be a rare presentation of
- Abstract 911: Cautions that rhinorrhea not responding to nasal
corticosteroids could possibly be central spinal fluid rhinorrhea with
its own implications.
- Abstract 956: Reports on the equivalent efficacy of high dose
continuous nebulized levalbuterol and racemic albuterol in pediatric
- Abstract 966: Reports on the treatment of asthmatic infants with
cumulative dose of Ventolin H'~AFA inhaler administered via AeroChamber
and face mask, every 20 minutes in the first hour and hourly for the
next 2 hours for a total 6 doses.
- Abstract 973: Reports on the safety of Ventolin HFA in children
under 48 months of age.
- Abstract 976: Reports on the value of starting inhaled
corticosteroids within 1 year after onset of asthma symptoms to avoid
- Abstract 988: Reports on IgG subclass deficiencies with some
results including tooth decay, pharyngeal tonsillitis, Helicobacter
manifestation, and mucocutaneous herpes.
- Resistance to glucocorticoid therapy is a characteristic of
severe asthma and is related in part to the inflammatory cytokines.
- Item 1055: Reports on a patient who originally had allergy to
human recombinant DNA insulin, was desensitized for that problem and
then developed a different type of reaction, avasculitis to the insulin.
- Abstract 1067: Reports on dose-dependent urticaria reaction to
marijuana smoke exposure in a non-atopic patient who had positive
pregnancy test and IgE determination.
- Abstract 1109: Reports that cetirizine promotes a shift in the
Thl, Th2 balance toward Thl type response and stimulatef the production
of immunoregulatory cytokines, IL-10, and TGF-beta which have
anti-inflammatory effects suppressing allergic responses.
- Abstract 1111: Reports that severe refractory atopic dermatitis
is primarily an atopic disease associated with increased levels of both
total serum IgE and specific IgE to inhalant allergens, a multiple
- Abstract 1182: Reports on aspirin desensitization. This is proven
to be effective with sustained therapy in reducing morbidity associated
with inflamatory diseases.
ABSTRACTS OF PAPERS PRESENTED AT
ALLERGY. ASTHMA AND IMMUNOLOGY
62ND ANNUAL MEETING
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
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,
measures should be used in children, such as peak expiratory flow
4) Vascular Endothelial Growth Factor
(VEGF) is highly expressed in
the airway of asthmatic child patients and is responsible for increase
13) Exercise-induced bronchospasm is found
to a greater degree in obese
32) Other abstracts provide evidence that
omalizumab (Xolair) is effective
in use in moderately to severely affected asthmatics. It is also
useful as an add-on treatment to concurrent allergy immunotherapy.
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,
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
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.
any patient allergic to peanut or to a tree nut should essentially
intake of nuts in general, partly because of the common production
for packaging of these nuts and also peanuts. Peanut allergy associated
with high household exposure to peanut in infancy is reported in
140. The message here is to delay an infants exposure to peanut for a
time. However, no special effect of maternal consumption during
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,
190) Reports cases of scurvy associated with oral allergy syndrome
resulting from elimination of the related important foods from the
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
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
330) We learn that breast feeding for at
least twelve weeks and the
absence of being overweight appeared to play synergistic roles in
33l) We learn that elevated body mass
index at age three predicts wheezing
at age five independent of wheezing earlier in life. Thus, the
evidence of relationship between obesity and asthma.
339) Early life exposure to maternal
stress is associated with development
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
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
with pulmonary function tests before and after bronchodilator, to
possible occult bronchospasm.
425) Reports the clinical syndrome of
specific antibody deficiency (SAD)
in children, an immune deficiency characterized by normal
levels and antibody responses to protein antigens, but impaired
responses to polysaccharide antigens. It is fairly commonwith a
of 15% in children with recurrent infection without another defined
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
swellings including extremity, facial, genital and trunk. Treatment for
this condition continues to include long-term andrigen therapy, which
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
523) Reports delayed anaphylactic reaction
to immunotherapy injection,
delayed for over two hours and requiring abundant immediate epinephrine
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
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.
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
skin testing and allergy immunotherapy is a relative contraindication
not a strong one in our experience.
884) Describes serum sickness-like
reactions following placement of
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
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
Th2 cell recruitment. It will be recalled that the hygiene
involving early exposure to infections and other endotoxin-containing
works to push Th2 cell reactions toward Thl cell reactions, thereby
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
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
1009) Benzalkonium chloride as a
preservative in saline nasal sprays
impairs nasal mucociliary clearance. "Due to development of modern
devices, it is obsolete to use this preservative in nasal solutions."
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
TH-1 response and induction of an allergen specific non-IgE antibody
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
1062) Reports that children that undergo
adenoidectomy and tonsillectomy
are likely to experience a significant improvement in their asthma
1068) Reports on the use of macrolide
antibiotics in the management
of asthma since these antibiotics have known anti inflammatory
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
blooms. The differential diagnoses here includes pufferfish and
1163) Reports regarding oral allergy
syndrome wherein isolated symptoms
are most commonly due to melon. However, systemic reactions are
commonly due to peach.
1164) Reports a high prevalence of
sensitization to tomato although
most sensitized subjects are asymptomatic. There are a number of
involving eosinophil esophagitis.
1176) Reports on the relatively mediocre
treatment of anaphylaxis in
emergency rooms, mainly due to the under-use of epinephrine and
In fact, abstract 1178 recommends the availability of two epi-pens to
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
testing. There are a number of abstracts discussing venom
1196) Reports bed bug bites as a basis for
More next year...
PEARLS from Abstracts of papers to be presented
18-22, 2005 at the annual meeting of the American Academy of Allergy,
(Published in the Journal of Allergy and Clinical Immunology, Vol.
115, No. 2, Feb. 2005)
- In children with established bronchial asthma (eg. three
or persistent long-standing dry cough), inhalational steroids
better started early. (#4)
- Combinations of medicines continue to appear, the newest
being Budesonide / Formoterol (inhalation steroid and long-acting
(#8). These may be convenient, but I prefer to use and titrate
individual components as needed.
- Minocycine (minocin) has been found to be
But the potential side-effects preclude, in my opinion, its use in all
but the really difficult cases...which become much less difficult if
are treat comprehensively, including with Allergy Immunotherapy.
- Xolair (the anti-IgE agent) is useful for, and should be
for, only the severe cases. Again remember allergy immunotherapy,
often ignored...especially by Pulmonologists.
- "All that wheezes is not asthma". And all asthmatics
same. See Abstract #23 regarding asthma phenotypes.
Being able to categorize asthma patients genetically, with treatment
may become clinically very useful...but not yet.
- For example, Aspirin - sensitive asthmatics are generally
- Evidence is now developing th suggest that, besides being a
condition, Obesity may be primarily pro-inflamatory and may
complicate bronchial asthma. Yet another reason for all of us to
work to reverse this rampaging epidemic. (See www.medidietresourcers.com).
- Cystic Fibrosis is often accompanied by nasal polyps. But
are rarely accompanied by cystic fibrosis. (#61)
- Bovine collagen injections in cosmetic surgery can
reactions, and might be associated with auto-immune disease. (#66)
- Insulin antibodies, known to underly some insulin resistance, can
produce hypoglycemic reactions as the bound insulin is sporadically
- Diesel fume exposure potentiates allergy - causing IgE
worsens bronchial asthma. (#92)
- Automobile air-bag deployment can precipitate an
and produce new-onset asthma, in addition to producing "corneal injury
, burns, skin hyper-sensitivity reactions, pneumothorax, cardiac
and aortic rupture." (#95)
- Lasik eye surgery can produce occupational rhinitis and
allergic reaction to corneal antigens. (#111).
- We read about lipstick allergic cheilitls (#125), swim cap latex
(#124), and allergy to Play-Doh and its wheat content. (#127).
- Persons allergic to soy should know that soy sauce
despite the fermentation process. (#128).
- Penicillin and other beta lactam allergy often tends to reduce
But the sensitivity can boosted by use of amoxycillin. (#129).
in these cases it is wise to use other antibiotics.
- Acute allergic reaction to peanut can occur with "first
because it probably was not the first exposure in the patient's
- Xolair has been used successfully to treat fire ant
after standard allergy immunotherapy had for some reason failed.
(#151). It should be remembered this use. like that for treatment
of peanut allergy, are "off label" and for which the clinical
should be quite strong.
- Anaphylaxis in the peri-operative period, usually
relaxants or to latex reactions, may also be due to starch-based plasma
volume expanders. (#158)
- Regarding CPR for anaphylaxis, it was found that patients
blockers were generally not greatly compromised. (#160)
- The importance of availability of Epi-Pen, and
its indications and use for a given individual, is stressed.
- Persistent and severe allergic rhinitis may be a prelude to aspirin
sensitivity, including aspirin - asthma. (#188)
- The use of steroid nasal inhalation had no effect on exhaled
oxide / asthmatic inflamation. (#201)
- After endoscopic nasal-sinus surgery, look out for
and P. aeruginosa superinfection. (#229)
- The re-growth of adenoidal tissue after removal may be
allergies and also to GERD. (#231)
- Early environmental intervention significantly reduces
of asthma at age 7 in high-risk children. (#245)
- Post-IVIG treatment headache may be secondary to the
of the product. So, try other brands. (#325)
- Sub-cutaneous Ig is a safe alternative to IVIG.
- Glucosamine derived from shrimp shells is tolerated by
- Sodium hypochlorite - containing disinfectants are
the growth and allergenicity of mold in homes. (#393)
- In the treatment of atopic dermatitis, prior treatment
topicals...or staph. superinfection...reduces the effectiveness of
- Xolair use reportedly helped in the treatment of atopic
resistant to other (?) forms of treatment. (#417) It should be
that allergy immunotherapy in appropriate cases of atopic
can produce very good results. But the treatment must be slowly
carefully advanced, since it is quite easy to cause a "flare"of the
- A case of concurrent seminal fluid and latex allergy is
- In a study of severe and difficult-to-treat asthma, skin
well with IgE level. (#497). This is really not news,
it should be remembered that about 10% of clearly atopic patients have
negative skin tests and should be treated according to history -
with allergy immunotherapy.
- A case of interstitial cystitis (with pelvic pain and
accompanied by allergic rhinitis and asthma was successfully treated
allergy immunotherapy and anti-IgE therapy. (#501) Although
a long shot, this connection should be considered in such cases.
The same is true in cases of "Chronic Fatigue Syndrome", which carry a
two-fold incidence of concomitant allergic disorders than in the normal
- Here is a "dog bites man" story: the finding of relatively
between ER treatment of asthma and the relevant guidelines.
The same can be said for the non-specialty treatment of asthma in all
- An important note relates to the existence of both acidic and
esophageal reflux in some infants and children, the latter
responding to proton pump inhibitors. In these cases, further
and treatment are necessary. (#606)
- A number of abstracts discussed "rush immunotherapy" as
What was not clear was the long-term efficacy of this approach, and the
fact that the high % of systemic reactions (about 15%) boost the same
whose reduction is the purpose of the treatment. Furthermore, one
abstract found a difference of only $300 between rush and standard
over the course of a year. I do not use this approach, unless
is a special reaxon for the rush. (#644,645)
- Clinical cat allergy can dissipate over about two years
It can also return with restored exposure. (#657)
- Stachybotrys chartarum, "toxic black mold",
mycotoxins with various and serious organic effects on exposure.
This contamination in water- damaged structures, and possibly even
to current new construction techniques, is creating havoc among
persons and in the insurance industry. Now a specific antigen has
been developed as a marker to quatify exposure. (#660)
- Oral desensitization to egg in egg-allergic children is
to be successful, but with a 58% incidence of substantial
and respiratory reactions. The indication for this should be
And great care should be exercised. (#668,669)
- Early life exposure to antibiotics for non-respiratory
was found to increase the occurrence of asthma by age 7. This is
likely related to Hygiene Theory effects on the young immune
- Another correlation regarding the increased incidence of
in recent decades was found in the reduced intake of anti-oxidants
(including beta carotene and vitaminesC and E. (#693)
- Chronic Urticaria is very commonly associated with thyroid
(including antiperoxidase and anti-thyroglobulin antibodies).
cases should be carefully worked up regarding thyroid function and
the presence of such antibodies. And the use of thyroid therapy,
in the form of levothyroxine 100 ugms daily for at least two months, is
recommended in in a euthyroid state. (#703,705)
- A connection between serum leptin levels and chronic urticaria
discussed in #704.
- Aspirin urticaria and angioedema can occur with as
of aspirin. In such patients, plavix should be substituted for
cardio-vascular indication. (#708)
- The evaluation of chronic urticaria should includ
of a form fruste of Celiac Disease. (#709)
- The use of dry powder inhalers has been found to be
persistent urticaria and eczema. (#713).
- The use of cephalosporins in patients with a history of penicillin
allergy - and after a finding of negative pcn. skin testing, is
- Several abstracts discuss the DRESS Syndrome (severe drug
systemic signs including fever, adenopathy and organ failure).
relates to Trimethaprim-Sulfa.
- Delayed-type hypersensitivity reaction can occur after injection
non-ionic radio-contrast media despite standard
- Allergy to pork can produce allergic reaction to
medications including heparin. (#724).
- Aspirin sensitivity can produce substantial decrease in
in non-asthmatic persons. (#730).
- Possible sensitivity to amide-group local anesthetics
and mepivacaine is better evaluated through controlled challenge
with preservative-and-epinephrine free agent than with skin
- Trimethaprin-Sulfa hypersensitivity can be successfully
with desensitization over two days. This is important in cases of
HIV - Pneumocystis infection and for peri-transplantation use.
- Mast cells, the predominant leucocyte in middle ear mucosa, may
another connection (in addition to eustacean tube blockage) between allergy
and otitis media. (#748).
- Eosinophilic Esophagitis seems to be a recurring
- A good marker of airway inflamation during inhaled steroid
is sputum eosinophile count. (#777).
- A high prevalence of migraine headaches in patients with allergic
rhinitis has been found. This may be related to histamine or
other mediators. (#786). In any case, I have found that,
the combination is present, the migraine problem improves in many cases
as the allergic rhinitis is effectively treated.
- The standard of care for treatment of chronic rhinosinusitis
medical / allergy treatment before considering surgery. (#788)
- In patients with nasal polyposis and persistent sinusitis,
allergic fungal sinusitis, especially in an immuno-compromised
(#791). Think also about lymphoma(#796)
- Check out Kimura Disease, new to me. (#797)
- An association between asthma and obesity is reported,
related to obesity as a pro-inflamatory condition. (#812)
- Here is a treatment in search of a rationale: Xolaire and Rush
for ragweed hayfever. (#827). "Publish or perish" is still
alive and well, I guess.
- Severe allergic reaction in the course of allergy
is widely acknowledged to be extremely rare. Such reactions
always occur within 30 minutes of receipt of injections, and are
worsened by delay in administering epinephrine. (#829)
- Early childhood viral-induced wheezing, or its
a marker for later obstructive airway problems. (#860)
- There seems to be an increased incidence of allergy in HIV
- HIV can be associated with sub-clinical adrenal insufficiency,
cah become suddenly clinically significant in the course of a routine
prednisone treatment and step-down for another condition. (#897)
- "It says here" that cat Fel D antigen can be affected by
- More on the Dress Syndrome. (#959)
- Very low birth weight and very premature birth has been
a higher incidence of food allergy later. (#963)
- The safety of open oral food challenge in an office
(#973). I would be very careful before accepting that.
- Peanut oral immunotherapy/desensitization is discussed
#979. This obviously has clinical utility, but should be further
researched before trying it.
- In a patient with neck and facial "angioedema", gradual or
think also of Superior Vena Cava Syndrome. (#984).
any case, time is critical.
- In patients with history of egg allergy, the ability to
amount of egg enables receipt of Flu vaccine. Where the history
uneqivocal, a puncture-prick test probably precludes ise of Flu
a negative test allows it. (#996)
- Acute angioedema from TPA intravenously (eg. for stroke)
likely to occur in a patient taking an ACE inhibitor. (#997)
- The value of 2nd generation antihistamines in the treatment of
asthma is reported in Abstract #1048.
- Check for staph superinfection in patients with nasal polyposis
Finally, there is ample clinical and research evidence for the long-term
benefit derived from a program of allergy immunotherapy of
to five years duration, on average. Most patients remain
for over five years. (#1057). In my experience, about 85%
patients so treated do not need further AI. 10-15% of patients
to relapse within 2-3 years and benefit long-term for a further 2 year
course of AI. A very small number of patients do not
discontinuation of AI for more than 4-5 months and - if their condition
is sufficiently troublesome, including all active asthma - require
AI. Abstract #1055 describes IgG4 and IgE changes after
PEARLS FROM ABSTRACTS OF PAPERS PRESENTED AT
AAAAI 60th ANNUAL MEETING, MARCH 19-23, 2004
In addition, both allergists and pulmonologists are beginning to use
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
At least now their IgE mediated disease process will finally be
- Heparin inhalation inhibits mast cell activation and may be
molecular weight heparin as add-on treatment for bronchial asthma.
- Astelin is clinically useful as a nasal spray, similar to
- Effective inhalation drug delivery for children: blow-by with
tube is cimilar to close-full mask, and is better tolerated by young
- "Singular is better than theophyllin in asthma". Maybe, but
- There are patients with irreversible asthma despite all
Efforts are being made to identify this cohort of patients early.
- Cockroach allergy is very important, especially in urban
- Some children fail to respond immunologically to
- IVIG preparations canbe given safely sub-cutaneously, with
This is especially useful in patients who develop recurring troublesome
reactions from the IV route.
- Job's Syndrome often includes also skeletal abnormalities.
- Mold contamination (especially toxic molds like stachybotyrum
is becoming ever-more important...not only in homes and in the
but also in autos.
- Latex allergy substantially reduces in an individual with
Also, cutaneous latex allergy can evolve...sometimes suddenly...into
- Respiratory reactions have been detected from exposure to
to the gasoline additive MBTS.
- Allergic reactions are reported to many agents (eg. hops, beer,
Just assume that anything, including cortisone, can be allergenic.
- Allergy to the important drug methytrexate can be reduced with
- There is cross-reactivity between beta-methasone and
So that's why dexa-methasone is a fair substitute for celestone in
who are otherwise steroid-resistant.
- Alcohol-related eruptions from tacrolimus are reported.
- In "penicillin-allergics", there is a low risk of allergy
generation cephalosporins like cefuroxime.
- Rapid desensitization is possible for allergy to TMP-SMX used for
"Easy and safe".
- Regarding the question of stinging insect venom immunotherapy in
to large local reactions, the authors report a 10% incidence of
to generalized reaction. ??
- The drug allergy history reported for hospitalized patients is
and innacurate. Beware.
- Interferon alpha is being used in treatment of systemic
- One interesting report suggests that the likelihood of later
to outdoor aero-allergens may be related to month of birth. The
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
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.
- Even in a soy allergic person, soybean oil is reported to be not
- Here's a peculiar one (abstract #388). Researchers in San
report a "Creative Syndrome": ..."artistically creative atopic
demonstrated more severe and more frequent Total IgE Deficiency (less
21 IU/ml) compared to the control group of atopic non-creative
From this they suggest extra-immunologic function for IgE. ??
- One abstract found no correlation between the findings of
and skin testing, one the one hand, and total and specific IgE.
authors suggest that using the former parameters is enough. Of
that is what most of us do most of the time.
- Regarding peanut allergy: the sensitivity may not resolve; if it
it may recur; it is difficult to avoid completely exposure everywhere;
Epi-pen should be carried at all times; roasting and boiling enhances
allergenic properties of peanuts. Therefore, Beware!
- In abstract #560 we learn that there may be a connection between
areata and very high eosinophile count; that eosinophiles are activated
by necrotic epithelial cells; and that eosinophiles can be activated
- Sodium Hypochlorite solution (2.4%) is useful for cleaning moldy
- In abstract #619 we learn that patients sensitive to
can generally tolerate non-antimicrobial solfonamides like sulfonureas,
diazide and loop diuretics, carbonic anhydrase inhibitors, celebrex and
- NSAID sensitivity generally does not involve Cox-2 inhibitors
and vioxx. However, there is cross-reactivity in 10% of
Therefore, careful challenge testing is appropriate.
- There was found to be a 56% incidence of exercise-induced
in recreational road-runners. This seems quite high, but may be
by the fact that EIB can be overcome often by "running through
Of course, that could be risky. Thus the need for awareness,
pre-medication, and the availability of a rescue inhaler (albuterol) in
- The effect of paranasal sinus surgery on maxillary sinus mucosal
is slow and partial. Such surgery, including intra-nasal surgery,
generally follow - and often may be obviated by- proper allergy
and comprehensive treatment. This is true for children as well as
- See abstract #714 for a discussion of "Hyper-IgD Syndrome".
- Viteligo is an auto-immune process.
- In Stevens-Johnson Syndrome, IVIG may be useful.
- A new, potent, selective PDE4 inhibitor, Roflumilast, holds
another anti-inflamatory agent in the treatment of bronchial asthma
abstracts #773,780,784,and 785).
- As part of the "Hygiene Theory", early life exposure to sources
may protect against allergic later in life. As noted in abstract
#812, this appears to be true also for eczema (atopic dermatitis).
- There is ample evidence of under-utilization of Epi-Pen in
circumstances by parents and teachers. This is unfortunate and
- It is suggested that gender-based Epi-Pens may have to be
view of the finding that the generally greater depth of sub-cutaneous
in women makes the desired intra-muscular administration of the
- IgE level tested shortly after an episode of anaphylaxis may be
deminished or negative.
- Swimming in lakes has produced anaphylaxis secondary to allergy
- Abstract #857 is an important report on "Idiopathic Anaphylaxis",
and recurrent event for patient and physician alike. One ray of
"Episodes decline over time in severity and frequency".
- Pectin used during barium enema procedure may produce anaphylaxis.
- Intra-operative anaphylaxis my rersult from latex sensitivity.
- Specialty care is more effecive and cost-effective than that
family physicians and pediatricians.
- Abstract #935 describes bi-phasic anaphylaxis, occurring in
of cases, and within 10-38 hours. In these patients, time to
of initial episode was significantly longer; and they generally
less epinephrine and corticosteroids. Thus, the issue of
should always be considered, as well as sufficient discharge
- Abstract #936 emphasizes the importance of the intra-muscular
epinephrine in the treatment of anaphylaxis.
- "Promising" studies are underway of a sub-lingual epinephrine
- The occurrence of RS virus infection early in life increases both
of asthma and of Th2 mediated allergic disorders later in life.
- A condition new to me is described in abstract #978:"Exercise
Prolapse in Elite Athletes - 'Curable Asthma'"
- Beta blockers may be used judiciously for congestive heart
with bronchial asthma or COPD.
- Beware sudden-onset near-fatal or fatal asthma. Abstract
One circumstance where this can occur is in an aspirin-sensitive
- Cancer Chemotherapy anaphylaxis (or anaphylactoid reaction) is
with some increased frequency. Abstract #1131 notes that this reaction
may not be IgE mediated and is not prevented by conventional
- Abstract #1155 describes one approach to the vexing problem of
Drug Allergy Syndrome".
- Abstract # 1215 discusses the possible role of IgA in allergic
- Abstract #1240 discusses the possible non-psychogenic,
of Lexapro in the treatment of atopic dermatitis.
- Abstract #1241 discusses the use of Efalizumab (a humanized
IgG1 antibody in moderate to severe plaque psoriasis.
The latest pearls from Allergy Abstracts, 2003
The following are "pearls" extracted from the 2003 Year Book of
Asthma, And Clinical Immunology (Mosby), a yearly feature of this
site. Please see also earlier year book offerings in this
These are the main themes for the last year. Where appropriate,
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
treated by a certified allergist for most of the above
Only in that way can you be sure of comprehensive evaluation and
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
is always better to work to interrupt causes than to try to modify
- Always suspected and generally assumed, specific genetic bases
inheritance of both bronchial asthma and IgE / atopic allergies are
worked out, holding promise for the future of genetic therapy for these
- Dendritic cells are involved in the Th1-Th2 balance
cells, the Th2 cells being responsible for atopic diseases. (See
the Hygiene Theory). Atopic
cells produce less IL 10 and IL 12, this leading to more Th2
Th2 cytokines include IL4,5, and 13.
- Mycoplasma and Chlamydia pneumonia organisms are
58% of exascerbations of bronchial asthma. The Macrolide
(Biaxin) is a good antibiotic for such infections. Zithromax
generally ineffective as treatment for respiratory tract
One mechanism of action by which these infections worsen asthma is
an increase in cytokine production.
- One important theme this year, amplifying on similar concerns
in recent years, is the increasing finding that some asthmatics do
respond to appropriate treatment with inhalational cortico-steroids
(and the spectrum of other medications used for this condition).
The reason for this is unclear, but the result is a progressive decline
in lung function over years despite such treatment.
once again no mention is made of the use of allergy immunotherapy,
only treatment that addresses causal agents instead of effects.
This treatment should be an integral part of the comprehensive
of all asthmatics in whom a historical and/or skin test basis for
basis is sought and detected. In the experience of those of
us who do this, progression of asthmatic debility is a rare occurrence.
- There is a striking amount of sensitivity to cockroach
populations. This is very likely a cause of the
high prevalence and severity of asthma in such populations, especially
in the children. It must be sought out and can be treated with
- Nocturnal awakening in asthmatic children is a clear
asthma and must be treated.
- Several studies have found that the proper use of MDI's is as
as Inhalation Nebulizers. The key is proper instruction and
- Several studies found that, despite good instruction, environmental
control in allergic households is usually poor. This should
the basic mainstay of allergy treatment and must be required by the
- Many studies show that parents, physicians, and sometimes even
chronically under-estimate the severity of the patient's asthma.
This is serious...and can be fatal.
- Viral infections are responsible for over 80% of asthma
In chronic asthmatics and especially in patients with COPD, however,
bronchial tree may be chronically colonized with bacteria. Thus,
when an exascerbation becomes associated with purulent mucus discharge
over 12-24 hours, appropriate antibiotics are indicated.
- There are several conditions that can mimic asthma, known
of "pseudoasthma": vocal cord dysfunction; rhinitis; GERD, chronic
post-viral cough, hyperventilation, and obstructive sleep apnea.
These should be distinguishable by means of a thorough medical and
hostory; but pulmonary function testing - with or without methacholine
challenge - may be necessary. In addition, many patients have
several of these conditions simultaneously. One of the most
combinations include bronchial asthma, allergic rhinitis, GERD and
sleep apnea. This latter condition is very important and should
be missed. Please see information and a questionaire on that
in another section of this web-site.
- Exclusive breast feeding of an infant for
four months of life has been found to reduce the later incidence of
asthma in childhood.
- Inhalation cortico-steroids must always be a part of the
of anything but mild, sporadic asthma. Thus, any asthma
on two or more days per week warrants this approach. Furthermore,
treatment with these agents must be constant and not "as needed" in
to be effective.
- Persistent, "refractory" asthma warrants re-evaluation
allergies, any exposure to cigarette smoke, occupational
evidence of persistent airway inflamation reflected in elevated induced
sputum eosinophiles and/or in marked improvement in post-bronchodilator
pulmonary function testing despite apparently good clinical
Non-responsiveness to prednisone and to methyl-prednisolone can often
overcome by use of celestone (betamethasone), when available, or
by use of dexamethasone. Regarding cigarette smoking (or
smoking, for that matter), my long-standing rule is that an asthmatic
who simply wants to continue smoking and not to avail himself or
of our effective help to stop smoking is discharged from my
Smoking and asthma is a sure prescription for advanced chronic
disease at an early age.
- Cardio-selective B blockers are generally tolerated in mild to
asthma. Related eye drops may still be a problem, however.
- There is a rather high (20%?) incidence of persistent cough
with the use of ACE inhibitors, much less so with ACE receptor
- Bronchial asthma can lead to COPD / chronic
It also often accompanies COPD (20-40%?) and may then be the only
part of the patient's condition. Thus, it must always
- "World Trade Center Cough" is an unfortunate new entity
It is characterized by chronic cough and bronchial
It may be chronic.
- The incidence of atopic/allergic disease (asthma,
atopic dermatitis) has increased to 30% in developed countries, for
- Allergic rhinitis has been found to lead to bronchial
not adequately treated, in about 40% of cases.
- Children with asthma are as likely to "grow into" more
"grow out" of asthma. Therefore, delay in applying adequate
is a big mistake.
- One article gives a guide to the proper dose of Epi-Pen for
up to 15 kg weight, use Epi-Pen Jr; over this weight, use the standard
product. Occasionally, the severity of an expected reaction
my modify this upward.
- Fatal allergic food reactions are most commonly due to
peanut, in that order. This outcome is especially possible if
is part of the allergic reaction. Great care must be taken
for prevention. For treatment, monoclonal anti-IgE (Xolair) is
- One "old adage" that I just made up is: if you wish to do
research, read the medical literature of 40 years ago...and do it
That seems true of the recent and increasing interest in endotoxin
lipo-polysaccharides as immunomodulators. Stock bacterial
- Benadryl, found in many OTC medications, is worse than
impairing reflexes and affecting driving ability.
- The treatment of atopic dermatitis (infantile eczema) now
not only topical steroids but also tacrolimus and pimecrolimus
The latter may also be used, with fewer side effects, as chronic
- Bone marrow transplants (especially the allo-geneic
produce IgE-mediated allergic reactions in the recipient.
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
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
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
personal experience (over 40 years in practice in this field - and
- There are many articles regarding the proven effectiveness of Allergy
Immunotherapy ("shots, desensitization") for a variety of allergic
problems, notably allergic rhinitis and bronchial asthma
- The uses of leukotriene receptor inhibitors like Singulair
to include allergic rhinitis and chronic sinusitis in addition to
asthma, in children as well as in adults (#10,313).
- The safety of orally inhaled steroids in children
documented, especially regarding those agents least absorbable
(Flovent, Nasonex); (#12,607,800). See below for more reasons to
consider their use much earlier in affected children.
- Zyrtec continues to lose the debate regarding somnolence/reflex
impairment side-effects of second generation anti-histamines,
as compared with Allegra, Claritin and Clarinex.(#14). It
is best for allergic rashes and itching. And all are much better
than Benadryl for effectiveness and for side-effect profile.
- Simple saline irrigation of the nasal passages
Spray) is effective in reducing nasal congestion, not only in dry
conditions but throughout the year. (#23). "Try it. You'll
- Chronic Rhinitis and Sinusitis in children is
recognized as a significant problem, both in its own right and as
to accompanying or later bronchial asthma. But it must be thought
of to be diagnosed, by procedures including allergy evaluation,
for immune deficiency and for ciliary dysfunction, and ENT
- Anti-Ig E, in the form of Omalizumab and Xolair, has
the research labs and is entering the clinical realm, despite practical
shortcomings. Stay tuned. (#54,295,299,534).
- The central importance of mold sensitization (in
and cockroach emanations in urban settings) is clear - even without
the toxic molds (Stachybotyrum) that are beginning to create havoc in
homes and businesses throughout the country. (60,92,287).
- Toxic mold infestation can be insidious and pervasive,
only water damage and darkness added to the building practices of the
25 years, and leading to generalized, vague but very troublesome
and impairment, including cognitive impairment. It is
to diagnose and to treat. But prompt and thorough mold
in an affected structure can be very effective. (#92,548,549,712).
- A large variety of allergic reactions to medications,
other agents are reported.
Bottom line: anything can cause an allergic reaction in a
individual...even anti-histamines and cortisone.
- An article regarding Latex allergy points out that the use of
gloves can go a long way to mitigating this problem in the workplace
- In some patients with exercise-induced anaphylaxis, often
post-prandial setting, wheat - containing foods have been eskpecially
- Abstract #126 documents the compliance problem with the
availability of Epi-Pen for patients susceptible to acute generalized
reactions. It is of no use to you if it is not with you at the
- As GERD has been diagnosed more frequently in infants, the
condition called eosinophilic esophagitis has been reported to be
with food allergies in children (#131).
- A large number of abstracts discuss the treatment of Bronchial
still probably the most poorly diagnosed and poorly treated serious
in America today - with no excuse for that state of affairs
- Tacrolimus and related agents (Protopic, Eladil) are proving to
addition to the treatment of atopic dermatitis and also other
long-term safety appears to exist also (#244, 352).
- More uses for the "black box" called IVIg (an immunomodulator
uses) are reported (#289,668).
- It has now become evident that, although ACE inhibitors are the
associated with angioedema, ACE Receptor Inhibitors also can
have this adverse effect (#394).
- Aspirin desensitization, around since the mid-1980's, is
resurgence of interest for some patients with Aspirin sensitivity
of its very useful anti-inflamatory effects. But it must be
under a specific and carefully-controlled protocol - because aspirin
can kill! (#410).
- The special case of pruritis in the course of hemodialysis is
in Abstract #435).
- Of course, chronic urticaria, the bane of patient and physician
is represented (#453,674).
- Peanut allergy, very dangerous, was discussed under anti-IgE
is also found in Abstract #502 et al).
- Flushing, rashes and other symptoms that may be confused with
are the serious problems of systemic mastocytosis and carcinoid
- The possible relationship between the histamine content of some
food-associated reactions is discussed in Abstract #750.
- Abstract #895 discusses newer approaches to the diagnosis of
and its "forms fruste".
- The Hygiene Theory is alive and well, with more and more being
regarding a central role for endotoxin (#903,1111). We may yet
an FDA -approved form of Stock Bacterial Vaccine.
- The possible utility of Vitamine C as a beneficial immune
noted in Abstract #1004.
- The perennial and serious problem of Hereditary Angioneurotic
C1 esterase inhibitor (quantitative and/or functional) deficiency is
in Abstracts #1018 and 1019.
- Abstract #1042 reviews the established relationship between
(both before and after delivery) and illnesses in children, including
diseases. That is why I consider tobacco use in these contexts to
be forms of child abuse.
- There are several Abstracts which discuss the feasibility of skin
and also of desensitization for antibiotic sensitivities.
- The tablet forms of plain Robitussin - type mucolytics, such as
G (1,200 mg. twice a day) and Humibid LA (twice a day) are useful in
ancillary treatment of bronchitis, asthma and URI - sinusitis.
- Added to the many useful effects of Theophyllin agents
mucolytic, cardiotonic, ciliary stimulant, diaphgramatic musculotonic)
can now be added anti-inflamatory agent, through now well-defined
- Eye drop use such as Ketotifen may now improve also nasal
through the lachyrmal duct connection.
- Allergic Rhinitis and large-tonsil-associated Obstructive Sleep
children can be confused with ADHD, a very unhelpful error on several
- Substantial chronic airway inflamation in the young (ie. chronic
even in the first few years of life) is now being increasingly
- Mast cell-derived chemicals like histamine are associated with
well as early-phase inflamatory-allergic reactions. Thus the
of reducing and even eliminating the release of these chemicals in the
first place by means of properly applied allergy immunotherapy.
Serum Tryptase levels can be auseful marker for suspected
reactions. In fact, elevated serum tryptase levels have been
in infant deaths diagnosed as SIDS.
DIVING FOR PEARLS
YEAR BOOK OF ALLERGY, ASTHMA, AND CLINICAL
The above developments, expanded minute by minute throughout the
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!
- IL 4 and IL 5 both contribute to airway inflammation in bronchial
by promoting airway eosinophylia through a mechanism of suppressing
- IL 18 may be an important non-invasive inflamatory marker of
being higher with active disease.
- Exhaled nitric oxide (NO) is such a marker, although it is not
NO plays a harmful or beneficial functional role.
- Lung function is not a good predictor of “health related quality
- HRQL”; this reflects the substantial variability from patient to
regarding tolerance to bronchospasm, shortness of breath and consequent
hypoxia. Particularly dangerous to themselves and to their
are those patients with a high tolerance. They must be identified
promptly and watched closely, both clinically and with frequent peak
flow testing. See also Abstract 2-36.
- Both local and systemic responses to inhaled lipopolysacchride
endotoxin), ubiquitous contaminants of our environment, were found to
inversely with atopic status. These chemicals are now considered
immune modulators that may be the explanation behind the paradox called
the “Hygiene Theory”. “...some, but not all, the effects in LPS
want to be examined and used for treatment of atopic disease in
Abstract 2-13, p36. Of course, this is what many of us allergists
trained in the use of “stock bacterial vaccine” were achieving for
- until the FDA took the product off the market as being “without proof
of efficacy”. Too bad. But maybe....
- One article supports the use of the telephone for evaluating
in our asthmatic patients. We have recognized and used this for
- Several articles reflect the often poor treatment asthmatic
and often adults - get in emergency rooms.
- Abstract 2-23 points out that the presence of pets in the house
children is associated with an increased incidence of childhood
Thus, having pets is not the way to get the benefits of the “Hygiene
in our opinion.
- Abstract 2-27 is entitled “Reasons for Pediatrician
Asthma Guidelines”. Really! These physicians as a
generalists in the care of children, frequently “don’t know what they
know”. They certainly do not make proper use of specialists and
specialty guidelines for the care of their patients. It pains me
to say this. But I, and my patients who were referred
by their mothers, have experienced it all too often...and have had to
up the pieces. See also Abstract 2-46, and the note below.
- Now there is some evidence that pre-born children with atopic
may benefit - not only from maternal pre-natal diet manipulation - but
also from maternal pre-natal environmental control. Abstract 2-29.
- The benefits of inhaled levalbuterol (Xopenex) over racemic
are outlined in Abstract 2-34. My patients and I can
attest to that. It is to be hoped that an appropriate oral
may be developed soon. See also Abstracts 6-14,15.
- Abstract 2-39 addresses the long and increasingly common
experience of non-allergic,
non-asthmaticchildren and adults developing a viral respiratory
infection that produces wheezing and related dry cough. If not
early and aggressively, sometimes requiring not only inhalational but
oral steroids and other medications, it can be the beginnning of years
of asthma. These conditions are called “acute asthmatic
and “post-viral hyper-reactive airways syndrome”. Some of
incriminated viruses include RS virus, rhinovirus and coronavirus.
Some specific bacterial infections, including Mycoplasma and
pneumonia, may be especially associated with asthmatic responses
with chronic bronchial asthma. Abstract 2-42.
- Non-invasive predictors of asthma control, both generally and
of inhaled steroids, include sputum eosinophilia and exhaled NO.
- Dexamethasone may be a better steroid for short-term asthma
prednisone, with fewer side effects and shorter dose schedule.
- “Airway Responsiveness in Early Infancy Predicts Asthma,
and Respiratory Symptoms by School Age”. Abstract 2-46.
No, you don’t wait until “the kid outgrows it”. You evaluate,
and treat it appropriately from the beginning.
- The relationship between bronchodilator overuse (and
underuse) and mortality from asthma is addressed in Abstract
This is a very big problem, and physicians are generally not dealing
- Abstract 2-51 deals with those serious asthmatics who, despite
treatment, progress on a down-hill course through the years, as
by deterioration on serial pulmonary function
This is undoubtedly a heterogeneous group of patients. But the
denominators to dealing with this issue include: complete and accurate
initial diagnoses, including a search for underlying atopic disease
even where inapparent, and including a search for serious upper
disease; comprehensive medicinal treatment, clearly understood by
the patient; insistence upon adherence to treatment and
total and permanent discontinuation of tobacco use; regular
of pulmonary function tests to detect those patients who - although
controlled - demonstrate high-grade airway reversibility...and
continuing active airway inflammation; and comprehensive
of any underlying atopic activity with allergy immunotherapy, the
form of modulation which deals with causes and not only consequences.
With this approach, it is the very rare patient with bronchial asthma
whom I cannot demonstrate improved or at least stable lung function
decades of follow-up.
- Once again it is demonstrated that leukotriene receptor
singulair) are not adequate substitutes for inhaled steroids; but
they enhance the benefit to be derived from inhaled steroids when used
- Similarly, adding a long-acting inhaled B-agonist (Serevent or
to a regimen including an inhaled steroid produces better results than
even doubling the steroid dose. This combination is also more
than is either chemical alone. This relates directly to
and possibly to reversal of “airway remodeling”, as reflected in
of the basement membrane with types 3 and 5 collagen and related
activity, hyperplasia and hypertrophy of smooth muscle, goblet cell
- There are two types of croup in children: one associated with
related to RS virus infection); and the other not associated with
(usually related the parainfluenza infection). Only the one
with wheezing is very often followed by persistent wheezing for years
come. Abstract 2-56.
- Aspirin, besides being a potential cause of serious allergic
is also a potent immunomodulator in achieving its anti-inflamatory
It has been found to significantly inhibit IL-4, a cytokine that
bronchial hyperreactivity. Thus, it should be part of our
although it should be used carefully and selectively, in view of its
at times to “blow up in our hands”.
- In addition to the well-known activities of eosinophiles, IL-4
in the inflamatory processes affecting Asthma, studies are now
PMI’s, through the action of IL-8 and IL-8 as involved in similar
These findings are important in providing more targets for possible
- Several mechanisms are proposed for the established efficacy of
immunotherapy in modulating - desensitizing - allergic sensitivities:
of blocking IgG antibodies; reducing CD-4 cell helper activity or
stimulating CD-8 cell suppresser activity to effect the
reduction in specific IgE levels. To these must now be added the
promotion of rapid apoptosis (cell death) of Th2 lymphocytes when
- after immunotherapy - with specific antigens. Abstract 3-6.
- The Hygiene Theory has produced a debate regarding whether the
of pets in the house (specifically cats) is beneficial or detrimental
atopic infants and children. (See Abstract 3-14). I, for
believe that the probable beneficial effects of early exposure to
pollution, infection and other sources of endotoxin can be attained in
ways other than by introducing such sources of strong allergens into
household of allergic individuals. See Abstract 3-25. In fact, I
have for some time suspected that Cats are the first Aliens to
Earth, and that they are about to take over!
- Several articles offer evidence that premature birth reduces the
of later atopic sensitization. This appears to depend on the fact
that the more immature immune system, when first encountering the
environment, may be more able to develop tolerance to antigens.
3-15. Indeed, the risk of atopic sensitization was found to
progressively with gestations of 35 weeks or more. Abstract 3-16.
- The bacterial colonization of infants born by the vaginal route
from that resulting from caesarean section birth. And it has been found
in at least one study that children born by caesarean section
a much higher incidence of asthma later in life. Abstract 3-18.
- The use of “probiotic milk”, containing cultures of
by the pregnant woman and also by infants and children has been shown
substantially decrease the incidence of allergy and of respiratory
in these children. This is another offshoot of the Hygiene
- Childhood exposure to second-hand smoke is well-known to produce
bad results: increase in middle ear infections, bronchitis, pneumonia,
and stunting of the ultimate size of the developing lung. To all
this is now added the finding that such exposure may promote allergic
Abstract 3-22. I fact, I advise parents of children referred to
that, after receiving such information, their continued smoking in
child’s household will be considered by me a form of child abuse.
- There are many articles describing the benefits of tacrolimus
(protopic, elidel) in the treatment of atopic dermatitis. Indeed,
this is probably the greatest advance in this area sinde the advent of
topical steroids. And another article describes its effectiveness
in the treatment of the skin manifestations of chronic Graft-vs-Host
a common complication of allogeneic bone marrow transplntation, used
a variety of cancers. Abstract 4-5.
- The utility of leukotriene receptor inhibitors (eg. montelukast -
for treatment of atopic dermatitis is also described. Abstract
- The benefits of higher - dose IVIG in the treatment of
states is described. Abstract 5-3.
- Omalizumab, a recombinant humanized anti-IgE monoclonal antibody
block the interaction of IgE with mast cells and basophiles in allergic
reactions, has been found to be both safe and effective in the
of serious bronchial asthma patients in a Phase 3 trial, as required by
the FDA before approval. Its availability must be that much
to reality - but not yet.
- Once again, over and over again in the last four decades,
is found to be useful in the treatment of bronchial asthma (and
It is a remarkable medicine that has many therapeutic effects.
6-22. In fact, if you want to do “original research”, read the
of 40 years ago - and do it again.
NEW AND NOTABLE - 2002: ABSTRACTS OF
RESEARCH IN ALLERGY, IMMUNOLOGY AND BRONCHIAL ASTHMA FROM AROUND THE
The following represent my “take” on the Year 2002 research and
offerings previewed for the March, 2002 annual meeting of the
Academy of Allergy, Asthma and Immunology held in New York
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,
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
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
many physicians, and a devil-may-care attitude on the part of many
The numbers which accompany each personal commentary refer to the
abstract(s). Many if not most of the abstracts will be published
as complete articles during the coming months in the Journal of
and Clinical Immunology.
1) Aspirin / NSAID-Induced Asthma (#50,220):
Contrary to decades - old clinical impressions, aspirin -
asthma commonly is associated with underlying allergic (atopic)
Such patients should thus be fully evaluated. Potential reactions
fall into two categories, although not totally separate: urticarial /
reactions; and severe (or suddenly lethal) asthmatic reactions.
desensitization under controlled circumstances is not only possible,
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
It has several other pharmacologic properties which may find clinical
One of these is its anti-inflamatory property which, when applied by
has been reported to reduce both early and late phase asthmatic
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
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
reason for the epidemic of asthma in the western world during the last
two decades. In fact, the particular preponderance of bronchial
in children of inner cities may well be related to the inordinate
of time school - age children spend on school buses with diesel engines
running, estimated to be about 180 hours per year. Local and
agencies are beginning to address the issue of school bus engine
4) The Hygiene Theory (#80):
This theory is based upon numerous observations
an inverse relationship between exposure to air pollutants and/or
of respiratory tract infections on the one hand, and the incidence of
The immunologic effect associated with this connection is the tendency
for infections to stimulate the immune system from Th2 reactions
allergic disorders) to Th1 activity. Although the connection is
likely valid, a few reports have tended to confound the lessons to be
from these experiments of Nature. One study, referenced here,
that allergic tendencies might protect against respiratory tract
Other studies suggest that having a pet in the house might be of
to allergic individuals. Both of these suggestions fly in the
of broad clinical experience that relates allergies to increased
and severity of infections, and that associates prolonged exposure to
and cats in the home environment with almost inevitable sensitization
worsening of the allergic manifestations. (If chronic urticaria
the bane of allergists’ existence, CATS especially are their
Might CATS really be the first aliens to arrive on this planet,
to take over the world??) Indeed, the preponderance of evidence
the Hygiene Theory and related research seem to support the
use by some allergists - myself included - of “stock bacterial
especially in children as a useful adjunct to reducing asthmatic
to respiratory tract infections. It has always been suspected
its effectiveness was probably due to the endotoxin content of the
(#96,104,580,611). This product is no longer available because of
“lack of proof of efficacy”. Too bad...but that may change as
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
of many studies. The “Tenor Study”, as established, is positioned
to provide much epidemiologic and longitudinal information, perhaps
to the Framingham Study. The Denver Study describes troublesome
that - despite all the therapeutic modalities in use - loss of lung
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
- who should know better - with the numerous treatment protocols
established for the proper treatment of bronchial asthma; b) although
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
failure of most physicians, pulmonologists and even some timid
to implement the clear theoretical and abundant evidence-based
supporting the use of immunomodulation - in the form of specific
allergy immunotherapy - to eliminate the causes of the asthmatic
process, rather than pursuing its effects. The proper approach to
bronchial asthma is a complete medical and allergy evaluation by a
allergist (since no one else seems able or willing to do it
The proper treatment is comprehensive, including environmental control,
absolute cessation of smoking, expert use of the multiple medications
available and - where unavoidable allergenic agents are detected -
immunotherapy to reduce or eliminate the patient’s reactivity to such
Using this approach, the vast majority of asthmatics (85%+) can
at least stabilization and very often reversal of their disease
with the ability to discontinue the immunotherapy after a few
This has been my experience over the last 40 years, dealing with a
predominating in bronchial asthma, adult and pediatric. The
here for patients is clear:
6) Sick Building Syndrome - Related to Multiple Chemical
“Caveat emptor...Let the Buyer Beware!”
Nothing like adding an enigma to a puzzle. But the
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
7) Indoor Air Quality and Vacuum Cleaners (#114, 121, 1118):
This appears to be a victory for HEPA - type air cleaners
adequate air-handling size over fancy vacuum cleaners, if one or the
must be chosen.
8) Leukotriene Receptor Inhibitors (particularly Montelucast -
- Other Uses Besides in Bronchial Asthma (#131,281, 415, 472, 507,
Although by no means as great a break-through as were the
which came on the scene around 1950, the anti-leukotrienes (Accolate,
are important. They are agents which block the pro-inflamatory
of leukotrienes, products of white blood cells involved in the defenses
and immune mechanisms of the body. Clinically, the best of the
appears to be singulair (montelukast); and it has found wide
in the comprehensive treatment of bronchial asthma. Since this
also has bronchodilator properties, it is also under study as an
medication for emergency use in acute asthma.
9) Other Allergies: What you don’t suspect can hurt you.
The above references describe other uses being studied for this class
- Reduction of pain and itching from local reactions to allergy
Rarely, a patient may experience recurrent delayed (12-24 hour)
local reactions which interfere with compliance and with progression of
treatment. Singulair, 10 mg., taken two hours before injections
be useful here.
- Treatment of nasal polyposis, an inflamatory condition often
with, but distinct from, nasal allergy.
- Treatment of “Samter Syndrome”: asthma, nasal polyposis and
- Pre-treatment for aspirin/NSAID intolerance manifesting as
This, however, is not to be tried (other than possibly in association
aspirin desensitization) when the sensitivity has manifested as
asthma. Such a reaction can be quickly fatal. (See item 1,
- Possible utility, not yet established, for atopic dermatitis
- Reduction of exercise-induced asthma.
Copper, Hepatitis -B Vaccine, heparin, beta-methasone
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),
menthol - peppermint oil - mint (included in toothpastes). So...an
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
10) Mastocytosis (Ref. #202):
This is a condition characterized by an excess number of
cells in the body (in skin and/or in mast cell tumors), the major
of histamine and other chemicals that can produce allergic reactions or
allergic-looking reactions. It can be an occult cause of
reaction. It can be detected fairly easily with a blood and/or
test, and occasionally with a biopsy.
11) The Allergic Rhinitis...Asthma Connection. (Ref. #239):
Numerous studies have shown that allergic rhinitis (hay
with or without ”sinus trouble”) is often a precursor to the
of bronchial asthma, a sequence which can be avoided by treating the
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.
where circumstances warrant a more definitive diagnosis with
effect on the choice among limited antibiotics, skin testing is very
and dependable. It can reduce the use of more high-tech
and thus reduce the development of resistance to these important
for which there are sometimes no substitutes.
13) GERD and Allergies: Not only an association, but also a causal
Dyspepsia may be just another manifestation, reflecting
tissue changes, of allergic reactions in some patients.
the frequency of such symptoms is increased over normal levels in
with asthma as well as in those with allergic rhinitis and atopic
In any case, such symptoms should be treated aggressively, primarily
proton pump inhibitors (prilosec, prevacid, nexium, aciphex),
lower esophageal acidity can produce reflex bronchospasm; and actual
can substantially complicate both upper and lower respiratory tract
14) Steroid Oral And Nasal Inhalers: (Ref # 282, 543, 734, 770):
Budesonide (Pulmocort) has emerged as a prerferred
Meanwhile, the side effects in children appear to be overestimated,
to the under-use of budesonide and other inhaled steroids. And
potential steroid side-effects in adults (such as osteoporosis and
insufficiency) appear to be underestimated.
15) Chronic Urticaria: The Pain and Bane Of Allergists’
(Ref.# 355, 357, 358, 360, 363, 365):
Prudent use is the message here.
Here is another area where we constantly “practice”
we never get it right!
16) ACE Inhibitors / Angioedema Connection. (Ref.#370, 428)
These articles again point out the frequent association between
“chronic” hives (6 or more months duration) and auto-immune diseases
auto-antibodies (expecially anti-thyroid and ANA antibodies).
associations discussed include insulin (definite) land H. pylori
The prolonged use of sulfadiazine (6 weeks) is also suggested
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
(eg. foods), infections (eg. urinary tract or dental infections,
etc.), or to a malignancy.
17) Acquired C1 Esterase Inhibitor Deficiency and
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
are overuse, leading liver toxicity, and deliberate overdosage - with
fatal consequences if not treated promply.
20) Anti-IgE (Omalizumab) (Ref.#458, 460):
This agent, still in clinical trials, will very likely be
effective addition to our treatment modalities. But, is
another “anti-”drug rather than an effort to reverse the
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
If this doesn’t work, the authors suggest a really big gun:
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
cause through an ill-defined mechanism generally assumed to be
And it works many times!
23) Latex Allergy (Ref.#785, 873,1033):
The treatment is, however, somewhat laborious to administer; and it
carries a small risk of side effects, including the possibility of
- type reaction. The above reference describes the sub-cutaneous
administration of Ig, avoiding the inconvenience and the
with reportedly better trough levels. This is worth checking out
if you are in that arena.
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
26) Anti-Histamines and Skin Testing (Ref.#805):
25) Gluten Intolerance (Celiac Syndrome) and Wheat Intolerance
Avoiding gluten in foods is more difficult than might be expected for
patients so afflicted. It is, of course, the entire basis for
treatment and is thus highly important.
Skin testing, (particularly intradermal skin testing,
as the gold standard), is very important, second only to a carefully
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
from the antigen-antibody reaction being sought. 1st generation
(Chlortrimeton, Benadryl) should no longer be used, except in an
because of the sedative effects and also because of their reflex
impairing activity (eg. in driving). 2nd generation
generally lack these side effects. But their effect on skin tests
is of much longer duration. This is true of claritin, allegra,
and astelin; and it is especially true of clarinex, the newest arrival
on the scene. Based upon the latest reported evidence,
of these anti-histamines should be taken by a patient scheduled for
testing for one week before the procedure. Of course, the
patient’s symptoms must be otherwise controlled during that
This can ordinarily be accomplished with inhalational or nasal steroid
sprays - or in more complicated cases with a short course of oral
ALLERGIC SYMPTOMS CAN ALWAYS BE CONTROLLED. THE TRICK IS TO DO SO
WITH THE MOST EFFECTIVE COMBINATION OF MEDICATIONS, THE FEWEST SIDE
WITH A COMMITMENT TO TREATING - AND REVERSING - THE UNDERLYING
PROCESS RATHER THAN MERELY TREATING SYMPTOMS. THAT IS THE
ALLERGIST’S STOCK IN TRADE.
The following are summaries of the latest
in this field reported at the 57th annual meeting of the American
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
Diesel fumes, toxic and carcinogenic in many ways, also stimulate
IgE, the allergy - producing antibody in everyone. This problem
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
including mother’s smoking, secondary smoke, pet avoidance and other
control measures, and also mother’s diet during breast -
Skin tests, puncture - prick and especially
intradermal, are the gold
of allergy diagnosis and are far more useful and reliable than the
Penicillin is the most common cause of medicinal allergic
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
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
causation -- but it is real. (#40)
Eosinophilic Gastroenteritis is a particular ailment which can
and other GI conditions. After a positive diagnosis, Singulair
be helpful. (#641, 99,643)
Anxiety/depression is reported to be more common in patients with
Urticaria ( hives, acute and especially chronic) continues
a challenge for both physician and patient. But much can be
Latex allergy is a problem of increasing frequency, especially in
care workers. It can be mild or severe and life-threatening; it
be obvious or obscure. It is diagnosed by history, blood tests,
possibly skin tests. Treatment ultimately consists of avoidance,
since the sensitivity tends not to disappear. There
also cross-reaction with a group of foods. (#384,794)
Occupational diseases include chronic beryllium
In addition to pulmonary and skin involvement, there is reported an
contact reaction the gums from beryllium-containing dental
Soy protein sensitivity is not ruled out by tolerance to soy
Also, soy oil may cause problems. (#464,623)
Chronic sinus disease, complicating fungus infection, the
asthma, and the potential utility of leukotriene inhibitors (eg.
are discussed. (#536,537, 549,551)
Cat protein sensitivity, as manifested in skin testing, is the
allergen: fluffy, sticky, easily and persistently airborne, nearly
to get rid of, and easy to be exposed to on others’ clothing, is a bad
Oral Allergy Syndrome, involving allergic mouth symptoms on
certain foods (particularly certain fruits), may progress to
symptoms. Thus, patients so afflicted should carry an
or ana-kit for self-administration. (#656)
Bumble Bee venom allergy can be yet another occupational illness,
workers in vegitable crop greenhouses that use bumble bees for
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
syndrome”; but it is not considered to cause asthmatic reactions.
“Food-Dependent Exercise-Induced Anaphylaxis” can exist despite
food skin tests and negative RAST tests. (#877) Thus, the
Grape allergy is rare but exists. (#887)
Myasthenia Gravis is an immunologic disease which may at times
from treatment with IVIG, an important immunomodulator for many
with an immunologic base.
“Graft-vs-Host Disease is another immunologic disease which
treatment efforts which are associated with host immunodeficiency,
natural or acquired (eg. secondary to some treatments for
Stachybotyris fungus toxicity/allergy is an emerging causal
in a variety of clinical syndromes occurring in the context of exposure
to homes or buildings which have been water-damaged. This goes well
well-known mold allergy found in similar circumstances. (#1034)
C) Drug Reactions:
Bupropion (Welbutrin, Zyban), a psychotropic agent
widely used and
for smoking cessation, may rarely produce a serum sickness-like
(fever, rash, arthralgias) even days after beginning its use.
Steroids, used topically, orally or by injection, may rarely
reactions, the precise problems for which they are ordinarily
This is true also for H1 (claritin, allegra, zyrtec, etc.) and H2
pepcid, etc.) antihistamines. (#31) The moral of this
story is that any medications or chemicals used for medical purposes
produce allergic or ideocyncratic, as well as toxic, reactions.
Insulin, even human-derived (Humulin) can produce anaphylactic
in addition to local and cutaneous allergy. (#35)
NSAID’s (and aspirin) are well known to react allergically with
(like bactrim, septra, gantricin, etc). Cox-2 agents (vioxx,
may react in the same way, although to a lesser extent.
The worst of the possible reactions is sudden, severe, sometimes fatal
asthma. This, like penicillin allergy, can kill you!
inhibitor increasingly prescribed for lower and also upper respiratory
allergic disorders, as well as for some other inflamatory disorders,
rarely cause a serious systemic condition called a “vasculitis”.
Although some reported “reactions” may really represent the unmasking
“Churg-Strauss Syndrome”, patients should be given the benefit of
the doubt by discontinuing Singulair.
“Natural or Alternative” products may themselves produce
and toxic reactions. (#886) This is really a “black box”
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.
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
adrenergic” drugs only “as needed”, or on a maintenance basis (eg.
serevent-salmeterol). (#338,339,365) I try to avoid
maintenance use of these drugs, for both theoretical and practical
2) Steroid burst treatment (#448), steroid withdrawal
steroid resistance (#771) and the side effects of inhaled
(more prominent with fluticasone).
3) Monoclonal anti-IgE antibody under investigation for the
of allergic disorders.
The concomitant use of “beta-blockers” and/or ACE
the treatment of rare systemic reactions to allergy injection
but they are not contraindicated. The physician should have
and ipatropium, in addition to adrenalin, benadryl, etc. available to
if needed. (#236)
“Stock bacterial vaccine” is a product used for the last
by many, but not all, allergists and initially introduced by the
Dr. Robert Cooke. It has always been suspected,
in the absence of confirmatory research but based upon decades of
experience, to be effective in the reduction of “allergic”
to infectious agents, particularly in children (eg. recurrent acute
bronchitis). The mechanism has been thought to be its endotoxin
Now comes increasing evidence to support this, including the
hypothesis” and related studies of TH2/Th1 cell changes,
“design-allergen for DNA -based desensitization.
Notes Taken from Articles Abstracted in
Allergy, Asthma, and Clinical Immunology 2000
- Many articles address the various functions of different
the pathogenesis of allergies.
- An article on page 17 demonstrates that Staphylococcal toxin, a
super antigen, augments specific IgE responses by atopic patients
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
- An article on page 23 describes the hyper-IgE (Job’s) syndrome
by very high levels of serum IgE together with chronic dermatitis and
severe infections of skin, paranasal sinuses, and lungs.
- The article on page 24 reviews further evidence that atopy and
been on the rise in developed countries, while remaining uncommon in
developed countries, especially in rural areas. The increase is
marked in urban groups. Inverse relationships are reported
atopy and number of siblings and atopy and early entry into communal
- Another article on page 29 discusses this finding further,
infectious diseases produce TH1 type responses resulting in
rich in interferon gamma which participates in the suppression of TH2
- An article on page 43 discusses the fact that polyaeromatic
associated with diesel exhaust particles favor IgE production,
hyper-responsiveness, and airway inflammation.
- In two articles beginning on page 49, the observation is
there is substantial expression of Cox-2 in airway, epithelial, and
cell in the absence of evident airway inflammation. This, in
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
a role in treatment of this condition.
- An article on page 57 reports the contribution of IL4 in the
of allergy inflammation and asthma. Conversely, it discusses the
utility of soluble human IL4 receptor (Nevance) in reducing asthmatic
- An article on page 60 describes the utility of anti-IgE in
cell activation, although without interfering with eosinophilic
Thus treatment with anti-IgE is limited in its effectiveness to early
response. It was also found that concurrent treatment with
suppresses eosinophilic infiltration and interferes with the
- An article on page 63 defines the pathophysiology of allergic
involving TH2 cytokines including interleuken 4 and interleuken 5.
- An article on page 68 supports the evidence of discordance
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
including allergy immunotherapy and environmental control.
- An article on page 72 points out that aerobic exercise, in this
raises exercise tolerance resulting in increased oxygen uptake and
ventilation requirement, thus allowing an individual with
bronchospasm to exercise for a longer period before triggering
It is emphasized, however, that “working through” EIB is to be
because it can produce severe reaction.
- An article on page 74 also addresses EIB noting that numerous
are effective including Cromalin, Tilade, and Singulair. One
the use of Salmeterol powder by Discus for 12-hour protection.
- An article on page 86 emphasizes that importance of introducing
steroids early in the treatment of childhood asthma in order to avoid
responsiveness later, probably associated with airway remodeling.
- An article on page 90 describes the central role of eosinophils
cationic protein and major basic protein in the development and
of airway inflammation. This appears to be true regardless of
the underlying mechanism is allergic or otherwise.
- An article on page 93 reiterates the central role of RSV virus
respiratory tract infection in early childhood stimulating both
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
proven, that patients who have had acute bronchiolitis are much more
to develop asthma subsequently.
- An article on page 101 notes a significant correlation between
nitric oxide and sputum eosinophils as markers of airway inflammation
children with mild to moderate asthma.
- An article on page 102 once again suggests that some degree of
persists despite inhaled leukocorticoid therapy and in the absence of
- An article on page 105 notes that treatment with Singulair
levels of exhaled nitric oxide.
- An article on page 107 demonstrates that allergen avoidance is
with fall exhaled nitric oxide supporting the importance of
- Two articles on page 113 and 115 discuss vocal cord dysfunction
as well as adults. This problem is identified as a paradoxical
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
treated with respiratory phonation exercises, and perhaps psychotherapy.
- An article on page 125 discusses the occupational asthma
cedar and notes that the reactions to this antigen manifest late or
asthmatic reactions to the plicatic antigen.
- An article on page 129 describes glucocorticoid insensitive
a problem which changes over time, so that individuals may vary between
steroid-sensitive and steroid-insensitive situation.
- An article on page 136 describes airway hyper-responsiveness in
of asthma, noting that the development of asthma symptoms apparently
both atopy and hereditary factors. In addition, the presence of
inflammation and remodeling in patients with asymptomatic AHR is
It also notes that some of these asymptomatic patients go on to develop
clinical asthma, those being uniformly atopic with positive family
There is also a suggestion that a critical threshold in airway
must occur in asymptomatic AHR before the development of asthma.
This increases the importance of identifying patients with AHR even
asthma as in the case of patients with upper respiratory allergies
the development as yet of overt asthma.
- An article on page 138 describes IVIG as a
in patients with chronic severe asthma. The mechanism is probably
immunomodulation, so far not elucidated.
- An article on page 140, addressing recognition of early asthma,
at least 40 percent of all children with wheezing, lower respiratory
during their first three years will still have wheezing episodes at six
years of age when more specifically several major and minor criteria
identified in predicting persistent asthma. Major criteria are
for bronchiolitis/wheezing, at least three wheezing lower respiratory
during previous six months, parental history of asthma, and atopic
The minor criteria are rhinorrhea separate from colds, wheezing
from colds, eosinophilia, and male sex.
- Further information from the University of Arizona group
difficulty in identifying those wheezing infants who will or will not
to persistent asthma and also emphasizing the importance of initiating
anti-inflammatory treatment in present and future asthmatics as early
possible; thus the need to give these infants the benefit of the doubt
with anti-inflammatory treatment.
- On page 150, there is further evidence of the importance of the
process in the pathophysiology of severe asthma. The paper notes
two distinct pathologic subtypes of severe asthma: (1) the
eosinophilic process with inflammation, (2) the other, eosinophil
with little evidence of classic asthmatic inflammation. The
type was associated with greater inflammatory cell infiltrate and
incidence of respiratory failure.
- On page 156, we find once again the importance of endotoxin, in
inhaled endotoxin highly concentrated in organic dust. This is a
potent inflammatory agent likely to have a significant role in airway
in patients with asthma. This relates to our premise over many
that the stock bacterial vaccine effectiveness is related at least in
to its endotoxin content.
- On page 161, we find a new name for exercise-induced
“thermally-induced asthma” by E. R. McFadden. He holds that the
of exercise-induced asthma depends largely on the rate of airway
after the cessation of exercise.
- The article on page 163 addresses the issue of remissions of
It is noted that in adults, remissions are relatively rare and
to mild cases and elimination of cigarette smoke. In children,
variability is the defining characteristic. The prognosis is
unpredictable, although children will retain increase airway
and will remain at risk as they reach middle age.
- An important observation is noted on page 169, namely severe
of asthma occurring with the use of interferon A for the treatment of
hepatitis C. The problem diminished with cessation of interferon
therapy. Reinstitution of interferon therapy produced severe
- The next article on page 170 finds that there is no evidence
term asthma leads to the development of emphysema in non-smoking
However, it is noted that non-reversible airflow obstruction is more
to occur with highly variable airflow obstruction at baseline.
some patients with apparently stable asthma who have high bronchodilate
reversibility may need more intense anti-asthma therapy to improve
function and control inflammation. However, in this ten-year
study, it was once again noted that individuals with moderate to severe
asthma remain at risk for development of non-reversible airway
despite treatment with inhaled leukocorticoids. Thus, we should
more aggressive with anti-inflammatory treatment in patients with
reversibility and we should treat them comprehensively including the
of allergy immunotherapy in appropriate cases to avoid the entire
toward chronic inflammation and airway remodeling.
- Articles on page 175 and 176 discuss the delayed-type relations
penicillins, exploring diagnostic approaches. These include patch
testing and intradermal skin testing looking for delayed intradermal
results. These latter tests were found to be a more sensitive
- The article on page 181 casts doubt on previously reported
that MSG ingestion causes asthma.
- On page 188 an article reviews breast-feeding in allergic
the desirability of initiating breast-feeding on atopic infants.
- The article on page 192 discusses the “latex-fruit syndrome”
the now recognized cross-sensitization between latex and the growing
of fruits including chestnut, avocado, and banana. Latex
may also exist without the concurrent fruit sensitivity.
- Another article on page 197 notes that the prevalence of
to natural rubber latex is reported to be between 8 and 17
The incidents of latex-induced occupational asthma are between 2 and 6
- On page 199, the article addresses skin test safety and notes
large experience, there were only six systemic reactions and no deaths
in more than 18,000 patients undergoing allergy skin tests.
- On page 207, we notice once again reference to superantigen
in T-cell stimulation, in this case complicating atopic dermatitis,
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
to use in the 1960s when it was still available.
- On page 227, an article addressing the bane of the allergist’s
namely chronic urticaria, pointing out that often these cases have
autoimmune processes. This is the first report of IgE antithyroid
antibody in a patient with chronic urticaria.
- The next article is on page 234 through 236 relating to common
immunodeficiency, clinical, and also pulmonary manifestations.
the article on page 243 regarding immunoglobulin replacement treatment
by rapid subcutaneous infusion and page 244, renal insufficiency as a
- Also the pages 247 and 248 relate to Churg-Strauss Syndrome and
- On page 251, the major cause of acquired heart disease in
syndrome. The etiology is undetermined, but it appears to be an immune
activation possibly by bacterial superantigens with antibodies
vascular endothelial cells. IVIG has been shown to be an
- The article on page 255 discusses asthma morbidity and
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
care physician for treatment and follow-up.
- The article on page 258 compares the use of nebulizer treatment
metered dose inhalant with holding chamber in children.
is approximately the same but total dose deliver is much higher with
nebulizer. This is true also for inhalational steroids.
- The article on page 263 once again points out that many
disease appears under clinical control still have airway
and airway inflammation, chronic abnormalities that may lead to airway
remodeling, and a worse long-term outcome. Thus the
to treat patients with few symptoms, nearly normal lung function but
airway hyperactivity with higher dose of inhaled steroids than a
with similar symptoms baseline function but with mild airway
- The article on page 265 describes the use of leukotriene
like Singulair for severe premenstrual asthma, a problem in up to 40
of women with asthma.
- We should add here that the article on page 248 regarding
syndrome should also be reproduced as above.
- On page 268, the use of Heliox in a kid’s severe asthma is
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
effects. This of course is in addition to other therapies
IV beta-agonist, IV Theophylline, and IV magnesium. This is for
status asthmaticus. The ratio of Heliox being 70 percent helium,
30 percent oxygen.
- The article on page 272 reports the effectiveness of monoclonal
antibody in the treatment of both rhinitis and asthma.
- The article on page 274 discusses the use of menopausal
replacement therapy and breast cancer risk. The findings are that
the addition of progesterone and estrogen may significantly increase
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
This use of course is for prevention of osteoporosis and importance
- The article on 280 discusses corticosteroid resistance, well
cases of severe asthma but here described in occasional cases of mild
The question is whether the problem is a genetic trait or an
inflammatory response to allergen.
- The article on page 283 discusses the early emergency room use
corticosteroids in children in the ER or hospitalized for acute asthma.
- The article on page 295 is another discussing the benefits of
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,
and adolescents appear to respond more favorably to IVIG than
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.
- A comment on page 305 relates to the debate regarding the
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
- On page 313, the article provides evidence for the improved
of Levalbuterol (Xopenex). “Recent studies have suggested that
summer may actually be deleterious”.
- On page 317 is another article discussing Salmeterol, this time
steroid-sparing agent and suggesting the combined use the two.
- The articles on page 325 and 327 discuss allergy immunotherapy
mechanism of action.
selected results of medical research recently reported at the annual
of the American Academy of Allergy, Asthma and Immunology.
Abstracts of the actual papers
be found in the January 2000 Edition of the Journal of Allergy and
Immunology, Volume 105, No.1, Part 2.
No. 1: reinforcing the well-known
relationship between allergies, allergic rhinitis, and bronchial
abstract No. 3 reports that higher numbers of positive skin test are
in patients with allergic rhinitis, with the diagnosis of asthma.
No. 2: orally exhaled nitric
may move from the research laboratory to clinical use as yet another
reflecting the presence of pulmonary inflammation associated with
Abstract No. 7 found a strong correlation between levels of exhaled
oxide and serum IGE levels,again supporting the important
between asthma and allergic predisposition.
No. 3: in abstract No. 27
is reported a decrease asthma mortality in Israel during the years
probably associated with the increased use of inhaled corticosteroids
asthma. This use promises to be the easiest and best intervention
to reverse the ongoing epidemic of morbidity and also deaths from
No. 4: abstract No. 33 and
other abstracts report the correlation between regular use of inhaled
and reduced levels of exhaled nitric oxide, reflecting reduction in
pulmonary inflammation, the mechanism for ultimate lung scarring.
No. 5: abstract 52 reports on the
beneficial effects of high dose IVIG administration as
steroid-sparing agent in the population of patients with severe
No. 6: several abstracts
on the continued reliance of many asthmatics, particularly in
on the emergency room for the care of their asthma. The abstracts
also show that, apart from the resolving the acute attack, emergency
treatment is poor with regard to establishing for the patient a
program of treatment.
No. 6: increasing evidence
that levalbuteral (Xopenex) is more effective for treatment of
than the usually used albuteral for inhalation. See
No. 7: abstract 82 reports that
addition to Wegener’s Granulomatosis, nasal mucosal
septal perforation may also result from cocaine abuse.
No. 8: abstract No. 92 reports
evidence that microbial infection early in life may have a
efffect on the development of atopic disease. This abstract also
investigates the role of endotoxin in this
an issue which may well be related to the effectiveness of stock
vaccine, used by some allergens including myself, as part of a
of Allergy Immunotherapy. (See that section on this web-site).
No. 9: abstract No. 220
the importance of gastro-esophageal reflux disease, not only in
evaluation and treatment of asthma, but also in the evaluation of
upper airway disease .
No. 10: several abstracts
the utility of the newer leucotriene receptor antagonists like
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
even in childhood. See abstract No. 307.
No. 12: abstract No. 371
that fragrances frequently cause respiratory symptoms asthmatic
Their use should be minimized both by asthmatics and by
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
of insect pest control has led to increased allergic sensitization to
insects, producing reactions including asthma, allergic rhinitis,
and allergic conjunctivitis.
No. 14: there are numerous
regarding the increasing problem of latex sensitization. One report
that reasonable precautions taken by affected health care personnel,
elimination of contact with latex gloves, can often resulted in the
of being able to maintain health-care employment.
No. 15: although the clinical
of this is often difficult to evaluate, abstract 408 describes
foods containing varying levels of naturally occurring salicylates and
reports that exposure to these foods may precipitate symptoms in
patients. Such foods include almonds, Apples,
many types of berries, grapes, oranges, peaches, plums, prunes,
pickles, and tomatoes.
No. 16: abstract No. 415 reminds
us that, in addition to the ingestion of a food allergen,
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
out a marked difference in prescribing patterns for asthma between
practitioners, on the one hand, and allergists and pulmonologists on
other hand. General practitioners have not yet
and incorporated into their practice the comprehensive management of
asthma. This is a continuing problem with no excuse and with an
solution: “when all else fails, please follow directions.”
No. 18: abstract 566
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
this syndrome can progress in the same individual to generalized
from one or more of these foods in future years. Thus, carrying
No. 19: abstract No. 569 reports
that “stress may trigger autonomic responses that result in
in asthmatics”. This relates to the perennial question regarding
whether emotion can produce asthma. The perennial answer it is
emotion can be a potent trigger; but it requires the necessary
No. 20 abstract 570 addresses the
problem of asthmatics who do not realize how sick
are at times. Substantial numbers of moderate to severe
were found to have poor perception of their air flow limitation,
in a much greater risk of sudden suffocation from an acute asthmatic
This is a continuing problem for physicians, a problem which can only
resolved by careful objective monitoring of the air flow
expiratory flows) of all their asthmatic patients.
No. 21 abstract No. 585 notes the
importance of identifying obstructiive sleep apnea in some
patients and of treating that problem with nasal CPAP ( see our
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
“step-down therapy starting with high dose of inhaled steroids and
oral steroids is more effective in gaining prompt control asthma
and in reducing the maintenance dose of inhaled steroids than
therapy starting with low dose of inhaled steroids in patients with
No. 24 abstract 813 addresses the
question whether inhalation of epinephrin from a metered dose
may be used as a substitute for injected epinephrine as
treatment for anaphylaxis. The results of this study showed that
most children were unable to inhale an adequate number of
to produce comparable and necessary blood levels. Thus,
injection of epinephrine remains the mainstay of
of anaphylaxis. The one exception may be allergic
(or vocal cord swelling) with change in or loss of voice, where
epinephrine directly onto the affected cords may be life-saving. This
the only safe and indicated usefulness of Primitine Mist or of
No. 25: abstract 904 reviews a
differential diagnosis of “exercise-induced asthma and adds to it
to the occasional possibility of acute pulmonary emboli (blood
to the lung, a potentially life-threatening condition frequently missed
No. 26 abstract 915 reports that
allergens imunotherapy has “ well-documented clinical
efficacy, but the underlying immunologic mechanisms are not
clear”. The authors propose a unifying theory of the
mechanism of action, based upon the role of “blocking IgG” in
TH2 cells to TH1 cells and thus modulating the immune system away
No. 27: abstract No. 939
the high incidence of GERD in asthmatics and reports on the
of “silent GERD” in asthmatics. Thus, special attention
possibly a trial of medicinal treatment would appear appropriate.
No. 28 abstract 949
a study of the risk of adenoidal hypertrophy in children with
rhinitis, and found that respiratory allergens, especially dust
and mold, together with exposure to smoking, are highly related
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