A familial occurrence of allergic bronchopulmonary aspergillosis: a probable environmental source

This is the first article of a familial occurrence of allergic bronchopulmonary aspergillosis in a father and daughter. Serologic studies revealed serum precipitins and elevated IgG or IgE antibody activity against certain Aspergillus species. Investigation of the home revealed an environmental source of exposure. Another family member demonstrated serum precipitins and an IgG antibody response to the isolated Aspergillus species without evidence of allergic bronchopulmonary aspergillosis.     

Brief report: evaluation of polymerized ragweed extracts by intradermal end point titration, RAST inhibition, and parallel line bioassay

We have evaluated six polymerized ragweed extracts on the basis of RAST inhibition, parallel line bioassay, and intradermal end point titration. The results of the parallel line bioassay and intradermal end point titration are highly correlated (r = 0.995, df = 2, p less than 0.01). Both intradermal end point titration (r = 0.973, df = 4, p less than 0.01) and parallel line bioassay (r = 0.985, df = 2, p less than 0.05) are highly correlated with RAST inhibition. We have evaluated the utility of intradermal end point titration as a quantitative assay of relative allergenicity of polymerized extracts. The between assay reproducibility was derived by comparing a reference polymerized ragweed extract against itself. The 99% confidence limits of relative allergenicity were 53% to 188% when four assays were used. This compares favorably to the published 99% confidence limits of the parallel line bioassay 60% to 166% when three assays were used. Intradermal end point titration is highly reproducible, is highly correlated with RAST inhibition or parallel line bioassay, and thus is an appropriate bioassay of allergenic activity.     

Factitious sneezing

We report a case of hysterical, intractable paroxysmal sneezing in an adolescent girl. The patient had been observed by two pediatricians, an allergist, an emergency room physician, and a chiropractor. She had been treated with antihistamines, epinephrine, corticosteroid nasal spray, and a 1-week course of an oral corticosteroid without improvement. She was referred for evaluation of an allergic etiology before continuing her workup with a computed tomographic head scan. The patient had been sneezing almost daily for 3 mo up to 2000 times a day. The patient did not sneeze at night. She had nasal congestion but no rhinorrhea or eye symptoms. She did not sneeze during the interview. The results of a physical examination were normal except for mild obesity. No organic cause was found. Most cases of intractable paroxysmal sneezing reported in the literature occur in adolescents and appear to have a psychogenic etiology. The problem was discussed with the child and parents, and psychologic therapy was recommended. Considerable decrease in sneezing subsequently occurred, but the parents credited this is further chiropractic therapy.     

Long-term effects of beclomethasone dipropionate on prednisone dosage in the corticosteroid-dependent asthmatic

The average prednisone dosage of 54 corticosteroid-dependent asthmatics was computed for one year prior to initiation of beclomethasone dipropionate. This was compared to the average prednisone dosage after nine months on the beclomethasone with progressive tapering of prednisone to either dose compatible with control of asthma or discontinuation. Beclomethasone was found clinically useful in the great majority of these patients because it permitted a significant decrease in dosage of prednisone, a change from daily to alternate-day prednisone, or discontinuation of prednisone after cautious tapering. The first two advantages were most evident in those asthmatics who initially required higher doses of oral steroids while the latter was evident in those requiring lower doses. Those patients whose prednisone dosage does not appear to be beneficially affected by the use of beclomethasone should be suspect as to adherence to proper medical dosage schedule.     

Hypersensitivity lung disease: Early diagnosis

The early diagnosis of hypersensitivity lung disease (HLD) is important because of its progressive morbidity. It is often difficult to establish the diagnosis in the early stages because of the absence of defined symptoms. Case histories of 2 patients with pigeon breeder's HLD are reported. Both patients presented with unusual manifestations of the disease: one patient was asymptomatic but had an abnormal chest radiograph; the other patient had a normal chest radiograph but experienced occasional symptoms of exertional dyspnea. Both patients had abnormal pulmonary function and precipitin bands against pigeon serum. Following inhalation challenge with pigeon serum both patients developed fever and leukocytosis, but no significant pulmonary function response was observed. In both patients pulmonary function tests returned to near normal levels after corticosteroid therapy. Early detection of HLD may prevent progressive irreversible pulmonary damage. This requires a high index of clinical suspicion and appropriate screening tests. Inhalation challenge procedures are useful in establishing the diagnosis.     

Acute urticaria and bronchospasm following radiographic contrast media in a dog.

An immediate-type systemic reaction in a dog following intravenous radiographic contrast media (RCM) manifested by urticaria and wheezing on one occasion and urticaria alone on another occasion is described. This reactivity disappeared spontaneously and plans to study the mechanisms of such a reaction were not possible. If such reactivity is more persistent in certain other dogs, a model for study of immediate type reactivity to RCM would be available.     

A multi-institutional trial of polymerized whole ragweed for immunotherapy of ragweed allergy

Eighty ragweed-sensitive patients in four cities were recruited to study the safety and efficacy of partially purified, polymerized whole ragweed (PRW) as an improved form of immunotherapy. Groups of 20 patients in Chicago, Boston, Memphis, and St. Louis had blood drawn for immunologic studies before and after the 1978 and 1979 ragweed seasons and completed detailed daily symptom score sheets each day of the 1978 and 1979 ragweed pollen seasons. Beginning in March, 1979, all patients except one received 15 weekly injections of PRW totaling 50,000 protein nitrogen units (PNU) and containing about 500 μg ragweed AgE. One patient received 25,000 PNU. Symptom score indices of the posttreatment 1979 season were compared with those from the pretreatment 1978 season and also with the scores of similar groups of ragweed-sensitive patients in each city treated only with medication for symptomatic relief during the 1979 season. Local reactions to polymerized ragweed immunotherapy were minimal. No abnormalities in complete blood count, erythrocyte sedimentation rate, chest x-ray film, urinalysis, or rheumatoid factor occurred in the immunotherapy-treated groups. Total serum antibody binding of ragweed AgE increased 12-fold following immunotherapy. When compared either with their 1978 untreated group scores or when compared with scores from the untreated group in each city in 1979 (control group), the symptom score indices of the immunotherapy-treated groups in 1979 were significantly improved. PRW is efficacious in the treatment of ragweed hay fever and can be administered more safely and in higher doses with fewer injections than conventional extracts. It represents an improved form of immunotherapy.     

Radiographic contrast media studies in high-risk patients

Patients with prior anaphylactoid reactions (AR) to radiographic contrast media (RCM) are at increased risk for another reaction upon repeat exposure to RCM. One hundred one patients, who had prior AR to RCM, who gave informed consent, and who had an essential need for a repeat RCM study, were pretreated with prednisone, 50 mg orally every 6 hours for 3 doses ending one hour prior to RCM study, and diphenhydramine, 50 mg intramuscularly, one hour prior to RCM study. The repeat RCM study was then carried out using standard procedures with resuscitation equipment readily available. Ninety-six patients had no reaction. Five of the 101 (4.95%) developed AR. These AR consisted only of mild urticaria or pruritus. No significant or life-threatening reactions occurred. Pretreatment decreases the risk in this population of patients and is recommended as standard prophylaxis for patients requiring RCM who have had a previous AR.     

Immunology and immunopathology of trimellitic anhydride pulmonary reactions

Inhaled trimellitic anhydride (TMA) reacts with airway proteins to produce trimellityl (TM) proteins. The TM-proteins result in both systemic and local immune responses, of which various proteins present in the airway can be used for markers. Thus TM-human serum albumin (HSA), TM-IgG, and TM-IgA can be used as hapten-protein complexes for immunologic studies in sera of humans exposed to TMA by inhalation. Various immunologic assays have been established to measure antibodies against TM-proteins and have various purposes. With TM-HSA as a model antigen, total serum antibody may be measured by the ammonium sulfate technique of coprecipitation of TM-¹²⁵I HSA. By solid-phase radioimmunoassays, IgE, IgG, IgA, and IgM antibodies can be measured. Lymphocyte reactivity can be measured by ³H thymidine uptake of TM-protein-stimulated lymphocytes. Biologic effects of IgE antibody can be measured by allergy skin tests and leukocyte histamine release with TM-proteins such as TM-HSA. The reaction of TMA with proteins results in alteration of those proteins that include changes in charge and physical conformation, the latter resulting in an apparent change in molecular size. These changes may relate to the observations that human antibody is not merely directed against the hapten in the hapten-human protein complex but also against new antigenic determinants formed by the TM-protein complex. Correlations have been made with certain human immunologic responses and lung disease after TMA inhalation, as follows: IgE antibody against TM-proteins correlates with TMA-induced rhinitis, conjunctivitis, and asthma; high levels of total antibody, IgG, and IgA antibody appear to correlate with the late respiratory systemic syndrome, probably a variant of hypersensitivity pneumonitis; workers exposed to TMA fumes (rather than TMA powder) have the highest levels of antibody, and this may correlate with occurrence of the hemorrhagic pneumonitis seen in this group of workers; patients with no symptoms or mild irritative symptoms have the lowest or no antibody levels. The immunopathogenetic relationships may be better understood with the further development of animal models of TMA lung disease now available.     

The effect of histamine-1 and histamine-2 antagonists on airway responses to histamine in the rhesus monkey.

This study used rhesus monkeys with consistent respiratory responses to aerosolized histamine. Two systems of histamine challenge were evolved to study the effects of histamine antagonists on the histamine-induced respiratory response. One system consisted of administering increasing subreactive concentrations of histamine until an airway response (H) occurred. This threshold histamine dose was repeated (H'). The pulmonary function changes occurring with the H' challenge were less intense than those with H. M, a histamine-2 receptor antagonist, when given before the H' dose was associated with a potentiated H' response compared with the threshold H response. This provides evidence for histamine-2 receptor sites in rhesus monkey airways. A second system used duplicate histamine challenges with a known reactive dose of histamine. In this system, the pulmonary function changes occurring with the repeated challenge (H') were greater than with the first reactive challenge dose (H). This H' response was inhibited partially with diphenhydramine, a histamine-1 receptor antagonist. These two systems of histamine challenge provide an experimental model for evaluating pharmacologic alteration of histamine-induced respiratory responses. There is evidence for the existence of histamine-1 and histamine-2 receptor sites in the airways of the rhesus monkey.     

The immune response of patients with ragweed hay fever treated with polymerized ragweed antigens.

This report describes the immune response of patients with ragweed hay fever treated with polymerized ragweed antigens (PRW). Their IgG antibody responses to crude ragweed extract, antigen E, antigen K, and antigen Ra3 were determined by a solid-phase radioimmunoassay. The results indicate that PRW contains an array of clinically important antigens that are available for immunologic processing and result in an immune response in patients treated with this new form of immunotherapy for ragweed hay fever.     

Inhibition of immunoglobulin E-mediated, antigen-induced monkey asthma and skin reactions by 5, 8, 11, 14-eicosatetraynoic acid

The immediate-type, IgE-mediated rhesus monkey model of asthma due to aerosol challenge with ascaris has been developed to the status of an analytic system for agents capable of inhibiting the antigen-induced airway response. Two antigen-challenge systems have been developed. The standard ascaris challenge uses a dose of antigen that will induce an airway response in all reactive animals. In the threshold antigen-challenge system, the threshold dose of antigen that will induce an airway response is determined and is relatively constant for the individual animal. Both of these types of response were inhibited by 5,8,11,14-eicosatetraynoic acid (ETYA). This action may be through the inhibition of the lipoxygenase and cyclooxygenase metabolic pathways of arachidonic acid and possibly through inhibition of production of slow-reacting substance. ETYA also inhibits cutaneous immediate-type reactivity to ascaris antigen in a dose-response relationship. This may be the result of inhibition of mast cell histamine release or the inhibition of production of other vasoactive mediators. An alternative explanation for the action of ETYA in the airway and skin responses is that ETYA may act as an end-organ antagonist to released bioactive mediators. ETYA is the first agent, other than beta agonists or cromolyn, that we have been able to demonstrate as clearly having an inhibitory action on the rhesus monkey model of asthma.     

Comparison of immune reactivity to polyvalent monomeric and polymeric ragweed antigens

The proteins of an aqueous extract of ragweed pollen (RW) were precipitated at 90% saturation with (NH4)2SO4, solubilized, and sieved through Sephadex G-15. The excluded fraction, termed the monomeric form (MRW), was cross-linked with glutaraldehyde to form polymerized ragweed (PRW). As compared with MRW, PRW is more immunogenic in rabbits in the production of antibody against RW antigen E (AgE). MRW and PRW resulted in equal peak reaginic responses in rabbits but the duration of reagin production was longer after immunization with MRW than with PRW. Both MRW and PRW have exposed antigenic determinants of AgE but PRW had approximately 1/3 the number as shown by neutralization of human antibody against RW AgE. PRW had 100-to 1,000-fold less human cutaneous reactivity than MRW. PRW may be a more easily effective therapeutic agent for human RW immunotherapy than currently used aqueous extracts and may be more readily obtainable than polymerized AgE.     

Serum IgE concentration in atopic dermatitis. Relationship to severity of disease and presence of atopic respiratory disease

A survey was conducted to evaluate the serum IgE concentrations of 58 patients with atopic dermatitis of varying severity and activity. The determination of serum IgE concentrations does not provide a diagnostic criterion for atopic dermatitis because 57% of the patients had levels of IgE considered to be within a normal range. When serum IgE concentrations are elevated in atopic dermatitis, this is associated with an increased severity of the disease, with coexistent atopic respiratory disease or with both. This association may have relevance to the pathogenesis of the respiratory disease, which is IgE-mediated, the severity of the dermatitis, or both. The manner in which this may occur, if there is more than a coincidental relationship, is uncertain.     

Studies of perennial ragweed immunotherapy.

Perennial ragweed immunotherapy was studied in 24 patients with ragweed pollenosis. Cellular responsiveness was determined by measuring the cellular reactivity and sensitivity to ragweed antigen E (RW-AgE) by RW-AgE-induced leukocyte histamine release. Serum blocking antibody content was determined by measuring the serum RW-AgE binding capacity by ammonium sulfate coprecipitation of bound RW-AgE. Specific IgE (anti-RW-AgE) concentration was determined by polystyrene tube radioimmunoassay. Cellular responsiveness decreased with continuing immunotherapy, as did the specific IgE concentrations. The serum RW-AgE binding capacity, in contrast, increased as treatment continued. The absence of demonstrable correlations between RW-AgE binding capacity and cellular reactivity, cellular sensitivity, and specific IgE concentrations contrasted impressively with the demonstration of multiple significant correlations between the change in the RW-AgE binding capacity and the other parameters studied. The degree of increase in RW-AgE binding capacity correlated significantly with the degree of decrease in both the specific IgE concentration (p is less than 0.04) and the cellular sensitivity to RW-AgE (p is less than 0.003). these findings suggest that the active process of blocking antibody production, rather than the passive presence of blocking antibody, is related to the process which decreases the specific IgE concentration and the degree of cellular responsiveness and therefore results in clinical improvement.     

Polymerized whole ragweed: Human safety and immune response

Polymerized ragweed (PRW) has been shown to have reduced allergenicity while maintaining immunogenicity. In order to evaluate whether the reduced allergenicity would permit high initial doses and rapid progression to maintenance, two groups of subjects with ragweed pollenosis were placed on immunotherapy with PRW standardized for antigen E (AgE) content. Group I, 28 subjects, received an initial dose of 100 protein nitrogen units (PNU) (1 μg AgE) and reached a maintenance dose of 1,000 PNU (10 μg AgE) in four weekly injections. In the first 10 wk each subject received 7,850 PNU (78.5 μg AgE). Group II, six subjects, received an initial dose of 100 PNU (1 μg AgE) and after 11 weekly injections received 30,000 PNU (300 μg AgE). No anaphylactic reactions occurred in the study groups. In group I, three large immediate-type local reactions and nine large late-type reactions occurred in 110 injections. Anti-AgE antibody activity in group I rose from a pretreatment mean value of 264 ng AgE bound per milliliter serum to a posttreatment value of 3,182. The major rise occurred after only 4 wk of therapy. In group II, anti-AgE antibody activity rose from 66 to 2,123 after the 11 wk of therapy. IgE antibody to AgE did not change to any extent in either group, and histamine release in response to AgE measured in group II patients did not change. Symptom score evaluation of group I patients revealed a marked decrease in symptoms after therapy with PRW. Immunotherapy with PRW can be initiated at higher doses, with rapid attainment of maintenance dosage with safety resulting in a brisk immune response and symptomatic improvement.     

Immediate-type reactions in patients with allergic bronchopulmonary aspergillosis

Allergic features of 38 patients with allergic bronchopulmonary aspergillosis (ABPA) were reviewed. These features included skin reactivity to other inhalant antigens and to molds other than Aspergillus fumigatus (Af) plus clinical manifestations of rhinitis, conjunctivitis, asthma, eczema, urticaria, anaphylaxis, food allergy, and drug allergy. ABPA patients have a high degree of allergic reactivity in all these clinical features, in particular, clearly documented food allergy. These findings differ from those previously reported in ABPA patients in England, where it was noted that patients with ABPA whose asthma began after age 30 had few manifestations of other allergic diseases. By contrast, our patients in the same age group (onset of asthma after age 30) had the same multiple allergic manifestations as younger patients. These results show that ABPA patients are a subset of atopic individuals with a greater predisposition for the development of a wide spectrum of allergic diseases, despite the lack of manifestations of other major immunologic disease patterns.     

Persistence of efficacy after a brief course of polymerized ragweed allergen: a controlled study

Immunotherapy with PRW has been demonstrated to be safe and effective. To determine whether the efficacy would remain in successive ragweed seasons without further therapy, a trial was conducted comparing PRW to histamine placebo therapy in patients that had received courses of PRW previously. Those patients were also compared to previously untreated ragweed-sensitive patients. In a double-blind fashion, 21 previously treated patients were treated before the 1982 ragweed season with four injections of PRW therapy, whereas 21 previously treated patients were treated with four injections of placebo therapy. An additional control group of 21 previously untreated ragweed-sensitive patients received no injections. Daily symptom and medication score sheets were completed by patients each day of the ragweed season. Blocking antibody rose elevenfold with treatment (p less than 0.0001) in the PRW group. There was a statistically significant difference in symptom score mean between untreated patients (1007 +/- 174) and previously treated patients whether they received supplemental injections (554 +/- 180) (p less than 0.01) or whether they did not (650 +/- 168) (p less than 0.03). In summary the efficacy of 15 injections of PRW immunotherapy persists at least several years without need for supplemental immunotherapy.