Induction of oral tolerance to peanut: a successful home-based protocol.

In Spain, peanut allergy is increasingly prevalent. Successful protocols for the induction of oral tolerance (LOT) with several foods have been reported. We aimed to induce clinical tolerance to peanut in a child with severe peanut allergy (age 4 years, facial urticaria and lip angioedema upon licking a peanut; peanut skin prick test, 13 x 10 mm; specific immunoglobulin (Ig) E > 100 kUA/L). At age 6, the threshold oral challenge dose was 62.5 mg. Several peanut solutions were prepared and sequentially administered at the patient's home. Over 138 days, the dose was increased from 0.625 to 5500 mg. There were 43 mild-to-moderate reactions (28% of the doses administered). Pre-LOT and post-LOT peanut IgE and IgG4 values were 265 vs 487 kUA/L, and 6.11 vs 14.8 mg/L. This is the first report of successful LOT to peanut in Spain. This home-based regimen is safe under permanent and close medical supervision by an allergist.

[Clinical processes in a high resolution clinic of specialist outpatient clinics]. / Procesos médicos susceptibles de alta resolución en consultas ambulatorias.

OBJECTIVES: The high resolution clinic (HRC) is an outpatient care process by which treatment and diagnosis are established, recorded, and completed in a single day. The aim of this study was to assess the extent to which patients with medical conditions may benefit from a single consultation system. MATERIAL AND METHODS: A descriptive study of 795 first visit events, randomly selected as high-resolution consultations in cardiology, gastroenterology, internal medicine, and chest diseases. A discussion is presented on the percentage of patients who benefited from HRC and the complementary tests performed. RESULTS: A total of 559 (70%, 95% CI: 67-73%) of all first visits became HRCs, and 483 (61%, 95% CI: 57%-64%) required a diagnostic test that was reviewed on the same day. There were differences between medical consultations (86% in cardiology versus 44% in gastroenterology consultations, P<.001). Performing a test on the same day significantly increased the percentage of HRCs (49 versus 22%, P<.001). Ischaemic heart disease, dyspepsia, headache, and asthma were the conditions most commonly leading to HRC. The most common tests were cranial tomography, blood analysis, and ultrasound. CONCLUSIONS: Medical consultations may largely benefit from an HRC system, only requiring some organisational changes and no additional costs.

A simple and reproducible method to evaluate granulocyte adherence.

A simple method was devised to measure granulocyte adherence in whole blood. Columns of glass beads (4.5 mm diameter) in disposable plastic syringes were used. The assay showed great reproducibility when done in triplicate, the day to day variations in a given individual being minimal. Previous incubation of the blood with different ethanol concentrations diminished granulocyte adherence. The assay is easy to perform and does not require special equipment.

Nephrotic syndrome and respiratory allergy in childhood.

The etiology and pathogenesis of idiopathic nephrotic syndrome remain obscure. Several investigations have reported a role for allergy in the development and maintenance of this disease, especially in childhood. We have studied 20 pediatric patients with relapses of nephrotic syndrome related in time to respiratory symptoms. Sensitization was demonstrated to one or more allergens in 7 patients with episodes of proteinuria of seasonal tendency. Preventive management with disodium cromoglycate was successful in preventing new relapses in 3 patients; specific immunotherapy was assayed in another 2 without beneficial outcome. There appears to be a pathogenic relationship between respiratory allergy and proteinuria in some cases of nephrotic syndrome.

Atopy and bronchial hyperresponsiveness in pure extrinsic childhood asthma.

Nonspecific bronchial hyperresponsiveness and atopy are considered risk factors in the development of asthma. Bronchial responsiveness to allergens could be the most important factor in extrinsic asthma. The trial was designed to investigate the role of specific and nonspecific bronchial responsiveness and atopy in a pure model of extrinsic asthma in children. One hundred and thirty-seven patients with pollen allergy were evaluated. Twenty children with allergy to grass pollen (Lolium perenne) alone, with symptoms only in the grass pollen season, were selected. Their score of symptoms, airway responsiveness to methacholine in and out of season, airway responsiveness to Lolium perenne out of season, and total and specific IgE were assessed. Twelve were male and eight female. Mild asthma was observed in 14, and moderate asthma in six. Age of onset of symptoms ranged from three to 13 years of age. Significant seasonal increase in airway responsiveness to methacholine was found (p = 0.002). Specific bronchial challenge test was positive in all patients. Lolium pernne PD20 ranged from 2.3 to 155.5 inhalation units. An inverse association between age of onset of symptoms and severity of asthma was shown (p = 0.001). Increase in nonspecific bronchial responsiveness was related to the appearance of symptoms during the spring, but it showed no relationship to the severity of symptoms. Severity of asthma during the spring correlated with the intensity of allergen airway responsiveness (p = 0.02). Levels of total and specific IgE were not related to the degree of specific or nonspecific airway responsiveness. Severity of extrinsic childhood asthma is determined by bronchial response to allergens. Bronchial hyperresponsiveness to methacholine during the spring can be the consequence of environmental exposure to allergens. The intensity of airway responsiveness to methacholine has no predictive value in the severity of pure extrinsic childhood asthma.

Evaluation of drug-related hypersensitivity reactions in children.

Patients with drug reactions are often referred to allergists for "allergy". Skin testing and clinical history seem to have a good negative predictive value, however, although drug challenge could be dangerous, it is the only way to confirm the diagnosis. We aimed to demonstrate that most children with a history of non-life-threatening drug reactions do not have a true drug allergy and examined the use of drug challenge in childhood. Patients with reactions were referred to our clinic by pediatricians. In 1 year, 354 reactions were studied in 239 children. Patients were classified according to their positive or negative history of drug allergy. Skin prick testing was done in all cases. Exclusion criteria for challenge included drug anaphylaxis, Stevens-Johnson syndrome, systemic reactions with severe concomitant illness, beta-inhibitor drug therapy or positive skin test to the implicated drug with a positive history. It was found that the beta-lactam antibiotics were involved in 50% of suspected reactions, aspirin in 10% and sulfonamides in 9%. Histories were considered positive only in 25%. Drug challenges confirmed only 4% of all reactions. It was concluded that drug challenge may be the gold standard for most childhood reactions that are considered to be allergic, non-life-threatening and drug-related. Only 4% of these suspected reactions were exclusively caused by drug allergy.

A possible consequence of long-term elimination diet in IgE mediated subclinical food hypersensitivity.

IgE-mediated sub-clinical food hypersensitivity is recognized, but the hypersensitivity indicated is not always in accord with the observed symptoms. Study of 2 cases shows the inefficacy of a prescribed exclusion diet, without confirmation of the relationship between symptomatology and the food allergy. In addition, elimination of the foods aggravated the sensitivity of the patients and symptoms after provocation tests. Further studies must be made to decide whether there is a sound basis for long-term exclusion diets in sub-clinical food hypersensitivity.

Microtubule function in leukocytes from umbilical cord blood.

Polymorphonuclear neutrophils and lymphocytes from umbilical cord blood had a normal distribution of concanavalin A receptors on their surfaces and do not show an abnormal sensitivity to the microtubule disrupting drug colchicine. These experiments suggest that leukocytes from úmbilical cord blood do not show any developmental deficiency of the microtubule system.

[Immunologic condition of the newborn (author's transl)]. / Respuesta inmunológica del recién nacido.

Partial immaturity of the immunocompetent system is accounted for by the increased susceptibility to infections seen in human newborns. This immunodeficiency that includes specific and non-specific branches of immunity, affects both humoral and cellular components. Authors present a revision of the present knowledge, including their experience in this field.

[Behavior of immunoglobulin E in primary immunodeficiencies]. / Comportamiento de la inmunoglobulina E en inmunodeficiencias primarias.

The complexity of IgE synthesis and regulation is expressed in the IgE serum levels of 81 patients with primary immunodeficiency diseases. IgE serum levels were often elevated in patients with partial cellular deficiency and also in some with predominantly antibody defect, as isolated IgA and IgM deficiency. The lowest levels were found in the wider spectrum immunodeficiencies, such as the X-linked agammaglobulinemia and severe combined immunodeficiency. Due to the heterogeneity and variability of the immunological defects, even in these well defined immunodeficiency diseases, it is very difficult to establish a typical feature of IgE serum levels in these conditions.

[Food allergy in children. II. Prognostic factors and long-term development]. / Alergia a alimentos en el niño. II. Factores pronósticos y evolución a largo plazo.

The evolution of 109 allergic children with 129 IgE-mediated food sensitizations has been evaluated. The follow-up period was from nine months to 14 years. The period up to clinical tolerance was analyzed, together with the influence of two possible prognostic factors: specific IgE antibody levels at the beginning of symptomatology and the sensitizing food. Moreover, when clinical tolerance was achieved, the presence of specific IgE antibodies was again assessed. Probability estimations indicated that 30% of food-allergic children become clinically tolerant before 3 years of evolution, 40% before 6 years, 50% before 9 years and 53% before 12 years. Onset of clinical tolerance varies in dependence with the offending food: clinical tolerance to cow's milk seems to be far earlier and easier to reach than those to egg and fish (p less than 0.001, at 9 years' evolution); allergy to egg disappears also earlier and easier than fish allergy (p less than 0.01). Levels of specific IgE antibodies at the onset of the disease show significant difference (p less than 0.01) between the patients which will become tolerant and those with persistence of clinical sensitivity, being higher in the last group. However, a high number of patients who become clinically tolerant (67.5%) remained positive at skin prick testing or had elevated specific IgE serum antibodies against the offending food.

[Food allergy in children. I. Clinical aspects and diagnosis]. / Alergia a alimentos en el niño. I. Clínica y diagnóstico.

Two hundred and thirty children with suspected food allergy have been reviewed retrospectively. One hundred and nine fulfilled the following three selection criteria: suggestive anamnesis, presence of specific IgE antibodies (in serum or by skin prick test), and having been reassessed at least once. The major clinical data analyzed were: age of onset, sensitising foods, symptomatology and diagnostic procedures. The results show a mean age of onset for food allergy of 11.5 months, with variations related to the sensitizing food, cow's milk allergy being the earliest in onset time. The most frequent sensitizing foods in this group of patients were eggs, fish and cow's milk. The skin and the gastrointestinal tract have been the most affected shock organs, both together or isolated; respiratory symptoms were an uncommon finding and their isolated presentation as the sole manifestation of food allergy exceptional. The skin prick tests were positive in 99.2 percent of the sensitizations and in 84 percent high levels of specific IgE antibodies were found. Food allergy seems to be a common situation in children, clinical symptomatology is similar to that of the other atopic diseases and the diagnosis is based on the demonstration of specific IgE antibodies against the sensitizing foods.

Allergy to white potato.

Allergy to potato is uncommon, and even more uncommon is allergy to potato pollen. The occurrence of both phenomena in the same patient made it possible to study cross-reactivity patterns of potato antigens. An 11-year-old girl, exclusively breast-fed for her first 4 months, developed anaphylactic symptoms after ingestion of potato at 5 months of age when she was fed potato for the first time. Subsequently, she developed urticaria, angioedema, and respiratory and systemic symptoms on contact with potatoes, ingestion of potatoes, and exposure to cooking potatoes or potato pollen. Three allergenic extracts from potato pulp, peel, and pollen were prepared. Polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate and isoelectrofocusing of the three extracts were performed. IgE-mediated allergy to these extracts was demonstrated by means of immediate skin test reactivity, positive passive transfer, RAST, RAST inhibition, and leukocyte histamine release. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the pulp extract followed by electroblotting and autoradiography demonstrated specific IgE antibodies directed against several proteins ranging from 14,000 to 40,000 daltons.

Asthma with sulfite intolerance in children: a blocking study with cyanocobalamin.

Sulfites have been implicated as the cause of bronchospasm in some subjects with asthma. However, there is still no universally accepted explanation of the pathogenesis of these reactions. We have studied five children with asthma with metabisulfite intolerance confirmed by oral challenge testing. The challenge test with metabisulfite was repeated after premedication of all the patients with 1.5 mg of oral cyanocobalamin. In four of the five patients treated with cyanocobalamin, bronchospasm did not develop in the second metabisulfite challenge. The possible mechanisms are discussed.

IgE crossreactivity between mugwort pollen (Artemisia vulgaris) and hazelnut (Abellana nux) in sera from patients with sensitivity to both extracts.

BACKGROUND: An association between sensitization to Compositae pollens and hypersensitivity to hazelnut has been previously described. There is no previous in vitro study about crossreactivity between mugwort pollen and hazelnut. OBJECTIVES: To study mugwort pollen and hazelnut allergens and to assess if there is IgE crossreactivity between mugwort pollen and hazelnut. METHODS: A serum pool formed by 28 individual sera with specific IgE to mugwort pollen and hazelnut was used to investigate IgE crossreactivity. RAST-inhibition, SDS-PAGE/IEF immunoblotting inhibition assays were performed by preincubation of the sera with mugwort pollen and hazelnut. RESULTS: RAST to hazelnut was inhibited up to 63% by mugwort pollen, but the mugwort pollen RAST was only inhibited up to 36% by hazelnut. In SDS-PAGE immunoblotting mugwort pollen showed nine allergens ranging from <16 to 65 kDa and hazelnut had four main allergens: 42 kDa, 17 kDa and <16 kDa (two bands). In the SDS-PAGE immunoblotting inhibition hazelnut partially inhibited all the mugwort pollen bands, except that with 19kDa, whereas mugwort pollen produced a nearly total inhibition of all the hazelnut allergens. In isoelectrofocusing immunoblotting mugwort pollen had two groups of allergens: pI 7.5-8.5 and pI 3.5-5.2 and hazelnut one group of allergens: pI 5.2-5.8. In the isoelectrofocusing immunoblotting inhibition hazelnut produced a partial inhibition of all the bands of mugwort pollen and mugwort pollen partially inhibited all the allergenic bands of hazelnut. CONCLUSIONS: The RAST and SDS-PAGE/IEF immunoblotting inhibition results provide evidence of IgE cross reactivity between mugwort pollen and hazelnut allergens. The inhibition of hazelnut by mugwort pollen is higher than the inhibition of mugwort pollen by hazelnut in both RAST inhibition and SDS-PAGE immunoblotting inhibition. These results suggest that mugwort pollen allergens would behave as primary immunogens in the association between sensitivity to mugwort pollen and hazelnut.

[Complement system in disseminated lupus erythematosus]. / Système du complément dans le lupus érythémateux dissémine.

The levels of C3, C4 and CH50 in patients with lupus erythematosus disseminatus (LED) were lower than in the controls. However, although in many patients these levels were below the normal values, there was no statistically significant difference between the two group. The levels are reduced during the acute phases and in some patients they remain high. On the whole, C3 was lower in patients with nephropathy (p less than 0,025) than in patients presenting with clinical activity (p less than 0,02). The positive relationship existing between C3 and C4 (r = 0,641, p less than 0,01) suggests activation of the complement system in LED via the classic route. In cases with concurrent lupus nephropathy a relationship between C3 and C3PA was seen, suggesting that in this case the alternative route is involved.

Defective neutrophil chemotaxis and hyperimmunoglobulinemia E-a reversible defect?

An eleven-month-old boy is presented with chronic atopic dermatitis and recurrent infections of the skin and respiratory tract, including subcutaneous abscesses. Immunological studies disclosed a neutrophil chemotactic defect, blood eosinophilia and serum hyper IgE. The clinical and analytical data are similar to those of patients previously dermatitis reversed the chemotatic defect, the blood eosinophilia and the clinical symptoms.

Lymphocytes bearing single or double surface immunoglobulins in umbilical cord blood.

Lymphocytes from the umbilical cord blood of 20 newborn infants and the peripheral blood of 18 adult volunteers, were studied for surface-stable immunoglobulins by the direct immunofluorescence technique. Goat antiserums to human light and heavy chains were used. Cord blood yielded a significantly higher percentage of lymphocyte bearing mu + delta chains, and a lower percentage bearing only delta chains. The number of B cells bearing light chains (K + lambda) or heavy chains (mu + delta +(mu + delta) was higher in cord blood than in the adult peripheral blood. The high percentage of cells bearing double markers (probably virgin B-cells) and the low number of cells bearing only IgD, (probably the cells responsible for secondary antibody responses) could be explained by the inhibition of the IgM-to-IgG switch in the antibody production of newborns.

[IgG and complement receptors in neutrophils from cord blood (author's transl)]. / Receptores para complemento e IgG en neutrófilos de cordón umbilical.

Percentage of cord blood polymorphonuclear leukocytes (PMN) bearing receptors for Fc portion of the IgG and for complement byproduct C3b are studied in 18 term newborns. Results are compared with those obtained in 20 healthy controls. Statistical analysis did not disclosed significative differences between both groups. Study was performed on total PMN population and not in a selected subpopulation as was done by previous authors.