[Interests of recombinant allergens in the practice of allergy]. / Allergologie: 3. Intérêts des allergènes recombinants dans la pratique de l'allergologie.

Compared to total allergenic extracts, recombinant allergens available for specific IgE measurement represent an important advance in the diagnosis and treatment of IgE-mediated allergies. Recombinant allergens lead to define the sensitization profile of allergic patients, to identify markers of sensitization and to understand better polysensitivities related to cross-reactions and markers of severity of allergic reactions. They also contribute to the decision to establish tolerance induction (allergen specific immunotherapy) and the optimal selection of the allergenic composition of the vaccine.

[Hymenoptera venom allergy: new diagnostic tools and management]. / Allergie aux venins d'hyménopteres: nouveautés diagnostiques et prise en charge.

Anaphylactic reactions to hymenoptera venoms are common and, in our latitudes, mainly concern wasps and bees. Recently, molecular biology techniques have contributed to identifying and to sequencing the major allergens of insect venoms and led to the production of recombinant allergens. Assays for specific IgE directed against these recombinant allergens have recently been made available in clinical practice. They provide considerable assistance in identifying the insect responsible for an anaphylactic reaction, in particular when standard tests are positive for both wasp and bee. This article focuses on these new laboratory tests and also reviews the management of patients experiencing an anaphylactic reaction after hymenoptera sting.

[Allergen specific immunotherapy: review of new perspectives]. / Désensibilisation: vers de nouvelles perspectives.

Allergic diseases constitute a health problem worldwide. More than just a treatment option, the classical desensitization (SIT--Specific immunotherapy) by subcutaneous injection has profiled over time as a unique approach, able to attenuate the immune response to allergic stimuli proved. For a long time conservative, desensitization has now progressed in the knowledge of allergens, in the understanding of the mechanisms involved in immune response and in production techniques. From recombinants to alternative routes of allergen delivery, this article gives an overview of new perspectives and assesses SIT in order to provide guidance to the general physician before choosing to initiate such treatment or not in patients with respiratory allergy.

[What to expect from allergy tests?]. / Qu'attendre du futur du diagnostic en allergologie?

Diagnosis in allergology is facing novel challenges because of the availability not only of purified or recombinant allergens, but also of multitests such as allergen micro-arrays. These new diagnostic opportunities contribute to a better understanding of crossreactivities between respiratory and food allergens. In comparison to current diagnosis based on whole allergen extracts, this novel generation of specific IgE tests is expected to provide better information on the risk of reaction to allergens as well as on its severity. However these new technologies are expensive, and will have to be carefully analyzed in terms of medical usefulness and public health costs.

[Cardiac involvement in connective tissue disease: the example of systemic lupus erythematosus]. / Atteintes cardiaques dans les connectivites: l'exemple du lupus érythémateux systémique.

When we think of cardiac affection in the context of systemic lupus erythematosus (SLE), we usually refer to pericarditis first. As frequent as this affection is, it is actually not the only cardio-vascular problem that occurs with this systemic inflammatory disease. Are the cardiac events--ranging from multiple heart valve involvements to increased cardiovascular risks--clinically significant? And are they involving a specific follow-up, treatment or support? We are therefore trying to evaluate these questions in order to give some recommendations to any practitioners following up a lupus patient, or a patient suffering from any other inflammatory systemic disease.

[Rare food allergies]. / Allergies alimentaires rares.

A limited number of foods explain the majority of food allergies. These allergies can be due to a weak allergenicity (garlic, onion, potato), or a weak (or increasing) exposure to emergent food allergens which can be imported (exotic fruits), or recently introduced (lupin, buckwheat, sesame, inulin) or modified by the industry (lysats, lecithins, traces of antibiotics, caseinates, molds, dust mite). Others are in relation with rarer cross-reactivity food allergy syndrome (Apiaceae-Compositae-mugwort syndrome, egg-bird syndrome, cat epithelium-pork meat syndrome). Others are rarely identified, because the food is masked (pepper, basilic). We illustrate rare cases of food allergy and discuss the diagnostic management which is based on a meticulous patient history.

[The multiple etiologies of angioedema]. / Multiples etiologies de l'angioedème.

Angioedema is a frequent disorder with multiple aetiologies. Angioedemas associated with urticaria are usually caused by histamine release and respond to anti-histamines and adrenalin. They include allergic angioedemas, anaphylactoid reactions (mostly drug-induced, e.g. NSAID), physical angioedemas and recurrent idiopathic angioedema. Bradykinin probably plays a causative role in the pathogenesis of ACE-inhibitor or angiotensin II receptor blocker related angioedemas, as well as in the pathogenesis of the rare hereditary or acquired C1-inhibitor deficiency angioedemas. Urticaria is then typically absent and anti-histamines, as well as adrenalin, are ineffective.

[Behçet's disease: from hippocrates to TNF-alpha-blockers]. / Maladie de Behçet: d'Hippocrate aux antagonistes du TNF-alpha.

Behçet's disease is a systemic vasculitis affecting small and large vessels (arteries, veins, veinules), characterized by recurrent oral ulcerations, genital ulcerations, inflammation of the eye and skin lesions. It can also involve articulations, central nervous system and gastro-intestinal tract. The etiology of this disease is still unknown, but the most largely discussed hypothesis is that of an important inflammatory response triggered by an infectious agent in a genetically susceptible host. The diagnostic is a based on clinical elements, because no specific diagnostic test exists. The treatment of Behçet's disease is depending on the clinical involvement and has been enlarged in recent years by TNF-alpha-blockers which constitute undoubtedly an important progress in the management of this complex disease.

[Allergic reactions to nonsteroidal anti-inflammatory drugs]. / Allergo-immunologie. 2. Les réactions alltergiques aux anti-inflammatoires non stéroïdiens.

Allergy to nonsteroidal antiinflammatory drugs (NSAIDs) is a very common affliction, especially among patients with asthma and chronic urticaria. These reactions are most often of a non-immunological nature but related to pharmacologic intolerance and linked to arachidonic acid metabolism and leukotriene release. Therefore, crossed reactions implying all non-selective and semi-selective NSAIDs constitute the rule, especially during respiratory reactions to NSAIDs and for patients with chronic urticaria. In isolated acute urticaria, crossed reactions are difficult to predict so caution is necessary. Tolerance induction is possible, especially when aspirin has to be administered in small doses as antiplatelet agent. Finally, acetaminophen and selective NSAIDs as celecoxib are well tolerated by most of these patients.

[Modern nutrition and development of new allergies]. / Alimentation à l'ère industrielle: les nouveaux risques allergologiques.

The prevalence of food allergy varies between 1 and 8% and depends on age, countries, symptoms and allergens. Main food allergens remain peanut, nuts, egg, cow milk, wheat, soybeans and fish. However, novel food industrial processes have induced new food allergies. Some are related to unusual components, like lupine seeds or flour or to modified food, like wheat or soybean isolates. Other unexpected allergies are due to residues of strong allergens--like peanut or egg--which are present in very small amounts in processed food. Swiss and european legislation have edicted lists of allergenic foods which have to be specified to the consumers. However, the legislation remains still incomplete and labelling of novel food components or modified allergens as well as as trace allergens is still far from being exhautive.

[Treatment of asthma and rhinitis during pregnancy and breast feeding]. / Traitement de l'asthme et de la rhinite durant la grossesse et l'allaitement.

Inhaled therapies are preferred to systemic ones during pregnancy and breast feeding. A real paradox exists however between the necessity to ensure an optimal treatment for pregnant women with asthma, in order to prevent fetal hypoxia, and the precaution linked to any drug prescription during pregnancy. Thus, the use of topical corticosteroids remains the first choice for asthma as well as rhinitis. Inhaled beta2-agonists are also recommended. Systemic corticosteroids may however be prescribed without hesitation when their use is required for asthma treatment. It is also interesting to note that oral second-generation antihistamines are currently allowed during pregnancy and breast feeding. This type of antihistamines is indeed to be preferred to first-generation ones that generate more side-effects and generally are thus not to be prescribed during breast feeding.

[Lake Geneva Region guidelines on management of adult asthma]. / Recommandations suisses romandes sur la prise en charge de l'asthme de l'adulte.

Asthma is a major cause of chronic morbidity throughout the world. In Switzerland, 6.9% of the adult population is suffering from asthma. The standards of treatment are unfortunately not met in most western countries, as well as in Switzerland. We put forward a complete guideline on management of adult asthma, inspired from GINA and BTS guidelines, and adapted to the specific needs of general practitioners working in french part of Switzerland. This guideline reflects a consensus between allergy, lung and emergency specialists, working in the 2 university hospitals of the Lake Geneva Region (HUG and CHUV).

[Pathogenic mechanisms in systemic sclerosis and their therapeutical consequences. Part 1: pathogenesis]. / Mécanismes pathogéniques de la sclérodermie et leurs conséquences thérapeutiques. 1ère partie: pathogénie.

Systemic sclerosis I(cleroderma) is a connective tissue disease caracterized by an aberrant immune activation, a vasculopathy and a fibrosis of skin and multiple internal organs (lung, kidneys, gut, among others). At present no unifying pathogenetic hypothesis exists to explain all aspects of this disease. The current hypothesis is that in patients with a favourable genetic background, certain environmental factors could produce alterations of cellular and humoral immunity and alterations of the microcirculation resulting in excessive fibrosis. A crucial component in systemic sclerosis pathogenesis is the persistent and unregulated activation of genes encoding the various extracellular matrix proteins. This is in correlation with different cytokines and growth factors produced mainly by T lymphocytes.

[Pathogenic mechanisms in systemic sclerosis and their therapeutical consequences. Part 2: treatment]. / Mécanismes pathogéniques de la sclérodermie et leurs conséquences thérapeutiques. 2e partie: traitement.

Systemic sclerosis (scleroderma) is considered as the most severe connective tissue disease. It is characterized by an abnormal immune activation, a vasculopathy and a fibrosis of the skin and of multiple internal organs. Numerous progress in the understanding of the pathogenesis with identification of key molecules have permit to introduce novel treatments that improve the management of some aspects of the disease. ACE inhibitors are effective in resolving renal crisis. Cyclophosphamide is useful for treatment of fibrosing alveolitis. Prostaglandins, endothelin receptor antagonists and phosphodiesterase type 5 inhibitors permit to improve the treatment of the vascular complications (digital ulcerations, pulmonary arterial hypertension) of scleroderma.

[Allergo-immunology]. / Allergo-immunologie.

Allergic rhinitis is a frequent illness. New therapeutic options are being developed to counteract its impact on quality of life and health costs. This article presents two of these options, laser rhinophototherapy and Butterbur Ze 339, a drug derived from petasites. The immunodepressing effect of phototherapy has been tested in nasal mucosa. This application has shown satisfactory anti-inflammatory results in nasal cleaning fluid and, consequently, has enabled to reduce allergic rhinitis. The effect of butterbur on the symptoms of allergic rhinitis has to be understood in relation with the inhibition of cysleucotrienes synthesis, as well as its action on eosinophils and mastocytes. However, long-term studies involving large cohorts of patients are needed if we want to prescribe these treatments without restrictions.

[Skin tests in allergology: really so simple?]. / Tests cutanés en allergologie: si simple en apparence...

In allergology, skin tests (ST) are one of the main tools. Their simplicity, rapidity of the result, low cost, near absence of risk make them complements of choice to the patient history which remains the crucial step of the diagnosis. ST demonstrate in vivo the capacity of the cutaneous mast cells to potentially react to allergens. Their sensitivity is good, some precautions have to be taken into account (no antihistaminic drugs, quality of the extracts). Specificity is also good, but a positive test (which is suggestive of the presence of IgE) not always predicts clinical allergic manifestations. Knowledge of limits and pitfalls of ST is of major importance, especially when it comes to selecting extracts for specific immunotherapy and to investigate severe anaphylactic reactions to food or drugs.

[Oral allergy syndrome and food allergy]. / Syndrome oral croisé et allergies alimentaires.

To obtain a precise diagnosis of food allergy, it is essential to take a careful and detailed clinical history. This allows for directing further investigations and the patient should receive adequate information. In a research setting, recombinant allergens obtained by biotechnologies permit to reach a precise identification of allergenic proteins, with the hope of treating patients exclusively with the proteins to which they are allergic. In case of light reactions, a strict allergen avoidance is not required, but it is preferable to avoid the consumption of potentially dangerous food in isolated sites and before or during physical effort. In case of severe anaphylactic reactions with potent allergens like hazelnuts, peanuts and sea food, strict information about allergen avoidance and prescription of an emergency kit will be given.

[Sarcoidosis: new therapeutic and pathogenic aspects for an "old" disease]. / Sarcoïdose: nouveaux concepts pathogéniques et théra- peutiques pour une (vieille) maladie.

Sarcoidosis is a multisystemic disorder of unknown etiology characterized by non-caseating epithelioid granuloma. Clinical features are protean and the lack of a specific diagnostic test can make diagnosis difficult. The cause of this disease is still unknown but the diverse manifestations of this disorder help fuel the prevailing hypothesis that sarcoidosis has more than one cause each of which may promote a different pattern of illness. Recent progress, especially in immunology and molecular biology, has advanced our understanding of the pathogenesis of the disease and improved our ability to diagnose and treat this complex condition. This article gives an overview about current concepts in sarcoidosis and focus on immunopathogenic and therapeutic aspects.

[Widal triad (Asthma-Nasal polyposis-aspirin intolerance): an inflammatory metabolism abnormality]. / 2. La triade de Widal (asthme-polypose nasale-intolérance à l'aspirine): une anomalie du métabolisme inflammatoire.

Widal disease is characterized by symptomatic triad of aspirin intolerance, nasal polyposis and asthma. This disease is closely linked to abnormalities of the arachidonic acid metabolism. Partly of genetic origin, these anomalies are also related to the immune system function and probably to age. These factors induce an increase of cysleukotriene synthetase enzyme, and consequently an overproduction of cysleukotrienes that have both proinflammatory and bronchoconstrictive effects. In recent years, encouraging results were obtained with anti-leukotrienes, especially when they are associated with topic corticosteroids. Finally, numerous research that attempt to reach a better understanding of arachidonic acid metabolism are underway, which enables us to hope for future therapeutic advances.

Intravenous immunoglobulin replacement prevents severe and lower respiratory tract infections, but not upper respiratory tract and non-respiratory infections in common variable immune deficiency.

BACKGROUND: Although the dose of 400 mg/kg body weight intravenous immunoglobulins (IVIG) every 3-4 weeks is now standard for treating patients with common variable immune deficiency, studies demonstrating its long-term benefits over low 200 mg/kg dose and its effects on infectious subsets (upper vs lower respiratory vs non-respiratory infections) are rare. METHODS: All patients from a single center with the diagnosis of common variable immune deficiency and whose clinical chart was available during three successive therapeutic periods [a pre-IVIG replacement period, a low-dose (200 mg/kg every 3 weeks) and a standard-dose replacement period (400 mg/kg every 3 weeks)] were screened retrospectively. RESULTS: Seven patients followed up for a total of 116 patient-years over the three defined periods of observation were recruited. When compared with low-dose therapy, standard-dose intravenous immunoglobulin therapy raised trough IgG levels from 4.3 to 6.5 g/l and significantly decreased the overall frequency of infections, with marked effects on lower respiratory tract and severe infection number. In contrast, non-respiratory and upper respiratory infections were, in comparison, resistant to therapy. CONCLUSIONS: Overall, these data support the use of standard-dose 400 mg/kg intravenous immunoglobulin therapy, despite the high cost, to raise trough IgG levels to 5-7 g/l, but underlines that some categories of infectious events (non-respiratory, upper respiratory) may need parallel surgical or pharmacological approaches to be optimally prevented or treated.