Knowledge of their own allergic sensitizations in asthmatic patients and its impact on the level of asthma control.

BACKGROUND: Asthma guidelines recommend the adoption of allergen avoidance measures (AAM). To do so, patients need to know their own allergies. However, this degree of knowledge has not yet been assessed. The aims of this study were to determine, in allergic asthma patients: i)the degree of knowledge of their own allergic sensitizations; ii)the percentage of those who knew all their allergies and, in addition, adopted AAM against all of them, and iii)the possible impact of this degree of knowledge on the level of asthma control. PATIENTS AND METHODS: Descriptive, prospective and multicentre study, including 147patients from 9 Respiratory Medicine outpatient clinics. After confirming the previous allergic asthma diagnosis, a questionnaire was completed. It included asthma control and severity levels, results of previous allergy tests, and the description and number of allergic sensitizations known by the patients and AAM followed. RESULTS: Only 72 (49%) patients knew all their allergic sensitizations and only 48 (33%) were also following AAM against all the allergens to which they were allergic. No relationship was established between the degree of knowledge of their own allergies and the level of asthma control (P=.544). CONCLUSIONS: Overall knowledge about the allergic nature of their disease among asthmatic patients attending Spanish Respiratory Medicine Departments is inadequate. Furthermore, a higher degree of knowledge of their allergies does not seem to lead, by itself, to better asthma control. Both findings seem to question the effectiveness of current educational strategies in this field and consequently, they should be revised.

Bird fancier's lung: a series of 86 patients.

Bird fancier's lung (BFL) is one of the most common types of hypersensitivity pneumonitis. Nevertheless, the criteria for diagnosing this condition are not standardized. The current study is an in-depth investigation into the clinical characteristics of BFL in the largest series examined for this purpose by a single group, to our knowledge, taking into account the acute, subacute, or chronic clinical presentation. From 1977 to 2003, BFL was diagnosed in 86 patients using a homogeneous protocol. Data from the clinical history and physical examination were analyzed, as well as the results from the following complementary examinations: laboratory analyses, specific serum IgG antibodies determination, chest X-ray, chest computed tomography (CT), pulmonary function testing, immediate hypersensitivity skin testing, delayed cutaneous hypersensitivity testing, bronchofibroscopy with bronchoalveolar lavage (BAL) and/or transbronchial biopsy, bronchial challenge testing, and surgical lung biopsy. In addition, clinical and epidemiologic characteristics were determined in a control group of 60 pigeon breeders who did not meet the diagnostic criteria of BFL. Eighty-six patients (21 men and 65 women) with a mean age of 47 years were studied. Seven (8%) patients were younger than 15 years of age at the time of the diagnosis. In 3 cases, the disease was caused by exposure to feather-filled bedding. Nearly 1 in 5 patients was diagnosed in the chronic phase of the disease. The mean diagnostic delay was 1.6 years overall, and 3.2 years in patients diagnosed in the chronic phase of the disease. Among the 17% of patients with chronic disease, the mean interval from initiation of exposure to diagnosis was 16 years, a higher value than in the acute or subacute presentation forms. Dyspnea and cough were the most common clinical symptoms (98% and 82%, respectively), and nearly 25% had grade III or IV dyspnea at diagnosis. Only 18% of patients experienced chest tightness, a symptom classically considered to be frequent in this condition. Erythrocyte sedimentation rate was elevated (>30 mm/h) in 44% of patients. Urinary calcium was elevated in 20% of patients. Angiotensin-converting enzyme was not elevated in any of the patients in which it was measured. Lactate dehydrogenase increases were found in 51% of patients. Specific IgG antibodies to avian antigens were documented in 92% of BFL patients, but also in 87% of pigeon breeder controls. The most frequent radiologic finding was an interstitial pattern in 79% of patients. Common chest CT features were ground glass areas (68%) and a mosaic pattern (61%); areas of emphysema were found in 7/41 (17%) patients, 5 of whom had never smoked. Two patients had a CT pattern of pulmonary fibrosis indistinguishable from idiopathic pulmonary fibrosis. Immediate hypersensitivity skin testing with bird sera and pigeon bloom was positive in 78% and 100% of BFL patients, respectively, and in 64% and 88% of control pigeon breeders, respectively. Almost one-third of the patients (29%) presented an anergic response on delayed cutaneous hypersensitivity testing. Restrictive ventilatory impairment was the most frequent functional pattern (77%), although 9% and 4% showed a pure obstructive and mixed pattern, respectively. The carbon monoxide diffusing capacity was decreased (<80% of the predicted value) in 85% of cases. Forty-one percent of patients had PaO2 <60 mm Hg at diagnosis when blood gas analysis was performed. Lymphocytosis (>20% lymphocytes) was documented in 83% of patients who underwent BAL, with a similar frequency in the 3 presentation forms: 70% acute, 89% subacute, and 85% chronic. In addition, inversion of the CD4/CD8 ratio (<1) was observed in 62% of the patients, but 38% of cases showed a CD4 predominance. The characteristic triad of histopathologic findings in hypersensitivity pneumonitis was found in only 9% of patients undergoing transbronchial biopsy, but at least 1 of these findings was seen in 69%. Surgical lung biopsy was undertaken in 14/86 (16%) patients; the complete triad was observed in 50% and at least 1 finding in 100%. In 54/86 (63%) patients, the diagnosis was confirmed by bronchial challenge testing, a test with a sensitivity of 92% and specificity of 100%. BFL is a potentially severe disease that can progress to respiratory failure secondary to pulmonary fibrosis or chronic obstructive pulmonary disease, as a form of chronic occupational respiratory disease. Respiratory symptoms in exposed patients, including children and adults who have only 1 pet bird at home, should raise the suspicion of BFL. Diagnosis in the chronic phase is frequent, and the delay to diagnosis was greatest in these cases. Elevated urinary calcium, lactate dehydrogenase, and erythrocyte sedimentation rate in a bird fancier may constitute a combined marker for suspected BFL. Chest CT frequently discloses emphysema and a pattern of idiopathic pulmonary fibrosis in some patients. An anergic response on delayed cutaneous hypersensitivity testing is not infrequent. The presentation with respiratory failure and the predominance of CD4 T lymphocytes in some patients' BAL are both remarkable. Lymphocytosis on BAL also persists in the chronic phase of the disease. Bronchial challenge testing has a high diagnostic yield, and surgical lung biopsy is not needed to reach the final diagnosis in the vast majority of cases.

Occupational vocal cord dysfunction due to exposure to wood dust and xerographic toner.

OBJECTIVES: Vocal cord dysfunction is a poorly understood entity that is often misdiagnosed as asthma. Both irritant and non-irritant vocal cord dysfunction have been described. This report presents two cases of irritant vocal cord dysfunction secondary to specific environmental exposure, the first to iroko and western red cedar wood (a carpenter) and the second to xerographic printing toner (a secretary). METHODS: Several tests were performed, including chest radiographs, measurements of total serum immunoglobulin E, skin prick tests with common pneumoallergens (as well as iroko and western red cedar in the first case), pulmonary function studies, methacholine challenge testing, specific inhalation challenge performed with suspected agents in a single-blinded fashion, and peak expiratory flow testing and fiberoptic rhinolaryngoscopy (in case 1). RESULTS: During the specific inhalation challenge, the patients showed dysphonia, chest tightness, inspiratory stridor, and flattening of the inspiratory limb of the maximum flow-volume loop in spirometry, with no significant decreases in the level of forced expiratory volume in 1 second; fiberoptic rhinolaryngoscopy confirmed the diagnosis of vocal cord dysfunction in case 1. CONCLUSIONS: It is important to know that agents that can cause occupational asthma can also cause vocal cord dysfunction. The mechanisms by which these agents produce vocal cord dysfunction are unknown. The differences in the clinical presentation of the patients described relative to the reported cases suggest that more than one pathophysiological mechanism may be implicated in the genesis of this entity.

[Monitoring of asthma outpatients after adapting treatment to meet international guidelines]. / La población de asmáticos ambulatorios y su control tras adaptar el tratamiento a las recomendaciones internacionales (ASMACAP I).

OBJECTIVE: Poor control of asthma treated in outpatient settings has been demonstrated. The aim of this study was to perform a short intervention, readily replicable in everyday practice, to try to improve control of the disease. PATIENTS AND METHODS: Two primary health care clinics made appointments with asthma patients to administer a questionnaire and adapt their treatment to the guidelines of the Global Initiative for Asthma. Patients also received an explanation of the disease lasting not more than 5 minutes. The protocol was repeated at a second visit 4 months later. Health care parameters were compared with those from the previous visit. RESULTS: The characteristics of the 180 patients were as follows: 70% were women, 17% were smokers, 8% were illiterate, 46% had only primary education, 45% were in contact with cleaning products, and 63% had extrinsic asthma. The asthma severity was as follows: mild in 73%, moderate in 23%, and severe in 4%. Twenty-two percent had received previous explanations of the disease, 50% had a written treatment plan, 14% had a plan for exacerbations, and 54% were taking inhaled corticosteroids. The second appointment was kept by 110 (61%) of the patients, who showed differences with respect to the previous visit 4 months earlier in the percentage taking inhaled corticosteroids (78%, P< .001), the number of visits to the physician (P< .01), visits to the physician due to exacerbations (P< .001), emergency visits to the outpatient clinic (P< .002), and disease severity (P< .02). CONCLUSIONS: This minimal clinical intervention reduced the need for visits to health care centers and improved the control of asthma symptoms.

Suberosis: clinical study and new etiologic agents in a series of eight patients.

BACKGROUND: Penicillium frequentans is considered to be the causal agent of suberosis, hypersensitivity pneumonitis due to cork dust inhalation. Nevertheless, other fungi can colonize cork during its storage period in humid conditions. The aims of the study were to assess the etiologic role of several fungi and cork itself in the genesis of suberosis, and to review the clinical characteristics of patients with this disease. METHODS: Eight patients with suberosis were studied. Chest radiography, high-resolution chest CT, pulmonary function testing, bronchofibroscopy with BAL and transbronchial biopsy, and delayed cutaneous hypersensitivity tests were performed. Fungal and suberin (cork that is culture negative for fungi) antigens were used for serum determination of specific IgG antibodies, immediate hypersensitivity specific skin tests, and specific bronchial challenge tests. RESULTS: Serum specific IgG antibody determinations and specific skin tests against Aspergillus fumigatus and suberin demonstrated the capacity of both these antigenic extracts to induce an immunologic response. Positive specific bronchial challenge tests performed not only with P frequentans but also with A fumigatus, and cork itself were recorded in some patients for the first time in this disease. Dyspnea and cough were the most frequent symptoms. Clinical and functional improvement occurred after antigen avoidance. CONCLUSIONS: In addition to P frequentans, A fumigatus and cork dust itself may contribute to the development of suberosis.

[Hypersensitivity pneumonitis in construction plasterers (espartosis): study of 20 patients]. / Neumonitis por hipersensibilidad en los yeseros de la construcción (espartosis): estudio de 20 casos.

BACKGROUND AND OBJECTIVE: Espartosis is a type of hypersensitivity pneumonitis which frequently affects construction workers handling esparto fibres used as support material inside gypsum plaster. Exactly which agents produce this disease remains under discussion. The aims of this study were: a) to assess the possible etiologic role of the fungi colonizing esparto grass fibres and esparto itself in the genesis of this disease, and b) to describe the clinical characteristics of this disease in a large series of patients. PATIENTS AND METHOD: Twenty patients diagnosed of hypersensitivity pneumonitis due to esparto grass exposure were studied. Mycologic cultures of the esparto grass fibre samples provided by each patient were performed. Fungi and/or esparto were used for determination of specific IgG antibodies, specific skin tests and specific bronchial challenge tests. RESULTS: Most frequently isolated fungi in causal esparto samples were Aspergillus sp. (60%) and Mucor sp. (47%). Specific IgG antibody determinations and/or specific bronchial challenge tests showed antigenicity not only for Aspergillus sp. but also for non-fungi-contaminated esparto grass and other fungi such as Penicillium sp. or Mucor sp. These results were helpful for establishing a new etiologic approach to the diagnosis of this disease. CONCLUSIONS: Aspergillus fumigatus is recognized as a causal agent in hypersensitivity pneumonitis due to esparto grass exposure; however, other antigenic sources such as Penicillium frequentans and other fungi, as well as esparto grass fibres, also appear to play a role in the genesis of this disease.