Molecular profiling in bee venom allergy: clinical and therapeutic characterization in a Portuguese cohort.

Summary: Background. Bee venom allergy (BVA) can trigger local and systemic allergic reactions, including anaphylaxis. Recently, the molecular sensitization profile has gained importance in the reaction's stratification and venom immunotherapy (VIT). Methods. Retrospective analysis of patients with hypersensitivity to BVA, confirmed by specific sIgE to Apis mellifera ≥0.35 kU/L and/or positive skin tests to bee venom commercial extract, evaluated in specialized consultation. Demographic, clinical, and laboratory data (including molecular Api m 1, 4, and 10) were analyzed, looking for risk factors associated with the severity of the index reaction and reactions during VIT. Results. 93 patients were included (55.9% male; median age of 46 years), 57.3% with atopic comorbidities, and 23.4% with cardiovascular comorbidities. The median specific IgE to Apis mellifera was 6.7 kU/L (IQR 1.0-20.3) kU/L. Regarding the molecular profile, the median IgE to Api m 1 was 0.5 kU/L (57.5% positive out of all measurements); Api m 4 - 0.01 kU/L (11.9% positive), and Api m 10 - 0.3 kU/L (50.0% positive). No patient was monosensitized to Api m 4. The median age of the most severe sting reaction was 36 (IQR 26-48) years, with a median severity (Müeller scale) of 3 (IQR 2-3). Forty-seven patients (50.5%) underwent VIT, with 35.6% of reactions recorded. Allergic reactions during VIT were recorded in 35.6% of cases. The severity of the index reaction correlated positively with older ages (p=0.040; r=0.249), in contrast to monosensitization to Api m 1, which was an independent predictor of milder reactions (p=0.015). Sensitization to Api m 10 was associated with a higher likelihood of reactions during VIT (p=0.038) but potentially less systemic reactions at re-stings (p=0.097). Conclusions. Molecular sensitization profile appears to be relevant not only to the severity of index reactions but also during VIT. Studies of a large cohort of patients with molecular profiles are essential to validate these results and improve the clinical and therapeutic approach to BVA.

Sensitization to genuine markers of timothy grass pollen (Phleum pratense) in the North-Central region of Portugal.

Summary: Pollens are the main cause of respiratory allergies which prevalence is increasing. The most important cause of pollinosis in Europe and especially in the Mediterranean countries as Portugal is Poaceae family pollen. Timothy grass (Phleum pratense) is one of the most common pollen sources, and one of the best characterized allergenic grasses. The major allergens Phl p1 and Phl p5 are considered markers of genuine grass pollen sensitization. A characterization of Phl p1 and Phl p5 sensitization in the North-Central region of Portugal was made in children and adults. Phl p1 sensitization was the most frequent.

Streptococcal tonsillitis as a cause of urticaria: tonsillitis and urticaria.

BACKGROUND: The primary role of infections in chronic urticaria (CU) is controversial. We hypothesised that streptococcal tonsillitis (ST) could be a primary cause of CU or acute recurrent urticaria (ARU). METHODS: Retrospective study of 14 outpatients observed between January 2000 and December 2009, with CU/ARU and clinical and/or laboratorial suspicion of an aetiopathogenic link with ST. Clinical history, objective examination and laboratorial study were looked for. Three groups were defined: spontaneous resolution of urticaria, resolution after tonsillectomy, and still symptomatic. RESULTS: In these patients, a causal relationship between ST and urticaria is supported by: markers of streptococcal infection, the perception of a clinical relationship between tonsillitis and urticaria, the decrease of urticaria severity with early antibiotherapy to tonsillitis and urticaria resolution after tonsillectomy. CONCLUSIONS: Our study encourages the investigation of tonsillitis in these otherwise idiopathic patients, especially until young adulthood and even in the absence of any symptoms.

Airways hyperresponsiveness to different inhaled combination therapies in adolescent asthmatics.

BACKGROUND: Inhaled combined therapy improves the pulmonary function in asthmatic patients. The effect on the airway hyperresponsiveness (AHR) and the efficacy of different pharmacological schedules is not well clarified on adolescent asthmatics. OBJECTIVE: Evaluate the responses to different combined inhaled therapies in adolescent asthmatics and study its impact on exercise induced AHR. METHODS: Basal lung function tests (LFT) were performed in 30 adolescents (13 to 16 years old; 19 female) with allergic asthma. They were submitted to exercise challenge test (EC) followed by bronchodilator test (BD). During 4 weeks, 15 adolescents were submitted to inhaled fluticasone/salmeterol (group A) and other 15 to inhaled budesonide/formoterol (group B). After this period, they underwent another functional evaluation as previous. RESULTS: Before treatment, pulmonary function was similar in both groups. After 4 weeks of treatment, these groups showed an improvement of the basal LFT (p = 0.001 for FEV1 in both), decrease on bronchoconstriction induced by exercise (NS for both) and less recovery on BD response (p = 0.001 and 0.002, for FEV1 respectively groups A and B). Group B showed a better performance, with higher improvement of basal FEF 25/75 (p = 0.001), reduced bronchoconstriction response to EC (p = 0.008 for FEV1) and fewer response to BD test (p < 0.0001 for FEV1 and 0.024 for FEF 25/75) No adverse events were observed. CONCLUSION: After 4 weeks of inhaled combined therapy, these patients improved their pulmonary function and bronchomotricity. Those under budesonide/formoterol showed the highest improvement. These medications are a safe measure in controlling the asthma in these patients.

T cell receptor excision circles (TREC) and recent thymic migrant cells in specific immunotherapy and respiratory allergy to Dermatophagoides pteronyssinus.

INTRODUCTION: T cell receptor excision circles (TREC) on CD31+ T cells are related to recent thymic emigrant cells (RTEs). The involvement of the functional thymic tissue occurs early in the IgE-mediated allergic reaction, and in response to specific immunotherapy (SIT). AIM: Evaluation of specific immunotherapy effects on TREC number in peripheral T cells in patients allergic to Dermatophagoides pteronyssinus (Dpt). METHOD: 85 respiratory allergic patients (both genders), 41 of them (Group II) under maintenance treatment to Dpt SIT (21 sublingual-SLIT, and 20 subcutaneous-SCIT), were selected. The allergic patients (Group I) without specific treatment were submitted to an allergen challenge test (22 nasal and 22 conjunctival). Peripheral cell analysis was performed immediately before treatment and 60 or 240 minutes after allergenic extract administration. TREC quantification was performed in CD4+CD31+ and CD8+CD31+. The results were expressed per 100.000 cells related to RTEs. Samples from 10 healthy individuals (Control - Group III) were obtained with the same method. RESULTS: The value of TRECs on RTEs was constant in control groups. For Group I patients (nasal or conjunctival test), TREC quantification in CD31+ T cells showed relevant individual changes, even in the patients tested earlier (60 minutes), and statistical significant at 240 minutes. Both SCIT and SLIT had also demonstrated enormous individual changes, particularly on TRECs/CD4+CD31+ cells assay. Basal values in Group III were significantly higher than those observed in active patients groups. CONCLUSION: Thymic functional activity is earlier involved in the allergic reaction and SIT IgE-mediated allergy is able to induce RTEs in the periphery, particularly TRECs/CD4+CD31+ cells. Both SLIT and SCIT showed reduced RETs in the periphery, probably due to maturation of regulatory T cells. Our results suggest a crucial role of the functional thymic tissue on the central mechanism of this therapy.

Intragastric pH effect of 20mg of levo-pantoprazole versus 40mg of racemic pantoprazole the first seven days of treatment in patients with gastroesophageal reflux disease. / Efecto sobre el pH intragástrico de 20mg de levopantoprazol versus 40mg de pantoprazol racémico durante los primeros 7 días de tratamiento en pacientes con enfermedad por reflujo gastroesofágico.

INTRODUCTION/AIM: Levo-pantoprazole, the S-enantiomer of pantoprazole, is a proton pump inhibitor that has been shown in animal studies to be faster and stronger than its racemic formulation. There are no studies on humans and therefore our aim was to evaluate the effects of levo-pantoprazole versus racemic pantoprazole on intragastric pH. MATERIALS AND METHODS: A randomized controlled study was conducted on patients with erosive gastroesophageal reflux disease that were given 20mg of levo-pantoprazole (n = 15) versus 40mg of racemic pantoprazole (n = 15) for 7 days. Baseline and end-of-treatment symptom evaluation and intragastric pH measurement were carried out. RESULTS: There were no differences between the groups in the baseline evaluations. From 40 to 115min after the first dose of levo-pantoprazole, the mean intragastric pH was higher, compared with that of racemic pantoprazole (p < 0.05). After one week, levo-pantoprazole and racemic pantoprazole significantly reduced intragastric acid production and its esophageal exposure (p < 0.05). Even though there was no statistically significant difference, a larger number of patients that received levo-pantoprazole stated that their heartburn improved within the first 3 days. CONCLUSIONS: The S-enantiomer of pantoprazole (levo-pantoprazole) had a faster and stronger effect with respect to acid suppression, compared with its racemic formulation. Although the effect on symptoms was faster with levo-pantoprazole, occurring within the first days of treatment, it was equivalent to that of the racemate at one week of treatment.

Itraconazole, an effective adjunctive treatment for allergic bronchopulmonary aspergillosis.

We report the case of a 21-year old man with a long-standing history of severe asthma and allergic rhinosinusitis who developed progressive worsening of dyspnea, wheezing, productive cough, and nasal obstruction, with little response to antibiotics and repeated short courses of oral corticosteroids. A diagnosis of allergic bronchopulmonary aspergillosis was made on the basis of a combination of clinical, laboratory and radiographic findings.Treatment with oral methylprednisolone and itraconazole resulted in an improvement in symptoms, lung function and computed tomography results, as well as in a decrease in total serum immunoglobulin E. This case report highlights the importance of a high degree of clinical suspicion in order to diagnose and treat allergic bronchopulmonary aspergillosis in patients with a long-standing history of severe asthma as early as possible as this has a major impact on prognosis. It also highlights the effectiveness of itraconazole as adjunctive therapy to systemic corticosteroids in this condition.

Thoracic high resolution computed tomography (HRCT) in asthma.

INTRODUCTION: High-resolution computed tomography (HRCT) is a widespread medical imaging method for the study of thoracic diseases. In asthma it is very useful particularly when it is difficult to achieve an effective control of disease, and in severe deterioration. AIM: It was intended to evaluate the imaging changes by HRCT in asthmatic patients and to assess the expression according to the symptoms and duration of disease. MATERIAL AND METHODS: Thirty three patients from the Outpatient Department, with asthma classified in the different clinical severity stages according to GINA, were randomly included. They were submitted to HRCT (Somaton Plus-4, Siemens). The lesions were classified in reversible (mucoid impaction, acinar pattern centrilobular nodules and lobar collapse) and irreversible (bronchiectasis, bronchial wall-thickening, sequellar line shadows and emphysema). RESULTS: The 33 asthmatic patients (20 female) had an average age of 44.76 +/- 16.98 years and a mean disease evolution time of 23.39 +/-14.83 years. 30% had mild persistent asthma, 43% moderate persistent asthma and 27% severe persistent asthma. All the patients were under inhaled corticotherapy. Only 6 patients had normal HRCT 4 with mild persistent asthma (4 to 25 years of duration of disease) and 2 with moderate persistent (10 to 48 years of duration of disease). 81.81% of the patients had changes in HRCT, being the irreversible lesions the most frequent. The most important irreversible lesions were observed in severe asthma patients with longer duration of disease. All the patients with reversible lesions had also irreversible changes. Most of the bronchiectasis were centrally located and were found in severe asthma patients. Irreversible changes were identified in 3 patients with mild asthma and a maximum of 6 years of duration of disease. DISCUSSION: HRCT findings were related with asthma severity and long lasting disease but there are some asthmatics that also present early abnormalities, even in milder forms. All the groups of asthmatic patients presented all types of imaging changes, including the irreversible ones. In asthma these changes can be the result of individual patterns of response to frequent exacerbations, leading to a persistent chronic inflammatory process that will determine airway remodelling, even in early stages of disease and/or mild asthma.

Body mass index and airway hyper-responsiveness in individuals without respiratory disease.

BACKGROUND: Overweight and obesity are major health issues in Western societies. They are related with a higher risk of different co-morbidities but their relationship with airway hyperresponsiveness (AHR) is still under discussion. Nevertheless, they are related to higher severity in asthma and other respiratory diseases. The aim of the study was to analyze the AHR in individuals with normal lung function without respiratory disorders, according to body mass index (BMI) calculation. METHODS: We performed clinical observation and basal lung function tests (LFT) in 595 consecutive individuals in order to exclude respiratory disease. 377 individuals fulfilled the criteria of normal values according international guidelines. They were submitted to standardized treadmill exercise test followed by bronchodilator test. FVC, FEV1, FEF 25/75, RV and Raw were obtained at different conditions according to BMI groups (I: lean; II: normal; III: overweight; IV obese). RESULTS: 55.2% of the sample was overweight or obese, and a signficant relationship was found with female gender and older ages (p=0.0046 and p<0.0001 respectively). The positive response to exercise test or bronchodilator beta2 agonists was not significantly frequent compared with the other groups. In obese individuals the exercise markedly reduced basal Raw and increased FEF 25/75. Lean individuals showed higher basal values of RV that was reduced upon exercise. Response to 12 agonists showed no differences according to weight biotypes. CONCLUSION: BMI hampers lung function in normal individuals, and seems not to be related to AHR. Regular exercise should be encouraged in overweight and obese individuals, since it increases their bronchial permeability as shown in lower frequency of positive exercise tests. The same is advisable for lean individuals for different reasons. Their increased basal RV and Raw improve upon exercise. Despite overweight and obesity are being related to a low-grade of basal systemic inflammation, there was no association with a higher basal bronchial hyperresponsiveness in these individuals.

Low-dose intravenous gammaglobulin in the treatment of severe autoimmune urticaria.

BACKGROUND: An autoimmune pathogenic mechanism is implicated in about one-third of patients with chronic urticaria (CU), involving circulating functional autoantibodies to either the high affinity IgE receptor (LgG1/IgG3 anti-FcARI) or to IgE, with histamine releasing activity. New therapeutic approaches had been developed for patients with severe or unresponsive to treatment symptoms, including the use of intravenous immunoglobulins (IVIG) as immunomodulators. AIM: To assess the efficacy of IVIG treatment in patients with evidence of autoimmune CU. METHODS: A group of 29 patients (F = 20, M = 9) with the diagnosis of autoimmune CU were selected from the outpatient department. All the patients showed daily symptoms of urticaria and/or angioedema, with unsatisfactory response to conventional therapy and a positive intradermal autologous serum test (AST). They were submitted to low dose of IVIG treatment each 4 weeks (0.15 g/kg), for a minimum of 6 months and a maximum of 51 months. They were evaluated for clinical scores, need of oral medication and AST results, before and after treatment. RESULTS: A clinical improvement was observed in 26 patients, with reduction of urticaria or angioedema complaints (p < 0.0001) and decreasing need for oral antihistamine medication (p = 0.002). 3 patients drop-out the treatment: one depending of severe adverse event and the other 2 with no response after the 5th treatment. 19:26 patients achieved complete remission of symptoms. A reduction of histamine-releasing activity was found in the majority of the patients, documented by the decrea, se of reactivity in AST at the end of the treatment (p = 0.002). 20 patients remained without symptoms during 12 months after. the active treatment, and the other 6 only reported non-severe complaints. CONCLUSION: IVIG is an effective therapeutic option in patients suffering from severe CU refractory to conventional treatment, in which autoimmune mechanism is involved. The efficacy persists for at least 12 months after treatment. However, the number of infusions needed to achieve clinical control, showed great range between patients.

Development of new IgE specificities to hymenoptera allergens during venom-specific immunotherapy.

BACKGROUND: Despite the benefits of specific immunotherapy (SIT) being clinically well documented for allergic diseases, new IgE specificities to SIT extract allergens could be induced during the treatment. The authors evaluated these changes in patients allergic to Hymenoptera. METHODS: Six patients allergic to Hymenoptera venom were included in the study. Specific IgE (sIgE) levels determination and IgE immunoblots to Apis mellifera, Vespula spp. and Polistes spp. venom were performed before and after one year of SIT. RESULTS: All patients had sIgE levels reduction, after the first year of treatment, except one in whom there was an increase in sIgE levels to Apis mellifera venom, and two patients that maintained a similar value for Vespula spp. venom sIgE before and after one year of treatment. The immunoblot analysis revealed that most of the bands detected before beginning SIT, decreased in intensity or disappeared after one year of treatment. 3/6 patients developed new IgE specificities to venom extracts: one patient to the venom allergens in the treatment, other patient to allergens in other venom and another patient to both. After one year of treatment one of these patients tolerated a field sting by the corresponding insect. The newly recognised proteins were all minor allergens. CONCLUSION: These results confirm that sIgE levels tend to reduce during SIT, and the bands identifying some allergens in the blot tend to decrease or disappear. Nonetheless venom SIT can be responsible for the induction of new sensitisations to other venom allergens, apparently without clinical relevance.

Urban versus rural environment--any differences in aeroallergens sensitization in an allergic population of Cova da Beira, Portugal?

Cova da Beira is an interior central region of Portugal, with a population of 93000 inhabitants divided in urban and rural living areas. The aim of this study was to access the prevalence of aeroallergens sensitisation in an allergic population, according to the urban and the rural environmental exposure and according to age. 1096 patients observed for suspected allergic symptoms, for a five-year period (1995-2000) were submitted to skin prick tests and were included in this study. They were divided in two environmental exposure groups (A: urban; B: rural) and in to four age subgroups (subgroup I: < or = 10yr; subgroup II: 11-20yr; subgroup III: 21-40yr; subgroup IV: >40yr). The total population included 444 male (40.5%) and 652 female (59.4%) with an average age of 26.5 +/- 17.2 yr. 83% of the 1096 performed SPT were positive. The frequency of aeroallergens sensitisation, comparing the urban versus the rural environment, was respectively: D. pteronyssinus 32% and 34.7%, D. farinae 28.5% and 30.7%, moulds mixture 15.3% and 12%, cat dander 17.1% and 15.2%, dog dander 11% and 10%, grasses mixture 51.3% and 36.4%, Parietaria judaica 29.4% and 14%, Olea europea 30.2% and 23.3%. The sensitisation to indoor aeroallergens, was similar in all the age subgroups and it was lower than that to pollens. There were important differences concerning the pollen sensitisation, when comparing the urban and the rural environmental exposure. We admit that pollution could enhance the sensitisation to pollens in the urban environment.

Specific immunotherapy for severe latex allergy.

We studied 4 patients (3 adult females + 13y old boy) with latex allergy. All patients had anaphylaxis related with latex and oral-latex-fruit syndrome. All 3 females had severe symptoms in the workplace. The boy had spina bifida with 9 previous surgeries and needed further surgical interventions. Positive skin prick tests (SPT), the presence of serum latex specific IgE (CAP-RAST, Pharmacia-Upjohn, Sweden- class 3 in the 3 females and class 4 in the boy) demonstrated the sensitisation. All 4 patients were treated with specific immunotherapy (SIT) with aqueous extract (ALK-ALK-ABELLO SA, Spain) administered subcutaneously at the hospital, by a modified rush schedule. A maintenance dose (MD) of 0.35_g protein was established according to the magnitude of local reactions (LRs). In one patient a higher dose induced the appearance of a systemic reaction (SR) 40 min after administration, which promptly remitted with treatment. After reaching MD, all 3 females remained assymptomatic at workplace. A challenge test with latex gloves was performed. Two months after MD was reached 2 females had no symptoms and one other had mild symptoms of rhinoconjunctivitis. The boy was subjected to a surgical intervention with no allergic reaction. We also observed a reduction on skin reactivity to latex in all patients by prick tests. We consider SIT with latex to be highly effective, safe and well tolerated provided we use this dose of the allergenic extract.

Goat's milk allergy.

BACKGROUND: Goat's milk (GM) allergy not associated with allergy to cow's milk (CM) is a rare disorder. Caseins have been implicated has the major allergens eliciting symptoms. METHODS: We report the case of a 27 years-old female patient that experienced two episodes of urticaria related to ingestion of goat's cheese (GC). She tolerated CM, dairy products and sheep cheese. Skin prick tests were performed with GM, CM, bovine casein and alpha -lactalbumin and fresh milk and GC. Serum specific IgE to GM, CM and its fractions, and GM and CM immunobloting assays with inhibition were also evaluated. RESULTS: Skin tests were positive to GM and GC and negative to CM. GM immunoblot showed an IgE-binding 14 kDa band that was totally inhibited after serum pre-incubation with GM. CONCLUSIONS: Allergens other than casein can be involved in allergy to GM. Even small quantities of protein can elicit symptoms.

Aeroallergens sensitization in an allergic paediatric population of Cova da Beira, Portugal.

Cova da Beira is an interior central region of Portugal, with a population of 93,000 inhabitants. The first pollen counts performed in Portugal revealed the highest values of the country in this area. The aim of this study was to assess the aeroallergens sensitization in an allergic population, according to the age groups. In a 5 year period (1995-2000) 1790 consecutive outpatients were observed for suspected allergic symptoms. We included in this study all the 557 paediatric (< or = 15 years old) observed patients (317 male (57%) and 240 female (43%) with an average age of 7.6 < or = 4.2 years old). They were divided in three age groups (Group I: < or = 5 yr; Group II: 6-10 yr; Group III: 11-15 yr). 371 patients were submitted to skin prick tests to aeroallergens. 86.5% of these patients were sensitised to at least one allergen extract. The most representative aeroallergens sensitization were grasses mixture (44.9%), D. pteronyssinus (32.5%), D. farinae (29.1%), Olea europea (27.5%), Parietaria judaica (23.4%), cat dander (16.1%), Artemisia vulgaris (17.6%), Robinia pseudoacacia (12.2%), Platanus acerifolia (11.4%), Tilia cordata (11.4%) moulds mixture (11.2%), Plantago lanceolata (10.6%), dog dander (10.4%), and Pinus radiata (7.5%). The sensitisation to indoor aeroallergens, was similar in all age groups and it was less important than that of pollens. The prevalence of sensitisation to grasses was the greatest in all ages and the house dust mites sensitization was the second most prevalent. The highest pollens counts in this region could explain the early sensitisation even in young children.