[From conduct disorder in childhood to psychopathy in adult life].

Mental health professionals seldom recognize psychopathy in their daily practice. Usually forensic psychiatrists and psychologists are involved because individuals with psychopathic personality are involved in serious criminal behavior and implicated with the law. Most of the times the profiles of children who evolve in adult psychopaths have components from other disorders, especially conduct disorder. The term psychopathy originates from the Greek words "psyche" (soul) and "pathos" (passion) and was used to identify initially every mental illness. Although in the bibliography the terms Antisocial Personality Disorder, Psychopathic Personality, Psychopathy and Sociopathy are used as synonyms, it has not been clarified if the Antisocial Personality Disorder and Psychopathic Personality constitute two different entities or if the latter constitutes the more serious and hard core subtype of the first. The prevalence of Psychopathic Personality in the general population is estimated as 1%, with the proportion of men: women to be 3:1. The adult male psychopaths are responsible for almost 50% of the serious criminal behavior. Diagnosis of Psychopathic Personality is completed with the use of specific psychometric tools: Psychopathy Checklist-Revised (PCL-R) and Psychopathy Checklist: Screening Version (PCL: SV). The most recognizable elements of psychopathy are the non-existence of conscience and their shallow emotional relations. They are individuals with persuasion, that use the suitable phraseology in order to approach, impress and charm their prey. Nuclear characteristic is the inability to feel guilt, remorse and the nonexistence of moral rules. They lose their temper easily and present aggressiveness without obvious or insignificant reason. They develop various antisocial behaviors that are repeated with success, the gravity of violent behavior tends to increase and they have problems with the law. Nevertheless, people with Psychopathic Personality at one point were children, without diagnosis of Psychopathic Personality, as such a diagnosis is not appropriate at early childhood or adolescence. Psychopathic or/and antisocial tendencies sometimes are recognized in children and early adolescent age. Such behaviors lead usually to the diagnosis of Conduct Disorder or Oppositional Defiant Disorder or Attention Deficit and Hyperactivity Disorder in early years of life and increase the possibility to have a diagnosis of Antisocial Personality Disorder and Psychopathic Personality as an adult. There are many studies on the underlying risk factors for Psychopathic Personality, focusing in genetic, neurobiological, developmental, environmental, social and other factors. There is no effective treatment for Psychopathic Personality in adult life. Children with a specific neurobiological profile or behavioral disturbances that increase the risk of developing a Psychopathic Personality in adult life, have better chances to respond in exceptionally individualized interventions, depending on the character of the child. The parents are educated to supervise their children, to overlook annoying behaviors and to encourage the positive ones. It appears that the punishment does not attribute, on the contrary it strengthens undesirable behaviors. Use of reward appears to have better results. Programs of early highly focused therapeutic interventions in vulnerable members of the population are our best hope for the reduction of fully blown psychopaths in the general adult population.

Tacrolimus ointment 0.1% in the treatment of allergic contact eyelid dermatitis.

BACKGROUND: Tacrolimus inhibits T-lymphocyte activation and dermal Langerhans' cells, without the side-effects of corticosteroids. The safety profile of tacrolimus makes it a promising therapeutic option for dermatitis affecting the delicate periorbital skin. OBJECTIVE: To access the efficacy and tolerability of tacrolimus ointment 0.1% in the treatment of allergic contact eyelid dermatitis. PATIENTS AND METHODS: Twenty adults (16 women, 4 men) with eyelid dermatitis and with at least one positive patch test reaction to relevant contact allergens were treated with topical tacrolimus in a prospective, open-label, non-comparative clinical study. Dermatitis was graded at baseline, at day 30 and day 60, using a 4-point grading system for the following parameters: erythema, oedema, scaling, lichenification, fissuring (investigator assessment) and burning/stinging and pruritus (patient assessment). RESULTS: All patients completed the study. Erythema, oedema, scaling and lichenification showed improvement from baseline to 30 days of treatment ( P < 0.001), but fissuring was not significantly affected. At 60 days, no further improvement of these investigator parameters was observed. Patient parameters improved significantly by day 30 ( P < 0.004) and there was a trend for further improvement at the end of 60 days (for burning, P = 0.046; for pruritus, P = 0.059). Ten per cent of patients mentioned burning and itching, at the application site, during the first days of treatment. No other adverse events were observed. CONCLUSION: Topical tacrolimus is a promising alternative in patients with allergic contact eyelid dermatitis. Therapy was effective by 1 month and was well tolerated. These preliminary results merit a larger, controlled, study.

Allergy to olive pollen: a study of four family members.

We describe four family members with respiratory and dermatological manifestations of olive pollen allergy. The purpose of this study was 1) to investigate whether these patients' sera react to the same or different olive allergens, and 2) to identify common HLA class II antigens.

Effect of an antioxidant (quercetin) on sodium-lauryl-sulfate-induced skin irritation.

Quercetin is a bioflavonoid with antioxidant and anti-inflammatory activity. The purpose of this study was to examine the effect of quercetin on acute skin irritation, with special interest in the skin barrier function recovery. Acute irritant contact dermatitis was induced in 15 patients by 24-h occlusion of 2% sodium lauryl sulfate (SLS) (day (D) 1). The influence of application on SLS-irritated skin of topical quercetin for 5 consecutive Ds, compared to vehicle and controls, was studied. Parameters measured were transepidermal water loss (TEWL) and erythema index. Final measurements were taken on D 7 after a 1-D rest period. TEWL and the erythema index continued to rise 2 D after application of SLS and 1 D after treatment with quercetin, vehicle or controls. Both TEWL and erythema values at D 7 did not return to values before the SLS barrier disruption at all the test sites. Therefore, quercetin topically applied after induction of irritant contact dermatitis does not appear to increase the recovery of barrier function and erythema caused by SLS.

Frequency of immediate reactions to the European standard series.

Immediate contact reactions (contact urticaria) can occur after skin contact with a wide range of substances. We studied the incidence of immediate contact reactions (wheal and flare) to the European standard series allergens in 664 patients. Patch tests were first examined at 30 min for immediate patch test (IPT) reactions, and again at D2 and D4 for delayed patch test (DPT) reactions. Almost all the allergens of the European standard series caused IPT reactions. IPT reactions were most commonly seen with Myroxylon Pereirae (balsam of Peru) (113 reactions), fragrance mix (112 reactions), paraben mix (30 reactions) and clioquinol (13 reactions); these reactions were followed by DPT reactions to the same substance in 13.4%, 8.8%, 10% and 7.7%, respectively. For certain substances, patients with (+) IPT reactions had a significantly higher incidence of DPT reactions to the same allergen, as compared to patients with (-) IPT reactions (fragrance compounds p<0.001, formaldehyde p<0.005, thiuram mix p<0.01, paraben mix p<0.05). Thus, perhaps the mechanisms involved in IPT reactions are not the same for all substances. At least for certain substances, an IPT reaction may be related to the development of a DPT reaction.

Contact reactions to fragrances.

BACKGROUND: The most common reaction to fragrances is contact dermatitis, a delayed hypersensitivity reaction; however, other reactions include immediate contact reactions (contact urticaria) and photo-allergic reactions. Fragrance mix (FM) and balsam of Peru (BP) are used to screen for fragrance allergy. OBJECTIVE: To study the different types of allergic skin reactions to fragrance compounds. METHODS: Delayed hypersensitivity reactions to FM and BP were studied in 4,975 patients with suspected contact dermatitis by routine patch testing interpreted at 48 and 96 hours. In 664 of the patients, patch tests were read at 30 minutes to evaluate for immediate (wheal-and-flare) contact reactions and again at 48 and 96 hours. Photopatch tests to FM were performed in 111 patients with suspected photo-allergic dermatitis. RESULTS: Delayed contact reactions to FM occurred in 6.6% of females and 5.4% of males and to BP in 3.9% of females and 4.1% of males. Analysis of data over time (12 study years) showed an increased trend for reactions to fragrances, particularly in males. Sensitivity to other contact allergens (polysensitivity) was found in 62% of patients and polysensitivity presented more often with generalized contact dermatitis. The most sensitizing components of the fragrance mix that were tested in 38 patients were cinnamic alcohol, oak moss, and cinnamic aldehyde. There were 112 immediate patch test reactions to FM and 113 to BP in 664 patients. Immediate contact reactions were followed by delayed contact reactions in 13.4% of patients for FM and 8.8% for BP, representing a significant increase in the frequency of delayed contact reactions. Patients with immediate contact reactions to fragrances did not have a higher incidence of atopy (25.9%). No cases of positive photopatch test reactions to FM were seen. CONCLUSION: Fragrances commonly cause both delayed and immediate patch test reactions and patients with immediate contact reactions have an increase in delayed contact reactions to the same allergen.

Contact allergens in patients with leg ulcers.

BACKGROUND: Contact dermatitis can complicate the treatment of leg ulcers and is an acquired phenomenon resulting from the use of topical medications. OBJECTIVE: To show the incidence of contact dermatitis reactions to topical medications applied to leg ulcers and to evidence changing trends in such reactions through comparison of two case series about 20 years apart. SUBJECTS AND METHODS: We studied two groups of patients with leg ulcers that were patch tested with contact allergens in 1973-1974 and in 1994-1995. RESULTS: One or more positive patch tests was present in 75% and 40% of the patients, respectively. A decrease in the incidence of positive reactions to neomycin, local anesthetics and parabens mix was seen in 1994-1995. The most important contact allergens in 1994-1995 were fragrance mix, colophony and the excipients wool alcohols and amerchol. Other relevant sensitizers were formaldehyde, neomycin and gentamycin. CONCLUSION: The changing trends in contact allergens over the last 20 years may be explained by changes in the components of topical agents used for treatment.

Classic Kaposi's sarcoma in two young heterosexual men.

Classic Kaposi's sarcoma is primarily a skin disease of the lower extremities affecting predominantly elderly men of Mediterranean origin. We report classic Kaposi's sarcoma first presenting in the third decade in two heterosexual, HIV-negative, males of Greek origin from Albania. Ten years after onset, the disease became aggressive with unusual clinical features that included exophytic tumors, extensive lesions on the hands as well as the legs, and prominent leg edema. One of the patients also presented lesions on the face, trunk and palate, and bubonic lymphadenopathy. In both cases, CD4 counts were normal and HLA-DR5 was positive. Treatment included radiation therapy, subcutaneous interferon (alpha-2b) and combined chemotherapy (ABV). At follow up 1 and 2 years later, both patients remain in partial remission with significant improvement in clinical disease, on maintenance interferon.

Study of persistence and loss of patch test reactions to dichromate and cobalt.

Hyposensitization is a poorly understood phenomenon that refers to the conversion from a positive to a negative (or less positive) patch test. We studied 180 cement workers with contact dermatitis, who originally had a total of 163 positive patch test reactions to potassium dichromate and 98 positive reactions to cobalt chloride. They were patch tested a 2nd time after 2-6 years. On the 2nd patch test to dichromate, 103 (63%) remained positive, while reactivity decreased in 33 (20%) and 27 (17%) had become non-reactive. Cobalt sensitivity persisted in 47%, diminished in 13%, and 40% of the patch tests became non-reactive. In 10 patients with persistent patch test reactions and 10 matched patients with diminished reactions or loss of reactivity, circulating T-cell responses to dichromate and cobalt were studied in vivo. Circulating T cells that proliferated only to specific contact allergens were isolated and in all patients they were primarily CD4+. However, in patients with persistent reactions, they were CD4+ CD45RA+ (suppressor - inducer cells). These differences support an immunologic basis for hyposensitization.

Anaphylaxis induced by lentils.

BACKGROUND: The legume food family is large and includes peanut and soybean, two of the most frequent causes of food allergy. Literature on type I hypersensitivity to lentils, also a legume, is scarce. OBJECTIVE: To describe a child with repeated anaphylactic reactions related to lentils. METHODS: Skin prick tests with both commercial and cooked extracts and serum-specific IgE measured by CAP-RIA were used to identify specific IgE antibodies to various legumes. RESULTS: An 8-year-old girl suffered four episodes of anaphylaxis related to lentils from ages 3 to 7 years. The first three involved ingestion of cooked lentils and each time smaller amounts induced symptoms. The fourth episode occurred with inhalation exposure to cooking lentil soup. Subsequently, she presented with contact urticaria from raw chickpeas and an anaphylactic reaction after ingestion of cooked chickpeas. Prick tests showed strongly positive reactions to lentil and chickpea and weaker positive reactions to peanut, pea, soybean, and white bean. CAP-RIA was class 6 to lentil; class 5 to peanut, pea, and soybean; class 4 to white bean, and class 0 to green bean. CONCLUSION: Severe type I hypersensitivity to lentils occurred in this patient and was associated with clinically relevant hypersensitivity to chickpeas. Prick tests and CAP-RIA demonstrated multiple positive reactions to other legumes.

Influence of the menstrual cycle on skin-prick test reactions to histamine, morphine and allergen.

The purpose of this study was to examine the possible influence of the phases of the menstrual cycle on dermal reactivity to skin-prick testing. We studied 15 atopic, menstruating women with seasonal rhinoconjunctivitis and/or asthma, with known sensitivity to olive and parietaria (mean age 25.2 years) and 15 non-atopic, healthy, female controls (mean age 24.7 years). Skin-prick tests with histamine, morphine, and in the atopic group with parietaria/and/or olive, were repeated three times during the same menstrual cycle, corresponding to bleeding (day 1-4), midcycle (day 12-16) and the late progesterone phase (day 24-28). None of the patients had received oral antihistamines or exogenous hormones for at least 1 month prior to testing. Results indicate a significant increase in weal-and-flare size to histamine, morphine, and parietaria on days 12-16 of the cycle, corresponding to ovulation and peak oestrogen levels. This was observed in both atopic and non-atopic women. Differences in skin reactivity to histamine and morphine between the groups were not significant. Therefore, in women, the phase of the menstrual cycle is another factor that may influence skin-test results.

Familial cold urticaria: a father and daughter with typical clinical and laboratory features.

BACKGROUND: Familial cold urticaria is a rare, autosomally dominant disease of interest to physicians treating urticarial-type diseases. OBJECTIVE: To describe two patients, a father and daughter with the characteristics of this disease and review the features that differentiate it from other cold-induced syndromes. METHODS: Both patients underwent a cold room challenge, a lesional skin biopsy, and an ice-cube test, P-K test and extensive laboratory studies pre- and post-cold-room challenge. RESULTS: A careful history revealed winter outbreaks of erythematous, nonpruritic lesions occurring hours after cold air exposure since early childhood. Systemic symptoms included burning, chills, and arthralgias rather than the anaphylactic symptoms associated with acquired urticarias. Cold room challenge induced "non-urticarial" lesions after a delay of one-half to two hours. Lesional biopsy demonstrated polymorphonuclear infiltration with increased eosinophils. Ice-cube tests and P-K tests were negative, and laboratory studies were remarkable only for a rise in leukocytes and erythrocytic sedimentation rate after positive challenge. Abnormal serum proteins were not found. CONCLUSION: Familial cold urticaria is an inherited disease with distinct characteristics that distinguish it from acquired cold urticarias and other cold-induced syndromes. Most importantly, lesions occur with a delay after exposure to cold air and are not urticarial. Anaphylactic symptoms do not occur and abnormal serum proteins are not found.

Serum immunoglobulins and IgG subclass levels in adults with chronic sinusitis: evidence for decreased IgG3 levels.

Serum immunoglobulin class and IgG subclasses were measured in 30 adult patients with chronic sinusitis documented by CT scans of the paranasal sinuses. Results were compared to 30 age-and-sex matched patients with chronic rhinitis who had normal sinus CT scans, and a matched group of asymptomatic, healthy subjects. None of the patients was taking oral corticosteroids and none had ever received allergen immunotherapy. IgA deficiency was present in 3% (2/60) of the patients with chronic rhinitis or sinusitis and IgG deficiency was seen in another two (3%). None of the normals had low IgA or IgG. Low levels of IgG1 or IgG3 were found in some patients in all three groups, while none had low IgG2 levels. Serum levels of IgG, IgA, IgM, IgG1, IgG2, and IgG4 were not significantly different between the groups. Mean serum IgG3 levels, however, were significantly lower in the chronic sinusitis group than the chronic rhinitis group (P < .003) or the normals (P < .0005). The incidence of below normal levels of IgG3 was also more frequent in chronic sinusitis than in chronic rhinitis (P < .04) or normals (P < .002). Patients in the chronic sinusitis group had a high incidence of asthma (57%) and atopy (45%) but there was no difference in immunoglobulin class or IgG subclass levels in matched asthmatics compared with nonasthmatic patients with chronic sinusitis. Atopic patients with chronic sinusitis had a higher frequency of IgG3 subclass deficiency than nonatopics (P = .04). Normalization of low immunoglobulin class or IgG subclass levels that coincided with clinical improvement was documented in two patients with sinusitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaphylaxis associated with a change in premarin dye formulation.

Coloring agents are frequently added to drugs, foods, and cosmetics. If approved by the FDA, these additives may be added or substituted without notifying physicians. A patient developed angioedema, wheezing, urticaria, and dizziness one hour after taking the first Premarin tablet from a new refill. She had previously tolerated Premarin daily for 7 months without any adverse reactions. The new tablets were noted to be a slightly different shade of maroon and subsequent investigation revealed that the dye formulation had been changed (FD&C red #3 and FD&C yellow #6 were changed to FD&C red #40 and D&C #27). Puncture skin testing with a suspended tablet from the new Premarin batch was positive but was negative to a different drug (dye-free). Premarin skin testing in two normal volunteers was negative. The patient has since tolerated transdermal estrogen without any adverse reactions. These findings suggest that an additive in the Premarin tablet, most likely one of the new dyes, and not the estrogen, was the cause of the anaphylaxis. Physicians need to be aware that inactive ingredients can be changed without warning and these new constituents may cause sudden and potentially very severe allergic reactions to previously tolerated medication.

Increased immune reactivity to house dust mites in adults with chronic rhinosinusitis.

Sixty-three adults with symptomatic chronic rhinosinusitis had computerized tomographic (CT) scans of the paranasal sinuses, which were used to quantify disease severity. These patients were divided into three closely age- and sex-matched groups: a CT scan-negative group (chronic rhinitis only), a mild sinusitis group and a severe sinusitis group. Serum dust mite-specific IgG levels were found to be significantly elevated in the sinusitis patients compared with a matched group of asymptomatic normal individuals. Levels were highest in the more severe sinusitis group, in which the mean titre was 559 U/ml and the incidence of titres greater than 400 U/ml was 48%, as compared with a mean titre of 139 U/ml and only a 10% incidence of titres greater than 400 U/ml in the normal subjects (P < 0.005 and < 0.01). In contrast, although the frequency of immediate hypersensitivity to dust mite, as assessed by intradermal skin tests, tended to be higher in patients with sinusitis, it was not significantly different from normal individuals. The association between mite IgG and disease was most striking in the patient sub-group with negative mite skin tests. In this group, mite IgG levels were significantly higher than normal, even in those patients with only chronic rhinitis. These findings demonstrate that increased serum levels of IgG against dust mites are strongly associated with chronic rhinosinusitis, especially in the sub-group of patients who are not allergic to mites.