[Allergic bronchopulmonary aspergillosis. A report of a case and literature review]. / Aspergilosis broncopulmonar alérgica. Comunicación de un caso y revisión de la bibliografía.

Allergic bronchopulmonary aspergillosis is a world rare disease with a prevalence between 1 and 2%. It presents in moderate-severe asthma and cistic fibrosis patients. The diagnosis is made in the basis of Rossenberg and Greenberg criteria that can be essential or non essential. We present the case of a 3-year-old boy with allergic bronchopulmonary aspergillosis without bronchiectasies and with a good response to corticosteroids. His mother complained of two years of nasal obstruction, purulent rinorrea, nasal pruritus, sneezing, chronic cough and recurrent wheezing, twice to thrice a month. He also occasionally had vomits and diarrhea in relation with strawberries, banana, cow's milk and chocolate. We made the diagnosis of asthma, allergic rhinitis, sinusitis, and probably food allergy. We treated him with step approach of ICS according to GINA 2006, albuterol PRN, and elimination diet, with bad response. Laboratory exams: Blood white cells with eosinophilia (6%), total serum IgE: 1684 ng/L, aspergillus skin prick test: 4mm, serum IgG-Aspergillus fumigatus: 2.3 mcg/mL, serum IgE-Aspergillus fumigatus: negative, chest roentgenographic parahiliar and apical infiltrates, and chest computed tomography without bronchiectasies. We added prednisone to the treatment for four months, and we observed a very good response; he is now in treatment as mild persistent asthma with ICS low doses. ABPA must be suspected in patients with moderate-severe persistent asthma and a skin prick test positive to Aspergillus fumigatus regardless the age. The treatment with oral corticosteroids is the mainstream of management, and most of the patients have a good response, as we observed with this patient.

Cyclophosphamide hypersensitivity in a leukemic child.

Although hypersensitivity reactions to chemotherapeutic drugs have rarely been reported, they may occur with any of these agents. A Mexican native 44-kg 13-year-old boy suffering from acute lymphoblastic leukemia (ALL) received chemotherapy for 7 years. Three years later, a recurrence of ALL was detected in his right testicle. The patient was scheduled to receive 12 weekly cycles of 50 mg/kg of cyclophosphamide (CPM) as a 1-hour intravenous infusion. The patient did not have any history of drug allergies or any other type of ADR. Immediately after the fourth cycle of CPM, the patient developed itchy, maculopapular rash, sweating, respiratory distress, and anxiety. According to the algorithm developed by Naranjo et al, the ADR was classified as probably secondary to CPM. Skin tests were negative to hypersensitivity to CPM, and a new cycle of CPM was administered. However, the patient developed a similar hypersensitivity reaction to CPM. After an analysis of the clinical course of the ADR and the need to continue the chemotherapeutic treatment with CPM, we decided to desensitize the patient to this drug. Total duration of the procedure was 5 hours and was performed on only 1 occasion. The program of 12 cycles of chemotherapy was successfully completed without any sign or symptom of hypersensitivity to CPM. In conclusion, we have reported a case of hypersensitivity to CPM who was successfully desensitized to CPM.

[Eosinophilic colitis. A report of two cases with non conventional treatment]. / Colitis eosinofílica. Comunicación de dos casos con tratamiento no convencional.

Eosinophilic colitis is a rare entity of unknown etiology characterized by diarrhea, abdominal pain, and gastrointestinal bleeding. Diagnosis includes histopathological infiltration of more than 20 eosinophils in colon. It is frequently associated with milk hypersensitivity and, less usual, with other foods and increased IgE. Histopthological appearance of eosinophil mediators has been observed in the gut. It is sometimes related to the degree of infiltration of eosinophils in the gut as well as to the disease severity. There is not an established treatment for this entity, although systemic steroids have been used with certain efficacy. However, there is a recurrence of the symptoms when the therapy stops, besides the well known side effects of the long-term use of steroids. Cromolyn inhibits mast cell degranulation and prevents liberation of mediators. It is successful in certain cases, specially the severe ones. However, it is not available for its use in our country. Ketotifen, as last resource in our patients with bad response to habitual treatment and restriction diet, was used. Although its use is controversial, we consider that stabilizing mast cell membrane with subsequent inhibition of degranulation and recruitment of eosinophils to sites of inflammation, would also restrain histamine liberation and blockage of H1 receptors, which would diminish local damage induced by eosinophils. Nonetheless ketotifen mechanism of action is unknown, our patients improved after treatment with this drug.

[Changes in lung function after a bronchial provocation test with cockroach antigens]. / Cambios en la función pulmonar después de una prueba de reto bronquial con antígenos de cucaracha.

BACKGROUND: Cockroach allergens sensitized patients at a very young age and can predispose to severe asthma on atopic children. OBJECTIVE: To evaluate the FEV, changes induced after bronchoprovocation with Blatella germanica (Bg) or placebo on allergic respiratory children. MATERIAL AND METHODS: A prospective transversal study was performed in 25 children from 8 to 16 yr with allergic rhinitis and/or asthma diagnosis with sensibility only to Bg (Bayer Corp allergens) by Prick skin test, with a 1:20 weight/volume dilution. After previous training on spirometry, they assisted for a double blind bronchial challenge with 10, 25, 50, 75, 100, 150, 200, 300, 400, 500 until 750 proteic nitrogen units of Bg or 0.9% NaCl solution in a nebulized open circuit, with a 5 litter flow for 3 min. A week after, they returned for the crossover double blind bronchial challenge. At the beginning of the study a basal spirometry was performed and subsequent spirometrics at 1.5 and 3 min after each challenge with a 10 min rest between the challenges. The test was interrupted if cough, dyspnea, wheezing and/or a 15% or more FEV1 fall appeared. RESULTS: Twelve patients showed a FEV1 fall with the antigen challenge, all with specific lgE for Bg. All they had positive skin test to Bg, 9 had asthma and rhinitis and 3 only asthma. When placebo was used 6 patients showed a FEV1 fall. When comparing the average basal and final FEV1 values after the challenges, the fall was statistical significant in both groups with a p = 0.0015 when Bg was used, and p = 0.046 with placebo. CONCLUSION: These results show that two times fold number of patients challenged with Bg had a FEV1 fall than placebo, and the t Student test showed that antigen challenge was more significant than placebo. We demonstrated that respiratory allergic patients sensitised with Bg after a bronchial challenge with these allergens show a FEV1 fall. This suggests that cockroach allergen sensitisation can be on account of children's asthma.

[Hypersensitivity detected by skin tests to food in allergic patients in the Hospital Infantil de México Federico Gómez]. / Hipersensibilidad por prueba cutánea a alimentos en pacientes alérgicos en el Hospital Infantil de México Federico Gómez.

BACKGROUND: The prevalence of food allergy depends on the feeding practices of different parts of the world. Peanuts and nuts cause a great part of allergies in the United States; in Spain and Portugal are commonly due to fish, milk; in Italy seafood and mustard in France. In Mexico we don't know the frequency of food allergy and involved groups of age or specific foods. OBJECTIVE: To determine the frequency of immediate hypersensitivity for foods in allergic children from Hospital Infantil de México Federico Gómez. MATERIAL AND METHODS: A retrospective study was performed between January 1995 to December 1999. The skin prick test (SPT) to food was reviewed according to Aas classification. Male and female from 12 months to 18 years old were reviewed. RESULTS: We documented 1,419 patients with allergy. Of them 442 (31%) had positive skin prick test (SPT) to some of the 33 tested foods. The average age of the study group was of 12.8 years. The most affected was from 4 to 7 years (49%); the second group from 1 to 3 years with 23.7%, and the third was from 12 to 17 years with 13.5%. Fish, milky, seafood, soy, beans, orange, onion, tomato, chicken, nut, lettuce and strawberry, were responsible for 58% of the total of allergic reactions. Of those fish, milk, seafood, soy and orange (39%) had the highest frequency. Hypersensitivity to several foods is low, finding just one allergen in 50% of the cases, two allergens in 25%, three allergens in 9%, four in 7%, five in 5% and more than 6 only in 3% of cases. CONCLUSION: We concluded that almost any kind of food reaction seen in our study was due to alimentary habits of different populations, socioeconomic status, and availability of foods. This indicates the diversity of costumes in Mexican people due to the wide geographical area and cultural background of our country. Results could be increased because of only 33 allergens were tested.

Desensibilización a insulina DNA recombinante humana en una adolescente con diabetes mellitus insulinodependiente / Desensitization to human recombinant DNA insulin in an adolescent with insulin-dependent diabetes mellitus

Antecedentes: las reacciones adversas a fármacos se han incrementado durante los últimos años, en cerca del 15 por ciento de esos efectos quizá haya una participación inmunológica de acuerdo con el mecanismo de daño involucrado de la clasificación de Gell y Coombs, que pueden ser tipo I (inmediatas), tipo II (citotóxica), tipo III (influidas por complejos inmunitarios), y tipo IV (retardada). La alergia a la insulina se define como una respuesta inmunológica tipo I y, en menor frecuencia, tipo II o III a las preparaciones de insulina exógena y ocurre del 0.1 al 0.2 por ciento de los pacientes. Pacientes: se comunica el caso de una paciente de 13 años de edad, con antecedentes de diabetes mellitus dependiente de insulina, con manifestaciones de hipersensibilidad a la insulina recombinante humana (exantema urticariforme y prurito generalizado) sin respuesta favorable a la terapia previa a la medicación e imposibilidad para utilizar un tratamiento alternativo para su control metabólico. Por esta razón se procedió a la desensibilización con insulina. Métodos: la prueba cutánea con insulina rápida fue positiva a una dilución 1:10, los anticuerpos específicos IgE para insulina resultaron negativos y la IgE total fue normal. La desensibilización se inició con insulina rápida, a una dilución de 1:1000 por vía intradérmica, posteriormente subcutánea hasta alcanzar la dosis acumulada necesaria para la paciente durante el día. En el transcurso del proceso apareció un exantema maculopapular y prurito generalizado que remitió con antihistamínicos intravenosos. Resultados: la paciente toleró la desensibilización muy bien. Los últimos 14 meses ha sido tratada con insulina recombinante humana administrada por vía subcutánea sin problemas. Discusión: la desensibilización a fármacos no es un procedimiento frecuente y sólo se debe utilizar cuando es imposible sustituir la terapéutica. Nuestra paciente quizá tuvo una reacción de hipersensibilidad tipo I a insulina; sin embargo, no se puede descartar una reacción citotóxica influida por anticuerpos IgG o IgM o por complejos inmunitarios. La desensibilización fue bien tolerada y 14 meses después la paciente ha tolerado en forma adecuada su dosis diaria de insulina recombinante humana.

Procedimiento para realizar pruebas broncodinámicas con alergenos inhalados / Proccedings to bronchodynamics tests with inhalated allergens

El asma es una de las enfermedades crónicas más frecuentes de los niños. Se caracteriza por hiperreactividad de las vías aéreas a estímulos inespecíficos (metacolina e histamina) y específicos (alergenos). Las pruebas broncodinámicas determinan la broncolabilidad del niño asmático y ayudan a establecer el diagnóstico funcional. Deben realizarse con extractos antigénicos de alta calidad, acuosos liofilizados y estandarizados; se puede utilizar un circuito abierto o cerrado y un dosímetro, la dosis inicial del alergeno es más baja que con la que se obtuvo la reactividad cutánea positiva, realizando incrementos sucesivos hasta que el VEF-1 descienda 15 por ciento o más. La seguridad del paciente es fundamental, por eso las pruebas debe realizarlas personal especialmente adiestrado.

Medición de la flujimetría en niños alérgicos a ácaros antes y después del reto con pruebas por prick / Flujimetry subsequent to the Dermatophagoides pteronisinnus through tests cutaneous for prick in allergy children

Objetivo. Determinar la obstrucción del flujo aéreo por flujimetría posterior a la aplicación de pruebas cutáneas específicas (dermathophagoides pteronisinnus), en niños sensibles a éste. Material y método. Se estudiaron 44 pacientes de uno y otro sexo con diagnóstico de asma y antecedente de sensibilidad al ácaro Dermathophagoides pteronisinnus mediante pruebas cutáneas por prick, con una edad promedio de 6 a 16 años, captados de la consulta externa del servicio de alergia del Hospital Infantil de México Federico Gómez. Es un estudio longitudinal, prospectivo, ciego cruzado, en el que previamente se hizo una prueba de reto con antígeno estandarizado de Dermatophagoides pteronisinnus o glicerina, previa lectura de flujimetría. Resultados. De los pacientes retados con antígeno en 23 hubo descenso del flujo espiratorio máximo, con una p<0.05, pero sin significado clínico. Cuando se retaron con placebo sólo disminuyó en siete pacientes el flujo espiratorio máximo, también estadísticamente significativo, pero sin relevancia clínica. Conclusión. Las pruebas cutáneas son una herramienta útil en alergia y seguras, pues casi no producen reacciones sistémicas graves