Tolerability and immunological effect of short up-dosing immunotherapy with 2 standardized native allergen extracts derived from the pollen of Salsola kali and Cupressus arizonica

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Satisfaction and perceived effectiveness in patients on subcutaneous immunotherapy with a high-dose hypoallergenic pollen extract.

This study was designed to determine the level of satisfaction, tolerance and perceived effectiveness by patients in the first pollen season after starting treatment with Alergovit(®). For this purpose, a nationwide, retrospective, multicentre and cross-sectional observational study was carried on 256 patients. Perceived effectiveness by the patients was measured using a visual analogue scale and was clinically significant in 92.4% of the patients. The satisfaction level was evaluated with a specific questionnaire. 32.5% of the patients were totally satisfied with Allergovit(®) and 48.8% reported a high degree of satisfaction. The treatment was well tolerated by 99.2% of the patients. Our results demonstrate that subcutaneous immunotherapy with Allergovit(®) is effective and well-tolerated in routine clinical practice.

La alergología en el sistema sanitario público de la Comunidad de Madrid: situación actual y oportunidades en el sistema sanitario público del siglo XXI / Allergology in the public health service of the Community of Madrid: current situation and opportunities in the XXI century public health system

La alta prevalencia de las enfermedades alérgicas y una mayor complejidad diagnóstica y terapéutica, exigen un alergólogo altamente capacitado profesionalmente y organizaciones sanitarias conocedoras de los recursos humanos y estructurales disponibles. En España faltan datos actualizados en alergología e indicadores de actividad que reflejen esta complejidad. Este trabajo analiza la situación, detecta necesidades y plantea soluciones de mejora para la alergología en la Comunidad de Madrid. Los 24 jefes de servicio de Alergología de los hospitales públicos madrileños con asistencia alergológica, completaron voluntariamente la encuesta diseñada específicamente para este trabajo, con datos de actividad asistencial (2010), docencia e investigación (2009-2010). Se realizó un análisis DAFO y se diseñaron líneas estratégicas y propuestas de mejora orientadas a adoptar las soluciones más idóneas. Un total de 117 alergólogos (41% doctores) en el sistema público de salud (4,6 profesionales/centro; ≤ 3 en 10 hospitales), realizaban consulta externa (4000 primeras consultas/ hospital/año, 36% de alta resolución; 6200 visitas sucesivas/ hospital/año). Se ejecutaban procedimientos básicos diagnósticos y terapéuticos, incluyendo pruebas complejas propias de hospital de día, mayoritariamente no reconocidas en los indicadores de actividad. Dos hospitales tenían hospitalización propia y 10 disponían de acreditación docente (2,78 MIR/año). Bianualmente, un servicio participaba en 4 proyectos de investigación, 2 ensayos clínicos, 16 publicaciones y 17 comunicaciones a congresos, con notables diferencias entre hospitales. Madrid cuenta con alergólogos bien preparados y una organización asistencial alergológica adecuada aunque posiblemente insuficiente. Nuevas herramientas de registro de actividad y el incremento de la cooperación corporativa, aprovechando nuevas tecnologías y la proximidad geográfica, mejorarían la calidad y la eficiencia (AU)

The high prevalence of allergic diseases and the use of more complex diagnostic techniques and therapeutic options require allergists to be highly trained professionals and healthcare organizations to be knowledgeable about available structural and human resources. Updated information is lacking in Spain, and current activity indicators do not reflect complexity. The present article analyzes the situation of allergology in Madrid and proposes improvements where necessary. The heads of the allergy departments of public hospitals in Madrid voluntarily completed a purpose-designed survey. Data on care activity (2010) and on teaching and research activity (2009-2010) were provided. A SWOT analysis was performed, and strategic lines and proposals for improvement were designed. One hundred and seventeen allergists (41% with a PhD) worked in 24 hospitals with an allergology department (4.6 physicians/center; ≤3 in 10 hospitals). All the institutions had an outpatient clinic (4,000 first consultations/hospital/year, 36% high-resolution rate; 6200 successive visits/hospital/year) performing complex diagnostic and therapeutic procedures, most of which were not taken into account by activity indicators. Two hospitals had their own hospitalization facilities and 10 were accredited teaching hospitals (2.78 medical residents/ year). The survey revealed that, twice yearly, a typical allergology service participated in 4 research projects, 2 clinical trials, 16 publications and 17 communications at scientific meetings, with notable differences between hospitals. Allergists in Madrid are well prepared. The allergology care structure is adequate, although possibly insufficient. Quality and efficiency can be improved with new tools for recording activity and by increasing coordination and taking advantage of new technologies and geographical proximity (AU)

[Allergology in the public health service of the Community of Madrid: current situation and opportunities in the XXI century public health system]. / La alergología en el sistema sanitario público de la Comunidad de Madrid: situación actual y oportunidades en el sis. sanitario público del siglo XXI.

The high prevalence of allergic diseases and the use of more complex diagnostic techniques and therapeutic options require allergists to be highly trained professionals and health-care organizations to be knowledgeable about available structural and human resources. Updated information is lacking in Spain, and current activity indicators do not reflect complexity. The present article analyzes the situation of allergology in Madrid and proposes improvements where necessary. The heads of the allergy departments of public hospitals in Madrid voluntarily completed a purpose-designed survey. Data on care activity (2010) and on teaching and research activity (2009-2010) were provided. A SWOT analysis was performed, and strategic lines and proposals for improvement were designed. One hundred and seventeen allergists (41% with a PhD) worked in 24 hospitals with an allergology department (4.6 physicians/center; ≤3 in 10 hospitals). All the institutions had an outpatient clinic (4,000 first consultations/hospital/year, 36% high-resolution rate; 6200 successive visits/hospital/year) performing complex diagnostic and therapeutic procedures, most of which were not taken into account by activity indicators. Two hospitals had their own hospitalization facilities and 10 were accredited teaching hospitals (2.78 medical residents/year). The survey revealed that, twice yearly, a typical allergology service participated in 4 research projects, 2 clinical trials, 16 publications and 17 communications at scientific meetings, with notable differences between hospitals. Allergists in Madrid are well prepared. The allergology care structure is adequate, although possibly insufficient. Quality and efficiency can be improved with new tools for recording activity and by increasing coordination and taking advantage of new technologies and geographical proximity.

Vasculitis during immunotherapy treatment in a patient with allergy to Cupressus arizonica.

UNLABELLED: Allergen immunotherapy dates back to 1911 and has been used successfully to treat large numbers of patients throughout the last century. CASE REPORT: a 66-year-old woman presented with symptoms of allergic rhinitis and asthma due to sensitization to Cupressus arizonica. Specific immunotherapy was prescribed as a continuous 2-year treatment with a depot preparation of standarized and characterized allergen extracts of Cupressus arizonica pollen. Forty-eight hours after one maintenance dose of 0.8 cc, the patient presented palpable violaceous purpuric lesions and pruritus on both legs. We performed skin prick and intradermal tests with Cupressus arizonica. Twenty-four hours later, the 1/1 dilution intradermal skin test was positive. Biopsy showed leukocytoclastic vasculitis. CONCLUSIONS: A middle-aged woman experienced cutaneous non-necrotizing vasculitis after 2 years of maintenance immunotherapy. The interval between injections and the first appearance of cutaneous lesions suggests a type III hypersensitivity immune reaction. Skin biopsy of the positive intradermal test also supports this hypothesis.

Vasculitis during immunotherapy treatment in a patient with allergy to Cupressus arizonica

Allergen immunotherapy dates back to 1911 and has been used successfully to treat large numbers of patients throughout the last century. Case report: a 66-year-old woman presented with symptoms of allergic rhinitis and asthma due to sensitization to Cupressus arizonica. Specific immunotherapy was prescribed as a continuous 2-year treatment with a depot preparation of standarized and characterized allergen extracts of Cupressus arizonica pollen. Forty-eight hours after one maintenance dose of 0.8 cc, the patient presented palpable violaceous purpuric lesions and pruritus on both legs. We performed skin prick and intradermal tests with Cupressus arizonica. Twenty-four hours later, the 1/1 dilution intradermal skin test was positive. Biopsy showed leukocytoclastic vasculitis. Conclusions: A middle-aged woman experienced cutaneous non-necrotizing vasculitis after 2 years of maintenance immunotherapy. The interval between injections and the first appearance of cutaneous lesions suggests a type III hypersensitivity immune reaction. Skin biopsy of the positive intradermal test also supports this hypothesis

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[Treatment with nebulized lidocaine in steroid-dependent asthma]. / Tratamiento con lidocaína nebulizada del asma corticodependiente.

BACKGROUND: The management of glucocorticoid dependent and resistant asthma encompasses a group of problems, affecting as much control of clinical symptoms as the onset of adverse effects to prolonged use of steroids. MATERIALS AND METHODS: Woman 52 years old, steroid dependent asthma fifteen years ago. She has important adverse effects in consequence of the use of systemic glucocorticoids. The employment of methotrexate attained decrease in the dosage of steroids temporarily. The worsening of the clinical situation and deterioration of secondary effects by use of steroids necessitated treatment with nebulized lidocaine. A 2% solution to initial dosage was administered three times daily. The maximal dosage needed was 80 mg three times daily. RESULTS: After three months of lidocaine treatment, the patient was able to reduce oral steroids eventually discontinuing these drugs, and the effects secondary to exogenous hypercortisolism disappeared. Moreover, an improvement in clinical symptoms and quality of life was observed with stability in the pulmonary function. CONCLUSIONS: The use of nebulized lidocaine could be useful and provide alternatives in patients with severe asthma.

[Safety of rush immunotherapy with Hymenoptera venom]. / Seguridad de la inmunoterapia con una pauta rápida con veneno de himenópteros.

OBJECTIVES: To determine the incidence and nature of adverse events associated with the induction of rush Hymenoptera venom immunotherapy. MATERIAL AND METHODS: Between 1998 and 2003, we administered venom immunotherapy to 48 patients allergic to bee or wasp venom, by means of a rush immunotherapy protocol (3 days). RESULTS: We observed no severe adverse reactions in any patients. 12 patients developed only local reactions at the site of injections that did not required any pharmacological treatment. Two patients experienced mild systemic reactions consisting of diffuse urticaria on day 3. Both adverse reactions were treated with intravenous antihistamines. CONCLUSIONS: Our experience confirms that rapid venom immunotherapy is safe and should be considered in every case especially for patients during the stinging insect season when a rapid protection is required.

Seguridad de la inmunoterapia con una pauta rápida con veneno de himenópteros / Safety of rush immunotherapy with hymenoptera venom

Objetivos: El estudio pretende determinar la incidencia de reacciones adversas asociada a la administración de inmunoterapia con veneno de himenópteros mediante una pauta de iniciación rápida. Material y métodos: Entre 1998 y 2003 realizamos un estudio, consistente en administrar a 48 pacientes tratamiento hiposensibilizante con veneno de avispa o abeja utilizando un protocolo diseñado por nosotros con una pauta rápida (3 días). Resultados: No obtuvimos reacciones adversas graves en ninguno de los pacientes. Dos de los 48 pacientes presentaron reacciones sistémicas leves (urticaria) al tercer día del tratamiento. Ambos pacientes fueron tratados con antihistamínicos intravenosos. Doce de los pacientes presentaron reacciones locales en el lugar de la inyección. Conclusión: El estudio confirma que la pauta rápida empleada es segura y podría ser de elección en pacientes donde fuera necesario conseguir una protección rápida

Objetives: To determine the incidence and nature of adverse events associated with the induction of rush Hymenoptera venom immunotherapy. Material and methods: Between 1998 and 2003, we administered venom immunotherapy to 48 patients allergic to bee or wasp venom, by means of a rush immunotherapy protocol (3 days). Results: We observed no severe adverse reactions in any patients. 12 patients developed only local reactions at the site of injections that did not required any pharmacological treatment. Two patients experienced mild systemic reactions consisting of diffuse urticaria on day 3. Both adverse reactions were treated with intravenous antihistamines. Conclussions: Our experience confirms that rapid venom immunotherapy is safe and should be considered in every case especially for patients during the stinging insect season when a rapid protection is required

Tratamiento con lidocaína nebulizada del asma corticodependiente / Treatment with nebulized lidocaine to steroid-dependent asthma

Antecedentes: El cuidado de los pacientes con asma bronquial corticodependiente y corticorresistente supone un conjunto de problemas, que afectan tanto a la situación clínica como al desarrollo de efectos adversos secundarios a una prolongada terapia esteroidea. Material y métodos: Mujer de 52 años con asma corticodependiente de 15 años de evolución con manifestaciones clínicas de hipercortisolismo. El uso de metotrexato oral consiguió un descenso transitorio en las dosis de esteroides. El agravamiento de la situación clínica obligó a un aumento de las dosis de esteroides con el consiguiente empeoramiento de los efectos secundarios. Por este motivo se instauro tratamiento con lidocaína nebulizada al 2 % a dosis iniciales de 40 mg cada 8 horas hasta una dosis máxima de 80 mg cada 8 horas. Resultados: Tras 3 meses de tratamiento con lidocaína nebulizada se reducen las dosis de corticoides orales hasta la suspensión total de estos con la desaparición o mejoría de los efectos secundarios al hipercortisolismo. Se produjo una mejoría en su situación clínica así como un aumento en la calidad de vida de la paciente con estabilidad en los parámetros de función pulmonar. Conclusiones: El uso de lidocaína nebulizada podría representar una alternativa eficaz y segura en el tratamiento del asma de difícil manejo

Background: The management of glucocorticoid dependent and resistant asthma compases a group of problems, So much control of clinical symptoms and onset of adversa effects to prolongad use of steroids. Materials and methods: Woman 52 years cid, steroid dependent asthma fifteen years ago. She was important adversa effects in consecuence the use sistemic glucocorticoids. The employment of metotrexate attained decrease in the dosage of steroids temporally. The wrong of clinical situation and deterioration secondary effects by use of steroids maked to start treatment with nebulized lidocaine of a 2 % solution to initial dosage was a three times daily. The maximal dosage needy was made of 80 mg three times daily. Results: After three months of beginning from lidocaine treatment, patient obtained to reduce orally steroid up to discontinuance or these drugs and the effects secondary to exogenous hypercortisolism disappeared. Moreover, A improvement in clinical symptoms and quality of lita was observad with stability in the pulmonary function. Conclusions: The use of nebulized lidocaine could be a useful and gafe alternativa in patients with severa asthma

[Treatment strategies in rhinoconjunctivitis and asthma during pregnancy]. / Estrategias de tratamiento de la rinoconjuntivitis y el asma durante el embarazo.

BACKGROUND: The incidence of asthma is high, especially in young people, a population group that includes women of reproductive age. We reviewed recent publications on asthma control during pregnancy to avoid undesired effects on both the mother and fetus. The prevalence of rhinoconjunctivitis is also high, although this disease is often under-treated by physicians. The use of beta2-agonists, corticoids (systemic/inhaled/nebulized), epinephrine and specific allergen immunotherapy is discussed. METHODS: We reviewed recent publications on asthma during pregnancy as well as other articles of interest. Articles providing data on drug therapy, overall strategies and patient education were selected. Sufficient drugs are available for the management of this disease and under-treatment cannot be justified. CONCLUSIONS: Pregnancy is not a disease, but constitutes a period when special care must be taken with underlying diseases. The aim of asthma treatment during pregnancy is to prevent fetal complications due to the effects of medication and asthma crises by keeping the mother symptom free and preventing possible exacerbations. Almost all authors agree that asthma crises in pregnant women should be treated no differently from those in non-pregnant women. Treatment of rhinoconjunctivitis should not be stopped during pregnancy since a wide variety of FDA category B drugs is available. Specific allergen immunotherapy should not be suspended during pregnancy as it is not contraindicated. However, this therapy should not be initiated during pregnancy.

Estrategias de tratamiento de la rinoconjuntivitis y el asma durante el embarazo / Treatment strategies in rhinoconjunctivitis and asthma during pregnancy

Introducción: El asma es una enfermedad con alta incidencia sobre todo en gente joven, grupo de población al que pertenecen las mujeres en edad fértil. Hemos revisado los últimos artículos sobre el tema para poder mantener el asma bien controlada y así evitar efectos no deseados tanto en la madre como en el feto. Igualmente se aborda el control de la rino-conjuntivitis, tan incapacitante para multitud de personas y tan olvidada e infratratada por muchos profesionales. Intentamos dar una perspectiva que nos parece razonable para el uso de medicación como β -adrenérgicos, corticoides (sistémicos/inhalados/nebulizados), epinefrina e inmunoterapia específica con alergenos inhalantes. Material y métodos: Hemos revisado los últimos artículos sobre el tema y los que nos han parecido más relevantes. Además no sólo nos hemos centrado en el aspecto farmacológico, sino que hemos tratado de buscar aquellos textos donde se da también una estrategia de tratamiento global, sin descuidar la educación en el manejo de su enfermedad. En esta revisión se comprueba que existe medicación suficiente para el control de estas enfermedades por lo que no hay motivo para infratratar. Conclusiones: El embarazo no es una enfermedad, sino un momento en la vida de una mujer en el que hay que tener mayor control del habitual sobre su patología de base. El objetivo del tratamiento del asma en el embarazo es que la paciente esté libre de síntomas y prevenir las posibles exacerbaciones, para así evitar un mayor daño fetal, tanto por la medicación que se necesita, como por los efectos de la crisis sobre el feto. Es importante destacar que casi todos los autores coinciden en que una crisis asmática en una mujer embarazada se trata igual que en una paciente no embarazada. No hay que dejar de tratar la rino-conjuntivitis por parecer una patología menor ya que se dispone de un importante arsenal terapéutico catalogado como de categoría B por la FDA. La inmunoterapia específica con alergenos no está contraindicada en el embarazo, ni hay que suspenderla, pero no está recomendado iniciarlo durante el mismo

Background: The incidence of asthma is high, especially in young people, a population group that includes women of reproductive age. We reviewed recent publications on asthma control during pregnancy to avoid undesired effects on both the mother and fetus. The prevalence of rhinoconjunctivitis is also high, although this disease is often under-treated by physicians. The use of β2-agonists, corticoids (systemic/inhaled/nebulized), epinephrine and specific allergen immunotherapy is discussed. Methods: We reviewed recent publications on asthma during pregnancy as well as other articles of interest. Articles providing data on drug therapy, overall strategies and patient education were selected. Sufficient drugs are available for the management of this disease and under-treatment cannot be justified. Conclusions: Pregnancy is not a disease, but constitutes a period when special care must be taken with underlying diseases. The aim of asthma treatment during pregnancy is to prevent fetal complications due to the effects of medication and asthma crises by keeping the mother symptom free and preventing possible exacerbations. Almost all authors agree that asthma crises in pregnant women should be treated no differently from those in non-pregnant women. Treatment of rhinoconjunctivitis should not be stopped during pregnancy since a wide variety of FDA category B drugs is available. Specific allergen immunotherapy should not be suspended during pregnancy as it is not contraindicated. However, this therapy should not be initiated during pregnancy

[Baboon syndrome]. / Síndrome de baboon.

Andersen et al described baboon syndrome in 1984. It was characterized by a clinical presentation of systemic contact dermatitis with pruritic and confluent maculopapular light-red eruption, localized in the gluteal area and the major flexures, developed several hours or days after drug or agent contact. This syndrome has a pathognomonic distribution but its cause has not been elucidated yet. Histopathology of the lesions shows non-specific features of dermatitis. Several drugs have been previously described as responsible for the Baboon syndrome origin. Mercury is the most frequent implicated agent; other agents are nickel, different antibiotics, heparine, aminophylline, pseudoephedrine, terbinafine and immunoglobulins

[Hereditary angioedema of delayed onset]. / Angioedema hereditario de comienzo tardío.

Hereditary angioedema is a disorder characterized by episodes of angioedema of the skin, respiratory and gastrointestinal tract resulting from a defect in the C1 esterase inhibitor. The disease is hereditary. Inheritance is autosomal dominant with incomplete penetration. We report a 56-year-old man with edema in different locations as forearm, testicles and palms. It started recently. The study showed low levels of C4, and C1 inhibitor. He was diagnosed of hereditary angioedema and it was necessary the family study.

Angioedema hereditario de comienzo tardío / Hereditary angioedema of delayed onset

El angioedema hereditario es una patología caracterizada por episodios repetidos de edema que afecta a la piel y a mucosas de vías respiratorias superiores y del tubo digestivo, debido a un déficit o disfunción del inhibidor de la C1 esterasa. Tiene un carácter hereditario con una herencia autosómica dominante con penetración variable. Presentamos un paciente de 56 años con episodios leves de edema, de reciente comienzo, en diferentes localizaciones como antebrazos, testículos y palmas de manos. Tras el estudio se objetiva una disminución de los valores de C4, C1 inhibidor y C1 inhibidor funcional, diagnosticándole de angioedema hereditario, haciéndose obligatorio realizar un estudio familiar (AU)

Síndrome de baboon / Baboon syndrome

El síndrome de baboon fue descrito por primera vez por Andersen en 1984 que lo definió como la presentación clínica de una dermatitis de contacto sistémica caracterizada por la presencia de prurito y erupción maculopapular eritematosa confluente en el área de los glúteos y de las flexuras mayores que aparece varias horas después e incluso varios días, tras el contacto con un fármaco u otro agente. La distribución de las lesiones es patognomónica aunque se desconoce la patogénesis. En la mayoría de los casos descritos, la anatomía patológica de las lesiones confirman cambios inespecíficos de dermatitis. Se han demostrado numerosos fármacos como desencadenantes de este tipo de reacciones. No obstante, el agente más frecuente es el mercurio, según numerosos casos publicados. Otros agentes causantes son: niquel, diferentes antibióticos, heparina, aminofilina, pseudoefedrina, terbinafina e inmunoglobulinas (AU)

Andersen et al described baboon syndrome in 1984. It was characterized by a clinical presentation of systemic contact dermatitis with pruritic and confluent maculopapular light-red eruption, localized in the gluteal area and the major flexures, developed several hours or days after drug or agent contact. This syndrome has a pathognomonic distribution but its cause has not been elucidated yet. Histopathology of the lesions shows non-specific features of dermatitis. Several drugs have been previously described as responsible for the Baboon syndrome origin. Mercury is the most frequent implicated agent; other agents are nickel, different antibiotics, heparine, aminophylline, pseudoephedrine, terbinafine and immunoglobulins (AU)

Auriculotemporal nerve syndrome.

INTRODUCTION: Auriculotemporal nerve syndrome is characterized by erythema, perspiration, heat and pain localized in the area supplied by the auriculotemporal nerve in response to gustatory stimuli after the ingestion of different types of food. This syndrome may be confused with food allergy. CASE REPORT: A 21-year-old woman complained of erythema, sweat and heat in the right cheek after intake of several foods such as chocolate, fruits, and nuts for the previous 8 months. She had fractured her jaw two years previously. METHODS: Skin prick tests were performed with a standard battery of common inhalant allergens and with an extensive panel of food allergens. Prick-by-prick tests were also performed with fruits, nuts, and cacao. Total and specific IgE were measured. Open oral food challenge test was performed. RESULTS: Skin prick tests were positive for grass and olive pollen. Prick-by-prick tests and specific IgE antibodies to the different foods were all negative. Open oral challenge test with apple reproduced the symptoms. CONCLUSIONS: This benign syndrome is often misdiagnosed as a food allergy.