Adrenal suppression secondary to inhaled fluticasone propionate.

BACKGROUND: Inhaled glucocorticoids are the medical treatment of choice in many of patients with asthma. Fluticasone propionate is an inhaled glucocorticoid with little systemic bioavailability via the oral route and infrequent association with systemic adverse effects at the recommended dosage. OBJECTIVE: To report a case of adrenal suppression and exogenous glucocorticoid excess from inhaled fluticasone propionate. METHODS: A 9-year-old girl with a previous history of episodic asthma was placed on 550 microg of fluticasone propionate daily for severe labile asthma diagnosed by history and methacholine challenge. The patient returned 6 months later with complaints of increased appetite, nausea, and feeling "hot and flushed." On physical exam she had stigmata of Cushing's syndrome. The patient subsequently developed orthostatic hypotension and moderate dehydration following a viral illness. After a long taper of fluticasone propionate the patient' s adrenal function returned to normal and she had no acute or chronic exacerbations of her asthma. RESULTS: Her 8 AM cortisol was undetectable with an ACTH of 21 pg/mL. The serum prolactin, TSH, free thyroxine, insulin-like growth factor I, and renin activity were all normal. An MRI study of her head was also normal. Repeat methacholine challenges while receiving a much smaller dose fluticasone propionate showed a significant decrease in airway reactivity. CONCLUSION: Adrenal suppression can occur from inhaled fluticasone propionate at a dosage less than has been previously reported.

Nebulized lidocaine in the treatment of severe asthma in children: a pilot study.

BACKGROUND: Glucocorticoids have been used to treat asthma since the 1950s; however, their adverse systemic effects have limited their duration of use and dosage. Unfortunately, many patients with severe asthma often require oral glucocorticoids in addition to inhaled glucocorticoids. Alternatives to glucocorticoids have been sought with mixed success. Recently, lidocaine has been added to the list of potent glucocorticoid sparing agents for the treatment of severe asthma. OBJECTIVE: We report the first group of pediatric patients with severe asthma treated with nebulized lidocaine. METHODS: The study was performed in an open manner with 6 severely asthmatic patients followed in the Pediatric Allergy and Immunology Section, Mayo Clinic. The only intervention was the institution of nebulized lidocaine (0.8 mg/kg/dose to 2.5 mg/kg/dose t.i.d to q.i.d). The average daily steroid requirement was followed during the administration of the nebulized lidocaine. RESULTS: During a mean of 11.2 months of therapy (range 7 to 16 months) 5 of the 6 patients completely discontinued their oral glucocorticoids within an average time of 3.4 months (range 1 to 7 months). CONCLUSIONS: After further study, lidocaine may prove to be the first non-toxic, steroid alternative to patients with severe steroid-dependent asthma.

Childhood sinusitis.

Childhood sinusitis is difficult to diagnose. It is classified on the basis of duration of inflammation--acute or chronic--and cause of inflammation--infectious or noninfectious. Infectious sinusitis is often a result of obstruction of the osteomeatal complex. Inflammation in noninfectious sinusitis is similar to the inflammatory changes detected in respiratory mucosa of patients with asthma. Acute sinusitis is primarily an infectious process similar to a prolonged infection of the upper respiratory tract. Plain radiography has limited value for the diagnosis of acute sinusitis in children. The most effective treatment of acute sinusitis is administration of a beta-lactamase-resistant antibiotic. Chronic sinusitis may be infectious, noninfectious, or both. Coronal computed tomography of the sinuses and nasal endoscopy are the preferred methods for determining the presence of chronic sinusitis. When physicians prescribe therapy for chronic sinusitis, they need to consider whether the underlying cause is infectious, noninfectious, or both. Treatment of chronic infectious sinusitis is most effective when a beta-lactamase-resistant antibiotic is administered. Chronic noninfectious sinusitis may respond to topically intranasally applied corticosteroids. If medical treatment fails to resolve the disease within 3 months, surgical intervention may be necessary. Finally, although an association between asthma and sinusitis exists, a cause-and-effect relationship has not been established.

Unusual diffuse pulmonary lymphatic proliferation in a young boy.

We describe a 4-year-old boy who died of an unusual generalized pulmonary lymphatic proliferation. His condition cannot clearly be categorized with any of the previously described pulmonary lymphatic disorders.

Cough-type asthma: a review.

Cough-type asthma is a well-defined entity. The patients typically have a chronic, nonproductive cough that is exacerbated by exercise and upper respiratory tract infections. Bronchial provocation maneuvers are helpful in diagnosing cough-type asthma in older children and adults. Bronchodilators are the mainstay of therapy, although some patients may require cromolyn sodium or inhaled corticosteroids. The natural history of this process suggests that approximately a third to a half of these patients may progress to "classical" asthma with wheezing.

Exposure to an aeroallergen as a possible precipitating factor in respiratory arrest in young patients with asthma.

BACKGROUND: Exposure to airborne spores of the common mold Alternaria alternata has been implicated in asthma attacks. Such exposure is particularly frequent in the Midwest during the summer and fall months. To determine the role of A. alternata in triggering severe asthma attacks, we investigated the cases of 11 patients with asthma who had sudden respiratory arrest and determined the frequency of sensitivity to this allergen in these patients. METHODS: The 11 patients (age range, 11 to 25 years) with initial episodes of respiratory arrest, which was fatal in 2 patients, were identified in the course of their care in our pediatric and adult clinical allergy practice and by a retrospective review of all Mayo Clinic records of patients with severe asthma cared for between 1980 and 1989. Skin-test reactivity to A. alternata and levels of IgE antibody against this mold in the 11 patients were compared with those in 99 matched controls with asthma who had no history of respiratory arrest. RESULTS: All the patients came from the upper Midwest, and the episodes of respiratory arrest occurred in the summer or early fall. Ten of the 11 patients with asthma who had respiratory arrest (91 percent) had positive skin-puncture tests for sensitivity to alternaria, as compared with 31 percent of the controls (P less than 0.001), and the serum levels of IgE antibodies to alternaria were elevated in all 9 patients tested. Among the covariates we examined (age, sex, and distance from the Mayo Clinic), only age was a significant confounder. After adjustment for age, alternaria skin-test reactivity was found to be associated with an increase of approximately 200-fold in the risk of respiratory arrest (adjusted odds ratio, 189.5; 95 percent confidence interval, 6.5 to 5535.8). CONCLUSIONS: Exposure to the aeroallergen A. alternata is a risk factor for respiratory arrest in children and young adults with asthma.

Effect of inhaled methacholine on inspiratory flow.

One hundred consecutive outpatients with symptoms suggestive of asthma who came to the Pulmonary Function Laboratory for a methacholine challenge test were studied. In addition to the forced expiratory maneuvers, forced inspiratory maneuvers were performed before and after the maximal response to methacholine. In 24 patients, the methacholine challenge suggested that they had asthma (forced expiratory volume in 1 s [FEV1] decrease greater than or equal to 20 percent). Six of these 24 patients also had a decrease in maximal forced inspiratory flow (FIFmax) greater than or equal to 20 percent and nine had a decrease in forced inspiratory flow at 50 percent of vital capacity (FIF50) greater than or equal to 20 percent, suggesting that bronchoconstriction can cause decreased inspiratory as well as expiratory flows. In 76 patients, the methacholine challenges were "negative" (FEV1 decrease less than or equal to 20 percent), suggesting that they did not have asthma. Nevertheless, in 11 of these 76 patients the FIFmax decrease was greater than or equal to 20 percent, and in 14 patients the FIF50 decrease was greater than or equal to 20 percent, suggesting that intermittent central airway obstruction is responsible for these patients' symptoms.

Anaphylactoid reaction to ethanol.

We studied a 14-year-old boy who developed a pruritic rash and facial swelling after ingestion of beer or wine. A blinded challenge with purified ethanol was positive demonstrating ethanol itself to be the offending agent. An IgE-mediated reaction to ethanol or one of its metabolites as a hapten is possible, or the reaction may involve unusual metabolism of ethanol with accumulation of acetaldehyde and/or direct mast cell degranulation.

Approaches to acute asthma and status asthmaticus in children.

Asthma is the most common chronic disease in pediatric patients and is the leading cause of childhood disability. The functional abnormalities of this disease--namely, airway obstruction and hyperresponsiveness--are consequences primarily of airway inflammation. Outpatient therapy for acute asthma, as well as therapy for status asthmaticus (episodes of asthma unresponsive to usually effective outpatient therapy and necessitating hospitalization), primarily addresses treatment of airway inflammation. The goal of office and emergency room management of acute asthma is reversal of airway obstruction by the administration of inhaled beta-adrenergic medications. The therapy for status asthmaticus consists of intravenously administered aminophylline, corticosteroids, nebulized beta-adrenergic agents, and oxygen. Respiratory failure, the inability to maintain adequate elimination of CO2, may be effectively treated by adding continuous nebulization of albuterol. Mechanical ventilation will still be necessary in the rare patient who does not respond to pharmacologic therapy. Acute exacerbations of asthma, as well as status asthmaticus, can best be prevented by establishing effective maintenance programs individualized for each patient.

Pharmacokinetic properties of sustained-release theophylline (Theolair-SR) in relation to timing of doses after low-fat meals.

Pharmacodynamic and pharmacokinetic properties of sustained-release anyhdrous theophylline (Theolair-SR) were similar when doses were given either immediately after or two hours after low-fat meals in children with moderate asthma requiring daily theophylline maintenance. Asthma and pulmonary function values were maintained and approached values for healthy subjects during both treatment regimens.

Intractable paroxysmal sneezing in an adolescent.

Intractable paroxysmal sneezing in an 11 1/2-year-old girl was characterized by sneezing with her eyes open, no sneezing while asleep, and sneezing that was refractory to various medications. Results of physical examination were unremarkable. A review of the literature reveals that the disorder is usually psychogenic and responds to psychotherapy.

Cross-reactivity of foods--mechanisms and clinical significance.

We have been most fortunate to witness advances in techniques related to the field of allergy. The development and implementation of RAST, RAST inhibition, crossed immunoelectrophoresis, and CRIE have allowed us to determine what food moieties have the potential to be allergenic. Furthermore, using the above techniques, it has become possible to delineate whether allergenic moieties in particular food stuffs share their allergenic determinants with other food materials. Despite these advances, it is difficult to make definite statements concerning clinically significant cross-reactivity among nuts, legumes, and crustacea. There is still, obviously, a role for the use of open and double-blind food challenges, as demonstrated by the peanut oil, soybean oil, and sunflower oil studies. Although food challenges, in situations where anaphylaxis is a possibility, should only be done under controlled circumstances and under the guidance of a well-defined protocol, this technique should remain available to further study cross-reactivity among foods. At the present time, the following conclusions concerning cross-reactivity among foods may be entertained. (1) Cross-reactivity among foods from different food groups is extremely rare. (2) Individuals having IgE-mediated reactions to legume proteins, for example peanut and soybean, do not respond to the corresponding oil derived from those substances. (3) Cross-reactivity among legumes may occur, but in vitro studies defining common allergenic determinants among these food substances cannot be automatically interpreted as reflecting in vivo cross-reactivity. Furthermore, very limited attempts at open and double-blind challenges in specific patients have not confirmed cross-reactivity in peanut-sensitive individuals to other legumes.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidental farm injuries in children.

Eighty-seven children with 88 farm injuries presented to our emergency room in Rochester, Minn, from November 1974 to July 1985. Seventy-four accidents (84.1%) occurred in boys, and 14 (15.9%) in girls. Ages ranged from 1 to 16 years. Farm machines involved included corn augers in 37 accidents (42.0%); tractors, 22 (25.0%); power takeoffs, ten (11.4%); conveyor belts, five (5.7%); and miscellaneous, 14 (15.9%). Fractures and lacerations were the most common injuries, occurring in 55 (62.5%) and 30 (34.1%), respectively. Significant long-term disability occurred in 36 (40.9%). Eleven children required multiple reconstructive surgical procedures; two died. Preventive measures that can be employed by physicians, family members, educators, and legislators are discussed.

Hypersensitivity pneumonitis due to dove antigens in an adolescent.

Hypersensitivity pneumonitis is infrequently reported in children. This article describes a 15-year-old girl who presented with insidious onset of dyspnea and weight loss. A hamster and doves were housed in her bedroom. Chest radiographs showed bilateral nodular infiltrates. Pulmonary function tests showed a restrictive pattern with O2 desaturation at rest. The diagnosis was substantiated by the presence of precipitating antibody to dove serum and droppings and by clinical improvement, along with marked improvement in pulmonary function test, after the doves were removed from her environment. The importance of making an early diagnosis to prevent debilitating fibrotic lung disease is emphasized. A detailed environmental history is essential.

Exercise-induced "asthma" as a presentation of bronchial carcinoid.

Exercise-induced wheezing developed in a previously healthy 14-year-old boy. Chest radiographs revealed hyperlucency of the left lung. Bronchial tomography and bronchoscopy revealed a mass in the left mainstem bronchus, identified as a carcinoid tumor after surgical excision. The patient is now asymptomatic. Exercise-induced wheezing as the sole manifestation of this tumor has not been previously reported.

Serum IgG4 concentrations and allergen-specific IgG4 antibodies compared in adults and children with asthma and nonallergic subjects.

We describe the development of specific immunoassays for IgG4 protein and for allergen-specific IgG4 antibodies. We also measured the concentrations of IgG4 protein and determined the frequencies of detectable IgG4 antibodies to several common allergens in sera from adults and children with asthma and from nonallergic subjects. Serum concentrations of IgG4 protein increase with age but are not different in children with asthma and nonallergic children, nor does a raised serum concentration predict a severe clinical course in childhood asthma. IgG4 antibodies to milk and egg are common in children and adults and are more common in children with asthma than in nonallergic children less than 3 years of age. The presence of detectable IgG4 antibodies or a raised concentration of IgG4 protein in serum is not useful empirically as a diagnostic indicator of asthma but more likely results from antigen exposure occurring at mucosal surfaces.