Acquired C1-inhibitor deficiency: a case report.

Angioedema due to C1--inhibitor deficiency may be hereditary (HAE) or acquired (AAE). AAE is a very rare condition, whose prevalence is possibly underestimated, as it is often unrecognized. AAE usually occurs after the fourth decade of life, and it is commonly associated to an underlying disease, mainly lymphoproliferative disorders. We report a 74-years old woman with recurrent episodes of angioedema involving upper airways in which diagnosis was obtained a long time after symptoms onset. A concomitant B cell leukaemia was also diagnosed This report stresses the importance of the recognition of AAE: a delayed diagnosis is indeed associated to the risk of severe life-threatening episodes, unresponsive to the usual therapy of common form of angioedema. AAE should be considered as a possible diagnosis in subjects with adult onset of angioedema: a careful clinical history is basic, since the clinical features and the time-course are often suggestive of the disease.

House dust mites (Der p 1, Der f 1), cat (Fel d 1) and cockroach (Bla g 2) allergens in indoor work-places (offices and archives).

BACKGROUND: Exposure to indoor allergens has already been shown to occur in many public places, including workplaces, in several countries. Aim of this study was to measure the levels of house dust mites, cat and cockroach allergens in indoor workplaces (offices and archives) in Italy and to evaluate the possible relationships between allergen levels and building characteristics, type of ventilation, indoor relative humidity and temperature. METHODS: Der f 1 and Der p 1, Fel d 1, Bla g 2 were measured by ELISA in dust samples collected from floors or upholstered seats of 160 workplaces. RESULTS: Detectable Der p 1 levels were found in 86 (54%) workplaces Der f 1 in 87 (55%), Fel d 1 in 86 (54%) and Bla g 2 in 3 (1.9%). Der p 1 allergen concentrations expressed per weight were higher than the proposed sensitization thresholds in 7 samples, Der f 1 in 5, Fel d 1 in 6 and Bla g 2 in 3. The highest allergen levels were detected in samples from upholstered seats. A significant correlation was found between Der f 1 level on floors, expressed per surface, and indoor temperature (r = 0.39; P < 0.01). CONCLUSIONS: In our study we found that upholstered seats in workplaces in Italy may constitute a significant reservoir both of house dust mites and cat allergens. Exposure to these allergens in workplaces may represent a risk factor for elicitation of symptoms and/or induction/maintenance of inflammation in allergic individuals and might also constitute a risk factor for sensitization.

Exacerbation of asthma related to Eucalyptus pollens and to herb infusion containing Eucalyptus.

Eucalyptus is known as a potential cause of cutaneous diseases due to contact with oil or pollens, and of respiratory allergic diseases due to exposure to pollens. We report the case of a 30-year-old woman with asthma and rhinoconjunctivitis in which symptoms appeared to be exacerbated by Eucalyptus pollens and by ingestion of an infusion containing Eucalyptus. Specific IgE were positive for Eucalyptus pollens and negative for common aeroallergens. Our report shows that Eucalyptus may elicit asthma and rhinitis with an IgE-mediated mechanism both by inhalation of pollens and by ingestion of herb infusions, and suggests that care should be taken in administering herbal medications in asthmatic subjects.

Increased CD69 expression on peripheral blood eosinophils after specific inhalation challenge.

BACKGROUND: CD69 is a molecule expressed on human eosinophils after cytokine-activation. Different studies have described the eosinophil activation, evaluated by CD69 expression, at the site of an allergic inflammation. In this study we evaluated the expression of CD69 on peripheral blood eosinophils after a specific inhalation challenge (SIC), in order to better define the state of activation of peripheral blood eosinophils after exposure to sensitizers. METHODS: CD69 expression was evaluated by flow cytometry in nine asthmatic patients before and after a positive SIC with high or low molecular weight agents (pollens, house dust mites, Penicillia, isocyanates) and in 11 asthmatic patients who underwent an inhalation challenge with placebo. CD69 expression was evaluated at baseline, 120 min, and 240 min after the SIC or the placebo. RESULTS: Baseline (before challenge) CD69 expression was comparable between the group of SIC positive patients and the placebo group. CD69 expression on peripheral eosinophils significantly increased 240 min after the challenge in positive SIC patients compared to placebo. In patients with a positive SIC the percentage of peripheral blood eosinophils significantly decreased at 120 and 240 min after the inhalation challenge with respect to the baseline. CONCLUSION: CD69 expression on peripheral blood eosinophils is significantly increased in asthmatic patients after exposure to the sensitizing agent. These data show that the effects of a bronchial stimulation are also detectable on peripheral blood eosinophils.

Prevention of occupational asthma.

Occupational asthma (OA) is a type of bronchial asthma due to causes and conditions attributable to a particular occupational environment. It is the most prevalent occupational lung disease in industrialized countries, accounting for approximately 5% of asthma in adults. Since OA has important medical, social and economic consequences, its prevention is mandatory, and the most important measure is primary prevention at the workplace. Control of environmental exposure can be realized by completely eliminating the causative substances, or, failing that, by reducing exposure to the lowest practicable levels. This goal may be achieved in a variety of ways, e.g. by automation of a process, improvement of ventilation, modification of the process or agents, and use of personal protection devices. However, the control of environmental exposure presents several difficulties. First of all, exposure levels that favour respiratory sensitization to high molecular weight (HMW) or low molecular weight (LMW) agents are not completely defined. There is a critical need for the development of methods able to quantify the airbone levels of sensitizing agents at the workplace and to establish limits of exposure for respiratory sensitization. Development of assays (e.g. immunochemical assays) able to quantify airbone allergen levels should facilitate determination both of exposure-response relationships and of exposure limits for preventing respiratory sensitization and development of OA. Quantification of risk at the workplace is also often rough and based on indirect markers of exposure. At present, the target for an optimal approach to the primary prevention of OA is the development of methods able to evaluate both the sensitizing and the asthmogenic properties of the substances before their introduction in the work environment.

[Sampling of allergens in dust deposited in the workplace]. / Il campionamento degli allergeni nelle polveri depositate nei luoghi di lavoro.

Some workplaces share with domestic dwellings many characteristics favouring house dust mite growth. Moreover it has recently been shown that pets owners can bring allergens to public places with their clothes. So it is possible that significant exposure to indoor allergens can occur outside homes, at the workplace. The recent availability of immunoassays with monoclonal antibodies for indoor allergens has enabled many investigators to quantify exposure to such allergens in epidemiological studies. Analysis of allergens in settled dust is a simple method of quantification exposure to indoor allergens. The concentrations of indoor allergens in public places have already been investigated and high levels of indoor allergens have been reported. A study performed by our group in offices (banks and media) in different regions of Italy has also shown significant levels of indoor allergens. Thus, evaluating exposure to indoor allergens at the workplace is critical to evaluate risk factors for sensitization and elicitation of symptoms in sensitized subjects and such data help in addressing correctly the problem of reducing exposure levels.

Study of the explosive strength of the rectus femoris muscle using electromyography.

The rectus femoris muscle was electromyographically studied in eleven individuals of the masculine sex. The objective was to study the action potential and the explosive strength of this particular muscle in the movement utilized to kick the field soccer ball and in other exercises of the orthostatic position. The following movements were analyzed: flexibility of the hip with the knee bent, flexibility and extension of the knee (completely crouched), flexibility of the hip with the knee extended, movement of the kick without contact with the ball and movement of the kick in contact with the ball. The results were: the rectus femoris muscle showed much stronger action potential in flexing the hip with the knee flexed more than 90 degrees; with the knee extended 60 to 90 degrees; in the movement extending the knee from a complete crouch and at the moment of the kick in contact with the ball. The action potential was strong in the movements flexing the knee (crouch) and in the initial movement of the kick.

Levels of house-dust-mite allergen in homes of nonallergic people in Pavia, Italy.

BACKGROUND: HDM distribution varies between geographic areas and may be affected by housing characteristics. We quantified Der p 1 and Der f 1 and assessed the relationships between their levels and housing characteristics in homes of nonallergic subjects. METHODS: Der f 1 and Der p 1 were measured by ELISA in dust samples from living-room floors and mattresses of 44 homes of nonallergic subjects in Pavia. Information about household characteristics was obtained by questionnaire. RESULTS: Der p 1 and Der f 1 concentrations (microg/g dust, median) were 0.34 and 7.8 on mattresses, and 0.15 and 0.83 on living-room floors. Higher Der f 1 levels on mattresses were associated with synthetic pillows (P<0.05), and (only when expressed as microg/m2) with bedding washing temperature of < or = 60 degrees C (P<0.05). Der f 1 levels were higher on the living-room floors of homes located on lower (< or =first) floors (P<0.05). Good correlations were found between Der p 1 and Der f 1 expressed as microg/g dust and microg/m2 on both mattresses and living-room floors. CONCLUSIONS: In homes of nonallergic subjects in northern Italy, Der f 1 exceeded the threshold for sensitization in a high proportion of mattress samples.

Serum eosinophil cationic protein (sECP) in subjects with a history of asthma symptoms with or without rhinitis.

BACKGROUND: Serum eosinophil cationic protein (sECP) has been proposed as a marker of disease activity in bronchial asthma. The study aimed to evaluate the role of sECP in screening asthmatics in a group of subjects with asthma and rhinitis symptoms, and the relationship between sECP and clinical and functional parameters of asthma. METHODS: A total of 185 subjects with asthma symptoms, 149 of them with rhinitis as well, underwent skin tests, spirometry, methacholine (MCH) test, blood sampling for eosinophil percentage (bEOS%) and sECP determination, and nasal secretions smear for eosinophil percentage (nEOS%) determination; PEF values, symptoms, and medication over a period of 4 weeks after sampling for sECP quantitation were recorded on a diary. RESULTS: A total of 99 (53%) subjects received a diagnosis of asthma (asthmatics), and 86 did not (nonasthmatics). In asthmatics, neither sECP nor bEOS% was significantly different from nonasthmatics. In asthmatics, sECP was higher in subjects with increased than in those with normal daily PEF variability (16.4, 6.8-24.4 vs 5.3, 3.9-8.4 microg/l; P<0.001). sECP was higher in moderate persistent asthma than in intermittent asthma (24.8, 10.6-53 vs 8.4, 5.6-14.1; P<0.05). In nonasthmatics (73 with a history of rhinitis), both sECP and bEOS% correlated with nEOS% (rho=0.35; P<0.01 and rho=0.53; P<0.001). CONCLUSIONS: In adults with asthma symptoms with or without rhinitis, sECP did not distinguish asthmatics from nonasthmatics. In asthmatics, sECP was associated with PEF variability and symptom severity. In subjects with asthma and rhinitis, as well as in subjects with only rhinitis, sECP levels are possibly influenced by nasal inflammation.

Occupational asthma: a longitudinal study on the clinical and socioeconomic outcome after diagnosis.

AIM: To evaluate the clinical outcome and socioeconomic consequences of occupational asthma (OA). SUBJECTS AND METHODS: Twenty-five patients with OA both to high- and low-molecular-weight agents (3 and 22, respectively) confirmed by specific inhalation challenge were followed up for 12 months after the diagnosis. Upon diagnosis, each patient received a diary on which to report peak expiratory flow rate (PEFR), symptoms, drug consumption, expenses directly or indirectly related to the disease, as well as information regarding personal socioeconomic status. At each follow-up visit (1, 3, 6, and 12 months), the patients underwent clinical examination, spirometry, methacholine (Mch) challenge, and assessment of diary-derived parameters and socioeconomic status. Asthma severity (AS) was classified into four levels, based on symptoms, drug consumption, and PEFR variability. RESULTS: At 12 months, 13 patients (group A) had ceased exposure; the remaining 12 patients (group B) continued to be exposed. At diagnosis, FEV1 percent and provocative dose causing a 20% fall in FEV1 (PD20) of Mch were lower in group A than in group B; patients of group A were also characterized by significantly higher basal AS levels. At 12 months, no significant variation in FEV1 percent or PD20 was found for either group, while AS levels improved in both groups, the change being more marked for group A than group B. Pharmaceutical expense at 12 months significantly (p < 0.05) decreased, as compared with the first month, in group A, whereas it tended to increase in group B. In group A, 9 of 13 subjects had reported a deterioration of their socioeconomic status as compared with 2 of 12 in group B (p < 0.01). A significant loss of income was registered in patients of group A (median 21.45, 25th to 75th percentiles 16.9 to 25.8 Italian liras x 10(6) on the year preceding diagnosis and 15.498, 10.65 to 21.087 Italian liras x 10(6) on the year after diagnosis; p < 0.01), whereas no significant change was seen for patients in group B. CONCLUSIONS: In OA, cessation of exposure to the offending agent results in a decrease in asthma severity and in pharmaceutical expenses, but it is associated with a deterioration of the individual's socioeconomic status (professional downgrading and loss of work-derived income). There appears to be a great need for legislation that facilitates the relocation of these patients.

[Role and significance of information tools in occupational asthma]. / Il ruolo e l'importanza degli strumenti informativi nell'asma professionale.

Role of education in occupational asthma. Subjects' education, i.e. information and training in the specific topic, has a substantial role in several medical fields and is considered to be the challenge to reach the primary, secondary and tertiary preventive goals. In occupational medicine workers information and training is considered particularly relevant and it has been included in a recent governative law regarding prevention and health care at the workplace. The present short review deals with the role of education in occupational asthma, which at present appears the most frequently compensated occupational lung disease.

Clinical evaluation of occupational asthma.

In this paper, the procedures in the assessment of occupational asthma (OA) are discussed. Only the most common subtype of OA is considered here, i.e. that in which symptoms appear after a latency period from the beginning of exposure. OA is characterized by variable bronchial obstruction, and variable bronchial hyperresponsiveness caused by specific agents inhaled at work. The clinical investigation of OA is a stepwise approach which includes a comprehensive history together with physiological and immunological studies. The first step is to identify symptoms and relate exposure at work to the presence in the workplace of substances known to provoke OA. The presence of bronchial asthma must then be confirmed; this is achieved by assessing the reversibility of bronchial obstruction and/or the presence of nonspecific bronchial hyperreactivity and/or the presence of significant peak expiratory flow (PEF) variability. The relationship between work and symptoms may first be assessed by means of serial measurements of PEF and of nonspecific bronchial hyperreactivity during periods at work and away from work. When the suspected agent is a high-molecular-weight (HMW) or a low-molecular-weight (LMW) agent known to act through an immunoglobulin E (IgE)-mediated mechanism, skin tests and/or research for specific IgE should be performed. In case of sensitization, where a relationship between asthma and work has been demonstrated by means of serial monitoring of PEF, a diagnosis can be made. If the suspected agent is a LMW agent, a specific inhalation challenge test in the laboratory or at the workplace is necessary.

Electromyography analysis of the rectus abdominis and external oblique muscles of children 8 to 10 years old.

The objective of this work was to study through in the electromyography the upper and lower umbilical rectus abdominis and the anterior and posterior parts of the external oblique muscles of children 8 to 10 years old. The children studied practice artistic and rhythmical gymnastic sports at the training and learning level and the study was made during abdominal exercise in the dorsal decubitus position on the ground and on a board. The children were divided into 2 groups: Group I - ten already trained children; Group II - nineteen learners. The participants in Group I practiced an average of 5 times a week and those in Group II practiced 2 times a week. The exercises analyzed were: on the ground, lifting the legs 30, 20 and 10 cm high with the knees flexed 90 degrees; flexing the trunk while maintaining the legs elevated and the knees flexed; flexing the trunk with homo and heterolateral rotation of the trunk while maintaining the legs elevated and the knees flexed. On the board, flexing the trunk with the knees flexed 90 degrees on top of the board inclined 30, 20 and 10 cm; flexing the trunk with rotation of the trunk homo and heterolateral with the knees flexed on the board inclined 30, 20 and 10 cm. The results showed that the superior umbilical part of the rectus abdominis muscle presented more intense action potential than the inferior-umbilical part; the more intense action potential occurred at the flexing of the trunk and at the flexing of the trunk with homo and heterolateral rotation. The anterior part of the external oblique muscle presented more intense action potential than the posterior part; the more intense action potential occurred at the flexing of the trunk and at the flexing of the trunk with heterolateral rotation. In both of the muscles the more intense action potential occurred between 45 and 60 degrees of flexing the trunk; the children in Group I presented more intense action potential than those in Group II; the exercise of lifting the flexed legs did not prove efficient for strengthening the analyzed abdominal muscle structure.

Occupational asthma, rhinitis and urticaria due to piperacillin sodium in a pharmaceutical worker.

A 28 year old man with no history of atopy was referred to our hospital for possible work-related asthma. He had been employed in the production section of a pharmaceutical company for 2 yrs, and in the last 2 months he had complained of dyspnoea, wheezing, chest tightness, symptoms of rhinitis and a cutaneous rash when exposed to powdered antibiotics. Symptoms disappeared after being transferred to the packaging section. When the subject was admitted to our department he was asymptomatic. Basal lung function tests were in the normal range. Bronchial challenges with methacholine and with ultrasonically-nebulized distilled water were negative. Skin-prick test with piperacillin sodium gave a strong positive response at a very low concentration. Specific inhalation challenge with piperacillin sodium resulted in an immediate asthmatic reaction, and also reproduced rhinitis symptoms and the cutaneous rash. A control challenge with lactose, and the specific challenge test with cefuroxime sodium (another antibiotic to which the patient was exposed at the workplace) were negative. We conclude that piperacillin sodium is an agent that can cause occupational asthma.