Alergia a medicamentos en la infancia. Valor de las pruebas in vitro / Drug allergy in childhood. Value of in vetro tests

Las reacciones a medicamentos no siempre son de causa alérgica, pues los diversos componentes de los preparados en uso pueden causar reacciones diversas, a veces difíciles de distinguir y que, como es natural, preocupan a los familiares, especialmente si se trata de niños. La presentación clínica varía entre una simple reacción tópica (edema, urticaria) hasta el grave choque anafiláctico. Como pruebas diagnósticas se pueden utilizar desde el test cutáneo o la provocación, no exentas de riesgo, o bien los tests in vitro, como la Degranulación de Basófilos (TDB) o la Transformación Linfoblástica (TTL), utilizados en los pacientes presentados en este estudio, salvo los afectados por aspirina, que requirieron provocación oral, método internacionalmente reconocido (AU)

Drug reactions do not always have an allergic cause, since the different components of the preparations in use can cause different reactions, sometimes difficult to distinguish and that, as is natural, concern the families, especially when dealing with children. The clinical presentation varies from a simple topic reaction (edema, urticaria) to serious anaphylactic shock. As diagnostic tests, skin test or challenge, not exempt of risk, can be used or in vitro tests, such as the Basophil degranulation test (BDT) or Lymphoblastic transformation test (LTT), used in the patients presented in this study, except for those affected by aspirin, who required oral challenge, an internationally recognized method (AU)

Ejercicio físico: asma y equivalentes asmáticos en la infancia. Broncomotricidad / Physical excercise: asthma and asthmatic equivalents in childhood. Bronchomotricity

Se hace un recuerdo de la patogenia del asma, desde los antecedentes familiares, y posibles diagnósticos de otros procesos con sintomatología similar. Esta revisión se centra en la valoración y estudio de los episodios de disnea causados por el ejercicio físico, un hecho frecuente tanto en pacientes asmáticos como en los que faltando las crisis agudas de disnea, se diagnostican de bronquitis asmatiforme. Se presenta un estudio de 40 pacientes de entre 7 y 18 años de edad, todos ellos con antecedentes familiares de alergia, de los que 23 fueron diagnosticados de asma y los otros 17 de bronquitis asmatiforme. En todos constan episodios de disnea causada por ejercicio físico. Se efectuó prueba de provocación con metacolina para conocer el grado de hiperreactividad y también prueba de ejercicio físico. En los asmáticos la prueba de sobreesfuerzo fue positiva en el 65,2% mientras que en el otro grupo fue en el 41,1% de los bronquíticos. Se proponen las medidas terapéuticas apropiadas (AU)

A review is made of the pathogeny of asthma from the family histories and possible diagnoses of other processes with similar symptoms. This review focuses on the evaluation and study of dyspnea episodes caused by physical exercise, a frequent event in both asthmatic patients and in those who, without acute dyspnea episodes, are diagnosed of asthmatiform bronchitis. A study of 40 patients, aged 7 to 18 years, is presented. All had family histories of allergy. Of these, 23 were diagnosed of asthma and 17 others of asthmatiform bronchitis. Episodes of dyspnea caused by physical exercise was reported in all of them. Methacholine challenge test to know the degree of hyperreactivity’ and a physical exercise test were performed. The overexertion test was positive in 65.2% in the asthmatic patients while in the other group it was 41.1% of the bronchitic patients. Appropriate therapeutic measures are proposed (AU)

Tratamiento etiológico del asma en preescolares / Etiological treatment of asthma in pre-school children

En base a las características familiares y cantidad de alérgenos a que estaban sensibilizados, se comentan tres grupos de niños afectos de rinitis/asma, el primero de ellos de entre 2 y 5 años, edad en la que se inició tratamiento básico con inmunoterapia, y los otros dos, entre 5 y 8 años y de 8 a 18 años, todos ellos con procesos similares cuyos síntomas se habían manifestado con bastante anterioridad pero que solo habían recibido tratamiento sintomático o antiinflamatorio. Se hace una revisión de la necesidad del inicio temprano de inmunoterapia en base a su principal mecanismo por el que se modifica la reacción inmunológica, lográndose el equilibrio Th1/Th2 ya que en los pacientes atópicos predomina la actividad de los linfocitos Th2, que promueven la producción de IgE específica frente a los alérgenos (AU)

Three groups of children affected by rhinitis/asthma are reviewed based on the family characteristics and amount of allergens they were sensitized to. The first group included those between 2 and 5 years, age when basic treatment with immunotherapy was initiated. The two remaining groups included those between 5 and 8 years and 8 and 18 years, all with similar conditions whose symptoms had been manifested sufficiently before but who had only received symptomatic or anti-inflammatory treatment. A review is made of the need for early onset of immunotherapy based on their principal mechanism by which the immunological reaction is modified, achieving TH1/Th2 balance since the activity of the Th2 lymphocytes that promote the allergen-specific IgE production already predominates in the atopic patients (AU)

Síndrome de Down: valoración de la inmunidad / Down’s syndrome: assessment of the immune system

Antecedentes: dada la frecuencia de procesos infecciosos en personas con el síndrome de Down, puede plantearse la necesidad de un estudio inmunitario. Objetivo: comparar los valores de distintos parámetros de la inmunidad en un amplio grupo de pacientes, para conocer los porcentajes que se separan de los valores normales. Material y métodos: en un total de 433 casos se valoró la IgG total, la IgA y la IgM y en menos casos también las IgG2 y las IgG4 o las IgG1 y las IgG3, así como los linfocitos T4, T8 y el porcentaje T4/T8. En 85 de ellos se valoró también el nivel sérico de zinc. Los valores de las tres primeras inmunoglobulinas se han comparado con los correspondientes de 211 niños no afectados por el síndrome. Resultados: los aumentos, disminuciones o valores normales de las IgG, IgA e IgM en comparación con los de individuos no afectados son significativos para IgG (p < 0,01), no significativos para IgA (p ≥ 0,05) y altamente significativos para IgM (p < 0,001). En las subclases de IgG predominan los valores normales, con aumentos de IgG1 e IgG3 (30,9% y 29%) superiores a IgG2 e IgG4 (5,4% y 4,1%) y disminución más significativa de IgG2 e IgG4 (29,7% y 44,7%) que para IgG1 e IgG3 (16,6% y 16,2%). Linfocitos: predominio de valores normales, con disminución del 23,3% de T4 y 6,6% de T8 y del 26,6% de T4/T8. En el 89,5% de los casos, los valores de zinc son normales, con un descenso en el 5,8%. Conclusiones: la frecuencia y/o gravedad de las infecciones obliga a efectuar un estudio de la inmunidad, inicialmente con los parámetros aquí estudiados, que deberán ampliarse cuando los valores se aparten excesivamente de la normalidad (AU)

Background: Given the frequency of infectious processes in individuals with Down’s syndrome, the need for an immune study may arise. Objective: To compare the values of certain immune parameters in a wide group of patients, and to determine the percentages that are outside the normal values. Material and methods: A total of 433 cases were studied, in which total IgG, IgA and IgM were evaluated, and in fewer cases the IgG2 and IgG4 or IgG1 and IgG3, as well as T4 and T8 lymphocytes and T4/T8 ratio. In 85 of these cases the serum zinc level was also measured. The IgG, IgA and IgM values were compared with those of 211 children unaffected by the syndrome. Results: The increased, decreased or normal values of IgG, IgA and IgM, in comparison with those with who do not have Down’s syndrome, are significant for IgG (p < 0.01), nonsignificant for IgA (p ≥ 0.05), and highly significant for IgM (p < 0.001). In the IgG subclasses, normal values predominated, with increases in IgG1 and IgG3 (30.9% and 29%), higher to IgG2 and IgG4 (5.4% and 4.1%), and a more significant decrease in IgG2 and IgG4 (29.7% and 44.7%) than for IgG1 and IgG3 (16.6% and 16.2%). Lymphocyte values showed more normal values, with 23.3% and 6.6% with a decrease in T4 and T8, respectively, and 26.6% with a decreased T4/T8. The zinc values are normal in 89.5% of the cases, with a decrease in 5.8%, Conclusions: The frequency and severity of the infections makes it obligatory to carry out an immune study, which must be extended when the values are excessively outside the normal ranges (AU)

Bronchial hyperresponsiveness and asthma in the paediatric population

OBJECTIVE: To determine whether the intensity of bronchial hyperresponsiveness (BHR) is correlated to other clinical data such as patient age at the onset of asthma, the serum IgE levels and familial genetic susceptibility, with the purpose of establishing a prognosis or phenotype. MATERIAL AND METHODS: BHR was evaluated using the methacholine provocation test, with the patients divided into six groups according to the amount of methacholine needed to obtain PD20. A total of 138 children and adolescents up to age 18 years (94 males and 44 females) were included. Most had a clinical diagnosis of asthma, while tracheobronchitis or rhinitis was diagnosed among the least reactive subjects. The patients were divided into subjects with a family history of atopic disease (84 cases) and those without such a history (54 cases). In this latter case we discuss possible causes of BHR or dyspnoea triggering factors. RESULTS: There were no significant differences in patient age at onset or in serum IgE among the patients with different intensities of BHR, or between those with a family history of atopic disease and those without. CONCLUSIONS: No differences were found among the groups. It is therefore concluded that the intensity of BHR is not a valid parameter for establishing a prognosis or phenotype, although it can be used to assess the severity of asthma

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Estudio del mesoflujo en pacientes asmáticos con distinta intensidad de hiperreactividad bronquial / Study of mesoflow in asthmatic patients with different bronchial hyperactivity intesity

Objetivo. Las llamadas pequeñas vías aéreas representan el 99.9% del árbol bronquial, de ahí que sea notable su afectación en los pacientes asmáticos, por lo que es necesario conocer su estado funcional valorando el flujo medio forzado (FMF25-75) de la curva espirométrica. Material y métodos. Valoración de la curva espirométrica previa a la prueba de metacolina que se efectuó para conocer el grado de hiperreactividad bronquial en un total de 82 niños diagnosticados de asma, que se distribuyeron en tres grupos de acuerdo con la respuesta a esta prueba: Grupo 1: PD20 con <1.000 µg, Grupo 2: PD20 entre 1.000 y 2.000 µg, Grupo 3: PD20 con > 2.000 µg. Resultados. Se estimó la diferencia porcentual entre el total de flujo espiratorio (FEV1) y el mesoflujo (FMF25-75) en cada uno de los grupos, siendo significativo para los grupos 1 y 2 (p<0,0001) y poco significativo para el Grupo 3: (p<0,07), lo que evidencia la mayor participación de las pequeñas vías en la reacción asmática y su relación con la hiperreactividad bronquial. Conclusiones. La noción del estado real de las vías aéreas a lo largo de la evolución del asma, precisa conocer el estado de las pequeñas vías por la medición del mesoflujo, de ahí la necesidad de efectuar la espirometría periódicamente en contra de otros procedimientos usuales (pico flujo: peak flow), que sólo informan de la totalidad del flujo (AU)

Objective. The so-called small airways account for 99,9% of the bronchial tree. Thus, their affectation in asthma patients is significant, which is why it is necessary to know their functional status by evaluating the forced mean flow (FMF25-75) of the spirometry curve. Material and methods. Evaluation of the spirometry curve prior to the methacholine test that was permormed to know the grade of bronchial hyperreactivity in a total of 82 children diagnosed of asthma. The children were distributed into three groups according to the response to this test: Group 1: PD20 with < 1000 µg, Group 2: PD20 between 1000 and 2000 µg, Group 3: PD20 with >2000 µg. Results. The percentage difference was estimated between the total expiratory flow (FEV1) and the mesoflow (FMF25-75) in each one of the groups. This was significant for groups 1 and 2 (p<0,0001) and not significant for Group 4 (p<0,07). This manifests the greater participation of the small airways in the asthmatic reaction and their relation with bronchial hyperreactivity. Conclusions. Knowing the real status of the airways during the course of asthma requires knowledge about the sate of the small airways by means of measuring periodically versus other usual procedures (e.g., peak flow), which only show the totality of the flow (AU)

Bronchial hyperresponsiveness and asthma in the paediatric population.

OBJECTIVE: To determine whether the intensity of bronchial hyperresponsiveness (BHR) is correlated to other clinical data such as patient age at the onset of asthma, the serum IgE levels and familial genetic susceptibility, with the purpose of establishing a prognosis or phenotype. MATERIAL AND METHODS: BHR was evaluated using the methacholine provocation test, with the patients divided into six groups according to the amount of methacholine needed to obtain PD20. A total of 138 children and adolescents up to age 18 years (94 males and 44 females) were included. Most had a clinical diagnosis of asthma, while tracheobronchitis or rhinitis was diagnosed among the least reactive subjects. The patients were divided into subjects with a family history of atopic disease (84 cases) and those without such a history (54 cases). In this latter case we discuss possible causes of BHR or dyspnoea triggering factors. RESULTS: There were no significant differences in patient age at onset or in serum IgE among the patients with different intensities of BHR, or between those with a family history of atopic disease and those without. CONCLUSIONS: No differences were found among the groups. It is therefore concluded that the intensity of BHR is not a valid parameter for establishing a prognosis or phenotype, although it can be used to assess the severity of asthma.

Sinusitis asociada a patología respiratoria alérgica / Sinusitis associated to allergic respiratory condition

Objetivo: Llamar la atención sobre la elevada incidencia sinusitis, cuyo síntoma más destacado suele ser la tos, que puede predominar en posición de cúbito, en niños con asma y patología similar. Material y métodos. Revisión de 100 historias clínicas de niños hasta 18 años de edad, visitados consecutivamente, con sintomatología sugestiva de asma, bronquitis o rinitis alérgicas. Además de la historia y examen clínicos, se hicieron pruebas alérgicas (prick-test), valoración de IgE sérica total y específica para los alérgenos sospechosos, otras Igs (G, M, A), hemograma, función pulmonar y test de metacolina, en niños colaboradores y de edad adecuada. Radiografía de senos paranasales y valoración de eosinófilos en moco, cuando la tos y sobre todo nocturna, dominaban el cuadro clínico. Resultados. En 53 años se confirmó el diagnóstico de asma, de los cuales 10 padecían también sinusitis alérgica y 8 infecciosa. En otras 26 no se confirmó la existencia de asma, sino broncopatía, acompañada de sinusitis alérgica en 2 de ellos y sinusitis infecciosa en otros 7. Solo rinitis se diagnosticó en 10 niños ya acompañada de sinusitis alérgica en otros 2 e infecciosa en otros 9. Conclusiones. Sinusitis alérgica la padecían 14 niños, que no necesitaron tratamiento específico para la misma, mientras que si lo precisaron los 24 en los que se diagnosticó sinusitis infecciosa, especialmente con antibióticos y descongestivos nasales en y en algunos casos corticoides tópicos y/o antihistamínicos (AU)

Background. To draw attention to the high incidence of sinusitis, whose most prominent symptom usually is cough, which may predominate in prone position, in children with asthma and similar pathology. Material and methods. Review of 100 medical history of children under 18 years old, visited consecutively, with symptoms suggestive of asthma, bronchitis or allergic rhinitis. Furthermore history and physical examination, prick test, assessment of total and specific IgE to suspected allergens, other Igs (G,M,A), blood count, lung function and methacholine challenge test in children of the right age and collaborators, were realized. Sinus radiography and measurement of eosinophils in mucus, when cough was present, particularly at night, was a significant symptom. Results. In 53 children the diagnosis of asthma was confirmed, 10 of with also suffered from allergic sinusitis, whereas infectious sinusitis was present in 8. In other 26 the existence of asthma was not confirmed, but another bronchial disease was present; allergic sinusitis accompanied in 2 cases, and infectious sinusitis in another 7. Rhinitis only, was diagnosed in 10 children, and accompanied by allergic sinusitis in other 2 and infectious sinusitis in 9. Conclusion. Allergic sinusitis was suffered by 15 children who did not require specific treatment for it; while the 24 in which infectious sinusitis diagnosis required specific treatment, specially with antibiotics and nasal decongestants and in some cases topical corticosteroids and/or antihistaminics (AU)

The interest of FEF 25-75 in evaluating bronchial hyperresponsiveness with the methacholine test

Background: Bronchial hyperresponsiveness is the pathogenic basis of asthma, and measurement of its intensity is investigated using the methacholine provocation test, which not only and particularly evaluates the reduction in FEV1 (PD20) but also takes forced mid-expiratory flow or FEF25-75 (PD40) into account. The present study aims to evaluate the usefulness of both parameters. Material and methods: Provocation testing was carried out in 151 patients between 7 and 22 years of age diagnosed with asthma, tracheobronchitis and/or rhinitis, using a short method that allows quantification of the methacholine administered. The subjects were divided into three groups according to the amount of methacholine needed to obtain the mentioned parameters (group 1: minor=1000 micreg; group 2: 1001-2000 micreg; group 3: major=2001 micreg). Results: Greater variability was recorded for FEF25-75 than for FEV1. Paired comparison among the three groups for FEV1 proved significant, in the same way as for FEF25-75 between groups 2 and 3, and 1 and 3, but not between groups 1 and 2. Calculation was made of the amount of methacholine required to obtain PD20 and PD40 from the same dose. Only the significant differences corresponded to the comparison of group 1 versus the rest, with no differences between the means of the total mean values. Conclusions: The utility of PD20 is more evident, considering the variability of PD40; the latter may be useful in patients with rhinitis or tracheobronchitis when PD20 proves scantly demonstrative(AU)

The interest of FEF(25-75) in evaluating bronchial hyperresponsiveness with the methacholine test.

BACKGROUND: Bronchial hyperresponsiveness is the pathogenic basis of asthma, and measurement of its intensity is investigated using the methacholine provocation test, which not only and particularly evaluates the reduction in FEV1 (PD20) but also takes forced mid-expiratory flow or FEF(25-75) (PD40) into account. The present study aims to evaluate the usefulness of both parameters. MATERIAL AND METHODS: Provocation testing was carried out in 151 patients between 7 and 22 years of age diagnosed with asthma, tracheobronchitis and/or rhinitis, using a short method that allows quantification of the methacholine administered. The subjects were divided into three groups according to the amount of methacholine needed to obtain the mentioned parameters (group 1: ≤1000µg; group 2: 1001-2000µg; group 3: ≥2001µg). RESULTS: Greater variability was recorded for FEF(25-75) than for FEV1. Paired comparison among the three groups for FEV1 proved significant, in the same way as for FEF(25-75) between groups 2 and 3, and 1 and 3, but not between groups 1 and 2. Calculation was made of the amount of methacholine required to obtain PD20 and PD40 from the same dose. Only the significant differences corresponded to the comparison of group 1 versus the rest, with no differences between the means of the total mean values. CONCLUSIONS: The utility of PD20 is more evident, considering the variability of PD40; the latter may be useful in patients with rhinitis or tracheobronchitis when PD20 proves scantly demonstrative.

Pediatría, síndrome de Down y patología alérgica / Pediatrics, Down’s syndrome and allergic disease

Las enfermedades alérgicas tienen una base genética (atopia), por lo que la herencia es determinante para presentar estos procesos, en los que la enfermedad respiratoria es predominante, aunque no faltan las reacciones frente a alimentos o medicamentos, cuyas manifestaciones clínicas más comunes tienen lugar en la piel y el aparato digestivo, con reacciones generales en no pocas ocasiones (anafilaxia) que pueden ser graves, incluso mortales. El aumento de la afección respiratoria en los últimos años se ha relacionado con la disminución de las enfermedades infecciosas en los países desarrollados, con un desequilibrio en la actuación de los linfocitos Th1/Th2, inclinada hacia los Th2, encargados de la producción de anticuerpos frente a alérgenos (“hipótesis higiénica”). A pesar de esto, en los niños con trisomía 21, con gran alteración de genes encargados de otros muchos de los procesos asociados a la entidad, en pocas ocasiones presentan enfermedades de causa alérgica, como refleja la escasez de publicaciones que se ocupen de este tema. Por el contrario, la afectación de la respuesta inmunitaria frente a patógenos (mayor incidencia de infecciones con necesidad de producción de anticuerpos específicos a cargo de los linfocitos Th1) y otros procesos (autoinmunes, leucemia) relacionados con la inmunidad, se mantienen de forma constante, lo cual puede ser la causa de la menor posibilidad de reacciones alérgicas (AU)

Allergic diseases have a genetic basis (atopy), meaning that inheritance is a determining factor in the development of these processes. Respiratory pathologies are the most common, although reactions to foods and drugs also occur. The most common clinical manifestations occur in the skin and digestive tract, and generalised reactions (anaphylaxis) can often occur that can be severe or even fatal. The increase in respiratory pathologies in recent years has been linked to a reduction in infectious diseases in developed countries. The activity of Th1/Th2 lymphocytes has become imbalanced, leaning towards the Th2 that are responsible for producing antibodies against allergens (“hygiene hypothesis”). In spite of this, children with trisomy 21, with the wide gamut of altered genes responsible for many of the processes associated with this syndrome, rarely suffer from allergic diseases. This is reflected in the small number of publications on this field. In contrast, immune response to pathogens is constantly affected (greater incidence of infections requiring the production of specific antibodies produced by Th1 lymphocyte activity) along with other processes (auto-immune, leukaemia) related to patient immunity, and this could be the cause of the reduced possibility for allergic reactions (AU)

Prognostic bases of asthma. Natural history?

Different causes of asthma have been established. The most common cause is conditioned to a genetic predisposition towards atopy (atopic asthma), although other factors can also give rise to bronchial inflammation, such as over-exposure to environmental irritants (occupational asthma), altered arachidonic acid metabolism (aspirin-induced asthma) and also exercise – in which different thermal and osmotic mechanisms are known to intervene. The prognosis of these different variants of asthma depends on the severity of the condition; patient age at onset of the disease; patient age at the time of diagnosis; the treatment provided; and adherence to therapy. The concept of "natural history" refers to the spontaneous evolution or course of the disease process in the absence of pathogenic or etiological treatment, with the provision of only symptomatic treatment. In order to gain increased certainty regarding the course of these patients, the study groups must present similar baseline characteristics in terms of the start and severity of the condition; the start of treatment; compliance; and the clinical and functional control finding

Prognostic bases of asthma. Natural history?

Different causes of asthma have been established. The most common cause is conditioned to a genetic predisposition towards atopy (atopic asthma), although other factors can also give rise to bronchial inflammation, such as over-exposure to environmental irritants (occupational asthma), altered arachidonic acid metabolism (aspirin-induced asthma) and also exercise - in which different thermal and osmotic mechanisms are known to intervene. The prognosis of these different variants of asthma depends on the severity of the condition; patient age at onset of the disease; patient age at the time of diagnosis; the treatment provided; and adherence to therapy. The concept of "natural history" refers to the spontaneous evolution or course of the disease process in the absence of pathogenic or etiological treatment, with the provision of only symptomatic treatment. In order to gain increased certainty regarding the course of these patients, the study groups must present similar baseline characteristics in terms of the start and severity of the condition; the start of treatment; compliance; and the clinical and functional control findings.

Is Helicobacter pylori responsible for autoimmune diseases? That is the question / ¿Es el helicobacter pylori responsable de enfermedades autoinmunes? Esta es la cuestion

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Food allergy: oral tolerance or immunotherapy? / Alergia alimentaria: ¿tolerancia oral o inmunoterapia?

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Teaching patients: Role of summer camps for asthmatic children / Enseñando a los pacientes: papel de los campamentos de verano para niños asmáticos

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