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Exercise-induced anaphylaxis (EIA) was defined for the first time in 1980. EIA is associated with different kind of exercise, although jogging is the most frequently reported. The clinical manifestations progress from itching, erythema and urticaria to some combination of cutaneous angioedema, gastrointestinal and laryngeal symptoms and signs of angioedema and vascular collapse. Mast cell participation in the pathogenesis of this syndrome has been proved by the finding of an elevated serum histamine level during experimentally-induced attacks and by cutaneous degranulation of mast cells with elevated serum tryptase after attacks. As predisposing factors of EIA, a specific or even aspecific sensitivity to food has been reported and such cases are called "food-dependent EIA". Many foods are implicated but particularly wheat, vegetables, crustacean. Another precipitating factor includes drugs intake (non steroidal anti-inflammatory drugs), climate variations and menstrual cycle factors. Treatment of an attack should include all the manoeuvres efficacious in the management of conventional anaphylactic syndrome, including the administration of epinephrine and antihistamines. Prevention of the attacks may be achieved with the interruption of the exercise at the appearance of the first premonitory symptoms. To prevent the onset of EIA it is also suitable to delay the exercise practice after at least 4-6 hours from the swallowing of food.

Nowadays asthma treatment is based on topical beta2 short-acting and topical and systemic corticosteroids. Topical drugs do not control completely peripheral airways inflammation and also they are not able to control other disease frequently associated to asthma as rhinitis. Systemic steroids instead are very useful but not specific antinflammatory drug and can induce important side effects. For the reasons mentioned above it is important to use systemic drugs, acting on the numerous mediators typical of asthma, without modifying human physiological functions. We actually can use antileucotriens, but anti-IgE will be available also in Italy soon. Antileucotriens are effective and safe and are actually used in persistent asthma not completely controlled by inhaled steroids. They are administered per os; some of them are used once a day and can be used in paediatric age. In USA antileucotriens are also indicated in allergic rhinitis treatment. In atopic asthma, Omalizumab, an anti IgE drug, is safe and useful. It reduces the use of the systemic and inhaled steroids and the number of asthma exacerbations, in selected treated patients, without inducing important side effects. It is also useful in the treatment of rhinitis. Some proinflammatory cytochines, antiinflammatory cytochines and phosphodiesterasis inhibitor could be useful in the treatment of asthma but actually the use of these new drugs is still experimental.

Aspirin (ASA) is an important cause of asthma so that ASA induced asthma (AIA) is considered a disease. Its prevalence is of 0.3-0.6 in the general population but it raises to 21% in the asthmatic one. Middle aged female are the most affected. AIA generally begins with a non allergic rhinitis, complicated sometimes with polyps, that evolves secondarily in asthma. The disease is often so severe to need oral corticosteroids to be controlled. It persists independently to the intake of ASA. From a pathogenetic point of view the interaction of ASA with the arachidonic acid metabolism seems to be important. The inhibition of cyclo-oxygenase (COX) induces an activation of lypo-oxygenase with an increased synthesis of leukotrienes. In ASA intolerant patients there is also an activation of LTC4 synthetase, enzyme responsible for the synthesis of leukotrienes. Clinical history is very important to diagnose the disease but to confirm the diagnosis sometimes the provocation test is mandatory. Oral and bronchial challenges can be dangerous, while nasal challenge is safer even if must be better standardized. Patients must not use antiinflammatory drugs with the same mechanism of action of ASA; COX-2 inhibitors are generally well tolerated. Antileukotrienes are useful to treat asthma, in association with steroids. Desensitization can be used in very selected patients.

In the last years an increase of allergic diseases has been observed whose prevalence is about 20-30% in general population of western countries. However there is a risk of an over diagnosis of allergic diseases as many different diseases (migraine, chronic urticaria, chronic inflammatory bowel diseases, chronic-fatigue syndrome etc.) are considered due to food allergy or intolerance. In many patients the diagnosis is based on the results of alternative diagnostic tests such as the cytotoxic test, the provocation/neutralization sublingual or subcutaneous test, the heart-ear reflex test, the kinesiology, the biorisonance, the electro-acupuncture, and the hair analysis, or on immunological tests (immunocomplex or specific food IgG). We reviewed the scientific evidences of these tests (specificity, sensibility, rationale, reproducibility). According to most studies none of them had to be recommended as useful for the diagnosis of food allergy or intolerance. Physicians should alert patients about the risk of an indiscriminate use of these test in the diagnosis of food allergy. In fact the use of an incorrect diet could be dangerous, particularly in childhood, as recently shown.

A close anatomical and functional relationship between superior and inferior airways is well documented. A typical example is offered by the close relationship between allergic rhinitis and asthma whose close connection is documented by epidemiological and pathological data. The mechanisms which can explain this phenomenon are not fully known but naso-bronchial reflexes, mouth-breathing due to nasal obstruction and aspiration of nasal secretions seem all to be important. Moreover it has been recently proved that the treatment of rhinitis can improve the concomitant asthma thus confirming their relationship. Another less frequent association is between sinusitis and asthma. Such a connection seems to be frequent in patients suffering of atopic rhinitis but also in patients presenting a nasal obstruction of different nature such as deviations of the nasal septum, adenoid hypertrophy etc. Also in this case a correct medical or surgical treatment of sinusitis can improve asthma symptomathology. Finally a classic example of involvement of superior and inferior airways is represented by the syndrome of ASA intolerance. These patients in fact initially complain of rhinitis which afterwards is complicated by the onset of nasal polyposis and asthma which can prove clinically very severe. Nowadays, anyway, there is no evidence that the treatment of rhinitis or polypectomy can improve the clinical course of asthma. In conclusion, diseases of superior and inferior airways must be considered in strict connection and need the same global treatment.

Asthma is a chronic inflammatory disease of airways with a multifactorial pathogenesis. Both genetic and environmental factors contribute to the development of the disease which can vary in the same patient through time. Due to its complexity, natural history of asthma is poorly well-known. Generally, in the history of asthma three periods of life are taken into consideration: early childhood, adolescence and adult life. It has been demonstrated that less than one third of children who are affected by wheezing in early childhood develop a true asthma afterwards. Usually in these subjects who are male and atopic, viruses and subsequently allergens represent the most important factors responsible for the development of asthma. During adolescence airborne allergens represent the main cause of the disease: mites in infancy and pollens in late childhood. The incidence of asthma during adolescence is growing according to recent studies, and even if the symptomatology of asthma improves through time, about two thirds of patients remain asthmatic in their adult life. As regards adults etiology, it is less known, women are more frequently affected than men and the prognosis is generally poorer. Several factors negatively influence the course of asthma such as age, smoking, the severity of the disease during infancy, the persistence of functional obstructive alterations and the increased aspecific bronchial reactivity. Adequate therapy is crucially important to cope with these factors and can change the course of the disease.

Asthma is a chronic inflammatory lung disease in which eosinophils are one of the most important involved cells. These cells accumulate in the lung because of cytokines, which are able to regulate cellular responses. The role of cytokines is well known in allergic asthma: IL4, IL5, IL3, GMCSF are the principally cytokine involved. IL4 regulate IgE synthesis while IL5, (and IL3) cause the activation and accumulation of eosinophils. In non allergic asthma, whilst only IL5 seemed to be important recent data, shows that also IL4 plays an important role. Therefore nowadays no relevant difference seems to exist between allergic and non allergic asthma; instead the primer is different: the allergen in allergic asthma and often an unknown factor in the non allergic asthma. Recently other cytokines have been proved to play a role in the pathogenesis of asthma. IL8 is chemotactic not only for neutrophils but also for eosinophils and might cause chronic inflammation in severe asthma. IL13 works like IL4, while RANTES seems to be a more important chemotactic agent than IL5. Finally IL10, which immunoregulates T lymphocyte responses, may reduce asthma inflammation. In conclusion cytokine made us to learn more about the pathogenesis of asthma even if we do not yet know when and how asthma inflammation develops.

Over the last twenty years an increase of allergic respiratory diseases has been observed, even if a broad variability of incidence has been reported. Asthma and allergic rhinitis are more common among young subjects, but there are data of an increase of allergic respiratory diseases in older patients. Moreover it has to be underlined the increase of the severity of these diseases, as shown by the higher use of anti-allergic drugs and by the increase of fatal asthma. The reasons of this trend are not understood. One reason can be the more appropriate diagnosis of asthma by the general practitioners. Other factors must be considered: the most important one can be air pollution; many air components (i.e. SO2, NO2, O3), particularly in industrialized countries, may play a role in allergic sensitization through an irritative-inflammatory mechanism. Socio-economic factors can also influence the incidence of allergic diseases. Other factors as cigarette smoke, foods, allergenic load have to be mentioned. Finally a viral etiology has been reported. Very recently, the allergic inflammation has been considered as the crucial event in the pathogenesis of allergic respiratory diseases. As allergic diseases can lead to chronic inflammation, an early and long-lasting treatment is mandatory.

The drugs recently available for the treatment of allergic respiratory diseases include: 1) topical steroids as fluticasone and budesonide; 2) nasal and ocular sodium nedocromil; 3) nasal N-acetyl-aspartyl-glutamic acid; 4) topical antihistamines as levocabastine and azelastine; 5) antileukotrienes and anti PAF (experimental). Topical steroids are the most effective drugs; the new molecules have a low gastric absorption and a rapid liver-metabolism which decreases the risks of systemic side effects. In the treatment of allergic conjunctivitis ocular sodium nedocromil seems to be more effective than cromoglycate, however further studies are needed to evaluate the effectiveness of the nedocromil nasal formulation. In allergic rhinitis good clinical results are obtained using NAAGA. In the treatment of allergic rhino-conjunctivitis topical antihistamines seem as effective as the antihistamines administered by oral route; moreover they cause less side effects. The anti-leukotrienes drugs can be used in the treatment of moderate asthma. In the treatment of bronchial asthma no clinical and functional improvement has been reported using PAF or thromboxane A2 receptor antagonists.