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Tierallergien sind nach der Hausstaubmilbenallergie der häufigste Grund allergischer Atemwegsbeschwerden in Innenräumen. Falls eine ständige Allergenexposition besteht werden die Symptome wie Rhinitis, Hautjuckreiz oder Asthma gewöhnlich nicht als heftig empfunden und können daher auch nicht einem Tier oder einer Tierquelle zugeordnet werden. In vielen Fällen basiert die Tierallergie auf einer perenniale Allergenexposition. Auch wenn wahrscheinlich alle Tiere Ursache einer Atemwegsallergie sein können, sind doch Katzen, Hunde und Pferde die häufigsten Auslöser. Die Diagnose einer Allergie auf ein Tier muss mit Sorgfalt gestellt werden, weil sie häufig emotionale Reaktionen, verschiedene Konflikte, aber auch Unverständnis auslöst. Seltener sind Pilzallergien, auch wenn sie als Allergiequellen seit Jahrzehnten zur Differentialdiagnose der Atemwegsallergie gehören, speziell beim Spätsommerasthma. Pilze sind ubiquitär und sind in Wohnräumen wie auch in der Natur stets präsent. Leider ist das Gebiet der Pilzallergie wenig erforscht und die diagnostischen Möglichkeiten sind begrenzt. Die erfolgversprechendste Therapie sowohl bei einer Tier- oder einer Pilzallergie wäre den Kontakt mit der jeweiligen Allergenquelle vollständig zu meiden. Zwar werden diverse präventive Empfehlungen abgegeben, aber oft gelingt die Umsetzung nicht zufriedenstellend. In ausgewählten Fällen kann die spezifische Immuntherapie sowohl bei der Tier- wie auch bei der Pilzallergie eine therapeutische Option sein.

Background: The aim of this study was to analyze the influence of total serum IgE and other potential risk factors on severity of systemic allergic Hymenoptera sting reactions. Methods: In a retrospective analysis of one thousand and two patients referred for insect allergy over 5 years, 865 reported systemic allergic sting reactions, most often by honey bees and wasps. In 758, total IgE, venom-specific IgE, and baseline tryptase levels were available and analyzed together with atopy state, age, and sex in relation to severity of sting reactions according to H. L. Mueller. Results: In a binary logistic regression model considering, besides IgE, also other risk factors for severity, an influence of total and specific IgE on severity of systemic allergic sting reactions could not be shown, while high severity of systemic allergic sting reactions was significantly more often reported in patients with a baseline tryptase of ≥11.4 μg/l (P Language: en

Background: Anaphylaxis is an acute generalized hypersensitivity reaction initiated by various triggers which involves the entire organism and which may be life threatening. Although international guidelines for the emergency treatment of anaphylaxis have been published, the therapeutic recommendations are implemented differently. In this study besides the etiology of anaphylaxis, we were interested in how and where the patients have been treated and whether or not this reaction did occur for the first time. Methods: From January 1 to December 31 of 2008 1,075 patients have been referred to the allergy unit of the communal hospital in Berne (Zieglerspital) for an allergological work-up. 54 (5.0%) of them had had an anaphylaxis defined as shock, drop of blood pressure or collapse. The examination consisted of a detailed history and a comprehensive allergological assessment. Results: The average age of the 54 patients ― 28 women (52%) - was 43 years. In 46 (85%) of them the cause for anaphylaxis was a Hymenoptera venom allergy. Other triggers were: drugs [3], exercise-induced [2], multi-factorial [2] and food [1]. 20/54 subjects (37%) had a recurrent systemic reaction; all of them were allergic to Hymenoptera venom. 6 of them (30%) possessed emergency medications (antihistamines/corticosteroids); none of them had an epinephrine-autoinjector. 48/54 patients (89%) have been treated in a hospital or by the emergency doctor; 2/6 were supported by family members, and 4 recovered spontaneously. For therapy most often corticosteroids (92%) and antihistamines (89%) were used; epinephrine, however, only in 9 cases (17%). Conclusion: This investigation shows that emergency treatment of anaphylaxis in the region of Bern does not concur with the advocated guidelines. Epinephrine as first-line therapy in anaphylaxis has been used rarely. More than one-third of the patients already had a previous allergic generalized reaction elicited by the same culprit (in our case hymenoptera stings). Only one-third of these carried emergency medications but none of them possessed an epinephrine-autoinjector.

Background: Approximately 20% of subjects with asthma experience an acute bronchoobstruction after ingestion of ASA/NSAID. In specialized clinics the inhalative broncho-provocation test (IPT) with L-ASA is a well-established method to confirm the diagnosis of aspirin-induced asthma (AIA). The objective of this investigation was to establish a new, short-during IPT with L-ASA as a diagnostic tool in an outpatient clinic. Method: In the years 2001 to 2005, 65 patients (35 F, 30 M, mean age 42 years (16 - 73 years), performed an IPT with L-ASS. Group 1 comprised 37 patients with asthma and nasal polyposis, Group 2 17 patients with asthma but without nasal polyposis, and Group 3 11 patients with only cutaneous symptoms after intake of aspirin/NSAID. The IPT was performed stepwise with 5, 15 and 40 mg L-ASA up to a cumulative dose of 60 mg. Patients with a negative IPT underwent an oral provocation test with aspirin. Results: In group 1 11/37 (30%), in group 2 6/17 (35%), and in group 3 none of 11 (0%) had a positive IPT. The threshold dose was in 13 out of 17 reactors (76%) ≤ 20 mg L-ASA. Except in 1 patient, the bronchial-obstructive reaction was well-reversible after the inhalation ofsalbutamol. 24 out of 48 patients with a negative IPT with L-ASA underwent consecutively an oral provocation test with aspirin. 4 of them reacted with mild clinical symptoms after a cumulative dose of> 500 mg ASA. Conclusion: Our modified schema of IPT with L-ASA up to a cumulative dose of 60 mg L-ASA is suitable for diagnosing an AIA in an ambulatory setting. The IPT with L-ASA is a sensitive and safe provocation test lasting about 3 h. A negative IPT at 60 mg L-ASA excludes a significant reaction following the intake of low-dose aspirin (100 - 300 mg), this information may be essential in the prophylaxis and treatment of cardiovascular diseases.

Objective: It was the aim of this study to investigate the prevalence of otologic manifestations in a cohort of Samter’s syndrome patients (nasal polyps with chronic rhinosinusitis, aspirin intolerance and asthma). Methods: We analyzed a retrospective and prospective case review from 1995 to 2005, performed in the otorhinolaryngology outpatient clinic of a tertiary referral center. Ear history, clinical examinations, treatment and outcome were evaluated using office and hospital records in 23 cases. All subjects completed a questionnaire. Results: In 6 cases (26%), otological manifestations with ear pressure and conductive hearing loss occurred during an advanced stage of Samter’s syndrome (>5 years after onset of the first nasal symptoms) partially responsive to systemic steroids. Conclusion: Recognition of the association between Samter’s syndrome and otological disease is important (26% of the cases) because it could also be responsive to systemic steroids which prevent progression to irreversible hearing loss or infectious otomastoiditis.

An anaphylactic reaction due to a Hymenoptera sting is a clinical emergency, and patients, their caregivers as well as all healthcare professionals should be familiar with its recognition and acute management. This consensus report has been prepared by a European expert panel of the EAACI Interest Group of Insect Venom Hypersensitivity. It is targeted at allergists, clinical immunologists, internal medicine specialists, pediatricians, general practitioners, emergency department doctors, and any other healthcare professional involved. The aim was to report the scientific evidence on self-medication of anaphylactic reactions due to Hymenoptera stings, to inform healthcare staff about appropriate patient self-management of sting reactions, to propose indications for the prescription of an adrenaline auto-injector (AAI), and to discuss other forms of medication. First-line treatment for Hymenoptera sting anaphylaxis is intramuscular adrenaline. Prescription of AAIs is mandatory in the case of venom-allergic patients who suffer from mast cell diseases or with an elevated baseline serum tryptase level and in untreated patients with a history of a systemic reaction involving at least two different organ systems. AAI prescription should also be considered in other specific situations before, during, and after stopping venom immunotherapy.

BACKGROUND: Component resolution recently identified distinct sensitization profiles in honey bee venom (HBV) allergy, some of which were dominated by specific IgE to Api m 3 and/or Api m 10, which have been reported to be underrepresented in therapeutic HBV preparations.OBJECTIVE: We performed a retrospective analysis of component-resolved sensitization profiles in HBV-allergic patients and association with treatment outcome.METHODS: HBV-allergic patients who had undergone controlled honey bee sting challenge after at least 6 months of HBV immunotherapy (n = 115) were included and classified as responder (n = 79) or treatment failure (n = 36) on the basis of absence or presence of systemic allergic reactions upon sting challenge. IgE reactivity to a panel of HBV allergens was analyzed in sera obtained before immunotherapy and before sting challenge.RESULTS: No differences were observed between responders and nonresponders regarding levels of IgE sensitization to Api m 1, Api m 2, Api m 3, and Api m 5. In contrast, Api m 10 specific IgE was moderately but significantly increased in nonresponders. Predominant Api m 10 sensitization (>50% of specific IgE to HBV) was the best discriminator (specificity, 95%; sensitivity, 25%) with an odds ratio of 8.444 (2.127-33.53; P = .0013) for treatment failure. Some but not all therapeutic HBV preparations displayed a lack of Api m 10, whereas Api m 1 and Api m 3 immunoreactivity was comparable to that of crude HBV. In line with this, significant Api m 10 sIgG4 induction was observed only in those patients who were treated with HBV in which Api m 10 was detectable.CONCLUSIONS: Component-resolved sensitization profiles in HBV allergy suggest predominant IgE sensitization to Api m 10 as a risk factor for treatment failure in HBV immunotherapy.

Key Clinical Message “Flare-up” reactions are late manifestations of severe T-cell-mediated drug hypersensitivity reactions. Management is anti-inflammatory treatment and avoiding unnecessary medicines. Symptoms like fever, lymph node swelling, and blood count abnormalities may lead to confusion with bacterial infections. For prompt recognition it is important to keep the differential diagnosis in mind.

Intolerance reactions to local anesthetics are frequent complications in medical and dental offices, but true allergy to local anesthetics is very rare (< 1%). In this study, we aimed to characterize patients with recurrent - at least 2 - intolerance reactions to local anesthetics. All patients had negative skin tests to local anesthetics of the immediate (IgE-mediated) as well as of the delayed type (T cell-mediated), and all have been subcutaneously challenged with a local anesthetic. During the last 10 years, out of 477 patients with a history of intolerance reactions to local anaesthetics referred to us, 275 of them have been thoroughly tested for allergy, particularly to local anesthetics. Of 43 eligible patients, 36 could be interviewed and 23 of them agreed to new tests. Although many of the study patients experienced symptoms suggestive for a vagovasal reaction, they seemed not to have an overall higher tendency for psychovegetative dispositions. The clinical reaction of intolerance following local anesthetics was always of the same pattern. There was no evidence of an enhanced mast-cell releasability or tissue reactivity to specific and non-specific mast-cell stimulants, respectively, and basal serum tryptase level was within the normal range. Moreover, a negative challenge test with local anesthetics is no guarantee for recurrence of intolerance reactions to local anesthetics. Nevertheless, we are in agreement with the recommendation of other groups to do challenge tests in the diagnostic of intolerance reactions to local anesthetics. Based on our results, we consider pharmacological effects as the most likely explanation in subjects with recurrent episodes to local anesthetics resembling allergy. In contrast to allergy to local anesthetics, all patients recovered spontaneously within 30 minutes without any therapy.

The clinical impact of allergen tight mattress encasings has still been debated. Beside encasings, recommended measures include the use of HEPA filter in the vacuum cleaner, reducing the humidity by increased ventilation rate and weekly change of bed linen. Materials and methods: A double-blind, placebo-controlled crossover study was performed to evaluate the clinical efficacy of mattress covers (VarioProtect encasings, Sanders, Germany). We included 30 patients with rhinitis or asthma due to house dust mite allergy of which 26 completed the study. At an initial visit for evaluation of the inclusion criteria, patients received a hygrometer and were seen 4 additional times for blood sampling and delivery of the active cover and later the placebo cover (cotton cover) or vice versa. Both study phases lasted 9 - 11 weeks, the wash-out period in-between lasted 2 - 10 weeks to avoid any interference with pollen allergy. At the patients' homes, a study-independent person collected dust samples which were analyzed for house dust mite allergen using an immunodot assay with monoclonal antibodies against the house dust mite allergen Der p 1, Der f 1 and mite group 2. For the evaluation of allergen content, the sum of the 3 allergens was used. Serum eosinophil cationic protein was measured to define the underlying allergic inflammation. Subjective clinical complaints regarding rhinoconjunctivitis and asthma were asked using a standardized questionnaire by E. Juniper. All patients were informed to wash their bed linen weekly and to increase the level of air exchange. A score for medication intake was calculated and the sleeping comfort with the active or placebo covers was evaluated. Results: A statistically significant reduction of the allergen content from 1.43 μg/m 2 /2 min to 0.65 μg/m 2 /2 min was found after using the active cover, but not after using the placebo cover (1.49 μg/m 2 /2 min). The measurement of the relative humidity in the air revealed no change throughout the study. At the beginning of the study, 49.5% relative humidity was measured, at the end of the study in summer time 64.3% were measured. The clinical complaints did not significantly change comparing both groups (active/placebo or placebo/active). A carry-over effect could be excluded since baseline values were similar. Pooling all data for the subjective rhinitis score revealed a statistically significant decrease in all 26 patients receiving either placebo or active treatment. In 8 patients with an elevated serum ECP level (> 16 μg/l), an amelioration of rhinitis could be seen in the active phase compared to the placebo phase. In addition, 12 patients with asthma reported fewer symptoms using the active cover compared with the placebo cover. After the active cover phase, 6 of the 8 patients with elevated ECP had a lower level of ECP, while 6 patients with the placebo cover had a higher level of ECP (p < 0.025). The medication intake was reduced during the active phase as well as during the placebo phase. The general comfort using the active cover was good with the exception of some rustling. The data confirm the clinical efficacy of allergen impermeable covers: an allergen reduction as well as a clinical relieve can be achieved, whereby the patients with elevated ECP may be particularly susceptible to allergen avoidance measurements.

For decades airborne fungal spores have been implicated as causative factors in respiratory allergy. Exposure to high atmospheric spore counts and sensitization to specific fungal allergens have been associated with severe asthma, mainly in young adults. Although the prevalence of sensitization to commercial fungal extracts is approximately 3% in epidemiologic studies, in selected patients, particularly with asthma, the sensitization rate might increase to 30%. Of the estimated number of more than 1 million of different fungal species, approximately 80 fungi have been connected with respiratory allergy. Currently, diagnosis and specific therapy of fungal allergy is hampered by the poor quality of most of the commercially available extracts. Clinical efficacy of specific immunotherapy with fungal extracts has been shown in 79 actively treated patients in four controlled trials, with only two fungal species, namely Alternaria alternata and Cladosporium herbarum. The use of recombinant fungal allergens might create new prospects in diagnosis and specific immunotherapy for fungal allergy.

Background Leukotriene receptor antagonists have shown some efficacy in the treatment of asthma. Injection of LTC 4 , LTD 4 and LTE 4 into the skin leads to a weal-and-flare reaction, suggesting an involvement of leukotrienes in the pathogenesis of urticaria. Indeed, various reports have indicated a beneficial effect for leukotriene receptor antagonists in patients with chronic urticaria. Objective To determine the therapeutic effect of the leukotriene receptor antagonist zafirlukast in patients with chronic urticaria. Methods The study was a double-blind, placebo-controlled, cross-over study lasting for 12 weeks. Fifty-two patients with chronic urticaria were investigated at a university hospital. The patients were randomized to receive 20 mg zafirlukast b.i.d. or placebo and cross-over was scheduled after 6 weeks. The efficacy of the treatment was evaluated by a daily symptom score, six physical examinations, the requirement of rescue antihistamines (acrivastine) and an overall assessment by the patient and the investigating physician. Results Forty-six patients completed the study: zafirlukast was well tolerated without alteration of the investigated laboratory parameters. In comparison with placebo, treatment with zafirlukast resulted in no significant positive effect for any of the efficacy measures. Moreover, we were unable to identify any subgroup of patients with chronic urticaria responding with a therapeutic benefit. Conclusions The leukotriene receptor antagonist zafirlukast does not provide a significant therapeutic benefit at a dose of 20 mg b.i.d. in patients with chronic urticaria.

Whereas the efficacy of the specific immunotherapy (SIT) in pollen allergy has been established, its consequence on the pollen-associated food allergy particularly the oral allergy syndrome (OAS) is less clear. In a retrospective study, we investigated the effect of SIT with pollen extracts in pollen-allergic subjects on the OAS. In addition, we looked for factors that could be prognostic for the change of OAS. 72 subjects (39 male, 33 female with a mean age of 32 years) allergic to pollen with a concomitant pollen-associated food allergy, namely OAS, who have been treated for an average of 2,0 years by SIT were interviewed using a standardized questionnaire. For control served 40 individuals (17 male, 23 female; mean age 29 years) allergic to pollen and a pollen-associated food allergy (OAS) without SIT. 38 of 72 subjects (53%) treated with SIT had an improvement of their OAS. However, 23 (32%) claimed an unchangeable and 11 (15%) even an increase of the OAS. Of the controls, an improvement was realized in only 3 individuals (8%). 20 of them (50%) declared no change and 17 a worsening of the OAS. In conclusion, our results suggest that pollen-associated food allergy, specifically the OAS, can be reduced in more than half of the patients by SIT. On the other hand, in 15% of the SIT-treated collective an expansion of the spectrum of foods inducing symptoms was experienced. A successful development of the OAS by SIT seems to occur if patients are older than 20 years of age, have a clinical relevant birch pollen allergy and suffer from an intensive OAS. Failure regarding OAS seems more likely if SIT with birch pollen is combined with grass pollen extracts.

Summary Background Fungal components can cause allergic symptoms either through inhalation, ingestion or contact. Whereas respiratory allergy is thought to be induced by spores, allergic reactions following ingestion are attributed to other parts of the mushroom. Reports of food-related allergic reactions due to the edible mushroom Boletus edulis have occasionally been reported. Objective The aim of the study was to investigate whether separate allergens may be detected in alimentary allergy to Boletus edulis. Methods Sera of two subjects, one with recurrent anaphylaxis and the other with a predominantly oral allergy syndrome following ingestion of Boletus edulis, have been analysed by a time-course digestion assay using simulated gastric fluid and by SDS-PAGE immunoblotting. Sera of four Boletus edulis skin prick test-negative subjects and all without clinical symptoms to ingested Boletus edulis served as controls. Results In lyophilized Boletus edulis extract, at least four water-soluble proteins were detected, the most reactive at 55 kDa and at 80 kDa. Following the time-course digestion assay, IgE binding was found to a 75-kDa protein, but only if the sera of the subject with recurrent anaphylaxis was used. Conclusion The data indicate that Boletus edulis can cause an IgE-mediated food allergy due to a digestion-stabile protein at 75 kDa. No IgE immune response to this protein was detected in the serum of a subject with respiratory allergy and oral allergy syndrome to Boletus edulis nor in control sera.

We describe a patient who suffered from intestinal perforation after abdominal trauma. Perioperatively, he was treated with a single dose of piperacillin and 9 doses of imipenem/cilastatin over 3 days. The patient was discharged 5 days after surgery in good clinical condition and with normal liver values except for a marginal elevation of alanine aminotransferase. Two weeks after discharge, he developed fatigue, fever and pruritus, necessitating rehospitalization. He was jaundiced and had elevated alkaline phosphatase and transaminases. After exclusion of an intra-abdominal fluid collection, a vascular problem, and infectious or autoimmune liver disease, a liver biopsy was performed. The biopsy revealed centrizonal bilirubinostasis, a portal infiltrate rich in eosinophils and cholangitis. Lymphocyte transformation tests for piperacillin and imipenem/cilastatin were positive, suggesting an immunological mechanism for the observed hepatopathy. Cholestasis gradually decreased but was detectable for several weeks. The patient had a full clinical and biochemical recovery after 3 months. We conclude that short-term therapy with piperacillin, imipenem/cilastatin or the combination of these drugs can lead to the same type of hepatopathy as described for amoxycillin/clavulanic acid or antistaphylococcal penicillins. Liver biopsy and positive lymphocyte transformation are compatible with an immunological mechanism.

Pets particularly dog and cat are the men's best friend. In the daily practice respiratory allergy to animal proteins are not uncommon and in some areas the frequency is even higher than allergy to house dust mites. In Switzerland nearly half of the households keeps some kind of a domestic animal with cats followed by dogs as the principal pets. Because the exposure to domestic animals is perennial, allergic symptoms such as rhinoconjunctivitis or asthma usually are less acute than due to pollen or an occupational allergen. The best and most effective management of a domestic animal allergy is to avoid having contact with the relevant pet. Because of personal and emotional conflicts other strategies are employed to reduce allergen levels of the pet such as by washing or by restriction of the territory. For many years, fungal spores have been recognized as potential causes of respiratory allergies. Besides the more community recognized microfungi or molds such as Alternaria alternata, Aspergillus fumigatus or Cladosporium herbarum the class of basidiomycetes--physically the largest and morphologically the most complex fungi--are known to produce allergic symptoms. This class consists of about 14,000 species, including mushrooms, bracket fungi, puffballs, toad stools and jelly fungi, as well as the plant-pathogenic rusts and smuts. Clinically, symptoms due to fungal allergens are not distinguishable from those due to pollen, however, in recent years asthma attacks particularly in young people have been associated with high spore counts in the air. Upon contact fungal components may cause eczema or trigger inflammatory skin eruptions in a subgroup of patients with atopic eczema. Though food allergies to mushrooms are largely anecdotal, a few well documented cases mainly due to Boletus edulis (king bolete or cepe) have been published recently. Since fungal spores are ubiquitous atmospheric components avoidance measures are often not achievable. Nevertheless, some preventive steps especially at home may help to control growth of molds. Specific immunotherapy may be indicated for both domestic animal and fungal (mold) allergies in certain circumstances. Clinical relevance, however, needs to be demonstrated by an accurate allergological assessment.

Die Klasse der Standerpilze (Basidiomyzeten) umfasst etwa 14000 verschiedene Arten der morphologisch grosten Pilze. Standerpilzsporen kommen in verschiedenen Regionen in bedeutenden Konzentrationen in der Luft vor und konnen die Ursache allergischer, IgE-vermittelter Atemwegserkrankungen wie Asthma oder Rhinitis sein. Ferner konnen die Standerpilze kutane Erscheinungen wie ein Kontaktekzem oder eine Exazerbation atopischer Ekzeme auslosen oder sie konnen Anlass zu einer alimentaren Allergie sein. Die Standerpilze reprasentieren eine relevante, allerdings oft verkannte Allergenquelle in verschiedenen Bereichen der Allergologie. Das Hauptproblem bei der Erfassung einer Sensibilisierung bzw. Allergie auf Standerpilze liegt darin, dass keine zuverlassigen, kommerziellen Extrakte existieren. Daher ist es wichtig, dass in Zukunft weiterhin Forschung auf dem Gebiet der Protein- und Allergencharakterisierung von Standerpilzen betrieben wird, zumal neuere Untersuchungen darauf hinweisen, dass Standerpilze neue, bisher vollig unbekannte Proteine enthalten.

Background Local anaesthetics are known to elicit T-cell reactions after epicutaneous application, namely contact dermatitis. In addition, adverse reactions like urticaria and angioedema are rather common after submucosal or subcutaneous injection. The pathogenesis of these side-effects, which appear frequently hours after application, is unknown, but thought to be not immunoglobulin E-mediated, since immediate skin tests are mostly negative. Objectives We investigated whether patients who developed urticaria and angioedema after subcutaneous application have a T-cell sensitization to local anaesthetics, which might be responsible for the symptoms. Methods Twenty patients with generalized and/or local cutaneous reactions after LA were examined with intradermal testing using a standard panel of six LAs and patch testing using between seven and nine LAs in vaseline and four LAs in PBS. In 10 patients, a lymphocyte transformation test (LTT) was performed. Results Only 2/20 patients had an immediate skin reaction (positive intradermal test), whereas 6/20 patients had a positive delayed skin reaction (positive patch test). In 6/10 subjects the LTT was positive. Conclusions Delayed appearance of urticaria and angioedema after subcutaneous application of local anaesthetics may be related to a T cell- mediated sensitization, which might be detected by patch testing or LTT.

Background: Montelukast, a leukotriene receptor antagonist, and salmeterol, a long-acting β 2 -receptor agonist, each have demonstrated benefits in the treatment of exercise-induced bronchoconstriction (EIB) in short-term studies. Direct comparisons between these agents in long-term studies are limited. Objective: We sought to compare montelukast and salmeterol in the long-term treatment of EIB. Methods: One hundred ninety-seven patients with mild asthma and a postexercise fall in FEV 1 of at least 18% were randomized (double-blind) to receive montelukast 10 mg once daily or salmeterol 50 μg twice daily for 8 weeks. Exercise challenge was repeated at day 3, week 4, and week 8 after randomization near the end of the dosing interval for both drugs. The primary efficacy endpoint was the maximal percent fall in postexercise FEV 1 at week 8. Results: Montelukast was effective in treating EIB without inducing tolerance and provided superior ( P ≤ .001) protection than salmeterol at weeks 4 and 8, with comparable protection at day 3. The frequency of respiratory clinical adverse events ( P = .046) and discontinuations because of clinical adverse events ( P = .052) were less with montelukast. Conclusion: The effect of montelukast was greater than that of salmeterol in the chronic treatment of EIB over a period of 8 weeks in patients with mild asthma as demonstrated by effect size, maintenance of effect, and fewer respiratory clinical adverse events during the study period. Montelukast may be a better alternative to salmeterol as a controller agent for the chronic treatment of EIB. (J Allergy Clin Immunol 1999;104:547-53.)

Background: Fungal spores are universal components in the air and established as important causes of respiratory allergies. Whereas fungi imperfecti are accepted sources of allergic asthma and rhinitis, the significance of basidiomycetes as respiratory allergens is not established. Objectives: The aims of the present study were to investigate the rate of sensitization in subjects referred to an allergy clinic to 3 basidiomycetes commonly found in Europe. We demonstrate the clinical relevance of basidiomycete sensitization by active anterior rhinomanometry and identified basidiomycete allergens by immunoblotting. Methods and Results: Consecutive outpatient clinic attendees (n = 1207, >12 years of age) were given the skin prick test with a panel of common inhalant allergens and extracts of Boletus, Coprinus, and Pleurotus. To evaluate a cause-and-effect relation between basidiomycete allergens and respiratory allergies, 12 Pleurotus pulmonalis spore–sensitized subjects with respiratory symptoms and 6 control subjects were challenged by anterior rhinomanometry. SDS-PAGE immunoblots were used to identify basidiomycete- specific IgE antibodies in sera from subjects with positive skin prick test results. Of 1207 subjects tested, 48 (4%) reacted to at least 1 of the basidiomycete extracts. Whereas all of the 12 subjects with Pleurotus pulmonalis –positive skin test results showed a significant decrease in nasal air flow (mean 73%), none of the control subjects reacted. Immunoblots revealed several different IgE-binding proteins in Pleurotus and Coprinus extracts. Conclusions: Our results demonstrate that sensitization to basidiomycetes in subjects with respiratory allergies is frequent. Furthermore, Pleurotus pulmonalis spore extracts can definitely induce respiratory allergy in sensitized subjects. Immunoblot assays disclosed different IgE-reactive bands indicating the existence of basidiomycete allergens. (J Allergy Clin Immunol 1998;102:853-8.)

Occasional patients with urticaria pigmentosa and anaphylaxis after Hymenoptera stings have been described. In this situation the question arises: Is anaphylaxis IgE-mediated or induced by pharmacologic mediator release from mast cells?We investigated 10 patients with histologically confirmed urticaria pigmentosa and a history of anaphylaxis after honeybee or Vespula stings before and during immunotherapy with the respective venom.In eight of 10 patients, an elevated serum tryptase level was found. In two of 10 patients, no venom-specific IgE could be detected by either skin tests or RAST. Five patients had no detectable venom-specific serum IgE, and in the remaining patients the level was low (1 Phadebas RAST unit). Venom immunotherapy was well tolerated and caused only one mild systemic reaction in a patient during the dose increase phase. Six patients were re-stung while receiving venom immunotherapy: only one had a mild systemic reaction (angioedema) after a Vespula sting.Anaphylactic symptoms after Hymenoptera stings in patients with urticaria pigmentosa are most often IgE-mediated but can occasionally be observed in the absence of IgE sensitization to venom allergens. Venom immunotherapy can be safely and successfully used in patients with urticaria pigmentosa and sting anaphylaxis.

Background According to the World Health Organization position paper, immunodeficiency such as human immunodeficiency virus (HIV) infection is a relative contraindication for specific immunotherapy (SIT). Since the introduction of highly active antiretroviral therapy, a significant reconstitution of immune competence in individuals with HIV is possible.Case Report In a 52-year-old man, HIV infection was diagnosed in 1987. Antiretroviral therapy was started in 1998. He presented himself in July 2001 because of an increasingly severe seasonal rhinoconjunctivitis. Symptoms were not sufficiently alleviated by various antiallergic drugs.Results The investigations showed a relevant sensitization to tree pollens. Specific immunotherapy with a tree pollen mix (hazel, birch, ash, and alder, 25% each) was started in November 2001. Viral load at this time was less than 50 copies/mL, the CD4+ cell count was 307/μL. Therapy was given in monthly intervals until mid-April 2005 without any side effects. Viral load and CD4+ cell counts did not change during SIT. Clinically, rhinoconjunctivitis was experienced only intermittently and symptom relief was almost 90%.Conclusions This report indicates that in patients with well-controlled HIV infection on highly active antiretroviral therapy, SIT with pollen extracts is a potential and successful therapeutic option. Keywords: human immunodeficiency virus, pollen allergy, respiratory allergy, allergy treatment, specific immunotherapy

Diagnostic tests in patients with Hymenoptera venom allergy are frequently positive to venoms of both honey bee and wasp (Vespula). Component-resolved analysis with recombinant species-specific major allergens (rSSMA) may help to distinguish true double sensitization from crossreactivity.Included were 121 patients with systemic allergic reactions to Hymenoptera stings, 76 with double positivity of serum-specific IgE (sIgE) to both venoms, 45 with single positivity to bee or wasp venom, and 32 controls without history of systemic reactions to Hymenoptera stings and no sIgE to whole venoms. In venom-allergic patients and controls, sIgE to rSSMA Api m 1 of bee venom and to Ves v 1 and Ves v 5 of wasp venom were tested by ImmunoCAP.Only 47% of 76 patients with double positivity to whole venoms reacted also to rSSMA of both species. Specificity of sIgE to the 3 rSSMA was very high, with no sIgE to rSSMA of the other species in single-positive venom-allergic patients and only one control with low sIgE to Ves v 1. All wasp-allergic single-positive patients had sIgE to Ves v 5 and/or Ves v 1, and 78.3% of single-positive bee venom-allergic patients had sIgE to Api m 1.Specificity of sIgE to rSSMA of both species is excellent. Sensitivity of sIgE to rSSMA was optimal for wasp venom. Sensitivity of bee venom Api m 1 could be increased by adding rSSMA of other important bee venom allergens.

DRESS (Drug Rash with Eosinophilia and Systemic Symptoms), auch DiHS (Drug-induced Hypersensitivity Syndrome) genannt, ist eine Systemerkrankung, welche durch eine immunologische Reaktion auf vereinzelte Medikamente ausgelost werden kann [1–4]. Es resultiert eine oft eosinophilenreiche Entzundungsreaktion in verschiedenen Organen. Da die initialen Symptome (Fieber, Exanthem, Lymphknotenschwellungen, Hepatitis) an virale oder schwere autoimmune Erkrankungen erinnern, oft erst nach wochenlanger zunachst gut tolerierter Therapie auftreten und das Krankheitsbild selten ist (wahrscheinlich ca. 150–200 Falle pro Jahr in der Schweiz), verzogert sich die korrekte Diagnose in vielen Fallen. Die Komplexitat des Krankheitsbildes zeigt sich auch in seinen vielen Namen. Ursprunglich als Drug Hypersensitivity Syndrome (DHS) benannt, wurde es spater als DRESS bezeichnet; japanischen Forscher nannten es Drug-induced Hypersensitivity Syndrome (DiHS), und andere verwenden den Namen Anticonvulsant Hypersensitivity Syndrome (Tab. 1 p) [1–6]. Im Folgenden beschranken wir uns auf den Namen DRESS, obwohl dieser Name zu Recht etwas umstritten ist, da ein Leitsymptom, die Eosinophilie, nur in ca. 70% der Falle vorhanden ist und bei einigen Medikamenten (Lamotrigin, Abacavir) kaum auftritt. Andererseits ist die zum Teil massive Eosinophilie ein sehr diskriminierendes Symptom und hilfreich, DRESS von anderen Erkrankungen abzugrenzen. DRESS wird hautsachlich nur von relativ wenigen Medikamenten ausgelost (Tab. 2 p). Es handelt sich um Antikonvulsiva (Phenytoin, Carbamazepin, Lamotrigin), sulfonamidhaltige Substanzen wie Dapson, Sulfasalazin (wegen der Sulfapyridin-Komponente) und Sulfamethoxazol sowie um Allopurinol, Minocyclin, Abacavir und Nevirapin.

Background: During a systemic hypersensitivity reaction (SR), an increase in serum tryptase compared to the baseline value is an indicator of mast cell activation, most often due to an IgE-mediated mechanism.Objective: To study the relevance of an increase in serum tryptase below the upper normal value of 11.4 ng/mL.Methods: Serum tryptase levels were measured in 35 patients with Hymenoptera venom hypersensitivity before and during venom exposure. Of these, 20 developed SR to stings or following venom injections during immunotherapy (reactors), while 15 tolerated reexposure to stings or venom injections during immunotherapy without SR (non-reactors). Serum tryptase was estimated at 2, 5 and 24 h after exposure and was compared to a baseline value obtained before or at least 72 h after exposure.Results: Considering circadian variation of serum tryptase, a relative increase to ≥135% of the baseline value (relative delta bound) was defined to indicate mast cell activation. Such an increase was observed in 17 of 20 reactors (85%), but none of 15 non-reactors. A serum tryptase of ≥11.4 ng/mL following venom exposure was observed in eight of the 20 reactors (40%) and 2 (13.3%) of the 15 non-reactors. Both these non-reactors also had an elevated baseline serum tryptase.Conclusions and clinical relevance: Serum tryptase values obtained during a suspected hypersensitivity reaction must always be compared to a baseline value. A relative tryptase increase to ≥135% of the baseline value during a suspected hypersensitivity reaction indicates mast cell activation even below 11.4 ng/mL.

Background: Basidiospores are an important cause of respiratory allergy in mold-sensitive atopic subjects. Collection of the large amounts of spores required for extract preparation is tedious and difficult. A desirable alternative could be mycelium grown in vitro if it is allergenically similar to spores. Methods: Therefore this study compared the allergen contents of Psilocybe cubensis spore and mycelium extracts by different techniques with the use of pooled sera from subjects who had skin test and RAST results that were positive to P. cubensis spores. Results: Isoelectric focusing immunoprints revealed six common IgE-binding bands at isoelectric points 4.7, 5.0, 5.5, 5.6, 8.7, and 9.3. Two additional bands at isoelectric points 3.9 and 5.7 were detected only in the spore extract. Sodium dodecylsulfate polyacrylamide gel electrophoresis immunoblots exhibited six common IgE-binding bands at 16, 35, 487, 52, 62, and 76 kd, 20 and 40 kd bands were present only in the spore extract. Although RAST and isoelectric focusing inhibition demonstrated that P. cubensis spore and mycelium extracts share many allergens, spores were allergenically more potent than mycelium. Conclusion: The results indicate that mycelium is a useful source of P. cubensis allergen, even though several spore allergens were not detected in mycelium.

Concerns about possible reactions to vaccines or vaccinations are frequently raised. However, the rate of reported vaccine-induced adverse events is low and ranges between 4.8-83.0 per 100,000 doses of the most frequently used vaccines. The number of true allergic reactions to routine vaccines is not known; estimations range from 1 per 500,000 to 1 per 1,000,000 doses for most vaccines. When allergens such as gelatine or egg proteins are components of the formulation, the rate for serious allergic reactions may be higher. Nevertheless, anaphylactic, potentially life-threatening reactions to vaccines are still a rare event (approximately 1 per 1,500,000 doses). The variety of reported vaccine-related adverse events is broad. Most frequently, reactions to vaccines are limited to the injection site and result from a non specific activation of the inflammatory system by, for example, aluminium salts or the active microbial components. If allergy is suspected, an accurate examination followed by algorithms is the key for correct diagnosis, treatment and the decision regarding revaccination in patients with immediate-type reactions to vaccines.

Seafood is a common cause of food allergy. Allergic reactions are reported by consumers following ingestion of seafood meat and by processing workers after occupational exposure to seafood by inhalation of vapors generated during cooking. Although seafood allergy is commonly observed in clinical practice, its precise prevalence is not established. Based on our estimates, approximately 100,000 to 250,000 Americans are at risk of developing allergic reactions to seafood products. In this study, skin testing, in vitro assays and double-blind, placebo-controlled food challenge were employed to investigate seafood allergy in shrimp-allergic individuals. As in most food allergy studies only 1/3 of the alleged shrimp-sensitive subjects had a positive shrimp challenge test. The combination of a positive shrimp skin test and shrimp RAST (>11% bound) had the best predictive value (87%) for a positive challenge response. Although occupational seafood allergy is not well-studied, based on a Canadian investigation, it can be estimated that 57,000 American seafood workers are at risk of developing work-related allergic reactions. Since seafood is a major food allergen in consumers and industrial workers, further studies are necessary. Despite developments of new antiallergic therapies, avoidance continues to be the best “treatment”for allergic ingestive, inhalative and occupational disease.

Venom immunotherapy (VIT) for Hymenoptera allergy is accepted as safe and effective. However, widely varying success rates and frequencies of side effects are reported. Differences between various Hymenoptera species could account for these diverging results. We therefore analyzed 205 patients with a history of systemic allergic reactions to either honeybee (148 patients) or yellow jacket stings (57 patients) during VIT. All patients had a positive skin test to the respective venom before VIT, were monitored for side effects of VIT, and submitted to a sting challenge while they were receiving VIT. Patients with honeybee-venom allergy had a higher sensitivity in both skin tests (p less than 0.05) and RAST (p less than 0.001) than patients with yellow jacket-venom allergy. They developed systemic side effects to VIT injections significantly more often (41% versus 25%; p less than 0.01) and also reacted more frequently to the sting challenge (23% versus 9%; p less than 0.01) than patients with yellow jacket-venom allergy. We conclude that results obtained from studies on the allergy to one Hymenoptera venom cannot be extrapolated to allergies to other Hymenoptera venoms.

Our overall aim is to monitor iodine supply in a prospective study before and after the September 1998 increase of salt iodide content in Switzerland. Because iodide is supplied by alimentation, we moreover wondered whether urinary iodine concentration (UI) is governed by circadian rhythmicity. Forty-two subjects (18 males and 24 females, including 13 children) collected 3023 urine spots between May 1996 and May 1998, at a rate of three to five samples per month, at any time of the day. The results show that circadian rhythmicity of UI in adults and children was found independent of the individual subject, age, gender, and season. Lowest UI levels were found between 8-11 h. A curve increasing progressively between 12 and 24 h was obtained. UI returned to base-line levels between 21 and 22 h in children only. UI peaks occurred 4-5 h after main meals; children's peaks occurred later than that of adults. Although the existence of a circadian rhythm of UI is probably universal, its profile, however, depends on alimentation. Because nadir of UI is represented by morning spots, this might seem an appropriate collecting period. In view of the significant circadian rhythmicity of UI, studies with restriction of sampling time to morning hours, for example, cannot be directly compared with studies in which urine is sampled all over the day.

Respiratory type-IV hypersensitivity reactions due to corticosteroids is a rare phenomenon. We describe two such cases. The first is a 37-year-old atopic woman who developed labial angioedema and nasal itching after the use of budesonide nasal spray. A month later, after the first puffs of a formoterol/budesonide spray prescribed for asthma, she noticed symptoms of tongue and oropharyngeal itching and redness with subsequent dysphagia, labial and tongue angioedema, and facial oedemia. The second is a 15-year-old non-atopic woman who reported pruritic eruptions around the nostrils after using a budesonide nasal spray. A year later she presented with nasal pruritus with intense congestion and labial and facial oedema after using the same spray. Both patients were evaluated with patch-tests using the commercial T.R.U.E. test(®), a budesonide solution, and corticosteroid creams. Test evaluation was performed at 48 and 96 hours. In both patients, patch tests were positive to budesonide (++) on the second day. The first patient also had a positive (+) reaction to tixocortol-21-pivalate. All the other patch tests were negative. Clinicians sholud be aware that hypersensitivity reactions may occur during the use of nasal or inhaled corticosteroids.

BACKGROUND: Exhaled nitric oxide (FENO) is a marker for allergic airway inflammation. We wondered whether in patients with intermittent allergic rhinitis only (i) natural pollen exposure and (ii) artificial pollen exposure by repeated nasal allergen provocations may lead to an elevation of FENO. METHODS: In two prospective studies, we compared the FENO of nonatopic controls with the FENO of nonasthmatic individuals with mild intermittent rhinitis to tree and/or grass pollen. Study I: 13 atopic individuals and seven controls had measurements of FENO, blood eosinophils and eosinophilic cationic protein (ECP) before, during and after pollen season. Study II: 16 atopic individuals and 12 controls had nasal allergen provocations on four following days out of pollen season, with daily measurements of FENO before, 2 and 6 h after provocation, and determination of blood eosinophils, ECP and FEV1 at baseline, on days 5 and 10-12. RESULTS: Natural pollen exposure (study I) caused a significant elevation of FENO in allergic individuals. Nasal allergen provocations (study II) did not elicit a statistically significant rise neither of FENO nor of blood eosinophils between baseline and day 5. However, a subgroup of four individuals with a rise of blood eosinophils during nasal allergen provocations showed also a rise of FENO. CONCLUSIONS: We suppose that in allergic rhinitis a concomitant reaction of the bronchial system is dependent on a strong local inflammation leading to a generalized immune stimulation.

OBJECTIVE: To determine the characteristics of asthma (A) and allergic rhinitis (AR) among asthma patients in primary care practice. RESEARCH DESIGN AND METHODS: Primary care physicians, pulmonologists, and allergologists were asked to recruit consecutive asthma patients with or without allergic rhinitis from their daily practice. Cross-sectional data on symptoms, severity, treatment and impact on quality of life of A and AR were recorded and examined using descriptive statistics. Patients with and without AR were then compared. RESULTS: 1244 asthma patients were included by 211 physicians. Asthma was controlled in 19%, partially controlled in 27% and not controlled in 54%. Asthma treatment was generally based on inhaled corticosteroids (ICS) with or without long acting beta 2 agonists (78%). A leukotriene receptor antagonist (LTRA) was used by 46% of the patients. Overall, 950 (76%) asthma patients had AR (A + AR) and 294 (24%) did not (A - AR). Compared to patients with A - AR, A + AR patients were generally younger (mean age +/- standard deviation: 42 +/- 16 vs. 50 +/- 19 years, p < 0.001) and fewer used ICS (75% vs. 88%, p < 0.001). LTRA usage was similar in both groups (46% vs. 48%). Asthma was uncontrolled in 53% of A + AR and 57% of A - AR patients. Allergic rhinitis was treated with a mean of 1.9 specific AR medications: antihistamines (77%), nasal steroids (66%) and/or vasoconstrictors (38%), and/or LTRA (42%). Rhinorrhoea, nasal obstruction, or nasal itching were the most frequently reported AR symptoms and the greatest reported degree of impairment was in daily activities/sports (55%). CONCLUSIONS: Allergic rhinitis was more common among younger asthma patients, increased the burden of symptoms and the need for additional medication but was associated with improved asthma control. However, most asthma patients remained suboptimally controlled regardl-ess of concomitant AR.

In 86 patients with a history of severe systemic reactions (SRs) to honeybee stings confirmed by a positive skin test and/or RAST to honeybee venom (HBV), immunotherapy (IT) with HBV was stopped after 3 to 10 years. All patients had tolerated well a honeybee sting during IT and were resubmitted to a sting 1 year after VIT was stopped. At the latter time, 15 patients (17%) developed an SR and 71 did not. There was no difference between the two groups regarding age, sex, IT duration, severity of the SR before treatment, as well as diagnostic tests with HBV (skin tests, RAST, and specific IgG) before the challenge. Patients with a relapse of their allergy had, however, developed allergic SRs to IT injections more frequently than patients with lasting protection ( p p

Background Although basidiospores are a major component of the air spora in many parts of the world, their clinical significance as triggers of respiratory allergy has rarely been demonstrated. Therefore, the class of basidiomycetes as an aeroallergen is not well known. Objective To demonstrate a cause and effect relationship between respiratory allergy and basidiospores, we illustrate this case report of a 38-year-old housewife. Methods Skin prick test, immunoblot, and active anterior rhinomanometry were used as diagnostic tools to verify specific reactivity of a Pleurotus pulmonalis spore extract. Two atopic subjects served as controls. Results The skin prick test positive study subject reacted with subjective and objective signs including a significant drop of the FEV 1 by nasal challenge at a concentration of 0.1 mg/mL of the Pleurotus spore extract while both controls were negative even at a higher test concentration. IgE-immunoblot revealed several distinct bands in the serum of the Pleurotus-sensitized subject. Conclusion Spores of Pleurotus pulmonalis , a common mushroom of the fungal class of basidiomycetes, can cause specific, IgE-mediated acute rhinoconjuncivitis and asthma in sensitized individuals.