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Background In the last twenty years, several studies have been conducted in the search for new therapeutic strategies in patients with food allergy; in particular, after the failure of injection immunotherapy, three different routes of administration, oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT), have been tested. The aim of this manuscript is to review OIT, SLIT, and EPIT clinical trials on food allergies and to suggest advantages and limits of the different routes of immunotherapy administration. Main body Of the three different routes of immunotherapy used in the treatment of food allergy, OIT is, at present, the only one actually able to induce an increase in tolerance in the majority of patients. However, its use is affected by serious secondary effects, such as major abdominal symptoms and anaphylaxis. The combination with omalizumab reduces the percentage of serious side effects. There are not many studies with SLIT for food allergy, but they have nevertheless shown that it is possible to obtain an increase in tolerance; however, this increase is modest in comparison with that obtained by OIT. EPIT, performed through the diffusion of allergens on intact skin, is the most recent form of immunotherapy. Although there are many works on EPIT carried out in laboratory animals, only few clinical studies have been published in humans. EPIT, unlike OIT and SLIT, is not responsible for systemic secondary effects such as anaphylaxis and eosinophilic oesophagitis but only for local and mild effects in areas where the devices are applied. Moreover, EPIT is characterized by high patient adherence. Conclusion OIT seems to have a prevalent application in patients who do not report previous symptoms of systemic or gastroenteric anaphylaxis, while SLIT and EPIT, in particular, could be more preferentially used in patients with a risk of anaphylaxis.

Asthma is one of the most common chronic respiratory diseases worldwide. It affects all ages but frequently begins in childhood. Initiation and exacerbations may depend on individual susceptibility, viral infections, allergen exposure, tobacco smoke exposure, and outdoor air pollution. The aim of this review was to analyze the role of the gut–lung axis in asthma development, considering all asthma phenotypes, and to evaluate whether microbe-based therapies may be used for asthma prevention. Several studies have confirmed the role of microbiota in the regulation of immune function and the development of atopy and asthma. These clinical conditions have apparent roots in an insufficiency of early life exposure to the diverse environmental microbiota necessary to ensure colonization of the gastrointestinal and/or respiratory tracts. Commensal microbes are necessary for the induction of a balanced, tolerogenic immune system. The identification of commensal bacteria in both the gastroenteric and respiratory tracts could be an innovative and important issue. In conclusion, the function of microbiota in healthy immune response is generally acknowledged, and gut dysbacteriosis might result in chronic inflammatory respiratory disorders, particularly asthma. Further investigations are needed to improve our understanding of the role of the microbiome in inflammation and its influence on important risk factors for asthma, including tobacco smoke and host genetic features.

Background Epicutaneous immunotherapy (EPIT) is a new way of allergen administration that has a high rate of adherence and safety. The aim of this manuscript is to review clinical trials on EPIT for respiratory and food allergies published in the last 10 years, taking into account how different variables (i.e., dose, patch application duration, skin preparation, and efficacy and safety evaluation) have influenced study results. Main body From a review of the literature, we identified eight placebo-controlled, double-blind trials conducted on children and adults, including four studies on grass pollen rhino-conjunctivitis, one on cow’s milk allergy and three on peanut allergy. Different methods for skin pre-treatment, such as skin abrasion and tape stripping or stratum corneous hydration by an occlusive system, different endpoints and cumulative allergen doses, and different durations of patch application and tape stripping, were used in the rhino-conjunctivitis studies. A visual analogue system was used for the efficacy evaluation. Several local skin reactions (eczema) and some systemic adverse reactions were reported at higher rates in the active group compared to placebo in one study, but this was not shown by other authors. Local eczema reactions were correlated to the times for applying the tape stripping, while systemic side effects were correlated to the deepness of scraping. In the food allergy trials, differences in the food challenge thresholds, endpoints and allergen sites of the cutaneous patch application influenced the study results. A slight dose-dependent efficacy was found in the peanut allergy studies, which was confirmed by a more significant increase in the following progressive open study. Few adverse events and high adherence in all of the food allergen trials were reported. Conclusions Overall, the EPIT study results, even if they were affected by great heterogeneity among the methodologies applied, have shown not only the high safety and adherence with this kind of immunotherapy but also suggested the possibility for obtaining definitive evidence of the efficacy of EPIT, especially for food allergies.

Allergic diseases are common worldwide and are prevalently caused by an inflammatory pathophysiology induced by the exposure to the specific allergen(s). The development of inflammation requires the involvement of regulatory cells that include antigen presenting cells and T lymphocytes, respectively orientating and orchestrating the immunological response, and the activity of cells such as mast cells and basophils, that release the typical mediators of allergic reactions, and eosinophils, which sustain the protracted inflammation. Differently from other sites of contact with allergen (s) such as respiratory or gastrointestinal tissues, the oral mucosa, based on the abundance of dendritic cells and their interaction with T cells, apparently works as a tolerogenic site concerning the response to allergen molecules. The other pivotal aspect of the oral mucosa is the minimal presence of inflammatory cells, especially eosinophils and mast cells. These characteristics play a crucial role in the sublingual administration of allergen immunotherapy, which in fact is easier to tolerate than injective immunotherapy, taking into account recent studies highlighting the important role of the Waldeyer's ring in developing tolerance to the sublingually administered allergen. Some patents addressing the identification of therapeutic agents for allergic inflammation are also summarized.

Sublingual immunotherapy (SLIT) currently represents, as indicated by meta-analysis of its efficacy and safety, a valid option to the generally used traditional subcutaneous immunotherapy (SCIT) for treating respiratory allergy. Regarding efficacy, recent studies demonstrated that, similar to what has already been observed in SCIT as well as in experimental and clinical studies about the magnitudo of allergen exposure, the effectiveness on both clinical symptoms and immunologic changes depends on the amount of allergen administered during treatment. In addition, in vitro studies addressed with the role of dendritic cells, currently considered to be of pivotal importance in orienting toward tolerance the immune response to allergens, showed that the internalisation of allergen molecules, which is followed by tolerogenic presentation to T cells, depends on the amount of allergen. However, such dose dependence is not apparent concerning the safety. In fact, the comparison of studies respectively conducted with high and low allergen doses did not show differences in the rate of systemic reactions, which in any case never had the presentation of anaphylaxis, and instead a significant difference in the rate of local reactions, following the oral and gastrointestinal contact with the allergen extract, in favour of high dose studies.

The most common allergic diseases, and especially the respiratory disorders such as rhinitis and asthma, are closely related to the allergic inflammation elicited by the causative allergen. This makes inflammation the main target of anti-allergic therapies. Among the available treatments, allergen specific immunotherapy (AIT) has a patent effect on allergic inflammation, which persists also after its discontinuation, and is the only therapy able to modify the natural history of allergy. The traditional, subcutaneous route of administration was demonstrated to modify the allergen presentation by dendritic cells (DCs) that in turn correct the phenotype of allergen-specific T cells, switching from the Th2-type response, typical of allergic inflammation and characterized by the production of IL-4, IL-5, IL-13, IL-17, and IL-32 cytokines to a Th1-type response. This immune deviation is related to an increased IFN-gamma and IL-2 production as well as to the anergy of Th2 or to tolerance, the latter being related to the generation of allergen-specific T regulatory (Treg) cells, which produce cytokines such as IL-10 and TGF-beta. Anti-inflammatory mechanisms observed during sublingual AIT with high allergen doses proved to be similar to subcutaneous immunotherapy. Data obtained from biopsies clearly indicate that the pathophysiology of the oral mucosa, with particular importance for mucosal DCs, plays a crucial role in inducing tolerance to the administered allergen.

European (Dermatophagoides pteronyssinus) and American (Dermatophagoides farinae) house dust mite species are considered the most common causes of asthma and allergic symptoms worldwide. Der p 1 protein, one of the main allergens of D. pteronyssinus, is found in high concentration in mites faecal pellets, which can became easily airborne and, when inhaled, can cause perennial rhinitis and bronchial asthma. Here we report the isolation of the Der p 1 gene from an Italian strain of D. pteronyssinus and the PVX-mediated expression of its mature form (I-rDer p 1) in Nicotiana benthamiana plants. Human sera from characterized allergic patients were used for IgE binding inhibition assays to test the immunological reactivity of I-rDer p 1 produced in N. benthamiana plants. The binding properties of in planta produced I-rDer p 1 versus the IgE of patients sera were comparable to those obtained on Der p 1 preparation immobilized on a microarray. In this paper we provide a proof of concept for the production of an immunologically active form of Der p 1 using a plant viral vector. These results pave the way for the development of diagnostic allergy tests based on in planta produced allergens.

Recent studies suggest that swimming in chlorinated pools during infancy may increase the risks of lower respiratory tract infection. The aim of the present study was to assess the influence of swimming in chlorinated pools on the risks of bronchiolitis and its late consequences. A total of 430 children (47% female; mean age 5.7 yrs) in 30 kindergartens were examined. Parents completed a questionnaire regarding the child's health history, swimming practice and potential confounders. Attendance at indoor or outdoor chlorinated pools ever before the age of 2 yrs was associated with an increased risk of bronchiolitis (OR 1.68; 95% CI 1.08-2.68; p = 0.03), which was exposure-dependent for both types of pool (p-value for trend0.01). Associations persisted, and were even strengthened, by the exclusion of other risk factors. Among children with no parental antecedents of atopic disease or no day-care attendance, odds ratios for bronchiolitis amounted to 4.45 (1.82-10.9; p = 0.001) and 4.44 (1.88-10.5; p = 0.007) after20 h spent in chlorinated pools during infancy. Infant swimmers who developed bronchiolitis also showed higher risks of asthma and respiratory allergies later in childhood. Swimming pool attendance during infancy is associated with a higher risk of bronchiolitis, with ensuing increased risks of asthma and allergic sensitisation.

Specific immunotherapy (IT) is an effective treatment for rhinitis and asthma caused by aeroallergens sensitization. Sublingual IT (SLIT) was introduced to solve the problem of systemic reactions to subcutaneous IT (SCIT) and developed to represent an actual treatment option. It is now generally accepted that allergen doses much higher than those administered by SCIT must be used to achieve clinical efficacy on allergic symptoms.To evaluate the characteristics of Staloral, an allergen extract produced by Stallergenes (Antony, France) in terms of practical administration, efficacy, safety and mechanism of action.Data were obtained from 20 double-blind, placebo-controlled studies using Staloral in patients sensitized to pollens and house-dust mites, and also from open studies concerning practical administration and the mechanism of action.Efficacy and safety of Staloral, as demonstrated by the revision of the studies, which used doses up to 1125 times those administered with SCIT, are very satisfactory and confer to this allergen extract optimal characteristics for treating patients with seasonal allergies due to pollens or with perennial symptoms induced by dust mites. The main mechanism of action is the interaction with dendritic cells of the oral mucosa and the subsequent tolerance induced in T cells.

Allergic inflammation is initiated by the contact between allergen(s) and specific IgE antibodies, driven by regulatory cells such as antigen presenting cells and T lymphocytes, which orientate and orchestrate the response, and sustained by effector cells such as mast cells, basophils, and eosinophils. Among tissues and organs targeted by allergy, the nose, the lungs and the skin have the property to spread in distant sites the initially local reaction, thus resulting in systemic disease. By contrast, the oral mucosa seems to be a tolerogenic site regarding the immunologic response to allergens. This mucosa is characterized by abundance of dendritic cells, which are antigen presenting cells specialized in uptaking, processing and presenting the antigens to T cells, and particularly to T regulatory cells which in turn can downregulate Th1 and Th2 immune responses by direct cell contact or by production of immunosuppressive cytokines. The other important aspect of the oral mucosa is the negligible presence of effector inflammatory cells, namely mast cells and eosinophils, which accounts for the reportedly good safety of sublingual administration of allergen immunotherapy. These peculiar aspects and patents have important implications in treatment and prevention of allergic diseases.

Parietaria pollen is one of the most important outdoor allergenic sources in all the Mediterranean countries, with a large number of subjects showing a positive skin prick test to both P. judaica and P. officinalis pollen extracts. A cross-reactivity between the two species has been already reported although few data are known at the molecular level. Twenty-five consecutive patients with Parietaria pollen allergy were selected on the basis of their clinical history. Skin prick test to P. judaica and officinalis extracts was performed. In vitro IgE measurement to both allergenic sources was performed by using a quantitative assay. ELISA inhibition experiments were made by using the rParj1 and rParj2 allergens. All the patients showed a positive skin prick test to both Parietaria species. Quantitative IgE measurement showed similar antibody concentration for P. judaica and P. officinalis extracts. ELISA inhibition experiments demonstrated that the cross-reactivity between the two species was due to the presence of the Parj1 and Parj2 allergens in the extracts with a high conserved IgE epitopes content. We conclude that P. judaica and P. officinalis pollens contain highly cross-reactive species-specific major allergens useful for the diagnosis and therapy of both allergenic sources.

Parallel follow-up of clinical and inflammatory markers during sub-lingual immunotherapy (SLIT) is highly beneficial. Twenty-four children (age 4-16) monosensitized to house dust mite were randomized to receive either active or placebo SLIT for 1 yr in a double-blind placebo controlled design (Marcucci et al., Allergy 2003: 58: 657-62). Thereafter, for 2 yr they all received active treatment. Symptom scores for rhinitis, asthma, and drug usage were daily recorded. Eosinophil cationic protein (ECP) and tryptase in sputum and nasal secretions, serum and nasal mite-specific immunoglobulin E (IgE) were recorded before treatment and at 10-12 months intervals. Nasal ECP and nasal tryptase after specific nasal provocation tests were significantly reduced as compared to baseline values (p = 0.0043 and 0.0195, respectively) in the third year of active treatment. None of the other inflammatory parameters was increased. In placebo treated patients all these parameters tended to decrease only after switching to active treatment. Clinical scores did not improve in treated vs. placebo patients in the double-blind placebo-controlled phase of the study. In both cohorts a clinical benefit was observed as intra-group score reduction as compared to baseline. A significant difference was reached in patients treated for 2 yr for rhinitis and asthma (p = 0.0009 and 0.0019, respectively) but not for drug usage and in patients treated for 3 yr for rhinitis, asthma, and drug usage (p = 0.0105, 0.0048, and 0.02, respectively). SLIT in children monosensitized to mites reverted the spontaneous increase in nasal IgE and in local parameters of allergic inflammation. These outcomes were followed by a consolidated clinical improvement in the second and third year of treatment.

Background The minimum age to start specific immunotherapy with inhalant allergens in children has not been clearly established, and position papers discourage its use in children younger than 5 years. Objective To assess the safety of high-dose sublingual-swallow immunotherapy (SLIT) in a group of children younger than 5 years. Methods Sixty-five children (51 boys and 14 girls; age range, 38-80 months; mean ± SD age, 60 ± 10 years; median age, 60 months) were included in this observational study. They were treated with SLIT with a build-up phase of 11 days, culminating in a top dose of 300 IR (index of reactivity) and a maintenance phase of 300 IR 3 times a week. The allergens used were house dust mites in 42 patients, grass pollen in 11 patients, olive pollen in 5 patients, Parietaria pollen in 4 patients, and cypress pollen in 3 patients. All adverse reactions and changes in the treatment schedule were compared in 2 subgroups: children 38 to 60 months old and children 61 to 80 months old. Results The average cumulative dose of SLIT was 36,900 IR. Adverse reactions were observed in 11 children, none of them severe enough to require discontinuation of immunotherapy. Six reactions occurred in the 60 months or younger age group and 7 in the older than 60 months age group, with no differences between these 2 groups. Conclusion High-dose immunotherapy in children younger than 5 years does not cause more adverse reactions than in children aged 5 to 7 years. There is no reason to forbear studies on safety and efficacy of these preparations in young children.

Eosinophil cationic protein (ECP) is a small, zinc‐containing molecule and one of the most abundant proteins in eosinophil granules of vertebrates. It is characterized by high cytotoxicity for a variety of parasites, bacteria, viruses and mammalian cells and tissues, and is thus recognized as an important component of the innate immune system. The presence of ECP molecules has been demonstrated in serum of major vertebrate taxa from fish to human. Now we report results, obtained using enzyme‐linked immunosorbent assay (ELISA) and western blotting analyses, on the presence of ECP‐like immunoreactive material in blood cells of the freshwater mollusc, Anodonta sp. Other freshwater invertebrates analysed, planarians (Dugesia polychroa) and sponges (Ephydatia fluviatilis) were devoid of any measurable immunoreactivity. The results were compared with those reported for vertebrates.

There is compelling evidence that hemopoietic precursor cells (HPC) play a crucial role in establishing cellular inflammation in allergic diseases. Increased levels of circulating CD34+ HPC committed to the myeloid lineage have been extensively reported in allergic rhinitis, asthma and eczema, whereas CD34+ cells have been identified within the cellular infiltrates of tissues, at peripheral sites of inflammation.We conducted a pilot study to evaluate CD34+ traffic in the peripheral blood of 22 consecutive patients (13 men and nine women; mean age 28.9 years), independently of treatment. The patients presented rhinitis, asthma, eczema, urticaria and adverse food reactions of suspected allergic origin. Allergic reactions were extrinsic in 18 patients and intrinsic in four. In 12 patients who underwent sublingual specific immunotherapy, CD34+ cells were quantified at enrollment (T0), one year later (T1) and two years later (T2). The severity of symptoms was graded on a five-point scale (0 = absence of symptoms and 4 = severe symptoms). Twenty healthy human subjects (10 men and 10 women; mean age 24.5 years) were evaluated as controls. To obtain information about the total amount of circulating HPC, independently of the lineage commitment (Lin+/-) and the degree of differentiation (CD34bright/dim), we used a modification of the Milan protocol of peripheral blood CD34+ cell estimation. The cells were analyzed using a BD FACScan or FACSCalibur and the results were expressed as the percentage of positive cells.CD34+ cell traffic in the control group was very low since all values were0.10 (median value: 0.03 %). Values in the patient group were increased in both extrinsic and intrinsic forms with a median value of 0.25 % (interquartile range: 0.13- 0.33 %). The relationship between CD34+ traffic and the severity score was highly significant (Spearman's rho = 0.954; test of Ho: CD34; independent score: Prt = 0.000).The data reported herein suggest that the method employed is effective in assessing acute allergic inflammation, as well as minimal persistent inflammation underlying an asymptomatic clinical condition. Evaluation of CD34bright/dim peripheral traffic, if confirmed by the outcomes of a multicenter study currently being planned together with traditional study of circulating IgE, could be a reliable non-invasive laboratory tool for monitoring allergic inflammation.

Background:Allergen specific immunotherapy was known to be useful in the treatment of respiratory allergic disease. Local nasal immunotherapy (LNIT) offers advantages such as a good efficacy/safety ratio and a more convenient allergen delivery. The aim of this study was to assess the safety and clinical efficacy of a modified scheduling of LNIT in 32 children with allergic rhinitis due to Dermatophagoides. Methods:A multicentre, randomized, double-blind placebo controlled study carried out for two years, with a modified schedule of LNIT treatment: a build-up phase at increasing dosages from 2.5 AU to 80 AU and a maintenance period at low dosage (80 AU) once a week. Symptom and medication scores, threshold dose with specific nasal provocation test (NPT) and immunological parameters (IgE and IgG4) were evaluated. Results:No important local or systemic side-effects were observed in children who completed the study. Compared to placebo, the active treatment group showed significant improvement in rhinitis symptoms and a reduction of drug consumption after 18 months of LNIT. These results were confirmed by a significant reduction of allergen specific nasal reactivity. Serum and nasal specific IgE and IgG4 did not show any difference in the two groups. Conclusions:The safety and clinical efficacy of low-dose LNIT suggests that this therapy may be useful in the treatment of allergic rhinitis disease in children.

Rhinitis and asthma are the most common respiratory diseases in children. We assessed whether airway inflammation markers were associated with nasal allergies and self-reported symptoms of wheeze and rhinitis in 130 children 6-12 year old in an epidemiological context. Independent of sex and age, the fraction of exhaled nitric oxide (FeNO) and nasal mast cell (MC) activation (tryptase >= 5 ng/mL) were positively associated with wheeze, rhinitis and with nasal allergy. Nasal eosinophil cationic protein (ECP) and exhaled breath condensate (EBC) markers (pH, 8-isoprostane, interleukin-1 beta) were not associated with symptoms or with nasal allergy. In conclusion, FeNO and nasal tryptase reflect allergic inflammation in the respiratory system.

Background: The clinical safety of sublingual immunotherapy (SLIT) has been repeatedly confirmed; nevertheless, the possible onset of local oral symptoms is still a concern, and nothing is known about the pathogenesis of this effect. We aimed to determine whether the administration of SLIT in allergic children can evoke an IgE-mediated reaction, by measuring the levels of sublingual tryptase and ECP. Methods: Thirty children (7–12 years old) with allergic rhinitis/asthma due to grass pollen were prescribed SLIT. In these children, an allergen-specific nasal challenge was performed, and nasal tryptase and ECP were measured before and after. Sublingual ECP and tryptase were also assessed before the SLIT, after 1 month, and after 6 months of treatment. Ten matched allergic children and 10 healthy ones served as controls for the baseline levels of sublingual ECP and tryptase. Results: The levels of nasal tryptase and ECP significantly increased after nasal challenge (P

Background: After allergen exposure, IgE-bearing mast cells surface in respiratory mucosa. Eosinophils are also recruited locally by chemotactic mediators; they are the main cell directly involved in the late phase of allergic inflammation. IgE antibody and eosinophil cationic protein (ECP) are routinely determined mainly in serum although they exert their pathogenetic role more directly on mucosal surfaces. Methods: We performed a comparative study of IgE antibody to grass and ECP on nasal mucosa and blood samples in order to evaluate the relevance of monitoring allergic inflammation in the target organ. Thirty-one patients and 10 nonatopic controls were enrolled in the protocol. Twenty-six subjects allergic to grass, 11 with rhinitis (group 1) and 15 with asthma and rhinitis (group 2), completed the study. Five patients dropped out. Specific IgE to grass and ECP was determined in nasal mucosa by our method based on in situ incubation. Results: Serum IgE to grass did not increase during the pollen peak, as did nasal IgE, in group 1 from before the pollen peak, from 2.3 to 3.2 kU/l (P=0.02), and in group 2 at the pollen peak, from 4.8 to 12.2 kU/l (P=0.01). Serum ECP did not show any significant variation in group 1, but it increased at pollen peak from 6 to 11.2 µg/l (P=0.01) in group 2. Nasal ECP increased significantly in both groups even before the pollen peak. In group 1, ECP values rose from 15 to 39.9 µg/l (P=0.01). In group 2, ECP increase was much higher than in group 1, from 9 to 213 µg/l (P=0.001). Serum eosinophils, like nasal ECP, showed a significant increase of values from before the pollen peak in both groups, without correlation with serum ECP in rhinitic patients. Conclusions: Both specific IgE and ECP in the nasal mucosa showed a better correlation with allergen exposure than serum evaluations. With an appropriate method, allergic inflammation may be best monitored in the nasal mucosa.

Sublingual immunotherapy (SLIT) is indicated in the treatment of allergic rhinitis and asthma. However, an issue scantly investigated is the patient's satisfaction and the consequent compliance. This study is aimed at evaluating the possible differences of SLIT administered continuously or intermittently on several parameters: clinical efficacy, Quality of Life (QoL), satisfaction, compliance and safety. Forty allergic patients were treated for 12 months. The treatment was carried out by sublingual administration of an allergen extract of a 50% mixture of Dermatophagoides pteronyssinus and Dermatophagoides farinae at 10 and 300 IR/ml concentrations. Patients were randomly treated continuously or intermittently (i.e. 2 month treatment alternate to 2 month suspension). Both schedules were significantly effective in reducing allergic symptoms and improving QoL. Compliance and satisfaction were good in both groups. Local and systemic reactions were few, self-resolving, and mild in both schedules. Intergroup analysis did not reveal any difference between the two groups regarding these parameters. In conclusion, this preliminary study provides the evidence that also intermittent SLIT is as effective and safe as traditional continuous treatment. In addition, compliance and satisfaction are super-imposable in the two groups.

This multicenter, parallel-group, open-label, randomized study was conducted in prepubertal children with mild asthma to investigate the efficacy and influence on bone and collagen turnover of a daily regimen of flunisolide 1200 μg alone (group A, n=14), flunisolide 600 μg in combination with sodium cromoglycate (SCG) 60 mg (group B, n=15), or SCG 60 mg alone (group C, n=15) for 4 months. All medications were administered by means of a jet nebulizer using a mouthpiece. Serum osteocalcin (OC), bone alkaline phosphate (B-ALP), and procollagen type I carboxyterminal propeptide (PICP) were measured as markers of bone formation, and type I collagen telopeptide (ICTP) was measured as a marker of bone resorption before and after treatment. The efficacy of the treatment schedules was assessed measuring forced expiratory volume in 1 second (FEV 1 ) and the use of rescue medication. No significant differences were found in the concentration of OC, B-ALP, PICP, or ICTP between the three treatment groups before the treatment period. In addition, no significant changes were found after the treatment period, although a wide variation in individual response was observed in all markers. In the group treated with flunisolide 1200 μg/d, FEV 1 improved significantly after treatment; no significant improvement in FEV 1 , was observed in the other two groups. The number of children who needed rescue medication was reduced to 14.3% in group A, 20.0% in group B, and 53.3% in group C. The results of the present study suggest that a 4-month regimen of nebulized flunisolide 1200 μg/d is effective in patients with mild asthma and does not alter bone or collagen turnover markers. However, the differences in individual response to therapy make it necessary to examine further the issues of bone metabolism in flunisolide-treated children with asthma.

glucocorticosteroids without the necessity for hospitalization. After resolution, the oral challenge test with a cephalosporin was well tolerated. Another amoxicillin patch test positive patient tolerated the oral challenge with penicillin, thereby revealing an isolated allergy to amoxicillin. As a challenge test would involve the risk for the patients to experience the same signs and symptoms of the previous drug reaction, the decision of four out of eight patients not to perform an oral challenge test was respected. Two of three patients, who were completely negative in the allergy diagnostic tests, agreed to an oral challenge with verum and revealed tolerance to the drug. It can be hypothesized that the third patch test negative subject may also have tolerated amoxicillin challenge. These three individuals may belong to the population, which only has a transient decrease in drug tolerance during EBV infection. Two amoxicillin patch test positive patients could be examined in a follow-up visit 2.2 and 1.5 years, respectively, after the first patch testing. Those patients revealed a patch test reaction similar in strength to the preliminary test result, which is indicative for a persistent delayed-type reaction to amoxicillin. In conclusion, this study does not only provide additional evidence that true delayed-type allergic reactions to aminopenicillins may develop during a florid viral infection, but that they may be definitely more prevalent than previously assumed and published (5, 6). Additionally, follow-up investigations on two patients revealed the persistence of the delayed-type reactions to amoxicillin, an approach, which has to the best of our knowledge not been published before. These observations should encourage the investigation of patients with aminopenicillin-induced exanthema for both, EBV-infection and true drug allergy. Particularly young women should be recommended an oral challenge with cephalosporins and maybe penicillins because the latter are antibiotics which may be given safely during pregnancy.

Background The actual prevalence of sensitization to Alternaria is not known, partly due to the unreliability of diagnostic extracts. Objectives To assess skin positivity to extracts of Alternaria in a wide population of Italian patients suffering from respiratory symptoms using a biologically standardized extract. Methods A total of 2942 patients were skin prick tested with Alternaria, and a panel of common inhalant allergens. Blood samples for specific IgE quantitation were taken both from patients positive and from patients negative (control group) to Alternaria extract. Results Three hundred six patients (10.4%, ranging from 1.8% in Turin to 29.3% in Cagliari) were positive to Alternaria; 37 were sensitized to only this mold, while the remaining 269 were sensitized to at least one other allergen. Of the Alternaria-positive patients, 79.7% suffered from rhinitis and 53.3% from asthma, either alone or associated with other symptoms. Conclusions We suggest that, at least in Italy and in countries with similar climatic and environmental situations, standardized Alternaria extract should be included in the panel commonly used in investigating the allergen responsible in patients suffering from respiratory allergy.

Background Recent studies suggest that allergic diseases might have their onset in early epithelial barrier defects. To test this hypothesis, we assessed associations between nasal epithelium biomarkers, environmental stressors, and the risks of allergic sensitization. Methods In a cross-sectional study of 288 kindergarten children (mean age, 5.7 years), we measured aeroallergen-specific IgE in nasal mucosa and the concentrations of urea, albumin, and Clara cell protein (CC16) in nasal lavage fluid (NALF). Albumin and CC16 in NALF were expressed per liter or as a ratio to urea. We also calculated the NALF CC16/albumin ratio as an index integrating the permeability and the secretory function of the nasal epithelium. Results Median NALF concentrations of CC16 and albumin were 8.2 μg/L and 34.5 mg/L, respectively. While there were no significant gender differences when proteins were expressed per liter, the CC16 to albumin and CC16 to urea ratios in NALF were higher in girls than in boys (P = 0.02 and 0.055, respectively. The nasal epithelial barrier function, as reflected by these NALF biomarkers, was positively influenced by probiotics and age, and negatively by environmental stressors such as pool chlorine. The risk of house dust mite (HDM) sensitization increased with decreasing log NALF CC16 concentration, whether expressed per liter (2.59, 95% CI: 1.15-5.82, P = 0.02), as a ratio to urea (1.98, 95% CI: 0.96-4.06, P = 0.06), or as a ratio to albumin (OR, 2.03, 95% CI: 1.10-3.74, P = 0.02). Children in the highest and intermediate tertiles of the NALF albumin/urea ratio were three times more likely to be sensitized to HDM than those in the lowest tertile (both P = 0.04). Conclusion Defects in the nasal epithelium barrier function of young children, as reflected by the concentrations of CC16 and albumin in NALF, are associated with environmental factors, including pool chlorine, and with increased risks of HDM sensitization. Pediatr Pulmonol. 2013; 48:571-578. © 2012 Wiley Periodicals, Inc. Copyright © 2012 Wiley Periodicals, Inc.

Prick tests, which are used on children up to the age of 2 in order to diagnose a suspected food allergy to milk and egg proteins, are difficult to carry out due to their lack of compliance. In order to overcome this problem, we have put into practice a method allowing to accurately carry out skin tests and reducing thereby by a single act the immobilization time. The method is based on the creation of a device which contains 3 needles 3 cm away from each other for testing 2 allergens, milk and egg white, and histamine at 1% from Stallergenes. The device we have created to perform the skin test is made up of a base in which centre the 3 needles for the prick test are fixed in sequence. The base comes with a handle to be held by the health worker to perform the multi-test on the forearm perpendicularly. In 18 children whose age ranges from 2 to 24 months already positive to egg and/or cow’s milk and in 10 negative skin tests children, the abovementioned allergens and the histamine were carried out with the traditional method and with the new one within a span of one week from each other. With the two methods 3 children were positive to milk and to egg, 5 only to milk and 10 only to egg in a perfectly identical way; 10 healthy controls were negative in all cases. By comparing the diameter of the wheals we observed that the results were completely superimposable. Based on our findings, we can say that the method we developed has the same sensitivity and specificity as the traditional method, with the advantage of being easier to carry out because it works faster and less painfully (1-2 sec) for these patients.

After a two week baseline, 209 asthmatic children (mean age 10 years, range 6-17) were randomly allocated to receive 4 mg nedocromil sodium (n = 110) or placebo (n = 99) four times daily for 12 weeks in addition to their current treatment. The children completed daily diary cards and visited the clinic at four week intervals. Statistically significant differences in favour of nedocromil sodium were seen for clinician assessment of asthma severity and diary card symptom scores, pulmonary function and inhaled beta 2 bronchodilator use. Total symptom score decreased by 50% from baseline in the nedocromil sodium group and by 9% in the placebo group during the final four weeks. Nedocromil sodium was considered very or moderately effective by 78% of children/parents (placebo 59%) and 73% of clinicians (placebo 50%). Nausea, headache and sleepiness, and dyspnoea led to withdrawal of one child from nedocromil sodium and placebo treatments, respectively. Reports of sore throat and headache were marginally greater with the nedocromil sodium treatment. It is concluded that nedocromil sodium was both effective and safe in the treatment of asthma in children.

Background Grass pollen is a worldwide cause of respiratory allergy. Identifying the causative species is essential, for example for choosing the appropriate immunotherapy, because not all grass allergens are totally cross-reacting, and the pollen calendars provide only a gross estimate. Phenologic analyses allow identification of the pollen release for each individual grass. Objectives To assess, using phenologic analyses, the true flowering periods of grasses and to compare the data with the standard pollen calendar. Methods Phenologic analyses were performed of the following grasses: black grass, sweet vernal grass, common wild oat, barren brome, cocksfoot, tall fescue, Yorkshire fog, ryegrass, Timothy grass, bulbous meadow-grass, Kentucky bluegrass, and Bermuda grass. Sampling was performed every 10 days, starting in April 2009, at 50 stations distributed across Italy. The flowering phase was assessed using a stereomicroscopy-based method for the detection of spreading stamens. The official pollen calendar was used for comparison. Results Relevant differences were found between grass pollen count and effective flowering of the grass species. Only some species contributed to the pollen peak, and a relevant pollen load for other species was also present out of the peak. Important Pooideae, such as Timothy grass, were not present during the pollen peak in northern and central Italy, and the same occurred with Bermuda grass. Conclusions The various species of grasses release their pollen grains at different times during the pollen season, and this information is missing with pollen calendars. This may have a relevant effect on the choice of an appropriate immunotherapy.

Grass pollen is a major cause of allergy throughout the world. The only treatment targeting the causes and not only the symptoms of allergy is specific immunotherapy (IT). A number of controlled trials demonstrated the efficacy of IT in grass pollen allergic subjects, most using extracts of multiple grasses but some using extracts of a single grass. The optimal grass extract for IT has not yet been established.This study is aimed at investigating the IgE-binding pattern in sera from IT-naïve patients from central Italy with allergic rhinitis and/or asthma caused by grass pollen. A 5-grass extract was used (containing Dactylis glomerata, Poa pratensis, Lolium perenne, Antoxanthum odoratum and Phleum pratense) and compared to Phleum pratense alone, which is the most frequently used single grass extract, by the RAST-inhibition technique.The 5-grass extract showed, by RAST-inhibition, a significantly higher binding compared to the Phleum pratense extract for Antoxanthum odoratum and Poa pratensis, while the two extracts for immunotherapy showed similar binding affinity for Phleum pratense and the non-Pooideae grass, Cynodon dactylon.The use of a mixed-grass pollen extract seems to be the optimal choice when applying specific IT in grass pollen-allergic subjects from the Mediterranean area.

Grafts of adipose tissue from adult Rosa26 mice from different sites of the body, irrespective of the sex of the donor, share with the mammary fat the property of giving rise to milk-secreting epithelial cells when exposed to the microenvironment of the mammary gland in pregnant and lactating females. To rule out the possibility that the labeled mammary glandular tissue was derived from stem cells associated with the stroma vascular part of the grafts, we injected into the mammary gland a pure suspension of adipocytes obtained by treating a fragment of adipose tissue with collagenase. X-gal–positive cells were inserted into the alveoli of the native gland, and electron microscopy showed that the labeled cells had transformed into milk-secreting glandular cells. At the site of the adipocyte injection, the labeled alveoli contained a mixture of X-gal–positive and X-gal–negative cells, and a single epithelial cell was occasionally stained in an otherwise unlabeled alveolus. This suggests that growing ducts individually recruit adjacent adipocytes that transdifferentiate into secretory epithelial cells as they became part of the glandular alveoli. After dissociation, the isolated adipocytes retained the morphology and protein markers typical of differentiated fat cells but expressed high levels of stem cell genes and the reprogramming transcription factor Klf4. Thus, the well-documented osteogenic, chondrogenic, myogenic, and angiogenic transformation of preadipocytes associated with the stroma vascular component of the adipose tissue may reflect an intrinsic capability of adipocytes to reprogram their gene expression and transform into different cytotypes. Disclosure of potential conflicts of interest is found at the end of this article.

Sublingual immunotherapy (SLIT) is safer than subcutaneous immunotherapy (SCIT) and this has lead to the reconsideration of the use of ultra-rush schedules for SLIT. The aim of this study was to assess the safety of ultra-rush SLIT in pollen-allergic children according to different timing of administration in relation to the pollen season.In total, 34 children with pollen-induced rhinitis and 36 with pollen-induced asthma and rhinitis, were enrolled and assigned to three study groups: group 1 (n = 17 patients): conventional pre-seasonal-SLIT treatment; group 2 (n = 23 patients), seasonal SLIT ended before the pollen seasonal peak; group 3 (n = 30 patients), SLIT began after the pollen seasonal peak and ended after the pollen season. SLIT was performed using extracts from Stallergenes (Antony, France) and following an ultra-rush schedule, consisting in four doses at a 30-min intervals, and maintenance treatment by administering the top dose three times a week.In all, 54 adverse events (AEs) were reported: 12 in nine patients in group 1 (9/17, 52.9%), 22 in 14 patients in group 2 (14/23, 60.9%), and 20 in 13 patients in group 3 (13/30, 43.3%). No statistically significant differences were found between the three groups. Local AEs (oral itching and burning) were short lasting and self-resolving. Systemic AEs were also mild, except for a case of asthma, which lasted 5 days, in a patient from group 1. There were no severe reactions, and none of the patients dropped out.This study suggests that SLIT with pollen extracts may be safely started at the beginning and also during the pollen season, with a tolerability profile comparable to the conventional pre-seasonal SLIT.

There is ample evidence to support the efficacy of sublingual immunotherapy (SLIT) on allergic rhinitis, while there is less solid data regarding asthma. We evaluated the effects of a high dose birch SLIT on birch-induced rhinitis and asthma in a controlled study.This double-blind, placebo-controlled, randomised, single centre trial on SLIT with birch pollen allergen extract (Stallergenes, Antony, France) included 24 patients presenting severe rhinitis and slight to moderate asthma, 14 actively and 10 placebo treated. SLIT was performed by a pre-coseasonal protocol, and was repeated for 2 years. The study plan included a selection visit, a visit at the start of the first and the second treatment cycle, a follow-up visit after 1-3 months from the start of each cycle, and a final visit at the end of each yearly cycle.A significant decrease (p0.05) in rhinorrhoea and nasal obstruction occurred in actively treated patients. The median number of days with asthma at visit 3 was 10 (0-27) in the active (SLIT) group and 13 (0-29) in the placebo group. The median number of days with asthma at visit 6 was 2 (0-6) in the SLIT group and 7 (0-15) in the placebo group (p0.05 between groups). A stepdown of asthma occurred in 77% of actively treated vs. none of placebo treated patients (p = 0.05). No severe adverse events were observed.This pilot study suggests that SLIT with high dose birch extract may be able to step down seasonal pollen-induced asthma after prolonged treatment.

The cells involved in allergic inflammation, such as mast cells, basophils, and eosinophils, have been thoroughly studied in the nose, the lungs and the skin, demonstrating an evident increase in response to the introduction of the specific allergen, while little is known in the mucosal system and particularly in the oral mucosa. We investigated such tissue by using the model of sublingual immunotherapy (SLIT), by which high doses of the specific allergen enter the mouth. Oral biopsies were carried out on seven subjects allergic to grass pollen and treated with SLIT by a grass extract. In biopsies carried out before SLIT there was a very low number of mast cells and eosinophils both in the epithelium and subepithelium layers, and insignificant changes were detected after SLIT. These findings show the lack of allergic inflammation in the oral mucosa upon contact with the specific allergen and confirm the role of the mouth as a tolerogenic site, which is conceivable considering the different attitude of the mouth, where the antigens transit to undergo digestion, in respect to the airways or the skin, where the antigen absorption is potentially dangerous.

The clinical expression of the most common allergic diseases reflects allergic inflammation and underlines that inflammation is the main target of anti-allergic therapies. Allergen specific immunotherapy (AIT) has a recognized impact on allergic inflammation, which persists after its discontinuation, and is the only therapy able to modify the natural history of allergic march. The traditional, subcutaneous route of administration is effective in altering the phenotype of allergen-specific T cells, switching from a Th2-type response, characterized by the production of IL-4, IL-5, IL-13, IL-17, and IL-32 cytokines to a Th1-type response. This immune deviation is related to an increased IFN-gamma and IL-2 production as well as to the anergy or tolerance of Th2, the latter related to the generation of allergen-specific T regulatory (Treg) cells, which produce cytokines such as IL-10 and TGF-beta. Anti-inflammatory mechanisms observed during sublingual IT with high allergen doses proved to be similar compared to subcutaneous immunotherapy. Recent data obtained in biopsies clearly indicate that the pathophysiology of the oral mucosa, and in particular mucosal dendritic cells, plays a pivotal role in inducing tolerance to the administered allergen.

Summary The gastrointestinal system plays a central role in immune system homeostasis. It is the main route of contact with the external environment and is overloaded every day with external stimuli, sometimes dangerous as pathogens (bacteria, protozoa, fungi, viruses) or toxic substances, in other cases very useful as food or commensal flora. The crucial position of the gastrointestinal system is testified by the huge amount of immune cells that reside within it. Indeed, gut-associated lymphoid tissue (GALT) is the prominent part of mucosal-associated lymphoid tissue (MALT) and represents almost 70% of the entire immune system; moreover, about 80% of plasma cells [mainly immunoglobulin A (IgA)-bearing cells] reside in GALT. GALT interacts strictly with gastrointestinal functions in a dynamic manner; for instance, by increasing intestinal permeability in replay to particular stimulations, or orientating the immune response towards luminal content, allowing either tolerance or elimination/degradation of luminal antigens, or sometimes provoking damage to the intestinal mucosa, such as in coeliac disease or food allergy. The immune mechanisms implicated in these actions are very complex and belong to both innate and adaptive immunity; innate immunity supplies an immediate non-specific response that is indispensable before specific adaptive immunity, which needs 7–10 days to be efficacious, takes place. The results of their interactions depend upon different contexts in which contact with external agents occurs and may change according to different genetic settings of the hosts.

Sublingual immunotherapy (SLIT) is an effective and safe treatment for respiratory allergy, and its mechanism of action currently is investigated with increasing attention. Studies of pharmacokinetics showed that allergen extracts administered via the sublingual route are not directly absorbed by the oral mucosa but are long retained at mucosal level, where the allergen molecules are captured by dendritic cells and, following their migration in the draining lymph nodes, presented to T cells. This seems to be the pivotal factor underlying the mechanisms of action of SLIT, at least for the long-term effects, and for the short-term efficacy, observed with ultrarush or coseasonal treatment, a down-regulation of mast cells resulting in hyporeactivity at the peak of the pollen season may be suggested. Regarding the clinically established long-lasting effects, the core mechanism is likely to consist of T regulatory (Treg) cell activation. In particular, Treg cells differentiate from naive T cells after application of soluble antigens to the mucosae, a crucial factor being the tolerogenic function of dendritic cells, and exert a suppressive effect on both Th1 and Th2 responses. Moreover, at least for the type 1 cells (Treg1), a production of IL-10 with consequent down-modulation of the immune response has been reported. Another characteristic of sublingual immunization is the absence of effectors cells, viz., mast cells, basophils, and eosinophils, in the oral mucosa of allergic subjects, which account for the excellent tolerability of SLIT.

Summary Background Upper and lower airways allergic disease is currently considered unitarily. Allergic inflammation in one site can extend to other sites of the respiratory tract. Objective To evaluate bronchial inflammation before and after allergen-specific nasal challenge (ASNC) in rhinitic and asthmatic children, considering the different levels of allergen exposure, i.e. summer (low) and winter (high). Methods Fourteen children with rhinitis and 15 with rhinitis and asthma, all monosensitized to mites and 10 healthy controls were studied. Nasal IgE were measured before ASNC in summer and in winter season. Nasal clinical score, eosinophil cationic protein (ECP), nasal tryptase, bronchial clinical score, FEV1, PEF, sputum ECP, sputum tryptase and exhaled nitric oxide (eNO) were evaluated before and after ASNC in summer and winter season. Results Nasal scores significantly increased after ASNC in rhinitic and asthmatic children in both seasons. Nasal IgE were significantly higher in summer compared to winter. Bronchial symptoms, FEV1 and PEF showed no mean differences in rhinitic and asthmatic children after ASNC, with an increase of bronchial symptoms and a decrease of FEV1 and PEF occurring in 3/15 asthmatic children. In both groups nasal tryptase and ECP after ASNC significantly increased in summer and winter, while sputum tryptase was undetectable before or after ASNC in both groups. Sputum ECP and eNO at baseline were significantly higher in patients than in controls (summer P = 0.002 , winter P = 0.001 ). Sputum ECP significantly increased after ASNC in 3/15 asthmatics in summer and in 11/15 in winter, as well as in 3/14 rhinitics in summer and in 4/14 in winter. eNO significantly increased after ASNC in 3/15 asthmatics in summer and in 10/15 in winter, and in 1/14 rhinitics in summer and in 4/14 in winter. A significant median increase of sputum ECP ( P = 0.0007 ) and eNO ( P = 0.0012 ) after ASNC in asthmatic and of eNO ( P = 0.013 ) in rhinitic children was also found in winter. Conclusions Basal sputum ECP and eNO values, significantly higher before ASNC in rhinitic patients compared to control subjects, confirm the inflammatory link of upper and lower airways. The more frequent detection of inflammatory changes induced by ASNC in winter suggests that allergen exposure favours the transfer of nasal inflammation to lower airways.

Background: Sublingual-swallow immunotherapy (SLIT) is an accepted treatment for allergic rhinitis but its optimal dosage is scantly investigated. We studied the dose dependence of clinical efficacy and immunological response to SLIT by administering two different dosages of the same allergen in rhinitic children monosensitized to grass pollen. Methods: Seventy-one patients with comparable age and symptoms were randomized to receive SLIT by the same grass pollen extract from Stallergenes (Antony, France), 40 of them with the 100 IR and 31 with the 300 IR extract. All patients recorded diary cards for symptoms, medications and side-effects of the treatment, and had measurements of specific IgE and IgG4 in serum by the CAP System FEIA (Pharmacia, Uppsala, Sweden) and in nasal secretion by an in situ incubation method with the same reagents of CAP System FEIA. Results: Symptom/medication scores during the pollen season were significantly higher in patients treated with the lower dosage compared with those treated with the 300 IR dosage. Side-effects occurred with a comparable rate (25.8%vs 27.5%) in the two groups. Serum-specific IgE and IgG4 had no significant changes after 3 months of SLIT in both groups, while a significant seasonal increase of nasal IgE (P = 0.015) and IgG4 (P = 0.019) was found only in patients treated with the lower dosage. Conclusions: A rise of specific IgG4 and a blunting of seasonal increase of specific IgE in serum was repeatedly reported during subcutaneous immunotherapy (SCIT) with pollen extracts. Our findings show such blunting of specific nasal IgE along with a low symptom/medication score in patients treated with SLIT with the higher dosage, but not a concomitant rise of specific nasal IgG4. This suggests a local immunological effect of SLIT, different from systemic mechanisms of SCIT.

Summary Background As the main target of sublingual immunotherapy (SLIT) is to reduce at most the occurrence of adverse events (AE), safety represents a critical issue. This aspect deserves particular mention when a higher dose of allergen extract than traditional subcutaneous immunotherapy (SCIT) is required to be effective: that may be up to 500 times that employed for SCIT. Objective All published controlled studies concerning SLIT-swallow were analysed to evaluate AE rates. Methods Studies were subdivided in two groups: (i) studies using low allergen dose (LAD), i.e. ranging from 1 to 50 times the dose commonly administered with SCIT, and (ii) studies with high allergen dose (HAD), i.e. ranging from 50 to 500 times the dose administered with SCIT. Results Twenty-five studies were altogether analysed: 13 studies belonged to the low-dose group, 12 belonged to the high-dose group. We considered all patients with at least one AE. Local reactions were significantly more frequent in the LAD group than in the HAD group (P

Background: Oral allergy syndrome (OAS) is often associated with pollen-induced rhinitis, and there are preferential associations between causative substances. If OAS and rhinitis are both immunoglobulin (Ig)E-mediated and there are cross-reacting proteins, it is expected that similar reactions can be elicited in the nose and mouth. In order to test this hypothesis we performed a series of ‘cross-challenges’ with foods and pollens in both the nose and the mouth. Methods: Nine patients with ascertained OAS due to vegetables and rhinitis due to pollens were studied. On the first day a nasal challenge with pollen extracts and an oral challenge with fresh food was carried out. After a week, washout nasal challenge with food and an oral challenge with pollens were performed. Immediate symptoms, mucosal tryptase and soluble eosinophil cationic protein (ECP) were assessed after each challenge. Results: The administration of pollen into the nose and food into the mouth elicited symptoms as expected, but the cross-challenge had no clinical effect. In parallel, tryptase and ECP increased after nasal challenge with pollens, whereas foods did not elicit a measurable response. Conclusion: The cross-reactivity between foods and pollens, when evaluated at the shock organ, was not clinically evident. This data can be explained with a low concentration of cross-reagent epitopes in pollen extracts and food homogenized because of degradation. The different behaviour upon challenge suggests that different immunological mechanisms may act in the nose and mouth.

The specific Nasal Provocation Test (sNPT) is a third level diagnostic tool. Fitted to reproduce natural exposure condition to pick the responsible allergen for nasal symptoms out, it is applied when prick test and RAST responses are doubtful. SNPT results have been evaluated measuring nasal resistance (anterior rhinomanometry) and nasal symptoms (clinical score), reaching 50% of sensitivity. This study focused on the determination of allergic response markers, triggered by nasal challenge: tryptase levels in the nose, specific IgE and ECP (Eosinophil Cationic Protein). The aim was to increase sNPT sensitivity. Twenty patients suffering from allergic rhinitis and 16 age-matched-nonallergic subjects were enrolled in the study. Tryptase, specific IgE and ECP were determined in nasal mucosa applying a new method, based on in situ incubation, before and after sNPT. The latter was performed following a standardized method. Tryptase levels increased in 13 patients (65%), were unchanged in four patients (20%), and slightly decreased in three patients (15%). The increase recorded was significant in mite allergic patients (p=0.005), but not significant (p> 0.05) in pollen allergic patients. ECP values increased in 13 patients (65%), were unchanged in two patients (10%), and highly decreased in five patients (25%). ECP increase was not significant (p> 0.05). Specific IgE levels increased in seven patients (35%), were unchanged in 11 patients (55%) and decreased in two patients (10%). The IgE increase was significant in pollen-allergic patients (p0.05). Tryptase, ECP, and specific IgE were not detected in the control group. The data obtained showed a positive sNPT response in 12 patients (60%). Comparing our results with those derived from classical-parameter employment, we gathered an improvement of 10%. On the basis of the usual parameters, in fact, we recorded 50% positivity, while the use of mediators provided an additional 10% improvement in sNPT sensitivity: taking together the usual parameters and nasal allergic mediators values, we reached an sNPT over-all sensitivity of 85%.

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.

Eosinophil cationic protein (ECP), a small, highly cationic, zinc—containing polypeptide of 16 to 22 kDa, is one of the most abundant proteins in eosinophil granules. It is markedly toxic for a variety of helminth parasites, hemoflagellates, bacteria, single—stranded RNA viruses and mammalian cells and tissues. While to date, the presence of ECP‐like molecules has only been demonstrated in humans and in some mammals, the Authors report some immunological evidence that indicates the presence of ECP—like immunoreactive proteins in serum of non‐mammalian vertebrates including chickens, two amphibian and several teleost species. Western blotting analysis on the same samples showed a complex electrophoretic pattern which suggests the existence of multiple ECP‐like proteins in the different evolutional level vertebrates.