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Background Systemic corticosteroids have been used in the treatment of asthma since 1950 and are still required for the treatment of acute severe asthma and corticosteroid dependent asthma. Objective To provide an updated overview of clinical considerations of systemic corticosteroids use in severe adult bronchial asthma. Methods PubMed searches were undertaken of studies published between 1950 and 2015. Results In this review the following concepts are discussed. 1) The onset of action of intravenous methylprednisone is 1-2 hours with a peak at 4-6 hours and duration of 12-30 hours. 2) Each patient should serve as their own control, using their best flow rates in the previous 6 months to 2 years. 3) The individual response to corticosteroid relates to the degree of obstruction at the time of onset of steroid treatment. 4) The pattern of response is variable but tends to be consistent for an individual patient. 5) In monitoring response to steroids frequent measures of peak expiratory flow rate and forced expiratory flow in 1 second are more useful than complete spirometric and lung mechanic tests measured less often. 6) In most cases oral steroids are as effective as parenteral regimens. 7) Patients usually respond in 3 days to 40 to 100 mg of methylprednisolone equivalent. 8) In corticosteroid resistant asthma consider compliance issues, allergen sensitivity, concomitant conditions, psychiatric factors and drug interactions. 9) Corticosteroid toxicity relates to the total lifetime dosage and serious side effects are usually not observed until a total dosage of 6.8 grams of prednisone equivalent. Conclusion Until we have a better understanding of the mechanisms of action of glucocorticoids, we will continue to rely on currently available systemic corticosteroids in severe asthma. The intrapatient consistency as discussed in this review, should guide therapy.

Background Obstructive sleep apnea syndrome (OSAS) and allergic rhinitis (AR) are common coexisting disorders. Upper airway, specifically al resistance, is thought to increase during exacerbations of AR and nonallergic rhinitis (NAR), as well as in OSAS. The study objective was to determine if a correlation exists between clinical control of rhinitis and OSAS. Methods This prospective study followed 43 patients with concurrent OSAS and AR or NAR. OSAS was diagnosed by polysomnography, and AR or NAR was diagnosed by history, skin testing, serum-specific IgE, and total IgE levels. Measurements of control of OSAS included the Epworth Sleepiness Scale (ESS) survey and compliance with continuous positive airway pressure (CPAP) device. Measurements of rhinitis control included Assessment of Nasal Symptom Severity and Assessment of Nonnasal Symptom Severity (NSS refers to both) and Global Assessment of Nasal and Nonnasal Symptom Severity surveys (GSS). Higher NSS scores correlate with more rhinitis symptoms, whereas higher GSS scores correlate with less symptoms. Results All patients completed the study. There was a positive correlation between ESS and NSS scores (p < 0.001), inverse correlation between ESS and GSS scores (p < 0.001), inverse correlation between CPAP compliance and NSS scores (p < 0.001), and positive correlation between CPAP compliance and GSS scores (p < 0.001). There was no statistically significant difference between the AR, NAR, and AR/NAR groups. Conclusion Our study showed a statistically significant positive correlation between clinical control of rhinitis symptoms and clinical control of OSAS. This study emphasizes the importance of achieving concurrent optimal control of both OSAS and AR/NAR.

Background Cell mediated immunity is suppressed by systemic corticosteroids. Inhaled corticosteroids have been shown to affect parameters including bone metabolism, hypothalamus–pituitary adrenal axis, linear growth, and lead to the development of cataracts. However, it is unclear if high dose inhaled corticosteroid therapy affects cell mediated immunity. Study objectives To evaluate if asthma patients taking high dose inhaled corticosteroids chronically have reduced cell mediated immunity compared to asthma patients not taking inhaled corticosteroids. Methods Eighteen asthmatic subjects participated in this cross-sectional study. Cell mediated immunity was evaluated in nine patients who had been taking high dose inhaled corticosteroids for >6 months and nine patients not taking inhaled corticosteroids. Cell mediated immunity was evaluated by delayed type hypersensitivity (DTH) skin testing with intradermal placement of candida and tetanus antigens. Results There was no significant difference in DTH skin test results between the high dose inhaled corticosteroid and no corticosteroid treated asthma group. Conclusion Patients with asthma taking high dose inhaled corticosteroids chronically (>6 months) did not have significantly greater impaired cell mediated immunity than patients not taking inhaled corticosteroids in this study.

Severe asthma in elderly patients is underdiagnosed, difficult to treat, and often accompanied by atopy. This study was designed to compare clinical outcomes of omalizumab therapy in an elderly veteran population with severe allergic asthma. A retrospective, observational data analysis was performed over 2 years. Cohort outcome measures 1 year before omalizumab therapy were compared with 1 year of active treatment. Statistical analysis included two sample t-tests. The total number of patients enrolled was 17 with median age of 60 years. Omalizumab therapy was associated with a significant reduction in acute asthma exacerbations requiring prednisone treatment (p0.01), a significant improvement in forced expiratory volume in 1 second of 0.28 L (p0.01), and significantly higher Asthma Control Test (ACT) scores at 3 (p = 0.043), 6 (p = 0.039), and 12 months of therapy (p0.01). Two of five patients on daily prednisone for6 months were able to discontinue systemic steroid use within 3 months of omalizumab treatment. Our study suggests elderly patients with severe atopic asthma show a significant positive clinical response to omalizumab.

Objectives To review clinical hypersensitivity reactions related to common cancer chemotherapy agents and to discuss potential management strategies. Data Sources PubMed searches were performed for articles published from 1970 to 2008 regarding hypersensitivity to cancer chemotherapy and related agents using the keywords hypersensitivity, allergy, chemotherapy, platinums, taxanes, asparaginase, epipodophyllotoxins , and procarbazine . Retrieved articles were surveyed for additional citations. Study Selection Articles were reviewed for relevance to the subject matter, and the most pertinent articles were included in this review. Results Hypersensitivity reactions are commonly associated with the use of certain cancer chemotherapy drugs, including platinums, taxanes, asparaginase, procarbazine, and epipodophyllotoxins. Platinum agents (cisplatin, carboplatin, oxaliplatin) are associated with IgE-mediated hypersensitivity reactions, and skin testing may be indicated. Taxane (paclitaxel, docetaxel)-related reactions are generally non-IgE mediated, and premedication with corticosteroids and antihistamines is usually effective. Asparaginase has a high rate of hypersensitivity reactions that are likely IgE mediated or related to complement activation. Skin testing has been recommended but has not been validated for asparaginase. Procarbazine reactions can be IgE mediated but are also associated with a type III reaction manifested by pulmonary toxicity and cutaneous reactions. Hypersensitivity reactions related to epipodophyllotoxins may involve both immunologic and nonimmunologic factors that may be avoided with a slow infusion and premedication. Conclusion With the increasing use of cancer chemotherapy agents, hypersensitivity reactions are commonly encountered. Knowledge of the presentations of these reactions and management options give the treating physician the means to make an informed decision of how best to proceed.

Emergency hospital utilization rates for asthma remain high despite advances in asthma controller medications and the presence of widely accepted asthma treatment guidelines. To explore this phenomenon, we analyzed administrative data to determine characteristics of patients seen in the emergency department (ED) for asthma. Complete pharmacy and diagnostic coding records were obtained from consecutive adults (aged 19-56 years) treated for asthma in the ED of a closed-network health maintenance organization between April and July of 2002. Subjects were stratified into asthma severity categories (persistent or non-persistent) based on the National Committee for Quality Assurance 2006 Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma. Eighty-one unique patients made a total of 89 ED visits for asthma during the study period. Of the 89 total ED visits for asthma, 44 (49%) occurred in patients that did not meet HEDIS criteria for persistent asthma. Of the 81 unique patients making asthma-related ED visits, 41 (51%) did not meet HEDIS criteria for persistent asthma. Over one-half (51%) of this nonpersistent population were not given either asthma reliever or asthma controller medications during the 12-month period before their index ED visit. Over the 24-month period before their index ED visit, 37% of nonpersistent patients were dispensed neither asthma reliever nor controller medications. Patients that do not meet HEDIS criteria for persistent asthma account for a substantial percentage of asthma-related ED visits. These patients have a history of low use of asthma medications before their ED visit.

Objective To identify novel aspects of the pathogenesis, therapeutic options, and prophylaxis measures of corticosteroid-dependent asthma. Data Sources PubMed searches were undertaken of studies published between 1966 and 2006 on the pathogenesis of and corticosteroid-sparing therapies for corticosteroid-dependent asthma. Identified review articles were surveyed for additional and earlier citations. Recent American Academy of Asthma, Allergy, and Immunology meeting abstracts were also searched to identify other recently published and unpublished studies. Study Selection Inclusion of studies in the review was decided by simple agreement of both reviewers, who independently read the "Methods" and "Discussion" sections of articles identified using the search strategy. Quality assessment was performed by the 2 reviewers. Results High-dose inhaled corticosteroids are the first-line option for corticosteroid-dependent asthmatic patients with clear efficacy. Omalizumab is effective in reducing oral corticosteroid requirements in allergic asthma. Methotrexate, gold, and cyclosporine have corticosteroid-sparing effects clinically that must be weighed against a serious adverse effect profile. Nebulized diuretics and lidocaine, with a low adverse effect profile, offer promising results but require further study. Clarithromycin and telithromycin seem to have an independent mechanism of inflammatory modulation, but their effect on corticosteroid-dependent asthma remains to be seen. Etanercept offers only early clinical evidence of a role in corticosteroid-dependent asthma. Conclusions With no clear consensus on corticosteroid-sparing treatment in corticosteroid-dependent asthmatic patients, systemic glucocorticoids remain the foremost therapy, with adverse effects that require monitoring and prophylaxis.

Penicillin (PCN) may cause a reaction in up to 10% of the population. No study has examined PCN skin testing longitudinally over a 20-year period. A total of 122 patients underwent PCN skin testing between September 1978 and May 1998. Patients were skin tested with the major determinant, penicilloyl polylysine, and three minor determinants, PCN, benzylpenilloate, and benzylpenicilloate. Ten of a total of 122 patients had positive skin test reactions. Nine reactions were to penicilloyl polylysine and one reaction was to the minor determinant benzylpenilloate. There was a total of four patients (3.6%) with false-negative results on skin testing. PCN skin testing with both the major and minor determinants should be performed when there is a history of PCN allergy, a serious illness, and no suitable alternatives. If either the major or minor determinants are positive without suitable alternative antibiotics, then the patient should undergo desensitization.

Objective The purpose of this study was to review consecutive cases of angiotensin-converting enzyme (ACE) inhibitor angioedema admitted to an intensive care unit. Methods Fifty subjects with ACE-inhibitor angioedema admitted from 1998-2011 were reviewed. Results All 50 subjects were men, 62.8 ± 8.4 years of age, 76% African Americans. Fifteen (30%) required ventilatory support and 2 (4%) required tracheostomy. Over half (56%) had taken ACE inhibitors for over a year. Logistic regression identified dyspnea and tongue involvement with the need for ventilatory support ( P 2 = 45.2 ± 6.7; P = 0.046) also identified patients needing ventilatory support. Conclusions Ventilatory support was provided for about one-third of those with ACE inhibitor-associated angioedema. Angioedema can occur even after extended use. Dyspnea and tongue involvement identified patients requiring ventilatory support.

Background: Polymorphisms of the β2-adrenergic receptor (ADRB2) have previously been associated with non-specific bronchial hyper-responsiveness, adverse response to β2-agonists and variable effects on lung function. The objective of this study was to determine whether genotypic variance in ADRB2 polymorphisms in a cohort of geriatric men and women with asthma and/or COPD correlate with disease severity, baseline pulmonary function, and the ability to maintain clinical control of their disease. Methods: This comparative, prospective cohort study sequenced two ADRB2 polymorphisms, Arg16 --> Gly and Gln27 --> Glu, in 103 geriatric patients with a clinical history of asthma and/or COPD. Primary endpoints included pulmonary exacerbation rate, hospitalization rate, and quality of life scores. Results: Arg/Arg genotype comprised 13.6% of the cohort. No significant differences in baseline pulmonary functions were noted across genotypic variants. No significant difference was associated with genotype and change in lung function, exacerbations, clinical hospitalizations, exercise tolerance and subjective quality of life assessment over 6 months of follow-up. Conclusion: We conclude that in a geriatric asthma and/or COPD population, ADRB2 polymorphisms are not a factor in the ability to control disease.

A single-masked, randomized, controlled, multicenter, parallel-group study compared the efficacy, tolerability, and specific treatment-related side effects of 4 weeks of intranasal therapy with 220-μg once-daily triamcinolone acetonide aerosol versus 168-μg twice-daily beclomethasone dipropionate aqueous spray in 313 patients with perennial allergic rhinitis. Both treatments produced similar improvement in rhinitis symptoms (nasal congestion, rhinorrhea, postnasal drip, sneezing, and nasal itching) and in mean total nasal symptom scores. There were no clinically or statistically significant between-group differences in physician global evaluation of symptom relief or in the number of patients who withdrew prematurely from the study because of insufficient therapeutic effect. The onset of action during the first week of therapy was comparable for the two treatments. The frequency of two specific treatment-related complaints—medication running down the throat and medication running out of the nose—was statistically significantly less with triamcinolone acetonide than with beclomethasone dipropionate. The severity of these two complaints, plus one other—bad medication taste—was statistically significantly greater with beclomethasone dipropionate. The frequency of drug-related adverse events was similar in the two treatment groups. The results of this trial indicate that triamcinolone acetonide, 220 μg once daily, is comparable to beclomethasone dipropionate, 168 μg twice daily, in relieving the nasal symptoms of perennial allergic rhinitis. Both treatments were well tolerated, although some specific treatment-related events were significantly more frequent and severe in the beclomethasone dipropionate aqueous spray group than in the triamcinolone acetonide aerosol group.

Mortality rates for asthma have increased significantly since 1980. During a 12-month period (1990) at the West Los Angeles VA Medical Center, six asthma patients required intubation. Contributing factors to intubation were steroid dependence, atopy, beta-agonist overuse, infection, non-compliance, adverse drug reaction, and undertreatment with steroids.

Background Patients with a history of beta-lactam antibiotic allergy are often admitted to the hospital with severe or life-threatening infections requiring beta-lactam antibiotics. Strict avoidance of beta lactams to such patients may prevent them from getting adequate coverage and can lead to an increase in the use of alternative antibiotics, which can predispose to antibiotic resistance. Past studies revealed a lower incidence of pen allergy then patients’ histories suggest. Fortunately today, there are three options for patients presenting with a history of beta-lactam allergy. Penicillin skin testing, beta-lactam challenge or beta-lactam desensitization. Recently Pre Pen has been FDA re-approved and when combined with Pen G is a valid way to determine if patients are able to tolerate beta-lactam antibiotic. When these agents are not available one must decide about desensitization or challenge. When a patient has a positive penicillin skin test, desensitization or beta-lactam avoidance are the only options. This paper reviews the safety of beta-lactam desensitization. Objective To perform a chart review on patients desensitised with beta lactam to determine if desensitizations can be performed safely without minimal complications. Methods A retrospective chart review was performed on allergy and immunology inpatient consultations for beta-lactam desensitization between September 2003 and August 2006 at the Cedars-Sinai Medical Centre in Los Angeles. Patient data and outcomes of desensitization were analysed. Results A total of 13 intravenous desensitizations were performed on 12 patients. The patients consisted of eight females and four males with an average age of 65 years. Age range was 36–92 years old. All 13 intravenous desensitizations were completed without complications. No patient required a slower rate of desensitization or discontinuance of the desensitization. Patients were able to tolerate the initial therapeutic dose of their beta-lactam antibiotic and were then able to complete full therapeutic courses of their antibiotic. Conclusion Beta-lactam antibiotic sensitivity continues to present a challenging problem for physicians. Patients with drug resistant infections who are unable to obtain skin testing or who test positive to skin tests may need either a challenge or desensitization. Desensitization, saved for those with a convincing beta-lactam hypersensitivity history is often the choice of last resort given the associated cost and risk of anaphylaxis. However, once desensitization is complete, patients are usually able to tolerate full doses of antibiotics for full treatment length with minimal side effects.

Background To use probability theory to establish threshold values for total serum IgE and eosinophil counts that support a diagnosis of allergic rhinitis and to compare our results with previously published data. Methods Prospective study of rhinitis patients using a modified version of Bayes’ theorem. Study included 125 patients at the West Los Angeles VA Medical Center diagnosed with rhinitis who completed allergy consultation and immediate hypersensitivity skin testing. Results Eighty-nine of 125 patients were atopic by prick and/or intradermal skin testing. Using a modified version of Bayes’ theorem and positive and negative probability weights, calculations for different thresholds of serum IgE and eosinophil counts were summated and a posttest probability for atopy was calculated. Calculated posttest probabilities varied according to the threshold used to determine a positive or negative test; however, IgE thresholds greater than 140 IU/ml and eosinophil counts greater that 80 cells/ml were found to have a high probability of predicting atopy in patients with rhinitis. Moreover, IgE had a greater influence than eosinophil count in determining posttest probability of allergy in this population. Considerable differences were noted in the IgE levels of atopic and non-atopic patients, including those with asthma or a history of smoking. However, these differences were not observed with eosinophil levels. Conclusions Using a modified version of Bayes’ theorem to determine posttest probability, IgE threshold levels greater than 140 IU/ml and eosinophil counts greater than 80 cells/ml in an individual with clinical signs and symptoms of rhinitis are likely to correlate with an atopic aetiology. This model of probability may be helpful in evaluating individuals for diagnostic skin testing and certain types of allergy-modifying treatment.

Omalizumab is a novel therapy approved for treating patients with moderate to severe persistent allergic asthma with a serum IgE ranging from 30 to 700 IU/mL. We examined the efficacy of omalizumab as a treatment for IgE-mediated food allergy. An Institutional Review Board-approved prospective pilot study was performed to assess the efficacy of omalizumab in 22 patients with persistent asthma and concomitant IgE-mediated food allergy. All patients showed skin test positivity to foods and experienced allergic food reactions based on history. Patients were interviewed on unintentional and/or unauthorized exposures to sensitized foods. Thirteen female and nine male patients (range, 4-66 years old; mean, 38 years) were evaluated in a private practice setting. Mean IgE level was 1120.74 IU/mL. Sensitized allergens included fish, shellfish, peanuts, tree nuts, egg, soybean, and wheat. All 22 (100%) patients maintained significant improvement as shown by a decrease/lack of clinical symptoms on reexposure to sensitized foods. Clinical improvement by the sixth dosage of omalizumab (150-300 mg q. 2-4 weeks) was noted by history and physical examination. Eight patients noted a decrease in their food-induced atopic dermatitis, 13 patients noted a decrease in their food-induced asthma symptoms, 3 patients noted a decrease in their food-induced urticaria, 6 patients noted a decrease in their food-induced rhinosinusitis symptoms, and 9 patients showed efficacy for angioedema and/or anaphylaxis. While treating asthma patients with omalizumab, patients subjectively observed a reduction in their concomitant IgE-mediated food allergy symptoms.

Introduction Chronic rhinosinusitis (CRS) is treated with both surgical and medication options. However, long term data on patient outcomes is rare. In a real world clinical environment, our objective was to identify CRS patients, gather patient characteristics, and follow symptoms over one year. Patients and methods This observational study enrolled patients with CRS. Primary clinical markers included atopy testing, serum IgE, and complete blood counts. A sinus computerized tomography (CT) scan was performed serially. Patients were enrolled into medical treatment Arm A and into surgical treatment Arm B. Symptom scores were calculated using the chronic sinusitis survey (CSS). Results Atopy testing was positive in 67%. IgE levels or atopy did not correlate with CSS scores. A 23% decrease in total CSS scores was noted in Arm A at one year (P=.01). Arm B demonstrated a 38% reduction in total CSS scores at 3 months (P=.02) only. CT evidence of CRS was found in 74% of patients. However, CT scores did not change significantly over 12 months. Conclusions No correlation was found between serum IgE levels or atopy versus CSS scores. CT scan scores did not change significantly over 12 months in either treatment group. A reduction of CSS scores was seen in both treatment groups; however a rebound effect was suggested in the surgical arm. Our study demonstrates the disconnection between clinical markers, radiographic evidence and response to therapy in CRS in a common clinical setting. It exemplifies the need for controlled studies with years of chronic rhinosinusitis outcome analysis.

We studied 24 corticosteroid dependent asthmatic patients over a period of 10 months to establish a baseline for future therapeutic trials with corticosteroid sparing agents. Clinical symptoms, steroid dose, peak expiratory flow rate (PF), forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) were recorded at clinic visits. Correlation was sought between PF and FEV1, steroid dose versus PF and symptom severity, and PF versus time and symptoms. There was considerable weekly variability of PF and FEV1. However, when viewed over almost a year, 54% had no significant change in PF. 29% actually worsened and 17% improved. The data suggest that to assess the effect of a steroid-sparing agent accurately, one must first establish a reliable baseline over several months to eliminate weekly variability. The current trend of obtaining a baseline over a 1 to 2 month interval is inadequate in this study population. We also found that neither patient assessment of severity of symptoms nor corticosteroid dosage correlate with objective spirometric measurements.

HISTORY OF PRESENT ILLNESS A 48-year-old Asian male was referred to our outpatient allergy clinic after experiencing oral ulcers, angioedema, and a penile skin eruption following tooth extraction and gum irrigation. Less severe reactions had occurred following two prior dental procedures. These reactions consisted of painful buccal blisters developing within 3 hours of each procedure, progressing over the next 3 days to extensive oral ulcerations. Penicillin was given before the first dental procedure in 1990. Ciprofloxacin was given before the second procedure in 1994. He did not receive any antibiotics before the third extraction in 1997. Thirty minutes before all procedures, the patient was pre-medicated with 1000 mg of oral diflunisal. During each procedure, 5.5 mL of the local anesthetic mepivacaine (2%) with the sympathomimetic vasoconstrictor neo-cobefin (1 20,000) was administered by injection. Within 1 hour following the third dental procedure, the patient complained of lip and facial swelling accompanied by burning eyes. Eighty milligrams of triamcinolone and 50 mg of diphenhydramine were given intramuscularly with moderate relief of facial swelling. He was sent home on a regimen of oral dexamethasone 1 mg tid and oral diphenhydramine 50 mg tid. Approximately 3 hours after the procedure, the patient noted the appearance of painful blisters on the buccal mucosa. The blisters progressed to oral ulcers in a manner and time course similar to that following the two prior dental procedures. On the third day post-procedure, the patient complained of severe dysphagia and noted a painful bullous, erythematous penile lesion. Neosporin ointment along with fluocinolone .025% ointment was applied topically to the penile lesion each day. Corticosteroid eye drops were also used daily. The symptoms continued to persist throughout the next 2 months, gradually diminishing in severity, and completely resolving within 3 months.

Background Allergen immunotherapy is a major therapeutic modality in the treatment of allergic rhinitis. However, with T-cell activation potential, its role in patients with human immunodeficiency virus (HIV) was theoretically limited. Objective To report the results of allergen immunotherapy in a patient with HIV treated with highly active antiretroviral therapy (HAART). Methods A 44-year-old man with a history of HIV did not respond to medical therapy for allergic rhinitis. His HIV status was well controlled with HAART. Owing to the severity of his allergic rhinitis symptoms, he accepted the risk of allergy immunotherapy despite the unknown effect of immunotherapy in patients with HIV. Results After 6 weeks of weekly immunotherapy injections, his viral load remained undetectable and his CD4 cell count changed from 540 to 570 cells/μL. After 16 weeks of weekly immunotherapy, his viral load increased to 10,900 copies/mL, and his CD4 cell count increased to 665 cells/μL. After 24 weeks of weekly immunotherapy, his viral load returned to an undetectable level, and his CD4 cell count stabilized at 356 cells/μL. Despite his notable change in HIV status, he continues to receive the same HAART. He currently continues en route to maintenance immunotherapy. Conclusions The effect of allergen immunotherapy on HIV infection has not been previously reported. A concern remains that any form of immunotherapy may negatively affect HIV disease progression. This case illustrates that weekly allergen immunotherapy may have induced limited T-cell proliferation and a modest increase in RNA viral load, which resolved with continuation of HAART.

Data from 12 Department of Veterans Affairs patients hospitalized for status asthmaticus were analyzed to determine the rate and degree of response to therapy. The time to achieve recovery was directly related to the level of baseline obstruction at the time of hospital admission. The recovery rate was constant and could be described by a single second-degree polynomial regression equation. Nomograms were constructed showing this rate of improvement of pulmonary function over time at four levels of baseline pulmonary obstruction.

Between 1985 and 1992, patients were evaluated as new outpatient consultations in the Allergy/Immunology Center at the Veterans Affairs Greater Los Angeles Health Care System (VAGLAHS). Data collected included age, gender, ethnicity, and diagnosis. After 10 years, patient follow-up status was determined and classified into five categories: gender, ethnic distribution, age distribution, disorders seen, and follow-up pattern. A total of 1116 patients were evaluated. The gender of our population was 7.8% women and 92.2% men. The ethnic distribution was 59.5% white, 32.2% black, 6.5% Hispanic, and 1.9% other. Neither age nor ethnic distribution was significantly different from the general veterans affairs population. Age of patients ranged from 20 to 90 years old. The largest peak for age at initial presentation was 60 years. The three most common disorders seen in the clinic were rhinitis (36.6%), asthma (24.5%), and sinusitis (12.3%). The 10-year follow-up pattern of patients revealed that 6% were seen in the past year, 6.2% of patients were seen longer than 1 year ago but within the 5 past years, 29% of patients who were still seen at VAGLAHS but were no longer patients of the allergy clinic, 32.7% of patients who were no longer seen at VAGLAHS, and 26.2% died. Women and patients who were 50-60 years old were more likely to follow-up. There was no difference in follow-up visits among ethnic groups.

Background The effects of chronic disease have been proposed as an explanation for conflicting results in studies of age effects on cell-mediated immunity. Objective To examine the hypothesis that declining cell-mediated immunity is more closely linked to chronic disease burden than to chronological age. Methods Fifty-eight elderly individuals were tested for delayed-type hypersensitivity (DTH) responses to Candida and tetanus antigens. Disease burden was quantified using the Cumulative Illness Rating Scale (CIRS). Higher CIRS scores reflect greater disease burden. Mean DTH response by age group ( 78 years) was compared with mean DTH response by CIRS score ( 15). Total serum IgE levels were measured and similarly stratified by age and CIRS score. Results Mean Candida DTH responsiveness declined progressively with increasing disease burden (increasing CIRS score). Mean DTH responses were 7.78, 3.05, and 0.0 mm for CIRS scores less than 11, 11 to 15, and greater than 15, respectively. Candida DTH responses showed no progressive decline with advancing age. Mean DTH responses were 4.7, 3.5, and 5.0 mm in participants younger than 71, 71 to 78, and older than 78 years, respectively. Total serum IgE levels increased with advancing age. Mean total IgE levels were 182, 249, and 342 IU/mL in participants younger than 71, 71 to 78, and older than 78 years, respectively. No correlation was observed between mean total IgE levels and CIRS scores. Conclusions An inverse relationship between Candida DTH response and CIRS score suggests that increased chronic disease burden is associated with diminished cell-mediated immune response. Advancing age did not predict a diminished DTH response in our patients. No relationship was observed between chronic disease burden and total serum IgE level.

In most cases, the diagnostic evaluation of angioedema is challenging, as there are many possible etiologies. We report a case of an infiltrating lipoma of the tongue that masqueraded as angioedema. The patient, a 68-year-old man, presented with tongue swelling that had followed a waxing and waning course over a 6-month period. Physical examination showed a diffusely enlarged tongue with no discrete mass. A laboratory evaluation for angioedema was unremarkable. After the patient's condition did not respond to treatment with antihistamines and oral prednisone, a further workup was initiated. Magnetic resonance imaging of the neck and computed tomography of the oral cavity revealed only diffuse enlargement of the tongue. The patient underwent a tongue biopsy, which identified the cause of the swelling to be an infiltrating lipoma of the tongue. Clinicians should be aware that other causes of tongue swelling may mimic angioedema.

A cross-sectional survey of 132 adult men referred to the outpatient allergy clinic at the West Los Angeles Veterans Affairs Medical Center was performed to assess age effects on allergic disease in the elderly. Total serum immunoglobulin E (IgE), immediate hypersensitivity skin testing, and serum eosinophil count were measured in all subjects. Subjects were stratified by age into one of five groups for comparison. In asthma, prevalence of allergy skin test reactivity and mean total serum IgE levels did not decline with advancing age, suggesting that IgE-dependent mechanisms continue to be significant in elderly patients with asthma. In subjects with rhinitis, prevalence of allergy skin test reactivity and mean total serum IgE did decline among elderly subjects relative to younger subjects. However, the prevalence of allergic rhinitis did not decline in the elderly. This suggests that although allergic rhinitis is common in elderly patients, nonallergic causes of rhinitis may become more prevalent with advancing age.

History of Present Illness A 51-year-old man was referred to our clinic for severe atopic dermatitis (AD) by our dermatology department. The patient had a history of childhood hay fever, asthma, and hives, as well as a strong family history of atopy. As a young adult, his atopic symptoms subsided, but 14 years ago he noted the onset of intermittent dermatitis and pruritus. Initially, symptoms were controlled with over-the-counter topical corticosteroids. However, they gradually worsened and the patient was referred to our dermatology department in 1998. He was treated with antihistamines, emollients, and topical steroids, but these eventually failed to control his symptoms. Oral steroids were tried next, and when those failed, leukotriene antagonists were added with no effect. By the time of referral, the patient was regularly receiving intramuscular injections of triamcinolone acetate. The patient described his rash as intensely pruritic and erythematous, and that over time he has observed darkening of his skin. He was having trouble sleeping because of the pruritus and would frequently scratch until he bled. The rash appeared randomly and was not associated with any particular detergent, soap, cologne, or clothing items. The patient did not notice any association between the onset of the rash and eating meals or with the time of day. There was no seasonal variation to the rash, and sun exposure neither improved nor worsened its severity.

Nonsedating H1 antihistamines such as terfenadine, loratadine, and astemizole are widely prescribed for the treatment of allergic rhinitis. The comparative efficacy of these agents has not been thoroughly studied. We studied 14 subjects in an open-label four-way crossover trial. Patients were recruited from an outpatient allergy clinic. Inclusion criteria were documented rhinitis symptoms for at least 2 years before the study and skin-test positivity in response to perennial allergens. Each subject underwent sequential 2-week trials of each of four H1 antihistamines: terfenadine, loratadine, astemizole, and chlorpheniramine. No placebo was included. Outcome measures were subjective rhinitis symptom scores, overall efficacy scores, and concomitant pseudoephedrine use. In addition, nasal-examination scores were obtained by way of physician assessment at the end of each 2-week trial, and side effects were tabulated. Nasal-examination scores for each of the four H1 antihistamines were significantly better than the baseline scores (p < 0.05). No statistically significant differences in rhinitis symptom scores, overall efficacy scores, or concomitant pseudoephedrine use were noted. We detected no clinically significant differences in efficacy among terfenadine, loratadine, astemizole, and chlorpheniramine in the treatment of perennial allergic rhinitis.

Background Persian Gulf War Veterans have been enrolled in the Veterans Administration Persian Gulf Health Registry for evaluation of unexplained symptoms and illnesses. The allergy and immunology division at the West Los Angeles Veterans Administration Medical Center evaluated 20 consecutive symptomatic Persian Gulf War vetersans. Objective The purpose of this study was to examine the immunologic profiles of symptomatic Persian Gulf War veterans. Methods A detailed history was obtained that included duties/responsiblities, length of time in the Persian Gulf, location, and exposures during the Gulf War. A complete physical examination was performed, with extensive laboratory testing and immediate and delayed hypersensitivity skin testing. Data from these Persian Gulf War veterans were compared with a control population consisting of 44 non-Persian Gulf War veterans enrolled in our allergy and immunology clinic. Presenting allergic symptoms, presence of atopy, and total serum IgE levels were compared. Results Persian Gulf study patients and registry patients had a broad spectrum of nonspecific symptoms as compared with allergy clinic control paitents who had dermatologic and respiratory symptoms. Persian Gulf study patients with allergy symptoms had a higher mean IgE level (88.7 IU/mL) than Persian Gulf study patients without allergy symptoms (47.5 IU/mL). Persian Gulf study patients with positive skin tests had a higher mean IgE level (161.5 IU/mL) than Persian Gulf study patients with negative skin tests (22.3 IU/mL). Laboratory data showed no significant immune abnormalitites. Conclusion Our study showed that 20 Persian Gulf veterans with a multitude of nonspecific symptoms had no immune abnormality. Mean IgE levels and eosinophil counts correlated with atopic state and reported allergy symptoms

Acquired angioedema (AAE) is a very rare condition caused by an acquired deficiency in C1 esterase inhibitor (C1 INH). Pathogenesis of AAE can entail abnormal B cell lymphoproliferation ranging from benign monoclonal gammopathy

Background Patients on prolonged corticosteroid therapy are at risk of developing osteoporosis. Some patients with severe asthma are difficult to wean off corticosteroids and are therefore at risk of developing bony complications due to steroids. Objective The purpose of this study was to examine the relationship of cumulative steroid dosage and duration of therapy with osteoporosis. Methods We obtained bone mineral density studies using dual photon absorptiometry, and radiographs of the lumbar spine of 16 steroid-dependent patients with asthma. Patients with conditions affecting bone metabolism were excluded. Results We studied 16 male steroid-dependent patients with asthma who received 4 to 41 grams equivalent dose of prednisone over a period of 1 to 15 years. The overall prevalence rate for abnormal age-matched bone mineral density was 50%. Abnormal bone mineral density was more commonly noted in the lumbar spine (38%) than in the femoral neck (19%). The lowest dose of corticosteroid associated with a decrease in bone mineral density was a cumulative steroid dose of 5.6 equivalent grams-prednisone. Conclusion Prolonged corticosteroid therapy can cause significant osteoporosis among male patients with steroid-dependent asthma. Bone loss due to corticosteroid therapy occurs at different rates at different bony sites.

IgG subclass levels were measured in three groups of adult patients with obstructive airways disease to discern the relationships among depressed IgG subclass levels, chronic corticosteroid use, and recurrent sinopulmonary infections. Group 1 consisted of patients with corticosteroid-dependent bronchial asthma, group 2 patients had corticosteroid-dependent chronic bronchitis/emphysema, and group 3 was comprised of asthma patients not requiring oral corticosteroids but associated with recurrent sinopulmonary infections. One or more IgG subclass deficiencies were noted in 66.7 percent of group 1, 46.7 percent of group 2, and 6.7 percent of group 3. Significant differences were noted between groups 1 and 3 (p = .0008) and between groups 2 and 3 (p = .018), but not between groups 1 and 2 (p = .5). IgG1 deficiency was the most common subclass deficiency found; 14 (77.8 percent) of 18 patients with detectable subclass deficiency demonstrated IgG1 deficiency. In this study population, IgG subclass level deficiencies appeared to be secondary to long-term low-dose corticosteroid therapy.

The patient was a 31-year-old black woman first diagnosed with vaginal Trichomonas 4 to 5 years ago. Approximately 10 minutes after taking a single dose of metronidazole (2 gm orally), she developed hives over her entire body, followed by shortness of breath. Her symptoms resolved spontaneously after 15 minutes. Two years ago, the patient again developed vaginal Trichomonas and was treated with metronidazole, followed by the same symptoms. The patient was treated in the emergency room with subcutaneous epinephrine. During the past year, the patient has had a persistent Trichomonas infection despite multiple clinic visits and alternative treatments to metronidazole, including topical clotrimazole cream and zinc oxide. The patient had no other drug or food allergies. Physical examination was significant only for vaginitis with a strawberry type cervix and yellow frothy discharge. Laboratory data were positive by wet-drop examination and Trichomonas direct fluorescent Ab test. The patient was referred for an allergy consultation for metronidazole desensitization for persistent Trichomonas (Table I). At approximately one half the therapeutic dose (750 mg), the patient developed an urticarial lesion associated with throat tightness within 10 minutes. Blood pressure remained stable, and her chest was clear to percussion and auscultation. Treatment with an antihistamine (astemizole, 10 mg orally, one dose) and corticosteroids (dexamethasone, 8 mg intramuscularly, one dose) was then administered. The urticarial lesion and chest tightness re

A report of three patients who developed angiodema while receiving enalapril. Patient 1 came in with an 8-hour history of facial swelling after enalapril had been started 2 days earlier. The second patient came in with severe angiodema of the tongue, larynx, and glottis requiring emergency tracheostomy, hydroxyzine, and steroids. He had been treated with enalapril for 1 year. The third patient developed facial swelling within a few hours of the first dose of enalapril. Angiodema with enalapril can occur early or late in the course of therapy. A possible mechanism for this drug reaction is the potentiation of bradykinin with resultant kinin system activation.

Rationale We used delayed type hypersensitivity (DTH) skin testing to examine the hypothesis that declining cell-mediated immunity is more closely linked to chronic disease burden than to chronological age. Methods 58 elderly subjects were tested for delayed type hypersensitivity (DTH) response to Candida antigen. Each subjects' disease burden was quantified using the Cumulative Illness Ratings Scale (CIRS). Higher CIRS score reflects greater disease burden. Mean DTH response by age group ( 79 yo) was compared with mean DTH response by CIRS score ( 15). Total serum IgE levels were measured and similarly stratified by age and CIRS score. Results Mean Candida DTH responsiveness declined progressively with increasing disease burden (increasing CIRS score). Mean DTH responses were 7.4 mm, 3.4 mm, and 0.0 mm for CIRS groups 15 respectively. Interestingly, Candida DTH response showed no progressive decline with advancing age. Mean DTH responses were 5.2 mm, 3.5 mm, and 5.0 mm in subjects 79 yo respectively. Total serum IgE levels increased with advancing age. Mean total IgE levels were 183, 249, and 342 in subjects >71 yo, 71-78 yo, and >79 yo respectively. No correlation was observed between mean total IgE levels and CIRS score. Conclusions We note an inverse relationship between Candida DTH response and CIRS score, suggesting that increased chronic disease burden is associated with diminished cell-mediated immune response. Surprisingly, advancing age did not predict a diminished DTH response in our subjects. No relationship was observed between disease burden and total serum IgE.