Biomedical subjects
Publications and source records attributed to R Jarisch.
The results of specific immuno-therapy are very satisfactory in allergic rhinitis and insect venom allergies (80-95%), less effective in bronchial asthma (60%) in cases of combined intrinsic asthma. Side effects can be avoided by using standardized allergen vaccines, with a premedication of antihistaminesca and with limitation of the maximal dose.
Allergy diagnosis is based on history, skin-test, RAST and lung functions test. For skin-test a modified PRICK-test is used. In allergic rhinitis and bronchial asthma the evaluation of this test is clear, in food-allergies however 50% false positive resp. negative results are seen. Very difficult is the diagnosis in drug allergies. In atopic dermatitis and contact-eczema a patch-test has to be done too.
Data on systemic side effects (SSE) of specific immunotherapy of allergic diseases recorded in 99 publications over the past 10 years were evaluated and compared with the figure of 0.4% SSE, according to number of injections, published in 1987 by the authors of the present study. The latter figure ranks among the lowest of comparable publications and under present conditions represents the standard. Reasons for the small number of side effects may be found in persistent use of antihistamine premedication before each injection and reduction of vaccination dosage to 50,000 SQ units maximally. Chemically modified allergens are by no means less liable to produce side effects than other allergens. The comparison was undertaken with respect to the following preparations: Alavac P, Allergovit, Allpyral, Alutard, Aquagen (ALK aqueous), Conjuvac, Diephuis, Migen, Novo Helisen, Pangramin Depot, Pharmalgen, Pollinex, Reless, Spectralgen, Stallergenes Depot, and some vaccines, prepared by the authors themselves.
The presence of antibodies against ethylene oxide, which is used for sterilization of dialyzers, was evaluated in 52 hemodialysis patients (30 male, 22 female). The aim of the prospective study was to evaluate a possible correlation of these antibodies with hypersensitivity reactions during hemodialysis. By means of a radio-allergo-sorbent-test (RAST) only 3.9% (2 patients) were detected to have ethylene oxide antibodies. There was no significant correlation between antibodies on the one hand, and symptoms, eosinophilia and IgE-elevation on the other hand. We could not find ETO-induced hypersensitivity reactions in our study population. Thorough rinsing and sufficient storage time of the dialyzers might be the reasons for these findings.
Allergen extracts for skin prick testing (SPT) are available from several manufacturers. Although these solutions are specified according to well-defined internal company standards, there is no generally accepted overall standardization. To assess the comparability of skin prick test solutions of various manufacturers, we compared extracts of nine different allergens from four companies by SPT in 29 children sensitive to one or more of the allergens, in a double blind fashion. RAST (Pharmacia) and EAST (Kallestad) were determined in simultaneous blood samples. Allergen extracts were also examined by rocket immunoelectrophoresis for their content of major allergens. Skin reactions, assessed by mean diameter of wheals, to identical allergen extracts varied significantly between the four vendors (P less than 0.05-0.001). Correlation between RAST and EAST was good for all allergens except birch pollen and mugwort. Content of the major allergen in corresponding extracts varied significantly between the different companies (less than 1%-2000%). These data underline the need for international reference extracts as intracompany standardization of test solutions alone is not enough to yield general reproducibility of skin prick test results.
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A 60 year-old female patient had worked for decades in a plant nursery helping to grow chrysanthemums and sell them around All Saints' Day. During the past several years she had suffered from eczema of the hands that became worse from season to season, and finally became generalized and persisted. Epicutaneous skin testing revealed a strong reaction to chrysanthemums and, in addition, cross-reactivity to several species of the compositae family. Due to these cross-reactivities, a switch to other garden work was impossible. Avoidance of all contact with flowers led to resolution of the patient's skin problems.
Immunotherapy with Hymenoptera venoms is widely used throughout the world and is accepted as an effective treatment for most patients with Hymenoptera venom allergy. There are, however, still some unresolved problems with this form of treatment. At present there is no definite test which makes it possible to identify patients at risk - and thus candidates for immunotherapy - unequivocally. On the basis of prospective studies on the natural history of Hymenoptera allergy, venom immunotherapy is indicated in adults with severe systemic anaphylaxis. It is usually not necessary in patients with large local reactions only. Children with mild systemic reactions, e.g. urticaria, will need immunotherapy only in case of repeated reactions and/or a high risk of re-exposure. The selection of venoms for immunotherapy may lead to some confusion owing to common antigenic determinants shared by venoms of various Hymenoptera species. Many different regimens for immunotherapy have been proposed. At present, the three main are: rush, stepwise or clustered and classical. The maintenance dose of 100 micrograms usually protects from life-threatening reactions. However, in some patients 200 micrograms are necessary for complete protection. The usual interval between maintenance injections is 4 to 6 weeks. In many patients a strong increase of venom specific serum IgG-antibodies usually parallels clinical protection induced by venom immunotherapy, although many exceptions have been reported. Allergic side effects of venom immunotherapy are not rare, especially with honey bee venom and during the initial phase of dose increase. The question of the duration of venom immunotherapy is handled differently: although some authors recommend treatment for life, most suggest treating patients until skin tests and RAST become negative.
In a pilot study on 869 trainee hairdressers eczematous changes of the hands, presenting as chronic toxic contact eczema, were found in 42-55% of the investigated persons. In a subsequent therapeutic study involving 144 trainee hairdressers who had marked chronic toxic contact eczema, it was shown that regular use of pH-stabilized creams and ointments and use of non-alkaline soaps are effective and the use of cortisone ointments should not be necessary. It was demonstrated that 70% of the probands showed clear improvement in eczematous changes as controlled by colour changes in the nitrazine yellow test. However, 30% of those investigated were not thought to be able to continue as hairdressers. These results enable early detection of persons in whom a change of occupation seems indicated. Furthermore, treatment of young persons permits maximal curative changes and represents a model of preventive medicine in dermatology.
Specific IgE antibodies against whole-milk-antigen mixture and against casein, alpha-lactalbumin and beta-lactoglobulin were determined using the radioallergosorbent test (RAST) in 125 sera of children with an initial diagnosis of suspected cow milk allergy. The results of the RAST were correlated with the clinical diagnosis. No specific IgE antibodies could be demonstrated in 98 children. Of these, 20 (20%) showed clinically intolerance to cow milk presumably on the basis of other immunological mechanisms. Specific IgE antibodies could be demonstrated in the sera of 27 children. Of these, 16 (60%) actually showed allergy to cow milk. A statistically significant association with chi 2 test could be established between positive RAST and clinical diagnosis (p = 0.001).
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38 children with bronchial asthma were investigated for allergy (RAST), non-specific bronchial hyperreactivity (acetylcholine challenge) and reaction to physical exercise (free running and bicycle ergometry). 17 patients showed EIA caused by free running and 11 by cycloergometry. Patients with clear-cut allergy (n = 27, high RAST values, class 3 and 4) showed exercise-induced bronchoconstriction in a high percentage of cases (16 of 27 following running, 10 of 27 after bicycle ergometry). Such patients also had non-specific bronchial hyperreactivity. This would explain treatment failures after correctly performed specific immunotherapy.
Fifty patients with suspected allergy to penicillin were tested. Skin tests were done with Na-penicillin G and penicilloyl-polylysin. Specific IgE antibody assays were done with penicilloyl G and V conjugates by means of RAST. The overall agreement between skin test and RAST results was 87%, borderline cases not included. In one case, skin tests were positive to penicillamine only, while RAST for penicilloyl G and V both proved to be positive. One case of penicillin allergy could be diagnosed in vitro post mortem only. Two cases of Hoigné syndrome showed no evidence of allergy. Patterns of skin manifestations varied but urticaria was the most commonly seen feature. Twenty patients without adverse reactions to penicillin treatment and seven patients who had not received penicillin over the last 10 years served as controls. None of them were positive in either skin tests of RAST. Two or our twenty control patients developed penicillin allergy during the study. Both showed positive RAST results.
Dialysable transfer factor (TF) was given in 10 paediatric patients with severe atopic dermatitis (AD). Ten patients with AD, matched for age and severity of disease, served as controls. Prior to the therapy with TF and at weekly intervals thereafter, T- and B-cells in the blood, PHA-stimulation, total IgE and specific IgG antibodies to inhalant and food antigens were determined. Therapy with TF was followed by IgE depression in 8/10 patients and was most pronounced in three patients with initially high levels. Some decrease of IgE levels was seen in four controls also, none of them, however, fell to normal levels as was seen in two of the treated patients. Specific IgE levels decreased slightly, but always remained within the pathological range. T-cell counts in the blood increased in 2/10 cases as well as PHA-stimulation, B-cells counts remained within normal limits. Clinical improvement was seen in one patient, five improved slightly and four remained unchanged. Our results indicate, that transfer factor can lower total IgE levels in cases with atopic dermatitis. The effect is most marked in patients with high total IgE levels. Skin involvement, however, does not closely follow in vitro findings.
In 25 patients with primary and 24 patients with recurrent herpetic corneal disease the cell-mediated immunity to Herpes simplex virus antigen (type I) was measured using a leukocyte migration inhibition assay. After a period of one to 24 months 25 of the patients were tested again. The diagnostic possibilities offered by this method, especially in respect of control of immune-stimulating therapy, and its pitfalls are discussed.
Based on the results of 500 patients suffering from bee-venom allergy, allergic rhinitis, bronchial asthma, atopic dermatitis and food allergy the necessary diagnostic procedures leading to specific immunotherapy are discussed. The immunstimulating potential of the vaccines varies from patient to patient and is decreased after some viral infections. Good results are seen in young patients and when a low number of allergens is incorporated in the vaccine. Side effects of minor importance are seen in about half the patients. Systemic reactions following specific immunotherapy are seen more often in aqueous solutions compared to depot vaccines. The treatment should be reconsidered, if the patient has not improved after half a year.
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Using a direct assay of leukocyte migration inhibitory factor (LMIF), cell-mediated immunity to herpes simplex virus (HSV) antigen was measured in patients who had primary and recurrent ocular HSV infections. Those with primary and recurrent epithelial disease had a significantly lower production of LMIF than a control population than had had no herpetic infection for at least a year or longer (P less than 0.001). On the contrary, patients with deep stromal involvement and anterior uveitis showed significant migration inhibition with HSV antigen, similar to the one found in the healthy control group. The clinical and possible therapeutic implications of thes findings are discussed.