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1/53. New occupational allergen in citrus farmers: citrus red mite (Panonychus citri).

    BACKGROUND: There have been several reports of occupational allergy to spider mites (tetranychidae), but no published report has described citrus red mite (CRM, Panonychus citri)-induced occupational asthma confirmed by specific bronchial challenge. OBJECTIVE: The purpose of this study was to evaluate clinical and immunologic characteristics of CRM-induced occupational asthma. methods AND RESULTS: We encountered 16 cases of CRM-induced occupational asthma among farmers cultivating citrus fruits. Asthmatic attacks corresponded closely with their work on citrus farms. The mean duration of the latent period was 12.9 (range 7 to 20) years. During their first visit to our clinic, nine patients with FEV1 lower than 70% of predictive value showed reversible airway obstruction after inhalation of bronchodilator, and seven with FEV1 greater than 70% of predictive value showed airway hyperresponsiveness to methacholine. Fifteen of the 16 also complained of recurrent nasal symptoms, which had developed at an earlier time than the asthmatic symptoms. They showed strong positive reactions to CRM extract on skin prick test (A/H ratio > or = 1.0) and had high serum specific IgE antibody against CRM which was detected by ELISA. skin prick test with common inhalant allergens revealed that 10 had an isolated positive response to CRM with negative results to common inhalant allergens in their environment. The ELISA inhibition tests with CRM demonstrated significant inhibitions by CRM in a dose-dependent manner, while minimal inhibitions were noted by D. pteronyssinus and mugwort allergens. CONCLUSION: These findings suggest that CRM could induce IgE-mediated bronchoconstriction in exposed workers on citrus farm.
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2/53. Treating allergic rhinitis in pregnancy. safety considerations.

    Allergic rhinitis affects approximately one-third of women of childbearing age. As a result, symptoms ranging from sneezing and itching to severe nasal obstruction may require pharmacotherapy. However, product labels state that medications for allergic rhinitis should be avoided during pregnancy due to lack of fetal safety data, even though the majority of the agents have human data which refute these notions. We present a systematic and critical review of the medical literature on the use of pharmacotherapy for the management of allergic rhinitis during pregnancy. Electronic databases and other literature sources were searched to identify observational controlled studies focusing on the rate of fetal malformations in pregnant women exposed to agents used to treat allergic rhinitis and related diseases compared with controls. immunotherapy and intranasal sodium cromoglycate (cromolyn) and beclo-methasone would be considered as first-line therapy, both because of their lack of association with congenital abnormalities and their superior efficacy to other agents. First-generation (e.g. chlorpheniramine) and second-generation (e.g. cetirizine) antihistamines have not been incriminated as human teratogens. However, first-generation antihistamines are favoured over their second generation counterparts based on their longevity, leading to more conclusive evidence of safety. There are no controlled trials with loratadine and fexofenadine in human pregnancy. Oral, intranasal and ophthalmic decongestants (e.g. pseudoephedrine, phenylephrine and oxymetazoline, respectively) should be considered as second-line therapy, although further studies are needed to clarify their fetal safety. No human reproductive studies have been reported with the ophthalmic antihistamines ketorolac and levocabastine, although preliminary data reported suggest no association between pheniramine and congenital malformations. There are no documented epidemiological studies with intranasal corticosteroids (e.g. budesonide, fluticasone propionate, mometasone) during pregnancy; however, inhaled corticosteroids (e.g. beclomethasone) have not been incriminated as teratogens and are commonly used by pregnant women who have asthma. In summary, women with allergic rhinitis during pregnancy can be treated with a number of pharmacological agents without concern of untoward effects on their unborn child. Although the choice of agents in part should be based on evidence of fetal safety, issue of efficacy needs to be addressed in order to optimally manage this condition.
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3/53. Occupational IgE-mediated asthma, rhinoconjunctivitis, and contact urticaria caused by Easter lily (lilium longiflorum) and tulip.

    BACKGROUND: We report on IgE-mediated asthma, rhinoconjunctivitis, and contact urticaria to two liliaceae plants, tulip and Easter lily (lilium longiflorum), diagnosed in a floral shop worker. methods: Occupational asthma was diagnosed according to patient history, PEF monitoring, and a work-simulating provocation test. Flower-specific IgE was studied, and RAST inhibition tests were performed. RESULTS: skin prick testing showed positive reactions to tulip, Easter lily, and chrysanthemum. Total IgE was 180 kU/I, and specific IgE to tulip was 2.6 and to Easter lily 6.5 kU/I. In the RAST-inhibition test, no cross-reactivity was found. Occupational asthma was diagnosed by peak flow monitoring at work and at home, as well as specific inhalation challenge with Easter lily, with an immediate 18% reduction in PEF. In addition, contact urticaria and conjunctivitis were diagnosed. After a 9-year follow-up without exposure to lilies, the skin prick tests to L. longiflorum and tulip were still positive, but the specific IgE had disappeared. CONCLUSIONS: A case of IgE-mediated occupational asthma, rhinoconjunctivitis, and contact urticaria caused by L. longiflorum and tulip is presented. RAST inhibition tests indicated concomitant sensitization to the two liliaceae plants.
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4/53. Respiratory allergy to mushroom spores: not well recognized, but relevant.

    BACKGROUND: Although basidiospores are a major component of the air spora in many parts of the world, their clinical significance as triggers of respiratory allergy has rarely been demonstrated. Therefore, the class of basidiomycetes as an aeroallergen is not well known. OBJECTIVE: To demonstrate a cause and effect relationship between respiratory allergy and basidiospores, we illustrate this case report of a 38-year-old housewife. methods: skin prick test, immunoblot, and active anterior rhinomanometry were used as diagnostic tools to verify specific reactivity of a pleurotus pulmonalis spore extract. Two atopic subjects served as controls. RESULTS: The skin prick test positive study subject reacted with subjective and objective signs including a significant drop of the FEV1 by nasal challenge at a concentration of 0.1 mg/mL of the pleurotus spore extract while both controls were negative even at a higher test concentration. IgE-immunoblot revealed several distinct bands in the serum of the pleurotus-sensitized subject. CONCLUSION: spores of pleurotus pulmonalis, a common mushroom of the fungal class of basidiomycetes, can cause specific, IgE-mediated acute rhinoconjuncivitis and asthma in sensitized individuals.
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5/53. Seven cases of complete and incomplete forms of churg-strauss syndrome not related to leukotriene receptor antagonists.

    BACKGROUND: Various forms of churg-strauss syndrome have been reported in association with the use of leukotriene receptor antagonists in asthmatic patients. OBJECTIVE: Our purpose was to increase awareness that different forms of the churg-strauss syndrome occur in patients not receiving leukotriene modifiers. methods: We searched for all the cases of churg-strauss syndrome that were seen in the University of Rochester Medical Center, new york, in the past 4 years. RESULTS: We identified 7 patients, 6 of whom fulfilled the American College of rheumatology criteria for the classification of churg-strauss syndrome. None of them used leukotriene receptor antagonists. All had asthma and sinus disease. The duration and severity of their asthma varied considerably. In the majority of the patients the features of churg-strauss syndrome became obvious as the systemic corticosteroid dose was being tapered or discontinued, although 3 patients had not been receiving maintenance oral corticosteroids at disease onset. Three patients had positive antineutrophil cytoplasmic antibodies test result (perinuclear pattern). There was histologic documentation of vasculitis in 4 patients. Five of 7 patients responded to high-dose corticosteroid treatment. CONCLUSION: Our 7 cases are similar to the various forms of churg-strauss syndrome that have been reported in association with the leukotriene receptor antagonists. Complete or incomplete forms of this syndrome can become apparent in asthmatic patients as systemic corticosteroids are being tapered but can also occur in patients with mild asthma of short duration who use only inhaled corticosteroids.
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keywords = asthma
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6/53. fever of unknown origin in a 10-year-old boy with allergic rhinitis and asthma.

    We believe this case represents a clear example of drug fever, and it appears to be the first report to implicate ketotifen as the responsible agent, confirmed with double rechallenge. The recognition of drug fever is clinically important. Failure to recognize the etiologic relationship between the drug and fever has unnecessary consequences, including extra testing, empiric therapy, and longer hospital stays. We suggest that ketotifen should be considered as a possible cause of fever in allergic patients receiving this drug.
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keywords = asthma
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7/53. Occupational IgE-mediated allergy to tribolium confusum (confused flour beetle).

    BACKGROUND: We report on IgE-mediated allergy in a worker caused by tribolium confusum (confused flour beetle). These beetles lived in the "old" flour to which he was exposed in his work. CASE REPORT: A 35-year-old, nonatopic mechanic in a rye crispbread factory developed rhinitis, conjunctivitis, and asthmatic symptoms, as well as urticaria on his wrists, lower arms, hands, neck, and face, during the maintenance and repair of machines contaminated by flour. This flour had been in and on the machines for a long time, and it contained small beetles. The patient did not suffer any symptoms when handling fresh, clean flour. RESULTS: skin prick tests with standard environmental allergens, storage mites, enzymes, flours, and molds were negative. A prick test with flour from the machines gave a 10-mm reaction. An open application of the same flour caused urticarial whealing on the exposed skin. Prick tests with fresh flour from the factory were negative. A prick test with minced T. confusum from the flour in the machines gave a 7-mm reaction. Histamine hydrochloride 10 mg/ml gave a 7-mm reaction. Specific serum IgE antibodies to T. confusum were elevated at 17.2 kU/l. Prick tests with the flour from the machines were negative in five control patients. CONCLUSIONS: The patient had occupational contact urticaria, rhinitis, conjunctivitis, and asthmatic symptoms from exposure to flour. His symptoms were caused by immediate allergy to the beetle T. confusum. Immediate allergy to this beetle has rarely been reported in connection with respiratory symptoms, but it may be more common. Contact urticaria from this source has not been reported before.
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ranking = 0.5
keywords = asthma
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8/53. Occupational asthma and rhinitis caused by multiple herbal agents in a pharmacist.

    BACKGROUND: Herb agents have been widely used for centuries in the Orient and they have been cultivated throughout asia. There have been a few cases of occupational allergy caused by herb materials. We report a case of occupational asthma and rhinitis caused by six herb materials in a pharmacist working at a pharmacy. OBJECTIVE: We sought the role of immediate hypersensitivity in herbal agent-induced asthma in a pharmacist. methods AND RESULTS: The patient had strong positive responses on skin prick test to extracts of six herb materials: Chunkung (Cnidii rhizoma), Banha (pinellia ternata), Sanyak (dioscorea radix), Kangwhal (Ostericum koreanum), Danggui (angelica radix), and Kunkang (Zingiberis rhizoma). Bronchoprovocation tests showed an early asthmatic response to Danggui extract. serum specific IgE antibodies to Chunkung, Banha, and Sanyak were detected by ELISA with no specific IgE bindings to Kangwhal, Danggui, and Kunkang extracts. Twelve percent sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and IgE immunoblotting revealed one IgE binding component (60 kD) within Chunkung extract, two (10, 25 kD) in Banha, and four (33, 34, 65, 98 kD) in Sanyak. Basophil histamine release test revealed that Danggui extract could release a greater amount of histamine from basophils in the patient than in a healthy control. CONCLUSIONS: Chunkung, Banha, and Sanyak may induce IgE-mediated bronchoconstriction in an exposed worker, and Danggui can cause bronchoconstriction by direct histamine-releasing effect from mast cells in a sensitized patient.
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ranking = 1.75
keywords = asthma
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9/53. Allergic fungal rhinosinusitis: report of 4 cases from saudi arabia.

    Allergic fungal rhinosinusitis is a newly recognized clinical entity of chronic rhinosinusitis. Over the past 3 years, 4 such patients were treated in our hospital. The clinical and pathological features of these 4 cases which merited the criteria for such diagnosis, are described. All the 4 cases had history of nasal polyps, asthma, or both with radiographical evidence of pansinusitis. Histologically, the thick greenish-brown inspissated material specimens which were collected and submitted to the laboratory showed, eosinophils, Charcot-Leyden crystals but no fungal elements were detected on routine hematoxylin and eosin sections and no tissue invasion was noted. However, scanty aspergillus hyphae were detected on sections stained with silver. All 4 cases grew aspergillus flavus only from the swabs and no other fungi were seen and all were treated by surgical debridement, aeration, oral itraconazole with no steroids.
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keywords = asthma
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10/53. Allergic vulvovaginitis in infancy: study of a case.

    BACKGROUND: the role of dust mites (Dermatophagoides pt.) in the pathogenesis of allergic vulvovaginitis is still controversial. association between this mite and atopic dermatitis, conjunctivitis, rhinitis or asthma is already known.Some authors study the possible relationship between some vulvovaginitis and local hypersensitivity. The aim of this study was to corroborate the allergic aetiology due to the mite Dermatophagoides pt. in a girl with vulvovaginitis and perennial rhinitis. methods AND RESULTS: we studied a nine year-old patient with symptoms of perennial rhinitis and unspecific vulvovaginitis of torpid evolution. In vivo and in vitro allergologic tests were performed as well as complete analytic tests including immunoglobulins, urine tests, nasal culture, exudative vaginal culture, and parasitic test.skin test was positive for Dermatophagoides pt. as well as specific IgE (99.5 kU/L). Total IgE was elevated for her age (492 kU/L). In the rest of the complementary tests, no values out of normality or pathological findings were obtained. CONCLUSIONS: considering these results, it was suspected that the nasal symptoms and the vulvovaginitis presented by the patient are of allergic aetiology by hypersensitivity to the mite Dermatophagoides pt. The study did not prove relation with bacteria, parasites, candida albicans or any inhalant allergens other than mites.After three months of treatment with oral antihistamines and topical chromones, as well as environmental avoiding measures, the symptoms totally yielded.
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