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1/23. 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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2/23. 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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3/23. Rush immunotherapy in a dog with severe ragweed and grass pollen allergy.

    BACKGROUND: Forty years of study of naturally occurring IgE-mediated allergy in animals is briefly reviewed. These studies provided models for study of bioactive mediators and innovative pharmacologic therapies for IgE-mediated asthma. Objective: Based on our experience with canine allergy we evaluated and treated a dog with severe grass and ragweed allergy whose allergic dermatitis was uncontrolled by H1 blockers and topical corticosteroids. The dog was miserable during the chicago grass and ragweed pollen seasons. methods: Rush immunotherapy was initiated during the ragweed season of 1997. RESULTS: Dramatic improvement was seen which persisted through the grass and ragweed seasons of 1998 after maintenance immunotherapy. CONCLUSION: The case is presented not as a model for canine immunotherapy but as an example of how animal research can be of value to both animals and humans.
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4/23. 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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5/23. Rhinoconjunctivitis and occupational asthma caused by Diplotaxis erucoides (wall rocket).

    Wall rocket (Diplotaxis erucoides) is a common Crucifera plant that grows in European and American vineyards and olive groves. We present the cases of 2 farmers with rhinoconjunctivitis and asthma related to wine-growing tasks during D erucoides pollination (March-April). The aim of this work was to demonstrate that occupational symptoms were caused by D erucoides pollen sensitization. Cutaneous tests, specific IgE measurements, conjunctival and bronchial provocation tests, and peak-flow measurements during working days were performed.
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6/23. asthma, rhinitis and dermatitis triggered by fungal infection: therapeutic effects of terbinafine.

    We report 2 atopic patients suffering from tinea unguium caused by trichophyton rubrum. In addition, both patients had symptoms of allergies: one had perennial rhinoconjunctivitis and bronchial asthma, the other had chronic dermatitis of the face and neck. In both cases, their allergy symptoms improved dramatically during oral therapy with the antifungal agent terbinafine (250 mg/day) and relapsed after its discontinuation.
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7/23. Response of asthma-related voice dysfunction to allergen immunotherapy: a case report of confirmation by methacholine challenge.

    Professional singers and other serious voice users are particularly susceptible to alterations in their vocal apparatus. As the support for vocalization, lung function is an essential element of the production of speech and song. patients have been described who presented with voice complaints along with minimal or no abnormalities on spirometry, but responded to conventional bronchodilator and other asthma therapy. It was proposed that this represented an exercise-induced asthmalike condition, brought on by the hyperventilation associated with performing. The objective of this study was to establish whether improvement in vocalization while performing correlated with a decrease in non-specific bronchial reactivity. We concluded that resolution of vocal complaints in conjunction with a decrease in methacholine reactivity supports the hypothesis that these patients do have an exercise-induced asthmalike condition brought on by airway drying. As with other patients with asthma, it appears to respond to allergy-directed therapy.
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8/23. Influence of natural exposure to pollens and domestic animals on airway responsiveness and inflammation in sensitized non-asthmatic subjects.

    BACKGROUND: Atopy may be a risk factor in the development of asthma. Indoor allergens are considered to be more potent asthma inducers than outdoor ones such as pollens. Lower airway inflammation may be present in non-asthmatic subjects during natural exposure to relevant allergens and may eventually lead to the development of asthma. AIMS: To document seasonal variation in lower airway responsiveness and inflammation in sensitized non-asthmatic subjects, during natural exposure to allergens, and to determine whether it is more marked in those exposed to animals to which they are sensitized. methods: Twenty-two atopic subjects were seen during and out of the pollen season. All (but the controls) were sensitized to domestic animals, and to trees, grasses or ragweed. Eleven were not exposed to animals at home and 8 were exposed. They were compared with 3 normal controls. A respiratory questionnaire was administered, allergy skin prick tests, spirometry, methacholine challenge, blood and induced sputum with differential cell counts were obtained during the pollen season for all subjects. These tests were repeated out of the pollen season. RESULTS: Throughout the study, none of the subjects had asthma symptoms. Mean PC(20) was significantly lower in subjects exposed to animals compared with unexposed subjects or controls, both during and out of the pollen season. In season, subjects exposed to animals had significantly higher sputum eosinophil numbers than unexposed or normal control subjects. CONCLUSIONS: Non-asthmatic atopic subjects show variable degrees of airway responsiveness and inflammation. However, subjects exposed to animals show higher airway eosinophilia, which may suggest they are at increased risk of developing airway hyperresponsiveness and asthma.
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9/23. A case of anaphylaxis due to rose pollen ingestion.

    BACKGROUND: Recent publications have demonstrated that in Guneykent (turkey), a rose-cultivating area, some workers experience various allergic reactions due to contact with rose or its pollen. CASE REPORT: A 47-year-old man, originally from Guneykent although he no longer lived there, suffered perennial rhinitis, asthma and rhinoconjunctivitis in spring related to sensitization to dust mites and various pollens, respectively. On several occasions, he had presented oral and cutaneous symptoms and angioedema due to contact with rose or intake of honey or other products. Finally, he had an anaphylactic reaction on drinking dew collected in the tulips of a rose that possibly contained rose pollen. methods: Specific IgE was evaluated with rosa rugosa extract and was 30.3 IU (class IV). Sensitization to other pollens and to mites was also confirmed. Oral provocation test was not deemed ethical. CONCLUSION: This may be the first reported case of anaphylactic reaction due to rose pollen ingestion.
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10/23. Non-occupational allergy caused by the pine processionary caterpillar (Thaumetopoea pityocampa).

    Contact with the pine processionary caterpillar induces dermatitis, usually located in exposed areas, and, less frequently, ocular lesions through a toxic-irritative mechanism. Recently, the existence of an immediate hypersensitivity mechanism has been demonstrated, mainly in occupationally exposed patients. OBJECTIVE: To present four patients who experienced allergic reactions (urticaria-angioedema and rhinitis-asthma) after non-occupational exposure to pine processionary caterpillar. patients AND methods: The four patients underwent allergy testing through skin prick tests (SPT), specific IgE detection and SDS-PAGE immunoblotting. One patient also underwent a specific bronchial challenge test with the pine processionary antigen. RESULTS: In all patients, both SPT with the caterpillar extract and specific IgE were positive. Western blotting showed several IgE-binding bands with molecular mass values ranging from 18 to 107 kDa. A shift in the electrophoretic mobility of some of the relevant allergens occurred under the presence of a reductive agent (beta -mercaptoethanol). The specific bronchial challenge test with pine processionary antigen performed in one of the patients also produced positive results. CONCLUSIONS: The results of this study show an immunologic IgE-mediated immediate hypersensitivity mechanism in these reactions. The processionary caterpillar's airborne urticating hairs or spicules should be considered, at least in some locations, not only as contact and occupational allergens, but also as seasonal aeroallergens.
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