Atopic Asthma: T-Cell Response to Corticosteroids

Atopic Asthma: T-Cell Response Corticosteroids*

to

Adi Gerblich, M.D.;t Gregory Urda, B.S.; and Mark Schuyler, M.D., F.C.C.P.:j:

Atopic asthma is associated with diminished cell-mediated immunity and elevated levels of IgE, both of which may be caused by imbalances ofT-lymphocyte subsets. We analyzed the response of peripheral blood T-cell subsets to two commonly used corticosteroid preparations as a probe ofT-cell subset regulation. We administered prednisone (P) 60 mg or 20 mg, beclomethasone dipropionate (BDP) aerosol, 336 JJ.g, placebo, or BDP vehicle in a double-blind protocol to 15 atopic asthmatic patients and ten nonatopic subjects. No difference was found between the groups of the baseline num-

her ofT-cells with T4, T8, Ml, and Ia antigens, nor the ratio ofT4+ (helper) to T8+ (suppressor) cells. Five hours after administration of BDP aerosol, BDP vehicle, and oral placebo, there was no change of these values in either the atopic or in the nonatopic group. In contrast, P, 20 and 60 mg, caused a fall ofT4!1'8 ratio in the atopic, but not in the nonatopic population. Atopic asthma is not associated with baseline imbalances of peripheral blood T-cell subsets, but is associated with an abnormal response to systemic, but not inhaled corticosteroid.

is associated with markers of defective cellmediated immunity, such as increased susceptibility to infections with viruses and fungi and depressed delayed type skin test reactivity to both recall and neoantigens.u Elevated levels oflgE (characteristic of atopy) are present in patients with diseases that exhibit immunologic dysfunction such as WiskottAldrich syndrome, graft vs host disease, Hodgkins disease, mycosis fungoides, and the hyperimmunoglobulin E syndrome. In experimental animals, serum IgE level is under exquisite control ofT-cells so that T-suppressor cells can down-regulate lgE production. Despite these links between elevated serum lgE and abnormal T-cell function in both animals and humans, most reports indicate normal T-cell number (defined by sheep red blood cell receptors), mitogen-induced T-lymphocyte proliferation, and T-cell subsets in atopic subjects. 1 T-cells include many different functional subclasses, such as helper and suppressor cells, which are characterized by different cell surface antigens and can be detected with monoclonal antibodies. Corticosteroids are often administered to patients with respiratory atopy. Systemic corticosteroids in man induce a prompt, transient T-lymphocytopenia and depressed lymphocyte responsiveness to mitogens and antigens caused by redistribution of recirculating T-cells to bone marrow. 3•4 TherefOre, both to examine the effects of commonly

used medications in patients with respiratory atopy, and to use corticosteroids as a probe to detect subtle differences of T-cell subsets in atopic asthmatic and nonatopic subjects, we examined the effects of corticosteroids on T-cell subsets. Corticosteroids differ in their in vivo effect on lymphocyte function 5 so that administration of only one preparation might not be sufficient to reveal a limited difference between atopic and nonatopic subjects. We therefOre compared the effects of prednisone and beclomethasone dipropionate (BDP) aerosol and used two different amounts of prednisone to discern dose-response relationships. In this study, we used monoclonal antibodies to define the helper, suppressor, natural killer, and activated T-cell populations present in peripheral blood. We examined natural killer and activated T-cells because patients with diseases associated with imbalances ofT-cell subsets have abnormalities of these T-cell subsets. 6 •7 It was found that compared to a nonatopic population, atopic asthmatic patients exhibited a larger fall of T-cells that were T4 +, and consequent statistically significant fall of the T4ff8 ratio in response to both 20 and 60 mg prednisone. Inhaled beclomethasone dipropionate induced no changes ofT-cell subsets in either group.

~opy

•From the Department of Medicine, Case Western Reserve School of Medicine, and Cleveland VA Medical Center, Cleveland. Supported by NIOSH grant 00992 and the Veterans Administration Research Service. Presented in part at the 49th Annual Scientific Assembly, American College of Cliest Physicians, Chicago, Oct 23-27, 1983. t Assistant Professor of Medicine. *Associate Professor of Medicine. Manuscript received April30; revision accepted July 24. Reprint requests: Dr. Schuyler, VA Medical Center, Brecksville, Ohlo 44141

44

METHODS Subjects After informed consent, 15 atopic asthmatic patients and ten nonatopic subjects were studied. All subjects had skin prick tests performed with the following aeroallergens: oak, elm, cottonwood, hickory, birch, June grass, Bermuda grass, timothy, mixed ragweed, plantain, Alternaria, Aspergillus, cat and dog dander, and house dust (Center Labs, Yonkers, NY). A subject was considered atopic ifhe or she had one or more positive tests (2 mm or greater wheal diameter). The nonatopic group had negative skin tests to the above allergens. Forced expired volume in one second (FEV1) and specific conductance (SGaw) were measured with a Collins spirometer and a Atopic Asthma (Gerbllch, Urda, Schuyler)

Table I-Study Population Characteristics* Group

Number

Age {yr)*

Sext {M:F)

Asthmatic Nonatopic p

15 10

23.7±1.3 24.8±1.6 ns

5:10 4:6 ns

FEV1

SGaw

lgE*

10.5%±2.5% ND

66%±8.3% ND

141 33 <0.01

*Values are mean and standard error of the mean. FEV1, mean increase of furred expired volume in one second after inhalation of 200 J.Lg isoproterenol; SGaw, mean increase of specific conductance after inhalation of 200 1-Lg isoproterenol; IgE, international units per milliliter, geometric mean; ND, not determined; and ns, not significant. tGroups compared using Chi square test. *Groups compared using Mann Whitney rank sum test. variable pressure total body plethysmograph, respectively, by methods standard in our laboratory. 8 Asthma was defined as reversible airway disease as demonstrated by either a 15 percent increase of FEV1 or a 35 percent increase of SGaw after inhalation of 200 J.Lg isoproterenol aerosol. These changes are twice the coefficient of variation of repeated measurements of asthmatic subjects in our laboratory9.1° and more than three times the coefficient of variation of repeated measurements of normal subjects. u All subjects had chest roentgenograms, ECGs, urinalysis, complete blood count, and fasting blood sugar level determinations. On five different days, separated by two to 21 days, the following regimens were administered to the subjects: 1. Prednisone 20 mg (capsule) and eight puffs of inhaled BOP aerosol vehicle. 2. Prednisone 60 mg {capsule) and eight puffs of inhaled BOP aerosol vehicle. 3. Lactose {capsule) and respiratory maneuvers simulating inhalation of eight puffs of aerosol using an empty canister. 4. Lactose {capsule) and eight puffs of inhaled beclomethasone dipropionate (BOP, 336 J.Lg total). 5. Lactose {capsule) and eight puffs of inhaled BOP aerosol vehicle. Thirty milliliters of anticoagulated (20 units heparin per milliliter) venous blood was obtained at 8 to 8:30AM (baseline) and five hours thereafter, at the time of maximal corticosteroid effect on circulating lymphocytes. 3.!2 Neither the subjects nor the investigators were aware of the identity of the drugs until after the study was completed. The subjects were exposed to no medications for 48 hours prior to study. Total white blood cell count was determined with an automated cell counter, and the percentage of lymphocytes, monocytes, and polymorphonuclear leukocytes was determined by a differential count of 200 cells of a Wright-stained smear. Lymphocyte Analysis Mononuclear cells were separated by sedimentation over FicollHypaque {specific gravity 1.076) and depleted of adherent cells by the use of iron particles and a magnet. Purified T-cell populations were obtained by two sequential rosette fOrmation steps with neuraminadase treated sheep red blood cells (SRBC) and separation of the rosette fOrming cells over Ficoll-Hypaque gradients. The cells were incubated in 50 percent fetal calf serum at 37"C fur one hour to elute absorbed immunoglobulin. The final cell population consisted of 85 percent to 89 percent T-cells as defined by the ability to furm rosettes with SRBC, 1 percent to 2 percent surface immunoglobulin positive cells, and less than 2 percent monocytes (nonspecific esterase positive cells). 13 The cells were incubated with mouse antihuman monoclonal antibody to 1'3, T4, TS, M1, or Ia antigen in 0.2 percent bovine serum albumin containing media fur 30 minutes at 4"C. After washing and further incubation with fluorescein-conjugated goat antibody to mouse immunoglobulin, the cells were examined fur fluorescence with a Leitz Diavert microscope using Ploem epi-

fluorescent illumination. The percentage of 200 cells that were fluorescent was recorded. Most circulating T-cells exhibit surface T3 antigen; helper/inducer T-cells, T4 antigen; and suppressor/cytotoxic T-cells, T8 antigen. 14 The M1 antigen is present on B cells and natural killer T-cells. 1l1 The Ia antigen, a product of the HLA-DR gene complex, is present on monocytes, B-cells and activated T-cells. 1 Serum lgE A solid phase radioimmunoassay using a monoclonal antibody directed against human IgE was used. Total Eosinophil Count The total eosinophil count (TEC) was determined by dilution of blood with Dunger's solution and counting eosinophils on a FuchsRosenthal hemocytometer. 18 Statistics Values are expressed as mean and standard error of the mean. Data were analyzed by performing a one-way analysis of variance (ANOVA) and paired Students t-tests if ANOVA indicated that the variance of the two sets of values were similar and the Mann Whitney two-sample rank test if ANOVA indicated that the sets were dissimilar. The Chi-square test was used to compare characteristics of the two groups. 11.18 RESULTS

Characteristics of Study Population

We studied 15 atopic asthmatic patients and ten nonatopic subjects (Table 1). The mean age of the asthmatic patients was 23.7 years and of the nonatopic subjects, 24.8 years. The atopic asthmatic subjects had multiple positive immediate skin tests (mean and SEM 6. 8 ± 1. 0, range 3 to 13). Most of the asthmatic subjects had mild asthma as indicated by 10.5±2.5 percent (mean, SEM) improvement of FEV, and 66 perTable 2-Blood Work-Ups*

WBC Lymphocyte % Lymphocyte No. (percu mm) TEC

Atopic Asthmatics (15)

Nonatopic Subjects (10)

p

6016± 163 31.4±0.8 1874±63

5648±217 31.8± 1.3 1740±76

ns ns ns

259± 14

123± 10

<0.01

*TEC, total eosinophil countlcu mm; ns, not significant; WBC, total white blood cell countlcu mm. Values are mean and standard error of the mean. The p values derived from unpaired t-test and Mann Whitney rank sum test. CHEST I 87 I 1 I JANUARY, 1985

45

Table 3-T-CeU Subsets (Percent)*

1'3% T4% 1'8% M1% Ia% T4/f8 Ratio

Atopic Asthmatics

Nonatopic Subjects

p

94.3±0.4 51.7±1.0 31.4±0.9 10.0±0.8 1.6±0.2 1.80±0.09

92.5±0.7 52.9± 1.2 30.9±0.9 9.4± 1.0 1.5±0.3 1.81±0.08

<.05 ns ns ns ns ns

*Values mean and standard error of mean; ns, not significant; and p values derived from unpaired t-test and Mann Whitney rank sum test.

cent± 8.3 percent improvement of SGaw after bronchodilator inhalation. Fourteen of the 15 subjects had more than 40 percent improvement of SGaw {range 42 percent to 127 percent). The remaining subject had a 20 percent improvement ofFEV1• Serum lgE level was higher in the atopic asthmatic group. None of the nonatopic subjects and six of the atopic asthmatic subjects were taking long-term medication, and no subject had received medication within 48 hours of the study days. Chest roentgenogram, ECG, urinalysis, complete blood count, and fasting blood glucose level were normal in all subjects. As indicated in Table 2, compared to the nonatopic subjects, the atopic asthmatics' total eosinophil count was higher. There was no difference of the total white blood cell count, lymphocyte percentage, or number.

Baseline Values The percentage of purified T-cells that express T4, T8, M1, and Ia antigens was the same in the atopic asthmatic and nonatopic groups {Table 3). There was a small difference in the percentage that were T3 + . Both groups exhibited variability when repetitively tested, but one-way analysis of variance of the percentage of cells with T4, 1'8, M1, and Ia surface antigens indicated no significant difference of variance between Table 4-Peripheral Blood Leukocytes* Regimen P20mg Inhalation Vehicle Atopic Asthmatics (15) -92t TEC WBC +33t Lymph% -76t Nonatopic Subjects (10) -95t TEC WBC +33t Lymph% -79t Oral

Post Medication Values Both 20 and 60 mg prednisone caused a significant increase of total WBC, a fall of percentage of cells that were lymphocytes, and a profound fall of the total eosinophil count in both the atopic asthmatic and the nonatopic populations {Table 4). Performance of respiratory maneuvers associated with inhalation (regimen 3) and inhalation of vehicle (regimen 5) had no significant effect on the above values. Inhalation of BDP (regimen 4) caused a small decrease of lymphocyte percentage in the atopic asthmatic, but not in the nonatopic group. Although BDP caused a decrease of lymphocyte percentage compared to baseline values, there was no difference between inhalation of BDP (regimen 4) and placebo (regimen 3). In the nonatopic group, none of the treatment regimens had a statistically significant effect on the percentage ofT-cells that expressed T3, T4, T8, M1, or Ia antigens (Table 5 and Fig 1). In contrast, the atopic asthmatic population responded to both 20 mg and 60 mg prednisone with a statistically significant decrease of the proportion of purified T-cells that were T4 +, a small increase ofT8 + cells, and a subsequent statistically significant decrease of the T4fl'8 ratio {Table 5 and Fig 2). Inhalation maneuvers without vehicle (regimen 3), vehicle aerosol (regimen 5), and Table 5-T-CeU Subsets* Regimen

P60mg Vehicle

Placebo 0

Placebo Vehicle

Placebo BDP

-97t +60t -79t

-18 +15 -18

-28 +5 +9 -10

-18

-2lt

-98t +38t -sot

-29 +4 -12

-26 -6 -17

-31 +8 -23

tp
234

P20mg P60mg Vehicle Inhalation Vehicle Atopic Asthmatics (15) -3.0 -7.7 1'3% T4% -9.7t -10.7t 1'8% +2.9 +3.7 -1.5 M1% +5.1 Ia% -0.7 0 Nonatopic Subjects (10) 1'3% -3.4 -2.2 T4% -9.6 -4.9 1'8% -4.1 -3.2 M1% +2.2 +1.3 -1.8 -0.7 Ia% Oral

2345

*WBC is white blood cells/cu mm; TEC, total eosinophil count; P, prednisone; BDP, beclomethasone dipropionate aerosol (336 j.Lg). Results expressed as mean percent change from baseline values. Baseline values are not significantly different from each other (analysis of variance).

48

the groups, so that the unpaired t-test was used. Analysis of variance of the percentage ofT-cells that expressed T3 antigen indicated significant difference of variance between the groups, so that the MannWhitney test was applied. Although the percentage of T3 + cells was higher in the atopic asthmatic than in the nonatopic group, the magnitude of this difference was small (94.3 percent vs 92.5 percent) and is of doubtful biologic significance.

5 Placebo 0

Placebo Vehicle

Placebo BDP

-1.5 -0.3 +0.5 +0.3 +0.3

-2.5 -3.1 -1.3 + 1.8 +1.1

-0.9 -0.9 -0.9 + 1.9 -0.1

+ 1.5 +0.8 +3.0 +2.9 -0.1

-0.4 -2.0 -1.7 -5.7 -1.7 +4.5 +0.8 +3.5 -0.3 +0.5

•p is prednisone; BDP, beclomethasone dipropionate aerosol (336 j.Lg). Results expressed as mean change from baseline values of the percent of purified T-cells expressing antigen. Baseline values are not significantly different from each other (analysis of variance). tp
T4/T8 Ratio Non-Atopic Controls(IO)

lngestial: Prednisone 20mg lriholotion ..eicle

Prednisone 60mg ~~ehicle

placebo

0

placebo whicle

placebo Beclomelhasone

336 f'9 FIGURE 1. T4ff8 Ratio before and five hours after administration of corticosteroid or placebo in a double blind protocol to 10 nonatopic subjects. Mean and standard error of the mean. There are no significant differences between the pretreatment values or between pretreatment and posttreatment values.

BDP aerosol (regimen 4) did not change T-cell subset composition. Results of the six atopic asthmatic subjects who received medication more than 48 hours before administration of the test medication did not differ from the results of the remaining nine atopic asthmatic subjects.

The atopic asthmatic and nonatopic groups were compared as to the change caused by the various regimens using t-tests and Mann-Whitney rank sum tests. The values of WBC, lymphocyte percent, T4 percent, T8 percent, Ml percent, and Ia percent responded similarly to all regimens in both groups with

T4/T8 Ratio Atopic Asthmatics (15)

Ingestion : Prednisone 20mg Inhalation: whicle

Prednisone 60mg vehicle

placebo 0

placebo Beclomethosone

plocebo veh1cle

33Gf'Q FIGURE 2. T4ff8 Ratio before and five hours after administration of corticosteroid or placebo in a doubleblind protocol to 15 atopic asthmatic patients. There are no significant differences between the pretreatment values. Mean and standard error of the mean. Asterisk is p
CHEST I 87 I 1 I JANUARY. 1985

47

the exceptions of total eosinophil count and T4ff8 ratio after prednisone, 20 mg and 60 mg (p<0.05). These regimens caused a greater fall of values in the atopic asthmatic patient than in the nonatopic group confirming a difference of response of the two groups to prednisone. DISCUSSION

Three conclusions derive from our study. First, despite links between atopy and defective T-cell subset composition, baseline values ofT-cell subsets are the same in a population of atopic mild asthmatic and a nonatopic population. Second, administration of a substantial bolus of systemic corticosteroid causes a decrease of the T4ff8 ratio in the atopic asthmatic, but not in the nonatopic group. Third, a single large quantity of inhaled beclomethasone dipropionate aerosol causes no changes ofT-cell subset composition in either group. Atopy, the hyperimmunoglobulin E (hyperlgE) syndrome and other diseases are associated with defects of lgE production and increased susceptibility to infections which could result from abnormalities in T-cell regulation. 19 A central feature of the hyperlgE syndrome is abnormalities of peripheral blood T-cell subsets consistent with a deficiency of suppressor cells. There are decreased numbers of circulating isotype specific (lgE) T8 + suppressor cells and increased in vitro lgE production by peripheral blood cells which can be corrected by addition ofT8 + cells. 20 Studies of T-helper and suppressor subsets in patients with atopic diseases have yielded conflicting subsets. For example, atopic dermatitis is associated with a decrease of circulating suppressor T-cells (T8 +) and an increase ofT helper/suppressor ratio. 21 ·22 The number ofT-cells inhibited from binding to SRBC by theophylline is depressed in patients with atopic diseases. 23 •24 These T-cells can act as suppressor cells for the differentiation of B-cells. 23 Both concanavalin A induced and spontaneous T-suppressor cell activity in atopic subjects has been reported to be decreased by some, 24 •25 but not all investigators. 26-2ll In contrast, baseline values ofT-cell subsets are normal in patients with atopic respiratory tract disease. 22 ·27 ·29 There are several possible reasons for this disagreement about the presence ofT-cell subset abnormalities in atopy. First, the events that cause sensitization or the manifestations of clinical disease might be transient and be missed by a single examination. 21 •22 ·24 ·211 Second, defects could be more striking in subjects with more severe disease and thus be missed in subjects with mild disease. 26-2ll Third, peripheral blood is not the site of interaction oflymphocytes and environmental stimuli, nor the site of events that lead to inflammation and tissue damage, and thus, might imperfectly reflect cellular events that result in sensitization and 48

clinical manifestations of atopic disease. Corticosteroids have many antiinflammatory effects, 4 including transient redistribution of circulating lymphocytes to bone marrowl·5 and can be viewed as powerful probes that alter lymphocyte distribution and function. In addition, these drugs are often administered to patients with diseases characterized by abnormalities ofT-cell subsets. Previous reports indicate that corticosteroids either decrease12 or do not change T4/ T8 ratio. 30 The disparity between these studies may be due to differences of the composition of the studied population. Atopic status of the subjects was characterized in neither previous study. Chance inclusion of a different proportion of atopic subjects in study populations could have produced these apparent discrepancies. Both 20 and 60 mg prednisone caused the same changes of peripheral blood cell values (Table 4). This may be due to the relatively large amounts of prednisone that we used. Maximal corticosteroid effects on lymphocyte number occur at the equivalent ofl5 to 25 mg prednisone with little further effects after higher amounts. 3 •4 1fT-cell subset composition responds similarly, the use of smaller amounts of prednisone might have permitted a dose response relationship to become evident. Although we did not measure values at times other than five hours after drug administration, Slade and Hepburn 12 examined T-cell subsets at l, 2, 3, 4, 5, 6, 7, 8, 24, and 48 hours after prednisone administration and found maximal and identical effects at four to eight hours. Therefore, we included the time period at which prednisone effects are most evident. Beclomethasone diproprionate aerosol has been used for many years as a systemic steroid sparing agent in asthma. There is general agreement that it has little or no systemic effect when administered at less than 400 J..Lg/day to adults. 31 Although the mechanisms by which systemic corticosteroids exert their undesired effects are unknown, redistribution oflymphocytes is a prominent candidate. For example, corticosteroids selectively affect those lymphocytes responsible for resistance to infection with intracellular organisms in animals. 32 We found that BDP had no effect on T-cell subsets of both atopic asthmatic and nonatopic subjects. This can be viewed as both another indicator of lack of systemic corticosteroid effect of inhaled BDP aerosol and a predictor of lack of increased suspectibility to infection. The lymphocyte percentage decreased slightly after BDP administration in the atopic asthmatic group when compared to baseline values. However, there was no difference between BDP and placebo (Table 4). This finding is the same that we observed in an earlier study" and most likely results from normal circadian variationJJ.35 or the respiratory maneuvers associated Atopic Asthma (Gerblich, Urde, Schuyler)

with aerosol inhalation, as similar changes occurred after regimen 3 (Table 4). We found that the number ofT-cells with surface Ml antigen is the same in atopic asthmatic and nonatopic subjects. This is somewhat surprising, since asthma is associated with decreased peripheral blood cellular cytotoxicity activity. 36 This apparent discrepancy could be due to different subject characteristics, or to discordance of cellular markers and functional activity. The percentage of our highly purified T-cell population that expressed Ia antigen was low in both the atopic asthmatic and the nonatopic groups and similar to previous reports6 •7 and was not affected by prednisone administration. This indicates that the number of activated T-cells are not increased in the peripheral blood of atopic asthmatic individuals in an immunologically unstimulated state. Although Jackson et al 6 reported that the prednisone decreased Ia + T-cell number, he studied patients with an elevated level of Ia + cells befOre and after one week's therapy with prednisone. We found no difference ofT-cell subsets in peripheral blood of asymptomatic atopic asthmatic patients compared to nonatopic subjects, but did find differences in the response to exogenous stimuli. Atopic subjects are constantly exposed to environmental agents which may lead to sensitization and later production of clinical symptoms. If the signal that we applied (ie, corticosteroids) is analogous to the agents that induce sensitization, atopic asthma may be associated with abnormal responses to other stimuli. In fact, we recently demonstrated that exposure of atopic asthmatics to aeroallergens changes peripheral T-cell subset composition. 37 Thus, atopic asthma may be the first example of disease states associated with normal Tcell subset composition in the unperturbed state, but abnormal response to pharmacologic or physiologic challenges. ACKNOWLEDGMENT: The BDP, BDP vehicle, and empty canisters were kindly supplied by Dr. Frank Vogt, Schering Corporation. REFERENCES 1 Strannegard 0, Strannegard I. T Lymphocyte numbers and function in human lgE mediated allergy. lmmunol Rev 1978; 41:149-65 2 Wang S, McGeady S, Mansmann H. Cellular immunity and lgE levels in asthmatic children. Clin Allerg 1983; 13:323-28 3 Yu D, Clements P, Paulus H, Peter J, Levy L, Bomette E. Human lymphocyte subpopulations. Effect of C.'Orti<:osteroids. J Clin Invest 1974; 53:565-71 4 Parrillo J, Fauci A. Mechanisms of gluC.'OCOrtkoid action on immune processes. Ann Rev PharmaC.'Ol ToxiC.'Ol1979; 19:179-201 5 Fauci A. Mechanisms of C.'Orticosteroid action on lymphocyte subpopulations: ll. Differential effect of in vivo hydrocortisone, prednisone and dexamethasone on in vitro expression oflymphocyte function: Clin Exp lmmunol 1976; 24:54-62 6 Jackson R, Morris M, Haynes B, Eisenberg G. Increased circulating !a-antigen-bearing T cells in type I diabetes mellitus.

N Eng) J Med 1982; 306:785-88 7 Yu D, Winchester R, Fu S, Gibofsky H, Ko S, Kunkel H. Peripheral blood !a-positive T cells: increases in certain diseases and after immunization. J Exp Med 1980; 151:91-100 8 Schuyler M, Bondarevsky E, Schwartz H, Schmitt D. Corticosteroid-sensitive lymphocytes are normal in atopic asthma. J Allerg Clin Immunoll981; 68:72-78 9 Gerblich A, Horowitz J, Chester E, SchwMtz H, Fleming G. A proposed standardized method fur bronchoprovocation tests in toluene diisocyanate-induced asthma. J Allerg Clin Immunol 1979; 64:658-61 lO Chester E. Martinez-Catinchi F. Schwartz H, Horowitz J, Fleming G M, Gerblich AA, et al. Patterns of airway reactivity to asthma produced by exposure to toluene diisocyanate. Chest 1979; 75:229-31 11 Nickerson B, Lemen R, Gerdes C, Weymann A, Robertson G. Within-subject variability and per cent change fur significance of spirometry in normal subjects and in patients with cystic fibrosis. Am Rev Respir Dis 1980; 122:859-66 12 Slade J, Hepburn B. Prednisone-induced alterations of circulating human lymphocyte subsets. J Lab Clin Med 1983; 101:479-87 13 Birch R, Rosenthal A, Polmar S. Pharmological modulation of immunoregulatory T lymphocytes cell surface characteristics. Clin Exp lmmunol1982; 48:231-38 14 Reinherz E. Schlossman S. Regulation of the immune responseinducer and suppressor T subsets in human beings. N Eng) J Med 1980; 303:370-73 15 Zarling J, Kung P. Monoclonal antibodies which distinguish between human NK cells and cytotoxic T lymphocytes. Nature 1980; 288:394-96 16 Discombe G. Criteria of eosinophilia. Lancet 1946; I: 195-98 17 Goldstein A. Biostatistics. New York: Macmillian Inc, 55-60 18 Levene H. Robust tests for equality of variance. In: Olkin I, ed. Contributions to probability and statistics. Palo Alto, CA: Stanford Univ Press, 1980: 278-192 19 Buckley R, Becker W. Abnormalities in the regulation of human lgE synthesis. lmmunol Rev 1978; 41:288-314 20 Geha R, Reinherz E. Leung D, McKee K, Schlossman S, Rosen F. Deficiency of suppressor T cells in the hyperimmunoglohulin E syndrome. J Clin Invest 1981; 68:783-91 21 Faure M, Nicholas J, Thivolet J, Gaucher.md M, Gernielewski J. Studies on T-cell subsets in atopic dermatitis: human T-cell subpopulations defined by specific monoclonal antibodies. Clin lmmunol1mmunopath 1982; 33:139-46 22 Leung D, Rhodes A, Geha R. Enumeration ofT cell subsets in atopic dermatitis using monoclonal antibodies. J Allerg Clin lmmunol 1981; 67:450-55 23 Rola-Pleszczynski M, Blanchard R. Abnormal suppressor cell function in atopic dermatitis. J Invest Dermatol1981; 76:279-83 24 Rola-Pleszczynski M, Blanchard R. Suppressor cell function in respiratory allergy. lnt Arch Allergy Appl lmmonol 1981; 64: 361-66 25 Saxon A, Morrow C, Stevens R. Subpopulations of circulating B cells and regulatory T ~:.-el s involved in in vitro immunoglobulin E production in atopic patients with elevated serum immunoglobulin E. J Clin Invest 1980; 65:1457-68 26 Martinez J, Santos J, Stechshulte D, Abdou N. Nonspecific suppressor cell function in atopic subjects. J Allerg Clin lmmunol 1979; 64:485-90 27 Schuster D, Pierson D, Bongiovanni B, Levinson A. Suppressor cell function in atopic dermatitis associated with elevated immunoglobulin E. J Allerg Clin lmmunoll979; 64:139-45 28 Dorval G, Yang W, Goodfriend L, Roy R, Espinoza L, Hebert J. Circulating immune complexes may be associated with increase suppressor T-cell activity in atopic allergy. Clin lmmunollmmunopath 1980; 16:245-53 29 Schuster D, Bongiovanni B, Pierson D, Barbaro J, Wong D, CHEST I 87 I 1 I JANUARY, 1985

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31 32

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Levinson A. Selective deficiency of a T cell subpopulation in active atopic dermatitis. J Immunol1980; 124:1662-67 Schuyler M, Gerblich A, Urda G. Prednisone and Tlymphocyte subpopulations. Arch Intern Med 1984; 144:973-75 Williams M. Beclomethasone dipropionate. Ann Intern Med 1981; 95:461-67 North R. The action of cortisone acetate on cell mediated immunity to infection: histogenesis of lymphoid cell response and selective elimination of committed lymphocytes. Cell Immunol1972; 3:501-15 Eskola J, Frey H, Molnar G, Sappi E. Biological rhythm of cellmediated immunity in man. Clin Exp Immunol1976; 26:253-57

34 Kaplan M, Byers V, Levin A. Circadian rhythm of stimulated lymphocyte blastogenesis. J Allerg Clin Immunol 1976; 58:

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35 Roitman B, Walsh G, Halberg T, Sothern R, Blumenthal M. Circadian rhymometry in adult patients with asthma. J Allerg Clin Immunol1979; 63:199 36 Flaherty D, Martin J, Storms W. Antibody-dependent cellular cytotoxicity in asthmatics. I Allerg Clin Immunol1977; 59:48-53 37 Gerblich A, Campbell A, Schuyler M. Changes in T lymphocyte subpopulations following antigenic induced bronchoprovocation in asthmatics. N Eng! J Med 1984; 310:1349-52

21st Annual Arizona Chest Symposium The 21st Annual Arizona Chest Symposium willbe held at the Doubletree Inn, Tucson, March 28-30. Sponsor is the University of Arizona Health Sciences Center. For information, contact Ms. Sandy Younker-Hellman, PO Box 42195, Tucson 85733 (602:327-5461, ext 5110).

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The Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of South Florida College of Medicine, in co-sponsorship with the American Lung Association of Florida, will present this course on March 2 at the Rusty Pelican, Tampa. For information, contact: David A. Solomon, M. D., Section of Pulmonary and Critical Care Medicine (IIIC), 1300 North 30th Street, Tampa 33612 (813:972-2000).

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Atopic Asthma (Gerbllch, Urda, Schuyler)