- Email: [email protected]
Case report and self assessment
Case Report and Self Assessment Marianne
Castells,
Department
Lawrence
M.D.
of Medicine
B. Schwartz,
M.D.,
Ph.D.
Section of Allergy and Clinical Immunolog> Medical College of Virginia Richmond, Virginia
Case Report A IO-yr-old boy had been healthy until 5 yr of age, when he began to complain of itchy eyes, rhinorrhea, and sneezing episodes that occurred at night and with exposure to dust. An antihistamine was administered, resulting in significant relief of his symptoms. At the age of 10, he also began to complain of paroxysms of dry cough, wheezing, and dyspnea that were related to exercise, dust and cold air exposure, and emotional stress. The asthma attacks occurred daily and required emergency room visits about twice per month; tapering courses of corticosteroids had been given several times over the past 2 yr. His attendance at school had suffered, his family was overprotective, and he had few friends. An uncle of the patient had suffered from hay fever in his youth. The patient’s physical examination and chest x-ray were normal. The blood count was normal except for a mild eosinophilia (500/mm3), and a nasal smear showed 10% eosinophils.
Self Assessment 1. Which of the following is the most suitable diagnosis? a. Recurrent viral bronchitis b. Cystic fibrosis c. Asthma d. Foreign body aspiration e. (Y-1 antitrypsin deficiency 2. An atopic condition was suspected in this patient. Which one of the following is least useful to support that statement? a. Positive immediate skin tests to extracts of dust and molds b. High IgE levels in serum provC. Positive allergen bronchial ocation test d. Positive cold air bronchial provocation test
Clinical Immunology
Newsletter 7:9, 1986
e. Eosinophilia in serum and/or secretions 3. The immediate skin tests performed in this patient were positive to dust mites, and the total IgE level was high. Which one of the following is false? a. Dust mites are probably the most important source of allergen(s) associated with perennial asthma. b. At least 80% of atopic asthmatic patients have positive skin tests to dust mite extracts. of acute episodes C. The incidence of asthma in dust mite-sensitive patients is related to those times of the year when mites grow well. d. In areas of the world where mites do not thrive, the prevalence of atopic asthma is low. e. Cold weather and low humidity favor growth of mites. 4. The major allergen(s) of dust mites is (are) characterized by all of the following except: a. A glycoprotein (Pl) with an apparent Mr of 24,000 is the major allergen derived from the mite, Dermatophagoides
pteronys-
sinus.
b. They exist as soluble proteins in the outer coat of mite fecal partitles . and bioC. They are antigenically chemically distinct from common pollen allergens. d. They are mostly found in live mites. 5. Atopic patients with asthma who are sensitive to dust mites and have high IgE levels most likely express all the following except: Exercise-induced asthma Late phase asthmatic response to allergen bronchial provocation Positive cold air challenge Bronchial hyperreactivity Onset of allergic manifestations late in life 6. Bronchial hyperactivity was assessed in this patient by methacholine challenge. A 20% decrease in FEVl occurred at a very low concentration of methacholine. Which of the following is not true? a. There is a correlation between
0 1986 Elsevier Science Publishing Co.. Inc.
methacholine sensitivity and clinical severity of asthma. b. Allergen avoidance does not seem to reduce methacholine sensitivity. C. Challenge or exposure to the offending allergen in atopic asthmatic patients may enhance bronchial hyperreactivity. d. Those patients with a high degree of methacholine sensitivity may not show symptoms of asthma, even if the intensity of their allergic reactivity is mild. e. Methacholine sensitivity may persist for years, even in the absence of asthmatic symptoms and in the presence of a normal FEVl. 7. All of the following except one are useful in our natient’s treatment: a. Environme’ntal control and allergen avoidance b. Inhaled cromolyn, QID and/or before exercise C. Inhaled B-adrenergic drug, like albuterol, QID and/or before exercise d. Theophylline, PO, on a regular basis like Seldane, PO e. Antihistamines, on a regular basis
Comment Asthma is the most likely diagnosis in our patient by the history of recurrent, but reversible, wheezing associated with exposure to allergen (dust) and noxious stimuli (cold air). Test results that help confirm an atopic state in this patient include an elevated total IgE; positive bronchial challenge and immediate skin tests to allergens; and increased numbers of peripheral blood, sputum, and nasal eosinophils. A positive family history for atopy is common, though both penetrance and expression of atopy is either rhinitis, asthma, or both are not predictable in such families. Most atopic asthmatics (80%) are dust-sensitive, and the prin* cipal allergen(s) are derived from dust mites, Dermatophagoides pteronyssinus and Dermatophagoides farinae. Corresponding IgE is directed primarily at soluble glycoproteins found in the outer coat of mite fecal particles.
0197-1859/86/$0.00
+ 02.20
143
AdvisoryBoard:Joseph
Editors: Herman Mario Noel
useful in asthma, suggesting that,mediators other than histamine are more important.
hyperreactivity occurs after a late phase bronchial provocation response to allergen (more common in individuals with high IgE levels) and with certain viral upper respiratory tract infections. Although strict allergen avoidance has been shown to reduce bronchial hyperreactivity in dust-sensitive subjects, a similar therapeutic response with medical treatment or with immunotherapy protocols has not been conclusively demonstrated. Medications useful in the prophylactic or acute treatment of bronchospasm include P-adrenergic drugs (inhaled, oral, or parenteral), disodium cromoglycate (inhaled), theophylline (oral or intravenous), and atropine (inhaled). Corticosteroids (oral, inhaled, or parenteral) are most important for treatment of the inflammatory components of asthma, prevent the late phase response to bronchial challenge, and are primarily responsible for reducing mortality in severe asthma. They may reduce bronchial hyperreactivity. Antihistamines have not proven to be
Appreciable amounts of these allergens are not present in intact mites. The major allergen of D. preronyssinus has been purified, termed Pl, and is now being used to standardize extracts of house dust that are used for skin testing and immunotherapy. The small size of fecal particles and fragments permit them to become airborne and enter the airway, where after impact with mucus their outer coat proteins are rapidly solubilized. Bronchial hyperreactivity is the hallmark of both atopic and nonatopic asthma and is qualitatively measured by cold air challenge. Quantitative determination of bronchial hyperreactivity is best performed by histamine or methacholine bronchial challenge, where the concentration required to cause a 20% decline in FEVl is determined. The degree of bronchial hyperreactivity and intensity of allergic reactivity are somewhat independent variables that together dictate the dose of allergen that causes a bronchospastic reaction in atopic individuals. Increased bronchial
A.
Bellanti.
M.D.,
Georgetown
University
References <. Goldstein,
R., ed. (1985). Advances in the diagnosis and treatment of asthma. Chest 87: Is- 113s.
2. Lawlor, G. J. and D. P. Tashkin (1981). Manual of allergy and immunology. G. J. Lawlor and T. J. Fisher (eds.) Little Brown and Co. Boston. 3. Siegel, S. C. and G. S. Rachelefsky (1985). Asthma in infants and children. Part I. J. Allergy Clin. Immunol. 76:1-14. 4. Rachelefsky G. S. and S. C. Siegel (1985). Asthma in infants and children -treatment of childhood asthma. Part II. J. Allergy Clin. Immunol. 76:409419. 5. Platts-Mills, T. A. E. (1982). Type 1 or immediate hypersensitivity: Hay fever and asthma, pp. 579-686. In P. J. Lachmann and D. P. Peters (eds.) Clinical aspects of immunology, fourth ed. vol 1. Blackwell Scientific Publications, Oxford. Answers: W
‘q(9)
School of Medicine;
John L. Fahey,
Medicine;AnthonyS. Fattci, M.D., National Institutes of Health; James D. Folds, Ph.D., Medicine;RobertA. Good. Ph.D.. M.D., Universityof South Florida College of Medicine;
Friedman
of Pittsburgh
R. Escobar R. Rose
Cancer Center;
Gerald
Medical
School; John L. Sever,
College
of Medicine;
of Texas Health
Information
C%nicd
Immunology
10017.
M.D.,
Newsle~er
Gabriel
printed in January,
This newsletter
Ph.D.,
April,
Ph.D.,
National
M.D., Virella,
is published
See page 2 for subscription
Contributors,
Penn, M.D.,
Szentivanyi,
Science Center:
General NY
Andor
M.
Institutes
University M.D.,
monthly
information.
Grant Hospital; of Health;
of South Florida
Ph.D.,
Medical
by Elsewer
Ronald
Steven Specter,
University
on preparation
Ph.D.,
Ph.D.,
Science publishing
Co.,
Inc.
on an article.
has been registered with the Copyright
Clearance
Center,
new collective
Elsevier
144
0197-1859/86/$0.00
+ 02.20
of South Florida
Talal,
Co.,
Inc.,
52 Vanderbilt
and submission
M.D.,
Avenue,
of material,
University
New
York.
see Invitation
to
that the copier pay through the
for copying beyond that permitted by the U.S. Copyright IO copy must be obtained directly
such as for general distribution.
resale. advertising
Law.
If no code appears
from the author. This
and promotional
purposes, or for
works.
10017. Claims
for miwng
addresses and six months for foreign addresses. Duplicate
copies will
Elsevier
University
of Pittsburgh
of South Carolina.
Address orders, changes of address. and claims for missmg issues to Journals Fulfillment Inc.. 52 Vanderbilt
M.D..
Inc. Consent is given for copying articles for personal or
the author has not given broad consent to copy. and permIssion
consent does not extend to other kinds of copying. creating
ISSN 0197-1859 CIMNDC 7 (9)129- 144, 1986
School of School of
July, and October.
Center the per-page fee stated in the code on each page 1986 Elsevier
UCLA Carolina
University
University Norman
internal use. or for the personal or internal use of specific clients. This consent is given on the condition 0
M.D..
of North
B. Herberman.
M.D.,
of Medicine:
Science Publishing
For information
University
Bruce S. Rabin, College
‘P(~)‘W‘P(Z)‘~(I)
‘W
Avenue, New York. NY
Department.
Elsevier
Science Publishing
Co.,
issues can be honored only up to three months for domestic not be sent to replace ones undelivered
due to failure to notify
of change of address.
0
1986 Elsevier
Science Publishing
Co.,
Inc.
Clinical
Immunology
Newsletter
7:9,
1986
.
Castells,
Department
Lawrence
M.D.
of Medicine
B. Schwartz,
M.D.,
Ph.D.
Section of Allergy and Clinical Immunolog> Medical College of Virginia Richmond, Virginia
Case Report A IO-yr-old boy had been healthy until 5 yr of age, when he began to complain of itchy eyes, rhinorrhea, and sneezing episodes that occurred at night and with exposure to dust. An antihistamine was administered, resulting in significant relief of his symptoms. At the age of 10, he also began to complain of paroxysms of dry cough, wheezing, and dyspnea that were related to exercise, dust and cold air exposure, and emotional stress. The asthma attacks occurred daily and required emergency room visits about twice per month; tapering courses of corticosteroids had been given several times over the past 2 yr. His attendance at school had suffered, his family was overprotective, and he had few friends. An uncle of the patient had suffered from hay fever in his youth. The patient’s physical examination and chest x-ray were normal. The blood count was normal except for a mild eosinophilia (500/mm3), and a nasal smear showed 10% eosinophils.
Self Assessment 1. Which of the following is the most suitable diagnosis? a. Recurrent viral bronchitis b. Cystic fibrosis c. Asthma d. Foreign body aspiration e. (Y-1 antitrypsin deficiency 2. An atopic condition was suspected in this patient. Which one of the following is least useful to support that statement? a. Positive immediate skin tests to extracts of dust and molds b. High IgE levels in serum provC. Positive allergen bronchial ocation test d. Positive cold air bronchial provocation test
Clinical Immunology
Newsletter 7:9, 1986
e. Eosinophilia in serum and/or secretions 3. The immediate skin tests performed in this patient were positive to dust mites, and the total IgE level was high. Which one of the following is false? a. Dust mites are probably the most important source of allergen(s) associated with perennial asthma. b. At least 80% of atopic asthmatic patients have positive skin tests to dust mite extracts. of acute episodes C. The incidence of asthma in dust mite-sensitive patients is related to those times of the year when mites grow well. d. In areas of the world where mites do not thrive, the prevalence of atopic asthma is low. e. Cold weather and low humidity favor growth of mites. 4. The major allergen(s) of dust mites is (are) characterized by all of the following except: a. A glycoprotein (Pl) with an apparent Mr of 24,000 is the major allergen derived from the mite, Dermatophagoides
pteronys-
sinus.
b. They exist as soluble proteins in the outer coat of mite fecal partitles . and bioC. They are antigenically chemically distinct from common pollen allergens. d. They are mostly found in live mites. 5. Atopic patients with asthma who are sensitive to dust mites and have high IgE levels most likely express all the following except: Exercise-induced asthma Late phase asthmatic response to allergen bronchial provocation Positive cold air challenge Bronchial hyperreactivity Onset of allergic manifestations late in life 6. Bronchial hyperactivity was assessed in this patient by methacholine challenge. A 20% decrease in FEVl occurred at a very low concentration of methacholine. Which of the following is not true? a. There is a correlation between
0 1986 Elsevier Science Publishing Co.. Inc.
methacholine sensitivity and clinical severity of asthma. b. Allergen avoidance does not seem to reduce methacholine sensitivity. C. Challenge or exposure to the offending allergen in atopic asthmatic patients may enhance bronchial hyperreactivity. d. Those patients with a high degree of methacholine sensitivity may not show symptoms of asthma, even if the intensity of their allergic reactivity is mild. e. Methacholine sensitivity may persist for years, even in the absence of asthmatic symptoms and in the presence of a normal FEVl. 7. All of the following except one are useful in our natient’s treatment: a. Environme’ntal control and allergen avoidance b. Inhaled cromolyn, QID and/or before exercise C. Inhaled B-adrenergic drug, like albuterol, QID and/or before exercise d. Theophylline, PO, on a regular basis like Seldane, PO e. Antihistamines, on a regular basis
Comment Asthma is the most likely diagnosis in our patient by the history of recurrent, but reversible, wheezing associated with exposure to allergen (dust) and noxious stimuli (cold air). Test results that help confirm an atopic state in this patient include an elevated total IgE; positive bronchial challenge and immediate skin tests to allergens; and increased numbers of peripheral blood, sputum, and nasal eosinophils. A positive family history for atopy is common, though both penetrance and expression of atopy is either rhinitis, asthma, or both are not predictable in such families. Most atopic asthmatics (80%) are dust-sensitive, and the prin* cipal allergen(s) are derived from dust mites, Dermatophagoides pteronyssinus and Dermatophagoides farinae. Corresponding IgE is directed primarily at soluble glycoproteins found in the outer coat of mite fecal particles.
0197-1859/86/$0.00
+ 02.20
143
AdvisoryBoard:Joseph
Editors: Herman Mario Noel
useful in asthma, suggesting that,mediators other than histamine are more important.
hyperreactivity occurs after a late phase bronchial provocation response to allergen (more common in individuals with high IgE levels) and with certain viral upper respiratory tract infections. Although strict allergen avoidance has been shown to reduce bronchial hyperreactivity in dust-sensitive subjects, a similar therapeutic response with medical treatment or with immunotherapy protocols has not been conclusively demonstrated. Medications useful in the prophylactic or acute treatment of bronchospasm include P-adrenergic drugs (inhaled, oral, or parenteral), disodium cromoglycate (inhaled), theophylline (oral or intravenous), and atropine (inhaled). Corticosteroids (oral, inhaled, or parenteral) are most important for treatment of the inflammatory components of asthma, prevent the late phase response to bronchial challenge, and are primarily responsible for reducing mortality in severe asthma. They may reduce bronchial hyperreactivity. Antihistamines have not proven to be
Appreciable amounts of these allergens are not present in intact mites. The major allergen of D. preronyssinus has been purified, termed Pl, and is now being used to standardize extracts of house dust that are used for skin testing and immunotherapy. The small size of fecal particles and fragments permit them to become airborne and enter the airway, where after impact with mucus their outer coat proteins are rapidly solubilized. Bronchial hyperreactivity is the hallmark of both atopic and nonatopic asthma and is qualitatively measured by cold air challenge. Quantitative determination of bronchial hyperreactivity is best performed by histamine or methacholine bronchial challenge, where the concentration required to cause a 20% decline in FEVl is determined. The degree of bronchial hyperreactivity and intensity of allergic reactivity are somewhat independent variables that together dictate the dose of allergen that causes a bronchospastic reaction in atopic individuals. Increased bronchial
A.
Bellanti.
M.D.,
Georgetown
University
References <. Goldstein,
R., ed. (1985). Advances in the diagnosis and treatment of asthma. Chest 87: Is- 113s.
2. Lawlor, G. J. and D. P. Tashkin (1981). Manual of allergy and immunology. G. J. Lawlor and T. J. Fisher (eds.) Little Brown and Co. Boston. 3. Siegel, S. C. and G. S. Rachelefsky (1985). Asthma in infants and children. Part I. J. Allergy Clin. Immunol. 76:1-14. 4. Rachelefsky G. S. and S. C. Siegel (1985). Asthma in infants and children -treatment of childhood asthma. Part II. J. Allergy Clin. Immunol. 76:409419. 5. Platts-Mills, T. A. E. (1982). Type 1 or immediate hypersensitivity: Hay fever and asthma, pp. 579-686. In P. J. Lachmann and D. P. Peters (eds.) Clinical aspects of immunology, fourth ed. vol 1. Blackwell Scientific Publications, Oxford. Answers: W
‘q(9)
School of Medicine;
John L. Fahey,
Medicine;AnthonyS. Fattci, M.D., National Institutes of Health; James D. Folds, Ph.D., Medicine;RobertA. Good. Ph.D.. M.D., Universityof South Florida College of Medicine;
Friedman
of Pittsburgh
R. Escobar R. Rose
Cancer Center;
Gerald
Medical
School; John L. Sever,
College
of Medicine;
of Texas Health
Information
C%nicd
Immunology
10017.
M.D.,
Newsle~er
Gabriel
printed in January,
This newsletter
Ph.D.,
April,
Ph.D.,
National
M.D., Virella,
is published
See page 2 for subscription
Contributors,
Penn, M.D.,
Szentivanyi,
Science Center:
General NY
Andor
M.
Institutes
University M.D.,
monthly
information.
Grant Hospital; of Health;
of South Florida
Ph.D.,
Medical
by Elsewer
Ronald
Steven Specter,
University
on preparation
Ph.D.,
Ph.D.,
Science publishing
Co.,
Inc.
on an article.
has been registered with the Copyright
Clearance
Center,
new collective
Elsevier
144
0197-1859/86/$0.00
+ 02.20
of South Florida
Talal,
Co.,
Inc.,
52 Vanderbilt
and submission
M.D.,
Avenue,
of material,
University
New
York.
see Invitation
to
that the copier pay through the
for copying beyond that permitted by the U.S. Copyright IO copy must be obtained directly
such as for general distribution.
resale. advertising
Law.
If no code appears
from the author. This
and promotional
purposes, or for
works.
10017. Claims
for miwng
addresses and six months for foreign addresses. Duplicate
copies will
Elsevier
University
of Pittsburgh
of South Carolina.
Address orders, changes of address. and claims for missmg issues to Journals Fulfillment Inc.. 52 Vanderbilt
M.D..
Inc. Consent is given for copying articles for personal or
the author has not given broad consent to copy. and permIssion
consent does not extend to other kinds of copying. creating
ISSN 0197-1859 CIMNDC 7 (9)129- 144, 1986
School of School of
July, and October.
Center the per-page fee stated in the code on each page 1986 Elsevier
UCLA Carolina
University
University Norman
internal use. or for the personal or internal use of specific clients. This consent is given on the condition 0
M.D..
of North
B. Herberman.
M.D.,
of Medicine:
Science Publishing
For information
University
Bruce S. Rabin, College
‘P(~)‘W‘P(Z)‘~(I)
‘W
Avenue, New York. NY
Department.
Elsevier
Science Publishing
Co.,
issues can be honored only up to three months for domestic not be sent to replace ones undelivered
due to failure to notify
of change of address.
0
1986 Elsevier
Science Publishing
Co.,
Inc.
Clinical
Immunology
Newsletter
7:9,
1986
.