Cockroach cause of allergic asthma

Original

Cockroach Its specificity

articles

cause of allergic asthma and immunologic

profile

Bann Kang, M.D., Devi Vellody, M.D., Henry Hornburger, M.D., and John W. Yunginger, M.D. Chicago, Ill., and Rochester, Minn.

TO assess the etiologic role of cockroach antigen in bronchial asthma, 46 asthmatic subjects were studied using in vitro assays for total and cockroach-specific IgE antibodies (IgE,,) and the responsiveness of the skin and bronchial tree to the antigen challenge in vivo. Asthmatic subjects were divided into skin test-positive (PCR) and skin test-negative (NCR) groups according to immediate skin response to cockroach antigen. The 28 in the PCR group showed high total IgE (1,901 nglml) and a high cockroach-spectfic IgE antibody level (329%) in the serum compared to the 10 in the NCR group (IgE: 915 ngiml, IgE,,: 8470) (p < 0.001). Bronchial challenge with the antigen revealed immediate asthmatic reaction (30133) and late asthmatic reaction (16133) in the PCR asthmatics, whereas the NCR asthmatics showed neither immediate asthmatic reaction (2113 showed questionable decrease in FEV,) nor late asthmatic reaction (p < 0.001). A marked increase in peripheral eosinophils (758cTovs 121%) was noted following antigen inhalation in the skin test-positive asthmatics (p < 0.025). The results indicate that cockroach antigen causes antigen-spectfic IgE-mediated bronchial asthma and peripheral eosinophilia in speci$cally sensitized asthmatic subjects.

Hypersensitivity to cockroach antigen has been reported sporadically in the literature,ie3 and many positive reactions to the cockroach antigen were documented by allergy skin testing on atopic populations from various urban communities.4-6 In some individuals, cockroach antigens (CRa) “atopic” cause immediate skin reaction as well as immediate bronchoconstriction, similar to the findings in ragweed hypersensitivity. However, unlike ragweed hypersensitivity, the cockroach hypersensitivity has not

From the Division of Allergy and Clinical Immunology, Department of Medicine, Rush Medical College, Mount Sinai Hospital Medical Center, and Mayo Medical School. Supported by Grant MSH-75-8 from the Mount Sinai Hospital Medical Center. Presented in part at the annual meeting of the American Academy of Allergy, San Juan, Puerto Rico, March, 1976, and in part in New York in March, 1977. Received for publication May 19, 1978. Accepted for publication Sept. 29, 1978. Reprint requests to: Bann Kang, M.D., Chief, Division of Allergy and Clinical Immunology, Department of Medicine, Mount Sinai Hospital Medical Center, Chicago, JL 60608.

Vol. 63, No. 2, pp. 80-86

been considered to be a significant entity among allergic diseases, and, consequently, it is not well understood. There was recently a report stating that cockroach hypersensitivity was highly prevalent among atopic urban population and it was even more prevalent than ragweed hypersensitivity. 7 Furthermore, a clear demonstration by Kang8 of the dual asthmatic reaction induced by bronchoprovocation using cockroach antigen enhanced the significance of cockroach hypersensitivity among allergic respiratory diseases. To elucidate the immunologic nature of cockroach hypersensitivity further, authors established a method assaying the cockroach antigen-specific IgE along with total IgE antibodies from the sera of a group of asthmatic subjects. To our knowledge, this is the first report in the literature of the measurement of cockroach-specific IgE antibodies. We also evaluated bronchial responsiveness and eosinophilic response in peripheral blood among asthmatic subjects following cockroach antigen inhalation. Eosindphilic response was observed over an extended period in order to assess its kinetics in vivo.

0091-6749/79/020080+07$00.70/0

63 1979 The C. V. Mosby

Co.

VOLUME NUMBER

Cockroach allergy

63 2

TABLE I. Characteristics subjects

of asthmatic

studied

No. of subjects

Male

Female

CR-positive

33

4

29

CR-negative

13

3

10

MATERIALS Subjects

Age mean (range) WI

Duration of asthma mean (range) (VI

29.8 (8-55) 35.4 (9-57)

10.2 (5-21) 8.5 (l-30)

AND METHOD

Forty-six volunteer subjects with bronchial asthma were selected for the study. They were divided into a skin testpositive (PCR) and a skin test-negative (NCR) group, according IO the result of the immediate allergic reaction against CRa by allergy skin testing. An asthmatic subject who showed a borderline skin reaction against CRa was excluded from the study group. The clinical data are summarized in Table I. All asthmatic subjects had mild to moderately severe asthmatic symptoms as documented by their physicians and by one of the investigators. They were symptomatic for a period of six months or longer and they received regularly one or more bronchodilators. Three subjects were treated with “alternate-day” steroid therapy in addition to regular bronchodilators at the time of the bronchial provocation test. Any subject who had extremely severe bronchial asthma so that he could not abstain from medications For over a IO-hr period, as well as any subject who had other associated pulmonary disease or cardiac disease, was excluded from the study. Measurements of serum IgE antibodies as well as routine laboratory tests were carried out.

Allergy

81

skin test

Routine allergy survey and allergy skin tests were carried out at the outpatient department. The skin testing was performecl by the prick method as a screening test followed by the intracutaneous method using 30 common inhalant allergens (I : 20 w/v for the prick test and 500 PNU/ml for the intracutaneous test). Results were read in 15 minutes by measuring d!ameters of wheals. Buffered saline and histamine phosphate solution (0.1 mg/ml) were used as a negative and a positive control, respectively. Antigen(s) showing strong positive reaction (diameter of wheal over 7 mm) by prick test was exempt from following intracutaneous testing. A criterion of a positive skin test used was the size of wheal over 7 mm in its longest diameter by prick method or the diameter of wheal over 13 mm and/or as large as the diameter of the positive control by the intracutaneous method. The CRa and other antigens were provided by Hollister-Stier Labs., Spokane, Washington.

1

0 I-I

5 IO COCKROACH SPECIFIC ,gE ,% TOTAL

20 25 I5 RADKIPCTIVE COUNTS BOUND

FIG. 1. A dose-response curve of RAST binding using a

cockroach-positive

Cockroach-specific assay in vitro

serum.

IgE antibody

(IgE,,)

Cockroach RAST (radioallergosorbent test) was established according to the previously published method,” using a microcrystalline cellulose-cockroach antigen conjugate to measure cockroach-specific IgE antibody. The conjugate was prepared by incubation of the crude CRa (HollisterStier Labs., Lot No. 832905) with CNBr-activated microcrystalline cellulose (Brinkman Instruments) and 1 ml of CRa (I : IO w/v)/100 mg of activated cellulose. Elevated RAST binding produced by a positive control serum (50 ~1) was inhibited completely by addition of soluble CRa (25 ~1). A dose-response curve of RAST binding using a positive control serum is shown in Fig. I. Sera were stored in a single batch at -20” C until tested. All tests were performed in duplicate.

Bronchial

provocation

test (BPT)

Bronchial provocative test was carried out in the hospital, with the informed consent of each subject, after completion of a basic “work-up” that included allergy skin testing, eosinophil count, determination of total IgE, IgE,, assay, and routine laboratory tests. Pulmonary function was evaluated by measurement of forced expiratory volume in one second (FEVI), forced vital capacity (FVC), and peak expiratory flow rate (PEFR) using an Expirometer (Warren E. Collins, Inc.). All subjects tested were free of acute attack of asthma for a period of one week or longer and their baseline values of pulmonary function (FEV, and FVC) were two-thirds or over of their predicted values at the time of BPT. Any bronchodilator and antihistamine were withheld over a IO-hr period, at least. A control challenge with buffered saline was carried out on each subject prior to the

82

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Kang et al.

TABLE II. Reaginic profile of cockroach-positive and negative asthmatics studied Number of

subjects

CR-positive

Mean total W (range) (nglml)

28

1,901* (20-5,080)

CR-negative

10

915 (150-1,948)

Mean cockroachspecific IgE (range) (%)

329* (85 1,069) 84 (77-98)

*p < 0.001 by Student’s t test. antigen challenge, and anyone who showed a significant bronchospasm with saline inhalation was excluded from the study. The detailed methods and precautions used have been described previously.’ Subjective symptoms and objective signs were observed closely, and a frequent spirometry was done during a period of 24 hr following the antigen challenge. The peripheral eosinophil counts were obtained at intervals of 12, 24, and 48 hr following BPT with cockroach antigen.

RESULTS Serum IgE and cockroach-specific antibodies

IgE

The reaginic profiles of the subjects studied are shown in Table II. Twenty-two asthmatics among 28 PCR subjects studied showed elevated IgE levels, whereas 5 of 10 NCR subjects studied showed IgE levels above the normal value (up to 780 rig/ml). The IgE,, assay yielded an average value of 329% of that in control sera in the PCR group; that in the NCR group was 84% of that in control sera (p < 0.001). Levels of IgE,, above 200% of pooled control sera (positive result) were noted in 14 of 28 tested subjects in the PCR group; none were elevated in the NCR group. Although average total IgE and IgE,, of the PCR group showed elevated values in comparison to those of the NCR group, the elevated total IgE antibody level was not a prerequisite for an elevated IgE,, value in the PCR group (correlation coefficient: 0.47). Bronchial

provocation

test

Table III summarizes the pulmonary functions and the peripheral eosinophilic responses following the CRa inhalation challenge for both asthmatic groups. PCR group. The BPT with CRa induced a significant immediate decrease in FEVl in the PCR group, whereas only a minimal immediate decrease in FEVl was noted in the NCR group. The immediate reductions in FVC and PEFR were comparable to the changes in FEV, for all subjects studied. Fig. 2 shows typical examples of the immediate changes in FEVl

CLIN. IMMUNOL. FEBRUARY 1979

following CRa challenge, together with antigen specificity, in two allergic asthmatic subjects. The immediate symptoms following the CRa challenge varied widely for each asthmatic subject, ranging from itchy throat, coughing, tightness in the chest, and wheezing to severe shortness of breath and dizziness, depending on the sensitivity to the CRa. Auscultatory findings of the chest also varied widely, ranging from clear lungs to severe wheezing in both lung fields. In the majority of the subjects, these immediate symptoms and signs were reversed promptly to their baseline value by the subsequent inhalations of isoproterenol ( 1: 200). CRa challenge also induced lateappearing asthmatic responses in 16 subjects among 33 asthmatics tested. These appeared as slowly developing shortness of breath and tightness in the chest subjectively, as well as bilateral wheezing by auscultation. Symptoms and signs of asthma (late asthmatic reaction) started to occur from 6 to 8 hr following the antigen challenge in the majority of the late asthmatic responders. All subjects but one (A. W.) who developed late asthmatic reaction had early asthmatic reaction immediately following the CRa challenge, showing the typical “dual pattern” in bronchial response to the CRa challenge. Fifteen of 16 asthmatics who showed “dual asthmatic response” received isoproterenol inhalation for their early asthmatic reaction following the CRa challenge. The late asthmatic responses usually did not improve promptly upon inhalation of isoproterenol, and most subjects with such responses continued to be symptomatic for the next 12 to 36 hr in spite of usual treatment with oral bronchodilators. In a few subjects, late asthmatic reaction was so severe that parenteral aminophylline had to be administered during the next 24 hr. None of these individuals showed any signs of fever or moist rales in the lung fields to be apparent by physical examination. No pulmonary infiltrates were seen in chest roentgenograms following the BPT, even in the subjects who developed severe late asthmatic reactions. All asthmatic subjects who had elevated IgE,, and 12 subjects who had normal level of IgE,, showed early and/or late asthmatic reactions following the CRa inhalation challenge. Two asthmatic subjects (M. G. and B. H.) among the PCR group who showed neither asthmatic reactions had normal levels of IgE,,; 1 had normal total IgE and the other had slightly high level of total IgE antibody in the sera. Subject A. W. developed very questionable itching sensation in her throat and mild coughing immediately following the CRa inhalation but showed about 10% drop in FEVl from baseline value for a period of the first hour. However, by 3 hr following the challenge, symptoms of bronchial asthma started, and by 6 hr after the

VOLUME NUMBER

Cockroach

63 2

Fi ‘Z

R.V ( 48, !$ 1 Resultof SkInTest

GM ( 37,q)

++++ +++

+ +++

-

IO

83

Resultof SkmTest

HouseDust Cockroach

5

allergy

S.Molds,Rogweed,How Dust,Cat and Tree + Cockroach

; .r-

Cockroach ( I 50 ) S Molds (I 50)

15

5

20

TIME

IO

15

20

(min)

FIG. 2. Typical example of changes in FEV, following the CRa inhalation, compared with the effect of other antigens on two allergic asthmatic subjects. Patient R. V. (left side) was allergic to cockroach and house dust antigens, but was not allergic to seasonal mold and mixed grass antigens. She had a marked decrease in FEV, (to 48%) following the CR challenge, but showed no change in FEV, following the seasonal mold or mixed grass challenge. Patient G. M. (right side) was allergic to many antigens, including seasonal mold, but was not allergic to cockroach antigen. Inhalation of cockroach antigen failed to induce any change in FEV,, whereas seasonal mold caused marked reduction in FEV,.

TABLE III. Response with

of cockroach-positive

and cockroach-negative

asthmatics

following

BPT

antigen

CR-positive (33) CR-negative (13)

Imm sx

Late

30 (93%)

16 (68%)

2 (20%)

SX

0

Mean rise in EOS

Mean fall in FEV, (range) (%I

(rawe) PO)

41.7* (O-75) 7.5 (O-15.8)

758t (83- 10,494) 121 (66-196)

Imm Sx: Immediate asthmatic response. Late Sx: Late asthmatic response. EOS: Peripheral eosinophil count. *p < 0.001, t p < 0.025 by Student’s t test.

challenge her decrease in FEV, became 60% from her baseline value (Fig. 3). Her antibody level of IgE and IgE,, were 2,13 1 rig/ml and 394% of control sera, respectively. Among all asthmatic subjects who reacted positively to skin testing to CRa, 94% showed positive asthmatic response to the antigen challenge (early and/or late asthmatic reaction). The specific IgE,, (RAST) measurement, however, was positive in 50% of the PCR subjects studied. Several subjects with negative IgE,, were tested for “end point titration” test, which revealed very high titer as 1: 1 million to 1: 10 million dilution. NCR grollp. Among the NCR asthmatics studied, neither immediate nor late asthmatic reactions were noted following the same antigen challenge as that given to the PCR subjects (p < 0.001). Two individuals had a minimum reduction in FEV, (15.6% and 15.8%) during the acute phase. Changes in FVC

and in PEFR were similar to changes in FEV,. Neither subjective symptoms nor objective signs were detected following the CRa challenge in all including the two subjects who had a minimal reduction in spirometric values. Eosinophils Fig. 4 shows changes in the peripheral eosinophils in two groups of asthmatics following the CRa challenge. Increase in peripheral eosinophils was apparent in the PCR group begun by 12 hr after the BPT, and it reached a peak at 24 hr after the antigen challenge (p < 0.025). When an increase in eosinophils of more than 150% of the baseline value was used as a criterion for a positive response to the antigen challenge, 24 of 33 PCR subjects had a positive response, whereas only 3 of 10 NCR subjects had a positive response. Though a significant peripheral eosinophilia

84

Kang et al.

J ALLERGY

TIME +20

t

o

A.W(15,?

1

2,

I IO

6I

14

(hours)

I8

20

24

28

32I

/ s

-20

>w -40

LL

.c -60

1 F \

t

z F 0 -80 t 6

\

,’

361,

P 42 I

/’ // \

\

\

&---

t

\ t

Result of Skin Test ++++:CR.RW.

P’ \

+++:WW.HD.SM Bronchodilator t.

t

t PM.DO

FIG. 3. Example of changes in FEV, following the cockroach antigen challenge, observed for an extended period in a mild asthmatic subject. t: lsoproterenol and theophylline administered.

was noted on early reactors among the PCR group, there was no significant relationship in regard to the development of late asthmatic reaction.

DISCUSSION The results of the study indicate that the majority of cockroach-sensitive asthmatic subjects had abnormally elevated serum IgE antibodies. They also have clearly demonstrable circulating IgE antibodies which are specific for cockroach antigen (antigen-specific IgE; CR RAST), in addition to a “fixed antigenspecific IgE antibody” in the skin apparent by the “wheal-and-flare” reaction following skin testing. The dual asthmatic reaction after the CRa bronchoprovocation is an antigen-specific reaction similar to the dual asthmatic phenomenon that has been observed in other types of allergic asthma.10-‘4 Cockroach-induced immediate bronchospasm was first observed by Bernton, McMahon, and Brown,‘” and subsequently the dual asthmatic reaction following CRa challenge was documented by Kang.a Though the former failed to report a late asthmatic reaction in the CR asthma, probably due to the short observation period following the antigen challenge, this study confirmed its occurrence once more. The documentation of the elevated IgE,, (CR RAST), accompanied by the BPI in the study, provides sufficient evidence that cockroach asthma is likely caused by anaphylactic mediators via “CR-IgE,,” phenomenon, in vivo, as well-understood allergic reaction.“-” The study also indicates that CR RAST assay is a very specific test to detect cockroach hypersensitivity as compared to the bronchial provocation test and allergy skin tests; however, its sensitivity is the lowest among three methods tested; there was 50% false-negative result and no false-positive result. Bronchial provocation testing, on the other hand, is a fairly specific

t

CR posltlve negative

/ I'

z F 100 0 ,

/I “t

o---o -CR

k .-E 180 6 .G 140 -

,A ----a,

in z % .e 0” 260P o 220-

CLIN. IMMUNOL FEBRUARY 1979

T 1

TN 0

24 12 TIME (hours)

FIG. 4. Response of peripheral eosinophils bronchial inhalation of cockroach antigen. dard error. #: p < 0.025.

48

following the Mean f stan-

and sensitive method in determining the antigenspecific asthmatic response if one can delineate a better objective criteria. A positive criterion was used as a reduction of FEVi over 15% of baseline value as used by others,*O, *I and there were 2 false-positive results among the 13 in the NCR group and 3 falsenegative results among the 33 in the PCR group. Among the latter, 1 (A. W.) had a positive late asthmatic reaction with elevated IgE,, of 394% of control sera; the other 2 had mild subjective symptoms such as itchy throat, sneezing, coughing, and tightness in the chest immediately after antigen inhalation. In the former, 2 asthmatic subjects (NCR) did not have any coughing or tightness of the chest following the antigen challenge in spite of borderline reduction in FEVi. The late asthmatic reaction following bronchial challenge with antigen is believed to be the result of “Arthus-like” (type III) reaction mediated by IgG, in vivo.ll* 13, 23 Allergic bronchial asthma and hypersensitivity pneumonitis are typical examples of IgG-mediated (type III) diseases in man. The late asthmatic reaction observed in cockroach asthma showed a similar pattern as in other allergic asthma. Its incidence, however, is higher than that reported in studies on house dust asthma by Booij-Noord, Orie, and devries” and on ragweed asthma by Robertson and co- workers. ’ ’ It is more comparable to that of wood dust hypersensitivity pneumonitis,** to bird fancier’s lung disease,‘* and to allergic lung diseases.23 Yet, in all subjects studied, there were no signs of alveolitis, which was a common phenomenon following the antigen challenge in hypersensitivity pneumonitis. I33 **, 23 Furthermore, the sera of the CR-sensitive asthmatics who had a severe late asthmatic reaction following antigen challenge failed to show any precipitating antibody (IgG)24 using the modified Ouchterlony method described by Smith.*” All subjects who showed asthmatic reaction of “dual pattern” (immediate and late asthmatic reactions) in

Cockroach allergy

VOLUME 63 NUMBER 2

this study received isoproterenol inhalations for their immediate bronchospasm. Subject A. W. however, did not receive isoproterenol since there was not a significant bronchospasm immediately after antigen inhalation; she developed atypical “late asthmatic reaction” slarting as early as 3 hr after the antigen challenge and continued to deteriorate over the next 24-hr period. Absence of IgG antibody against the antigen and documented high levels of IgE antibody against the CRa, along with clinical findings, make one wonder if the induced dual asthmatic reaction might be a continuous deterioration of early asthmatic reaction and might be solely caused by IgE-mediated phenomenon instead of IgE and IgG-mediated reaction, similar to the late-phase cutaneous allergic reaction eloquently demonstrated by Solley and coworkers. x Eosinophilia was not commonly reported in experimental allergic asthma”, “, ‘L I’, ‘:’ or in cockroach asthma’> but was mentioned in cockroach asthma by K.ang and co-workers.‘, I6 It was also noted briefly in the study on bird-fancier’s disease by Hargreave and Pepyslz-a significant eosinophilia within 48 hr following challenge of pigeon serum. The latent period of the observed eosinophilia in our study is also compatible with eosinophilic response observed in guinea pigs after injection of horse serum.“’ Peripheral eosinophilia observed seems to be an antigen-specific reaction slowly appearing in sensitized asthmatic subjects in response to a specific antigen cha!lenge. Although a significant difference in eosinophilic response in the two groups suggested that it is an antigen-induced reaction, there was not a clear correlation between the eosinophilia and the severity of immediate asthmatic reaction or the appearance of late asthmatic reaction in our study. Eosinophils were noted immediately after antigen challenge in sputum, but they appeared slowly in peripheral blood, reaching peak in 24 to 48 hr after challenge among positive responders. The phenomenon may be a consequence of their immunophysiologic role in allergic asthma, perhaps the role as a deactivator of slow-reacting substance of anaphylaxis (SRS-A) suggested by N’asserman, Goetzl, and Austen.” Further study is warranted to elucidate the relationship between the eosinophilia and the asthmatic reactions, and the extended observation period is recommended in the study for eosinophilia of allergic reaction. REFERENCES I. Roth LM, Willis ER: The medical and veterinary importance of cockroaches, Miscellaneous Smithsonian Collections 134: I-139. 1951. 2. Cornwell PB: Can cockroach cause asthma? Br Med J 1: I 159, 1977.

85

3. Bernton HS, Brown H: Insect allergy. preliminary studies of the cockroach, J ALLERGY 35:506-5 1.7, 1964. 4. Mendoza J, Snyder RD: Cockroach sensitivity in children with bronchial asthma, Ann Allergy 28: lS9- 163. 1970. 5. Bernton HS, Brown H: Cockroach allergy: Age of onset of skin reactivity. Ann Allergy 28~420-422. 1970. 6. Twarog FJ, Picone FJ. Strunk RS. et al: Immediate hypersensitivity to cockroach, J Allergy Clm Immunol 59: 1% 160, 1977. 7. Kang B. Sulit N: A comparative study of prevalence of skin hypersensitivity to cockroach and housedust antigens, Ann Allergy. (In press.) 8. Kang B: Study on cockroach antigen as a probable causative CI.IN IZIMUNOL agent in bronchial asthma. J ALWRGI 58~357-365. 1976. 9. Gleich GJ, Yunginger JW: Standardization of allergens, in Rose NR, Friedman H, editors: Manual of clinical immunology, Washington, D. C., 1976. pp. 575-584. IO. Booij-Noord H, Orie NGM, deVries K: Immediate and late bronchial obstructive reactions to inhalation of house dust and protective effects of disodium cromoglycate and predniaone, J ALLER~~Y CLIN IMMUNOL

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I97 I.

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12. Hargreave FE, Pepys J: Allergic respiratory reactions in birdfanciers provoked by allergen inhalation provocative tests: Relation to clinical features and allergic mechanisms, J ALL.ERGY CLlN IMibfuN0~ 50: 157-17.1, 1972. 13. Zeiss CR. Patterson R, Pruzansky

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JJ. et al: Trimellitic anhydride-induced airway syndromes. Clinical and immunologic studies, J ALLERGY CLIN IMMUNOL 60:96- 103. 1977. Colten HR. Rolakoff PL, Weinstein SF, et al: Immediate hypersensitivity to hog trypsin resulting from industrial exposure, N Engl J Med 292: 1050-1053, 1975. Bernton HS, McMahon TF. Brown H: Cockroach asthma. Br J Dis Chest 66:61-66. 1972. Kang B, Homburger H. Yunginger J: Radioallergosorbent test (RAST) and other immunologic profiles of cockroach (CR) asthma. Presented at First Annual Meeting of the American Congress of Allergy and Immunology. New) York, N. Y., March 2X-31. 1977. Davis RJ: Bronchial provocative test with common allergens and with chemical vapours, dusts and fumes, in Brent L. Holborow J. editors: Progress in immunology. II, New York. 1974, North-Holland Publishing Co., vol. 4, pp. 249-259. Orange RP. Kaliner MA, Austen KF: The immunological release of histamine and slow reacting substance of anaphylaxis from human lung. III. Biochemical control mechanisms involved in the immunologic release of the chemical mediators, in Austen KF, Becker EL. editors: Second International Symposium on the Biochemistry of Acute Allergic Reaction, Oxford, 1971, Blackwell Scientific Publications, p. 189, Austen KF. Grange RP: Bronchial asthma: The possible role of the chemical mediators of immediate hypersensitivity in the pathogenesis of subacute chronic disease. Am Rev Respir Dis 112:4X%436. 1975. Townley RG, Dennis M, Itkin IH: Comparative action of acetyl-beta-methylcholine, histamine, and pollen antigens in subjects with hay fever and patients with bronchial asthma, J ALLERGY 36:121-137,

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J. ALLERGY

western red cedar (Thuja plicatu), with special reference to bronchial reactivity, Br J Industr Med 27~235244, 1970. Fink JN, Sosman AJ: Allergic lung disease not mediated by IgE, Med Clin North Am 58: 157- 163, 1974. Homburger H, Kang B: Unpublished data. Smith DB: Three methods for increasing sensitivity of immunodiffusion reaction, Anal Biochem 22:543-545, 1968. Solley GO, Gleich GJ, Jordon RE, et al: The late phase of the

Information

CLIN. IMMUNOL. FEBRUARY 1979

immediate “wheal and Hare” skin reaction, its dependence upon IgE antibodies, J Clin Invest 58:408-420, 1976. 27. Hudson G: Quantitative study of the eosinophil granulocytes, Semin Hematol 5: 166-186, 1968. 28. Wasserman SI, Goetzl EJ, Austen KF: Inactivation of slow reacting substance of anaphylaxis by human eosinophil arylsulfatase, J Immunol 114:645-649, 1975.

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