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Dual bronchial reaction after bronchial challenge: a new interpretation
Correspondence
Dual bronchial reaction after bronchial challenge: a new interpretation To Ihe Editor: With reference to the Dr. Gleich’s article,’ we submit to your attention our observations about some late asthmatic reactions after bronchial challenge. Performing bronchial provocation tests with allergen inhalation by aerosol, we elicited late asthmatic responses, other than immediate, in about 10% of asthmatic patients positive to Dermatophagoides pteronyssinus.‘. ” These types of nonimmediate reactions began usually 2 to 3 hr after aerosol challenge with sensitizing allergen and reached the maximum at about 4 to 5 hr (Fig. 1). The absence of detectable general symptoms such as fever, leukocytosis, myalgla, and serum-specific IgG precipitating antibodies suggested to us that these late reactions were not dependent on antigen-antibody complexes and were different from Ar:hus-type bronchial late reactions.’ Considering that only a riery little amount of the aerosol solution can reach the bronchial mucosa and that the final route for the remaining inhaled allergen is the gastrointestinal tract, we examined the possibility that these late asthmatic reactions were induced by ingestion of aerosolized allergens. In order to confirm this hypothesis. we studied 14 asthmatic atopic patients with only immediate positive skin reactions to mite and with a high specific IgE serum level. They were all dual bronchial
reactors to specific allergen aerosol challenge. inhaled by a nebulizer connected with an intermittent positive-pressure apparatus Bennett PR2. Three days slier the bronchial challenge we administered to them by oral rotire the same dose of the same allergenic extract of D. prrronj LSMLJ rn gastrosoluble capsules. This test was repeated twice in each patient at intervals of 3 days. After a further period of 3 days. another test was performed in each patient by oral administration of a surely negative allergen. The effects of FEV, of oral administration and inhalation of the same dose of mite in one patient are compared in Fig. I; the pattern was strictly similar in all the other cases. Immediate reaction was always absent after oral administration r~f mite. On the contrary, the nonimmediate reaction was idways present, and the time of its development and its stret:gth and length were quite similar in the two single test: AU tests performed with surely nonreactive allergens were negative. The data brought out by such observation5 LXNIJ~clear the immunopathogenesis of this type of early nonimmediate reactions. It seems that these reactions are of type I, resulting from gastrointestinal absorption of antigen The interval of 2 to 4 hr between oral challenge and appearance ot bronchial constriction could be the time required t’or the oral absorption of a dose of allergen sufficient to elicit an allergic IgE-dependent reaction. After these observations. we now prefer !i\ define these
challenge
% decrease in
FEV, -4*-.-.-‘-
15
30
60
minutes Bronchial -s-e-
2
3
4
5
6
hours
Oral
provocation
test
challenge
) of the same dose FKi. 1. Effects on FEV, of oral administration (----) and of inhalation (----of house dust mite in one patient. The anaphylactic (1 type) allergic reaction, developing immediately after the inhalation, is absent after oral administration of the allergenic extract. On the contrary, the nonimmediate reaction is present and the time of its devi?lOpm8nt and its strength and length are quite similar in both tests. 105
106
J. ALLERGY CLIN. IMMUNOL. JANUARY 1984
Correspondence
“early nonimmediate” reactions as “late phases of immediate reaction”, like Solley et al.” for skin reactions.
Division
of Pneumology Hospital “A.
Giulio Cocco, M.D. Gennuro D’Amato, M.D. Gaetano Melillo, M.D. und Respiratory Allergy Cardarelli,” Naples, Italy
REFERENCES
1. Gleich GJ: The late phase of the immunoglobulin E-mediated reaction: a link between anaphylaxis and common allergic disease? 1 ALLERGY CLIN IMMUNOL 70:160, 1982
2. Melillo Cl, D’Amato G, Cocco G: Specific bronchial provocation tests. In Ricci M, Fauci A, Arcangeli P, Torzuoli P, editors: Developments in clinical immunology. New York, 1978, Academic Press, Inc., p 201 3. Cocco G, D’Amato G, Melillo G.: Non-immediate asthmatic reactions after bronchial challenge. In Melillo G, D’Amato G, Cocco G, Ceccucci M, editors: Respiratory allergy. Milano, 1980, Masson Italia, p 145 4. Pepys I: lmmunopathology of allergic lung disease, Clin ‘Allergy 3: 1, 1973 5. Solley GO, Gleich GJ, Jordan RE, Schroeter AL: Late phase of the immediate wheal and flare skin reaction: its dependence on IgE antibodies. J Clin Invest 58:408, 1976
Dual bronchial reaction after bronchial challenge: a new interpretation To Ihe Editor: With reference to the Dr. Gleich’s article,’ we submit to your attention our observations about some late asthmatic reactions after bronchial challenge. Performing bronchial provocation tests with allergen inhalation by aerosol, we elicited late asthmatic responses, other than immediate, in about 10% of asthmatic patients positive to Dermatophagoides pteronyssinus.‘. ” These types of nonimmediate reactions began usually 2 to 3 hr after aerosol challenge with sensitizing allergen and reached the maximum at about 4 to 5 hr (Fig. 1). The absence of detectable general symptoms such as fever, leukocytosis, myalgla, and serum-specific IgG precipitating antibodies suggested to us that these late reactions were not dependent on antigen-antibody complexes and were different from Ar:hus-type bronchial late reactions.’ Considering that only a riery little amount of the aerosol solution can reach the bronchial mucosa and that the final route for the remaining inhaled allergen is the gastrointestinal tract, we examined the possibility that these late asthmatic reactions were induced by ingestion of aerosolized allergens. In order to confirm this hypothesis. we studied 14 asthmatic atopic patients with only immediate positive skin reactions to mite and with a high specific IgE serum level. They were all dual bronchial
reactors to specific allergen aerosol challenge. inhaled by a nebulizer connected with an intermittent positive-pressure apparatus Bennett PR2. Three days slier the bronchial challenge we administered to them by oral rotire the same dose of the same allergenic extract of D. prrronj LSMLJ rn gastrosoluble capsules. This test was repeated twice in each patient at intervals of 3 days. After a further period of 3 days. another test was performed in each patient by oral administration of a surely negative allergen. The effects of FEV, of oral administration and inhalation of the same dose of mite in one patient are compared in Fig. I; the pattern was strictly similar in all the other cases. Immediate reaction was always absent after oral administration r~f mite. On the contrary, the nonimmediate reaction was idways present, and the time of its development and its stret:gth and length were quite similar in the two single test: AU tests performed with surely nonreactive allergens were negative. The data brought out by such observation5 LXNIJ~clear the immunopathogenesis of this type of early nonimmediate reactions. It seems that these reactions are of type I, resulting from gastrointestinal absorption of antigen The interval of 2 to 4 hr between oral challenge and appearance ot bronchial constriction could be the time required t’or the oral absorption of a dose of allergen sufficient to elicit an allergic IgE-dependent reaction. After these observations. we now prefer !i\ define these
challenge
% decrease in
FEV, -4*-.-.-‘-
15
30
60
minutes Bronchial -s-e-
2
3
4
5
6
hours
Oral
provocation
test
challenge
) of the same dose FKi. 1. Effects on FEV, of oral administration (----) and of inhalation (----of house dust mite in one patient. The anaphylactic (1 type) allergic reaction, developing immediately after the inhalation, is absent after oral administration of the allergenic extract. On the contrary, the nonimmediate reaction is present and the time of its devi?lOpm8nt and its strength and length are quite similar in both tests. 105
106
J. ALLERGY CLIN. IMMUNOL. JANUARY 1984
Correspondence
“early nonimmediate” reactions as “late phases of immediate reaction”, like Solley et al.” for skin reactions.
Division
of Pneumology Hospital “A.
Giulio Cocco, M.D. Gennuro D’Amato, M.D. Gaetano Melillo, M.D. und Respiratory Allergy Cardarelli,” Naples, Italy
REFERENCES
1. Gleich GJ: The late phase of the immunoglobulin E-mediated reaction: a link between anaphylaxis and common allergic disease? 1 ALLERGY CLIN IMMUNOL 70:160, 1982
2. Melillo Cl, D’Amato G, Cocco G: Specific bronchial provocation tests. In Ricci M, Fauci A, Arcangeli P, Torzuoli P, editors: Developments in clinical immunology. New York, 1978, Academic Press, Inc., p 201 3. Cocco G, D’Amato G, Melillo G.: Non-immediate asthmatic reactions after bronchial challenge. In Melillo G, D’Amato G, Cocco G, Ceccucci M, editors: Respiratory allergy. Milano, 1980, Masson Italia, p 145 4. Pepys I: lmmunopathology of allergic lung disease, Clin ‘Allergy 3: 1, 1973 5. Solley GO, Gleich GJ, Jordan RE, Schroeter AL: Late phase of the immediate wheal and flare skin reaction: its dependence on IgE antibodies. J Clin Invest 58:408, 1976