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Utilisation of an Environmental Challenge Chamber (ECC) to Explore Allergen Induced Bronchial Hyperresponsiveness (BHR) in Mild Asthmatic Patients with Co-morbid Rhinitis
Misdiagnosis of Exercise Induced Asthma in Two Patients Years After Surgical Repair of Congenital Anomalies Y. K. Persaud1, C. Lamm2, B. Silverman1, A. T. Schneider1; 1Allergy and Immunology, Long Island College Hospital, Brooklyn, NY, 2Allergy and Immunology, Mount Sinai Hospital, New York, NY. RATIONALE: Describe two children misdiagnosed with exercise-induced asthma(EIA) after repair of congenital tracheo-bronchial anomalies. Respiratory complications after surgery has not been well documented in this population. METHODS: Case Reports. RESULTS: After successful repair of congenital anomalies involving the tracheo-bronchial tree, respiratory complications including recurrent bronchitis, coughing and pneumonias persist. Case Report: Patient #1 is a 7y/o boy with esophageal atresia and distal TE fistula repaired shortly after birth. Subsequently, he developed dysphagia requiring numerous endoscopies for dilatation of esophageal stenosis. Persistent episodes of barking cough and dyspnea with noisy breathing during running occurred without improvement on bronchodilators for many years. Exercise testing reproduced the symptoms of EIA such as coughing, wheezing, and inspiratory/expiratory stridor. Spirometry showed FVC(-10%), FEV1(-7%), and flattening of the inspiratory loop. Bronchoscopy revealed tracheomalacia at the fistula site and bronchial stenosis. Patient #2 is a 12y/o girl diagnosed with double aortic arch requiring surgery at age 5. Thereafter she developed dyspnea with exercise and singing not improved with Albuterol and Cromolyn. Six minutes after exercise testing the O2% dropped from 100% to 98% with flattening of the inspiratory and expiratory loops. Bronchoscopy revealed left bronchus narrowing and bronchomalacia. CONCLUSIONS: These cases illustrate that EIA should be thoroughly investigated if there is stridor, a poor response to bronchodilators, or flattening of inspiratory/expiratory loops. Surgical repair of congenital anomalies may be associated with other defects that may mimick exercise-induced asthma. Exercise testing is vital for diagnosis and practitioners should look for flattening of the inspiratory/expiratory loops in this subset population to prevent unnecessary treatment.
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ROC Curve Analysis of Skin Testing and Specific IgE Antibodies Values to Predict Clinical Allergy to Alternaria in Asthmatic Subjects E. Bevilacqua, N. Fernández, C. Fernández, M. Garcimartin, S. Romero, A. Gomez, R. Vives; Servicio de alergia, HOSPITAL 12 DE OCTUBRE, MADRID, SPAIN. RATIONALE: It is difficult to know the clinical relevance of alternaria sensitization in asthmatic patients. The aim of this work has been to analyze the diagnostic accuracy of skin testing with alternaria (Alternaria alternata) and alternaria specific serum IgE determination in comparison with with alternaria bronchoprovocation test (BPT). METHODS: Fifty asthmatic patients (mean age 21.74±9.86, female/male 1.38) with a positive skin prick-test (SPT) (alternaria 10 BU, ALK-Abelló) and/or detectable alternaria allergens specific serum IgE (CAP System FEIA) underwent a bronchial provocation test (BPT) with alternaria (following ATS guidelines). Intradermal skin tests (ID) (1, 0.1, 0.01 BU/ml) were also performed. Statistical analysis of results was carried out by logistic regression analysis and Receiver Operating Characteristics (ROC) curve. RESULTS: Alternaria BPT was positive in 28 subjects (56%). The area under the curve for CAP values was 0.832. A cut-off point of 3.48 KU/L showed 71.4% sensitivity and 90.9% specificity. The estimated areas under the curve for SPT-10, ID-0.01, ID-0.1 and ID-1 were 0.89, 0.88, 0.86 and 0.81, respectively. A 3 mm cut-off point for SPT-10 showed 89.2% sensitivity and 81.82% specificity, a 7.5 mm cut-off point for ID-0.01 showed 75% sensitivity and 95.4% specificity. CONCLUSIONS: Skin testing with alternaria allergens and determination of specific serum IgE by CAP system are a proper diagnostic test in patients with asthma and allergy to alternaria. Quantitative analysis of the specific IgE levels and skin wheal diameters induced by skin test could be a useful predictor of the outcome of the specific bronchoprovocation testing. Funding: Fondo de Investigación sanitaria, Ministerio de sanidad y consumo, (grant RTIC03/11)
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Versican is Required for Hyaluronan (HA) Dependant Poly I:C Stimulated Leukocyte Binding to Human Lung Fibroblasts (HLF) L. C. Altman1,2, S. Perigo2, T. Wilkinson2, P. Johnson2, T. N. Wight3,2; 1Allergy, University of Washington School of Medicine, Seattle, WA, 2Benaroya Research Institute, Seattle, WA, 3University of Washington, Seattle, WA. RATIONALE: Since viruses are a frequent cause of inflammation and asthma, we examined the role of poly I:C, a viral mimetic, in promoting leukocyte adhesion to HLF and the role of the extracellular matrix (ECM) components versican and HA in this process. METHODS: HLF were maintained for 24 hours in 10% serum containing medium with or without poly I:C or IL-1 combined with TNF in 96 well trays and then incubated for 90 minutes at 4C with fluorescent labeled U937 mononuclear leukocytes. In some wells, LF99, an antibody to the N-terminus of versican was added. Cell layers and media were harvested for analysis of versican by western blotting and HA by ELISA. RESULTS: HA and versican were both present at significantly elevated levels in the cell layer of poly I:C treated HLF but only HA accumulation was increased in the cytokine treated cells. Poly I:C stimulated HLF ECM promoted leukocyte adhesion in contrast to cytokine stimulated HLF ECM which did not. These results were confirmed by immunofluorescent labeling which showed leukocyte adhesion to sites where versican and HA were co-localized on cytoplasmic processes of poly I:C treated HLF. There was much less immunofluorescent labeling of leukocytes or versican on IL-1 and TNF treated cells. Antibody LF99 prevented hyaluronidase sensitive leukocyte adhesion to the poly I:C stimulated HLF (n=3 experiments)(p=0.05). CONCLUSIONS: Versican and HA are both required for poly I:C induced adhesion of leukocytes to HLF. Viral infections may cause and exacerbate asthma because they stimulate an ECM which is uniquely pro-inflammatory. Funding: GlaxoSmithKline Inc.
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Utilisation of an Environmental Challenge Chamber (ECC) to Explore Allergen Induced Bronchial Hyperresponsiveness (BHR) in Mild Asthmatic Patients with Co-morbid Rhinitis N. Krug1, J. M. Hohlfeld1, A. Bruns1, P. Russell2, A. Weeks2, M. Larbig1, R. D. Murdoch2; 1Fraunhofer ITEM, Hannover, GERMANY, 2GSK, Stevenage, UNITED KINGDOM. RATIONALE: The potential to explore nasal responses in patients using an ECC is precedented. Using patients with co-morbid disease, to explore BHR to AMP and nasal symptoms in a single challenge paradigm is attractive but unprecedented and needs validation. METHODS: Mild asthmatics (AMP PC20<80mg/ml) with co-morbid pollen sensitive rhinitis were exposed to 1 or 2, 4hr exposures to pollen in an ECC. Four and 24hr later subjects had a bronchial challenge with AMP to assess BHR. Symptoms and exhaled NO measurements were taken throughout. RESULTS: BHR to AMP was increased from a baseline of 16mg/ml by 1DD following a single exposure to allergen at 4 and 24hr but the response was not potentiated following 2 allergen exposures. No overt bronchoconstriction was seen in the chamber. The TNSS scores of 7 were comparable between sessions, indicating high reproducibility, with little carryover. Exhaled NO was elevated 24hr after both chamber sessions by approximately 27% indicating low grade bronchial inflammation. CONCLUSIONS: In these mild asthmatic patients with normal lung function and mild BHR, clinically relevant and statistically significant changes in BHR were seen following exposure to pollen grains in an ECC. This effect was reduced following 2 exposures. Further validation of this paradigm is required in a more representative asthmatic population and in intervention studies. Funding: GSK
12
SATURDAY
Abstracts S3
J ALLERGY CLIN IMMUNOL VOLUME 117, NUMBER 2
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ROC Curve Analysis of Skin Testing and Specific IgE Antibodies Values to Predict Clinical Allergy to Alternaria in Asthmatic Subjects E. Bevilacqua, N. Fernández, C. Fernández, M. Garcimartin, S. Romero, A. Gomez, R. Vives; Servicio de alergia, HOSPITAL 12 DE OCTUBRE, MADRID, SPAIN. RATIONALE: It is difficult to know the clinical relevance of alternaria sensitization in asthmatic patients. The aim of this work has been to analyze the diagnostic accuracy of skin testing with alternaria (Alternaria alternata) and alternaria specific serum IgE determination in comparison with with alternaria bronchoprovocation test (BPT). METHODS: Fifty asthmatic patients (mean age 21.74±9.86, female/male 1.38) with a positive skin prick-test (SPT) (alternaria 10 BU, ALK-Abelló) and/or detectable alternaria allergens specific serum IgE (CAP System FEIA) underwent a bronchial provocation test (BPT) with alternaria (following ATS guidelines). Intradermal skin tests (ID) (1, 0.1, 0.01 BU/ml) were also performed. Statistical analysis of results was carried out by logistic regression analysis and Receiver Operating Characteristics (ROC) curve. RESULTS: Alternaria BPT was positive in 28 subjects (56%). The area under the curve for CAP values was 0.832. A cut-off point of 3.48 KU/L showed 71.4% sensitivity and 90.9% specificity. The estimated areas under the curve for SPT-10, ID-0.01, ID-0.1 and ID-1 were 0.89, 0.88, 0.86 and 0.81, respectively. A 3 mm cut-off point for SPT-10 showed 89.2% sensitivity and 81.82% specificity, a 7.5 mm cut-off point for ID-0.01 showed 75% sensitivity and 95.4% specificity. CONCLUSIONS: Skin testing with alternaria allergens and determination of specific serum IgE by CAP system are a proper diagnostic test in patients with asthma and allergy to alternaria. Quantitative analysis of the specific IgE levels and skin wheal diameters induced by skin test could be a useful predictor of the outcome of the specific bronchoprovocation testing. Funding: Fondo de Investigación sanitaria, Ministerio de sanidad y consumo, (grant RTIC03/11)
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Versican is Required for Hyaluronan (HA) Dependant Poly I:C Stimulated Leukocyte Binding to Human Lung Fibroblasts (HLF) L. C. Altman1,2, S. Perigo2, T. Wilkinson2, P. Johnson2, T. N. Wight3,2; 1Allergy, University of Washington School of Medicine, Seattle, WA, 2Benaroya Research Institute, Seattle, WA, 3University of Washington, Seattle, WA. RATIONALE: Since viruses are a frequent cause of inflammation and asthma, we examined the role of poly I:C, a viral mimetic, in promoting leukocyte adhesion to HLF and the role of the extracellular matrix (ECM) components versican and HA in this process. METHODS: HLF were maintained for 24 hours in 10% serum containing medium with or without poly I:C or IL-1 combined with TNF in 96 well trays and then incubated for 90 minutes at 4C with fluorescent labeled U937 mononuclear leukocytes. In some wells, LF99, an antibody to the N-terminus of versican was added. Cell layers and media were harvested for analysis of versican by western blotting and HA by ELISA. RESULTS: HA and versican were both present at significantly elevated levels in the cell layer of poly I:C treated HLF but only HA accumulation was increased in the cytokine treated cells. Poly I:C stimulated HLF ECM promoted leukocyte adhesion in contrast to cytokine stimulated HLF ECM which did not. These results were confirmed by immunofluorescent labeling which showed leukocyte adhesion to sites where versican and HA were co-localized on cytoplasmic processes of poly I:C treated HLF. There was much less immunofluorescent labeling of leukocytes or versican on IL-1 and TNF treated cells. Antibody LF99 prevented hyaluronidase sensitive leukocyte adhesion to the poly I:C stimulated HLF (n=3 experiments)(p=0.05). CONCLUSIONS: Versican and HA are both required for poly I:C induced adhesion of leukocytes to HLF. Viral infections may cause and exacerbate asthma because they stimulate an ECM which is uniquely pro-inflammatory. Funding: GlaxoSmithKline Inc.
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Utilisation of an Environmental Challenge Chamber (ECC) to Explore Allergen Induced Bronchial Hyperresponsiveness (BHR) in Mild Asthmatic Patients with Co-morbid Rhinitis N. Krug1, J. M. Hohlfeld1, A. Bruns1, P. Russell2, A. Weeks2, M. Larbig1, R. D. Murdoch2; 1Fraunhofer ITEM, Hannover, GERMANY, 2GSK, Stevenage, UNITED KINGDOM. RATIONALE: The potential to explore nasal responses in patients using an ECC is precedented. Using patients with co-morbid disease, to explore BHR to AMP and nasal symptoms in a single challenge paradigm is attractive but unprecedented and needs validation. METHODS: Mild asthmatics (AMP PC20<80mg/ml) with co-morbid pollen sensitive rhinitis were exposed to 1 or 2, 4hr exposures to pollen in an ECC. Four and 24hr later subjects had a bronchial challenge with AMP to assess BHR. Symptoms and exhaled NO measurements were taken throughout. RESULTS: BHR to AMP was increased from a baseline of 16mg/ml by 1DD following a single exposure to allergen at 4 and 24hr but the response was not potentiated following 2 allergen exposures. No overt bronchoconstriction was seen in the chamber. The TNSS scores of 7 were comparable between sessions, indicating high reproducibility, with little carryover. Exhaled NO was elevated 24hr after both chamber sessions by approximately 27% indicating low grade bronchial inflammation. CONCLUSIONS: In these mild asthmatic patients with normal lung function and mild BHR, clinically relevant and statistically significant changes in BHR were seen following exposure to pollen grains in an ECC. This effect was reduced following 2 exposures. Further validation of this paradigm is required in a more representative asthmatic population and in intervention studies. Funding: GSK
12
SATURDAY
Abstracts S3
J ALLERGY CLIN IMMUNOL VOLUME 117, NUMBER 2