Allergic rhinitis. Options for pharmacotherapy and immunotherapy

A trial of allergy medication can be both diagnostic and therapeutic in a patient with suspected allergic rhinitis, but with so many treatment options, it is sometimes difficult to know where to start. In this second of two articles on allergic rhinitis, Dr Ferguson provides information on efficacy and costs for various allergy drugs and discusses when to consider immunotherapy. The first article, beginning on page 110, discusses signs, symptoms, and triggering allergens.     

Etiologic study of chronic nonspecific bronchopneumopathies in the work environment

Epidemiological methods may be used to study the causes of respiratory troubles at work, to test the hypothesis that there is a statistically significant relationship between professional risk factors and respiratory disease. The prognostic value of certain indices and the impact of preventative measures may also be assessed. The choice of method, type of enquiry and selection of the population to be studied and the resources to be used depend on the aims of the study. The definitions both of occupational exposure and the disease should be clearly established in the protocol. The questionnaire, which is indispensable in all investigation into respiratory disorder, should be adapted to the specific research project (for contents, lay-out, relevance and order of questions, allowing for distorting factors). The final objective in the application of an epidemiological method to study occupational risk factors is to develop a preventative strategy at each stage, but most importantly at the very first stage to prevent the appearance of respiratory troubles.     

Allergic rhinitis

Allergic rhinitis is the most common of the allergic diseases with, according to a number of epidemiological studies, an incidence of about 15% in Central Europe. The condition is characterized morphologically by inflammation of the nasal mucosa resulting from an IgE-mediated allergic reaction of the immediate type. Depending on the allergen involved and the course of the disease several forms of allergic rhinitis are distinguished. The present paper describes the pathophysiology and clinical symptomatology, current diagnostic approaches and the therapeutic possibilities with an eye to their practical relevance.     

Allergen immunotherapy and avoidance

Since its introduction almost a century ago, immunotherapy continues to be an effective method of managing allergic rhinitis, allergic asthma, and insect anaphylaxis. Confusion and misinformation on the part of physicians and the public lead to the inappropriate use of this treatment. Before immunotherapy is started, appropriate avoidance techniques and pharmacotherapy should be instituted (except for insect anaphylaxis, where immunotherapy is a part of the initial treatment.) When these measures fail, or significant side effects are encountered, immunotherapy can be beneficial. This article eliminates as much as possible the ambiguity surrounding immunotherapy to help the clinician understand more clearly the appropriate use of immunotherapy and the treatment of allergic diseases.     

Allergic and immunologic skin disorders

The skin represents a unique immunologic organ poised to protect the host from invading organisms and environmental antigens. The skin is also an important target for a variety of allergic and autoimmune responses. Mast cells are key to the pathogenesis of urticaria, angioedema, and mastocytosis. Atopic dermatitis is the consequence of an immunoregulatory abnormality resulting in a skin-directed T helper type 2 response. Allergic contact dermatitis is an example of classic delayed type hypersensitivity. Circulating autoantibodies against the epidermis are a key mechanism by which bullous skin diseases occur.     

Allergic bronchopulmonary aspergillosis

A 38 year old male was diagnosed to have allergic bronchopulmonary aspergillosis which responded remarkably to prednisolone therapy.     

Immunopathogenesis and immunotherapy of psoriasis

The c-MET oncogene encodes the receptor for the Hepatocyte Growth Factor/Scatter Factor (HGF), a cytokine that stimulates the invasive growth of normal and neoplastic cells. The Met/HGF receptor is expressed by epithelial cells and its ligand by cells of mesenchymal origin. Receptor-ligand interaction occurs via a paracrine circuit. We studied the expression of the Met/HGF receptor and of its ligand in mesenchymal human tumours by examining 39 clinical samples of bone tumours. The Met/HGF receptor was not detectable in the majority of bone tumours, as expected from their mesenchymal origin. Notably, the receptor was overexpressed in 60% of the osteosarcomas examined. In 12 osteosarcoma cell lines the Met/HGF receptor was overexpressed, phosphorylated by HGF stimulation and fully functional. HGF was detected in two out of seven clinical specimens of osteosarcoma. The ligand and the receptor are co-expressed in two clonal osteosarcoma cell lines. In these lines the Met/HGF receptor was constitutively phosphorylated; phosphorylation was suppressed by suramin treatment, a known blocker of autocrine loops. These data suggest that activation of the Met/HGF receptor by a paracrine or an autocrine mechanism might play a role in the particularly aggressive behaviour of osteosarcomas.     

Allergic and photoallergic dermatitis from diphenhydramine

A 52-year-old man developed contact and photoallergic dermatitis caused by diphenhydramine hydrochloride as well as contact dermatitis from paraphenylenediamine. The diphenhydramine photoallergy was elicited by long-wave ultraviolet light. The action spectrum differs from that noted in a recent report in which wavelengths shorter than 320 nm were responsible for eliciting diphenhydramine photoallergy. To the best of my knowledge, this is the third case of diphenhydramine photosensitivity reported in the English literature. The combination of both contact and photosensitivity to diphenhydramine has not previously been described.     

Intralesional and topical chemotherapy and immunotherapy

This article covers the principles and applications of radiation therapy in horses. The goal in treating tumors by irradiation is tumor control with minimum treatment complications. Various treatment techniques are available to achieve this goal. The prognosis depends on many factors such as the extent and location of the tumor, tumor type and tumor cell proliferation. Radiation therapy is a very effective treatment modality for equine tumors but logistical reasons limit its impact in equine oncology.     

Allergic eye disease mechanisms

The histologic distinction between epithelial peritoneal mesothelioma and papillary serous carcinoma diffusely involving the peritoneum may be difficult. Although some investigators have indicated that immunohistochemistry can facilitate this differential diagnosis. only a few studies using a limited number of markers have been published. In this study, the immunoreactivity of keratin 5/6, vimentin, epithelial membrane antigen, thrombomodulin, calretinin, MOC-31, Ber-EP4, carcinoembryonic antigen, TAG-72 (B72.3), CD15 (Leu-M1), placental alkaline phosphatase, CA19-9, CA-125, HBME-1, 44-3A6, and S-100 protein was investigated in 35 epithelial peritoneal mesotheliomas, and 45 papillary serous carcinomas [30 ovarian (10 primary and 20 metastatic to the peritoneum) and 15 papillary serous carcinomas of the peritoneum]. After analyzing the results, it is concluded that calretinin, thrombomodulin, and keratin 5/6 are the best positive markers for differentiating epithelial malignant mesotheliomas from papillary serous carcinomas diffusely involving the peritoneum. The best diagnostic discriminators among the antibodies considered to be negative markers for mesothelioma are MOC-31, B72.3, Ber-EP4, CA19-9, and Leu-M1. Immunostaining for carcinoembryonic antigen, placental alkaline phosphatase, epithelial membrane antigen, vimentin, HBME-1, 44-3A6, CA-125, or S-100 have little or no diagnostic utility in establishing the differential diagnosis between these conditions. The results of this study also confirm previous observations indicating that both papillary serous carcinomas of the peritoneum and serous carcinomas of the ovary have a similar phenotype and, therefore, immunohistochemical studies are not useful in separating these entities.