Search

From 1978 until 1993 we diagnosed 167 cases of inhalative allergy to silk-filled bed quilts. The patients experienced asthma attacks predominantly during the night. Occupational exposure to silk materials was found in six cases. The mean age at first manifestation of symptoms (31 years, range 8 to 58) was relatively high, indicating an aggressive inhalation allergen. Beside a case of occupational asthma in a silk filature, we present two patients with nightly respiratory symptoms: an 8-year-old boy, whose asthma immediately disappeared during his holidays away from home, and a 48-year-old woman diagnosed only eight years after the beginning of an asthma unresponsive to therapy. Elimination of the silk-waste-containing bed quilts led to complete recovery of respiratory symptoms. Prick and intracutaneous skin testing as well as scratch tests using material of silk-filled quilts and the RAST (Pharmacia k 73) to silk waste turned out to be sensitive diagnostic parameters. Many of these bed quilts filled with silk-waste are still used today. Beside the house-dust mites they are a further cause of nightly attacks and should also be considered in allergic work-up.

Hyposensitization or allergenic immunotherapy has been used extensively for 80 years as a specific treatment of IgE-mediated allergic diseases. Highly effective is venom immunotherapy for patients with systemic reactions after hymenoptera stings and positive diagnostic tests for venom-specific IgE. The clinical efficacy of immunotherapy in hay fever has also been convincingly documented. 20 to 30% of patients with allergic rhinitis pollen develop asthma at a later stage of the disease. Some studies have shown a significant efficacy of immunotherapy in reducing the further development of rhinitis into asthma. The clinical efficacy of immunotherapy in allergic asthma to house-dust mites, animal danders or moulds has been questioned; however, a number of controlled studies published during the last decade shows a clear tendency towards a beneficial effect, especially in children. Recent data show a reduction in mediator release induced by immunotherapy and an inhibition of the late-phase reaction following skin and bronchial challenge tests. Immunotherapy and pharmacotherapy should be integrated components of the treatment strategy of allergic diseases in order to gain the optimal result for the allergic patient.

Hyposensitization (desensitization, immunotherapy) is--next to avoidance of allergens--the only causal treatment of IgE-mediated allergic diseases. In a number of well-controlled studies, immunotherapy has shown a clinical efficacy in allergic rhinitis, mainly hay fever, and in allergic asthma. Here, immunotherapy is primarily useful in children and young adults. Immunotherapy is highly effective in hymenoptera-venom allergy. The quality of the extracts in terms of potency and composition is essential both to the diagnosis of relevant allergens and to an optimal result of immunotherapy. The hyposensitization extracts used in Switzerland are listed in the 'Spezialitätenliste des Bundesamtes für Sozialversicherung' and have, therefore, to be payed for by the health insurance. Since the early seventies so-called semi-depot extracts are used in practice; here, the allergens are adsorbed to aluminium hydroxide and thus liberated in a delayed way. For a few years a short-term therapy, using so-called depot allergoids, is possible. A hyposensitization should be initiated only after a through evaluation and a careful allergological examination. With regard to pollen allergies one has to take into consideration especially the presence of the leading pollens, the cross-reactivity and the patient's account of his symptoms. The practice of hyposensitization is discussed extensively. The information of the patient regarding efficacy, length of treatment and risk of side effects is of great importance.

Among the perennial rhinitides three forms should be distinguished because of therapeutic and prophylactic consequences: allergic, nonallergic eosinophilic (NARES syndrome) and nonallergic non-eosinophilic (vasomotor) rhinitis. Their distinction is based on history as well as on clinical criteria and allergy tests, necessitating an optimal collaboration between the general practitioner, the otorhinolaryngologist and the clinical immunologist. The therapeutic approach to the three forms is outlined.

For controlled hyposensitization treatment over a period of three years 36 patients with confirmed grass pollen sensitization had been selected in 1986 and randomly distributed to receive preseasonal injection therapy: 23 patients were treated with an average of seven AGD (aluminium-adsorbed allergoid) injections, and 13 patients had received six TA (tyrosine-adsorbed allergoid) injections. Evaluation of the trial data collected during three years of preseasonal treatment showed the following results of tolerance and efficacy: Systemic side-reactions registered during therapy were only mild and transient and occurred in the average after 3% of the AGD injections and after 10% of the TA injections. Local reactions over 5 cm diameter were registered after 7% in the AGD group and after 9% in the TA group. Before therapy there was no significant difference (p greater than 0.05) between the groups; after three years of therapy the AGD injections had resulted in a mean net rise of specific IgG of 220% (significant, p = 0.001); during the same time, TA injections had resulted in a final net increase of 10% (not significant, p greater than 0.05). Both treatment forms did not lead to any statistically relevant changes of specific IgE values. After three years of hyposensitization treatment, patients of both groups had improved; but an advantage was documented for patients treated with AGD on the basis of scores for objective assessment as well as for registered symptom and medication scores.

Urticaria is a rather common, often vexing skin disease, characterized by evanescent, pruritic, erythematous wheals, and sometimes by giant hives (angioedema). The cause of chronic urticaria remains unknown in 75 to 80 percent of the cases. Its pathogenesis is related to the activation of tissue mast cells by many immunologic or non-immunologic mechanisms, resulting in a release of biologically active products. The therapeutic possibilities in practice are discussed. Non-sedative antihistaminic drugs of the H1 type (Terfenadine, Astemizole, Loratidine and Cetirizine) are the main stay in the treatment of urticaria. In case of failure the sedative non-selective antihistaminics from the old generation are used. Particular emphasis is given the possibilities to combining various antiallergic drugs. The combination of a H1 and H1 antihistamine can be effective in individual patients.