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The term "food allergy" is widely misused for all sorts of symptoms and diseases caused by food. Food allergy (FA) is an adverse reaction to food (food hypersensitivity) occurring in susceptible individuals, which is mediated by a classical immune mechanism specific for the food itself. The best established mechanism in FA is due to the presence of IgE antibodies against the offending food. Food intolerance (FI) are all non-immune-mediated adverse reactions to food. The subgroups of FI are enzymatic (e.g. lactose intolerance due to lactase deficiency), pharmacological (reactions against biogenic amines, histamine intolerance), and undefined food intolerance (e.g. against some food additives). The diagnosis of an IgE-mediated FA is made by a carefully taken case history, supported by the demonstration of an IgE sensitization either by skin prick tests or by in vitro tests, and confirmed by positive oral provocation. For scientific purposes the only accepted test for the confirmation of FA/FI is a properly performed double-blind, placebo-controlled food challenge (DBPCFC). A panel of recombinant allergens, produced as single allergenic molecules, may in future improve the diagnosis of IgE-mediated FA. Due to a lack of causal treatment possibilities, the elimination of the culprit "food allergen" from the diet is the only therapeutic option for patients with real food allergy.

Oral terbinafine (Lamisil) is a widely used and effective therapy of dermatophyte infections. A 20-year-old patient was treated with oral terbinafine for an inguinal-scrotal fungal infection and developed an acute generalized exanthematic pustulosis (AGEP) and fever. Histological examination of skin biopsy revealed subcorneal and spongiform pustules. The diagnosis of an AGEP induced by terbinafine was established based on the history, clinical manifestations, and laboratory findings. Clinical features, differential diagnosis, causative drugs, and the therapy of AGEP are discussed and the literature on cases of terbinafine-induced AGEP is reviewed.

The Swiss Study on Air Pollution and Lung Diseases in Adults (SAPALDIA) was carried out during 1991-1993 in eight Swiss areas with different environmental characteristics. The cross-sectional examination included 9651 adults, aged 18-60 years, who all participated in a detailed interview. In 8357 subjects complete allergy skin and in-vitro tests were available in addition. The prevalence of atopic sensitization (positive skin prick test to any of the tested inhalant allergens and/or a positive Phadiatop as an in-vitro screening test for atopy) was 32.3%, with a higher prevalence in males (35.7%) than in females (28.8%). Skin sensitization was predominantly caused by grass pollen (12.7%), followed by house dust mite (8.9%), silver birch pollen (7.9%) and cat epithelia (3.8%). 11.1% suffered from current hay fever, 6.8% from asthma, 4.5% from atopic asthma. Smokers had statistically significant (p0.001) higher mean serum IgE concentrations (geometric mean 39.7 kU/l) than nonsmokers (27.2 kU/l), In Phadiatop positive subjects, the IgE levels were highest, with a mean of 104.3 kU/l (99.0-109.8). The SCARPOL Study (Swiss Study on Childhood Allergy and Respiratory Symptoms with respect to Air Pollution and Climate) ist based on a sample of 4470 children from 10 different areas who completed parenteral questionnaire. 35.7% of the 2879 children who underwent skin prick testing were sensitized to at least one tested aeroallergen, 22.5% to gras pollen, 12.4% to house dust mites, 11.4% to birch pollen and 6.4% to cat epithelia. 17% of the 13- to 15-year-old (8th grade) suffered from hayfever. The prevalence of asthma (ever) for the whole sample was 9%, without differences between the age groups. The lifetime prevalence of atopic dermatitis was 13% and the current prevalence 8%. The risk of eczema was higher in Swiss children than in children of immigrants, in infants with a birthweight below 2500 g, in children with a positive family history of atopic dermatitis, and in children from higher socioeconomic classes. Farm children (n = 133) living in a rural area suffer less frequently from pollinosis (2.4%) and bronchial asthma (1.6%) than children (n = 966) with no direct contact to agriculture, but living in the same area (prevalence of hayfever 18.3%, of asthma 9.1%). This figures are similar to results from former East and Western Germany and from the former USSR and Baltic areas. These large Swiss epidemiologic studies confirmed both, the high prevalence of atopy and atopic diseases, and the health impact of moderate air pollution levels and of factors associated with the 'western lifestyle'.

Atopic dermatitis is a chronic-relapsing disease that often requires an individualized therapeutic approach. There are various treatment options that address known pathogenetic pathways and, when used in combination, are often very successfull. In view of the fact that a unifying pathogenic concept as well as a therapeutic regimen is not available to this very day, preventative measures that should be introduced in very early childhood. Therefore, one very important goal in treatment is to identify and eliminate triggering factors which include irritants, allergens and cutaneous bacterial, viral or fungial infections. The mainstay of therapy today are external emmollients, which when used appropriately, can reduce the need for systemic treatments. The reconvalescence can be speeded up by auxilliary therapies such as UVA or UVB, psychotherapeutical strategies such as stress reduction as well as so-called climate-("Klima") therapy.

In Switzerland, unlike other countries, allergic reactions to ants are a rare phenomenon when compared to the well known allergies to bee and wasp venom. In this report we present a series of case reports and a review of the different types of allergy to ants. Due to increased travel and heterogeneity of the population, we have observed several patients with sensitisation or allergy to the venom of imported fire ants (Solenopsis), a species of ant found in the Americas. Furthermore, allergic reactions to bites of the mound-building wood ant (Formica rufa), whose habitat is Central and Northern Europe, have been documented. Whereas reactions to fire ants can be life-threatening, reactions to mound-building wood ants have led to marked local reactions and in 2 cases to dyspnoea and wheezing. These reactions could be due either to primary sensitisation to ant venom or cross-reactivity in the presence of an allergy to wasp venom. Evaluation of patients presenting with a potential ant venom allergy includes a detailed personal history, skin testing and determination of specific IgE. However, to date only extracts from fire ants are commercially available for diagnostic tests. In the light of our observations we assume cross-reactivity between the venoms of fire ants and mound-building wood ants, and it therefore seems appropriate to use fire ant diagnostics in determining sensitisation to mound-building wood ants. In patients with severe fire ant-venom allergy we recommend desensitisation by immunotherapy, whereas in patients presenting with minor allergic reactions, e.g. after bites by mound-building wood ants, we provide the patients with emergency medication. Since current knowledge of ant allergies in Europe is limited, further studies are warranted.

The incidence of allergic reactions to nuts, seeds and grains is increasing. Reactions to nuts are typically observed as part of a pollen-associated food syndrome (oral allergy syndrome). Nevertheless, anaphylactic reactions such as shock with lethal outcome may occur. With the increasing use and consumption of eastern and Asian cuisine, with foodstuffs such as sesame, paranuts or cashew nuts, these allergies are more frequent than they were formerly. Peanut allergy has become an epidemic problem in the United States. In this article allergic reactions to nuts, seeds and grains are discussed. Illustrative cases are presented.

Climatotherapy of atopic dermatitis in a high alpine climate is a well-established therapy that meets the currently growing demand for a holistic approach in the treatment of this skin condition. The effectiveness of climatotherapy was evaluated in 97 patients with atopic dermatitis who were treated at the Zürich High Mountain Clinic in Davos during the period 1990-1994. The period of hospitalisation averaged 32 days. Upon discharge, 89% of patients were symptom-free or much improved. According to the patients' subjective recollection after a time interval of at least one year, 70% recalled being symptom-free or much improved at discharge. In the first year after climatotherapy, 81% of patients suffered a relapse. Nevertheless, in 56% the severity of the atopic dermatitis was reduced, and 74% of the patients who had previously been unable to work were able to resume their occupation. Before treatment, 73% of the patients were on corticosteroids, 14% systemically. The latter could be discontinued in all but one case; local steroids could be discontinued in 71% of cases. 62% of the patients had also tried "alternative" medical treatments and remedies, the majority with no measurable success. Thus, climatotherapy is a successful treatment for atopic dermatitis, but a mild relapse is to be expected. The popular, but less successful "alternative" medical treatment of atopic dermatitis needs to be evaluated scientifically according to international medical standards.

A 77-year old farmer presented with a history of three severe anaphylactoid reactions after hymenoptera stings for the last three years. No sensitisation to hymenoptera venoms could be shown on allergological work-up. The serum level of tryptase however was clearly elevated (37.1 micrograms/l; normal value:13.5 micrograms/l). The diagnosis of systemic mastocytosis could be confirmed by bone marrow biopsy. Patients with mastocytosis are at increased risk of anaphylactic/anaphylactoid reactions. They should be educated how to avoid trigger factors and they should always carry an emergency kit (H1 blocker, corticosteroid, adrenalin) and a "mastocytosis pass" with them. Venom immunotherapy is indicated in patients with proven hymenoptera allergy. Selected patients at very high risk of anaphylactic reactions may need a continuous prophylactic medication with H1 and H2 blocker and eventually a cyclooxygenase inhibitor.

Three patients developed recurrent anaphylactic reactions after ingestion of different kinds of food (Asian food, chocolate products, bakery products).In all three patients a severe peanut allergy was confirmed either by skin prick testing or serologically (specific IgE for peanut of CAP class 3,4 and 6 respectively). Peanut allergy in all patients explained the anaphylactic reactions due to ingestion of hidden peanut in the food.Patients were told to avoid the allergen. Because accidental ingestion is frequent in peanut allergy, they were equipped with a document stating the severity of the allergy and emergency medication (antihistamines, oral steroids, adrenaline injector).Peanuts can be concealed in different kinds of food because they are cheap, rich in protein and are often used to change the viscosity of other foods. Especially the American and Asian cuisines use peanuts in a wide variety of recipes. Furthermore accidental ingestion can occur due to false or lacking declaration of peanuts in processed food. Patients with peanut allergy should be informed about these possibilities.

We report the case of a a 60 year-old worker in the pharmaceutical industry who suffered from recurring contact dermatitis. Initially the contact dermatitis was limited to the hands; later on it became generalized. The patient had been working on a drug filling line in a pharmaceutical plant for more than 20 years. Eight years after starting this job he had developed allergic hand dermatitis to 2,6-diaminopyridine (patch test positive); this healed upon cessation of exposure. Ten years later he again developed hand dermatitis which progressed to generalized dermatitis and conjunctivitis. Under systemic and local therapy with corticosteroids and cessation of work, it healed nearly completely. Four months after returning to work, the patient experienced a first episode of severe asthma and generalized dermatitis with conjunctivitis following exposure to hydroxychloroquine the day before. The asthma and dermatitis improved after systemic corticosteroid therapy and stopping work. His condition continued to fluctuate, when though the patient was transferred at work and now wore rubber gloves. Eight months later he again developed a generalized dermatitis. Patch testing revealed delayed-type sensitizations to hydroxychloroquine (tested in concentrations of 0. 1%, 0.5%, 1% and 2%). Equivalent tests in five healthy volunteers were negative. The patch test reactions were pustular, while a biopsy was interpreted as a multiform contact dermatitis reaction. Bronchial exposure with hydroxychloroquine dust produced a delayed bronchial obstruction over the next 20 hours, which progressed to fever and generalized erythema (hematogenous contact dermatitis). After removing exposure to 2,6-diaminopyridine and hydroxychloroquine, the patient went on to develop a contact dermatitis to latex (patch test positive). However, skin prick tests with latex and patch tests with rubber additiva were negative. Hydroxychloroquine is well known to cause drug reactions. To our knowledge, contact dermatitis to this substance has not yet been reported. It is noteworthy that the patch test reactions were pustular and of multiform morphology and that bronchial exposure to the allergen resulted in asthma and a generalized drug reaction. Pathogenetically the asthmatic reaction seems to be on a delayed-type mechanism as is also seen with ampicillin, cobalt and nickel induced asthma.

The discovery of the immunoglobulin E 30 years ago, and the subsequent availability of serological techniques for in vitro allergy tests, have given fresh impetus to allergy diagnosis in clinical practice. Independently of the more refined allergy diagnosis, there has been a continuous increase in allergic diseases in recent decades. Various factors, summed by the term "Western lifestyle", have produced this increase. As well as individual measures (primary, secondary and tertiary allergy prevention), intensive interdisciplinary cooperation is necessary to arrive at a broad and successful prevention concept. Governments and the political community should accord higher priority than hitherto to fighting allergies, which are now the primary environmental diseases. Parallel to progress in fundamental immunology and the introduction of effective drugs for symptomatic treatment of the various atopic manifestations, a problem facing us today is the growing popularity among the public of "alternative medicine" for the treatment of allergies, even though many of these unconventional diagnostic and therapeutic methods are judged pseudoscientific and their efficacy is unproven. The allergy patient is increasingly caught in the tug-of-war between allopathic and "alternative" medicine, pharmacists, so-called "natural healers", patient and consumer organisations and the mass media. Expectations of successful results from "natural", "soft", "Chinese" or "Tibetan" medicine are high, along with the corresponding marked placebo effect and scepticism about allopathic medicine. This "nocebo" effect thrives on psychosocial territory and is fostered by public opinion. Evidence of this is the rise of new environment-related forms of disease for which there is no proof of a toxic or immunologic origin ("idiopathic environment-related intolerances", according to the new WHO terminology). Allopathic and complementary medicine are often consumed together, thus increasing treatment costs. At the same time, fewer and fewer allergy patients are treated by allergen immunotherapy, the only treatment which can affect the natural course of allergic disease and which may also prevent the development of asthma in patients which allergic rhinitis.

Adverse reactions to food and food additives must be classified according to pathogenic criteria. It is necessary to strictly differentiate between an allergy, triggered by a substance-specific immunological mechanism, and an intolerance, in which no specific immune reaction can be established. In contrast to views expressed in the media, by laymen and patients, adverse reactions to additives are less frequent than is believed. Due to frequently "alternative" methods of examination, an allergy to food additives is often wrongly blamed as the cause of a wide variety of symptoms and illness. Diagnosing an allergy or intolerance to additives normally involves carrying out double-blind, placebo-controlled oral provocation tests with food additives. Allergic reactions to food additives occur particularly against additives which are organic in origin. In principle, it is possible that during the manufacture of genetically modified plants and food, proteins are transferred which potentially create allergies. However, legislation exists both in the USA (Federal Drug Administration, FDA) and in Switzerland (Ordinance on the approval process for GM food, GM food additives and GM accessory agents for processing) which require a careful analysis before a genetically modified product is launched, particularly where foreign genes are introduced. Products containing genetically modified organisms (GMO) as additives must be declared. In addition, the source of the foreign protein must be identified. The "Round-up ready" (RR) soya flour introduced in Switzerland is no different from natural soya flour in terms of its allergenic potential. Genetically modified food can be a blessing for allergic individuals if gene technology were to succeed in removing the allergen (e.g. such possibilities exist for rice). The same caution shown towards genetically modified food might also be advisable for foreign food in our diet. Luckily, the immune system of the digestive tract in healthy people tolerates foreign antigens. Food allergies in adults occur mainly among those allergic to pollen.

Hereditary angioneurotic oedema or hereditary angiooedema (HAE) and acquired angiooedema (AAE) are disorders of the C1-inhibitor (C1-INH) protein, caused by the lack, dysfunction or exhaustion of the C1-INH molecule. Inadequate function of C1-INH results in inappropriate control of various enzymes of the fibrinolytic, complement and kinin systems as well as of factor XII, being the initial enzyme of the kinin and contact coagulation systems. As C1-INH functional deficiency is rare and the clinical manifestation little known, even nowadays the most feared complication of the deficiency may evolve: death from acute airway obstruction. Patients deficient in C1-INH function whose clinical manifestations are misinterpreted as allergic angiooedema are most at risk for fatal laryngeal oedema. The therapy of allergic and C1-INH-related angiooedema is fundamentally different. The background for the hereditary form of inadequate C1-INH function is a gene defect. The predominant primary underlying disease of the acquired form of the deficiency (AAE) is a lymphoproliferative process.

A 58 year old patient with hepatitis virus C (HCV) infection had a secondary polyclonal IgG-IgM cryoglobulinemia with a benign 20 year course. Clinically the patient suffered from progressive pigmented purpura (PPP). Histologic evaluation revealed a lymphocytic vasculitis. Food containing tartrazine triggered flares of the PPP, as demonstrated with controlled oral provocation testing. In most of the previously described cases of HCV and type III cryoglobulinemia, the typical cutaneous finding was palpable purpura with leukocytoclastic vasculitis.

Since the age of 16 years a now 25-year-old woman had been known to have C1-inhibitor (C1-INH) deficiency. She presented herself at the emergency department because of acute severe lower abdominal cramps. A urinary infection had been treated with antibiotics for the previous 4 days. There was marked pain on pressure over the lower abdomen, but there were no signs of peritonitis and bowel sound were normal. There had been no nausea or vomiting and the stools had been normal.There was a leukocytosis of 10,200/microliter, moderately elevated C-reactive protein (44.8 mg/l), haemoglobin concentration of 17 g/dl and haematocrit of 51%. Radiology revealed oedema of the duodenum and sonography showed free fluid in the abdomen.After excluding an acute abdomen and in view of the C1-INH deficiency treatment was symptomatic. All symptoms completely disappeared after 2 days.Exclusively gastrointestinal symptoms and ascites are rare in patients with hereditary angioedema. But knowledge of this manifestation of the disease is important because patients are sometimes operated under the false diagnosis of acute abdomen. In severe cases symptomatic treatment may have to be supplemented by C1-INH administration. Prevention with attenuated androgens should be started or modified, respectively.

A 58-year-old woman was admitted because of intermittent fever for 4 weeks accompanied by slowly developing anaemia and increase in inflammatory parameters. She was being treated for hypertension with atenolol and chlorthalidone, but until 6 weeks before the onset of the described symptoms she had only taken the beta blocker, at which time the diuretic was added because the hypertension was inadequately controlled. Other than slightly impaired general condition and nocturnal fever up to 39.5 degrees C physical examination was unremarkable.She had a normochromic normocytic anaemia and the erythrocyte sedimentation rate and C-reactive protein were clearly elevated. Other biochemical tests and blood cultures as well as serological and immunological tests were negative. Bone marrow biopsy showed nonspecific reactive changes. The chest radiograph, lung scintigraphy and abdominal ultrasound were unremarkable.There was no further fever after the antihypertensive medication had been discontinued. The patient's general condition rapidly improved and all biochemical tests became normal. The lymphocyte transformation test demonstrated stimulation by chlorthalidone.Drug fever, in this case due to a sulphonamide derivative, should always be considered in the differential diagnosis of fever of unknown aetiology. No previous case of hypersensitivity reaction to chlorthalidone has been found on a search of the literature.

A multicentre, retrospective study of hereditary deficiency of C1-esterase inhibitor (C1-INH) function, a deficiency which clinically manifests as hereditary angioedema (HAE), was performed in six centres in Germany, Austria and Switzerland. 242 individuals were registered with proven functional or quantitative deficiency of C1-INH who belonged to kindered with disease manifestation in 2 to 6 generations. Considering the total population in the three countries and the number of registered individuals, a frequency of the deficiency of 0.02 x 10(-4) was calculated. As this epidemiological study involved only 6 centres, a 10 to 100 times higher frequency of C1-INH deficiency is estimated to be a more realistic value. Out of the 242 registered individuals 110 were evaluated for type and location of clinical manifestation of the deficiency, the laboratory data and the therapy outcome. 86 (78.2%) of the patients belonged to the "common type" and 24 (21.8%) to the "variant type" of HAE. In 53.9% of the cases first manifestation of the disease was before the age of 20 years. In only 3.9% of the patient population did the disease begin after 40 years of age. A mean time lag of 5,3 years was observed, between the first manifestation and correct diagnosis. Initial diagnosis was correct in only 31.8% of the cases of which dermatologists provided 51.7%. False diagnoses include urticaria (41.3%), allergy (20%), acute abdomen (18.7%), angina (8%), rheumatoid disease (5.3%) and intracranial haemorrhage, CNS tumour, epilepsy, migraine (5.3%). The distribution pattern of HAE resembled that of intolerance reactions and pseudoallergies. Urticarial lesions were not associated with C1-INH deficiency. 24% of the patients had at least one episode of laryngeal edema. 40% of patients were unable to identify a trigger of edema formation. The others indicated as triggers trauma, hormonal changes, mental stress, insect stings and in a few cases food and drugs. Menstruation and oral contraceptives aggravated or made disease manifestations more frequent. In contrast, during pregnancy in many cases clinical manifestations improved and delivery posed no problems. The possibility of HAO is very much suggested by the tailure of edema to respond to classical anti-allergic therapy. Therapy of choice of acute attacks is C1-INH concentrate. No side reactions, antibody formation or virus transmission have been observed. For long term prophylaxis danazol, an attenuated androgen, or tranexamic acid, a protease inhibitor, was chosen. The daily dose of danazol should be kept as low as possible because of its anabolic, anti-estrogenic, anti-gestagenic, and anti-gonadotropic effects. Indeed, adverse reactions were observed in 41.7% of patients receiving danazol. Frequencies of adverse reactions were twice as common in women as in men. Adverse reactions were dose dependent and reversible except for one woman with irreversible deepening of her voice. Measuring C1r is a effective way to assess C1-INH function and monitor therapy.

Adverse reactions to seafood are common and may cause many types of symptoms that are difficult to define. The nature of these reactions are variable including allergic and toxic reactions as well as infectious diseases. The differentiation between these entities is essential in choosing therapy. We describe 9 patients with IgE mediated allergic reactions due to crustaceans and fish diagnosed from case history, clinical findings, skin tests and specific IgE antibodies. Most symptoms of a IgE mediated allergic reaction appear within 30 minutes after ingestion. Characteristics clinical features may include an urticarial rash, gastrointestinal symptoms and even anaphylaxis. In this case immediate therapy with intravenous glucocorticoids, antihistamine and perhaps subcutaneous epinephrine is required.

In the CAST, blood leukocytes are prestimulated with the cytokine IL-3 and exposed to allergen(s). Mainly basophiles react by synthesizing sulfidoleukotrienes (sLT), namely LTC4 and its metabolites LTD4 and LTE4. They are detected by ELISA technique. 66 patients with suspected allergy to hymenoptera venoms were evaluated. Allergic reactions comprised all severity grades (I-IV ref. H. L. Mueller). The workup included skin tests (up to 1 microgram/ml, Pharmacia), measurement of specific serum IgE with RAST-CAP (Pharmacia), and CAST with three concentrations of bee (Apis mellifera) and wasp (Vespula spec.) venom (Aquagen ALK). A control group of 13 nonallergic, RAST-CAP negative individuals was established. CAST demonstrated pronounced variations of individual s-LT synthesis in patients and controls. The use of elevated cut-offs improved the results, while the use of three allergen concentrations did not increase reliability. Diagnostic accuracy of CAST was evaluated by comparison with skin tests as the "gold standard". With bee venom and a cut-off at 3 standard deviations, a sensitivity and specificity of 73%/71% was obtained. Wasp venom showed better results at 2 standard deviations, with a sensitivity and specificity of 68%/100%. CAST results were not influenced by the severity of the allergic reaction nor by the time lapse since the sting had occurred. In conclusion, CAST is a valuable test in insect sting allergy. However, established methods such as skin tests and RAST-CAP achieve better results. CAST should therefore be considered a supplementary method in cases where established methods fail. It remains to be shown whether CAST can be used as a parameter for monitoring patients who have undergone immunotherapy.

Contrary to the lay and media perception, adverse reactions to foods (and food additives) occur less often than believed by the patients. The term food intolerance (FI) is widely misused as a cause of all sorts of symptoms and diseases. This diagnosis is often based on "alternative" techniques. Food allergy (FA) is the correct diagnosis if the symptoms resulting from the ingestion of a food (or an ingredient) are due to an immune mechanism. This diagnosis is seldom difficult in the case of a severe reaction immediately after ingestion of the food and when skin prick tests and/or IgE antibodies to the incriminated food are clearly positive. However, the best way to establish FA/FI is-apart from exclusion from the diet, which tends to have a marked placebo effect-the performance of proper double-blind, placebo-controlled food challenges (DBPCFC). Evidently, there are difficulties in conducting studies of this nature in a large population sample, and so far only three prevalence studies in Dutch and English adults have been based on DBPCFC. The reported prevalences of FA/FI (questionnaire answers) were 12% to 19%, whereas the confirmed prevalences varied from 0.8% to 2.4%. For additive intolerance the prevalence varied between 0.01 to 0.23%. The consequences of mistaken perception of FA/FI, which can have a major social impact in financial and health terms, require an information campaign for doctors, lay and media in connection with these problems.

A 63-year-old man developed a mild hemorrhagic diathesis which led to the diagnosis of chronic lymphatic leukemia. Treatment with prednisone and chlorambucil was initiated. During the first 10 day-cycle (10 mg chlorambucil and 100 mg prednisone) no side effects were noted. On the 8th day of second cycle (10 mg chlorambucil and 25 mg prednisone) the patient noticed fever, tiredness, myalgia, pruritus and erythema on the skin. The third cycle (10 mg chlorambucil alone) hat to be stopped on the second day due to the development of myalgia, generalized erythroderma with exfoliation and edema of the face and arms. In the patch-test with chlorambucil, a strongly positive (histologically verified) allergic reaction was noted. A lymphocyte stimulation test (detecting in vitro lymphocytes sensitized to chlorambucil) was also positive. These findings, together with the marked clinical reaction to chlorambucil alone, led to the diagnosis of a delayed hypersensitivity reaction to chlorambucil. Such well documented allergic reactions to chlorambucil are very rarely described in the literature. Up to now only 1 case of immune hemolytic anemia, 1 case of Lyell-syndrome, 2 cases of delayed hypersensitivity reactions and a few cases of less well documented type I reactions have been described. In all these cases no crossreactivity with other alkylating agents occurred, and hence all patients could be successfully treated with cyclophosphamide.

We describe 3 patients with a severe allergic immediate-type reaction to poppy-seeds, diagnosed from clinical findings, skin tests and specific IgE antibodies (CAP). All show a serologic positivity to sesame seed, possibly due to a cross reactivity to similar allergens. From 1978 until 1987 402 food allergy patients seen at the Allergy Unit, Department of Dermatology, University Hospital Zurich, Switzerland, included no case of allergy to poppy-seeds. Because of today's trend to vegetarian food such immediate type reactions can be expected to occur more frequently.

Paraneoplastic dermatoses or cutaneous paraneoplastic syndromes are a non neoplastic skin condition closely related to and in their manifestation directly influenced by an underlying malignancy. They are subdivided into two groups: one whose clinical picture reveals the presence of a malignant tumor and an association with a malign internal tumor in nearly 100%, and a second in which the possibility of a malignancy exists. Not included under the heading paraneoplastic dermatoses are changes with neoplastic cells appearing in the skin, tumors involving secondary illnesses, and genetically caused dermatologic syndromes accompanied by internal malignancies. Although the pathogenesis of the paraneoplastic dermatoses is very unclear, knowledge of these conditions is necessary, since it may in rare instances lead to an early diagnosis of a malignant tumor. On the other hand, only treatment of the underlying disease can improve the dermatoses.

A study was carried out in the southern part of Switzerland (Canton Ticino) in 1990-1993 to determine the spectrum of cutaneous sensitivity to a large amount of pollens and several perennial allergens (50), using skin prick tests in a sample of 503 consecutive patients suffering from hay fever. The Canton Ticino is a very specific geographical and botanical area which includes several plants of the alpine and Mediterranean flora as well as representatives of the tropical flora, forming a unique pattern from a botanical and allergological point of view. The results of the study indicate that in this region the patients have symptoms of hay fever almost 10 months a year (from December until October) with a peak in May and June (88% and 73% of the patients respectively have symptoms in these months). The symptoms are mainly localized in the upper respiratory tract and eyes. Asthmatic symptoms were found in about 23% of the patients. At the top of the allergen list were grass-pollens (72% of the patients had sensitivity); rye (69%); olive tree (54%); birch (46%); chestnut (37%); ash tree (36%); alder tree (33%); ragweed (17%); parietaria (18%). Of real interest in this study area are, besides the classical allergy-inducing pollens, those of chestnut, parietaria, olive tree, ash tree and cupressaceae (for example cypress). Chestnut pollens represent about 30% of the airborne pollens in this region. 30% of the patients had sensitivity against dust mites (Dermatophagoides pteronissimus und D. farinae), and 20% against cats. Sensitivity against 8 mould spores was 2-9%.

Hypertrichosis must be assessed in the light of the type of hair involved, the pattern of abnormal hair growth, associated abnormalities, age of onset, and family history including ethnic background. Associated diseases and the associated medication must be considered, as drug-induced hair growth is not uncommon. Although disorders of the hair usually have little medical significance and involve no interference with the general physical condition, they may be present in congenital syndromes or be associated with other abnormalities and metabolic disorders. The individual psychological impact of excessive hair growth also has a bearing on the problem with regard to its management. We describe in a 7-year-old girl and an 8-year-old boy a state of prepubertal hypertrichosis, characterized in otherwise normal children by a form of generalized excessive terminal hair growth which does not conform to the pattern of (androgen-mediated) hirsutism. The nosology of this form of excessive hair growth is discussed. The question whether it represents an atavistic trait is controverted.

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.

A total of 106 patients, 57 women and 49 men, had had atopic dermatitis even in infancy and were monitored by means of questionnaires at a mean age of 23.5 years. Items of interest were the course of the dermatosis, influences on its course and the frequency of respiratory allergic manifestations. The persistence rate of atopic dermatitis was 60.4%. It was possible to identify ten different courses of atopic dermatitis. Only 11.3% of these patients had suffered from the eczema exclusively during infancy. In 27.4% of cases the patients were free of manifestations for an average of 9 years, after which they had a new attack of the illness. Almost one third of the patients showed a continuous type of development of their atopic dermatitis, which had persisted since infancy. The most common localizations were the antecubal fossa (48.4%), the fingers (45.3%) and the face (37.5%). The course of atopic dermatitis was influenced by the seasons in 71% of these patients, and 59.4% observed a connection between psychic stress and the exacerbation of skin conditions or a new attack of the dermatosis. As adults, 59.4% of all patients suffered from one or more respiratory allergic manifestation: 41.5% had pollinosis, 24.5% allergic rhinitis, and 25.5% bronchial asthma. Respiratory allergies disappeared in 24 cases (19.8%), bronchial asthma at a mean age of 13 years, and pollinosis at 15.3 years and perennial rhinitis at 16 years on average.

Buckwheat allergy is frequent in Asian countries such as Japan because of widespread use of buckwheat in food and bed furniture. In Switzerland such reactions are very rare and mostly due to ingested buckwheat in the form of pizoccheri and buckwheat bread. We describe 6 cases of allergic reactions due to buckwheat comprising urticaria (all pat.), quincke edema (4 pat.) and asthma (5 pat.). 4 patients reacted to ingestion of buckwheat, and 2 patients with occupational exposure were allergic to inhaled buckwheat. Sensitizations were proven in all patients by positive skin tests and specific IgE (RAST). Treatment consisted of strict allergen elimination.

We present a clinically atypical case of discoid lupus erythematosus in the mother of a boy with chronic granulomatous disease. In this disorder, the phagocytes are unable to produce superoxide anion to degrade incorporated microorganisms. In addition to a discoid lupus erythematosus-like skin disease, recurrent stomatitis aphthosa, hidradenitis suppurativa and Raynaud phenomenon are markedly associated with heterozygote carriers of chronic granulomatous disease. Based on this conspicuous association, diverse models concerning the pathogenesis of lupus erythematosus are discussed.

12 patients are described with perennial allergic rhinoconjunctivitis or asthma, 3 had additionally urticarial eruptions and one edema of the eyelids. In all of them sensitization to Ficus benjamina was identified by skin prick tests, in 7 cases by the additional presence of specific IgE in vitro, and in 2 it was verified by a conjunctival provocation test. 10 patients were atopic with sensitization to other respiratory allergens such as pollen, house dust mite or animal dander. 2 patients, however, with a massive exposure to Ficus benjamina at home, were non-atopic with monovalent sensitization to this plant. Ficus benjamina is a tropical tree of the genus Ficus which belongs to the Moraceae family. The allergen is located in the plant sap, the so called latex, which after evaporation binds to dust particles on the leaf surface. Upon contact they are emanated from the leaves, thus imitating allergy to house dust components. Since Ficus benjamina is a very popular decorative plant, an increasing number of sensitized individuals is to be expected. The identification of a preventable respiratory allergen is of considerable importance for the patients.

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.

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.

In the last few years the allergenic potential of rubber has been receiving more and more attention. Its widespread application in medical devices and everyday objects has increased exposure to this allergen. The central role of rubber in the prevention of HIV infection has certainly played a part in this development. Latex allergy manifests itself as immediate type allergy (type I), delayed type allergy (type IV) or as a combination of both types of hypersensitivity. In this review the different types of latex allergy are illustrated by means of selected case reports. Immediate type allergy to latex leads to contact urticaria, but it may also cause generalized urticaria, bronchial asthma or even anaphylactic reactions (contact urticaria syndrome). Hence, not only dermatologists and allergologists are confronted with latex allergy. Immediate type hypersensitivity can be proven by skin prick test and RAST (radio allergosorbent test). Contact dermatitis in patients using rubber gloves is generally due to delayed type hypersensitivity to rubber additives. However, a recently observed case suggests the possibility of isolated delayed type hypersensitivity to natural latex.