Acute hepatitis and rash to fluconazole.
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Adult↗
Biomedical subjects
L C Grammer
Publications and source records attributed to L C Grammer.
Extrinsic allergic alveolitis from a proteolytic enzyme.
BACKGROUND: Subtilisins are proteolytic enzymes of bacterial origin found in detergents. They are high-molecular-weight antigens and have been implicated in allergic rhinitis and asthma. OBJECTIVE: This report describes a case of extrinsic allergic alveolitis due to subtilisins in a liquid cleaner. METHODS: Clinical, radiologic, and serologic information were used to make the diagnosis. CASE REPORT: A 53-year-old woman developed respiratory symptoms while working with a cleaner containing subtilisins. Her symptoms intensified in the work environment and improved away from work. A computed tomography scan demonstrated alveolar and interstitial infiltrates with subsequent scarring. A pulmonary function study revealed a restrictive pattern with diminished diffusion capacity. Bronchoalveolar lavage showed lymphocytosis and all cultures were negative. Precipitating antibodies to the enzyme were found in the patient's serum. Her symptoms improved once she changed her occupation. CONCLUSIONS: The combination of the patient's clinical history, physical, laboratory, and radiologic findings support the diagnosis of extrinsic allergic alveolitis from the enzyme contained in the cleaner.
Alveolitis, Extrinsic Allergic↗
Hypersensitivity to IFN-alpha.
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Antibodies↗
Case reports of evaluation and desensitization for anti-thymocyte globulin hypersensitivity.
BACKGROUND: Biologic products of heterologous sera have been used to treat a variety of conditions. One example is anti-thymocyte globulin (ATG), which is approved for use in the management of renal transplantation and for aplastic anemia. As ATG is a product of heterologous sera it has the potential for adverse reactions, including anaphylaxis. Patients can be skin tested prior to ATG administration to aid in determining hypersensitivity status to ATG. OBJECTIVE: To provide case reports to illustrate evaluation for ATG hypersensitivity. Also, to discuss desensitization procedures for patients who are found to have ATG hypersensitivity, and yet are to receive the medication as it is judged to be essential. CASE REPORTS: We report four patients who were to receive ATG. The results of skin testing and each patient's response to ATG are reviewed to illustrate problems that can occur in evaluating the hypersensitivity status of these patients. Further, some patients also underwent ATG desensitization, but none completed the entire protocol successfully. Their outcomes are reviewed to illustrate problems that can occur with the desensitization procedure. CONCLUSION: Anti-thymocyte globulin is a product of heterologous sera and has the potential to produce anaphylaxis. It is recommended that patients be skin tested prior to administration to aid in determining hypersensitivity status. Those patients who demonstrate hypersensitivity to ATG should not receive ATG unless it is deemed essential and benefits are judged to outweigh risks. In these circumstances, patients are candidates for ATG desensitization. Complications with desensitization occurred in the cases attempted, and highlights that desensitization to ATG, a xenogeneic protein, carries risk and can be difficult. Physicians involved in such cases should be familiar with interpretation of skin tests and problems that can occur with desensitization.
Aged↗
Lymphocyte subsets and activation markers in patients with acute episodes of idiopathic anaphylaxis.
BACKGROUND: Idiopathic anaphylaxis (IA), a type of anaphylaxis in which no external allergen can be identified, is a corticosteroid-responsive disease, that suggests that it may have an immunologic pathogenesis. OBJECTIVE: The objective of this study is to compare patients with acute episodes of IA with normals, patients with chronic idiopathic urticaria, and patients with IA in remission relative to lymphocyte subsets and activation markers. METHODS: This is a prospective cohort study of 38 adults: 5 normals, 4 idiopathic urticaria, 11 IA patients in remission, 9 IA patients with acute attacks who had not yet received prednisone, and 9 IA patients who had received prednisone. The main outcome measures were lymphocyte subset and activation markers determined by two and three color flow cytometry (CD2, CD3, CD4, CD5, CD8, CD16, CD19, CD23, CD25, CD56, and HLA-DR). RESULTS: Comparing patients with acute IA with those in remission, the only significant difference was that the acute IA patients had a significantly higher percentage of CD3+HLA-DR+ cells. Normals had a significantly lower percentage of CD3+ HLA-DR+ cells than all other groups. Patients with acute IA on prednisone as well as IA patients in remission had a significantly higher percentage of CD 19+ CD23+ cells than normals. CONCLUSIONS: These results suggest that there are more activated T cells in patients with acute episodes of IA than in patients in remission. Perhaps, these activated T cells have a role in the pathogenesis of IA.
Anaphylaxis↗
Human leucocyte antigens (HLA) and trimellitic anhydride (TMA) immunological lung disease.
Occupational immunological lung disease, due to low molecular weight, reactive chemicals such as trimellitic anhydride (TMA), is an emerging health problem. If there were a marker that was highly predictive of the ability of the immune system to recognize TMA as an allergen, better prevention strategies could be employed with at risk individuals. The purpose of this study is to evaluate whether human leucocyte antigen (HLA) class specificity is associated with the development of late respiratory systemic syndrome (LRSS) or asthma due to immunological sensitivity to trimellitic anhydride (TMA). This is a case control study of 17 individuals with LRSS, 12 with asthma and 22 TMA similarly exposed individuals who did not develop LRSS or asthma. Comparing the sensitized individuals (LRSS or asthma) with the non-sensitized individuals (controls), we found no difference in frequency of any HLA antigen. In summary, the lack of association of HLA antigens with LRSS or asthma due to TMA suggests that these will not be useful markers to identify at risk individuals.
Adult↗
Multicenter, double-blind, placebo-controlled, multiple-challenge evaluation of reported reactions to monosodium glutamate.
BACKGROUND: The frequency of reactions reported to occur after the consumption of monosodium glutamate (MSG) is the subject of controversy. OBJECTIVE: We conducted a multicenter, multiphase, double-blind, placebo-controlled study with a crossover design to evaluate reactions reportedly caused by MSG. METHODS: In 3 of 4 protocols (A, B, and C), MSG was administered without food. A positive response was scored if the subject reported 2 or more symptoms from a list of 10 symptoms reported to occur after ingestion of MSG-containing foods within 2 hours. In protocol A 130 self-selected reportedly MSG-reactive volunteers were challenged with 5 g of MSG and with placebo on separate days (days 1 and 2). Of the 86 subjects who reacted to MSG, placebo, or both in protocol A, 69 completed protocol B to determine whether the response was consistent and dose dependent. To further examine the consistency and reproducibility of reactions to MSG, 12 of the 19 subjects who responded to 5 g of MSG but not to placebo in both protocols A and B were given, in protocol C, 2 challenges, each consisting of 5 g of MSG versus placebo. RESULTS: Of 130 subjects in protocol A, 50 (38. 5%) responded to MSG only, 17 (13.1%) responded to placebo only (P <. 05), and 19 (14.6%) responded to both. Challenge with increasing doses of MSG in protocol B was associated with increased response rates. Only half (n = 19) of 37 subjects who reacted to 5 g of MSG but not placebo in protocol A reacted similarly in protocol B, suggesting inconsistency in the response. Two of the 19 subjects responded in both challenges to MSG but not placebo in protocol C; however, their symptoms were not reproducible in protocols A through C. These 2 subjects were challenged in protocol D 3 times with placebo and 3 times with 5 g of MSG in the presence of food. Both responded to only one of the MSG challenges in protocol D. CONCLUSION: The results suggest that large doses of MSG given without food may elicit more symptoms than a placebo in individuals who believe that they react adversely to MSG. However, neither persistent nor serious effects from MSG ingestion are observed, and the responses were not consistent on retesting.
Adult↗
Review of alleged reaction to monosodium glutamate and outcome of a multicenter double-blind placebo-controlled study.
Monosodium glutamate (MSG) has a long history of use in foods as a flavor enhancer. In the United States, the Food and Drug Administration has classified MSG as generally recognized as safe (GRAS). Nevertheless, there is an ongoing debate exists concerning whether MSG causes any of the alleged reactions. A complex of symptoms after ingestion of a Chinese meal was first described in 1968. MSG was suggested to trigger these symptoms, which were referred to collectively as Chinese Restaurant Syndrome. Numerous reports, most of them anecdotal, were published after the original observation. Since then, clinical studies have been performed by many groups, with varying degrees of rigor in experimental design ranging from uncontrolled open challenges to double-blind, placebo controlled (DBPC) studies. Challenges in subjects who reported adverse reactions to MSG have included relatively few subjects and have failed to show significant reactions to MSG. Results of surveys and of clinical challenges with MSG in the general population reveal no evidence of untoward effects. We recently conducted a multicenter DBPC challenge study in 130 subjects (the largest to date) to analyze the response of subjects who report symptoms from ingesting MSG. The results suggest that large doses of MSG given without food may elicit more symptoms than a placebo in individuals who believe that they react adversely to MSG. However, the frequency of the responses was low and the responses reported were inconsistent and were not reproducible. The responses were not observed when MSG was given with food.
Animals↗
Potential effect of the administration of substance P and allergen therapy on immunoglobulin E-mediated allergic reactions in human subjects.
Previously we observed and reported that immunoglobulin E-mediated (IgE-mediated) allergy in rhesus monkeys was decreased by the administration of substance P (SP) and an allergen. We extended these studies to human subjects, giving SP and 1 allergen to subjects with reactivity to more than 1 allergen, using reactivity to a second allergen as a control. SP and an allergen were initially given by aerosol delivery but subsequently were given by injection. The administration of SP and 1 allergen by aerosol delivery or injection resulted in decreased IgE-mediated reactivity to the allergen administered and also to the control allergen. This result occurred in 7 of 8 human subjects. The 2 initial subjects receiving 8 SP and allergen injections had a sharp reduction in their symptoms of ragweed hay fever lasting for 3 years to date. No significant reactions to the injection of SP occurred. Further controlled human research is necessary on the administration of SP and allergen and the mechanisms of action. Unexpected and serendipitous results first observed in rhesus monkeys and reproduced in allergic human subjects provide a new and potential mechanism for control and perhaps obliteration of common IgE-mediated allergies and even more-serious allergic problems.
Aerosols↗
Occupational allergic alveolitis.
Hypersensitivity pneumonitis is an important occupational pulmonary disease. A variety of antigens including foreign proteins and low molecular weight chemicals have been described as etiologic agents. The immunopathogenesis appears to involve activated CD8+ cells as well as activated macrophages. The clinical disease may be acute, subacute or chronic depending upon the nature and level of exposure. Reducing exposure to known antigens is a strategy that appears promising in terms of prevention of irreversible disease.
Alveolitis, Extrinsic Allergic↗
Allergen immunotherapy: a long-term perspective.
Efficacy of standard IT to reduce medications and symptoms by at least 50% has been demonstrated multiple times. Reports of negative studies of IT deserve only evaluation of why the study design failed to demonstrate efficacy. Emphasis in the US and worldwide should be on education on the appropriate use of allergen IT, improvements in IT therapy, and preparation for the increased demand for allergists-immunologists as Fellowship training programs decline in numbers and individual training slots decrease.
Desensitization, Immunologic↗
Immunoglobulin E antibody against environmental allergens in subjects with trimellitic anhydride-induced asthma.
The purpose of this study was to assess the relationship between atopy and the development of occupational asthma as a consequence of exposure to trimellitic anhydride (TMA). A case-control study was performed, which comprised 16 employees identified as having TMA-induced asthma and 44 similarly exposed controls. Specific immunoglobulin E measurements in response to cat, dust mite, ryegrass, and ragweed antigens were performed. Fifty-six percent of cases and 29% of controls were found to be atopic (P = 0.098). We demonstrated that there was a trend toward employees with TMA asthma being more atopic than those without TMA asthma. Atopy as an assessment of risk for the development of TMA asthma is unlikely to be useful, although further investigation may be warranted.
Adult↗
A clinical and immunologic study to assess risk of TMA-induced lung disease as related to exposure.
The objective of this study was to determine whether there are trimellitic anhydride (TMA) exposure levels that are very unlikely to cause immunologically mediated respiratory disease. A 3-year clinical and immunologic survey study of 286 employees was conducted at a facility that manufactures TMA. Each employee was assigned an exposure classification from 1 (highest) to 5 (lowest). Of the 28 individuals in exposure class 1, 8 (29%) developed disease; of the 57 class 2 employees, 2 (4%) developed disease; of the 79 class 3 employees, 4 (5%) developed disease. Of the 98 class 4 employees and the 24 class 5 employees, none developed disease. Inasmuch as individuals in class 4 and 5 (TMA exposure < 0.002 mg/m3) are at low risk of developing disease due to TMA, it appears that they do not warrant routine inclusion in surveillance studies.
Adult↗
Cutaneous allergy to recombinant human type I IL-1 receptor (rhu IL-1RI).
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Adult↗
Risk factors for immunologically mediated disease in workers with respiratory symptoms when exposed to hexahydrophthalic anhydride.
Occupational immunologic lung diseases caused by exposures to substances such as hexahydrophthalic anhydride are significant health problems. It would be useful to identify risk factors, other than exposure, for occupational immunologic lung diseases such as occupational asthma. Our objective was to identify risk factors for development of immunologically mediated disease in workers with respiratory symptoms associated with exposure to hexahydrophthalic anhydride. A medical and immunologic survey study was conducted of 33 employees with respiratory symptoms associated with hexahydrophthalic anhydride exposure. Of the 33 employees with respiratory symptoms, 20 had no immunologically mediated disease. Seven had both immunoglobulin E-mediated and immunoglobulin G-mediated disease, 5 had immunoglobulin E-mediated disease only, and 1 had immunoglobulin G-mediated disease only. Although larger samples would have rendered atopy a statistically significant risk factor (assuming effect replication), the associated effect strength represents less than a 16% improvement versus chance, which is indicative of marginal clinical significance. However, as expected, elevated levels of specific antibodies were statistically and clinically significant risk factors. Development of one type of immunologically mediated disease was highly predictive of development of the other type. In hexahydrophthalic anhydride-exposed employees with respiratory symptoms, development of immunologically mediated respiratory disease is most closely associated with presence of specific immunoglobulin E or immunoglobulin G antibodies. Neither race, age, smoking status, atopy, nor exposure levels emerged as significant risk factors in this symptomatic study population.
Adult↗
An intervention program to reduce the hospitalization cost of asthmatic patients requiring intubation.
BACKGROUND: Asthma is the single disease that accounts for the largest proportion of total health care cost in the US. OBJECTIVE: To analyze whether an asthma management program affected the cost of subsequent asthma care for patients in whom intubation had been necessary. METHODS: We evaluated patients with asthma who (1) had required intubation for treatment of status asthmaticus; (2) were 45 years old or younger; (3) had regular follow-up visits in our clinic for 1 year after initial evaluation; and (4) had complete medical records 1 year before and 1 year after the intervention for our evaluation. Medical costs of asthma treatment for each patient were determined for 1 year before and 1 year after intervention. The program included patient education, regular outpatient visits, specialist care, and access to the Allergy Immunology emergency call service. The outcome measures were the total cost of care, inpatient hospitalizations, outpatient services, emergency services, and medicine costs. RESULTS: Nine patients [mean age 19.6 years (SD = 9.9)] fulfilled the criteria (six women and three men). The mean duration of asthma was 14.0 years (SD = 9.7). The mean total cost of care decreased from $43,066 to $4,914 (t = -4.53, P < .001) and inpatient hospitalization costs decreased from $40,253 to $1,926 (t = -4.50, P <.001). There was, however, no significant difference in the mean pre-intervention versus post-intervention cost of emergency services, outpatient services, or medicine costs. CONCLUSIONS: The intervention--which included education, specialist care, regular outpatient visits, and access to an emergency call service--significantly reduced the cost of asthma care in our population of patients intubated for asthma.
Adolescent↗