A.W. van Toorenenbergen

Contact allergy to spices

A group of 103 patients suspected of contact allergy was tested with the European standard series, wood tars and spices; paprika, cinnamon, laurel, celery seed, nutmeg, curry, black pepper, cloves, while pepper, coriander, cacao and garlic. 32 patients (Group I) were selected on the basis of positive tests to one or more of possible indicators for allergy to spices: colophony, balsam of Peru, fragrance‐mix and/or wood tars. 71 patients (Group II) showed no response to these indicators. In Group I (n= 32) a statistically significantly higher % of patients (47%) showed positive reactions to 1 or more spices, compared with 15% in Group II (N= 71). Among the spices, the highest numbers of reactions were found to nutmeg (28%), paprika (19%) and cloves (12%) in the indicator‐positive Group I. Fragrance‐mix turned out to be a particularly important indicator allergen, especially for paprika, nutmeg and cloves. The contact allergy in 11 out of 32 (Group I) and 7 out of 25 patch‐tested patients (recruited from Group II) appeared to be‐directed mainly against the ether‐extractable volatile fractions of the spices.

Pancreatic fibrosis correlates with exocrine pancreatic insufficiency after pancreatoduodenectomy

Background: Obstruction of the pancreatic duct can lead to pancreatic fibrosis. We investigated the correlation between the extent of pancreatic fibrosis and the postoperative exocrine and endocrine pancreatic function. Methods: Fifty-five patients who were treated for pancreatic and periampullary carcinoma and 19 patients with chronic pancreatitis were evaluated. Exocrine pancreatic function was evaluated by fecal elastase-1 test, while endocrine pancreatic function was assessed by plasma glucose level. The extent of fibrosis, duct dilation and endocrine tissue loss was examined histopathologically. Results: A strong correlation was found between pancreatic fibrosis and elastase-1 level less than 100 µg/g (p < 0.0001), reflecting severe exocrine pancreatic insufficiency. A strong correlation was found between pancreatic fibrosis and endocrine tissue loss (p < 0.0001). Neither pancreatic fibrosis nor endocrine tissue loss were correlated with the development of postoperative diabetes mellitus. Duct dilation alone was neither correlated with exocrine nor with endocrine function loss. Conclusion: The majority of patients develop severe exocrine pancreatic insufficiency after pancreatoduodenectomy. The extent of exocrine pancreatic insufficiency is strongly correlated with preoperative fibrosis. The loss of endocrine tissue does not correlate with postoperative diabetes mellitus. Preoperative dilation of the pancreatic duct per se does not predict exocrine or endocrine pancreatic insufficiency postoperatively.

Elevated levels of plasma matrix metalloproteinase-9 in patients with atopic dermatitis: a pilot study

Matrix metalloproteinase (MMP)‐9 has been shown to play a role in the infiltration of inflammatory cells in various tissues. It is thus part of the pathogenesis of many inflammatory diseases, including asthma and allergic rhinitis/conjunctivitis. We compared plasma MMP‐9 levels of 20 patients with atopic dermatitis (AD) with that of 17 control subjects. Additional outcome parameters consisted of the modified objective SCORing Atopic Dermatitis and the Three Item Severity score in patients, and peripheral blood leucocytes and eosinophils in both groups. Plasma MMP‐9 levels were found to be significantly higher in patients compared with controls, supporting a role for MMP‐9 in the pathogenesis of AD.

Occupational allergy in strawberry greenhouse workers.

Background: Employees in strawberry greenhouses are highly exposed to several (potential) allergenic agents. However, no occupational allergy in this branch has been described before. First, the presence of work-related allergic symptoms in strawberry workers was explored. Second, we aimed to prove the concept that an IgE-mediated allergy could be responsible for work-related symptoms. To test the possibility of an IgE response secondary to cross-reactivity to birch or grass pollen, inhibition experiments were performed. Methods: First, a questionnaire survey concerning work-related allergic symptoms among strawberry workers in the Netherlands was carried out. Second, 3 workers with work-related symptoms were investigated in detail. Skin tests, serum-specific IgE tests with home-made extracts of strawberry pollen and other possible allergenic agents of the strawberry greenhouse environment were executed. Furthermore, immunoblots and nasal provocations with strawberry pollen extract were performed. In addition, inhibition experiments were performed. Results: 29 of 75 questionnaire respondents (38.7%) reported work-related symptoms. Sensitization to strawberry pollen was found in skin tests in all 3 employees with work-related symptoms. ELISA and immunoblotting with strawberry pollen showed positive results in 2 employees. Birch and grass pollen failed to inhibit IgE binding to strawberry pollen in 1 of 2 employees. Partial inhibition was seen in the second employee. Nasal provocation validated clinically relevant allergy to these pollens in 2 of 3 subjects. Conclusions: Allergic symptoms attributable to the workplace are present among a proportion of strawberry greenhouse employees. An IgE-mediated occupational allergy to strawberry pollen may contribute to these symptoms.

Urinary N‐methylhistamine as an indicator of bone marrow involvement in mastocytosis

Summary Thirty‐seven patients with mastocytosis and unexplained elevated levels of urinary N‐methylhistamine who were undergoing bone marrow biopsy were studied with respect to the diagnosis of mastocytosis and the manifestations of the disease. These patients were from a group of 66 patients from whom a bone marrow biopsy was obtained and urinary N‐methylhistamine levels were measured in the period 1990–1998. In seven (19%) of the 37 patients, mastocytosis was limited to the skin. Five (14%) of the 37 patients showed accumulation of mast cells in the bone marrow without characteristic skin lesions, whereas seven (19%) of the 37 patients showed increased numbers of mast cells both in the skin and the bone marrow. Eighteen (49%) of the 37 patients with elevated N‐methylhistamine did not have mast cell accumulation in either the skin or the bone marrow biopsy. The median level of N‐methylhistamine in the urine of patients with mastocytosis limited to the skin was 245 µmol/mol creatinine. The average level of N‐methylhistamine was 509 µmol/mol creatinine in patients with mast cell accumulation in the bone marrow and cutaneous mastocytosis. There was a significant difference in the levels of N‐methylhistamine in patients with mast cell accumulation in the bone marrow biopsy compared with those without. The likelihood of mastocytosis with mast cell accumulation in the bone marrow biopsy at a given level of N‐methylhistamine was calculated. It was established that an N‐methylhistamine level of 297 µmol/mol creatinine or higher may be considered as a threshold indicator for obtaining a bone marrow biopsy in patients suspected of mastocytosis with mast cell accumulation in the bone marrow. For practical purposes, we propose to consider the cut‐off level of ≈ 300 µmol/mol N‐methylhistamine creatinine for this assay.

Histamine release from human peripheral blood leukocytes analyzed by histamine radioimmunoassay.

Histamine release from human peripheral blood leukocytes, afterin vitro challenge with allergen extracts, is usually measured by fluorometry. In the present study we compared the results of the automated fluorometric histamine assay (Siraganian) with those of the Immunotech histamine radioimmunoassay. Histamine release dose — response curves obtained after histamine measurement by both methods were superimposable.

Occupational asthma to amaryllis

N GREENHOUSE workers, various decorative I flowers may cause occupational airway disease through an IgE-dependent mechanism. Immediatetype allergy has been documented to freesia, chrysanthemum, weeping fig, statis, and Lathyrus odoratus ( 1-6). We describe a greenhouse worker who developed an IgE-mediated allergy to hippeastrum (genus Hippeastrum, family Amaryllidaceae). Hybrid cultivars are mostly known as amaryllis. One year after beginning to work in a greenhouse where amaryllis plants were cultivated, a 50-yearold man developed

Birds or zebras

In this issue of Allergy, Curtis et al. (1) report the results of indoor pigeon allergen sampling in dust and air in order to establish allergen contamination data of outdoor animals. They found high indoor levels of pigeon allergens in the vicinity of outdoor pigeon nests, but also in houses and hospitals that did not have pigeons in the immediate surroundings. Their study was undertaken following questions on indoor exposure by pigeon sensitive patients and an occupational physician. Because of the high allergenicity of pigeon allergens, they reasoned that even a low exposure to wild pigeon allergens may cause respiratory disease, especially ‘hypersensitivity pneumonitis’ (2–7). One could seriously wonder why such an effort should be undertaken. Should we really consider pigeon allergens as a cause of substantial morbidity? Are allergy or allergic alveolitis due to wild pigeons diseases that are underreported, misclassified, easy to miss, sometimes hard to prove, but nevertheless often seriously disabling and potentially fatal (8), or are they ‘zebras’ (9)? With respect to diagnostics, the current study has several implications, and raises new questions. Extrinsic allergic alveolitis, hypersensitivity pneumonitis, or allergic alveolitis (AA) which is the recently recommended term (10) owing to the fact that organic material was recognized as a separate disease almost 300 years ago (11). More than 40 specific etiologic agents, including animal proteins, bacteria, fungi, insect proteins, chemicals, and drugs, have been identified since the 1960s (8, 12). Owing to effective preventive measures in occupational medicine, AA nowadays mainly occurs as a result of domestic exposures, and bird allergens constitute the majority of the causative agents (8). The estimated prevalence of AA among pigeon breeders varies between 1 and 10%, depending on the definition used (13, 14). AA has also been described in pigeon breeder’s offspring (15–22), but the prevalence of AA or allergy owing to wild pigeons in the general population is unknown. City pigeons have been able to adapt and survive efficiently in the larger metropolitan areas in the West: it is estimated that pigeon populations equal roughly 2% of the size of the human population of large cities (Bundes Arbeitgruppe, Stadttauben, Germany, personal communication), and are mainly concentrated in the inner city areas. Pigeon allergens may cause more respiratory disease than is generally assumed for several reasons. The current study suggests that pigeon allergens can be present in sufficiently high concentrations in public buildings to cause AA or allergy to pigeon allergens. There is no doubt that the prevalence of allergy and asthma in the Western world is increasing (23). Hence, allergens may induce allergy and/or asthma more easily than a few decades ago. Typical inner city allergens from cockroach and mice have been implicated to play a role in the worldwide increase of prevalence of asthma and allergy (24–26), and pigeon allergens may act likewise in causing allergy, asthma, AA, or both (27). Traditionally, pigeon breeder’s lung has been described in adults keeping pigeons and, occasionally, in their offspring. It is never considered in patients who do not keep birds themselves. However, in the last 2 years four case reports appeared on AA owing to wild city pigeons (2–5), and the presence of AA in a teacher of the pigeoninfested high school reported by Curtis et al. (1) may be regarded as the fifth one. It seems highly unlikely that AA as a result of wild pigeons would be limited to these cases: we may be looking at the tip of an iceberg. As allergen avoidance does not really apply or cannot be realized for wild pigeons, it seems to be of most importance that general physicians and (pediatric) pulmonologists realize that AA owing to pigeons may Allergy 2002: 57: 566–569 Printed in UK. All rights reserved Copyright # 2002 Blackwell Munksgaard

A prospective study on the prognostic value of cytology and tumour markers (CEA and CA 19-9) in peritoneal washings of patients with periampullary tumours

Background Peritoneal metastases and local recurrence continue to be the most frequent type of recurrent disease in pancreatic cancer patients. Microscopic dissemination of cancer cells from the primary tumour is likely to be present before resection or could result from the resection itself. Methods Fifty patients with either primary ductal adenocarcinoma of the pancreas ( n = 43) or tumour of the ampulla of Vater and distal common bile duct ( n = 7) underwent an exploratory laparotomy. Resectability of the tumour and peritoneal metastases at the time of the operation were documented. Cytology and tumour marker levels of CEA and CA19-9 were determined in two peritoneal washings. The first washing was performed before resection of the tumour, the second after resection. Results The tumour markers CEA and CA19-9 in the first peritoneal washing were both found to be independent predictors regarding resectability ( p 60 % of cases. A significant difference between the two washings, pre- and postresection, was found for both tumour marker levels. Postresection tumour marker levels correlated with tumour recurrence and survival ( p Discussion Combined levels of CEA and CA19-9 have the best predictive value regarding resectability, tumour recurrence and survival. The results from this study support the theory of preoperative tumour cell seeding and peroperative tumour spill.