Aderbal Sabra

IgE and non-IgE food allergy.

BACKGROUND Food allergy (FA) is characterized by an abnormal immunologic reactivity to food proteins. The gastro-intestinal tract serves not only a nutritive function but also is a major immunologic organ. Although previously thought to be triggered primarily by an IgE-mediated mechanism of injury, considerable evidence now suggests that non-IgE mechanisms may also be involved in the pathogenesis of FA. OBJECTIVE To review the immunologic disturbances that occur in FA and to correlate these with the clinical manifestations expressed in affected target organs based upon a classification of IgE and non-IgE mechanisms. METHODS Data collected from a computerized MEDLINE search were used for the analysis of the following topics: immediate GI hypersensitivity, oral allergy syndrome, acute urticaria and angioedema, acute bronchospasm, celiac disease, cows milk enteropathy, dietary protein enterocolitis, breast milk colitis, proctolitis, proctitis, dermatitis herpetiformis, Heiner syndrome, eosinophilic gastroenteritis, atopic dermatitis, asthma, attention-deficit-hyperactivity disorder and behavioral disorders, as well as systems affected by mucosal associated lymphoid tissue-mediated injury of associated lymphoid tissues and the immunologic deviation to Th1 or Th2 mechanisms of FA. CONCLUSIONS The results of this review allow the construction of a central, unifying hypothesis for a new classification of FA as follows: the clinical manifestations of FA, expressed in affected target organs, may be the result of immunologic injury mediated by interaction of food antigens with contiguous elements of mucosal associated lymphoid tissue. These appear to be modulated by relative imbalances of the Th1/Th2 paradigm, which may be the ultimate determinant governing the expression of FA as IgE-mediated, non--IgE-mediated, or mixed forms of IgE/non-IgE mechanisms of FA.

Guideline for the management of acute diarrhea in adults

provide a complete document that would be applicable to the case management of diarrhea. However, some explanation and amplification is necessary to clarify the terms and phrases that have been used, as well as to explain the basis for certain decision pathways in the algorithm. Adult: The definition of ‘adult’ varies from one country to another. As applied in this guideline, the term ‘adult’ refers to someone who is of age 12 years or above. Acute diarrhea: This is defined as the passage of three or more than three loose or watery stool in 24 h, or passage of one or more bloody stool. Acute diarrhea refers to illness not lasting longer than 14 days. Other conditions that may present as acute diarrhea: ‘Acute diarrhea’ is a clinical syndrome that is commonly understood to refer to infective gastroenteritis. However, as defined, acute diarrhea may be a symptom of other intra-abdominal or systemic illnesses. These other clinical conditions may require particular investigations and management, and will need to be recognized and excluded at the outset. Careful history and physical examination is necessary to exclude these conditions from the commonly understood ‘acute diarrhea’. Special attention should be paid to exclude signs of peritonism or peritonitis, which will indicate serious illnesses that might require surgical care. Examples of these diverse clinical conditions are presented in Table 1. Specific conditions of acute diarrhea that require special consideration: Although the term ‘acute diarrhea’ commonly refers to infectious, toxin-induced and drug-induced diarrhea, there are specific acute diarrhea syndromes that may need a specifically tailored approach and management, and where the general algorithm may need to be modified. For example, during epidemic acute diarrhea such as cholera, it is important to quickly identify the organism in the first patients presenting with illness, and to initiate public health meaINTRODUCTION

Developmental immunology: clinical application to allergy-immunology

BACKGROUND An increase in prevalence of allergic diseases has been seen at an unprecedented rate in many countries throughout the world. Associated with this increase in allergic disease has been a disturbing increase in morbidity and mortality of such diseases as asthma despite the availability of several new therapeutic agents over the past 2 to 3 decades. The search for both environmental factors, eg, new allergens, as well as biologic markers of genetic susceptibility, eg, respiratory viruses, has yielded considerable promise for an explanation for this rising prevalence of allergic disease. OBJECTIVE To present a central unifying hypothesis based upon recent knowledge concerning the developing human immune system and its interaction with external environmental factors, particularly viral infections, as a basis for a clearer understanding of the changing faces of the allergic diseases throughout the lifespan of the individual. DATA SOURCES English language articles were selected from PubMed, as well as selected abstracts that would have immediate, practical clinical implications. RESULTS Review of the current literature strongly suggests a relationship between delayed acquisition of Th1 function in the allergy-prone infant, not only as a predictive marker of susceptibility to the development of allergic disease but also as an explanation for the unique vulnerability of these infants to viral infection, eg, bronchiolitis. Furthermore, viral infection during early development in the allergy-prone infant appears to facilitate allergic sensitization in early infancy. This interesting triad of immune deficiency, viral infection, and atopic genetic susceptibility may provide a basis for early detection of allergic disease and may offer new intervention strategies for the prevention of allergic and infectious disease in the young infant.

Abnormalities of Th1 function in non-IgE food allergy, celiac disease, and ileal lymphonodular hyperplasia: a new relationship?

BACKGROUND Non-IgE mechanisms may also be involved food allergy (FA). Our group has been studying the immunopathogenesis clinical entities in children with gastro-intestinal symptoms and in whom biopsies of the terminal ileum show lymphoid tissue masses referred to as ileal lymphonodular hyperplasia. Our more recent studies have demonstrated Th1/Th2 cytokine profiles associated with non-IgE FA and other clinical entities. OBJECTIVE We investigated 12 subjects with non-IgE FA (group 1) and 4 subjects with celiac disease (group 2). Cytokine profiles and immunologic studies of lymphocytes in peripheral blood and from gastro-intestinal biopsy tissues from patients in groups 1 and 2 were also evaluated. METHODS Group 1 consisted of 12 children with clinical symptoms of anorexia, diarrhea, and abdominal pain. The diagnosis of non-IgE FA was established by positive double-blind, placebo-controlled food challenge and reduced or negative immediate-type skin testing and negative IgE radioallergosorbent tests. Group 2 consisted of four patients with celiac disease and three adult females with biopsy-proven clinical symptoms of celiac disease. RESULTS In group 1, peripheral blood CD4 and CD8 lymphocyte distributions were normal, with a predominance of CD4+ cells with a decreased intracellular Th1 cytokine pattern and a normal Th2 intracellular cytokine pattern. In contrast, all four patients in group 2 not only displayed abnormal CD4 and CD8 peripheral blood lymphocyte distributions (CD8 > CD4), but also an abnormal predominance of CD4+ cells with an increased Th1 and a normal Th2 cytokine pattern. A similar abnormal pattern of CD4 > CD8 ratio was observed in intestinal biopsies. All 12 patients in group 1 showed lymphonodular hyperplasia in each of the biopsies and by ileoscopy. CONCLUSIONS These studies suggest that abnormalities in Th1 function may not only play a role in some patients with non--IgE-mediated FA in whom decreased Th1 function is seen, but also in patients with celiac disease in whom an increased Th1 function is seen. The studies also suggest that lymphonodular hyperplasia may be a hallmark histologic lesion in patients with non--IgE-mediated FA.

Gastrointestinal immunopathology and food allergy

OBJECTIVE To review the current data that support the pivotal function of the gastrointestinal immune system in health and disease and its critical role in the pathogenesis of a wide variety of clinical disorders associated with food allergy (FA). DATA SOURCES Internet-based literature search and our own data. STUDY SELECTION The studies included in this review were selected based on the expert opinion of the authors. RESULTS In contrast to the beneficial expressions of gastrointestinal-associated lymphoid tissue, which are seen with relevance to newer methods of delivery of vaccines directly applied to the gastrointestinal mucosal surfaces (eg, oral poliovirus, rotavirus, Salmonella typhi vaccines), the adverse consequences of a mucosal immune response gone astray are evidenced in many diseases such as FA. A classification of clinical disorders associated with FA based on classic mechanisms of immunologic injury is presented, which includes the following: (1) IgE-mediated, (2) non-IgE-mediated, and (3) mixed IgE- and non-IgE-mediated disorders. Our study of immunologic disturbance in patients with non-IgE FA revealed a pattern of increased CD4+ and decreased TH1 cell counts in peripheral blood mononuclear cells in contrast to patients with celiac disease, where a pattern of increased CD8+ and TH1 cell counts in peripheral blood mononuclear cells and increased CD8+ cell counts was seen. CONCLUSIONS The gastrointestinal immune response thus plays a pivotal role in maintaining protective immunity in health and a critical role in the pathogenesis of a wide variety of clinical disorders associated with FA.

The prevalence of causes of cell mediated food allergy in children in Rio de Janeiro

The frequency of Food Allergy (FA) has been increasing in recent years. The prevalence of cell-mediated FA among this cases is unknown. The major cause for the difficulty of this diagnosis of cell-mediated FA is the absense of a major biomarquer. In this study we select patients with cell-mediated FA based in their Clinical Picture, normal IgE and clinical cure with the treatment with the withdrow of the offending food from the diet.

Cow's milk entheropathy

Results Chief Complain: 1 weightloss (16-40%), 2 abdominal pain (14-35%), 3 diarrhea (13 32.5%), 4 – associated respiratory complains (12-30% ), 5 vomiting (7 17.5%). Other clinical Picture with less ferquency: constipation and abdominal distension. Malt systemn affected and Homing response: GALT 40 (100%), BALT 30 (75%), SALT 28 (70%), CNSALT 18 (45%) Clinical main manifestations in each organ of shock: GALT: Diarrhea (19 to 47.5%), abdominal pain (15 37.5%), bulkystools (14-35%), lack of appetite (12-30%). Other less frequent: vomiting, reflux, bloating and abdominal distention. BALT: Rhinitis (11-36.66%), asthma / bronchitis (10 33.33%), pharyngotonsillitis (9-30%), phlegm (9-30%). Other less frequent: otitis, sinusitis, snoring and coughing. SALT: Facial pale (18 64.29%), shiners (9 32.14%), prurigoestrofilo (8 28.57%), atopic eczema (6-21,42%). Other less frequent: urticaria and erythemaperianal. CNSALT: Irritability (950%), sleepdisorder (738.88%), Hyperactivity (422.22%), headache (316.66%). Other less frequent: ADHD and fatigue.

Lactose intolerance at a day care center in the municipality of Duque de Caxias, Rio de Janeiro, Brasil

Objectives and study Lactose intolerance has a variable prevalence in different parts of the world. The differences may be explained by the diverse eating habits of each population, allowing over the years a selection of individuals with and without the ability to digest lactose – ontogenetic variation. The objective of this study is to identify the prevalence of lactose intolerance and their presenting main symptoms, developed by children at a Day care center in the municipality of Duque de Caxias, Rio de Janeiro, Brazil, after an oral lactose tolerance test.

Diseases induced by malfuction of the enteromammary circle

Objectives and study Breast milk is produced by the mammary gland under the influence of the enteromammary circle of the mother. The bipolar extremes of this circle is represented by the GALT system, in the GI tract of the mother. The other extreme is represented by the mammary gland. The present study are developed to explore the broad expectrum of the clinical picture of children presenting symptoms exclusively breastfed.

Decreased subsets of T lymphocytes CD8 in patients with IgE food allergy.

Objective To study the decrease of CD8 T lymphocytes in patients with FoodAllergy (FA) of the IgE type associating with its clinical manifestations. Method Analysis of 16 records of patients selected as having the IgE Food Allergy , who presented the CD4 / CD8 ratio, greater than 3, by reduction of CD8 bellow the average and evaluating its clinical presentation of FA. Material and methods Of these 16 records, 11 were girls (68.75%) and 5 were boys (31.25%). Results 8 children had gastrointestinal imediated hypersensitivity (42.10%), 6 had increased this ratio due to hives (31.57%), 3 had rhinitis (15.78%), 1 asthma (5.26 %) and 1 had anigioedema (5.26%). The main complaints of these children were also analyzed. The most frequent complaints were skin with 9 reports (33.33%), followed by constipation with 7 (25.94%) and respiratory complaints with 6 (22.22%). There were also 5 reports of accute diarrhea (18.51%), 3 with abdominal pain and vomiting, 3 with weight loss and 1 with reflux. In this study of the 16 children with CD4 / CD8 ratio high, 15 were born by cesarean delivery. Conclusion The analysis of the records of patients with IgE FA and high CD4 / CD8 ratio has shown that these patients will reflect in the clinic with symptoms of skin, respiratory and gastrointestinal disorders. Of these, we note that the most common symptoms are skin complaints (33.33%) and the most common disease that leads to decreased CD8 is the Immediate Gastrointestinal Hypersensitivity (42.10%). Hardest hit were the GALT systems and SALT. 15 of the 16 studied cases were born by cesarean delivery.