Ali Kokuludag

Psoriasiform contact dermatitis due to propolis in a beekeeper

BACKGROUND More than 250 cases of allergic contact dermatitis due to propolis have been described. A few of these occurred in beekeepers. OBJECTIVE To describe a case of psoriasiform dermatitis caused by propolis in a beekeeper who thought that his lesions were related to honeybee stings. METHODS A 45-year-old beekeeper experienced hand dermatitis for the past 5 years. He believed that the lesions occurred and worsened when he was stung by honeybees. He was prescribed topical corticosteroids several times, but because he was stung frequently, the drugs never helped control the lesions. In the past few years, he frequently had contact with propolis during honey collection, but he denied the role of propolis because he was wearing gloves while handling the beehives. For diagnostic evaluation, skin biopsy, skin prick tests (SPTs), identification of specific IgE antibodies, and atopic patch tests were performed. RESULTS Skin biopsy showed psoriasiform contact dermatitis. Results of SPTs to honeybee and serum specific IgE for Apis mellifera remained negative. Results of the atopic patch test performed using A mellifera SPT material were also negative in the first 20 minutes and on the second and third days. However, propolis showed a positive erythematopapular reaction on day 2. The patient never again worked as a beekeeper, and neither did he, as far as he knew, use any medical or cosmetic products that contained propolis. His hand lesions improved almost completely. CONCLUSION Dermatitis due to propolis should never be disregarded in beekeepers, and every effort should be put forth to make a correct diagnosis and to convince the patients of the cause.

Sensitization to cat allergens in non–cat owner patients with respiratory allergy

BACKGROUND Cats represent one of the most important sources of indoor allergens. The sensitization rate can reach up to 60% in western countries. Keeping cats indoors is uncommon in big cities in Turkey, but cats living in the streets are common. OBJECTIVE To investigate the prevalence of sensitization to cats in patients with respiratory allergy from Izmir, Turkey, and its relationship to home cat allergen levels. METHODS A total of 387 patients (70.8% female; mean age, 34.3 years) with respiratory allergic diseases (rhinitis and/or asthma) were included in this study. Skin prick test to cat was performed. House dust samples were collected from the living room of 25 patients and 14 healthy subjects. The major cat allergen (Fel d 1) levels were measured by Dustscreen. Fel d 1 levels given by the manufacturer were as follows: 0.05, 0.13, 0.40, 1.1, and 6.2 mU/mL. RESULTS The prevalence of cat sensitivity was 44.7% (n = 173). Only 6 patients (1.6%) had a history of feeding a cat in their houses. Thirty-six (92%) of 39 houses had detectable levels of cat allergen (mean Fel d 1 level, 2.24 +/- 2.69 mU/mL). The mean Fel d 1 levels were 1.58 +/- 2.51 mU/mL in the healthy group, 1.91 +/- 2.61 mU/mL in the asthmatic group, and 3.26 +/- 2.85 mU/mL in the group with allergic rhinitis (P = 0.12). The prevalence of cat sensitivity in patients who had 1.1 mU/mL of Fel d 1 in their homes was 57.1%. This rate was five times lower (11.1%) in patients who had the highest Fel d 1 level (6.2 mU/mL) in their homes. CONCLUSIONS The prevalence of cat sensitivity in Izmir, where cats are generally not kept within homes, is as high as in western countries. The sampled houses have measurable levels of Fel d 1 even in the absence of indoor cats. High prevalence of cat sensitivity in Izmir is probably due to indirect exposure.

The determinants of bronchial hyperresponsiveness in patients with allergic rhinitis

BACKGROUND Patients with allergic rhinitis and bronchial hyperresponsiveness (BHR) may be at higher risk of developing asthma. OBJECTIVE To investigate whether reactivity to aeroallergens in skin prick testing (SPT) and serum eosinophil cationic protein levels can be used to predict BHR in allergic rhinitis patients. METHODS Fifty-nine consecutive patients with allergic rhinitis underwent SPTs using grass, tree, weed, parietaria, Alternaria, Aspergillus, mites, and cat and dog dander extracts. Methacholine challenge tests were performed using spirometry. RESULTS Methacholine-induced BHR was detected in 23 patients (39%). Of 59 patients, 14 had 1 positive SPT response, 35 had 2 to 4 positive responses, and 10 had more than 4 positive responses. There was a significant inverse correlation between methacholine provocation concentration that caused a decrease in forced expiratory volume in 1 second of 20% (PC20) and the number of positive SPT responses (r = -0.28; P = .03). The BHR-positive patients had a mean of 4 positive SPT responses, whereas BHR-negative patients had a mean of 2.6 (P = .04). Nine BHR-positive patients (39%) and only 1 BHR-negative patient (3%) had more than 4 positive SPT responses (P < .001). There was no correlation between serum eosinophil cationic protein levels and methacholine PC20 doses. There was a strong association between hyperresponsiveness to methacholine and both cat and dog dander sensitivity (P < .001 and P = .001, respectively). CONCLUSIONS Allergic rhinitis patients with SPT responses to a higher number of allergens are more likely to have BHR. Whether the number of positive SPT responses correlates with the risk of developing asthma in allergic rhinitis patients remains to be determined.

Superior vena cava syndrome together with multiple venous thrombosis in Behçet's disease

In this paper, we describe a 25-year-old white man with Behçets disease who developed superior vena cava syndrome which was followed with the diagnosis of pseudotumour cerebri based on bilateral papilledema for 6 months. Complete superior vena cava obstruction was detected by magnetic resonance imaging (MRI). Secondary reasons for papilledema were all excluded. Treatment of prednisone, pulse cyclophosphamide and heparin was started and clinical symptoms and fundoscopic changes completely disappeared in 2 weeks. In conclusion, we think that Behçets disease should always be remembered in the differential diagnosis of unidentified neurological signs especially in regions where the disease is relatively common.

Serum Eosinophil Cationic Protein (ECP) Levels in Patients with Seasonal Allergic Rhinitis and Allergic Asthma

We studied serum ECP levels in 21 seasonal allergic patients (16 patients with rhinitis; 5 with rhinitis and asthma) diagnosed by history, skin tests, and RAST. Seventeen healthy subjects were selected as a control group. None of the patients had received medications. Total IgE levels were also measured and correlated with ECP levels. Mean IgE level was found to be higher in patients than controls (p < 0.05). Patients with asthma and rhinitis had higher IgE values than those with rhinitis alone (p < 0.05). Serum ECP levels in the patient group were significantly higher than those in the control group (p < 0.05). No statistically significant difference was found between ECP levels in patients with rhinitis and rhinitis plus asthma groups, although mean ECP was higher level in the later group. Total IgE and ECP levels were correlated positively in the patients (r = 0.630, p < 0.05). We conclude that the extent of allergic inflammation in mucosal surfaces such as allergic rhinitis plus asthma, might influence serum ECP levels.

Desensitization Effect of Preseasonal Seven-Injection Allergoid Immunotherapy with Olive Pollen on Basophil Activation: The Efficacy of Olive Pollen-Specific Preseasonal Allergoid Immunotherapy on Basophils

Background: It has previously been demonstrated that subcutaneous immunotherapy with allergoids positively affects clinical and immunological parameters even after 7 preseasonal injections. However, its effect on basophil activation remains unclear. We investigated the effect of preseasonal allergoid immunotherapy on basophils and concomitantly assessed its clinical and immunological efficacy in olive pollen-monosensitized patients. Methods: This study enrolled 437 consecutive patients with respiratory allergy and positive skin prick tests (SPTs); 212 (48.5%) patients were sensitized to olive pollen, and 33 (7.5%) patients were sensitized to olive pollen only. Of these patients, 23 received preseasonal immunotherapy with an olive pollen allergoid. The olive pollen-specific basophil activation, the titrated nasal provocation test, the nasal symptom score, and olive pollen-specific IgE, IgG1 and IgG4 levels were evaluated before immunotherapy and 8 months after the end of immunotherapy in the follow-up visit. Results: In comparison to baseline evaluation, 7 preseasonal injections of an allergoid resulted in a significant decrease in the percentage of basophils expressing CD63 (29 vs. 7%, respectively, p < 0.0001) and a significant increase in the titrated nasal provocative dose (1/10 vs. 1/1, respectively, p < 0.01). SPT induration diameters caused by an olive pollen extract decreased (12 mm at baseline vs. 5.5 mm at follow-up, p < 0.005), as did nasal symptom score (7 at baseline vs. 3 at follow-up, p < 0.01). Olive pollen-specific IgE (17.5 vs. 50 kU/l, p < 0.012), IgG1 (0.16 vs. 2.9 µg/ml, p < 0.0001) and IgG4 (0.07 vs. 1.92 µg/ml, p < 0.0001) levels significantly increased. Conclusions: Immunotherapy with 7 preseasonal injections of an olive pollen allergoid decreases olive pollen-specific basophil activation over 8 months, an effect observed in vitro and in vivo.

Chlamydia pneumoniae arthritis in a patient with common variable immunodeficiency

BACKGROUND Arthritis is an important and sometimes life-threatening complication in patients with common variable immunodeficiency (CVID). OBJECTIVE To describe a patient with CVID and arthritis due to Chlamydia pneumoniae, which is usually regarded as a respiratory tract pathogen and has not previously been detected in the synovial fluid by cell culture technique. METHODS Routine bacteriologic, virologic, mycologic, and tuberculosis cultures were performed. The patients synovial fluid was examined for fastidious organisms that might be causative pathogens of arthritis, such as chlamydiae, and special cell culture methods were used. Serologic tests were performed to determine viral and bacteriologic etiology. RESULTS The patient had a history of recurrent respiratory tract infections, and the latest exacerbation was followed by arthritis. Cytologic examination of the fluid yielded abundant lymphocytes. Chlamydia pneumoniae was detected in synovial fluid specimens by cell culture technique. Her nasopharyngeal swab and sputum culture specimens were also positive for this pathogen. She was diagnosed as having arthritis caused by C pneumoniae and was given antibiotherapy. CONCLUSION Chlamydia pneumoniae should be kept in mind as a causative pathogen in patients with CVID and arthritis, especially when effusion fluid is full of lymphocytes rather than polymorphonuclear cells and no organism is grown on routine cultures.

House dust mite allergens in Turkish homes

Exposure to house dust mites (HDMs) is a major risk factor for allergic sensitization and asthma (1). Assessing HDM allergen exposure at home is critical to evaluate risk factors for sensitization and can play a role in controlling environmental factors that contribute to asthma severity (2). Although it is reported that the predominated HDM was Dermatophagoides pteronyssinus in Turkish homes (3), data on mite allergen levels has never been reported. Therefore, we aimed to investigate HDM allergen levels of homes in Izmir, the third populated city in Turkey situated next to Aegean Sea and to identify predictors of dust mite allergen concentration. Dust samples were obtained from 25 homes of allergic patients with perennial symptoms, consecutively referred to our out patient clinic for the first time for their allergies. Fourteen healthy subjects served as a control group. House dust samples were collected from an area of 1 m with a 1200-W, filtered vacuum cleaner. Dust mite allergen (Der p 1 and Der f 1) concentration was determined by Dustscreen assay, a method easier to perform and as satisfactory as enzyme-linked immunosorbent assay (4). The HDM allergen levels were expressed as lg/m. The minimum detection level of Der p 1 and Der f 1 was 0.1 lg/m. Independent predictors of allergen concentration were assessed. Either Der p 1 or Der f 1 was detected in 21 of 39 homes (53.8%). Dermatophagoides pteronyssinus predominated in most of the houses (71.4%). Twentythree percent of houses were coinhabited by D. farinae and D. pteronyssinus. Der p 1 was detected in twenty houses in the range of 0.4–5.4 lg/m (median 2). We observed Der p 1 >2 lg/m of dust in 55% of the houses. Whereas Der f 1 was detected in only six houses (median 1, range 0.1–6.4 lg/m). Der p 1 levels were significantly higher in allergic subjects houses than healthy controls (median 2 vs 0.4 lg/m, P 1⁄4 0.041). Twenty-one of 25 allergic subjects (84%) were sensitive at least to D. farinae or D. pteronyssinus assessed by skin prick test. Independent predictors of higher levels were evidence of moisture, such as mildew or water stains in the home and residency at seaside. In conclusion, more than half of the houses in Izmir had detectable levels of dust mite allergen. Dermatophagoides pteronyssinus was the most frequently found species. Allergic patients encountered more HDM allergens than normal subjects in their home, and this situation may emphasize the importance of environmental factors in the development of allergic diseases. Indoor moisture and residency at seaside were predictors of higher mite allergens.

The side-effects of cardiopulmonary bypass on the lungs: changes in bronchoalveolar lavage fluids:

Although technical refinements have improved the safety of cardiac operations, postoperative dysfunction of lung and other organs occurs frequently after cardiopulmonary bypass (CPB). The aim of the present study was to search the aetiopathogenesis of pulmonary complications due to CBP. Ten patients with stable coronary artery disease, undergoing coronary artery bypass grafting (CABG) surgery, were included in the study. Forty bronchoalveolar lavage (BAL) fluid samplings were performed in the 10 patients. Samples were obtained at the following time periods: (1) preoperatively; (2) at the end of the first hour after anaesthetic induction; (3) at the conclusion of 30 min of crossclamp on CPB; and (4) at the conclusion of 20 h after the end of CPB, postoperatively. Cell contents of bronchoalveolar lavage fluid, alveolar macrophage viability, eosinophil cationic protein (ECP) levels and myeloperoxidase (MPO) concentrations were analysed in each bronchoalveolar lavage fluids. While the percentage of preoperative macrophages was 85.90% and the percentage of preoperative neutrophils was 2.40%, they were 77.00% and 11.30% in the postoperative samples, respectively. Mean alveolar macrophage viability was 96.20% preoperatively and 90.40% in the postoperative period. Preoperative eosinophil cationic protein mean concentration was < 2 μg/l and mean response value (RV) was 28.80. Pre-operative mean myeloperoxidase concentration was 7.66 ng/ml. Postoperative eosinophil cationic protein mean response value was 63.40 and mean myeloperoxidase concentration was 59.25 ng/ml. There were significant differences between third and final samples with regard to both neutrophil percentages (p = 0.028) and MPO levels (p = 0.005). While the preoperative mean PaO2 value was 89.39 mmHg and mean SaO2 value was 97.12%, they were calculated in the postoperative arterial blood specimens of patients, without inhaling O2, as 65.31 mmHg and 93.84%. These changes between blood gas analyses reflect the impairment of the lungs (p = 0.009 and p = 0.007, respectively). Neither alveolar macrophage viability nor ECP levels changed significantly between consecutive periods. However, when the results of the first and fourth samples were compared, we saw the cumulative effects of CPB, in that alveolar macrophages lost their viability and ECP mean RVs rose. These changes were statistically significant (p = 0.027 and p = 0.013, respectively). However, postoperative ECP levels were not like those found in a patient with asthma. Also, changes between alveolar macrophage percentages (p = 0.028), between neutrophil percentages (p = 0.036) and between MPO concentrations (p = 0.005) were statistically significant. Again, changes in neutrophil percentages between first and final samples correlated with changes in MPO levels between same periods (r = 0.657, p = 0.039).

Soluble P-selectin and the success of thrombolysis in acute myocardial infarction

BACKGROUND P-Selectin mediates adhesive interactions between platelets, leukocytes and endothelium to form thrombi. Our purpose was to investigate plasma soluble(s) P-selectin levels in patients with acute myocardial infarction (aMI) and the effect of thrombolysis on P-selectin levels. METHODS Patients with aMI within the first 6 h of chest pain were enrolled prospectively. sP-selectin levels were determined by ELISA in the plasma of patients with aMI (n=32), stable angina (n=18), and healthy controls (n=15). Samples were obtained before, 3 and 24 h after reperfusion therapy with tissue plasminogen activator. Seven patients showed recurrent angina or failure to reperfuse. RESULTS sP-selectin levels were significantly higher in aMI group than other groups (86.7+/-8.7 ng/ml, P<0.05). sP-selectin levels were similar in stable angina and control groups (28.8+/-4.4 vs. 25.4+/-7.3 ng/ml, P=NS). A significant increase in sP-selectin levels was observed 3 h after successful thrombolysis and this was followed by a decrease to near the baseline level late after reperfusion. But patients with failed reperfusion showed sustained high sP-selectin levels after 24 h of thrombolysis (P<0.05). CONCLUSION The plasma sP-selectin level is elevated in aMI and it increases further following thrombolytic therapy. This increase is probably induced by activation of endothelial cells or platelets after myocardial ischemia and reperfusion during aMI. As the elevated levels are sustained in patients with failed reperfusion, serial P-selectin levels may be used as a non-invasive indicator of successful thrombolysis in aMI.