Rosalba Buquicchio

Alternative glucocorticoids for use in cases of adverse reaction to systemic glucocorticoids: a study on 10 patients.

Background  Reactions to systemically administered corticosteroids are rare, despite their widespread use.

Clinical data and inflammation parameters in patients with cypress allergy treated with sublingual swallow therapy and subcutaneous immunotherapy.

The clinical efficacy of immunotherapy, either by high dose sublingual-swallow therapy (SLIT) or subcutaneous immunotherapy (SCIT), has been demonstrated in patients with pollinosis but few studies have been carried out analysing differences in these treatments in terms of an improvement of clinical and allergic phlogosis parameters. The aim of this double-blind placebo-controlled study is to investigate the efficacy of high dose SLIT and SCIT using a purified standardized Juniperus ashei extract in a population of allergic patients monosensitized to cypress. Forty patients with cypress-allergic rhino conjunctivitis were administered therapeutic or placebo SLIT or SCIT for 12 months. Laboratory parameters were studied, namely the eosinophil cationic protein (ECP) level in nasal lavage and in serum, as well as the number of eosinophils (EOS) in peripheral blood and in nasal lavage and the level of eosinophil chemotactic activity (ECA). These parameters were correlated with clinical symptoms, evaluated by means of the clinical symptoms score (CSS). After SCIT and SLIT the levels of ECP and ECA were reduced in nasal lavage. We also observed a significant reduction in the values of ECP in serum in the patients treated with SLIT. EOS were unchanged in peripheral blood, but significantly reduced in nasal lavage. These data were in accordance with the improvement of clinical symptoms, supported by the close correlation between CSS and laboratory parameters. Our data confirm a clinical improvement correlated with a decline in inflammation parameters after one year of immunotherapy, supporting the hypothesis that treatment with a major allergen of cypress is able to change the course of allergic rhinitis.

Clinical and cytologic characteristics of allergic rhinitis in elderly patients

BACKGROUND The constant increase in the elderly population worldwide has led to a greater interest in immunologic responses during aging. Thus, special attention to allergic diseases in elderly people has begun to emerge, but little is known about the effect and features of allergic rhinitis in elderly people. OBJECTIVE To evaluate the clinical and cytologic characteristics of respiratory allergy and its impact on the quality of life in elderly people. METHODS Elderly patients with rhinitis referred to our allergy unit during a 3-month period underwent clinical evaluation and responded to the Rhinasthma Questionnaire. All patients also underwent skin prick testing, measurement of total IgE level, and nasal cytologic analysis. The data were compared with a control group of young adults. RESULTS Fifty-four patients older than 65 years (mean age, 69.3 years) and 89 young adults (mean age, 26.3 years) with allergic rhinitis were studied. The elderly patients had a less positive family history of atopy (P=.02) and had rhinitis plus conjunctivitis more frequently (P=.002) than young adults, whereas the difference between groups in total IgE level was not statistically significant. On nasal cytologic analysis, the differential count of inflammatory cells did not differ between groups, but in the elderly patients the epithelial-goblet cell ratio was decreased. The quality of life in elderly people was more impaired than in young adults (P=.01). CONCLUSION In elderly people with allergic rhinitis, the clinical characteristics are different and quality of life is more heavily impaired compared with young adults.

Incidence of allergic diseases in an elderly population

Recent years have shown a progressive increase of allergic disease in the elderly population worldwide. Naturally, this phenomenon has coincided with attempts to guarantee the best possible quality of life for this age group. As a result, diseases that were previously overlooked are attracting ever greater attention. An epidemiological study of allergic manifestations in the elderly conducted in all consecutive patients referred to an Allergology Unit over a three-month period at the beginning of 2008 showed that 15% belonged to the elderly population and among these, 51.8 % were suffering from an allergic reaction to drugs. Skin manifestations, including both urticaria and eczema, accounted for 71.4% of cases but only in 13.8% of these patients was there a diagnosis of an allergic reaction made and the allergen responsible individuated. Rhinitis was present in 16.8 % of the patients and food allergy in 8 %. Certainly, age-induced modifications in the immunological system can be responsible for allergic reactions. In fact, non specific immunity components such as the production of mucus or a reduced function of the T- and IL-2 cells can induce the onset of symptoms referable to allergic disease. Further studies are ongoing to gain a better understanding of the pathogenic mechanisms that could justify the development in the elderly population of a cytokine phenotype that is more prone to develop allergic manifestations, and to assess the true incidence of respiratory, food and drug allergies in this stage of life.

Adverse drug reactions as the cause of emergency department admission: focus on the elderly.

The use of medications could be responsible of both side effects and adverse drug reaction (ADR). Identifying risk factors could improve the possibility of avoiding severe reactions in old people. We investigated the prevalence of unpredictable drug adverse reactions among patients admitted to the emergency departments (EDs) of three large Italian hospitals in the period 2005–2008. Clinical characteristics and demographics were carefully recorded in a dedicated database. The assessment of the drug reactions was carried out by an allergist after the first emergency evaluation. Over the considered period, 56,031 patients were admitted at the ED, 2644 (21.2%) of which for ADR. Out of those patients, 55 (2.1%) were identified as unpredictable ADRs. In 96% of the cases the clinical presentation was cutaneous and antibiotics were the most frequently responsible drugs. Patients over 65 years accounted for 37% of the reactions. In those patients the multiple drug regimens were significantly more frequent, as well as the presence of comorbidities. Smoking habit, alcohol abuse and personal and familiar history of atopy did not differ between the younger and the elderly. In the older group, antibiotics were more frequently involved, whereas in the <65 years, nonsteroidal antinflammatory drugs accounted for most reactions. Our date outline that in the elderly the comorbidities and correlated multiple regime therapy cause an increased incidence of ADRs, thus suggesting a careful management of therapeutics regimens by means of educational campaigns for patients and guidelines for doctors finalized to avoid excessive drug prescription.

Immunosenescence in aging: between immune cells depletion and cytokines up-regulation

BackgroundThe immunosenescence is a relatively recent chapter, correlated with the linear extension of the average life began in the nineteenth century and still in progress. The most important feature of immunosenescence is the accumulation in the “immunological space” of memory and effector cells as a result of the stimulation caused by repeated clinical and subclinical infections and by continuous exposure to antigens (inhalant allergens, food, etc.). This state of chronic inflammation that characterizes senescence has a significant impact on survival and fragility. In fact, the condition of frail elderly occurs less frequently in situations characterized by poor contact with viral infections and parasitic diseases. Furthermore the immunosenescence is characterized by a particular “remodelling” of the immune system, induced by oxidative stress. Apoptosis plays a central role in old age, a period in which the ability of apoptosis can change. The remodelling of apoptosis, together with the Inflammaging and the up-regulation of the immune response with the consequent secretion of pro-inflammatory lymphokines represents the major determinant of the rate of aging and longevity, as well as of the most common diseases related with age and with tumors. Other changes occur in the innate immunity, the first line of defence providing rapid, but unspecific and incomplete protection, consisting mostly of monocytes, natural killer cells and dendritic cells, acting up to the establishment of a adaptive immune response, which is slower, but highly specific, which cellular substrate consists of T and B lymphocytes. The markers of “Inflammaging” in adaptive immunity in centenarians are characterized by a decrease in T cells “naive.” The reduction of CD8 virgins may be related to the risk of morbidity and death, as well as the combination of the increase of CD8+ cells and reduction of CD4+ T cells and the reduction of CD19+ B cells. The immune function of the elderly is weakened to due to the exhaustion of T cell-virgin (CD95−), which are replaced with the clonal expansion of CD28-T cells.ConclusionsThe increase of pro-inflammatory cytokines is associated with dementia, Parkinson’s disease, atherosclerosis, diabetes type 2, sarcopenia and a high risk of morbidity and mortality. A correct modulation of immune responses and apoptotic phenomena can be useful to reduce age-related degenerative diseases, as well as inflammatory and neoplastic diseases.

An approach to urticaria in the elderly patients.

The guidelines for the management of urticaria in adults and children have been published in outstanding position papers. By contrast, the onset of urticaria in the elderly has not yet had a clear definition. In order to approach diagnosis and treatment in a population of elderly patients, we have performed an epidemiological study on a population of elderly people observed in the Immuno Allergology Unit in Bari University Hospital. The patients underwent skin prick test for food allergy and laboratory and instrumental tests. From the data it resulted that 49% of cases have had urticaria because of adverse drug reactions (ADRs), 16% of cases were positive to food, while in 21% of cases systemic and metabolic diseases (SMDs) have been diagnosed. If we consider the young controls, urticaria for ADR was present in 48% of cases; however, in 28% it was possible to make the diagnosis of food allergy, 12% cases had a SMD. Our results show that the main cause of urticaria in the elderly is related to drug assumption because of the high number of drugs taken, followed by internal pathologies correlated to the typical immune and metabolic changes of the elderly. Furthermore, from the observation of our data it was possible to give guidelines for the treatment of urticaria in geriatric age.

Contact Allergy to Topical Corticosteroids: Update and Review on Cross- Sensitization

Contact allergy to topical corticosteroids (TCs) is an emerging problem, whose diagnosis can be complex owing to the peculiar characteristics of steroid allergens and the possible inadequacy of current diagnostic methods, including concentration and vehicle used in patch testing. The occurrence of cross-reactions among different TCs is not rare, but prediction of these is not sufficiently reliable. Moreover, the distinction between true cross-reactivity and concomitant sensitization may be difficult. The original classification proposed by Coopman et al. has been distinguished corticosteroids into four groups according to their molecular structure. These authors hypothesized that allergic contact reactions were more frequent with corticosteroids belonging to the same group. However, the clinical practice has evidenced that cross reactivity exists also among corticosteroids belonging to different groups. The potential to cross-react among corticosteroids is thought to be related not only to the structural homology but also to the stereoisomerism and metabolism of these drugs. Recent evidence suggests that mechanisms responsible for cross-reactivity may occur at T lymphocyte level during antigen presentation. Further investigations are needed to gain a more complete understanding of this important topic. This article also reviews some patents related to the treatment of contact dermatitis and other inflammatory skin diseases.

Therapeutic hotline: Re-induction may be useful to manage psoriasis relapse during long-term maintenance treatment with infliximab: a retrospective analysis.

Infliximab is an anti‐tumor necrosis factor‐alpha monoclonal antibody that is highly effective for the treatment of psoriatic disease. During maintenance treatment, some patients may experience a disease relapse, and, in such circumstances, dose intensification is frequently used to regain efficacy. We report our cumulative experience on the use of infliximab re‐induction in patients whose psoriasis relapsed during long‐term maintenance treatment with infliximab. From September 2005 to January 2009, 22 patients required re‐induction because of a relapse of their psoriasis. Re‐induction was effective in restoring response in most patients and was well tolerated in all cases, without occurrence of serious or unexpected adverse events.

Local and systemic reactions occurring during immunotherapy: an epidemiological evaluation and a prospective safety-monitoring study.

The efficacy of specific immunotherapy in allergic patients with IgE-mediated rhino-conjunctivitis, asthma and allergic reaction for stinging insects suggests the opportunity of improving technical procedures to minimize risk and optimise the safety of immunotherapy. This study investigated both local and systemic reactions, occurring in a population of 218 patients undergoing immunotherapy, in an attempt to correlate them with some parameters as well as age, sex and allergenic extracts. The epidemiological evaluation was based on the administration of a questionnaire to 218 patients in order to assess possible reactions to immunotherapy. The following data were evaluated: personal data, diagnosis, specific allergens, adverse reactions undergone during treatment, number of reactions and symptoms. The patients were followed-up by the medical staff of the Section of Allergological and Immunological Disease (SAID), University of Bari (Bari-Italy) for compilation of questionnaires. We found a correlation between female sex and adverse reactions. Among 107 patients referring reactions to the immunotherapy, 71 patients (66.3%) presented only local reactions; 11 patients (10.3%) systemic reactions and 25 patients (23.4%) systemic reactions associated with local reactions. Parietaria was mostly involved in patients with local reactions, instead, in patients with systemic reactions the prevalent allergens seem to be Dermatophagoides and grass-pollen. Rhinitis was the most frequent diagnosis for patients who have presented both local and systemic reactions. In our study, we had frequently mild systemic reactions and some cases of respiratory difficulties, while it is evident that in our group of patients no cases of anaphylaxis occurred. In addition, we considered some events before the administration of immunotherapy, such as assumption of drugs, meals, exposure to sun, stress or physical activity and the percentage of adverse reactions. On the light of a small number of fatality, immunotherapy represents a safer therapy for allergic diseases; nevertheless, our data suggest that safety is strictly correlated with prescriptions by specialists, administration by trained physicians and accurate follow-up of patients. In particular it is recommended to avoid some events before the administration of immunotherapy, above all the assumption of drugs and physical exercise.