Production of leukotrienes in human skin and conjunctival mucosa after specific allergen challenge

Effects of academic exam stress on nasal leukotriene B4 and vascular endothelial growth factor in asthma and health

OBJECTIVE

To examine the effect of final exam stress on the concentrations of leukotriene B4 (LTB4) and vascular endothelial growth factor (VEGF) in the upper airways among healthy and asthmatic individuals.

METHOD

Nasal samples were collected from 12 individuals with asthma and 23 healthy controls early and late in a final exam period, and during a low-stress period in the semester. We determined LTB4 and VEGF concentrations using Enzyme-Linked Immunoassays.

RESULTS

Mixed effects analysis of variance models showed that asthmatic participants with allergies in contrast to healthy individuals experienced a decrease in nasal LTB4 during the final exam period as compared to mid-semester (low stress period). There were no significant changes in nasal VEGF across the observation period. Changes in nasal LTB4 and VEGF were not associated with salivary cortisol, exhaled nitric oxide, or spirometric lung function.

CONCLUSIONS

Our results suggest that nasal LTB4 concentrations change in periods of psychological stress for asthmatic individuals with allergies.

Leukotriene receptor antagonists in allergic eye disease: a systematic review and meta-analysis

BACKGROUND

Allergic eye diseases are common and cause significant morbidity. Leukotrienes are implicated in the pathogenesis of seasonal and perennial allergic conjunctivitis (AC), commonly seen in conjunction with allergic rhinitis, and in vernal keratoconjunctivitis and atopic keratoconjunctivitis.

OBJECTIVES

To assess the available evidence for an effect of leukotriene receptor antagonists (LTRAs) on the ocular symptoms of allergic eye diseases.

METHODS

Selected studies, identified with systematic review search methods, were single/double-blind, randomized, controlled trials that compared LTRAs with other common treatments.

RESULTS

Eighteen trials, using the LTRA montelukast (in AC only), were identified. Six studies were suitable for meta-analysis, in patients with seasonal AC [treated over a 2-week period, symptoms scored 0 (mild) to 3 (severe)]. These trials were at low risk of bias without significant heterogeneity. Six trials were analyzed and showed that montelukast improved patients' ocular symptoms to a greater extent than placebo, with a difference in mean change-from-baseline score of -0.10 (95% CI, -0.14 to -0.07; P < .00001). Three trials compared montelukast with oral antihistamine. The difference in mean change-from-baseline score was 0.08 (95% CI, 0.02 to 0.14; P = .007), in favor of antihistamines. Two trials compared montelukast and oral antihistamine with placebo. The difference in mean change-from-baseline score was -0.30 (95% CI, -0.38 to -0.21; P < .00001), in favor of combination treatment.

CONCLUSIONS

In seasonal AC LTRAs are more efficacious than placebo but less efficacious than oral antihistamines in adult patients. Clinical trials should be conducted to determine whether combination treatment with LTRA and oral antihistamine has a synergistic effect. Further research is required to clarify the role of LTRAs in other allergic eye diseases.

Atopic keratoconjunctivitis

Atopic keratoconjunctivitis (AKC) is a potentially blinding disease characterized by a bilateral chronic keratoconjunctivitis associated with atopic dermatitis. The disease usually manifests as severe itching and burning, excessive tearing, foreign body sensation, and mucoid discharge. The clinical characteristics of AKC show a broad spectrum including lid dermatitis, chronic blepharitis, cicatrizing conjunctivitis with fornix foreshortening and symblepharon formation, punctate epithelial keratitis, persistent epithelial defects, corneal scarring and neovascularization, lipid keratopathy, conjunctivalization of peripheral cornea, and peripheral ulcerative keratitis. The underlying pathophysiologic mechanism in AKC involves a combination of type-I IgE-mediated, and type-IV delayed hypersensitivity reactions. The immunoregulatory defect responsible for the overproduction of allergen-specific IgE antibody, the key component responsible for antigen binding, and subsequent mast cell degranulation, is probably multifactorial. The histopathologic characteristics of the conjunctiva in AKC include a mast cell and eosinophil invasion of the epithelium, epithelial pseudotubule formation, and prominent mast cell and mononuclear cell infiltration of the substantia propria. A number of ocular conditions have been reported to be associated with AKC, including keratoconus, herpes simplex keratitis, and cataracts. Successful long-term control of this potentially blinding disease requires a multidisciplinary approach involving systemic and environmental aspects. Scrupulous long-term environmental control of allergens is the single most important aspect in the management of patients with AKC. Systemic anti-histamine therapy, and long-term topical mast cell stabilizing therapy are also mandatory. Topical steroids should be reserved for exacerbations of the disease.

Leukotriene inhibition in small animal medicine

Leukotrienes are important mediators of inflammatory and allergic conditions in people and are suspected to play an important role in tumorigenesis and tumor growth of several different tumor types. Based on this, researchers are making great progress in identifying novel pharmacologic targets for several human diseases. Leukotriene inhibition has resulted in therapeutic benefit in clinical trials involving people with osteoarthritis, allergic asthma, and atopic dermatitis. Despite this progress and the possibility that leukotriene inhibition may also play an important therapeutic role in veterinary patients, parallel advances have not yet been made in veterinary medicine. This article summarizes leukotriene function and synthesis. It also reviews the published literature regarding potential therapeutic applications of leukotriene inhibition in both human and veterinary medicine, focusing primarily on osteoarthritis, NSAID induced gastrointestinal mucosal damage, allergic asthma, atopic dermatitis, and cancer.

Vernal conjunctivitis

Vernal conjunctivitis is a bilateral, seasonal, external ocular inflammatory disease of unknown cause. Afflicted patients experience intense itching, tearing, photophobia, and mucous discharge, and usually demonstrate large cobblestone papillae on their superior tarsal conjunctiva and limbal conjunctiva. It primarily affects children, may be related to atopy, and has environmental and racial predilections. Although usually self-limited, vernal conjunctivitis can result in potentially blinding corneal complications. Treatment of chronic forms of ocular allergies may necessitate collaborative efforts between the ophthalmologist and the allergist or immunologist.

Cysteinyl leukotrienes: multi-functional mediators in allergic rhinitis

Cysteinyl leukotrienes (CysLTs) are a family of inflammatory lipid mediators synthesized from arachidonic acid by a variety of cells, including mast cells, eosinophils, basophils, and macrophages. This article reviews the data for the role of CysLTs as multi-functional mediators in allergic rhinitis (AR). We review the evidence that: (1) CysLTs are released from inflammatory cells that participate in AR, (2) receptors for CysLTs are located in nasal tissue, (3) CysLTs are increased in patients with AR and are released following allergen exposure, (4) administration of CysLTs reproduces the symptoms of AR, (5) CysLTs play roles in the maturation, as well as tissue recruitment, of inflammatory cells, and (6) a complex inter-regulation between CysLTs and a variety of other inflammatory mediators exists.

Drug therapy for ocular allergy

The spectrum of ocular allergy ranges from mild, non-sight threatening disease, such as hay fever, to disorders such as atopic keratoconjunctivitis (AKC) which cause permanent ocular surface changes and reduced vision. The ideal treatment is with topical preparations. Launched topical preparations include anti-histamines and mast cell (MC) stabilisers, which are safe, but only moderately potent, steroids, which are very potent, but carry very serious side-effects, and cyclosporin A, which is not widely available and difficult to tolerate. There are a number of anti-histamines, MC stabilisers (and combinations thereof) and steroids in development which are of potential interest. Other possibilities for therapeutic intervention include inhibition of tryptase, cyclooxygenase (COX), leukotrienes (LTs), bradykinins (BKs), platelet activating factor (PAF) and immunoglobulin E (IgE). Therapies based on cytokine antagonism and agonism, T-cell inhibition and adhesion molecule antagonism might be expected to provide safe, but potent new modes of treatment. The increasing interest in research into the pathogenesis of ocular allergic inflammation may lead to more relevant approaches, such as eosinophil inhibition. Success will be highly dependent on the ability to produce suitable topical ophthalmic preparations.

Vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is an allergic eye disease that especially affects young boys. The most common symptoms are itching, photophobia, burning, and tearing. The most common signs are giant papillae, superficial keratitis, and conjunctival hyperaemia. Patients with VKC frequently have a family or medical history of atopic diseases, such as asthma, rhinitis, and eczema. However, VKC is not associated with a positive skin test or RAST in 42-47% of patients, confirming that it is not solely an IgE-mediated disease. On the basis of challenge studies as well as immunohistochemical and mediator studies, a Th2-driven mechanism with the involvement of mast cells, eosinophils, and lymphocytes has been suggested. Th2 lymphocytes are responsible for both hyperproduction of IgE (interleukin 4, IL-4) and for differentiation and activation of mast cells (IL-3) and eosinophils (IL-5). Other studies have demonstrated the involvement of neural factors such as substance P and NGF in the pathogenesis of VKC, and the overexpression of oestrogen and progesterone receptors in the conjunctiva of VKC patients has introduced the possible involvement of sex hormones. Thus, the pathogenesis of VKC is probably multifactorial, with the interaction of the immune, nervous, and endocrine systems. The clinical management of VKC requires a swift diagnosis, correct therapy, and evaluation of the prognosis. The diagnosis is generally based on the signs and symptoms of the disease, but in difficult cases can be aided by conjunctival scraping, demonstrating the presence of infiltrating eosinophils. Therapeutic options are many, in most cases topical, and should be chosen on the basis of the severity of the disease. The most effective drugs, steroids, should however be carefully administered, and only for brief periods, to avoid secondary development of glaucoma.A 2% solution of cyclosporine in olive oil or in castor oil should be considered as an alternative. The long-term prognosis of patients is generally good; however 6% of patients develop corneal damage, cataract, or glaucoma.

Conjunctival allergen challenge: models in the investigation of ocular allergy

Recently, the number of agents to treat ocular allergy has increased dramatically, from three (pheniramine, antazoline, cromolyn) to more than a dozen. A general increase in the incidence of atopy in recent years and the fact that patients are becoming less tolerant of bothersome signs and symptoms have been driving forces in this increase. As visual tasking, such as reading and working on a computer, has become more prevalent, there is an increased awareness of ocular allergy and the impact it has on quality of life and productivity at work and school. With the need for more effective medications, the development of models, such as the conjunctival allergen challenge (CAC), has made the identification of new agents more efficient. In this article, we review the relevant background on the science behind allergen challenges in the eye, how models are designed, and how models are used in the field today.

Update on the role of leukotrienes in the pathogenesis of atopy: a comparative review

The pathogenesis of atopic disease (AD) is controversial in humans and dogs. In humans, leukotrienes (LT) are thought to play an important role in this disease and LT inhibitors are commonly used as treatment for AD. Leukotrienes are a heterogeneous group of biologically active compounds that mediate many aspects of inflammatory and allergic reactions. This paper will review the role of LT in atopic disease in a comparative manner. Leukotriene inhibitors and their therapeutic use in the management of atopic disease in humans and dogs are discussed.

Sulphido-leukotriene production from peripheral leukocytes and skin in clinically normal dogs and house dust mite positive atopic dogs

Pathogenesis of canine atopy has not been completely elucidated. In humans, sulphido-leukotrienes (s-LT) play a role in atopy, and increased production of s-LT occurs in the skin and peripheral leukocytes after allergen challenge. The study population included 16 clinically normal and 13 atopic dogs. All atopic dogs had in common a positive reaction (4+) to the intradermal injection of house dust mite (allergen of reference). Blood samples and skin biopsies were collected. Sulphido-LT synthesis by peripheral leukocytes after stimulation was measured, and no statistically significant difference was found between clinically normal and atopic dogs. Sulphido-LT concentrations in skin samples from stimulated and unstimulated sites were measured, and no statistically significant difference was detected between clinically normal and atopic dogs or between lesional and nonlesional skin within the atopic group. Clinical signs of atopic dogs were graded by owners and no correlation was found between their severity and cutaneous concentrations of s-LT. In this study there was no increase in s-LT synthesis in atopic dogs.

Tear and conjunctival changes during the allergen-induced early- and late-phase responses

BACKGROUND

Allergic eye disease is common, but little is known about the underlying disease mechanisms. Conjunctival allergen challenge causes symptoms similar to those of seasonal allergic conjunctivitis and is a useful model to study.

OBJECTIVE

We have used allergen challenge to investigate the course of the ocular response, tear inflammatory mediators, tissue adhesion protein expression, and cellular infiltration.

METHODS

Eighteen atopic patients and 4 nonatopic control subjects were challenged with extracted mixed grass or Dermatophagoides pteronyssinus in one eye and control vehicle in the other. The clinical response was recorded, and tears were collected over a 6-hour period. Conjunctival biopsy specimens were taken from the challenged eye at 6 or 24 hours.

RESULTS

An early-phase response (maximal at 20 minutes) showed a significant increase in tear histamine and tryptase levels, reducing to control levels again by 40 minutes. At 6 hours, a late-phase response occurred with increased symptoms, a second peak of tear histamine and eosinophil cationic protein but not tryptase, upregulation of the adhesion molecules E-selectin and intercellular adhesion molecule, and a cellular infiltrate of mast cells, neutrophils, eosinophils, macrophages, and basophils, with T cells increased only in bulbar biopsy specimens.

CONCLUSIONS

The early peaks of tear histamine plus tryptase indicate that the mast cell is responsible for the early-phase response, but basophils may be involved in the late-phase response. Both tear and biopsy findings underline the significance of the late-phase response as the transition between a type I response and clinical disease.

Effect of lodoxamide on tear leukotriene levels in giant papillary conjunctivitis associated with ocular prosthesis

Leukotrienes have been shown to play a role in the pathogenesis of ocular inflammatory and allergic reactions like vernal keratoconjunctivitis and contact lens-associated giant papillary conjunctivitis. This study was designed to determine leukotriene B4 (LTB4) and leukotriene C4 (LTC4) levels in the tears of patients with ocular prosthesis-associated giant papillary conjunctivitis (OP-GPC) and to evaluate the effects of lodoxamide 0.1% on tear LTB4 and LTC4 levels of OP-GPC patients. Tear LTB4 and LTC4 levels were determined by an ELISA technique in the tears of ten OP-GPC patients before and after treatment with lodoxamide 0.1% for one month. The results were compared with that of ten healthy control subjects. The mean tear LTB4 and LTC4 levels of the OP-GPC patients were significantly higher than those of the control group. After treatment with lodoxamide 0.1%, tear LTB4 and LTC4 levels of the OP-GPC patients decreased significantly. This is the first report of elevated LTB4 and LTC4 levels in tears of OP-GPC patients and it points to the possible role of leukotrienes in the immunopathogenesis of OP-GPC. The results also indicate that lodoxamide 0.1%, a mast cell membrane stabilizer, is effective in significantly reducing tear LTB4 and LTC4 levels in OP-GPC patients.

Effects of lodoxamide, disodium cromoglycate and fluorometholone on tear leukotriene levels in vernal keratoconjunctivitis

PURPOSE

We compared tear leukotriene B4 (LTB4) and leukotriene C4 (LTC4) levels of vernal keratoconjunctivitis (VKC) patients with those of age-matched controls and evaluated the effects of disodium cromoglycate (DCG) 2%, lodoxamide 0.1% and fluorometholone 0.1% on the tear LTB4 and LTC4 levels of the VKC patients.

METHODS

Thirty VKC patients were divided into three groups and their tear LTB4 and LTC4 levels measured with an enzyme-linked immunoassay technique before and after treatment with either lodoxamide 0.1%, DCG 2% or fluorometholone 0.1%. The results were compared with the tear LTB4 and LTC4 levels of 10 healthy control subjects. During this trial period, clinical scores for signs and symptoms of VKC were also evaluated.

RESULTS

In the VKC patients median tear LTB4 and LTC4 levels were 349.0 pg/ml (range 213.3-707.7 pg/ml) and 225.2 pg/ml (range 196.1-241.1 pg/ml) respectively--significantly higher than the control group (p = 0.0065 for LTB4 and p = 0.0003 for LTC4). After treatment, LTB4 levels decreased significantly in all treatment groups when compared with baseline (for the lodoxamide group, p = 0.01; for the DCG group, p = 0.008; for the fluorometholone group, p = 0.045). LTC4 levels were also significantly reduced after treatment in all three treatment groups (for the lodoxamide group, p = 0.0209; for the DCG group, p = 0.0284; for the fluorometholone group, p = 0.0109).

CONCLUSIONS

Tear LTB4 and LTC4 levels are significantly higher in VKC patients than controls, which points to a possible role of lipoxygenase pathway products in the pathophysiology of ocular allergic disorders. Lodoxamide 0.1%, DCG 2% and fluorometholone 0.1% were all effective in reducing LTB4 and LTC4 levels in VKC.

Seasonal allergic conjunctivitis is accompanied by increased mast cell numbers in the absence of leucocyte infiltration

BACKGROUND

Seasonal allergic conjunctivitis (SAC) is the most common allergic disease to affect the eye, occurring alone or in association with allergic rhinitis. Infiltration with mast cells and eosinophils is characteristic of the chronic forms of allergic conjunctivitis such as vernal and atopic keratoconjunctivitis, and these cell types also contribute significantly to allergic inflammation in the skin. Indirect evidence for a similar pattern of cellular events in SAC comes from studies which demonstrate raised eosinophil and neutrophil numbers in conjunctival scrapings and elevated levels of mast cell tryptase in tears following allergen challenge.

OBJECTIVE

To directly characterize the inflammatory cell infiltrate in SAC and to determine its clinical relevance.

METHODS

We employed specific immunohistochemical staining to count mast cells, eosinophils and neutrophils in the conjunctival epithelium and lamina propria of eight atopic patients with SAC in, and 12 SAC patients out of the hay fever season. Sixteen patients with no history of ocular allergy were used as control subjects.

RESULTS

Mast cells were absent from normal epithelium. During the pollen season median mast cell numbers in the lamina propria were found to be increased by 61% in patients with SAC compared with normals (P=0.012). Eosinophils were found in the lamina propria in less than half of the symptomatic patients with SAC and in only three patients were eosinophils present in the epithelium. The neutrophil numbers in the lamina propria of patients with SAC tended to be higher than normals but these changes did not reach statistical significance.

CONCLUSION

These data based on the direct assessment of conjunctival tissue provide evidence that symptoms occur in SAC in the absence of detectable recruitment of eosinophils or neutrophils. This suggests that this disorder is related to mast cell-mediated changes.

Visualization and comparison of molecular dynamics simulations of leukotriene C4, leukotriene D4, and leukotriene E4

Molecular dynamics simulations of leukotriene C4 (LTC4), leukotriene D4 (LTD4), and leukotriene E4 (LTE4) were carried out, and the data were visualized in an animated video format. Three-dimensional ghost images show the positions of the heavy atoms of all three molecules throughout the simulations. The ghost images can be superimposed to give a single three-dimensional image in which the shapes of the most populated conformers of each molecule are apparent and can be compared. Leukotriene D4 was found to occupy mostly T-shaped conformations, while LTC4 occupied mostly cup-shaped conformations, and LTE4 occupied a wide range of conformations spanning the LTD4 and LTC4 types. Digital filtering and graphing of the internal geometries of the molecules as a function of time revealed differences in dynamic behavior. The results are discussed in light of current knowledge about leukotriene receptors.

IL-3 and IL-5 enhance the production of LTB4 stimulated by calcium ionophore in rat basophilic leukemia cells

To determine the regulatory mechanism of Leukotriene (LT) B4 synthesis by cytokines, we investigated the regulation of LTB4 generation by short-term (30 min) priming and long-term (15 h) enzyme-inducing actions of the four cytokines interleukin (IL)-3, IL-5, tumor necrosis factor alpha (TNF-alpha), and transforming growth factor alpha (TGF-alpha) in rat basophilic leukemia-1 (RBL-1) cells. Pretreatment of cells with IL-3 or IL-5 for 30 min increased A23187- (5x10(-9)M) stimulated synthesis of LTB4 by three to four times over control levels. However, IL-3 or IL-5 lacked this effect when stimulated with exogenous arachidonic acid A at 10(-4)M. TNF-alpha and TGF-alpha had no priming effect on LTB4 synthesis following stimulation with either A23187 (5x10(-9)M) or AA(10(-4)M). Stimulation with the calcium ionophore (A23187)(10(-5)M) or AA(10(-4)M) following 15-h exposure to these cytokines had no effect. These results suggest that IL-3 and IL-5 increase the production of LTB4 by priming the activity of phospholipase A2(PLA2) without inducing enzymes in the arachidonate 5-lipoxygenase pathway. Such a priming effect may be important in regulating the development of allergic and other diseases involving the inflammatory reaction.

Evaluation of 0.05% levocabastine versus 4% sodium cromolyn in the allergen challenge model

PURPOSE

This study was conducted to evaluate the efficacy of 0.05% levocabastine compared with 4% cromolyn for treating allergic conjunctivitis induced by ocular allergen challenge.

METHODS

Subjects who met all entry criteria and reacted positively to ocular allergen challenge at two previous visits (n = 50) received placebo in one eye and cromolyn in the fellow eye, four times daily for 2 weeks. On day 18, subjects received the final dose of cromolyn in the pretreated eye and one drop of levocabastine in the fellow eye. Subjects were challenged and evaluated after 3, 5, and 10 minutes. Four hours after drug administration, subjects were rechallenged and evaluated after 3, 5, and 10 minutes.

RESULTS

Levocabastine was significantly more effective than cromolyn in inhibiting itching, hyperemia, eyelid swelling, chemosis, and tearing after the initial challenge and 4-hour rechallenge (P < 0.05).

CONCLUSION

These results suggest that levocabastine is superior to cromolyn for treating allergen-induced conjunctivitis and has a duration of action of at least 4 hours.

Evaluation of the new ophthalmic antihistamine, 0.05% levocabastine, in the clinical allergen challenge model of allergic conjunctivitis

The objective of this study was to evaluate the efficacy of 0.05% levocabastine, a new antihistamine formulated for ophthalmic use, compared with the placebo vehicle for the treatment of allergic conjunctivitis induced by ocular allergen challenge. Subjects who reacted. positively in both eyes on two separate occasions to ocular allergen challenge with grass, ragweed, or cat dander (N = 47) received one dose of 1 to 2 drops of 0.05% levocabastine in one eye and its vehicle in the other eye. After 10 minutes, the predetermined dose of allergen was instilled in both eyes. Signs and symptoms of allergic conjunctivitis were evaluated with biomicroscopy and subjective evaluation of itching after 3, 5, and 10 minutes. Four hours after drug administration, subjects were rechallenged and reevaluated to determine levocabastine's duration of action. Results showed that levocabastine was significantly more effective than placebo in inhibiting itching, hyperemia, eyelid swelling, chemosis, and tearing after the initial challenge and in inhibiting all parameters except eyelid swelling after the rechallenge 4 hours later (p < 0.05). These results demonstrate that levocabastine, currently the only ophthalmic antihistamine available that is not combined with a vasoconstrictor, is efficacious in the inhibition of itching, as well as all of the allergic signs of a vascular origin, with a duration of action of at least 4 hours. Because of its strong effects on itching and hyperemia, chemosis, lid swelling, and tearing, levocabastine would be a valuable therapeutic agent to add to the heterogeneous family of antiallergic compounds presently available for the treatment of seasonal allergic conjunctivitis.

Involvement of leukotrienes in allergic inflammation in mice

The involvement of leukotrienes in the anaphylactic paw edema was investigated in sensitized boosted or unboosted mice. No difference was noted in the intensity of the antigen-induced paw edema between boosted and unboosted animals. Since the non-steroidal anti-inflammatory agents, indomethacin and aspirin, were inactive, cyclooxygenase products are not involved in the anaphylactic reaction in boosted or unboosted mice. In contrast, the mixed lipoxygenase/cyclooxygenase inhibitor, BW 755C (3-amino-1-m-(trifluoroethyl)phenyl-2-pyrazoline), and the LTD4 (leukotriene D4) receptor antagonist, LY 171883 (1-(2-hydroxy-3-propyl-4-(4-(1H-tetrazol-5-yl)butoxy)phenyl)eth anone, reduced the edema in boosted but not unboosted mice, suggesting the involvement of lipoxygenase metabolites in the allergic edema in boosted mice. Dexamethasone was only effective in inhibiting allergic edema in boosted mice when administered 12 h before provocation, but failed to reduce the edema in unboosted mice. Our results suggest that the booster injection during immunization shifts the anaphylactic mouse paw edema from a leukotriene-independent to a leukotriene-dependent reaction.

Comparison of Naphcon-A and its components (naphazoline and pheniramine) in a provocative model of allergic conjunctivitis

A double-masked, randomized, parallel group, placebo-controlled study demonstrated the efficacy of Naphcon-A (naphazoline HCl 0.025% and pheniramine maleate 0.3%). Seventy-two patients with a documented positive skin test or radioallergosorbent test were recruited. Three groups of 24 patients each received 1 drop of Naphcon-A instilled in one eye, and 1 drop of either naphazoline, pheniramine, or placebo in the other eye. After the instillation of test medication, a titrated dose of ragweed antigen was administered bilaterally, and ocular signs and symptoms were evaluated 10, 30, and 120 minutes later. All patients (excluding 4 who had persistent symptoms attributable to ragweed) were rechallenged with ragweed antigen at 120 minutes to assess the duration of action of the test medications. Naphcon-A was significantly more effective than placebo, naphazoline, and pheniramine in reducing redness. Naphcon-A and pheniramine were equally effective in relieving itching.

Human epidermis transforms exogenous leukotriene A4 into peptide leukotrienes: possible role in transcellular metabolism

Leukotriene B4 formation can take place by cell interaction between keratinocytes and neutrophils. Thus, keratinocytes without proven 5-lipoxygenase activity can transform neutrophil-derived leukotriene A4 into leukotriene B4. The purpose of the present study was to investigate whether human epidermis is able to transform leukotriene A4 sequentially into the peptide leukotrienes (LTC4, LTD4 and LTE4). Epidermis isolated using the suction blister technique or keratomed skin specimens were incubated with either neutrophils or exogenously added leukotriene A4. Peptide leukotrienes were determined by integrated optical density after RP-HPLC separation, and the identity of leukotrine C4 was confirmed by (1) the retention time similarity with authentic leukotriene C4; (2) the UV spectrum determined with an on-line diode array detector; and (3) conversion by gamma-glutamyl transpeptidase of the peak coeluting with authentic leukotriene C4 into a new peak coeluting with authentic leukotriene D4. The results of this study showed that while human epidermis cannot form detectable amounts of peptide leukotrienes by itself, it can transform exogenous leukotriene A4 into peptide leukotrienes. Furthermore, coincubation of human epidermis and neutrophils resulted in a marked increase (90%) in peptide leukotriene formation when compared with neutrophils alone, indicating that human epidermis can transform neutrophil-derived leukotriene A4 into peptide leukotrienes. These results indicate that human skin contains leukotriene C4 synthase activity capable of producing significant amounts of leukotriene C4 from leukotriene A4, and that the keratinocytes may play a more active role in peptide leukotriene formation in the skin than previously thought.(ABSTRACT TRUNCATED AT 250 WORDS)

Levels of prostaglandin E2 and leukotriene B4 in tears of vernal conjunctivitis patients during a therapeutic trial with indomethacin

A therapeutic trial of 1% indomethacin (Indoptic) eye drops was carried out in 21 children. Looking for possible mediators of inflammation in vernal conjunctivitis, prostaglandin E2 (PGE2) and leukotriene B4 (LTB4 levels in the tears of 9 patients were measured and the effect of the treatment on them examined. A control group of 10 unaffected children was added. Out of 42 eyes in which indomethacin treatment was instilled, only 17 remained in treatment through a 6-week follow-up period. In a few of them a moderate improvement was obtained. The mean level of PGE2 in the patients before treatment was found to be slightly lower than that in the control group, and it dropped even lower during treatment. The average LTB4 level found in patients before treatment was significantly higher than the control group; it decreased somewhat following treatment, but not significantly. This is the first report of elevated LTB4 levels in vernal conjunctivitis, previously not recorded in the literature, it points to the possible role of LTB4 in the pathogenesis of the disease. A constant relationship was observed between low PGE2 levels and high LTB4 content in the patients' tears during highly inflamed states of the eye. We conclude that: (a) indomethacin did not prove to be a highly effective topical treatment for vernal conjunctivitis; (b) PGE2 does not seem to be a dominant mediator of inflammation in this disease; and (c) LTB4, on the other hand, apparently has a role in the mechanism of inflammation of the disease, thus raising hopes for future addition to therapy.

Conjunctivitis of allergic origin: immunologic mechanisms and current approaches to therapy

The pathogenesis of ocular allergy involves multiple mechanisms, which lead to mast cell degranulation and the release of chemical mediators. Mast cell mediators that have been implicated in allergic ocular disease include histamine, eosinophil chemotactic factors, eosinophil granule major basic protein, platelet-activating factor, prostaglandin D2, and several other less well-defined preformed or newly synthesized mediators. The release of these chemical mediators ultimately results in conjunctival vasodilation, increased vascular permeability, leukocyte chemotaxis, and, rarely, ocular surface destruction. Current therapy of ocular allergy involves elimination of the offending allergen, modulation of the immune system, and pharmacologic inhibition of the chemical mediators. The purpose of this article is to provide a better understanding of the pathogenesis and current therapy of ocular allergic disorders and to review the central role of the mast cell and chemical mediators involved in ocular allergy.

Correlation between conjunctival provocation test (CPT) and systemic allergometric tests in allergic conjunctivitis

In order to assess the potential usefulness of CPT as a diagnostic tool for ocular allergy, the correlation between skin/RAST tests and CPT was determined in 144 patients affected by allergic 'hay fever' type conjunctivitis. The results showed that an agreement between skin/RAST tests and CPT occurred in 71% of the cases (130/183). Of the 29% uncorrelated cases, 23% (43/183) were positive for at least one specific antigen by skin/RAST tests but not by CPT, while 6% (10/183) were positive for at least one specific antigen by CPT, but not by skin/RAST tests. CPT dramatically increased the histamine levels in tears (p less than 0.001). These findings show that (1) systemic tests can be misleading in that they may suggest a specific sensitisation which, in fact, does not involve the conjunctiva (systemic test positive/CPT negative); (2) CPT can identify local conjunctival sensitisation in the absence of a systemic sensitisation (systemic test negative/CPT positive); (3) CPT can demonstrate that allergic 'hay fever' type conjunctivitis may be related to allergens different from those responsible for a systemic sensitisation.

The IgE- and calcium-dependent release of eicosanoids and histamine from human purified cutaneous mast cells

Cells dispersed from human foreskin were passively sensitized with IgE and then depleted or enriched in mast cells by density gradient centrifugation. Arachidonic acid metabolism was initially studied by radio-high-performance liquid chromatography analysis of incubation media from cells that had been prelabeled with [3H] arachidonic acid. In subsequent experiments with unlabeled cells the eicosanoids were quantified by radioimmunoassay. Prostaglandin (PG)D2 was the major cyclooxygenase product released from purified mast cells challenged with anti-IgE or A23187. In density gradient studies there was a significant correlation between PGD2 and histamine release (r = 0.52, p less than 0.01) and between PGD2 release and the numbers of mast cells (r = 0.42, p less than 0.02). There was no correlation with the total numbers of nucleated cells. Other cyclooxygenase products were also detected, the formation of 6-keto-PGF1 alpha and PGE2 being principally associated with gradient fractions containing endothelial cells. Leukotriene (LT)C4 was the major lipoxygenase product detected, reaching a maximum of 3.87 +/- 0.56 ng/10(6) mast cells upon activation with anti-IgE compared with 35.37 +/- 7.22 ng/10(6) mast cells of PGD2. When normalized to histamine release and expressed in molar terms, skin mast cells released approximately 20-fold more PGD2 than LTC4. Thus, the cutaneous mast cell is one likely source of the PGD2 and LTC4 released during cutaneous immediate hypersensitivity reactions.

Evaluation of the conjunctival provocation test in allergy diagnosis

Conjunctival provocation tests (CPT) were performed in 65 respiratory allergic patients, 24 of them with a clinical history of allergic conjunctivitis and 41 who had never complained of allergic conjunctivitis, to assess the role of the conjunctiva as a target organ. The usefulness of CPT and RAST to identify symptom-related and symptom-unrelated allergen in 51 patients sensitized to two allergens but only symptomatic to one of them was also studied. Conjunctiva was found to react in a similar way to skin in patients with and without clinical conjunctivitis. CPT was positive for both symptom-related and symptom-unrelated allergens in 33 of the 51 pluri-sensitized patients. Nevertheless, in the 18 patients showing positive CPT to only one allergen, agreement with clinical data was generally found. Thus CPT appears to be a useful test in the evaluation of atopic sensitization in patients reactive to a single allergen, but not in the identification of clinically relevant allergens in individuals who are skin or RAST positive to multiple agents.

Interactive effects of peptidoleukotrienes and histamine on microvascular permeability and their involvement in experimental cutaneous and conjunctival immediate hypersensitivity

The involvement of peptidoleukotrienes (LTs) in mediating the increase in microvascular permeability associated with experimental cutaneous immediate hypersensitivity was studied by examining the effect of SK&F 104353, a potent and selective LT-antagonist, on the response evoked by graded, intradermal injections of antigen. SK&F 104353, employed at doses that profoundly blocked LTC4, LTD4 and LTE4 responses, significantly reduced the response produced by experimental cutaneous immediate hypersensitivity. The response to the lowest antigen dose (0.1 microgram) was, however, entirely insusceptible to SK&F 104353. The effect of SK&F 104353 was also examined in combination with a pyrilamine-cimetidine dosing regimen sufficient to remove the histaminergic component of cutaneous immediate hypersensitivity. The non-histaminergic component associated with higher antigen doses (10 and 100 micrograms) was significantly reduced but not abolished by SK&F 104353; the non-histaminergic component associated with low antigen doses (0.1 and 1 microgram) was not susceptible to SK&F 104353. Thus, the increase in cutaneous microvascular permeability evoked by immediate hypersensitivity appears to comprise three components: (1) A histaminergic response apparent for all antigen doses; (2) a LT-mediated component which is manifest in response to high antigen doses; (3) a third, unidentified component that is present for the entire antigen dose-range but contributes less to the overall response when high antigen doses are used. A distinct non-histaminergic, non-leukotriene mediated component was not a feature of conjunctival immediate hypersensitivity. SK&F 104353 administered in combinatio with pyrilamine-cimetidine virtually abolished the response with a small residual remaining only for the highest antigen dose. In further contrast to cutaneous immediate hypersensitivity, SK&F 104353 alone was comparatively ineffective in type 1 allergic conjunctivitis. This difference in susceptibility to SK&F 104353 appears to reflect the type of histamine-LTD4 interactive effect on microvascular permeability. Histamine and LTD4 were additive in terms of cutaneous microvascular permeability. In the conjunctiva, histamine and LTD4 appeared mutually exclusive in that the level of response produced by the combination tended not to exceed that of the single component which caused the greater effect.

Leukotrienes. Biology and role in disease

Leukotrienes are a novel group of chemical messengers derived from arachidonic acid. They are produced by several different tissues by processes linked to phospholipid flux in response to specific stimuli. The leukotrienes interact with specific receptors in target cell membranes to initiate a response. Most of these responsive cells are derived from bone marrow, skin, smooth muscle, and vascular endothelium. Leukotrienes are powerful mediators of inflammation and smooth muscle contraction, and there is increasing evidence that they are important factors in immune-mediated disease. Several available effective antiinflammatory drugs may act partially by inhibiting the production of leukotrienes.

Effect of levocabastine, a new H1 antagonist, in a conjunctival provocation test with allergens

Levocabastine is a new, highly potent, and specific H1 antagonist. The effects of this drug, administered topically, were evaluated in a conjunctival provocation test (CPT) with allergens. CPT was performed by the instillation of one drop of allergen at increasing concentrations in the inferior conjunctival sac of each eye, alternatively, and stopped when both itching and redness of the conjunctiva were present. The concentration of allergen at this step was considered as the reaction threshold. Eleven patients, allergic to grass pollen, underwent, in winter, a first CPT without pretreatment (screening test); the CPT was then repeated twice after a 24-hour treatment, once, with a placebo, and once, with levocabastine (one drop twice a day, 0.5 mg/ml), administered in a double-blind fashion and in random order. The minimal interval between the two tests was 1 week. There was no significant difference between the thresholds determined in the two CPTs performed without medication (screening test and placebo), whereas the threshold was significantly increased (p less than 0.001) after pretreatment with levocabastine. Individually, the threshold increased in 10/11 patients (p less than 0.01). Levocabastine prevented both redness and itching. A late allergic reaction was observed by the patient in 6/11 CPTs performed after placebo treatment and 8/11 after levocabastine treatment. We conclude that, in this model of allergic conjunctivitis, levocabastine increased the conjunctival tolerance to an allergen. Further studies should help to determine the true place of this H1 antagonist in the treatment of allergic conjunctivitis.

5-Lipoxygenase inhibitors and allergic conjunctivitis reactions in the guinea-pig

The role of leukotrienes as mediators of microvascular permeability changes (assessed through the accumulation of [99mTc]albumin) associated with immediate hypersensitivity reactions in the guinea-pig conjunctiva was investigated by means of two novel, structurally dissimilar 5-lipoxygenase inhibitors, L-651,392 and L-651,896. Both compounds, when applied topically in vivo to the eyes of sensitized guinea-pigs as a 0.1% suspension significantly inhibited 5-lipoxygenase in the conjunctiva as assessed by ex vivo challenge with either antigen or ionophore A23187 and measurement of the release of leukotriene B4-immunoreactive material. Topical application of antigen (either single challenge or 2 challenges separated by 24 h) to the eyes of sensitized guinea-pigs produced changes in conjunctival permeability which were blocked in part by either mepyramine (H1-receptor antagonist) or the 5-lipoxygenase inhibitors. Combinations of mepyramine and L-651,896 resulted in near complete suppression of the permeability response, suggesting that the reaction is mediated only by histamine and leukotrienes.

Leukotrienes as mediators in frog virus 3-induced hepatitis in rats

The role of leukotrienes was investigated in frog virus 3-induced hepatitis in rats. Frog virus 3 elicited an enhanced generation of cysteinyl leukotrienes in vivo as monitored by measurement of N-acetyl-leukotriene E4 as the major endogenous metabolite of cysteinyl leukotrienes secreted into rat bile. N-Acetyl-leukotriene E4 concentrations were elevated for more than 4 hr after frog virus 3 injection. In vitro experiments using cultured rat liver Kupffer cells of high purity indicated that these cells can produce and metabolize leukotrienes and are thus a possible source of leukotrienes elicited in vivo by frog virus 3. The selective 5-lipoxygenase inhibitor AA 861 and the dual inhibitor of arachidonate lipoxygenase and cyclooxygenase, BW 755C, reduced the hepatocellular injury after a high dose of frog virus 3 by about 50 and 80%, respectively, as judged from plasma activities of ALT and sorbitol dehydrogenase at 24 hr after frog virus 3 administration. Our in vivo and in vitro studies argue in favor of an important role of leukotrienes as mediators in frog virus 3 hepatitis in rats.

The role of leukotriene D4 as a mediator of allergic conjunctivitis in the guinea-pig

The role of leukotriene D4 (LTD4) as a mediator of conjunctival microvascular permeability changes associated with immediate hypersensitivity reactions in the guinea-pig conjunctiva has been investigated using two novel, selective LTD4 receptor antagonists, L-648,051 and L-649,923. Changes in microvascular permeability were measured through the accumulation of [99mTc]albumin. LTD4 administered intravenously produced dose-related increases in conjunctival microvascular permeability through a mechanism which does not involve the generation of prostaglandins as indicated by the failure of indomethacin to attenuate the response. The response to LTD4 was significantly blocked by the receptor antagonists, L-648,051 and L-649,923. Topical application of antigen (either single challenge or 2 challenges separated by 24 h) to the eyes of sensitized guinea-pigs caused significant increases in conjunctival microvascular permeability. Following a single challenge, the antigen response was largely blocked by mepyramine (H1 receptor antagonist), but was unaffected by L-648,051 and L-649,923. Following a second challenge (24 h later) a substantial portion of the response was inhibited by L-648,051 and L-649,923. Indomethacin failed to inhibit either challenge. These results suggest that LTD4 may have a role in chronic allergic conjunctivitis.

Vascular effects of leukotriene D4 in human skin

Leukotriene D4 (LTD4) increased the blood flow rate in human skin, equipotent to histamine in the dose range of 3.1-200 pmol. The vasodilatation lasted for up to 60 min, and no late reactions occurred. Indomethacin did not affect the LTD4-induced blood flow rate. H1 and H2 antagonists reduced the increase in blood flow rate, but did not abolish the response to LTD4. Local nerve block inhibited the axon reflex-mediated flare component of the LTD4-induced blood flow rate, leaving a local red reaction. This local red reaction was not affected by H1 and H2 antagonists. These results indicate histamine as a mediator of the axon reflex, and show that LTD4 causes a direct vasodilatory effect that is not mediated via histamine or cyclooxygenase products. The laser-Doppler flowmeter was applied for dynamic studies of the vasopressor response in the skin during a Valsalva maneuver, and the relative changes in blood flow were confirmed by control estimates of the blood flow rate by a 133xenon washout method. The pressor response to a Valsalva maneuver was reversed by local nerve block, but not affected by LTD4. Therefore LTD4 did not interfere with the sympathetic activity on the cutaneous vessels. Leukotriene D4 caused a dose-dependent wheal reaction, equipotent to histamine in the dose range of 0.2-200 pmol. Only minor whealing occurred when the vasculature to the test arm was occluded before injection of LTD4 and the circulation restored 30 min later. Most of the LTD4 was apparently metabolized within this period. Subsequent injections of LTD4 into the same sites demonstrated the development of tachyphylaxis with respect to whealing. This evidence suggests that LTD4 cannot mediate sustained inflammation. The injections of LTD4 caused neither pain nor itching. In conclusion, the elucidated properties point to LTD4 as a possible mediator of microvascular changes during acute inflammation.

Chemotactic activity of LTB4 in man

An improved skin window chamber technique has been developed and used for a quantitative study of the chemotactic effect of leukotriene B4 (LTB4). LTB4 (0.5 microM) was exposed to a skin window on the forearm of eight healthy volunteers, while phosphate buffered saline served as control in a skin window on the other forearm. Skin window exudates and samples of blood draining the skin window areas were collected after 1, 2, 4, 8, and 24 h. The samples were quantitated for the different types of leukocytes as well as the intra- and extracellular concentration of the eosinophilic cationic protein and lactoferrin as markers of eosinophil and neutrophil granulocytes. A significantly increased migration of neutrophil granulocytes into the skin window chamber containing LTB4 was found from the 2nd to the 8th hour after the initial LTB4 exposure. The eosinophils reached a significant peak at the 4th hour. The rise in the actual number of eosinophil cells did not reach significance, whereas measurements of the eosinophilic cationic protein in the cellular fraction of the exudate exhibited a significant increase as a reflection of the number of eosinophils. This highlights the potential clinical value of eosinophilic cationic protein measurements to reveal eosinophilia instead of the traditional eosinophil counts. Extracellular eosinophilic cationic protein and lactoferrin did not change significantly in the LTB4-exposed skin window, implying that LTB4 does not activate the eosinophils and neutrophils to exocytosis of their enzymes. The present in vivo results support the concept of LTB4 being a potent chemoattractant to neutrophil and less so to eosinophil granulocytes in humans, a chemoattractant that recruits the leukocytes but does not seem to activate them.

Biological actions of leukotrienes. State of the art lecture

Leukotrienes are novel mediators derived from arachidonic acid through the 5-lipoxygenase enzyme system. Leukotriene B4 has potent effects on leukocyte function and in vivo induces leukocyte accumulation and changes in vascular permeability and modulates pain responses. Peptido-lipid leukotrienes are potent smooth muscle--contracting agents. They may have important cardiovascular actions through mechanisms involving either vasoconstriction or indirect vasodilatation. Evidence for leukotriene production has been found in subjects with allergic conditions and psoriasis, indicating a putative role for these substances in human disease.